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Biomedical subjects

Ram Nirula

Publications and source records attributed to Ram Nirula.

10 recordsLinked to original sources
PubMed2007

Practice patterns and outcomes of retrievable vena cava filters in trauma patients: an AAST multicenter study.

BACKGROUND: The purpose of this study is to describe practice patterns and outcomes of posttraumatic retrievable inferior vena caval filters (R-IVCF). METHODS: A retrospective review of R-IVCFs placed during 2004 at 21 participating centers with follow up to July 1, 2005 was performed. Primary outcomes included major complications (migration, pulmonary embolism [PE], and symptomatic caval occlusion) and reasons for failure to retrieve. RESULTS: Of 446 patients (69% male, 92% blunt trauma) receiving R-IVCFs, 76% for prophylactic indications and 79% were placed by interventional radiology. Excluding 33 deaths, 152 were Gunter-Tulip (G-T), 224 Recovery (R), and 37 Optease (Opt). Placement occurred 6 +/- 8 days after admission and retrieval at 50 +/- 61 days. Follow up after discharge (5.7 +/- 4.3 months) was reported in 51%. Only 22% of R-IVCFs were retrieved. Of 115 patients in whom retrieval was attempted, retrieval failed as a result of technical issues in 15 patients (10% of G-T, 14% of R, 27% of Opt) and because of significant residual thrombus within the filter in 10 patients (6% of G-T, 4% of R, 46% Opt). The primary reason R-IVCFs were not removed was because of loss to follow up (31%), which was sixfold higher (6% to 44%, p = 0.001) when the service placing the R-IVCF was not directly responsible for follow up. Complications did not correlate with mechanism, injury severity, service placing the R-IVCF, trauma volume, use of anticoagulation, age, or sex. Three cases of migration were recorded (all among R, 1.3%), two breakthrough PE (G-T 0.6% and R 0.4%) and six symptomatic caval occlusions (G-T 0, R 1%, Opt 11%) (p < 0.05 Opt versus both G-T and R). CONCLUSION: Most R-IVCFs are not retrieved. The service placing the R-IVCF should be responsible for follow up. The Optease was associated with the greatest incidence of residual thrombus and symptomatic caval occlusion. The practice patterns of R-IVCF placement and retrieval should be re-examined.

Adult↗
PubMed2006

Predicting severe head injury after light motor vehicle crashes: implications for automatic crash notification systems.

Motor vehicle crashes (MVC) are a leading public health problem. Improving notification times and the ability to predict which crashes will involve severe injuries may improve trauma system utilization. This study was undertaken to develop and validate a model to predict severe head injury following MVC using information readily incorporated into an automatic crash notification system. A cross-sectional study with derivation and validation sets was performed. The cohort was drawn from drivers of vehicles involved in MVC obtained from the National Automotive Sampling System (NASS). Independent multivariable predictors of severe head injury were identified. The model was able to stratify drivers according to their risk of severe head injury indicating its validity. The areas under the receiver-operating characteristic (ROC) curves were 0.7928 in the derivation set and 0.7940 in the validation set. We have developed a prediction model for head injury in MVC. As the development of automatic crash notification systems improves, models such as this one will be necessary to permit triage of what would be an overwhelming increase in crash notifications to pre-hospital responders.

Accidents, Traffic↗
PubMed2006

Do trauma centers improve functional outcomes: a national trauma databank analysis?

BACKGROUND: The development of a tiered trauma care system has lead to improved survival for the critically injured. The question as to whether the increased survival associated with the establishment of tiered levels of trauma care is paralleled by an improved functional outcome has not, however, been addressed. METHODS: Multivariate logistic regression analysis of the National Trauma Data Bank from 1994 to 2001 was performed with functional independence measure (FIM) as the primary outcome. Trauma centers were dichotomized as Level II or above versus Level III or below. Blunt and penetrating trauma patients were analyzed separately. Other covariates included age, gender, shock, comorbidities, alcohol, drugs, as well as head, chest, abdominal, spine, and lower extremity injury. Confidence intervals were set at an alpha of 0.05. RESULTS: A total of 474,024 patients were analyzed. Among minimally injured penetrating trauma patients, those receiving care at a higher tiered center had a higher likelihood of total independence (odds ratio [OR] = 1.4, 95% confidence interval [CI] = 1.0, 2.0). Among minimal, moderate and severely injured blunt trauma patients those receiving care at a higher tiered center had a higher likelihood of total independence (OR = 1.2, 95% CI = 1.0, 1.4, OR = 1.3, 95% CI = 1.1, 1.6, OR = 1.3, 95% CI = 1.3, 1.5, respectively). CONCLUSIONS: These data indicate that the complex care delivered by advanced level trauma centers is associated with improved functional outcomes. Further investigations to identify the reasons for differences in these outcomes are necessary to improve care at lower tiered hospitals particularly for minimally injured patients.

Activities of Daily Living↗
PubMed2006

Rib fracture stabilization in patients sustaining blunt chest injury.

Conservative management for the majority of patients with severe chest injuries has produced a reduction in mortality, complications, and hospital length of stay. More recently, operative stabilization of rib fractures has been used with the implication of improved outcome. We assessed the impact of operative rib fracture stabilization on outcome among trauma patients. A matched case-control study of patients undergoing operative rib fracture stabilization was performed. Thirty patients undergoing rib stabilization were matched with 30 controls. Length of intensive care unit (controls, 14.1 +/- 2.7 vs cases, 12.1 +/- 1.2, P = 0.51) and total hospital (controls, 21.1 +/- 3.9 vs cases, 18.8 +/- 1.8, P = 0.59) stay were similar for both groups. There was a trend toward fewer total ventilator days for operative patients (6.5 +/- 1.3 days vs 11.2 +/- 2.6 days, P = 0.12). Ventilator days for operative patients from the time of stabilization was 2.9 +/- 0.6 days compared with 9.4 +/- 2.7 days in controls (P = 0.02). Rib fracture fixation may reduce ventilator requirements in trauma patients with severe thoracic injuries. Long-term functional outcomes need to be assessed to ascertain the impact of this procedure.

Case-Control Studies↗
PubMed2005

Predicting significant torso trauma.

BACKGROUND: Identification of motor vehicle crash (MVC) characteristics associated with thoracoabdominal injury would advance the development of automatic crash notification systems (ACNS) by improving triage and response times. Our objective was to determine the relationships between MVC characteristics and thoracoabdominal trauma to develop a torso injury probability model. METHODS: Drivers involved in crashes from 1993 to 2001 within the National Automotive Sampling System were reviewed. Relationships between torso injury and MVC characteristics were assessed using multivariate logistic regression. Receiver operating characteristic curves were used to compare the model to current ACNS models. RESULTS: There were a total of 56,466 drivers. Age, ejection, braking, avoidance, velocity, restraints, passenger-side impact, rollover, and vehicle weight and type were associated with injury (p < 0.05). The area under the receiver operating characteristic curve (83.9) was significantly greater than current ACNS models. CONCLUSION: We have developed a thoracoabdominal injury probability model that may improve patient triage when used with ACNS.

Accidents, Traffic↗
PubMed2005

What mechanism justifies abdominal evaluation in motor vehicle crashes?

BACKGROUND: Significant resources are spent on assessment of the abdomen in motor vehicle crash (MVC) occupants based solely upon crash mechanism. Most have no clinically significant injuries. We sought to define crash and occupant characteristics that would be associated with a low probability of clinically significant abdominal injury. METHODS: Drivers in MVCs were analyzed from the National Automotive Sampling System from 1993 to 2001. The probability of abdominal injury with an Abbreviated Injury Score > 1 was measured over a range of crash velocities controlling for other covariates using multivariate logistic regression. A receiver operating curve was used to assess the model. RESULTS: Age, restraint use, net change in velocity, ejection, rollover, vehicle type, other passenger mortality, and other injuries were included in the model yielding an area under the receiver operating curve of 0.948. The probability of abdominal injury increased significantly at velocities >20 km/h and reached 5.0% at approximately 30 km/h. Age >75 years old or the presence of head, leg, or chest injuries significantly increased the risk of abdominal injury, even at low velocities. Absence of injury to the head, spine, legs, or chest indicated that the abdomen was unlikely to be injured regardless of crash velocity. CONCLUSION: Absence of injury to the head, chest, spine, and legs indicates an extremely low probability of abdominal injury, even at high velocities. Abdominal evaluation in this group of patients for reason of mechanism alone is therefore unnecessary.

Abbreviated Injury Scale↗
PubMed2004

The new car assessment program: does it predict the relative safety of vehicles in actual crashes?

BACKGROUND: Federal motor vehicle safety standards are based on crash test dummy analyses that estimate the relative risk of traumatic brain injury (TBI) and severe thoracic injury (STI) by quantifying head (Head Injury Criterion [HIC]) and chest (Chest Gravity Score [CGS]) acceleration. The New Car Assessment Program (NCAP) combines these probabilities to yield the vehicle's five-star rating. The validity of the NCAP system as it relates to an actual motor vehicle crash (MVC) remains undetermined. We therefore sought to determine whether HIC and CGS accurately predict TBI and STI in actual crashes, and compared the NCAP five-star rating system to the rates of TBI and/or STI in actual MVCs. METHODS: We analyzed frontal crashes with restrained drivers from the 1994 to 1998 National Automotive Sampling System. The relationship of HIC and CGS to the probabilities of TBI and STI derived from crash tests were respectively compared with the HIC-TBI and CGS-STI risk relationships observed in actual crashes while controlling for covariates. Receiver operating characteristic curves determined the sensitivity and specificity of HIC and CGS as predictors of TBI and STI, respectively. Estimates of the likelihood of TBI and/or STI (in actual MVCs) were compared with the expected probabilities of TBI and STI (determined by crash test analysis), as they relate to NCAP ratings. RESULTS: The crash tests overestimate TBI likelihood at HIC scores >800 and underestimate it at scores <500. STI likelihood is overestimated when CGS exceeds 40 g. Receiver operating characteristic curves demonstrated poor sensitivity and specificity of HIC and CGS in predicting injury. The actual MVC injury probability estimates did not vary between vehicles of different NCAP rating. CONCLUSION: HIC and CGS are poor predictors of TBI and STI in actual MVCs. The NCAP five-star rating system is unable to differentiate vehicles of varying crashworthiness in actual MVCs. More sensitive parameters need to be developed and incorporated into vehicle crash safety testing to provide consumers and automotive manufacturers with useful tools with which to measure vehicle safety.

Accident Prevention↗
PubMed2004

Futility of resuscitation criteria for the "young" old and the "old" old trauma patient: a national trauma data bank analysis.

BACKGROUND: Increasing geriatric trauma is producing disproportionate use of resources. In burn victims, age and burn extent correlate with mortality, yielding the establishment of criteria for futile resuscitation. Such criteria would be useful to trauma patients and their families in making withdrawal-of-care decisions while reducing resource use. Our objective, therefore, was to identify injury and physiologic parameters that would indicate a high probability of futile resuscitation among geriatric trauma patients. METHODS: Data pertaining to patients greater than or equal to 65 years of age within the National Trauma Databank from 1994 to 2001 were analyzed. Multivariate logistic regression-with mortality as the outcome variable and head, chest, and/or abdominal injury; base deficit; gender; comorbidities; and admission systolic blood pressure (SBP) as covariates-was performed to develop a stratification scheme providing criteria indicative of a high probability of futile resuscitation. RESULTS: There were 76,304 patients with a mean age of 79.4 years. Head, thoracic, and abdominal injury; age; gender; comorbidities; admission SBP; and base deficit were associated with mortality. Patients with severe chest and/or abdominal injury, moderate to severe head injury, admission SBP less than 90 mm Hg, and significant base deficit had mortalities approaching 100%. Older patients with modest shock and mild to moderate head injury admitted with severe chest and/or abdominal injury had a less than 5% chance of survival. CONCLUSION: Geriatric trauma patients with severe chest and/or abdominal trauma with moderate shock and mild to moderate head injury have an exceedingly low probability of survival. These data support early withdrawal of care in these individuals.

Aged↗
PubMed2003

Traumatic brain injury and automotive design: making motor vehicles safer.

BACKGROUND: Traumatic brain injury (TBI) remains a major public health problem in the United States. Identifying and modifying vehicle designs associated with TBI will have a significant impact on the frequency and severity of TBI in motor vehicle crashes (MVCs). Our objective, therefore, was to identify interior vehicle contact points associated with severe TBI (head Abbreviated Injury Scale score > 3) among drivers and determine the extent to which modifications of these contact points impact the likelihood of severe TBI. METHODS: We analyzed drivers in MVCs from the 1993 to 2001 National Automotive Sampling System database. The odds of severe TBI with respect to various vehicle contact points were estimated using multivariate logistic regression. Using computer simulation software, the magnitude of driver head deceleration was modeled while manipulating vehicle design features. The potential impact of this design modification on the frequency and hospital charges of TBI cases was estimated. RESULTS: There were 18,313 drivers involved who were victims of TBI, equating to a national sample size of 3,275,472 cases. The most frequent contact point associated with severe TBI was the roof rail (odds ratio, 2.0; 95% confidence interval, 1.2-3.3). Increasing roof rail padding thickness to 5.0 cm reduced the peak acceleration from 700 g to 218 g, which would potentially reduce the attributable number of severe TBI cases per year from 2,730 to 210, thereby reducing annual acute care charges from $136.5 million to $10.5 million US dollars. CONCLUSION: Contact with the roof rail significantly increases the likelihood of TBI in MVCs. Minor increases in padding at these points may reduce the frequency of severe TBI, which would have a substantial effect on health care costs.

Abbreviated Injury Scale↗