Louis J Magnotti

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Journals/Publications

• Otaibi, B. W., Khurshid, M. H., Hejazi, O., Hage, K., Stewart, C., Colosimo, C., Spencer, A. L., Ditillo, M., Magnotti, L. J., & Joseph, B. (2025). The abdomen does not lie, but the labs might: Predictors of intra-abdominal injury on computed tomography imaging in pediatric blunt trauma patients. The journal of trauma and acute care surgery.
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  Multiple studies have indicated that isolated abnormal laboratory results necessitate obtaining abdominal computed tomography (CT) for pediatric patients with blunt abdominal trauma (BAT), regardless of the normal abdominal examination. This study aims to identify the predictors of intra-abdominal injury (IAI) and the role of laboratory tests in CT imaging among pediatric BAT patients.
• Akl, M., Hejazi, O., Nelson, A., Khurshid, M. H., Stewart, C., Hosseinpour, H., Okosun, S., Magnotti, L. J., Bhogadi, S. K., & Joseph, B. (2024). From Procedure to Prognosis: The Association Between Obesity and Outcomes of Iliac Artery Injuries. The Journal of surgical research, 302, 621-627.
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  The management of injuries to the iliac artery presents a challenging clinical scenario due to the impeded anatomical access. Obesity is a common comorbid condition known to affect the outcomes of trauma patients; however, there is a paucity of data on the association of obesity with the treatment and outcomes of iliac artery injuries. The aim of this study was to assess the association between body mass index (BMI) on the management and outcomes of patients with iliac artery injuries.
• Alexander, H. D., Bhogadi, S. K., Hejazi, O., Nelson, A., Khurshid, M. H., Stewart, C., Hosseinpour, H., Colosimo, C., Magnotti, L. J., & Joseph, B. (2024). The Synergy Factor: Trauma and Cancer. The Journal of surgical research, 302, 393-397.
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  Trauma and cancer are the leading causes of death in the US. There is a paucity of data describing the impact of cancer on trauma patients. We aimed to determine the influence of cancer on outcomes of trauma patients.
• Colosimo, C., Bhogadi, S. K., Hejazi, O., Nelson, A., Hosseinpour, H., Stewart, C., Spencer, A. L., Ditillo, M., Magnotti, L. J., & Joseph, B. (2024). When Every Minute Counts: REBOA Before Surgery Is Independently Associated With a 15-Minute Delay in Time to Definitive Hemorrhage Control. Military medicine, 189(Suppl 3), 262-267.
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  Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a temporizing hemorrhage control intervention, but its inevitable effect on time to operating room (OR) has not been assessed. The aim of our study is to assess the impact of undergoing REBOA before surgery (RBS) on time to definitive hemorrhage control surgery.
• Colosimo, C., Otaibi, B., Bhogadi, S. K., Nelson, A., Spencer, A. L., Anand, T., Stewart, C., Magnotti, L. J., & Joseph, B. (2024). Obesity is a predictor of abdominal computed tomography imaging in pediatric trauma patients. The journal of trauma and acute care surgery.
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  Computed tomography (CT) has helped to reduce the morbidity due to missed injuries. However, CT imaging is associated with radiation exposure and thus has limited indications in pediatric patients. In this study, we aimed to identify the association between obesity and abdominal CT imaging in pediatric trauma patients.
• Culbert, M. H., Bhogadi, S. K., Hosseinpour, H., Colosimo, C., Alizai, Q., Anand, T., Spencer, A. L., Ditillo, M., Magnotti, L. J., & Joseph, B. (2024). Predictors of Receiving Mental Health Services in Trauma Patients With Positive Drug Screen. The Journal of surgical research, 298, 7-13.
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  Initial interaction with health care system presents an important opportunity to provide substance use disorder (SUD) rehabilitation in the form of mental health services (MHSs). This study aims to identify predictors of receipt of MHSs among adult trauma patients with SUD and positive drug screen.
• Hage, K., Nelson, A., Khurshid, M. H., Stewart, C., Hosseinpour, H., Okosun, S., Hejazi, O., Magnotti, L. J., Bhogadi, S. K., & Joseph, B. (2024). Diagnostic Laparoscopy in Trauma Patients: Do We Need to Open and See if We Can See Without Opening?. The Journal of surgical research, 303, 14-21.
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  Diagnostic laparoscopy (DL) has been advocated to reduce the incidence of nontherapeutic laparotomies (NL) among stable trauma patients. This study aimed to compare the outcomes of hemodynamically stable trauma patients undergoing DL versus NL.
• Hejazi, O., Ghaedi, A., Stewart, C., Khurshid, M. H., Spencer, A. L., Hosseinpour, H., Nelson, A., Bhogadi, S. K., Magnotti, L. J., & Joseph, B. (2024). The Harsh Reality: Outcomes of Patients With Operatively Managed Lung Injuries. The Journal of surgical research, 302, 656-661.
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  Most traumatic lung injuries are managed non-operatively. There is a paucity of recent data on the outcomes of operatively managed lung injuries. The aim of our study is to determine the survival rates of operatively managed traumatic lung injury patients on a nationwide scale.
• Hejazi, O., Spencer, A. L., Khurshid, M. H., Nelson, A., Hosseinpour, H., Anand, T., Bhogadi, S. K., Matthews, M. R., Magnotti, L. J., & Joseph, B. (2024). Failure to Rescue in Geriatric Ground-Level Falls: The Role of Frailty on Not-So-Minor Injuries. The Journal of surgical research, 302, 891-896.
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  The measure of mortality following a major complication (failure to rescue [FTR]) provides a quantifiable assessment of the level of care provided by trauma centers. However, there is a lack of data on the effects of patient-related factors on FTR incidence. The aim of this study was to identify the role of frailty on FTR incidence among geriatric trauma patients with ground-level falls (GLFs).
• Hosseinpour, H., Anand, T., Bhogadi, S. K., Nelson, A., Hejazi, O., Castanon, L., Ghaedi, A., Khurshid, M. H., Magnotti, L. J., Joseph, B., & , A. F. (2024). The implications of poor nutritional status on outcomes of geriatric trauma patients. Surgery, 176(4), 1281-1288.
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  Malnutrition is shown to be associated with worse outcomes among surgical patients, yet its postdischarge outcomes in trauma patients are not clear. This study aimed to evaluate both index admission and postdischarge outcomes of geriatric trauma patients who are at risk of poor nutritional status.
• Hosseinpour, H., Anand, T., Hejazi, O., Colosimo, C., Bhogadi, S. K., Spencer, A., Nelson, A., Ditillo, M., Magnotti, L. J., & Joseph, B. (2024). The Role of Whole Blood Hemostatic Resuscitation in Bleeding Geriatric Trauma Patients. The Journal of surgical research, 299, 26-33.
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  Whole blood (WB) has recently gained increased popularity as an adjunct to the resuscitation of hemorrhaging civilian trauma patients. We aimed to assess the nationwide outcomes of using WB as an adjunct to component therapy (CT) versus CT alone in resuscitating geriatric trauma patients.
• Hosseinpour, H., Magnotti, L. J., Huang, D. D., Weinberg, J. A., Tang, A., Hejazi, O., Stewart, C., Bhogadi, S. K., Anand, T., & Joseph, B. (2024). The role of number of affected vessels on radiologic and clinical outcomes of patients with blunt cerebrovascular injury. Journal of vascular surgery, 80(3), 685-692.
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  There is a lack of data on the role of characteristics of injured vessels on the outcomes of patients with blunt cerebrovascular injuries (BCVIs). The aim of this study was to assess the effect of the number (single vs multiple) of injured vessels on outcomes.
• Hosseinpour, H., Nelson, A., Bhogadi, S. K., Magnotti, L. J., Alizai, Q., Colosimo, C., Hage, K., Ditillo, M., Anand, T., & Joseph, B. (2024). Should We Keep or Transfer Our Severely Injured Geriatric Patients to Higher Levels of Care?. The Journal of surgical research, 300, 15-24.
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  Interfacility transfer to higher levels of care is becoming increasingly common. This study aims to evaluate the association between transfer to higher levels of care and prolonged transfer times with outcomes of severely injured geriatric trauma patients compared to those who are managed definitively at lower-level trauma centers.
• Hosseinpour, H., Stewart, C., Hejazi, O., Okosun, S. E., Khurshid, M. H., Nelson, A., Bhogadi, S. K., Ditillo, M., Magnotti, L. J., & Joseph, B. (2024). FINDING THE SWEET SPOT: THE ASSOCIATION BETWEEN WHOLE BLOOD TO RED BLOOD CELLS RATIO AND OUTCOMES OF HEMORRHAGING CIVILIAN TRAUMA PATIENTS. Shock (Augusta, Ga.), 62(3), 344-350.
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  Purpose: To evaluate the dose-dependent effect of whole blood (WB) on the outcomes of civilian trauma patients with hemorrhagic shock. Methods: We performed a 2-year (2020-2021) retrospective analysis of the ACS-TQIP dataset. Adult (≥18) trauma patients with a shock index (SI) >1 who received at least 5 units of PRBC and one unit of WB within the first 4 h of admission were included. Primary outcomes were 6-h, 24-h, and in-hospital mortality. Secondary outcomes were major complications and hospital and intensive care unit length of stay. Results: A total of 830 trauma patients with a mean (SD) age of 38 (16) were identified. The median [IQR] 4-h WB and PRBC requirements were 2 [2-4] U and 10 [7-15] U, respectively, with a median WB:RBC ratio of 0.2 [0.1-0.3]. Every 0.1 increase in WB:RBC ratio was associated with decreased odds of 24-h mortality (aOR: 0.916, P = 0.035) and in-hospital mortality (aOR: 0.878, P < 0.001). Youden's index identified 0.25 (1 U of WB for every 4 U of PRBC) as the optimal WB:PRBC ratio to reduce 24-h mortality. High ratio (≥0.25) group had lower adjusted odds of 24-h mortality (aOR: 0.678, P = 0.021) and in-hospital mortality (aOR: 0.618, P < 0.001) compared to the low ratio group. Conclusions: A higher WB:PRBC ratio was associated with improved early and late mortality in trauma patients with hemorrhagic shock. Given the availability of WB in trauma centers across the United States, at least one unit of WB for every 4 units of packed red blood cells may be administered to improve the survival of hemorrhaging civilian trauma patients.
• Huang, R., Hejazi, O., Khurshid, M. H., Nelson, A., Stewart, C., Anand, T., Matthews, M. R., Okosun, S. E., Magnotti, L. J., & Joseph, B. (2024). Diversity in crisis: The impact of race and ethnicity on failure to rescue among geriatric trauma patients over the years. The journal of trauma and acute care surgery.
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  Failure to rescue (FTR) is an indicator of the quality of care provided by trauma centers. The aim of this study was to examine the trends of FTR incidence in geriatric trauma patients over the years and to determine whether race, ethnicity, and sex impact the FTR incidence.
• Joseph, B., Hosseinpour, H., Sakran, J., Anand, T., Colosimo, C., Nelson, A., Stewart, C., Spencer, A. L., Zhang, B., & Magnotti, L. J. (2024). Defining the Problem: 53 Years of Firearm Violence Afflicting America's Schools. Journal of the American College of Surgeons, 238(4), 671-678.
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  Firearm violence and school shootings remain a significant public health problem. This study aimed to examine how publicly available data from all 50 states might improve our understanding of the situation, firearm type, and demographics surrounding school shootings.
• Khurshid, M. H., Hejazi, O., Spencer, A. L., Nelson, A., Stewart, C., Colosimo, C., Ditillo, M., Matthews, M. R., Magnotti, L. J., & Joseph, B. (2024). A little goes a long way: A comparison of enterolithotomy versus single-stage cholecystectomy in the management of gallstone ileus. The journal of trauma and acute care surgery.
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  Gallstone ileus is an infrequent complication of cholelithiasis with no specific guidelines for its management. This study aims to compare the outcomes of patients with gallstone ileus managed with both enterolithotomy with cholecystectomy (EL-CCY) versus those managed with enterolithotomy (EL) only.
• Khurshid, M. H., Yang, A. R., Hosseinpour, H., Colosimo, C., Hejazi, O., Spencer, A. L., Bhogadi, S. K., Ditillo, M., Magnotti, L. J., & Joseph, B. (2024). Final Lifelines: The Implications and Outcomes of Thoracic Damage Control Surgeries. The Journal of surgical research, 301, 385-391.
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  There is a lack of data on the outcomes of thoracic damage control surgery (TDCS). This study aimed to describe the characteristics and outcomes of patients undergoing TDCS.
• Lewis, R. H., Jacome, T., Dooley, D., Carr, B., & Magnotti, L. J. (2024). Impact of Concomitant Traumatic Pancreatic and Colon Injuries on Outcomes. The American surgeon, 90(9), 2217-2221.
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  Colon and pancreatic injuries have both long been independently associated with intraabdominal infectious complications in trauma patients. The goal of this study was to evaluate the impact of concomitant pancreatic injury on outcomes in patients with traumatic colon injuries.
• Magnotti, L. J., Bhogadi, S. K., Anand, T., Stewart, C., Colosimo, C., Spencer, A. L., Nelson, A., & Joseph, B. (2024). Less Is More: Dissecting Trauma Centers by Procedural Volume. Annals of surgery, 280(4), 667-675.
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  This study aims to examine the relationship between procedural volume and annual trauma volume (ATV) of ACS Level I trauma centers (TC).
• O'Connor, D., Hejazi, O., Colosimo, C., Stewart, C., Hosseinpour, H., Khurshid, M., Nelson, A. C., Joseph, B., Bhogadi, S. K., Anand, T., Spencer, A. L., & Magnotti, L. J. (2024). Role of endovascular management on outcomes in patients with traumatic inferior vena cava injuries. American journal of surgery, 238, 115836.
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  The aim of this study was to examine the association between the injury mechanism and repair type with outcomes in patients with traumatic inferior vena cava injuries.
• Otaibi, B. W., Bhogadi, S. K., Khurshid, M. H., Stewart, C., Hosseinpour, H., Spencer, A. L., Hejazi, O., Nelson, A., Magnotti, L. J., & Joseph, B. (2024). Endovascular Versus Open Repair in Adolescent Patients With Difficult-to-Access Vascular Injuries. The Journal of surgical research, 302, 385-392.
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  Management of subclavian artery injuries (SAI) and iliac artery injuries (IAI) in adolescent trauma patients poses a considerable challenge due to their complex anatomical locations. The aim of our study was to determine the association between the injury mechanism and type of repair with the outcomes of patients with traumatic SAI and IAI.
• Safdar, M., Colosimo, C., Khurshid, M. H., Spencer, A. L., Hejazi, O., Castanon, L., Hosseinpour, H., Magnotti, L. J., Bhogadi, S. K., & Joseph, B. (2024). Drugs, Delirium, and Trauma: Substance Use and Incidence of Delirium After Traumatic Brain Injury. The Journal of surgical research, 301, 45-53.
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  There is a paucity of data on the effect of preinjury substance (alcohol, drugs) abuse on the risk of delirium in patients with traumatic brain injury (TBI). This study aimed to assess the incidence of delirium among patients with blunt TBI in association with different substances.
• Spencer, A. L., Hosseinpour, H., Nelson, A., Hejazi, O., Anand, T., Khurshid, M. H., Ghaedi, A., Bhogadi, S. K., Magnotti, L. J., & Joseph, B. (2024). Predicting the time of mortality among older adult trauma patients: Is frailty the answer?. American journal of surgery, 237, 115768.
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  This study aims to evaluate the temporal trends of mortality among frail versus non-frail older adult trauma patients during index hospitalization.
• Terrani, K. F., Bhogadi, S. K., Hosseinpour, H., Spencer, A. L., Alizai, Q., Colosimo, C., Nelson, A., Castanon, L., Magnotti, L. J., & Joseph, B. (2024). What Is Going on in Our Schools? Review of Injuries Among School Children Across the United States. The Journal of surgical research, 295, 310-317.
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  Children spend most of their time at school and participate in many activities that have the potential for causing injury. This study aims to describe the nationwide epidemiology of pediatric trauma sustained in school settings in the United States.
• Zambetti, B. R., Nelson, A. C., Hosseinpour, H., Anand, T., Colosimo, C., Spencer, A. L., Stewart, C., Bhogadi, S. K., Hejazi, O., Joseph, B., & Magnotti, L. J. (2024). The optimal management of blunt aortic injury in the young. American journal of surgery, 237, 115943.
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  Blunt aortic injury (BAI) is relatively uncommon in the pediatric population. The goal of this study was to examine the management of BAI in both children and adolescents, using a large national dataset.
• Akl, M. N., El-Qawaqzeh, K., Anand, T., Hosseinpour, H., Colosimo, C., Nelson, A., Alizai, Q., Ditillo, M., Magnotti, L. J., & Joseph, B. (2024). Trauma Laparotomy for the Cirrhotic Patient: An Outcome-Based Analysis. The Journal of surgical research, 294, 128-136.
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  There is a lack of large-scale data on outcomes of cirrhotic patients undergoing trauma laparotomy. We aimed to compare outcomes of cirrhotic versus noncirrhotic trauma patients undergoing laparotomy.
• Alizai, Q., Colosimo, C., Hosseinpour, H., Stewart, C., Bhogadi, S. K., Nelson, A., Spencer, A. L., Ditillo, M., Magnotti, L. J., Joseph, B., & , A. F. (2023). It's Not All Black and White: The Effect of Increasing Severity of Frailty on Outcomes of Geriatric Trauma Patients. The journal of trauma and acute care surgery.
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  Frailty is associated with poor outcomes in trauma patients. However, the spectrum of physiologic deficits, once a patient is identified as frail, is unknown. The aim of this study was to assess the dynamic association between increasing frailty and outcomes among frail geriatric trauma patients.
• Anand, T., Reyes, A. A., Sjoquist, M. C., Magnotti, L., & Joseph, B. (2023). Resuscitating the Endothelial Glycocalyx in Trauma and Hemorrhagic Shock. Annals of surgery open : perspectives of surgical history, education, and clinical approaches, 4(3), e298.
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  The endothelium is lined by a protective mesh of proteins and carbohydrates called the endothelial glycocalyx (EG). This layer creates a negatively charged gel-like barrier between the vascular environment and the surface of the endothelial cell. When intact the EG serves multiple functions, including mechanotransduction, cell signaling, regulation of permeability and fluid exchange across the microvasculature, and management of cell-cell interactions. In trauma and/or hemorrhagic shock, the glycocalyx is broken down, resulting in the shedding of its individual components. The shedding of the EG is associated with increased systemic inflammation, microvascular permeability, and flow-induced vasodilation, leading to further physiologic derangements. Animal and human studies have shown that the greater the severity of the injury, the greater the degree of shedding, which is associated with poor patient outcomes. Additional studies have shown that prioritizing certain resuscitation fluids, such as plasma, cryoprecipitate, and whole blood over crystalloid shows improved outcomes in hemorrhaging patients, potentially through a decrease in EG shedding impacting downstream signaling. The purpose of the following paragraphs is to briefly describe the EG, review the impact of EG shedding and hemorrhagic shock, and begin entertaining the notion of directed resuscitation. Directed resuscitation emphasizes transitioning from macroscopic 1:1 resuscitation to efforts that focus on minimizing EG shedding and maximizing its reconstitution.
• Avila, M., Bhogadi, S. K., Nelson, A., Hosseinpour, H., Ditillo, M., Akl, M., Anand, T., Spencer, A. L., Magnotti, L. J., & Joseph, B. (2023). The long-term risks of venous thromboembolism among non-operatively managed spinal fracture patients: A nationwide analysis. American journal of surgery, 225(6), 1086-1090.
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  Long-term readmission data for venous thromboembolism (VTE) after spinal fractures is limited. We aimed to evaluate the 1-month and 6-month VTE readmission rates in non-operatively managed traumatic spinal fractures.
• Bhogadi, S. K., Alizai, Q., Colosimo, C., Spencer, A. L., Stewart, C., Nelson, A., Ditillo, M., Castanon, L., Magnotti, L. J., Joseph, B., , B. M., , A. A., Dultz, L., Black, G., Campbell, M., Berndtson, A. E., Costantini, T., Kerwin, A., Skarupa, D., , Burruss, S., et al. (2023). Not all traumatic brain injury patients on preinjury anticoagulation are the same. American journal of surgery.
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  Prognostic significance of different anticoagulants in TBI patients remains unanswered. We aimed to compare effects of different anticoagulants on outcomes of TBI patients.
• Bhogadi, S. K., Nelson, A., El-Qawaqzeh, K., Spencer, A. L., Hosseinpour, H., Castanon, L., Anand, T., Ditillo, M., Magnotti, L. J., & Joseph, B. (2023). Does preinjury anticoagulation worsen outcomes among traumatic hemothorax patients? A nationwide retrospective analysis. Injury, 54(9), 110850.
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  Up to a quarter of all traumatic deaths are due to thoracic injuries. Current guidelines recommend consideration of evacuation of all hemothoraces with tube thoracostomy. The aim of our study was to determine the impact of pre-injury anticoagulation on outcomes of traumatic hemothorax patients.
• Bhogadi, S. K., Stewart, C., El-Qawaqzeh, K., Colosimo, C., Hosseinpour, H., Nelson, A., Castanon, L., Spencer, A. L., Magnotti, L. J., & Joseph, B. (2023). Local Antibiotic Therapy for Open Long Bone Fractures: Appropriate Prophylaxis or Unnecessary Exposure for the Orthopedic Trauma Patient?. Military medicine, 188(Suppl 6), 407-411.
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  Prophylactic local antibiotic therapy (LAbT) to prevent infection in open long bone fracture (OLBF) patients has been in use for many decades despite lack of definitive evidence confirming a beneficial effect. We aimed to evaluate the effect of LAbT on outcomes of OLBF patients on a nationwide scale.
• El-Qawaqzeh, K., Anand, T., Alizai, Q., Colosimo, C., Hosseinpour, H., Spencer, A., Ditillo, M., Magnotti, L. J., Stewart, C., & Joseph, B. (2024). Trauma in the Geriatric and the Super-Geriatric: Should They Be Treated the Same?. The Journal of surgical research, 293, 316-326.
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  There is paucity of studies comparing the characteristics of trauma in geriatrics and super-geriatrics. We aimed to explore the injury characteristics and outcomes of older adult trauma patients on a nationwide scale.
• El-Qawaqzeh, K., Colosimo, C., Bhogadi, S. K., Magnotti, L. J., Hosseinpour, H., Castanon, L., Nelson, A., Ditillo, M., Anand, T., & Joseph, B. (2023). Unequal Treatment? Confronting Racial, Ethnic, and Socioeconomic Disparity in Management of Survivors of Violent Suicide Attempt. Journal of the American College of Surgeons, 237(1), 68-78.
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  Psychiatric inpatient hospitalization is nearly always indicated for patients with recent suicidal behavior. We aimed to assess the factors associated with receiving mental health services during hospitalization or on discharge among survivors of suicide attempts in trauma centers.
• El-Qawaqzeh, K., Hosseinpour, H., Gries, L., Magnotti, L. J., Bhogadi, S. K., Anand, T., Ditillo, M., Stewart, C., Cooper, Z., & Joseph, B. (2023). Dealing with the elder abuse epidemic: Disparities in interventions against elder abuse in trauma centers. Journal of the American Geriatrics Society, 71(6), 1735-1748.
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  Elder abuse is a major cause of injury, morbidity, and death. We aimed to identify the factors associated with interventions against suspected physical abuse in older adults.
• El-Qawaqzeh, K., Magnotti, L. J., Hosseinpour, H., Nelson, A., Spencer, A. L., Anand, T., Bhogadi, S. K., Alizai, Q., Ditillo, M., & Joseph, B. (2023). Geriatric trauma, frailty, and ACS trauma center verification level: Are there any correlations with outcomes?. Injury, 110972.
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  It remains unclear whether geriatrics benefit from care at higher-level trauma centers (TCs). We aimed to assess the impact of the TC verification level on frail geriatric trauma patients' outcomes. We hypothesized that frail patients cared for at higher-level TCs would have improved outcomes.
• Hosseinpour, H., Anand, T., Bhogadi, S. K., Colosimo, C., El-Qawaqzeh, K., Spencer, A. L., Castanon, L., Ditillo, M., Magnotti, L. J., & Joseph, B. (2023). Emergency Department Shock Index Outperforms Prehospital and Delta Shock Indices in Predicting Outcomes of Trauma Patients. The Journal of surgical research, 291, 204-212.
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  Multiple shock indices (SIs), including prehospital, emergency department (ED), and delta (ED SI - Prehospital SI) have been developed to predict outcomes among trauma patients. This study aims to compare the predictive abilities of these SIs for outcomes of polytrauma patients on a national level.
• Hosseinpour, H., Magnotti, L. J., Bhogadi, S. K., Anand, T., El-Qawaqzeh, K., Ditillo, M., Colosimo, C., Spencer, A., Nelson, A., & Joseph, B. (2023). Time to Whole Blood Transfusion in Hemorrhaging Civilian Trauma Patients: There Is Always Room for Improvement. Journal of the American College of Surgeons, 237(1), 24-34.
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  Whole blood (WB) is becoming the preferred product for the resuscitation of hemorrhaging trauma patients. However, there is a lack of data on the optimum timing of receiving WB. We aimed to assess the effect of time to WB transfusion on the outcomes of trauma patients.
• Hosseinpour, H., Magnotti, L. J., Bhogadi, S. K., Colosimo, C., El-Qawaqzeh, K., Spencer, A. L., Anand, T., Ditillo, M., Nelson, A., & Joseph, B. (2023). Interfacility transfer of pediatric trauma patients to higher levels of care: The effect of transfer time and level of receiving trauma center. The journal of trauma and acute care surgery, 95(3), 383-390.
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  Interfacility transfer of pediatric trauma patients to pediatric trauma centers (PTCs) after evaluation in nontertiary centers is associated with improved outcomes. We aimed to assess the outcomes of transferred pediatric patients based on their severity of the injury, transfer time, and level of receiving PTCs.
• Hosseinpour, H., Nelson, A., Bhogadi, S. K., Spencer, A. L., Alizai, Q., Colosimo, C., Anand, T., Ditillo, M., Magnotti, L. J., & Joseph, B. (2023). Delayed versus early hepatic resection among patients with severe traumatic liver injuries undergoing damage control laparotomy. American journal of surgery, 226(6), 823-828.
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  We aimed to assess the effect of time to hepatic resection on the outcomes of patients with high-grade liver injuries who underwent damage control laparotomy (DCL).
• Magnotti, L. J. (2023). The man, the myth, the method: an inside look at the open abdomen and abdominal wall reconstruction. Trauma surgery & acute care open, 8(Suppl 1), e001111.
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  Management of the open abdomen (or the abdomen that will not close) and subsequent abdominal wall reconstruction remains one of the most vexing situations for even the most experienced trauma surgeon. The contribution to the literature on this topic by Dr Timothy Fabian and the Memphis group at the Elvis Presley Trauma Center resulted in the contemporary recognition that the initial management as well as the long-term approach dictates optimal outcomes for patients with this problem. Over three decades, the Memphis group, under Dr Fabian's leadership, performed numerous clinical studies that led to the publication of multiple articles (including a step-by-step how-to manual) for managing the open abdomen from onset to closure. The purpose of this review is to survey the consecutive studies from Memphis specifically that led to the development of a simplified management scheme that has stood the test of time.
• Nelson, A. C., Bhogadi, S. K., Hosseinpour, H., Stewart, C., Anand, T., Spencer, A. L., Colosimo, C., Magnotti, L. J., & Joseph, B. (2023). There Is No Such Thing as Too Soon: Long-Term Outcomes of Early Cholecystectomy for Frail Geriatric Patients with Acute Biliary Pancreatitis. Journal of the American College of Surgeons, 237(5), 712-718.
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  Early cholecystectomy (CCY) for acute biliary pancreatitis (ABP) is recommended but there is a paucity of data assessing this approach in frail geriatric patients. This study compares outcomes of frail geriatric ABP patients undergoing index admission CCY vs nonoperative management (NOM) with endoscopic retrograde cholangiopancreatography (ERCP).
• Patel, D. D., Zambetti, B. R., & Magnotti, L. J. (2024). Timing to Rib Fixation in Patients With Flail Chest. The Journal of surgical research, 294, 93-98.
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  Flail chest (FC) after blunt trauma is associated with significant morbidity and prolonged hospitalizations. The goal of this study was to examine the relationship between timing of rib fixation (ORIF) and pulmonary morbidity and mortality in patients with FC.
• Schmidt, J. C., Huang, D. D., Fleming, A. M., Brockman, V., Hennessy, E. A., Magnotti, L. J., Schroeppel, T., McFann, K., Hamilton, L. D., & Dunn, J. A. (2023). Missed blunt cerebrovascular injuries using current screening criteria - The time for liberalized screening is now. Injury, 54(5), 1342-1348.
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  Diagnostic Criteria Study BACKGROUND: The morbidity and mortality associated with ischemic stroke attributable to blunt cerebrovascular injury (BCVI) warrant aggressive screening. The Denver Criteria (DC) and Expanded Denver Criteria (eDC) have imprecise elements that can be difficult and subjective in application and can delay or prevent screening. We hypothesize these screening criteria lack adequate ability to consistently identify BCVI and that the use of a liberalized screening approach with CT angiography (CTA) is superior without increasing risk of acute kidney injury (AKI).
• Zambetti, B. R., Patel, D. D., Stuber, J. D., Zickler, W. P., Hosseinpour, H., Anand, T., Nelson, A. C., Stewart, C., Joseph, B., & Magnotti, L. J. (2023). Role of Endovascular Stenting in Patients with Traumatic Iliac Artery Injury. Journal of the American College of Surgeons, 236(4), 753-759.
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  Common and external iliac artery injuries (IAI) portend significant morbidity and mortality. The goal of this study was to examine the impact of mechanism of injury and type of repair on outcomes and identify the optimal repair for patients with traumatic IAI using a large, national dataset.
• Zambetti, B. R., Zickler, W. P., Byerly, S., Garrett, H. E., & Magnotti, L. J. (2023). Risk Factors for Acute Renal Failure After Endovascular Aneurysm Repair. The American surgeon, 31348231191181.
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  Acute kidney injury (AKI) after endovascular aortic aneurysm repair (EVAR) is uncommon though carries significant morbidity. Procedural risk factors are not well established for acute renal failure (ARF) that requires initiation of dialysis. The goal of this study was to examine the impact of ARF on patients undergoing EVAR and identify risk factors for ARF using a large, national dataset.
• Zickler, W. P., Zambetti, B. R., Zickler, C. L., Zickler, M. K., Byerly, S., Garrett, H. E., & Magnotti, L. J. (2023). Impact of Patient and Procedural Factors on Outcomes Following Mesenteric Bypass. The American surgeon, 31348231198118.
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  Mesenteric bypass (MB) for patients with acute (AMI) and chronic mesenteric ischemia (CMI) is associated with cardiovascular (CV) and pulmonary morbidity.
• Berning, B. J., Magnotti, L. J., Lewis, R. H., Corley, C. E., Lim, G. H., Doty, J. B., Fabian, T. C., Croce, M. A., & Sharpe, J. P. (2022). Impact of Chemoprophylaxis on Thromboembolism Following Operative Fixation of Pelvic Fractures. The American surgeon, 88(1), 126-132.
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  Venous thromboembolism (VTE) is a common cause of serious morbidity and mortality. While chemoprophylaxis decreases VTE, there is the theoretical risk of increased hemorrhagic complications. The purpose of this study was to evaluate the impact of preoperative anticoagulation on VTE and bleeding complications in patients with blunt pelvic fractures requiring operative fixation.
• Byerly, S. E., Jones, M. D., Lenart, E. K., Seger, C. P., Filiberto, D. M., Lewis, R. H., Kerwin, A. J., & Magnotti, L. J. (2022). Serial CT for Nonoperatively Managed Splenic Injuries. The American surgeon, 88(7), 1504-1509.
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  The role of serial computed tomography (CT) in the nonoperative management of blunt splenic injuries (NOMSIs) remains unclear. The purpose of the study was to determine the utility of serial CT of Grade 2-5 NOMSI in the modern era.
• Filiberto, D. M., Jimenez, B. F., Lenart, E. K., Huang, D. D., Hare, M. E., Tolley, E. A., & Magnotti, L. J. (2022). Long-term functional outcomes after traumatic spine fractures. Surgery, 172(1), 460-465.
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  Traumatic spine fractures can result in chronic pain, disability, and prolonged rehabilitation. The purpose of this study is to determine the long-term effects of traumatic spine fractures on patients' functional outcomes after nonoperative and operative management.
• Filiberto, D. M., Toth, C., Afzal, M. O., Byerly, S., Lenart, E. K., Kerwin, A. J., Croce, M. A., & Magnotti, L. J. (2022). Radiographic and Clinical Predictors of Therapeutic Pelvic Angiography. The American surgeon, 88(7), 1432-1436.
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  Pelvic fractures are often complicated by hemorrhage contributing to morbidity and mortality. Management of these patients is multifaceted and computed tomography (CT) imaging plays an integral diagnostic role. The purpose of this study was to identify radiographic and clinical predictors of therapeutic angiography in patients with blunt pelvic fractures.
• Fleming, A. M., Shah, K. S., Byerly, S. E., Magnotti, L. J., Fischer, P. E., Seger, C. P., Kerwin, A. J., Croce, M. A., & Howley, I. W. (2022). Cryoprecipitate use during massive transfusion: A propensity score analysis. Injury, 53(6), 1972-1978.
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  Cryoprecipitate is frequently administered as an adjunct to balanced transfusion in the setting of traumatic hemorrhage. However, civilian studies have not demonstrated a clear survival advantage, and prior observational studies noted selection bias when analyzing cryoprecipitate use. Additionally, due to the logistics involved in cryoprecipitate administration, it is inconsistently implemented alongside standardized massive transfusion protocols. This study aims to evaluate the effects of early cryoprecipitate administration on inpatient mortality in the setting of massive transfusion for exsanguinating trauma and to use propensity score analysis to minimize selection bias.
• Huang, D. D., Manley, N. R., Lewis, R. H., Fischer, P. E., Lenart, E. K., Croce, M. A., & Magnotti, L. J. (2022). The sustained effect of a temporary measure: Urban firearm mortality following expiration of the Federal Assault Weapons Ban. American journal of surgery, 224(1 Pt A), 111-115.
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  The Federal Assault Weapons Ban (FAWB) was in effect from 1994 to 2004. We sought to examine its impact on firearm-related homicides.
• Huang, D. D., Manley, N. R., Lewis, R. H., Fischer, P. E., Magnotti, A., Davis, S., Croce, M. A., & Magnotti, L. J. (2022). Re-Sighting the Gun Debate: Defining Patterns of Firearm-Related Death to Help Focus Prevention Efforts. Journal of the American College of Surgeons, 234(4), 672-676.
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  Gun violence remains a significant public health problem. Although gun violence prevention efforts mostly target homicides, nationally, two-thirds of all firearm deaths are suicides. The purpose of this study was to define patterns of firearm-related deaths and examine the effect of population size.
• Lewis, R. H., Perkins, M., Fischer, P. E., Beebe, M. J., & Magnotti, L. J. (2022). Timing is everything: Impact of combined long bone fracture and major arterial injury on outcomes. The journal of trauma and acute care surgery, 92(1), 21-27.
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  Timing of extremity fracture fixation in patients with an associated major vascular injury remains controversial. Some favor temporary fracture fixation before definitive vascular repair to limit potential graft complications. Others advocate immediate revascularization to minimize ischemic time. The purpose of this study was to evaluate the timing of fracture fixation on outcomes in patients with concomitant long bone fracture and major arterial injury.
• Zambetti, B. R., Lewis, R. H., Chintalapani, S. R., Desai, N., Valaulikar, G. S., & Magnotti, L. J. (2022). Optimal time to thoracoscopy for trauma patients with retained hemothorax. Surgery, 172(4), 1265-1269.
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  Retained hemothorax remains a common problem after thoracic trauma with associated morbidity and prolonged hospitalizations. The goal of this study was to examine the impact of time to video assisted thoracoscopic surgery (VATS) on pulmonary morbidity using a large, national data set.
• Zambetti, B. R., Stuber, J. D., Patel, D. D., Lewis, R. H., Huang, D. D., Zickler, W. P., Fischer, P. E., Magnotti, A. L., Croce, M. A., & Magnotti, L. J. (2022). Impact of Endovascular Stenting on Outcomes in Patients with Traumatic Subclavian Artery Injury. Journal of the American College of Surgeons, 234(4), 444-449.
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  Traumatic subclavian artery injury (SAI) remains uncommon but can lead to significant morbidity and mortality. Although open and endovascular repair offer excellent limb salvage rates, their role in blunt and penetrating injuries is not well defined. The goal of this study was to examine the effect of mechanism of injury and type of repair on outcomes in patients with traumatic SAI.
• Zambetti, B. R., Zickler, W. P., Lewis, R. H., Pettigrew, B. D., Valaulikar, G. S., Afzal, M. O., Fischer, P. E., Croce, M. A., & Magnotti, L. J. (2022). Delayed Endovascular Repair With Procedural Anticoagulation: A Safe Strategy for Blunt Aortic Injury. Annals of vascular surgery, 84, 195-200.
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  Blunt aortic injury (BAI) and traumatic brain injury (TBI) are the leading causes of death after blunt trauma. The purposes of this study were to identify predictors of mortality for BAI and to examine the impact of procedural heparinization during thoracic endovascular aortic repair (TEVAR) on neurologic outcomes in patients with BAI/TBI.
• Zickler, W. P., Sharpe, J. P., Lewis, R. H., Zambetti, B. R., Jones, M. D., Zickler, M. K., Zickler, C. L., & Magnotti, L. J. (2022). In for a Penny, in for a Pound: Obesity weighs heavily on both cost and outcome in trauma. American journal of surgery, 224(1 Pt B), 590-594.
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  The current literature offers mixed conclusions regarding the effect of increased body mass index (BMI) on outcomes after trauma laparotomy. This study evaluated the impact of obesity on outcomes and cost for patients undergoing trauma laparotomy at a level 1 trauma center.
• Dooley, J. H., Dennis, B. M., Magnotti, L. J., Sharpe, J. P., Guillamondegui, O. D., Croce, M. A., & Fischer, P. E. (2021). Is NBATS-2 up to the Task? Actual vs. Predicted Patient Volume Shifts With the Addition of Another Trauma Center. The American surgeon, 87(4), 595-601.
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  Version 2 of the Needs-Based Assessment of Trauma Systems (NBATS) tool quantifies the impact of an additional trauma center on a region. This study applies NBATS-2 to a system where an additional trauma center was added to compare the tool's predictions to actual patient volumes.
• Filiberto, D. M., Afzal, M. O., Sharpe, J. P., Seger, C., Shankar, S., Croce, M. A., Fabian, T. C., & Magnotti, L. J. (2021). Radiographic predictors of therapeutic operative intervention after blunt abdominal trauma: the RAPTOR score. European journal of trauma and emergency surgery : official publication of the European Trauma Society, 47(6), 1813-1817.
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  Bowel and mesenteric injuries are rare in patients following blunt abdominal trauma. Computed tomography (CT) imaging has become a mainstay in the work-up of the stable trauma patient. The purpose of this study was to identify radiographic predictors of therapeutic operative intervention for mesenteric and/or bowel injuries in patients after blunt abdominal trauma.
• Lenart, E. K., Bee, T. K., Seger, C. P., Lewis, R. H., Filiberto, D. M., Huang, D. D., Fischer, P. E., Croce, M. A., Fabian, T. C., & Magnotti, L. J. (2021). Youth, poverty, and interpersonal violence: a recipe for PTSD. Trauma surgery & acute care open, 6(1), e000710.
• Manley, N. R., Huang, D. D., Lewis, R. H., Bee, T., Fischer, P. E., Croce, M. A., & Magnotti, L. J. (2021). Caught in the crossfire: 37 Years of firearm violence afflicting America's youth. The journal of trauma and acute care surgery, 90(4), 623-630.
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  Publicly available firearm data are difficult to access. Trauma registry data are excellent at documenting patterns of firearm-related injury. Law enforcement data excel at capturing national violence trends to include both circumstances and firearm involvement. The goal of this study was to use publicly available law enforcement data from all 50 states to better define patterns of firearm-related homicides in the young.
• Zambetti, B. R., Huang, D. D., Lewis, R. H., Fischer, P. E., Croce, M. A., & Magnotti, L. J. (2021). Use of Thoracic Endovascular Aortic Repair in Patients with Concomitant Blunt Aortic and Traumatic Brain Injury. Journal of the American College of Surgeons, 232(4), 416-422.
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  Blunt aortic injury (BAI) and traumatic brain injury (TBI) represent the 2 leading causes of death after blunt trauma. The goal of this study was to examine the impact of TBI and use of thoracic endovascular aortic repair (TEVAR) on patients with BAI, using a large, national dataset.
• Dooley, J. H., Ozdenerol, E., Sharpe, J. P., Magnotti, L. J., Croce, M. A., & Fischer, P. E. (2020). Location, location, location: Utilizing Needs-Based Assessment of Trauma Systems-2 in trauma system planning. The journal of trauma and acute care surgery, 88(1), 94-100.
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  In 2015, the American College of Surgeons Committee on Trauma introduced the Needs-Based Assessment of Trauma Systems (NBATS) tool to quantify the optimal number of trauma centers for a region. While useful, more focus was required on injury population, distribution, and transportation systems. Therefore, NBATS-2 was developed utilizing advanced geographical modeling. The purpose of this study was to evaluate NBATS-2 in a large regional trauma system.
• Farrar, J. E., Garner, K. M., Swanson, J. M., Magnotti, L. J., Croce, M. A., & Wood, G. C. (2020). Tigecycline to treat Stenotrophomonas maltophilia ventilator-associated pneumonia in a trauma intensive care unit as a result of a drug shortage: A case series. Journal of clinical pharmacy and therapeutics, 45(4), 836-839.
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  Stenotrophomonas maltophilia is an intrinsically multidrug-resistant (MDR) organism which commonly presents as a respiratory tract infection. S. maltophilia is typically treated with high-dose sulfamethoxazole/trimethoprim (SMX/TMP). However, SMX/TMP and other treatment options for S. maltophilia can be limited because of resistance, allergy, adverse events or unavailability of the drug; use of novel agents may be necessary to adequately treat this MDR infection and overcome these limitations.
• Huang, X., Magnotti, L. J., Fabian, T. C., Croce, M. A., & Sharpe, J. P. (2020). Does lack of thoracic trauma attenuate the severity of pulmonary failure? An 8-year analysis of critically injured patients. European journal of trauma and emergency surgery : official publication of the European Trauma Society, 46(1), 3-9.
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  Patients with thoracic trauma are presumed to be at higher risk for pulmonary dysfunction, but adult respiratory distress syndrome (ARDS) may develop in any patient, regardless of associated chest injury. This study evaluated the impact of thoracic trauma and pulmonary failure on outcomes in trauma patients admitted to the intensive-care unit (ICU).
• Lenart, E. K., Lewis, R. H., Sharpe, J. P., Fischer, P. E., Croce, M. A., & Magnotti, L. J. (2020). They only come out at night: Impact of time of day on outcomes after penetrating abdominal trauma. Surgery open science, 2(4), 1-4.
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  Patients who present at night following penetrating abdominal trauma are thought to have more severe injuries and increased risk for morbidity and mortality. The current literature is at odds regarding this belief. The purpose of this study was to evaluate time of day on outcomes following laparotomy for penetrating abdominal trauma.
• Lewis, R. H., Sharpe, J. P., Croce, M. A., Fabian, T. C., & Magnotti, L. J. (2020). How soon is too soon?: Optimal timing of split-thickness skin graft following polyglactin 910 mesh closure of the open abdomen. The journal of trauma and acute care surgery, 89(2), 377-381.
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  Various management strategies exist for the abdomen that will not close. At our institution, these patients are managed with polyglactin 910 mesh followed 14 days later (LATE) by split-thickness skin graft (STSG) or, in some cases, earlier (EARLY,
• Magnotti, L. J., Sharpe, J. P., Tolley, B., Thomas, F., Lewis, R. H., Filiberto, D. M., Evans, C., Kokorev, L., Fabian, T. C., & Croce, M. A. (2020). Long-term functional outcomes after traumatic popliteal artery injury: A 20-year experience. The journal of trauma and acute care surgery, 88(2), 197-206.
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  Traumatic popliteal arterial injury (TPAI) is associated with a risk of both limb loss and long-term morbidity due to prolonged ischemia and the often-associated musculoskeletal injuries. Long-term functional outcome following this injury has not been adequately studied. We evaluated patients with TPAI to determine if there was an improvement in functional outcome over time. We hypothesized that both the initial severity of ischemia and the associated injuries limited the ability of patients to improve functional outcome.
• Manley, N. R., Fischer, P. E., Sharpe, J. P., Stranch, E. W., Fabian, T. C., Croce, M. A., & Magnotti, L. J. (2020). Separating Truth from Alternative Facts: 37 Years of Guns, Murder, and Violence Across the US. Journal of the American College of Surgeons, 230(4), 475-481.
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  Gun violence remains a significant public health problem that is both understudied and underfunded, and plagued by inadequate or inaccessible data sources. Over the years, numerous trauma centers have attempted to use local registries to study single-institutional trends, however, this approach limits generalizability to our national epidemic. In fact, even easily accessible, health-centered data from the CDC lack national relevance because they are limited to those enrolled states only. We sought to examine how publicly available law enforcement data from all 50 states might complement our understanding of circumstances and demographics surrounding national firearm death and help forge the first step in partnering law enforcement with trauma centers.
• Tsao, M. W., Delozier, O. M., Stiles, Z. E., Magnotti, L. J., Behrman, S. W., Deneve, J. L., Glazer, E. S., Shibata, D., Yakoub, D., & Dickson, P. V. (2020). The impact of race and socioeconomic status on the presentation, management and outcomes for gastric cancer patients: Analysis from a metropolitan area in the southeast United States. Journal of surgical oncology, 121(3), 494-502.
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  Socioeconomic disparities in gastric cancer have been associated with differences in care and inferior outcomes. We evaluated the presentation, treatment, and survival for patients with gastric cancer (GC) in a metropolitan setting with a large African American population.
• Lewis, R. H., Sharpe, J. P., Berning, B., Fabian, T. C., Croce, M. A., & Magnotti, L. J. (2019). Impact of a simplified management algorithm on outcome following exsanguinating pelvic fractures: A 10-year experience. The journal of trauma and acute care surgery, 86(4), 658-663.
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  Optimal management of exsanguinating pelvic fractures remains controversial. Our previous experience suggested that management decisions based on a defined algorithm were associated with a significant reduction in transfusion requirements and mortality. Based on these outcomes, a clinical pathway (PW) for the management of exsanguinating pelvic fractures was developed. The purpose of this study was to evaluate the impact of this PW on outcomes.
• Manley, N. R., Croce, M. A., Fischer, P. E., Crowe, D. E., Goines, J. H., Sharpe, J. P., Fabian, T. C., & Magnotti, L. J. (2019). Evolution of Firearm Violence over 20 Years: Integrating Law Enforcement and Clinical Data. Journal of the American College of Surgeons, 228(4), 427-434.
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  Data linking ballistics to injury are lacking. To address this data chasm, a partnership with law enforcement was developed to describe clinical outcomes from specific firearms.
• Manley, N. R., Sharpe, J. P., Lewis, R. H., Iltis, M. S., Chaudhuri, R., Fabian, T. C., Croce, M. A., & Magnotti, L. J. (2019). Analysis of over 2 decades of colon injuries identifies optimal method of diversion: Does an end justify the means?. The journal of trauma and acute care surgery, 86(2), 214-219.
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  Conflicting evidence exists regarding the definitive management of destructive colon injuries. Although diversion with an end ostomy can theoretically decrease initial complications, it mandates a more extensive reversal procedure. Conversely, anastomosis with proximal loop ostomy diversion, while simplifying the reversal, increases the number of suture lines and potential initial morbidity. Thus, the purpose of this study was to evaluate the impact of diversion technique on morbidity and mortality in patients with destructive colon injuries.
• Schroeppel, T. J., Sharpe, J. P., Shahan, C. P., Clement, L. P., Magnotti, L. J., Lee, M., Muhlbauer, M., Weinberg, J. A., Tolley, E. A., Croce, M. A., & Fabian, T. C. (2019). Beta-adrenergic blockade for attenuation of catecholamine surge after traumatic brain injury: a randomized pilot trial. Trauma surgery & acute care open, 4(1), e000307.
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  Beta-blockers have been proven in multiple studies to be beneficial in patients with traumatic brain injury. Few prospective studies have verified this and no randomized controlled trials. Additionally, most studies do not titrate the dose of beta-blockers to therapeutic effect. We hypothesize that propranolol titrated to effect will confer a survival benefit in patients with traumatic brain injury.
• Evans, C. R., Sharpe, J. P., Swanson, J. M., Wood, G. C., Fabian, T. C., Croce, M. A., & Magnotti, L. J. (2018). Keeping it Simple: Impact of a Restrictive Antibiotic Policy for Ventilator-Associated Pneumonia in Trauma Patients on Incidence and Sensitivities of Causative Pathogens. Surgical infections, 19(7), 672-678.
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  An integral part of ventilator-associated pneumonia (VAP) therapy is the appropriate choice of empiric antibiotics. Our previous experience demonstrated adherence to an empiric therapy pathway was associated with only modest changes in organisms causing VAP. The purpose of the current study was to evaluate the impact of a restrictive antibiotic policy for VAP in trauma patients on the incidence and sensitivities of causative pathogens since the previous study.
• Filiberto, D. M., Sharpe, J. P., Croce, M. A., Fabian, T. C., & Magnotti, L. J. (2018). Traumatic atlanto-occipital dissociation: No longer a death sentence. Surgery, 164(3), 500-503.
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  Traumatic atlanto-occipital dissociation is considered highly unstable and was once believed to be uniformly fatal. With recent advances in prehospital care, coupled with early diagnosis and stabilization, these injuries are potentially survivable. The aim of this study was to identify potentially modifiable risk factors associated with improved outcomes after a traumatic atlanto-occipital dissociation.
• Gibson, B. H., Sharpe, J. P., Lewis, R. H., Newell, J. S., Swanson, J. M., Wood, G. C., Fabian, T. C., Croce, M. A., & Magnotti, L. J. (2018). Use of Aerosolized Antibiotics in Gram-Negative Ventilator-Associated Pneumonia in Trauma Patients. The American surgeon, 84(12), 1906-1912.
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  Ventilator-associated pneumonia (VAP) is associated with significant morbidity (ventilator days, ICU days, and cost) and mortality increase in trauma patients. Multidrug-resistant strains of causative VAP pathogens are becoming increasingly common. Aerosolized antibiotics achieve high alveolar concentrations and provide valuable adjuncts in the treatment of VAP. This study examined the impact of aerosolized antibiotics in the treatment of VAP in trauma patients. Patients with either or VAP over 10 years treated with aerosolized antibiotics (cases) were stratified by age, severity of shock, and injury severity. A frequency-matched (by causative pathogen) control group treated without aerosolized antibiotics was used for comparison. Multivariable logistic regression was used to identify predictors for the use of aerosolized antibiotics. One hundred twenty VAP episodes were identified in 100 patients. Microbiologic resolution was achieved in all patients treated with aerosolized antibiotics. There was no difference in mortality (14.5% vs 15.7%, = 0.87) and no antibiotic-related complications in either group. Multivariable logistic regression identified VAP persistence and relapse as independent predictors for the use of aerosolized antibiotics. Combined with systemic therapy, aerosolized antibiotics broaden the spectrum of therapy. They are valuable adjuncts with minimal risk of antibiotic resistance and/or systemic complications.
• Lewis, R. H., Sharpe, J. P., Swanson, J. M., Fabian, T. C., Croce, M. A., & Magnotti, L. J. (2018). Reinventing the wheel: Impact of prolonged antibiotic exposure on multidrug-resistant ventilator-associated pneumonia in trauma patients. The journal of trauma and acute care surgery, 85(2), 256-262.
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  Multidrug-resistant (MDR) strains of both Acinetobacter baumannii (AB) and Pseudomonas aeruginosa (PA) as causative ventilator-associated pneumonia (VAP) pathogens are becoming increasingly common. Still, the risk factors associated with this increased resistance have yet to be elucidated. The purpose of this study was to examine the changing sensitivity patterns of these pathogens over time and determine which risk factors predict MDR in trauma patients with VAP.
• Manley, N. R., Fabian, T. C., Sharpe, J. P., Magnotti, L. J., & Croce, M. A. (2018). Good news, bad news: An analysis of 11,294 gunshot wounds (GSWs) over two decades in a single center. The journal of trauma and acute care surgery, 84(1), 58-65.
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  Gun violence is a substantial public health problem accounting for significant physical, psychological, and financial costs. Although aggregate data sources demonstrate decreasing rates of firearm violence, analyses from individual trauma centers have shown that mortality and injury severity from gunshot wounds (GSWs) are increasing. To evaluate the evolving characteristics of gun violence in our region, we studied all GSWs admitted to our trauma center over a 20-year period.
• Manley, N. R., Magnotti, L. J., Fabian, T. C., Croce, M. A., & Sharpe, J. P. (2018). Impact of venorrhaphy and vein ligation in isolated lower-extremity venous injuries on venous thromboembolism and edema. The journal of trauma and acute care surgery, 84(2), 325-329.
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  Following venous injury, venorrhaphy can restore outflow, although it risks thrombosis and venous thromboembolism (VTE). Vein ligation is a faster option, although it potentially risks extremity edema. The purpose of this study was to evaluate the management of venous injury on VTE and extremity edema in patients with isolated lower-extremity venous injuries.
• Manley, N. R., Magnotti, L. J., Fabian, T. C., Cutshall, M. B., Croce, M. A., & Sharpe, J. P. (2018). Factors Contributing to Morbidity after Combined Arterial and Venous Lower Extremity Trauma. The American surgeon, 84(7), 1217-1222.
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  The purpose of this study was to evaluate the impact of management of venous injury on clinical outcomes in patients with combined lower extremity arterial and venous trauma. Patients with common and external iliac, common and superficial femoral, and popliteal artery injuries were identified. Patients who underwent vein repair and those who received vein ligation were compared. The analysis was repeated for those patients who required secondary intervention for their arterial injury and those who did not require secondary intervention. Seventy patients were identified with both arterial and venous injuries: 40 underwent vein ligation and 30 received vein repair. There was no difference in ischemic time between patients undergoing vein repair compared with ligation. Vein ligation did not produce a higher incidence of muscle debridement (10% vs 15%, P = 0.72), necessity for secondary intervention (10% vs 7.5%, P = 0.99), or amputation (3.3% vs 7.5%, P = 0.63). Patients who required secondary intervention had a greater degree of shock on presentation (packed red blood cells (PRBC), 13 units vs 6 units, P = 0.02) and were more likely to require muscle debridement (50% vs 9%, P = 0.02) and amputation (33% vs 3%, P = 0.03). Vein ligation did not impact muscle ischemia or success of arterial repair in patients with combined venous and arterial trauma in the lower extremities. Patient morbidity after extremity vascular trauma is most related to degree of shock.
• Nunn, A., Prakash, P., Inaba, K., Escalante, A., Maher, Z., Yamaguchi, S., Kim, D. Y., Maciel, J., Chiu, W. C., Drumheller, B., Hazelton, J. P., Mukherjee, K., Luo-Owen, X., Nygaard, R. M., Marek, A. P., Morse, B. C., Fitzgerald, C. A., Bosarge, P. L., Jawa, R. S., , Rowell, S. E., et al. (2018). Occupational exposure during emergency department thoracotomy: A prospective, multi-institution study. The journal of trauma and acute care surgery, 85(1), 78-84.
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  Occupational exposure is an important consideration during emergency department thoracotomy (EDT). While human immunodeficiency virus/hepatitis prevalence in trauma patients (0-16.8%) and occupational exposure rates during operative trauma procedures (1.9-18.0%) have been reported, exposure risk during EDT is unknown. We hypothesized that occupational exposure risk during EDT would be greater than other operative trauma procedures.
• Schroeppel, T. J., Clement, L. P., Barnard, D. L., Guererro, W., Ferguson, M. D., Sharpe, J. P., Magnotti, L. J., Croce, M. A., & Fabian, T. C. (2018). Propofol Infusion Syndrome: Efficacy of a Prospective Screening Protocol. The American surgeon, 84(8), 1333-1338.
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  Propofol infusion syndrome (PIS) is a potentially lethal complication of propofol marked by rhabdomyolysis, metabolic acidosis, and cardiac arrhythmias or collapse. The objective of this study was to determine the effectiveness of a prospective screening protocol to prevent PIS. All trauma patients admitted who received propofol as a continuous infusion were prospectively screened from November 1, 2013 to December 31, 2015. Variables studied included demographics, injury severity, laboratory values, infusion rates, and mortality. Serum creatine phosphokinase (CPK) and lactate were drawn daily. Propofol was stopped for a positive screen defined as an increase in CPK to greater than 5000 IU/L or lactate greater than 4 mmol/L. Positive and negative cohorts were compared. Two hundred and twenty-five patients met the inclusion criteria and 12 patients (5.3%) had propofol stopped because of elevated CPK. No differences were identified in demographics, transfusions, injury severity, hospital length of stay, or propofol dose. The positive screened group had longer intensive care unit length of stay (20 vs 13 days; P = 0.002) and increased vent days (14.5 vs 10 days; P = 0.008). Max serum osmolality (334 vs 305 mosm/kg; P = 0.049) and max serum CPK (6782 vs 1058 IU/L; P < 0.0001) were higher in the positive cohort. No cases of PIS occurred, and mortality (16.7 vs 15.5%; P = 0.999) was not different between the cohorts. The screening protocol was effective in eliminating PIS. Serial CPK evaluations provided an effective screening tool and serum lactate can be dropped from screening.
• Shahan, C. P., Sharpe, J. P., Stickley, S. M., Manley, N. R., Filiberto, D. M., Fabian, T. C., Croce, M. A., & Magnotti, L. J. (2018). The changing role of endovascular stenting for blunt cerebrovascular injuries. The journal of trauma and acute care surgery, 84(2), 308-311.
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  Few injuries have produced as much debate with respect to management as have blunt cerebrovascular injuries (BCVIs). Without question, early anticoagulation is the mainstay of therapy for these injuries. However, the role of endovascular stenting for BCVI remains controversial. Our purpose was to examine the use of endovascular stents for BCVI and outcomes and describe which injuries are being treated with stents.
• Shahan, C. P., Stavely, T. C., Croce, M. A., Fabian, T. C., & Magnotti, L. J. (2018). Long-Term Functional Outcomes after Blunt Cerebrovascular Injury: A 20-Year Experience. The American surgeon, 84(4), 551-556.
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  Since blunt cerebrovascular injury (BCVI) became increasingly recognized more than 20 years ago, significant improvements have been made in both diagnosis and treatment. Little is known regarding long-term functional outcomes in BCVI. The purpose of this study was to evaluate the impact of BCVI on those long-term outcomes. All patients with BCVI from 1996 to 2014 were identified from the trauma registry. Functional outcome was measured using the Boston University Activity Measure for Post-Acute Care. Multiple regression analysis was performed to identify potential predictors of outcomes. A total of 509 patients were identified. Overall mortality was 18 per cent (BCVI-related = 1%). Of the 415 survivors, follow-up was obtained in 77 (19%). Mean follow-up was five years, with a maximum of 19 years. Mean age and injury severity score were 47 and 25, respectively. Six (8%) patients suffered strokes. Mean Activity Measure for Post-Acute Care scores were 59 (mobility), 58 (activity), and 44 (cognitive function), each indicating significant impairment compared with normal. Multiple regression models identified 1) age as a predictor of decreased mobility, 2) injury severity score as a predictor of decreased mobility, activity, and cognitive function, and 3) stroke as a predictor of decreased activity, cognitive function, and likely mobility. Development of stroke and increased injury severity resulted in worse long-term functional outcomes after BCVI. Thus, stroke prevention with optimal diagnostic and treatment algorithms remains critical in the successful treatment of BCVI because it has significant impact on long-term functional outcomes and is the only modifiable predictor of outcomes in patients after BCVI.
• Sharpe, J. P., Fabian, T. C., Croce, M. A., & Magnotti, L. J. (2018). Re: Chemoprophylaxis for VTE prevention in spine surgery patients. The journal of trauma and acute care surgery, 85(6), 1133-1134.
• Wood, G. C., Jonap, B. L., Maish, G. O., Magnotti, L. J., Swanson, J. M., Boucher, B. A., Croce, M. A., & Fabian, T. C. (2018). Treatment of Achromobacter Ventilator-Associated Pneumonia in Critically Ill Trauma Patients. The Annals of pharmacotherapy, 52(2), 120-125.
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  Achromobacter sp are nonfermenting Gram-negative bacilli (NFGNB) that rarely cause severe infections, including ventilator-associated pneumonia (VAP). Data on the treatment of Achromobacter pneumonia are very limited, and the organism has been associated with a high mortality rate. Thus, more data are needed on treating this organism.
• Savage, S. A., Zarzaur, B. L., Brewer, B. L., Lim, G. H., Martin, A. C., Magnotti, L. J., Croce, M. A., & Pohlman, T. H. (2017). 1: 1 Transfusion strategies are right for the wrong reasons. The journal of trauma and acute care surgery, 82(5), 845-852.
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  Early assessment of clot function identifies coagulopathies after injury. Abnormalities include a hypercoagulable state from excess thrombin generation, as well as an acquired coagulopathy. Efforts to address coagulopathy have resulted in earlier, aggressive use of plasma emphasizing 1:1 resuscitation. The purpose of this study was to describe coagulopathies in varying hemorrhagic profiles from a cohort of injured patients.
• Savage, S. A., Zarzaur, B. L., Pohlman, T. H., Brewer, B. L., Magnotti, L. J., Croce, M. A., Lim, G. H., & Martin, A. C. (2017). Clot dynamics and mortality: The MA-R ratio. The journal of trauma and acute care surgery, 83(4), 628-634.
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  The coagulopathy of trauma, illustrated by a short R-time, is common and well understood. The physiology behind this may be early thrombin burst with rapid clot formation. Rapid consumption of fibrinogen, however, may result in weak clot and substrate depletion, resulting in low MA. While these characteristics are interesting, utilizing thromboelastography (TEG) to identify those at risk of subsequent bleeding diathesis, especially in those who do not demonstrate early signs of physiologic derangement, is challenging. We have developed a novel ratio utilizing TEG values to describe patients at specific risk of traumatic coagulopathy. The purpose of this study was to create a single TEG value, which would reflect both the hypercoagulability and hypocoagulability of TIC. We hypothesized that this ratio, at admission, would be indicative of TIC and predictive of both blood product transfusion volumes and subsequent mortality.
• Shahan, C. P., Croce, M. A., Fabian, T. C., & Magnotti, L. J. (2017). Impact of Continuous Evaluation of Technology and Therapy: 30 Years of Research Reduces Stroke and Mortality from Blunt Cerebrovascular Injury. Journal of the American College of Surgeons, 224(4), 595-599.
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  Blunt cerebrovascular injury (BCVI) was underdiagnosed until the 1990s when blunt carotid injuries were found to be more common than historically described. Technological advancements and regionalization of trauma care have resulted in increased screening and improved diagnosis of BCVI. The aim of this study was to demonstrate that systematic evaluation of the screening and diagnosis of BCVI, combined with early and aggressive treatment, have led to reductions in BCVI-related stroke and mortality.
• Shahan, C. P., Magnotti, L. J., & Fabian, T. C. (2017). Re: Screening for pediatric blunt cerebrovascular injury. The journal of trauma and acute care surgery, 82(1), 227-228.
• Sharpe, J. P., Gobbell, W. C., Carter, A. M., Pahlkotter, M. K., Muhlbauer, M. S., Camillo, F. X., Fabian, T. C., Croce, M. A., & Magnotti, L. J. (2017). Impact of venous thromboembolism chemoprophylaxis on postoperative hemorrhage following operative stabilization of spine fractures. The journal of trauma and acute care surgery, 83(6), 1108-1113.
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  Prophylactic anticoagulation may decrease the risk of venous thromboembolism (VTE) in patients with spine fractures following blunt trauma but comes with the threat of postoperative bleeding in patients requiring stabilization of these fractures. The purpose of this study was to evaluate the impact of preoperative anticoagulation on VTE and bleeding complications in patients with blunt spine fractures requiring operative stabilization.
• Sharpe, J. P., Khan, N. R., Chatterjee, A. R., Huang, J., Magnotti, L. J., Croce, M. A., & Fabian, T. C. (2017). Investigating Cyclooxygenase Inhibition in a Rat Pulmonary Contusion Model: A Laboratory Study Finding No Improvement with Ibuprofen. The American surgeon, 83(6), 666-672.
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  Minimal advances have been made in the management of pulmonary contusions (PCs). The purpose of this study was to evaluate the impact of cyclooxygenase inhibition on outcomes following PC in a rat model. PC was induced in anesthetized adult rats. Ibuprofen was given to the treatment group (TG) and water was given to the control group (CG). Lung injury was assessed with pulse oximetry, arterial blood gases, CT, and histopathologic examination. Inflammation was measured with both serum and bronchoalveolar lavage (BAL) levels of tumor necrosis factor α and interleukin-6. Rats in the TG did not differ from rats in the CG with respect to oxygenation. Pathologic examination demonstrated a trend toward more inflammatory infiltrate in the CG, yet the sizes of the contusions were larger in the TG. The CG trended toward decreased levels of interleukin-6 in the serum and BAL at both three and seven days. While BAL levels of tumor necrosis factor α were increased in the TG at three days compared to the CG, they trended toward a reduced amount at seven days. Our data do not support cyclooxygenase inhibition for treatment to decrease the respiratory compromise associated with PC in this model of rat PCs.
• Sharpe, J. P., Magnotti, L. J., Fabian, T. C., & Croce, M. A. (2017). Evolution of the operative management of colon trauma. Trauma surgery & acute care open, 2(1), e000092.
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  For any trauma surgeon, colon wounds remain a relatively common, yet sometimes challenging, clinical problem. Evolution in operative technique and improvements in antimicrobial therapy during the past two centuries have brought remarkable improvements in both morbidity and mortality after injury to the colon. Much of the early progress in management and patient survival after colon trauma evolved from wartime experience. Multiple evidence-based studies during the last several decades have allowed for more aggressive management, with most wounds undergoing primary repair or resection and anastomosis with an acceptably low suture line failure rate. Despite the abundance of quality evidence regarding management of colon trauma obtained from both military and civilian experience, there remains some debate among institutions regarding management of specific injuries. This is especially true with respect to destructive wounds, injuries to the left colon, blunt colon trauma and those wounds requiring colonic discontinuity during an abbreviated laparotomy. Some programs have developed data-driven protocols that have simplified management of destructive colon wounds, clearly identifying those high-risk patients who should undergo diversion, regardless of mechanism or anatomic location. This update will describe the progression in the approach to colon injuries through history while providing a current review of the literature regarding management of the more controversial wounds.
• Sharpe, J. P., Magnotti, L. J., Gobbell, W. C., Huang, X., Perez, E. A., Fabian, T. C., & Croce, M. A. (2017). Impact of early operative pelvic fixation on long-term self-reported outcome following severe pelvic fracture. The journal of trauma and acute care surgery, 82(3), 444-450.
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  Traumatic disruption of the pelvic ring is a significant cause of life-threatening hemorrhage. For those patients who survive the initial injury, these fractures are associated with long periods of immobilization and intense rehabilitation. There is little published information available regarding long-term functional outcomes in these patients. This study evaluated the impact of severe pelvic fractures on those long-term outcomes.
• Hendrick, L. E., Schroeppel, T. J., Sharpe, J. P., Alsbrook, D., Magnotti, L. J., Weinberg, J. A., Johnson, B. P., Lewis, R. H., Clement, L. P., Croce, M. A., & Fabian, T. C. (2016). Impact of Beta-Blockers on Nonhead Injured Trauma Patients. The American surgeon, 82(7), 575-9.
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  Catecholamine surge after traumatic injury may lead to dysautonomia with increased morbidity. Small retrospective studies have shown potential benefit of beta-blockers (BB) in trauma patients with and without traumatic brain injury (TBI). This study evaluates a large multiply injured cohort without TBI that received BB. Patients were identified from the trauma registry from January 1, 2003 to December 31, 2011. Patients who received >1 dose of BB were compared to controls. Patients with TBI, length of stay (LOS) < 2 days, and prehospital BB were excluded. Outcomes were mortality, intensive care unit (ICU) LOS, and LOS. Stepwise multivariable regression was used to identify variables significantly associated with mortality. During the study period, 19,151 eligible patients were admitted. The mean age was 39 years. Most were male (74%) and most sustained blunt mechanism (75%). A total of 1854 (11%) patients received BB. BB patients had longer LOS (16 vs 6 days), ICU LOS (7 vs 1 days), and higher mortality (2.8 vs 0.5%) (all P < 0.001). Multivariable regression demonstrated no benefit to BB after adjusting for potential confounding characteristics [odds ratio (OR) 0.952; confidence interval (CI) 0.620-1.461]. In conclusion, in this largest study to date, patients receiving BB were older, more severely injured, and had a higher mortality. Unlike TBI patients, multivariable regression showed no benefit from BB in this population.
• Newgard, C. D., Sanchez, B. J., Bulger, E. M., Brasel, K. J., Byers, A., Buick, J. E., Sheehan, K. L., Guyette, F. X., King, R. V., Mena-Munoz, J., Minei, J. P., Schmicker, R. H., & , R. I. (2016). A Geospatial Analysis of Severe Firearm Injuries Compared to Other Injury Mechanisms: Event Characteristics, Location, Timing, and Outcomes. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 23(5), 554-65.
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  Relatively little is known about the context and location of firearm injury events. Using a prospective cohort of trauma patients, we describe and compare severe firearm injury events to other violent and nonviolent injury mechanisms regarding incident location, proximity to home, time of day, spatial clustering, and outcomes.
• Schroeppel, T. J., Saleem, K., Sharpe, J. P., Magnotti, L. J., Weinberg, J. A., Fischer, P. E., Croce, M. A., & Fabian, T. C. (2016). Penetrating duodenal trauma: A 19-year experience. The journal of trauma and acute care surgery, 80(3), 461-5.
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  Multiple techniques are used for repair in duodenal injury ranging from simple suture repair for low-grade injuries to pancreaticoduodenectomy for complicated high-grade injuries. Drains, both intraluminal and extraluminal, are placed variably depending on associated injuries and confidence with the repair. It is our contention that a simplified approach to repair will limit complications and mortality. The major complication of duodenal leak (DL) was the outcome used to assess methods of repair in this study.
• Shahan, C. P., Magnotti, L. J., McBeth, P. B., Weinberg, J. A., Croce, M. A., & Fabian, T. C. (2016). Early antithrombotic therapy is safe and effective in patients with blunt cerebrovascular injury and solid organ injury or traumatic brain injury. The journal of trauma and acute care surgery, 81(1), 173-7.
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  Early antithrombotic therapy (AT) is the mainstay of treatment in the management of blunt cerebrovascular injury (BCVI). Despite this, optimal timing of initiation of AT in patients with BCVI in the presence of concomitant traumatic brain injury (TBI) or solid organ injury (SOI) remains controversial. The purpose of this study was to evaluate the impact of early initiation of AT on outcomes in patients with BCVI and TBI and/or SOI.
• Shahan, C. P., Magnotti, L. J., Stickley, S. M., Weinberg, J. A., Hendrick, L. E., Uhlmann, R. A., Schroeppel, T. J., Hoit, D. A., Croce, M. A., & Fabian, T. C. (2016). A safe and effective management strategy for blunt cerebrovascular injury: Avoiding unnecessary anticoagulation and eliminating stroke. The journal of trauma and acute care surgery, 80(6), 915-22.
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  Few injuries have produced as much debate with respect to management as have blunt cerebrovascular injuries (BCVIs). Recent work (American Association for the Surgery of Trauma 2013) from our institution suggested that 64-channel multidetector computed tomographic angiography (CTA) could be the primary screening tool for BCVI. Consequently, our screening algorithm changed from digital subtraction angiography (DSA) to CTA, with DSA reserved for definitive diagnosis of BCVI following CTA-positive study results or unexplained neurologic findings. The current study was performed to evaluate outcomes, including the potential for missed clinically significant BCVI, since this new management algorithm was adopted.
• Shahan, C. P., Weinberg, J. A., Magnotti, L. J., Fabian, T. C., & Croce, M. A. (2016). Trauma health literacy: In need of remediation. The journal of trauma and acute care surgery, 81(6), 1167-1170.
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  Little is known regarding health literacy among trauma patients. Anecdotal experience at our institution has suggested that a profound lack of understanding of basic health care information exists at some level in our patients after hospital discharge. The purpose of this study was to report the results of a pilot quality improvement project to determine trauma patient injury comprehension and how this affects their overall satisfaction with care received.
• Sharpe, J. P., Magnotti, L. J., Weinberg, J. A., Schroeppel, T. J., Fabian, T. C., & Croce, M. A. (2016). The old man and the C-spine fracture: Impact of halo vest stabilization in patients with blunt cervical spine fractures. The journal of trauma and acute care surgery, 80(1), 76-80.
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  Placement of a halo vest for cervical spine fractures is presumed to be less morbid than operative fixation. However, restrictions imposed by the halo vest can be detrimental, especially in older patients. The purpose of this study was to evaluate the impact of halo vest placement on outcomes by age in patients with cervical spine fractures without spinal cord injury.
• Weinberg, J. A., Moore, A. H., Magnotti, L. J., Teague, R. J., Ward, T. A., Wasmund, J. B., Lamb, E. M., Schroeppel, T. J., Savage, S. A., Minard, G., Maish, G. O., Croce, M. A., & Fabian, T. C. (2016). Contemporary management of civilian penetrating cervicothoracic arterial injuries. The journal of trauma and acute care surgery, 81(2), 302-6.
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  The management of arterial injury at the thoracic outlet has long hinged on the fundamental principles of extensile exposure and vascular anastomosis. Nonetheless, treatment options for such injuries have evolved to include both endovascular stent placement and temporary vascular shunts. The purpose of this study was to evaluate our recent experience with penetrating cervicothoracic arterial injuries in light of these developments in trauma care.
• Jarrell, A. S., Wood, G. C., Ponnapula, S., Magnotti, L. J., Croce, M. A., Swanson, J. M., Boucher, B. A., & Fabian, T. C. (2015). Short-duration treatment for catheter-associated urinary tract infections in critically ill trauma patients. The journal of trauma and acute care surgery, 79(4), 649-53.
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  The optimal treatment duration for catheter-associated urinary tract infection (CA-UTI) in critically ill patients is unclear. The Infectious Diseases Society of America recommends up to 14 days of therapy; however, short-duration therapy (SDT) for 3 days to 5 days is often used in trauma intensive care unit (ICU) patients at our center. The efficacy of SDT for CA-UTI has not been studied in this population. The objective was to evaluate the efficacy of SDT for CA-UTI in trauma ICU patients.
• McClellan, N., Swanson, J. M., Magnotti, L. J., Griffith, T. W., Wood, G. C., Croce, M. A., Boucher, B. A., Mueller, E. W., & Fabian, T. C. (2015). Adjunctive intraventricular antibiotic therapy for bacterial central nervous system infections in critically ill patients with traumatic brain injury. The Annals of pharmacotherapy, 49(5), 515-22.
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  Limited data exist on the role of adjunctive intraventricular (IVT) antibiotics for the treatment of central nervous system (CNS) infections in traumatic brain injury (TBI) patients.
• Schroeppel, T. J., Sharpe, J. P., Magnotti, L. J., Weinberg, J. A., Croce, M. A., & Fabian, T. C. (2015). How to Further Decrease the Efficiency of Care at a Level I Trauma Center: Implement the Amended Resident Work Hours. The American surgeon, 81(7), 698-703.
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  Work-hour restrictions were amended in 2011 to limit interns to 16 continuous duty hours, essentially requiring a night float system of 12-hour shifts. We hypothesize that there has been no improvement in outcomes after implementation of the amended work-hour restrictions. Outcomes from trauma admissions were queried from the trauma registry from 2009 to 2011 (PRE) and 2011 to 2013 (POST). The primary outcome was mortality with secondary outcomes intensive care unit length of stay (LOS)and LOS. Patients were stratified based on age, mechanism, gender, blood pressure, heart rate, and injury severity (Injury Severity Score, Glasgow Coma Scale, Base Deficit). Outcomes were then compared from admissions PRE to POST. A total of 9178 patients were included in the study population. The mean age was 42 with most being male (72%) and blunt mechanism (81%). Patient populations were well matched except patients in the POST period were slightly older (43 vs 42 years; P = 0.01). Intensive care unit LOS and LOS were higher in the POST period. After adjusted analysis, admission in the POST period was not a predictor of mortality (odds ratio 0.857; confidence interval 0.655-1.12). The POST period was an independent predictor for LOS (β = 0.74; P = 0.002). This study adds to the mounting evidence that the implementation of the amended limits on work hours leads to furthermore decreased efficiency of care.
• Seamon, M. J., Haut, E. R., Van Arendonk, K., Barbosa, R. R., Chiu, W. C., Dente, C. J., Fox, N., Jawa, R. S., Khwaja, K., Lee, J. K., Magnotti, L. J., Mayglothling, J. A., McDonald, A. A., Rowell, S., To, K. B., Falck-Ytter, Y., & Rhee, P. (2015). An evidence-based approach to patient selection for emergency department thoracotomy: A practice management guideline from the Eastern Association for the Surgery of Trauma. The journal of trauma and acute care surgery, 79(1), 159-73.
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  Within the GRADE (Grading of Recommendations Assessment, Development and Evaluation) framework, we performed a systematic review and developed evidence-based recommendations to answer the following PICO (Population, Intervention, Comparator, Outcomes) question: should patients who present pulseless after critical injuries (with and without signs of life after penetrating thoracic, extrathoracic, or blunt injuries) undergo emergency department thoracotomy (EDT) (vs. resuscitation without EDT) to improve survival and neurologically intact survival?
• Sharpe, J. P., Magnotti, L. J., Weinberg, J. A., Swanson, J. M., Schroeppel, T. J., Clement, L. P., Wood, G. C., Fabian, T. C., & Croce, M. A. (2015). Adherence to an established diagnostic threshold for ventilator-associated pneumonia contributes to low false-negative rates in trauma patients. The journal of trauma and acute care surgery, 78(3), 468-73; discussion 473-4.
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  The diagnosis of ventilator-associated pneumonia (VAP) in our institution has followed an established diagnostic threshold (DT) of equal to or greater than 10 colony-forming units (CFU) per milliliter on bronchoalveolar lavage (BAL) based on our previous study (PS). Because mortality from VAP is related to treatment delay, some have advocated a lower DT. The purpose of the current study (CS) was to evaluate the impact of adherence to this DT for VAP on false-negative (FN) rates and mortality in trauma patients.
• Sharpe, J. P., Magnotti, L. J., Weinberg, J. A., Swanson, J. M., Wood, G. C., Fabian, T. C., & Croce, M. A. (2015). Impact of pathogen-directed antimicrobial therapy for ventilator-associated pneumonia in trauma patients on charges and recurrence. Journal of the American College of Surgeons, 220(4), 489-95.
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  Ventilator-associated pneumonia (VAP) represents one of the driving forces behind antibiotic use in the ICU. In a previous study, we established a defined algorithm for treatment of hospital-acquired VAP dictated by the causative pathogen. The purpose of the current study was to evaluate the impact of this algorithm for hospital-acquired VAP on recurrence and charges in trauma patients.
• Nirula, R., Millar, D., Greene, T., McFadden, M., Shah, L., Scalea, T. M., Stein, D. M., Magnotti, L. J., Jurkovich, G. J., Vercruysse, G., Demetriades, D., Scherer, L. A., Peitzman, A., Sperry, J., Beauchamp, K., Bell, S., Feiz-Erfan, I., O'Neill, P., & Coimbra, R. (2014). Decompressive craniectomy or medical management for refractory intracranial hypertension: an AAST-MIT propensity score analysis. The journal of trauma and acute care surgery, 76(4), 944-52; discussion 952-5.
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  Moderate/severe traumatic brain injury (TBI) management involves minimizing cerebral edema to maintain brain oxygen delivery. While medical therapy (MT) consisting of diuresis, hyperosmolar therapy, ventriculostomy, and barbiturate coma is the standard of care, decompressive craniectomy (DC) for refractory intracranial hypertension (ICH) has gained renewed interest. Since TBI treatment guidelines consider DC a second-tier intervention after MT failure, we sought to determine if early DC (
• Paulus, E. M., Weinberg, J. A., Magnotti, L. J., Sharpe, J. P., Schroeppel, T. J., Fabian, T. C., & Croce, M. A. (2014). Admission red cell distribution width: a novel predictor of massive transfusion after injury. The American surgeon, 80(7), 685-9.
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  Admission red cell distribution width (aRDW) has been shown to predict mortality in trauma patients by an unclear mechanism. It has been speculated that aRDW is a marker of chronic health status, but elevated RDW may also reflect recent hemorrhage. We hypothesized that aRDW is a predictor of major hemorrhage in trauma patients. Shock trauma patients at a Level I trauma center over 6.5 years were evaluated. Patients were stratified by aRDW quintile (Q1: less than 13%, Q2: 13.1 to 13.5%, Q3: 13.6 to 14.0%, Q4: 14.1 to 14.9%, Q5: 15.0% or greater). Massive transfusion (MT) was defined as 10 or more packed red blood cells in the first 24 hours. From multiple logistic regression, odds ratios with 95 per cent confidence intervals (CIs) were determined to evaluate the association between aRDW quintile and MT. Three thousand nine hundred ninety-four met study criteria. Overall MT incidence was 10 per cent and in-hospital mortality was 17 per cent. MT and mortality increased in a stepwise fashion by aRDW quintile (P < 0.0001). From logistic regression, a threefold increased odds of MT was associated with aRDW Q4 (CI, 1.81 to 4.92), and a 3.5-fold increased odds of MT was associated with aRDW Q5 (CI, 2.70 to 5.83). aRDW independently predicted MT, suggesting that elevated aRDW is an indicator of major hemorrhage in trauma patients. The association between aRDW and mortality in trauma patients may be explained by acute hemorrhage rather than chronic health status.
• Schroeppel, T. J., Fabian, T. C., Clement, L. P., Fischer, P. E., Magnotti, L. J., Sharpe, J. P., Lee, M., & Croce, M. A. (2014). Propofol infusion syndrome: a lethal condition in critically injured patients eliminated by a simple screening protocol. Injury, 45(1), 245-9.
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  Propofol infusion syndrome (PIS) is defined by arrhythmia, rhabdomyolysis, lactic acidosis, and unrecognized leads to death. We sought to determine the incidence of PIS in trauma patients and evaluate the efficacy of a prospective screening protocol in this patient population.
• Schroeppel, T. J., Sharpe, J. P., Magnotti, L. J., Weinberg, J. A., Clement, L. P., Croce, M. A., & Fabian, T. C. (2014). Traumatic brain injury and β-blockers: not all drugs are created equal. The journal of trauma and acute care surgery, 76(2), 504-9; discussion 509.
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  Dysautonomia in traumatic brain injury patients may contribute to secondary injury. We hypothesize that propranolol is the best β-blocker (BB) to block the excess catecholamines and improve mortality in this patient population.
• Schroeppel, T. J., Sharpe, J. P., Magnotti, L. J., Weinberg, J. A., Croce, M. A., & Fabian, T. C. (2014). How to increase the burden on trauma centers: implement the 80-hour work week. The American surgeon, 80(7), 659-63.
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  The 80-hour week was implemented in 2003 to improve outcomes and limit errors. We hypothesize that there has been no change in outcomes postimplementation of the restrictions. Outcomes were queried from the trauma registry from 1997 to 2002 (PRE) and 2004 to 2009 (POST). Primary outcomes were mortality, intensive care unit length of stay (ICU LOS), and length of stay (LOS). Patients were stratified based on demographics, blood pressure, heart rate, and injury severity (Injury Severity Score, Glasgow Coma Score, base deficit). Outcomes were then compared PRE with POST. A total of 41,770 patients were admitted during the study period. The mean age was 38 years with most being male (73%) and blunt mechanism (78%). Although patients admitted in the POST period had a slightly higher blood pressure, they were older and had higher injury severity. ICU LOS, LOS, self-pay, and mortality were higher in the POST period. After adjusted analysis, admission in the POST period was no longer a predictor of mortality (odds ratio, 1.02; confidence interval, 0.92 to 1.14). Whereas patients were more slightly more injured in the POST period, the adjusted analysis shows no difference in mortality and both a longer LOS and ICU LOS. Whether the increase is the result of more severe injury in the POST period or less efficient disposition remains to be elucidated. This study adds to the mounting evidence that the implementation of the limits on work hours does not lead to better outcomes.
• Sharpe, J. P., Magnotti, L. J., Croce, M. A., Paulus, E. M., Schroeppel, T. J., Fabian, T. C., & Weinberg, J. A. (2014). Crystalloid administration during trauma resuscitation: does less really equal more?. The journal of trauma and acute care surgery, 77(6), 828-32; discussion 832.
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  Current direction in trauma resuscitation includes emphasis on minimizing crystalloid, along with early transfusion of blood products. Although evidence suggests that higher crystalloid volume during the first 24 hours is associated with negative outcomes, the effect of crystalloid administration during initial resuscitation remains unclear. The purpose of this study was to evaluate the impact of the ratio of crystalloid to packed red blood cells (C/PRBCs) infused during initial emergency department resuscitation on pulmonary morbidity and mortality.
• Sharpe, J. P., Magnotti, L. J., Weinberg, J. A., Brocker, J. A., Schroeppel, T. J., Zarzaur, B. L., Fabian, T. C., & Croce, M. A. (2014). Gender disparity in ventilator-associated pneumonia following trauma: identifying risk factors for mortality. The journal of trauma and acute care surgery, 77(1), 161-5.
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  Gender alone offers no survival advantage in humans following trauma. However, male gender does predict increased morbidity, specifically ventilator-associated pneumonia (VAP). Previous work has shown that despite lower incidence of VAP, females with VAP have increased mortality. The purposes of this study were to evaluate the impact of VAP and gender on outcome and to determine which characteristics of severe VAP predict mortality in trauma patients.
• Sharpe, J. P., Magnotti, L. J., Weinberg, J. A., Shahan, C. P., Cullinan, D. R., Marino, K. A., Fabian, T. C., & Croce, M. A. (2014). Applicability of an established management algorithm for destructive colon injuries after abbreviated laparotomy: a 17-year experience. Journal of the American College of Surgeons, 218(4), 636-41.
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  For more than a decade, operative decisions (resection plus anastomosis vs diversion) for colon injuries, at our institution, have followed a defined management algorithm based on established risk factors (pre- or intraoperative transfusion requirements of more than 6 units packed RBCs and/or presence of significant comorbid diseases). However, this management algorithm was originally developed for patients managed with a single laparotomy. The purpose of this study was to evaluate the applicability of this algorithm to destructive colon injuries after abbreviated laparotomy (AL) and to determine whether additional risk factors should be considered.
• Wood, G. C., Boucher, A. B., Johnson, J. L., Wisniewski, J. N., Magnotti, L. J., Croce, M. A., Swanson, J. M., Boucher, B. A., & Fabian, T. C. (2014). Effectiveness of pseudoephedrine as adjunctive therapy for neurogenic shock after acute spinal cord injury: a case series. Pharmacotherapy, 34(1), 89-93.
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  To evaluate the effectiveness of pseudoephedrine as adjunctive therapy for neurogenic shock in patients with acute spinal cord injury (SCI).
• DiCocco, J. M., Fabian, T. C., Emmett, K. P., Magnotti, L. J., Zarzaur, B. L., Khan, N., Kelly, J. M., & Croce, M. A. (2013). Functional outcomes following blunt cerebrovascular injury. The journal of trauma and acute care surgery, 74(4), 955-60.
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  There has been much debate on whom to screen, how to screen, and how to treat blunt cerebrovascular injury (BCVI), but there has been little published on long-term functional outcomes following diagnosis and treatment of BCVI. This study was conducted to address those long-term outcomes.
• Hill, D. M., Schroeppel, T. J., Magnotti, L. J., Clement, L. P., Sharpe, J. P., Fischer, P. E., Weinberg, J. A., Croce, M. A., & Fabian, T. C. (2013). Methicillin-resistant Staphylococcus aureus in early ventilator-associated pneumonia: cause for concern?. Surgical infections, 14(6), 520-4.
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  Ventilator-associated pneumonia (VAP) accounts for almost 90% of infections in mechanically ventilated patients and more than one-quarter of all patients requiring intubation, with associated mortality rates as high as 70%. The rise in methicillin resistance within the community has led to a national increase in methicillin-resistant Staphylococcus aureus (MRSA) rates in early VAP and associated healthcare expenditure.
• McGwin, G., Melton, S., Kerby, J., Rue, L. W., Magnotti, L. J., Croce, M. A., Fabian, T. C., & Weinberg, J. A. (2013). Survival bias revisited. The journal of trauma and acute care surgery, 74(1), 345-6.
• Sharpe, J. P., Magnotti, L. J., Weinberg, J. A., Shahan, C. P., Cullinan, D. R., Fabian, T. C., & Croce, M. A. (2013). Applicability of an established management algorithm for colon injuries following blunt trauma. The journal of trauma and acute care surgery, 74(2), 419-24; discussion 424-5.
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  Operative management at our institution for all colon injuries have followed a defined algorithm (ALG) based on risk factors originally identified for penetrating injuries. The purpose of this study was to evaluate the applicability of the ALG to blunt colon injuries.
• Sharpe, J. P., Weinberg, J. A., Magnotti, L. J., Fabian, T. C., & Croce, M. A. (2013). Does plasma transfusion portend pulmonary dysfunction? A tale of two ratios. The journal of trauma and acute care surgery, 75(1), 32-6; discussion 36.
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  An unresolved concern regarding resuscitation in the setting of massive hemorrhage is potential lung injury from the transfusion of relatively more plasma-rich components. However, the association between plasma-to-packed red blood cell (PRBC) ratio and subsequent pulmonary dysfunction remains unclear. The purpose of this study was to evaluate the impact of plasma/PRBC on PaO2-to-FIO2 (P/F) ratio in the setting of massive transfusion (MT).
• Sharpe, J. P., Weinberg, J. A., Magnotti, L. J., Nouer, S. S., Yoo, W., Zarzaur, B. L., Cullinan, D. R., Hendrick, L. E., Fabian, T. C., & Croce, M. A. (2013). Outcomes of operations performed by attending surgeons after overnight trauma shifts. Journal of the American College of Surgeons, 216(4), 791-7; discussion 797-9.
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  To date, work-hour restrictions have not been imposed on attending surgeons in the United States. The purpose of this study was to investigate the impact of working an overnight trauma shift on outcomes of general surgery operations performed the next day by the post-call attending physician.
• Swanson, J. M., Connor, K. A., Magnotti, L. J., Croce, M. A., Johnson, J., Wood, G. C., & Fabian, T. C. (2013). Resolution of clinical and laboratory abnormalities after diagnosis of ventilator-associated pneumonia in trauma patients. Surgical infections, 14(1), 49-55.
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  Guidelines advise that patients with ventilator-associated pneumonia (VAP) should respond clinically by Day 3 of antibiotics. White blood cell (WBC) count, maximum temperature (Tmax), and PaO2:FIO2 ratio are all said to respond significantly by Day 6. Resolution of abnormalities has not been evaluated in trauma patients.
• Weinberg, J. A., MacLennan, P. A., Vandromme-Cusick, M. J., Magnotti, L. J., Kerby, J. D., Rue, L. W., Angotti, J. M., Garrett, C. A., Hendrick, L. E., Croce, M. A., Fabian, T. C., Barnum, S. R., & Patel, R. P. (2013). The deleterious effect of red blood cell storage on microvascular response to transfusion. The journal of trauma and acute care surgery, 75(5), 807-12.
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  The transfusion of relatively older red blood cells (RBCs) has been associated with both morbidity and mortality in trauma patients in observational studies. Although the mechanisms responsible for this phenomenon remain unclear, alterations in the microcirculation as a result of the transfusion of relatively older blood may be a causative factor. To assess this hypothesis, we evaluated microvascular perfusion in trauma patients during RBC transfusion.
• Wells, D. L., Swanson, J. M., Wood, G. C., Magnotti, L. J., Boucher, B. A., Croce, M. A., Harrison, C. G., Muhlbauer, M. S., & Fabian, T. C. (2013). Authors' response. Critical care (London, England), 17(1), 401.
• DiCocco, J. M., Fabian, T. C., Emmett, K. P., Magnotti, L. J., Goldberg, S. P., & Croce, M. A. (2012). Components separation for abdominal wall reconstruction: the Memphis modification. Surgery, 151(1), 118-25.
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  Since the advent of damage control surgery, more patients are left with an open abdomen. Surgeons are then left with the challenge of how to restore continuity of the abdominal wall. Many different techniques have been utilized for reconstruction with widely variable recurrence rates, mainly depending on the length of follow-up. A modification of the components separation technique was developed in Memphis, Tennessee at the Presley Memorial Trauma Center. This modification greatly increased the length gained in the midline. Additionally, many patients can be reconstructed without the use of prosthetics, reducing the infectious complications. The purpose of this manuscript is to describe in detail how to perform a modification of the components separation technique that has been shown to have one of the lowest recurrence rates in the literature.
• Dickerson, R. N., Pitts, S. L., Maish, G. O., Schroeppel, T. J., Magnotti, L. J., Croce, M. A., Minard, G., & Brown, R. O. (2012). A reappraisal of nitrogen requirements for patients with critical illness and trauma. The journal of trauma and acute care surgery, 73(3), 549-57.
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  Studies regarding protein requirements for patients with critical illness are inconclusive owing to small sample size and population heterogeneity. The primary objectives of this study were to determine the amount of protein required to achieve nitrogen equilibrium or a positive nitrogen balance (NB, -4 g/d or better) and ascertain whether patients with traumatic brain injury (TBI) exhibit greater protein catabolism than those without TBI.
• Hamilton, L. A., Christopher Wood, G., Magnotti, L. J., Croce, M. A., Martin, J. B., Swanson, J. M., Boucher, B. A., & Fabian, T. C. (2012). Treatment of methicillin-resistant Staphylococcus aureus ventilator-associated pneumonia with high-dose vancomycin or linezolid. The journal of trauma and acute care surgery, 72(6), 1478-83.
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  The purpose of this study was to determine the clinical cure rate of high-dose vancomycin for the treatment of methicillin-resistant Staphylococcus aureus (MRSA) ventilator-associated pneumonia (VAP) in critically ill trauma patients. Recent trials suggest that a traditional dose of 1 g q12 hours results in unacceptable cure rates for MRSA VAP. Thus, more aggressive vancomycin dosing has the potential to improve efficacy. Based on pharmacokinetic principles, the goal initial dose at the study center has been 20 mg/kg q12 hours or q8 hours since the 1990s.
• Parks, N. A., Magnotti, L. J., Weinberg, J. A., Zarzaur, B. L., Schroeppel, T. J., Swanson, J. M., Fabian, T. C., & Croce, M. A. (2012). Use of the clinical pulmonary infection score to guide therapy for ventilator-associated pneumonia risks antibiotic overexposure in patients with trauma. The journal of trauma and acute care surgery, 73(1), 52-8; discussion 58-9.
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  The clinical pulmonary infection score (CPIS) has been advocated to guide both the diagnosis and duration of therapy in ventilator-associated pneumonia (VAP). However, the clinical, physiologic, and radiologic components of the CPIS may be difficult to differentiate from the systemic effects of injury and inflammation, unnecessarily prolonging VAP therapy. This study evaluates the use of CPIS in determining the appropriate duration of antimicrobial therapy for VAP in patients with critical illness and trauma.
• Sharpe, J. P., Magnotti, L. J., Weinberg, J. A., Parks, N. A., Maish, G. O., Shahan, C. P., Fabian, T. C., & Croce, M. A. (2012). Adherence to a simplified management algorithm reduces morbidity and mortality after penetrating colon injuries: a 15-year experience. Journal of the American College of Surgeons, 214(4), 591-7; discussion 597-8.
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  Our previous experience with colon injuries suggested that operative decisions based on a defined algorithm improve outcomes. The purpose of this study was to evaluate the validity of this algorithm in the face of an increased incidence of destructive injuries observed in recent years.
• Sharpe, J. P., Magnotti, L. J., Weinberg, J. A., Zarzaur, B. L., Shahan, C. P., Parks, N. A., Fabian, T. C., & Croce, M. A. (2012). Impact of location on outcome after penetrating colon injuries. The journal of trauma and acute care surgery, 73(6), 1428-32; discussion 1433.
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  Most studies examining suture line failure after penetrating colon injuries have focused on right- versus left-sided injuries. In our institution, operative decisions (resection plus anastomosis vs. diversion) are based on a defined management algorithm regardless of injury location. The purpose of this study was to evaluate the effect of injury location on outcomes after penetrating colon injuries.
• Sharpe, J. P., Magnotti, L. J., Weinberg, J. A., Zarzaur, B. L., Stickley, S. M., Scott, S. E., Fabian, T. C., & Croce, M. A. (2012). Impact of a defined management algorithm on outcome after traumatic pancreatic injury. The journal of trauma and acute care surgery, 72(1), 100-5.
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  The optimal management of pancreatic injuries, specifically with respect to defining ductal integrity, remains controversial. Our previous experience suggested that decisions based on probability of ductal injury might improve outcome. Consequently, a management algorithm (ALG) was developed and implemented. The purpose of this study was to evaluate the impact of this ALG on outcomes.
• Sharpe, J. P., Weinberg, J. A., Magnotti, L. J., Croce, M. A., & Fabian, T. C. (2012). Toward a better definition of massive transfusion: focus on the interval of hemorrhage control. The journal of trauma and acute care surgery, 73(6), 1553-7.
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  In clinical research, massive transfusion (MT) is commonly defined as transfusion of 10 or more red blood cell (RBC) units within 24 hours. However, the clinical relevance of this definition remains poorly understood. In this study, we evaluated whether patients who reach the MT threshold during hemorrhage control differ clinically from those who reach it after hemorrhage control (i.e., after intensive care unit [ICU] arrival) but before 24 hours.
• Sharpe, J. P., Weinberg, J. A., Magnotti, L. J., Maclennan, P. A., Schroeppel, T. J., Fabian, T. C., & Croce, M. A. (2012). Accounting for differences in transfusion volume: Are all massive transfusions created equal?. The journal of trauma and acute care surgery, 72(6), 1536-40.
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  Among patients subjected to massive transfusion (MT), some will require considerably more blood than others, depending on the rate and quantity of hemorrhage. In analyses concerning plasma to red blood cell (RBC) ratios and platelet to RBC ratios, this has yet to be examined. We sought to evaluate the effect of the number of RBC units transfused on both plasma:RBC and platelet:RBC and their association with mortality in MT patients.
• Weinberg, J. A., MacLennan, P. A., Vandromme-Cusick, M. J., Angotti, J. M., Magnotti, L. J., Kerby, J. D., Rue, L. W., Barnum, S. R., & Patel, R. P. (2012). Microvascular response to red blood cell transfusion in trauma patients. Shock (Augusta, Ga.), 37(3), 276-81.
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  Trauma patients are often transfused allogeneic red blood cells (RBCs) in an effort to augment tissue oxygen delivery. However, the effect of RBC transfusion on microvascular perfusion in this patient population is not well understood. To this end, we investigated the effect of RBC transfusion on sublingual microvascular perfusion in trauma patients. Sublingual microcirculation was imaged at bedside with a sidestream dark-field illumination microscope before and after transfusion of one RBC unit in hemodynamically stable, anemic trauma patients. The perfused proportion of capillaries (PPC) before and after transfusion was determined, and the percent change in capillary perfusion following transfusion (ΔPPC) calculated. Sublingual microcirculation was observed in 30 patients. Mean age was 47 (SD, 21) years, mean Injury Severity Score was 29 (SD, 16), and mean pretransfusion hemoglobin was 7.5 (SD, 0.9) g/dL. No patients had a mean arterial pressure of less than 65 mmHg (mean, 89 [SD, 17] mmHg) or lactate of greater than 2.5 mmol/L (mean, 1.1 [SD, 0.3] mmol/L). Following transfusion, ΔPPC ranged from +68% to -36% and was found to inversely correlate significantly with pretransfusion PPC (Spearman r = -0.63, P = 0.0002). Pretransfusion PPC may be selectively deranged in otherwise stable trauma patients. Patients with relatively altered baseline PPC tend to demonstrate improvement in perfusion following transfusion, whereas those with relatively normal perfusion at baseline tend to demonstrate either no change or, in fact, a decline in PPC. Bedside sublingual imaging may have the potential to detect subtle perfusion defects and ultimately inform clinical decision making with respect to transfusion.
• Wells, D. L., Swanson, J. M., Wood, G. C., Magnotti, L. J., Boucher, B. A., Croce, M. A., Harrison, C. G., Muhlbauer, M. S., & Fabian, T. C. (2012). The relationship between serum sodium and intracranial pressure when using hypertonic saline to target mild hypernatremia in patients with head trauma. Critical care (London, England), 16(5), R193.
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  Limited data suggest mild hypernatremia may be related to lower intracranial pressure (ICP) in patients with traumatic brain injury (TBI). The practice at the study center has been to use hypertonic saline (HTS) to generate a targeted serum sodium of 145 to 155 mEq/l in patients with TBI. The purpose of this study was to determine the relationship between serum sodium values and ICP, and to evaluate the acute effect of HTS on ICP.
• Amin, P. B., Magnotti, L. J., Fischer, P. E., Fabian, T. C., & Croce, M. A. (2011). Prophylactic antibiotic days as a predictor of sensitivity patterns in Acinetobacter pneumonia. Surgical infections, 12(1), 33-8.
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  Ventilator-associated pneumonia (VAP) secondary to Acinetobacter spp. in critically ill trauma patients has increased. More importantly, the incidence of multi-drug-resistant (MDR) Acinetobacter VAP has increased. The risk factors for this increase in resistance have yet to be elucidated. The purpose of this study was to evaluate the change in Acinetobacter sensitivity over time and determine which risk factors predict resistance in trauma patients.
• Czosnowski, Q. A., Wood, G. C., Magnotti, L. J., Croce, M. A., Swanson, J. M., Boucher, B. A., & Fabian, T. C. (2011). Clinical and microbiologic outcomes in trauma patients treated for Stenotrophomonas maltophilia ventilator-associated pneumonia. Pharmacotherapy, 31(4), 338-45.
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  To determine clinical and microbiologic plus clinical success rates in critically ill trauma patients who received treatment for Stenotrophomonas maltophilia ventilator-associated pneumonia (VAP).
• DiCocco, J. M., Fabian, T. C., Emmett, K. P., Magnotti, L. J., Zarzaur, B. L., Bate, B. G., Muhlbauer, M. S., Khan, N., Kelly, J. M., Williams, J. S., & Croce, M. A. (2011). Optimal outcomes for patients with blunt cerebrovascular injury (BCVI): tailoring treatment to the lesion. Journal of the American College of Surgeons, 212(4), 549-57; discussion 557-9.
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  Blunt cerebrovascular injuries (BCVI) once went unrecognized until cerebral ischemia or death occurred. We previously demonstrated that screening of high-risk asymptomatic patients and early treatment improved outcomes. However, major dissections, pseudoaneurysms, and fistulas rarely heal with antithrombotic therapy alone. Endovascular therapy in these lesions has increased without reports of outcomes. We sought to determine ischemic stroke and death rates after BCVI with and without endovascular treatment.
• Fischer, P. E., Zarzaur, B. L., Fabian, T. C., Magnotti, L. J., & Croce, M. A. (2011). Minor trauma is an unrecognized contributor to poor fetal outcomes: a population-based study of 78,552 pregnancies. The Journal of trauma, 71(1), 90-3.
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  Fetal outcomes after minor injury (MI) to pregnant women are difficult to study because these patients are discharged after emergency room evaluation and not entered in trauma registries. The purpose of this study was to determine the association of both minor and severe injury on fetal demise and prematurity/low birth weight (LBW) in a large population-based study using robust state databases.
• Magnotti, L. J., Bradburn, E. H., Webb, D. L., Berry, S. D., Fischer, P. E., Zarzaur, B. L., Schroeppel, T. J., Fabian, T. C., & Croce, M. A. (2011). Admission ionized calcium levels predict the need for multiple transfusions: a prospective study of 591 critically ill trauma patients. The Journal of trauma, 70(2), 391-5; discussion 395-7.
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  Deaths from uncontrolled exsanguinating hemorrhage occur rapidly postinjury. Any successful resuscitation strategy must also occur early, underscoring the importance of rapid identification of patients at risk for multiple transfusions. Previous studies have shown low ionized calcium (iCa) levels to be associated with hypotension and function as a predictor of mortality. We hypothesized that admission iCa levels could potentially predict the need for multiple transfusions in critically ill trauma patients.
• Magnotti, L. J., Croce, M. A., Zarzaur, B. L., Swanson, J. M., Wood, G. C., Weinberg, J. A., & Fabian, T. C. (2011). Causative pathogen dictates optimal duration of antimicrobial therapy for ventilator-associated pneumonia in trauma patients. Journal of the American College of Surgeons, 212(4), 476-84; discussion 484-6.
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  Recent ventilator-associated pneumonia (VAP) guidelines recommend considering abbreviated therapy in patients with non-Pseudomonas aeruginosa VAP if clinical signs resolve. However, using an arbitrary day cutoff or clinical signs can be suboptimal for some, especially multiply injured patients, resulting in relapse and/or antibiotic resistance. Previously, we showed that repeat bronchoalveolar lavage (BAL) could guide antimicrobial duration for community-acquired VAP in trauma patients. The purpose of this study was to determine the appropriate duration of antimicrobial therapy for VAP in trauma patients secondary to hospital-acquired pathogens.
• Magnotti, L. J., Zarzaur, B. L., Fischer, P. E., Williams, R. F., Myers, A. L., Bradburn, E. H., Fabian, T. C., & Croce, M. A. (2011). Improved survival after hemostatic resuscitation: does the emperor have no clothes?. The Journal of trauma, 70(1), 97-102.
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  In light of recent data, controversy surrounds the apparent 30-day survival benefit of patients achieving a fresh frozen plasma (FFP) to packed red blood cell (PRBC) ratio of at least 1:2 in the face of massive transfusions (MT) (≥10 units of PRBC within 24 hours of admission). We hypothesized that initial studies suffer from survival bias because they do not consider early deaths secondary to uncontrolled exsanguinating hemorrhage. To help resolve this controversy, we evaluated the temporal relationship between blood product administration and mortality in civilian trauma patients receiving MT.
• Zarzaur, B. L., DiCocco, J. M., Shahan, C. P., Emmett, K., Magnotti, L. J., Croce, M. A., Hathaway, D. K., & Fabian, T. C. (2011). Quality of life after abdominal wall reconstruction following open abdomen. The Journal of trauma, 70(2), 285-91.
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  Management of intra-abdominal hypertension with an open abdomen and planned ventral hernia results in decreased mortality. But, delayed abdominal wall reconstruction (DAWR) is necessary. Results after DAWR demonstrate acceptable recurrence, morbidity, and mortality rates. However, little is known about quality of life (QOL) after DAWR. The purpose of this study was to analyze QOL after DAWR.
• DiCocco, J. M., Magnotti, L. J., Emmett, K. P., Zarzaur, B. L., Croce, M. A., Sharpe, J. P., Shahan, C. P., Jiao, H., Goldberg, S. P., & Fabian, T. C. (2010). Long-term follow-up of abdominal wall reconstruction after planned ventral hernia: a 15-year experience. Journal of the American College of Surgeons, 210(5), 686-95, 695-8.
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  Although damage control strategies and the open abdomen have improved survival, they present their own unique set of challenges in caring for the multiply injured trauma patient. We previously reported the technique of staged abdominal wall closure for the management of the open abdomen. The purpose of this study was to evaluate the efficacy of various techniques of abdominal wall reconstruction (final stage of management) on long-term outcomes after planned ventral hernia, and to better define risk factors for recurrence.
• Swanson, J. M., Mueller, E. W., Croce, M. A., Wood, G. C., Boucher, B. A., Magnotti, L. J., & Fabian, T. C. (2010). Changes in pulmonary cytokines during antibiotic therapy for ventilator-associated pneumonia. Surgical infections, 11(2), 161-7.
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  A major unanswered question in ventilator-associated pneumonia (VAP) management relates to patient response to therapy. We investigated the use of pulmonary cytokines as biomarkers for response to antibiotic therapy for VAP.
• Zarzaur, B. L., Croce, M. A., Fabian, T. C., Fischer, P., & Magnotti, L. J. (2010). A population-based analysis of neighborhood socioeconomic status and injury admission rates and in-hospital mortality. Journal of the American College of Surgeons, 211(2), 216-23.
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  Research indicates that neighborhood socioeconomic status (N-SES) is inversely related to injury and injury-related mortality. We hypothesized that injury-related hospitalization rates would vary by N-SES and that N-SES would be related to in-hospital mortality.
• Zarzaur, B. L., Croce, M. A., Magnotti, L. J., & Fabian, T. C. (2010). Identifying life-threatening shock in the older injured patient: an analysis of the National Trauma Data Bank. The Journal of trauma, 68(5), 1134-8.
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  Reliance on traditional vital signs (TVS), particularly in older patients, to identify life-threatening shock after injury may be unreliable. Shock index (SI), defined as heart rate divided by systolic blood pressure (SBP), may be a better indicator of early shock after injury than TVS. Multiplying age by SI (age x SI) may be better in older injured patients. We hypothesized that age x SI would be a better predictor of 48-hour mortality in old patients (age, >55 years) compared with TVS, whereas for young patients (age,
• Zarzaur, B. L., Magnotti, L. J., Croce, M. A., Haider, A. H., & Fabian, T. C. (2010). Long-term survival and return on investment after nonneurologic injury: implications for the elderly trauma patient. The Journal of trauma, 69(1), 93-8.
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  As the population of the United States ages and as the healthcare system undergoes significant change, cost effectiveness of care will become more important, particularly for older injured patients. The purpose of this study was to evaluate the cost per 2-year survivor stratified by age after moderate- to severe-nonneurologic injury.
• Zarzaur, B. L., Stair, B. R., Magnotti, L. J., Croce, M. A., & Fabian, T. C. (2010). Insurance type is a determinant of 2-year mortality after non-neurologic trauma. The Journal of surgical research, 160(2), 196-201.
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  Lack of health insurance (NO-INS) is associated with increased long-term mortality after head and spinal cord injuries (NEURO-TRA). Less is known about the influence of insurance type and long-term mortality following non-NEURO-TRA. We hypothesized that NO-INS would be associated with 2-y mortality after moderate to severe injury.
• Croce, M. A., Zarzaur, B. L., Magnotti, L. J., & Fabian, T. C. (2009). Impact of motorcycle helmets and state laws on society's burden: a national study. Annals of surgery, 250(3), 390-4.
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  To analyze a large national database, the National Trauma Data Bank, regarding the contribution of motorcycle helmet use to outcome and the efficacy of state helmet laws.
• Czosnowski, Q. A., Wood, G. C., Magnotti, L. J., Croce, M. A., Swanson, J. M., Boucher, B. A., & Fabian, T. C. (2009). Adjunctive aerosolized antibiotics for treatment of ventilator-associated pneumonia. Pharmacotherapy, 29(9), 1054-60.
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  To determine clinical and microbiologic success in patients receiving adjunctive aerosolized antibiotics for the treatment of ventilator-associated pneumonia (VAP).
• Fischer, P. E., Fabian, T. C., Magnotti, L. J., Schroeppel, T. J., Bee, T. K., Maish, G. O., Savage, S. A., Laing, A. E., Barker, A. B., & Croce, M. A. (2009). A ten-year review of enterocutaneous fistulas after laparotomy for trauma. The Journal of trauma, 67(5), 924-8.
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  In the era of open abdomen management, the complication of enterocutaneous fistula (ECF) seems to be increasing in frequency. In nontrauma patients, reported mortality rates are 7% to 20%, and spontaneous closure rates are approximately 25%. This study is the largest series of ECFs reported exclusively caused by trauma and examines the characteristics unique to this population.
• Fischer, P. E., Schroeppel, T. J., Fabian, T. C., deRijk, W. G., Edwards, N. M., Magnotti, L. J., Doty, D. H., & Croce, M. A. (2009). Antibiotic-coated ePTFE decreases graft colonization and neointimal hyperplasia. The Journal of surgical research, 156(2), 199-204.
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  Synthetic vascular conduits used in traumatic or infected fields have a high failure rate leading to catastrophic consequences including amputation and death. Although efforts to coat vascular grafts with antibiotics have had varying results, we developed a novel coating technique for expanded-polytetrafluoroethylene (ePTFE), which has proven to be effective in vitro. Thus, we hypothesized that the coated grafts would resist infection and have decreased neointimal hyperplasia when used in vivo in a large animal model.
• Hargraves, M. B., Magnotti, L. J., Fischer, P. E., Schroeppel, T. J., Zarzaur, B. L., Fabian, T. C., & Croce, M. A. (2009). Injury location dictates utility of digital rectal examination and rigid sigmoidoscopy in the evaluation of penetrating rectal trauma. The American surgeon, 75(11), 1069-72.
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  Penetrating pelvic injuries (specifically rectal) pose a difficult diagnostic challenge. Although management of these injuries, once recognized, can be straightforward, the consequences of a missed injury can be devastating. The purpose of this study was to evaluate the utility of digital rectal examination (DRE) and rigid sigmoidoscopy (RS) as screening tests for penetrating rectal injuries. Patients with full-thickness penetrating rectal injury over a 10-year period were identified. All underwent DRE and RS before exploration. Injury location was classified as intraperitoneal (IP) or extraperitoneal (EP). Overall sensitivities for DRE and RS were calculated as well as sensitivities for RS in the identification of IP versus EP injuries. Seventy-seven patients were identified. Overall sensitivity for DRE and RS was 51 per cent (95% CI: 37-65%) and 78 per cent (95% CI: 65-92%), respectively. Sensitivity of RS for identification of rectal injury based on anatomic distinction was 58 per cent (95% CI: 30-86%) for IP and 88 per cent (95% CI: 75-100%) for EP injuries. Anatomic location determines the value of preoperative screening tests for identification of penetrating rectal injuries. RS proved better than DRE for diagnosis. The greatest benefit was observed with EP injuries. The possibility of a missed IP injury associated with a negative screen should prompt exploration if clinical suspicion is high.
• Magnotti, L. J., Schroeppel, T. J., Clement, L. P., Swanson, J. M., Bee, T. K., Maish, G. O., Minard, G., Zarzaur, B. L., Fischer, P. E., Fabian, T. C., & Croce, M. A. (2009). Efficacy of monotherapy in the treatment of Pseudomonas ventilator-associated pneumonia in patients with trauma. The Journal of trauma, 66(4), 1052-8; discussion 1058-9.
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  Controversy persists regarding the optimal treatment regimen for Pseudomonas ventilator-associated pneumonia (VAP). Combination antibiotic therapy is used to broaden the spectrum of activity of empiric treatment and provide synergistic bacteriocidal activity. The relevance of such "synergy" is commonly supposed but poorly supported. The purpose of this study was to evaluate the efficacy of monotherapy in the treatment of Pseudomonas VAP as measured by microbiological resolution.
• Stoikes, N., Nezakatgoo, N., Fischer, P., Bahr, M., & Magnotti, L. (2009). Salvage of inaccessible arteriovenous fistulas in obese patients: a review of 132 brachiocephalic fistulas. The American surgeon, 75(8), 705-9; discussion 709.
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  The two main factors leading to a functional fistula are maturity and accessibility. The aim of this review was to describe a technique of superficialization for inaccessible brachiocephalic fistulas, and to identify the patients that benefit from superficialization. One hundred and thirty-two brachiocephalic arteriovenous fistulas developed from November 2003 to December 2006 were reviewed for primary maturation. In the mature group, patients were evaluated for fistula accessibility. Inaccessible fistulas were selected for superficialization via our technique of vein mobilization using small skip incisions. Analysis of superficialized and nonsuperficialized groups included age, demographics, and comorbidities. Ninety-nine patients were in the mature group, and 33 in the immature group; primary nonmaturation was 25 per cent. Analysis within the mature group was between nonsuperficialized (n = 81) and superficialized (n = 18) patients. The superficialized group had less hypertension (83% vs 98%, P < 0.05), significantly higher BMI (31 vs 27, P < 0.05), and was mostly female (78% vs 49%, P < 0.05). All superficialized fistulas accommodated successful hemodialysis postoperatively. To conclude, patients with mature but inaccessible fistulas were salvaged by superficialization. This population had significantly higher BMI, less hypertension, and female prevalence. Identifying these patients is important because salvage of their fistula can prevent premature progression to alternate autogenous arteriovenous access procedures.
• Williams, R. F., Magnotti, L. J., Croce, M. A., Hargraves, B. B., Fischer, P. E., Schroeppel, T. J., Zarzaur, B. L., Muhlbauer, M., Timmons, S. D., & Fabian, T. C. (2009). Impact of decompressive craniectomy on functional outcome after severe traumatic brain injury. The Journal of trauma, 66(6), 1570-4; discussion 1574-6.
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  The beneficial effect of decompressive craniectomy (DC) in the treatment of traumatic brain injury (TBI) remains controversial. In many centers, it is used as a salvage procedure for uncontrollable intracranial pressure (ICP). It is our contention that DC represents a viable early option for head trauma patients. The purpose of this study was to evaluate the efficacy of DC on functional outcome after severe TBI in the largest single institutional series reported in the literature.
• Zarzaur, B. L., Vashi, S., Magnotti, L. J., Croce, M. A., & Fabian, T. C. (2009). The real risk of splenectomy after discharge home following nonoperative management of blunt splenic injury. The Journal of trauma, 66(6), 1531-6; discussion 1536-8.
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  The postdischarge natural history of nonoperative blunt splenic injury (BSI) has not been adequately elucidated. As a result, outpatient management is poorly defined. Population-based outpatient data would provide clinicians with an estimate of baseline risk of postdischarge splenectomy after nonoperative management of BSI. The purpose of this study was to analyze, using population-based data, the 180-day risk of splenectomy in a clinically relevant sample.
• Fischer, P. E., Fabian, T. C., deRijk, W. G., Edwards, N. M., DeCuypere, M., Landis, R. M., Barnard, D. L., Magnotti, L. J., & Croce, M. A. (2008). Prosthetic vascular conduit in contaminated fields: a new technology to decrease ePTFE infections. The American surgeon, 74(6), 524-8; discussion 528-9.
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  Vascular reconstruction using prosthetic materials in contaminated fields can lead to infection, graft loss, and subsequent amputation. We hypothesized that minocycline and rifampin bound to an ePTFE graft using a unique methacrylate technology would provide for resistance from infection and controlled antibiotic elution. Kirby Bauer susceptibility testing was performed on plates overlaid with Staph aureus (SA) and Staph epidermidis (SE) using 6 mm diameter discs of uncoated graft or antibiotic coated graft (ABX). Zones of inhibition (ZIH) were determined after 24 hours. ABX grafts were then placed in a continuous water bath and a recirculating, pulsatile flow device. Susceptibility testing and high performance liquid chromatography with mass spectroscopy was performed to determine graft performance and antibiotic elution rate. ABX grafts had an average ZIH of 35 mm for SA and 44 mm for SE (each P < 0.0001). After the 1 week water bath, the ZIH of the ABX grafts was 23 mm on both the SA and SE plates. The high performance liquid chromatography with mass spectroscopy revealed that after 24 hours, 50 per cent of the antibiotics remained on the graft, and there was a sustained elution for 7 days. Minocycline and rifampin can be bound to ePTFE vascular grafts using a unique methacrylate method. In vitro, the grafts provide a slow elution of antibiotics that provide resistance from infection by SA and SE for up to 2 weeks after graft insertion.
• Magnotti, L. J., Fischer, P. E., Zarzaur, B. L., Fabian, T. C., & Croce, M. A. (2008). Impact of gender on outcomes after blunt injury: a definitive analysis of more than 36,000 trauma patients. Journal of the American College of Surgeons, 206(5), 984-91; discussion 991-2.
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  The concept that premenopausal female patients are more resistant to shock than male patients has been shown in numerous preclinical models. The more relevant effect of gender on clinically important outcomes after trauma is less clear. Clinical studies have been conflicting, both supporting and refuting the protective effects of gender on outcomes, primarily because of limitations in sample size and patient stratification. In an attempt to resolve this ongoing dispute, we evaluated the effect of gender on various outcomes in the largest single institutional series of trauma patients reported in the literature after blunt injury.
• Magnotti, L. J., Schroeppel, T. J., Fabian, T. C., Clement, L. P., Swanson, J. M., Fischer, P. E., Bee, T. K., Maish, G. O., Minard, G., Zarzaur, B. L., & Croce, M. A. (2008). Reduction in inadequate empiric antibiotic therapy for ventilator-associated pneumonia: impact of a unit-specific treatment pathway. The American surgeon, 74(6), 516-22; discussion 522-3.
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  Empiric antibiotic therapy is routinely initiated for patients with presumed ventilator-associated pneumonia (VAP). Reported mortality rates for inadequate empiric antibiotic therapy (IEAT) for VAP range from 45 to 91 per cent. The purpose of this study was to determine the effect of a unit-specific pathway for the empiric management of VAP on reducing IEAT episodes and improving outcomes in trauma patients. Patients admitted with VAP over 36-months were identified and stratified by gender, age, severity of shock, and injury severity. Outcomes included number of IEAT episodes, ventilator days, intensive care unit days, hospital days, and mortality. Three hundred and ninety-three patients with 668 VAP episodes were identified. There were 144 (22%) IEAT episodes: significantly reduced compared with our previous study (39%) (P < 0.001). Patients were classified by number of IEAT episodes: 0 (n = 271), 1 (n = 98) and > or = 2 (n = 24). Mortality was 12 per cent, 13 per cent, and 38 per cent (P < 0.001), respectively. Multivariable logistic regression identified multiple IEAT episodes as an independent predictor of mortality (odds ratio = 4.7; 95% confidence interval: 1.684-13.162). Multiple IEAT episodes were also associated with prolonged mechanical ventilation and intensive care unit stay (P < 0.001). Trauma patients with multiple IEAT episodes for VAP have increased morbidity and mortality. Adherence to a unit-specific pathway for the empiric management of VAP reduces multiple IEAT episodes. By limiting IEAT episodes, resource utilization and hospital mortality are significantly decreased.
• Powell, B. S., Magnotti, L. J., Schroeppel, T. J., Finnell, C. W., Savage, S. A., Fischer, P. E., Fabian, T. C., & Croce, M. A. (2008). Diagnostic laparoscopy for the evaluation of occult diaphragmatic injury following penetrating thoracoabdominal trauma. Injury, 39(5), 530-4.
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  Occult diaphragmatic injury following penetrating thoracoabdominal trauma can be difficult to diagnose. Radiographic findings are often non-specific or absent. Undetected injuries may remain clinically silent, only to present later with life-threatening complications associated with diaphragmatic herniation. Diagnostic laparoscopy allows for the evaluation of trauma patients lacking clinical indications for a formal laparotomy. The purpose of this study was to evaluate the incidence of occult diaphragmatic injury and investigate the role of laparoscopy in patients with penetrating thoracoabdominal trauma who lack indications for exploratory laparotomy except the potential for a diaphragmatic injury.
• Stoikes, N. F., Magnotti, L. J., Hodges, T. M., Weinberg, J. A., Schroeppel, T. J., Savage, S. A., Fischer, P. E., Fabian, T. C., & Croce, M. A. (2008). Impact of intracranial pressure monitor prophylaxis on central nervous system infections and bacterial multi-drug resistance. Surgical infections, 9(5), 503-8.
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  Routine intracranial pressure monitor (ICP) prophylaxis is not practiced at our institution. Nevertheless, some patients receive de facto prophylaxis as a result of the use of antibiotics for injuries such as open or facial fractures. We tested the hypothesis that prophylactic antibiotics do not reduce the incidence of central nervous system (CNS) infections but instead are associated with the acquisition of multi-drug resistant (MDR) bacterial infections.
• Weinberg, J. A., Magnotti, L. J., Fischer, P. E., Edwards, N. M., Schroeppel, T., Fabian, T. C., & Croce, M. A. (2008). Comparison of intravenous ethanol versus diazepam for alcohol withdrawal prophylaxis in the trauma ICU: results of a randomized trial. The Journal of trauma, 64(1), 99-104.
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  Although benzodiazepines are the recommended first-line therapy for the prevention of alcohol withdrawal syndrome (AWS), the administration of intravenous ethanol as an alternative prophylactic agent persists in many surgical ICUs. Advocates of this therapy argue that ethanol provides effective prophylaxis against AWS without the excessive sedation observed with benzodiazepine therapy. No study to date, however, has compared the two therapies with regard to their sedative effects. The purpose of this study was to prospectively evaluate the efficacy of intravenous ethanol compared with benzodiazepines for the prevention of AWS with particular emphasis on the sedative effects of each therapy.
• Williams, R. F., Fabian, T. C., Fischer, P. E., Zarzaur, B. L., Magnotti, L. J., & Croce, M. A. (2008). Impact of airbags on a Level I trauma center: injury patterns, infectious morbidity, and hospital costs. Journal of the American College of Surgeons, 206(5), 962-8; discussion 968-9.
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  To date, no study has evaluated the potential impact of supplemental restraint use on resource use at a Level I trauma center. We hypothesized that airbag use would be related to decreased injury severity of motor vehicle collision survivors admitted to a Level I trauma center, leading to a decrease in infectious morbidity and hospital resource use.
• Zarzaur, B. L., Croce, M. A., Fischer, P. E., Magnotti, L. J., & Fabian, T. C. (2008). New vitals after injury: shock index for the young and age x shock index for the old. The Journal of surgical research, 147(2), 229-36.
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  The traditional view that tachycardia and hypotension accompany hemorrhagic shock following injury has been challenged. This is particularly true at extremes of age. Shock index (SI) may be an alternative indicator of life-threatening bleeding after injury. Because age negatively impacts physiological reserve, we hypothesized that age multiplied by SI (Age x SI) would be a better predictor of 48 h mortality (48 MORT) compared to heart rate (HR), systolic blood pressure (SBP), or SI.
• Caputo, F. J., Magnotti, L. J., Hauser, C. J., & Livingston, D. H. (2007). Descending necrotizing mediastinitis: unique complication of central venous catheterization. Surgical infections, 8(6), 611-4.
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  Central venous catheter placement is a common procedure in the intensive care unit. However, these devices are not without complications. We describe the first reported case of descending necrotizing mediastinitis secondary to central venous catheterization without evidence of associated vascular perforation.
• Croce, M. A., Magnotti, L. J., Savage, S. A., Wood, G. W., & Fabian, T. C. (2007). Emergent pelvic fixation in patients with exsanguinating pelvic fractures. Journal of the American College of Surgeons, 204(5), 935-9; discussion 940-2.
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  An alternative to embolization or external pelvic fixation (EPF) in patients with multiple pelvic fractures and hemorrhage is a pelvic orthotic device (POD), which may easily be placed in the resuscitation area. Little published information is available about its effectiveness. This study evaluated the efficacy of the POD compared with EPF in patients with life-threatening pelvic fractures.
• Magnotti, L. J., Weinberg, J. A., Schroeppel, T. J., Savage, S. A., Fischer, P. E., Bee, T. K., Maish, G. O., Minard, G., Zarzaur, B. L., Croce, M. A., & Fabian, T. C. (2007). Initial chest CT obviates the need for repeat chest radiograph after penetrating thoracic trauma. The American surgeon, 73(6), 569-72; discussion 572-3.
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  The use of serial chest radiographs (CXRs) to evaluate patients with penetrating thoracic trauma is common practice. However, the time interval between these studies and the duration of observation remains uncertain. The purpose of this study was to evaluate whether a noncontrast chest CT is as reliable as a 6-hour CXR for detecting delayed pneumothorax (PTX) after penetrating thoracic trauma. Hemodynamically stable patients with isolated penetrating thoracic trauma were prospectively evaluated with a CXR and a noncontrast chest CT. If there was no PTX or hemothorax, or a finding that did not require immediate intervention, a 6-hour CXR was obtained. Findings were treated as clinically indicated and patients were discharged if all three studies were negative. One hundred eighteen patients were evaluated (89 stab wounds and 29 gunshot wounds). All initial CXRs were negative. CT identified six PTXs and one hemothorax. Two patients required operative intervention. There were no delayed findings on CXR provided the CT was negative. The mean time to CT and before disposition was 19 minutes and 8 hours, respectively, with a potential decrease in charges of $313.32 per patient. The use of serial CXRs provided no additional information that was not available on the initial chest CT, allowing for expedited discharge, decompressing overcrowded emergency areas, and reducing the number of patients leaving before completion of their work-up.
• Rupani, B., Caputo, F. J., Watkins, A. C., Vega, D., Magnotti, L. J., Lu, Q., Xu, D. Z., & Deitch, E. A. (2007). Relationship between disruption of the unstirred mucus layer and intestinal restitution in loss of gut barrier function after trauma hemorrhagic shock. Surgery, 141(4), 481-9.
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  The factors involved in shock-induced loss of gut barrier function remain to be defined fully and studies investigating gut injury have focused primarily on the systemic side of the intestine.
• Weinberg, J. A., Magnotti, L. J., Croce, M. A., Edwards, N. M., & Fabian, T. C. (2007). The utility of serial computed tomography imaging of blunt splenic injury: still worth a second look?. The Journal of trauma, 62(5), 1143-7; discussion 1147-8.
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  Serial computed tomography (CT) imaging of blunt splenic injury (BSI) can identify the latent formation of splenic artery pseudoaneurysms (PSAs), contributing to improved success in splenic salvage. The practice of serial CT imaging, however, has not been embraced. The purpose of this study was to reevaluate the clinical practice of serial CT imaging within the context of an institutional protocol for the nonoperative management (NOM) of BSI.
• Weinberg, J. A., Magnotti, L. J., Edwards, N. M., Claridge, J. A., Minard, G., Fabian, T. C., & Croce, M. A. (2007). "Awake" laparoscopy for the evaluation of equivocal penetrating abdominal wounds. Injury, 38(1), 60-4.
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  Diagnostic laparoscopy is useful for the assessment of equivocal penetrating abdominal wounds, and has become the modality of choice for the evaluation of such wounds at our institution. We hypothesised that, in appropriate patients, diagnostic "awake" laparoscopy (AL) could be performed under local anaesthesia in the emergency department (ED), allowing for expedited discharge and potential cost savings.
• Croce, M. A., Swanson, J. M., Magnotti, L. J., Claridge, J. A., Weinberg, J. A., Wood, G. C., Boucher, B. A., & Fabian, T. C. (2006). The futility of the clinical pulmonary infection score in trauma patients. The Journal of trauma, 60(3), 523-7; discussion 527-8.
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  The Clinical Pulmonary Infection Score (CPIS) has received much attention recently. Advocates have touted its use for the diagnosis and duration of therapy in patients with ventilator-associated pneumonia (VAP). However, little has been written about its utility in trauma patients. The clinical, physiologic, and radiologic components of the CPIS may be difficult to differentiate from the systemic effects of injury. Quantitative cultures of the lower airway have been shown to be efficacious in differentiating VAP from the systemic inflammatory response syndrome (SIRS). In this study, we evaluated the potential use of CPIS as the sole means for diagnosis of VAP in critically injured patients.
• Weinberg, J. A., Fabian, T. C., Magnotti, L. J., Minard, G., Bee, T. K., Edwards, N., Claridge, J. A., & Croce, M. A. (2006). Penetrating rectal trauma: management by anatomic distinction improves outcome. The Journal of trauma, 60(3), 508-13; discussion 513-14.
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  Controversy persists regarding the optimal management of penetrating rectal injuries, specifically with respect to the routine application of diversion and presacral drainage. Our previous experience suggested that management decisions based on precise anatomic characterization of injury relative to retroperitoneal involvement might improve outcome. A clinical pathway was developed and implemented. Patients managed by the pathway (PATH) were compared with the previous study (PREV, n=58) to determine the impact of the clinical pathway on outcome.
• Magnotti, L. J., & Deitch, E. A. (2005). Burns, bacterial translocation, gut barrier function, and failure. The Journal of burn care & rehabilitation, 26(5), 383-91.
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  The development of systemic inflammation, acute lung injury, and multiple organ failure after a major thermal injury, as well as nonthermal forms of trauma, remain relatively common causes of morbidity and mortality. During the past two decades, increasing recognition that the ischemic gut may contribute to the development of sepsis and organ failure in burn patients, as well as other critically ill patient populations, has led to new hypotheses to explain burn-induced multiple organ failure as well as highlighted the importance of early enteral nutrition. Thus, the goal of this review will be to provide a perspective on the evolution of the gut hypothesis of systemic inflammation and distant organ dysfunction.
• Cohen, D. B., Magnotti, L. J., Lu, Q., Xu, D. Z., Berezina, T. L., Zaets, S. B., Alvarez, C., Machiedo, G., & Deitch, E. A. (2004). Pancreatic duct ligation reduces lung injury following trauma and hemorrhagic shock. Annals of surgery, 240(5), 885-91.
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  To determine whether pancreatic digestive enzymes released into the ischemic gut during an episode of T/HS are involved in the generation of distant organ injury. This hypothesis was tested by examining the effect of PDL on T/HS-induced intestinal injury, lung injury, and RBC deformability.
• Magnotti, L. J., Croce, M. A., & Fabian, T. C. (2004). Is ventilator-associated pneumonia in trauma patients an epiphenomenon or a cause of death?. Surgical infections, 5(3), 237-42.
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  Ventilator-associated pneumonia (VAP) is a common infection among patients in trauma intensive care units (ICUs). It has been suggested by different investigators that VAP is an indicator of injury severity and not necessarily associated with mortality. Crude mortality rates approximating 20% have been reported for trauma patients with VAP. Most studies have involved the most severely injured patients, making it difficult to determine the relative contribution of either VAP or injury severity to death. If VAP is independently associated with mortality, this relationship should be most evident in less severely injured patients. We studied patients with less severe injuries (Injury Severity Score, ISS < 25) to determine the impact of VAP on outcomes.
• Mohr, A. M., Lavery, R. F., Barone, A., Bahramipour, P., Magnotti, L. J., Osband, A. J., Sifri, Z., & Livingston, D. H. (2003). Angiographic embolization for liver injuries: low mortality, high morbidity. The Journal of trauma, 55(6), 1077-81; discussion 1081-2.
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  Angiographic embolization (AE) is a safe and effective method for controlling hemorrhage in both blunt and penetrating liver injuries. Improved survival after hepatic injuries has been documented using a multimodality approach; however, patients still have significant long-term morbidity. This study examines further the role of AE in both blunt and penetrating liver injuries and the outcomes of its use.
• Miller, P. R., Fabian, T. C., Croce, M. A., Magnotti, L. J., Elizabeth Pritchard, F., Minard, G., & Stewart, R. M. (2002). Improving outcomes following penetrating colon wounds: application of a clinical pathway. Annals of surgery, 235(6), 775-81.
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  During World War II, failure to treat penetrating colon injuries with diversion could result in court martial. Based on this wartime experience, colostomy for civilian colon wounds became the standard of care for the next 4 decades. Previous work from our institution demonstrated that primary repair was the optimal management for nondestructive colon wounds. Optimal management of destructive wounds requiring resection remains controversial. To address this issue, we performed a study that demonstrated risk factors (pre or intraoperative transfusion requirement of more than 6 units of packed red blood cells, significant comorbid diseases) that were associated with a suture line failure rate of 14%, and of whom 33% died. Based on these outcomes, a clinical pathway for management of destructive colon wounds was developed. The results of the implementation of this pathway are the focus of this report.

Reviews

• Bhogadi, S. K., Colosimo, C., Hosseinpour, H., Nelson, A., Rose, M. I., Calvillo, A. R., Anand, T., Ditillo, M., Magnotti, L. J., & Joseph, B. (2023. The undisclosed disclosures: The dollar-outcome relationship in resuscitative endovascular balloon occlusion of the aorta(pp 726-730).
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  Despite its rapid evolution, resuscitative endovascular balloon occlusion of the aorta (REBOA) remains a controversial intervention that continues to generate active research. Proper conflict of interest (COI) disclosure helps to ensure that research is conducted objectively, without bias. We aimed to identify the accuracy of COI disclosures in REBOA research.