Intentional injury treated in community hospitals.

BACKGROUND: The impact of intentional injury in major metropolitan trauma centers has been established. Nonaccidental injury has become an increasingly important component of trauma care in mid-sized urban areas. To determine the medical and economic impact of personal violence in the Spokane, Washington, community we undertook a 5-year retrospective review. PATIENTS AND METHODS: Trauma registries were used to identify all victims of intentional injury admitted between May 1, 1994, and April 31, 1999. Demographic data, blood alcohol, mechanism, injury severity, hospital course, and outcome were abstracted from the registries. Financial data were obtained from hospital financial offices. SETTING: Spokane, Washington, has a population of 200,000 with 400,000 in the metropolitan area. Trauma patients are triaged to hospitals according to Washington Administrative Code guidelines, supervised by central medical control. The two level II and two level III facilities are staffed by private practice surgeons and serve a referral area of 650,000. RESULTS: Five hundred eighty-one intentional injury patients were admitted. This represented 15% of all significant injuries. Males accounted for 80% of the patients and 84%were Caucasian. The mean patient age was 30 years, only one quarter were listed as employed. Sixteen percent of the injuries were self-inflicted, gunshot was the most common mechanism (39%). Alcohol was involved in one half of the injuries. Sixty-three patients died, 39 died prior to intensive care unit admission. Hospital stay averaged 6.4 days, with a mean hospital charge of $18,000. Hospitals were reimbursed at 67%. Surgeons collected 31% of billed fees. Fewer than one third of patients had any form of private insurance. CONCLUSIONS: Intentional injury is a significant component of trauma care in our community. Patients are seriously injured and the fatality rate is high. Care is expensive and poorly funded.

Incidence of abdominal wall hernia in aortic surgery.

BACKGROUND: True aneurysms of the abdominal aorta and its branches are at least in part due to defects in the structural integrity of the arterial wall. Whether the defect is isolated to the vascular wall is unclear. If the structural weakness involves other tissues, patients with aneurysmal disease should have a higher incidence of collagen and fascial defects, such as abdominal and inguinal hernias. METHOD: We reviewed 100 patients who underwent elective aortic reconstruction for aneurysmal or occlusive disease. All patients were operated on by the same group of vascular surgeons, through a midline incision, with fascia closed using running absorbable suture. Midline incisional and inguinal hernias were identified, and all patients were followed up for at least 1 year. Comparisons between groups were made for established risk factors for ventral hernias. RESULTS: Incisional hernias occurred in 18 of 58 (31%) aneurysm patients, compared with 5 of 42 (12%) occlusive disease patients (P = 0.025). Inguinal hernias occurred in 11 of 58 (19%) aneurysm patients versus 2 of 42 (5%) occlusive disease patients (P = 0.037). Risk factors were equally distributed between the two groups. Neither the size of the aneurysm nor the presence of an iliac artery aneurysm affected the incidence of abdominal wall hernias in the aneurysm patients. CONCLUSION: This study emphasizes the increased incidence of abdominal wall hernias in patients undergoing aortic surgery for aneurysm disease compared with aortoiliac occlusive disease. The size of the aneurysm and the association of an iliac artery aneurysm did not affect the incidence of hernias among these patients. Genetic and biochemical abnormalities are considered as possible explanations.

Cost-effective carotid endarterectomy.

BACKGROUND: Carotid endarterectomy is the most common vascular procedure performed, with an annual cost of $1.2 billion. Efforts to control the cost associated with this procedure include limiting preoperative studies, avoiding admissions to the intensive care unit, and encouraging early postoperative discharge. METHODS: To determine our surgical results and the cost associated with this procedure, we reviewed our experience at a single hospital and compared our cost data with those of other local facilities. RESULTS: During an 18-month period we performed 65 carotid endarterectomies at one community hospital. The average per-patient hospital cost was $8,060, which was $3,510 less than the average cost at the other facilities in our city. The median length of postoperative stay in our hospital was 1 day. One patient died and there was 1 postoperative stroke. CONCLUSIONS: Limited utilization of the intensive care unit and short postoperative stays reduced the overall hospital costs. Our 1.5% mortality and stroke rates demonstrate that these cost-saving measures can be implemented without adversely affecting patient outcome.

Errant percutaneous Greenfield filter placement into the retroperitoneum.

Percutaneous Greenfield filter placement through a femoral vein approach resulted in errant retroperitoneal placement in a patient with pulmonary emboli. A properly positioned filter was then placed surgically through the right internal jugular vein. The patient subsequently required removal of the errant retroperitoneal filter because of genitofemoral nerve irritation. Problems associated with percutaneous Greenfield filter placement and pertinent literature are discussed.

The role of fine-needle aspiration in the management of solid breast masses.

Fine-needle aspiration cytology is a safe, inexpensive, rapid method of establishing the diagnosis of breast cancer in patients with solid, palpable masses. The pathologist must be conservative in his interpretation of malignancy so that positive study results occur only in patients with cancer. We compared the cytologic diagnosis of 140 breast masses with the histologic diagnosis. Seventy of 98 breast cancers were diagnosed by this technique. Because 28 cancers could not be diagnosed with certainty, open biopsy should be performed on all breast masses with nonmalignant cytologic findings.

Outpatient inguinal herniorrhaphy with both regional and local anesthesia.

Fifty-three patients who were undergoing outpatient inguinal herniorrhaphy with short-acting regional anesthetic agents and local infiltration of a long-acting anesthetic were retrospectively compared with a matched population of 53 hospitalized patients who were undergoing herniorrhaphy with a long-acting regional anesthetic. There was a significantly greater incidence of urinary retention in the hospitalized patients who received long-acting regional anesthetic agents. Otherwise, complications in the two groups were similar. Inguinal herniorrhaphy can be accomplished as an outpatient procedure without increased morbidity. This can result in significant savings in hospital bills. We suggest that anesthesia for inguinal herniorrhaphy is most satisfactorily provided by the combination of a short-acting regional anesthetic agent and a long-acting local one.

Cholecystitis in teenage girls.

Cholecystectomy was carried out in 17 teenage girls for cholecystitis at Virginia Mason Hospital, Seattle, between 1971 and 1980. The incidence increased with increasing age. Gallbladder disease was associated with recent pregnancy or birth control pill use (71%), obesity (65%) and family history of gallbladder disease (47%). All but one patient had at least one of these risk factors. No patient had congenital anomalies, blood dyscrasias or other underlying illness. Patients most commonly had recurrent attacks of abdominal pain; seven had symptoms for more than six months. Although the clinical presentations were often mild, six patients had jaundice, three had chemical pancreatitis, one had hemorrhagic pancreatitis, one had pancreatic pseudocyst and abscess and one had a common duct stone. One patient had cholesterosis and 16 had cholelithiasis. All patients were cured by operation. During the same time period, only two boys, both aged 14 years, nonobese and with no family history of gallbladder disease, underwent cholecystectomy, both for acaculous cholecystitis.