Novel endovascular techniques for repair of traumatic bilateral axillary artery disruption with long-term follow-up.

We describe a case of innovative endovascular techniques to repair traumatic bilateral axillary artery disruption. A 36-year-old male construction worker fell eight stories from a scaffold and sustained bilateral axillary artery injuries. The injuries between the brachial and axillary arteries were bridged using long bare self-expanding stents (Zilver). To the best of our knowledge, this is a novel case report from a level-one trauma center where endovascular techniques were employed to repair bilateral axillary arteries with long-term follow-up.

Fever: Fact and fiction.

The significance and management of fever in surgical patients involves several misconceptions that have been perpetuated over the years. This review addresses nine such misconceptions and using evidence from the literature, attempts to clarify such diverse issues as the concept of normal body temperature, the investigation and rationale for the treatment of postoperative fever, the beneficial effects of fever and the potential adverse effects of suppressing fever.

An unusual complication of a laparoscopic nephrectomy: the "lost" kidney stone.

This is the first reported case of a complication resulting from a lost kidney stone after a laparoscopic nephrectomy. The patient presented with a calcified right adnexal mass 3 years after having had a laparoscopic left nephrectomy for a staghorn calculus and hydronephrotic kidney. The mass was thought to be a rapidly growing teratoma and was excised. It proved to be a calcium oxalate stone. No similar cases could be found in the literature. Complications of lost gallstones after laparoscopic cholecystectomy are discussed.

Does fever at the time of discharge have any impact on the incidence of readmission?

Most physicians believe that patients who have fever within 24 hours of the planned date of discharge should be kept in the hospital until the fever resolves. A search of the literature revealed very few articles addressing this topic. The object of this study was to review a number of patient discharges from the surgical service and to document the presence or absence of fever within 24 hours of the time of discharge. The primary end point of the study was to determine the rate of readmission for both patients discharged with fever and those discharged without fever. Secondary end points were to determine whether the readmission was related to the original discharge diagnosis or the presence of fever at the time of discharge. The records of all adult patients with a hospital length of stay of > or = 5 days discharged from the surgical and gynecology services from April through July of 2007 were reviewed. Deaths were excluded. The following data elements were recorded: primary discharge diagnosis; age; highest recorded temperature within 24 hours of discharge; date time and cause of readmission within 30 days; and outcome. Fever was defined as a temperature of > or = 100 degrees F. Data were entered into an Excel (Microsoft, Redmond, WA) spreadsheet, and statistical analysis was performed using chi2 and Fisher's exact tests using Primer of Biostatistics (McGraw-Hill, New York, NY). The records of 300 consecutive patients were reviewed. Follow-up was available for 86.7 per cent of the patients, 84.4 per cent of the febrile patients, and 87.1 per cent of the nonfebrile patients. A fever of > or = 100 degrees within 24 hours of discharge was noted in 45 (15.0%) patients. The mean fever was 100.5 degrees, with a range of 100 degrees to 102.1 degrees. There were 38 readmissions. Of the 45 patients with fever, seven (15.6%) were readmitted. Of those seven, four readmissions were related to the previous admitting diagnosis. Of the patients who were discharged without fever, 31 (12.2%) were readmitted with 24 of those readmissions for diagnoses related to the first admission. The rate of readmission for fever and nonfever patients was not statistically significantly different (P = 0.697). Similarly, the rate of related versus nonrelated diagnoses in both the fever and nonfever groups was not statistically significantly different (P = 0.351). The presence or absence of fever within 24 hours of patient discharge seems to have no impact on the rate of readmission within 30 days.

Pancreaticoduodenectomy for presumed pancreatic cancer.

A literature search revealed only five recent articles with specific information on the incidence of performance of pancreaticoduodenectomy when the preoperative diagnosis is uncertain. The collected incidence of benign diagnoses in the five papers was 13.1%. Five other papers describing patients from before 1990 reported rates of benign diagnoses of 9.7%, p<0.007 compared to the more recent series. The introduction of advanced diagnostic tests has not decreased the incidence of benign pathology after pancreaticoduodenectomy for presumed cancer. Pancreaticoduodenectomy should be performed without a definitive diagnosis of cancer if, in the opinion of an experienced surgeon, clinical suspicion is high.

Correlation of urinalysis and dipstick results with catheter-associated urinary tract infections in surgical ICU patients.

OBJECTIVE: To determine the utility of urinalysis and dipstick results in predicting urinary tract infections in catheterized ICU patients. DESIGN AND SETTING: Urine samples were collected for 4months from patients admitted a ten-bed surgical ICU of an urban public teaching hospital designated by the state of New York as a level I trauma center. The correlation was analyzed between urinalysis and dipstick results from urine samples and subsequent quantitative culture results. PATIENTS: All patients with indwelling urinary catheters admitted to the ICU were considered eligible; 106 patients were enrolled, and 300 individual urine samples were analyzed. MEASUREMENTS AND RESULTS: There were 44 catheter-associated urinary tract infections. Nitrite presence was the best indicator of infection (91.8% specificity) but was not a reliable clinical test due to a sensitivity of 29.5% and positive and negative likelihood ratios of 3.52 and 0.56, respectively. None of the other parameters (leukocyte esterase, white blood cell count, urobilinogen, presence of yeast or bacteria) were independently correlated with the culture results either individually or in combination. CONCLUSIONS: Based on our data we cannot recommend the use of urinalysis or dipstick in screening for potential catheter-associated urinary tract infections.

Should an Allen test be performed before radial artery cannulation?

BACKGROUND: This study aims to determine the current status of the Allen test for assessing the circulation of the hand. METHODS: The Ovid electronic database was searched using multiple search terms and keywords. Bibliographies of pertinent articles were examined. Data involving results of Allen tests, criteria for abnormality and outcomes, specifically those related to adverse events, were extracted. RESULTS: The criteria for an abnormal Allen test are not agreed upon. The significance of an equivocal or abnormal test is unclear. The test is not accurate in predicting postcannulation hand ischemia. Results of the test suffer from poor interrater reliability. Most critically ill patients cannot cooperate for the performance of the test as described. CONCLUSIONS: Performance of an Allen test before radial artery cannulation should not be considered a "standard of care."

The drive to survive: unplanned extubation in the ICU.

STUDY OBJECTIVES: To assess the consequences of unplanned extubation (UE) in the ICU. DESIGN: Case-control study. SETTING: Fourteen-bed, medical-surgical ICU of a university-affiliated community teaching hospital. PATIENTS: One hundred patients who underwent UE compared to 200 control patients who underwent mechanical ventilation (MV) without UE between January 1, 1999, and June 30, 2004. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Patients with UE had longer ICU and hospital length of stay (LOS) and longer duration of MV than did control subjects. Hospital mortality was 20% among UE and 35% among control patients (p = 0.011). Of the 100 patients with UE, reintubation within 48 h (UE R+) was required in 44 patients and no reintubation within 48 h (UE R-) was required in 56 patients. ICU and hospital LOS; duration of MV; rate of ICU-acquired infections; ICU pharmacy, laboratory and diagnostic imaging charges; and mortality were all much higher among UE R+ patients than among UE R- patients. Multiple logistic regression analysis revealed that age was the only predictor of the need for reintubation after UE and that age and the need for reintubation were the only predictors of mortality after UE. CONCLUSIONS: UE was associated with increased hospital and ICU LOS but decreased mortality in this heterogeneous population of critically ill adult patients. These findings were entirely explained by the divergent outcomes of the UE R+ and UE R- groups. Patients with UE who did not require reintubation had remarkably good outcomes. It remains incumbent on ICU teams to institute protocols for regular identification of patients ready to be liberated from MV.

Evidence-based medicine applied to sentinel lymph node biopsy in patients with breast cancer.

Sentinel lymph node biopsy (SLNB) has not been examined using the principles of evidence-based medicine (EBM). Specifically, likelihood ratios have not been used to assess the validity of SLNB. The Surveillance, Epidemiology, and End Results (SEER) public database of the National Cancer Institute was used to establish the baseline or pretest probability of finding a positive lymph axillary node for each stage of breast cancer. Rates of false negative results of SLNB for all breast cancer stages were determined from the surgical literature. Positive and negative likelihood ratios (LR) were calculated. For each stage of breast cancer, the Bayesian nomogram was used to find the post-test probability of missing a metastatic axillary node when the SLN was negative. The SEER database of 213,292 female patients with breast cancer yielded the following rates of positivity of axillary lymph nodes for each breast tumor size: T1a, 7.8 per cent; T1b, 13.3 per cent; T1c, 28.5 per cent; T2, 50.2 per cent; T3, 70.1 per cent. The combined data from 13 published studies of SLNB (6444 successful SLNBs) demonstrated a false negative rate of 8.5 per cent. The LR of a negative test is 0.086. According to the nomogram, the chances of missing a positive node for stage of cancer are as follows: T1a, 0.7 per cent; T1b, 1.5 per cent; T1c, 3.0 per cent; T2, 7 per cent; T3, 18 per cent. The risk of missing a positive axillary node can accurately be estimated for each stage of breast cancer using the LR, which is much more useful than the simple false negative rate. Surgeons should use this information when deciding whether to perform SLNB and in their informed consent discussions.

The rate of adenocarcinoma in endoscopically removed colorectal polyps.

The purpose of this study was to determine the rate of cancer in a modern series of colorectal polyps. All pathology reports from colon and rectal polyps from 1999 to 2002 were reviewed. Reports of bowel resections, cancer-free polyps, and polyp-free mucosal biopsies were excluded. Polyps were grouped by size, and the rate of adenocarcinoma was determined. x2 was used for analysis. A total of 4,443 polyps were found, of which 3,225 were adenomatous [2,883 (89.4%) tubular adenomas, 399 (9.3%) tubulo-villous adenomas, 32 (1.0%) villous adenomas, and 11 (0.3%) carcinomas]. The rate of adenocarcinoma by size was 0.07 per cent for polyps <1 cm, 2.41 per cent for polyps 1-2 cm, and 19.35 per cent for polyps >2 cm, representing significantly fewer cancers for each category of polyp size than the accepted standard. The rate of carcinoma in colon polyps is much lower than previously thought and currently stated in many texts. These data do not alter the recommendations for polyp removal, however, failure to retrieve a specimen in a polyp <1 cm in size is unlikely to have an adverse outcome because the chances of malignancy are very low.

Resident work hours: the five stages of grief.

The authors describe their reactions, as surgical educators, to the mandate of the Accreditation Council for Graduate Medical Education to reduce resident work hours. They explain these reactions in terms of Dr. Elizabeth Kübler-Ross's five stages of grief: denial, anger, bargaining, depression, and finally acceptance ("which should not be mistaken for a happy stage"). The authors describe each stage of grief and use it to make specific comments on the difficulties that the mandate imposes. They then reveal that their views about the work-hours regulations differ: Dr. Ivy now sees them as an opportunity to grow and improve, and likens the resistance to the new restrictions to that of Europeans to the printing press. But Dr. Barone ("the older of the coauthors and a known curmudgeon") is not so sure, and shares many of the concerns described earlier in the five stages of grief, even though he has outwardly accepted the work-hours rules and insists on full compliance by his residents and faculty. In particular, he is saddened that some residents feel they have the absolute right to go home regardless of the situation on the surgery service, and this feeling is validated by the work-hours rules.

Requirement for hourly Glasgow Coma Scores in the emergency department: process or outcome based?

BACKGROUND: The lack of hourly Glasgow Coma Score (GCS) documentation in trauma patients while in the emergency department (ED) is frequently cited by American College of Surgeons (ACS) Trauma Center Verification Review Committee site visitors. The basis for this requirement is unclear. We suspected that hourly recording of GCS has no impact on patient outcome. METHODS: The trauma registry of a 300-bed ACS-verified, state-designated Level II trauma center was reviewed retrospectively for head trauma patients over 16 years of age. Demographic data, field and ED GCS, presence or absence of hourly GCS in the ED, objective injury scores, complications, discharge status, and hospital length of stay were determined. RESULTS: A total of 463 patients were identified. Hourly GCS was recorded in the ED in 244 (53%) patients. No significant difference was found in the Trauma and Injury Severity Score or the Abbreviated Injury Score of the head between those who had hourly GCS recorded and those who did not. Patients who had hourly GCS recorded were significantly younger, 42.3 +/- 19.7 years vs 53.9 +/- 24.9 years for those who did not have hourly GCS recorded (P < 0.001). Seventy percent (126/179) of patients involved in a motorcycle or motor vehicle crash had hourly GCS recorded while only 39% (69/175) of patients admitted for falls had hourly GCS (P < 0.001). There were no differences in mortality or complication rates between the groups. CONCLUSION: The recording of hourly GCS on head injured patients is reflective of the initial presentation of the patient and not an objective evaluation of the patient. The presence or absence of hourly GCS in the ED was not associated with any increase in complications or mortality. The ACS should reevaluate the requirement for hourly recording of GCS in trauma patients.