Post-traumatic stress disorder (PTSD) is not a contraindication to gastric bypass in veterans with morbid obesity.

BACKGROUND: The veteran population is routinely screened for post-traumatic stress disorder (PTSD). The prevalence of obesity in this population continues to increase. We examined whether weight loss outcomes in veterans with PTSD is comparable to results in veterans who do not suffer from PTSD, after gastric bypass. We also examined the effect of bariatric surgery on PTSD symptoms. METHODS: This retrospective review of prospective data compares veterans with and without PTSD who underwent laparoscopic gastric bypass. Differences between the means of age, initial BMI, and percent excess weight loss were compared between the groups using a Student's t test. Pearson's chi(2) was used to evaluate the relationship between a diagnosis of PTSD, major depressive disorder (MDD), and other Axis I psychiatric disorders. A similar analysis was done to assess for a relationship between PTSD and obesity-related comorbidities, including diabetes mellitus (DM), hypertension (HTN), hyperlipidemia, and GERD. RESULTS: We identified 24 patients who had gastric bypass and a diagnosis of PTSD before surgery and compared them to those without PTSD. Both groups had a similar mean age and initial BMI. There was no significant difference between the percent excess weight lost after 1 year follow-up between the PTSD group (66%) and the non-PTSD group (72%) (p = 0.102). In assessing comorbid conditions, we found a significant association between the diagnosis of PTSD and MDD (p = 0.002), PTSD and other Axis I disorders (p = 0.004), and PTSD and GERD (p = 0.002). However, we saw no significant association between PTSD and DM (p = 0.977), HTN (p = 0.332), and obstructive sleep apnea (OSA) (p = 0.676). The severity of PTSD symptoms fluctuated in the postoperative period. CONCLUSIONS: Veterans with PTSD have comparable weight loss to those without PTSD after gastric bypass. In addition, surgery does not seem to have an adverse effect on PTSD symptoms, although PTSD symptomatology tends to fluctuate over time. Further study in this patient population is warranted.

Continuous muscle tissue oxygenation in critically injured patients: a prospective observational study.

BACKGROUND: Despite normalization of vital signs, critically injured patients may remain in a state of occult underresuscitation that sets the stage for sepsis, organ failure, and death. A continuous, sensitive, and accurate measure of resuscitation after injury remains elusive. METHODS: In this pilot study, we evaluated the ability of two continuous measures of peripheral tissue oxygenation in their ability to detect hypoperfusion: the Licox polarographic tissue oxygen monitor (PmO2) and the InSpectra near-infrared spectrometer (StO2). We hypothesized that deltoid muscle tissue oxygenation measurements could detect patients in "occult shock" who are at increased risk for post-injury complications. The study was designed to (1) define values for PmO2 and StO2 in patients who by all standard measures appeared to be clinically resuscitated; (2) evaluate the relationship between PmO2, StO2 and other physiologic variables including mean arterial pressure (MAP), lactate and base deficit (BD); and (3) examine the relationship between early low tissue oxygen values and the subsequent development of infections and organ dysfunction. Licox probes were inserted into the deltoid muscle of critically injured patients after initial surgical and radiologic interventions, and transcutaneous StO2 monitors were applied over the same muscle bed. PmO2, StO2, and standard physiologic data were collected continuously using a multimodal bioinformatics system. RESULTS: Twenty-eight critically injured patients were enrolled in this study at admission to the intensive care unit (ICU). For patients who appeared to be well resuscitated (defined as MAP > or = 70 mm Hg, heart rate [HR] < or = 110 bpm, BD > or = -2, and partial pressure of arterial oxygen (PaO2) = 80 and 150 mm Hg), the mean PmO2 was 34 +/- 11 mm Hg and StO2 was 63 +/- 27%. There was a strong relationship between PmO2 and BD (p < 0.001) but no significant relationship between StO2 and BD. The relationship between PmO2 and StO2 was weak but statistically significant. Early low values of both PmO2 and StO2 identified patients at risk for infectious complications or multiple organ failure (MOF). In patients who were well resuscitated by standard continuous parameters (HR and MAP), low PmO2 during the first 24 hours after admission (PmO2 < or = 25 for at least 2 hours) was strongly associated with the development of infectious complications (Odds Ratio = 16.5, 95% CI 1.49 to 183, p = 0.02). CONCLUSIONS: PmO2 is a responsive, reliable and continuous monitor of changes in base deficit. Initial low values for either PmO2 or StO2 were associated with post-injury complications. PmO2 monitoring may be useful in identifying patients in the state of occult underresuscitation who remain at risk for developing infection and MOF.

Profile of mothers at risk: an analysis of injury and pregnancy loss in 1,195 trauma patients.

BACKGROUND: Trauma is the number one cause of maternal death during pregnancy, but incidence of fetal loss exceeds maternal loss by more than 3 to 1. We hypothesized that we could identify women at risk for injury during pregnancy and focus our prevention efforts. STUDY DESIGN: Women of childbearing age in the American College of Surgeon's National Trauma Data Bank served as the study population. Pregnant patients were compared with nonpregnant patients with respect to age, race, mechanism of injury, injury patterns and severity, risk-taking behaviors, and outcomes. Multivariate logistic regression analysis was used to identify risk factors for loss of pregnancy in mothers who survived their trauma. RESULTS: Pregnant trauma patients (n = 1,195) were younger, less severely injured, and more likely to be African American or Hispanic as compared with the nonpregnant cohort (n = 76,126). Twenty percent of injured pregnant patients tested positive for drugs or alcohol, and approximately one-third of those involved in motor vehicle crashes were not using seatbelts. Independent risk factors for fetal loss after trauma included Injury Severity Score > 15; Adjusted Injury Score > or = 3 in the head, abdomen, thorax, or lower extremities; and Glasgow Coma Score < or = 8. CONCLUSIONS: Young, African-American, and Hispanic pregnant women are at higher risk for trauma in pregnancy and are most likely to benefit from primary trauma prevention efforts. Those with severe head, abdominal, thoracic, or lower extremity injuries are at high risk for pregnancy loss. Reduction of secondary insults and early recognition of fetal distress may improve outcomes for both the mother and fetus in this high-risk group.

Venous thromboembolism after trauma.

PURPOSE OF REVIEW: The trauma population is at increased risk of venous thromboembolic disease, a potentially preventable cause of mortality and morbidity. Although the association between trauma and venous thromboembolism has been recognized for more than a century, there is still great variability in the clinical practices with respect to prophylaxis. This thorough review of recent literature aims to clarify the incidence and risk factors for deep venous thrombosis and pulmonary embolism after trauma, review options and recommendations for detection of deep venous thrombosis and pulmonary embolism, and give evidence-based recommendations for prophylaxis. Special attention is paid to patients with spinal cord injury, patients with head injury, and pediatric trauma patients. RECENT FINDINGS: Highlights in this field during the past year include stratification of venous thromboembolism risk factors after trauma using a large national database, the expanded use of venous duplex ultrasound surveillance in the ICU and during rehabilitation, and investigations into the safety of low molecular weight heparins in patients with solid organ and traumatic brain injuries. Additionally, two new classes of anticoagulant drugs have been introduced for venous thromboembolism prophylaxis, and there are some preliminary studies on a temporary vena cava filter for the prevention of pulmonary embolism. SUMMARY: Venous thromboembolism remains an area of active clinical research focusing on evolving diagnostic techniques, newer methods of chemical and mechanical prophylaxis, and improved understanding of the etiologic factors of posttraumatic venous thromboembolism. These efforts will undoubtedly decrease the posttraumatic morbidity and mortality associated with venous thromboembolism.

Thromboembolism after trauma: an analysis of 1602 episodes from the American College of Surgeons National Trauma Data Bank.

OBJECTIVE: Venous thromboembolic events (VTE) are potentially preventable causes of morbidity and mortality after injury. We hypothesized that the current clinical incidence of VTE is relatively low and that VTE risk factors could be identified. METHODS: We queried the ACS National Trauma Data Bank for episodes of deep venous thrombosis (DVT) and/or pulmonary embolism (PE). We examined demographic data, VTE risk factors, outcomes, and VTE prophylaxis measures in patients admitted to the 131 contributing trauma centers. RESULTS: From a total of 450,375 patients, 1602 (0.36%) had a VTE (998 DVT, 522 PE, 82 both), for an incidence of 0.36%. Ninety percent of patients with VTE had 1 of the 9 risk factors commonly associated with VTE. Six risk factors found to be independently significant in multivariate logistic regression for VTE were age > or = 40 years (odds ratio [OR] 2.01; 95% confidence interval [CI] 1.74 to 2.32), lower extremity fracture with AIS > or = 3 (OR 1.92; 95% CI 1.64 to 2.26), head injury with AIS > or = 3 (OR 1.24; 95% CI 1.05 to 1.46), ventilator days >3 (OR 8.08; 95% CI 6.86 to 9.52), venous injury (OR 3.56; 95% CI 2.22 to 5.72), and a major operative procedure (OR 1.53; 95% CI 1.30 to 1.80). Vena cava filters were placed in 3,883 patients, 86% as PE prophylaxis, including in 410 patients without an identifiable risk factor for VTE. CONCLUSIONS: Patients who need VTE prophylaxis after trauma can be identified based on risk factors. The use of prophylactic vena cava filters should be re-examined.