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  • 1
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    Online Resource
    Long-Term Evaluation of Autologous Chondrocyte Implantation : Minimum 7-Year Follow-Up
    SAGE Publications ; 2012
    In:  CARTILAGE Vol. 3, No. 4 ( 2012-10), p. 342-350
    Details
    In: CARTILAGE, SAGE Publications, Vol. 3, No. 4 ( 2012-10), p. 342-350
    Abstract: The purpose of this study was to report the clinical outcomes of autologous chondrocyte implantation (ACI) procedures performed by a single orthopedic surgeon at a minimum of 7 years follow-up. Methods: A retrospective review of prospectively collected data was performed on 29 patients who underwent ACI of the knee between the years of 1998 and 2003. Prospective data were collected to assess changes in standardized outcome measures preoperatively and 2, 4, and 7 years postoperatively. All patients enrolled in the study were also recruited to undergo physical examination when possible. Results: The final cohort consisted of 29 patients with a mean final follow-up time of 8.40 years (range = 7.14-10.88 years). Comparing preoperative scores to 7-year postoperative values, the mean International Knee Documentation Committee (IKDC) score improved from 39.80 to 59.24 ( P 〈 0.001), mean Tegner-Lysholm score increased from 48.07 to 74.17 ( P 〈 0.001), SF-12 physical score improved from 40.38 to 48.66 ( P 〈 0.001), and SF-12 mental score improved from 44.14 to 48.98 ( P 〈 0.05). Significant improvement occurred in Knee Injury and Osteoarthritis Outcome Score (KOOS) pain (56.03 to 80.36), symptoms (54.19 to 74.75), activities of daily living (72.01 to 85.90), sports (23.34 to 55.34), and quality of life (24.56 to 56.03) ( P 〈 0.001). In addition, 7-year postoperative scores were at or near levels seen at 2 years (mean = 2.16; range = 0.94-4.03 years) and 4 years (mean = 4.43; range = 2.16-5.88 years) postoperatively, reflecting durable improvement. Subjectively, on a scale of 1 to 10 (10 being completely satisfied), the mean postoperative satisfaction rate was 8.14. Additionally, 88.9% of the patients would elect to have this surgery again if the same problem was to occur in the contralateral joint. Conclusions: The results of ACI in patients who present with symptomatic, full-thickness chondral defects remain durable at a minimum of 7-year follow-up with persistent, high levels of patient satisfaction. Level of Evidence: Case series; Level of evidence, IV.
    Type of Medium: Online Resource
    ISSN: 1947-6035 , 1947-6043
    URL: Article
    DOI: 10.1177/1947603512439460
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2012
    detail.hit.zdb_id: 2515870-3
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  • 2
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    Improving Injection Accuracy of the Elbow, Knee, and Shoulder : Does Injection Site and Imaging Make a Difference? A Systematic Review
    SAGE Publications ; 2011
    In:  The American Journal of Sports Medicine Vol. 39, No. 3 ( 2011-03), p. 656-662
    Details
    In: The American Journal of Sports Medicine, SAGE Publications, Vol. 39, No. 3 ( 2011-03), p. 656-662
    Abstract: Background: Joint injections and aspirations are used to reduce joint pain and decrease inflammation. The efficacy of these injections is diminished when they are placed inadvertently in the wrong location or compartment. The purpose of this study was to determine whether the use of varying sites or imaging techniques affects the rate of accurate needle placement in aspiration and injection in the shoulder, elbow, and knee. Hypotheses: (1) Accuracy rates of different joint injection sites will demonstrate variability. (2) Injection accuracy rates will be improved when performed with concomitant imaging. Study Design: Systematic review of the literature. Methods: Studies reporting injection accuracy based on image verification were identified through a systematic search of the English literature. Accuracy rates were compared for currently accepted injection sites in the shoulder, elbow, and knee. In addition, accuracy rates with and without imaging of these joints were compared. Results: In the glenohumeral joint, there is a statistically higher accuracy rate with the posterior approach when compared with the anterior approach (85% vs 45%). Injection site selection did not affect accuracy for the subacromial space, acromioclavicular joint, elbow, or knee. The use of imaging improved injection accuracy in the glenohumeral joint (95% vs 79%), subacromial space (100% vs 63%), acromioclavicular joint (100% vs 45%), and knee (99% vs 79%). Conclusion: Injection accuracy rates are significantly higher for the posterior approach compared with the anterior approach for the glenohumeral joint. Similarly, the accuracy rates are also higher when imaging is used in conjunction with injection of the glenohumeral joint, subacromial space, acromioclavicular joint, and knee.
    Type of Medium: Online Resource
    ISSN: 0363-5465 , 1552-3365
    URL: Article
    DOI: 10.1177/0363546510390610
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2011
    detail.hit.zdb_id: 2063945-4
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  • 3
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    Factors Influencing Length of Stay after Elective Bowel Resection within an Enhanced Recovery Protocol
    SAGE Publications ; 2018
    In:  The American Surgeon Vol. 84, No. 7 ( 2018-07), p. 1240-1245
    Details
    In: The American Surgeon, SAGE Publications, Vol. 84, No. 7 ( 2018-07), p. 1240-1245
    Abstract: A multimodality approach to enhance recovery after bowel surgery is demonstrated to reduce complications and decrease patient length of stay (LOS). This study evaluates the factors that influence patient LOS within a formal enhanced recovery protocol. From January 2014 to December 2016, all consecutive patients admitted to one ward, who had undergone bowel resection and were enrolled in an enhanced recovery protocol, were evaluated prospectively. We entered every patient's data into the American College of Surgeons Risk Calculator (ACSRC) to compare predicted versus actual outcomes. Statistical analysis of clinical factors, patient participation, and outcomes compared with the overall LOS was performed. Of 670 bowel resections performed during the study period, a total of 127 (19%) patients met the criteria and were analyzed for comorbidities, type of surgery, complications, and participation in recovery protocols. The median length of stay (mLOS) for all patients was 4.0 days (1.8–24.6 days). Factors influencing mLOS included laparoscopic versus open surgery (P = 0.006), COPD (P = 0.003), missing 24 hours of ambulation (P 〈 0.001), use of patient-controlled analgesia (P = 0.011), and diagnosis of insulin-dependent diabetes mellitus (P = 0.041). Increasing the use of morphine equivalents (MEs) increased mLOS beyond the ACSRC estimate (P = 0.003). Developing a major complication increased mLOS by 8.5 times the ACSRC estimate. Conclusion: A multimodality approach to enhance surgical recovery after bowel surgery decreases the LOS. The surgical approach, participation in ambulation, insulin-dependent diabetes mellitus, and COPD influenced the overall LOS. Increasing use of morphine equivalents and developing a complication increased mLOS beyond the ACSRC preoperative risk estimates.
    Type of Medium: Online Resource
    ISSN: 0003-1348 , 1555-9823
    URL: Article
    DOI: 10.1177/000313481808400746
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2018
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  • 4
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    Improving Opioid Prescribing Post-Discharge for Trauma Patients With Rib Fractures: Factors in Prevention of Prolonged Use and Dependency
    SAGE Publications ; 2022
    In:  The American Surgeon Vol. 88, No. 7 ( 2022-07), p. 1459-1466
    Details
    In: The American Surgeon, SAGE Publications, Vol. 88, No. 7 ( 2022-07), p. 1459-1466
    Abstract: Rib fracture (RF) pain management provides analgesia while reducing opioids. We postulated: (1) Prescriber factors affect opiate duration, and (2) lidocaine infusion curtails dependency. Materials and Methods Retrospective study of RF patients undergoing multimodal analgesia at ACS-verified Level 1 Trauma Center April 2018-February 2020. Exclusions: age 〈 18 y/o, GCS 〈 14, hospital length of stay (LOS) 〈 3 d, 〈 3 RF, ventilator support, injury-related mortality, disclosed/discoverable, acute/chronic opiate Rx within 90 days preadmission, substance abuse, patient inaccessible via Controlled Substance Monitoring Database (CSMD), and/or not using opioids in-/post-hospitalization. CSMD queried regarding opioid prescriptions filled by cohort. Cohort variable analysis performed on SPSS Version 27sf (Armonk, NY: IBM Corp). Results 153 patients included – 113 (74%) stopped opiates by 30 days post-discharge (NORx30), 40 (26%) continued beyond 30 days (Rx+). No significant differences in age, gender, ISS, number of RF, bilaterality, flail chest, and discharge disposition. Significant differences included hospital LOS (7.62 NORx30 vs. 10.22 Rx+, p = .02), number of prescribers (1.73 NORx30 vs. 2.98 Rx+, p 〈 .01), average MME/day during initial 30 days post-discharge (36.7 ± 17 NORx30 vs. 45.4 ± 30.2 Rx+, p = .03), and number of pills (49 ± 38 NORx30 vs. 120 ± 85 Rx+, p 〈 .01). Patients who received lidocaine infusion (LIDO+) had lower MME/day prescribed (32.24 ± 19.9, p = .03), were younger (61.2 vs. 65.6, p 〈 .01), had more RFs (7.1 vs. 6.05, p = .03), and shorter LOS (7.71 vs 10.2, p = .01). Discussion Prescriber attention to MME/day and number of pills dispensed affects opioid dependency. We recommend 35–40 MME/day with 50 pill/month limit prescribed by a single provider monitoring patient and CSMD. Early LI offers post-discharge opioid cessation advantage.
    Type of Medium: Online Resource
    ISSN: 0003-1348 , 1555-9823
    URL: Article
    DOI: 10.1177/00031348221082275
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2022
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  • 5
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    Does Alcohol Intoxication Alter the Assessment and Outcome of “Observation-Status” Trauma Patients?
    SAGE Publications ; 2001
    In:  The American Surgeon Vol. 67, No. 11 ( 2001-11), p. 1110-1112
    Details
    In: The American Surgeon, SAGE Publications, Vol. 67, No. 11 ( 2001-11), p. 1110-1112
    Abstract: We assessed the effect of blood alcohol concentration (BAC) on the evaluation, outcome, and hospital charges of our observation-status trauma patient population. We conducted a retrospective study over 18 months; any patient initially admitted with 〈 24-hour observation status, Glasgow Coma Score of 15, and negative drug screen was eligible. Patients were divided on the basis of BAC (BAC+ = 〉 80 mg/dL; BAC- = 〈 80 mg/dL). Two hundred twenty-six patients were observed during the study (2765 admissions). For the 66 BAC+ patients (range 90–392 mg/dL) there was a strong male predominance. There was no difference in diagnostic evaluation schema, delayed diagnosis, complications, cost, or conversions to full admission between the groups. We conclude that evaluation, outcome, and charges of observation trauma patients are the same regardless of BAC. Intoxication did not mask injury; therefore BAC+ patients do not require observation on the sole basis of intoxication if their evaluation is otherwise negative.
    Type of Medium: Online Resource
    ISSN: 0003-1348 , 1555-9823
    URL: Article
    DOI: 10.1177/000313480106701117
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2001
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  • 6
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    Influence of Preoperative Computed Tomography on Patients Undergoing Appendectomy
    SAGE Publications ; 2001
    In:  The American Surgeon Vol. 67, No. 11 ( 2001-11), p. 1017-1021
    Details
    In: The American Surgeon, SAGE Publications, Vol. 67, No. 11 ( 2001-11), p. 1017-1021
    Abstract: The frequency of computed tomography (CT) ordered by emergency department physicians at our facility was noted to sharply increase in early 1998 after a New England Journal of Medicine (NEJM) article recommending routine CT in patients with suspected appendicitis. Numerous studies have proven the accuracy of CT for detecting acute appendicitis; however, the most appropriate use of CT continues to evolve. We sought to evaluate the effect of increased CT use on negative appendectomy rate and perforation rate at our institution and to better delineate in whom CT is most beneficial. CT use was retrospectively evaluated and found to sharply increase in April 1998. The authors then reviewed the medical records of 291 consecutive patients undergoing appendectomy 18 months before and after the NEJM article. Patients with interval appendectomies and those 12 years of age or younger were excluded. The remaining 226 patients constitute the study cohort. The study cohort was then divided into the two groups. The “Discriminate Group” consists of patients from the 18 months before the NEJM article impact and a period of selective CT use. The “Indiscriminate Group” comprises patients from the subsequent 18 months in which CT use was substantially higher and routinely obtained before surgical evaluation. After chart review an objective clinical score (Alvarado score) was assigned to each patient. Comparison was then made between the two groups on perforation rate, negative appendectomy rate, time delay to operating room, and Alvarado score. Additionally patients undergoing preoperative CT were compared with those without CT. These groups were also evaluated on the basis of negative appendectomy rate, perforation rate, and delay to the operating room. CT in patients with abdominal symptoms associated with appendicitis increased from 188 in the Discriminate Group to 1035 in the Indiscriminate Group. In the Discriminate Group the negative appendectomy rate was 15.1 per cent. After the indiscriminate use of CT the negative appendectomy rate decreased to 13.3 per cent, but this was not significant. Males experienced a decrease in the negative appendectomy rate from 10.1 to 6.9 per cent, whereas the rate for females increased slightly from 21.3 to 22.9 per cent. Again we found no statistical significance in these changes. The overall perforation rate of 17.9 per cent in the first 18 months decreased to 13.3 per cent in the following 18 months but again was not statistically significant. The Alvarado scores between the Discriminate and Indiscriminate groups were 6.7 and 7.3, respectively ( P = 0.02). Patients with preoperative CT averaged 11.9 hours to the operating room compared with 6.5 hours for those without CT ( P = 0.03). Use of CT did not decrease perforation rate but did globally reduce negative exploration ( P = 0.05). This reduction in negative exploration however was not discriminated by sex. CT use in suspected acute appendicitis has greatly increased over the past several years. The dramatic increase in CT use at our institution has not resulted in dramatic decreases in negative appendectomy rate or statistically significant changes in perforation rate. The optimal use of CT in evaluating patients with suspected appendicitis has yet to be determined. Surgical consultation should be obtained early to avoid indiscriminate tests.
    Type of Medium: Online Resource
    ISSN: 0003-1348 , 1555-9823
    URL: Article
    DOI: 10.1177/000313480106701101
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2001
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  • 7
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    Improving Outcomes in Elective Colorectal Surgery: A Single-institution Retrospective Review
    SAGE Publications ; 2016
    In:  The American Surgeon Vol. 82, No. 4 ( 2016-04), p. 325-330
    Details
    In: The American Surgeon, SAGE Publications, Vol. 82, No. 4 ( 2016-04), p. 325-330
    Abstract: Our hospital, a Tennessee Surgical Quality Collaborative (TSQC) member, adopted a statewide colorectal care bundle intended to reduce surgical site infections (SSI) in elective colorectal cases. The bundle includes proper antibiotics/dosing, normoglycemia, normothermia, supplemental oxygen six hours postoperatively, and early enteral nutrition. A single-institution retrospective study of our National Surgical Quality Improvement Program (NSQIP) database for the rates of SSI before and after the colorectal bundle. We compared our SSI rates to TSQC hospitals as well as NSQIP datasets. Because of low case numbers in the NSQIP data, National Healthcare Safety Network (NHSN) data collected at our institution was used to compare our colorectal SSI before and after our colorectal bundle. From January 2010 to December 2011, 188 patients underwent nonemergent colorectal surgery in the NSQIP data. Of these, 5.4 per cent (10/188) developed superficial SSIs. During this same time, the rate of the TSQC superficial SSI was 7.1 per cent and NSQIP was 7.8 per cent. From January 2013 to October 2014, after the colorectal bundle started, 76 patients in NSQIP underwent nonemergent colorectal surgery. Of these, 6.5 per cent (5/76) developed superficial SSI, compared with 5.5 per cent in TSQC and 5.5 per cent in NSQIP. NHSN data showed a prebundle rate of 11 per cent and a postbundle rate of 3.5 per cent ( P 〈 00.1, χ 2 ). After adopting a colorectal bundle aimed at reducing SSIs, we did not improve our SSI rates in NSQIP; however, our NHSN data demonstrated considerable improvement. Differences in data collection may affect SSI rates, and ultimately “quality” based reimbursement. Implementation of the bundle did improve outcomes in colorectal surgery.
    Type of Medium: Online Resource
    ISSN: 0003-1348 , 1555-9823
    URL: Article
    DOI: 10.1177/000313481608200417
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2016
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  • 8
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    Treatment With Oral Versus Intravenous Acetaminophen in Elderly Trauma Patients With Rib Fractures: A Prospective Randomized Trial
    SAGE Publications ; 2020
    In:  The American Surgeon Vol. 86, No. 8 ( 2020-08), p. 926-932
    Details
    In: The American Surgeon, SAGE Publications, Vol. 86, No. 8 ( 2020-08), p. 926-932
    Abstract: Rib fractures are common injuries among traumatically injured patients, and elderly patients with rib fractures are at increased risk for adverse events and death. The purpose of this study was to determine if oral Per os (PO) acetaminophen is as effective as intravenous (IV) acetaminophen in treating the pain associated with rib fractures. Methods We performed a single-center, randomized, placebo-controlled, double-blinded study. Trauma patients who were ≥65 years old and had ≥1 rib fracture were included in this study. Patients were randomized into IV acetaminophen and oral placebo (n = 63) or IV placebo and oral solution acetaminophen (n = 75) groups. The primary outcome was a mean reduction in pain score at 24 hours, and secondary outcomes included opioid use, intensive care unit (ICU) length of stay (LOS), hospital LOS, hospital mortality, the difference in incentive spirometry, and development of pneumonia. Results Among the 138 patients included, there was no statistically significant difference between the 2 study groups in a mean reduction in pain score at 24 hours after injury (PO: 3.24, IV: 2.49; P = .230). Opioid pain medication use was equivalent between groups ( P = .212), and there was no significant difference in hospital mortality rate between groups ( P = .827). There was no statistically significant difference in ICU LOS, hospital LOS, or development of pneumonia. Discussion In elderly trauma patients (age ≥65 years) with 1 or more rib fractures, PO acetaminophen is equivalent to IV acetaminophen for pain control, with no difference in morbidity or mortality. Oral acetaminophen should be preferentially used over IV acetaminophen when treating the elderly trauma patient with rib fractures.
    Type of Medium: Online Resource
    ISSN: 0003-1348 , 1555-9823
    URL: Article
    DOI: 10.1177/0003134820940268
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2020
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  • 9
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    Pneumatosis Intestinalis in Patients Receiving Tube Feeds
    SAGE Publications ; 2017
    In:  The American Surgeon Vol. 83, No. 8 ( 2017-08), p. 825-831
    Details
    In: The American Surgeon, SAGE Publications, Vol. 83, No. 8 ( 2017-08), p. 825-831
    Abstract: Pneumatosis intestinalis (PI) identified on computed tomography (CT) suggests an underlying pathology including bowel ischemia. Patients receiving tube feeds can develop PI, potentially requiring surgical intervention. We identify clinical factors in PI to predict those that may be safe to observe versus those that need immediate intervention. We retrospectively reviewed patients from a single institution from 2008 to 2016 with CT findings of PI and an enteric feeding tube. Patients who had not received tube feeds within one week of the CT were excluded. We analyzed clinical, operative, and outcome data to differentiate benign from pathologic outcomes. P values 〈 0.05 were set as significant. Forty patients were identified. We classified 24 as benign (no intervention) and 16 as pathologic (requiring intervention). A pathologic outcome was demonstrated for free fluid on CT [odds ratio (OR) = 5.00, confidence interval (CI) 1.23-20.30, P = 0.03)], blood urea nitrogen (BUN) elevation (OR = 8.27, CI 1.53-44.62, P = 0.01), creatinine (Cr) elevation (OR = 5.00, CI 1.27-19.62, P = 0.02), BUN/Cr ratio 〉 30 (OR = 8.57, CI 1.79-40.98, P = 0.006), and vomiting/ feeding intolerance (OR = 9.38, CI 1.64-53.62, P = 0.01). Bowel function within 24 hours of the CT, bowel dilatation (small ≥ 3 cm; large ≥6 cm), and lactic acidemia were not significant. Peritonitis was only seen in pathologic states, but this did not reach statistical significance (P = 0.06). This represents the largest single-center retrospective analysis of tube feeding-induced PI to date. The presence of free fluid on CT, BUN and Cr elevation, BUN/Cr 〉 30, vomiting/feeding intolerance and peritonitis were predictive of a pathologic etiology of PI.
    Type of Medium: Online Resource
    ISSN: 0003-1348 , 1555-9823
    URL: Article
    DOI: 10.1177/000313481708300830
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2017
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  • 10
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    Continued Relevance of Initial Temperature Measurement in Trauma Patients
    SAGE Publications ; 2022
    In:  The American Surgeon Vol. 88, No. 3 ( 2022-03), p. 424-428
    Details
    In: The American Surgeon, SAGE Publications, Vol. 88, No. 3 ( 2022-03), p. 424-428
    Abstract: Hypothermia occurs in 30-50% of severely injured trauma patients and is associated with multiple metabolic derangements and worsened outcomes. However, hypothermia continues to be under-diagnosed which leads to inadequate triage and treatment in trauma patients. Our study set out to determine if hypothermia is an independent predictor of mortality in trauma patients. Methods We retrospectively reviewed data of all trauma activation patients over a 5-year period. Data were collected on patient demographics, initial core temperature, Glasgow Coma Scale (GCS) on presentation, and injury severity score (ISS). Patients were then stratified into groups based on presenting temperature, ISS, and GCS. Outcomes compared were mortality, blood products received, and intensive care unit (ICU) length of stay. Correlations and logistic regression were used to test the hypotheses. Results Survival and temperature data were reviewed on 15,567 patients. Initial temperature was not significantly associated with ICU length of stay or blood products transfused ( P = .21 and P = .08, respectively). However, odds ratio of mortality in hypothermic patients ( 〈 35°C) compared to normothermic patients (35-39°C) was 3.95 (95% CI 2.90-5.41). When controlling for GCS and ISS, separately, temperature remained an independent predictor of mortality. Conclusions Hypothermia is an independent risk factor for mortality in trauma patients. It remains crucial to obtain accurate presenting temperatures in trauma patients in order to triage and treat hypothermia. Based on our data, obtaining core temperatures and rapidly treating hypothermia continues to be a vital part of the secondary survey of trauma patients.
    Type of Medium: Online Resource
    ISSN: 0003-1348 , 1555-9823
    URL: Article
    DOI: 10.1177/00031348211048833
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2022
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