Reported Clinical and Financial Performance of Hospitals With Physician CEOs Compared to Those With Nonphysician CEOs.

EXECUTIVE SUMMARY: Little work has been done comparing the performance of hospitals with physician CEOs versus nonphysician CEOs, despite the ease of identifying this characteristic and extant leadership theories suggesting a relationship between technical expertise and success in leading highly technical organizations. We performed a detailed analysis of several widely accepted measures of clinical and financial performance across a randomly selected group of U.S. acute care hospitals with more than 40 beds and found no statistically significant differences between the two groups. The 30-day acute myocardial infarction mortality rate showed a positive statistically significant difference in the bivariate analysis (p < .001), but the effect was nullified in the multivariable regression analysis.

Executive summary: Guidelines for the prevention of infections associated with combat-related injuries: 2011 update: endorsed by the Infectious Diseases Society of America and the Surgical Infection Society.

Despite advances in resuscitation and surgical management of combat wounds, infection remains a concerning and potentially preventable complication of combat-related injuries. Interventions currently used to prevent these infections have not been either clearly defined or subjected to rigorous clinical trials. Current infection prevention measures and wound management practices are derived from retrospective review of wartime experiences, from civilian trauma data, and from in vitro and animal data. This update to the guidelines published in 2008 incorporates evidence that has become available since 2007. These guidelines focus on care provided within hours to days of injury, chiefly within the combat zone, to those combat-injured patients with open wounds or burns. New in this update are a consolidation of antimicrobial agent recommendations to a backbone of high-dose cefazolin with or without metronidazole for most postinjury indications and recommendations for redosing of antimicrobial agents, for use of negative pressure wound therapy, and for oxygen supplementation in flight.

Guidelines for the prevention of infections associated with combat-related injuries: 2011 update: endorsed by the Infectious Diseases Society of America and the Surgical Infection Society.

Despite advances in resuscitation and surgical management of combat wounds, infection remains a concerning and potentially preventable complication of combat-related injuries. Interventions currently used to prevent these infections have not been either clearly defined or subjected to rigorous clinical trials. Current infection prevention measures and wound management practices are derived from retrospective review of wartime experiences, from civilian trauma data, and from in vitro and animal data. This update to the guidelines published in 2008 incorporates evidence that has become available since 2007. These guidelines focus on care provided within hours to days of injury, chiefly within the combat zone, to those combat-injured patients with open wounds or burns. New in this update are a consolidation of antimicrobial agent recommendations to a backbone of high-dose cefazolin with or without metronidazole for most postinjury indications, and recommendations for redosing of antimicrobial agents, for use of negative pressure wound therapy, and for oxygen supplementation in flight.

Prevention of infections associated with combat-related central nervous system injuries.

Combat-related injuries to the central nervous system (CNS) are of critical importance because of potential catastrophic outcomes. Although the overall infection rate of combat-related CNS injuries is between 5% and 10%, the development of an infectious complication is associated with a very high morbidity and mortality. This review focuses on the prevention of infections related to injuries to the brain or the spinal cord and provides evidence-based medicine recommendations from military and civilian data for the prevention of infection from combat-related CNS injuries. Prevention strategies emphasize the importance of expert evaluation and management by a neurosurgeon as expeditiously as possible. Areas of focus include elimination of cerebrospinal fluid leaks, wound coverage, postinjury antimicrobial therapy, irrigation, and debridement. Given that these recommendations are not supported by randomized control trials or adequate cohort studies in a military population, further efforts are needed to determine the best treatment strategies. This evidence-based medicine review was produced to support the Guidelines for the Prevention of Infections Associated With Combat-Related Injuries: 2011 Update contained in this supplement of Journal of Trauma.

Cranioplasty complications following wartime decompressive craniectomy.

OBJECT: In support of Operation Iraqi Freedom (OIF) and Operation Enduring Freedom-Afghanistan (OEF-A), military neurosurgeons in the combat theater are faced with the daunting task of stabilizing patients in such a way as to prevent irreversible neurological injury from cerebral edema while simultaneously allowing for prolonged transport stateside (5000-7000 miles). It is in this setting that decompressive craniectomy has become a mainstay of far-forward neurosurgical management of traumatic brain injury (TBI). As such, institutional experience with cranioplasty at the Walter Reed Army Medical Center (WRAMC) and the National Naval Medical Center (NNMC) has expanded concomitantly. Battlefield blast explosions create cavitary injury zones that often extend beyond the border of the exposed surface wound, and this situation has created unique reconstruction challenges not often seen in civilian TBI. The loss of both soft-tissue and skull base support along with the need for cranial vault reconstruction requires a multidisciplinary approach involving neurosurgery, plastics, oral-maxillofacial surgery, and ophthalmology. With this situation in mind, the authors of this paper endeavored to review the cranial reconstruction complications encountered in these combat-related injuries. METHODS: A retrospective database review was conducted for all soldiers injured in OIF and OEF-A who had undergone decompressive craniectomy with subsequent cranioplasty between April 2002 and October 2008 at the WRAMC and NNMC. During this time, both facilities received a total of 408 OIF/OEF-A patients with severe head injuries; 188 of these patients underwent decompressive craniectomies in the theater before transfer to the US. Criteria for inclusion in this study consisted of either a closed or a penetrating head injury sustained in combat operations, resulting in the performance of a decompressive craniectomy and subsequent cranioplasty at either the WRAMC or NNMC. Excluded from the study were patients for whom primary demographic data could not be verified. Demographic data, indications for craniectomy, as well as preoperative, intraoperative, and postoperative parameters following cranioplasty, were recorded. Perioperative and postoperative complications were also recorded. RESULTS: One hundred eight patients (male/female ratio 107:1) met the inclusion criteria for this study, 93 with a penetrating head injury and 15 with a closed head injury. Explosive blast injury was the predominant mechanism of injury, occurring in 72 patients (67%). The average time that elapsed between injury and cranioplasty was 190 days (range 7-546 days). An overall complication rate of 24% was identified. The prevalence of perioperative infection (12%), seizure (7.4%), and extraaxial hematoma formation (7.4%) was noted. Twelve patients (11%) required prosthetic removal because of either extraaxial hematoma formation or infection. Eight of the 13 cases of infection involved cranioplasties performed between 90 and 270 days from the date of injury (p = 0.06). CONCLUSIONS: This study represents the largest to date in which cranioplasty and its complications have been evaluated in a trauma population that underwent decompressive craniectomy. The overall complication rate of 24% is consistent with rates reported in the literature (16-34%); however, the perioperative infection rate of 12% is higher than the rates reported in other studies. This difference is likely related to aspects of the initial injury pattern-such as skull base injury, orbitofacial fractures, sinus injuries, persistent fluid collection, and CSF leakage-which can predispose these patients to infection.

Guidelines for the prevention of infection after combat-related injuries.

Management of combat-related trauma is derived from skills and data collected in past conflicts and civilian trauma, and from information and experience obtained during ongoing conflicts. The best methods to prevent infections associated with injuries observed in military combat are not fully established. Current methods to prevent infections in these types of injuries are derived primarily from controlled trials of elective surgery and civilian trauma as well as retrospective studies of civilian and military trauma interventions. The following guidelines integrate available evidence and expert opinion, from within and outside of the US military medical community, to provide guidance to US military health care providers (deployed and in permanent medical treatment facilities) in the diagnosis, treatment, and prevention of infections in those individuals wounded in combat. These guidelines may be applicable to noncombat traumatic injuries under certain circumstances. Early wound cleansing and surgical debridement, antibiotics, bony stabilization, and maintenance of infection control measures are the essential components to diminish or prevent these infections. Future research should be directed at ideal treatment strategies for prevention of combat-related injury infections, including investigation of unique infection control techniques, more rapid diagnostic strategies for infection, and better defining the role of antimicrobial agents, including the appropriate spectrum of activity and duration.

Prevention and management of infections associated with combat-related central nervous system injuries.

Combat-related injuries to the central nervous system (CNS) are of critical importance because of potential catastrophic outcomes. Although the overall infection rate of combat-related CNS injuries is less than 5%, if an infection develops there is a very high associated morbidity and mortality. This review focuses on the management and prevention of infections related to injuries to the brain or the spinal cord. Management strategies emphasize the importance of expert evaluation and management by a neurosurgeon. This review provides evidence-based recommendations from military and civilian data to the management of combat-related CNS injuries. Areas of focus include bacteria cultures, antimicrobial therapy, irrigation and debridement, timing of surgical care, and wound coverage. Given these recommendations are not supported by randomized control trials or adequate cohorts studies in a military population, further efforts are needed to answer best treatment strategies.

Visual disturbance associated with postoperative cerebellar mutism.

Cerebellar mutism is an uncommon complication of posterior fossa surgery. Manifestations include disturbances of articulation, prosody, and pitch, and, if severe, complete mutism. Symptoms are independent of recognizable cortical or brainstem injury, and recovery is variable, with permanent deficits frequently observed. Cerebellar dysfunction is commonly invoked as an etiology, although controversy remains concerning the mechanism. Visual impairment has been reported only once before in the setting of this disorder. We report a confirmatory case of sudden, severe visual loss in association with cerebellar mutism after resection of a midline medulloblastoma in a 7-year-old.

Credible threat: assessing the likelihood of a chemical or biologic attack.

Threat assessment for weapons of mass destruction is a complex task,requiring many assumptions. As a general rule, weapons of mass destruction are expensive, complex, and difficult-to-use weapons. It is not likely that any current terrorist group has the capability to strike the United States with a weapon capable of producing millions of casualties. Smaller-scale attacks with weapons of mass destruction, however. may result in significant disruption from social and psychologic changes. even though actual casualty rates would probably be quite low. It is., however, highly unlikely that any terrorist attack on the United States could completely undermine national security or threaten the survival of the United States as a nation.

Threat credibility and weapons of mass destruction.

Individual or collective preparedness for an attack involving weapons of mass destruction (WMD) must be based on an analysis of the threat. In threat assessment one takes many factors into account, including the physical and psychological parameters of the attacker. Although the potential devastation caused by WMD is significant, there are many limitations to the effective use of such weapons. Casualty rates will likely be measured in the thousands rather than millions because of factors that will be discussed. The psychological ramifications, it should be noted, the permutations of which have not yet been defined, will be much longer lasting. In this paper the author discusses these and other characteristics of the current threat.

Weapons of mass destruction: radiation.

The purpose of this review is to present a concise overview of the types of radiation, methods of dispersal, injury patterns, and treatment considerations in a scenario involving radiation-based weapons of mass destruction. Radiation-related casualties, although uncommon, are a potential threat because more nations and organizations are developing the technology for producing radioactive substances capable of being used as weapons.

Weapons of mass destruction and the role of the neurosurgeon.

The desire to assist in a crisis should be tempered by a serious assessment of the technical preparation one has undertaken. Additionally, in the same way that a needs assessment is undertaken before prescribing a course of treatment, one should evaluate the actual staffing requirements of the situation. Many physician volunteers were turned away after the World Trade Center attacks because the overwhelming response of available medical personnel quickly exceeded the requirement. Finally, the duration and intensity of preparation should be based on a realistic evaluation of the likelihood of an event occurring that would necessitate use of the training. Before jumping into action in a situation in which weapons of mass destruction have been used, several issues must be addressed. Prior to the crisis, all professionals, neurosurgeons included, should ask how they can prepare themselves and their communities. During the crisis, neurosurgeons should evaluate their roles based on specialized triage training and experience, personal and equipment decontamination training, and the importance of neurosurgical skills. Finally, one should continually ask if there is anything he/she should be doing during the crisis in addition to performing neurosurgical tasks.