Case report: Case series featuring anastomotic colonic adenocarcinoma following jejunoileal bypass requiring oncologic resection and jejunoileal bypass reversal.

Like all surgical fields, bariatric surgery has evolved immensely, so much so that previous procedures are now obsolete. For instance, the jejunoileal bypass has fallen out of favor after severe metabolic consequences resulted in prolonged morbidity and even mortality. Despite this, several patients persevered long enough to develop other pathology, such as cancer. This progression has been validated in animal models but not human patients. Nonetheless, contemporary surgeons may encounter situations where they must resect and re-establish intestinal continuity in patients with this antiquated anatomy. When faced with this scenario, the question of whether or not the previously bypassed small bowel can be safely reunited plagues the surgeon remains unanswered. Unfortunately, the literature does not effectively answer this question, even anecdotally through case reports or series. Therefore, we share our experience with three patients who developed colon cancer following jejunoileal bypass and subsequently underwent oncologic resection with simultaneous reversal of their jejunoileal bypasses.

Routine platelet transfusion in patients with traumatic intracranial hemorrhage taking antiplatelet medication: Is it warranted?

BACKGROUND: After a traumatic intracranial hemorrhage (tICH), patients often receive a platelet transfusion to reverse the effects of antiplatelet medication and to reduce neurologic complications. As platelet transfusions have their own risks, this study evaluated their effects on tICH progression, need for operations and mortality. METHODS: In this retrospective study, we identified patients admitted to a level 1 trauma centre with a tICH from 2011 to 2015 who were taking acetylsalicylic acid (ASA) or clopidogrel, or both. We categorized patients into 2 groups: platelet transfusion recipients and nonrecipients. We collected data on demographic characteristics, changes in brain computed tomography findings, neurosurgical interventions, in-hospital death and intensive care unit (ICU) length of stay (LOS). We used multivariable logistic regression to compare outcomes between the 2 groups. RESULTS: We identified 224 patients with tICH, 156 (69.6%) in the platelet transfusion group and 68 (30.4%) in the no transfusion group. There were no between-group differences in progression of bleeds or rates of neurosurgical interventions. In the transfusion recipients, there was a trend toward increased ICU LOS (adjusted odds ratio [OR] 1.59, 95% confidence interval [CI] 0.74-3.40) and in-hospital death (adjusted OR 3.23, 95% CI 0.48-21.74). CONCLUSION: There were no differences in outcomes between patients who received platelet transfusions and those who did not; however, the results suggest a worse clinical course, as indicated by greater ICU LOS and mortality, in the transfusion recipients. Routine platelet transfusion may not be warranted in patients taking ASA or clopidogrel who experience a tICH, as it may increase ICU LOS and mortality risk.

Safety and Communication in the Operating Room: A Safety Questionnaire After the Implementation of a Blood-Borne Pathogen Exposure Checkpoint in the Surgical Safety Checklist Preprocedure Time-Out.

INTRODUCTION: The Surgical Safety Checklist (SSC) decreases patient morbidity and mortality and improves operating room (OR) communication. However, the SSC does not currently include any discussion on employee safety. One institution has implemented a blood-borne pathogen exposure (BBPE) checkpoint in the SSC in order to improve employee safety and to further improve communication. The aim of this study was to determine if the implementation of a BBPE checkpoint improved caregiver safety and communication in the OR. METHODS: This was a multidisciplinary prospective survey study in which an anonymous questionnaire was distributed to all OR personnel who handle sharps. Survey responses were analyzed for demographics and BBPE safety attitudes. The frequency of reported BBPE incidents collected from quality improvement data 12 months before and after the implementation of the BBPE checkpoint were reviewed. RESULTS: Caregivers feel safer in the OR with the BBPE checkpoint (p < 0.001). Communication was improved. Compliance in trauma surgeries was less than elective. Reported BBPE incidents were significantly decreased based on quality improvement data (p = 0.045). CONCLUSION: The BBPE checkpoint was implemented in the SSC at one institution in order to emphasize employee safety and improve communication. The results shed light on the attitudes of OR personnel by suggesting an improvement in safety and communication. In addition, there has been decrease of reported BBPE incidents among OR personnel. Universal implementation of a BBPE checkpoint could improve provider safety and communication in all ORs.

Similarities Between Large Animal-Related and Motor Vehicle Crash-Related Injuries.

OBJECTIVE: Many Americans sustain large animal-related injuries (LARIs) from blunt trauma. We compare the injuries and management of LARI in our region of the United States with those of motor vehicle crashes (MVCs). METHODS: A 15-year retrospective study of trauma patients with LARI matched to MVC controls by Injury Severity Score (ISS), age, and sex was conducted. Values were statistically compared, and differences were considered statistically significant at P < .05. RESULTS: There were 156 LARI cases, of which 87% were related to horses, 8% to bulls, and the remainder to deer, mules, bison, cows, and rams. In the LARI group, the age was 42±18 years (mean±SD), ISS was 7±4, and 61% were females. The MVC group had a significantly longer length of hospital stay (5±5 vs 4±3 days) and blood alcohol concentration (35±84 vs 3±20 g/L). There were no significant differences in injury patterns between LARI and MVC; however, additional radiological studies (RS) were performed on MVC (9±6 vs 7±5). LARI patients were more often transferred from rural locations (39% vs 25%) and traveled further to our trauma center (40±32 vs 24±29 km) than did MVC patients. CONCLUSIONS: LARI has a similar pattern of injury to MVC, but fewer RS. LARI typically occurred further away, requiring transfer from rural areas to our institution. We recommend a similar approach for the evaluation of LARI and MVC.

Effect of Hospital Length of Stay on Functional Independence Measure Score in Trauma Patients.

OBJECTIVE: The purpose of this study was to determine whether prolonged hospital length of stay (HLOS) and rehabilitation facility length of stay (RLOS) lead to poor functional outcomes, defined as a Functional Independence Measure (FIM) score of less than 76 (LFIM) at rehabilitation facility (RF) discharge. DESIGN: This study analyzed retrospective data collected between 2002 and 2009 on 326 patients in a trauma center and affiliated RF. Factors predicting LFIM at RF discharge were determined using multivariate logistic regression, χ tests, and t tests. RESULTS: Significant multivariate predictors of LFIM included age (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.02-1.07; P < 0.0001), spinal cord injury (OR, 7.22; 95% CI, 2.73-19.02; P = 0.000), female sex (OR, 2.34; 95% CI, 1.17-4.65; P = 0.01), and RF admission FIM (OR, 0.93; 95% CI, 0.91-0.95; P < 0.001). An increased risk of LFIM (OR, 2.21; 95% CI, 1.41-3.45; P = 0.001) was observed with an increased ratio of HLOS/RLOS after adjusting for injury severity score. CONCLUSION: An increased ratio of HLOS/RLOS increases the risk of LFIM more than 2-fold after adjusting for injury severity score, spinal cord injury, and FIM upon RF admission. Delays in transfer to an RF negatively affect patient functional outcomes. Studies to identify factors affecting delays in transfer from hospitals to RF should be conducted.

A comparison between survival from cancer before and after a physical traumatic injury: physical trauma before cancer is associated with decreased survival.

BACKGROUND: Prior traumatic experiences have been associated with poorer coping strategies, greater distress, and more posttraumatic stress disorder (PTSD) symptoms following a subsequent cancer diagnosis affecting their survival. However, the impact of prior physical traumatic injury on cancer survival has not been examined. METHODS: The present study matched patients from the same Level 1 Trauma center who appeared in both the trauma and cancer registries. A total of 498 patients met the criteria between 1998 and 2014 who have experienced both a diagnosis of cancer and a physical traumatic injury. The survival between the patients who had physical trauma before cancer (TBC) versus those that had physical trauma after the cancer diagnosis (TAC) were compared. RESULTS: The TBC group had a higher percentage of males (48 % vs 33 % p = 0.001) and motor vehicle collisions (18 % vs 7 %, p < 0.001), than the TAC group. TBC patients were also significantly younger than TAC patients at the time of the physical traumatic event (68.7 ± 14.6 vs 76.2 ± 12.0 years, p < 0.001), and longer length of time between the cancer diagnosis and physical traumatic injury (2.9 ± 2.9 vs 1.7 ± 2.6 years, p < 0.001). The overall probability of survival for the entire sample was 68 %. Percent survival for the TBC (n = 251) and TAC (n = 247) groups was 56 and 80 % respectively (p < 0.001). Results were consistent regardless of stage of cancer at diagnosis (hazard ratio (HR (Standard Error)). After adjusting for comorbidities Charlson comorbidity index (CCI) (HR = 1.2 (0.06), p = 0.009)), cancer stage (HR = 2.8 (0.12), p < 0.001)), lung cancer (HR = 1.7 (0.25), p < 0.001) and bladder cancer (HR = 3.5 (0.55), p = 0.02), experiencing a prior physical traumatic injury was associated with an increased HR for mortality of 4.6 (0.93), p < 0.001). CONCLUSIONS: A physical traumatic episode before cancer diagnosis (TBC) increased the risk of death 4.6 fold compared to the TAC group even after adjusting for CCI, stage of cancer at diagnosis, lung cancer, and bladder cancer. These findings suggest considering a history of physical traumatic injury in cancer patients as a possible risk factor for faster cancer progression and mortality.

Predictors of new findings on repeat head CT scan in blunt trauma patients with an initially negative head CT scan.

BACKGROUND: Our goal was to determine the need for a repeat head CT scan when the initial CT was negative. STUDY DESIGN: Data were collected from January 1, 2002 to December 31, 2008. There were 281 patients admitted to the trauma center with an initial negative head CT, who had a repeat CT during the same hospitalization. Repeat CTs were categorized into negative/negative (NNG) and negative/positive (NPG) groups. RESULTS: There were 281 patients who underwent a repeat head CT for changes in neurologic status, persistent symptoms, follow-up, decreased mental status, or suspected bleed. Of these, 241 patients remained negative (NNG) and new abnormal findings were noted in 40 patients (NPG). There were no differences in sex (NNG, 63% males vs NPG, 75% females; p = 0.14) or average age (NNG, 51.6 ± 22.5 years vs NPG, 45.2 ± 24.6 years; p = 0.07). There was no difference in positive toxicology (NNG, 29% vs NPG, 30%; p = 0.94) or mechanism of injury (NNG, 51% motor vehicle crash [MVC] vs NPG, 62% MVC; p = 0.18). There was a significant difference in Injury Severity Score (ISS) (NNG, 10.7 ± 8.1 vs NPG, 17.9 ± 11.0; p = 0.0002) and initial Glasgow Coma Scale (GCS) (NNG, 12.7 ± 3.5 vs NPG, 10.9 ± 4.2; p = 0.006). Patients with an ISS > 15 and who were intubated were associated with an increased odds of having a positive repeat CT scan (odds ratio [OR] 2.6; 95%CI 1.2, 5.5 and OR 3.5; 95% CI, 1.7, 7.3, respectively). CONCLUSIONS: Patients with a high ISS score and/or those who are intubated have significantly higher odds of having a positive repeat head CT when repeated for follow-up or when clinically warranted.

Hospital outcomes and disposition of trauma patients who are intubated because of combativeness.

BACKGROUND: The purpose of this study was to determine whether trauma patients who are intubated because of combativeness, and not because of medical necessity, have more complications resulting in longer lengths of stay. METHODS: Data were retrospectively collected from 2001 through 2004 on trauma patients who were intubated because of combative behavior before hospital admission (group 1, N = 34). Cases were matched 1:2 by age, sex, injury severity score (ISS), and injury to controls each who were not intubated (group 2, N = 68). Additionally, there were 187 patients identified who were intubated because of medical necessity before hospital admission; these represented unmatched intubated controls and were divided based on ISS <15 (group 3, N = 58) and ISS >15 (group 4, N = 129). RESULTS: There were no significant differences between groups 1, 2, and 3 with regard to age, sex, or ISS. There was no significant difference between the groups 1 and 2 in frequency of head injuries as demonstrated by positive computed tomography (50 vs. 37%, p = 0.28); however, there was a significant difference in frequency of neurologic deficit at discharge (33 vs. 6%, p = 0.006). There was a significant difference in the frequency of head injuries between groups 1 and 3 (50 vs. 22%, p = 0.006); however, there was no significant difference in neurologic deficit at discharge (33 vs. 22%, p = 0.24). There was a significant difference in hospital length of stay between groups 1 and 2 (7.4 +/- 5.9 vs. 4.3 +/- 4.5 days, p = 0.0009). The incidence of pneumonia was significantly greater in group 1 than in group 2 (29 vs. 0%, p < 0.0001). The amount of lorazepam in average mg per day was also significantly greater in group 1 versus group 2 (4.4 +/- 11.5 vs. 0.4 +/- 1.6, p < 0.0001). There was also a difference in the discharge status, with significantly fewer group 1 cases being discharged home compared with group 2 (56 vs. 91%, p < 0.0001). There was no significant difference between groups 1 and 3 with regard to length of stay, ventilator days, pneumonia, or discharge status. There was a significant difference between groups 1 and 3 in the amount of lorazepam per day (4.4 +/- 11.5 vs. 0.4 +/- 1.6, p = 0.002). CONCLUSION: The results from this study indicate that trauma patients who are intubated because of combativeness, and not because of medical necessity, have longer lengths of stay, increased incidence of pneumonia, and poorer discharge status when compared with matched controls. The outcomes of this group are similar to that of patients who are intubated because of medical necessity.

The relationship between psychiatric medication and course of hospital stay among intoxicated trauma patients.

INTRODUCTION: The purpose of this study was to determine whether trauma patients requiring psychiatric medication who were admitted with positive alcohol or drug screen require more pain medications or sedation resulting in longer length of stay. METHODS: Data were retrospectively collected from 1997 through 2003 on patients with positive alcohol or drug screen who also received psychiatric medication during their hospital stay in a trauma center. Patients were matched by age, injury severity score, and injury to controls who had negative alcohol and toxicology screens and no psychiatric medication. An additional group consisted of positive alcohol or drug-screen trauma patients without psychiatric medication during hospitalization. Each group had 25 patients. RESULTS: No significant differences between the three groups regarding comorbidities or pain-medication doses given per day were found. The patients with positive alcohol and with psychiatric medication were more likely to have respiratory complications such as pneumonia or respiratory failure requiring ventilator support (36 versus 4%, P=0.005), to develop other infections (8 versus 0%), or other complications (26 versus 4%, P=0.0007) compared with the controls. A significant difference in hospital length of stay between the group with positive toxicity and psychiatric medication and that with negative toxicity and psychiatric medication (mean: 12.8 and 5.5 days, respectively; P=0.01) was found. CONCLUSION: Psychiatric medication and positive drug or alcohol screens are associated with longer length of stay and increased respiratory complications. Factors influencing these outcomes need more clarification and prospective studies.

Preinjury warfarin and geriatric orthopedic trauma patients: a case-matched study.

BACKGROUND: This study examined the hypothesis that patients on warfarin before sustaining orthopedic injuries will have increased morbidity and mortality compared with matched control patients not on warfarin. METHODS: Records of consecutive trauma patients on warfarin with orthopedic fractures who presented from January 1997 to June 2002 to a Level I trauma center were retrospectively analyzed. Data were evaluated using the chi and Student's t tests and nonparametric tests when appropriate; values of p < 0.05 were considered significant. RESULTS: A study group of 53 patients was available for review. In comparison with the control group, significant differences were found in time delay from admission to surgery (p = 0.005), hospital length of stay (p = 0.03), total units of blood transfused (p = 0.03), and discharge disposition (p < 0.0003). No difference was found in number of intensive care unit days, complications, or mortality. CONCLUSION: Preinjury warfarin impacts outcomes of geriatric trauma patients sustaining orthopedic injuries.