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Tyler, TX, United States

Nouri K.H.,University of Houston | Brish E.L.,East Texas Medical Center
Pain Medicine | Year: 2011

Objective. We report a case of malignancy-related testicular pain successfully treated by placement of spinal cord stimulator electrodes. Effective analgesia was provided by epidural lead placement over the dorsal columns. The rationale for our technique was based on contemporary understanding of spinal cord stimulation mechanism in conjunction with analysis of our patient's anatomical lesion location. Case Report. A 57-year-old man with a history of prostate carcinoma status post a radical retropubic prostatectomy presented to our clinic with a 2-year history of progressive burning and stabbing left scrotal and inguinal pain. Given his inability to tolerate opioid analgesics, he underwent ilioinguinal, iliohypogastric, and ganglion impar nerve blocks, which relieved his inguinal pain. His testicular pain nevertheless persisted, and he therefore underwent a successful dual-lead trial of spinal cord stimulation prompting a permanent implant. Outcome Measures. Patient's responses to the visual analog scale (VAS) were collected at 10 time points over the course of 2 years under two conditions: no stimulation and dual-lead stimulation. Results. Our patient's VAS questionnaire responses indicate a sustained 80% decrease of pain at 6 weeks status post-permanent spinal cord stimulator implant with self-reported increase of function at work and complete weaning off oral analgesics. Conclusions. Testicular pain may be difficult to treat particularly in patients unable to tolerate opioid analgesics. In cases that have failed conservative therapy, a trial of spinal cord stimulation should be explored. Wiley Periodicals, Inc.

Keilani Z.M.,Ochsner Clinic Foundation | Berne J.D.,East Texas Medical Center | Agko M.,University of Toledo
Journal of Vascular Surgery | Year: 2010

Blunt cerebrovascular injuries, defined as blunt injuries to the internal carotid or vertebral arteries, are uncommon and usually occur in victims of high-speed deceleration motor vehicle crashes. A blunt cerebrovascular injury after an equestrian accident is an extremely unusual presentation. In recent years, advances in screening and treatment with pharmacologic anticoagulation before the onset of neurologic symptoms have improved outcomes for these patients. Endovascular stenting and embolization, although unproven, offer a new potential approach for these complex injuries. We present a unique case of four-vessel blunt cerebrovascular injuries after a horse-riding injury that required multidisciplinary management. Copyright © 2010 Published by Elsevier Inc.

Matsushima K.,Pennsylvania State University | Cook A.,East Texas Medical Center | Tollack L.,University of Texas Southwestern Medical Center | Shafi S.,Baylor University | Frankel H.,Pennsylvania State University
Journal of Surgical Research | Year: 2011

Background: The impact by integration of emergency general surgery (EGS) with trauma in an acute care surgery model on the timeliness and quality of care in patients of each type at a high volume level I trauma center is still indeterminate. We hypothesized that trauma and EGS can be successfully integrated in an academic institution. Methods: Retrospective review of prospectively collected trauma/EGS database was conducted at a high-volume, urban academic level I trauma center. Patients admitted to or requested consultation from trauma and EGS services were included. We explored the covariates affecting time to operating room (TOR), morbidity and in-hospital mortality rate. Results: There were 1794 trauma patients and 1565 EGS patients identified over a 6-month period. Linear regression models failed to demonstrate a correlation between TOR and surgical team workload (WL), injury severity score (ISS), and caseload for the operating room staff and facility. While lower TOR, Glasgow coma scale, ISS and age were associated with an increased likelihood of complications, WL did not correlate with the occurrence of complications. TOR and surgical team WL had no association with death in trauma patients. The occurrence of complications was associated with a nearly 8-fold increase in the risk of death (odds ratio 7.56, 95% confidence interval [CI] 1.49-39.32, P = 0.02). Conclusion: Increased workload during combined trauma/EGS call in an acute care surgery model did not affect the TOR nor worsen patient outcome. Implementation of a trauma/EGS model is justified even in high-volume academic institutions, if appropriately staffed and resourced. © 2011 Elsevier Inc. All rights reserved.

Gale S.C.,East Texas Medical Center | Gale S.C.,The New School | Shafi S.,Baylor Research Institute | Dombrovskiy V.Y.,The New School | And 2 more authors.
Journal of Trauma and Acute Care Surgery | Year: 2014

BACKGROUND: Emergency general surgery (EGS) represents illnesses of very diverse pathology related only by their urgent nature. The growth of acute care surgery has emphasized this public health problem, yet the true "burden of disease" remains unknown. Building on efforts by the American Association for the Surgery of Trauma to standardize an EGS definition, we sought to describe the burden of disease for EGS in the United States. We hypothesize that EGS patients represent a large, diverse, and challenging cohort and that the burden is increasing. METHODS: The study population was selected from the Nationwide Inpatient Sample, 2001 to 2010, using the AAST EGS DRG International Classification of Diseases - 9th Rev. codes, selecting all EGS patients 18 years or older with urgent/emergent admission status. Rates for operations, mortality, and sepsis were compiled along with hospital type, length of stay, insurance, and demographic data. The χ test, the t test, and the Cochran-Armitage trend test were used; p < 0.05 was significant. RESULTS: From 2001 to 2010, there were 27,668,807 EGS admissions, 7.1% of all hospitalizations. The population-adjusted case rate for 2010 was 1,290 admissions per 100,000 people (95% confidence interval, 1,288.9-1,291.8). The mean age was 58.7 years; most had comorbidities. A total of 7,979,578 patients (28.8%) required surgery. During 10 years, admissions increased by 27.5%; operations, by 32.3%; and sepsis cases, by 15% (p < 0.0001). Mortality and length of stay both decreased (p < 0.0001). Medicaid and uninsured rates increased by a combined 38.1% (p < 0.0001). Nearly 85% were treated in urban hospitals, and nearly 40% were treated in teaching hospitals; both increased over time (p < 0.0001). CONCLUSION: The EGS burden of disease is substantial and is increasing. The annual case rate (1,290 of 100,000) is higher than the sum of all new cancer diagnoses (all ages/types): 650 per 100,000 (95% confidence interval, 370.1-371.7), yet the public health implications remain largely unstudied. These data can be used to guide future research into improved access to care, resource allocation, and quality improvement efforts. LEVEL OF EVIDENCE: Epidemiologic study, level III. © 2014 Lippincott Williams & Wilkins.

Ogola G.O.,Baylor Scott and White Health | Gale S.C.,East Texas Medical Center | Haider A.,Brigham and Womens Hospital | Shafi S.,Baylor Scott and White Health
Journal of Trauma and Acute Care Surgery | Year: 2015

BACKGROUND Adoption of the acute care surgery model has led to increasing volumes of emergency general surgery (EGS) patients at trauma centers. However, the financial burden of EGS services on trauma centers is unknown. This study estimates the current and future costs associated with EGS hospitalization nationwide. METHODS We applied the American Association for the Surgery of Trauma's DRG International Classification of Diseases - 9th Rev. criteria for defining EGS to the 2010 National Inpatient Sample (NIS) data and identified adult EGS patients. Cost of hospitalization was obtained by converting reported charges to cost using the 2010 all-payer inpatient cost-to-charge ratio for all hospitals in the NIS database. Cost was modeled via a log-gamma model in a generalized linear mixed model to account for potential correlation in cost within states and hospitals in the NIS database. Patients' characteristics and hospital factors were included in the model as fixed effects, while state and hospital were included as random effects. The national incidence of EGS was calculated from NIS data, and the US Census Bureau population projections were used to estimate incidence for 2010 to 2060. Nationwide costs were obtained by multiplying projected incidences by estimated costs and reported in year 2010 US dollar value. RESULTS Nationwide, there were 2,640,725 adult EGS hospitalizations in 2010. The national average adjusted cost per EGS hospitalization was $10,744 (95% confidence interval [CI], $10,615-$10,874); applying these cost data to the national EGS hospitalizations gave a total estimated cost of $28.37 billion (95% CI, $28.03-$28.72 billion). Older age groups accounted for greater proportions of the cost ($8.03 billion for age ≥ 75 years, compared with $1.08 billion for age 18-24 years). As the US population continues to both grow and age, EGS costs are projected to increase by 45% to $41.20 billion (95% CI, $40.70-$41.7 billion) by 2060. CONCLUSION EGS constitutes a significant portion of US health care costs and is expected to rise with the demographic changes in the population. Trauma centers should conduct careful financial analyses of their EGS services, based on their unique case mix and payer mix. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

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