American Surgeon最新文献

Background: The precautions brought on by the COVID-19 pandemic led to the growing practice of bundling lines in patients requiring intubation. Our study aims to examine the effect of immediate bundled lines (IBL) on traumatic injuries. We hypothesized that severely injured patients may benefit from IBL.

Methods: A retrospective review of all intubated trauma patients (1/2015-12/2020) at a Level I Trauma Center was conducted. Patients ≤18 years and those who died or were transferred prior to intensive care unit (ICU) admission were excluded. IBL was defined as placement of central venous catheter (CVC) and arterial line (AL) ≤4 hours after intubation. Delayed lines were any lines placed >4 hours after intubation. Primary outcome was time from intubation to CVC and AL.

Results: 728 patients were included. The majority received CVC and/or AL with 17.7% in a delayed fashion. Severe head injury (AIS ≥3) most often had immediate AL or delayed bundled lines (P < 0.001). IBL were more common with gunshot wounds (GSW) (P < 0.001) and blood transfusions (P < 0.001). IBL were associated with significantly lower GCS (P = 0.018) and higher median ISS. Multivariate logistic regression revealed severe/profound ISS, GSW, and pedestrian struck were predictive of IBL.

Discussion: Intubated trauma patients who presented with certain mechanisms (GSW, pedestrian struck), received blood transfusions, or exhibited severe/profound ISS may be more likely to receive IBL. IBL is not superior to either immediate AL or to no lines in terms of mortality. No lines had a significant effect on ICU LOS or hospital LOS, except in the setting of severe head injury.

Purpose: Concerns exist regarding increased trauma activation fees at the expense of vulnerable patients. In contrast, elective open inguinal hernia repair (E-OIHR) has remained relatively fixed in terms of technique. This study aimed to examine health care costs for E-OIHR and trauma patients, hypothesizing trauma cost would increase from 2010 to 2018, while E-OIHR cost would remain unchanged. Methods: The Nationwide Inpatient Sample database was queried (2010-2018) for admitted patients undergoing unilateral E-OIHR or trauma-related admission. Health care costs per admission, total annual costs, and trends of E-OIHR and trauma admissions were also examined. Multiple linear regression was used to estimate the association of individual- and hospital-level variables with total costs. Results: Unilateral E-OIHR admission cost more than doubled per case in 2018. Trauma cost per admission also increased, however, only by 34%. Total costs for all E-OIHR admissions increased 26%, whereas trauma admission costs increased 32%. Both trauma admissions and unilateral E-OIHR admissions decreased; however, E-OIHR admissions decreased more. Multiple linear regression demonstrated compared to the cost of E-OIHR, trauma care decreased when adjusting for year, age, severity, hospital type, and length of stay (P < .001). Conclusion: The rate of increase in cost per unilateral E-OIHR admission exceeded that of trauma. However, the total economic burden for trauma care increased by billions of dollars due to a steady increase in per incidence cost and only slightly lower rates of trauma admissions. Increased focus on high-value care to curtail increasing costs of E-OIHR and especially trauma appears warranted.

The diagnostic and therapeutic approach to the axilla in breast cancer patients has changed significantly over the past 30 years, with the replacement of complete axillary lymph node dissection practices by less invasive approaches. Reference is made to clinical findings that have led to practical treatment recommendations and are paving the way to new levels of de-escalation in breast cancer surgery.

Introduction: American College of Surgeons-Committee on Trauma (ACS-COT) defines minimum Standard Criteria (SC) for Level 1 trauma. In our hospital, discretion of prehospital personnel ("Paramedic Judgment" [PJ]) can initiate Full Trauma Triage Activation (FTTA) in the absence of ACS-COT criteria. The aim of this study was to evaluate overtriage and undertriage for PJ vs SC.

Methods: 1846 patients met criteria from 1/1/19 to 1/5/23. This study utilized the Cribari Matrix to define under, over, and appropriate triage, and utilizes Chi-Squared Test to determine significance. We performed an adjusted binomial logistic regression comparing overtriage and undertriage for PJ vs SC. We analyzed the Need for Emergent Intervention-6 (NEI-6) model to see if it could be a way to accurately assess triage.

Results: Overtriage for the PJ group was 68.9%, compared to 54.8% for SC, with a P-value ≤.05, and undertriage for the PJ group was 1.23% compared to 0.13%. After adjusting for confounders, the risk of overtriage by the PJ group was 2.04 times as likely compared to the SC group (OR 2.04; P < .01). The OR for undertriage was not calculated due to lack of power. The odds of needing a blood transfusion for the PJ patients compared to the SC patients is approximately one-third (OR 0.33; P < .01). The other variables were lacking in power.

Conclusion: The aim of this study is to evaluate over and undertriage for PJ and SC at our large urban center. We found that overtriage was 2 times as likely when using PJ compared with the SC.

Physicians face constant pressures to learn and adapt to new knowledge, techniques, and technology. Mental practice-the process of rehearsing a task without the physical action of performing it-is a cognitive tool that is used by many professions to hone abilities and prepare for difficult undertakings. Mental practice can help optimize physician performance but there is minimal research on its application in practice. In this systematic review we assessed the usefulness of mental practice for surgeons to aid in skill acquisition. Using PRISMA guidelines, 12 studies were selected for evaluation. The results of these studies show clear advantages to using mental practice to improve overall surgical performance. Here, we discuss mental practice, the evidence for its use, and how it can be learned and performed.

Aims: The purpose of this systematic review was to assess the safety and effectiveness of beta antagonists for improving clinical care in burn patients, compared to placebo.

Methods: Articles from randomized-controlled trials were identified by a literature search on PubMed and Cochrane. We included relevant trials involving patients with burn. Trials were eligible if they evaluated propranolol and compared to usual care or placebo. We conducted a meta-analysis using a random-effects model.

Results: A total of 2114 patients were included from 14 RCTs. Beta-blocker-treated patients had decreased heart rates (WMD = -14.73, 95% CIs = [-19.14, -10.32]), mean arterial pressure (WMD = -2.76, 95% CIs = [-3.81, -1.70]), rate pressure product (WMD = -1.13, 95% CIs = [-1.56, -0.71]), reduced time for wound healing (WMD = -5.08, 95% CIs [-8.97, -1.18]), and lower resting energy expenditure (WMD = -168.83, 95% CIs [-232.03, -105.63]). However, use of beta-blockers did not reduce mortality rate (WMD = 0.98, 95% CIs [0.68, 1.41]), incidence of sepsis (RR = 0.82, 95% CIs = [0.50, 1.35]), or length of stay in hospital (WMD = -1.50, 95% CIs [-4.76, 1.77]) compared with placebo.

Conclusion: Our findings indicate that the administration of propranolol to burned patients does not contribute to increased mortality rates, reduced length of hospital stays, or heightened sepsis occurrence. It demonstrates a protective effect on heart function by reducing heart rate, resting energy expenditure, rate pressure product, and wound healing. More randomized-controlled and multi-center studies are needed to effectively establish the use of beta antagonists in burn patients.

Fungal growth is common in intraoperative cultures of patients with perforated peptic ulcer (PPU) leading to the common use of empiric antifungal therapy, with current evidence not clearly supporting this practice. The goal of this updated systematic review and meta-analysis was to synthesize the effect of empiric antifungals in patients with PPU. Eligible studies were identified through a comprehensive literature search in the MEDLINE (PubMed) and EMBASE databases, following the PRISMA 2020 statement. A total of eight studies were identified reporting on 1802 patients. The population consisted of 67.3% males (n = 121/1802), with a mean age of 59.1 ± 13.2 years. Most of the population underwent surgery (n = 1763/1802, 97.8%), which was most frequently omental patch (n = 1169/1411, 82.8%), while 12.8% (n = 140/1096) underwent laparoscopic repair. Intraoperative cultures were obtained in 73.7% (n = 1262/1713); blood cultures were obtained in 54.5% (n = 467/857) and were positive for fungus in 44.1% (n = 558/1262) and in 5.6% (n = 26/467), respectively. Empiric antifungal treatment was administered in 19.6% (n = 353/1802). The most common agent was fluconazole reported in 6 studies. At a mean follow-up of 34.4 ± 9.9 days, 191/1787 (10.7%) patients died. Patients with fungus-positive intraoperative cultures had significantly increased odds of having diabetes mellitus (OR: 1.55; 95% CI: 1.05-2.30), history of malignancy (OR: 2.80; 95% CI: 1.22-6.45), being on steroids (OR: 5.13; 95% CI: 1.37-19.3), and increased mortality (OR: 2.49; 95% CI: 1.67-3.70). Empiric antifungal therapy did not significantly decrease the odds for death (OR: 1.45; 95% CI: 0.33-6.41). The presence of fungi in the peritoneal fluid is associated with increased risk of death, that is not affected by administration of empiric antifungal therapy.

Background/aim: The aim of this study was to investigate the prognostic impact of the inflammatory burden index (IBI), a novel inflammation-based biomarker, in patients with colorectal liver metastases (CRLM) after hepatic resection.

Patients and methods: One hundred fifty patients with CRLM who underwent hepatectomy were retrospectively analyzed. The IBI was defined as C-reactive protein × neutrophil count/lymphocyte count. The relationship of the IBI with overall survival was investigated by univariate and multivariate analyses.

Results: Seventy-three (49%) patients had a high IBI (>3.45). In univariate analysis, overall survival was significantly worse in patients with lymph node metastases (P = 0.048), high NLR (P = 0.03), and high IBI (P < 0.01). In multivariate analysis, high IBI (P = 0.048) was an independent and significant predictor of overall survival. Patients with a high IBI had more postoperative complications compared with those with a low IBI (P < 0.01).

Conclusion: The IBI was a strong predictor for both short- and long-term outcomes in patients who underwent hepatic resection for CRLM.