Acute cholecystitis.

INTRODUCTION: Of people admitted to hospital for biliary tract disease, 20% have acute cholecystitis. Up to the age of 50 years, acute calculous cholecystitis is three times more common in women than in men, and about 1.5 times more common in women than in men thereafter. About 95% of people with acute cholecystitis have gallstones. Optimal therapy for acute cholecystitis, based on timing and severity of presentation, remains controversial. METHODS AND OUTCOMES: We conducted a systematic review and aimed to answer the following clinical question: What are the effects of treatments for acute cholecystitis? We searched: Medline, Embase, The Cochrane Library, and other important databases up to December 2006 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS: We found 12 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS: In this systematic review we present information relating to the effectiveness and safety of the following interventions: early cholecystectomy, laparoscopic cholecystectomy, minilaparoscopic cholecystectomy, observation alone, and open cholecystectomy.

Tracheostomy in ventilator dependent trauma patients: a prospective, randomized intention-to-treat study.

BACKGROUND: Tracheostomy is a commonly performed procedure in ventilator dependent patients. Many critical care practitioners believe that performing a tracheostomy early in the postinjury period decreases the length of ventilator dependence as well as having other benefits such as better patient tolerance and lower respiratory dead space. We conducted a randomized, prospective, single institution study comparing the length ventilator dependence in critically ill multiple trauma patients who were randomized to two different strategies for performance of a tracheostomy. We hypothesized that earlier tracheostomy would reduce the number of days of mechanical ventilation, frequency of pneumonia and length of intensive care unit (ICU) stay. METHODS: Patients were eligible if they were older than 15 years and either a Glasgow Coma Score (GCS) >4 with a negative brain computed tomography (CT) (no anatomic head injury), or a GCS >9 with a positive head CT (known anatomic head injury). Patients who required tracheostomy for facial/neck injuries were excluded. Patients were randomized to an intention to treat strategy of tracheostomy placement before day 8 or after day 28. RESULTS: The study was halted after the first interim analysis. There were 60 enrolled patients, who had comparable demographics between groups. There was no significant difference between groups in any outcome variable including length of ventilator support, pneumonia rate, or death. CONCLUSION: A strategy of tracheostomy before day 8 postinjury in this group of trauma patients did not reduce the number of days of mechanical ventilation, frequency of pneumonia or ICU length of stay as compared with the group with a tracheostomy strategy involving the procedure at 28 days postinjury or more.

Evaluation of the applicability, efficacy, and safety of a thromboembolic event prophylaxis guideline designed for quality improvement of the traumatically injured patient.

BACKGROUND: Thromboembolic events (TE) such as deep venous thrombosis (DVT) and pulmonary embolism (PE) are common after trauma. Our Trauma Practice Management Committee developed an evidence-based DVT/PE prophylaxis guideline using a modified Delphi approach to standardize care and reduce TE rates. Our objective was to evaluate the applicability, efficacy, and safety of this guideline in the traumatized patient, especially those admitted first to the intensive care unit (ICU). METHODS: We developed a risk-stratified DVT/PE prophylaxis guideline incorporating specific injuries, pertinent history, and physiologic parameters, favoring aggressive therapy in those at highest risk of dying from a PE. We prospectively collected data using this guideline in all patients admitted to the trauma or orthopedic-trauma services that were expected to stay for more than 48 hours (March-December 2003). Comparison was made with historical controls. Data collected included DVT, PE, prophylaxis level chosen, inferior vena cava filters, admission service and location, TRISS scores, length of stay, outcomes, adverse events, and specific risk factors. RESULTS: TE rates after implementation of the guideline were lower than historical controls for all patients (1.9% vs. 1.0%, p = 0.059) and for patients admitted first to the ICU (6.3% vs. 2%, p = 0.018). Completed sheets were collected for 46% of the targeted population. No bleeding events caused by guideline anticoagulation were noted, and one death occurred after inferior vena cava filter placement. Nine of the 12 TEs in the treatment group were in patients with spine or closed-head injury, delaying chemical prophylaxis. CONCLUSION: Form-based, risk-adjusted prophylaxis against TE leads to lower TE rates in a general and orthopedic ICU trauma population. Protocol compliance should be enforced.