Showing papers by "Robert F. Lavery published in 2014"
TL;DR: GSW violence remains a significant public health problem, with escalating mortality and health costs, and policy makers must understand that the determinants of firearm violence reside at the community level.
Abstract: BACKGROUND: Perceptions of violence are too often driven by individual sensational events, yet "routine" gunshot wound (GSW) injuries are largely underreported. Previous studies have mostly focused on fatal GSW. To illuminate this public health problem, we studied the health care burden of interpersonal GSW at a Level I trauma center. METHODS: Retrospective analysis of GSW injuries (excluding self and law enforcement) treated from January 2000 to December 2011. Data collected included body regions injured, number of wounds per patient, and mortality. Costs were calculated using Medicare cost-charge modifiers. Geographic information system mapping of the incident location and home addresses were determined to identify hot spot locations and the characterization of those neighborhoods. RESULTS: A total of 6,322 patients were treated. There were significant increases in patients with three or more wounds (13-22%, p Language: en
67 citations
TL;DR: Primary repair or delayed anastomosis following DCL is feasible, with complication rates similar to SL when successful fascial closure is completed on the first post-DCL reoperation, however, if fasful closure is not possible on the second operation, patients should be treated with a stoma.
Abstract: BACKGROUND The optimal management of colonic injuries in patients requiring damage-control laparotomy (DCL) remains controversial. Primary repair, delayed anastomosis, or colostomy have all been advocated after DCL; however, some evidence suggests that colon-related complications are increased in patients with delayed primary fascial closure. We hypothesized that increased complications associated with colonic repair/anastomosis occur in those patients undergoing DCL who cannot achieve fascial closure on their initial reoperation. METHODS A retrospective review of adult patients sustaining colonic injury between 2001 and 2010 who survived four or more days was performed. Patients were classified as having all their abdominal injuries managed during a single laparotomy (SL), DCL with complete treatment and fascial closure on the initial reoperation (DCL1), or DCL with open abdomen for more than two operations (DCL2). Data on postoperative complications and need for intervention were collected. Kruskal-Wallis analysis of variance was used to determine differences between groups. RESULTS A total of 317 patients with colonic injuries were treated during the study period; 70 were excluded, leaving 247 patients as the study group. The group was primarily male (93%), with a mean age of 29 years. Ninety-two percent sustained penetrating injuries. Injury Severity Scores (ISSs) were similar between groups. Mean (SD) time for the DCL1 was 1.2 (0.6) days after injury and 4.1 (2.8) days for DCL2. Inability to achieve fascial closure by the time of the initial reoperation was associated with significant increase in intra-abdominal abscess (SL, 17% vs. DCL1, 31% vs. DCL2, 50%; p < 0.001) and anastomotic leaks (SL, 2% vs. DCL1, 2% vs. DCL2, 19%; p < 0.001). CONCLUSION Primary repair or delayed anastomosis following DCL is feasible, with complication rates similar to SL when successful fascial closure is completed on the first post-DCL reoperation. However, if fascial closure is not possible on the second operation, patients should be treated with a stoma because there is an eightfold increase in the incidence of anastomotic leak. We believe that these data indicate that there is a single opportunity for reestablishing colonic continuity following DCL. LEVEL OF EVIDENCE Therapeutic study, level IV.
29 citations
TL;DR: Trauma patients with B-VAP have a similar mortality but greater morbidity than those with VAP alone, and the number of units of red blood cell concentrates received is the most significant risk factor for developing B- VAP.
Abstract: Background: Ventilator-associated pneumonia (VAP) is a well-known complication of mechanical ventilation in severely injured patients. A subset of patients with VAP develop an associated bacteremia (B-VAP), but the risk factors, microbiology, morbidity, and mortality in this group are not well described. The goal of this study was to examine the incidence, predictors, and outcome of B-VAP in adult trauma patients. Methods: We conducted a retrospective review of trauma patients who developed VAP or B-VAP from January 2007 to December 2009 at a single, university-affiliated medical center. Ventilator-associated pneumonia was defined as a clinician-documented instance of VAP together with confirmed positive respiratory cultures (bronchoalveolar lavage [BAL] fluid specimen with ≥104 colony forming units (CFU)/mL or tracheal aspirate with moderate-to-many organisms and polymorphonuclear neutrophils [PMN]). Bacteremia associated with VAP (B-VAP) was defined as the blood culture of an organism that matc...
22 citations