JAMA surgery
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Comparative Study
Outcomes of laparoscopic vs open repair of primary ventral hernias.
More primary ventral hernias (PVHs) are being repaired using the technique of laparoscopic ventral hernia repair (LVHR). Few studies exist comparing the outcomes of LVHR with the outcomes of open ventral hernia repair (OVHR) for PVHs. We hypothesize that LVHR of PVHs is associated with fewer surgical site infections (SSIs) but more hernia recurrences and more clinical cases of bulging (bulging not associated with recurrence or seroma). ⋯ Compared with OVHR of PVHs, LVHR of PVHs is associated with fewer SSIs but more clinical cases of bulging and with the risk of developing a port-site hernia. Further study is needed to clarify the role of LVHR of PVHs and to mitigate the risk of port-site hernia and bulging.
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Inadvertent carotid sheath insertion during central venous catheter placement could lead to serious complications. ⋯ Inadvertent carotid artery sheath placement during attempted central venous cannulation for pulmonary artery catheter insertion mandates catheter removal and repair of the carotid artery puncture site. The closure device permits percutaneous repair of the carotid artery expeditiously. Our experience showed this treatment modality to be as safe and effective as operative repair.
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Up to 25% of patients with normal lungs develop acute lung injury (ALI) secondary to mechanical ventilation, with 60% to 80% progressing to acute respiratory distress syndrome (ARDS). Once established, ARDS is treated with mechanical ventilation that can paradoxically elevate mortality. A ventilation strategy that reduces the incidence of ARDS could change the clinical paradigm from treatment to prevention. ⋯ Continuous mandatory ventilation in normal rats for 6 hours with Vt and PEEP settings similar to those of surgery patients caused ALI. Preemptive application of APRV blocked early drivers of lung injury, preventing ARDS. Our data suggest that APRV applied early could reduce the incidence of ARDS in patients at risk.
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Multicenter Study
NEXUS chest: validation of a decision instrument for selective chest imaging in blunt trauma.
Chest radiography (chest x-ray [CXR] and chest computed tomography [CT]) is the most common imaging in blunt trauma evaluation. Unnecessary trauma imaging leads to greater costs, emergency department time, and patient exposure to ionizing radiation. OBJECTIVE To validate our previously derived decision instrument (NEXUS Chest) for identification of blunt trauma patients with very low risk of thoracic injury seen on chest imaging (TICI). We hypothesized that NEXUS Chest would have high sensitivity (>98%) for the prediction of TICI and TICI with major clinical significance. ⋯ We have validated the NEXUS Chest decision instrument, which may safely reduce the need for chest imaging in blunt trauma patients older than 14 years.
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Reduction in length of hospital stay is a veritable target in reducing the overall costs of health care. However, many existing approaches are flawed because the assumptions of what cause excessive length of stay are incorrect; we methodically identified the right targets in this study. ⋯ System-related issues, not severity of illness, prolong hospital stay excessively. Cost-reduction efforts should target operational bottlenecks between acute and postacute care.