Effects of the new Accreditation Council for Graduate Medical Education work hour rules on surgical interns: a prospective study in a community teaching hospital.

Background: On July 1, 2011, the Accreditation Council for Graduate Medical Education (ACGME) eliminated 30-hour call in an attempt to improve resident wakefulness. We surveyed interns on the Newton Wellesley Hospital (NWH) surgery service before and after the transition from Q4 overnight call to a night float schedule.

Methods: For 15 weeks, interns completed weekly surveys including the Epworth Sleepiness Scale (ESS).

How many sunsets? Timing of surgery in adhesive small bowel obstruction: a study of the Nationwide Inpatient Sample.

Background: Best practices promulgated by the Eastern Association for the Surgery of Trauma suggest that delay in surgery for adhesive small bowel obstruction (ASBO) should not exceed 5 days. This study aimed to probe the relationship between operative delay and adverse outcomes, defined as occurrence of a complication, requirement for bowel resection, prolonged postoperative stay, or death in ASBO using the Nationwide Inpatient Sample.

Methods: We used the Nationwide Inpatient Sample for 2009.

Women's preferences for minimally invasive incisions.

Study Objective: To determine whether traditional, robotic, or single-site laparoscopic incisions are more appealing to women.

Design: Descriptive study using a survey (Canadian Task Force classification III).

Setting: Single-specialty referral-based gynecology practice.

Presenting blood pressure in traumatic brain injury: a bimodal distribution of death.

Background: Recent research explores the relationship between vital signs on arrival to the emergency department and early outcomes. This work has not included traumatic brain injury (TBI). We aimed to evaluate the relationship of the initial emergency department systolic blood pressure (EDSBP) with outcome.

Analysis of occupational exposures associated with emergency department thoracotomy.

Background: Although previous studies have examined the cost effectiveness of emergency department thoracotomy (EDT), provider risk has not been included in these analyses. This study examined the costs associated with provider exposure to human immunodeficiency virus (HIV) and hepatitis from percutaneous injury during EDT.

Methods: A decision tree describing the occupational risks and costs associated with EDT was created.

Factors associated with mortality in trauma: re-evaluation of the TRISS method using the National Trauma Data Bank.

Background: TRISS remains a standard method for predicting survival and correcting for severity in outcome analysis. The National Trauma Data Bank (NTDB) is emerging as a major source of trauma data that will be used for both primary research and outcome benchmarking. We used NTDB data, to determine whether TRISS is still an accurate predictor of survival coefficients and to determine whether the ability of TRISS to predict survival could be improved by updating the coefficients or by building predictive models that include information on co-morbidities.

Outcomes and costs of acute treatment of traumatic brain injury.

Background: Although there are nearly a quarter of a million hospitalizations for traumatic brain injury (TBI) in the United States each year, data on the outcomes and costs of TBI treatment in the acute-care setting are limited.

Methods: Using a large, geographically diverse, multihospital database, we examined inpatient records for persons aged 16 years or older who were hospitalized for TBI between January 1, 1997, and June 30, 1999. Patients were stratified by TBI severity using an adaptation of the Abbreviated Injury Scale for administrative data (ICD/AIS), as follows: 2 = "moderate"; 3 = "serious"; 4 = "severe"; and 5 = "critical.

Guidelines for improving nutritional delivery in the intensive care unit.

Optimizing nutritional delivery in the intensive care unit (ICU) continues to be a challenge. Nutritional guidelines were developed at a metropolitan Level I trauma center as an institutional response to ensure the timeliness of patient evaluation, initiation of therapy, and attainment of goal therapy. A post-implementation review of 525 consecutive ICU patients revealed that the guidelines enabled the staff to evaluate 86% of all ICU patients and initiate appropriate therapy in 68% of them within 48 hours of admission.

Relationship between weather and seasonal factors and trauma admission volume at a Level I trauma center.

Background: We sought to determine whether trauma patient admission volume to our Level I trauma center was correlated with observable weather or seasonal phenomena.

Methods: Trauma registry data and national weather service data for the period between September 1, 1992, and August 31, 1998, were combined into a common data set containing trauma admission data and weather data for each day. Sequential linear regression models were constructed to determine relationships between variables in the data set.

Emergency room thoracotomy for penetrating chest injury: effect of an institutional protocol.

Background: Emergency room thoracotomy (ERT) can be life saving in patients with penetrating chest injury. A protocol was established at our institution stating that ERT be performed for cases of cardiac tamponade secondary to penetrating chest trauma on patients with vital signs/mentation in the field or on arrival to the emergency room. To validate our protocol, we reevaluated patients undergoing ERT at our institution.

Development and implementation of clinical pathways for the management of four trauma diagnoses.

Clinical pathways are similar to the production algorithms developed by industry. They are being adapted for use in healthcare to reduce resource utilization, decrease variability, and control expenditures. At Boston Medical Center we identified four trauma diagnoses that we believed to be amenable to the design and implementation of clinical pathways: closed head injury, penetrating wound to the abdomen, penetrating wound to the chest, and penetrating wound to an extremity.

Penetrating thoracic trauma in a pediatric population.

Introduction: Penetrating thoracic trauma in the pediatric population is increasing at an alarming rate. We sought to describe this population and to define prognostic factors that might be of benefit in the management of these patients.

Methods: We retrospectively reviewed the charts and trauma registry records of 65 patients 18 years of age and younger admitted to an urban level I trauma center with the diagnosis of penetrating thoracic trauma.

Management of the trauma patient with pre-existing renal disease.

Chronic renal disease is associated with fluid retention, electrolyte disturbances, anemia, platelet dysfunction, malnutrition, and, often, underlying disease such as diabetes, hypertension, and coronary artery disease. The mortality and morbidity of trauma increases when the victim has pre-existing renal disease. Special attention must be given to fluid resuscitation in these patients because of their limited or absent ability to excrete solutes and fluids.

Surface expression of human CD14 in Chinese hamster ovary fibroblasts imparts macrophage-like responsiveness to bacterial endotoxin.

Cardiovascular collapse associated with Gram-negative septicemia is believed to result from the stimulation of phagocytes by bacterial lipopolysaccharide (endotoxin, LPS). It remains unclear how endotoxin activates phagocytes, but recent evidence suggests the involvement of the glycosyl phosphatidylinositol-linked myelocyte antigen, CD14. We report that transfection of human CD14 into Chinese hamster ovary fibroblasts transfers macrophage-like responsiveness to otherwise LPS-unresponsive cells.

Survival determinants in patients undergoing emergency room thoracotomy for penetrating chest injury.

Survival determinants were examined in patients undergoing ERT-PCI who were admitted to the Surgical Intensive Care Unit (SICU) between January 1, 1982 and August 1, 1991. Twenty-one of 290 patients undergoing ERT-PCI (aged 14-36 years) were admitted to the SICU. Of the 21, nine survived to discharge with normal neurologic function.

Temporary thoracotomy wound closure following penetrating thoracic aorta injury.

On rare occasions, thoracic injuries require resuscitative efforts including emergent thoracotomy that result in edematous changes to the lungs and heart. Hemodynamic compromise occurs when these organs are placed in their anatomic position and closure of the thoracotomy is attempted. Adaptation of a temporary abdominal closure to a thoracic injury is described.

Vesico-diverticular fistula: a rare complication of Meckel's diverticulum.

Enterovesical fistulas usually result from diverticulitis, Crohn's disease, or colorectal cancer. A perforated Meckel's diverticulum can also result in an vesico-diverticulum fistula, as noted in three previously reported cases. In all three cases, bladder or bowel disease was associated with the fistula.

Carinal injury: diagnosis and treatment--case report.

Injury to the thoracic trachea is a potentially lethal condition in a patient with multiple injuries. Several clinical signs are commonly associated with this process: subcutaneous emphysema, aphonia, stridor, pneumothorax refractory to thoracostomy tube drainage, pneumomediastinum, and hemoptysis. The clinical appearance of tracheobronchial rupture may be delayed for hours or even weeks following injury.

Intraaortic balloon pump entrapment.

Catheter entrapment is a rare complication of intraaortic balloon counterpulsation caused by the formation of hard blood clot within the balloon itself. We present two cases of intraaortic balloon pump entrapment seen at the University Hospital, Boston. This phenomenon usually presents as a limb threatening vascular emergency.