Biomedical subjects
Publications and source records attributed to Frederick B Rogers.
The case reported here is a 32-year-old man with a sudden onset of chest pain and an acute deterioration of lung function. An incarcerated Morgagni hernia was diagnosed with a computer tomographic CT scan, and repaired electively via a midline laparotomy. Morgagni hernia is a rare type of congenital diaphragmatic hernia, which may not be symptomatic until adulthood when the patient presents with acute symptoms or incarceration.
Arterioportal fistulas (APFs) are arteriovenous communications between the splanchnic arteries and the portal vein that represent an infrequent cause of presinusoidal portal hypertension. They can be acquired or congenital. Penetrating hepatic trauma, including liver biopsies, represent the most common etiology. They can be asymptomatic or manifest with portal hypertension. An abdominal bruit is a valuable physical finding. Persistence of an APF can cause hepatoportal sclerosis and possibly portal fibrosis. A detailed radiologic evaluation is mandatory. One must differentiate between small peripheral intrahepatic APFs (type 1) and large central APFs (type 2). The former usually resolve spontaneously, whereas the latter can cause portal hypertension and hepatic parenchymal changes. Type 1 APFs caused by needle injury can be followed by Doppler ultrasound. All other fistulas need treatment. Arterioportal fistulas are first treated by transcatheter embolization. Surgical approaches are reserved for complex cases. Congenital APFs (type 3) are diffuse and intrahepatic and can be difficult to manage. Overall, the prognosis is good. Herein, we propose a novel classification for arterioportal fistulas with therapeutic implications.
OBJECTIVE: To describe the clinical progression of an adult patient with traumatic brain injury who survived propofol infusion syndrome. DESIGN: Case report. SETTING: Tertiary care surgical intensive care unit. PATIENT: A 21-yr-old male with traumatic brain injury was administered high doses of propofol for sedation and intracranial pressure control combined with vasopressor therapy to maintain cerebral perfusion pressure >60 mmHg. He developed a significant metabolic acidosis with a lactic acid level of 10.9 mmol/L. INTERVENTIONS: Exploratory laparotomy, discontinuation of propofol infusion. MEASUREMENTS AND MAIN RESULTS: An exploratory abdominal laparotomy was negative for traumatic injury. During the procedure, the propofol infusion was considered a possible cause and was discontinued. On review, it became apparent that a combination of high-dose propofol and catecholamines were responsible for the lactic acidosis. An echocardiogram revealed severe left ventricular dysfunction and cardiomyopathy, which resolved within 19 days. CONCLUSIONS: High-dose propofol should be avoided and alternative agents should be instituted for sedation and intracranial pressure management. The use of catecholamine infusions to maintain cerebral perfusion pressure in the setting of a high-dose propofol infusion may be pharmacologically unsound and may be a triggering factor for propofol infusion syndrome. Identification of the syndrome and discontinuation of propofol resulted in complete reversal of symptoms in the case described.
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The use of vena cava filters has increased rapidly over the past few years to more than 140,000 filters inserted worldwide in 2003. Continued improvements in filter design have increased the safety of intravascular caval filtration. Although there are many factors attributed to this increase, the most significant contributing factor has been the development of optional vena cava filters. That is, filters that can be left as a permanent device or can be removed endovascularly at a later date. Three filters are approved for removal in the United States, the Günther Tulip, the OptEase, and the Recovery. Recent reports have demonstrated the safety and feasibility of these devices in appropriate patients, but a number of questions have arisen regarding their use.
Systems of trauma care in urban areas have a demonstrated survival benefit. Little is known of the benefit of trauma system organization in rural areas. We hypothesized that examination of all trauma deaths during a 1-year period would provide opportunities to improve care in our rural state. We used a medical examiner database of trauma deaths occurring during a 1-year period. Five board-certified surgeons analyzed deaths as preventable (P), potentially preventable (PP), and non-preventable (NP) using modified Delphi technique. There were 223 trauma deaths during a 1-year period. Most (63%) died at the scene prior to any medical intervention. Adjudication of the deaths demonstrated 5 P (2%; 95% CI 1-5%), 36 PP (16%; 95% CI 12-27%), and 179 NP (81%; 95% CI 76-86%). Agreement among trauma surgeons was only moderate with a k of 0.46. Suicide accounted for a significant number of the overall trauma deaths at 32 per cent. Rural trauma system design should focus on discovery, as that is where the majority of deaths occur. Suicide is a significant problem in this rural state that should be aggressively targeted with prevention programs.
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OBJECTIVE: To identify the level of current intensivist's knowledge regarding risk assessment and intensive care unit (ICU) clinical practice pertaining to stress-related mucosal bleeding, including pharmacologic approaches for stress ulcer prevention. DESIGN: A nationwide survey of critical care physicians. STUDY POPULATION: Two thousand random physician members of the Society of Critical Care Medicine. MEASUREMENTS AND MAIN RESULTS: The response rate was 519 (26%) of 2000, with data analysis from 501 (25.1%) usable surveys. Respondents were affiliated with internal medicine (44.3%), surgery (42.3%), and anesthesiology (12.6%). Gut ischemia was indicated as the perceived major cause of stress ulceration (59.7%). The estimated incidence of clinically important bleeding was 2% or less by 62% of respondents; however, 28.6% of physicians surveyed initiate stress ulcer prophylaxis in all ICU patients, regardless of bleeding risk. Respiratory failure was most frequently indicated as a reason for stress ulcer prophylaxis (68.6%), followed by shock/hypotension (49.4%), sepsis (39.4%), and head injury/major neurologic insult (35.2%). The first-line agents selected for stress ulcer prophylaxis include histamine-2 receptor antagonists (63.9%), followed by proton pump inhibitors (23.1%), and sucralfate (12.2%). Concern for nosocomial pneumonia was regarded as more prevalent with antisecretory therapies in those who chose sucralfate (61%) as initial therapy compared with overall respondents (26.9%) (p < .001). CONCLUSIONS: The majority of intensivists surveyed recognize stress-related mucosal bleeding as a relatively infrequent event; however, implementation of a stress ulcer prophylaxis risk stratification scheme for ICU patients is necessary. Histamine-2 receptor antagonists are consistently perceived as appropriate initial agents, although proton pump inhibitors have become first-line therapy in an increasing percentage of critical care patients, despite limited data regarding their use in this population.
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OBJECTIVE: The purpose of this study was to document the initial experience, indications, technical success, and complications with an optional vena caval filter at a Level I trauma center. METHODS: The trauma registry and interventional radiology database were reviewed for all venal caval filters placed during a 15-month period. Records were reviewed for age of patient, indication, type of filter, and duration between placement and removal of the filter. RESULTS: One hundred thirty-six filters were placed into 130 patients (55 trauma patients), and the most frequently placed filter was the Günther Tulip (n = 58, 29 in trauma patients). Forty-five of 1,257 trauma patients received a prophylactic vena cava filter, for a rate of 4%. Twenty-two repositioning (n = 8) or removal procedures (n = 14, 9 in trauma patients) were performed in 15 patients, with a technical success rate of 93%. No minor complications and one major complication occurred. The average duration between placement and removal was 19 days (range, 11-41 days). The mean age of patients selected prospectively for filter removal (29 years; range, 18-71 years) was significantly lower than the mean age (49 years; range, 19-82 years) of trauma, surgical, and intracranial hemorrhage patients selected for placement of prophylactic permanent filters (p < 0.002; 95% confidence interval, 18.0-22.4). CONCLUSION: The Günther Tulip filter is commonly used at this Level I trauma center as an optional filter that can be left in place as a permanent filter or removed up to 41 days after placement. Without an intervening repositioning procedure, the manufacturer suggests that the Günther Tulip filter can be safely removed within 14 days of implantation, or it can remain in place as a permanent filter.
Patients injured in rural areas die at roughly twice the rate of those patients with similar injuries in urban areas. A multitude of explanations have been suggested for higher mortality rates from trauma in the rural areas of the United States. Since rural emergency room (ER) staff see far fewer traumas than ER staff at large metropolitan trauma centers, their lack of exposure to this low-volume problem certainly contributes to the problem. To address discrepancies in trauma education and the delivery of care in our rural region, a telemedicine system was utilized to provide rapid consultation from surgeons at the level 1 trauma center and to provide enhanced educational opportunities for rural ambulance emergency first responders. Clinical outcome measures and evaluation questionnaires were designed in advance of implementation. Forty-one "tele-trauma consults" were performed over the first 30 months of the project, all for major, multi-system trauma. Though many clinical recommendations were made, the system was judged to be life saving in three instances, and both rural and trauma center providers felt the system enhanced clinical care. In addition, educational sessions for rural first responders were well attended and favorably reviewed. Early results of a telemedicine system provide encouragement as a means to address discrepancies in the outcomes after major trauma in rural areas, although more work needs to be completed and evaluated.
BACKGROUND: A Level I trauma center must provide immediate availability general (trauma) surgical expertise. In the current practice few patients require a general surgical procedure. The expertise of subspecialists may also be required and frequently these patients will require subspecialty operative care. We hypothesized that trauma surgeons would receive less reimbursement than their subspecialty colleagues despite a greater commitment of time and effort in taking care of the multiply-injured patient. METHODS: Three fellowship trained trauma surgeons were specifically hired to cover the trauma service for the year 2000. Professional billings, contribution to margin (reimbursement minus direct costs) of the trauma surgeons and subspecialists were obtained from the hospital financial information system. A surrogate for effort was assessed by the number of attending notes in the chart. A surrogate for complexity of care was assessed by the length of notes in the chart. Weekly time sheets assessed the percentage of time involved in the care of trauma patients. RESULTS: There were 344 patients cared for exclusively on the trauma service for the year 2000. The billing generated per patient was $1005 for the trauma surgeon, $5904 for the subspecialists, and $27,554 for the hospital. Orthopedics and radiology generated more professional billing on the trauma patients than the trauma surgeons. The trauma surgeons spent 52% of their weekly clinical activity in the care of trauma patients, yet this activity accounted for only 16% of their billings (the rest came from general surgery and ICU care). The effort and complexity of care provided by the trauma surgeons was significantly greater than the subspecialists. CONCLUSION: The Level I trauma service is a conduit for patients coming into the hospital that provides a significant remuneration to the subspecialty services. Trauma surgeons are able to bill much less than many of their subspecialty colleagues despite expending significantly greater amounts of time and effort in the care of these patients. Strategies for improved reimbursement for trauma surgeons must be devised or trauma surgery will suffer the same fate as other areas of surgery, losing our brightest and best to more financially sound subspecialty services such as radiology and orthopedics.
BACKGROUND: The Glasgow Coma Scale (GCS) has served as an assessment tool in head trauma and as a measure of physiologic derangement in outcome models (e.g., TRISS and Acute Physiology and Chronic Health Evaluation), but it has not been rigorously examined as a predictor of outcome. METHODS: Using a large trauma data set (National Trauma Data Bank, N = 204,181), we compared the predictive power (pseudo R2, receiver operating characteristic [ROC]) and calibration of the GCS to its components. RESULTS: The GCS is actually a collection of 120 different combinations of its 3 predictors grouped into 12 different scores by simple addition (motor [m] + verbal [v] + eye [e] = GCS score). Problematically, different combinations summing to a single GCS score may actually have very different mortalities. For example, the GCS score of 4 can represent any of three mve combinations: 2/1/1 (survival = 0.52), 1/2/1 (survival = 0.73), or 1/1/2 (survival = 0.81). In addition, the relationship between GCS score and survival is not linear, and furthermore, a logistic model based on GCS score is poorly calibrated even after fractional polynomial transformation. The m component of the GCS, by contrast, is not only linearly related to survival, but preserves almost all the predictive power of the GCS (ROC(GCS) = 0.89, ROC(m) = 0.87; pseudo R2(GCS) = 0.42, pseudo R2(m) = 0.40) and has a better calibrated logistic model. CONCLUSION: Because the motor component of the GCS contains virtually all the information of the GCS itself, can be measured in intubated patients, and is much better behaved statistically than the GCS, we believe that the motor component of the GCS should replace the GCS in outcome prediction models. Because the m component is nonlinear in the log odds of survival, however, it should be mathematically transformed before its inclusion in broader outcome prediction models.
Critically ill patients routinely receive H(2) antagonists for stress ulcer prophylaxis while at risk for gastrointestinal bleeding. In these patients it is often difficult to assess accurately the cause of adverse effects such as thrombocytopenia. We evaluate the literature to better define thrombocytopenia related to H(2) antagonist administration and discuss mechanism, potential as a risk factor and case reports describing the severity and duration of thrombocytopenia.
HYPOTHESIS: Complications are common in hospitalized surgical patients. Provider error contributes to a significant proportion of these complications. DESIGN: Surgical patients were concurrently observed for the development of explicit complications. All complications were reviewed by the attending surgeon and other members of the service and evaluated for the severity of sequelae (major or minor) and for whether the complication resulted from medical error (avoidable) or not. SETTING: University teaching hospital with a level I trauma designation. PATIENTS: All inpatients (operative or nonoperative) from 4 different surgical services: general surgery, combined general surgery and trauma, vascular surgery, and cardiothoracic surgery. MAIN OUTCOME MEASURES: Total complication rate (number of complications divided by the number of patients) and the number of patients with complications. Complications were separated into those with major or minor sequelae and the proportion of each type that were due to medical error (avoidable). Rates of complications in a recent Institute of Medicine report were used as a criterion standard. RESULTS: The data for the respective groups (general surgery, vascular surgery, combined general surgery and trauma, and cardiothoracic surgery) are as follows. The number of patients was 1363, 978, 914, and 1403; number of complications, 413, 409, 295, and 378; total complication rate, 30.3%, 42.4%, 32.3%, and 26.9%; minor complication rate, 13.3%, 19.9%, 13.5%, and 13.0% (percentage of minor complications that were avoidable, 37.4%, 59.0%, 51.2%, and 49.5%); major complication rate, 16.2%, 21.1%, 18.1%, and 12.9% (percentage of major complications that were avoidable, 53.4%, 60.7%, 38.8%, and 38.7%); and mortality rate, 1.83%, 3.33%, 2.28%, and 3.34% (percentage of mortality that was avoidable, 28.0%, 44.1%, 19.0%, and 25.0%). CONCLUSIONS: Despite mortality rates that compare favorably with national benchmarks, a prospective examination of surgical patients reveals complication rates that are 2 to 4 times higher than those identified in an Institute of Medicine report. Almost half of these adverse events were judged contemporaneously by peers to be due to provider error (avoidable). Errors in care contributed to 38 (30%) of 128 deaths. Recognition that provider error contributes significantly to adverse events presents significant opportunities for improving patient outcomes.
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BACKGROUND: TRISS has reigned as the preeminent trauma outcome prediction model for 20 years. Despite this endorsement, the calibration of TRISS has been poor in most data sets where it has been examined. We hypothesized that the lack of calibration of TRISS was because of the inappropriate mathematical specification of the model that TRISS is based on, rather than the predictors in the model. In particular, we hypothesized that the nonlinearity of the Injury Severity Score (ISS) in the log odds of death was responsible for the poor calibration of TRISS, and further, that this nonlinearity could be corrected by the simple addition of an ISS squared term to the TRISS model. METHODS: We examined ISS in the log odds of mortality for linearity in one large trauma data set, the National Pediatric Trauma Registry (NPTR) (n = 53,113 from 1985-1996; mortality, 1.3%); and two small data sets, the University of New Mexico (UNM) (n = 3,142 from 1991-1995; mortality, 8.6%) and Portland, Oregon (PORT) (n = 2,916 from 1990-1994; mortality, 1.75%). In addition, in the NPTR we compared the calibration of TRISS models with and without linearity in the log odds of death. RESULTS: In the NPTR, ISS was profoundly nonlinear in the log odds of death for both blunt and penetrating trauma (p < 0.001). Moreover, the overall calibration of the TRISS model for the NPTR data was significantly improved when the nonlinearity of ISS was corrected by the addition of a quadratic ISS term as demonstrated by a 70% reduction (improvement) in the Hosmer-Lemeshow statistic. Interestingly, the addition of the ISS squared term did not affect the discrimination of the model. The log odds of survival in the UNM and PORT data sets were also better modeled when an ISS squared term was added (UNM, p = 0 0.052; PORT, p = 0.014), but improvements in the Hosmer-Lemeshow statistic were smaller, possibly because of the small size of these data sets. CONCLUSION: The TRISS model for outcome prediction currently uses ISS in a mathematically inappropriate way that impairs the calibration, but not the discrimination, of its predictions. If TRISS is to continue as the prediction standard for trauma, a quadratic ISS term must be added to the model. In the future, outcome prediction models should undergo thorough statistical modeling and evaluation before being released. Injury severity descriptors other than ISS (such as ASCOT, ICISS, or NISS) may require other modeling techniques to optimize the calibration of survival models that use these injury scores.