Primary Skin Closure after Repair of Hollow Viscus Injuries.

Decisions regarding whether to close the skin in trauma patients with hollow viscus injuries (HVIs) are based on surgeon discretion and the perceived risk for an SSI. We hypothesized that leaving the skin open would result in fewer wound complications in patients with HVIs. We performed a retrospective analysis of all adult patients who underwent operative repair of an HVI. The main outcome measure was superficial or deep SSIs. Of 141 patients, 38 (27%) had HVIs. Twenty-six patients developed SSIs, of which 13 (50%) were superficial or deep SSIs. On adjusted analysis, only female gender (P = 0.03) and base deficit were associated (P = 0.001) with wound infections Open wound management was not associated with a decreased incidence of SSIs (P = 0.19) in patients with HVIs. Further research is required to determine optimal strategies for reducing wound complications in patients sustaining HVIs.

Predictors of Peripheral Vascular Injury in Patients with Blunt Lower Extremity Fractures.

BACKGROUND: Early identification of peripheral vascular injuries is crucial to prevent acute limb ischemia and amputation. We sought to identify predictors of vascular injury in patients with blunt lower extremity fractures. METHODS: A single institutional retrospective analysis of patients with blunt lower extremity fractures at a university-affiliated, county hospital over a 2-year period was performed. Patients with lower extremity vascular injury were compared to patients without lower extremity vascular injury. Multivariate logistic regression analysis was performed to identify independent predictors of vascular injury. RESULTS: Two hundred seventy-four patients were identified. The mean age was 37.2 ± 17.6 years, and 73.7% were male. The most common mechanisms were auto versus pedestrian/bicycle (44.2%) and motor vehicle accidents (27.7%). Twenty-two patients (8.0%) had vascular injuries, of which the most commonly injured arteries were the anterior tibial artery (8, 36.4%) and the posterior tibial artery (8, 36.4%). Patients with vascular injuries were more likely to have a tibia-fibula fracture (90.9% vs 52.4%, P < 0.01), an open fracture (63.6% vs 21.8%, P < 0.01), and a mid-shaft fracture (59.1% vs 19.4%, P < 0.01). Amputation was required in 3 patients (13.6%) with a vascular injury. On multivariate analysis, a tibia-fibula fracture (odds ratio [OR] = 5.48, 95% confidence interval [CI] = 1.15-26.1, P < 0.05), an open fracture (OR = 3.87, 95% CI = 1.37-11.0, P = 0.01), and mid-shaft fracture (OR = 2.91, 95% CI = 1.04-8.1, P < 0.05) were associated with the presence of a vascular injury. CONCLUSIONS: Open tibia-fibula fractures particularly those involving a mid-shaft location are independent predictors of vascular injuries in patients with blunt lower extremity fracture. These findings may help identify patients requiring diagnostic and surgical intervention.

Pain and Depression: A Systematic Review.

BACKGROUND: Pain comorbid with depression is frequently encountered in clinical settings and often leads to significant impaired functioning. Given the complexity of comorbidities, it is important to address both pain and depressive symptoms when evaluating treatment options. AIM: To review studies addressing pain comorbid with depression, and to report the impact of current treatments. METHOD: A systematic search of the literature databases was conducted according to predefined criteria. Two authors independently conducted a focused analysis of the full-text articles and reached a consensus on 28 articles to be included in this review. RESULTS: Overall, studies suggested that pain and depression are highly intertwined and may co-exacerbate physical and psychological symptoms. These symptoms could lead to poor physical functional outcomes and longer duration of symptoms. An important biochemical basis for pain and depression focuses on serotonergic and norepinephrine systems, which is evident in the pain-ameliorating properties of serotonergic and norepinephrine antidepressants. Alternative pharmacotherapies such as ketamine and cannabinoids appear to be safe and effective options for improving depressive symptoms and ameliorating pain. In addition, cognitive-behavioral therapy may be a promising tool in the management of chronic pain and depression. CONCLUSION: The majority of the literature indicates that patients with pain and depression experience reduced physical, mental, and social functioning as opposed to patients with only depression or only pain. In addition, ketamine, psychotropic, and cognitive-behavioral therapies present promising options for treating both pain and depression.

Advance Directive and Do-Not-Resuscitate Status among Advanced Cancer Patients with Acute Care Surgical Consultation.

Formal communication of end-of-life preferences is crucial among patients with metastatic cancer. Our objective is to describe the prevalence of advance directives (AD) and do-not-resuscitate (DNR) orders among stage IV cancer patients with acute care surgery consultations, and the associated outcomes. This is a single institution retrospective review over an eight-year period. Two hundred and three patients were identified; mean age was 55.3 ± 11.4 years and 48.8 per cent were male. Fifty (24.6%) patients underwent exploratory surgery. Nineteen (10.6%) patients had another type of surgery. Twenty-one (10.3%) patients had a DNR order, and none had an AD on-admission. Fifty-four (26.6%) patients had a DNR order placed and four (2%) patients completed an AD postadmission. DNR postadmission was associated with the highest mortality at 42.6 per cent compared with 14.3 per cent for DNR on-admission and 1.56 per cent for full-code patients (P < 0.001). Compared with patients that remained full-code and those with DNR on-admission, DNR postadmission was associated with longer length of stay (19.6 days; P < 0.001) and ICU length of stay (7.72 days; P < 0.001). The prevalence of AD and DNR orders among stage IV cancer patients is low. The higher in-hospital mortality of patients with DNR postadmission reflects the use of DNR orders during clinical decline.

Utility of Repeat Head CT in Patients on Preinjury Antithrombotic Medications.

Presently, there are no standardized guidelines regarding the necessity or timing of repeat head imaging in patients on antithrombotics (antiplatelet agents, warfarin, or novel oral anticoagulants) with suspected traumatic brain injury. This is a two-year single institutional retrospective analysis of patients with suspected traumatic brain injury on antithrombotic medications. Patients with a stable or negative repeat head CT were compared with patients who developed a new bleed or demonstrated progression of intracranial hemorrhage (ICH). Of 110 patients, 55 patients (50%) had a positive initial CT, two patients (1.8%) developed a new bleed after initially normal head CT, and 21 patients (19.1%) demonstrated worsening ICH. Patients with worsening or delayed ICH had a higher median Injury Severity Score (14 vs 5, P < 0.001), higher head/neck and face Abbreviated Injury Severity scores (both P < 0.05), and were more likely to be receiving combination therapy with warfarin and clopidogrel (4.3% vs 0%, P = 0.05). On multivariate analysis, lower face and head/neck Abbreviated Injury Severity scores were associated with a decreased risk for delayed or worsening hemorrhage (odds ratio = 0.21 and 0.46, respectively, P < 0.05). Repeat head CT in patients on a preinjury antithrombotic has a low yield. The use of combination therapy may result in an increased risk for delayed hemorrhage or hemorrhage progression.