Journal of the American College of Surgeons
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Multicenter Study
A multisite assessment of the American College of Surgeons Committee on Trauma field triage decision scheme for identifying seriously injured children and adults.
The American College of Surgeons Committee on Trauma (ACSCOT) has developed and updated field trauma triage protocols for decades, yet the ability to identify major trauma patients remains unclear. We estimate the diagnostic value of the Field Triage Decision Scheme for identifying major trauma patients (Injury Severity Score [ISS] ≥ 16) in a large and diverse multisite cohort. ⋯ The sensitivity of the Field Triage Decision Scheme for identifying major trauma patients is lower and specificity higher than previously described, particularly among elders.
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Posthospitalization care is important for recovery after trauma. Disadvantaged populations, like racial or ethnic minorities and the uninsured, make up substantial percentages of trauma patients, but their use of posthospitalization facilities is unknown. ⋯ Disadvantaged populations have more limited use of posthospitalization care such as rehabilitation after trauma, suggesting a potential improvement in trauma care for the underprivileged.
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Penetrating wounds to the upper abdomen and lower precordium mandate exclusion of intra-abdominal and cardiac injuries. The most sensitive test to exclude cardiac injury is direct visualization of the pericardial fluid. Since 2001, we have examined the abdomen and performed transdiaphragmatic (central tendon) pericardial window via laparoscopy in stable patients at risk for both cardiac and peritoneal injuries. ⋯ Diagnostic laparoscopy with transdiaphragmatic pericardial window allows for thorough evaluation of both abdominal and cardiac injuries with a resultant short length of stay and no morbidity or mortality. In this, the largest series in the literature, laparoscopic pericardial window was a safe and effective modality to evaluate hemodynamically stable patients who are at risk for both cardiac and abdominal injuries.
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Palliative care is an important and necessary humanistic facet of ICU care. Wide variations exist in selection and implementation of palliative care decisions. Understanding patient factors associated with these decisions is crucial. ⋯ Higher severity of illness and history play no role in the decision to limit care. Sex plays a strong and independent role. Factors influencing end-of-life care require additional study.
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Urinary tract infections (UTIs) are the most common hospital-acquired infections in the United States. We hypothesized that the risk of UTI after colorectal surgery exceeds the risk after other gastrointestinal operations. ⋯ Colorectal resections incur substantial risk of postoperative UTI, exceeding rates predicted by the NSQIP model. Because of their patients' unanticipated high incidence of UTI, surgeons with a specialty interest in colorectal surgery risk being flagged as "high outliers," particularly if they perform many rectal resections. A simple set of risk factors discriminates 10-fold differences in the rate of UTI after colorectal resection.