Clinical Studies of Acutely and Critically Injuried Patients
The Use of Tissue Oxygen Monitoring in Critically Injured
Patients
Our assessment of resuscitation status in trauma patients is
limited by a lack of precise markers that reflect perfusion of
critical organ beds. The purpose of this prospective observational
study of severely injured polytrauma patients is to investigate
tissue oxygen tension and microcirculatory flow as markers for
resuscitation status.
Read More
Investigation of Glucose Control in the Intensive Care Unit
(ICU) via Strict Versus Moderate Insulin Infusion Protocol
Unfortunately, little data exists on the glucose control
parameters and outcome in trauma patients. We are currently in the
middle of a trial to examine the level and effectiveness of glucose
control protocols currently applied to our severely injured and ill
ICU population at SFGH. We have collected data from 2405 patients
regarding the effect of differing insulin protocols on glycemic
control and outcome after trauma.
Read More
Continuous Hemoglobin Monitoring in Severly Injured
Patients
We are testing the use of continuous hemoglobin (SpHb)
monitoring to measure hemoglobin (Hb) concentration and whether
this technology will provide a clinically useful measure of
bleeding and anemia after trauma that is superior to current
invasive, discontinuous techniques.
Read More
Ventilation and Weaning in Spinal Cord Injury Patients after
Injury
Spinal cord injury (SCI) is unfortunately common after injury
and carries potentially devastating respiratory implications
depending on injury level. Guidance for the ventilatory weaning and
strategies for mechanical ventilation in the acute post trauma
setting are non-existent. This study aims to review our experience
to identify predictors of successful extubation after SCI.
Read More
Hemostatic Resuscitation and Traumatic Coagulopathy
Coagulopathy is present in 25-38% of trauma patients on arrival
to the hospital and these patients are four times more likely to
die. Recently, a high Fresh Frozen Plasma (FFP):Packed Red Blood
Cell (PRBC) ratio has been shown to decrease mortality in massively
transfused trauma patients. Drawing on our work in acute traumatic
coagulopathy we have through the SFIC continued work on the ideal
hemostatic resuscitation protocols.
Read
More
The Use of rFVIIa in Trauma Patients: A Multi-Center Case
Registry Study
Recombinant activated factor VII (rFVIIa) is being utilized as
an adjunctive measure to control coagulopathic bleeding associated
with major trauma without clear evidence of its efficacy. The
present study was undertaken to gather data from U.S. trauma
centers on the use of rFVIIa for hemorrhage. We hypothesized that
we could identify the patients and describe the setting in which
rFVIIa would be successful in reducing mortality from
post-traumatic hemorrhage.
Read More
Applied Bioinformatics for Injury and Resuscitation
New applications of techniques in bioinformatics and data mining
have been developed in the disparate fields of high throughput
genomics, physics, and business data management that are aimed at
dealing with increasingly large and complex data sets. We are
continuing our work with ICU bioinformatics and continue to test
the overall hypothesis that applied bioinformatic techniques can
identify previously unrecognized physiologic patterns, which can
predict outcome and guide care in severely injured patients.
Read
More
Pulmonary Embolism After Trauma
Investigators at the Injury Center have had a long-standing
interest in preventing post-traumatic thromboembolic complications
(venous thromboembolic events (VTE); deep venous thrombosis (DVT)
and pulmonary embolism (PE). Recently, despite vigorous application
of prophylactic measure for VTE prevention, we have noted an
increase in the number of PE discovered, likely the result of
increased imaging with chest CT scans which are capable of
detecting event small peripheral clots.
Read More
Prevention of DVT after Injury: Comparing Standard LMWH
Prophylaxis with Adjust Dose LMWH
As mentioned above, DVT and PE prevention have been a major
focus of the San Francisco Injury Center since its inception in
1989. We have recently received a grant from the National Trauma
Institute to join a multi-center study investigating standard dose
administration of the LMWH enoxaparin with adjusted-dose enoxaparin
based on thromboelastography (TEG) measurements.
Read More
Development and Evaluation of an Interactive Injury Prevention Video Game for School Aged Children
Ace's Adventure Game is a high quality, market-ready interactive
computer-based video game which focuses on elementary school-aged
pedestrian safety. The game, which was designed by members of the
San Francisco Injury Center, was developed by REALTIME ASSOCIATES
in Los Angeles. In order to test the "translation" of game-based
lessons into performance, a life-size simulated Safety Street was
designed by a Hollywood company to resemble the game and to test
the child's behavior as he/she walks through the street. The
"testing" stations on the street replicate the same safety lessons
that are contained in the game. Once we have demonstrated the
feasibility of teaching prevention lessons using game-play, we will
expand our efforts to additional schools as well as adding
additional games that focus on other prevention messages for
elementary school children.
Read More
Preparing the Next Generation of Injury Control/Prevention Professionals
We are actively engaged in preparing the next generation of
injury control/prevention professionals through:
- Supporting the NIH Shock Trauma
Postdoctoral Research Fellow
- Training 17 premedical and medical student
research assistants in the past 18 months
- Disseminating injury research and control
messages nationally and internationally through leadership in
national trauma organizations and participating in education
venues
- Training personnel in low income countries
in the basics of first aid for trauma victims and in the use of
low-cost diagnostic methods to detect serious injuries
We also collaborated with 3 other universities (University of
Vermont, University of Pittsburgh, and the University of Colorado)
in a study aimed at investigating the attitudes of premedical
students toward careers in trauma and emergency surgery. We found
that among students interested in pursuing careers in surgery;
orthopedics, pediatric surgery, and trauma/emergency surgery were
their top 3 choices at all four institutions. Life-style choices
and personal/family time became more significant influences as
students progressed from their pre-clinical years to the time on
surgical wards. However, the influence of role models in
emergency/trauma surgery became significant in influencing their
choice of careers. The study was presented at the 2011 Annual
Meeting of the Western Trauma Association and the manuscript is
currently under review at the Journal of Trauma (co-authors Knudson
and Kornblith, UCSF surgical resident).
Read More
Epidemiology and Development of Programs in Uganda
We have contining efforts in Mulago Hospital and the greater
Kampala, Uganda region. We have been involved in three areas of
activity there:
- Teaching and implementation of ultrasound
as a modality for use in acute trauma care
- Detailing the burden of injury in
Kampala
- Developing a prehospital training program
for lay first responders (taxi drivers and police)
Our epidemiology work includes a comparative analysis of
mortality and an outlining of morbidity. One key finding is that
deaths from trauma (25% of the total deaths) were
disproportionately higher in Kampala compared to only 6% in San
Francisco. Much of this work was performed by medical students and
one of our UCSF surgical residents who is planning a career in
trauma, Dr. Sudha Jayaraman. The manuscript has been published in
the World Journal of Surgery. Finally, we have assisted the faculty
at Mulago Hospital to obtain a grant which supports the education
and training of lay-person first responders to road traffic crashes
(basic first aid and life support measures) in a city where there
is no 9-1-1- system.
Read More
Wraparound Project
Our hospital-based violence prevention program targets
individuals who are at particularly high risk for injury
recidivism, traditionally running at a rate of 35% in our hospital.
The three basic tenants are 1) provide long-term culturally
competent case management to victims of violent injury, 2) seize
the "teachable moment" during acute hospitalization when
individuals are perhaps most amenable to change and are most
motivated, 3) shepherd clients to risk reduction resources in our
community. We partner with a host of community based organizations
and lead a city-wide crisis response team for violent injury. Our
program has obtained funding as a line item in the Mayor's budget
for the past three years and is dually supported by our Board of
Supervisors. In an interim evaluation, we demonstrated success at
risk reduction over 50% of the time with our clients within 6
months of program enrollment. Most recently, a Master's student
from UC Berkeley presented a poster for the American Association
for the Surgery of Trauma on our longer-term outcomes: We have
screened over 600 patients and enrolled 186 "intense" clients. Our
recidivism rate over 4 years fell to 11%. In this study, we also
demonstrated that if we prevented just 3 reinjuries, our violence
prevention program would be cost-neutral. In addition to our
findings, we have created an encrypted web-accessible database,
with the assistance of our case managers, that will allow
uniformity across sites as we expand. We expanded to UC Davis in
Sacramento in 2010 and are starting to design a fidelity study. Our
program is also the model of a violence prevention program at
Wishard Trauma Center in Indianapolis. Finally, we are part of the
leadership of a national consortium of violence prevention programs
and are in the process of developing a white paper as a group. The
program has received praise from US Representative Jackie Speier
and State Congressman Mark Leno.
Read More
Injury Surveillance and Associated Hospital Costs
Evaluation of Pedestrian Injury and its Associated Hospital
Costs in San Francisco
This study aims to describe the injured
pedestrian population in San Francisco, the associated hospital
costs for treatment at San Francisco General Hospital (SFGH), and
the nature of cost by collision location. One of the unique
features of the study is the reporting of cost rather than charge
data. The few medical expenditure studies published in the
literature have generally reported charge data, which refers to the
amount billed for medical care. Our study reports actual cost,
which refers to the amount actually paid for care, by insurance
companies or patients themselves. Data from patient medical
records, the trauma registry, hospital billing information system,
and police reports for all patients involved in an
auto-versus-pedestrian collision (AVP) from 2004-2008 and treated
at SFGH, the city's only Level I Trauma Center, were included in
this study. The analysis included total cost of pedestrian injury
per year and by Supervisory District. An abstract was submitted and
the work was presented at the March 2010 Western Trauma Association
Conference. The corresponding manuscript is in review at the
Journal of Trauma.
Read More
Evaluation of Bicycle Injury and its Associated Hospital Costs
in San Francisco
Police reports are the industry standard for assessing
transportation-related collisions and informing policies and
interventions that address the issue. Previous studies have
suggested that police reports miss a substantial portion of bicycle
crashes not involving motor vehicles. Trauma centers may be the
only source for surveillance and cost data on "cyclist only"
injuries. No study to date has explored the health and economic
impact of cyclist-only injuries. Our objective was to report
medical cost of injuries from our trauma center databases to make
an economic case for prevention. We aimed to compare the incidence,
injury severity, admission rate, and cost for cyclist-only and
bicycle-versus-auto (BVA) injuries. We hypothesized that
cyclist-only injuries carry an equal or greater burden of injury
and cost when compared to BVA injuries. We conducted a
retrospective cohort analysis of hospital records for 3,049
patients treated for bicycle-related injuries at our city's only
level I trauma center. We compared injury type by injury severity,
admission status, and cost. We calculated cost using cost-to-charge
ratios, ambulance, and professional fees, inflated to 2009 dollars.
We analyzed data using parametric and non-parametric statistical
tests.
Read More
The Truama Center as an Opportunity for Screening, Intervention, and Injury Prevention
In a retrospective study, our group found that mental illness is
an independent risk factor for unintentional injury and re-injury.
Our findings were published in the Journal of Trauma. We are
collaborating with the Department of Psychiatry for the prospective
phase of our study. The purpose of this most recent study was to
administer a standard validated screening instrument and
psychosocial needs assessment to admitted patients who suffer
unintentional injury. We aimed to prospectively measure the
prevalence of mental illness. A bedside structured interview,
including the mini international neuropsychiatric interview(MINI),
and a needs assessment was performed by lay research personnel
trained by faculty from the Department of Psychiatry. The validated
needs assessment questions were from the Camberwell Assessment of
Need Short Appraisal Schedule (CANSAS) instrument. A total of 1829
people were screened during the study period. Of the 854 eligible
people, 348 were able to be approached by researchers prior to
discharge with a positive response rate of 63% (N=219 enrolled).
This inpatient pilot screening program prospectively identified
preexisting MI as a risk factor for unintentional injury.
Implementation of validated psychosocial and mental health
screening instruments is feasible and efficient in the acute trauma
setting. Administration of a validated mental health screening
instrument can be achieved by training college level research
assistants. This system of screening can lead to identification and
treatment of mental illness as a strategy for unintentional injury
prevention. We are currently following our population long term and
screening for post traumatic stress disorder.
Read
More
|