Ross Fleischman

All Publications

• Nonoperative Treatment of Appendicitis and Implications for Emergency Department Management: A Narrative Review. Annals of emergency medicine Talan, D. A., Moran, G. J., Machado-Aranda, D., Chiang, W. K., Faine, B. A., Fleischman, R., Hoyt, D. B., Jones, A. E., Sabbatini, A., Yealy, D. M., Yu, J. T., Saltzman, D. J. 2026; 87 (6): 735-745

  Abstract

  For more than 100 years, physicians and patients considered appendicitis a surgical emergency requiring hospitalization for urgent removal of the obstructed and inflamed appendix to prevent rupture and sepsis. With the advent of modern imaging, uncomplicated appendicitis is identifiable, and later evidence showed that surgical delay does not increase the risk of appendiceal perforation. Perforation appears to be a separate disease, with uncomplicated appendicitis likely related to infection, which sometimes self-resolves. Most recently, studies compared nonoperative treatment of uncomplicated appendicitis with antibiotics and observation followed by selective surgery to urgent appendectomy, including 4 multicenter trials involving more than 2,000 adults and 2,000 children. The results led the American College of Surgeons to endorse nonoperative treatment of uncomplicated appendicitis as a safe alternative treatment. Furthermore, emergency department discharge and outpatient management appears feasible in as many as 90% of nonoperative treatment of uncomplicated appendicitis-treated patients. We review methods and results of these trials and evaluate implications for emergency care.

  View details for DOI 10.1016/j.annemergmed.2025.09.035

  View details for PubMedID 41348058

• Elimination of the Opioid Sliding Scale Is Associated with Improved Opioid Stewardship Metrics. Joint Commission journal on quality and patient safety DeUgarte, D. A., Fleischman, R. J., Trotsky, R., Moubarak, G., Vu, D., Gordon, H., Huynh, P., Amaya, R. 2026

  Abstract

  Hospitals traditionally use an opioid sliding scale, prescribing lower doses for pain scores of 4-6 and higher doses for pain score 7-10. The authors hypothesized that elimination of the opioid sliding scale and implementation of additional electronic health record (EHR) "nudges" could improve adoption of best practices and improve opioid stewardship metrics.Focus groups with key stakeholders were employed to design, implement, and evaluate the intervention. The intervention used the EHR to eliminate the conventional opioid sliding scale with a novel order set favoring non-opioids and setting a new single threshold for opioid administration (pain score of 5-10). Baseline and postintervention data for inpatients with hospital stay ≤ 30 days were extracted from the medical record. Subanalysis was performed for patients undergoing at least one operative procedure. Mean morphine milligram equivalents (MME) administered and prescribed at discharge were compared using analysis of variance.This multicenter study included 60,464 inpatients for the baseline and postintervention time periods. Interventions were associated with a 31.4% (95% confidence interval [CI] 26.3%-36.5%) reduction in the mean inpatient MME administered and a 12.4% (95% CI 6.7%-18.3%) reduction in the mean MME prescribed. For the subset of patients who underwent an operative procedure (22.6% of the cohort), there was a 37.3% (95% CI 31.0%-43.7%) reduction in the mean inpatient MME administered and 12.1% (95% CI 8.3%-15.9%) reduction in MME prescribed.Elimination of the conventional opioid sliding scale and other EHR "nudges" have the potential to reduce opioids administered. These findings support safe pain management practices and demonstrate a scalable model for health system opioid stewardship.

  View details for DOI 10.1016/j.jcjq.2026.05.010

  View details for PubMedID 42420046

  View details for PubMedCentralID PMC13429228

• Association of residency application data with subsequent general surgery residency graduate performance. Surgery Purdy, A. C., Amersi, F., Calhoun, K. E., Tolles, J., Dauphine, C., Neville, A. L., Salcedo, E. S., Dickinson, K. J., Han, A. Y., Smith, B. R., Roy, M., Joppru, K. T., Frey, E. S., Poola, V. P., Fleischman, R. J., Mudgway, R., Wexner, S. D., de Virgilio, C. 2025; 180: 109057

  Abstract

  When selecting surgical residents, programs emphasize quantifiable data from the Electronic Residency Application Service application. However, it is unclear whether Electronic Residency Application Service data are associated with future resident performance or any of the qualities (surgical judgment, leadership, and medical knowledge) that our group has identified as being predictive of graduate performance. Our objective was to determine whether residency application variables are associated with subsequent residency graduate performance as rated by surgical educators.Faculty from 12 general surgery residency programs rated graduates from 2017 to 2020 on 4 outcomes: overall performance, surgical judgment, leadership, and medical knowledge. Graduates' Electronic Residency Application Service data were collected, including medical school type, United States Medical Examination scores, honors society memberships, extracurriculars, clerkship honors, and class rank. Data were analyzed using the Spearman rank-order correlation. Least absolute shrinkage and selection operator regression was performed to select a model predictive of each outcome from preresidency variables.A total of 258 graduates were evaluated. Regarding overall residency graduate performance rating, there were weak associations with the United States Medical Examination step 2 score (r = 0.23, P < .01); honors in family medicine (r = 0.17, P = .02), obstetrics/gynecology (r = 0.17, P = .01), pediatrics (r = 0.15, P = .02), and surgery (r = 0.14, P = .03); proportion of clerkship honors (r = 0.2, P < .01); and class rank (r = 0.18, P = .03). None of the preresidency variables were selected for a predictive model via least absolute shrinkage and selection operator regression for any of the 4 outcomes measured.There is a weak correlation between measurable residency application data and subsequent resident performance as rated by surgical educators. On least absolute shrinkage and selection operator regression, no residency application variables were predictive of graduate performance. These findings question the value of measurable application data in resident selection and highlight the importance of cultivating outstanding surgeons throughout training.

  View details for DOI 10.1016/j.surg.2024.109057

  View details for PubMedID 39742717

• Correlation Between Medical School Performance and Receiving Awards in General Surgery Residency. Journal of surgical education Ugarte, R., de Virgilio, C., Purdy, A. C., Tolles, J., Fleischman, R. J., Singer, G., Smith, B. R., Amersi, F., Roy, M., Jarman, B. T., Han, A. Y., Dickinson, K. J., Salcedo, E. S., Frey, E. S., Poola, V. P., Wu, E., Cryer, C., Lewis, C., Calhoun, K. E. 2024; 81 (12): 103250

  Abstract

  It is uncertain whether current measures of achievement during medical school predict exceptional performance during surgical residency. One surrogate of excellence during residency may be awards, especially those given for teaching and annual overall accomplishment.Determine whether markers of superior performance during medical school documented in the Electronic Residency Application Service (ERAS) application and student record correlated with receiving awards during residency.Data was analyzed from ERAS and student applications of 296 residency graduates. Spearman correlation coefficients were calculated.296 residency graduates from 14 US general surgery residency programs.The relationship between each residency and preresidency variable and the outcome of receiving any qualifying award. Secondary analysis included the correlation with winning a teaching or annual overall award.Although 140 (48%) residents received an award during residency, only 69 (23.3%) received a teaching award, while 50 (17.6%) received one for annual overall performance. Membership in Alpha Omega Alpha (AOA) and honors in pediatrics rotation correlated with receiving any award. USMLE step 1 score and AOA membership reached statistically significant positively correlation with receiving a teaching award, while completing a sub-internship at that institution was negatively associated. For annual overall awards, only completing a sub-internship at the same institution reached statistical significance.None of the traditional metrics in the ERAS or global student record consistently correlated with receiving an award during residency. Our findings suggest that preresidency factors available on the global application, including grades, test scores, and honor society membership, poorly correlate with exceptional general surgery residency performance as measured by receiving awards. Residency programs should shift away from using traditional ERAS metrics as the primary criteria for selection, but rather as 1 component of holistic applicant review.

  View details for DOI 10.1016/j.jsurg.2024.07.032

  View details for PubMedID 39437651

• Process and Impact of Development of an Adolescent Emergency Psychiatry Unit at a Large Urban Hospital. Pediatric emergency care Claudius, I., Tolles, J., Fleischman, R., Muller, V., Padlipsky, P., Kelly, P., Saidinejad, M. 2024; 40 (8): 598-602

  Abstract

  Boarding of adolescent patients with mental health concerns requiring ongoing observation and treatment is of increasing concern across US emergency departments. The objective was a proof of concept of developing an adolescent psychiatric emergency unit and assessment of the impact of this unit on lengths of stay (LOS).We describe the creation of the unit designed to allow safe assessment and boarding of patients, and appropriate interventions and services, while arranging transfer to inpatient facility or safe discharge home. Using a precreation and postcreation analysis and comparison with a similar facility that did not create such a unit, we utilized linear regression to investigate the primary outcome of total length of stay and secondary outcomes of psychiatric emergency department and pediatric emergency department length of stay for both unit-eligible patients and all patients.The overall length of stay was not associated with a statistically significant change for unit-eligible patients; however, there was a significant decrease in the pediatric emergency department LOS for unit-eligible patients. This was associated with a decrease in beds lost to boarding in the pediatric emergency department of 544 hours per month.Creation of an adolescent psychiatric emergency unit without allotment of significant additional resources is an option to decrease pediatric emergency department boarding times for adolescent patients requiring ongoing emergent therapy for mental health concerns.

  View details for DOI 10.1097/PEC.0000000000003212

  View details for PubMedID 38781459

• Association of Residency Applicants' Hobbies and Subsequent Technical Proficiency Ratings as General Surgery Chief Residents: A Multi-Institutional Study. Journal of surgical education Cook, J., de Virgilio, C., Purdy, A., Poola, V. P., Tolles, J., Smith, B., Simms, E., Calhoun, K. E., Jarman, B., Salcedo, E. S., Frey, E., Wu, E., Agopian, V., Cryer, C., Fleischman, R., Dickinson, K. J., Roy, M., Han, A., Amersi, F. 2024; 81 (3): 339-343

  Abstract

  To determine whether participation in certain hobbies (e.g., participation in sports, playing musical instruments, or other hobbies requiring fine motor skills), preresidency, are associated with higher technical skills ratings at the time of residency graduation.Faculty members from 14 general surgery residency programs scored individual graduates from 2017 to 2020 on their technical skills using a 5-point Likert scale. Hobbies for these residents were collected from their Electronic Residency Application Service (ERAS) data. A single reviewer classified each ERAS hobby into predefined categories including musical instruments, sports requiring hand-eye coordination, team sports, and activities necessitating hand-eye coordination. Spearman correlation coefficients were calculated for the relationship between each category of hobby-as well as the total number of hobbies in each category-and the outcome of surgical faculty ratings of residents' technical surgical skills during their last year of residency. A proportional odds model including the above predictive variables was also fit to the data.Fourteen general surgery residency programs.General surgery residency graduates from 14 different programs from 2017 to 2020.There were 296 residents across 14 institutions. The average ranking of residents' technical skills was 3.24 (SD 1.1). A total of 40% of residents played sports involving hand-eye coordination, 31% played team sports, 28% participated in nonsport hobbies that require eye-hand coordination, and 20% played musical instruments. Correlation coefficients were not statistically significant for any of the categories. In the proportional odds model, none of the variables were associated with statistically significant increased odds of a higher technical skills rating.There was no correlation between general surgery chief residents' technical skills as rated by faculty, and self-reported pre-residency hobbies on the ERAS application. These findings suggest such hobbies prior to residency are unlikely to predict future technical skills prowess.

  View details for DOI 10.1016/j.jsurg.2023.11.021

  View details for PubMedID 38302298

• The Effect of Language on the Decision to Image in the Evaluation of Atraumatic Headache. The Journal of emergency medicine Preston-Suni, K., Fleischman, R. J., Garrett, A., Yadav, K. 2024; 66 (3): e323-e330

  Abstract

  Patients with limited English proficiency seen in the emergency department (ED) experience lower quality of care and higher diagnostic resource utilization unless they are evaluated in their own language. Despite a low rate of serious pathology identified and the availability of guidelines to direct its use, computed tomography (CT) is commonly used to evaluate atraumatic headache in the ED.Our aim was to determine whether Spanish-speaking patients with atraumatic headache were more likely than their English-speaking counterparts to undergo head CT, and whether evaluation by a clinician who passed a Spanish proficiency test mitigated this difference.This retrospective observational study used electronic health record data of adult patients presenting with atraumatic headache to a level I trauma center during a 2-year period. Spanish-language testing of clinicians consisted of a brief, unvalidated, in-person, nonmedical verbal test administered by human resources staff.A total of 3030 patients with atraumatic headache were identified; 1437 were English speaking and 1593 were Spanish speaking. Spanish-speaking patients were older (48.3 vs. 41.9 years), more likely to be women (68.8% vs. 60.5%), and more likely to undergo head CT (31.8% vs. 26.4%). Evaluation by a clinician who passed the Spanish proficiency test had no significant influence on the likelihood of head CT for Spanish-speaking patients after controlling for confounding variables (adjusted odds ratio 0.95; 95% CI 0.75-1.20).Spanish-speaking patients are more likely to undergo head CT when evaluated for atraumatic headache than English-speaking patients. Evaluation by a clinician who passed a brief Spanish proficiency test did not mitigate this disparity.

  View details for DOI 10.1016/j.jemermed.2023.10.001

  View details for PubMedID 38423862

• Assessment of an Opioid Stewardship Program on Perioperative Opioid Prescribing in a Safety-Net Health System. JAMA surgery DeUgarte, D. A., Fleischman, R., Mccollough, M., Ault, G., Rolfe, K., de Virgilio, C. 2023; 158 (3): 318-319

  View details for DOI 10.1001/jamasurg.2022.4499

  View details for PubMedID 36515920

  View details for PubMedCentralID PMC9856683

• Characteristics Associated With Outstanding General Surgery Residency Graduate Performance, as Rated by Surgical Educators. JAMA surgery Purdy, A. C., Smith, B. R., Amersi, F., Calhoun, K. E., Tolles, J., Dauphine, C., Holloway, J., Roy, M., Jarman, B. T., Han, A. Y., Neville, A. L., Dickinson, K. J., Salcedo, E. S., Shields Frey, E., Poola, V. P., Murayama, K. M., Chen, F., Wu, E., Fleischman, R. J., de Virgilio, C. 2022; 157 (10): 918-924

  Abstract

  Characteristics of outstanding graduating surgical residents are currently undefined. Identifying these qualities may be important in guiding resident selection and resident education.To determine characteristics that are most strongly associated with being rated as an outstanding graduating surgical resident.The multi-institutional study had 3 phases. First, an expert panel developed a list of characteristics embodied by top graduating surgical residents. Second, groups of faculty from 14 US general-surgery residency programs ranked 2017 through 2020 graduates into quartiles of overall performance. Third, faculty evaluated their graduates on each characteristic using a 5-point Likert scale. Data were analyzed using Spearman rank-order correlation to identify which individual characteristics were associated with overall graduate performance. A least absolute shrinkage and selection operator (LASSO) ordinal regression was performed to select a parsimonious model to predict the outcome of overall performance rating from individual characteristic scores.Surgical educators' rankings of general surgery residency graduates' overall performance.Fifty faculty from 14 US residency programs with a median of 13 (range, 5-30) years of surgical education experience evaluated 297 general surgery residency graduates. Surgical educators identified 21 characteristics that they believed outstanding graduating surgical residents possessed. Two hundred ninety-seven surgical residency graduates were evaluated. Higher scores in every characteristic correlated with better overall performance. Characteristics most strongly associated with higher overall performance scores were surgical judgment (r = 0.728; P < .001), leadership (r = 0.726; P < .001), postoperative clinical skills (r = 0.715; P < .001), and preoperative clinical skills (r = 0.707; P < .001). The remainder of the characteristics were moderately associated with overall performance. The LASSO regression model identified 3 characteristics from which overall resident performance could be accurately predicted without measuring other qualities: surgical judgment (odds ratio [OR] per 1 level of 5-level Likert scale OR, 1.27; 95% CI, 1.03-1.51), leadership (OR, 1.27; 95% CI, 1.06-1.48), and medical knowledge (OR, 1.16; 95% CI, 1.01-1.33).All individual characteristics identified by surgical educators as being qualities of outstanding graduating surgical residents were positively associated with overall graduate performance. Surgical judgment and leadership skills had the strongest individual associations. Assessment of only 3 qualities (surgical judgment, leadership, and medical knowledge) were required to predict overall resident performance ratings. These findings highlight the importance of developing specific surgical judgment and leadership skills curricula and assessments during surgical residency.

  View details for DOI 10.1001/jamasurg.2022.3340

  View details for PubMedID 35947371

  View details for PubMedCentralID PMC9366653

• Establishing a research informatics program in a public healthcare system: a case report with model documents. Journal of the American Medical Informatics Association : JAMIA Meeker, D., Fu, P., Garcia, G., Dyer, I. E., Yadav, K., Fleishman, R., Yee, H. F. 2022; 29 (4): 694-700

  Abstract

  While much is known about governance models for research informatics programs in academic medical centers and similarly situated cancer centers, community and public health systems have been less well-characterized. As part of implementing an enterprise research governance framework, leaders in the Los Angeles County Department of Health Services established a research informatics program, including research data warehousing. The strategy is focused on high-priority, patient-centered research that leverages the investment in health IT and an efficient, sustained contribution from 2 affiliated Clinical Translational Sciences Institutes. This case study describes the foundational governance framework and policies that were developed. We share the results of several years of planning, implementation, and operations of an academically funded research informatics service core embedded in a large, multicenter county health system. We include herein a Supplementary Appendix of governance documents that may serve as pragmatic models for similar initiatives.

  View details for DOI 10.1093/jamia/ocab226

  View details for PubMedID 35289368

  View details for PubMedCentralID PMC8922175

• Machine Learning and Precision Medicine in Emergency Medicine: The Basics. Cureus Lee, S., Lam, S. H., Hernandes Rocha, T. A., Fleischman, R. J., Staton, C. A., Taylor, R., Limkakeng, A. T. 2021; 13 (9): e17636

  Abstract

  As machine learning (ML) and precision medicine become more readily available and used in practice, emergency physicians must understand the potential advantages and limitations of the technology. This narrative review focuses on the key components of machine learning, artificial intelligence, and precision medicine in emergency medicine (EM). Based on the content expertise, we identified articles from EM literature. The authors provided a narrative summary of each piece of literature. Next, the authors provided an introduction of the concepts of ML, artificial intelligence as an extension of ML, and precision medicine. This was followed by concrete examples of their applications in practice and research. Subsequently, we shared our thoughts on how to consume the existing research in these subjects and conduct high-quality research for academic emergency medicine. We foresee that the EM community will continue to adapt machine learning, artificial intelligence, and precision medicine in research and practice. We described several key components using our expertise.

  View details for DOI 10.7759/cureus.17636

  View details for PubMedID 34646684

  View details for PubMedCentralID PMC8485701

• A Randomized Trial Comparing Antibiotics with Appendectomy for Appendicitis NEW ENGLAND JOURNAL OF MEDICINE Flum, D. R., Davidson, G. H., Monsell, S. E., Shapiro, N. I., Odom, S. R., Sanchez, S. E., Drake, F., Fischkoff, K., Johnson, J., Patton, J. H., Evans, H., Cuschieri, J., Sabbatini, A. K., Faine, B. A., Skeete, D. A., Liang, M. K., Sohn, V., McGrane, K., Kutcher, M. E., Chung, B., Carter, D. W., Ayoung-Chee, P., Chiang, W., Rushing, A., Steinberg, S., Foster, C. S., Schaetzel, S. M., Price, T. P., Mandell, K. A., Ferrigno, L., Salzberg, M., DeUgarte, D. A., Kaji, A. H., Moran, G. J., Saltzman, D., Alam, H. B., Park, P. K., Kao, L. S., Thompson, C. M., Self, W. H., Yu, J. T., Wiebusch, A., Winchell, R. J., Clark, S., Krishnadasan, A., Fannon, E., Lavallee, D. C., Comstock, B. A., Bizzell, B., Heagerty, P. J., Kessler, L. G., Talan, D. A., CODA Collaborative 2020; 383 (20): 1907-1919

  Abstract

  Antibiotic therapy has been proposed as an alternative to surgery for the treatment of appendicitis.We conducted a pragmatic, nonblinded, noninferiority, randomized trial comparing antibiotic therapy (10-day course) with appendectomy in patients with appendicitis at 25 U.S. centers. The primary outcome was 30-day health status, as assessed with the European Quality of Life-5 Dimensions (EQ-5D) questionnaire (scores range from 0 to 1, with higher scores indicating better health status; noninferiority margin, 0.05 points). Secondary outcomes included appendectomy in the antibiotics group and complications through 90 days; analyses were prespecified in subgroups defined according to the presence or absence of an appendicolith.In total, 1552 adults (414 with an appendicolith) underwent randomization; 776 were assigned to receive antibiotics (47% of whom were not hospitalized for the index treatment) and 776 to undergo appendectomy (96% of whom underwent a laparoscopic procedure). Antibiotics were noninferior to appendectomy on the basis of 30-day EQ-5D scores (mean difference, 0.01 points; 95% confidence interval [CI], -0.001 to 0.03). In the antibiotics group, 29% had undergone appendectomy by 90 days, including 41% of those with an appendicolith and 25% of those without an appendicolith. Complications were more common in the antibiotics group than in the appendectomy group (8.1 vs. 3.5 per 100 participants; rate ratio, 2.28; 95% CI, 1.30 to 3.98); the higher rate in the antibiotics group could be attributed to those with an appendicolith (20.2 vs. 3.6 per 100 participants; rate ratio, 5.69; 95% CI, 2.11 to 15.38) and not to those without an appendicolith (3.7 vs. 3.5 per 100 participants; rate ratio, 1.05; 95% CI, 0.45 to 2.43). The rate of serious adverse events was 4.0 per 100 participants in the antibiotics group and 3.0 per 100 participants in the appendectomy group (rate ratio, 1.29; 95% CI, 0.67 to 2.50).For the treatment of appendicitis, antibiotics were noninferior to appendectomy on the basis of results of a standard health-status measure. In the antibiotics group, nearly 3 in 10 participants had undergone appendectomy by 90 days. Participants with an appendicolith were at a higher risk for appendectomy and for complications than those without an appendicolith. (Funded by the Patient-Centered Outcomes Research Institute; CODA ClinicalTrials.gov number, NCT02800785.).

  View details for DOI 10.1056/NEJMoa2014320

  View details for Web of Science ID 000588782400008

  View details for PubMedID 33017106

• Epidemiology of Admissions From the Emergency Department Among Febrile Infants Younger Than 90 Days in the United States, 2002 to 2012. Pediatric emergency care Nguyen, D. K., Fleischman, R. J., Friedlander, S., Zangwill, K. M. 2020; 36 (8): e438-e446

  Abstract

  Febrile infants younger than 90 days are often subjected to invasive diagnostic evaluation and hospitalization to monitor for serious bacterial infection (SBI) despite recent changes in SBI risk and advances in diagnostics. Nationwide provider practices, over time, are unknown for this group. Our objective was to determine the likelihood of admission and associated complications of care for such infants, particularly those at lowest risk for SBI.This is a retrospective cohort study including multisite emergency department (ED) visits using administrative data from the Pediatric Emergency Care Applied Research Network Core Data Project. We examined uncomplicated febrile infants younger than 90 days seen in the ED from 2002 to 2012 who did not have an explicit infectious diagnosis, critical illness, or chronic condition.We identified 38,224 infants, among whom, 11,600 (31%) were admitted. We observed a 3% increase in ED admission every year during the study period (P < 0.05). Age less than 30 days and black race were independent predictors of admission (P < 0.01). We identified 227 complications of care in the ED. Among those with a specified cause, 49% were attributed to antibiotic use or procedures related to the diagnosis and empiric treatment of suspected infection.Despite the decreasing risk of SBI and diagnostic advances during the study period, the odds of hospital admission increased for febrile infants at low risk for sepsis. We also provide first data on therapeutic and diagnostic test-related adverse events in this setting. These data provide further justification for a consensus guideline on management of such infants.

  View details for DOI 10.1097/PEC.0000000000001262

  View details for PubMedID 28885390

• A randomized trial of a behavioral intervention to decrease hospital length of stay by decreasing bedrest. PloS one Tolles, J., Waterman, G., Coffey, C. E., Sandoval, R., Fleischman, R. J., Hess, M., Sarff, L., Lewis, R. J., Spellberg, B. 2020; 15 (1): e0226332

  Abstract

  Approximately half of hospitalized patients suffer functional decline due to spending the vast majority of their time in bed. Previous studies of early mobilization have demonstrated improvement in outcomes, but the interventions studied have been resource-intensive. We aimed to decrease the time hospital inpatients spend in bed through a pragmatic mobilization protocol.This prospective, non-blinded, controlled clinical trial assigned inpatients to the study wards per routine clinical care in an urban teaching hospital. All subjects on intervention wards were provided with a behavioral intervention, consisting of educational handouts, by the nursing staff. Half of the intervention wards were supplied with recliner chairs in which subjects could sit. The primary outcome was hospital length of stay. The secondary outcome was the '6-Clicks' functional score.During a 6-month study period, 6082 patient encounters were included. The median length of stay was 84 hours (IQR 44-175 hours) in the control group, 80 hours (IQR 44-155 hours) in the group who received the behavioral intervention alone, and 88 hours (IQR 44-185 hours) in the group that received both the behavioral intervention and the recliner chair. In the multivariate analysis, neither the behavioral intervention nor the provision of a recliner chair was associated with a significant decrease in length of stay or increase in functional status as measured by the '6-Clicks' functional score.The program of educational handouts and provision of recliner chairs to discourage bed rest did not increase functional status or decrease length of stay for inpatients in a major urban academic center. Education and physical resources must be supplemented by other active interventions to reduce time spent in bed, functional decline, and length of stay.ClinicalTrials.gov, HS-16-00804.

  View details for DOI 10.1371/journal.pone.0226332

  View details for PubMedID 31923203

  View details for PubMedCentralID PMC6953761

• A Multifaceted Intervention Improves Prescribing for Acute Respiratory Infection for Adults and Children in Emergency Department and Urgent Care Settings. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine Yadav, K., Meeker, D., Mistry, R. D., Doctor, J. N., Fleming-Dutra, K. E., Fleischman, R. J., Gaona, S. D., Stahmer, A., May, L. 2019; 26 (7): 719-731

  Abstract

  Antibiotics are commonly prescribed during emergency department (ED) and urgent care center (UCC) visits for viral acute respiratory infection (ARI). We evaluate the comparative effectiveness of an antibiotic stewardship intervention adapted for acute care ambulatory settings (adapted intervention) to a stewardship intervention that additionally incorporates behavioral nudges (enhanced intervention) in reducing inappropriate prescriptions.This study was a pragmatic, cluster-randomized clinical trial conducted in three academic health systems comprising five adult and pediatric EDs and four UCCs. Randomization of the nine sites was stratified by health system; all providers at each site received either the adapted or the enhanced intervention. The main outcome was the proportion of antibiotic-inappropriate ARI diagnosis visits that received an outpatient antibiotic prescription by individual providers. We estimated a hierarchical mixed-effects logistic regression model comparing visits during the influenza season for 2016 to 2017 (baseline) and 2017 to 2018 (intervention).There were 44,820 ARI visits among 292 providers across all nine cluster sites. Antibiotic prescribing for ARI visits dropped from 6.2% (95% confidence interval [CI] = 4.5% to 7.9%) to 2.4% (95% CI = 1.3% to 3.4%) during the study period. We found a significant reduction in inappropriate prescribing after adjusting for health-system and provider-level effects from 2.2% (95% CI = 1.0% to 3.4%) to 1.5% (95% CI = 0.7% to 2.3%) with an odds ratio of 0.67 (95% CI = 0.54 to 0.82). Difference-in-differences between the two interventions was not significantly different.Implementation of antibiotic stewardship for ARI is feasible and effective in the ED and UCC settings. More intensive behavioral nudging methods were not more effective in high-performance settings.

  View details for DOI 10.1111/acem.13690

  View details for PubMedID 31215721

  View details for PubMedCentralID PMC8146207

• Resident Clinical Experience in the Emergency Department: Patient Encounters by Postgraduate Year. AEM education and training Douglass, A., Yip, K., Lumanauw, D., Fleischman, R. J., Jordan, J., Tanen, D. A. 2019; 3 (3): 243-250

  Abstract

  During emergency medicine (EM) training, residents are exposed to a wide spectrum of patient complaints. We sought to determine how resident clinical experience changes based on training level in relation to the patient acuity levels, chief complaints, and dispositions.We performed a retrospective chart review of patients seen at a safety-net, academic hospital in Los Angeles from July 1, 2015, to June 30, 2016. Resident postgraduate year (PGY) level and specialty, patient acuity (based on the Emergency Severity Index), chief complaint (based on one of 30 categories), and disposition were abstracted. Our primary objective was to examine the progression of EM resident experience throughout the course of training. As a secondary objective, we compared the cases seen by EM and off-service PGY-1s.A total of 49,535 visits were examined, and of these, 32,870 (66.4%) were in the adult ED (AED) and 16,665 (33.6%) were in the pediatric ED (PED). The median acuity level was 3, and 27.4% of AED patients and 7.3% of PED patients were admitted. Data from 126 residents were analyzed. This included 94 PGY-1 residents (16 EM and 78 off-service), 16 PGY-2 EM, and 16 PGY-3 EM residents. Residents of different training levels evaluated different types of patients. Senior EM residents were more likely to care for higher-acuity patients than junior EM residents. EM PGY-3s saw higher percentages of acuity level 1 and 2 patients (2.3 and 37.8%, respectively, of their total patients) than EM PGY-1s (0.3 and 18.7%, respectively). Conversely, EM PGY-1s saw higher percentages of acuity level 4 and 5 patients (27.9 and 1.6%, respectively) compared to EM PGY-3s (10.7 and 0.7%, respectively). There was a significant linear trend for increasing acuity with training year among EM residents (p < 0.001). EM PGY-1s saw more patients than off-service PGY-1s with slightly higher acuities and admission rates.The clinical experience of EM residents varies based on their level of training. EM residents show a progression throughout residency and are more likely to encounter higher volumes of patients with higher acuity as they progress in their training. When designing EM residency curriculums, this is a model of an EM residency program.

  View details for DOI 10.1002/aet2.10326

  View details for PubMedID 31360817

  View details for PubMedCentralID PMC6637008

• Length of Stay and Complications Associated With Febrile Infants <90 Days of Age Hospitalized in the United States, 2000-2012. Hospital pediatrics Nguyen, D. K., Friedlander, S., Fleischman, R. J., Zangwill, K. M. 2018; 8 (12): 746-752

  Abstract

  It is not known how changes in the epidemiology of serious bacterial infection (SBI) and greater availability of rapid viral diagnostic tests have impacted the hospital length of stay (LOS) and associated complications among young infants with suspected SBI.We used national administrative data from the Healthcare Cost and Utilization Project Kids' Inpatient Database and other state-specific data to identify febrile infants <90 days of age hospitalized in 2000, 2003, 2006, 2009, and 2012. We used multivariate analysis to determine LOS, risk factors for prolonged LOS, and complications of care among infants with isolated fever or viral respiratory disease, without concomitant serious infection.We identified 44 875 infants. LOS for each clinical group did not change over time in a clinically significant way. Mean LOS was ≤2 days for approximately two-thirds of all infants and ≥4 days for 11% in each clinical group. Factors associated with longer LOS included age <31 days, critical clinical status, concomitant chronic disease, and the presence of complications (P < .05). We identified 289 (0.8%) infants with 351 complications of care, 18 (6%) of whom had >1. These infants had longer LOS (P < .001), and those with chronic disease and older age were at increased risk (P < .01).Despite the changing epidemiology of SBI and increased availability of viral diagnostic testing, we did not detect a clinically significant change in LOS for febrile infants with suspected SBI. Complications associated with hospitalization of these infants was associated with increased LOS.

  View details for DOI 10.1542/hpeds.2018-0132

  View details for PubMedID 30482790

• Impact of individual clinical outcomes on trial participants' perspectives on enrollment in emergency research without consent CLINICAL TRIALS Whitesides, L. W., Baren, J. M., Biros, M. H., Fleischman, R. J., Govindarajan, P. R., Jones, E. B., Pancioli, A. M., Pentz, R. D., Scicluna, V. M., Wright, D. W., Dickert, N. W. 2017; 14 (2): 180-186

  Abstract

  Evidence suggests that patients are generally accepting of their enrollment in trials for emergency care conducted under exception from informed consent. It is unknown whether individuals with more severe initial injuries or worse clinical outcomes have different perspectives. Determining whether these differences exist may help to structure post-enrollment interactions.Primary clinical data from the Progesterone for the Treatment of Traumatic Brain Injury trial were matched to interview data from the Patients' Experiences in Emergency Research-Progesterone for the Treatment of Traumatic Brain Injury study. Answers to three key questions from Patients' Experiences in Emergency Research-Progesterone for the Treatment of Traumatic Brain Injury study were analyzed in the context of enrolled patients' initial injury severity (initial Glasgow Coma Scale and Injury Severity Score) and principal clinical outcomes (Extended Glasgow Outcome Scale and Extended Glasgow Outcome Scale relative to initial injury severity). The three key questions from Patients' Experiences in Emergency Research-Progesterone for the Treatment of Traumatic Brain Injury study addressed participants' general attitude toward inclusion in the Progesterone for the Treatment of Traumatic Brain Injury trial (general trial inclusion), their specific attitude toward being included in Progesterone for the Treatment of Traumatic Brain Injury trial under the exception from informed consent (personal exception from informed consent enrollment), and their attitude toward the use of exception from informed consent in the Progesterone for the Treatment of Traumatic Brain Injury trial in general (general exception from informed consent enrollment). Qualitative analysis of interview transcripts was performed to provide contextualization and to determine the extent to which respondents framed their attitudes in terms of clinical experience.Clinical data from Progesterone for the Treatment of Traumatic Brain Injury trial were available for all 74 patients represented in the Patients' Experiences in Emergency Research-Progesterone for the Treatment of Traumatic Brain Injury study (including 46 patients for whom the surrogate was interviewed due to the patient's cognitive status or death). No significant difference was observed regarding acceptance of general trial inclusion or acceptance of general exception from informed consent enrollment between participants with favorable neurological outcomes and those with unfavorable outcomes relative to initial injury. Agreement with personal enrollment in Progesterone for the Treatment of Traumatic Brain Injury trial under exception from informed consent, however, was significantly higher among participants with favorable outcomes compared to those with unfavorable outcomes (89% vs 59%, p = 0.003). There was also a statistically significant relationship between more severe initial injury and increased acceptance of personal exception from informed consent enrollment ( p = 0.040) or general exception from informed consent use ( p = 0.034) in Progesterone for the Treatment of Traumatic Brain Injury trial. Many individuals referenced personal experience as a basis for their attitudes, but these references were not used to support negative views.Patients and surrogates of patients with unfavorable clinical outcomes were somewhat less accepting of their own inclusion in the Progesterone for the Treatment of Traumatic Brain Injury trial under exception from informed consent than were patients or surrogates of patients with favorable clinical outcomes. These findings suggest a need to identify optimal strategies for communicating with patients and their surrogates regarding exception from informed consent enrollment when clinical outcomes are poor.

  View details for DOI 10.1177/1740774516677276

  View details for PubMedID 28359192

• Accuracy of the Broselow Tape in South Sudan, "The Hungriest Place on Earth". Academic emergency medicine : official journal of the Society for Academic Emergency Medicine Clark, M. C., Lewis, R. J., Fleischman, R. J., Ogunniyi, A. A., Patel, D. S., Donaldson, R. I. 2016; 23 (1): 21-8

  Abstract

  The Broselow tape is a length-based tool used for the rapid estimation of pediatric weight and was developed to reduce dosage-related errors during emergencies. This study seeks to assess the accuracy of the Broselow tape and age-based formulas in predicting weights of South Sudanese children of varying nutritional status.This was a retrospective, cross-sectional study using data from existing acute malnutrition screening programs for children less than 5 years of age in South Sudan. Using anthropometric measurements, actual weights were compared with estimated weights from the Broselow tape and three age-based formulas. Mid-upper arm circumference was used to determine if each child was malnourished. Broselow accuracy was assessed by the percentage of measured weights falling into the same color zone as the predicted weight. For each method, accuracy was assessed by mean percentage error and percentage of predicted weights falling within 10% of actual weight. All data were analyzed by nutritional status subgroup.Only 10.7% of malnourished and 26.6% of nonmalnourished children had their actual weight fall within the Broselow color zone corresponding to their length. The Broselow method overestimated weight by a mean of 26.6% in malnourished children and 16.6% in nonmalnourished children (p < 0.001). Age-based formulas also overestimated weight, with mean errors ranging from 16.2% over actual weight (Advanced Pediatric Life Support in nonmalnourished children) to 70.9% over actual (Best Guess in severely malnourished children).The Broselow tape and age-based formulas selected for comparison were all markedly inaccurate in both the nonmalnourished and the malnourished populations studied, worsening with increasing malnourishment. Additional studies should explore appropriate methods of weight and dosage estimation for populations of low- and low-to-middle-income countries and regions with a high prevalence of malnutrition.

  View details for DOI 10.1111/acem.12854

  View details for PubMedID 26671318

• Test characteristics of quick brain MRI for shunt evaluation in children: an alternative modality to avoid radiation. Journal of neurosurgery. Pediatrics Yue, E. L., Meckler, G. D., Fleischman, R. J., Selden, N. R., Bardo, D. M., Chu O'Connor, A. K., Vu, E. T., Fu, R., Spiro, D. M. 2015; 15 (4): 420-6

  Abstract

  Quick brain magnetic resonance imaging (QB-MRI) is a rapid, radiation-free technique to detect life-threatening CSF shunt malfunction. QB-MRI has not been widely studied or adopted. The primary objective of this study was to evaluate the test characteristics of QB-MRI for detecting shunt malfunction. Test characteristics of brain computed tomography (CT) and QB-MRI were then compared. Secondary objectives included comparison of time to study completion and use of sedatives for both modalities, as well as comparison of time to study completion for QB-MRI before and after implementation of a Pediatric Emergency Department (PED) shunt clinical pathway.A retrospective chart review was performed at 2 tertiary care hospital PEDs. The authors reviewed the charts of children who underwent QB-MRI or CT for suspected shunt malfunction between July 2008 and June 2012. They also reviewed the patients' neuroradiology reports and classified ventricular size as positive (enlarged) or negative (normal, smaller, or unchanged). Shunt malfunction was defined by surgical revision within 30 days.Nine hundred ninety-seven PED visits (involving 724 QB-MRIs and 273 CTs) were included. Surgical revision was performed in 235 cases (23.6%). For QB-MRI, sensitivity was 58.5% (95% CI 51.1%-65.6%) and specificity was 93.3% (90.8%-95.3%). For CT, sensitivity was 53.2% (95% CI 38.1%-67.9%) and specificity was 95.6% (92%-97.9%). The mean time to completion of QB-MRI was 115 minutes versus 83 minutes for CT (difference 32 minutes, 95% CI, 22-42 minutes, p < 0.001). The mean time from presentation to completion of QB-MRI prior to application of the CSF shunt pathway was 132 minutes versus 112 minutes after application of the CSF shunt pathway (difference 20 minutes, 95% CI 5-35 minutes, p = 0.01). Anxiolytic medications were used in 3.7% of CT studies and 4.4% of QB-MRI studies (p = 0.74).QB-MRI and CT have similar test characteristics for detecting CSF shunt malfunction in children and similar requirements for sedation. The longer interval from order placement to imaging completion for QB-MRI is arguably justified by reduction of radiation exposure in this population subject to frequent brain imaging.

  View details for DOI 10.3171/2014.9.PEDS14207

  View details for PubMedID 25634816

• Patients' perspectives of enrollment in research without consent: the patients' experiences in emergency research-progesterone for the treatment of traumatic brain injury study*. Critical care medicine Dickert, N. W., Scicluna, V. M., Baren, J. M., Biros, M. H., Fleischman, R. J., Govindarajan, P. R., Jones, E. B., Pancioli, A. M., Wright, D. W., Pentz, R. D. 2015; 43 (3): 603-12

  Abstract

  Research in acute illness often requires an exception from informed consent. Few studies have assessed the views of patients enrolled in exception from informed consent trials. This study was designed to assess the views of patients and their surrogates of exception from informed consent enrollment within the context of a randomized, placebo-controlled trial of an investigational agent for traumatic brain injury.Interactive interview study.Nested within the Progesterone for the Treatment of Traumatic Brain Injury trial, a Phase III randomized controlled trial in acute traumatic brain injury.Patients and surrogates (for patients incapable of being interviewed) enrolled in Progesterone for the Treatment of Traumatic Brain Injury under exception from informed consent at 12 sites.None.Interviews focused on respondents' acceptance of exception from informed consent enrollment in Progesterone for the Treatment of Traumatic Brain Injury, use of placebo and randomization, understanding of major study elements, and views regarding regulatory protections. Descriptive statistical analysis was performed; textual data were analyzed thematically. Eighty-five individuals were interviewed. Eighty-four percent had positive attitudes toward Progesterone for the Treatment of Traumatic Brain Injury inclusion. Seventy-eight percent found their inclusion under exception from informed consent acceptable, and 72% found use of exception from informed consent in Progesterone for the Treatment of Traumatic Brain Injury acceptable in general. Only two respondents clearly disagreed with both personal and general exception from informed consent enrollment. The most common concerns (26%) related to absence of consent. Eighty percent and 92% were accepting of placebo use and randomization, respectively. Although there were few black respondents (n = 11), they were less accepting of personal exception from informed consent enrollment than white respondents (55% vs 83%; p = 0.0494).Acceptance of exception from informed consent in this placebo-controlled trial of an investigational agent was high and exceeded acceptance among community consultation participants. Exception from informed consent enrollment appears generally consistent with patients' preferences.

  View details for DOI 10.1097/CCM.0000000000000747

  View details for PubMedID 25574795

• A simple intervention to improve hospital flow from emergency department to inpatient units. JAMA internal medicine Fleischman, R. J., Kaji, A. H., Diaz, V. M., McKenzie, K., Soltero, P., Van Natta, T. L., Spellberg, B. 2015; 175 (2): 289-90

  View details for DOI 10.1001/jamainternmed.2014.6689

  View details for PubMedID 25545454

• Evaluation of a novel pediatric appendicitis pathway using high- and low-risk scoring systems. Pediatric emergency care Fleischman, R. J., Devine, M. K., Yagapen, M. N., Steichen, A. J., Hansen, M. L., Zigman, A. F., Spiro, D. M. 2013; 29 (10): 1060-5

  Abstract

  This study aimed to determine the test characteristics of a pathway for pediatric appendicitis and its effects on emergency department (ED) length of stay, imaging, and admissions.Children age 3 to 18 years with suspicion for appendicitis at 1 tertiary care ED were prospectively enrolled, using validated low- and high-risk scoring systems incorporating history, physical examination, and white blood cell count. Low-risk patients were discharged or observed in the ED. High-risk patients were admitted. Those meeting neither low-risk nor high-risk criteria were evaluated by surgery, with imaging at their discretion. Chart review or telephone follow-up was conducted 2 weeks after the visit. A retrospective study before and after was also performed. Charts of a random sample of patients evaluated for appendicitis in the 8 months before and after the pathway implementation were reviewed.Appendicitis was diagnosed in 65 of 178 patients. Of those with appendicitis, 63 were not low-risk (sensitivity, 96.9%; specificity, 40.7%). The high-risk criteria had a sensitivity of 75.3% and specificity of 75.2%. We reviewed 292 visits before and 290 after the pathway implementation. Emergency department length of stay was similar (253 minutes before vs 257 minutes after, P = 0.77). Computed tomography was used in 12.7% of visits before and 6.9% of visits after (P = 0.02). Use of ultrasound was not significantly different (47.3% vs 53.7%). Admission rates were not significantly different (45.5% vs 42.7%).The low-risk criteria had good sensitivity in ruling out appendicitis. The high-risk criteria could be used to guide referral or admission. Neither outperformed the a priori judgment of experienced providers.

  View details for DOI 10.1097/PEC.0b013e3182a5c9b6

  View details for PubMedID 24076607

• The Cost Of Overtriage: More Than One-Third Of Low-Risk Injured Patients Were Taken To Major Trauma Centers HEALTH AFFAIRS Newgard, C. D., Staudenmayer, K., Hsia, R. Y., Mann, N. C., Bulger, E. M., Holmes, J. F., Fleischman, R., Gorman, K., Haukoos, J., McConnell, K. J. 2013; 32 (9): 1591-1599

  Abstract

  Regionalized trauma care has been widely implemented in the United States, with field triage by emergency medical services (EMS) playing an important role in identifying seriously injured patients for transport to major trauma centers. In this study we estimated hospital-level differences in the adjusted cost of acute care for injured patients transported by 94 EMS agencies to 122 hospitals in 7 regions, overall and by injury severity. Among 301,214 patients, the average adjusted per episode cost of care was $5,590 higher in a level 1 trauma center than in a nontrauma hospital. We found hospital-level differences in cost among patients with minor, moderate, and serious injuries. Of the 248,342 low-risk patients-those who did not meet field triage guidelines for transport to trauma centers-85,155 (34.3 percent) were still transported to major trauma centers, accounting for up to 40 percent of acute injury costs. Adhering to field triage guidelines that minimize the overtriage of low-risk injured patients to major trauma centers could save up to $136.7 million annually in the seven regions we studied.

  View details for DOI 10.1377/hlthaff.2012.1142

  View details for Web of Science ID 000324681500012

  View details for PubMedID 24019364

• Predicting ambulance time of arrival to the emergency department using global positioning system and Google maps. Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors Fleischman, R. J., Lundquist, M., Jui, J., Newgard, C. D., Warden, C. 2013; 17 (4): 458-65

  Abstract

  To derive and validate a model that accurately predicts ambulance arrival time that could be implemented as a Google Maps web application.This was a retrospective study of all scene transports in Multnomah County, Oregon, from January 1 through December 31, 2008. Scene and destination hospital addresses were converted to coordinates. ArcGIS Network Analyst was used to estimate transport times based on street network speed limits. We then created a linear regression model to improve the accuracy of these street network estimates using weather, patient characteristics, use of lights and sirens, daylight, and rush-hour intervals. The model was derived from a 50% sample and validated on the remainder. Significance of the covariates was determined by p < 0.05 for a t-test of the model coefficients. Accuracy was quantified by the proportion of estimates that were within 5 minutes of the actual transport times recorded by computer-aided dispatch. We then built a Google Maps-based web application to demonstrate application in real-world EMS operations.There were 48,308 included transports. Street network estimates of transport time were accurate within 5 minutes of actual transport time less than 16% of the time. Actual transport times were longer during daylight and rush-hour intervals and shorter with use of lights and sirens. Age under 18 years, gender, wet weather, and trauma system entry were not significant predictors of transport time. Our model predicted arrival time within 5 minutes 73% of the time. For lights and sirens transports, accuracy was within 5 minutes 77% of the time. Accuracy was identical in the validation dataset. Lights and sirens saved an average of 3.1 minutes for transports under 8.8 minutes, and 5.3 minutes for longer transports.An estimate of transport time based only on a street network significantly underestimated transport times. A simple model incorporating few variables can predict ambulance time of arrival to the emergency department with good accuracy. This model could be linked to global positioning system data and an automated Google Maps web application to optimize emergency department resource use. Use of lights and sirens had a significant effect on transport times.

  View details for DOI 10.3109/10903127.2013.811562

  View details for PubMedID 23865736

  View details for PubMedCentralID PMC4288957

• The trade-offs in field trauma triage: A multiregion assessment of accuracy metrics and volume shifts associated with different triage strategies JOURNAL OF TRAUMA AND ACUTE CARE SURGERY Newgard, C. D., Hsia, R. Y., Mann, N. C., Schmidt, T., Sahni, R., Bulger, E. M., Wang, N. E., Holmes, J. F., Fleischman, R., Zive, D., Staudenmayer, K., Haukoos, J. S., Kuppermann, N. 2013; 74 (5): 1298-1306

  Abstract

  BACKGROUND: National benchmarks for trauma triage sensitivity (≥95%) and specificity (≥50%) have not been rigorously evaluated across broad populations of injured patients. We evaluated the impact of different field triage schemes for identifying seriously injured patients across a range of sensitivity values. Impact metrics included specificity and number of undertriaged and overtriaged patients compared with current triage practices. METHODS: This was a retrospective cohort study of injured children and adults transported by 48 emergency medical service (EMS) agencies to 105 hospitals in 6 regions of the Western United States from 2006 through 2008. Hospital outcomes were probabilistically linked to EMS records through trauma registries, state discharge databases, and state emergency department databases. The primary outcome was an Injury Severity Score (ISS) of 16 or greater. We evaluated 40 field predictor variables, including 31 current field triage criteria, using classification and regression tree analysis and cross-validation to generate estimates for sensitivity and specificity. RESULTS: A total of 89,261 injured patients were evaluated and transported by EMS providers during the 3-year period, of whom 5,711 (6.4%) had ISS of 16 or greater. As the 95% sensitivity target for triage was approached (from the current value of 87.5%), decision tree complexity increased, specificity decreased (from 62.8% to 18.7%), and the number of triage-positive patients without serious injury doubled (67,927 vs. 31,104). Analyses restricted to children and older adults were similar. The most consistent modification to the current triage algorithm to increase sensitivity without a major decrease in specificity was altering the Glasgow Coma Scale (GCS) score cutoff point from 13 or less to 14 or less (sensitivity increase to 90.4%). CONCLUSION: Reaching the field triage sensitivity benchmark of 95% would require a large decrease in specificity (increase in overtriage). A 90% sensitivity target seems more realistic and may be obtainable by modest changes to the current triage algorithm. LEVEL OF EVIDENCE: Diagnostic test, level II.

  View details for DOI 10.1097/TA.0b013e31828b7848

  View details for PubMedID 23609282

• The association between hospital type and mortality among critically ill children in US EDs. Resuscitation Hansen, M., Fleischman, R., Meckler, G., Newgard, C. D. 2013; 84 (4): 488-91

  Abstract

  Little is known about the setting of care for critically ill children and whether differences in outcomes are related to the presenting hospital type. This study describes the characteristics of hospitals to which critically ill children present and explores the associations between hospital factors and mortality.This is a retrospective cohort study using data from the 2007 Healthcare Cost and Utilization Project National Emergency Department Sample, representative of all US ED visits. Subjects include children aged 0-18 with ICD9 codes for cardiac arrest, respiratory arrest and/or respiratory failure. Predictor variables include: age, sex, presence of chronic illness, self-pay, public insurance, trauma diagnosis, major trauma center, urban hospital, ED volume and teaching hospital. Multivariate logistic regression estimates predictors of mortality. Analyses integrate clusters, strata, and weights from the probability sample.There were an estimated 29 million pediatric ED visits in 2007 including 42,036 (0.1%) visits for cardiac or respiratory failure. Teaching hospitals (OR 0.57, 95% CI 0.50-0.66), trauma centers (OR 0.76, 95% CI 0.67-0.86), and urban hospitals (OR 0.78, 95% CI 0.63-0.97) were associated with lower mortality odds. Presence of a chronic illness (OR 14.5, 95% CI 10.5-20.1), diagnosis of an injury (OR 1.2, 95% CI 1.1-1.4) and self-pay status (OR 3.6, 95% CI 2.9-4.4) were associated with increased mortality odds.The majority of children with cardiac and respiratory arrest present to urban teaching hospitals and trauma centers. After accounting for important confounders, mortality is lower at teaching hospitals and/or major trauma centers.

  View details for DOI 10.1016/j.resuscitation.2012.07.032

  View details for PubMedID 22902464

• Is futile care in the injured elderly an important target for cost savings? The journal of trauma and acute care surgery Fleischman, R. J., Mullins, R. J., McConnell, K. J., Hedges, J. R., Ma, O. J., Newgard, C. D. 2012; 73 (1): 146-51

  Abstract

  This study proposes a definition of futile care and quantifies its cost in injured elders.This was a retrospective study of Medicare patients with an International Classification of Diseases-9 injury diagnosis admitted to 171 Oregon and Washington facilities from January 1, 2001, through December 31, 2002, who died within 6 months of admission. Futile care was defined as death within 7 days of discharge from a hospitalization of at least 14 days. We compared health care costs in the last 6 months of life with those who did and did not meet our definition of futility. To simulate predicting and preventing futility early in the hospital course, we examined the effect of reducing spending on the futile care cohort to the level of those who survived 7 to 10 days after injury.There were 6,832 elders who died within 6 months of injury, of whom 230 (3.4%) met our definition of futility. The median cost of care in the last 6 months of life was $33,373 for those not meeting our definition of futility and $87,391 for the futile care group (p < 0.001). The 3.4% receiving futile care incurred 8.9% of total costs. Reducing expenditures in the futile care group to the level of those who died from 7 to 10 days after injury (median, $25,633) would result in an overall cost savings of 6.5%.End-of-life health care costs were significantly higher for those who received futile care. However, even aggressive reductions in futile care would result in small savings overall.Economic analysis, level III.

  View details for DOI 10.1097/TA.0b013e318251f9aa

  View details for PubMedID 22743384

  View details for PubMedCentralID PMC3510698

• Deciphering the use and predictive value of "emergency medical services provider judgment" in out-of-hospital trauma triage: A multisite, mixed methods assessment JOURNAL OF TRAUMA AND ACUTE CARE SURGERY Newgard, C. D., Kampp, M., Nelson, M., Holmes, J. F., Zive, D., Rea, T., Bulger, E. M., Liao, M., Sherck, J., Hsia, R. Y., Wang, N. E., Fleischman, R. J., Barton, E. D., Daya, M., Heineman, J., Kuppermann, N. 2012; 72 (5): 1239-1248

  Abstract

  "Emergency medical services (EMS) provider judgment" was recently added as a field triage criterion to the national guidelines, yet its predictive value and real world application remain unclear. We examine the use and independent predictive value of EMS provider judgment in identifying seriously injured persons.We analyzed a population-based retrospective cohort, supplemented by qualitative analysis, of injured children and adults evaluated and transported by 47 EMS agencies to 94 hospitals in five regions across the Western United States from 2006 to 2008. We used logistic regression models to evaluate the independent predictive value of EMS provider judgment for Injury Severity Score ≥ 16. EMS narratives were analyzed using qualitative methods to assess and compare common themes for each step in the triage algorithm, plus EMS provider judgment.213,869 injured patients were evaluated and transported by EMS over the 3-year period, of whom 41,191 (19.3%) met at least one of the field triage criteria. EMS provider judgment was the most commonly used triage criterion (40.0% of all triage-positive patients; sole criterion in 21.4%). After accounting for other triage criteria and confounders, the adjusted odds ratio of Injury Severity Score ≥ 16 for EMS provider judgment was 1.23 (95% confidence interval, 1.03-1.47), although there was variability in predictive value across sites. Patients meeting EMS provider judgment had concerning clinical presentations qualitatively similar to those meeting mechanistic and other special considerations criteria.Among this multisite cohort of trauma patients, EMS provider judgment was the most commonly used field trauma triage criterion, independently associated with serious injury, and useful in identifying high-risk patients missed by other criteria. However, there was variability in predictive value between sites.

  View details for DOI 10.1097/TA.0b013e3182468b51

  View details for PubMedID 22673250

• A Multisite Assessment of the American College of Surgeons Committee on Trauma Field Triage Decision Scheme for Identifying Seriously Injured Children and Adults JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS Newgard, C. D., Zive, D., Holmes, J. F., Bulger, E. M., Staudenmayer, K., Liao, M., Rea, T., Hsia, R. Y., Wang, N. E., Fleischman, R., Jui, J., Mann, N. C., Haukoos, J. S., Sporer, K. A., Gubler, K. D., Hedges, J. R. 2011; 213 (6): 709-721

  Abstract

  The American College of Surgeons Committee on Trauma (ACSCOT) has developed and updated field trauma triage protocols for decades, yet the ability to identify major trauma patients remains unclear. We estimate the diagnostic value of the Field Triage Decision Scheme for identifying major trauma patients (Injury Severity Score [ISS] ≥ 16) in a large and diverse multisite cohort.This was a retrospective cohort study of injured children and adults transported by 94 emergency medical services (EMS) agencies to 122 hospitals in 7 regions of the Western US from 2006 through 2008. Patients who met any of the field trauma triage criteria (per EMS personnel) were considered triage positive. Hospital outcomes measures were probabilistically linked to EMS records through trauma registries, state discharge data, and emergency department data. The primary outcome defining a "major trauma patient" was ISS ≥ 16.There were 122,345 injured patients evaluated and transported by EMS over the 3-year period, 34.5% of whom met at least 1 triage criterion and 5.8% had ISS ≥ 16. The overall sensitivity and specificity of the criteria for identifying major trauma patients were 85.8% (95% CI 85.0% to 86.6%) and 68.7% (95% CI 68.4% to 68.9%), respectively. Triage sensitivity and specificity, respectively, differed by age: 84.1% and 66.4% (0 to 17 years); 89.5% and 64.3% (18 to 54 years); and 79.9% and 75.4% (≥55 years). Evaluating the diagnostic value of triage by hospital destination (transport to Level I/II trauma centers) did not substantially improve these findings.The sensitivity of the Field Triage Decision Scheme for identifying major trauma patients is lower and specificity higher than previously described, particularly among elders.

  View details for DOI 10.1016/j.jamcollsurg.2011.09.012

  View details for PubMedID 22107917

• Basic life support instructor training: comparison of instructor-led and self-guided training. Journal for nurses in staff development : JNSD : official journal of the National Nursing Staff Development Organization Einspruch, E. L., Lembach, J., Lynch, B., Lee, W., Harper, R., Fleischman, R. J. 2011; 27 (3): E4-9

  Abstract

  In this randomized trial, the authors compared the instructional quality of instructor candidates trained in instructional methods through an Internet-based versus a traditional classroom-led version of the American Heart Association Core Instructor Course. The self-guided, Internet-based group had significantly higher posttest scores than did the traditional instructor-led group (although not when adjusted for pretest scores). The Internet-based group scores changed from 54% to 67%, exceeding the a priori definition of 8% as a minimally practically significant improvement (instructor-led group scores changed from 49% to 53%). The Internet-based course appeared to be a suitable alternative to the traditional course.

  View details for DOI 10.1097/NND.0b013e318217b421

  View details for PubMedID 21602625

• Trauma in the neighborhood: a geospatial analysis and assessment of social determinants of major injury in North America. American journal of public health Newgard, C. D., Schmicker, R. H., Sopko, G. n., Andrusiek, D. n., Bialkowski, W. n., Minei, J. P., Brasel, K. n., Bulger, E. n., Fleischman, R. J., Kerby, J. D., Bigham, B. L., Warden, C. R. 2011; 101 (4): 669–77

  Abstract

  We sought to identify and characterize areas with high rates of major trauma events in 9 diverse cities and counties in the United States and Canada.We analyzed a prospective, population-based cohort of injured individuals evaluated by 163 emergency medical service agencies transporting patients to 177 hospitals across the study sites between December 2005 and April 2007. Locations of injuries were geocoded, aggregated by census tract, assessed for geospatial clustering, and matched to sociodemographic measures. Negative binomial models were used to evaluate population measures.Emergency personnel evaluated 8786 major trauma patients, and data on 7326 of these patients were available for analysis. We identified 529 (13.7%) census tracts with a higher than expected incidence of major trauma events. In multivariable models, trauma events were associated with higher unemployment rates, larger percentages of non-White residents, smaller percentages of foreign-born residents, lower educational levels, smaller household sizes, younger age, and lower income levels.Major trauma events tend to cluster in census tracts with distinct population characteristics, suggesting that social and contextual factors may play a role in the occurrence of significant injury events.

  View details for DOI 10.2105/AJPH.2010.300063

  View details for PubMedID 21389292

  View details for PubMedCentralID PMC3052353

• Matching Trauma Triage Criteria to Adult Age: Development of Field Triage Guidelines for Identifying High-Risk Young and Older Adults Newgard, C., Zive, D., Bulger, E., Rea, T., Fleischman, R., Staudenmayer, K., Liao, M., Schmidt, T., Wittwer, L., Hsia, R., Barton, E., Holmes, J. LIPPINCOTT WILLIAMS & WILKINS. 2010

  View details for Web of Science ID 000208231600147

• Development of a Pediatric Field Trauma Triage Algorithm for Identifying Children With Serious Injuries or Need for Major Surgical Intervention Newgard, C., Rea, T., Bulger, E., Fleischman, R., Wang, E., Hsia, R., Warden, C., Liao, M., Sahni, R., Mann, C., Kuppermann, N., WESTRN Investigators LIPPINCOTT WILLIAMS & WILKINS. 2010

  View details for Web of Science ID 000208231600282

• The optimum follow-up period for assessing mortality outcomes in injured older adults. Journal of the American Geriatrics Society Fleischman, R. J., Adams, A. L., Hedges, J. R., Ma, O. J., Mullins, R. J., Newgard, C. D. 2010; 58 (10): 1843-9

  Abstract

  To compare mortality rates of hospitalized injured aged 67 and older across commonly used follow-up periods (e.g., in-hospital, 30-day, 1-year) and to determine the postinjury time after which mortality rates stabilize.Retrospective analysis of Medicare claims.Oregon and Washington Medicare patients.Patients admitted to 171 Oregon and Washington facilities during 2001/02 with injuries identified according to International Classification of Diseases, Ninth Revision, code and followed for 1 year.The primary outcome was in-hospital mortality and mortality at 30, 60, 90, 180, and 365 days. Kaplan-Meier survival curves and daily postadmission mortality rates were also evaluated. The rate of change (slope) of the survival curves and daily mortality rates were analyzed to select the point after which mortality rates were no longer decreasing.There were 32,135 injured older adults hospitalized over the 2-year period, with a median age of 82 (interquartile range 77-88). Cumulative in-hospital mortality and at 30, 60, 90, 180, and 365 days was 4.1%, 9.7%, 13.6%, 16.1%, 21.3%, and 28.4%, respectively. Mortality rates stabilized by 6 months after injury, with 89% of the change occurring within 60 days. Although serious injuries, medical comorbidities, and preinjury nursing facility residence were all associated with higher mortality, they did not affect the pattern of mortality after injury.In-hospital mortality is much lower than postdischarge mortality in injured older adults, with a substantial portion of persons dying shortly after discharge from the hospital. Mortality appears to stabilize by 6 months after injury, although 60-day postadmission follow-up captures most of the excess daily mortality rate.

  View details for DOI 10.1111/j.1532-5415.2010.03065.x

  View details for PubMedID 20831727

  View details for PubMedCentralID PMC2952068

• Injury hospitalization as a marker for emergency medical services use in elderly patients. Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors Fleischman, R. J., McConnell, K. J., Adams, A. L., Hedges, J. R., Newgard, C. D. 2010; 14 (4): 425-32

  Abstract

  The elderly utilize emergency medical services (EMS) at a higher rate than younger patients, yet little is known about the influence of injury on subsequent EMS utilization and costs.To assess injury hospitalization as a potential marker for subsequent EMS utilization and costs by Medicare patients.This observational study analyzed a retrospective cohort of all Medicare patients (> or = 67 years old) with an International Classification of Diseases, Ninth Revision (ICD-9) injury diagnosis admitted to 125 Oregon and Washington hospitals during 2001 and 2002 who survived to hospital discharge. The numbers of EMS transports and the total EMS costs were compared one year before and one year following the index hospitalization.There were 30,655 injured elders in our cohort. Their median ICD-9-based injury severity score was 0.97, with 4.1% meeting a definition of serious injury and 37% having hip fractures. The mean (range) numbers of EMS transports before and after the injury were 0.5 (0-45) and 0.9 (0-56), for an unadjusted incidence rate ratio (IRR) of 1.7 (95% confidence interval [CI] 1.7-1.8). The increase in EMS utilization following an injury hospitalization was even greater after adjusting for risk period and other model predictors (IRR 2.4, 95% CI 2.3-2.5). Annual mean EMS costs rose 74% following the injury hospitalization, from $211 to $367 per person. The greatest increase was in nonemergent EMS use, accounting for 67% of the increase in the number of uses. Institutionalization in a skilled nursing or rehabilitation facility either before or after injury was strongly associated with the need for EMS care.An injury hospitalization in the elderly serves as a sentinel marker for an abrupt increase in EMS utilization and costs, even after accounting for confounders.

  View details for DOI 10.3109/10903127.2010.493986

  View details for PubMedID 20586586

  View details for PubMedCentralID PMC2992380

• Effectiveness and safety of fentanyl compared with morphine for out-of-hospital analgesia. Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors Fleischman, R. J., Frazer, D. G., Daya, M., Jui, J., Newgard, C. D. 2010; 14 (2): 167-75

  Abstract

  Fentanyl has several potential advantages for out-of-hospital analgesia, including rapid onset, short duration, and less histamine release. Objective. To compare the effectiveness and safety of fentanyl with that of morphine.This was a retrospective before-and-after study of a protocol change from morphine to fentanyl in an advanced life support emergency medical services system in January 2007. Charts from nine months prior to the change and for nine months afterward were abstracted by two reviewers using a standardized instrument. The first three months after the change were excluded. Effectiveness was measured by change in pain scores on a 0-10 scale. A priori-defined adverse events included out-of-hospital events: respiratory rate <12 breaths/min, pulse oximetry <92%, systolic blood pressure <90 mmHg, any fall in Glasgow Coma Scale score, nausea or vomiting, intubation, and use of antiemetic agents or naloxone. Emergency department charts were reviewed for initial pain scores and the same adverse events during the first two hours. Events clearly not attributable to the opioid were discounted. The changes in pain scores were also compared adjusting for confounders by multivariable linear regression.Three hundred fifty-five patients aged 13 to 99 years received morphine during the nine months before the protocol change and 363 received fentanyl following the washout period. Initial pain scores for morphine (8.1) and fentanyl (8.3) were comparable (95% confidence interval [CI] for difference -1.1 to 0.3). Fentanyl patients received a higher equivalent dose of opioid (7.7 mg morphine equivalents for morphine, 9.2 mg for fentanyl, CI for the difference 0.9 to 2.3). The mean decreases in pain score were similar between the drugs (2.9 for morphine, 3.1 for fentanyl, CI for the difference -0.3 to 0.7). With regard to adverse events, 9.9% of the morphine patients and 6.6% of the fentanyl patients experienced an adverse event in the field (CI for the difference -0.8 to 7.3%). The most common event was nausea, with a rate of 7.0% for morphine vs. 3.8% for fentanyl (CI for the difference -0.1% to 6.5%).Morphine and fentanyl provide similar degrees of out-of-hospital analgesia, although this was achieved with a higher dose of fentanyl. Both medications had low rates of adverse events, which were easily controlled.

  View details for DOI 10.3109/10903120903572301

  View details for PubMedID 20199230

  View details for PubMedCentralID PMC2924527

• Validation of length of hospital stay as a surrogate measure for injury severity and resource use among injury survivors. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine Newgard, C. D., Fleischman, R., Choo, E., Ma, O. J., Hedges, J. R., McConnell, K. J. 2010; 17 (2): 142-50

  Abstract

  While hospital length of stay (LOS) has been used as a surrogate injury outcome when more detailed outcomes are unavailable, it has not been validated. This project sought to validate LOS as a proxy measure of injury severity and resource use in heterogeneous injury populations.This observational study used four retrospective cohorts: patients presenting to 339 California emergency departments (EDs) with a primary International Classification of Diseases, Ninth Revision (ICD-9), injury diagnosis (years 2005-2006); California hospital injury admissions (a subset of the ED population); trauma patients presenting to 48 Oregon EDs (years 1998-2003); and injured Medicare patients admitted to 171 Oregon and Washington hospitals (years 2001-2002). In-hospital deaths were excluded, as they represent adverse outcomes regardless of LOS. Duration of hospital stay was defined as the number of days from ED admission to hospital discharge. The primary composite outcome (dichotomous) was serious injury (Injury Severity Score [ISS] >or= 16 or ICD-9 ISS or=65 years), hospital type, and hospital annual admission volume.The four cohorts included 3,989,409 California ED injury visits (including admissions), 236,639 California injury admissions, 23,817 Oregon trauma patients, and 30,804 Medicare injury admissions. Composite outcome rates for the four cohorts were 2.1%, 29%, 27%, and 22%, respectively. Areas under the ROC curves for overall LOS were 0.88 (California ED), 0.74 (California admissions), 0.82 (Oregon trauma patients), and 0.68 (Medicare patients). In general, the discriminatory value of LOS was highest among children, tertiary trauma centers, and higher volume hospitals, although this finding differed by the injury population and outcome assessed.Hospital LOS may be a reasonable proxy for serious injury and resource use among injury survivors when more detailed outcomes are unavailable, although the discriminatory value differs by age and the injury population being studied.

  View details for DOI 10.1111/j.1553-2712.2009.00647.x

  View details for PubMedID 20370743

  View details for PubMedCentralID PMC4715859

• Acetazolamide 125 mg BD is not significantly different from 375 mg BD in the prevention of acute mountain sickness: the prophylactic acetazolamide dosage comparison for efficacy (PACE) trial. High altitude medicine & biology Basnyat, B., Gertsch, J. H., Holck, P. S., Johnson, E. W., Luks, A. M., Donham, B. P., Fleischman, R. J., Gowder, D. W., Hawksworth, J. S., Jensen, B. T., Kleiman, R. J., Loveridge, A. H., Lundeen, E. B., Newman, S. L., Noboa, J. A., Miegs, D. P., O'Beirne, K. A., Philpot, K. B., Schultz, M. N., Valente, M. C., Wiebers, M. R., Swenson, E. R. 2006; 7 (1): 17-27

  Abstract

  750 mg per day of acetazolamide in the prevention of acute mountain sickness (AMS), as recommended in the meta-analysis published in 2000 in the British Medical Journal, may be excessive and is controversial. To determine if the efficacy of low-dose acetazolamide 125 mg bd (250 mg), as currently used in the Himalayas, is significantly different from 375 mg bd (750 mg) of acetazolamide in the prevention of AMS, we designed a prospective, double-blind, randomized, placebo-controlled trial. The participants were sampled from a diverse population of (non-Nepali) trekkers at Namche Bazaar (3440 m) in Nepal on the Everest trekking route as they ascended to study midpoints (4280 m/4358 m) and the endpoint, Lobuje (4928 m), where data were collected. Participants were randomly assigned to receive 375 mg bd of acetazolamide (82 participants), 125 mg bd of acetazolamide (74 participants), or a placebo (66 participants), beginning at 3440 m for up to 6 days as they ascended to 4928 m. The results revealed that composite AMS incidence for 125 mg bd was similar to the incidence for 375 mg bd (24% vs. 21%, 95% confidence interval, -12.6%, 19.8%), in contrast to significantly greater AMS (51%) observed in the placebo group (95% confidence interval for differences: 8%, 46%; 12%, 49% for low and high comparisons, respectively). Both doses of acetazolamide improved oxygenation equally (82.9% for 250 mg daily and 82.8% for 750 mg daily), while placebo endpoint oxygen saturation was significantly less at 80.7% (95% confidence interval for differences: 0.5%, 3.9% and 0.4%, 3.7% for low and high comparisons, respectively). There was also more paresthesia in the 375-mg bd group (p < 0.02). We conclude that 125 mg bd of acetazolamide is not significantly different from 375 mg bd in the prevention of AMS; 125 mg bd should be considered the preferred dosage when indicated for persons ascending to altitudes above 2500 m.

  View details for DOI 10.1089/ham.2006.7.17

  View details for PubMedID 16544963

• Antigen-specific accumulation of naïve, memory and effector CD4 T cells during anterior uveitis monitored by intravital microscopy. Cellular immunology Dullforce, P. A., Seitz, G. W., Garman, K. L., Michael, J. A., Crespo, S. M., Fleischman, R. J., Planck, S. R., Parker, D. C., Rosenbaum, J. T. 2006; 239 (1): 49-60

  Abstract

  Uveitis is an immune-mediated ocular disease and a leading cause of blindness. We characterized a novel model of uveitis with intravital microscopy. Transfer of ovalbumin-specific T cells from DO11.10 spleen to BALB/c recipients and subsequent challenge with ovalbumin in the anterior chamber of the eye resulted in anterior uveitis. Antigen-specificity was verified by injection of irrelevant antigen and transfer of T cells with a different specificity. Subsets of CD4 T cells, including naive (DO11.10 RAG(-/-)) and in vitro-activated Th2 effector CD4 T cells, infiltrated anterior segment tissues early in the inflammation. Memory-like CD44(high) CD4 T cells from unprimed transgenic mice and in vitro-activated Th1 effector CD4 T cells accumulated to larger numbers than naive or Th2 effector cells at 48 and 72 h. Of these, the alpha(2)-integrin+CD4 unprimed T cells entered the eye more efficiently, and antibody to alpha(2)-integrin markedly inhibited the inflammatory response. Intravital microscopy revealed the early arrival and antigen-specific accumulation of CD4 T cells in inflamed tissue and should be helpful in understanding T cell migration to other organs.

  View details for DOI 10.1016/j.cellimm.2006.03.005

  View details for PubMedID 16712823

• APCs in the anterior uveal tract do not migrate to draining lymph nodes. Journal of immunology (Baltimore, Md. : 1950) Dullforce, P. A., Garman, K. L., Seitz, G. W., Fleischmann, R. J., Crespo, S. M., Planck, S. R., Parker, D. C., Rosenbaum, J. T. 2004; 172 (11): 6701-8

  Abstract

  The migration of APCs from sites of infection and their maturation are critical elements in the generation of immune responses. However, the paths by which intraocular Ags migrate to draining lymph nodes are not known because the eye has limited lymphatic vessels. To date, only dendritic cells from the cornea and conjunctiva have been shown to emigrate. We demonstrate that phagocytic APCs in the anterior uveal tissues of the murine eye that ingest fluorescent latex beads do not migrate to regional lymph nodes. The beads are ingested in the uveal tract by cells expressing MHC class II, CD11c, or F4/80. Using intravital time-lapse videomicroscopy to monitor iris APC migration after anterior chamber injection of fluorescent Ag, fluorescently labeled APCs fail to move at multiple observation times, even in the presence of Ag and LPS. Whereas an as yet unidentified ocular nonphagocytic APC subset might migrate from the anterior uveal tissues, it is more probable that immune responses in the draining lymph nodes are engendered by soluble Ag escaping the eye through interstitial spaces. The inability of anterior uveal tissue APCs to migrate to lymph nodes may contribute to deviant immune responses that dominate after Ags are introduced into the anterior chamber.

  View details for PubMedID 15153486

• Immunohistology of antigen-presenting cells in vivo: a novel method for serial observation of fluorescently labeled cells. Investigative ophthalmology & visual science Becker, M. D., Planck, S. R., Crespo, S., Garman, K., Fleischman, R. J., Dullforce, P., Seitz, G. W., Martin, T. M., Parker, D. C., Rosenbaum, J. T. 2003; 44 (5): 2004-9

  Abstract

  Dendritic cells and macrophages are phagocytic antigen-presenting cells that bridge the innate and acquired immune systems. The coexistence of subtypes of dendritic cells and macrophages with overlapping properties complicates resolution of their precise roles in an immune response within a given tissue. This report documents a method to identify and observe these cells over time in a living animal and thereby to visualize them during a dynamic immune response.To label potential antigen-presenting cells, fluorescently tagged ovalbumin was injected into the anterior chambers of mouse eyes. Fluorescently tagged antibodies to cell surface proteins were injected to label specific cell types. Intravital fluorescence microscopy with digital image recording was used to visualize the labeled cells in the irises at various times after the injection.The pattern and density (116-148 cells/mm(2)) of cells labeled in vivo by fluorescent ovalbumin or F4/80 antibodies were similar to that identified by conventional wholemount immunostaining for macrophages and dendritic cells. Fluorescent antibodies specific for CD11b, CD11c, CD80, CD86, or major histocompatibility complex (MHC) class II protein each labeled selective populations of cells in vivo. In contrast to conventional histology, in vivo immunohistology permitted serial observations. The phenotype of cells labeled by fluorescent ovalbumin was not the same at 6 (95% CD11c(+)) and 24 hours (24% CD11c(+)) after injection.This method of in vivo immunohistology provides a tool for studying cell kinetics and dynamic interactions that cannot be assessed by conventional immunohistology. Furthermore, it avoids potential artifacts from tissue fixation and may work with antibodies that label cells poorly in vitro.

  View details for PubMedID 12714636

• Validating the Use of ICD-9 Code Mapping to Generate Injury Severity Scores. Journal of trauma nursing : the official journal of the Society of Trauma Nurses Fleischman, R. J., Mann, N. C., Dai, M. n., Holmes, J. F., Wang, N. E., Haukoos, J. n., Hsia, R. Y., Rea, T. n., Newgard, C. D. ; 24 (1): 4–14

  Abstract

  The Injury Severity Score (ISS) is a measure of injury severity widely used for research and quality assurance in trauma. Calculation of ISS requires chart abstraction, so it is often unavailable for patients cared for in nontrauma centers. Whether ISS can be accurately calculated from International Classification of Diseases, Ninth Revision (ICD-9) codes remains unclear. Our objective was to compare ISS derived from ICD-9 codes with those coded by trauma registrars. This was a retrospective study of patients entered into 9 U.S. trauma registries from January 2006 through December 2008. Two computer programs, ICDPIC and ICDMAP, were used to derive ISS from the ICD-9 codes in the registries. We compared derived ISS with ISS hand-coded by trained coders. There were 24,804 cases with a mortality rate of 3.9%. The median ISS derived by both ICDPIC (ISS-ICDPIC) and ICDMAP (ISS-ICDMAP) was 8 (interquartile range [IQR] = 4-13). The median ISS in the registry (ISS-registry) was 9 (IQR = 4-14). The median difference between either of the derived scores and ISS-registry was zero. However, the mean ISS derived by ICD-9 code mapping was lower than the hand-coded ISS in the registries (1.7 lower for ICDPIC, 95% CI [1.7, 1.8], Bland-Altman limits of agreement = -10.5 to 13.9; 1.8 lower for ICDMAP, 95% CI [1.7, 1.9], limits of agreement = -9.6 to 13.3). ICD-9-derived ISS slightly underestimated ISS compared with hand-coded scores. The 2 methods showed moderate to substantial agreement. Although hand-coded scores should be used when possible, ICD-9-derived scores may be useful in quality assurance and research when hand-coded scores are unavailable.

  View details for PubMedID 28033134