Impact of ATLS guidelines, trauma team introduction, and 24-hour mortality due to severe trauma in a busy, metropolitan Italian hospital: A case control study.

BACKGROUND: Advanced Trauma Life Support (ATLS) guidelines are widely accepted for use in initial management of trauma patients. The application of ATLS guidelines and introduction of management by means of trauma team (TT) both took place in April 2011. The aim of the present study was to evaluate related effects on mortality in the shock room (SR) and at 24 hours after admission. METHODS: Data were retrieved by administrative software based on patient admission for trauma of at least 48 hours. Study period was from April 2011 to December 2012, and control period was from January 2007 to March 2011. All admitted patients were identified by first diagnosis (ICD 9-CM), excluding traumatic brain injuries, and only patients admitted to the general intensive care, general surgery, and orthopedics units were included. RESULTS: The control group (CG) included 198 patients; the study group (SG) included 141. Differences were determined in patient age, which was mean 45.2 years (SD: 19.2) in the CG and mean 49.3 years (SD±18.3) in the SG (p=0.03). Differences were not found regarding gender, length of hospital stay, or Injury Severity Score (ISS). Among the patients who died, no differences were found in terms of systolic blood pressure, metabolic acidosis, or packed red blood cell consumption. Mortality was significantly higher in the CG, compared to the SG (14.1% vs 7.1%, respectively; p=0.033; confidence interval [CI]: 0.21-0.95). Mortality in the shock room was significantly lower in the SG, compared to the CG (0.7% vs 7.1%, respectively; p=0.002; CI: 0.004-0.592). CONCLUSION: The introduction of ATLS guidelines and TT had a positive impact on mortality in the first 24 hours, both in the SR and after admission.

Laparoscopic right colectomy: Miles away or just around the corner?

BACKGROUND: Despite the drive toward centralization of surgery in high-volume centers, the majority of colectomies are still performed by low- or medium-volume surgeons. MATERIALS AND METHODS: A modification of the technique of laparoscopic right colectomy (LRC) originally described by Young-Fadok and Nelson was developed. The key points of that technique were maintained, but a different port-site layout and a counterclockwise approach were adopted, to warrant better trocar triangulation, to reduce the need of right colon manipulation and to avoid dissection along false planes. This modified technique was applied in 82 patients by 16 surgeons with no previous experience in LRC. RESULTS: Average operative time was 125 ± 35 min. Conversion occurred in 10 cases (12.2%). Grade III postoperative complications occurred in 3 patients (3.6%). No postoperative mortality was observed. Average number of lymph nodes retrieved was 19 ± 6. Average length of stay was 7 ± 4 days. CONCLUSION: Providing low-volume surgeons with simplified and easy-to-learn surgical techniques could improve outcomes and lead to an increased use of laparoscopy.

A randomized controlled trial of 24-hour vaginal dinoprostone pessary compared to gel for induction of labor in term pregnancies with a Bishop score < or = 4.

OBJECTIVE: To compare 24-hour controlled-release vaginal dinoprostone pessary vs. gel for induction of labor at term in women with an unfavorable cervix. DESIGN: Randomized controlled trial. SETTING: University hospital. POPULATION: A total of 133 women with singleton pregnancies, fetal cephalic presentation, Bishop score < or = 4, gestational age of 37-42 weeks, no previous cesarean section and intact membranes admitted for induction of labor. METHODS: Random allocation to either 24-hour 10-mg controlled-release vaginal dinoprostone pessary or repeat doses of 2 mg vaginal dinoprostone gel. MAIN OUTCOME MEASURES: Rate of spontaneous vaginal, operative vaginal and cesarean delivery. RESULTS: The rate of spontaneous vaginal delivery was significantly higher in the pessary group (72%) than in the gel group (54%), paralleled by a lower rate of operative vaginal deliveries (3 vs. 15%). The difference in cesarean section rate (25 vs. 31%) did not reach statistical significance. Both methods of induction of labor appeared to be safe, with no cases of 5-minute Apgar scores < 7 or episodes of uterine hyperstimulation in either group. The medication cost was lower in the pessary group, with a median saving of 50.20 euro compared to the gel group. CONCLUSIONS: Both the 24-hour dinoprostone vaginal pessary and the vaginal gel appear to be safe for labor induction. In women induced at term with a Bishop score < or = 4 the pessary achieved a significantly higher rate of spontaneous vaginal delivery.