Mohammad A. Khasawneh

A prospective analysis of urinary tract infections among elderly trauma patients

BACKGROUND Catheter-associated urinary tract infections (CAUTIs) have been deemed “reasonably preventable” by the Centers for Medicare and Medicaid, thereby eliminating reimbursement. Elderly trauma patients, however, are at high risk for developing urinary tract infections (UTIs) given their extensive comorbidities, immobilization, and environmental changes in the urine, which provide the ideal environment for bacterial overgrowth. Whether these patients develop CAUTI as a complication of their hospitalization or have asymptomatic bacteriuria (ASB) or UTI at admission must be determined to justify the “reasonably preventable” classification. We hypothesize that a significant proportion of elderly patients will present with ASB or UTI at admission. METHODS Institutional review board permission was obtained to perform a prospective, observational clinical trial of all elderly (≥65 years) patients admitted to our Level I trauma center as a result of injury. Urinalysis (UA) and culture (UCx) were obtained at admission, 72 hours, and, if diagnosed with UTI, at 2 weeks after injury. Mean cost of UTI was calculated based on Centers for Disease Control and Prevention estimates of

Impact of BMI on Ability to Successfully Create an IPAA.

862 to

Successful laparoscopic cholecystectomy after percutaneous cholecystostomy tube placement.

1,007 per UTI. RESULTS Of 201 eligible patients, 129 agreed to participate (64%). Mean (SD) age was 81 (8.6) years. All patients had a blunt mechanism of injury (76% falls), with a mean Injury Severity Score (ISS) of 13.8 (7.6). Of the 18 patients (14%) diagnosed with CAUTI, 14 (78%) were present at admission. In addition, there were 18 patients (14%) with ASB at admission. The most common bacterial species present at admission urine culture were Escherichia coli (24%) and Enterococcus (16%). Clinical features associated with bacteriuria at admission included a history of UTI, positive Gram stain result, abnormal microscopy, and pyuria. The estimated loss of reimbursement for 18 UTIs at admission was

Botulinum toxin A-induced paralysis of the lateral abdominal wall after damage-control laparotomy: A multi-institutional, prospective, randomized, placebo-controlled pilot study.

15,516 to

Long-term outcomes of gastrografin in small bowel obstruction

18,126; however, given an estimated cost of

Optimum Methods for Keeping the Abdomen Open

1,981 to screen all patients with UA and UCx at admission, up to

Post-Splenectomy Sepsis in Children: A 48-Year Population-Based Study

16,144 savings was realized. CONCLUSION Many elderly trauma patients present with UTI. Screening UA and UCx at admission for elderly trauma patients identifies these UTIs and is cost-effective. LEVEL OF EVIDENCE Epidemiologic study, level II.

Outcomes of chemical component paralysis using botulinum toxin for incisional hernia repairs.

BACKGROUND:IPAA is the surgical treatment of choice for patients with ulcerative colitis. Limited data exist on how obesity impacts the ability of the surgeon to successfully create an IPAA. OBJECTIVE:We aimed to determine how BMI affects the ability to successfully complete the operation. DESIGN:This was a retrospective cohort study. SETTINGS:The study was conducted at a single tertiary care center. PATIENTS:We included all of the patients undergoing an IPAA for ulcerative colitis between January 2002 and August 2013 at our institution. A total of 1175 patients underwent proctocolectomy for ulcerative colitis during the study period; 129 were not offered IPAA (reasons included patient preference (n = 53), advanced age/comorbidity (n = 28), obesity (n = 23), incontinence (n = 8), suspicion of Crohn’s disease (n = 8), rectal cancer (n = 3), and other (n = 6)). Twenty-six patients had a concurrent cancer diagnosis, and 5 had a polyposis syndrome. MAIN OUTCOME MEASURES:We used logistic regression modeling to estimate the association between BMI and unsuccessful pouch attempts. RESULTS:Of the 1046 patients offered IPAA, 19 (1.82%) could not be technically completed at the time of surgery. Increasing BMI was associated with a higher risk of not being able to technically perform IPAA (OR = 1.26 (95% CI, 1.17–1.34)). The chance of an unsuccessful pouch rose from 2.0% at a BMI of 30 to 5.7% at a BMI of 35 and 15.0% at a BMI of 40 (p < 0.01). The area under the receiver operator characteristics curve was 0.82. BMI explained 21% of the variation in pouch success rate. LIMITATIONS:This study is limited in its generalizability. Also, the verbosity within the operative dictations varied among surgeons, making it impossible to be certain which maneuvers were performed to gain length in each patient. In addition, we were limited to BMI as a surrogate for visceral obesity, and we did not include medical therapy at the time of IPAA attempt. CONCLUSIONS:There is a strong association between increasing BMI and the ability to technically perform IPAA. Obese patients should be counseled to lose weight preoperatively to increase the probability of successful IPAA construction at the time of operation.

Role of gastrografin challenge in early postoperative small bowel obstruction.

BACKGROUND Interval cholecystectomy (IC) after percutaneous cholecystostomy tube (PCT) placement is the definitive treatment for cholecystitis in patients who are operative candidates after optimization of medical comorbidities. It is not clear, however, which patients will be able to have a laparoscopic IC after PCT placement. We aimed to identify factors associated with successful laparoscopic IC in these patients. METHODS This is a retrospective review of patients who had a PCT from 2009 to 2011. Patient’s baseline demographics, clinical data, and outcomes were analyzed. Univariable and multivariable comparisons were performed between patients who did and did not undergo IC. A subgroup analysis of patients who had laparoscopic IC and open IC was performed. Data are presented as percentages, medians with interquartile ranges (IQRs), or odds ratios with 95% confidence interval as appropriate. RESULTS A total of 245 patients had PCT placement, with a median age of 71 years (IQR, 59–80 years); 63% were male, of whom 72 (29%) underwent IC. The median time from PCT placement to IC was 55 days (IQR, 42–75 days). IC patients had a lower Charlson Comorbidity Index (5 [4–6] vs. 6 [4–8], p = 0.005) at the time of PCT placement. When controlling for other factors, lower Charlson Comorbidity Index and fewer previous abdominal operations were associated with performance of IC. Laparoscopic surgery was planned for 89% of the patients and completed successfully in 78%. The only factor associated with successful laparoscopic IC was fewer previous abdominal operations. CONCLUSION Patients who have been medically optimized following PCT can undergo laparoscopic IC with a high rate of success. The degree of illness at the time of PCT placement did not seem to influence the rate of success of laparoscopic IC. LEVEL OF EVIDENCE Therapeutic/care management study, level III.

Validation of the anatomic severity score developed by the American Association for the Surgery of Trauma in small bowel obstruction

BACKGROUND Damage-control laparotomy (DCL) is a lifesaving operation used in critically ill patients; however, interval primary fascial closure remains a challenge. We hypothesized that flaccid paralysis of the lateral abdominal wall musculature induced by botulinum toxin A (BTX) would improve rates of primary fascial closure, decrease duration of hospital stay, and enhance pain control. METHODS Consenting adults who had undergone a DCL at two institutions were prospectively randomized to receive ultrasound-guided injections of their external oblique, internal oblique, and transversus abdominus muscles with either BTX (150 mL, 2 U/mL) or placebo (150-mL 0.9% NaCl). Patients were excluded if they had a body mass index of greater than 50, remained unstable or coagulopathic, were home O2 dependent, or had an existing neuromuscular disorder. Outcomes were assessed in a double-blinded manner. Univariate and Kaplan-Meier estimates of cumulative probability of abdominal closure were performed. RESULTS We randomized 46 patients (24 BTX, 22 placebo). There were no significant differences in demographics, comorbidities, and physiologic status. Injections were performed on average 1.8 ± 2.8 days (range, 0–14 days) after DCL. The 10-day cumulative probability of primary fascial closure was similar between groups: 96% for BTX (95% confidence interval [CI], 72–99%) and 93% for placebo (95% CI, 61–99%) (HR, 1.0; 95% CI, 0.5–1.8). No difference between BTX and placebo groups was observed for hospital length of stay (37 days vs. 26 days, p = 0.30) or intensive care unit length of stay (17 days vs. 11 days, p = 0.27). There was no difference in median morphine equivalents following DCL. The overall complication rate was similar (63% vs. 68%, p = 0.69), with two deaths in the placebo group and none in the BTX group. No BTX or injection procedure complications were observed. CONCLUSION The use of BTX after DCL was safe but did not seem to affect primary fascial closure, hospital length of stay, or pain modulation after DCL. Given higher-than-expected rates of primary fascial closure, Type II error may have occurred. LEVEL OF EVIDENCE Therapeutic study, level III.