Surgery
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Hypothermia is a well-known risk factor for postoperative complications because it prolongs the monocyte inflammatory response. The purpose of this study was to investigate whether temperature-activated ion channels (transient receptor protein channels [TRP] A1 and V1) mediate the effects of temperature on monocytes. ⋯ These results demonstrate that hypothermia mediates its effects on monocytes through TRPA1. Blockade of TRPA1 or activation of TRPV1 may be used to modify the effects of hypothermia on the monocyte inflammatory response.
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Every experienced surgeon has a patient whose life was saved by a blood transfusion (the "good"). In contrast, an overwhelming amount of evidence suggests that perioperative blood transfusion can be associated with adverse surgical outcomes (the "bad"). We wondered what patient characteristics, if any, can explain this clinical dichotomy with certain patients benefiting from transfusion, whereas others are harmed by this intervention. ⋯ We found that high-risk patients do not have a significant risk from blood transfusion, but low-risk patients have between an 8- and 10-fold excess risk of adverse outcomes when they receive a blood transfusion. We speculate that careful preoperative assessment of transfusion risk and intervention based on this assessment could minimize operative morbidity and mortality, especially because the patients at least risk are more likely to undergo elective operations and provide time for therapeutic interventions to improve transfusion risk profiles.
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Hyperfibrinolysis (HF) on admission is associated with increased mortality in adult patients with trauma. Several studies have demonstrated that 9% of severely injured adults present to the emergency department (ED) with HF. Our aim was to (1) define HF in pediatric patients and develop a relevant cut-point for therapeutic intervention (if any); (2) identify the prevalence of HF in severely injured pediatric patients; and (3) determine whether HF on admission is as lethal a phenomenon as it is in adults. ⋯ Similar to adults, admission HF appears to reach a critical threshold at a LY30 ≥3% in pediatric patients. Admission HF in pediatric patients occurs more frequently than in adults (24 vs 9%) but is associated similarly with a substantial increase in mortality (6-14%). When controlling for additional factors, we found that admission LY-30 ≥3% has an odds ratio of 6.2 (P < .001) for mortality among severely injured pediatric patients. HF on admission may serve to identify rapidly those injured children and adolescents likely to benefit from hemostatic resuscitation efforts and to guide antifibrinolytic therapy.
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Multicenter Study Observational Study
Splenectomy is associated with hypercoagulable thrombelastography values and increased risk of thromboembolism.
Previous investigators have demonstrated that postinjury thrombocytosis is associated with an increase in thromboembolic (TE) risk. Increased rates of thrombocytosis have been found specifically in patients after splenectomy for trauma. We hypothesized that patients undergoing splenectomy (1) would demonstrate a more hypercoagulable profile during their hospital stay and (2) that this hypercoagulable state would be associated with increased TE events. ⋯ This multicenter, prospective study demonstrates that patients undergoing splenectomy have a more hypercoagulable state than other trauma patients. This hypercoagulable state (identified by greater α-angle and mA values) begins at approximately 48 hours after injury and continues through at least day 5. Moreover, this hypercoagulable state is associated with increased risk of TE complications.
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Comparative Study
Cost effectiveness of nonoperative management versus laparoscopic appendectomy for acute uncomplicated appendicitis.
Appendectomy remains the gold standard in the treatment of acute, uncomplicated appendicitis in the United States. Nonetheless, there is growing evidence that nonoperative management is safe and efficacious. ⋯ Nonoperative management without IA is the least costly, most effective treatment for acute, uncomplicated appendicitis and warrants further evaluation in a disease thought to be definitively surgical.