Clinical Focus

  • General Surgery
  • Trauma
  • Surgical Critical Care

Academic Appointments

Professional Education

  • Board Certification: Surgical Critical Care, American Board of Surgery (2007)
  • Residency:University of Texas Sourthwestern Medical Center (2006) TX
  • Medical Education:University of Texas Sourthwestern Medical Center (1999) TX
  • Master's Degree, Stanford University, Health Services Research (2010)
  • Fellowship:UCSF/San Francisco Gen Hosp (2008) CA
  • Board Certification: General Surgery, American Board of Surgery (2006)


2015-16 Courses


All Publications

  • Prediction of neurosurgical intervention after mild traumatic brain injury using the national trauma data bank WORLD JOURNAL OF EMERGENCY SURGERY Sweeney, T. E., Salles, A., Harris, O. A., Spain, D. A., Staudenmayer, K. L. 2015; 10
  • Adding Insult to Injury: Discontinuous Insurance Following Spine Trauma JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME Kastenberg, Z. J., Hurley, M. P., Weiser, T. G., Cole, T. S., Staudenmayer, K. L., Spain, D. A., Ratliff, J. K. 2015; 97A (2): 141-146


    Spine trauma patients may represent a group for whom insurance fails to provide protection from catastrophic medical expenses, resulting in the transfer of financial burden onto individual families and public payers. This study compares the rate of insurance discontinuation for patients who underwent surgery for traumatic spine injury with and without spinal cord injury with the rate for matched control subjects.We used the MarketScan database to perform a retrospective cohort study of privately insured spine trauma patients who underwent surgery from 2006 to 2010. Kaplan-Meier survival analysis was used to assess the time to insurance discontinuation. Cox proportional-hazards regression was used to determine hazard ratios for insurance discontinuation among spine trauma patients compared with the matched control population.The median duration of existing insurance coverage was 20.2 months for those with traumatic spinal cord injury, 25.6 months for those with traumatic spine injury without spinal cord injury, and 48.0 months for the matched control cohort (log-rank p < 0.0001). After controlling for multiple covariates, the hazard ratios for discontinuation of insurance were 2.02 (95% CI [confidence interval], 1.83 to 2.23) and 2.78 (95% CI, 2.31 to 3.35) for the trauma patients without and with spinal cord injury, respectively, compared with matched controls.Rates of insurance discontinuation are significantly higher for trauma patients with severe spine injury compared with the uninjured population, indicating that patients with disabling injuries are at increased risk for loss of insurance coverage.

    View details for DOI 10.2106/JBJS.N.00148

    View details for Web of Science ID 000348217200012

  • Prediction of neurosurgical intervention after mild traumatic brain injury using the national trauma data bank. World journal of emergency surgery Sweeney, T. E., Salles, A., Harris, O. A., Spain, D. A., Staudenmayer, K. L. 2015; 10: 23-?


    Patients with mild traumatic brain injury (TBI) as defined by an admission Glasgow Coma Score (GCS) of 14-15 often do not require neurosurgical interventions, but which patients will go on to require neurosurgical care has been difficult to predict. We hypothesized that injury patterns would be associated with need for eventual neurosurgical intervention in mild TBI.The National Trauma Databank (2007-2012) was queried for patients with blunt injury and a diagnosis of TBI with an emergency department GCS of 14-15. Patients were stratified by age and injury type. Multiple logistic regression for neurosurgical intervention was run with patient demographics, physiologic variables, and injury diagnoses as dependent variables.The study included 50,496 patients, with an overall 8.8 % rate of neurosurgical intervention. Neurosurgical intervention rates varied markedly according to injury type, and were only correlated with age for patients with epidural and subdural hemorrhage. In multiple logistic regression, TBI diagnoses were predictive of need for neurosurgical interventions; moreover, after controlling for injury type and severity score, age was not significantly associated with requiring neurosurgical intervention.We found that in mild TBI, injury pattern is associated with eventual need for neurosurgical intervention. Patients with cerebral contusion or subarachnoid hemorrhage are much less likely to require neurosurgical intervention, and the effects of age are not significant after controlling for other patient factors. Prospective studies should validate this finding so that treatment guidelines can be updated to better allocate ICU resources.

    View details for DOI 10.1186/s13017-015-0017-6

    View details for PubMedID 26060506

  • Patient and Trauma Center Characteristics Associated With Helicopter Emergency Medical Services Transport for Patients With Minor Injuries in the United States ACADEMIC EMERGENCY MEDICINE Cheung, B. H., Delgado, M. K., Staudenmayer, K. L. 2014; 21 (11): 1232-1239

    View details for DOI 10.1111/acem.12512

    View details for Web of Science ID 000345237300007

  • Ground-level Falls Are a Marker of Poor Outcome in the Injured Elderly AMERICAN SURGEON Gerry, J. M., Spain, D. A., Staudenmayer, K. L. 2014; 80 (11): 1171-1173
  • PHYSIOLOGIC FIELD TRIAGE CRITERIA FOR IDENTIFYING SERIOUSLY INJURED OLDER ADULTS PREHOSPITAL EMERGENCY CARE Newgard, C. D., Richardson, D., Holmes, J. F., Rea, T. D., Hsia, R. Y., Mann, N. C., Staudenmayer, K., Barton, E. D., Bulger, E. M., Haukoos, J. S. 2014; 18 (4): 461-470
  • Environmental sampling for Clostridium difficile on alcohol-based hand rub dispensers in an academic medical center. Surgical infections Forrester, J. D., Banaei, N., Buchner, P., Spain, D. A., Staudenmayer, K. L. 2014; 15 (5): 581-584


    Clostridum difficile is a gram-positive, spore-forming anaerobic bacillus that has substantial associated morbidity, mortality, and associated healthcare burdens. Clostridium difficile spores are not destroyed by alcohol. Alcohol gel dispensers are used commonly as the hand sanitization method of choice in hospitals. It is possible that gel dispensers are fomites for C. difficile.Thirty alcohol-based gel dispenser handles outside of rooms of patients with active C. difficile infection were sampled. The samples were assessed for C. difficile by both culture and polymerase chain reaction (PCR). The samples were also assessed for other organisms by culture.No C. difficile was cultured or detected by PCR on any of the gel dispensers. Coagulase-negative Staphyloccus spp., diptheroids, and Bacillus spp. were the organisms detected most commonly.At our institution, C. difficile is not present on alcohol-based gel dispensers, but other potentially pathogenis are.

    View details for DOI 10.1089/sur.2013.102

    View details for PubMedID 25126976

  • Environmental Sampling for Clostridium difficile on Alcohol-Based Hand Rub Dispensers in an Academic Medical Center SURGICAL INFECTIONS Forrester, J. D., Banaei, N., Buchner, P., Spain, D. A., Staudenmayer, K. L. 2014; 15 (5): 581-584
  • Factors Associated With the Disposition of Severely Injured Patients Initially Seen at Non-Trauma Center Emergency Departments Disparities by Insurance Status JAMA SURGERY Delgado, M. K., Yokell, M. A., Staudenmayer, K. L., Spain, D. A., Hernandez-Boussard, T., Wang, N. E. 2014; 149 (5): 422-430
  • Variability in California triage from 2005 to 2009: A population-based longitudinal study of severely injured patients JOURNAL OF TRAUMA AND ACUTE CARE SURGERY Staudenmayer, K., Lin, F., Mackersie, R., Spain, D., Hsia, R. 2014; 76 (4): 1041-1047


    Timely access to trauma care requires that severely injured patients are ultimately triaged to trauma centers. We sought to determine triage patterns for the injured population within the state of California to determine those factors associated with undertriage.We conducted a retrospective analysis of all hospital visits in California using the Office of Statewide Health Planning and Development Database from January 1, 2005, and December 31, 2009. All visits associated with injury were linked longitudinally. Sixty-day and one-year mortality was determined using vital statistics data. Primary field triage was defined as field triage to a Level I/II trauma center; retriage was defined as initial triage to a non-Level I/II center followed by transfer to a Level I/II. Regions were organized by local emergency medical services agencies. The primary outcomes were triage patterns and mortality.The undertriage rate was 35% (n = 20,988) but was variable across regions (12-87%). Primary field triage ranged from 7% to 77%. Retriage rates not only were overall low (6% of all severely injured patients) but also varied by region (1-38%). In adjusted analysis, factors associated with a lower odds ratio (OR) of primary field triage included the following: age of 55 years or greater (OR, 0.78; p = 0.001), female sex (OR, 0.88; p = 0.014), greater number of comorbidities (OR, 0.92; p < 0.001), and fall mechanism versus motor vehicle collision (OR, 0.54; p < 0.001). One-year mortality was higher for undertriaged patients (25% vs. 16% and 18% for primary field and retriage, respectively, p < 0.001).This is the first study to create a longitudinal database of all emergency department visits, hospitalizations, and long-term mortality for every severely injured patient within an entire state during a 5-year period. Undertriage varied substantially by region and was associated with multiple factors including access to care and patient factors.Epidemiologic study, level III.

    View details for DOI 10.1097/TA.0000000000000197

    View details for Web of Science ID 000334161500028

  • The epidemiology of trauma-related mortality in the United States from 2002 to 2010 JOURNAL OF TRAUMA AND ACUTE CARE SURGERY Sise, R. G., Calvo, R. Y., Spain, D. A., Weiser, T. G., Staudenmayer, K. L. 2014; 76 (4): 913-919


    Epidemiologic trends in trauma-related mortality in the United States require updating and characterization. We hypothesized that during the past decade, there have been changing trends in mortality that are associated with multiple public health and health care-related factors.Multiple sources were queried for the period of 2002 to 2010: the National Trauma Data Bank, the National Centers for Disease Control, the National Highway Traffic Safety Administration, the Nationwide Emergency Department Sample, and the US Census Bureau. The incidence of injury and mortality for motor vehicle traffic (MVT) collisions, firearms, and falls were determined using National Centers for Disease Control data. National Highway Traffic Safety Administration data were used to determine motor vehicle collision information. Injury severity data were derived from the Nationwide Emergency Department Sample and National Trauma Data Bank. Analysis of mortality trends by year was performed using the Cochran-Armitage test for trend. Time-trend multivariable Poisson regression was used to determine risk-adjusted mortality over time.From 2002 to 2010, the total trauma-related mortality decreased by 6% (p < 0.01). However, mortality trends differed by mechanism. There was a 27% decrease in the MVT death rate associated with a 20% decrease in motor vehicle collisions, 19% decrease in the number of occupant injuries per collision, lower injury severity, and improved outcomes at trauma centers. While firearm-related mortality remained relatively unchanged, mortality caused by firearm suicides increased, whereas homicide-associated mortality decreased (p < 0.001 for both). In contrast, fall-related mortality increased by 46% (5.95-8.70, p < 0.01).MVT mortality rates have decreased during the last decade, owing in part to decreases in the number and severity of injuries. Conversely, fall-related mortality is increasing and is projected to exceed both MVT and firearm mortality rates should current trends continue. Trauma systems and injury prevention programs will need to take into account these changing trends to best accommodate the needs of the injured population.Epidemiologic study, level III.

    View details for DOI 10.1097/TA.0000000000000169

    View details for Web of Science ID 000334161500003

    View details for PubMedID 24662852

  • Gunshot Injuries in Children Served by Emergency Services PEDIATRICS Newgard, C. D., Kuppermann, N., Holmes, J. F., Haukoos, J. S., Wetzel, B., Hsia, R. Y., Wang, N. E., Bulger, E. M., Staudenmayer, K., Mann, N. C., Barton, E. D., Wintemute, G. 2013; 132 (5): 862-870


    To describe the incidence, injury severity, resource use, mortality, and costs for children with gunshot injuries, compared with other injury mechanisms.This was a population-based, retrospective cohort study (January 1, 2006-December 31, 2008) including all injured children age ≤ 19 years with a 9-1-1 response from 47 emergency medical services agencies transporting to 93 hospitals in 5 regions of the western United States. Outcomes included population-adjusted incidence, injury severity score ≥ 16, major surgery, blood transfusion, mortality, and average per-patient acute care costs.A total of 49,983 injured children had a 9-1-1 emergency medical services response, including 505 (1.0%) with gunshot injuries (83.2% age 15-19 years, 84.5% male). The population-adjusted annual incidence of gunshot injuries was 7.5 cases/100,000 children, which varied 16-fold between regions. Compared with children who had other mechanisms of injury, those injured by gunshot had the highest proportion of serious injuries (23%, 95% confidence interval [CI] 17.6-28.4), major surgery (32%, 95% CI 26.1-38.5), in-hospital mortality (8.0%, 95% CI 4.7-11.4), and costs ($28,510 per patient, 95% CI 22,193-34,827).Despite being less common than other injury mechanisms, gunshot injuries cause a disproportionate burden of adverse outcomes in children, particularly among older adolescent males. Public health, injury prevention, and health policy solutions are needed to reduce gunshot injuries in children.

    View details for DOI 10.1542/peds.2013-1350

    View details for Web of Science ID 000326475000055

    View details for PubMedID 24127481

  • Cost-effectiveness of helicopter versus ground emergency medical services for trauma scene transport in the United States. Annals of emergency medicine Delgado, M. K., Staudenmayer, K. L., Wang, N. E., Spain, D. A., Weir, S., Owens, D. K., Goldhaber-Fiebert, J. D. 2013; 62 (4): 351-364 e19


    STUDY OBJECTIVE: We determine the minimum mortality reduction that helicopter emergency medical services (EMS) should provide relative to ground EMS for the scene transport of trauma victims to offset higher costs, inherent transport risks, and inevitable overtriage of patients with minor injury. METHODS: We developed a decision-analytic model to compare the costs and outcomes of helicopter versus ground EMS transport to a trauma center from a societal perspective during a patient's lifetime. We determined the mortality reduction needed to make helicopter transport cost less than $100,000 and $50,000 per quality-adjusted life-year gained compared with ground EMS. Model inputs were derived from the National Study on the Costs and Outcomes of Trauma, National Trauma Data Bank, Medicare reimbursements, and literature. We assessed robustness with probabilistic sensitivity analyses. RESULTS: Helicopter EMS must provide a minimum of a 17% relative risk reduction in mortality (1.6 lives saved/100 patients with the mean characteristics of the National Study on the Costs and Outcomes of Trauma cohort) to cost less than $100,000 per quality-adjusted life-year gained and a reduction of at least 33% (3.7 lives saved/100 patients) to cost less than $50,000 per quality-adjusted life-year. Helicopter EMS becomes more cost-effective with significant reductions in patients with minor injury who are triaged to air transport or if long-term disability outcomes are improved. CONCLUSION: Helicopter EMS needs to provide at least a 17% mortality reduction or a measurable improvement in long-term disability to compare favorably with other interventions considered cost-effective. Given current evidence, it is not clear that helicopter EMS achieves this mortality or disability reduction. Reducing overtriage of patients with minor injury to helicopter EMS would improve its cost-effectiveness.

    View details for DOI 10.1016/j.annemergmed.2013.02.025

    View details for PubMedID 23582619

  • Cost-Effectiveness of Helicopter Versus Ground Emergency Medical Services for Trauma Scene Transport in the United States ANNALS OF EMERGENCY MEDICINE Delgado, M. K., Staudenmayer, K. L., Wang, N. E., Spain, D. A., Weir, S., Owens, D. K., Goldhaber-Fiebert, J. D. 2013; 62 (4): 351-364
  • Triage of Elderly Trauma Patients: A Population-Based Perspective JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS Staudenmayer, K. L., Hsia, R. Y., Mann, N. C., Spain, D. A., Newgard, C. D. 2013; 217 (4): 569-576


    Elderly patients are frequently undertriaged. However, the associations between triage patterns and outcomes from a population perspective are unknown. We hypothesized that triage patterns would be associated with differences in outcomes.This is a population-based, retrospective, cohort study of all injured adults aged 55 years or older, from 3 counties in California and 4 in Utah (2006 to 2007). Prehospital data were linked to trauma registry data, state-level discharge data, emergency department records, and death files. The primary outcome was 60-day mortality. Patients treated at trauma centers were compared with those treated at nontrauma centers. Undertriage was defined as an Injury Severity Score (ISS) >15, with transport to a nontrauma center.There were 6,015 patients in the analysis. Patients who were taken to nontrauma centers were, on average, older (79.4 vs 70.7 years, p < 0.001), more often female (68.6% vs 50.2%, p < 0.01), and less often had an ISS >15 (2.2% vs 6.7%, p < 0.01). There were 244 patients with an ISS >15 and the undertriage rate was 32.8% (n = 80). Overall 60-day mortality for patients with an ISS >15 was 17%, with no difference between trauma and nontrauma centers in unadjusted or adjusted analyses. However, the median per-patient costs were $21,000 higher for severely injured patients taken to trauma centers.This is the first population-based analysis of triage patterns and outcomes in the elderly. We have shown high rates of undertriage that are not associated with higher mortality, but are associated with higher costs. Future work should focus on determining how to improve outcomes for this population.

    View details for DOI 10.1016/j.jamcollsurg.2013.06.017

    View details for Web of Science ID 000325152100003

  • 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


    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

  • Patient Choice in the Selection of Hospitals by 9-1-1 Emergency Medical Services Providers in Trauma Systems ACADEMIC EMERGENCY MEDICINE Newgard, C. D., Mann, N. C., Hsia, R. Y., Bulger, E. M., Ma, O. J., Staudenmayer, K., Haukoos, J. S., Sahni, R., Kuppermann, N. 2013; 20 (9): 911-919


    Reasons for undertriage (transporting seriously injured patients to nontrauma centers) and the apparent lack of benefit of trauma centers among older adults remain unclear; understanding emergency medical services (EMS) provider reasons for selecting certain hospitals in trauma systems may provide insight to these issues. In this study, the authors evaluated reasons cited by EMS providers for selecting specific hospital destinations for injured patients, stratified by age, injury severity, field triage status, and prognosis.This was a retrospective cohort study of injured children and adults transported by 61 EMS agencies to 93 hospitals (trauma and nontrauma centers) in five regions of the western United States from 2006 through 2008. Hospital records were probabilistically linked to EMS records using trauma registries, state discharge data, and emergency department data. The seven standardized reasons cited by EMS providers for selecting hospital destinations included closest facility, ambulance diversion, physician choice, law enforcement choice, patient or family choice, specialty resource center, and other. "Serious injury" was defined as an Injury Severity Score (ISS) ≥ 16, and unadjusted in-hospital mortality was considered as a marker of prognosis. All analyses were stratified by age in 10-year increments, and descriptive statistics were used to characterize the findings.A total of 176,981 injured patients were evaluated and transported by EMS over the 3-year period, of whom 5,752 (3.3%) had ISS ≥ 16 and 2,773 (1.6%) died. Patient or family choice (50.6%), closest facility (20.7%), and specialty resource center (15.2%) were the most common reasons indicated by EMS providers for selecting destination hospitals; these frequencies varied substantially by patient age. The frequency of patient or family choice increased with increasing age, from 36.4% among 21- to 30-year-olds to 75.8% among those older than 90 years. This trend paralleled undertriage rates and persisted when restricted to patients with serious injuries. Older patients with the worst prognoses were preferentially transported to major trauma centers, a finding that was not explained by field triage protocols.Emergency medical services transport patterns among injured patients are not random, even after accounting for field triage protocols. The selection of hospitals appears to be heavily influenced by patient or family choice, which increases with patient age and involves inherent differences in patient prognosis.

    View details for DOI 10.1111/acem.12213

    View details for Web of Science ID 000324579700007

    View details for PubMedID 24050797

  • Variability of ICU use in adult patients with minor traumatic intracranial hemorrhage. Annals of emergency medicine Nishijima, D. K., Haukoos, J. S., Newgard, C. D., Staudenmayer, K., White, N., Slattery, D., Maxim, P. C., Gee, C. A., Hsia, R. Y., Melnikow, J. A., Holmes, J. F. 2013; 61 (5): 509-517 e4


    Patients with minor traumatic intracranial hemorrhage are frequently admitted to the ICU, although many never require critical care interventions. To describe ICU resource use in minor traumatic intracranial hemorrhage, we assess (1) the variability of ICU use in a cohort of patients with minor traumatic intracranial hemorrhage across multiple trauma centers, and (2) the proportion of adult patients with traumatic intracranial hemorrhage who are admitted to the ICU and never receive a critical care intervention during hospitalization. In addition, we evaluate the association between ICU admission and key independent variables.A structured, historical cohort study of adult patients (aged 18 years and older) with minor traumatic intracranial hemorrhage was conducted within a consortium of 8 Level I trauma centers in the western United States from January 2005 to June 2010. The study population included patients with minor traumatic intracranial hemorrhage, defined as an emergency department (ED) Glasgow Coma Scale (GCS) score of 15 (normal mental status) and an Injury Severity Score less than 16 (no other major organ injury). The primary outcome measure was initial ICU admission. The secondary outcome measure was a critical care intervention during hospitalization. Critical care interventions included mechanical ventilation, neurosurgical intervention, transfusion of blood products, vasopressor or inotrope administration, and invasive hemodynamic monitoring. ED disposition and the proportion of ICU patients not receiving a critical care intervention were compared across sites with descriptive statistics. The association between ICU admission and predetermined independent variables was analyzed with multivariable regression.Among 11,240 adult patients with traumatic intracranial hemorrhage, 1,412 (13%) had minor traumatic intracranial hemorrhage and complete ED disposition data (mean age 48 years; SD 20 years). ICU use within this cohort across sites ranged from 50% to 97%. Overall, 847 of 888 patients (95%) with minor traumatic intracranial hemorrhage who were admitted to the ICU did not receive a critical care intervention during hospitalization (range between sites 80% to 100%). Three of 524 (0.6%) patients discharged home or admitted to the observation unit or ward received a critical care intervention. After controlling for severity of injury (age, blood pressure, and Injury Severity Score), study site was independently associated with ICU admission (odds ratios ranged from 1.5 to 30; overall effect P<.001).Across a consortium of trauma centers in the western United States, there was wide variability in ICU use within a cohort of patients with minor traumatic intracranial hemorrhage. Moreover, a large proportion of patients admitted to the ICU never required a critical care intervention, indicating the potential to improve use of critical care resources in patients with minor traumatic intracranial hemorrhage.

    View details for DOI 10.1016/j.annemergmed.2012.08.024

    View details for PubMedID 23021347

  • 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


    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 Web of Science ID 000319316600024

    View details for PubMedID 23609282

  • Predictors of emergency department death for patients presenting with ruptured abdominal aortic aneurysms JOURNAL OF VASCULAR SURGERY Mell, M. W., Callcut, R. A., Bech, F., Delgado, M. K., Staudenmayer, K., Spain, D. A., Hernandez-Boussard, T. 2012; 56 (3): 651-655


    Ruptured abdominal aortic aneurysm (rAAA) is a critically time-sensitive condition with outcomes dependent on rapid diagnosis and definitive treatment. Emergency department (ED) death reflects the hemodynamic stability of the patient upon arrival and the ability to mobilize resources before hemodynamic stability is lost. The goals of this study were to determine the incidence and predictors of ED death for patients presenting to EDs with rAAAs.Data for patients presenting with International Classification of Disease, 9th Revision, Clinical Modification codes for rAAA from 2006 to 2008 were extracted from discharge data using the Nationwide Emergency Department Sample (NEDS), Healthcare Cost and Utilization Project, and Agency for Healthcare Research and Quality. The NEDS is the largest stratified weighted sample of US hospital-based ED visits with links to inpatient files. We compared those transferred to those admitted and treated. Sample weights were applied to produce nationally representative estimates. Patient and hospital factors associated with transfer were identified using multivariate logistic regression. These factors were then analyzed for a relationship with ED deaths.A total of 18,363 patients were evaluated for rAAAs. Of these, 7% (1201) died in the ED, 6% (1160) were admitted and died without a procedure, 42% (7731) were admitted and died after repair, and 41% (7479) were admitted, treated, and survived. Transfers accounted for 4% (793) of all ED visits for rAAAs. ED death was more likely for patients seen in nonmetropolitan hospitals (12.7%) vs metropolitan nonteaching (7.0%) or metropolitan teaching hospitals (4.5%; P < .0001). Compared with other regions, the West had a higher ED mortality rate (9.6% vs 5.1%-6.9%; P = .0038). On multivariate analysis, ED death was associated with hospital groups exhibiting both high and low transfer rates.ED death remains a significant cause for mortality for rAAAs and varies by hospital type, rural/urban location, and geographic region. Both delays in ED arrival and delays in providing definitive care may contribute to increased ED death rates, suggesting that improved regional systems of care may improve survival after rAAA.

    View details for DOI 10.1016/j.jvs.2012.02.025

    View details for Web of Science ID 000308085500010

    View details for PubMedID 22560234

  • Evaluating Age in the Field Triage of Injured Persons ANNALS OF EMERGENCY MEDICINE Nakamura, Y., Daya, M., Bulger, E. M., Schreiber, M., Mackersie, R., Hsia, R. Y., Mann, N. C., Holmes, J. F., Staudenmayer, K., Sturges, Z., Liao, M., Haukoos, J., Kuppermann, N., Barton, E. D., Newgard, C. D. 2012; 60 (3): 335-345


    We evaluate trauma undertriage by age group, the association between age and serious injury after accounting for other field triage criteria and confounders, and the potential effect of a mandatory age triage criterion for field triage.This was a retrospective cohort study of injured children and adults transported by 48 emergency medical services (EMS) agencies to 105 hospitals in 6 regions of the western United States from 2006 through 2008. We used probabilistic linkage to match EMS records to hospital records, including trauma registries, state discharge databases, and emergency department databases. The primary outcome measure was serious injury, as measured by an Injury Severity Score greater than or equal to 16. We assessed undertriage (Injury Severity Score ?16 and triage-negative or transport to a nontrauma center) by age decile and used multivariable logistic regression models to estimate the association (linear and nonlinear) between age and Injury Severity Score greater than or equal to 16, adjusted for important confounders. We also evaluated the potential influence of age on triage efficiency and trauma center volume.Injured patients (260,027) were evaluated and transported by EMS during the 3-year study period. Undertriage increased for patients older than 60 years, reaching approximately 60% for those older than 90 years. There was a strong nonlinear association between age and Injury Severity Score greater than or equal to 16. For patients not meeting other triage criteria, the probability of serious injury was most notable after 60 years. A mandatory age triage criterion would have decreased undertriage at the expense of overtriage, with 1 patient with Injury Severity Score greater than or equal to 16 identified for every 60 to 65 additional patients transported to major trauma centers.Trauma undertriage increases in patients older than 60 years. Although the probability of serious injury increases among triage-negative patients with increasing age, the use of a mandatory age triage criterion appears inefficient for improving field triage.

    View details for DOI 10.1016/j.annemergmed.2012.04.006

    View details for Web of Science ID 000308620500015

    View details for PubMedID 22633339

  • Payer status is associated with the use of prophylactic inferior vena cava filter in high-risk trauma patients SURGERY Pickham, D. M., Callcut, R. A., Maggio, P. M., Mell, M. W., Spain, D. A., Bech, F., Staudenmayer, K. 2012; 152 (2): 232-237


    It is controversial whether patients at high risk for pulmonary embolism (PE) should receive prophylactic inferior vena cava filters (IVC) filters. This lack of clarity creates the potential for variability and disparities in care. We hypothesized there would be differential use of prophylactic IVC filters for patients at high risk for PE on the basis of insurance status.We performed a retrospective analysis using the National Trauma Databank (2002-2007). We included adult patients at high risk for PE (traumatic brain injury or spinal cord injury) and excluded patients with a diagnosis of deep venous thrombosis (DVT) or PE. Logistic regression was performed to control for confounders and a hierarchical mixed effects model was used to control for center.A prophylactic filter was placed in 3,331 (4.3%) patients in the study cohort. Patients without insurance had an IVC filter placed less often compared with those with any form of insurance (2.7% vs 4.9%, respectively). After adjusting for confounders, we found that patients without insurance were less likely to receive a prophylactic IVC filter, even when we controlled for center (OR 5.3, P < .001).When guidelines lack clarity, unconscious bias has the potential to create a system with different levels of care based on socioeconomic disparities.

    View details for DOI 10.1016/j.surg.2012.05.041

    View details for Web of Science ID 000307157500013

    View details for PubMedID 22828145

  • Evaluating the Use of Existing Data Sources, Probabilistic Linkage, and Multiple Imputation to Build Population-based Injury Databases Across Phases of Trauma Care ACADEMIC EMERGENCY MEDICINE Newgard, C., Malveau, S., Staudenmayer, K., Wang, N. E., Hsia, R. Y., Mann, N. C., Holmes, J. F., Kuppermann, N., Haukoos, J. S., Bulger, E. M., Dai, M., Cook, L. J. 2012; 19 (4): 469-480


    The objective was to evaluate the process of using existing data sources, probabilistic linkage, and multiple imputation to create large population-based injury databases matched to outcomes.This was a retrospective cohort study of injured children and adults transported by 94 emergency medical systems (EMS) agencies to 122 hospitals in seven regions of the western United States over a 36-month period (2006 to 2008). All injured patients evaluated by EMS personnel within specific geographic catchment areas were included, regardless of field disposition or outcome. The authors performed probabilistic linkage of EMS records to four hospital and postdischarge data sources (emergency department [ED] data, patient discharge data, trauma registries, and vital statistics files) and then handled missing values using multiple imputation. The authors compare and evaluate matched records, match rates (proportion of matches among eligible patients), and injury outcomes within and across sites.There were 381,719 injured patients evaluated by EMS personnel in the seven regions. Among transported patients, match rates ranged from 14.9% to 87.5% and were directly affected by the availability of hospital data sources and proportion of missing values for key linkage variables. For vital statistics records (1-year mortality), estimated match rates ranged from 88.0% to 98.7%. Use of multiple imputation (compared to complete case analysis) reduced bias for injury outcomes, although sample size, percentage missing, type of variable, and combined-site versus single-site imputation models all affected the resulting estimates and variance.This project demonstrates the feasibility and describes the process of constructing population-based injury databases across multiple phases of care using existing data sources and commonly available analytic methods. Attention to key linkage variables and decisions for handling missing values can be used to increase match rates between data sources, minimize bias, and preserve sampling design.

    View details for DOI 10.1111/j.1553-2712.2012.01324.x

    View details for Web of Science ID 000302858200014

    View details for PubMedID 22506952

  • The forgotten trauma patient: Outcomes for injured patients evaluated by emergency medical services but not transported to the hospital JOURNAL OF TRAUMA AND ACUTE CARE SURGERY Staudenmayer, K., Hsia, R., Wang, E., Sporer, K., Ghilarducci, D., Spain, D., Mackersie, R., Sherck, J., Kline, R., Newgard, C. 2012; 72 (3): 594-599


    Injured patients who are not transported by an ambulance to the hospital are often not included in trauma registries. The outcomes of these patients have until now been unknown. Understanding what happens to nontransports is necessary to better understand triage validity, patient outcomes, and costs associated with injury. We hypothesized that a subset of patients who were not transported from the scene would later present for evaluation and that these patients would have a nonzero mortality rate.This is a population-based, retrospective cohort study of injured adults and children for three counties in California from 2006 to 2008. Prehospital data for injured patients for whom an ambulance was dispatched were probabilistically linked to trauma registry data from four trauma centers, state-level discharge data, emergency department records, and death files (1-year mortality).A total of 69,413 injured persons who were evaluated at the scene by emergency medical services were included in the analysis. Of them, 5,865 (8.5%) were not transported. Of those not transported, 1,616 (28%) were later seen in an emergency department and discharged and 92 (2%) were admitted. Seven (0.2%) patients later died.Patients evaluated by emergency medical services, but not initially transported from the field after injury, often present later to the hospital. The mortality rate in this population was not zero, and these patients may represent preventable deaths.III, therapeutic study.

    View details for DOI 10.1097/TA.0b013e31824764ef

    View details for Web of Science ID 000301371100016

    View details for PubMedID 22491541

  • 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


    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 Web of Science ID 000298003700005

    View details for PubMedID 22107917

  • Ruptured Biliary Cystadenoma Managed by Angiographic Embolization and Interval Partial Hepatectomy DIGESTIVE DISEASES AND SCIENCES Ghole, S. A., Bakhtary, S., Staudenmayer, K., Sze, D. Y., Pai, R. K., Visser, B. C., Norton, J. A., Poultsides, G. A. 2011; 56 (7): 1949-1953

    View details for DOI 10.1007/s10620-011-1677-z

    View details for Web of Science ID 000291481800006

    View details for PubMedID 21445579

  • Systematic Review: Benefits and Harms of In-Hospital Use of Recombinant Factor VIIa for Off-Label Indications ANNALS OF INTERNAL MEDICINE Yank, V., Tuohy, C. V., Logan, A. C., Bravata, D. M., Staudenmayer, K., Eisenhut, R., Sundaram, V., McMahon, D., Olkin, I., McDonald, K. M., Owens, D. K., Stafford, R. S. 2011; 154 (8): 529-W190


    Recombinant factor VIIa (rFVIIa), a hemostatic agent approved for hemophilia, is increasingly used for off-label indications.To evaluate the benefits and harms of rFVIIa use for 5 off-label, in-hospital indications: intracranial hemorrhage, cardiac surgery, trauma, liver transplantation, and prostatectomy.Ten databases (including PubMed, EMBASE, and the Cochrane Library) queried from inception through December 2010. Articles published in English were analyzed.Two reviewers independently screened titles and abstracts to identify clinical use of rFVIIa for the selected indications and identified all randomized, controlled trials (RCTs) and observational studies for full-text review.Two reviewers independently assessed study characteristics and rated study quality and indication-wide strength of evidence.16 RCTs, 26 comparative observational studies, and 22 noncomparative observational studies met inclusion criteria. Identified comparators were limited to placebo (RCTs) or usual care (observational studies). For intracranial hemorrhage, mortality was not improved with rFVIIa use across a range of doses. Arterial thromboembolism was increased with medium-dose rFVIIa use (risk difference [RD], 0.03 [95% CI, 0.01 to 0.06]) and high-dose rFVIIa use (RD, 0.06 [CI, 0.01 to 0.11]). For adult cardiac surgery, there was no mortality difference, but there was an increased risk for thromboembolism (RD, 0.05 [CI, 0.01 to 0.10]) with rFVIIa. For body trauma, there were no differences in mortality or thromboembolism, but there was a reduced risk for the acute respiratory distress syndrome (RD, -0.05 [CI, -0.02 to -0.08]). Mortality was higher in observational studies than in RCTs.The amount and strength of evidence were low for most outcomes and indications. Publication bias could not be excluded.Limited available evidence for 5 off-label indications suggests no mortality reduction with rFVIIa use. For some indications, it increases thromboembolism.

    View details for Web of Science ID 000289622000016

    View details for PubMedID 21502651

  • Outcomes and complications of open abdomen technique for managing non-trauma patients. Journal of emergencies, trauma, and shock Kritayakirana, K., M Maggio, P., Brundage, S., Purtill, M., Staudenmayer, K., A Spain, D. 2010; 3 (2): 118-122


    Damage control surgery and the open abdomen technique have been widely used in trauma. These techniques are now being utilized more often in non-trauma patients but the outcomes are not clear. We hypothesized that the use of the open abdomen technique in non-trauma patients 1) is more often due to peritonitis, 2) has a lower incidence of definitive fascial closure during the index hospitalization, and 3) has a higher fistula rate.Retrospective case series of patients treated with the open abdomen technique over a 5-year period at a level-I trauma center. Data was collected from the trauma registry, operating room (OR) case log, and by chart review. The main outcome measures were number of operations, definitive fascial closure, fistula rate, complications, and length of stay.One hundred and three patients were managed with an open abdomen over the 5-year period and we categorized them into three groups: elective (n = 31), urgent (n = 35), and trauma (n = 37). The majority of the patients were male (69%). Trauma patients were younger (39 vs 53 years; P < 0.05). The most common indications for the open abdomen technique were intraabdominal hypertension in the elective group (n = 18), severe intraabdominal infection in the urgent group (n = 19), and damage control surgery in the trauma group (n = 28). The number of abdominal operations was similar (3.1-3.7) in the three groups, as was the duration of intensive care unit (ICU) stay (average: 25-31 days). The definitive fascial closure rates during initial hospitalization were as follows: 63% in the elective group, 60% in the urgent group, and 54% in the trauma group. Intestinal fistula formation occurred in 16%, 17%, and 11%, respectively, in the three groups, with overall mortality rates of 35%, 31%, and 11%.Intra-abdominal infection was a common reason for use of the open abdomen technique in non-trauma patients. However, the definitive fascial closure and fistula rates were similar in the three groups. Despite differences in indications, damage control surgery and the open abdomen technique have been successfully transitioned to elective and urgent non-trauma patients.

    View details for DOI 10.4103/0974-2700.62106

    View details for PubMedID 20606786

  • Comparison of Thromboembolic Event Rates in Randomized Controlled Trials and Observational Studies of Recombinant Factor VIIa for Off-Label Indications. Yank, V., Logan, A. C., Tuohy, C. V., Bravata, D. M., Staudenmayer, K., Eisenhut, R., Sundaram, V., McMahon, D., McDonald, K. M., Owens, D., Stafford, R. S. AMER SOC HEMATOLOGY. 2009: 571-572
  • Trauma training in simulation: Translating skills from SIM time to real time JOURNAL OF TRAUMA-INJURY INFECTION AND CRITICAL CARE Knudson, M. M., Khaw, L., Bullard, M. K., Dicker, R., Cohen, M. J., Staudenmayer, K., Sadjadi, J., Howard, S., Gaba, D., Krummel, T. 2008; 64 (2): 255-263


    : Training surgical residents to manage critically injured patients in a timely fashion presents a significant challenge. Simulation may have a role in this educational process, but only if it can be demonstrated that skills learned in a simulated environment translate into enhanced performance in real-life trauma situations.: A five-part, scenario-based trauma curriculum was developed specifically for this study. Midlevel surgical residents were randomized to receiving this curriculum in didactic lecture (LEC) fashion or with the use of a human performance simulator (HPS). A written learning objectives test was administered at the completion of the training. The first four major trauma resuscitations performed by each participating resident were captured on videotape in the emergency department and graded by two experienced judges blinded to the method of training. The assessment tool used by the judges included an evaluation of both initial trauma evaluation or treatment skills (part I) and crisis management skills (part II) as well as an overall score (poor/fail, adequate, or excellent).: The two groups of residents received almost identical scores on the posttraining written test. Average SIM and LEC scores for part I were also similar between the two groups. However, SIM-trained residents received higher overall scores and higher scores for part II crisis management skills compared with the LEC group, which was most evident in the scores received for the teamwork category (p = 0.04).: A trauma curriculum incorporating simulation shows promise in developing crisis management skills that are essential for evaluation of critically injured patients.

    View details for DOI 10.1097/TA.0b013e31816275b0

    View details for Web of Science ID 000253287100001

    View details for PubMedID 18301184

  • Angiopoietin-2, marker and mediator of endothelial activation with prognostic significance early after trauma? ANNALS OF SURGERY Ganter, M. T., Cohen, M. J., Brohi, K., Chesebro, B. B., Staudenmayer, K. L., Rahn, P., Christiaans, S. C., Bir, N. D., Pittet, J. 2008; 247 (2): 320-326


    To measure plasma levels of angiopoietin-1 (Ang-1), angiopoietin-2 (Ang-2), and vascular endothelial growth factor (VEGF) early after trauma and to determine their clinical significance.Angiopoietins and VEGF play a central role in the physiology and pathophysiology of endothelial cells. Ang-2 has recently been shown to have pathogenetic significance in sepsis and acute lung injury. Little is known about the role of angiopoietins and VEGF early after trauma.Blood specimens from consecutive major trauma patients were obtained immediately upon arrival in the emergency department and plasma samples assayed for Ang-1, Ang-2, VEGF, markers of endothelial activation, protein C pathway, fibrinolytic system, and complement. Base deficit was used as a measure of tissue hypoperfusion. Data were collected prospectively.Blood samples were obtained from 208 adult trauma patients within 30 minutes after injury before any significant fluid resuscitation. Plasma levels of Ang-2, but not Ang-1 and VEGF were increased and correlated independently with severity of injury and tissue hypoperfusion. Furthermore, plasma levels of Ang-2 correlated with markers of endothelial activation, coagulation abnormalities, and activation of the complement cascade and were associated with worse clinical outcome.Ang-2 is released early after trauma with the degree proportional to both injury severity and systemic hypoperfusion. High levels of Ang-2 were associated with an activated endothelium, coagulation abnormalities, complement activation, and worse clinical outcome. These data indicate that Ang-2 is a marker and possibly a direct mediator of endothelial activation and dysfunction after severe trauma.

    View details for DOI 10.1097/SLA.0b013e318162d616

    View details for Web of Science ID 000252758500018

    View details for PubMedID 18216540

  • Ethnic disparities in long-term function outcomes after traumatic brain injury JOURNAL OF TRAUMA-INJURY INFECTION AND CRITICAL CARE Staudenmayer, K. L., Diaz-Arrastia, R., de Oliveira, A., Gentilello, L. M., Shafi, S. 2007; 63 (6): 1364-1369


    Ethnic disparities in access to acute rehabilitation and in long-term global neurologic outcomes after traumatic brain injury (TBI) have been previously documented. The current study was undertaken to determine whether there are specific types of functional deficits that disproportionately affect ethnic minorities after TBI.The TBI Clinical Trials Network is a National Institutes of Health-funded multicenter prospective study. Local data from trauma centers in a single ethnically diverse major metropolitan study site were analyzed. Functional outcomes were measured in 211 patients with blunt TBI (head Abbreviated Injury Scale score 3-5) who were alive >/=6 months after discharge using the Functional Status Examination (FSE), which measures outcome in 10 functional domains and compares current functional status to preinjury status. For each domain, patients were classified as functionally independent (FSE score 1, 2) or dependent upon others (FSE score 3, 4). Ethnic minorities (n = 66) were compared with non-Hispanic whites (n = 145), with p < 0.05 considered significant.The two groups had similar injury severity (head Abbreviated Injury Scale score, initial Glasgow Coma Scale score, Injury Severity Score) and were equally likely to be placed in rehabilitation after trauma center discharge (minorities 51%, whites 46%, p = 0.28). Minority patients experienced worse long-term functional outcomes in all domains, which reached statistical significance in post-TBI standard of living, engagement in leisure activities, and return to work or school.Ethnic minorities with TBI suffer worse long-term deficits in three specific functional domains. TBI rehabilitation programs should target these specific areas to reduce disparities in functional outcomes in ethnic minorities.

    View details for DOI 10.1097/TA.0b013e31815b897b

    View details for Web of Science ID 000251768100031

    View details for PubMedID 18212662

  • Civilian hospital response to mass casualty events: basic principles. Bulletin of the American College of Surgeons Staudenmayer, K., Schecter, W. P. 2007; 92 (8): 16-20

    View details for PubMedID 17715580

  • Hypertonic saline modulates innate immunity in a model of systemic inflammation SHOCK Staudenmayer, K. L., Maier, R. V., Jelacic, S., Bulger, E. M. 2005; 23 (5): 459-463


    We sought to determine if hypertonic saline (HTS) impacted alveolar macrophage (AM) activation and intracellular inflammatory gene signaling in a model of systemic inflammation. Rats received an intravenous administration of 4 mL/kg of 7.5% HTS or L-lactate lactated Ringer's (L-LR). They were simultaneously treated with an intraperitoneal injection of zymosan, which induces noninfectious systemic inflammation. AM were harvested by bronchoalveolar lavage 24 h after treatment. AM activation was analyzed by measurement of baseline and lipopolysaccharide (LPS)-induced TNF-alpha production. Intracellular signaling was analyzed for activation of the mitogen-activated protein kinases (MAPKs): ERK1/2, JNK, and p38. AM from HTS-treated rats produced less TNF-alpha than from L-LR-treated rats (927 +/- 335 pg/mL [SEM] vs. 3628 +/- 783 pg/mL [SEM], P = 0.001) and were also less responsive to LPS (4444 +/- 86 pg/mL [SEM] vs. 6666 +/- 91 pg/mL [SEM], P = 0.058). However, there was no difference in MAPK activation. In vivo HTS prevents excessive AM activation during systemic inflammation. This suppression is mediated through alternate pathways and does not induce the classic MAPK signaling cascade.

    View details for DOI 10.1097/01.shk.0000160523.37106.33

    View details for Web of Science ID 000228913500011

    View details for PubMedID 15834313

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