Browsing by Author "Holder, Erik"

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    Early or Late Gastrografin Challenge for the Non-Operative Management of Small Bowel Obstruction
    (2020-09-10) Holder, Erik; Murphy, Patrick; Meagher, Ashley; Rodriguez, Rachel
    Introduction: Gastrogafin (GG) challenge is becoming the standard of care for the non-operative management of adhesive small bowel obstruction (aSBO). Protocols vary in the timing of GG challenge from early (≤ 24 hours) to late (> 24 hours). Concerns remain regarding the safety of early GG due to inadequate stomach and bowel decompression raising fear of complication such as aspiration. Few studies have investigated the relationship between the timing of GG and patient outcomes, including time to OR, length of stay or complication rate. We hypothesized early GG challenge would be non-inferior to late GG challenge and would have shorter length of stay. Methods: A retrospective cohort study of 215 patients over two years (2018-2019) who underwent non-operative management of adhesive SBO. We stratified patients by timing of GG challenge, ≤ 24 hours (Early GG) or > 24hours (Late GG). Our primary outcome was success of GG challenge defined by discharge without an operation. Secondary outcomes included bowel resection, re-admission rate, hospital length of stay, and mortality. Our non-inferiority margin was 4%. We used the Chen Quasi-Exact method to determine confidence intervals for small sample sizes to determine non-inferiority. Continuous data was assessed by one-way ANOVA and categorical data with Fischer’s Exact test. Results: A total of 215 patients underwent planned non-operative management of adhesive SBO over the study period, of whom 102 received a GG challenge. Early GG was administered in 33 (32%), Late GG was administered in 79 (68%). There was no difference in age or gender, but more African Americans received Late GG (40% vs 15%, p = 0.01). The need for operative intervention was lowest in the early group, 6.1% compared to 17.7% in the late group. The difference of -11.6% [95% CI -22.9% - 3.3%] was non-inferior (p=0.03) but did not meet superiority. No patient receiving Early GG required bowel resection compared to 5 (35%) in the Late GG group (p = 0.45). Hospital length of stay was a median of 3 (IQR 2) for Early GG compared to 4 (IQR 8) for Late GG (p < 0.001). There was no difference in mortality, re-admission rates, ICU admission or ICU length of stay between groups. Conclusion: Early GG challenge (≤ 24 hours) is non-inferior to late GG challenge (> 24 hours) for the non-operative management of adhesive SBO. Patients who received early GG had a shorter length of stay, and no complications associated with early GG. Additionally, fewer patients who received early GG received a bowel resection, although this is not statistically significant. This indicates need for multi-center evaluation of GG administration and development of practice management guidelines for patients with adhesive SBO. We recommend early GG challenge to decrease the time for operative decision making and reduce length of stay. A prospective study comparing early versus late GG challenge is needed to determine optimal timing.
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    Impact of a Daytime Operating Room on Resource Use and Outcomes in Emergency General Surgery
    (2020-02-05) Murphy, Patrick; Patterson, Alicia; Holder, Erik; Scifres, Aaron; Rodriguez, Rachel
    Introduction: The implementation of acute care surgery (ACS) services has not been standardized. There is no known “best” model or optimal infrastructure required to care for emergency general surgery (EGS) patients. The addition of dedicated daytime operative room (OR) resources may increase patient access and reduce overnight operations. Methods: We performed a retrospective cohort study of patients who underwent emergency appendectomy, cholecystectomy, or hernia repair at a tertiary care center from Feb 1, 2015 to Dec 31, 2018. A daytime ACS room was implemented on Jan 18, 2017, dividing patients into two cohorts: the “Pre-Access” period prior to and “Post-Access” period after implementation. Resources were allocated to the ACS room only if cases were booked by 430 PM the day prior. Outcomes included after-hour ORs (5 pm – 7 am), time to OR, time of scheduled ORs (AM or PM) and relevant patient outcomes. Results: Over 4-years, 925 patients underwent appendectomy (42%), cholecystectomy (50%) or hernia repair (8%) on an emergent basis. There was a 49% increase in volume in the Post-Access period, without an increase in time to OR [14 h, IQR 38 for both groups], after-hours OR (42.1% v 42.1%, p=0.99) or timing of ORs (28.3% v 29.1% AM start and 29.4% v 28.7% PM start, p=0.96). There was no change in hospital length of stay [2 d, IQR 4 v 3 d, IQR 4, p=0.39] or complication rates (14% v 18%, p=0.15). On subgroup analysis, only delayed cholecystectomies for gallstone pancreatitis (GSP) showed a reduction in after-hours ORs (13% v 0%, p=0.03) and an increase in AM OR start times (43% v 71%, p=0.02), suggesting that pre-scheduled cases are most affected by this OR allocation model. Conclusion: Despite a significant increase in volume there was no increase in after-hours resource utilization, hospital length of stay, or worse patient outcomes. The addition of an ACS room improved daytime access for GSP but not for other diagnoses. Dedicated infrastructure results in efficient use of resources and the ability to manage increasing patient volumes. Efficiency may be further improved by dedicated staffing of ACS rooms.
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    Is Manipulation Under Anesthesia Effective in Improving Patient Reported Outcomes After Total Knee Arthroplasty? A Matched Cohort Analysis.
    (2019-12) Ciesielski, Alex; Holder, Erik; Deckard, Evan; Ziemba-Davis, Mary; Meneghini, R Michael
    Introduction: Manipulation under anesthesia (MUA) after total knee arthroplasty (TKA) is considered effective for postoperative stiffness, but strong scientific justification is lacking. This study compared outcomes in two matched cohorts: patients who met criteria and underwent MUA and patients who met criteria but did not undergo MUA. Methods: MUA (experimental) cases had ≤ 90° flexion 4-weeks postoperatively and underwent MUA surgery within 12 weeks of the index TKA. Control cases had ≤ 90° flexion 4-weeks postoperatively and did not undergo MUA. The latter group was alternatively treated with aggressive flexion exercises, frequent follow-up, and pain control modalities per surgeon discretion. 42 MUAs performed by three surgeons between 2011 and 2017 at the same center using the same standardized clinical and rehabilitation protocols were retrospectively reviewed. Six MUAs were excluded for potential confounds. The remaining 36 MUA cases were matched one-to one on sex (p= 1.00), age (p=0.893), race (p=0.938), BMI (p=0.069), and implant manufacturer (p= 1.00) to 36 control cases. Outcome variables included amount of improvement in flexion from preoperative baseline to latest follow-up and standardized PROMS. Covariates potentially affecting outcomes were taken into account. Results: Overall MUA incidence during the time period was 1.9%. Experimental and control groups did not differ on preoperative fibromyalgia, depression, and narcotic use; or intraoperative analgesia (p≥0.084). Four control patients and no experimental patients had inflammatory disease (p=0.054), and six of the former compared to none of the latter had lumbar spine pain or disease (p=0.025). Flexion data are provided in Table 1. Mean pre-primary TKA flexion was significantly greater in experimental patients (112.4 vs. 98.6°, p=0.002). On average, between pre-primary surgery and latest follow-up, experimental patients lost 10.7° of flexion compared to a gain of 12.7° by control patients (p<0.001). Pre-primary to latest follow-up improvement in pain walking on level ground (-3.3 and -4.7 points, p=0.190) and climbing stairs (-3.7 vs. -5.1, p=0.192) did not significantly differ between experimental and control patients respectively. As shown in Figure 1, prior to primary surgery experimental and control patients had similar activity levels (p=0.624). At latest follow-up, however, control patients were significantly more active than experimental patients (Figure 1, p=0.009). Figure 2 shows the proportions of patients in each group who reported their knee never feels normal prior to primary surgery (p=0.580) and at latest follow-up (p=0.0004). Surgery significantly improved this metric for control but not experimental patients. At latest follow-up 88.6% of control patients and 50% of experimental patients were satisfied or very satisfied with their knee surgery (p=0.001). Conclusion: Patients with ≤ 90° flexion 4-weeks after TKA who underwent MUA had significantly worse flexion and PROM scores than matched control patients who did not undergo MUA. These findings question the effectiveness of MUA as a legitimate treatment for postoperative TKA stiffness.
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    Is Operative Diagnosis for Aseptic Revision Total Hip Arthroplasty Related to Patient Reported Outcomes?
    (2018-07) Holder, Erik; Ciesielski, Alex; Ziemba-Davis, Mary; Meneghini, R. Michael
    Background and Hypothesis: Component loosening and instability are the leading causes of revision total hip arthroplasty (THA). The purpose of this study was to compare patient-reported outcomes after revision THA based on failure etiology. We hypothesized that outcomes would differ based on reason for revision. Project Methods: 187 consecutive revision THAs performed between 2010 and 2017 were retrospectively reviewed. Prospectively collected preoperative and minimum one-year Hip Disability and Osteoarthritis Outcome Score/HOOS Jr., UCLA Activity Level, WOMAC Index, and patient satisfaction were assessed based on failure etiology. Demographic variables and covariates were accounted for including sex, age, BMI, ASA classification, heart disease, lumbar spine pathology, narcotic use, fibromyalgia, depression, and autoimmune arthritis. Results: Latest UCLA activity level did not differ based on failure etiology (p=0.381). However, the degree of improvement in activity level was higher (p= 0.04) in patients revised for loosening, instability, and infection compared to ALTR and polyethylene wear. HOOS Jr (p=0.949) and WOMAC total (p=0.147) scores did not differ based on failure etiology at latest follow-up, although patients revised for loosening had greater WOMAC improvement compared to all other groups except polyethylene wear (p=0.016). Satisfaction did not vary based on failure etiology (p=0.365), and demographic and covariates were unrelated to outcomes (p³0.165). Conclusion and Potential Impact: We observed that patient-reported outcomes following revision THA vary based on revision reason and activity level improvement is mitigated patients revised for ALTR and poly wear. These findings may help surgeons and patients alike set expectations for recovery following revision THA.
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    Moringa Oleifera, Miracle Tree and Superfood: Antibacterial Evidence and Nutritional Benefits
    (2018-07-15) Miller, Grace J; Embalabala, Rebecca; Bennett, Claire; Buck, Jacob; Russell, Blake; Holder, Erik; Blanchard, Hope; Henry, Laura
    Moringa oleifera is a tropical plant that has high nutritional qualities. It has been used in India and other parts of Asia as a food and medicine for many years. It is now used in feeding programs in developing nations.  Recently, it has been marketed as a “superfood” in the USA. We have showed in our laboratory that the leaf and seed extracts are antimicrobial. The seeds of M. oleifera can also be used for water purification. We have made some observations from the GCMS data on the medicinal qualities of the leaves, seeds and roots. As a member of the order Brassicales, there is potential for crop improvement for drought and cold tolerance. We are interested in the biochemical and molecular studies of this plant. We present here successful callus formation through tissue culture of M. oleifera.  Several combinations of auxins and cytokinins were tested to induce callus formation of leaf and stem explants of M. oleifera The tissues were evaluated for callus formation. Explants were incubated in full light or dark for 4-8 weeks. We have successfully regenerated moringa plants from callus.
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    Optimal Timing of Venous Thromboembolic Chemoprophylaxis Initiation Following Blunt Solid Organ Injury: Meta-Analysis and Systematic Review
    (2021-04-22) Murphy, Patrick; de Moya, Marc; Karam, Basil; Menard, Laura; Holder, Erik; Inaba, Kenji; Schellenberg, Morgan
    PURPOSE: The need to prevent venous thromboembolism (VTE) following blunt solid organ injury must be balanced against the concern for exacerbation of hemorrhage. The optimal timing for initiation of VTE chemoprophylaxis is not known. The objective was to determine the safety and efficacy of early (≤48 hours) VTE chemoprophylaxis initiation following blunt solid organ injury. METHODS: An electronic search was performed of medical libraries for English-language studies on timing of VTE chemoprophylaxis initiation following blunt solid organ injury published from inception to April 2020. Included studies compared early (≤48 hours) versus late (>48 hours) initiation of VTE chemoprophylaxis in adults with blunt splenic, liver and/or kidney injury. Estimates were pooled using random-effects meta-analysis. Odds ratios were utilized to quantify differences in failure of nonoperative management, need for blood transfusion and rates of VTE. RESULTS: The search identified 2,111 studies. Of these, ten studies comprising 14,675 patients were included. All studies were non-randomized and only one was prospective. The overall odds of failure of nonoperative management were no different between early and late groups, OR 1.09 (95%CI 0.92-1.29). Similarly, there was no difference in the need for blood transfusion either during overall hospital stay, OR 0.91 (95%CI 0.70-1.18), or post prophylaxis initiation, OR 1.23 (95%CI 0.55-2.73). There were significantly lower odds of VTE when patients received early VTE chemoprophylaxis, OR 0.51 (95%CI 0.33-0.81). CONCLUSIONS: Patients undergoing nonoperative management for blunt solid organ injury can be safely and effectively prescribed early VTE chemoprophylaxis. This results in significantly lower VTE rates without demonstrable harm.
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    Optimal timing of venous thromboembolic chemoprophylaxis initiation following blunt solid organ injury: meta-analysis and systematic review
    (Springer, 2022-09-18) Murphy, Patrick B.; de Moya, Marc; Karam , Basil; Menard, Laura; Holder, Erik; Inaba, Kenji; Schellenberg, Morgan; Library and Information Science, Luddy School of Informatics, Computing, and Engineering
    Purpose: The need to prevent venous thromboembolism (VTE) following blunt solid organ injury must be balanced against the concern for exacerbation of hemorrhage. The optimal timing for initiation of VTE chemoprophylaxis is not known. The objective was to determine the safety and efficacy of early (≤ 48 h) VTE chemoprophylaxis initiation following blunt solid organ injury. Methods: An electronic search was performed of medical libraries for English language studies on timing of VTE chemoprophylaxis initiation following blunt solid organ injury published from inception to April 2020. Included studies compared early (≤ 48 h) versus late (> 48 h) initiation of VTE chemoprophylaxis in adults with blunt splenic, liver, and/or kidney injury. Estimates were pooled using random-effects meta-analysis. Odds ratios were utilized to quantify differences in failure of nonoperative management, need for blood transfusion and rates of VTE. Results: The search identified 2,111 studies. Of these, ten studies comprising 14,675 patients were included. All studies were non-randomized and only one was prospective. The overall odds of failure of nonoperative management were no different between early and late groups, OR 1.09 (95%CI 0.92-1.29). Similarly, there was no difference in the need for blood transfusion either during overall hospital stay, OR 0.91 (95%CI 0.70-1.18), or post prophylaxis initiation, OR 1.23 (95%CI 0.55-2.73). There were significantly lower odds of VTE when patients received early VTE chemoprophylaxis, OR 0.51 (95%CI 0.33-0.81). Conclusions: Patients undergoing nonoperative management for blunt solid organ injury can be safely and effectively prescribed early VTE chemoprophylaxis. This results in significantly lower VTE rates without demonstrable harm.