Timothy L. McMurry
University of Virginia
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Publication
Featured researches published by Timothy L. McMurry.
The Lancet | 2016
Jie Liu; James A. Platts-Mills; Jane Juma; Furqan Kabir; Joseph Nkeze; Catherine Okoi; Darwin J. Operario; Jashim Uddin; Shahnawaz Ahmed; Pedro L. Alonso; Martin Antonio; Stephen M. Becker; William C. Blackwelder; Robert F. Breiman; Abu S. G. Faruque; Barry S. Fields; Jean Gratz; Rashidul Haque; Anowar Hossain; M. Jahangir Hossain; Sheikh Jarju; Farah Naz Qamar; Najeeha Talat Iqbal; Brenda Kwambana; Inacio Mandomando; Timothy L. McMurry; Caroline Ochieng; John B. Ochieng; Melvin Ochieng; Clayton O. Onyango
BACKGROUND Diarrhoea is the second leading cause of mortality in children worldwide, but establishing the cause can be complicated by diverse diagnostic approaches and varying test characteristics. We used quantitative molecular diagnostic methods to reassess causes of diarrhoea in the Global Enteric Multicenter Study (GEMS). METHODS GEMS was a study of moderate to severe diarrhoea in children younger than 5 years in Africa and Asia. We used quantitative real-time PCR (qPCR) to test for 32 enteropathogens in stool samples from cases and matched asymptomatic controls from GEMS, and compared pathogen-specific attributable incidences with those found with the original GEMS microbiological methods, including culture, EIA, and reverse-transcriptase PCR. We calculated revised pathogen-specific burdens of disease and assessed causes in individual children. FINDINGS We analysed 5304 sample pairs. For most pathogens, incidence was greater with qPCR than with the original methods, particularly for adenovirus 40/41 (around five times), Shigella spp or enteroinvasive Escherichia coli (EIEC) and Campylobactor jejuni o C coli (around two times), and heat-stable enterotoxin-producing E coli ([ST-ETEC] around 1·5 times). The six most attributable pathogens became, in descending order, Shigella spp, rotavirus, adenovirus 40/41, ST-ETEC, Cryptosporidium spp, and Campylobacter spp. Pathogen-attributable diarrhoeal burden was 89·3% (95% CI 83·2-96·0) at the population level, compared with 51·5% (48·0-55·0) in the original GEMS analysis. The top six pathogens accounted for 77·8% (74·6-80·9) of all attributable diarrhoea. With use of model-derived quantitative cutoffs to assess individual diarrhoeal cases, 2254 (42·5%) of 5304 cases had one diarrhoea-associated pathogen detected and 2063 (38·9%) had two or more, with Shigella spp and rotavirus being the pathogens most strongly associated with diarrhoea in children with mixed infections. INTERPRETATION A quantitative molecular diagnostic approach improved population-level and case-level characterisation of the causes of diarrhoea and indicated a high burden of disease associated with six pathogens, for which targeted treatment should be prioritised. FUNDING Bill & Melinda Gates Foundation.
Journal of The American College of Surgeons | 2015
Robert H. Thiele; Kathleen M. Rea; Florence E. Turrentine; Charles M. Friel; Taryn E. Hassinger; Bernadette J. Goudreau; Bindu A. Umapathi; Irving L. Kron; Robert G. Sawyer; Traci L. Hedrick; Timothy L. McMurry
BACKGROUND Colorectal surgery is associated with considerable morbidity and prolonged length of stay (LOS). Recognizing the need for improvement, we implemented an enhanced recovery (ER) protocol for all patients undergoing elective colorectal surgery at an academic institution. STUDY DESIGN A multidisciplinary team implemented an ER protocol based on: preoperative counseling with active patient participation, carbohydrate loading, multimodal analgesia with avoidance of intravenous opioids, intraoperative goal-directed fluid resuscitation, immediate postoperative feeding, and ambulation. Discharge requirements remained identical throughout. A before and after study design was undertaken comparing patients before (August 2012 to February 2013) and after implementation of an ER protocol (August 2013 to February 2014). Risk stratification was performed using the NSQIP risk calculator to calculate the predicted LOS for each patient based on 23 variables. RESULTS One hundred and nine consecutive patients underwent surgery within the ER protocol compared with 98 consecutive historical controls (conventional). The risk-adjusted predicted LOS was similar for each group at 5.1 and 5.2 days. Substantial reductions were seen in LOS, morphine equivalents, intravenous fluids, return of bowel function, and overall complications with the ER group. There was a
Vascular Health and Risk Management | 2014
Sherita N. Chapman; Prachi Mehndiratta; Michelle Johansen; Timothy L. McMurry; Karen C. Johnston; Andrew M. Southerland
7,129/patient reduction in direct cost, corresponding to a cost savings of
The Journal of Thoracic and Cardiovascular Surgery | 2014
Yinin Hu; Timothy L. McMurry; James M. Isbell; George J. Stukenborg; Benjamin D. Kozower
777,061 in the ER group. Patient satisfaction as measured by Press Ganey improved considerably during the study period. CONCLUSIONS Implementation of an ER protocol led to improved patient satisfaction and substantial reduction in LOS, complication rates, and costs for patients undergoing both open and laparoscopic colorectal surgery. These data demonstrate that small investments in the perioperative environment can lead to large returns.
The Journal of Thoracic and Cardiovascular Surgery | 2015
Timothy L. McMurry; Yinin Hu; Eugene H. Blackstone; Benjamin D. Kozower
In 1995, the NINDS (National Institute of Neurological Disorders and Stroke) tPA (tissue plasminogen activator) Stroke Study Group published the results of a large multicenter clinical trial demonstrating efficacy of intravenous tPA by revealing a 30% relative risk reduction (absolute risk reduction 11%–15%) compared with placebo at 90 days in the likelihood of having minimal or no disability. Since approval in 1996, tPA remains the only drug treatment for acute ischemic stroke approved by the US Food and Drug Administration. Over the years, an abundance of research and clinical data has supported the safe and efficacious use of intravenous tPA in all eligible patients. Despite such supporting data, it remains substantially underutilized. Challenges to the utilization of tPA include narrow eligibility and treatment windows, risk of symptomatic intracerebral hemorrhage, perceived lack of efficacy in certain high-risk subgroups, and a limited pool of neurological and stroke expertise in the community. With recent US census data suggesting annual stroke incidence will more than double by 2050, better education and consensus among both the medical and lay public are necessary to optimize the use of tPA for all eligible stroke patients. Ongoing and future research should continue to improve upon the efficacy of tPA through more rapid stroke diagnosis and treatment, refinement of advanced neuroimaging and stroke biomarkers, and successful demonstration of alternative means of reperfusion.
The Annals of Thoracic Surgery | 2014
Yinin Hu; Timothy L. McMurry; Kristen M. Wells; James M. Isbell; George J. Stukenborg; Benjamin D. Kozower
OBJECTIVES Postoperative readmission affects patient care and healthcare costs. There is a paucity of nationwide data describing the clinical significance of readmission after thoracic operations. The purpose of this study was to evaluate the relationship between postoperative readmission and mortality after lung cancer resection. METHODS Data were extracted for patients undergoing lung cancer resection from the linked Surveillance Epidemiology and End Results-Medicare registry (2006-2011), including demographics, comorbidities, socioeconomic factors, readmission within 30 days from discharge, and 90-day mortality. Readmitting facility and diagnoses were identified. A hierarchical regression model clustered at the hospital level identified predictors of readmission. RESULTS We identified 11,432 patients undergoing lung cancer resection discharged alive from 677 hospitals. The median age was 74.5 years, and 52% of patients received an open lobectomy. Thirty-day readmission rate was 12.8%, and 28.3% of readmissions were to facilities that did not perform the original operation. Readmission was associated with a 6-fold increase in 90-day mortality (14.4% vs 2.5%, P<.001). The most common readmitting diagnoses were respiratory insufficiency, pneumonia, pneumothorax, and cardiac complications. Patient factors associated with readmission included resection type; age; prior induction chemoradiation; preoperative comorbidities, including congestive heart failure and chronic obstructive pulmonary disease; and low regional population density. CONCLUSIONS Factors associated with early readmission after lung cancer resection include patient comorbidities, type of operation, and socioeconomic factors. Metrics that only report readmissions to the operative provider miss one-fourth of all cases. Readmitted patients have an increased risk of death and demand maximum attention and optimal care.
Anesthesiology | 2016
Randal S. Blank; Douglas A. Colquhoun; Marcel E. Durieux; Benjamin D. Kozower; Timothy L. McMurry; S. Patrick Bender; Bhiken I. Naik
OBJECTIVE To review the published literature using propensity scoring, describe shortcomings in the use of this technique, and provide conceptual background for understanding and correctly implementing studies that use propensity matching. METHODS We survey the published statistical literature and make recommendations for a set of standard criteria for studies that use propensity matching. We evaluated adherence to these criteria in recent publications in the Journal of Thoracic and Cardiovascular Surgery and determined how well the standards were applied. RESULTS We found that studies that use propensity matching are rarely documented well enough to be convincing in their results. When documentation is available, statistical shortcomings are common. CONCLUSIONS Improved statistical practice is needed when using propensity scoring. This article suggests standard criteria for using this method in Journal publications.
Journal of Nonparametric Statistics | 2004
Timothy L. McMurry; Dimitris N. Politis
BACKGROUND Postoperative mortality is the most commonly reported surgical quality measure. However, such metrics may be incapable of identifying performance outliers. The purpose of this study was to compare different measures of postoperative mortality after lung cancer resection using a large multiinstitutional database. METHODS Data were extracted for lung cancer resection patients from the linked Surveillance Epidemiology and End Results-Medicare Registry (2006 to 2010), which provides detailed and longitudinal information about Medicare beneficiaries with cancer. Four definitions of postoperative mortality were evaluated: in-hospital, 30-day, perioperative, and 90-day. Hierarchical regression models were used to estimate mortality risk at 30 and 90 days, and provider quality was assessed by comparing observed versus expected mortality. RESULTS We identified 11,787 lung cancer resection patients from 686 hospitals. The median age was 74 years, and 52% of patients were treated with open lobectomy. Although 30-day, perioperative, and in-hospital mortality rates were between 3% and 4%, 90-day mortality was almost double (6.89%). Clinical variables associated with 90-day mortality included sex, preexisting comorbidities, and procedure type. There were no statistically significant differences in 30-day or 90-day mortality rates among providers. CONCLUSIONS Currently reported measures of in-hospital and 30-day postoperative mortality do not adequately represent a patients true mortality risk as mortality almost doubles by 90 days. Because of low occurrence rate and variable provider volumes, neither 30-day nor 90-day mortality is a suitable quality indicator for lung resection.
The Journal of Infectious Diseases | 2017
Darwin J. Operario; James A. Platts-Mills; Sandrama Nadan; Nicola Page; Mapaseka Seheri; Jeffrey Mphahlele; Ira Praharaj; Gagandeep Kang; Irene Trigueiros Araújo; José Paulo Gagliardi Leite; Daniel Cowley; Sarah Thomas; Carl D. Kirkwood; George Armah; Jason M. Mwenda; Pushpa Ranjan Wijesinghe; Gloria Rey; Varja Grabovac; Chipo Berejena; Chibumbya J. Simwaka; Jeannine Uwimana; Jeevan B. Sherchand; Hlaing Myat Thu; Geethani Galagoda; Isidore Juste O. Bonkoungou; Sheriffo Jagne; Enyonam Tsolenyanu; Amadou Diop; Christabel Enweronu-Laryea; Sam-Aliyah Borbor
Background:The use of lung-protective ventilation (LPV) strategies may minimize iatrogenic lung injury in surgical patients. However, the identification of an ideal LPV strategy, particularly during one-lung ventilation (OLV), remains elusive. This study examines the role of ventilator management during OLV and its impact on clinical outcomes. Methods:Data were retrospectively collected from the hospital electronic medical record and the Society of Thoracic Surgery database for subjects undergoing thoracic surgery with OLV between 2012 and 2014. Mean tidal volume (VT) during two-lung ventilation and OLV and ventilator driving pressure (&Dgr;P) (plateau pressure − positive end-expiratory pressure [PEEP]) were analyzed for the 1,019 cases that met the inclusion criteria. Associations between ventilator parameters and clinical outcomes were examined by multivariate linear regression. Results:After the initiation of OLV, 73.3, 43.3, 18.8, and 7.2% of patients received VT greater than 5, 6, 7, and 8 ml/kg predicted body weight, respectively. One hundred and eighty-four primary and 288 secondary outcome events were recorded. In multivariate logistic regression modeling, VT was inversely related to the incidence of respiratory complications (odds ratio, 0.837; 95% CI, 0.729 to 0.958), while &Dgr;P predicted the development of major morbidity when modeled with VT (odds ratio, 1.034; 95% CI, 1.001 to 1.068). Conclusions:Low VT per se (i.e., in the absence of sufficient PEEP) has not been unambiguously demonstrated to be beneficial. The authors found that a large proportion of patients continue to receive high VT during OLV and that VT was inversely related to the incidence of respiratory complications and major postoperative morbidity. While low (physiologically appropriate) VT is an important component of an LPV strategy for surgical patients during OLV, current evidence suggests that, without adequate PEEP, low VT does not prevent postoperative respiratory complications. Thus, use of physiologic VT may represent a necessary, but not independently sufficient, component of LPV.
Laryngoscope | 2013
J. Jared Christophel; Andrew K. Johnson; Timothy L. McMurry; Stephen S. Park; Paul A. Levine
The problem of nonparametric regression is addressed, and a kernel smoothing estimator is proposed which has favorable asymptotic performance (bias, variance and mean squared error). The proposed class of kernels is characterized by a Fourier transform which is flat near the origin and infinitely differentiable. This property allows the bias of the estimate to decrease at the maximal rate without harming the rate at which the variance decreases, thus leading to a faster rate of convergence.