Surgery
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Pneumonia is a major complication for hospitalized patients and has come under the scrutiny of health care regulating bodies, which propose that hospital-acquired pneumonia should not be reimbursed and potentially be a "never event." We hypothesized that many of our acutely injured patients develop pneumonia at the time of their initial traumatic event despite aggressive measures to prevent pneumonia during hospitalization. ⋯ Many intubated patients in the surgical ICU had evidence of early pneumonia or bacterial growth within 48 hours after arrival, suggesting early infection or colonization occurred before ICU admission. In addition, 33% with early bacterial growth on early BAL had resistant organisms or GNR on BAL culture, which suggests a patient-derived rather than environmentally acquired source.
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Review Meta Analysis
Use of antibiotics alone for treatment of uncomplicated acute appendicitis: a systematic review and meta-analysis.
The use of antibiotics alone in the treatment of uncomplicated acute appendicitis has been controversial. The present report is based on a systematic review and meta-analysis of existing studies that compared antibiotics treatment to appendectomy in patients with uncomplicated acute appendicitis. ⋯ In some cases, antibiotic treatment may fail, and there is a risk of recurrence. However, surgically treated patients, including those with the potential for spontaneous resolution and those with a normal appendix, are subjected to the risks of operative morbidity and mortality. Antibiotic therapy incurs significantly fewer complications. Prospective randomized studies are urgently needed to conclusively define the roles of appendectomy and antibiotic treatment in the management of uncomplicated acute appendicitis.
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Comparative Study
In-house direct supervision by an attending is associated with differences in the care of patients with a blunt splenic injury.
There continues to be controversy over the added value of direct supervision of residents, particularly its effect on patient outcomes. The purpose of this study was to compare direct and indirect resident supervision for the management of blunt spleen injuries and to evaluate differences in patient care. ⋯ This study shows that there were significant differences in the management of blunt splenic injury depending on the type of supervision. Indirect supervision was associated with less compliance with a management protocol, fewer patients undergoing initial operation, more ICU use, increased hospital charges, and a greater use of splenic artery embolization without indication. These results emphasize the value of direct supervision in the management of a select group of trauma patients.
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The observed to expected (O:E) mortality based on Injury Severity Scores (ISS) has been used to assess quality of trauma center (TC) care. Injuries in the elderly have increased, and these patients often have advanced directives, on occasion limiting aggressive care even for potentially survivable injuries; unfortunately, there are few data on the impact of these demographic changes on mortality. Additionally, many patients arrive moribund and care provided is likely to be futile. We sought to examine the impact of these situations on TC mortality. ⋯ There has been a major shift in the demographics of the injured with a high proportion of elderly and head injured and/or those who have little likelihood of survival. Crude mortality or O:E based on ISS overestimates preventable deaths. Societal factors, presence of advanced directives, and WOC decisions must be considered when assessing TC performance. Although our crude mortality rate was 6.4%, it was only 2.4% in patients we were actually permitted to treat. We suggest a WOC factor should be added to TC data to characterize mortality rates more accurately.
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Platelet transfusion is utilized increasingly for traumatic brain injury (TBI) for the reversal of aspirin (ASA) therapy. Assessment of platelet inhibition and reversal by platelet transfusion after TBI has not been adequately characterized. ⋯ The ART should be used to better target and guide platelet transfusions in TBI patients with known or suspected ASA use history. Patients with occult platelet dysfunction can be identified, unnecessary platelet transfusions avoided, and the adequate volume of platelets administered to correct drug-induced dysfunction. A dose-response relationship between quantity of platelets transfused and reversal of ASA inhibition was observed.