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The data regarding rates of deep venous thrombosis and pulmonary embolism after foot and ankle trauma remain sparse. In this study of the National Trauma Data Bank Data set (2007-2009 and 2010-2016), these rates were reexamined and risk factors associated with these complications were assessed. Data quality is improved in the later data set; the incidence of deep venous thrombosis and pulmonary embolism was 0.28% and 0.21%, respectively, in the 2010-2016 data. Prophylaxis, male gender, treatment in a university hospital, open reduction, chronic obstructive pulmonary disease, and hypertension were notable significant risk factors for pulmonary embolism. For deep venous thrombosis, male gender, bleeding disorder, angina, and prophylaxis were risk factors. Careful, individualized assessment of the risk factors associated with deep venous thrombosis and pulmonary embolism is important, and the merits of routine prophylaxis remain in question.

Traumatic injuries account for millions of emergency room visits and hospital admissions annually. Motor vehicle crashes (MVCs) remain a leading cause of mortality between the ages of 1 and 44 years. With the popularity of smart devices, drivers are ever more distracted on the road. Programs that educate drivers on safe actions and to raise awareness of the perils of drunk and distracted driving exist, but there are few data that demonstrate a reduction in motor vehicle injury rates. We sought to determine if the implementation of such a program in our community would impact the rates of MVCs. Assessing the effectiveness of the Save A Life Tour, a risk reduction program, this intervention was instituted at a single area high school. The numbers of adolescent drivers aged 16 to 21 years involved in MVCs treated at the regional Level I trauma center were compared over two time intervals and between two adjoining counties. The time intervals consisted of preintervention and postintervention surveillance, each over a period of 3 years. Using our trauma registry, we compared the incidence of MVC between the two counties and between the two age groups. The data were also compared with the incidence among these populations nationally. In the preintervention period, the number of adolescent MVCs treated from the catchment area was 166, and the number in the postintervention period was 105. This represented a risk reduction of 37% (p < 0.05). During the same intervals, the incidence in the nonintervention control catchment area increased by 12%. There was no significant change in the population aged 16 to 21 years over the time intervals in either area. These results suggest that ongoing educational intervention programs aimed at adolescent drunk and distracted driving can have an impact on these life-threatening behaviors and on the incidence of MVCs. LEVEL OF EVIDENCE Therapy, level IV.

BACKGROUND Recent management of acute cholecystitis favors same admission (SA) or emergent cholecystectomy based on overall shorter hospital stay and therefore cost savings. We adopted the practice of SA cholecystectomy for the treatment of acute cholecystitis at our tertiary care center and wanted to evaluate the economic benefit of this practice. We hypothesized that the existence of complications, particularly among patients with a higher degree of disease severity, during SA cholecystectomy could negate the cost savings. AIM To compare complication rates and hospital costs between SA vs delayed cholecystectomy among patients admitted emergently for acute cholecystitis. METHODS Under an IRB-approved protocol, complications and charges for were obtained for SA, later after conservative management (Delayed), or elective cholecystectomies over an 8.5-year period. Patients were identified using the acute care surgery registry and billing database. Data was retrieved via EMR, operative logs, and Revenue Cycle Operations. The severity of acute cholecystitis was graded according to the Tokyo Guidelines. TG18 categorizes acute cholecystitis by Grades 1, 2, and 3 representing mild, moderate, and severe, respectively. Comparisons were analyzed with χ2, Fisher's exact test, ANOVA, t-tests, and logistic regression; significance was set at P < 0.05. RESULTS Four hundred eighty-six (87.7%) underwent a SA while 68 patients (12.3%) received Delayed cholecystectomy. Complication rates were increased after SA compared to Delayed cholecystectomy (18.5% vs 4.4%, P = 0.004). The complication rates of patients undergoing delayed cholecystectomy was similar to the rate for elective cholecystectomy (7.4%, P = 0.35). Mortality rates were 0.6% vs 0% for SA vs Delayed. Patients with moderate disease (Tokyo 2) suffered more complications among SA while none who were delayed experienced a complication (16.1% vs 0.0%, P < 0.001). Total hospital charges for SA cholecystectomy were increased compared to a Delayed approach ($44500 ± $59000 vs $35300 ± $16700, P = 0.019). The relative risk of developing a complication was 4.2x [95% confidence interval (CI): 1.4-12.9] in the SA vs Delayed groups. Among eight patients (95%CI: 5.0-12.3) with acute cholecystitis undergoing SA cholecystectomy, one patient will suffer a complication. CONCLUSION Patients with Tokyo Grade 2 acute cholecystitis had more complications and increased hospital charges when undergoing SA cholecystectomy. This data supports a selective approach to SA cholecystectomy for acute cholecystitis.

Evidence-based guidelines recommend cholecystectomy during initial hospitalization for complicated gallstone disease. Previous studies and quality initiative data from our institution demonstrated that only 40% to 75% of patients underwent cholecystectomy on index admission.In January 2009, we implemented a critical pathway to improve cholecystectomy rates for all patients emergently admitted for acute cholecystitis, mild gallstone pancreatitis, or common bile duct stones. We compared cholecystectomy rates during initial hospitalization, time to cholecystectomy, length of initial stay, and readmission rates in prepathway (January 2005 to February 2008) and postpathway patients (January 2009 to May 2010).Demographic and clinical characteristics were similar between prepathway (n = 455) and postpathway patients (n = 112). Cholecystectomy rates during initial hospitalization increased from 48% to 78% after pathway implementation (p0.0001). There were no differences in operative mortality or operative complications between the 2 groups. For patients undergoing cholecystectomy on initial hospitalization, the mean length of stay decreased after pathway implementation (7.1 days to 4.5 days; p0.0001), primarily due to a decrease in the time from admission to cholecystectomy (4.1 days to 2.1 days; p0.0001). Thirty-three percent of prepathway and 10% of postpathway patients required readmission for gallstone-related problems or operative complications (p0.0001), and each readmission generated an average of $19,000 in additional charges.Implementation of a multidisciplinary critical pathway improved cholecystectomy rates on initial hospitalization and lowered costs by shortening length of stay and markedly decreasing readmission rates for gallstone-related problems. Broader implementation of similar pathways offers the potential to translate evidence-based guidelines into clinical practice and minimize the cost of medical care.

Background: Postburn insulin dysfunction is a significant contributor to morbidity and mortality. A satisfactory mechanism for explaining this phenomenon remains elusive; however, resistin has been postulated to be involved. Initially discovered as an insulin antagonist secreted from adipose tissue in murine models, resistin’s function in humans has been more obscure. Resistin is not expressed significantly in human adipocytes although it has been detected in monocytes. We postulate that mononuclear activation at the site of burn injury affects the release of resistin and contributes to insulin dysfunction. Methods: Plasma from burned and healthy control individuals was characterized for glucose, insulin, and resistin protein levels. Adipose tissue from both groups was analyzed for resistin transcript; levels were found to be somewhat higher in the burned group though not significantly so. Circulating monocyte expression of resistin transcript was assayed in similar fashion. Results: In addition to finding that insulin and glucose were elevated postburn, a finding in agreement with past studies, we demonstrate that circulating resistin levels are significantly elevated as well. Insulin resistance was found to increase at a similar rate to resistin expression in the burn population, suggesting a correlation in these events. Adipose tissue from both groups was analyzed for resistin transcript; levels were found to be somewhat higher in the burned group though not significantly so. Circulating monocyte expression of resistin transcript was assayed and found to be profoundly elevated in the burn population. Conclusions: This data suggests that resistin is produced by activated monocytes in the adipose tissue around the periphery of burn wound. We suggest that postburn insulin function is adversely affected by resistin produced as a result of this monocyte activation.

The purpose of this study was to show the relation between McBurney's point and the appendix in patients undergoing 3D MDCT and to investigate the effect of this information on a surgeon's choice of appendectomy incision.Among 142 adults undergoing consecutive MDCT studies, 100 patients (35 women, 65 men; mean age, 52.1 years) with an identifiable appendix on abdominopelvic MDCT examinations were selected for the study group. The presence of intraabdominal mass or a history of abdominal surgery were the exclusion criteria. Three-dimensional reconstruction of the CT data was performed with a surface shaded display algorithm. The locations of the base of the appendix and McBurney's point were marked on a single 3D image that allowed display of the skin surface markings for each patient. The superoinferior and mediolateral distances from the level of the appendix to the level of McBurney's point were measured, and the radial distance was calculated from these measurements. A surgeon experienced in emergency abdominal surgery reviewed 3D CT images and one axial image showing the appendix, and his choice of incision for each patient based on the CT information was recorded. The influence of the superoinferior and mediolateral distances of the appendix from McBurney's point on the surgeon's decision was analyzed with a multivariate logistic regression model.The appendix was exactly at McBurney's point in only 4% of the patients. In 36% of the cases, the appendix was within 3 cm, in 28% of cases it was 3-5 cm, and in 36% of the cases it was more than 5 cm away from McBurney's point. Mean +/- SD superoinferior, mediolateral, and radial distances between the appendix and McBurney's point were 33.0 +/- 24.1, 20.8 +/- 19.3, and 42.1 +/- 26.7 mm, respectively. After reviewing the images, the surgeon would have altered his incision site in 35% of the cases. The surgeon preferred a higher incision in 28% and a lower incision in 7% of the cases. Both positive and negative superoinferior displacement away from McBurney's point were significant factors regarding the surgeon's decision to alter the incision (p = 0.005), and the superoinferior distance was more than 3 cm in 94% of the cases in which the surgeon would have altered the incision.The location of the appendix varies widely among individuals, and McBurney's point has limitations as an anatomic landmark. Three-dimensional MDCT findings can be useful to surgeons customizing appendectomy incisions. Additional information about the location of the appendix in the CT report (if possible, together with a 3D image showing the location of the appendix) may be beneficial for surgeons performing appendectomy.

The purpose of this study was to determine the sensitivity and specificity of computed tomography (CT) without administration of oral contrast in confirming suspected acute appendicitis. One hundred seventy-three patient studies were retrieved by a computer-generated search for the word "appendicitis" in radiology reports. Patients presenting to the emergency department over an 8-month period were examined for acute abdominal pain or suspected acute appendicitis. IV-contrast-enhanced CT scans of the abdomen and pelvis were obtained without oral or rectal contrast. Criteria for diagnosis of acute appendicitis included a dilated appendix (>6 mm), periappendiceal inflammation, or abscess. Final diagnoses were established with surgical/clinical follow-up, histopathological analysis or both. The standard time (1 h) for the administration of oral contrast prior to the CT scan was eliminated. Fifty-nine CT diagnoses were made of acute appendicitis, 56 of which were histologically verified and three of which resulted in another diagnosis. One hundred fourteen CT diagnoses were negative for appendicitis. This corresponds to a sensitivity of 100% and specificity of 97%, a positive predictive value of 95%, and a negative predictive value of 100%. CT with IV contrast is sensitive and specific for the confirmation or exclusion of acute appendicitis. By eliminating the time required to administer oral contrast, the diagnosis might be made more rapidly.

Purpose: The surgical resident experience with trauma has changed. Many residents are exposed to predominantly nonoperative patient care experiences while on trauma rotations. Data from a large multicenter study were analyzed to estimate surgical resident exposure to trauma laparotomy, diagnostic peritoneal lavage (DPL), and focused abdominal sonography for trauma (U/S). Methods: Centers completed a self-report questionnaire on their institutional demographics, admissions, and procedure for a 2-year period (1998-1999). Results: A total of 82 trauma centers that provide resident teaching were included. The included centers represent over 247,000 trauma admissions. The majority of trauma centers (65.9%) had > 80% blunt injury. Although all centers performed laparotomies, other results were more variable. For U/S, 24.2% performed none at all and 47.0% performed fewer than two U/S examinations per month. For DPLs, 3.8% performed none and 66.7% performed fewer than two per month. Assuming 1 night of 4 on call, the average surgical resident training at a trauma center performing > 80% blunt trauma has the potential to participate in only 15 trauma laparotomies, 6 diagnostic peritoneal lavages, and 45 ultrasound examinations per year. In addition, the resident will care for an average of 500 blunt trauma patients before performing a splenectomy or liver repair. Conclusion: Surgical resident experience on most trauma services is heavily weighted to nonoperative management, with a relatively low number of procedures, little experience with DPL, and highly variable experience with ultrasound. These data have serious implications for resident training and recruitment into the specialty.

Evaluation of burn wound depth in pediatric patients is often difficult. A Laser Doppler Flowmeter with a temperature-controlled multichannel probe was used to measure burn wound perfusion as a tool to predict wound outcome. The average perfusion levels for wounds that healed spontaneously in fewer than 21 days was significantly higher than the average perfusion levels for wounds that required excision and grafting or were not healed by day 21 after burn injury. Laser Doppler Flowmetry showed high positive predictive values for "nonhealing" wounds on postburn days 1, 2, and 3. These results suggest that Laser Doppler Flowmetry is a useful tool for burn wound assessment in pediatric patients.

Despite considerable experience the reported frequency of misdiagnosis in patients undergoing appendectomy continues in the range of 20% to 40% in some populations.We developed a clinical guideline that recommended abdominal computed tomography (CT) for all nonpregnant adults in whom the diagnosis of appendicitis was suspected unless the diagnosis could be ruled out clinically. The records of adult patients that underwent appendectomy from July 1998 through October 2001 were reviewed. The clinical guideline was developed in July 2000.There were 194 appendectomies performed, 114 prior to the guideline and 80 after the development of the guideline. The rate of misdiagnosis decreased from 25% to 6% (P0.05), the rate of CT use increased from 32% to 84% (P0.05), and the perforation rate remained unchanged.These results support the effectiveness of a clinical guideline that encourage the use of abdominal CT in decreasing the frequency of misdiagnosis in cases of suspected appendicitis.

The seminal importance of DNA sequencing to the life sciences, biotechnology and medicine has driven the search for more scalable and lower-cost solutions. Here we describe a DNA sequencing technology in which scalable, low-cost semiconductor manufacturing techniques are used to make an integrated circuit able to directly perform non-optical DNA sequencing of genomes. Sequence data are obtained by directly sensing the ions produced by template-directed DNA polymerase synthesis using all-natural nucleotides on this massively parallel semiconductor-sensing device or ion chip. The ion chip contains ion-sensitive, field-effect transistor-based sensors in perfect register with 1.2 million wells, which provide confinement and allow parallel, simultaneous detection of independent sequencing reactions. Use of the most widely used technology for constructing integrated circuits, the complementary metal-oxide semiconductor (CMOS) process, allows for low-cost, large-scale production and scaling of the device to higher densities and larger array sizes. We show the performance of the system by sequencing three bacterial genomes, its robustness and scalability by producing ion chips with up to 10 times as many sensors and sequencing a human genome.

Background The use of antimicrobial solutions for irrigation in appendicitis is controversial. Numerous antiseptic and antibiotic solutions have been suggested for use as an intraoperative irrigant. We sought to determine whether there was a difference in postoperative surgical site infections (SSIs) comparing normal saline (.9%), antiseptic solution (Dakin's, .25%), and an antibiotic solution (imipenem 1 mg/mL). Methods We performed a retrospective study of adult appendectomies from January 1997 through November 2007 at a single institution The data were evaluated by multivariate logistic regression analysis and chi-square test. The incidences of postoperative overall SSI, wound infection, and abdominal abscess were compared. Results A total of 1,063 cases were identified. Saline (n = 661) had an SSI rate of 9.8% (65/661), a wound infection rate of 7.3% (48/661), and an abdominal abscess rate of 4.2% (28/661). Dakin's (n = 208) had an SSI rate of 20.7% (43/208), a wound infection rate of 15.9% (33/208), and an abdominal abscess rate of 9.1% (19/208). Imipenem (n = 194) irrigation had an SSI rate of .5% (1/194), a wound infection rate of .5% (1/194), and an abdominal abscess rate of .5% (1/194). Conclusions These results suggest that abdominal irrigation with an antibiotic solution (imipenem 1 mg/mL) is superior to both normal saline and Dakin's solution.

Transesophageal echocardiography has become a commonly used screening tool for traumatic tears of the descending aorta. The role of transesophageal echocardiography for ascending aortic tears is not yet well-defined. We report an ascending aortic tear imaged by aortography but missed on transesophageal echocardiography.

Traditional methods of judging burn depth by clinical evaluation of the wound based on appearance and sensation remain in wide use but are subject to individual variation by examiner. In addition to the clinical difficulties with burn wound management, observer dependency of wound assessment complicates clinical trials of burn wound therapy. A laser Doppler flowmeter with a multichannel probe was used to measure burn wound perfusion as a tool to predict wound outcome. Serial measurement with laser Doppler flowmetry had an 88% specificity and a positive predictive value of 81% for identifying nonhealing wounds. These results suggest that laser Doppler flowmetry is a potentially useful tool for burn wound assessment.

Background: A randomized, prospective, multicenter, double-blind, placebo-controlled, phase II clinical trial was performed to determine whether inhibition of leukocyte adherence by administration of monoclonal antibody directed against intercellular adhesion molecule-1 would improve burn wound healing. Methods: One hundred ten patients with burn injury ranging from 10% to 30% total body surface area were enrolled. Fifty-six patients received placebo (saline) and 54 patients received murine monoclonal antibody to the human intercellular adhesion molecule-1 (enlimomab). Treatment was initiated within 6 hours of injury. Patients had three distinct partial-thickness wound sites assessed. Laser Doppler flowmetry was used to stratify wounds on the day of injury. Wounds were assessed for healing status on day 21 postburn and categorized as healed, non-healed, or grafted. Results: Patients treated with enlimomab had a significantly increased percentage of wounds that healed spontaneously in less than 21 days overall and when stratified by burn wound laser Doppler blood flow readings for those wounds at greatest risk for nonhealing. Conclusion: These results support the concept that leukocyte adherence is involved in the pathogenesis of burn wound necrosis and suggest a therapeutic mechanism for modulating the inflammatory response after the burn injury that may improve wound healing.

A 77-year-old woman with osteogenesis imperfecta was admitted with symptomatic choledocholithiasis. Endoscopic retrograde cholangiopancreatography (ERCP) was carried out and mild resistance was encountered in the distal esophagus with “red out” during intubation. The duodenoscope was withdrawn and gastroscopy revealed a tear in the distal esophagus (● " Fig.1). As a perforation was suspected, a nasogastric tube was deployed, intravenous antibiotics were started, and surgery was consulted. An esophagogram confirmed the esophageal leak (● " Fig.2) and thoraco-abdominal computed tomography (CT) showed a 0.7-cm esophageal perforation and air– fluid collection (3cm×10cm) in the posterior mediastinum (● " Fig.3). Conservative management was decided on due to clinical stability and poor operative candidacy. Within 48 hours the liver function tests normalized and parenteral nutrition was started. The day 7 esophagogram showed partial healing. Enteral feeding was started with a nasojejunal tube placed fluoroscopically. An esophagogram on day 27 showed complete healing (● " Fig.4). The patient started an oral diet and was discharged with plan for elective cholecystectomy. Osteogenesis imperfecta is an autosomal dominant disorder of collagen synthesis (1 in 10000 births). Gastrointestinal manifestations in osteogenesis imperfecta are rare although spontaneous colon perforation has been reported, where histopathological examination showed absence of muscle layers in the perforated segment [1]. Murine models of osteogenesis imperfecta showed thinner esophageal submucosa and muscularis compared with wild mice [2]. ERCP-related perforations are infrequent (0.4%) and are commonly related to improper guidewire insertion or sphincterotomy [3]. Esophageal perforation in ERCP is rare and is attributed to use of sharp accessories [3,4]. This is the first reported case of esophageal perforation in osteogenesis imperfecta. We believe that perforation in our patient occurred due to abnormal esophageal submucosa and muscularis and limited view with duodenoscope. Esophageal perforations are traditionally managed surgically; however, good outcomes are reported with conservative management in smaller perforations and contained leaks [5]. The present case highlights the propensity for esophageal perforation in osteogenesis imperfecta. We recommend caution and low threshold to suspect perforation during gastrointestinal endoscopy in osteogenesis im

The clinical benefit of aeromedical transportation of injured patients in the civilian population has been debated. The purpose of this study was to examine the effects of discontinuing a hospital-based helicopter transport program on trauma patient outcomes, with the hypothesis that the loss of an air ambulance would result in increased transport time and increased mortality among severely injured patients.Data on injury severity and patient outcomes were collected prospectively for the 12 months immediately preceding and 24 months following discontinuation of the helicopter ambulance service. Transport time, mortality rate, and hospital length of stay was compared.The number of trauma patient admissions decreased 12%, with a 17% decrease in admissions of severely injured patients. Transport time decreased, with no change in mortality.Discontinuation of a hospital-based air ambulance service did not increase transport time or increase mortality for trauma patients.

The evaluation of wound outcome after burn injury is a challenging problem in the performance of clinical trials evaluating potential impact on wound healing and scar formation. The purpose of this study was to determine whether an ocular tonometer could be adapted to provide an objective measurement of scar compliance. A pneumatonometer was used to perform measurements of cutaneous compliance at 8 anatomic areas (14 separate sites) on each of 17 normal volunteers and on 59 burn scars. Comparison of different anatomic sites showed there to be significant differences in the cutaneous compliance of different areas. The aggregate compliance of the burn scars in all sites was less than that of the control sites. These results indicate that the pneumatonometer can discern differences in the compliance of normal skin and differences between normal skin and scar and suggest that it may be a useful tool in the objective assessment of scar formation.

Background: Pancreatic injury is often associated with multiple complications related to uncontrolled pancreatic exocrine secretion, including pancreatic fistula, pseudocyst, and intra-abdominal abscesses. Somatostatin analogues such as octreotide have been shown to decrease pancreas-related morbidity following major pancreatic resection in patients with pancreatic neoplasms and acute severe pancreatitis. This study was conducted to determine whether or not the administration of octreotide influences the incidence and severity of abdominal complications following pancreatic injury. Patients and methods: Patients with intraoperative diagnosis of pancreatic injury over a 6-year period were studied retrospectively. Specific complications assessed include abdominal abscesses, pseudocyst, pancreatitis, and pancreatic fistula. Statistical analysis of qualitative variables was by chi-square analysis, and analysis of quantitative variables by Student's t-test (P

Traditional methods for judgment of burn depth by clinical evaluation of the wound based on appearance and sensation remain in wide use but are subject to individual variation by examiner. In addition to the clinical difficulties with burn wound management, observer dependency of wound assessment complicates clinical trials of burn wound therapy. A laser Doppler flowmeter with a newly designed multichannel probe was used to measure burn wound perfusion as a tool to predict wound outcome. Wounds that healed spontaneously in fewer than 21 days showed higher average perfusion levels than those that required excision and grafting or that were not healed by day 21 after the burn. Laser Doppler flowmetry had a positive predictive value of 100% for nonhealing wounds on postburn days 1 and 3. These data suggest that laser Doppler flowmetry is a potentially useful tool for burn wound assessment.

Sepsis, shock, and resuscitation may result in various degrees of ischemia-perfusion injury that may produce widespread organ dysfunction through complex interactions and activation of host immunoinflammatory processes. As the pathophysiologic mechanisms of the inflammatory response are better defined, we may be able to modulate the generalized inflammatory state we know as sepsis and prevent the development of multiple organ failure syndrome. At present, however, the mainstay of therapy remains prompt resuscitation to eliminate regions of hypoperfusion and to limit as much as possible those factors that predispose to further organ injury while the source of inflammatory stimulation is being identified and controlled.

Traumatic diaphragmatic rupture is a frequently missed diagnosis. We present a patient with traumatic diaphragmatic hernia. Diagnosis was suggested by a emergent computed tomography (CT) examination without oral contrast. Diaphragmatic rupture and herniation of stomach were confirmed by repeating CT examination after the administration of oral contrast and using multiplanar reconstruction.

Four hundred five consecutive cases of low anterior colon resection were studied to determine the best treatment of anastomotic leak. The triad of fever, leukocytosis, and pelvic pain was present in 15 of the 16 cases with leaks. Four (25%) of the 16 patients died. Eleven were managed by proximal decompression and drainage; four died (36%). Three patients underwent takedown of the anastomosis, end colostomy, and distal closure or exteriorization; none died. Neither of the two patients who had drainage alone died. Anastomotic leakage accounted for two thirds of the deaths in this series. Recognition of the clinical triad of fever, leukocytosis, and pelvic pain could lead to earlier diagnosis and improved outcome. Our data suggest that a procedure that includes takedown of the anastomosis, end colostomy, and closure of the rectum is the most efficacious treatment of anastomotic leakage after low anterior colon resection.