60 results on '"Mora AG"'
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2. Ten-year analysis of transfusion in Operation Iraqi Freedom and Operation Enduring Freedom: Increased plasma and platelet use correlates with improved survival.
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Pidcoke HF, Aden JK, Mora AG, Borgman MA, Spinella PC, Dubick MA, Blackbourne LH, and Cap AP
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- 2012
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3. Posttraumatic stress disorder in combat casualties with burns sustaining primary blast and concussive injuries.
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Mora AG, Ritenour AE, Wade CE, Holcomb JB, Blackbourne LH, and Gaylord KM
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- 2009
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4. Differential expression of the immunoinflammatory response in trauma patients: burn vs. non-burn.
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Mace JE, Park MS, Mora AG, Chung KK, Martini W, White CE, Holcomb JB, Merrill GA, Dubick MA, Wolf SE, Wade CE, Schwacha MG, Mace, James E, Park, Myung S, Mora, Alejandra G, Chung, Kevin K, Martini, Wenjun, White, Christopher E, Holcomb, John B, and Merrill, Gerald A
- Abstract
Rationale: Cytokines are central mediators of the immune-inflammatory response to injury and subsequent multiple organ dysfunction syndrome (MODS). Although previous studies evaluated cytokine levels after trauma, differences between patients with burn and non-burn trauma have not been assessed systematically.Methods: A prospective database of trauma patients admitted between May 2004 and September 2007 to the burn or surgical intensive care units within 24 h of injury with an anticipated stay of at least 72 h was analyzed. Sequential clinical and laboratory parameters were collected in the first week, including multiplex analysis data for plasma levels of inflammatory cytokines (IL-6, and IL-8). Patients with known pre-injury coagulopathy were excluded. A Marshall score of 10 or greater was defined as MODS.Results: A total of 179 patients were enrolled (67 burn and 112 non-burn). Plasma IL-6 and IL-8 levels were markedly elevated in both burn and non-burn patients compared to healthy volunteers. Burn subjects had higher levels of IL-6 and IL-8 than the non-burn on days 1 through 7 after injury. Subjects with burns and at least 30% total body surface area were older and had a lower injury severity score, a higher prevalence of MODS, and correspondingly higher mortality. Multivariate analysis of injury type, MODS, and time did not demonstrate an influence of MODS.Conclusions: Burns were associated with a greater and more sustained immune-inflammatory response than non-burn trauma as evidenced by elevated plasma IL-6 and IL-8 levels during the first week. There was no association between MODS and plasma cytokine levels. [ABSTRACT FROM AUTHOR]- Published
- 2012
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5. Management of Combat Casualties during Aeromedical Evacuation from a Role 2 to a Role 3 Medical Facility.
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Maddry JK, Araña AA, Mora AG, Schauer SG, Reeves LK, Cutright JE, Paciocco JA, Perez CA, Davis WT, and Ng PC
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- Humans, Retrospective Studies, Male, Adult, Female, Air Ambulances statistics & numerical data, Iraq War, 2003-2011, Military Personnel statistics & numerical data, Wounds and Injuries therapy, Wounds and Injuries complications, Afghan Campaign 2001-, Transportation of Patients methods, Transportation of Patients statistics & numerical data
- Abstract
Introduction: Emergent clinical care and patient movements through the military evacuation system improves survival. Patient management differs when transporting from the point-of-injury (POI) to the first medical treatment facility (MTF) versus transporting from the Role 2 to the Role 3 MTF secondary to care rendered within the MTF, including surgery and advanced resuscitation. The objective of this study was to describe care provided to patients during theater inter-facility transports and compare with pre-hospital transports (POI to first MTF)., Materials and Methods: We performed a retrospective chart review of patients with the Role 2 to the Role 3 transports in Afghanistan and Iraq from 2007 to 2016. Data collected included procedures and events at the MTF and during transport. We compared the intra-theater transport data (Role 2 to Role 3) to data from a previous study evaluating pre-hospiital transports (POI to first MTF)., Results: We reviewed the records of 869 Role 2 to Role 3 transport patients. Role 2 to Role 3 transports were longer in duration compared to POI transports (39 minutes vs. 23 minutes) and were more likely to be staffed by advanced personnel (nurses, physician assistants, and physicians) (57% vs. 3%). The sample primarily consisted of military-aged males (mean age 27 years) who suffered from explosive or blunt force injuries. Procedures performed during each phase of care reflected the capabilities of the teams and locations. Pain and cardiac events were more common in POI evacuations compared to the Role 2 to Role 3 transports, but documentation of respiratory events, hemodynamic events, neurologic events, and equipment failure was more common during the Role 2 to Role 3 transports. Survival rates were slightly higher among the Role 2 to Role 3 cohort (98% vs. 95%, difference 3% [95% confidence interval of the difference 1-5%])., Conclusions: Inter-facility transports (Role 2 to Role 3) are longer in duration, transport more complex patients, and are staffed by more advanced level provider types compared to transports from POI., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2023. This work is written by (a) US Government employee(s) and is in the public domain in the US.)
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- 2024
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6. Phenotypic Heterogeneity of Cancer Associated Fibroblasts in Cervical Cancer Progression: FAP as a Central Activation Marker.
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Bueno-Urquiza LJ, Godínez-Rubí M, Villegas-Pineda JC, Vega-Magaña AN, Jave-Suárez LF, Puebla-Mora AG, Aguirre-Sandoval GE, Martínez-Silva MG, Ramírez-de-Arellano A, and Pereira-Suárez AL
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- Humans, Female, Vimentin metabolism, Matrix Metalloproteinase 9 metabolism, Neoplastic Processes, Phenotype, Tumor Microenvironment, Cancer-Associated Fibroblasts metabolism, Uterine Cervical Neoplasms metabolism
- Abstract
Cervical cancer (CC) is the fourth leading cancer among women and is one of the principal gynecological malignancies. In the tumor microenvironment, cancer-associated fibroblasts (CAFs) play a crucial role during malignant progression, exhibiting a variety of heterogeneous phenotypes. CAFs express phenotypic markers like fibroblast activation protein (FAP), vimentin, S100A4, α-smooth muscle actin (αSMA), and functional markers such as MMP9. This study aimed to evaluate the protein expression of vimentin, S100A4, αSMA, FAP, and MMP9 in mesenchymal stem cells (MSC)-CAF cells, as well as in cervical cancer samples. MSC cells were stimulated with HeLa and SiHa tumor cell supernatants, followed by protein evaluation and cytokine profile to confirm differentiation towards a CAF phenotype. In addition, automated immunohistochemistry (IHQa) was performed to evaluate the expression of these proteins in CC samples at different stages. Our findings revealed a high expression of FAP in stimulated MSC cells, accompanied by the secretion of pro/anti-inflammatory cytokines. In the other hand, CC samples were observed to have high expression of FAP, vimentin, αSMA, and MMP9. Most importantly, there was a high expression of their activation proteins αSMA and FAP during the different stages. In the early stages, a myofibroblast-like phenotype (CAFs αSMA+ FAP+), and in the late stages a protumoral phenotype (CAF αSMA- FAP+). In summary, FAP has a crucial role in the activation of CAFs during cervical cancer progression.
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- 2024
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7. Pleiotrophin and the Expression of Its Receptors during Development of the Human Cerebellar Cortex.
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Santana-Bejarano MB, Grosso-Martínez PR, Puebla-Mora AG, Martínez-Silva MG, Nava-Villalba M, Márquez-Aguirre AL, Ortuño-Sahagún D, and Godínez-Rubí M
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- Infant, Newborn, Humans, Carrier Proteins metabolism, Receptor Protein-Tyrosine Kinases metabolism, Receptor-Like Protein Tyrosine Phosphatases, Class 5 metabolism, Cerebellar Cortex metabolism, Cytokines metabolism
- Abstract
During embryonic and fetal development, the cerebellum undergoes several histological changes that require a specific microenvironment. Pleiotrophin (PTN) has been related to cerebral and cerebellar cortex ontogenesis in different species. PTN signaling includes PTPRZ1, ALK, and NRP-1 receptors, which are implicated in cell differentiation, migration, and proliferation. However, its involvement in human cerebellar development has not been described so far. Therefore, we investigated whether PTN and its receptors were expressed in the human cerebellar cortex during fetal and early neonatal development. The expression profile of PTN and its receptors was analyzed using an immunohistochemical method. PTN, PTPRZ1, and NRP-1 were expressed from week 17 to the postnatal stage, with variable expression among granule cell precursors, glial cells, and Purkinje cells. ALK was only expressed during week 31. These results suggest that, in the fetal and neonatal human cerebellum, PTN is involved in cell communication through granule cell precursors, Bergmann glia, and Purkinje cells via PTPRZ1, NRP-1, and ALK signaling. This communication could be involved in cell proliferation and cellular migration. Overall, the present study represents the first characterization of PTN, PTPRZ1, ALK, and NRP-1 expression in human tissues, suggesting their involvement in cerebellar cortex development.
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- 2023
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8. Improved Adherence to Best Practice Ventilation Management After Implementation of Clinical Practice Guideline (CPG) for United States Military Critical Care Air Transport Teams (CCATTs).
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Maddry JK, Mora AG, Perez CA, Arana AA, Medellin KL, Paciocco JA, Ng PC, Davis WT, Hunninghake JC, and Bebarta VS
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- Humans, United States, Retrospective Studies, Critical Care methods, Respiration, Artificial, Ventilators, Mechanical, Guideline Adherence, Military Personnel, Respiratory Distress Syndrome therapy
- Abstract
Background: Critical Care Air Transport Teams (CCATTs) play a vital role in the transport and care of critically ill and injured patients in the combat theater to include mechanically ventilated patients. Previous research has demonstrated improved morbidity and mortality when lung protective ventilation strategies are used. Our previous study of CCATT trauma patients demonstrated frequent non-adherence to the Acute Respiratory Distress Syndrome Network (ARDSNet) protocol and a corresponding association with increased mortality. The goals of our study were to examine CCATT adherence with ARDSNet guidelines in non-trauma patients, compare the findings to our previous publication of CCATT trauma patients, and evaluate adherence before and after the publication of the CCATT Ventilator Management Clinical Practice Guideline (CPG)., Methods: We performed a retrospective chart review of ventilated non-trauma patients who were evacuated out of theater by Critical Care Air Transport Teams (CCATT) between January 2007 and April 2015. Data abstractors collected flight information, oxygenation status, ventilator settings, procedures, and in-flight assessments. We calculated descriptive statistics to determine the frequency of compliance with the ARDSNet protocol before and after the CCATT Ventilator CPG publication and the association between ARDSNet protocol adherence and in-flight events., Results: We reviewed the charts of 124 mechanically ventilated patients transported out of theater via CCATT on volume control settings. Seventy percent (n = 87/124) of records were determined to be Non-Adherent to ARDSNet recommendations predominately due to excessive tidal volume settings and/or high FiO2 settings relative to the patient's positive end-expiratory pressure setting. The Non-Adherent group had a higher proportion of in-flight respiratory events. Compared to our previous study of ventilation guideline adherence in the trauma population, the Non-Trauma population had a higher rate of non-adherence to tidal volume and ARDSNet table recommendations (75.6% vs. 61.5%). After the CPG was rolled out, adherence improved from 24% to 41% (P = 0.0496)., Conclusions: CCATTs had low adherence with the ARDSNet guidelines in non-trauma patients transported out of the combat theater, but implementation of a Ventilator Management CPG was associated with improved adherence., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2021. This work is written by (a) US Government employee(s) and is in the public domain in the US.)
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- 2023
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9. Treatment of melasma with platelet-rich plasma: A self-controlled clinical trial.
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González-Ojeda A, Cervantes-Guevara G, Chejfec-Ciociano JM, Cervantes-Cardona GA, Acevedo-Guzman D, Puebla-Mora AG, Cortés-Lares JA, Chávez-Tostado M, Álvarez-Villaseñor AS, Cervantes-Pérez E, Ramos-Álvarez MP, Pacheco-Vallejo LR, Barbosa-Camacho FJ, and Fuentes-Orozco C
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- Adult, Female, Humans, Melanins therapeutic use, Middle Aged, Quality of Life, Treatment Outcome, Melanosis drug therapy, Platelet-Rich Plasma
- Abstract
Melasma is a common circumscribed hypermelanosis of sun-exposed areas of the skin. Platelet-Rich Plasma therapy has been evidenced to inhibit melanin synthesis in animals and humans. To determine the effectiveness of platelet-rich plasma as a treatment for melasma. Twenty female patient with melasma were involved in this study. The intervention included three Platelet-Rich Plasma application sessions at 15-day intervals. Patients were evaluated before and after treatment. Variables measured included the facial melanin concentration using the melasma area and severity index score, melasma quality of life scale satisfaction grade, and histologic changes. Mean age was 41 ± 7 years. An initial MELASQOL score of 42 ± 14.8 and final score of 16.6 ± 7.2 (p = 0.008) were reported; the initial and final MASI score were 15.5 ± 8.4 and 9.5 ± 7.2 (p = 0.001), respectively. The dermatoscopy examination revealed a decrease in pigmentation after intervention (p = 0.001). Histopathologic improvement was detected in reductions in cutaneous atrophy (14 [70%] vs. 11 [55%]), solar elastosis (15 [75%] vs.11 [55%]), and inflammatory infiltrate (9 [45%] vs. 6 [30%]), before and after treatment, respectively. The intervention was associated with decreased intensity of the melasma patch and improved skin quality, shown by the MELASQOL and MASI scores., (© 2022 Wiley Periodicals LLC.)
- Published
- 2022
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10. Tadalafil treatment improves cardiac, renal and lower urinary tract dysfunctions in rats with heart failure.
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Mora AG, Andrade DR, Janussi SC, Goncalves TT, Krikorian K, Priviero FBM, and Claudino MA
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- Animals, Male, Oxidation-Reduction drug effects, Rats, Rats, Sprague-Dawley, Heart Failure drug therapy, Heart Failure metabolism, Heart Failure physiopathology, Kidney metabolism, Kidney physiopathology, Lower Urinary Tract Symptoms drug therapy, Lower Urinary Tract Symptoms metabolism, Lower Urinary Tract Symptoms physiopathology, Tadalafil pharmacology, Urinary Bladder metabolism, Urinary Bladder physiopathology
- Abstract
Tadalafil, a phosphodiesterase-5 (PDE5) inhibitor, shown to exert a protection to heart failure (HF) associated damage or lower urinary tract symptoms (LUTS). Thus, we investigated the contribution of tadalafil chronic treatment in the alterations of LUTS in HF rats. Male rats were subjected to aortocaval fistula model for HF induction. Echocardiography, cystometric, renal function and redox cell balance, as well as concentration-response curves to carbachol, KCl, ATP and frequency-response curves to electrical field stimulation (EFS) were evaluated in Sham, HF, Tadalafil and HF-Tadalafil (12 weeks endpoint) groups. HF group to present increased in left-ventricle (LV) mass and in LV end-diastolic- and LV end-systolic volume, with a decreased ejection fraction. Tadalafil treatment was able to decrease in hypertrophy and improve the LV function restoring cardiac function. For micturition function (in vivo), HF animals shown an increase in basal pressure, threshold pressure, no-voiding contractions and decreased bladder capacity, being that the tadalafil treatment restored the cystometric parameters. Contractile mechanism response (in vitro) to carbachol, KCl, ATP and EFS in the detrusor muscles (DM) were increased in the HF group, when compared to Sham group. However, tadalafil treatment restored the DM hypercontractility in the HF animals. Moreover, renal function as well as the oxidative mechanism was impaired in the HF animals, and the tadalafil treatment improved all renal and oxidative parameters in HF group. Our data shown that tadalafil has potential as multi-therapeutic drug and may be used as a pharmacological strategy for the treatment of cardiovascular, renal and urinary dysfunctions associated with HF., (Copyright © 2021 Elsevier Inc. All rights reserved.)
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- 2022
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11. Characterization of Long-range Aeromedical Transport and Its Relationship to the Development of Traumatic Extremity Compartment Syndrome: A 7-year, Retrospective Study.
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Maddry JK, Mora AG, Perez CA, Reeves LK, Paciocco JA, Clemons MA, Sheean A, Kester NM, and Bebarta VS
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- Animals, Extremities, Humans, Iraq War, 2003-2011, Retrospective Studies, Air Ambulances, Compartment Syndromes complications, Compartment Syndromes epidemiology
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Background: Military aeromedical transport evacuates critically injured patients are for definitive care, including patients with or at risk for developing traumatic compartment syndrome of the extremities (tCSoE). Compartment pressure changes of the extremities have not been determined to be associated with factors inherent to aeromedical transport in animal models, but the influence of aeromedical evacuation (AE) transport on the timing of tCSoE development has not been studied in humans. Using a registry-based methodology, this study sought to characterize the temporal features of lower extremity compartment syndrome relative to the timing of transcontinental AE. With this approach, this study aims to inform practice in guidelines relating to the timing and possible effects of long-distance AE and the development of lower extremity compartment syndrome. Using patient care records, we sought to characterize the temporal features of tCSoE diagnosis relative to long-range aeromedical transport. In doing so, we aim to inform practice in guidelines relating to the timing and risks of long-range AE and postulate whether there is an ideal time to transport patients who are at risk for or with tCSoE., Methods: We performed a retrospective record review of patients with a diagnosis of tCSoE who were evacuated out of theater from January 2007 to May 2014 via aeromedical transport. Data abstractors collected flight information, laboratory values, vital signs, procedures, in-flight assessments, and outcomes. We used the duration of time from injury to arrival at Landstuhl Regional Medical Center (LRMC) to represent time to transport. We compared groups based on time of tCSoE (inclusive of upper and lower extremity) diagnosis relative to injury day and time of transport (preflight versus postflight). We used descriptive statistics and multivariable regression models to determine the associations between time to transport, time to tCSoE diagnosis, and outcomes., Results: Within our study window, 238 patients had documentation of tCSoE. We found that 47% of patients with tCSoE were diagnosed preflight and 53% were diagnosed postflight. Over 90% in both groups developed tCSoE within 48 hours of injury; the time to diagnosis was similar for casualties diagnosed pre- and postflight (P = .65). There was no association between time to arrival at LRMC and day of tCSoE diagnosis (risk ratio, 1.06; 95% CI, 0.96-1.16)., Conclusion: The timing of tCSoE diagnosis is not associated with the timing of transport; therefore, AE likely does not influence the development of tCSoE., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2021. This work is written by (a) US Government employee(s) and is in the public domain in the US.)
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- 2022
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12. Impact of a Standardized EMS Handoff Tool on Inpatient Medical Record Documentation at a Level I Trauma Center.
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Maddry JK, Arana AA, Clemons MA, Medellin KL, Shults NM, Perez CA, Savell SC, Gutierrez XE, Reeves LK, Mora AG, and Bebarta VS
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- Documentation, Humans, Inpatients, Medical Records, Trauma Centers, Emergency Medical Services, Patient Handoff
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Background: The emergency department (ED) poses challenges to effective handoff from emergency medical services (EMS) personnel to ED staff. Despite the importance of a complete and accurate patient handoff report between EMS and trauma staff, communication is often interrupted, incomplete, or otherwise ineffective. The M echanism of injury/ M edical Complaint, I njuries or I nspections head to toe, vital S igns, and T reatments (MIST) report initiative was implemented to standardize the handoff process. The objective of this study was to evaluate whether documentation of prehospital care in the inpatient medical record improved after MIST implementation., Methods: Research staff abstracted data from the EMS and inpatient medical records of trauma patients transported by EMS and treated at a Level I trauma center from January 2015 through June 2017. Data included patient demographics, mechanism and location of injury, vital signs, treatments, and period of data collection (pre-MIST and post-MIST). We summarized the MIST elements in EMS and inpatient medical records and assessed the presence or absence of data elements in the inpatient record from the EMS record and the agreement between the two sets of records over time to determine if implementation of MIST improved documentation., Results: We analyzed data from 533 trauma patients transported by EMS and treated in a Level I trauma center (pre-MIST: n = 281; post-MIST: n = 252). For mechanism of injury, agreement between the two records was ≥96% before and after MIST implementation. Cardiac arrest and location of injury were under-reported in the inpatient record before MIST; post-MIST, there were no significant discrepancies, indicating an improvement in reporting. Reporting of prehospital hypotension improved from 76.5% pre-MIST to 83.3% post-MIST. After MIST implementation, agreement between the EMS and inpatient records increased for the reporting of fluid administration (45.6% to 62.7%) and decreased for reporting of pain medications (72.2% to 61.9%)., Conclusions: The use of the standardized MIST tool for EMS to hospital patient handoff was associated with a mixed value on inpatient documentation of prehospital events. After MIST implementation, agreement was higher for mechanism and location of injury and lower for vital signs and treatments. Further research can advance the prehospital to treatment facility handoff process.
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- 2021
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13. Response to Letter to the Editor: The Next Step in Maintaining Peacetime Readiness Level 1 Trauma Centers and OEF/OIF Emergency Departments: Comparison of Trauma Patient Populations.
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Savell SC, Blessing A, Shults NM, Mora AG, Medellin KL, Muir MT, Kester N, and Maddry JK
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- Afghan Campaign 2001-, Humans, Iraq War, 2003-2011, Trauma Centers
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- 2021
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14. Impact of a Standardized Patient Hand-off Tool on Communication between Emergency Medical Services Personnel and Emergency Department Staff.
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Maddry JK, Simon EM, Reeves LK, Mora AG, Clemons MA, Shults NM, Savell S, Blessing A, and Walrath BD
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- Communication, Emergency Service, Hospital, Humans, Occupations, Texas, Emergency Medical Services, Patient Handoff
- Abstract
Introduction: Handoff communication between Emergency Medical Services (EMS) and Emergency Department (ED) staff is critical to ensure quality patient care. In January 2016, the Southwest Texas Regional Advisory Council (STRAC) implemented MIST (Mechanism, Injuries, vital Signs, Treatments), a standardized EMS to ED handoff tool. The En route Care Research Center conducted a Pre-MIST implementation survey of ED staff in December 2015 and a Post-MIST follow-up survey in July 2017 to determine the impact of the MIST handoff tool on the perceived quality of transmission of pertinent patient information and in the overall handoff experience., Methods: We administered a nine-item Likert scale questionnaire to Brooke Army Military Medical Center (BAMC) ED providers and nurses before and after implementation of MIST. The questionnaire captured perceived competence and satisfaction with handoff communication (Cronbach's alpha 0.73). We analyzed responses for the total sample and by occupation (providers and nurses), and we calculated odds ratios to determine items that may be most predictive of a positive handoff experience from the perspective of the ED staff. We performed chi-square tests and reported data as percentages., Results: Total respondents Pre- and Post-MIST were 128 (62%) nurses and 80 (38%) providers (MDs, DOs, and PAs). Following the implementation of MIST, more respondents reported that they were "informed of prehospital treatments" (p < 0.001), that "Red/Blue Trauma Alert Criteria were conveyed" (p < 0.001), and that the "time to give the report was sufficient to convey pertinent information" (p < 0.001). Nurses more frequently reported that "Red/Blue Trauma Alert Criteria were conveyed" post-MIST (p < 0.01). Providers more frequently reported that "Assessment findings were conveyed" (p < 0.05), that they 'interrupted the report for clarification" (p < 0.04), that "time to give the report was sufficient to convey pertinent information" (p < 0.001) and that they "felt positive about the overall handoff experience" (p < 0.03) Post-MIST. Overall satisfaction with the handoff was associated with frequently being informed of prehospital treatments (OR 5.5; 2.1-14.4) and frequently receiving a copy of the prehospital record (OR 2.9; 1.1-7.2)., Conclusions: These data demonstrate that providers and nurses reported an improvement in the handoff experience Post-MIST. This study supports the use of a standardized handoff tool at this critical step in patient care.
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- 2021
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15. Advancing Prehospital Combat Casualty Evacuation: Patients Amenable to Aeromedical Evacuation via Unmanned Aerial Vehicles.
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Maddry JK, Arana AA, Mora AG, Perez CA, Cutright JE, Kester BM, Ng PC, Schauer SG, and Bebarta VS
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- Blast Injuries, Humans, Medical Records, Retrospective Studies, Wounds, Nonpenetrating, Air Ambulances, Military Personnel
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Introduction: The U.S. military currently utilizes unmanned aerial vehicles (UAVs) for reconnaissance and attack missions; however, as combat environment technology advances, there is the increasing likelihood of UAV utilization in prehospital aeromedical evacuation. Although some combat casualties require life-saving interventions (LSIs) during medical evacuation, many do not. Our objective was to describe patients transported from the point of injury to the first level of care and characterize differences between patients who received LSIs en route and those who did not., Materials and Methods: We conducted a retrospective review of the records of traumatically injured patients evacuated between January 2011 and March 2014. We compared patient characteristics, complications, and outcomes based on whether they had an LSI performed en route (LSI vs. No LSI). We also constructed logistic regression models to determine which characteristics predict uneventful flights (no en route LSI or complications)., Results: We examined 1,267 patient records; 47% received an LSI en route. Most patients (72%) sustained a blast injury and injuries to the extremities and head. Over 78% experienced complications en route; the LSI group had higher rates of complications compared to the No LSI group. Logistic regression showed that having a blunt injury or the highest abbreviated injury scale (AIS) severity score in the head/neck region are significant predictors of having an uneventful flight., Conclusion: Approximately half of casualties evaluated in our study did not receive an LSI during transport and may have been transported safely by UAV. Having a blunt injury or the highest AIS severity score in the head/neck region significantly predicted an uneventful flight., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2020. This work is written by (a) US Government employee(s) and is in the public domain in the US.)
- Published
- 2021
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16. Patients With Traumatic Brain Injury Transported by Critical Care Air Transport Teams: The Influence of Altitude and Oxygenation during Transport.
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Maddry JK, Araña AA, Reeves LK, Mora AG, Gutierrez XE, Perez CA, Ng PC, Griffiths SA, and Bebarta VS
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- Critical Care, Humans, Retrospective Studies, Altitude, Brain Injuries, Traumatic therapy
- Abstract
Introduction: Traumatic brain injuries (TBIs) are life-threatening, and air transport of patients with TBI requires additional considerations. To mitigate the risks of complications associated with altitude, some patients fly with a cabin altitude restriction (CAR) to limit the altitude at which an aircraft's cabin is maintained. The goal of this study was to examine the effects of CARs on patients with TBI transported out of theater via Critical Care Air Transport Teams., Materials and Methods: We conducted a retrospective chart review of patients with moderate-to-severe TBI evacuated out of combat theater to Landstuhl Regional Medical Center via Critical Care Air Transport Teams. We collected demographics, flight and injury information, procedures, oxygenation, and outcomes (discharge disposition and hospital/ICU/ventilator days). We categorized patients as having a CAR if they had a documented CAR or maximum cabin altitude of 5,000 feet or lower in their Critical Care Air Transport Teams record. We calculated descriptive statistics and constructed regression models to evaluate the association between CAR and clinical outcomes., Results: We reviewed the charts of 435 patients, 31% of which had a documented CAR. Nineteen percent of the sample had a PaO2 lower than 80 mm Hg, and 3% of patients experienced a SpO2 lower than 93% while in flight. When comparing preflight and in-flight events, we found that the percentage of patients who had a SpO2 of 93% or lower increased for the No CAR group, whereas the CAR group did not experience a significant change. However, flying without a CAR was not associated with discharge disposition, mortality, or hospital/ICU/ventilator days. Further, having a CAR was not associated with these outcomes after adjusting for additional flights, injury severity, injury type, or preflight head surgery., Conclusions: Patients with TBI who flew with a CAR did not differ in clinical outcomes from those without a CAR., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2020.)
- Published
- 2020
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17. Level 1 Trauma Centers and OEF/OIF Emergency Departments: Comparison of Trauma Patient Populations.
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Savell SC, Blessing A, Shults NM, Mora AG, Medellin KL, Muir MT, Kester N, and Maddry JK
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- Animals, Emergency Service, Hospital, Hospitals, Military, Humans, Texas epidemiology, United States, Military Health Services, Military Personnel, Trauma Centers
- Abstract
Introduction: Brooke Army Medical Center (BAMC), the largest military hospital and the only level 1 trauma center in the DoD, cares for active duty, retired uniformed services personnel, and beneficiaries. In addition, BAMC works in collaboration with the Southwest Texas Regional Advisory Council (STRAC) and University Hospital (UH), San Antonio's other level 1 trauma center, to provide trauma care to residents of the city and 22 counties in southwest Texas from San Antonio to Mexico (26,000 square mile area). Civilian-military partnerships are shown to benefit the training of military medical personnel; however, to date, there are no published reports specific to military personnel experiences within emergency care. The purpose of the current study was to describe and compare the emergency department trauma patient populations of two level 1 trauma centers in one metropolitan city (BAMC and UH) as well as determine if DoD level 1 trauma cases were representative of patients treated in OEF/OIF emergency department settings., Materials and Methods: We obtained a nonhuman subjects research determination for de-identified data from the US Air Force 59th Medical Wing and the University of Texas Health Science Center at San Antonio Institutional Review Boards. Data on emergency department patients treated between the years 2015 and 2017 were obtained from the two level 1 trauma centers (BAMC and UH, located in San Antonio, Texas); data included injury descriptors, ICU and hospital days, and department procedures., Results: Two-proportion Z-tests indicated that trauma patients were similar across trauma centers on injury type, injury severity, and discharge status; yet trauma patients differed significantly in terms of mechanism of injury and regions of injury. BAMC received significantly greater proportions of patients injured from falls, firearms and with facial and head injuries than UH, which received significantly greater proportion of patients with thorax and abdominal injuries. In addition, a significantly greater proportion of patients spent more than 2 days in the ICU and greater than two total hospital days at BAMC than in UH. In comparison to military emergency departments in combat zones, BAMC had significantly lower rates of blood product administration and endotracheal intubations., Conclusions: The trauma patients treated at a military level 1 trauma center were similar to those treated in the civilian level 1 trauma center in the same city, indicating the effectiveness of the only DoD Level 1 trauma center to provide experience comparable to that provided in civilian trauma centers. However, further research is needed to determine if the exposure rates to specific procedures are adequate to meet predeployment readiness requirements., (Published by Oxford University Press on behalf of Association of Military Surgeons of the United States 2020. This work is written by (a) US Government employee(s) and is in the public domain in the US.)
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- 2020
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18. Prehospital Life-Saving Interventions Performed on Pediatric Patients in a Combat Zone: A Multicenter Prospective Study.
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Reeves LK, Savell SC, Maddry JK, Samsey KM, Mora AG, and Lairet JR
- Subjects
- Adult, Afghanistan, Child, Hemorrhage epidemiology, Hemorrhage etiology, Hemorrhage prevention & control, Humans, Infusions, Intraosseous, Male, Prospective Studies, Emergency Medical Services, Wounds and Injuries therapy
- Abstract
Objectives: We aimed to describe and evaluate prehospital life-saving interventions performed in a pediatric population in the Afghanistan theater of operations., Design: Our study was a post hoc, subanalysis of a larger multicenter, prospective, observational study., Setting: We evaluated casualties enrolled upon admission to one of the nine military medical facilities in Afghanistan between January 2009 and March 2014., Patients: Adult and pediatric (<17 yr old) patients., Measurements: We conducted initial descriptive analyses followed by comparative tests. For comparative analysis, we stratified the study population (adult vs pediatric), and subsequently, we compared injury descriptions and the interventions performed. Following tests for normality, we used the t test or Wilcoxon rank-sum test (nonparametric) for continuous variables and chi-square or Fisher exact for categorical variables. We reported percentages and 95% CIs., Main Results: We enrolled 2,106 patients, of which 5.6% (n = 118) were pediatric. Eighty-two percent of the pediatric patients were male, and 435 had blast related injuries. A total of 295 prehospital life-saving interventions were performed on 118 pediatric patients, for an average of 2.5 life-saving interventions per patient. Vascular access (IV 96%, intraosseous 91%) and hypothermia prevention-related interventions (69%) were the most common. Incorrectly performed life-saving interventions in pediatric patients were rare (98% of life-saving interventions performed correctly) and n equals to 24 life-saving interventions over the 6-year period were missed. The most common incorrectly performed and missed life-saving interventions were related to vascular access. When compared with adult life-saving interventions received in the prehospital environment, pediatric patients were more likely to receive intraosseous access (p < 0.0001), whereas adult patients were more likely to have a tourniquet placed (p = 0.0019), receive wound packing with a hemostatic agent (p = 0.0091), and receive chest interventions (p = 0.0003)., Conclusions: In our study, the most common intervention was vascular access followed by hypothermia prevention and hemorrhage control. The occurrence of missed or incorrectly performed life-saving interventions were rare.
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- 2020
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19. Influence of Time to Transport to a Higher Level Facility on the Clinical Outcomes of US Combat Casualties with TBI: A Multicenter 7-Year Study.
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Maddry JK, Arana AA, Perez CA, Medellin KL, Paciocco JA, Mora AG, Holder WG, Davis WT, Herson PS, and Bebarta VS
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- Afghan Campaign 2001-, Air Ambulances, Humans, Iraq War, 2003-2011, Retrospective Studies, Brain Injuries, Traumatic therapy, Military Personnel
- Abstract
Introduction: Traumatic brain injury (TBI) is a leading cause of death and disability worldwide and is associated with mortality rates as high as 30%. Patients with TBI are at high risk for secondary injury and need to be transported to definitive care expeditiously. However, the physiologic effects of aeromedical evacuation are not well understood and may compound these risks. Combat TBI patients may benefit from delayed aeromedical evacuation. The goal of this study was to evaluate the impact of transport timing out of theater via Critical Care Air Transport Teams (CCATT) to a higher level facility on the clinical outcomes of combat casualties with TBI., Materials and Methods: We performed a retrospective review of patients with TBI who were evacuated out of theater by CCATT from January 2007 to May 2014. Data abstractors collected flight information, vital signs, procedures, in-flight assessments, and outcomes. Time to transport was defined as the time from injury to CCATT evacuation out of combat theater. We calculated descriptive statistics and constructed regression models to determine the association between time to transport and clinical outcomes. This study was approved by the U.S. Air Force 59th Medical Wing Institutional Review Board., Results: We analyzed the records of 438 patients evacuated out of theater via CCATT and categorized them into three groups: patients who were transported in one day or less (n = 165), two days (n = 163), and three or more days (n = 110). We used logistic regression models to compare outcomes among patients who were evacuated in two days or three or more days to those who were transported within one day while adjusting for demographics, injury severity, and injury type. Patients who were evacuated in two days or three or more days had 50% lower odds of being discharged on a ventilator and were twice as likely to return to duty or be discharged home than those who were evacuated within one day. Additionally, patients transported in three or more days were 70% less likely to be ventilated at discharge with a GCS of 8 or lower and had 30% lower odds of mortality than those transported within one day., Conclusions: In patients with moderate to severe TBI, a delay in aeromedical evacuation out of the combat theater was associated with improved mortality rates and a higher likelihood of discharge to home and return to duty dispositions. This study is correlational in nature and focused on CCATT transports from Role III to Role IV facilities; as such, care must be taken in interpreting our findings and future studies are needed to establish a causal link between delayed evacuation and improved discharge disposition. Our study suggests that delaying aeromedical evacuation of TBI patients when feasible may confer benefit., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2019. This work is written by (a) US Government employee(s) and is in the public domain in the US.)
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- 2020
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20. Prehospital Use of Ketamine in the Combat Setting: A Sub-Analysis of Patients With Head Injuries Evaluated in the Prospective Life Saving Intervention Study.
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Bebarta VS, Mora AG, Bebarta EK, Reeves LK, Maddry JK, Schauer SG, and Lairet JR
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- Adult, Afghanistan, Emergency Medical Services methods, Female, Humans, Male, Prospective Studies, Registries statistics & numerical data, Craniocerebral Trauma drug therapy, Ketamine therapeutic use, Warfare
- Abstract
Objectives: Ketamine is used as an analgesic for combat injuries. Ketamine may worsen brain injury, but new studies suggest neuroprotection. Our objective was to report the outcomes of combat casualties with traumatic brain injury (TBI) who received prehospital ketamine., Methods: This was a post hoc, sub-analysis of a larger prospective, multicenter study (the Life Saving Intervention study [LSI]) evaluating prehospital interventions performed in Afghanistan. A DoD Trauma Registry query provided disposition at discharge and outcomes to be linked with the LSI data., Results: For this study, we enrolled casualties that were suspected to have TBI (n = 160). Most were 26-year-old males (98%) with explosion-related injuries (66%), a median injury severity score of 12, and 5% mortality. Fifty-seven percent (n = 91) received an analgesic, 29% (n = 46) ketamine, 28% (n = 45) other analgesic (OA), and 43% (n = 69) no analgesic (NA). The ketamine group had more pelvic injuries (P = 0.0302) and tourniquets (P = 0.0041) compared to OA. In comparison to NA, the ketamine group was more severely injured and more likely to require LSI procedures, yet, had similar vital signs at admission and disposition at discharge., Conclusions: We found that combat casualties with suspected TBI that received prehospital ketamine had similar outcomes to those that received OAs or NAs despite injury differences., (© Association of Military Surgeons of the United States 2020. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)
- Published
- 2020
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21. Analysis of Injuries and Prehospital Interventions Sustained by Females in the Iraq and Afghanistan Combat Zones.
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Schauer SG, Naylor JF, Long AN, Mora AG, Le TD, Maddry JK, and April MD
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- Adult, Afghanistan, Analgesics administration & dosage, Female, Hospitalization, Humans, Iraq, Ketamine, Male, Military Personnel, Morphine, Registries, Sex Distribution, United States, Wounds and Injuries therapy, Armed Conflicts, Emergency Medical Services, Wounds and Injuries epidemiology
- Abstract
Background: Women served in both combat and non-combat units in the recent conflicts in Iraq and Afghanistan. Moreover, the recent conflicts lacked traditional separation of civilians from combatants carrying additional risk for injury to local civilians. There is a relative paucity of data specific to this topic. We compare injury patterns and interventions performed in the prehospital, combat setting among females versus males. Methods: This is a secondary analysis of previously published data from the Department of Defense Trauma Registry. We included all subjects that had at least one prehospital intervention documented. We compared variables between females and males. Results: From January 2007 to August 2016, our inclusion criteria captured 19,485 males and 533 females. Female casualties were older (median age 29 vs. 25), less likely to have sustained injuries from explosives (48.0% vs. 56.8%), and more severely injured as measured by median composite injury scores (10 vs. 9). Most subjects were in Afghanistan for both females and males (52.9% vs. 73.9%). Among United States (US) service members, findings were similar to the overall study population, except female service members had lower median composite injury scores than males (5 vs. 9). In unadjusted analyses, females were less likely to survive to hospital discharge (OR 0.68, 95% CI 0.48-0.97). There was no difference in survival (OR 0.73, 95% CI 0.50-1.07), when controlling for confounders. In both unadjusted and adjusted analyses specific to US forces, we were unable to detect any differences in survival or for select analgesic administration. In both unadjusted and adjusted analyses specific to host nation civilians, we were unable to detect any differences in survival; however, even when controlling for confounders females were less likely to receive ketamine and IV morphine (OR 0.31, 95% CI 0.15-0.63; 0.69, 95% CI 0.49-0.98, respectively). Conclusions: Females accounted for a small proportion of total casualties within our dataset. After controlling for confounders, survival was comparable between males and females, but host nation females were less likely to receive ketamine and intravenous morphine. Future studies should seek to elucidate the reasons for these subtle differences between males and females in prehospital combat casualty care.
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- 2019
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22. Interventions Performed on Multipurpose Military Working Dogs in the Prehospital Combat Setting: A Comprehensive Case Series Report.
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Reeves LK, Mora AG, Field A, and Redman TT
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- Afghan Campaign 2001-, Animals, Dogs, Iraq War, 2003-2011, Survival Analysis, Treatment Outcome, War-Related Injuries mortality, Wounds, Gunshot mortality, Wounds, Gunshot therapy, Wounds, Gunshot veterinary, Emergency Medical Services, Veterinary Service, Military, War-Related Injuries therapy, War-Related Injuries veterinary
- Abstract
Introduction: The military working dog (MWD) has been essential in military operations such as Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF). MWDs sustain traumatic injuries that require point of injury and en route clinical interventions. The objective of this study was to describe the injuries and treatment military working dogs received on the battlefield and report their final disposition., Methods: This was a convenience sample of 11 injury and treatment reports of US MWDs from February 2008 to December 2014. We obtained clinical data regarding battlefield treatment from the 160th Special Operations Aviation Regiment (SOAR) database and supplemental operational sources. A single individual collected the data and maintained the dataset. The data collected included mechanism of injury, clinical interventions, and outcomes. We reported findings as frequencies., Results: Of the 11 MWD casualties identified in this dataset, 10 reports had documented injuries secondary to trauma. Eighty percent of the cases sustained gunshot wounds. The hindlegs were the most common site of injury (50%); however, 80% sustained injuries at more than one anatomical location. Seventy percent of cases received at least one clinical intervention before arrival at their first treatment facility. The most common interventions included trauma dressing (30%), gauze (30%), chest seal (30%), and pain medication (30%). The survival rate was 50%., Conclusion: The majority of the MWD cases in this dataset sustained traumatic injuries, with gunshot being the most common mechanism of injury. Most MWDs received at least one clinical intervention. Fifty percent did not survive their traumatic injuries., (2019.)
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- 2019
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23. Bis-cations with two 2,3-diferrocenylcyclopropenium fragments stabilized with diamino-alkanes: Synthesis and cytotoxic activity.
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García-Valdés J, Sánchez García JJ, Sánchez-Castell A, Alpizar-Mora AG, Flores-Álamo M, Martínez-Klimova E, Ramírez Apan T, and Klimova EI
- Subjects
- Animals, COS Cells, Chlorocebus aethiops, Humans, K562 Cells, MCF-7 Cells, Structure-Activity Relationship, Antineoplastic Agents chemical synthesis, Antineoplastic Agents chemistry, Antineoplastic Agents pharmacology, Cytotoxins chemical synthesis, Cytotoxins chemistry, Cytotoxins pharmacology
- Abstract
Bis-cations with two 2,3-diferrocenylcyclopropenium fragments 3a-d, and the cis-2-(1,2-diferrocenylvinyl)-2-imidazolinium tetrafluoroborates 4a, d or the cis-2-(1,2-diferrocenylvinyl)-3,4,5,6-tetrahydropyrimidin-2-ium tetrafluoroborates 4b, c were obtained by interactions of 2,3-diferrocenyl-1-ethoxycyclopropenium tetrafluoroborate 1 with bis-1,4-N,N-(2a, d) or bis-1,5-N,N-(2b, c) nucleophiles. The reactions of 3a-d with sodium azide proceed with high regioselectivity, forming tetraferrocenyl-substituted compounds: N,N'-bis-(4',6'-diferrocenyl-1',2',3'-triazin-5'-yl)-piperazine 5a, N,N'-bis-(4',6'-diferrocenyl-1',2',3'-triazin-5'-yl)-N,N'-dialkyl-1,3- or 1,2-alkanediamines 5b-d. Sodium hydrogencyanamide reacts with 3a-d to form N,N'-bis-(1'-aza-1'-cyano-3',4'-diferrocenyl-1',3'-butadien-2'-yl)-piperazine 6a, N,N'-dialkyl-1,3- or 1,2-alkanediamines 6b-d and N-(1'-cyano-3',4'-diferrocenyl-1'-aza-1',3'-butadien-2'-yl)-N,N'-dialkyl-alkanediamines 7a-d. The characterization of new compounds was done by IR,
1 H and13 C NMR spectroscopy, mass-spectrometry, elemental analysis, and X-ray diffraction analysis only for the compounds 4b, 4d, and 7a. The biological activity of compounds 5a, 6a, 6b, 6c was assessed regarding anticancer activity against U-251, K-562, SKLU-1, HCT-15, and MCF-7 cell lines. All tested compounds showed good activity but compounds 6a and 6b had the best anticancer activity against U-251 (human glioblastoma) and SKLU-1 (human lung adenocarcinoma) cultures., (Copyright © 2019. Published by Elsevier Inc.)- Published
- 2019
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24. Descriptive Analysis of Cardiac Patients Transported by Critical Care Air Transport Teams.
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Savell SC, Arana AA, Medellin KL, Bebarta VS, Perez CA, Reeves LK, Mora AG, and Maddry JK
- Subjects
- Adult, Chi-Square Distribution, Critical Care methods, Critical Care statistics & numerical data, Critical Illness classification, Critical Illness epidemiology, Female, Heart Diseases complications, Heart Diseases epidemiology, Humans, Male, Middle Aged, Patient Transfer statistics & numerical data, Retrospective Studies, Heart Diseases classification, Patient Transfer methods
- Abstract
Introduction: Critical Care Air Transport Teams (CCATTs) transport critically ill patients within and out of theaters of combat operations. Studies of the CCATT population reveal as many as 35% of patients have a non-trauma diagnosis, of which more than half are cardiac.The purpose of this retrospective study was to describe the epidemiology of critically ill patients with cardiac diagnoses evacuated from theater via CCATT., Materials and Methods: We conducted a retrospective review of 290 medical patients with a primary cardiac diagnosis transported from any theater of operation to Landstuhl Regional Medical Center, Germany from January 2007 to April 2015., Results: The majority of patients were male with an average age of 46 ± 11 years, US contractors (47%, n = 137), followed by US Active Duty (32%, n = 93). Patients had an average BMI of 29 ± 5; 62% of cardiac patients were either overweight or obese. The most common cardiac diagnoses were ST elevation myocardial infarction, Non-ST elevation myocardial infarction, and angina. Pre-flight vital signs indicate overall patients were stable prior to evacuation, with the majority receiving supplemental oxygen and only 5% requiring mechanical ventilation. Eighty-one percent of patients experienced at least one cardiac event during flight, however less than 5% required adjustment to oxygen or ventilator settings., Conclusions: Critically ill cardiac patients make up a significant portion of patients transported out of the combat theater. These patients are older, overweight and have identified risk factors for cardiac morbidity. More strenuous pre-deployment screening for risk factors and prevention strategies could minimize the use of military resources to evacuate these patients from the combat theater., (© Association of Military Surgeons of the United States 2018. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)
- Published
- 2019
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25. Progression of micturition dysfunction associated with the development of heart failure in rats: Model of overactive bladder.
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Mora AG, Furquim SR, Tartarotti SP, Andrade DR, Janussi SC, Krikorian K, Rocha T, Franco-Penteado CF, Priolli DG, Priviero FBM, and Claudino MA
- Subjects
- Animals, Disease Models, Animal, Disease Progression, Heart Failure complications, Heart Failure metabolism, Male, Muscle Contraction, Rats, Rats, Sprague-Dawley, Receptors, Muscarinic, Urinary Bladder, Urinary Bladder Diseases, Urinary Bladder, Overactive metabolism, Heart Failure physiopathology, Urinary Bladder, Overactive physiopathology, Urination physiology
- Abstract
Heart failure (HF) has a strong association with the development of lower urinary tract symptoms, especially overactive bladder (OAB); although this condition remains poorly investigated. In this study, we assess the aortocaval fistula (ACF) model as a novel experimental model of micturition dysfunction, associated with HF, focused on the molecular and functional studies to evaluate the autonomic nervous system and urinary bladder remodeling. Male rats were submitted to ACF for HF induction. Echocardiography, cystometric, histomorphometry and molecular analysis, as well as concentration-response curves to carbachol and ATP and frequency-response curves to electrical field stimulation (EFS) were evaluated in Sham and HF (4- and 12-weeksendpoint) groups. Compared to SHAM, HF groups exhibited progressive increases in the left ventricle (LV) mass and fractional shortening which indicates cardiac dysfunction, although HF was characterized only after 12 weeks by the reduced ejection fraction. For micturition function, HF groups presented increased non-voiding contractions (NVC) and decreased bladder capacity; however, when comparing HF groups, these urinary parameters were significantly impaired over the weeks (12-weeks). The contractile responses induced by CCh, ATP and EFS were greater in detrusor muscle (DSM) from HF rats. mRNA expression for muscarinic receptors (M2 and M3) was higher in DSM only after 12 weeks of ACF, in addition to MMP9 and TGF-beta. Histomorphometric revealed increased urothelium thickness in both HF groups, whereas DSM thickness occurred only after 12 weeks. Thus, the ACF model induced cardiac dyfunction with progressive micturition dysfunction over the weeks, characterized by increased DSM contractile mechanisms as well as extracellular matrix remodeling in the urinary bladder, representing a useful tool to evaluate the OAB associated with HF., (Copyright © 2019 Elsevier Inc. All rights reserved.)
- Published
- 2019
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26. Cardiac massage for trauma patients in the battlefield: An assessment for survivors.
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Anderson KL, Mora AG, Bloom AD, Maddry JK, and Bebarta VS
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- Administration, Intravenous, Adult, Cardiopulmonary Resuscitation methods, Cardiopulmonary Resuscitation statistics & numerical data, Female, Humans, Injury Severity Score, Male, Outcome and Process Assessment, Health Care, Prognosis, Registries statistics & numerical data, Survival Analysis, United States epidemiology, Wounds and Injuries diagnosis, Cardiovascular Agents administration & dosage, Emergency Medical Services methods, Heart Arrest etiology, Heart Arrest mortality, Heart Arrest therapy, Heart Massage methods, Heart Massage mortality, Heart Massage statistics & numerical data, Military Health Services statistics & numerical data, Wounds and Injuries complications
- Abstract
Introduction: Survival from traumatic cardiopulmonary arrest (TCA) has been reported at a rate as low as 0-2.6% in the civilian pre-hospital setting, and many consider resuscitation of this group to be futile. The aim of this investigation was to describe patients who received cardiac massage during TCA in a battlefield setting; we also aimed to identify predictors of survival., Methods: We conducted a review of the Department of Defense Trauma Registry to identify patients who received cardiac massage in the battlefield between 2007 and 2014. Patients were also grouped according to location of cardiac arrest: pre-hospital (PH) and in-hospital (IH). The groups were compared and evaluated by injury, transport time, type of resuscitation, and pre-hospital procedures. Outcome variables included survival to discharge and 30-day survival. Categorical variables were analysed using chi-square or Fisher's exact tests. Wilcoxon tests were performed for continuous variables. Regression modelling was used to assess for predictors of survival., Results: 75 of all 582 patients (13%, 95% CI 10-16) survived to 30 days, and all survivors were transported out of the battlefield; 23 PH (7.8%, 95% CI 5.2-12) and 52 IH (17%, 95% CI 13-22) patients survived to 30 days (p < 0.001). Closed-chest cardiac massage with the administration of intravenous medications was associated with 30-day survival among IH patients., Conclusions: We report a 13% survival to 30 days among all patients receiving cardiac massage in a battlefield setting. Closed-chest cardiac massage predicted survival among IH TCA victims who also received intravenous medications in this review of combat-related TCA., (Copyright © 2019 Elsevier B.V. All rights reserved.)
- Published
- 2019
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27. Impact of prehospital medical evacuation (MEDEVAC) transport time on combat mortality in patients with non-compressible torso injury and traumatic amputations: a retrospective study.
- Author
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Maddry JK, Perez CA, Mora AG, Lear JD, Savell SC, and Bebarta VS
- Subjects
- Adult, Afghanistan, Female, Humans, Injury Severity Score, Male, Proportional Hazards Models, Retrospective Studies, Torso injuries, United States, Young Adult, Afghan Campaign 2001-, Amputation, Traumatic epidemiology, Military Personnel, Time Factors, Transportation of Patients, Wounds and Injuries mortality
- Abstract
Background: In combat operations, patients with traumatic injuries require expeditious evacuation to improve survival. Studies have shown that long transport times are associated with increased morbidity and mortality. Limited data exist on the influence of transport time on patient outcomes with specific injury types. The objective of this study was to determine the impact of the duration of time from the initial request for medical evacuation to arrival at a medical treatment facility on morbidity and mortality in casualties with traumatic extremity amputation and non-compressible torso injury (NCTI)., Methods: We completed a retrospective review of MEDEVAC patient care records for United States military personnel who sustained traumatic amputations and NCTI during Operation Enduring Freedom between January 2011 and March 2014. We grouped patients as traumatic amputation and NCTI (AMP+NCTI), traumatic amputation only (AMP), and neither AMP nor NCTI (Non-AMP/NCTI). Analysis was performed using chi-squared tests, Fisher's exact tests, Cochran-Armitage Trend tests, Shapiro-Wilks tests, Wilcoxon and Kruskal-Wallis techniques and Cox proportional hazards regression modeling., Results: We reviewed 1267 records, of which 669 had an injury severity score (ISS) of 10 or greater and were included in the analysis. In the study population, 15.5% sustained only amputation injuries (n=104, AMP only), 10.8% sustained amputation and NCTI (n=72, AMP+NCTI), and 73.7% did not sustain either an amputation or an NCTI (n=493, Non-AMP/NCTI). AMP+NCTI had the highest mortality (16.7%) with transport time greater than 60 min. While the AMP+NCTI group had decreasing survival with longer transport times, AMP and Non-AMP/NCTI did not exhibit the same trend., Conclusions: A decreased transport time from the point of injury to a medical treatment facility was associated with decreased mortality in patients who suffered a combination of amputation injury and NCTI. No significant association between transport time and outcomes was found in patients who did not sustain NCTI. Priority for rapid evacuation of combat casualties should be given to those with NCTI.
- Published
- 2018
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28. Survey of Casualty Evacuation Missions Conducted by the 160th Special Operations Aviation Regiment During the Afghanistan Conflict.
- Author
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Redman TT, Mayberry KE, Mora AG, Benedict BA, Ross EM, Mapp JG, and Kotwal RS
- Subjects
- Adult, Animals, Child, Dogs, Female, Humans, Male, Military Medicine, Retrospective Studies, Transportation of Patients statistics & numerical data, Wounds and Injuries therapy, Wounds and Injuries veterinary, Aerospace Medicine methods, Aerospace Medicine statistics & numerical data, Afghan Campaign 2001-, Air Ambulances statistics & numerical data, Military Personnel, Wounds and Injuries epidemiology
- Abstract
Background: Historically, documentation of prehospital combat casualty care has been relatively nonexistent. Without documentation, performance improvement of prehospital care and evacuation through data collection, consolidation, and scientific analyses cannot be adequately accomplished. During recent conflicts, prehospital documentation has received increased attention for point-of-injury care as well as for care provided en route on medical evacuation platforms. However, documentation on casualty evacuation (CASEVAC) platforms is still lacking. Thus, a CASEVAC dataset was developed and maintained by the 160th Special Operations Aviation Regiment (SOAR), a nonmedical, rotary-wing aviation unit, to evaluate and review CASEVAC missions conducted by their organization., Methods: A retrospective review and descriptive analysis were performed on data from all documented CASEVAC missions conducted in Afghanistan by the 160th SOAR from January 2008 to May 2015. Documentation of care was originally performed in a narrative after-action review (AAR) format. Unclassified, nonpersonally identifiable data were extracted and transferred from these AARs into a database for detailed analysis. Data points included demographics, flight time, provider number and type, injury and outcome details, and medical interventions provided by ground forces and CASEVAC personnel., Results: There were 227 patients transported during 129 CASEVAC missions conducted by the 160th SOAR. Three patients had unavailable data, four had unknown injuries or illnesses, and eight were military working dogs. Remaining were 207 trauma casualties (96%) and five medical patients (2%). The mean and median times of flight from the injury scene to hospital arrival were less than 20 minutes. Of trauma casualties, most were male US and coalition forces (n = 178; 86%). From this population, injuries to the extremities (n = 139; 67%) were seen most commonly. The primary mechanisms of injury were gunshot wound (n = 89; 43%) and blast injury (n = 82; 40%). The survival rate was 85% (n = 176) for those who incurred trauma. Of those who did not survive, most died before reaching surgical care (26 of 31; 84%)., Conclusion: Performance improvement efforts directed toward prehospital combat casualty care can ameliorate survival on the battlefield. Because documentation of care is essential for conducting performance improvement, medical and nonmedical units must dedicate time and efforts accordingly. Capturing and analyzing data from combat missions can help refine tactics, techniques, and procedures and more accurately define wartime personnel, training, and equipment requirements. This study is an example of how performance improvement can be initiated by a nonmedical unit conducting CASEVAC missions., (2018.)
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- 2018
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29. Effect of Moringa oleifera consumption on diabetic rats.
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Villarruel-López A, López-de la Mora DA, Vázquez-Paulino OD, Puebla-Mora AG, Torres-Vitela MR, Guerrero-Quiroz LA, and Nuño K
- Subjects
- Alloxan, Animals, Body Weight drug effects, Enterobacteriaceae drug effects, Feces microbiology, Hyperglycemia metabolism, Hypoglycemic Agents administration & dosage, Hypoglycemic Agents pharmacology, Hypoglycemic Agents toxicity, Lactobacillales drug effects, Male, Mutagens toxicity, Rats, Rats, Sprague-Dawley, Blood Glucose drug effects, Diabetes Mellitus, Experimental metabolism, Moringa oleifera, Plant Extracts administration & dosage, Plant Extracts pharmacology, Plant Extracts toxicity
- Abstract
Background: Therapeutic use of leaves of M. oleifera has been evaluated in diabetes because of its possible capacity to decrease blood glucose and lipids concentration after ingestion, as result of the polyphenols content and others compounds. Nevertheless most results have been obtain from leaf extract, therefore this study would use leaf powder as the regular way of consumption of population to know effects over toxicity glucose, triglycerides, cholesterol, corporal weight, and predominant groups of microbiota., Methods: Powdered leaf was administrated in different doses to know toxicity and genotoxicity using LD50 and micronuclei assay. Hyperglycemia was induced by alloxan on Sprague Dawley rats. Glucose and body weight were measured once a week meanwhile cholesterol and triglycerides were analyzed at the end of the study by commercial kits. Different organs were examined by hematoxylin-eosin technique. Lactic acid bacteria and Enterobacteriaceae were enumerated from stool samples., Results: The tested doses revealed no lethal dose and no significant differences in genotoxicity parameter. The consumption of the leaves showed a hypoglycemic effect (< 250 mg/dL in diabetic M. oleifera treated group), however in corporal weight showed an increased (> 30 g over no M. oleifera treated groups). There was no change in enumeration of lactic acid bacteria (8.4 CFU/g) but there were differences in the predominance of type of lactobacillus and enterobacteria enumeration., Conclusions: These results help to increase information over the most popular use of M. oleifera and its safety. However there are needed more studies over the hypoglycemic mechanisms and effects over intestinal microbiota.
- Published
- 2018
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30. En Route Care Provided by US Navy Nurses in Iraq and Afghanistan.
- Author
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Blackman VS, Walrath BD, Reeves LK, Mora AG, Maddry JK, and Stockinger ZT
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- Adult, Afghan Campaign 2001-, Female, Humans, Iraq War, 2003-2011, Male, United States, Young Adult, Critical Care methods, Critical Care statistics & numerical data, Military Nursing methods, Military Nursing statistics & numerical data, Military Personnel statistics & numerical data, War-Related Injuries nursing
- Abstract
Background: US Navy nurses provide en route care for critically injured combat casualties without having a formal program for training, utilization, or evaluation. Little is known about missions supported by Navy nurses., Objectives: To characterize the number and types of patients transported and skill sets required by Navy nurses during 2 combat support deployments., Methods: All interfacility casualty transfers between 2 separate facilities in Iraq and Afghanistan were assessed. Number of patients treated, number transported, en route care provider type, transport priority level and duration, injury severity, indication for critical care transport, en route care interventions, and vital signs were evaluated., Results: Of 1550 casualties, 630 required medical evacuation to a higher level of care. Of those, 133 (21%) were transported by a Navy nurse, with 131 (98.5%) classified as "urgent," accounting for 46% of all urgent transports. The primary indication for en route care nursing was mechanical ventilation of intubated patients (97%). Mean (SD) patient transport time was 29.8 (7.9) minutes (range, 17-61 minutes). The most common en route care interventions were administration of intravenous sedation (80%), neuromuscular blockade (79%), and opioids (48%); transfusions (18%); and ventilation changes (11%). No intubations, cricothyroidotomies, chest tube placements, or needle decompressions were performed en route. No deaths occurred during transport., Conclusions: US Navy nurses successfully transported critically injured patients without observed adverse events. Establishing en route care as a program of record in the Navy will facilitate continuous process improvement to ensure that future casualties receive optimized en route care., (©2018 American Association of Critical-Care Nurses.)
- Published
- 2018
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31. Disease and Non-Battle Traumatic Injuries Evaluated by Emergency Physicians in a US Tertiary Combat Hospital.
- Author
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Bebarta VS, Mora AG, Ng PC, Mason PE, Muck A, and Maddry JK
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- Adult, Afghan Campaign 2001-, Emergency Medicine methods, Female, Gastrointestinal Diseases diagnosis, Gastrointestinal Diseases epidemiology, Gastrointestinal Diseases therapy, Headache diagnosis, Headache epidemiology, Headache therapy, Humans, Injury Severity Score, Iraq, Iraq War, 2003-2011, Male, Musculoskeletal Diseases diagnosis, Musculoskeletal Diseases epidemiology, Musculoskeletal Diseases therapy, Outcome Assessment, Health Care, Tertiary Care Centers, Wounds and Injuries epidemiology, Young Adult, Hospitals, Military organization & administration, Military Personnel statistics & numerical data, Wounds and Injuries diagnosis, Wounds and Injuries therapy
- Abstract
Introduction Analysis of injuries during military operations has focused on those related to combat. Non-combat complaints have received less attention, despite the need for many troops to be evacuated for non-battle illnesses in Iraq. This study aims to further characterize the disease and non-battle injuries (DNBIs) seen at a tertiary combat hospital and to describe the types of procedures and medications used in the management of these cases., Methods: In this observational study, patients were enrolled from a convenience sample with non-combat-related diseases and injuries who were evaluated in the emergency department (ED) of a US military tertiary hospital in Iraq from 2007-2008. The treating emergency physician (EP) used a data collection form to enroll patients that arrived to the ED whose injury or illness was unrelated to combat., Results: Data were gathered on 1,745 patients with a median age of 30 years; 84% of patients were male and 85% were US military personnel. The most common diagnoses evaluated in the ED were abdominal disorders, orthopedic injuries, and headache. Many cases involved intravenous access, laboratory testing, and radiographic testing. Procedures performed included electrocardiogram, lumbar puncture, and intubation., Conclusion: Disease and non-battle traumatic injuries are common in a tertiary combat hospital. Emergency providers working in austere settings should have the diagnostic and procedural skills to evaluate and treat DNBIs. Bebarta VS , Mora AG , Ng PC , Mason PE , Muck A , Maddry JK . Disease and non-battle traumatic injuries evaluated by emergency physicians in a US tertiary combat hospital. Prehosp Disaster Med. 2018;33(1):53-57.
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- 2018
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32. Impact of Critical Care Air Transport Team (CCATT) ventilator management on combat mortality.
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Maddry JK, Mora AG, Savell SC, Perez CA, Mason PE, Aden JK, and Bebarta VS
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- Adolescent, Adult, Afghan Campaign 2001-, Clinical Protocols, Female, Guideline Adherence, Humans, Iraq War, 2003-2011, Male, Respiratory Distress Syndrome epidemiology, Retrospective Studies, Tidal Volume, Wounds and Injuries complications, Young Adult, Air Ambulances, Critical Care, Respiration, Artificial, Respiratory Distress Syndrome prevention & control, Wounds and Injuries mortality, Wounds and Injuries therapy
- Abstract
Background: Aeromedical evacuation platforms such as Critical Care Air Transport Teams (CCATTs) play a vital role in the transport and care of critically injured and ill patients in the combat theater. Mechanical ventilation is used to support patients with failing respiratory function and patients requiring high levels of sedation. Mechanical ventilation, if not managed appropriately, can worsen or cause lung injury and contribute to increased morbidity. The purpose of this study was to evaluate the impact of ARDSNet protocol compliance during aeromedical evacuation of ventilated combat injured patients., Methods: We performed a retrospective chart review of combat injured patients transported by CCATTs from Afghanistan to Landstuhl Regional Medical Center (LRMC) in Germany between January 2007 and January 2012. After univariate analyses, we performed regression analyses to assess compliance and post-flight outcomes. Cox proportional hazard models were used to evaluate associations between the risk factor of non-compliance with increased number of ventilator, ICU, or hospital days. Nominal logistic regression models were performed to evaluate the association between non-compliance and mortality., Results: Sixty-two percent (n = 669) of 1,086 patients required mechanical ventilation during transport. A total of 650 patients required volume-controlled mechanical ventilation and were included in the analysis. Of the 650 subjects, 62% (n = 400) were non-compliant per tidal volume and ARDSNet table recommendations. The groups were similar in all demographic variables, except the Non-compliant group had a higher Injury Severity Score compared to the Compliant group. Subjects in the Compliant group were less likely to have an incidence of acute respiratory distress, acute respiratory failure, and ventilator-associated pneumonia when combing the variables (2% vs. 7%, p < 0.0069). The Non-compliant group had an increased incidence of in-flight respiratory events, required more days on the ventilator and in the ICU, and had a higher mortality rate., Conclusions: Compliance with the ARDSNet guidelines was associated with a decrease in ventilator days, ICU days, and 30-day mortality., Level of Evidence: Therapeutic/care management, level IV.
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- 2018
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33. TYMS 2R3R polymorphism and DPYD [IVS]14+1G>A gene mutation in Mexican colorectal cancer patients.
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Gallegos-Arreola MP, Zúñiga-González GM, Sánchez-López JY, Cruz AYN, Peralta-Leal V, Figuera LE, Puebla-Pérez AM, Ronquillo-Carreón CA, and Puebla-Mora AG
- Subjects
- Adult, Aged, Female, Genetic Predisposition to Disease, Genotype, Hematologic Diseases genetics, Humans, Male, Mexico epidemiology, Middle Aged, Stomach Diseases genetics, Tobacco Use, Colorectal Neoplasms genetics, Dihydrouracil Dehydrogenase (NADP) genetics, Mutation, Polymorphism, Genetic, Thymidylate Synthase genetics
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Objective: To examine the association between TYMS 2R3R polymorphism and DPYD [IVS]14+1G>A mutation by comparing healthy subjects with colorectal cancer (CRC) patients in the Mexican population., Method: Genotyping of the 2R/3R was performed by polymerase chain reaction (PCR) and [IVS]14+1G>A mutation by real-time PCR analysis., Results: The observed frequencies of the TYMS 2R3R polymorphism and the -[IVS]14+1G>A mutation in DPYD did not indicate an increased risk for CRC (p>0.05). However we observed an association of the 2R/2R (OR 3.08, 95% CI 1.66-6.08, p=0.0017) and heterozygous (OR 1.98, 95% CI 1.32-2.97, p=0.0012) genotypes as risk factors when comparing controls and CRC patients that were also tobacco consumers. An association between the genotype and the disease was evident. The distribution of the 2R/2R genotype and hematological toxicity (adjusted OR 2.26, 95% CI 1.54-4.45, p=0.0259), heterozygous (2R/3R) with tumor stage III-IV (OR 1.81, 95% CI 1.11-2.94, p=0.020) and 2R/2R-2R/3R in non-chemotherapy response CRC patients with hematological (OR 2.3, 95% CI 1.21-4.4, p=0.014) and gastric toxicities (OR 3.11, 95% CI 1.18-8.2, p=0.035) confirmed that this factor may significantly contribute to the CRC susceptibility., Conclusion: TYMS 2R3R polymorphism and the -[IVS]14+1G>A mutation in DPYD was not associated with susceptibility to CRC. However, the 2R/2R and 2R/3R genotypes of TYMS polymorphism could significantly contribute to hematological and gastric toxicity in CRC patients in this sample population.
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- 2018
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34. A novel experimental model of erectile dysfunction in rats with heart failure using volume overload.
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Silva FH, Veiga FJR, Mora AG, Heck RS, De Oliveira CC, Gambero A, Franco-Penteado CF, Antunes E, Gardner JD, Priviero FBM, and Claudino MA
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- Animals, Dose-Response Relationship, Drug, Electric Stimulation, Male, Nitroprusside pharmacology, Penis drug effects, Polymerase Chain Reaction, Rats, Rats, Sprague-Dawley, Erectile Dysfunction, Heart Failure physiopathology
- Abstract
Background: Patients with heart failure (HF) display erectile dysfunction (ED). However, the pathophysiology of ED during HF remains poorly investigated., Objective: This study aimed to characterize the aortocaval fistula (ACF) rat model associated with HF as a novel experimental model of ED. We have undertaken molecular and functional studies to evaluate the alterations of the nitric oxide (NO) pathway, autonomic nervous system and oxidative stress in the penis., Methods: Male rats were submitted to ACF for HF induction. Intracavernosal pressure in anesthetized rats was evaluated. Concentration-response curves to contractile (phenylephrine) and relaxant agents (sodium nitroprusside; SNP), as well as to electrical field stimulation (EFS), were obtained in the cavernosal smooth muscle (CSM) strips from sham and HF rats. Protein expression of endothelial NO synthase (eNOS) and neuronal NO synthase (nNOS) and phosphodiestarese-5 in CSM were evaluated, as well as NOX2 (gp91phox) and superoxide dismutase (SOD) mRNA expression. SOD activity and thiobarbituric acid reactive substances (TBARs) were also performed in plasma., Results: HF rats display erectile dysfunction represented by decreased ICP responses compared to sham rats. The neurogenic contractile responses elicited by EFS were greater in CSM from the HF group. Likewise, phenylephrine-induced contractions were greater in CSM from HF rats. Nitrergic response induced by EFS were decreased in the cavernosal tissue, along with lower eNOS, nNOS and phosphodiestarese-5 protein expressions. An increase of NOX2 and SOD mRNA expression in CSM and plasma TBARs of HF group were detected. Plasma SOD activity was decreased in HF rats., Conclusion: ED in HF rats is associated with decreased NO bioavailability in erectile tissue due to eNOS/nNOS dowregulation and NOX2 upregulation, as well as hypercontractility of the penis. This rat model of ACF could be a useful tool to evaluate the molecular alterations of ED associated with HF.
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- 2017
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35. Multicenter, Prospective Study of Prehospital Administration of Analgesia in the U.S. Combat Theater of Afghanistan.
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Schauer SG, Mora AG, Maddry JK, and Bebarta VS
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- Adult, Afghanistan, Female, Fentanyl administration & dosage, Humans, Injury Severity Score, Ketamine therapeutic use, Male, Morphine therapeutic use, Pain diagnosis, Pain etiology, Pain Measurement, Prospective Studies, United States, Young Adult, Afghan Campaign 2001-, Analgesics administration & dosage, Emergency Medical Services, Pain drug therapy
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Background: Published data on prehospital medical care in combat is limited, likely due to the chaotic and unpredictable nature of care under fire and difficulty in documentation There is limited data on how often analgesic agents are administered, which drug are being used, and whether there is an association with injury patterns., Methods: This study was a prospective, multicenter, observational study to determine which analgesic agents are being used prehospital and whether there is an association with injury patterns. Data was collected and recorded as casualties were brought into combat surgical hospitals in Afghanistan from October 2012 to April 2014. Onsite, trained investigators collected the data as part of a IRB approved protocol. Outcome data to 30 days was obtained from the DoD Trauma Registry (DODTR) within the Joint Trauma System., Results: During the study period 532 patient encounters available for inclusion with 378 receiving an analgesic agent (total of 541 administrations). The average age was 27 (range 21-31), 99% male, 40% were US or coalition forces. Parenteral medications used were ketamine, fentanyl, morphine, hydromorphone and ketorolac. Penetrating injuries were more likely to receive analgesic agent (89% vs 79%, p=0.0057). Blunt trauma was less likely to receive ketamine (p=0.008). Fentanyl was used more for patients with an Injury Severity Score (ISS) >15 (p=0.016)., Conclusion: Patients with penetrating trauma are more likely to receive analgesic agents in the combat prehospital setting. The most common analgesic used was ketamine. Patient ISS was not associated with administration of analgesia. Patients receiving analgesia were more likely to still be hospitalized at 30 days. The prospective nature of this study supports feasibility for future, larger, more comprehensive projects.
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- 2017
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36. Critical Care Air Transport Team Evacuation of Medical Patients Without Traumatic Injury.
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Maddry JK, Arana AA, Savell SC, Reeves LK, Perez CA, Mora AG, and Bebarta VS
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- Adult, Aerospace Medicine methods, Aerospace Medicine statistics & numerical data, Afghan Campaign 2001-, Air Ambulances statistics & numerical data, Analysis of Variance, Critical Care methods, Critical Illness epidemiology, Female, Humans, Iraq War, 2003-2011, Male, Medical Errors statistics & numerical data, Middle Aged, Military Personnel statistics & numerical data, Retrospective Studies, United States epidemiology, Critical Care statistics & numerical data, Critical Illness classification, Patient Transfer methods
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Background: Air Force Critical Care Air Transport Teams (CCATTs) provide fixed-wing aeromedical evacuation for combat casualties. Multiple studies have evaluated CCATT trauma patients; however, nearly 50% of patients medically evacuated from combat theaters are for nontraumatic medical illnesses to include stroke, myocardial infarctions, overdose, and pulmonary emboli. Published data are limited regarding illness types, in-flight procedures, and adverse events., Objective: The objective of our study was to characterize patients with nontraumatic medical illnesses transferred via CCATT to include a description of in-flight procedures and events., Study Design: We performed a retrospective review of CCATT medical records of patients with nontraumatic medical illnesses transported via CCATT from theater of operations to Landstuhl Regional Medical Center between January 2007 and April 2015. We abstracted data from CCATT records to include demographics, description of current illness, vital signs, labs, in-flight procedures and medications, and in-flight adverse events. Following descriptive analysis, comparative tests were performed based on service status of patients and primary diagnoses., Results: We reviewed 672 records of critically ill medical patients transported via CCATT, most of whom were male (90%, n = 606). Approximately 56% of the patients were U.S. active duty members; the remainder included U.S. contractors and civilians, and foreign citizens or unknown. The three categories (active duty, contractor/civilian, foreign/unknown) significantly differed from one another in age. Over half of the patients received a primary or secondary cardiac diagnosis. The most common in-flight procedures and medications included supplementary oxygenation, anticoagulant/antiplatelet medications, analgesics, and ventilation. Up to 20% of patients required continuous medication infusions other than analgesics. Patients most frequently experienced in-flight complications related to their primary diagnoses., Conclusions: Fifty-six percent (672) of 1,209 CCATT records that were queried were of patients with medical conditions. The most common primary diagnoses of CCATT medical patients were cardiac, pulmonary, and neurological in etiology. Mechanical ventilation and continuous medication infusions were required in approximately 20% of patients. The data provided by this study may assist in guiding future CCATT training requirements and resource allocation, as well as clinical practice guideline development., (Reprint & Copyright © 2017 Association of Military Surgeons of the U.S.)
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- 2017
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37. Platelet-Rich Plasma for the Treatment of Photodamage of the Skin of the Hands.
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Cabrera-Ramírez JO, Puebla-Mora AG, González-Ojeda A, García-Martínez D, Cortés-Lares JA, Márquez-Valdés AR, Contreras-Hernández GI, Bracamontes-Blanco J, Saucedo Ortiz JA, and Fuentes-Orozco C
- Subjects
- Adult, Biopsy, Cell Count, Collagen analysis, Female, Fibroblasts pathology, Humans, Injections, Subcutaneous, Middle Aged, Severity of Illness Index, Skin blood supply, Skin chemistry, Skin pathology, Skin radiation effects, Hand, Platelet-Rich Plasma, Skin Aging
- Abstract
Background: Platelet-rich plasma (PRP) provides growth factors that stimulate fibroblast activation and induce the synthesis of collagen and other components of the extracellular matrix. The objective of this study was to evaluate the effect of PRP in the treatment of photodamage of the skin of the hands., Material and Methods: Experimental study enrolling persons with photoaged skin on the dorsum of the hands (Glogau photoaging scale, type III, or Fitzpatrick wrinkle classification, type II) were included between August 2012 and January 2013. A histological comparison was made of skin biopsies taken before and after the application of PRP to the skin of the dorsum of the hands., Results: The mean (SD) age of the 18 women enrolled was 47.9 (4.3) years. Histological analysis showed an increase in the number of fibroblasts (P<.001), number of vessels (P<.001), and collagen density (P=.27). These changes produced significant improvements in the Fitzpatrick wrinkle and elastosis scale (P<.001) and in the Glogau photoaging scale (P=.01)., Conclusions: PRP induced a reduction in the manifestations of skin aging, including an improvement in wrinkles and elastosis., (Copyright © 2017 AEDV. Publicado por Elsevier España, S.L.U. All rights reserved.)
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- 2017
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38. Combat MEDEVAC: A comparison of care by provider type for en route trauma care in theater and 30-day patient outcomes.
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Maddry JK, Mora AG, Savell S, Reeves LK, Perez CA, and Bebarta VS
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- Adult, Afghan Campaign 2001-, Humans, Injury Severity Score, Male, Nurses, Patient Outcome Assessment, Physicians, Retrospective Studies, Survival Rate, Workforce, Wounds and Injuries mortality, Young Adult, Air Ambulances, Emergency Medical Services, Emergency Medical Technicians, Military Medicine, Military Personnel, Wounds and Injuries therapy
- Abstract
Background: Medical evacuation (MEDEVAC) is the movement and en route care of injured and medically compromised patients by medical care providers via helicopter. Military MEDEVAC platforms provide lifesaving interventions that improve survival in combat. There is limited evidence to support decision making related to en route care and allocation of resources. The association between provider type and en route care is not well understood. Our objective was to describe MEDEVAC providers and identify associations between provider type, procedures performed, and outcomes., Methods: We conducted an institutional review board-approved, retrospective record review of patients traumatically injured in combat, evacuated by MEDEVAC from the point of injury, between 2011 and 2014. Data abstracted included injury description, provider type, procedures performed, medications administered, survival, and 30-day outcomes. Subjects were grouped according to provider type: medics, paramedics, and ADVs (advanced-level providers to include nurses, physician assistants, and physicians). Groups were compared. Analyses were performed using χ tests for categorical variables and analysis of variance tests (Kruskal-Wallis tests) for continuous variables; p < 0.05 was considered significant., Results: The MEDEVAC records were reviewed, and data were abstracted from 1,237 subjects. The providers were composed of medics, 76%; paramedics, 21%; and ADVs, 4%. Patient and injury demographics were similar among groups. The ADVs were most likely to perform intubation, chest needle decompressions (p < 0.0001), and hypothermia prevention (p = 0.01). Paramedics were most likely to administer blood en route (p < 0.0001). All other procedures were similar between groups. Paramedics were most likely to administer ketamine (p < 0.0001), any analgesic (p < 0.0001), or any medication en route (p < 0.0001). Incidence rates of en route events (pain, hypoxia, abnormal hemodynamics, vital signs) were similar between provider types. In-theater and 30-day survival rates were similar between provider types., Conclusion: Providers with higher-level training were more likely to perform more advanced procedures during en route care. Our study found no significant association between provider type and in-theater or 30-day mortality rates. Upon subgroup analysis, no difference was found in patients with an injury severity score greater than 16. More evidence is needed to determine the appropriate level of MEDEVAC personnel training and skill maintenance necessary to minimize combat mortality., Level of Evidence: Therapeutic study, level III.
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- 2016
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39. A 3-Year Comparison of Overdoses Treated in a Military Emergency Department-Complications, Admission Rates, and Health Care Resources Consumed.
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Ganem VJ, Mora AG, Nnamani N, and Bebarta VS
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- Adult, Aged, Aged, 80 and over, Benzodiazepines adverse effects, Benzodiazepines toxicity, Drug Overdose therapy, Emergency Service, Hospital economics, Female, Humans, Male, Middle Aged, Opioid-Related Disorders complications, Opioid-Related Disorders epidemiology, Retrospective Studies, United States epidemiology, Drug Overdose epidemiology, Emergency Service, Hospital statistics & numerical data, Military Personnel statistics & numerical data
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Background: Drug overdose has become a leading cause of death in the United States and is a growing issue in civilian and military populations. Increasing prescription drug misuse and poisonings translate into greater utilization of medical resources. Our objective was to describe the incidences of overdoses and their associated events and outcomes following emergency department consult., Methods: We performed a retrospective cohort study on cases evaluated in 2 military hospital emergency departments over 3 years. Subjects were identified using International Classification of Diseases, 9th Revision codes 960-970. Variables collected included demographics, military service, method of arrival, vital signs, clinical complications, and hospital admission, if overdose was documented as intentional or unintentional and drug ingested., Results: Over 3 years, 342 overdoses were treated. Mean age was 35 ± 19 and gender was 53% female. 47% were active duty and 32% were dependents. 21% of overdoses involved benzodiazepines and 20% opioids. Active duty and benzodiazepine overdoses were more likely to arrive by ambulance (p = 0.0006, p = 0.03), were more likely to have overdosed intentionally (p = 0.02, p = 0.009), and were more likely to be admitted (p = 0.04, p = 0.007). Active duty had a longer length of stay (p = 0.02)., Conclusion: Overdoses involving the active duty population and benzodiazepines consume greater military health care resources than other overdoses., (Reprint & Copyright © 2016 Association of Military Surgeons of the U.S.)
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- 2016
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40. En route intraosseous access performed in the combat setting.
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Savell S, Mora AG, Perez CA, Bebarta VS, and Maddry MJ
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- Adult, Afghan Campaign 2001-, Air Ambulances, Female, Hospitalization statistics & numerical data, Humans, Infusions, Intravenous, Length of Stay statistics & numerical data, Male, Retrospective Studies, Survival Rate, United States, Emergency Medical Services, Infusions, Intraosseous methods, Military Medicine, Military Personnel, Wounds and Injuries therapy
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Objective: To describe and compare vascular access practices used by en route care providers during medical evacuation (MEDEVAC)., Design: This was a retrospective cohort study. Medical records of US military personnel injured in combat and transported by MEDEVAC teams were queried., Patients: The subjects were transported by military en route care providers, in the combat theater during Operation Enduring Freedom (OEF) between January 2011 and March 2014. The authors reviewed 1,267 MEDEVAC records of US casualties and included 832 subjects that had vascular access attempts., Main Outcome Measures: The outcome measures for this study were vascular access success rates, including intravenous (IV) and intraosseous (IO) attempts. Subjects were grouped by type of vascular access: None, peripheral intravenous (PIV), IO, and PIV + IO (combination of PIV and IO) and by vascular access (PIV or IO) success (No versus Yes). Survival rate, in-flight events, ventilator, intensive care and in hospital days, and 30-day outcomes were compared among groups., Statistical Analysis: The authors used chisquare or Fisher's exact tests to evaluate categorical variables. Analysis of variance (ANOVA) or Kruskal-Wallis tests were used for continuous variables., Results: Vascular access was attempted in 832 (66 percent) of the 1,267 subjects transported by MEDEVAC during this study period. The majority (n = 758) of the access attempts were PIV of which 93 percent (706/758) were successful. In 74 subjects, IO was the only access attempted with an 85 percent (n = 63) success rate. The overall success rate with IO placement was 88 percent., Conclusions: Intraosseous access has been used successfully in the combat setting and accounts for approximately 12 percent of vascular access in the MEDEVAC population the authors studied.
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- 2016
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41. Preflight Variables Are Associated With Increased Ventilator Days and 30-Day Mortality in Trauma Casualties Evacuated by Critical Care Air Transport Teams: An Exploratory Retrospective Study.
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Barnard E, Mora AG, and Bebarta VS
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- Adult, Aerospace Medicine, Afghan Campaign 2001-, Afghanistan, Air Ambulances standards, Air Ambulances statistics & numerical data, Cohort Studies, Critical Care standards, Female, Humans, Injury Severity Score, Length of Stay, Logistic Models, Male, Military Personnel, Monitoring, Physiologic statistics & numerical data, Mortality, Registries statistics & numerical data, Respiration, Artificial standards, Retrospective Studies, Travel statistics & numerical data, Critical Care methods, Respiration, Artificial methods, Wounds and Injuries mortality, Wounds and Injuries therapy
- Abstract
Background: There are no tools to predict outcomes in the U.S. Air Force Critical Care Air Transport Team (CCATT) trauma patients. The objective of this study was to identify associations between preflight variables and outcomes that could assist planning of ongoing critical care., Methods: This Institutional Review Board approved retrospective study included all patients evacuated from Afghanistan by CCATT between 2007 and 2011. Preflight variables were assessed for associations and examined in logistic regression models. Ventilator time over 72 hours, and 30-day mortality were the primary and secondary outcomes respectively., Results: 1,308 trauma patients (24 years, 98% male) were included; 72% blast. Injury severity score (odds ratio [OR] = 1.04 [1.03-1.06]), preflight packed red blood cell units transfused (OR = 1.05 [1.04-1.07]), and preflight intubated status (OR = 11.9 [8.53-16.89]) were independently associated with increased ventilator days; a composite produced an area under the curve of 0.85 with 86% sensitivity and 56% specificity. Injury severity score (OR = 1.06 [1.03-1.09]), prothrombin time (OR = 2.13 [1.18-4.47]), preflight intubated status (OR = 9.2 [1.88-166.11]), and whole blood (OR = 3.18 [1.38-7.04]) were associated with 30-day mortality; a composite produced an area under the curve of 0.84 with 71% sensitivity and 57% specificity., Conclusion: In our large CCATT study a number of preflight variables were associated with outcomes, which may assist in the future planning of critical care services., (Reprint & Copyright © 2016 Association of Military Surgeons of the U.S.)
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- 2016
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42. En Route Use of Analgesics in Nonintubated, Critically Ill Patients Transported by U.S. Air Force Critical Care Air Transport Teams.
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Mora AG, Ganem VJ, Ervin AT, Maddry JK, and Bebarta VS
- Subjects
- Adult, Aerospace Medicine, Afghan Campaign 2001-, Air Ambulances statistics & numerical data, Analgesics adverse effects, Analgesics therapeutic use, Critical Care standards, Drug-Related Side Effects and Adverse Reactions epidemiology, Drug-Related Side Effects and Adverse Reactions etiology, Female, Fentanyl pharmacology, Fentanyl therapeutic use, Humans, Hydromorphone pharmacology, Hydromorphone therapeutic use, Iraq War, 2003-2011, Ketamine pharmacology, Ketamine therapeutic use, Male, Military Personnel statistics & numerical data, Morphine pharmacology, Morphine therapeutic use, Retrospective Studies, Travel statistics & numerical data, Treatment Outcome, United States epidemiology, Wounds and Injuries epidemiology, Analgesics pharmacology, Critical Care methods, Critical Illness, Wounds and Injuries complications, Wounds and Injuries drug therapy
- Abstract
Introduction: U.S. Critical Care Air Transport Teams (CCATTs) evacuate critically ill patients with acute pain in the combat setting. Limited data have been reported on analgesic administration en route, and no study has reported analgesic use by CCATTs. Our objective was to describe analgesics used by CCATTs for nonintubated, critically ill patients during evacuation from a combat setting., Methods: We conducted an institutional review board-approved, retrospective review of CCATT records. We included nonintubated, critically ill patients who were administered analgesics in flight and were evacuated out of theater (2007-2012). Demographics, injury description, analgesics and anesthetics, and predefined clinical adverse events were recorded. Data were presented as mean ± standard deviation or percentage (%)., Results: Of 1,128 records, we analyzed 381 subjects with the following characteristics: age 26 ± 7.0 years; 98% male; and 97% trauma (70% blast, 17% penetrating, 11% blunt, and 3% burn). The injury severity score was 19 ± 9. Fifty-one percent received morphine, 39% hydromorphone, 15% fentanyl, and 5% ketamine. Routes of delivery were 63% patient-controlled analgesia (PCA), 32% bolus intravenous (IV) administration, 24% epidural delivery, 21% continuous IV infusions, and 9% oral opioids. Patients that were administered local anesthetics (nerve block or epidural delivery) with IV opioids received a lower total dose of opioids than those who received opioids alone. No differences were associated between analgesics and frequency of complications in flight or postflight., Conclusion: About half of nonintubated, critically ill subjects evacuated out of combat by CCATT received morphine and more than half had a PCA. In our study, ketamine was not frequently used and pain scores were rarely recorded. However, we detected an opioid-sparing effect associated with local anesthetics (regional nerve blocks and epidural delivery)., (Reprint & Copyright © 2016 Association of Military Surgeons of the U.S.)
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- 2016
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43. Clinical competency evaluation of Brazilian chiropractic interns.
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Facchinato AP, Benedicto CC, Mora AG, Cabral DM, and Fagundes DJ
- Abstract
Objective: This study compares the results of an objective structured clinical examination (OSCE) between 2 groups of students before an internship and after 6 months of clinical practice in an internship., Methods: Seventy-two students participated, with 36 students in each cohort. The OSCEs were performed in the simulation laboratory before the participants' clinical practice internship and after 6 months of the internship. Students were tested in 9 stations for clinical skills and knowledge. The same procedures were repeated for both cohorts. The t test was used for unpaired parametric samples and Fisher's exact test was used for comparison of proportions., Results: There was no difference in the mean final score between the 2 groups (p = .34 for test 1; p = .08 for test 2). The performance of the students in group 1 was not significantly different when performed before and after 6 months of clinical practice, but in group 2 there was a significant decrease in the average score after 6 months of clinical practice., Conclusions: There was no difference in the cumulative average score for the 2 groups before and after 6 months of clinical practice in the internship. There were differences within the cohorts, however, with a significant decrease in the average score in group 2. Issues pertaining to test standardization and student motivation for test 2 may have influenced the scores.
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- 2015
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44. Emergency Department Opioid Prescribing Practices for Chronic Pain: a 3-Year Analysis.
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Ganem VJ, Mora AG, Varney SM, and Bebarta VS
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- Chronic Pain diagnosis, Drug Prescriptions, Drug Utilization Review, Electronic Health Records trends, Female, Hospitals, Military trends, Humans, Male, Retrospective Studies, Tertiary Care Centers trends, Time Factors, Analgesics, Opioid therapeutic use, Chronic Pain drug therapy, Emergency Service, Hospital trends, Pain Management trends, Practice Patterns, Physicians' trends
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Chronic pain is a common reason for emergency department (ED) visits. Our objective was to describe opioid prescribing practices of ED providers when treating patients with chronic pain. We retrospectively evaluated opioid prescriptions from EDs at two tertiary care military hospitals. We queried the outpatient record database to obtain a list of opioid medications prescribed and ICD-9 codes associated with visits for chronic pain. We collected provider type and gender, number of pills, opioid type, and refills. We compared the incidence with chi-square or Fisher's exact tests. Wilcoxon test was used for non-parametric continuous variables. Over 3 years, 28,103 visits generated an opioid prescription. One thousand three hundred twenty-two visits were associated with chronic pain, and 443 (33 %) visits were associated with an opioid prescription. Providers were 79 % physicians, 19 % physician assistants (PAs), 81 % male, and 69 % active duty military. Medications were 43 % oxycodone, 30 % hydrocodone, 9.5 % tramadol, 2.5 % codeine, and 15 % other. The number of pills was 20 [interquartile range (IQR) 15-30] (range 1-240), morphine equivalents (M.E.) per pill was 7.5 [7.5-7.5] (2.5-120) and total M.E. per prescription was 150 [112.5-270] (15-6000). Physicians were more likely to prescribe a non-opioid than PAs (77 vs 45 %, p < 0.0001). Civilian providers were more likely to prescribe an opioid than active duty providers (58 vs 42 %, p < 0.0001). Providers prescribed a median of 20 pills per prescription and most commonly prescribed oxycodone. PAs were more likely to prescribe an opioid for chronic pain than physicians. Civilian providers were more likely to prescribe an opioid than active duty providers.
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- 2015
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45. Impact of Anemia in Critically Ill Burned Casualties Evacuated From Combat Theater via US Military Critical Care Air Transport Teams.
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Hamilton JA, Mora AG, Chung KK, and Bebarta VS
- Subjects
- Adult, Air Ambulances, Blood Transfusion, Critical Illness, Female, Hemoglobins analysis, Humans, Injury Severity Score, Male, Military Personnel, Retrospective Studies, Risk, Treatment Outcome, United States, Warfare, Young Adult, Anemia complications, Burns blood, Transportation of Patients
- Abstract
Background: US military Critical Care Air Transport Teams (CCATT) transport critically ill burn patients out of theater. Blood transfusion may incur adverse effects, and studies report lower hemoglobin (Hgb) value may be safe for critically ill patients. There are no studies evaluating the optimal Hgb value for critically ill burn patients prior to CCATT evacuation., Objective: The aim of the study was to determine if critically ill burn casualties with an Hgb of 10 g/dL or less, transported via CCATT, have similar clinical outcomes at 30 days as compared with patients with an Hgb of greater than 10 g/dL., Methods: We conducted an institutional review board-approved retrospective cohort study involving patients transported via CCATT. We separated our study population into two cohorts based on Hgb levels at the time of theater evacuation: Hgb ≤10 g/dL or Hgb ≥10 g/dL. We compared demographics, injury description, physiologic parameters, and clinical outcomes., Results: Of the 140 subjects enrolled, 29 were Hgb ≤10, and 111 were Hgb ≥10. Both groups were similar in age and percent total body surface area burned. Those Hgb ≤10 had a higher injury severity score (34 ± 19.8 vs. 25 ± 16.9, P = 0.02) and were more likely to have additional trauma (50% vs. 25%, P = 0.04). Modeling revealed no persistent differences in mortality, and other clinical outcomes measured., Conclusions: Critical Care Air Transport Teams transport of critically ill burn patients with an Hgb of 10 g/dL or less had no significant differences in complications or mortality as compared with patients with an Hgb of greater than 10 g/dL. In this study, lower hemoglobin levels did not confer greater risk for worse outcomes.
- Published
- 2015
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46. Aeromedical evacuation of combat patients by military critical care air transport teams with a lower hemoglobin threshold approach is safe.
- Author
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Mora AG, Ervin AT, Ganem VJ, and Bebarta VS
- Abstract
Background: Military critical care air transport teams (CCATT) evacuate critically ill and injured patients out of theater for tertiary treatment. Teams are led by a physician, nurse, and respiratory technician. Current aeromedical guidelines require a hemoglobin (Hgb) of 9 g/dL or greater to evacuate; however, civilians report that an Hgb of 8 g/dL or less is safe in critically ill patients. This study aimed to compare postflight short-term and 30-day patient outcomes for CCATT patients evacuated out of theater with an Hgb of 8 g/dL or less with those with an Hgb of greater than 8 g/dL., Methods: We conducted a retrospective record review of all traumatically injured patients evacuated from theater by CCATT between March 2007 and December 2011. We recorded demographics, injury descriptions, vital signs, laboratory values, adverse events, and disposition at 30 days. Patients were separated into those with a preflight Hgb of 8 g/dL or less versus those with greater than 8 g/dL. Continuous data were analyzed using Student's t tests or Wilcoxon tests and reported as mean ± SD. χ or Fisher's exact tests were performed. Stepwise, multifactorial logistic regression models were used. Statistical significance was considered with p < 0.05., Results: Of 1,252 patients, 1,033 had a preflight Hgb of greater than 8 and 219 had an Hgb of 8 or less. Age, sex proportions, vitals, laboratory values, and Injury Severity Score (ISS; 24±13) were similar. The group with 8 or less had more blast injuries (68% vs. 76%, p = 0.01). No associations were identified between preflight Hgb levels and adverse outcomes. Disposition at 30 days was similar. We also compared preflight Hgb greater than 7 versus 7 or less (n = 1,212 vs. 45). Those with an Hgb greater than 7 had a greater incidence of hospitalization at 30 days (77% vs. 67%, p = 0.04). The group with an Hgb of 7 or less had more subjects discharged home or returning to duty (10% vs. 21%, p = 0.04)., Conclusion: Evacuating CCATT patients with an Hgb of 8 or less had similar adverse outcomes and mortality at 30 days compared with those with an Hgb greater than 8. Patients with an Hgb of 7 or less had higher rates of hospital discharge and decreased incidence of hospitalization at 30 days., Level of Evidence: Prognostic/epidemiologic study, level III.
- Published
- 2014
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47. Signals from fat after injury: plasma adipokines and ghrelin concentrations in the severely burned.
- Author
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Wade CE, Mora AG, Shields BA, Pidcoke HF, Baer LA, Chung KK, and Wolf SE
- Subjects
- Adiponectin blood, Adult, Blood Glucose analysis, Body Mass Index, Burns metabolism, Burns mortality, Female, Humans, Hydrocortisone blood, Insulin blood, Insulin Resistance physiology, Leptin blood, Male, Resistin blood, Adipokines blood, Burns immunology, Ghrelin blood
- Abstract
Introduction: Hypermetabolism is universal in the severely burned and is characterized by catabolism of lean mass and body fat with associated insulin resistance. Adipokines are likely to play a role in these changes but have not been identified to date in burn patients., Methods: From a single burn ICU, 17 burn patients with an expected stay>14 days were studied. Study period began within 14 days of admission. Over 7 days, plasma samples were collected for measurement of leptin, adiponectin, resistin, ghrelin, insulin, and cortisol by ELISA. For comparison, samples from 15 healthy controls of similar age, BMI, and blood glucose were obtained., Results: Mean age was 33±17 years and BMI 26±3.4. Average burn size was 45±20% TBSA and ISS 32±10 with 72% having inhalation injury; in-hospital mortality was 29%. Estimated energy needs were 3626±710 kcal, of which 84±21% were met by enteral feeding with intensive insulin treatment (glucose 80-110 mg/ml). Using the homeostasis model assessment of insulin resistance, burned subjects were more resistant than controls (17±11.3 and 8±10.0). Insulin levels were elevated (57±35.6 μU/ml in burned subject vs. 26±31.1 μU/ml in controls), and cortisol concentrations increased (50±41.2 μg/dl vs. 12±3.9 μg/dl). These traditional hormone changes were associated with increased resistin (16.6±5.5 ng/ml vs. 3.8±0.9 ng/ml) and decreased leptin (8.8±8.9 ng/ml vs. 19.4±23.5 ng/ml), adiponectin (9±3.5 ng/ml vs. 17±10.2 ng/ml), and ghrelin (0.37±0.14 ng/ml vs.0.56±0.26 ng/ml)., Conclusion: Patients with burns, who are characteristically hypermetabolic with hypercortisolism and insulin resistant, have significant changes in adipokine levels that appear independent of the magnitude of initial injury or metabolic derangement. In addition, suppression of ghrelin in the presence of decreased leptin and adiponectin levels in combination with increased insulin and resistin levels represent unexpected changes in the metabolic milieu of the injured patient possibly due to dramatic activation of inflammatory pathways, indicating strategies for treatment., (Copyright © 2012 Elsevier Ltd. All rights reserved.)
- Published
- 2013
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48. Primary hemostatic capacity of whole blood: a comprehensive analysis of pathogen reduction and refrigeration effects over time.
- Author
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Pidcoke HF, McFaul SJ, Ramasubramanian AK, Parida BK, Mora AG, Fedyk CG, Valdez-Delgado KK, Montgomery RK, Reddoch KM, Rodriguez AC, Aden JK, Jones JA, Bryant RS, Scherer MR, Reddy HL, Goodrich RP, and Cap AP
- Subjects
- Adult, Blood Banking methods, Blood-Borne Pathogens radiation effects, Cryopreservation methods, Hemostasis, Humans, Infections transmission, Photosensitizing Agents pharmacology, Platelet Activation radiation effects, Riboflavin pharmacology, Thrombelastography radiation effects, Ultraviolet Rays, Blood Preservation methods, Blood Safety methods, Blood Transfusion methods, Hemorrhage therapy, Hemostatic Techniques, Infections blood
- Abstract
Background: Whole blood (WB) has been used in combat since World War I as it is readily available and replaces every element of shed blood. Component therapy has become standard; however, recent military successes with WB resuscitation have revived the debate regarding wider WB use. Characterization of optimal WB storage is needed. We hypothesized that refrigeration preserves WB function and that a pathogen reduction technology (PRT) based on riboflavin and ultraviolet light has no deleterious effect over 21 days of storage., Study Design and Methods: WB units were stored for 21 days either at 4°C or 22°C. Half of each temperature group underwent PRT, yielding four final treatment groups (n = 8 each): CON 4 (WB at 4°C); CON 22 (WB at 22°C); PRT 4 (PRT WB at 4°C); and PRT 22 (PRT WB at 22°C). Testing was at baseline, Days 1-7, 10, 14, and 21. Assays included coagulation factors; platelet activation, aggregation, and adhesion; and thromboelastography (TEG)., Results: Prothrombin time (PT) and partial thromboplastin time increased over time; refrigeration attenuated the effects on PT (p ≤ 0.009). Aggregation decreased over time (p ≤ 0.001); losses were attenuated by refrigeration (p ≤ 0.001). Refrigeration preserved TEG parameters (p ≤ 0.001) and PRT 4 samples remained within normal limits throughout the study. Refrigeration in combination with PRT inhibited fibrinolysis (p ≤ 0.001) and microparticle formation (p ≤ 0.031). Cold storage increased shear-induced platelet aggregation and ristocetin-induced platelet agglutination (p ≥ 0.032), as well as GPIb-expressing platelets (p ≤ 0.009)., Conclusion: The in vitro hemostatic function of WB is largely unaffected by PRT treatment and better preserved by cold storage over 21 days. Refrigerated PRT WB may be suitable for trauma resuscitation. Clinical studies are warranted., (© 2013 American Association of Blood Banks.)
- Published
- 2013
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49. Average daily risk range as a measure of glycemic risk is associated with mortality in the intensive care unit: a retrospective study in a burn intensive care unit.
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Farhy LS, Ortiz EA, Kovatchev BP, Mora AG, Wolf SE, and Wade CE
- Subjects
- Adult, Age Factors, Aged, Critical Care, Female, Humans, Injury Severity Score, Intensive Care Units, Male, Middle Aged, Retrospective Studies, Risk, Blood Glucose, Burns mortality
- Abstract
Background: Although tight glycemic control has been associated with improved outcomes in the intensive care unit (ICU), glycemic variability may be the influential factor in mortality. The main goal of the study was to relate blood glucose (BG) variability of burn ICU patients to outcomes using a sensitive measure of glycemic variability, the average daily risk range (ADRR)., Method: Data from patients admitted to a burn ICU were used. Patients were matched by total body surface area (TBSA) and injury severity score (ISS) to test whether increased BG variability measured by ADRR was associated with higher mortality risk and whether we could identify ADRR-based classifications associated with the degree of risk., Results: Four ADRR classifications were identified: low risk, medium-low, medium-high, and high. Mortality progressively increased from 25% in the low-risk group to over 60% in the high-risk group (p < .001). In a post hoc analysis, age also contributed to outcome. Younger (age < 43 years) survivors and nonsurvivors matched by TBSA and ISS had no significant difference in age, mean BG or standard deviation of BG; however, nonsurvivors had higher ADRR (p < .01)., Conclusions: Independent of injury severity, glycemic variability measured by the ADRR was significantly associated with mortality in the ICU. When age was considered, ADRR was the only measure of glycemia significantly associated with mortality in younger patients with burns., (© 2011 Diabetes Technology Society.)
- Published
- 2011
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50. [Necrotizing scleritis and recurrent erythema nodosum: a diagnostic challenge].
- Author
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Pedroza-García EM, Reynoso-von Drateln C, Márquez-Pérez P, Neri-Gutiérrez E, and Puebla-Mora AG
- Subjects
- Female, Humans, Middle Aged, Recurrence, Erythema Nodosum diagnosis, Scleritis diagnosis
- Abstract
The necrotizing scleritis and recurrent erythema nodosum, two clinical entities difficult to diagnose and which represent a challenge to the physician. Tuberculosis produces both processes by an immune reaction of delayed hypersensitivity type IV to various antigenic components of mycobacteria. Most tuberculosis patients have no ocular history of pulmonary or systemic disease in up to 50 % and no evidence of pathology in the chest radiograph. An adequate treatment leads to a favorable prognosis. It occurs when the diagnosis of infection is made on time. We describe the case of a woman with necrotizing scleritis associated with recurrent erythema nodosum secondary to infection with Mycobacterium tuberculosis complex.
- Published
- 2010
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