Injury to the inferior vena cava (IVC) can produce bleeding that is difficult to control. Endovascular balloon occlusion provides rapid vascular control without extensive dissection and may be useful ...in large venous injuries, especially in the juxtarenal IVC. We describe the procedural steps, technical considerations, and clinical scenarios for using the Bridge occlusion balloon (Philips) in IVC trauma. We present a single-center case series of 5 patients in which endovascular balloon occlusion of the IVC was used for hemorrhage control. All 5 patients were men (median age 35, range 22 to 42 years). They all sustained penetrating injuries-4 gunshot wounds and 1 stab wound. Median presenting Shock Index was 0.7 (range 0.5 to 1.5). Median initial lactate was 5.4 mmol/L (range 4.6 to 6.9 mmol/L). There were 2 suprarenal IVC injuries, 2 juxtarenal injuries, and 3 infrarenal injuries. Four patients underwent primary repair of their injury, and one underwent IVC ligation. Four patients had intraoperative Resuscitative Endovascular Balloon Occlusion of the Aorta for inflow control and afterload support. The median number of total blood products transfused during the initial operation was 37 units (range 16 to 77 units). Four patients underwent damage control operations, and one patient had a single definitive operation. Four of the 5 patients (80%) survived to discharge with the lone mortality being due to other injuries. Endovascular balloon occlusion serves as a valuable adjunct in the management of IVC injury and demonstrates the potential of hybrid open-endovascular operative techniques in abdominal vascular trauma.
Perforated appendicitis, as defined by a visible hole in the appendix or an appendicolith free within the abdomen, carries significant morbidity in the pediatric population. Accurate diagnosis is ...challenging as there is no single symptom or sign that accurately predicts perforated appendicitis. Younger patients and those with increased duration of symptoms are at higher risk of perforated appendicitis. Elevated leukocytosis, bandemia, high C-reactive protein, hyponatremia, ultrasound, and CT are all useful tools in diagnosis. Distinguishing patients with perforation from those without is important given the influence of a perforation diagnosis on the management of the patient. Treatment for perforated appendicitis remains controversial as several options exist, each with its indications and merits, illustrating the complexity of this disease process. Patients may be managed non-operatively with antibiotics, with or without interval appendectomy. Patients may also undergo appendectomy early in the course of their index hospitalization. Factors known to predict failure of non-operative management include appendicolith, leukocytosis greater than 15,000 white blood cells per microliter, increased bands, and CT evidence of disease beyond the right lower quadrant. In this review, the indications and benefits of each treatment strategy will be discussed and an algorithm to guide treatment decisions will be proposed.
The purpose of our study was to assess the outcomes and costs of appendectomies performed at rural and urban hospitals.
The National Inpatient Sample (2001–2012) was queried for appendectomies at ...urban and rural hospitals. Outcomes (disease severity, laparoscopy, complications, length of stay (LOS), and cost) were analyzed.
Rural patients were more likely to be older, male, white, and have Medicaid or no insurance. Rural hospitals were associated with higher negative appendectomy rates (OR = 1.26,95%CI = 1.18–1.34,p < 0.01), less laparoscopy use (OR = 0.65,95%CI = 0.58–0.72,p < 0.01), and slightly shorter LOS (OR = 0.98,95%CI = 0.97–0.99,p < 0.01). There was no consistent association with perforated appendicitis and no difference in complications or costs after adjusting for hospital volume. Yearly trends showed a significant increase in the cases utilizing laparoscopy each year at rural hospitals.
Rural appendectomies are associated with increased negative appendectomy rates and less laparoscopy use with no difference in complications or costs compared to urban hospitals.
•Rural patients tend to be male, older, white, and have Medicaid or no insurance.•Low-volume centers perform 72% of rural appendectomies; 0.2% at high-volume centers.•Higher negative appendectomy rates and less laparoscopy use at rural hospitals.•No difference in complications or costs when hospital volume adjusted for.•Significant increase in rural appendectomies utilizing laparoscopy each year.
Objective: This study examined typologies of childhood violence exposure (CVE) and the associations of profiles with current demographic characteristics and mental health in emerging adulthood. ...Participants: The study evaluated a sample of college students from 2 US geographic regions (Midwest, n = 195; Southeast, n = 200). Methods: An online questionnaire (collected 2013-2014) assessed CVE and current mental health. Latent class analysis was used to identify typologies of CVE. Follow-up analyses were conducted to distinguish differences between typologies in demographic characteristics and mental health. Results: Four distinct profiles emerged: High-Exposed, Domestic-Exposed, Community-Exposed, and Low-Exposed. High- and Domestic-Exposed groups were more likely to be first-generation college students and to experience symptoms of psychopathology. Conclusions: This study offers a unique presentation of CVE profiles and a nuanced interpretation of their differential relationship to current demographic characteristics and mental health. It may befit university mental health initiatives to engage first-generation students and utilize comprehensive assessments of previous victimization.
This study sought to determine factors associated with shelter residence in women with recent histories of intimate partner violence (IPV). The sample included 113 women, approximately half of whom ...resided in a shelter over the past year. Participating women provided demographic information and completed standardized measures of IPV, trauma, and depression. Ethnicity, income, housing stability, and mental health, but not violence exposure, differentiated the shelter and community groups. Trauma symptoms, housing instability, and ethnicity best predicted shelter residence. Future research should focus on determining what types of services and interventions will best address the unique needs of each population.
Early surgical intervention decreases mortality in necrotizing soft tissue infections (NSTIs). Yet, a subset of patients will not have NSTIs (non-NSTIs) at the time of exploration. We hypothesized ...that NSTI and non-NSTI patients had similar causative organisms and that intraoperative wound cultures could help guide management. Culture results and outcomes were compared for all patients undergoing surgery for suspected NSTIs over a seven-year-period. Of 295 patients, 240 (81.4%) had NSTIs. Of the 55 non-NSTI patients (18.6%), 50 had cellulitis and 5 had abscesses. NSTI and non-NSTI patients had similar rates of bacteremia (20.4% vs 17.6%, P = 0.66), septic shock (15.9% vs 12.7%, P = 0.68), and mortality (10.4% vs 7.2%, P = 0.62). Wound cultures were collected more often in NSTI patients (229/240, 95.4%) than in non-NSTI patients (42/55, 76.4%, P < 0.01). Non-NSTI patients had positive deep wound cultures more than half of the time (23/42, 54.8%). The microbiologic profile was similar between groups, with Methicillin Resistant Staphylococcus aureus and Group A Streptococcus occurring with the same frequency. We advocate for deep wound cultures in all patients being evaluated operatively for NSTIs even if the exploration is considered negative because these patients have similar clinical characteristics and virulent microbiology, and culture results can help guide antimicrobial therapy.
Evidence suggests that social support may act as a potential protective factor for psychological maladjustment, but few studies have examined the social support networks of young children exposed to ...intimate partner violence (IPV). The present study examined the in-home networks for 120 preschool-age children who were recently exposed to male-to-female IPV. Results indicated that larger in-home networks were associated with fewer child internalizing and externalizing problems. Mother’s education level was found to moderate the relationship between total in-home network size and child adjustment, such that that when mothers had low levels of education, children had fewer overall adjustment problems as network size increased. When mothers had high levels of education, child adjustment did not significantly vary as network size increased. These findings suggest that the presence of extended family members in the home can positively influence child functioning following exposure to male-to-female IPV.
BackgroundNecrotizing soft tissue infections (NSTI) are aggressive infections associated with significant morbidity and mortality. Despite multiple predictive models for the identification of NSTI, a ...subset of patients will not have an NSTI at the time of surgical exploration. We hypothesized there is a subset of patients without NSTI who are clinically indistinguishable from those with NSTI. We aimed to characterize the differences between NSTI and non-NSTI patients and describe a negative exploration rate for this disease process.MethodsWe conducted a retrospective review of adult patients undergoing surgical exploration for suspected NSTI at our county-funded, academic-affiliated medical center between 2008 and 2015. Patients were identified as having NSTI or not (non-NSTI) based on surgical findings at the initial operation. Pathology reports were reviewed to confirm diagnosis. The NSTI and non-NSTI patients were compared using χ2 test, Fisher’s exact test, and Wilcoxon rank-sum test as appropriate. A p value <0.05 was considered significant.ResultsOf 295 patients undergoing operation for suspected NSTI, 232 (79%) were diagnosed with NSTI at the initial operation and 63 (21%) were not. Of these 63 patients, 5 (7.9%) had an abscess and 58 (92%) had cellulitis resulting in a total of 237 patients (80%) with a surgical disease process. Patients with NSTI had higher white cell counts (18.5 vs. 14.9 k/mm3, p=0.02) and glucose levels (244 vs. 114 mg/dL, p<0.0001), but lower sodium values (130 vs. 134 mmol/L, p≤0.0001) and less violaceous skin changes (9.2% vs. 23.8%, p=0.004). Eight patients (14%) initially diagnosed with cellulitis had an NSTI diagnosed on return to the operating room for failure to improve.ConclusionsClinical differences between NSTI and non-NSTI patients are subtle. We found a 20% negative exploration rate for suspected NSTI. Close postoperative attention to this cohort is warranted as a small subset may progress.Level of evidenceRetrospective cohort study, level III.
Preschool children who witness severe intimate partner violence (IPV) are at increased risk for a wide range of emotional, behavioural, cognitive, and health problems. Although much of intervention ...research has focused on alleviating their psychological symptoms, we know little about efforts to provide these children with preventative safety training. The Preschool Kids' Club Program is a 10-session intervention that addresses the psychological adjustment of children and mothers exposed to IPV. It is based on the Kids' Club Program, which has already proved effective for school-aged children in decreasing behaviour problems and increasing safety-planning skills. The current study describes specific therapeutic strategies for teaching young children safety-planning, and uses qualitative methods to examine children's baseline knowledge of safety-planning and whether or not knowledge of safety-planning improves following participation in the Preschool Kids' Club Program. Results indicate preschool-aged children are able to learn adaptive safety-planning skills through intervention, but high rates of non-response indicate that much more needs to be done to reinforce safety-planning skills in young children. Clinical implications and recommendations for future research of the current findings are discussed.
Role of Sex on Outcomes and Costs of Appendectomy Tom, Cynthia M.; Howell, Erin C.; Sakai-Bizmark, Rie ...
Journal of the American College of Surgeons,
October 2018, 2018-10-00, Volume:
227, Issue:
4
Journal Article
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