Risk factors for postoperative wound infections and prolonged hospitalization after ventral/incisional hernia repair.

PURPOSE: The purpose of this study was to identify predictive factors for postoperative surgical site infections (SSIs), and increased length of hospital stay (LOS) after ventral/incisional hernia repair (VIHR) using multi-center, prospectively collected data. STUDY DESIGN: Cases of VIHR from 2009 to 2010 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Using logistic regression, a prediction model utilizing 41 variables was developed to identify risk factors for postoperative SSIs, and increased LOS. Separate analyses were carried out for reducible and incarcerated/strangulated cases. RESULTS: A total of 28,269 cases of VIHR were identified, 25,172 of which met inclusion criteria. 18,263 cases were reducible hernias, and 6,909 cases were incarcerated/strangulated hernias. Our prediction model demonstrated that body mass index ≥30 kg/m(2), smoking, American Society of Anesthesiology (ASA) class 3, open surgical approach, prolonged operative times, and inpatient admission following VIHR were significant predictors of postoperative SSIs. In addition, risk factors associated with prolonged LOS included older age, African American ethnicity, history of alcohol abuse, ASA classes 3 and 4, poor functional status, operation within the last 30 days of the index operation, history of chronic obstructive pulmonary disease, congestive heart failure, and bleeding disorder, as well as open surgical approach, non-involvement of residents, prolonged operative times, recurrent hernia, emergency operation, and low preoperative serum albumin level. CONCLUSIONS: Obesity and smoking are modifiable risk factors for SSIs after VIHR, whereas a low serum albumin level is a modifiable risk factor for prolonged LOS. Addressing factors preoperatively might improve patient outcome, and reduce health care expenditures associated with VIHR. In addition, if feasible, the laparoscopic approach should be strongly considered.

Venous thrombosis incidence in burn patients: preliminary results of a prospective study.

There are few prospective data on the incidence of deep venous thrombosis (DVT) in burn patients. In an on-going prospective study, hospitalized burn patients 18 years or older with an expected hospital length of stay more than 72 hours were imaged with baseline venous duplex ultrasound of all extremities within the first 48 hours after admission and weekly until discharge. Patient demographics and clinical risk factors for DVT were assessed. At the time of submission, 40 patients met screening criteria, and 30 were enrolled. Ultrasound diagnosed seven patients with 11 acute DVT for an incidence of 23%. One pulmonary embolism was documented. DVT patients had a mean age of 49 +/- 23 years with an average TBSA burn of 15 +/- 4% compared with those without thrombosis with a mean age of 44 +/- 17 years (P = NS) and TBSA burn of 18 +/- 25% (P = NS). There were no statistically significant differences for DVT patients in terms of age, number of central line days, hospital length of stay, or TBSA burned. Given the preliminary findings of this small study, we believe that all hospitalized burn patients are at risk for DVT. On-going investigation will be helpful in defining level of risk and improved prevention strategies for thromboembolic complications in burn patients.

The utility of endovascular stents in the treatment of blunt arterial injuries.

BACKGROUND: The objective of this review is to evaluate our institutional experience with percutaneously placed vascular stents in multiply injured patients with blunt arterial injuries. METHODS: Patients were identified through our trauma registry from 9/95 through 12/99. All injuries were diagnosed by angiography. Palmaz and Wallstent prostheses were used. RESULTS: Six patients had blunt arterial injuries. Age ranged from 20 to 67 years (average, 45). Each patient had one or more stents placed. There were no immediate complications related to stent placement. There were no deaths or complications attributable to stent placement. All of the patients survived to leave the hospital. Follow-up ranged from 1 month to 2 years with no occlusion, stenosis, or stent malfunction. CONCLUSION: The use of interventional angiography and endovascular stenting is safe and efficacious in treating arterial injuries in certain circumstances.

Potential risk factors for deep venous thrombosis in burn patients.

Risk factors and prophylaxis for prevention of deep venous thrombosis (DVT) and pulmonary embolism remain controversial in burn patients. From January 1996 through June 1999, we reviewed all adult burn patients admitted to our burn center with the in-hospital diagnosis of DVT and assessed each affected patient for DVT risk factors. There were 8 symptomatic DVTs and 2 pulmonary embolisms detected in 327 adult burn patients (2.4% incidence). No DVT patient had the risk factors of morbid obesity, previous DVT, congestive heart failure, or neoplastic disease. One patient was older than 65 years. All of the DVTs occurred in veins draining a burned extremity. Seven of 8 patients had burn wound infections as complications. Burns on the extremity developing the DVT as well as the diagnosis of a burn wound infection were significant risk factors for DVT formation. These findings prompt us to consider routine screening for DVT in burn patients with these risk factors.

Necrotizing soft tissue infections: a surgical disease.

Despite advances in antibiotics and infection control practices necrotizing fasciitis is still a potentially lethal disease. We reviewed 37 patients with necrotizing fasciitis to identify prognostic factors indicating outcome. Overall mortality was 24 per cent. Mortality was significantly increased for elderly patients. Solid-organ transplant recipients also represented a subset of patients with increased mortality. Most infections were polymicrobial. There was no Clostridium perfringens cultured. Rapid diagnosis and treatment with surgical debridement remains the cornerstone of therapy.

Blunt thoracic aortic injury: delayed or early repair?

OBJECTIVE: To evaluate the safety and benefit of delayed repair of blunt thoracic aortic injury (BTAI) in trauma patients with multiple injuries and to assess the financial impact of delayed repair. METHODS: A retrospective review of charts was performed on 55 patients with the diagnosis of BTAI from January 1, 1992, through December 31, 1997, at our Level I trauma center. Early repair was defined as operative repair of BTAI within 12 hours of admission. Seven patients were excluded from analysis due to death before BTAI diagnosis (two deaths were from rupture in the emergency department and five were from massive blunt trauma without rupture). The groups were compared by using a McNemar chi2 test, for which p less than or equal to 0.05 is significant. RESULTS: There were 30 patients in the early repair (ER) group repaired at 5.3+/-2.4 hours, and 18 patients in the delayed repair (DR) group repaired at 8.5 days (range, 17 hours-67 days). There were no significant differences between the ER and DR groups in age (37+/-18 years vs. 41+/-19 years), Injury Severity Score (39+/-15 vs. 45+/-14), intensive care unit days (12+/-14 days vs. 18+/-11 days), hospital length of stay (21+/-19 days vs. 28+/-14 days), or mortality rates (7% vs. 6%). There was a trend toward longer lengths of stay in the DR group. Most DR patients required beta-blocker therapy and/or other antihypertensives for systolic BP more than 120 mm Hg during admission. There were no deaths from aortic rupture in either group. By using financial data that was available from July of 1994 onward, we performed a subset analysis of the direct costs associated with BTAI. Total direct and variable direct costs for patients undergoing delayed repair were over two times the costs for early repair patients (p < 0.05). CONCLUSION: The management of trauma patients with multiple injuries requires prioritization of injuries so that the outcomes from these injuries can be optimized. Although delayed aortic repair was safely practiced in this series, there was not an obvious outcome benefit to delayed repair. The patients undergoing late repair required increased attention to hemodynamics, and there was a trend toward increased length of stay. In addition, analysis of the costs associated with delayed repair demonstrated a twofold increase in the direct costs for delayed repair compared with early repair.

Tissue coexpression of LBP and CD14 mRNA in a mouse model of sepsis.

BACKGROUND: Lipopolysaccharide binding protein (LBP) markedly increases the sensitivity of immune cells to LPS and CD14 expression correlates with cellular responsiveness to LPS. LBP gene expression can be induced in multiple organs following injury and CD14 upregulation on monocytes correlates with the infection and mortality rates in severely injured patients. We sought to determine the time-course induction of LBP and CD14 gene expression following experimental peritonitis. MATERIAL AND METHODS: BALB/c mice were subjected to laparotomy alone or laparotomy with cecal ligation and puncture and treated with Imipenem. At serial time points, animals were sacrificed and tissues harvested for isolation of RNA and protein. LBP, CD14, and cytokine mRNAs were analyzed by Northern blot analysis and TaqMan fluorescent quantitative RT-PCR. RESULTS: LBP and CD14 mRNA levels were significantly increased in all three organs from CLP mice compared to sham-operated mice. IL-1 mRNA levels increased in all three organs following CLP with significantly higher levels found in the lungs compared to the kidney and liver. No significant differences were noted in local TNF mRNA levels. CONCLUSIONS: LBP, CD14, and IL-1 mRNA levels are induced concurrently in the lung, kidney, and liver after cecal ligation and puncture. Given the synergistic affect of LBP and CD14 in potentiating LPS-induced production of inflammatory cytokines and the hypothesized role of such cytokines in the etiology of MSOF following injury and sepsis, our findings suggest a mechanism by which these organs may be rendered more susceptible to a "second hit" from endotoxemia after initial injury.

Trauma service cost: the real story.

OBJECTIVE: The objective was to define and characterize the costs associated with trauma care at a level I trauma center. Once the costs were identified, attending physician-led teams were designed to reduce costs within each cost center. SUMMARY BACKGROUND DATA: The location and magnitude of the costs on a trauma service remain largely unknown. Focused cost-containment strategies remain difficult to implement because the expected return on these interventions is unknown. METHODS: Cost center data were reviewed for the 40 major DRGs admitted for the first 6 months of the fiscal years 1996 and 1997. Data were obtained from the hospital finance department using the Transition Systems Inc. accounting system. We focused on variable direct costs, those that vary with patient volume (e.g., staff nursing expense and medical/surgical supplies). To address issues of inflation, pay raises, and changing costs, a proxy value was created for 1996 and costs were held constant for the 1997 calculation. The major services that constitute cost centers identified in the system were nursing, surgical, pharmacy, laboratory, radiology, and emergency services. Attendings were assigned to develop and oversee customized cost-reduction modalities specific to each cost center. The cost-reduction modalities used to achieve significant savings were as follows: nursing, case management approach focusing on early discharge; surgical, meeting with operating room (OR) purchasing to modify expensive behavior patterns; pharmacy, integrating clinical pharmacist with direct attending support; laboratory, enforcing protocol for lab draws; radiology, increasing the use of emergency room ultrasound and accepting outside x-rays; and emergency services, 24-hour in-house attending staff to reduce emergency room time. The surgical and emergency services cost centers predominately generate costs by the length of time care is delivered in that area. RESULTS: For each period, data from 363 patients were compared. Mean length of stay decreased between the study periods from 8.72 to 7.06 days, while the average injury severity score was unchanged. Together, these cost centers constituted 87.4% of the total cost of care delivered. Significant cost reduction was achieved in all six variable cost centers: nursing (24%), surgical (5%), pharmacy (57%), laboratory (27), radiology (7%), and emergency (36). The mean cost per case was reduced by 25%. CONCLUSIONS: Identification of the true cost centers and directed attending surgeon involvement are essential to the development and implementation of a successful cost-reduction process.

Consequences of high-dose steroid therapy for acute spinal cord injury.

OBJECTIVE: High-dose Solu-Medrol (Upjohn, Kalamazoo, Mich) therapy has become standard care in the management of acute spinal cord injury (ASCI). This study attempts to define the adverse effects that Solu-Medrol therapy has on these patients. DESIGN: Retrospective review with historical control. MATERIALS AND METHODS: From May 1990 to April 1994, all patients with ASCI admitted within 8 hours of injury received high-dose Solu-Medrol per the National Acute Spinal Injury Study (NASCIS-2) protocol. Their demographic and outcome parameters were compared with those of a group admitted from March 1986 to December 1993 with an associated ASCI who received no steroid therapy. MEASUREMENTS AND MAIN RESULTS: Steroid therapy was associated with a 2.6-fold increase in the incidence of pneumonia and an increase in ventilated and intensive care days. However, it was associated with a decrease in duration of rehabilitation and had no significant impact on other outcome parameters, including mortality. CONCLUSIONS: Although the NASCIS-2 protocol may promote early infectious complications, it has no adverse impact on long-term outcome in patients with ASCIs.

Blunt force injury of the abdominal aorta.

OBJECTIVE: To review the clinical presentation, diagnosis, and management of injury to the abdominal aorta after blunt force trauma. DESIGN: This study was a retrospective review. RESULTS: A total of 5,676 patients were admitted to the University of Michigan Medical Center with traumatic injury. Seven had injuries to the abdominal aorta after a blunt force mechanism. Five patients had operative repair of the aortic injury, of which four involved orthotopic graft placement and one had an extra-anatomic bypass. Two patients had the aortic injury repaired by endovascular stent placement in the angiography suite. One patient died, and lower extremity amputations were performed in three patients. CONCLUSIONS: Surgical repair of abdominal aortic injury is preferable for the unstable patient or those with threatened extremities. In the stable patient with viable limbs, treatment with radiologic placement of endovascular stents may provide a nonoperative option for management.

Generation of therapeutic T-lymphocytes after in vivo tumor transfection with an allogeneic class I major histocompatibility complex gene.

In an effort to enhance the generation of tumor-reactive T-lymphocytes for adoptive immunotherapy, we examined the effects of in vivo transfection of an allogeneic major histocompatibility complex (MHC) class I gene (H-2Ks) of the poorly immunogenic B16BL6 (BL6) melanoma of H-2b origin. Cells from lymph nodes (LNs) draining these tumors after transfection were assessed in adoptive immunotherapy experiments for tumor reactivity after sequential activation with anti-CD3 monoclonal antibody (mAb) followed by culture in interleukin (IL)-2. H-2Ks lipofection of progressively growing BL6 subcutaneous tumors did not reduce tumorigenicity. However, in vivo lipofection of BL6 by intratumor inoculation or admixture of H-2Ks cDNA/liposome complexes and tumor cells prior to inoculation resulted in enhanced development of sensitized T-lymphocytes in the draining LN, which mediated the reduction of the numbers of established 3-day parental lung metastases in six of six experiments. In subsequent studies, in vivo transfection of BL6 with naked H-2Ks cDNA was found to be more effective than lipofection in eliciting sensitized T-cells in the draining LN. Admixture of liposomes alone or control plasmid DNA did not have an adjuvant effect similar to H-2Ks cDNA. Relative tumor transfection efficiency was assessed by an indirect assay with the chloramphenicol acetyltransferase (CAT) reporter gene. BL6 tumors were more efficiently transfected by intratumor inoculation with naked cDNA compared with lipofection. In summary, in vivo allogenization of the poorly immunogenic BL6 tumor resulted in enhanced generation of therapeutic T-cells effective in the treatment of parental tumor.

Adoptive immunotherapy of murine intracerebral tumors with anti-CD3/interleukin-2-activated tumor-draining lymph node cells.

We have recently identified a source of potent antitumor effector cells that can be generated by the sequential culture of tumor-draining lymph node (TDLN) cells with anti-CD3 monoclonal antibody (anti-CD3) and interleukin-2 (IL-2). In this study the therapeutic efficacy of these immune effector cells in the treatment of experimentally induced brain metastases was evaluated. With use of the MCA 205 sarcoma, TDLN cells were harvested from syngeneic B6 mice 9-10 days after subcutaneous inoculation with 10(6) tumor cells. These TDLN cells were activated in vitro by exposure to anti-CD3 for 2 days followed by expansion with IL-2 (10 U/ml) for 3 days. In a neutralization assay, anti-CD3/IL-2-activated cells admixed with MCA 205 tumor cells at an effector/tumor cell ratio of 10 effectively suppressed the growth of tumor cells after intracranial inoculation. In mice with 3-day established brain tumors, multiple intracranial administrations of activated TDLN cells resulted in prolonging survival for which a 50-fold increase in number of cells given intravenously did not. However, the therapeutic effectiveness of systemically (intravenously) administered activated TDLN cells in the treatment of 3-day brain tumors was achieved if tumor-bearing mice were sublethally whole-body irradiated (500 cGy). In two experiments irradiated animals that were not treated or received therapy with IL-2 alone had median survival times (MSTs) of 16 and 17 days, respectively. By contrast, in irradiated animals that received TDLN cells plus IL-2, MST was not reached beyond the observation period of 90 days.(ABSTRACT TRUNCATED AT 250 WORDS)