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Abraham V, Jardine D, Pasque C, Weller A, Osier C. Surgical team simulation: assessing milestones, identifying gaps and enhancing active learning in military surgical residents. BMJ Mil Health 2023:military-2023-002386. [PMID: 36931656 DOI: 10.1136/military-2023-002386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 03/11/2023] [Indexed: 03/19/2023]
Affiliation(s)
- Vivek Abraham
- Department of Orthopaedic Surgery, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA
| | - D Jardine
- Department of Otolaryngology, Naval Medical Center Camp Lejeune, Camp Lejeune, North Carolina, USA
| | - C Pasque
- Department of Orthopaedic Surgery, University of Oklahoma Medical Center, Oklahoma City, Oklahoma, USA
| | - A Weller
- Department of Orthopaedic Surgery, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA
| | - C Osier
- Department of Orthopaedic Surgery, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA
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Lucha PA, Wallace D, Pasque C, Brickhouse N, Olsen D, Styk S, Dortch M, Beckman WA. Surgical wound morbidity in an austere surgical environment. Mil Med 2010; 175:357-61. [PMID: 20486509 DOI: 10.7205/milmed-d-10-00049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Surgical wound morbidity was analyzed for a U.S. military field hospital deployed to the Republic of Haiti in support of Operation New Horizons 1998. The purpose of the analysis was to determine whether procedures performed in the field hospital had greater infectious risks as a result of the environment compared with historical reports for traditional hospital or clinic settings. Acceptable historical infection rates of 1.5% for clean surgical cases, 7.7% for clean contaminated cases, 15.2% for contaminated cases, and 40% for dirty cases have been noted. There were 827 operations performed during a 6-month period, with the majority of patients assigned American Society of Anesthesiologists (ASA) Physical Status Classification class I or II. The distribution of these cases was: 72% clean cases, 5% clean contaminated cases, 4% contaminated cases, and 19% dirty cases. The overall wound complication rate was 3.6%, which included 5 wound infections, 11 wound hematomas, 8 superficial wound separations, and 6 seromas. The infectious morbidity for clean cases, the index for evaluation of infectious complications, was 0.8%, well within the accepted standards. There were two major complications that required a return to the operating room: a wound dehiscence with infection in an orchiectomy and a postoperative hematoma with airway compromise in a subtotal thyroidectomy. There were no surgical mortalities. The infectious wound morbidity for operations performed in the field hospital environment was found to be equivalent to that described for the fixed hospital or clinic settings. No special precautions were necessary to ensure a low infection rate. The safety for patients undergoing elective surgical procedures has been established. Further training using these types of facilities should not be limited based on concerns for surgical wound morbidity.
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Affiliation(s)
- Paul A Lucha
- Department of Surgery, Naval Medical Center Porsmouth, 620 John Paul Jones Circle, Portsmouth, VA 23708-2197, USA
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Abstract
OBJECTIVE The purpose of this chapter is to review critically the existing studies on the epidemiology of pediatric wrestling injuries and to discuss suggestions for injury prevention and further research. DATA SOURCES Data were obtained from the sports medicine and science literature since 1951. Literature searches were performed using the National Library of Medicine, Pubmed, Medline, Grateful Med, Sports Sciences, SportsDiscus. Keywords used included "Wrestling, Wrestle, Wrestling Injuries, Fractures, and Dermatologic". MAIN RESULTS Only eight prospective or retrospective studies were found dealing with pediatric wrestling injuries and that provided sufficient information to allow the estimation of injury rates. Exposure-based injury rates were between 6.0 and 7.6 injuries per 1,000 athletic-exposures. Injury rates increased with age, experience, and level of participation. The head/spine/trunk was the body region that incurred the greatest frequency of injuries, followed by the upper and lower extremities. CONCLUSIONS There are several potential areas for decreasing injury risk in wrestlers, including equipment, coaching, officiating and training. However, informed decisions with regard to preventing injuries are dependent upon the quality of the basic epidemiological data available, and at this time, analyses of risk factors and potential preventive measures are lacking.
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Affiliation(s)
- Timothy E Hewett
- Cincinnati Children's Hospital Research Foundation, Cincinnati Children's Medical Hospital Center Sports Medicine Biodynamics Center, Ohio, USA
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Pasque C, Noyes FR, Gibbons M, Levy M, Grood E. The role of the popliteofibular ligament and the tendon of popliteus in providing stability in the human knee. J Bone Joint Surg Br 2003; 85:292-8. [PMID: 12678372 DOI: 10.1302/0301-620x.85b2.12857] [Citation(s) in RCA: 87] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Techniques for the selective cutting of ligaments in cadaver knees defined the static contributions of the posterolateral structures to external rotation, varus rotation and posterior tibial translation from 0 degrees to 120 degrees of flexion under defined loading conditions. Sectioning of the popliteofibular ligament (PFL) (group 1) produced no significant changes in the limits of the knee movement studied. Sectioning of the PFL and the popliteus tendon (femoral attachment, group 2) produced an increase of only 5 degrees to 6 degrees in external rotation from flexion of 30 degrees to 120 degrees (p < 0.001). Even when other ligaments were sectioned first (group 3), the maximum effect of the PFL was negligible. Our findings show that the popliteus muscle-tendon-ligament complex, lateral collateral ligament, and posterolateral capsular structures function as a unit. No individual structure alone is the primary restraint for the movements studied. Operative reconstruction should address all of the posterolateral structures, since restoration of only a portion may result in residual instability.
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Affiliation(s)
- C Pasque
- University of Cincinnati, Ohio 45219, USA
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Lucha PA, Wallace D, Pasque C, Brickhouse N, Olsen D, Styk S, Dortch M, Beckman WA. Surgical Wound Morbidity in an Austere Surgical Environments. Mil Med 2000. [DOI: 10.1093/milmed/165.1.13] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Paul A. Lucha
- Department of Surgery, Naval Medical Center Portsmouth, 620 John Paul Jones Circle, Portsmouth, VA 23708-2197
| | - Douglas Wallace
- Department of Surgery, Naval Medical Center Portsmouth, 620 John Paul Jones Circle, Portsmouth, VA 23708-2197
| | - Charles Pasque
- Department of Orthopedic Surgery, Naval Medical Center Portsmouth, 620 John Paul Jones Circle, Portsmouth, VA 23708-2197
| | - Neal Brickhouse
- 2nd Medical Battalion, 2n FSSG, Camp LeJeune, Jacksonville, NC 28542
| | - David Olsen
- Department of Anesthesia, Naval Medical Center Portsmouth, 620 John Paul Jones Circle, Portsmouth, VA 23708-2197
| | - Stan Styk
- Department of Nursing, Naval Medical Center Portsmouth, 620 John Paul Jones Circle, Portsmouth, VA 23708-2197
| | - Myra Dortch
- Department of Nursing, Naval Medical Center Portsmouth, 620 John Paul Jones Circle, Portsmouth, VA 23708-2197
| | - William A. Beckman
- Department of Surgery, Naval Medical Center Portsmouth, 620 John Paul Jones Circle, Portsmouth, VA 23708-2197
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Lucha PA, Wallace D, Pasque C, Brickhouse N, Olsen D, Styk S, Dortch M, Beckman WA. Surgical wound morbidity in an austere surgical environment. Mil Med 2000; 165:13-7. [PMID: 10658421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023] Open
Abstract
Surgical wound morbidity was analyzed for a U.S. military field hospital deployed to the Republic of Haiti in support of Operation New Horizons 1998. The purpose of the analysis was to determine if procedures performed in the field hospital had greater infectious risks as a result of the environment compared with historical reports for traditional hospital or clinic settings. Acceptable historical infection rates of 1.5% for clean surgical cases, 7.7% for clean contaminated cases, 15.2% for contaminated cases, and 40% for dirty cases have been noted. There were 827 operations performed during a 6-month period, with the majority of patients assigned American Society of Anesthesiologists Physical Status Classification class I or II. The distribution of these cases was: 72% clean cases, 5% clean contaminated cases, 4% contaminated cases, and 19% dirty cases. The overall wound complication rate was 3.6%, which included 5 wound infections, 11 wound hematomas, 8 superficial wound separations, and 6 seromas. The infectious morbidity for clean cases, the index for evaluation of infectious complications, was 0.8%, well within the accepted standards. There were two major complications that required a return to the operating room: a wound dehiscence with infection in an orchiectomy, and a postoperative hematoma with airway compromise in a subtotal thyroidectomy. There were no surgical mortalities. The infectious wound morbidity for operations performed in the field hospital environment was found to be equivalent to that described for the fixed hospital or clinic settings. No special precautions were necessary to ensure a low infection rate. The safety for patients undergoing elective surgical procedures has been established. Further training using these types of facilities should not be limited based on concerns for surgical wound morbidity.
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Affiliation(s)
- P A Lucha
- Department of Surgery, Naval Medical Center Portsmouth, VA 23708-2197, USA
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Kollef MH, Vlasnik J, Sharpless L, Pasque C, Murphy D, Fraser V. Scheduled change of antibiotic classes: a strategy to decrease the incidence of ventilator-associated pneumonia. Am J Respir Crit Care Med 1997; 156:1040-8. [PMID: 9351601 DOI: 10.1164/ajrccm.156.4.9701046] [Citation(s) in RCA: 234] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
The purpose of this study was to determine the impact of a scheduled change of antibiotic classes, used for the empiric treatment of suspected gram-negative bacterial infections, on the incidence of ventilator-associated pneumonia and nosocomial bacteremia. Six hundred eighty patients undergoing cardiac surgery were evaluated. During a 6-mo period (i.e., the before-period), our traditional practice of prescribing a third generation cephalosporin (ceftazidime) for the empiric treatment of suspected gram-negative bacterial infections was continued. This was followed by a 6-mo period (i.e., the after-period) during which a quinolone (ciprofloxacin) was used in place of the third-generation cephalosporin. The incidence of ventilator-associated pneumonia was significantly decreased in the after-period (n = 327) compared with the before-period (n = 353) (6.7 versus 11.6%; p = 0.028). This was primarily due to a significant reduction in the incidence of ventilator-associated pneumonia attributed to antibiotic-resistant gram-negative bacteria (0.9 versus 4.0%; p = 0.013). Similarly, we observed a lower incidence of bacteremia attributed to antibiotic-resistant gram-negative bacteria in the after-period compared with the before-period (0.3 versus 1.7%; p = 0.125). These data suggest that a scheduled change of antibiotic classes can reduce the incidence of ventilator-associated pneumonia attributed to antibiotic-resistant gram-negative bacteria.
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Affiliation(s)
- M H Kollef
- Department of Internal Medicine, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri 63110, USA
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Kollef MH, Sharpless L, Vlasnik J, Pasque C, Murphy D, Fraser VJ. The impact of nosocomial infections on patient outcomes following cardiac surgery. Chest 1997; 112:666-75. [PMID: 9315799 DOI: 10.1378/chest.112.3.666] [Citation(s) in RCA: 202] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
STUDY OBJECTIVE To evaluate the relationship between nosocomial infections and clinical outcomes following cardiac surgery, and to identify risk factors for the development of nosocomial infections in this patient population. DESIGN Prospective cohort study. SETTING Barnes-Jewish Hospital, St. Louis, a university-affiliated teaching hospital. PATIENTS Six hundred five consecutive patients undergoing cardiac surgery. INTERVENTIONS Prospective patient surveillance and data collection. MAIN OUTCOME MEASURES Occurrence of nosocomial infections, multiorgan dysfunction, hospital mortality, and risk factors for the acquisition of nosocomial infections. RESULTS One hundred thirty-one (21.7%) patients acquired at least one nosocomial infection following cardiac surgery. Four independent risk factors for the development of a nosocomial infection were identified: the duration of mechanical ventilation, postoperative empiric antibiotic administration, the duration of urinary tract catheterization, and female gender. Thirty (5.0%) patients died during their hospitalization. The mortality rate of patients acquiring a nosocomial infection (11.5%) was significantly greater than the mortality rate of patients without a nosocomial infection (3.2%) (odds ratio [OR]=4.0; 95% confidence interval [CI]=2.7 to 5.8; p<0.001). Multiorgan dysfunction was found to be the most important independent determinant of hospital mortality (adjusted OR=23.8; 95% CI=13.5 to 42.1; p<0.001) along with the aortic cross-clamp time (adjusted OR=2.3; 95% CI=1.7 to 3.0; p=0.002) and severity of illness as measured by APACHE II (acute physiology and chronic health evaluation) (adjusted OR=1.1; 95% CI=1.1 to 1.2; p=0.019). Ventilator-associated pneumonia, clinical sepsis, female gender, the cardiopulmonary bypass time, and severity of illness were identified as independent risk factors for the development of multiorgan dysfunction. Among hospital survivors, patients acquiring a nosocomial infection had longer hospital lengths of stay compared to patients without a nosocomial infection (20.1+/-13.0 days vs 9.7+/-4.5 days; p<0.001). CONCLUSIONS Nosocomial infections, which are common following cardiac surgery, are associated with prolonged lengths of hospitalization, the development of multiorgan dysfunction, and increased hospital mortality. These data suggest potential interventions for the prevention of nosocomial infections following cardiac surgery that could substantially improve patient outcomes and decrease medical care costs.
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Affiliation(s)
- M H Kollef
- Department of Internal Medicine, Pulmonary and Critical Care, Washington University School of Medicine, St. Louis, MO 63110, USA.
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Kollef MH, Wragge T, Pasque C. Determinants of mortality and multiorgan dysfunction in cardiac surgery patients requiring prolonged mechanical ventilation. Chest 1995; 107:1395-401. [PMID: 7750337 DOI: 10.1378/chest.107.5.1395] [Citation(s) in RCA: 121] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVES To identify characteristics associated with mortality and the development of multiorgan dysfunction in patients who had undergone cardiac surgery and required prolonged mechanical ventilation, ie, > 48 h. DESIGN A prospective cohort study. SETTING Barnes Hospital, St. Louis, an academic tertiary care center. PATIENTS OR OTHER PARTICIPANTS A total of 107 consecutive patients undergoing cardiac surgery and requiring prolonged mechanical ventilation. INTERVENTIONS Prospective patients surveillance and data collection. MAIN OUTCOME MEASURES ICU mortality and multiorgan dysfunction. RESULTS Among 472 consecutive patients admitted to the cardiac surgery ICU following surgery, 107 (22.7%) required prolonged mechanical ventilation. Twenty-one of these patients (19.6%) died during their hospitalization. In a logistic-regression analysis, the development of an organ system failure index (OSFI) of 3 or greater was the only characteristic independently associated with ICU mortality (p < 0.001). The occurrence of an antibiotic-resistant infection (adjusted odds ratio [AOR] = 6.1, 95% confidence interval [CI] = 2.5 to 14.6 p = 0.006), an aortic cross-clamp time equal to or greater than 1.25 h (AOR = 3.9, CI = 2.3 to 6.8, p = 0.016), the development of ventilator-associated pneumonia (AOR = 3.6, CI = 2.4 to 5.3, p < 0.001), and an APACHE III score equal to or greater than 30 (AOR = 3.1, CI = 1.8 to 5.3, p = 0.036) were independently associated with the development of an OSFI of 3 or greater. CONCLUSIONS These data confirm that acquired multiorgan dysfunction is the best predictor of mortality in patients requiring prolonged mechanical ventilation following cardiac surgery. Additionally, they identify potential determinants of multiorgan dysfunction and suggest possible interventions for its reduction in this patient population.
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Affiliation(s)
- M H Kollef
- Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA
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