Browsing by Author "Hernandez, Adrian"

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    Absence of July Phenomenon in Acute Ischemic Stroke Care Quality and Outcomes.
    (Journal of the American Heart Association, 2018-01-31) Gonzalez-Castellon, Marco; Ju, Christine; Xian, Ying; Hernandez, Adrian; Fonarow, Gregg C; Schwamm, Lee; Smith, Eric E; Bhatt, Deepak L; Reeves, Matthew; Willey, Joshua Z
    BACKGROUND:Lower care quality and an increase in adverse outcomes as a result of new medical trainees is a concept well rooted in popular belief, termed the "July phenomenon." Whether this phenomenon occurs in acute ischemic stroke has not been well studied. METHODS AND RESULTS:We analyzed data from patients admitted with ischemic stroke in 1625 hospitals participating in the Get With The Guidelines-Stroke program for the 5-year period between January 2009 and December 2013. We compared acute stroke treatment processes and in-hospitals outcomes among the 4 quarters (first quarter: July-September, last quarter: April-June) of the academic year. Multivariable logistic regression models were used to evaluate the relationship between academic year transition and processes measures. A total of 967 891 patients were included in the study. There was a statistically significant, but modest (<4 minutes or 5 percentage points) difference in distribution of or quality and clinical metrics including door-to-computerized tomography time, door-to-needle time, the proportion of patients with symptomatic intracranial hemorrhage within 36 hours of admission, and the proportion of patients who received defect-free care in stroke performance measures among academic year quarters (P<0.0001). In multivariable analyses, there was no evidence that quarter 1 of the academic year was associated with lower quality of care or worse in-hospital outcomes in teaching and nonteaching hospitals. CONCLUSIONS:We found no evidence of the "July phenomenon" in patients with acute ischemic stroke among hospitals participating in the Get With The Guidelines-Stroke program.
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    Association of Brain Injury Biomarkers and Circulatory Shock Following Moderate-Severe Traumatic Brain Injury: A TRACK-TBI Study.
    (Journal of neurosurgical anesthesiology, 2021-12) Toro, Camilo; Jain, Sonia; Sun, Shelly; Temkin, Nancy; Barber, Jason; Manley, Geoffrey; Komisarow, Jordan M; Ohnuma, Tetsu; Foreman, Brandon; Korley, Frederick; James, Michael L; Laskowitz, Daniel; Vavilala, Monica S; Hernandez, Adrian; Mathew, Joseph P; Markowitz, Amy J; Krishnamoorthy, Vijay; TRACK-TBI Investigators

    Introduction

    Early circulatory shock following traumatic brain injury (TBI) is a multifactorial process; however, the impact of brain injury biomarkers on the risk of shock has not been evaluated. We examined the association between neuronal injury biomarker levels and the development of circulatory shock following moderate-severe TBI.

    Methods

    In this retrospective cohort study, we examined adults with moderate-severe TBI (Glasgow Coma Scale score <13) enrolled in the TRACK-TBI study, an 18-center prospective TBI cohort study. The exposures were day-1 levels of neuronal injury biomarkers (glial fibrillary acidic protein, ubiquitin C-terminal hydrolase-L1 [UCH-L1], S100 calcium-binding protein B [S100B], neuron-specific enolase), and of an inflammatory biomarker (high-sensitivity C-reactive protein). The primary outcome was the development of circulatory shock, defined as cardiovascular Sequential Organ Failure Assessment Score ≥2 within 72 hours of admission. Association between day-1 biomarker levels and the development of circulatory shock was assessed with regression analysis.

    Results

    The study included 392 subjects, with a mean age of 40 years; 314 (80%) were male and 165 (42%) developed circulatory shock. Median (interquartile range) day-1 levels of UCH-L1 (994.8 [518.7 to 1988.2] pg/mL vs. 548.1 [280.2 to 1151.9] pg/mL; P<0.0001) and S100B (0.47 μg/mL [0.25 to 0.88] vs. 0.27 [0.16 to 0.46] μg/mL; P<0.0001) were elevated in those who developed early circulatory shock compared with those who did not. In multivariable regression, there were associations between levels of both UCH-L1 (odds ratio, 1.63 [95% confidence interval, 1.25-2.12]; P<0.0005) and S100B (odds ratio, 1.73 [95% confidence interval 1.27-2.36]; P<0.0005) with the development of circulatory shock.

    Conclusion

    Neuronal injury biomarkers may provide the improved mechanistic understanding and possibly early identification of patients at risk for early circulatory shock following moderate-severe TBI.
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    Association of Early Beta-Blocker Exposure and Functional Outcomes in Critically Ill Patients With Moderate to Severe Traumatic Brain Injury: A Transforming Clinical Research and Knowledge in Traumatic Brain Injury Study.
    (Critical care explorations, 2023-09) Kelly-Hedrick, Margot; Liu, Sunny Yang; Temkin, Nancy; Barber, Jason; Komisarow, Jordan; Manley, Geoffrey; Ohnuma, Tetsu; Colton, Katharine; Treggiari, Miriam M; Monson, Eric E; Vavilala, Monica S; Grandhi, Ramesh; Laskowitz, Daniel T; Mathew, Joseph P; Hernandez, Adrian; James, Michael L; Raghunathan, Karthik; Goldstein, Ben; Markowitz, Amy J; Krishnamoorthy, Vijay

    Objectives

    We aimed to 1) describe patterns of beta-blocker utilization among critically ill patients following moderate-severe traumatic brain injury (TBI) and 2) examine the association of early beta-blocker exposure with functional and clinical outcomes following injury.

    Design

    Retrospective cohort study.

    Setting

    ICUs at 18 level I, U.S. trauma centers in the Transforming Clinical Research and Knowledge in TBI (TRACK-TBI) study.

    Patients

    Greater than or equal to 17 years enrolled in the TRACK-TBI study with moderate-severe TBI (Glasgow Coma Scale of <13) were admitted to the ICU after a blunt TBI.

    Interventions

    None.

    Measurements

    Primary exposure was a beta blocker during the first 7 days in the ICU, with a primary outcome of 6-month Glasgow Outcome Scale-Extended (GOSE). Secondary outcomes included: length of hospital stay, in-hospital mortality, 6-month and 12-month mortality, 12-month GOSE score, and 6-month and 12-month measures of disability, well-being, quality of life, and life satisfaction.

    Main results

    Of the 450 eligible participants, 57 (13%) received early beta blockers (BB+ group). The BB+ group was on average older, more likely to be on a preinjury beta blocker, and more likely to have a history of hypertension. In the BB+ group, 34 participants (60%) received metoprolol only, 19 participants (33%) received propranolol only, 3 participants (5%) received both, and 1 participant (2%) received atenolol only. In multivariable regression, there was no difference in the odds of a higher GOSE score at 6 months between the BB+ group and BB- group (odds ratio = 0.86; 95% CI, 0.48-1.53). There was no association between BB exposure and secondary outcomes.

    Conclusions

    About one-sixth of subjects in our study received early beta blockers, and within this group, dose, and timing of beta-blocker administration varied substantially. No significant differences in GOSE score at 6 months were demonstrated, although our ability to draw conclusions is limited by overall low total doses administered compared with prior studies.
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    Association of Severe Acute Kidney Injury with Mortality and Healthcare Utilization Following Isolated Traumatic Brain Injury.
    (Neurocritical care, 2021-01-13) Luu, David; Komisarow, Jordan; Mills, Brianna M; Vavilala, Monica S; Laskowitz, Daniel T; Mathew, Joseph; James, Michael L; Hernandez, Adrian; Sampson, John; Fuller, Matt; Ohnuma, Tetsu; Raghunathan, Karthik; Privratsky, Jamie; Bartz, Raquel; Krishnamoorthy, Vijay

    Background/objective

    Traumatic brain injury (TBI) is a leading cause of morbidity, mortality, and disability in the USA. While cardiopulmonary dysfunction can result in poor outcomes following severe TBI, the impact of acute kidney injury (AKI) is poorly understood. We examined the association of severe AKI with hospital mortality and healthcare utilization following isolate severe TBI.

    Methods

    We conducted a retrospective cohort study using the National Trauma Data Bank from 2007 to 2014. We identified a cohort of adult patients with isolated severe TBI and described the incidence of severe AKI, corresponding to Acute Kidney Injury Network stage 3 disease or greater. We examined the association of severe AKI with the primary outcome of hospital mortality using multivariable logistic regression models. In secondary analyses, we examined the association of severe AKI with dialysis catheter placement, tracheostomy and gastrostomy utilization, and hospital length of stay.

    Results

    There were 37,851 patients who experienced isolated severe TBI during the study period. Among these patients, 787 (2.1%) experienced severe (Stage 3 or greater) AKI. In multivariable models, the development of severe AKI in the hospital was associated with in-hospital mortality (OR 2.03, 95% CI 1.64-2.52), need for tracheostomy (OR 2.10, 95% CI 1.52-2.89), PEG tube placement (OR 1.88, 95% CI 1.45-2.45), and increased hospital length of stay (p < 0.001).

    Conclusions

    The overall incidence of severe AKI is relatively low (2.1%), but is associated with increased mortality and multiple markers of increased healthcare utilization following severe TBI.
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    D-Dimer elevation and adverse outcomes.
    (J Thromb Thrombolysis, 2015-01) Halaby, Rim; Popma, Christopher J; Cohen, Ander; Chi, Gerald; Zacarkim, Marcelo Rodrigues; Romero, Gonzalo; Goldhaber, Samuel Z; Hull, Russell; Hernandez, Adrian; Mentz, Robert; Harrington, Robert; Lip, Gregory; Peacock, Frank; Welker, James; Martin-Loeches, Ignacio; Daaboul, Yazan; Korjian, Serge; Gibson, C Michael
    D-Dimer is a biomarker of fibrin formation and degradation. While a D-dimer within normal limits is used to rule out the diagnosis of deep venous thrombosis and pulmonary embolism among patients with a low clinical probability of venous thromboembolism (VTE), the prognostic association of an elevated D-dimer with adverse outcomes has received far less emphasis. An elevated D-dimer is independently associated with an increased risk for incident VTE, recurrent VTE, and mortality. An elevated D-dimer is an independent correlate of increased mortality and subsequent VTE across a broad variety of disease states. Therefore, medically ill subjects in whom the D-dimer is elevated constitute a high risk subgroup in which the prospective evaluation of the efficacy and safety of antithrombotic therapy is warranted.
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    Echocardiogram Utilization Patterns and Association With Mortality Following Severe Traumatic Brain Injury
    (Anesthesia & Analgesia, 2020-08-12) Chen, Fangyu; Komisarow, Jordan M; Mills, Brianna; Vavilala, Monica; Hernandez, Adrian; Laskowitz, Daniel T; Mathew, Joseph P; James, Michael L; Haines, Krista L; Raghunathan, Karthik; Fuller, Matt; Bartz, Raquel R; Krishnamoorthy, Vijay
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    Hospital Factors Associated With Interhospital Transfer Destination for Stroke in the Northeast United States.
    (Journal of the American Heart Association, 2020-01) Zachrison, Kori S; Onnela, Jukka-Pekka; Reeves, Mathew J; Hernandez, Adrian; Camargo, Carlos A; Zhao, Xin; Matsouaka, Roland A; Goldstein, Joshua N; Metlay, Joshua P; Schwamm, Lee H
    Background We aimed to determine if there is an association between hospital quality and the likelihood of a given hospital being a preferred transfer destination for stroke patients. Methods and Results Data from Medicare claims identified acute ischemic stroke transferred between 394 northeast US hospitals from 2007 to 2011. Hospitals were categorized as transferring (n=136), retaining (n=241), or receiving (n=17) hospitals based on the proportion of acute ischemic stroke encounters transferred or received. We identified all 6409 potential dyads of sending and receiving hospitals, and categorized dyads as connected if ≥5 patients were transferred between the hospitals annually (n=82). We used logistic regression to identify hospital characteristics associated with establishing a connected dyad, exploring the effect of adjusting for different quality measures and outcomes. We also adjusted for driving distance between hospitals, receiving hospital stroke volume, and the number of hospitals in the receiving hospital referral region. The odds of establishing a transfer connection increased when rate of alteplase administration increased at the receiving hospital or decreased at the sending hospital, however this finding did not hold after applying a potential strategy to adjust for clustering. Receiving hospital performance on 90-day home time was not associated with likelihood of transfer connection. Conclusions Among northeast US hospitals, we found that differences in hospital quality, specifically higher levels of alteplase administration, may be associated with increased likelihood of being a transfer destination. Further research is needed to better understand acute ischemic stroke transfer patterns to optimize stroke transfer systems.
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    The Project Baseline Health Study: a step towards a broader mission to map human health.
    (NPJ digital medicine, 2020-01) Arges, Kristine; Assimes, Themistocles; Bajaj, Vikram; Balu, Suresh; Bashir, Mustafa R; Beskow, Laura; Blanco, Rosalia; Califf, Robert; Campbell, Paul; Carin, Larry; Christian, Victoria; Cousins, Scott; Das, Millie; Dockery, Marie; Douglas, Pamela S; Dunham, Ashley; Eckstrand, Julie; Fleischmann, Dominik; Ford, Emily; Fraulo, Elizabeth; French, John; Gambhir, Sanjiv S; Ginsburg, Geoffrey S; Green, Robert C; Haddad, Francois; Hernandez, Adrian; Hernandez, John; Huang, Erich S; Jaffe, Glenn; King, Daniel; Koweek, Lynne H; Langlotz, Curtis; Liao, Yaping J; Mahaffey, Kenneth W; Marcom, Kelly; Marks, William J; Maron, David; McCabe, Reid; McCall, Shannon; McCue, Rebecca; Mega, Jessica; Miller, David; Muhlbaier, Lawrence H; Munshi, Rajan; Newby, L Kristin; Pak-Harvey, Ezra; Patrick-Lake, Bray; Pencina, Michael; Peterson, Eric D; Rodriguez, Fatima; Shore, Scarlet; Shah, Svati; Shipes, Steven; Sledge, George; Spielman, Susie; Spitler, Ryan; Schaack, Terry; Swamy, Geeta; Willemink, Martin J; Wong, Charlene A
    The Project Baseline Health Study (PBHS) was launched to map human health through a comprehensive understanding of both the health of an individual and how it relates to the broader population. The study will contribute to the creation of a biomedical information system that accounts for the highly complex interplay of biological, behavioral, environmental, and social systems. The PBHS is a prospective, multicenter, longitudinal cohort study that aims to enroll thousands of participants with diverse backgrounds who are representative of the entire health spectrum. Enrolled participants will be evaluated serially using clinical, molecular, imaging, sensor, self-reported, behavioral, psychological, environmental, and other health-related measurements. An initial deeply phenotyped cohort will inform the development of a large, expanded virtual cohort. The PBHS will contribute to precision health and medicine by integrating state of the art testing, longitudinal monitoring and participant engagement, and by contributing to the development of an improved platform for data sharing and analysis.
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    Utilization of Brain Tissue Oxygenation Monitoring and Association with Mortality Following Severe Traumatic Brain Injury.
    (Neurocritical care, 2022-04) Komisarow, Jordan M; Toro, Camilo; Curley, Jonathan; Mills, Brianna; Cho, Christopher; Simo, Georges Motchoffo; Vavilala, Monica S; Laskowitz, Daniel T; James, Michael L; Mathew, Joseph P; Hernandez, Adrian; Sampson, John; Ohnuma, Tetsu; Krishnamoorthy, Vijay

    Background

    The aim of this study was to describe the utilization patterns of brain tissue oxygen (PbtO2) monitoring following severe traumatic brain injury (TBI) and determine associations with mortality, health care use, and pulmonary toxicity.

    Methods

    We conducted a retrospective cohort study of patients from United States trauma centers participating in the American College of Surgeons National Trauma Databank between 2008 and 2016. We examined patients with severe TBI (defined by admission Glasgow Coma Scale score ≤ 8) over the age of 18 years who survived more than 24 h from admission and required intracranial pressure (ICP) monitoring. The primary exposure was PbtO2 monitor placement. The primary outcome was hospital mortality, defined as death during the hospitalization or discharge to hospice. Secondary outcomes were examined to determine the association of PbtO2 monitoring with health care use and pulmonary toxicity and included the following: (1) intensive care unit length of stay, (2) hospital length of stay, and (3) development of acute respiratory distress syndrome (ARDS). Regression analysis was used to assess differences in outcomes between patients exposed to PbtO2 monitor placement and those without exposure by using propensity weighting to address selection bias due to the nonrandom allocation of treatment groups and patient dropout.

    Results

    A total of 35,501 patients underwent placement of an ICP monitor. There were 1,346 (3.8%) patients who also underwent PbtO2 monitor placement, with significant variation regarding calendar year and hospital. Patients who underwent placement of a PbtO2 monitor had a crude in-hospital mortality of 31.1%, compared with 33.5% in patients who only underwent placement of an ICP monitor (adjusted risk ratio 0.84, 95% confidence interval 0.76-0.93). The development of the ARDS was comparable between patients who underwent placement of a PbtO2 monitor and patients who only underwent placement of an ICP monitor (9.2% vs. 9.8%, adjusted risk ratio 0.89, 95% confidence interval 0.73-1.09).

    Conclusions

    PbtO2 monitor utilization varied widely throughout the study period by calendar year and hospital. PbtO2 monitoring in addition to ICP monitoring, compared with ICP monitoring alone, was associated with a decreased in-hospital mortality, a longer length of stay, and a similar risk of ARDS. These findings provide further guidance for clinicians caring for patients with severe TBI while awaiting completion of further randomized controlled trials.