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News Article | March 1, 2017
Site: www.eurekalert.org

CHICAGO: At one time, trauma surgeons considered an operation mandatory to treat gunshot wounds to the abdomen, but a study published online as an "article in press" on the Journal of the American College of Surgeons website has found that in selected patients, avoiding an operation--a practice known as nonoperative management--is an acceptable and effective treatment. "Selective nonoperative management of abdominal gunshot wounds is safe and avoids unnecessary laparotomies, which are invasive open operations that may sometimes cause complications in the short and long term," said lead study author George C. Velmahos, MD, PhD, FACS, chief of trauma, emergency surgery and surgical critical care at Massachusetts General Hospital and the John F. Burke professor of surgery at Harvard Medical School, Boston. While severe gunshot injuries almost always require an operation to repair damaged organs, selective nonoperative management--known by the acronym SNOM among trauma care professionals--is an alternative for less severe injuries that do not involve any major organ damage or significant blood loss. The researchers evaluated medical records of 922 gunshot wound patients admitted to 10 Level I and II trauma centers in New England from January 1996 to June 2015. The centers are members of the Research Consortium of New England Centers for Trauma (ReCoNECT). Of the 922 patients in the study, 707 (77 percent) had an immediate operation and 215 were managed with SNOM. Trauma professionals determine the level of a patient's injuries by using a scoring system called the Injury Severity Score (ISS). The study subjects who had SNOM had an average ISS of 8 (moderate to serious) vs. 16 (severe) for those who had an operation. SNOM patients had significantly lower rates of complications (8.5 percent vs. 34.7 percent for patients who underwent an operation) and death (0.5 percent vs. 5.2 percent), and shorter stays in the intensive care unit (median of zero days vs. one) and hospital overall (median of two days vs. eight). Of the patients initially assigned to SNOM, 8.4 percent eventually underwent an operation, none with complications related to the delay in having a procedure, and none of them died. Only one in the entire SNOM group died in the hospital due to a gunshot wound to the head. Trauma teams have become more comfortable with the idea of not operating on abdominal gunshot wounds, Dr. Velmahos said, and one reason is the wider availability of sophisticated imaging technology. "The explosive evolution of high-speed, high-resolution, multi-slice CT scan has definitely made clinicians more comfortable to practice selective nonoperative management," Dr. Velmahos said. "A good, reliable CT scan that has been read by a qualified individual--that is, an attending radiologist and/or an attending trauma surgeon--can be very helpful because it can map the trajectory of the bullet quite accurately and tell the trauma team whether the bullet traveled through or close to internal organs, or if it traveled completely outside the abdominal cavity." However, the key factor in determining the need for an operation still remains a good clinical exam, including the assessment of abdominal pain. "The patient will inevitably have pain around the gunshot wound site, but the question becomes, does the patient have pain away from this area?" Dr. Velmahos said. "If the latter happens, there's an injury inside the abdomen that has spilled blood or abdominal contents throughout the abdomen." That situation would almost always dictate an operation, he said. Also, patients who are hemodynamically unstable--that is, have unstable blood pressure--should go promptly to the operating room. Avoiding an unnecessary operation in a gunshot wound victim can be an important step in the patient's recovery, Dr. Velmahos explained. "The risks of a non-therapeutic laparotomy in any setting are real. Opening and closing the abdominal muscles, creating adhesions, providing general anesthesia, and intubating the patients are associated with multiple adverse events." Previous studies by Dr. Velmahos and colleagues have shown that even with a SNOM policy in place, about 10 percent of those who undergo an operation may have a non-therapeutic laparotomy. He does not consider that rate excessive. "I've called it an irreducible rate of unnecessary laparotomy," he said. "If you tried to eliminate that 10 percent, you may risk missing injuries and delaying operations in cases that require an operation." While SNOM has been embraced by many trauma centers, its adoption is not universal. "There are academic and community hospitals with high trauma volumes that practice SNOM based on their experience and available resources," Dr. Velmahos said. "The concept becomes more challenging for smaller community hospitals that lack the experience and/or resources." SNOM is not a panacea, he said. "Clinicians should practice what is best for their patients given the setting in which they work." Study coauthors are: Thomas Peponis, MD, of Massachusetts General Hospital; George Kasotakis, MD, MPH, FACS, and Jielin Yu, BA, of Boston Medical Center; Reginald Alouidor, MD, FACS, and Barbara Burkott, RN, BSN, CCRP, of Baystate Medical Center, Boston; Adrian A. Maung, MD, FACS, and Dirk C. Johnson, MD, FACS, of Yale School of Medicine, New Haven, Conn.; Noelle Saillant, MD, and Heath Walden, MD, of Beth Israel Deaconess Medical Center, Boston; Ali Salim, MD, FACS, and Elizabeth Bryant, MPH, of Brigham and Women's Hospital, Boston; Jon D. Dorfman, MD, FACS, of University of Massachusetts Memorial Medical Center, Boston; Eric N. Klein, MD, and Ronen Elefant, MD, FACS, of Hartford Hospital, Hartford, Conn.; Maryam B. Tabrizi, MD, of North Shore Medical Center, Salem, Mass.; Nikolay Bugaev, MD, FACS, and Sandra S. Arabian, CSTR, CRAISS, of Tufts Medical Center, Boston. The study was presented at the 97th Annual Meeting of the New England Surgical Society, Boston, in September 2016. NOTE: "FACS" designates that a surgeon is a Fellow of the American College of Surgeons Citation: Selective Nonoperative Management of Abdominal Gunshot Wounds - From Heresy to Adoption: A Multicenter Study of the Research Consortium of New England Centers for Trauma (ReCoNECT). Journal of the American College of Surgeons. DOI: http://dx. . About the American College of Surgeons The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for all surgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 80,000 members and is the largest organization of surgeons in the world. For more information, visit http://www. (.)


McCabe J.M.,University of Washington | Kennedy K.F.,St Lukes Mid America Heart Institute | Eisenhauer A.C.,Brigham and Women's Hospital | Waldman H.M.,North Shore Medical Center | And 4 more authors.
Circulation | Year: 2014

BACKGROUND-: For patients who undergo primary percutaneous coronary intervention (PCI) for ST-segment-elevation myocardial infarction, the door-to-balloon time is an important performance measure reported to the Centers for Medicare & Medicaid Services (CMS) and tied to hospital quality assessment and reimbursement. We sought to assess the use and impact of exclusion criteria associated with the CMS measure of door-to-balloon time in primary PCI. METHODS AND RESULTS-: All primary PCI-eligible patients at 3 Massachusetts hospitals (Brigham and Women's, Massachusetts General, and North Shore Medical Center) were evaluated for CMS reporting status. Rates of CMS reporting exclusion were the primary end points of interest. Key secondary end points were between-group differences in patient characteristics, door-to-balloon times, and 1-year mortality rates. From 2005 to 2011, 26% (408) of the 1548 primary PCI cases were excluded from CMS reporting. This percentage increased over the study period from 13.9% in 2005 to 36.7% in the first 3 quarters of 2011 (P<0.001). The most frequent cause of exclusion was for a diagnostic dilemma such as a nondiagnostic initial ECG, accounting for 31.2% of excluded patients. Although 95% of CMS-reported cases met door-to-balloon time goals in 2011, this was true of only 61% of CMS-excluded cases and consequently 82.6% of all primary PCI cases performed that year. The 1-year mortality for CMS-excluded patients was double that of CMS-included patients (13.5% versus 6.6%; P<0.001). CONCLUSIONS-: More than a quarter of patients who underwent primary PCI were excluded from hospital quality reports collected by CMS, and this percentage has grown substantially over time. These findings may have significant implications for our understanding of process improvement in primary PCI and mechanisms for reimbursement through Medicare. © 2013 American Heart Association, Inc.


Schuur J.D.,Harvard University | Tibbetts S.A.,North Shore Medical Center | Tibbetts S.A.,University of Pennsylvania | Pines J.M.,University of Pennsylvania
Annals of Emergency Medicine | Year: 2010

Study objective: We assess performance and explore definitions for a new emergency department (ED) quality measure: the proportion of women aged 14 to 50 years who have abdominal pain and receive pregnancy testing (aimed at detecting ectopic pregnancy). Methods: We analyzed data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) (2002 to 2006) to test trends and predictors of the new measure, using both restrictive and broad definitions from the International Classification of Diseases, Ninth Revision (ICD-9) and reason-for-visit codes, and determine the proportion of women with ectopic pregnancy who had undergone pregnancy testing. For comparison, we conducted a detailed chart review in 4 US hospitals among patients who visited the ED in 2006. Results: Using a broad ICD-9 definition for inclusion in NHAMCS, 2.13 million women aged 14 to 50 years with abdominal pain visited an ED annually between 2002 and 2006. Of those, 33.0% (95% confidence interval [CI] 30.5% to 35.5%) received pregnancy testing. Testing rates were materially stable, regardless of the definition used (broad or restrictive ICD-9 or reason-for-visit code). Among women with an ICD-9 diagnosis of ectopic pregnancy, 55.6% (95% CI 43.7% to 67.6%) had a documented pregnancy test. In the chart review, among 200 women aged 14 to 50 years and with abdominal pain, 89.4% (95% CI 85.0% to 94.0%) were eligible for the measure; of those, 93.9% (95% CI 90.3% to 97.4%) received testing. Conclusion: Analysis of national ED survey data demonstrated a large performance gap for a new pregnancy testing quality measure, whereas focused chart review at 4 sites showed a smaller gap. Given these discrepancies, additional study is recommended before the widespread implementation of the pregnancy testing measure as an assessment of ED performance. © 2009 by the American College of Emergency Physicians.


The International Association of HealthCare Professionals (IAHCP) proudly welcomes Dr. David N. Agorvor, MD, FACOG with his publication in The Leading Physicians of the World. Dr. Agorvor has 14 years of medical experience. In addition to running his private practice, Private Practice Women and Teens Healthcare, Inc., he serves as Chairman for the OBGYN Department of North Shore Medical Center, he is a Clinical Assistant Professor in the OBGYN Department at Florida International University College of Medicine, and an attending physician for Jackson North Medical Center, North Shore Medical Center, Hialeah Hospital, and Memorial Miramar, as well as west and regional hospitals. Dr. Agorvor began his journey to becoming an OBGYN at St. George University, followed by completing his internship at Brookdale University Hospital and Medical Center in 2002. Today, he is board-certified by the American Board of Obstetrics and Gynecology. Dr. Agorvor has been the recipient of several honors and awards, and has research interest in various areas such as the role of catechol estrogens in the initiation of labor in humans and the role of fetal fibronectin in the management of preterm labor in the high-risk population. When not tending to his patients, Dr. Agorvor enjoys football, jogging, soccer, music, and song writing. To learn more about Dr. Agorvor, visit his profile here: david-agorvor.findatopdoc.me and be sure to read his upcoming publication in The Leading Physicians of the World. FindaTopDoc.com is a hub for all things medicine, featuring detailed descriptions of medical professionals across all areas of expertise, and information on thousands of healthcare topics. Each month, millions of patients use FindaTopDoc to find a doctor nearby and instantly book an appointment online or create a review. Findatopdoc.com features each doctor’s full professional biography highlighting their achievements, experience, patient reviews and areas of expertise. A leading provider of valuable health information that helps empower patient and doctor alike, FindaTopDoc enables readers to live a happier and healthier life. For more information about FindaTopDoc, visit http://www.findatopdoc.com.


Mulita A.,North Shore Medical Center
BMJ case reports | Year: 2014

Even though Streptococcus bacteraemia is an infrequent presentation of colonic malignancies, there is a well-established link between Streptococcus bovis bacteraemia and colonic malignancies. Most of the physicians are well aware of this correlation and further workup is pursued in most of the cases. However, many physicians may not be aware that other species of Streptococcus viridians, other than S. bovis, can be associated with colonic malignancies. In this case report, we present a case of Streptococcus viridians (anginosus) bacteraemia as a complication of an undiagnosed sigmoid adenocarcinoma. While further evidence is needed to warrant a gastrointestinal (GI) workup in a patient with other species of Streptococcus viridians bacteraemia, we would like to increase the awareness in the physicians' community regarding Streptococcus viridians, other than S. bovis bacteraemia. This would be especially relevant for patients who have no GI screening, as Streptococcus viridians bacteraemia can be an early sign of colonic neoplasm. 2014 BMJ Publishing Group Ltd.


Saini N.,North Shore Medical Center | Mahindra A.,Massachusetts General Hospital
Expert Opinion on Investigational Drugs | Year: 2013

Introduction: The treatment options for patients with multiple myeloma (MM) remain limited. Immunomodulatory agents (IMiDs), such as thalidomide and lenalidomide, have changed the landscape in the treatment of patients with MM while newer IMiDs such as pomalidomide are showing promise in early clinical trials. Areas covered: This review focuses on the biologic rationales of IMiDs and the clinical results supporting their use in MM. It includes data on the new IMiD, pomalidomide and also explores the possible utility of combining IMiDs with other agents. A PubMed search and abstracts from oncology scientific meetings (ASCO and ASH) of articles related to IMiDs and MM was conducted. Expert opinion: IMiDs have shown clinical activity as single agents and in combination. Thalidomide was the first in class drug. Lenalidomide has a better toxicity profile than thalidomide. Pomalidomide may overcome resistance to lenalidomide indicating differences in their mechanisms of action and resistance. Molecular biomarkers may allow us to identify patients who will respond to IMiDs. © 2012 Informa UK, Ltd.


Alexander M.P.,Mayo Medical School | Nasr S.H.,Mayo Medical School | Watson D.C.,North Shore Medical Center | Mendez G.P.,Harvard University | Rennke H.G.,Harvard University
American Journal of Kidney Diseases | Year: 2011

Heavy chain deposition disease (HCDD) is a comparatively recently described entity characterized by glomerular and tubular basement membrane deposition of monoclonal heavy chains without associated light chains. To our knowledge, review of the literature shows only 24 previously reported cases of HCDD with unequivocal evidence of monoclonal heavy chain deposition in the kidney using immunofluorescence microscopic and electron microscopic studies. The predominant heavy chain subtype was γ. There has been a single case of μ HCDD and 2 previously reported cases of α HCDD. In this report, we describe 3 additional cases of α HCDD, all with a crescentic pattern of injury and one of which was associated with cutis laxa. We compare their clinicopathologic features with all previously reported cases of HCDD. © 2011 National Kidney Foundation, Inc.


Goldenberg A.,University of California at San Diego | Ortiz A.,University of California at San Diego | Kim S.S.,North Shore Medical Center | Jiang S.B.,University of California at San Diego
Journal of the American Academy of Dermatology | Year: 2015

Background: Squamous cell carcinoma with aggressive subclinical extension (SCC-ASE) is a tumor whose extensive spread becomes revealed during surgery or pathologic review, particularly during Mohs micrographic surgery. Limited clinical awareness of these lesions may result in unanticipated longer surgical times and larger postoperative defects. SCC-ASE - associated clinical risk factors are not well studied. Objective: We sought to evaluate the incidence of and risk factors associated with SCC-ASE. Methods: We conducted a retrospective analysis of SCC treated with Mohs micrographic surgery between 2007 and 2012 at a single academic surgical center. SCC-ASE was defined as a lesion requiring at least 3 Mohs stages with a final surgical margin of ≥1 cm. Results: Of 954 cases studied, 31% were SCC-ASE. In multivariable analysis, sex (P = .001), history of previous nonmelanoma skin cancer (P < .001), Fitzpatrick skin types II and III (P = .004 and <.001, respectively), immunosuppression related to solid organ transplant (P < .001), and cigarette use (P < .001) were significant predictors of SCC-ASE. Limitations: Single academic center selection bias, not-controlled for sun exposure differences, no information on medication regimens of solid organ transplant patients, and a small sample size are all limitations of our study. Conclusion: Easily attainable demographic factors, especially immunosuppressed status and cigarette use, can help predict the occurrence of SCC-ASE and thereby optimize surgical planning and patient preparedness. © 2015 American Academy of Dermatology, Inc.


Schuur J.D.,Brigham and Women's Hospital | Schuur J.D.,Harvard University | Carney D.P.,Harvard University | Lyn E.T.,North Shore Medical Center | And 5 more authors.
JAMA Internal Medicine | Year: 2014

IMPORTANCE The mean cost of medical care in the United States is growing at an unsustainable rate; from 2003 through 2011, the cost for an emergency department (ED) visit rose 240%, from $560 to $1354. The diagnostic tests, treatments, and hospitalizations that emergency clinicians order result in significant costs. OBJECTIVE To create a "top-five" list of tests, treatments, and disposition decisions that are of little value, are amenable to standardization, and are actionable by emergency medicine clinicians. DESIGN, SETTING, AND PARTICIPANTS Modified Delphi consensus process and survey of 283 emergency medicine clinicians (physicians, physician assistants, and nurse practitioners) from 6 EDs. INTERVENTION We assembled a technical expert panel (TEP) and conducted a modified Delphi process to identify a top-five list using a 4-step process. In phase 1, we generated a list of low-value clinical decisions from TEP brainstorming and e-mail solicitation of clinicians. In phase 2, the TEP ranked items on contribution to cost, benefit to patients, and actionability by clinicians. In phase 3, we surveyed all ordering clinicians from the 6 EDs regarding distinct aspects of each item. In phase 4, the TEP voted for a final top-five list based on survey results and discussion. MAIN OUTCOMES AND MEASURES A top-five list for emergency medicine. The TEP ranked items on contribution to cost, benefit to patients, and actionability by clinicians. The survey asked clinicians to score items on the potential benefit or harm to patients and the provider actionability of each item. Voting and surveys used 5-point Likert scales. A Pearson interdomain correlation was used. RESULTS Phase 1 identified 64 low-value items. Phase 2 narrowed this list to 7 laboratory tests, 3 medications, 4 imaging studies, and 3 disposition decisions included in the phase 3 survey (71.0%response rate). All 17 items showed a significant positive correlation between benefit and actionability (r, 0.19-0.37 [P < .01]). One item received unanimous TEP support, 4 received majority support, and 12 received at least 1 vote. CONCLUSIONS AND RELEVANCE Our TEP identified clinical actions that are of low value and within the control of ED health care providers. This method can be used to identify additional actionable targets of overuse in emergency medicine. Copyright © 2014 American Medical Association. All rights reserved.


Uggen C.,Kerlan Jobe Orthopaedic Clinic | Dines J.,Hospital for Special Surgery | McGarry M.,Orthopaedic Biomechanics Laboratory | Grande D.,North Shore Medical Center | And 2 more authors.
Arthroscopy - Journal of Arthroscopic and Related Surgery | Year: 2010

Purpose: The purpose of this study was to determine whether suture could be coated with recombinant human platelet-derived growth factor BB (rhPDGF-BB) and whether the coated suture would improve histologic scores and biomechanical strength of sheep rotator cuff repairs. Methods: FiberWire sutures (Arthrex, Naples, FL) were dip coated in a collagenrhPDGF-BB solution. Coating was confirmed by use of enzyme-linked immunosorbent assay. Rotator cuff tears were created in 18 sheep. The tendons were wrapped in Gortex (Gore Medical, Flagstaff, AZ) and allowed to scar for 2 weeks. Tendons were then repaired to bone by use of standard anchors loaded with either rhPDGF-BBcoated sutures or uncoated sutures. Gross examination, histologic analysis, and biomechanical testing were performed 6 weeks after repair. Results: Enzyme-linked immunosorbent assay confirmed successful loading of the growth factor onto the sutures. Gross examination showed well-healed tendon-to-bone interfaces in both rhPDGF-BBaugmented repairs and controls. Histologic analysis using a semiquantitative rating scale showed improved tendon-to-bone healing in the rhPDGF-BBaugmented repairs. There was no significant difference in the ultimate load to failure of rhPDGF-BBaugmented rotator cuff repairs compared with standard suture repairs at 6 weeks after repair. Conclusions: We were able to coat No. 2 FiberWire with rhPDGF-BB. At short-term follow-up, rhPDGF-BBcoated sutures enhanced histologic scores of sheep rotator cuff repairs; however, ultimate load to failure was equivalent to standard suture repairs. Clinical Relevance: rhPDGF-BBcoated sutures seem to produce a more histologically normal tendon insertion. © 2010 Arthroscopy Association of North America.

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