A Case of Delayed Cecal Perforation After Abdominal (Seat Belt) Injury.

Seatbelts have reduced the number of fatal head, facial, and chest injuries. They have, however, introduced a set of injuries comprising abdominal wall bruising, Intra-abdominal injuries, and lumbar spine fractures collectively termed the seat belt syndrome. Surgical repair is the treatment for encountered bowel injuries. We present a case of delayed bowel perforation following presentation with signs of seat belt trauma identifying a decisional dilemma in the surgical management of serosal tears with no apparent signs of perforation.

The economic footprint of acute care surgery in the United States: Implications for systems development.

BACKGROUND: Acute care surgery (ACS) comprises trauma, surgical critical care, and emergency general surgery (EGS), encompassing both operative and nonoperative conditions. While the burden of EGS and trauma has been separately considered, the global footprint of ACS has not been fully characterized. We sought to characterize the costs and scope of influence of ACS-related conditions. We hypothesized that ACS patients comprise a substantial portion of the US inpatient population. We further hypothesized that ACS patients differ from other surgical and non-surgical patients across patient characteristics. METHODS: We queried the National Inpatient Sample 2014, a nationally representative database for inpatient hospitalizations. To capture all adult ACS patients, we included adult admissions with any International Classification of Diseases-9th Rev.-Clinical Modification diagnosis of trauma or an International Classification of Diseases-9th Rev.-Clinical Modification diagnosis for one of the 16 AAST-defined EGS conditions. Weighted patient data were presented to provide national estimates. RESULTS: Of the 29.2 million adult patients admitted to US hospitals, approximately 5.9 million (20%) patients had an ACS diagnosis. ACS patients accounted for US $85.8 billion, or 25% of total US inpatient costs (US $341 billion). When comparing ACS to non-ACS inpatient populations, ACS patients had higher rates of health care utilization with longer lengths of stay (5.9 days vs. 4.5 days, p < 0.001), and higher mean costs (US $14,466 vs. US $10,951, p < 0.001. Of all inpatients undergoing an operative procedure, 27% were patients with an ACS diagnosis. Overall, 3,186 (70%) of US hospitals cared for both trauma and EGS patients. CONCLUSION: Acute care surgery patients comprise 20% of the inpatient population, but 25% of total inpatient costs in the United States. In addition to being costly, they overall have higher health care utilization and worse outcomes. This suggests that there is an opportunity to improve clinical trajectory for ACS patients that in turn, can affect the overall US health care costs. LEVEL OF EVIDENCE: Epidemiologic, level III.

Analysis of nonfatal dog bites in children.

BACKGROUND: Dog bites are a significant public health problem among children. The purpose of this study was to examine the hospital incidence, hospital charges, and characteristics of dog bite injuries among children by age group and hospitalization status who were treated at our health care system to guide prevention programs and policies. METHODS: An electronic hospital database identified all patients younger than 18 years who were treated for dog bites from 1999 to 2006. Demographics, injury information, hospital admission status, length of stay, hospital charges, and payer source were collected. A further review of the narrative part of the inpatient electronic database was examined to identify owner of the dog, type of dog, and circumstances surrounding the incident. RESULTS: During 8 years, 1,347 children younger than 18 years were treated for dog bites. The majority were treated and released from the emergency department (91%). Of the 66 children (4.9%) requiring inpatient admission, the median length of stay was 2 days. Victims were frequently male (56.9%) and <8 years (55.2%). Children younger than 5 years represented 34% of all dog bite victims, but 50% of all children requiring hospitalization. Thirty-seven percent of all children admitted to the hospital were bitten by a family dog. The cost of direct medical care during the study was $2.15 million. CONCLUSION: Dog bite visits comprised 1.5% of all pediatric injuries treated in our hospital system during the study period. The majority (91%) of all dog bite visits were treated and released from the emergency department. Injuries to the head/neck region increased the odds of requiring 23 hour observation (OR, 1.95) and age less than 5 years increased the odds of being admitted as an inpatient (OR, 3.3).

Pediatric blunt abdominal injury: age is irrelevant and delayed operation is not detrimental.

BACKGROUND: During the past 40 years, management of solid organ injury in pediatric trauma patients has shifted to highly successful nonoperative management. Our purpose was to characterize children requiring operative intervention. We hypothesized that older children would be more likely to require operative intervention. In particular, we wanted to examine potential outcome disparities between children who were operated upon immediately and those in whom attempted nonoperative management failed. Additionally, we asked whether attempted nonoperative management, when failed, put children at higher risk for mortality or morbidities such as increased blood product transfusions or lengths of stays. METHODS: Retrospective cohorts from seven Level I pediatric trauma centers were identified. Blunt splenic, hepatic, renal, or pancreatic injuries were documented in 2,944 children <1 to 19 years of age from January 1993 to December 2002. Data collected included demographics, hemodynamics, blood transfusions, Glasgow Coma Scale score, Injury Severity Score, hospital length of stay (LOS), intensive care unit (ICU) LOS, and mortality. Analysis involved 140 (4.8%) of 2,944 patients requiring operation. Two cohorts were characterized: (1) immediate operation (IO), defined as laparotomy 3 hours after arrival (n = 59; 42%). RESULTS: Comparing the two cohorts, no age differences were found. Compared with F-NOM, IO had significantly worse hemodynamics, Injury Severity Score, and Glasgow Coma Scale score and was associated with liver injuries. Pancreatic injuries were significantly associated with F-NOM. While controlling for injury severity to compare IO versus F-NOM, linear regression revealed equivalent blood transfusions, ICU LOS, hospital LOS, and mortality rates. CONCLUSION: IO and F-NOM are rare events and independent of age. When operated upon for appropriate physiology, the timing of operation in pediatric solid organ injury is irrelevant and not detrimental with respect to blood transfusion, mortality, ICU and hospital LOS, and resource utilization.

Incidence of abdominal wall defects is related to surface water atrazine and nitrate levels.

BACKGROUND: Gastroschisis and omphalocele are congenital abdominal wall defects (AWD). Atrazine and nitrates are common agricultural fertilizers. METHODS: The Centers for Disease Control and Prevention natality data set was used to collect data for patients with AWD born between January 1990 and December 2002. Similar data were obtained from the Indiana State Department of Health. An estimated date of conception was calculated by birth date and gestational age. Surface water nitrate and atrazine levels for Indiana were collected from US Geological Survey data. Midwest was defined as Indiana, Illinois, Iowa, Ohio, and Nebraska. Statistical analysis was performed by chi2 test and Pearson correlation for P < or = .05. RESULTS: The Centers for Disease Control and Prevention identified 9871 children with AWD in 1990 and in 1995-2001 of 35,876,519 live births (rate 2.75/10(5)). In Indiana, 358 children from 1990-2001 had AWD of 1,013,286 live births (rate 3.53/10(5)). The AWD rate in Indiana was significantly higher than the national rate in 1996 (P = .0377), 1998 (P = .0005), and 2001 (P = .0365) and significantly higher than the Midwest rate in 1998 (P = .0104). Monthly comparison demonstrated a positive correlation of AWD rate and mean atrazine levels (P = .0125). CONCLUSION: Indiana has significantly higher rates of AWD compared with national rates. Increased atrazine levels correlate with increased incidence of AWD.

Appendicitis in childhood hematologic malignancies: analysis and comparison with typhilitis.

BACKGROUND/PURPOSE: Recognition of appendicitis in the child with hematologic malignancy may be difficult particularly in the setting of neutropenia and multiple medications causing an altered inflammatory response. Typhilitis may produce a similar constellation of clinical findings causing further diagnostic confusion. This review compares the relative frequency of these two conditions in children with hematologic malignancy with a focus on the clinical presentation, distinguishing features, surgical management, and outcome for patients with appendicitis. METHODS: This institutional review board-approved retrospective study evaluated 464 pediatric patients treated for hematologic malignancy at our institution from 1997 to 2003. From this cohort, we identified all children with a diagnosis of appendicitis or typhilitis. Data include demographics, clinical presentation, laboratory studies, and computed tomography (CT) scan findings. Groups were compared using the Fisher exact test. Significance was defined as P < .05. RESULTS: Eight (1.7%) of 464 children were diagnosed with typhilitis and 7 (1.5%) with appendicitis. There were no demographic differences between patients with appendicitis and typhilitis. Distinguishing clinical features in children with typhilitis included presence of fever and diarrhea. Clinical presentation in children with appendicitis was atypical in 5 of 7 cases yielding an incorrect preoperative diagnosis in all 5. Radiographic evaluation by CT scan accurately defined typhilitis, but not appendicitis. An operation was performed on all 7 children with appendicitis with no operative morbidity or mortality. CONCLUSIONS: Appendicitis and typhilitis occur with similar frequency in children with leukemia and lymphoma. Typhilitis is accurately diagnosed with clinical findings of fever, diarrhea, abdominal pain, and typical CT scan findings. Appendicitis tends to present with atypical findings, but can be successfully managed with standard surgical care.