bluuebunny/crossref_metadata_2025 huggingface dataset:
Evaluation of Prehospital and Emergency Department Systolic Blood Pressure as a Predictor of In-Hospital Mortality
Authors: Lalezarzadeh Fariborz , Wisniewski Paul , Huynh Katie , Loza Maria , Gnanadev Dev
Published: June 2020

Hypotension is a trauma activation criterion validated by multiple studies. However, field systolic blood pressures (SBP) are still met with skepticism. How significant is the role of prehospital (PH) and emergency department (ED) SBP in the patient's overall condition? A review of the trauma registry over a 5-year period was conducted. PH SBPs were stratified into four categories: severe (SBP 80 mmHg or less), moderate (81-100 mmHg), mild hypotension (101-120 mmHg), and normotension (greater than 120 mmHg). These four groups were further subcategorized into the patients who were hypotensive, SBP 90 mmHg or less in the ED, versus those that were not (SBP greater than 90 mmHg). Data for 6964 patients were analyzed. Patients with PH SBP of 80 mmHg or less compared with patients who had PH SBP of greater than 80 mmHg had higher mortality (OR, 9; 95% CI, 6.45-12.84). Patients with both PH SBP 80 mmHg or less and ED SBP 90 mmHg or less had the highest risk of mortality (50%) and highest need for emergent operative intervention (54%). PH and ED hypotension is a strong predictor of in-hospital mortality and need for emergent surgical intervention in trauma patients. Field or ED blood pressures should serve as a significant marker of the patient's condition.
Initial Surgical Experience Evaluating Early Tolerance and Toxicities in Patients Undergoing Accelerated Partial Breast Irradiation Using the Contura® Multi Lumen Balloon Breast Brachytherapy Catheter
Authors: Israel Philip Z. , Robbins Angela B. , Shroff Paulomi , Haile Kenneth , Pope D. Keith
Published: June 2020

We reviewed our surgical experience with the Contura® Multi Lumen Balloon breast brachytherapy catheter used to deliver accelerated partial breast irradiation and determined short-term treatment efficacy, cosmesis, and toxicity. Forty-six patients undergoing breast conserving therapy, including the use of Contura® catheter, were analyzed. Thirty-four Gray were delivered in 10 fractions. Fourteen patients had stage 0, 24 had stage I, and 8 had stage II breast cancer. Catheters were placed with a closed cavity technique. Median minimum skin spacing was 10 mm (range, 2-18 mm). Median maximum skin doses were 99.7 per cent of the prescription dose. Nine patients were treated with a skin spacing ≤5 mm (2 patients with 2 mm skin spacing). The percentage of patients with excellent/good cosmesis at 6 (n = 26) and 12 (n = 13) months was 100 per cent, respectively. Patient tolerance was assessed on a scale of 0-10 (0 = no pain, 10 = requiring narcotic analgesics). Pain was graded ≤3 in 98 per cent of patients at catheter insertion and 84 per cent at catheter removal. Four breast infections (8.8%) and one symptomatic seroma developed. Adjuvant accelerated partial breast irradiation using the Contura Multi Lumen Balloon exhibited similar toxicities to standard single lumen, single dwell balloon brachytherapy with improvements in dosimetric capabilities allowing the treatment of patients with skin spacing ≤5 mm.
Endoscopic Retrograde Cholangiopancreatography in General Surgery: How Much are We Outsourcing?
Authors: Jones Wesley B. , Roettger Richard H. , Cobb William S. , Carbonell Alfredo M.
Published: June 2020

Although surgeons can safely perform endoscopic retrograde cholangiopancreatography (ERCP), it has fallen within the domain of gastroenterologists. We sought to quantify the role of ERCP in a tertiary-care surgery department. The hospital discharge database was queried for all ERCPs performed from January 2007 to December 2007. Gastroenterologists performed all ERCPs in our query. Surgical patients were admitted and/or under the care of a surgeon; whereas nonsurgical patients had no surgeon involvement. Patient characteristics and diagnoses were compared between groups. ERCP procedural details were recorded. Surgical patients comprised 48 per cent (n = 151) of the total 311 ERCPs performed. The mean time interval from a surgeon's request for ERCP to actual procedure was 2.43 days (standard deviation [SD] 2.55; range, 0-13 days). The surgical group had significantly different diagnoses and underwent less diagnostic (22% vs 56%) and more therapeutic ERCPs (72% vs 38%). Surgical patients were more likely inpatients (82.1% vs 16.8%) with a longer length of stay (6.7 vs 3.9 days; P = 0.0029) compared with nonsurgical patients. We found surgical patients requiring ERCP differ significantly from nonsurgical patients, with a significant number of technical interventions being outsourced. Given the benefits of a surgical ERCP program and the potential volume of these unique patients, this procedure should be performed by appropriately trained surgeons.
HAZUS Modeling for Hurricane Effect on a Healthcare Campus: Implications for Health Care Planning
Authors: Tran Paul , Weireter Leonard , Sokolowski Whitney , Lawsure Kaleen , Sokolowski John
Published: June 2020

The purpose of this study was to model the damage sustained by the healthcare campus, in the aftermath of a hurricane, as a tool to facilitate pre- and post-storm planning for provision of healthcare services or campus evacuation. Using HAZUS analysis for estimating disaster associated losses, storm surge, residual flooding, and wind damage were modeled for hurricane categories 1 thru 5. The ability of the healthcare campus to deliver services was assessed as a function of the residual functional infrastructure. Implications for peristorm planning were developed. A Category 2 storm surge of 6 to 8 feet would completely isolate the campus and flood the adult hospital while leaving the adjacent pediatric hospital as a dry island. Residual 8 foot flooding would allow campus access via two of the four entrances but only after damage from the storm surge had been incurred. When combined with winds exceeding 100 mph, sufficient damage would occur to predict that the campus is not useable for a minimum of 44 days. A low intensity hurricane has the potential to render our healthcare campus nonoperational. Disaster planning needs to allow a realistic assessment of the post storm capability to deliver care so that alternatives and prestorm evacuation plans can be developed.
Injury Location Dictates Utility of Digital Rectal Examination and Rigid Sigmoidoscopy in the Evaluation of Penetrating Rectal Trauma
Authors: Hargraves M. Brinson , Magnotti Louis J. , Fischer Peter E. , Schroeppel Thomas J. , Zarzaur Ben L. , Fabian Timothy C. , Croce Martin A.
Published: June 2020

Penetrating pelvic injuries (specifically rectal) pose a difficult diagnostic challenge. Although management of these injuries, once recognized, can be straightforward, the consequences of a missed injury can be devastating. The purpose of this study was to evaluate the utility of digital rectal examination (DRE) and rigid sigmoidoscopy (RS) as screening tests for penetrating rectal injuries. Patients with full-thickness penetrating rectal injury over a 10-year period were identified. All underwent DRE and RS before exploration. Injury location was classified as intraperitoneal (IP) or extraperitoneal (EP). Overall sensitivities for DRE and RS were calculated as well as sensitivities for RS in the identification of IP versus EP injuries. Seventy-seven patients were identified. Overall sensitivity for DRE and RS was 51 per cent (95% CI: 37-65%) and 78 per cent (95% CI: 65-92%), respectively. Sensitivity of RS for identification of rectal injury based on anatomic distinction was 58 per cent (95% CI: 30-86%) for IP and 88 per cent (95% CI: 75-100%) for EP injuries. Anatomic location determines the value of preoperative screening tests for identification of penetrating rectal injuries. RS proved better than DRE for diagnosis. The greatest benefit was observed with EP injuries. The possibility of a missed IP injury associated with a negative screen should prompt exploration if clinical suspicion is high.
The Relative Influence of Surgical Disease and Co-Morbidities on Patient Responses to a Generic Health-Related Quality-of-Life Instrument
Authors: France Emily , Velanovich Vic
Published: June 2020

Generic health-related quality-of-life (QoL) instruments are increasingly used to assess the outcomes of surgical interventions. However, it is unclear to what extent the patient's associated comorbidities have on the responsiveness of these instruments to measure changes caused by the operation. The purpose of this study was to assess the relative influence of comorbidities to surgical disease in how patients answered the items of the most frequently used generic instrument, the SF-36. Sixty-nine preoperative patients completed the SF-36, which contains 36 items covering eight domains and a health transition question. For each of the 36 items, patients were asked to rate the influence of their surgical disease and their comorbidities on how they answered the items from 1 to 10. The surgical disease, comorbidities, and medications were recorded. Data was analyzed using the Mann-Whitney U test and linear regression analysis. Of the 36 items of the SF-36, patients reported that their surgical disease influences nine items greater than their comorbidities (P < 0.05). Using linear regression analysis, the number of comorbidities did not effect the influence of the surgical disease in any item; however, this number had a direct relationship (P < 0.05) with the influence of comorbidities on how the patient answered the item. However, the magnitude of the influence was low. There was an inverse (negative slope, P < 0.05) relationship between the number of comorbidities and the score of six of eight domains. Although the surgical disease has more of an influence on how patients answered the items of the SF-36, as the number of comorbidities increased, these seem to have more influence. Therefore, the SF-36 would be a good choice for assessing QoL in most surgical disease. However, as the overall magnitude of this influence was low, this may be a cause of the lack of responsiveness of generic QoL instruments in measuring the effect of operations on QoL. Importantly, as the number of comorbidities increased, the scores of the SF-36 decreased, implying that the effect of the surgical disease would be greater in patients with fewer comorbidities.
An Efficient Hand-Tying Technique for Vessel Ligation
Authors: Sandwell Stephen , Hazani Ron , Kasdan Morton
Published: June 2020

Vessel ligation is a fundamental surgical skill that must be performed efficiently. By identifying and eliminating redundant hand movements, we developed a more smooth method for tying a first knot around a hemostat-clamped vessel. The knot is made while the suture is being passed around the hemostat. In addition to being an exceptionally fast method, this technique allows a flat knot to be placed without the need to cross hands.
Does Platelet Administration Affect Mortality in Elderly Head-Injured Patients Taking Antiplatelet Medications?
Authors: Downey Douglas M. , Monson Benjamin , Butler Karyn L. , Fortuna Gerald R. , Saxe Jonathan M. , Dolan James P. , Markert Ronald J. , Mccarthy Mary C.
Published: June 2020

A significant portion of patients sustaining traumatic brain injury (TBI) take antiplatelet medications (aspirin or clopidogrel), which have been associated with increased morbidity and mortality. In an attempt to alleviate the risk of increased bleeding, platelet transfusion has become standard practice in some institutions. This study was designed to determine if platelet transfusion reduces mortality in patients with TBI on antiplatelet medications. Databases from two Level I trauma centers were reviewed. Patients with TBI 50 years of age or older with documented preinjury use of clopidogrel or aspirin were included in our cohort. Patients who received platelet transfusions were compared with those who did not to assess outcome differences between them. Demographics and other patient characteristics abstracted included Injury Severity Score, Glasgow Coma Scale, hospital length of stay, and warfarin use. Three hundred twenty-eight patients comprised the study group. Of these patients, 166 received platelet transfusion and 162 patients did not. Patients who received platelets had a mortality rate of 17.5 per cent (29 of 166), whereas those who did not receive platelets had a mortality rate of 16.7 per cent (27 of 162) ( P = 0.85). Transfusion of platelets in patients with TBI using antiplatelet therapy did not reduce mortality.
Isolated Rollover Mechanism Does Not Warrant Trauma Center Evaluation
Authors: Haan James M. , Glassman Erik , Hartsock Robbi , Radcliffe James , Scalea Thomas M.
Published: June 2020

Significant resources are expended on the assessment of trauma patients who arrive at the trauma center based solely on mechanism of injury. We hypothesized that rollover motor vehicle crashes (ROMVC) are not an independent predictor for trauma center care. All patients seen between January 1, 2001, and December 31, 2005, involved in a ROMVC, were reviewed. Patients with any confounding factors were removed, leaving those transported to the trauma center based on mechanism only. Five hundred sixty-nine patients were transported to our center for the mechanism of ROMVC. Of the 569 patients, 369 (65%) were evaluated and discharged with minimal Injury Severity Score and regional Abbreviated Injury Scale scores. Of the remaining 200 (35%) patients admitted, 130 required surgery, predominantly for closed extremity and facial fractures. Six patients required immediate surgery for life-threatening injuries: 3 splenectomies, 1 subdural evacuation, and 2 vascular repairs (1.1%). Of the remaining 123 (4.2%) patients requiring surgery, 24 required urgent surgery (2 craniotomies, 9 laparotomies, and 13 spinal fixations). None of the patients with spinal injury had neurologic deficit. Eight patients were admitted to the intensive care unit for neurologic monitoring (1.4%). Only 6.7 per cent benefited from initial Trauma Triage Criteria. Therefore, ROMVC is not an independent predictor of the need for trauma center evaluation or admission. The majority of these patients could be safely evaluated and treated at nontrauma centers or transferred later.
The Morbidity of Trauma Nephrectomy
Authors: Edwards Norma M. , Claridge Jeffrey A. , Forsythe Raquel M. , Weinberg Jordan A. , Croce Martin A. , Fabian Timothy C.
Published: June 2020

Mortality has been shown to be high in patients after trauma nephrectomy (TN). However, there are little data regarding morbidity in survivors. The objective of this study was to determine the morbidity rates associated with TN with attention directed to renal failure (RF) and formation of intra-abdominal abscess (IAA). Patients who underwent TN over a 9-year period (1996 to 2004) were identified from the trauma registry. Records were reviewed for all complications after TN in patients surviving at least 48 hours. Eighty-nine patients were identified with TN; 61 per cent resulted after penetrating trauma. Overall mortality was 34 per cent. Seventy-one patients survived greater than 48 hours; 51 (72%) experienced at least one morbidity. There was no difference in morbidity rates between patients undergoing blunt trauma and those undergoing penetrating trama. Patients with morbidities were significantly older, more severely injured, and had higher mortality rates and longer hospital courses. Infectious complications were seen in 52 per cent, respiratory in 48 per cent, gastrointestinal in 30 per cent, coagulopathy in 25 per cent, and RF and IAA were each seen in 14 per cent of patients. Patients undergoing TN are severely injured with significant morbidity. The results from this study allow us to establish benchmarks to assess complication rates for patients who undergo TN, which can provide prognostic information and goals to improve patient outcomes.
Coverage Strategies in Exposed Implants
Authors: Cyrochristos Dimitris J. , Papadopoulos Othon , Liapis Christos , Felekouras Evagelos L. , Giannopoulos Athanasios M. , Bastounis Elias
Published: June 2020

Implants are widely used and are not without complications. The most serious complication is infection with consequent exposure of the implant and is characterized by increased morbidity and mortality. Until recently, infected implants were removed and replaced with another one. These operations are accompanied by increased morbidity and might result in permanent disability. Coverage of the implant with a flap is an alternative solution. The objective of this article is to study the effectiveness of muscle or myocutaneous flaps in covering infected and exposed implants. A series of 17 patients with infected implants, which were treated with coverage of the implant with muscle or myocutaneous flap, is presented. Eight patients had an orthopedic implant, seven a vascular implant, and two had a pacemaker. The flaps ensured immediate coverage of the implant and the biologic ability of eliminating the infectious process with the increased concentration of antibiotics resulting from increased blood flow of the muscle. In all the patients, the implants were preserved and the infectious process was eliminated. The use of muscle and myocutaneous flaps in the treatment of infected implants is therefore effective and in some cases it is superior to other methods because of lower morbidity and cost.
A Central Venous Line Protocol Decreases Bloodstream Infections and Length of Stay in a Trauma Intensive Care Unit Population
Authors: Duane TherÈSe M. , Brown Holly , Borchers C. Todd , Wolfe Luke G. , Malhotra Ajai K. , Aboutanos Michel B. , Ivatury Rao R.
Published: June 2020

We evaluated the benefit of a central venous line (CVL) protocol on bloodstream infections (BSIs) and outcome in a trauma intensive care unit (ICU) population. We prospectively compared three groups: Group 1 (January 2003 to June 2004) preprotocol; Group 2 (July 2004 to June 2005) after the start of the protocol that included minimizing CVL use and strict universal precautions; and Group 3 (July 2005 to December 2006) after the addition of a line supply cart and nursing checklist. There were 1622 trauma patients admitted to the trauma ICU during the study period of whom 542 had a CVL. Group 3 had a higher Injury Severity Score (ISS) compared with both Groups 2 and 1 (28.3 ± 13.0 vs 23.5 ± 11.7 vs 22.8 ± 12.0, P = 0.0002) but had a lower BSI rate/1000 line days (Group 1:16.5; Group 2:15.0; Group 3: 7.7). Adjusting for ISS group, three had shorter ICU length of stay (LOS) compared with Group 1 (12.11 ± 1.46 vs 18.16 ± 1.51, P = 0.01). Logistic regression showed ISS ( P = 0.04; OR, 1.025; CI, 1.001-1.050) and a lack of CVL protocol ( P = 0.01; OR, 0.31; CI, 0.13-0.76) to be independent predictors of BSI. CVL protocols decrease both BSI and LOS in trauma patients. Strict enforcement by a nurse preserves the integrity of the protocol.
Is There a Benefit to Multidisciplinary Rounds in an Open Trauma Intensive Care Unit regarding Ventilator-Associated Pneumonia?
Authors: Van Johnson , Mangram Alicia , Mitchell Christopher , Lorenzo Manuel , Howard Dot , Dunn Ernest
Published: June 2020

Multidisciplinary rounds (MDRs) have been instituted for patient care since June 2005. Before June 2005, all care was provided by individual practitioners. MDRs include the surgical intensivist, surgical resident, patient's nurse, case manager, pharmacist, chaplain, nutritionist, and respiratory therapist. Our study examined the effect of MDRs on ventilator-associated pneumonia in trauma patients in open intensive care units (ICUs). Group 1 included patients from June 2003 to May 2005 before the implementation of MDRs, and Group 2 included patients after the institution of MDRs from June 2005 to May 2007. In Group 1, there were 83 ventilator-associated pneumonias (VAPs) during 2414 ventilator days. In Group 2, there were 49 VAPs during 2094 ventilator days. The ratio of VAPs per thousand ventilator days decreased from 34.4 to 23.4 between the two groups ( P = 0.04). When comparing trauma patients in our open ICU with similar mean Injury Severity Score and mean Abbreviated Injury Score for chest and for head and neck, implementing MDRs significantly decreased our incidence of VAP.
Apoptosis and Microvessel Density in Gastric Cancer: Correlation with Tumor Stage and Prognosis
Authors: Aurello Paolo , Bellagamba Riccardo , Del Monte Simone Rossi , D'Angelo Francesco , Nigri Giuseppe , Cicchini Claudia , Ravaioli Matteo , Ramacciato Giovanni
Published: June 2020

Gastric cancer remains one of the most common human malignancies with a poor prognosis. Apoptosis is known to be a programmed cell death and its inhibition is involved in the unregulated cellular growth that leads to neoplasms. Microvessel density (MVD) has been investigated as a promoting factor for angiogenesis with conflicting results about its relation to survival. The aim of our study was to search a correlation between these factors and some clinicopathological features and prognosis. Identification of apoptotic cells was performed applying the terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick-end labeling technique and recorded as apoptotic index (A.I.), whereas monoclonal antibodies were used for the study of MVD. A significant correlation was found between low and high A.I. and the subgroup of patients in Stages I and II (P < 0.02); 20 per cent of patients with a low A.I. showed an overall survival longer than 5 years versus 44 per cent of patients with an high A.I. (P = 0.041). High MVD was significantly related to the T stage ( P = 0.036) and to a poorer 5-year overall survival (P < 0.05). Further studies are required to confirm the role of apoptosis and MVD in the development and progression of gastric cancer.
Laparoscopic Repair of a Man with Massive Bilateral Femoral Hernias
Authors: Stoikes Nathaniel , Mangiante Eugene , Voeller Guy
Published: June 2020

In this review, we describe a laparoscopic totally extraperitoneal (TEP) repair of a man with massive bilateral femoral hernias that had been chronically incarcerated, which has not previously been described in the literature. Our purpose is to not only to describe our laparoscopic technique and postoperative management, but also to comprehensively review the literature regarding the principles of laparoscopic hernia repair and specifically laparoscopic femoral hernia repair. TEP repair is a safe approach to the surgical management of femoral hernias, including those that are incarcerated, and furthermore offers the advantage of repairing other concomitant hernias, which may be more prevalent than expected.
The Effect of ACGME Duty Hour Restrictions on Operative Continuity of Care
Authors: Nakayama Don K. , Thompson William M. , Wynne Julie L. , Dalton Martin L. , Bozeman Andrew T. , Innes Bruce J.
Published: June 2020

Resident work restrictions limit participation in operations that address problems created by a prior operation, because complications occur at any time. We compared resident and attending surgeon staffing of operative complications. We reviewed all complications that required a second operation reported at our Morbidity and Mortality Conference over 1 year, noting surgeons present, their postgraduate year level, and call shift. Comparisons were done using χ2. Of 142 cases, 39 involved a second operation. The same attending surgeon was present for both in 79 per cent of cases, whereas the same resident was present in only 44 per cent ( P = 0.002). Postgraduate year 4 to 5 were less likely to be present for second operations than attendings (48% vs 87%, P = 0.011). Resident shift (day, night float, and weekend) was known in 32 cases. When the first operation occurred during day hours, attendings and residents were equally likely to be present at the second (55% and 45%, P = 0.16). When original operations took place during night float or weekend shifts, residents were less likely to be present (33%) than attendings (83%) at second operations ( P = 0.036). Duty hour restrictions interfere with operative continuity of care. Reoperations should be exempted from duty hour restrictions.
Anatomical and Surgical Considerations on Lumbar Hernias
Authors: Cavallaro Giuseppe , Sadighi Arash , Paparelli Claudia , Miceli Mario , D'Ermo Giuseppe , Polistena Andrea , Cavallaro Antonino , De Toma Giorgio
Published: June 2020

Lumbar hernias, which are rare hernias of the posterolateral abdominal wall, can be divided into two groups: primary lumbar hernias, often the expression of a congenital defect, which typically arise in two areas of weakness, the superior triangle and inferior triangle and acquired (or diffuse) lumbar hernias which are usually due to previous lumbar trauma or surgery. Clinical examination may be adjuvated by ultrasound or CT scan, which can reveal the abdominal wall defect with the hernia content (viscera or extraperitoneal tissue). Surgical repair of lumbar hernias, both primary and acquired, has rapidly developed through recent years, similarly to the treatment of more frequent kinds of hernia (groin, epigastric), evolving from direct repair to mini-invasive techniques, even if, since the rarity of these hernias, precise knowledge of this complex anatomic region is required. Nowadays there are two valid alternatives: open tension-free repair (with use of mesh), and mini-invasive repair. Both are safe and effective, even if smaller hernias can be treated by open approach, with loco-regional anesthesia and good cosmetic effect. Larger hernias, or hernias with suspected viscera involvement, should require larger incisions and viscera exploration. For this reason laparoscopic access would be preferable.
A Betrayal of Our Handiwork: Postoperative Hemorrhage and the Need for Reoperation
Authors: Grinberg Roman , Helling Thomas S.
Published: June 2020

Postoperative hemorrhage (PH) that requires reoperation to control bleeding represents a potentially life-threatening and avoidable complication that could have serious implications for recovery. All surgical patients were reviewed who developed PH and required reoperation for control of hemorrhage over a 12-year period, to examine contributing factors possibly related to surgeon misadventure. Of 89,663 operations during this period, there were 1,031 patients (1.2%) who developed PH. Of these, 36 patients required reoperation for control of PH (0.04%), including, general surgery (17), otolaryngologic (9), cardiovascular (9), and gynecologic (1) patients. In 27 general, cardiovascular, and gynecologic patients (29 reoperations), the age ranged from 6 to 91 years. Almost one-half of patients (56%) developing PH were on preoperative anticoagulation. Estimated operative blood loss (EBL) was moderate (EBL = 100-500 mL, 48%). Most patients were normothermic (80%) and normotensive (93%) intraoperatively. The decision to reoperate was not made for at least 8 hours in 55 per cent of patients. At reoperation 10/29 patients were hypotensive. In 20/36 patients (56%) the reoperation note did not identify a single source of bleeding. PH is a distinctly uncommon complication of surgery and often not due to obvious surgeon misadventure. Reoperation for PH is even rarer and embarked upon with reluctance, frequently not yielding a discernible cause for hemorrhage.
Lack of Complications in Skin Surgery of Patients Receiving Clopidogrel as Compared with Patients Taking Aspirin, Warfarin, and Controls
Authors: Kramer Eyal , Hadad Eran , Westreich Melvyn , Shalom Avshalom
Published: June 2020

Clopidogrel, a new antiplatelet agent that irreversibly inhibits platelet aggregation, is widely used today. This prospective work was conducted to evaluate the safety of performing skin surgery on patients taking clopidogrel. Patients undergoing surgery for excision of skin or subcutaneous lesions under local anesthesia taking clopidogrel were the study group. The control group comprised 2073 historical patients who had undergone a similar procedure. Data collected included: age, sex, past medical history, medications, and late complications. Follow-up was done at 1 to 2 weeks and 3 to 6 months. There were 32 patients on clopidogrel, having 38 lesions removed. Of these, seven patients were on aspirin and clopidogrel combined. The groups taking clopidogrel, aspirin, and warfarin had significantly more males, were older, and had significantly more comorbid medical conditions. There was no significant difference in the incidence of any of the complications in any of the groups. This study shows that patients taking clopidogrel before skin surgery, though older and with more associated medical conditions, do not experience a greater rate of complications. We conclude that patients undergoing minor excisional cutaneous surgery should continue taking clopidogrel because there is no apparent risk for increased complications when good meticulous surgical techniques are used.
Extreme Blood Alcohol Level is Associated with Increased Resource use in Trauma Patients
Authors: Swearingen Alissa , Ghaemmaghami Vafa , Loftus Terrence , Swearingen Christopher J. , Salisbury Helen , Gerkin Richard D. , Ferrara John
Published: June 2020

This study aims to examine resource utilization and outcomes of trauma patients with extremely high blood alcohol concentrations. We hypothesized that higher blood alcohol concentration (BAC) predicts greater resource utilization and poorer outcomes. A retrospective analysis was performed on trauma patients admitted to an urban Level I trauma center over a 5-year period. Admission BAC categories were constructed using standard laboratory norms and legal definitions. Demographic data, premorbid conditions, injury severity scores (ISS), resource utilization (intensive care unit (ICU) admission rates/length of stay, total hospital days, use of consultants), and mortality were analyzed. Positive BAC on admission was associated with increased ISS ( P < 0.001), length of stay ( P < 0.003), and total ICU days ( P < 0.001). Increased BAC admission level of patients was associated with a decreased ISS score ( P = 0.0073), a higher probability of ICU admission ( P = 0.0013), and an increased percentage of ICU days ( P = 0.001). A positive BAC at admission was a significant predictor of both ICU admission and mortality (odds ratios 1.72 and 1.27, respectively). This study demonstrates that a positive BAC is associated with increased ISS, increased resource utilization, and worsened outcomes. Extreme levels of BAC are associated with increased resource utilization despite lower injury severity scores.
Surgical Anatomy of the Retroperitoneal Spaces Part II: The Architecture of the Retroperitoneal Space
Authors: Mirilas Petros , Skandalakis John E.
Published: June 2020

The extraperitoneal space extends between peritoneum and investing fascia of muscles of anterior, lateral and posterior abdominal and pelvic walls, and circumferentially surrounds the abdominal cavity. The retroperitoneum, which is confined to the posterior and lateral abdominal and pelvic wall, may be divided into three surgicoanatomic zones: centromedial, lateral (right and left), and pelvic. The preperitoneal space is confined to the anterior abdominal wall and the subperitoneal extraperitoneal space to the pelvis. In the extraperitoneal tissue, condensation fascias delineate peri- and parasplanchnic spaces. The former are between organs and condensation fasciae, the latter between this fascia and investing fascia of neighboring muscles of the wall. Thus, perirenal space is encircled by renal fascia, and pararenal is exterior to renal fascia. Similarly for the urinary bladder, paravesical space is between the umbilical prevesical fascia and fascia of the pelvic wall muscles—the prevesical space is its anterior part, between transversalis and umbilical prevesical fascia. For the rectum, the “mesorectum” describes the extraperitoneal tissue bound by the mesorectal condensation fascia, and the pararectal space is between the latter and the muscles of the pelvic wall. Perisplanchnic spaces are closed, except for neurovascular pedicles. Prevesical and pararectal (presacral) and posterior pararenal spaces are in the same anatomical level and communicate. Anterior to the anterior layer of the renal fascia, the anterior interfascial plane (superimposed and fused mesenteries of pancreas, duodenum, and colon) permits communication across the midline. Thus parasplanchnic extraperitoneal spaces of abdomen and pelvis communicate with each other and across the midline.
The Association of Race and Survival from Sepsis after Injury
Authors: Plurad David S. , Lustenberger Thomas , Kilday Patrick , Zhu Jay , Green Donald J. , Inaba Kenji , Talving Peep , Belzberg Howard , Demetriades Demetrios
Published: June 2020

Genetic variation is associated with outcome disparity in critical illness. We sought to determine if race is independently associated with the development of posttraumatic sepsis and subsequent related mortality. Our Intensive Care Unit database was queried for admissions from January 1, 2000 to June 30, 2007. Patients were prospectively followed for sepsis (Any four of the following symptoms: temperature ≥ 38° C, heart rate (HR) ≥ 90 b/m, RR ≥ 20 b/m (or PaCO2 ≤ 32 mm Hg), white blood cell count (WBC) ≥ 12, or vasopressor requirement all with an infectious source). White, Black, Hispanic, and Asian groups were defined. “Other” race was excluded. Most of the 3998 study patients were male (3157, 79.0%). Blunt trauma (2661, 66.6%) predominated. Six-hundred-seventy-seven (16.9%) met sepsis criteria. Mortality was 14.0 per cent (560). Sepsis was increased in Asians versus all others combined (23.7% vs 16.1%). Race was independently associated with sepsis (adjusted odds ratio (OR) 1.12 (1.01-1.24), P value = 0.03). Sepsis associated mortality was 36.9 per cent (250/677). Black race demonstrated an increased survival versus all others after sepsis (25.4% vs 37.7%) but this was not statistically significant (adjusted OR 0.96 (0.73-1.18), P value = 0.71). Race is independently associated with posttraumatic sepsis and possibly subsequent sepsis associated mortality. Further related study is needed with the ultimate goal of genetically based treatments for the prevention and treatment of sepsis after injury.
The ‘Whip-Stow’ Procedure: An Innovative Modification to the Whipple Procedure in the Management of Premalignant and Malignant Pancreatic Head Disease
Authors: Jeyarajah D. Rohan , Khithani Amit , Curtis David , Galanopoulos Christos A.
Published: June 2020

Pancreaticoduodenectomy (PD) is the standard of care in the treatment of premalignant and malignant diseases of the head of the pancreas. Variability exists in anastomosis with the pancreatic remnant. This work describes a safe and easy modification for the pancreatic anastomosis after PD. Ten patients underwent the “Whip-Stow” procedure for the management of the pancreatic remnant. PD combined with a Puestow (lateral pancreaticojejunostomy [LPJ]) was completed using a running single-layer, 4-0 Prolene obeying a duct-to-mucosa technique. LPJ and pancreaticogastrostomy (PG) historical leak rates are reported to be 13.9 and 15.8 per cent, respectively. Mortality, leak, and postoperative bleeding rates were 0 per cent in all patients. The Whip-Stow was completed without loops or microscope with a 4-0 single-layer suture decreasing the time and complexity of the anastomosis. Average time was 12 minutes as compared with the 50 minutes of a 5 or 6-0 interrupted, multilayered duct–mucosa anastomosis. Benefits included a long-segment LPJ. In this study, the Whip-Stow procedure has proven to be a safe and simple approach to pancreatic anastomosis in selected patients. This new technique provides the benefit of technical ease while obeying the age old principles of obtaining a wide duct to mucosa anastomosis.
Transition from Chief Residency to Specialty Training: Issues and Solutions
Authors: Nakayama Don K. , Phillips Linda G. , Newsome R. Edward , Fuhrman George M. , Tarpley John L.
Published: June 2020

Three fourths of chief residents in general surgery receive further specialty training. The end to start-of-year transition can create administrative conflicts between the residency and the specialty training program. An Internet-based questionnaire surveyed general surgery and surgical specialty program directors to define issues and possible solutions associated with end to start-of-year transitions using a Likert scale. There was an overall response rate of 17.5 per cent, 19.6 per cent among general surgery directors, and 15.8 per cent among specialty directors. Program directors in general surgery felt strongly that the transition is an administrative problem ( P < 0.001). They opposed extra days off at the end of the chief resident year or ending in mid-June, which specialty directors favored ( P < 0.001). Directors of specialty programs opposed starting the year 1 or 2 weeks after July 1, a solution that general surgery directors favored ( P < 0.001). More agreement was reached on whether chief residents should take vacation week(s) at the end of the academic year, having all general surgery levels start in mid-June, and orientation programs in July for specialty trainees. Program directors acknowledge that year-end scheduling transitions create administrative and patient care problems. Advancing the start of the training year in mid-June for all general surgery levels is a potential solution.
An Immunohistochemical Study of Osteopontin in Pigment Gallstone Formation
Authors: Imano Motohiro , Satou Takao , Itoh Tatsuki , Takeyama Yoshifumi , Yasuda Atsushi , Peng Ying-Feng , Shinkai Masayuki , Haji Seiji , Yasuda Chikao , Nakai Takuya , Yasuda Takushi , Imamoto Haruhiko , Okuno Kiyotaka , Shiozaki Hitoshi , Ohyanagi Harumasa
Published: June 2020

Mucin glycoproteins from the gallbladder epithelium are thought to contribute to the matrix or nucleus of gallstones and other biomineralization systems. The involved acidic glycoproteins have been reported in bile and gallstones. In addition, osteopontin (Opn) is a noncollagenous acidic bone matrix glycoprotein that possesses calcium-binding properties. To investigate the role of Opn in pigment gallstone formation, the involvement of Opn in pigment gallstone formation was studied immunohistochemically in the gallbladder wall and in the stones. Staining for Opn was strongly positive in the epithelium of stone-laden gallbladders and in their stones. The stone-laden gallbladders were infiltrated by macrophages, which intensely stained for Opn. Sections of the pigment stones, under low magnification, showed a lamellar pattern of Opn immunolabeling and showed a reticular pattern under high magnification. Our results indicate that Opn, an acidic glycoprotein from the gallbladder epithelium, seems to be involved in lithiasis. Opn from macrophages and/or the epithelium seems to help form the matrix protein.
A Massive Pulmonary Embolism Treatment Protocol: How Trauma Performance Improvement Affects Outcome Throughout the Hospital System
Authors: Velopulos Catherine Garrison , Zumberg Mark , Mcauliffe Priscilla , Lottenberg Lawrence , Layon A. Joseph
Published: June 2020

Trauma performance improvement is the hallmark of a mature trauma center. If loop closure is to be complete, preventable deaths must result in significant change in management and the establishment of protocol-driven improvements so such an instance does not recur. The trauma performance improvement committee reviewed a case of a massive pulmonary embolus and determined that this was a preventable death. The hospital performance improvement committee then initiated a root cause analysis, which led to creation of a treatment protocol for patients with massive or submassive pulmonary embolism. A focused review of the first 6 months of the implementation of the protocol was undertaken. Four patients over a 6-month period had massive or submassive pulmonary embolus. All four had sudden death or near sudden death and were appropriately resuscitated. All four sustained right heart failure. Two patients were treated by catheter-directed fibrinolysis, one with catheter-directed suction embolectomy, and one by surgical pulmonary embolectomy. All survived with full neurologic function. Trauma performance improvement is the model by which all hospital performance improvement should be done. Preventable deaths can result in change, which can have a future impact on survival in potentially lethal scenarios.
Gluteal Fascial Advancement: An Innovative, Effective Method for Treating Pilonidal Disease
Authors: Washer Joshua D. , Smith Dane E. , Carman Mary E. , Blackhurst Dawn W.
Published: June 2020

The ideal elective surgical procedure for pilonidal disease is debated. Simple excision and closure is commonly performed but is associated with a high incidence of wound complications and recurrence. We developed a simple modification of primary closure, which involves the elevation, mobilization, and closure of the gluteal fascia. The purpose of this study is to compare outcomes of this gluteal fascial advancement technique with standard primary closure for the treatment of pilonidal disease. We retrospectively reviewed our surgical database to include all patients who underwent surgery for pilonidal disease from 2004 to 2007. Patients who underwent primary closure (n = 66) were compared with patients who underwent gluteal fascial advancement (n = 17). Demographic data as well as recurrence and the incidence of wound complications were examined. There was a significant difference in incidence of wound breakdown (0 vs 21%), recurrence (0 vs 20%), and early wound drainage (6 vs 32%). Overall there was an 80 per cent reduction in wound complications after gluteal fascial advancement compared with primary closure. Gluteal fascial advancement is a simple modification of standard primary closure and is associated with fewer wound complications and recurrences.
Health Disparity in Complicated Colorectal Cancer
Authors: Bowman Kimberly C. , Tabrizian Parissa , Telem Dana A. , Boudourakis Leon , Divino Celia M.
Published: June 2020

The purpose of this study was to assess for disparity within a cohort of patients presenting with complicated colorectal cancer. A retrospective study of 522 patients who underwent surgery for colorectal cancer at a tertiary care institution was performed. Complicated cancer was defined by perforating or obstructing colonic lesions. Statistical analysis was conducted by χ2 test and analysis of variance. Of the 522 patients, 72 patients (14%) presented with complicated colorectal cancer. Blacks in low-income brackets (36 vs 0%, P < 0.001) and those with public insurance (55 vs 16%, P < 0.05) had increased presentation with complicated colorectal cancers as compared with whites. Black (91%) and Hispanic women (86%), when compared with white women (37%) had increased incidence of complicated colorectal cancer ( P < 0.05). Patients in low-income brackets, regardless of race, had increased cancer recurrence rates (57 vs 8%, P < 0.001) compared with patients in average or high-income brackets. Mortality rate was 57 per cent in Hispanic, 29 per cent in white, and 27 per cent in black patients ( P = nonsignificant). Specific targeting of colorectal cancer screening, education, and follow-up programs is imperative for minority women and patients of low socioeconomic status.
A Special Skin Grafting Technique for Concave Surfaces and for Traumatic Amputations of Fingers
Authors: Tribble David E.
Published: June 2020

Skin grafting of traumatic finger amputations and concave raw surfaces poses special problems for skin grafting. In grafting finger amputations, oozing of blood tends to form a film of blood separating the graft from the raw amputation site. In concave raw surfaces, the skin must be made to conform to the concave surface. A technique of secure fixation of the graft allowing for frequent irrigation of the graft affords a better chance for a good skin graft take.
Impact of Traumatic Suicide Methods on a Level I Trauma Center
Authors: Bittner James G. , Hawkins Michael L. , Atteberry Linda R. , Ferdinand Colville H. , Medeiros Regina S.
Published: June 2020

Suicide is a major, preventable public health issue. Although firearm-related mechanisms commonly result in death, nonfirearm methods cause significant morbidity and healthcare expenditures. The goal of this study is to compare risk factors and outcomes of firearm and nonfirearm traumatic suicide methods. This retrospective cohort study identified 146 patients who attempted traumatic suicide between 2002 and 2007 at a Level I trauma center. Overall, mean age was 40.2 years, 83 per cent were male, 74 per cent were white, and mean Injury Severity Score (ISS) was 12.7. Most individuals (53%) attempted suicide by firearms and 25 per cent died (84% firearm, 16% nonfirearm techniques). Subjects were more likely to die if they were older than 60 years-old, presented with an ISS greater than 16, or used a firearm. On average, patients using a firearm were older and had a higher ISS and mortality rate compared with those using nonfirearm methods. There was no statistical difference between cohorts with regard to gender, ethnicity, positive drug and alcohol screens, requirement for operation, intensive care unit admission, and hospital length of stay. Nonfirearm traumatic suicide prevention strategies aimed at select individuals may decrease overall attempts, reduce mechanism-related mortality, and potentially impact healthcare expenditures.
Prophylactic Fluconazole Does Not Improve Outcome in Patients with Purulent and Fecal Peritonitis due to Lower Gastrointestinal Perforation
Authors: Khoury Wisam , Szold Oded , Soffer Dror , Kariv Yehuda , Wasserlauf Ruth , Klausner Joseph M. , Ogorek Daniel , Weinbroum Avi A.
Published: June 2020

The benefit of anticandida treatment in addition to standard antibiotic therapy in the presence of perforation/leakage of the lower gastrointestinal tract (LGIT) is still controversial. We retrospectively assessed the clinical effects of empiric anticandida treatment in patients with LGIT perforation who had undergone exploratory laparotomy due to perforated/leaking bowel or appendix between 1999 and 2004, including generalized fecal/purulent peritonitis. Two groups of patients emerged: those receiving empiric anticandida treatment (fluconazole, n = 24) and those who did not (n = 77). All the fluconazole-treated and 40/77 nonfluconazole-treated patients required intensive care unit care and were the subject of this assessment. Postoperative Candida infection and mortality rates were similar in the critically-ill fluconazole-treated and nontreated patients (4% vs 7%, 21% vs 22.5%, respectively, P = NS); resistant candidiasis rates were also similar. Hospital and intensive care unit stays were longer in the treated group, however not reaching statistical difference (26.5 ± 18 vs 21.4 ± 18.3 days, 14.8 ± 14.2 vs 9.3 ± 14.1 days, respectively). The rates of morbidity, pneumonia, and multiorgan failure were significantly higher ( P < 0.05) in the treated patients (87% vs 63%, 37% vs 7.5%, and 58% vs 35%, respectively). Empiric fluconazole in patients with peritonitis associated with LGIT perforation did not improve patients’ outcome compared with those without empiric treatment.