Anupamaa Seshadri

Malnutrition at Intensive Care Unit Admission Predicts Mortality in Emergency General Surgery Patients.

BACKGROUND Emergency general surgery (EGS) patients are at an increased risk for morbidity and mortality compared with non-EGS patients. Limited information exists regarding the contribution of malnutrition to the outcome of critically ill patients who undergo EGS. We hypothesized that malnutrition would be associated with increased risk of 90-day all-cause mortality following intensive care unit (ICU) admission in EGS patients. MATERIALS AND METHODS We performed an observational study of patients treated in medical and surgical ICUs at a single institution in Boston. We included patients who underwent an EGS procedure and received critical care between 2005 and 2011. The exposure of interest, malnutrition, was determined by a registered dietitians formal assessment within 48 hours of ICU admission. The primary outcome was all-cause 90-day mortality. Adjusted odds ratios were estimated by multivariable logistic regression models. RESULTS The cohort consisted of 1361 patients. Sixty percent had nonspecific malnutrition, 8% had protein-energy malnutrition, and 32% were without malnutrition. The 30-day readmission rate was 18.9%. Mortality in-hospital and at 90 days was 10.1% and 17.9%, respectively. Patients with nonspecific malnutrition had a 1.5-fold increased odds of 90-day mortality (adjusted odds ratio [OR], 1.51; 95% confidence interval [CI], 1.09-5.04; P = .009) and patients with protein-energy malnutrition had a 3.1-fold increased odds of 90-day mortality (adjusted OR, 3.06; 95% CI, 1.89-4.92; P < .001) compared with patients without malnutrition. CONCLUSION In critically ill patients who undergo EGS, malnutrition at ICU admission is predictive of adverse outcomes. In survivors of hospitalization, malnutrition at ICU admission is associated with increases in readmission and mortality.

Phenotyping the Immune Response to Trauma: A Multiparametric Systems Immunology Approach*

Objective: Trauma induces a complex immune response that requires a systems biology research approach. Here, we used a novel technology, mass cytometry by time-of-flight, to comprehensively characterize the multicellular response to trauma. Design: Peripheral blood mononuclear cells samples were stained with a 38-marker immunophenotyping cytometry by time-of-flight panel. Separately, matched peripheral blood mononuclear cells were stimulated in vitro with heat-killed Streptococcus pneumoniae or CD3/CD28 antibodies and stained with a 38-marker cytokine panel. Monocytes were studied for phagocytosis and oxidative burst. Setting: Single-institution level 1 trauma center. Patients or Subjects: Trauma patients with injury severity scores greater than 20 (n = 10) at days 1, 3, and 5 after injury, and age- and gender-matched controls. Interventions: None. Measurements and Main Results: Trauma-induced expansion of Th17-type CD4+ T cells was seen with increased expression of interleukin-17 and interleukin-22 by day 5 after injury. Natural killer cells showed reduced T-bet expression at day 1 with an associated decrease in tumor necrosis factor-&bgr;, interferon-&ggr;, and monocyte chemoattractant protein-1. Monocytes showed robust expansion following trauma but displayed decreased stimulated proinflammatory cytokine production and significantly reduced human leukocyte antigen - antigen D related expression. Further analysis of trauma-induced monocytes indicated that phagocytosis was no different from controls. However, monocyte oxidative burst after stimulation increased significantly after injury. Conclusions: Using cytometry by time-of-flight, we were able to identify several major time-dependent phenotypic changes in blood immune cell subsets that occur following trauma, including induction of Th17-type CD4+ T cells, reduced T-bet expression by natural killer cells, and expansion of blood monocytes with less proinflammatory cytokine response to bacterial stimulation and less human leukocyte antigen - antigen D related. We hypothesized that monocyte function might be suppressed after injury. However, monocyte phagocytosis was normal and oxidative burst was augmented, suggesting that their innate antimicrobial functions were preserved. Future studies will better characterize the cell subsets identified as being significantly altered by trauma using cytometry by time-of-flight, RNAseq technology, and functional studies.

Gene manipulation with stereotaxic viral infection for psychiatric research: spatiotemporal components for schizophrenia.

Schizophrenia (SZ) is a highly polygenic disease with strong genetic predisposition. Although genetic susceptibility factors for SZ are likely to have an influence in some brain regions and related neural circuits during neurodevelopment, direct proof for spatiotemporal causality in the development of SZ, and the alteration of what gene function at what brain region during what developmental stage, remains to be elucidated. Gene manipulation by viral vector stereotaxically injected into a specific brain region is now becoming available for psychiatric research. This technique has several advantages, e.g., the exceptional spatiotemporal control, simultaneous manipulation of multiple genes, and its simple protocol. These properties can make this technique one of the most valuable approaches for research in SZ, which is a complex brain disorder with multifactorial, genetic, and developmental features. This review summarizes the benefits and actual use of this technique together with discussion of spatiotemporal aspect for SZ.

Revascularization and rescue of a failed kidney transplant in a case of autosomal dominant polycystic kidney disease

Autosomal dominant polycystic kidney disease is a cause of end-stage renal disease associated with abdominal aortic aneurysms. We report a patient with autosomal dominant polycystic kidney disease who received an allograft kidney and subsequently underwent treatment of an abdominal aortic aneurysm with aortic ligation and axillary-bifemoral bypass. After years of graft function, bypass thrombosis resulted in dialysis-dependent renal failure. Aortobifemoral bypass resulted in immediate restoration of allograft function despite 6 months of prior renal failure. Aortic reconstruction restored renal function to a hibernating allograft long after clinical graft failure from arterial ischemia, a phenomenon not previously reported in the literature.

Internal hernia through a congenital peritoneal defect in the vesico-uterine space.

Highlights • Internal hernias are difficult to diagnose given their vague, non-specific presentation; they should always be on the clinician’s differential for SBO symptoms.• Acquired internal hernias develop most often due to adhesions or mesenteric defects from prior surgery.• Congenital internal hernias can arise from peritoneal defects.• We present the first reported case of an SBO from a congenital vesico-uterine defect.

BWH emergency radiology—surgical correlation: sigmoid volvulus

We describe the radiological and intraoperative correlation of large bowel obstruction due to sigmoid volvulus in a 52-year-old female. The purpose of this article is to emphasize the importance of recognizing sigmoid volvulus as a cause of bowel obstruction in patients presenting with abdominal pain, since it can lead to bowel ischemia and necrosis.

Risk stratification tools in emergency general surgery

The use of risk stratification tools (RST) aids in clinical triage, decision making and quality assessment in a wide variety of medical fields. Although emergency general surgery (EGS) is characterized by a comorbid, physiologically acute patient population with disparately high rates of perioperative morbidity and mortality, few RST have been explicitly examined in this setting. We examined the available RST with the intent of identifying a tool that comprehensively reflects an EGS patients perioperative risk for death or complication. The ideal tool would combine individualized assessment with relative ease of use. Trauma Scoring Systems, Critical Care Scoring Systems, Surgical Scoring Systems and Track and Trigger Models are reviewed here, with the conclusion that Emergency Surgery Acuity Score and the American College of Surgeons National Surgical Quality Improvement Programme Universal Surgical Risk Calculator are the most applicable and appropriate for EGS.

Red cell distribution width predicts out of hospital outcomes in critically ill emergency general surgery patients

Introduction Red cell distribution width (RDW) is associated with mortality and bloodstream infection risk in critically ill patients. We hypothesized that an increase in RDW at hospital discharge in critically ill patients who received emergency general surgery (EGS) would be associated with increased mortality after hospital discharge. Methods We performed a two-center observational study of patients treated in medical and surgical intensive care units. We studied 1567 patients, who received critical care between 1998 and 2012 who underwent EGS and survived hospitalization. The exposure of interest was RDW within 24 hours of hospital discharge and categorized a priori in quintiles as ≤13.3%, 13.3% to 14.0%, 14.0% to 14.7%, 14.7% to 15.8%, 15.8% to 17.0% and >17.0%. The primary outcome was 90-day all-cause mortality. Adjusted ORs were estimated by multivariable logistic regression models with inclusion of covariate terms for age, race, gender, Deyo-Charlson Index, sepsis and number of organs with acute failure. Results The cohort patients were 51.4% male and 23.2% non-white. 23.9% had sepsis and the mean age was 58 years. 90-day postdischarge mortality was 6.8%. Patients with a discharge RDW 15.8% to 17.0% or RDW >17.0% have an adjusted OR of 90-day postdischarge mortality of 3.64 (95% CI 1.04 to 12.68; p=0.043) or 4.58 (95% CI 1.32 to 15.93; p=0.02), respectively, relative to patients with a discharge RDW ≤13.3%. Further, patients with a discharge RDW ≥15.8 have an adjusted OR of 30-day hospital readmission of 2.12 (95% CI 1.17 to 3.83; p=0.013) relative to patients with a discharge RDW ≤13.3%. Conclusions In EGS patients requiring critical care who survive hospitalization, an elevated RDW at the time of discharge is a robust predictor of all-cause patient mortality and hospital readmission after discharge. Level of evidence Level II, prognostic retrospective study.

A multicenter study of post-traumatic stress disorder after injury: Mechanism matters more than injury severity

Background: Traumatic injury is strongly associated with long‐term mental health disorders, but the risk factors for developing these disorders are poorly understood. We report on a multi‐institutional collaboration to collect long‐term patient‐centered outcomes after trauma, including screening for post‐traumatic stress disorder. The objective of this study is to determine the prevalence of and risk factors for the development of post‐traumatic stress disorder after traumatic injury. Methods: Adult trauma patients (aged 18–64) with moderate to severe injuries (Injury Severity Score ≥ 9) admitted to 3 level I trauma centers were screened between 6 and 12 months after injury for post‐traumatic stress disorder. Patients were divided by mechanism: fall, road traffic injury, and intentional injury. Multiple logistic regression models were used to determine the association between baseline patient and injury‐related characteristics and the development of post‐traumatic stress disorder for the overall cohort and by mechanism of injury. Results: A total of 450 patients completed the screen. Overall 32% screened positive for post‐traumatic stress disorder, but this differed significantly by mechanism, with the lowest being after a fall (25%) and highest after intentional injury (60%). Injury severity was not associated with post‐traumatic stress disorder for any group, but lower educational level was associated with post‐traumatic stress disorder within all the groups. Only 21% of patients who screened positive for post‐traumatic stress disorder were receiving treatment at the time of the survey. Conclusion: Post‐traumatic stress disorder is common after traumatic injury, and the prevalence varies significantly by injury mechanism but is not associated with injury severity. Only a small proportion of patients who screen positive for post‐traumatic stress disorder are currently receiving treatment.

Brain Death Evaluation and Determination

Brain death is a critical concept for surgical intensivists to be aware of, and the diagnosis of brain death has been controversial over time. This chapter outlines the basic diagnosis of brain death as described by the American Academy of Neurology guidelines. This includes the cardinal findings of brain death, as well as confirmatory tests that can be used as ancillary evidence of brain death. It also covers pitfalls in diagnosis and strategies for these clinical scenarios. Finally, this chapter delineates the appropriate documentation for brain death.