Jeffrey Wild

The Fort Hood Massacre: Lessons learned from a high profile mass casualty.

BACKGROUND On November 5, 2009, an army psychiatrist at Fort Hood in Killeen, TX, allegedly opened fire at the largest US military base in the world, killing 13 and wounding 32. METHODS Data from debriefing sessions, news media, and area hospitals were reviewed. RESULTS Ten patients were initially transferred to the regional Level I trauma center. The remainder of the shooting victims were triaged to two other local regional hospitals. National news networks broadcasted the Level I trauma center’s referral phone line which resulted in more than 1,300 calls. The resulting difficulties in communication led to the transfer of two victims (one critical) to a regional hospital without a trauma designation. CONCLUSIONS Triage at the scene was compromised by a lack of a secure environment, leading to undertriage of several patients. Overload of routine communication pathways compounded the problem, suggesting redundancy is crucial. LEVEL OF EVIDENCE Prognostic study, level V.

Same-day combined endoscopic retrograde cholangiopancreatography and cholecystectomy: Achievable and minimizes costs.

BACKGROUND It is estimated that choledocholithiasis is present in 5% to 20% of patients at the time of laparoscopic cholecystectomy (LC). Several European studies have found decreased length of stay (LOS) when performing LC and intraoperative endoscopic retrograde cholangiopancreatography (ERCP) on the same day for choledocholithiasis. In the United States, common bile duct stones are usually managed preoperatively and typically on a day separate from the day LC was performed. Our aim was to evaluate LOS and total hospital cost for separate-day versus same-day ERCP/cholecystectomy. METHODS This was a retrospective study of patients undergoing ERCP and cholecystectomy during the same admission for the management of choledocholithiasis from 2010 to 2014 at Geisinger Medical Center. The separate-day group underwent ERCP at least 1 day before cholecystectomy and often underwent two separate anesthesia events, while the same-day group had ERCP and cholecystectomy performed on the same day under one general anesthesia event. The primary outcome measured was LOS. RESULTS The study population included 240 patients. There were 175 patients in the separate-day group and 65 patients in the same-day group. Median age was similar between the two groups. The separate-day group had a median of one minor comorbidity compared with zero within the same-day group using the Charlson Comorbidity Index. Overall, LOS for the separate-day group was 5 days compared with 3 days in the same-day group (p < 0.0001). There was no difference in conversion rates to open cholecystectomy between the two groups (14% in the separate-day vs. 12% in the same-day group). Total median hospital cost for the separate-day group was

Severe complicated Clostridium difficile infection: Can the UPMC proposed scoring system predict the need for surgery?

102,537 compared with

Utility of Prophylactic Antibiotics in Nonoperative Facial Fractures.

90,269 in the same-day group (p < 0.0001). CONCLUSION Same-day ERCP and cholecystectomy is feasible and minimizes costs. Same-day procedures decreased hospital LOS by 2 days and had approximately

Clinical indications of computed tomography (CT) of the head in patients with low-energy geriatric hip fractures

12,000 in cost savings. Future goals include a multidisciplinary protocol to study outcomes in larger numbers. LEVEL OF EVIDENCE Therapeutic study, level IV. Economic study, level III.

Laparoscopic versus robotic adrenalectomy: a review of the national inpatient sample

INTRODUCTION Clostridium difficile infection (CDI) is one of the most common health care–associated infections, and it continues to have significant morbidity and mortality. The onset of fulminant colitis often requires total abdominal colectomy with ileostomy, which has a mortality rate of 35% to 57%. University of Pittsburgh Medical Center (UPMC) developed a scoring system for severity and recommended surgical consultation for severe complicated disease. The aim of this study was to evaluate if the UPMC-proposed scoring system for severe complicated CDI can predict the need for surgical intervention. METHODS This is a retrospective review of all patients who developed severe complicated CDI at Geisinger Medical Center between January 2007 and December 2012 as defined by the UPMC scoring system. Main outcomes were the need for surgical intervention and 30-day mortality. RESULTS Eighty-eight patients had severe complicated CDI based on the UPMC scoring system. Fifty-nine patients (67%) required surgery and 29 did not. All patients had a diagnosis of CDI as shown by positive toxin assays. There was no difference between the groups with respect to age, sex, body mass index, or comorbidities. When comparing the surgical group to the nonsurgical cohort, the surgical cohort averaged 20 points on the scoring system compared to 9 in the nonoperative cohort. In patients with severe complicated CDI, 15 or more points predicted the need for surgery 75% of the time. Forty-two percent of the surgical cohort had respiratory failure requiring mechanical ventilation compared to 0% in the nonsurgical cohort (p < 0.0001). Forty-nine percent of the surgical cohort required vasopressors for septic shock before surgery compared to 0% in the nonsurgical cohort (p < 0.0001). Acute kidney injury was present in 92% of the surgical cohort versus 72% within the nonsurgical cohort (p = 0.026). Seventy-six percent of the surgical patients were admitted to the ICU before surgery. Within the nonsurgical cohort, only 24% of patients required ICU stay during admission. Overall, 30-day mortality in the surgical cohort was 30%, and there was no mortality in the nonsurgical cohort. CONCLUSIONS The UPMC scoring system for severe complicated CDI can help us predict patients who need a surgical consult and the need for surgical intervention. In patients with severe complicated CDI, evidence of end-organ failure predicts surgical intervention. LEVEL OF EVIDENCE Prognostic study, level III; therapeutic study, level IV.

Analyzing the Impact of Compliance with National Guidelines for Pancreatic Cancer Care Using the National Cancer Database

AbstractFacial fractures are commonly managed nonoperatively. Patients with facial fractures involving sinus cavities commonly receive 7 to 10 days of prophylactic antibiotics, yet no literature exists to support or refute this practice. The aim of this study was to compare the administration and duration of antibiotic prophylaxis on the incidence of soft tissue infection in nonoperative facial fractures. A total number of 289 patients who were admitted to our level I trauma center with nonoperative facial fractures from the beginning of 2012 to the end of 2014 were studied. Patients were categorized into 3 groups: no antibiotic prophylaxis, short-term antibiotic prophylaxis (1–5 days), and long-term antibiotic prophylaxis (>5 days). The primary outcome was the incidence of facial soft tissue infection and Clostridium difficile colitis. Fifty patients received no antibiotic prophylaxis. Sixty-three patients completed a short course of antibiotic prophylaxis and 176 patients received long-term antibiotics. Ampicillin/sulbactam, amoxicillin/clavulanic acid, or a combination of both were used in 216 patients. Twenty-three patients received clindamycin due to penicillin allergy. Short and long courses of antibiotic prophylaxis were administered more commonly in patients with concomitant maxillary and orbital fractures (P <0.0001). No mortality was found in any group. Soft tissue infection was not identified in any patient. C. difficile colitis was identified in 1 patient who had received a long course of antibiotic prophylaxis (P = 0.7246). There was no difference in the outcome of patients receiving short-term, long-term, and no antibiotic prophylaxis. Prospective randomized studies are needed to provide further clinical recommendations.

External Validation of a Survival Nomogram for Non-Small Cell Lung Cancer Using the National Cancer Database

OBJECTIVE To define the role of head computed tomography (CT) scans in the geriatric population with isolated low-energy femur fractures and describe the pertinent clinical variables which are associated with positive CT findings with the objective to decrease the number of unnecessary CT scans performed. DESIGN Retrospective review. SETTING Level I trauma centre. PATIENTS Eleven hundred ninety-two (1192) patients sustaining a femur fracture following a low-energy fall. MAIN OUTCOME MEASUREMENT Pertinent clinical variables that were associated with CTs that yielded positive findings. RESULTS Two hundred fifty patients (21%) underwent a head CT scan as part of their evaluation. Of these patients, 83% suffered proximal femur fractures, 11% shaft fractures and 6% distal fractures. The majority of the patients were evaluated by the emergency department (ED) with only 18% (44/250) being evaluated by the trauma team. Average patient age was 83 years (range 65-99 years). One hundred seventy-three patients (69%) were on some form of antiplatelet medication or anticoagulation. Of the 250 patients who underwent head CT scan, 16 (6%) patients had acute findings (haemorrhage - 15, infarct - 1), and none of the patients required neurosurgical intervention. CONCLUSION None of the patients with a traumatic injury required a neurosurgical invention after sustaining a low energy fall (0/1192). Head CT scans should have a limited role in the work-up of this patient population and should be reserved for patients with a history and physical findings that support head trauma. LEVEL OF EVIDENCE Prognostic level III. See instructions for authors for a complete description of levels of evidence.

Analgesic Choice in Management of Rib Fractures: Paravertebral Block or Epidural Analgesia?

BackgroundLaparoscopic adrenalectomy (LA) has become the standard treatment of adrenal lesions. Recently, robotic-assisted adrenalectomy (RA) has become an option, however, short-term outcomes for RA have not been well studied and benefits over LA are debatable. The aim of this study was to explore differences in short-term outcomes between LA and RA using the national inpatient sample (NIS) database.MethodsPatient data were collected from the NIS. All patients undergoing LA or RA from January 2009 to December 2012 were included. Univariate analysis and propensity matching were performed to look for differences between the groups.ResultsA total of 1006 patients (66.4% in LA group and 33.6% in RA group) were identified. Patient age group, gender, race, risk of mortality, severity of illness or indication for adrenalectomy did not differ significantly between the LA or RA cohorts. Insurance type predicted procedure type (45% of medicare patients underwent RA versus 29% of patients with private insurance, p < 0.0001). Patients living in the highest income areas were more likely to receive the laparoscopic approach (31.7 versus 17.4%, p < 0.0001). Hospital volume, bed size and teaching status of the hospital were not significant factors in the decision of RA versus LA. There was no difference in complication and conversion rates between RA versus LA. The mean length of stay was shorter in the RA group (2.2 versus 1.9 days, p = 0.03). Total charges were higher in the RA group (

Outcomes of complicated appendicitis: Is conservative management as smooth as it seems?

42,659 versus