Pneumothorax in a term newborn.

With the advent of surfactant and gentle ventilation, the incidence of neonatal pneumothorax has decreased over the last two decades. Pneumothorax associated with respiratory distress syndrome is more common in preterm infants, but term infants often present with isolated pneumothorax. The use of CPAP or non-invasive respiratory support in the delivery room for a term infant with respiratory distress increases transpulmonary pressures and increases the risk of pneumothorax. Prompt diagnosis with a high index of suspicion, quick evaluation by transillumination, chest X-ray or lung ultrasound is critical. Management includes observation, needle thoracocentesis and if necessary, chest tube placement. This manuscript reviews the incidence, pathogenesis, diagnosis and management of a term infant with isolated pneumothorax, summarizing the combination of established knowledge with new understanding, including data on diagnostic modes such as ultrasound, reviewing preventative measures, and therapeutic interventions such as needle thoracocentesis and a comparison of pigtail vs. straight chest tubes.

Health Care Provider Practices and Perceptions During Family-Centered Rounds With Limited English-Proficient Families.

OBJECTIVE: To increase understanding of current practices and perceptions of family-centered rounds (FCR) by providers for limited English-proficient (LEP) families relative to English-proficient families. METHODS: Using grounded theory methodology, we conducted ethnographic observations of FCR for LEP and English-proficient families on the pediatric wards at an urban teaching hospital. Focused coding of observation fieldnotes was performed independently, followed by regular group meetings to discuss discrepancies, refine codes, and identify theoretical direction. Data informed development of an interview guide used to conduct interviews with pediatric physicians, nurses, and interpreters. The iterative analysis process continued with interview transcriptions. RESULTS: FCR of 36 unique patient families were observed, of which 10 were LEP families. We conducted 20 interviews with 7 residents, 3 attendings, 5 nurses, and 5 interpreters. Major themes included: 1) standardization of FCR is needed to address equity issues for LEP families, 2) redefining the roles of medical interpreters would enhance the interpersonal interactions and relationships between families and health care providers, and 3) improving resources to allow interpreters to be used consistently will increase equity for LEP families. CONCLUSIONS: Many differences exist in FCR for LEP versus English-proficient families. FCR for LEP families may be optimized with standardization and training, redefining the interpreters' roles, and improving access to interpreters.

Loss of muscle mass: a significant predictor of postoperative complications in acute diverticulitis.

BACKGROUND: Severe muscle mass depletion, sarcopenia, has been shown to be associated with poor operative outcomes. However, its impact on emergency abdominal operations remains unclear. The purpose of this study was to examine the association between low muscle mass (LMM) and outcomes after emergency operations for acute diverticulitis. PATIENTS AND METHODS: Patients ≥18 y requiring an emergency operation for acute diverticulitis between January 2007 and September 2014 were included. On preoperative computed tomography, the cross-sectional area (CSA) and transverse diameter (TVD) of the right and left psoas muscle were measured at the level of the third lumbar vertebral body. Sensitivity analysis was performed to determine appropriate CSA and TVD cutoff values defining low skeletal muscle mass. Clinical outcomes of patients with low muscle mass (LMM group) were compared with the non-LMM group. RESULTS: A total of 89 patients met our inclusion criteria. Median CSA and TVD were 794 mm2 and 24 mm, respectively. There was a strong correlation between the CSA and TVD (R2 = 0.84). In univariable analysis, significantly higher rates of postoperative major complications (63% versus 37%, P = 0.027) and surgical site infection (47% versus 19%, P = 0.008) were identified in the LMM group. After adjusting for clinically important covariates in a logistic regression model, patients with LMM were significantly associated with higher odds of major complications and surgical site infection. CONCLUSIONS: Preoperative assessment of the psoas muscle CSA and TVD on computed tomography can be a practical method for identifying patients at risk for postoperative complications.

The role of computed tomography after emergent trauma operation.

BACKGROUND: Although computed tomography (CT) has become the preferred diagnostic modality, immediate surgical intervention is often required for severely injured patients with minimum preoperative radiographic evaluation. The utility of postoperative CT (postop-CT) for the identification of undiagnosed injuries and its impact on patient management remain unclear. The purpose of this study was to evaluate the utility of postop-CT for the identification of clinically significant injuries in patients who underwent an emergent life-saving procedure. METHODS: A 5-y retrospective study from 2009 to 2013 was conducted at a high-volume level I trauma center. We included blunt and penetrating trauma patients who underwent an emergent operation (neck exploration, thoracotomy, and laparotomy) without preoperative CT. Postop-CT was obtained within 48 h after the initial operation at the discretion of the attending trauma surgeon. Characteristics of newly diagnosed injuries on postop-CT were analyzed. These injuries were considered clinically significant when the patient required (1) immediate intervention; (2) new consultation from a specialty service; or (3) a higher level of care. RESULTS: A total of 89 patients met our inclusion criteria (five neck explorations, 16 thoracotomies, and 74 laparotomies) with the following characteristics: median age of 30 y, 87.6% male, 47.2% penetrating injury, and median injury severity score of 24. New injuries were identified on postop-CT in 59 cases (66%), and clinical management was changed in 51 cases (57%). Patients with an admission Glasgow Coma Scale <15 and solid organ injury identified during the index operation were more likely to have new injuries on postop-CT. CONCLUSIONS: In patients undergoing an emergent operation before having their full diagnostic workup completed, postop-CT often demonstrates clinically significant injuries. Further prospective study to identify the patients who will benefit from postop-CT is warranted.