The American surgeon
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The American surgeon · Oct 2010
Defining hypotension in moderate to severely injured trauma patients: raising the bar for the elderly.
Hypotension, defined as systolic blood pressure less than 90 mm Hg, is recognized as a sign of hemorrhagic shock and is a validated prognostic indicator. The definition of hypotension, particularly in the elderly population, deserves attention. We hypothesized that the systolic blood pressure associated with increased mortality resulting from hemorrhagic shock increases with increasing age. ⋯ The optimal definition of hypotension was systolic blood pressure of 100 mm Hg for patients 20 to 49 years, 120 mm Hg for patients 50 to 69 years, and 140 mm Hg for patients 70 years and older. The optimal systolic blood pressure for improved mortality in hemorrhagic shock increases significantly with increasing age. Elderly trauma patients without major head injuries should be considered hypotensive for systolic blood pressure less than 140 mm Hg.
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The American surgeon · Oct 2010
Does health care insurance affect outcomes after traumatic brain injury? Analysis of the National Trauma Databank.
Increasing evidence indicates insurance status plays a role in the outcome of trauma patients; however its role on outcomes after traumatic brain injury (TBI) remains unclear. A retrospective review was queried within the National Trauma Data Bank. Moderate to severe TBI insured patients were compared with their uninsured counterparts with respect to demographics, Injury Severity Score, Glasgow Coma Scale score, and outcome. ⋯ However, when controlling for confounding variables, the presence of insurance had a significant protective effect on mortality (adjusted odds ratio 0.89; 95% confidence interval: 0.82-0.97, P = 0.007). This effect was most noticeable in patients with head abbreviated injury score = 5 (adjusted odds ratio 0.7; 95% confidence interval: 0.6-0.8, P < 0.0001), indicating insured severe TBI patients have improved outcomes compared with their uninsured counterparts. There is no clear explanation for this finding however the role of insurance in outcomes after trauma remains a topic for further investigation.
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Blood cultures are often obtained in postoperative patients to rule out bloodstream infections. Our study objectives were to determine the efficacy of blood cultures in postoperative patients with suspected sepsis and to determine variables predisposing patients to positive cultures. This was a retrospective study including patients with blood cultures drawn from January to March 2009 at our institution. ⋯ There was no statistical difference (P > 0.05) between patients with positive and negative cultures except that those with negative cultures were more likely to have received preoperative antibiotics (P = 0.0186). Blood cultures are invasive, expensive tests with low yield. We recommend that blood cultures be drawn in patients not receiving preoperative antibiotics who have undergone surgery more than 4 days before culture.
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The American surgeon · Oct 2010
The clinical significance of occult thoracic injury in blunt trauma patients.
Increased use of thoracic CT (TCT) in diagnosis of blunt traumatic injury has identified many injuries previously undetected on screening chest x-ray (CXR), termed "occult injury". The optimal management of occult rib fractures, pneumothoraces (PTX), hemothoraces (HTX), and pulmonary contusions is uncertain. Our objective was to determine the current management and clinical outcome of these occult blunt thoracic injuries. ⋯ Occult and no injury patients had similar ventilator needs and mortality, but occult injury patients remained hospitalized longer. No patient with isolated occult thoracic injury required intubation or tube thoracostomy. Occult injuries, diagnosed by TCT only, have minimal clinical consequences but attract increased hospital resources.
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The American surgeon · Oct 2010
Is postoperative chronic pain syndrome higher with mesh repair of inguinal hernia?
Chronic postoperative pain has been associated with mesh repair in meta-analysis of clinical trials. We compared the incidence of early complications, recurrence, and chronic pain syndrome in anatomic and mesh repairs in 200 patients. ⋯ The clinical outcomes did not reveal a significant disparity between the 100 consecutive patients who had mesh repair versus the 100 patients who had anatomic repair with regard to the incidence of superficial wound infection (0 vs. 2%, P = 0.497), testicular swelling (12 vs. 7%, P = 0.335), hematoma (1 vs. 0%, P = 0.99), recurrence (3 vs. 2%, P = 0.99), or chronic postoperative pain (4 vs. 1%, P = 0.369). The anatomic procedure without mesh should continue to be offered to patients who have an initial inguinal hernia repair.