IU Indianapolis ScholarWorks :: Browsing by Author "Zarzaur, Ben L."

Browsing by Author "Zarzaur, Ben L."

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Augmented Reality Future Step Visualization for Robust Surgical Telementoring
(Wolters Kluwer, 2019-02) Andersen, Daniel S.; Cabrera, Maria E.; Rojas-Muñoz, Edgar J.; Popescu, Voicu S.; Gonzalez, Glebys T.; Mullis, Brian; Marley, Sherri; Zarzaur, Ben L.; Wachs, Juan P.; Surgery, School of Medicine
Introduction Surgical telementoring connects expert mentors with trainees performing urgent care in austere environments. However, such environments impose unreliable network quality, with significant latency and low bandwidth. We have developed an augmented reality telementoring system that includes future step visualization of the medical procedure. Pregenerated video instructions of the procedure are dynamically overlaid onto the trainee's view of the operating field when the network connection with a mentor is unreliable. Methods Our future step visualization uses a tablet suspended above the patient's body, through which the trainee views the operating field. Before trainee use, an expert records a “future library” of step-by-step video footage of the operation. Videos are displayed to the trainee as semitransparent graphical overlays. We conducted a study where participants completed a cricothyroidotomy under telementored guidance. Participants used one of two telementoring conditions: conventional telestrator or our system with future step visualization. During the operation, the connection between trainee and mentor was bandwidth throttled. Recorded metrics were idle time ratio, recall error, and task performance. Results Participants in the future step visualization condition had 48% smaller idle time ratio (14.5% vs. 27.9%, P < 0.001), 26% less recall error (119 vs. 161, P = 0.042), and 10% higher task performance scores (rater 1 = 90.83 vs. 81.88, P = 0.008; rater 2 = 88.54 vs. 79.17, P = 0.042) than participants in the telestrator condition. Conclusions Future step visualization in surgical telementoring is an important fallback mechanism when trainee/mentor network connection is poor, and it is a key step towards semiautonomous and then completely mentor-free medical assistance systems.
Clinical indicators of hemorrhagic shock in pregnancy
(BMJ, 2017-11-07) Jenkins, Peter C.; Stokes, Samantha M.; Fakoyeho, Stephen; Bell, Teresa M.; Zarzaur, Ben L.; Surgery, School of Medicine
Background Several hemodynamic parameters have been promoted to help establish a rapid diagnosis of hemorrhagic shock, but they have not been well validated in the pregnant population. In this study, we examined the association between three measures of shock and early blood transfusion requirements among pregnant trauma patients. Methods This study included 81 pregnant trauma patients admitted to a level 1 trauma center (2010–2015). In separate logistic regression models, we tested the relationship between exposure variables—initial systolic blood pressure (SBP), shock index (SI), and rate over pressure evaluation (ROPE)—and the outcome of transfusion of blood products within 24 hours of admission. To test the predictive ability of each measure, we used receiver operating characteristic (ROC) curves. Results A total of 10% of patients received blood products in the patient cohort. No patients had an initial SBP≤90, so the SBP measure was excluded from analysis. We found that patients with SI>1 were significantly more likely to receive blood transfusions compared with patients with SI<1 (OR 10.35; 95% CI 1.80 to 59.62), whereas ROPE>3 was not associated with blood transfusion compared with ROPE≤3 (OR 2.92; 95% CI 0.28 to 30.42). Furthermore, comparison of area under the ROC curve for SI (0.68) and ROPE (0.54) suggested that SI was more predictive than ROPE of blood transfusion. Conclusion We found that an elevated SI was more closely associated with early blood product transfusion than SBP and ROPE in injured pregnant patients. Level of evidence Prognostic, level III
The Coalition for National Trauma Research supports the call for a national trauma research action plan
(Lippincott, Williams, and Wilkins, 2017-03) Coimbra, Raul; Kozar, Rosemary A.; Smith, Jason W.; Zarzaur, Ben L.; Hauser, Carl J.; Moore, Frederick A.; Bailey, Jeffrey A.; Valadka, Alex; Jurkovich, Gregory J.; Jenkins, Donald H.; Davis, Kimberly A.; Price, Michelle A.; Maier, Ronald V.; Department of Surgery, School of Medicine
Comparison of Automated Posttonsillectomy Bleed Capture With Self-report
(American Medical Association, 2017-08-01) Phillips, D. Ryan; Ellsperman, Susan E.; Matt, Bruce H.; Zarzaur, Ben L.; Otolaryngology -- Head and Neck Surgery, School of Medicine
Importance: Tonsillectomy is one of the most common procedures performed by otolaryngologists and is associated with postoperative bleeding. Bleed rates are usually monitored by self-report. Objective: To evaluate whether using automated capture and reporting of pediatric posttonsillectomy bleeding is feasible and accurate compared with traditional self-reporting by the surgical team. Design, Setting, and Participants: An automated complication-reporting algorithm was designed to query the local health information exchange and then tested against self-reported tonsillectomy complication data collected from January 1, 2014, through December 31, 2015, at a tertiary pediatric hospital. The algorithm identified patients undergoing tonsillectomy and searched their postoperative encounters for a hand-selected set of diagnosis codes from the International Classification of Diseases, Ninth Revision and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision and free-text words to identify complication events. Five months of the 2014-2015 data set were used to help design the algorithm. Data from the remaining 19 months were compared with self-reported complications. Main Outcomes and Measures: Automated system findings compared with self-reported bleeding events. Results: During the 19-month period, 1017 tonsillectomies were performed. We compared the algorithm's effectiveness in finding tonsillectomy and adenotonsillectomy procedures for the evaluated surgeons with the hand-reviewed master tonsillectomy list. The algorithm reported 51 false-positive (5.01% missed) and 74 false-negative (7.28% misidentified) procedures. The algorithm agreed with self-report for 986 tonsillectomies and disagreed on 31 cases (3.05%) (κ = 0.69; 95% CI, 0.66-0.73). The algorithm was found to be sensitive to correctly identifying 60.53% (95% CI, 48.63%-71.34%) of tonsillectomies as having bleeding complications, with a specificity of 98.30% (95% CI, 97.19%-98.99%). Conclusions and Relevance: Capture of posttonsillectomy bleeding is possible through an automatic search of the medical record, although the algorithm will require continued refinement. Leveraging health information exchange data increases the possibilities of capturing complications at hospitals outside the local health system. Use of these algorithms will allow repeatable automated feedback to be provided to surgeons on a cyclical basis.
The conference effect: National surgery meetings are associated with increased mortality at trauma centers without American College of Surgeons verification
(PLOS, 2019-03-26) Jenkins, Peter C.; Painter, Scott; Bell, Teresa M.; Kline, Jeffrey A.; Zarzaur, Ben L.; Surgery, School of Medicine
BACKGROUND: Thousands of physicians attend scientific conferences each year. While recent data indicate that variation in staffing during such meetings impacts survival of non-surgical patients, the association between treatment during conferences and outcomes of a surgical population remain unknown. The purpose of this study was to examine mortality resulting from traumatic injuries and the influence of hospital admission during national surgery meetings. STUDY DESIGN: Retrospective analysis of in-hospital mortality using data from the Trauma Quality Improvement Program (2010-2011). Identified patients admitted during four annual meetings and compared their mortality with that of patients admitted during non-conference periods. Analysis included 155 hospitals with 12,256 patients admitted on 42 conference days and 82,399 patients admitted on 270 non-conference days. Multivariate analysis performed separately for hospitals with different levels of trauma center verification by state and American College of Surgeons (ACS) criteria. RESULTS: Patient characteristics were similar between meeting and non-meeting dates. At ACS level I and level II trauma centers during conference versus non-conference dates, adjusted mortality was not significantly different. However, adjusted mortality increased significantly for patients admitted to trauma centers that lacked ACS trauma verification during conferences versus non-conference days (OR 1.2, p = 0.008), particularly for patients with penetrating injuries, whose mortality rose from 11.6% to 15.9% (p = 0.006). CONCLUSIONS: Trauma mortality increased during surgery conferences compared to non-conference dates for patients admitted to hospitals that lacked ACS trauma level verification. The mortality difference at those hospitals was greatest for patients who presented with penetrating injuries.
Empiric tranexamic acid use provides no benefit in urgent orthopedic surgery following injury
(BMJ, 2023-03-10) Carr, Bryan; Li, Shi-Wen; Hill, Jamel G.; Feizpour, Cyrus; Zarzaur, Ben L.; Savage, Stephanie; Surgery, School of Medicine
Background: Orthopedic literature has demonstrated a significant decrease in postoperative transfusion requirements when tranexamic acid (TXA) was given during elective joint arthroplasty. The purpose of this study was to evaluate the empiric use of TXA in semi-urgent orthopedic procedures following injury. We hypothesized that TXA would be associated with increased rates of venous thromboembolic events (VTE) and have no effect on transfusion requirements. Methods: Patients who empirically received TXA during a semi-urgent orthopedic surgery following injury (TXA+) were matched using propensity scoring to historical controls (CONTROL) who did not receive TXA. Outcomes included VTE within 6 months of injury and packed red blood cell utilization. Multivariable logistic regression and generalized linear modeling were used to determine odds of VTE and transfusion. Results: 200 patients were included in each group. There was no difference in mortality between groups. TXA+ patients did not have an increase in VTE events (OR 0.680, 95% CI 0.206 to 2.248). TXA+ patients had a significantly higher odds of being transfused during their hospital stay (OR 2.175, 95% CI 1.246 to 3.797) and during the index surgery (increased 0.95 units (SD 0.16), p<0.0001). Overall transfusion was also significantly higher in the TXA+ group (p=0.0021). Conclusion: Empiric use of TXA in semi-urgent orthopedic surgeries did not increase the odds of VTE. Despite the elective literature, TXA administration did not associate with less transfusion requirements. A properly powered, prospective, randomized trial should be designed to elucidate the risks and benefits associated with TXA use in this setting.
Establishing a core outcome set for blunt cerebrovascular injury: an EAST modified Delphi method consensus study
(BMJ, 2023-06-15) Ziesmann, Markus; Byerly, Saskya; Yeh, Daniel Dante; Boltz, Melissa; Gelbard, Rondi; Haut, Elliott R.; Smith, Jason W.; Stein, Deborah M.; Zarzaur, Ben L.; Bensard, Denis D.; Biffl, Walter L.; Boyd, April; Brommeland, Tor; Burlew, Clay Cothren; Fabian, Timothy; Lauerman, Margaret; Leichtle, Stefan; Moore, Ernest E.; Timmons, Shelly; Vogt, Kelly; Nahmias, Jeffry; Surgery, School of Medicine
Objectives: Our understanding of blunt cerebrovascular injury (BCVI) has changed significantly in recent decades, resulting in a heterogeneous description of diagnosis, treatment, and outcomes in the literature which is not suitable for data pooling. Therefore, we endeavored to develop a core outcome set (COS) to help guide future BCVI research and overcome the challenge of heterogeneous outcomes reporting. Methods: After a review of landmark BCVI publications, content experts were invited to participate in a modified Delphi study. For round 1, participants submitted a list of proposed core outcomes. In subsequent rounds, panelists used a 9-point Likert scale to score the proposed outcomes for importance. Core outcomes consensus was defined as >70% of scores receiving 7 to 9 and <15% of scores receiving 1 to 3. Feedback and aggregate data were shared between rounds, and four rounds of deliberation were performed to re-evaluate the variables not achieving predefined consensus criteria. Results: From an initial panel of 15 experts, 12 (80%) completed all rounds. A total of 22 items were considered, with 9 items achieving consensus for inclusion as core outcomes: incidence of postadmission symptom onset, overall stroke incidence, stroke incidence stratified by type and by treatment category, stroke incidence prior to treatment initiation, time to stroke, overall mortality, bleeding complications, and injury progression on radiographic follow-up. The panel further identified four non-outcome items of high importance for reporting: time to BCVI diagnosis, use of standardized screening tool, duration of treatment, and type of therapy used. Conclusion: Through a well-accepted iterative survey consensus process, content experts have defined a COS to guide future research on BCVI. This COS will be a valuable tool for researchers seeking to perform new BCVI research and will allow future projects to generate data suitable for pooled statistical analysis with enhanced statistical power.
Financial Toxicity Is Associated With Worse Physical and Emotional Long-term Outcomes After Traumatic Injury
(Wolters Kluwer, 2019-11) Murphy, Patrick B.; Severance, Sarah; Savage, Stephanie; Obeng-Gyasi, Samilia; Timsina, Lava R.; Zarzaur, Ben L.; Surgery, School of Medicine
Background Increasing healthcare costs and high deductible insurance plans have shifted more responsibility for medical costs to patients. After serious illnesses, financial responsibilities may result in lost wages, forced unemployment, and other financial burdens, collectively described as financial toxicity. Following cancer treatments, financial toxicity is associated with worse long-term health related quality of life outcomes (HRQOL). The purpose of this study was to determine the incidence of financial toxicity following injury, factors associated with financial toxicity, and the impact of financial toxicity on long-term HRQOL. Methods Adult patients with an injury severity score of 10 or greater and without head or spinal cord injury were prospectively followed for 1 year. The Short-Form-36 was used to determine overall quality of life at 1, 2, 4 and 12 months. Screens for depression and post-traumatic stress syndrome (PTSD) were administered. The primary outcome was any financial toxicity. A multivariable generalized estimating equation was used to account for variability over time. Results 500 patients were enrolled and 88% suffered financial toxicity during the year following injury (64% reduced income, 58% unemployment, 85% experienced stress due to financial burden). Financial toxicity remained stable over follow-up (80–85%). Factors independently associated with financial toxicity were lower age (OR 0.96 [0.94–0.98]), and lack of health insurance (OR 0.28 [0.14–0.56]) and larger household size (OR 1.37 [1.06–1.77]). After risk adjustment, patients with financial toxicity had worse HRQOL, and more depression and PTSD in a step-wise fashion based on severity of financial toxicity. Conclusions Financial toxicity following injury is extremely common and is associated with worse psychological and physical outcomes. Age, lack of insurance, and large household size are associated with financial toxicity. Patients at risk for financial toxicity can be identified and interventions to counteract the negative effects should be developed to improve long-term outcomes. Level of Evidence Prognostic/epidemiologic study, level III
Insights into the association between coagulopathy and inflammation: abnormal clot mechanics are a warning of immunologic dysregulation following major injury
(AME, 2020-12) Savage, Stephanie A.; Zarzaur, Ben L.; Gaski, Greg E.; McCarroll, Tyler; Zamora, Ruben; Namas, Rami A.; Vodovotz, Yoram; Callcut, Rachael A.; Billiar, Timothy R.; McKinley, Todd O.; Orthopaedic Surgery, School of Medicine
Background: Severe injury initiates a complex physiologic response encompassing multiple systems and varies phenotypically between patients. Trauma-induced coagulopathy may be an early warning of a poorly coordinated response at the molecular level, including a deleterious immunologic response and worsening of shock states. The onset of trauma-induced coagulopathy (TIC) may be subtle however. In previous work, we identified an early warning sign of coagulopathy from the admission thromboelastogram, called the MAR ratio. We hypothesized that a low MAR ratio would be associated with specific derangements in the inflammatory response. Methods: In this prospective, observational study, 88 blunt trauma patients admitted to the intensive care unit (ICU) were identified. Concentrations of inflammatory mediators were recorded serially over the course of a week and the MAR ratio was calculated from the admission thromboelastogram. Correlation analysis was used to assess the relationship between MAR and inflammatory mediators. Dynamic network analysis was used to assess coordination of immunologic response. Results: Seventy-nine percent of patients were male and mean age was 37 years (SD 12). The mean ISS was 30.2 (SD 12) and mortality was 7.2%. CRITICAL patients (MAR ratio ≤14.2) had statistically higher shock volumes at three time points in the first day compared to NORMAL patients (MAR ratio >14.2). CRITICAL patients had significant differences in IL-6 (P=0.0065), IL-8 (P=0.0115), IL-10 (P=0.0316) and MCP-1 (P=0.0039) concentrations compared to NORMAL. Differences in degree of expression and discoordination of immune response continued in CRITICAL patients throughout the first day. Conclusions: The admission MAR ratio may be the earliest warning signal of a pathologic inflammatory response associated with hypoperfusion and TIC. A low MAR ratio is an early indication of complicated dysfunction of multiple molecular processes following trauma.
Long-term evaluation of a hospital-based violence intervention program using a regional health information exchange
(Wolters Kluwer, 2018-01) Bell, Teresa M.; Gilyan, Dannielle; Moore, Brian A.; Martin, Joel; Ogbemudia, Blessing; McLaughlin, Briana E.; Moore, Reilin; Simons, Clark J.; Zarzaur, Ben L.; Surgery, School of Medicine
BACKGROUND: Hospital-based violence intervention programs (HVIP) aim to reduce violent-injury recidivism by providing intensive case management services to high-risk patients who were violently injured. Although HVIP have been found effective at reducing recidivism, few studies have sought to identity how long their effects last. Additionally, prior studies have been limited by the fact that HVIP typically rely on self-report or data within their own healthcare system to identify new injuries. Our aim was to quantify the long-term recidivism rate of participants in an HVIP program using more objective and comprehensive data from a regional health information exchange. METHODS: The study included 328 patients enrolled in Prescription for Hope (RxH), an HVIP, between January 2009 and August 2016. We obtained RxH participants' emergency department (ED) encounter data from a regional health information exchange database from the date of hospital discharge to February 2017. Our primary outcome was violent-injury recidivism rate of the RxH program. We also examined reasons for ED visits that were unrelated to violent injury. RESULTS: We calculated a 4.4% recidivism rate based on 8 years of statewide data, containing 1,575 unique encounters. More than 96% of participants were matched in the state database. Of the 15 patients who recidivated, only five were admitted for their injury. More than half of new violence-related injuries were treated outside of the HVIP-affiliated trauma center. The most common reasons for ED visits were pain (718 encounters), followed by suspected complications or needing additional postoperative care (181 encounters). Substance abuse, unintentional injuries, and suicidal ideation were also frequent reasons for ED visits. CONCLUSION: The low, long-term recidivism rate for RxH indicates that HVIPs have enduring positive effects on the majority of participants. Our results suggest that HVIP may further benefit patients by partnering with organizations that work to prevent suicide, substance use disorders, and other unintentional injuries. LEVEL OF EVIDENCE: Therapeutic study, level III.

Browsing by Author "Zarzaur, Ben L."

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