Kent Choi

Long-term outcomes of patients with necrotizing fasciitis.

Context:Necrotizing fasciitis is an aggressive infection affecting the skin and soft tissue. It has a very high acute mortality. The long-term survival and cause of death of patients who survive an index hospitalization for necrotizing fasciitis are not known. Objective:To define the long-term survival of patients who survive an index admission for necrotizing fasciitis. We hypothesize that survivors will have a shorter life span than population controls. Design:Long-term follow-up of a registry of patients from 1989 to 2006 who survived a hospitalization for necrotizing fasciitis. Last date of follow-up was January 1, 2008. Settings:A university-based Burn and Trauma Center. Patients:A prospective registry of patients with necrotizing fasciitis has been collected from 1989 to 2006. This registry was linked to data from the Department of Health, Department of Motor Vehicles, and the University Hospital Medical Records Department in January 2008 to obtain follow-up and vital status data. Intervention:None. Main Outcome Measures:Date and cause of death were abstracted from death certificates. Date of last live follow-up was determined from the medical record and by the last drivers license renewal. The death rate of the cohort was standardized for age and sex against 2005 statewide mortality rates. Cause of death was collated into infectious and noninfectious and compared with the statewide causes of death. Statistical analysis included standardized mortality rates, Kaplan-Meier survival curves, and Aalens additive hazard model. Results:Three hundred forty-five patients of the 377 in the registry survived at least 30 days and were analyzed. Average age at presentation was 49 years (range, 1–86; median, 49). Patients were followed up an average of 3.3 years (range, 0.0–15.7; median, 2.4). Eighty-seven of these patients died (25%). Median survival was 10.0 years (95% confidence interval: 7.25–13.11). There was a trend toward higher mortality in women. Twelve of the 87 deaths were due to infectious causes. Using three different statistical analytic techniques, there was a statistically significant increase in the long-term death rate when compared with population-based controls. Infectious causes of death were statistically higher than controls as well. Conclusions:Patients who survive an episode of necrotizing fasciitis are at continued risk for premature death; many of these deaths were due to infectious causes such as pneumonia, cholecystitis, urinary tract infections, and sepsis. These patients should be counseled, followed, and immunized to minimize chances of death. Modification of other risk factors for death such as obesity, diabetes, smoking, and atherosclerotic disease should also be undertaken. The sex difference in long-term survival is intriguing and needs to be addressed in further studies.

Helmets Prevent Motorcycle Injuries with Significant Economic Benefits

Objective: The number of registered motorcycles in the United States has been steadily increasing, as have the number of motorcycle injuries and fatalities. The Midwest has the lowest incidence of helmet use in the country. Iowa in particular has no helmet law. Materials and Methods: We conducted a retrospective study of the motorcycle crash victims treated at our level 1 trauma center between 2002 and 2008. Data from 713 motorcycle trauma victims were analyzed for correlations between helmet use and multiple outcome measures. Results: The helmeted cases were similar to the unhelmeted cases in demographic and most crash characteristics. Unhelmeted patients suffered more severe injuries as measured by the Injury Severity Score (P < .01) and Glasgow Coma Score (P < .01) and they had lower survival probability (P = .01). The unhelmeted patients were more likely to be smokers (P < .01), to drink alcohol (P < .01), to use drugs (P < .01), and to be involved in crashes at night (P = .03). Helmeted cases suffered fewer injuries (P < .01). Helmets reduced the risk of injury to the head by at least two thirds (P < .01) and to the cervical spine by at least half (P = .03). Helmeted patients were less likely to require mechanical ventilation or intensive care or to have infections. They were discharged an average of 3 days earlier (P < .01) and were less likely to be discharged to a care facility for additional institutional care (P = .02). Total hospital cost savings exceeded

A pediatric cervical spine clearance protocol to reduce radiation exposure in children

20,000 (P = .02) per helmeted patient. Conclusion: Helmets protect patients from head and neck injuries, which results in less severe injuries and a more benign hospital course. Helmet use results in significant inpatient cost savings plus additional care and social cost savings by reducing the need for further institutional care. We recommend legal and social measures to induce and encourage helmet use. Supplemental materials are available for this article. Go to the publishers online edition of Traffic Injury Prevention to view the supplemental file.

The use of the Mitek anchoring system on the iliac crest for flank incisional hernia repair

BACKGROUND To minimize radiation exposure in children and reduce resource use, we implemented an age-specific algorithm to evaluate cervical spine injuries at a Level 1 trauma center. The effects of protocol implementation on computed tomography (CT) use in children (≤ 10 y) were determined. METHODS With institutional review board approval, we conducted a retrospective review using the institutional trauma registry. All pediatric patients (≤ 10 y) (n = 324) between January 2007 and present were reviewed. We excluded cases in which no imaging or outside imaging was performed. Patients were evaluated by physical exam alone, with the aid of plain radiograms or with cervical spine CT. All patients who required head CT also had CT of cervical spine to C3. We analyzed demographic, injury, and outcome data using STATA to perform chi-square and t-test, and to determine P value. P < 0.05 was defined as significant. We used the WinDose program to calculate the radiation-effective dose used in cervical spine CT. RESULTS There were 123 and 124 patients in the pre-protocol and post-protocol groups, respectively. Demographics, GCS, and injury analysis, specifically head-neck and face Injury Severity Scores showed no significant difference between groups. There was a 60% (P < 0.001) decrease in the use of full CTs after protocol implementation. We estimated that the protocol reduced the exposed area by 50% and decreased the radiation dose to the thyroid by > 80%. We extrapolated the combined effect results in a threefold reduction in radiation exposure. CONCLUSIONS Implementation of a cervical spine protocol led to a significant reduction in radiation exposure among children.

Not just an urban phenomenon: uninsured rural trauma patients at increased risk for mortality

Large incisional or ventral hernia repairs continue to be a challenge for general and plastic surgeons. Hernias without tangential fascial substance eventually face problems with recurrence. We present a case report of a patient who had undergone multiple repairs for a right flank incisional hernia which eventually recurred. We demonstrated the successful use of the Mitek® anchoring system in this repair. Using the Mitek® system in hernia repair is an innovative approach for large abdominal hernias with limited areas for fixation of synthetic mesh.Level of Evidence: Level V, therapeutic study

Duration of prehospital intubation is not a risk factor for development of early ventilator-associated pneumonia☆

Introduction National studies of largely urban populations showed increased risk of traumatic death among uninsured patients, as compared to those insured. No similar studies have been done for major trauma centers serving rural states. Methods We performed retrospective analyses using trauma registry records from adult, non-burn patients admitted to a single American College of Surgeons-certified Level 1 trauma center in a rural state (2003–2010, n=13,680) and National Trauma Data Bank (NTDB) registry records (2002–2008, n=380,182). Risk of traumatic death was estimated using multivariable logistic regression analysis. Results We found that 9% of trauma center patients and 27% of NTDB patients were uninsured. Overall mortality was similar for both (~4.5%). After controlling for covariates, uninsured trauma center patients were almost five times more likely to die and uninsured NTDB patients were 75% more likely to die than commercially insured patients. The risk of death among Medicaid patients was not significantly different from the commercially insured for either dataset. Conclusion Our results suggest that even with an inclusive statewide trauma system and an emergency department that does not triage by payer status, uninsured patients presenting to the trauma center were at increased risk of traumatic death relative to patients with commercial insurance.

Entero-paraspinous fistula from recurrent spinal metastatic renal cell carcinoma

PURPOSE Ventilator-associated pneumonia (VAP) is a significant cause of morbidity and mortality among critically ill patients with trauma. Few VAP prevention strategies have been studied in the prehospital environment. The objectives of this study are to measure the association between duration of prehospital intubation and intubation location with subsequent incidence of early (within 5 days) VAP. MATERIALS AND METHODS Single-center retrospective cohort study of all intubated adult (age≥18 years) patients with trauma presenting to a 711-bed Midwestern Level I trauma center between January 2005 and December 2011 (n=860). RESULTS Thirty-five patients (6.4%) were diagnosed as having early VAP during the study period. Using multivariable logistic regression to adjust for age, injury severity score, and year (corresponding to VAP bundle implementation), the duration of intubation prior to hospital admission was not associated with subsequent diagnosis of VAP (adjusted odds ratio, 0.90 per hour; 95% confidence interval, 0.70-1.15). Location of intubation was similarly not associated with VAP. CONCLUSIONS Duration of prehospital intubation and intubation location were not different in patients with trauma who developed early VAP. Further prospective analyses should be conducted to better elucidate the effect of prehospital management on the development of traditionally in-hospital complications.

Use of hyperbaric oxygen therapy and PEGylated carboxyhemoglobin bovine in a Jehovah’s Witness with life-threatening anemia following postpartum hemorrhage

The authors report a case of entero-paraspinous fistula 2 years after T-12 corpectomy and instrumentation for spinal metastasis from renal cell carcinoma. The pathogenesis in the present case seems to have arisen from local recurrence of T-12 metastatic carcinoma in spite of radiation and corpectomy. As a result of previous nephrectomy and anterolateral dissection for the T-12 corpectomy, the jejunum adhered to the surgical site. Recurrent tumor at T-12 invaded the adherent small bowel loop, resulting in a fistulous communication between the small bowel lumen and the spinal wound. Loss of retroperitoneal fat, scarring, and adhesions from previous surgeries contributed to this complication by having the jejunum close to the T-12 corpectomy site, and eventually to its invasion by recurrent tumor. Avoidance of such a complication is difficult; however, total excision of the spinal malignancy, and when possible, creating a barrier cuff of fascia or fat around the spine to protect abdominal contents, are potential solutions.

Patient education and recall regarding postsplenectomy immunizations

We present a case of a Jehovahs Witness patient who refused blood products, with the exception of albumin and clotting factors, and underwent cesarean section under spinal anesthesia complicated by postpartum hemorrhage. She was fluid resuscitated and treated with multiple uterotonics and internal iliac artery embolization. Because of agitation she required emergency tracheal intubation. Her hemoglobin concentration dropped from a preoperative value of 12mg/dL to 3mg/dL on postoperative day one. She was acidotic, requiring vasopressors for hemodynamic stability and remained ventilated and sedated. She was treated with daily erythropoietin, iron therapy and cyanocobalamin. Because of ongoing hemorrhage, continued acidemia and vasopressor requirements she was co-treated with PEGylated carboxyhemoglobin bovine and hyperbaric oxygen therapy to reverse her oxygen debt. On postoperative day eight her hemoglobin concentration was 7mg/dL, she was hemodynamically stable and vasopressors were discontinued. She was extubated and discharged from the intensive care unit on postoperative day eight. This report highlights the multiple modalities used in treating a severely anemic patient who refused blood, the use of an investigational new drug, the process of obtaining this drug via the United States Food and Drug Administration emergency expanded access regulation for single patient clinical treatment, and ethical dilemmas faced during treatment.