Disparities in trauma: the impact of socioeconomic factors on outcomes following traumatic hollow viscus injury

Background

This piece aims to examine the relationships between hollow viscus injury (HVI) and socioeconomic factors in determining outcomes. HVI has well-defined injury patterns with complex postoperative convalescence and morbidity, representing an ideal focus for identifying potential disparities among a homogeneous injury population.

Materials and methods

A retrospective review included patients admitted to a level I trauma center with HVI from 2000–2009, as identified in the Trauma Registry of the American College of Surgeons. Patients with concomitant significant solid organ or vasculature injury were excluded. US Census (2000) median household income by zip code was used as socioeconomic proxy. Demographic and injury-related variables were also included. Endpoints were mortality and outcomes associated with HVI morbidity.

Results

A total of 933 patients with HVI were identified and 256 met inclusion criteria. There were 23 deaths (9.0%), and mortality was not associated with race, gender, income, or payer source. However, lower median household income was significantly associated with longer intervals to ostomy takedown (P = 0.032). Additionally, private payers had significantly lower rates of anastomotic leak (0% [0/73] versus 7.1% [13/183], P = 0.019) and fascial dehiscence (5.5% [4/73] versus 16.9% [31/183], P = 0.016), while self-payers had significantly higher rates of abscess formation, both overall (24% [24/100] versus 10.2% [16/156], P = 0.004) and among penetrating injuries (27.4% [23/84] versus 13.6% [12/88], P = 0.036).

Conclusions

Socioeconomic status may not impact overall mortality among trauma patients with hollow viscus injuries, but private insurance appears to be protective of morbidity related to anastomotic leak, fascial dehiscence, and abscess formation. This supports that socioeconomic disparity may exist within long-term outcomes, particularly regarding payer source.     

Small bowel perforation from unit rod posterior spinal fusion

An unusual complication of bowel perforation after unit rod posterior spinal fusion and anterior spine release via a retroperitoneal approach is described. This complication has not been previously described. The pediatric surgical specialist should be aware of this consideration in the differential diagnosis of abdominal pain after unit rod posterior spinal fusion.     

从“肺为娇脏”谈五脏的非均衡性

藏象学说的核心是五脏,五脏之间强弱属性的非均衡性又指导着中医临床辨证治疗。文章从"肺为娇脏"的角度、肺与五脏之间的关系、肺之生理病理等对五脏的非均衡性做了细致的探讨,强调重视五脏的非均衡性,提高临床辨证水平。     

APACHE-II scoring system in perforative peritonitis

BACKGROUND: Prospective assessment of the Acute Physiology and Chronic Health Evaluation-II (APACHE-II) scoring system of stratification of disease severity has been shown to provide objective discrimination between low-risk and high-risk groups of patients with intra-abdominal sepsis. The current study was undertaken to evaluate the performance of APACHE-II score in prediction of mortality risk in patients with peritonitis due to hollow viscus perforation. STUDY DESIGN: Fifty patients admitted to a teaching hospital with peritonitis due to hollow viscus perforation were prospectively studied over a 2-year period. APACHE-II points were assigned to all patients in order to calculate their individual risk of mortality before undergoing emergency surgery. The accuracy in outcome prediction of the APACHE-II system was assessed by means of receiver operating characteristic (ROC) curve and the Pearson correlation coefficient and its significance test. RESULTS: Of the 50 patients admitted during the study period, there were 42 (84%) survivors and 8 (16%) nonsurvivors. Mean APACHE-II score of the study population was 11.38 with a range of 1 to 23. The predicted death rate was 23% and the observed death rate was 16%. Mean APACHE-II score in survivors was 9.88, whereas in nonsurvivors it was 19.25. Using ROC analysis, the area under the curve was found to be .984. Correlation of APACHE-II score and predicted death rate showed perfect correlation, with r = .99 and P <.001 [R2 = .9993]. APACHE-II score between 11 and 15 showed a sensitivity and specificity of 100% and 73.8%, respectively, and APACHE-II score of 16 to 20 had a sensitivity and specificity of 87.5% and 100%, respectively. CONCLUSION: APACHE-II score between 11 and 20 was shown to be a better predictor of risk of mortality in patients with peritonitis due to hollow viscus perforation. Predicted mortality did not correlate with observed mortality in patients with APACHE-II scores of 1 to 10 and greater than 20. The APACHE-II scoring system can be used to assess group outcomes in patients with peritonitis due to hollow viscus perforation. However, it does not provide sufficient confidence for outcome prediction in individual patients.     

Incidence of unexplained intra-abdominal free fluid in patients with blunt abdominal trauma

BACKGROUND:Intra-abdominal free fluid is commonly caused by injuries of solid or hollow organs in patients suffering from blunt abdominal trauma(BAT).However,it presents a diagnostic dilemma for surgeons when free fluid is unexplained,especially in stable BAT patients.This study was to analyze the incidence of such unexplained free fluid in BAT patients and its diagnostic value in abdominal organ injury.METHODS:Altogether 597 patients with BAT who had been treated at our trauma center over a 10-year period ...     

Perforated jejunal diverticulitis in a nonagenarian veteran: A case report

IntroductionJejunal diverticular (JD) disease is an uncommon occurrence that frequently present as a diagnostic dilemma. The correct diagnosis from complications of JD is typically made at laparotomy. Most JD are asymptomatic. Of clinically significant small bowel diverticula, only 15% present with surgical problems including obstruction, gastrointestinal bleed, and perforation.Presentation of caseA 90-year-old man presented to the hospital with abdominal pain. He was clinically stable with local tenderness in the left lower quadrant. Computed tomography demonstrated a dot of free air near the sigmoid and sigmoid diverticula. He continued to have pain and clinically deteriorated following a short period of observation. He underwent an exploratory laparotomy that revealed perforated JD.ConclusionPerforation from JD is exceedingly rare. Due to their infrequent clinical significance, complications from JD are difficult to diagnose and therapeutic options are typically made intraoperatively. Any deviation from the expected positive pathway in the management of a suspected entity should prompt an immediate reassessment as well as definitive therapeutic options.     

基于“肺为血脏”探讨络脉在系统性硬化症合并间质性肺病中的作用

从“肺为血脏”角度出发,结合现代临床和科学研究,重新分析和认识络脉在特发性肺纤维化发展中的作用。众所周知,络脉为全身气血运行的通道,可以说络脉在气血的运行中起关键作用,“肺为血脏”理论认为气血的失常最易造成肺部瘀滞,痰阻血瘀,肺络不通,形成痰、毒、瘀、虚等病理产物,肺脏长期得不到滋养,最终发展为间质性肺疾病,肺痿弱不用。“肺为血脏”,易滞易瘀、易入难出,肺虚是形成间质性肺病的基础,络脉不通,气滞血瘀是特发性肺纤维化的病机,而络病理论又反过来证明了“肺为血脏”这一理论,临床上补肺益气、活血通络法应贯穿疾病治疗的始终。     

不同周龄CB6F1小鼠的脏器及血液学参数测定

摘要 目的：测定4周龄和8周龄不同性别C57-ras转基因模型杂交1代CB6F1的脏器及血液生理生化指标正常值,并比较周龄性别对各项指标的影响。 方法：分别取20只雌雄各半的4周龄和8周龄的CB6F1小鼠,活体称重,解剖称取主要脏器重量,采血测定血液生理指标和血清生化指标。 结果：4周龄和8周龄CB6F1在体重、心、肝、脾、右卵巢、左睾丸、右睾丸、WBC、RBC、HGB、HCT、MCV、MCH、PCT、MPV、PDW、LYM、TP、ALT、ALB、P、TG这22项指标上存在显著差异（P<0.01）,在左肾、右肾、右肾上腺、胸腺、左卵巢、RDW、MON%,BUN这8项指标上有统计学差异（P<0.05）。从性别上比较,4周龄CB6F1在体重、心、肝、脾、肺、左肾、右肾、MCHC、LYM、ALT、ALP、GLU、P、CHO这14项指标上都有雌雄间的显著差异（P<0.01）,在右肾上腺、WBC、PCT、MPV、TP、BUN这6项指标上存在雌雄间的统计学差异（P<0.05）;8周龄CB6F1在体重、心、肝、肺、左肾、右肾、MCV、PCT、LYM、LYM%、NEUT%、ALT、GLU、P、CHO这15项指标上都有雌雄间的显著差异（P<0.01）,在WBC、RBC、MPV、NEUT、TP这5项指标上存在雌雄间的统计学差异（P<0.05）。结论：本文测定了不同周龄不同性别CB6F1小鼠的脏器及血液生理生化指标,为其建立正常检测指标和应用提供参考。     

Comparison of mathematical methods for calculating colonic compliance in humans: power exponential, computer-based and manual linear interpolation models

Abstract  Measuring compliance allows differentiation of sensory changes from changes in thresholds because of altered compliance. As compliance of the colorectum is sigmoidal, a power exponential analysis was recommended. We aimed to develop and validate simpler measurements of compliance. Forty subjects (23 female, 17 male) underwent colonic barostat procedures comparing dronabinol vs placebo. Results of the effects on compliance were reported elsewhere. Compliance was determined as volume response to pressures ranging from 0 to 36 mmHg. Pressures corresponding to 10%, 50% and 90% (Pr10, Pr50 and Pr90) of maximum volume at 36 mmHg were estimated using a power exponential model, computer-based and manual linear interpolation. Data were compared and concordance evaluated. Pr50 and Pr90 were not significantly different by all methods for baseline and post-treatment. Respectively, concordance correlation coefficients were: pretreatment, 0.879, 0.464 and post-treatment, 0.879, 0.623. There is larger variation in Pr10 comparing all methods and manual calculations allow for the closest fit to the data. Concordance correlation coefficients were pretreatment = 0.189 and post-treatment = 0.322. There were no gender differences in compliance measurements. Results of compliance are highly concordant amongst all models. However, computer-based or manual interpolations appear superior to power exponential models for estimating Pr10.     

Perforated diverticulitis managed by laparoscopic lavage

BACKGROUND: Traditionally the management of acute diverticulitis complicated by perforation has been the Hartmann's procedure, which may be associated with significant morbidity and mortality and the unpleasantness of a colostomy. We present our early experience in managing perforated diverticulitis acutely by laparoscopic lavage and drainage. METHODS: A retrospective review was conducted of all patients with surgically confirmed perforated diverticulitis. Details concerning the nature of presentation, operative findings, postoperative course and medium-term progress were investigated. RESULTS: Fourteen patients with a mean age of 57.2 years were identified over a 3-year period. All patients presented with peritonitis and systemic sepsis. Ten patients had extraluminal gas on preoperative imaging. Laparoscopic lavage and drainage, without resection or stoma, was the initial management in all cases. Sigmoid diverticulitis was confirmed in all cases, complicated by Hinchey grade 3 purulent peritonitis in 10 patients, grade 2 contamination in 2 patients and grade 4 faeculent peritonitis in 2 patients. Eleven patients (79%) improved and were discharged following a median of 6.5 days (range, 5-32 days). Three patients did not improve and underwent acute resection. Eight patients have subsequently undergone elective resection without a stoma at a mean interval of 6 weeks, which was carried out laparoscopically in all but one case. CONCLUSION: Laparoscopic lavage and drainage in the acute management of perforated acute diverticulitis may be a promising alternative to more radical procedures, including the Hartmann's procedure. Acute resection should still be carried out in patients found to have faecal peritonitis or who fail to improve following lavage.