Early tracheostomy in severe traumatic brain injury: evidence for decreased mechanical ventilation and increased hospital mortality.

OBJECTIVE: In the past, the authors performed a comprehensive literature review to identify all randomized controlled trials assessing the impact of early tracheostomy on severe brain injury outcomes. The search produced only two trials, one by Sugerman and another by Bouderka. SUBJECTS AND METHODS: The current authors initiated an Institutional Review Board-approved severe brain injury randomized trial to evaluate the impact of early tracheostomy on ventilator-associated pneumonia rates, intensive care unit (ICU)/ventilator days, and hospital mortality. Current study results were compared with the other randomized trials and a meta-analysis was performed. RESULTS: Early tracheostomy pneumonia rates were Sugerman-48.6%, Bouderka-58.1%, and current study-46.7%. No early tracheostomy pneumonia rates were Sugerman-53.1%, Bouderka-61.3%, and current study-44.4%. Pneumonia rate meta-analysis showed no difference for early tracheostomy and no early tracheostomy (OR 0.89; p = 0.71). Early tracheostomy ICU/ventilator days were Sugerman-16 ± 5.9, Bouderka-14.5 ± 7.3, and current study-14.1 ± 5.7. No early tracheostomy ICU/ventilator days were Sugerman-19 ± 11.3, Bouderka-17.5 ± 10.6, and current study-17 ± 5.4. ICU/ventilator day meta-analysis showed 2.9 fewer days with early tracheostomy (p = 0.02). Early tracheostomy mortality rates were Sugerman-14.3%, Bouderka-38.7%, and current study-0%. No early tracheostomy mortality rates were Sugerman-3.2%, Bouderka-22.6%, and current study-0%. Randomized trial mortality rate meta-analysis showed a higher rate for early tracheostomy (OR 2.68; p = 0.05). Because the randomized trials were small, a literature assessment was undertaken to find all retrospective studies describing the association of early tracheostomy on severe brain injury hospital mortality. The review produced five retrospective studies, with a total of 3,356 patients. Retrospective study mortality rate meta-analysis demonstrated a larger mortality for early tracheostomy (OR 1.97; p < 0.0001). CONCLUSION: For severe brain injury, analyses indicate that ventilator-associated pneumonia rates are not decreased with early tracheostomy. Further, this study implies that mechanical ventilation is reduced with early tracheostomy. Both the randomized trial and retrospective meta-analysis indicate that risk for hospital death increases with early tracheostomy. Findings imply that early tracheostomy for severe brain injury is not a prudent routine policy.

Hepatic abscess associated with Salmonella serotype B in a chronic alcoholic patient.

BACKGROUND: Hepatic abscess secondary to Salmonella is extremely rare in the United States and other Western countries. METHODS: A 43-year-old Caucasian man, with a history of chronic alcohol abuse, was admitted to the hospital for intermittent abdominal pain, fever and diarrhea. Clinical, radiological and laboratory results were analyzed. Medical literature in PubMed pertaining to similar cases was reviewed. RESULTS: Stool culture was positive for Salmonella serotype B and a CT scan of the abdomen with contrast was consistent with a solitary hepatic abscess. Appropriate intravenous antibiotics followed by oral maintenance therapy for six weeks resulted in a complete clinical recovery and radiographic resolution. CONCLUSIONS: The cause of Salmonella hepatic abscess in our patient was most likely associated with decreased mucosal resistance to the bacteria, seeding of infection via transient portal bacteremia and loss of host immunity. Our case highlights the fact that appropriate antibiotic alone is sufficient in the management of a solitary hepatic abscess less than 3-5 cm.

Rhodotorula minuta: an unusual fungal infection in hip-joint prosthesis.

Fungal infections of total joint arthroplasty are uncommon complications, and most cases have been associated with Candida species. In this article, we present a case in which a total hip arthroplasty was infected with Rhodotorula minuta. Intraoperative gram stain showed yeast formsand led to early detection and immediate treatment with amphotericin B and bacitracin. Successful reimplantation was performed 12 months later. To our knowledge, this is the first reported case of arthroplasty infection caused by R minuta.