Swallowing dysfunction after prolonged intubation: analysis of risk factors in trauma patients.

BACKGROUND: The clinical significance of post-extubation swallowing dysfunction (PSD) is profound, resulting in both increased morbidity and mortality. Specific risk factors have not been described in an injured patient cohort. The purpose of this pilot study was to elucidate independent factors that predict PSD in this population. METHODS: A retrospective cohort analysis was performed on 150 consecutive trauma patients intubated for more than 48 hours. Assessment of swallowing function after extubation was performed by a simple bedside speech pathology evaluation. Patients then were divided into 2 groups: those with and those without PSD. Backwards stepwise logistic regression analysis then was used to determine independent predictors of PSD after controlling for important injury characteristics and patient demographics. RESULTS: The incidence of PSD in our study cohort was 41%. Patients with PSD, although older than non-PSD patients (48 vs 37.5 y; P = .001), were similar with respect to admission Glasgow coma score (GCS) and injury severity score. Regression analysis revealed that age older than 55 years (odds ratio, 2.60; P = .037; 95% confidence interval, 1.1-6.4) and ventilator days (odds ratio, 1.14; P = .001; 95% confidence interval, 1.1-1.2) were significant independent risk factors for PSD. Interpretation of these odds ratios revealed that those patients older than age 55 had more than a 2.5-fold greater risk of PSD. The risk increased by 14% for every day a patient required intubation. There was no significant association between PSD and injury severity score, GCS, presence of medical comorbidities, or development of nosocomial pneumonia. CONCLUSIONS: PSD is a common occurrence in trauma patients. Age older than 55 years and ventilator days are independent risk factors for PSD. Injury severity, altered GCS upon arrival, comorbidities, and nosocomial pneumonia were not independent risk factors for PSD in our cohort. These results suggest that older patients with extended intensive care unit stays and ventilator requirements may benefit from early swallowing evaluation.

Design, development, and validation of a take-home simulator for fundamental laparoscopic skills: using Nintendo Wii for surgical training.

Assuring quality surgical trainees within the confines of reduced work hours mandates reassessment of educational paradigms. Surgical simulators have been shown to be effective in teaching surgical residents, but their use is limited by cost and time constraints. The Nintendo Wii gaming console is inexpensive and allows natural hand movements similar to those performed in laparoscopy to guide game play. We hypothesize that surgical skills can be improved through take-home simulators adapted from affordable off-the-shelf gaming consoles. A total of 21 surgical residents participated in a prospective, controlled study. An experimental group of 14 surgical residents was assigned to play Marble Mania on the Nintendo Wii using a unique physical controller that interfaces with the WiiMote controller followed by a simulated electrocautery task. Seven residents assigned to the control group performed the electrocautery task without playing the game first. When compared with the control group, the experimental group performed the task with fewer errors and superior movement proficiency (P < 0.05). The experimental group demonstrated increased ambidexterity with improvement in proficiency of the nondominant hand over time. In conclusion, the Nintendo Wii gaming device along with Marble Mania serves as an effective take-home surgical simulator.

Rapid disappearance of an endothelial ulceration in the left main coronary artery.

A case is presented of a 65-year-old male who presented with an acute anterior wall myocardial infarction. An initial coronary angiogram demonstrated an ulcerated atherosclerotic plaque in the left main coronary artery. After 48 h of aggressive medical therapy including a 2b3a glycoprotein blocking agent, repeat angiography demonstrated resolution of the ulcerated plaque. The process of atherosclerotic plaque rupture is of dynamic nature.