Obesity delays functional recovery in trauma patients.

BACKGROUND: Obesity is known to complicate trauma hospital stays. We hypothesize that obesity delays functional recovery in trauma patients. MATERIALS AND METHODS: Between 2005 and 2007, adult patients with a hospital length of stay >24 h were prospectively recruited for the study. Functional Independence Measurement (FIM) scores were calculated at the time of admission, discharge, and 6 mo after discharge. Patients were classified as nonobese (body mass index [BMI] <25), overweight (BMI ≥25 and <30), obese (BMI ≥30 and <35), and morbidly obese (BMI ≥35). Multivariate analyses were performed to determine the impact of obesity on FIM scores. RESULTS: Two hundred thirty-five patients met the study inclusion criteria. Average injury severity scores was >18. We recorded no mortality at the time of discharge and follow-up. During acute hospital stay stage, nonobese patients had an average of 24 points increase on FIM scores compared with morbidly obese patients with 16 points improvement (P = 0.023). Compared with nonobese patients, the rate of recovery was reduced by 30% in overweight (P = 0.034), 37% in obese (P = 0.025), and 48% in morbidly obese patients (P = 0.003). Alternatively, we found that for every unit increase in BMI, the functional recovery rate was reduced by 4% (P < 0.001). Changes in FIM scores during the postdischarge period were not significantly different by obesity classification, and all groups achieve similar functional outcome at follow-up (P = 0.482). CONCLUSIONS: Most trauma patients achieve full functional recovery some time after hospital discharge, but the recovery is delayed in obese patients and the delay is directly correlated with the severity of obesity.

Long-term outcomes of patients with necrotizing fasciitis.

CONTEXT: Necrotizing fasciitis is an aggressive infection affecting the skin and soft tissue. It has a very high acute mortality. The long-term survival and cause of death of patients who survive an index hospitalization for necrotizing fasciitis are not known. OBJECTIVE: To define the long-term survival of patients who survive an index admission for necrotizing fasciitis. We hypothesize that survivors will have a shorter life span than population controls. DESIGN: Long-term follow-up of a registry of patients from 1989 to 2006 who survived a hospitalization for necrotizing fasciitis. Last date of follow-up was January 1, 2008. SETTINGS: A university-based Burn and Trauma Center. PATIENTS: A prospective registry of patients with necrotizing fasciitis has been collected from 1989 to 2006. This registry was linked to data from the Department of Health, Department of Motor Vehicles, and the University Hospital Medical Records Department in January 2008 to obtain follow-up and vital status data. INTERVENTION: None. MAIN OUTCOME MEASURES: Date and cause of death were abstracted from death certificates. Date of last live follow-up was determined from the medical record and by the last driver's license renewal. The death rate of the cohort was standardized for age and sex against 2005 statewide mortality rates. Cause of death was collated into infectious and noninfectious and compared with the statewide causes of death. Statistical analysis included standardized mortality rates, Kaplan-Meier survival curves, and Aalen's additive hazard model. RESULTS: Three hundred forty-five patients of the 377 in the registry survived at least 30 days and were analyzed. Average age at presentation was 49 years (range, 1-86; median, 49). Patients were followed up an average of 3.3 years (range, 0.0-15.7; median, 2.4). Eighty-seven of these patients died (25%). Median survival was 10.0 years (95% confidence interval: 7.25-13.11). There was a trend toward higher mortality in women. Twelve of the 87 deaths were due to infectious causes. Using three different statistical analytic techniques, there was a statistically significant increase in the long-term death rate when compared with population-based controls. Infectious causes of death were statistically higher than controls as well. CONCLUSIONS: Patients who survive an episode of necrotizing fasciitis are at continued risk for premature death; many of these deaths were due to infectious causes such as pneumonia, cholecystitis, urinary tract infections, and sepsis. These patients should be counseled, followed, and immunized to minimize chances of death. Modification of other risk factors for death such as obesity, diabetes, smoking, and atherosclerotic disease should also be undertaken. The sex difference in long-term survival is intriguing and needs to be addressed in further studies.

Complications after therapeutic trauma laparotomy.

BACKGROUND: Therapeutic trauma laparotomy (TTL) is a common emergency procedure after traumatic abdominal injury, but it can lead to complications and even death. We explored the role of the time from emergency department (ED) arrival to surgical intervention as a predictor of complications and mortality from TTL. STUDY DESIGN: This is a retrospective study of 175 patients receiving TTL between July 1997 and October 2003 in a Level I teaching hospital serving a primarily rural population. Mortality after TTL and complications, both general and abdominal, were the main outcomes. Time from ED arrival to operation was the primary exposure. Confounders, including time from injury to ED arrival, age, gender, injury severity, and patient status, were controlled in logistic models. RESULTS: Of the 175 TTL patients, 23 (13.1%) died, 102 (58.3%) had abdominal complications, and 119 (68.0%) had general complications. Controlling for confounders, patients whose operation began more than 1 hour after ED arrival were 11.3 (95% CI=2.2 to 58.8) times more likely to die and 3.1 (95% CI=1.44 to 6.60) times more likely to have complications. CONCLUSIONS: The traumatologist has little control over patient treatment and transfer before ED arrival. After arrival the traumatologist can reduce negative outcomes by reducing the time for patient assessment and start of TTL, when warranted.