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Biomedical subjects

Jorge L Rodriguez

Publications and source records attributed to Jorge L Rodriguez.

18 recordsLinked to original sources
PubMed2005

Selective management of blunt hepatic injuries including nonoperative management is a safe and effective strategy.

BACKGROUND: The justification and preference for operative versus nonoperative management of hepatic injuries caused by blunt trauma remains ambiguous. This review assesses the outcome of operative and nonoperative management of liver injury after blunt trauma. METHODS: We retrospectively reviewed the demographics, severity of injury, severity of liver injury, associated concomitant injuries, management scheme, and outcome of patients with documented hepatic injury from 1993 to 2003. RESULTS: The overall mortality rate was 9.4%, with 3.7% caused by the liver injury itself. Fifty-nine percent (330 of 561) of liver injuries were of low severity (grades I and II), with an overall mortality rate of 6.6% caused by concomitant injuries and liver-related mortality of 0%. Forty-one percent (231 of 561) of liver injuries were high-severity injuries (grades III, IV, and V). Mortality for nonoperative management of high-severity liver injuries was 2.2%. If operative intervention was required because of hemodynamic instability or concomitant injuries then the mortality rate was significantly higher at 30%. Forty-two of the 378 (11%) liver injuries treated nonoperatively required an adjunctive procedure for successful management. CONCLUSIONS: Selective management of liver injuries presented a low liver-related mortality rate. Low-grade injuries can be managed nonoperatively with excellent results. High-grade injuries can be managed nonoperatively, if operative intervention is not required for hemodynamic instability or associated injuries, with a low mortality. In these patients, adjunctive procedures will be required selectively for successful nonoperative management of high-grade liver injuries. High-grade injuries requiring operative management because of hemodynamic instability or concomitant injuries continue to have significantly higher mortality.

Adult↗
PubMed2005

Profitable versus unprofitable expansion of trauma and critical care surgery.

BACKGROUND: The American Association for the Surgery of Trauma has proposed that the specialty of trauma and critical care include emergency surgery. We assessed whether this change will have an impact on the financial challenges that this specialty confronts, including inadequate reimbursement for efforts exerted. METHODS: Over a 2-year period, we collected financial data on 6 trauma and critical care surgeons. Three included emergency surgery as part of their practice, but no private elective component. The other 3 included both emergency surgery and a private elective component. RESULTS: Trauma and critical care surgeons who had included emergency surgery but no private elective component had significantly lower charges (5,941,482 US dollars vs 9,209,535 US dollars), collections (1,439,913 US dollars vs 2,973,319 US dollars), generated relative value units (50,440 vs 80,327), generated reimbursement per relative value units (28.55 US dollars vs 37.02 US dollars), and margins (0.20 US dollars vs 1.48 US dollars) than their counterparts who had an elective surgery component. CONCLUSION: The addition of emergency surgery did not improve the financial viability of trauma and critical care as a specialty. Without significant hospital or governmental financial support, the only viable financial option is to develop a substantial private practice that cross-subsidizes the practice of trauma and critical care. The appropriate professional bodies should incorporate changes in work processes that will allow the specialty to survive professionally but also financially.

Critical Care↗
PubMed2005

Physician extenders impact trauma systems.

BACKGROUND: The implementation of revised surgical resident work hours has led many teaching hospitals to integrate health care extenders into the trauma service. We undertook this review to assess the effectiveness of these individuals in meeting the goals of the work hour restrictions and whether they impact other hospital and patient outcomes. METHODS: During the year 2002, we integrated two nurse practitioners into the trauma service of a teaching hospital. We prospectively collected data a year before (2001), during (2002), and a year after (2003) the integration that included number of admissions, hospital length of stay, intensive care stay, floor length of stay, mortality, direct cost per case, and weekly resident work hours on 44 residents at all levels. RESULTS: After the incorporation of physician extenders, we observed statistically significant reductions in floor, intensive care unit, and overall hospital lengths of stay. Patient mortality and cost per patient remained unchanged. Furthermore, we were able to obtain compliance with the Accreditation Council for Graduate Medical Education requirements for residency work hour limitations, as the average number of hours worked per resident on the trauma service decreased from 86 hours to 79 hours per week. CONCLUSION: As graduate medical education becomes ever more regulated, physician extenders can be successfully integrated into busy academic Level I trauma centers. This integration positively impacts patient flow and resident work hours without altering patient outcomes or direct hospital cost.

Academic Medical Centers↗
PubMed2005

Trauma/critical care surgeon: a specialist gasping for air.

BACKGROUND: In the last 10 years, trauma/critical care has become less attractive because of the decreasing surgical caseload, the nocturnal work hours, and the economics of the practice. Nevertheless, during the same period, the number of verified trauma centers has significantly increased. This study assesses the economic drive behind this dichotomy. METHODS: Over a 1-year period, we collected financial data on 1,907 trauma patients for both Level I trauma centers and trauma/critical care surgeons. Financial data, including payor source, cost, reimbursement, margin, and reimbursement-to-charge and reimbursement-to-direct cost ratios, were calculated. RESULTS: For commercial- and government-insured patients, the reimbursement-to-direct cost ratio was 2-and 35-fold greater, respectively, for the trauma centers than for the trauma/critical care surgeons. For uninsured patients, the addition of local government funds allowed the trauma center to cover direct cost with no margin. In contrast, even with the addition of supplemental salary dollars from the institution, for every dollar in direct cost generated by the trauma/critical care surgeons in caring for uninsured patients, they recovered 55 cents, or a loss of 45 cents per direct cost dollar spent. CONCLUSION: The economic dichotomy that exists between trauma centers and trauma/critical surgeons is significant. It drives institutional growth and, at the same time, discourages surgeons from entering the subspecialty. As physician reimbursement decreases and the number of uninsured patients increases, this economic dichotomy will amplify. Over the next decade, without a significant adjustment, the subspecialty is in danger of extinction.

Career Choice↗
PubMed2005

Damage control orthopaedics: evolving concepts in the treatment of patients who have sustained orthopaedic trauma.

In some groups of polytrauma patients, particularly those with chest injuries, head injuries, and those with mangled extremities, early total care of major bone fractures may be potentially harmful. Delaying all orthopaedic surgery, however, is also not always the best approach. In these situations, damage control orthopaedics, which emphasizes the stabilization and control of the injury rather than repair will add little additional physiologic insult to the patient and is a treatment option that should be considered.

Fracture Fixation↗
PubMed2005

Cirrhosis and trauma: a deadly duo.

It has been previously reported that trauma patients with cirrhosis undergoing emergency abdominal operations exhibit a fourfold increase in mortality independent of their Child's classification. We undertook this review to assess the impact of cirrhosis on trauma patients. We reviewed the records of patients from 1993 to 2003 with documented hepatic cirrhosis and compared them to a 2:1 control population without hepatic cirrhosis and matched for age, sex, Injury Severity Score (ISS), and Glasgow Coma Score (GCS). Demographic, severity of injury, and outcome data were recorded. Student's t test and X2 were used for statistical analysis and a P < 0.05 was significant. Sixty-one patients had documented cirrhosis and were compared to 156 matched controls. Comparing the two groups demonstrates there was no difference in age, ISS, or GCS. Intensive care stay, hospital length of stay, blood requirements in the first 24 hours postinjury, and mortality (33% vs 1%) was significantly greater in the trauma patients with cirrhosis. Fifty-five per cent of deaths in the cirrhosis group was due to sepsis, and, as the Child's class increases, so does the mortality (Child's A, 15%; B, 37%; and C, 63%). In 64 per cent of cirrhotics without an emergent abdominal operation, mortality was 21 per cent. In the 36 per cent of cirrhotics who had emergent abdominal operation, mortality was 55 per cent. Hepatic cirrhosis in trauma patients, regardless of severity of injury or the need for an abdominal intervention, is a poor prognostic indicator. The necessity of an abdominal operative intervention further amplifies this effect. Trauma and cirrhosis is, in fact, a deadly duo.

Abdominal Injuries↗
PubMed2004

Laryngotracheal injuries: does injury mechanism matter?

Laryngotracheal injuries are potentially lethal injuries whose diagnosis can be difficult. The purpose of this study was to delineate the effect of injury mechanism on the types of injury sustained and patient outcome. Patient records during a 7-year period were reviewed for injury mechanism, patient demographics, clinical presentation, patient evaluation, injury location, associated injuries, operative interventions, and outcome. Fifteen patients with laryngotracheal injuries were studied. Blunt injuries were more common (60%). Patient demographics, mortality, average length of stay, and Injury Severity Score were similar for both groups. Prevalent physical findings on examination included subcutaneous air (53%), hoarseness (47%), stridor (20%), and neck tenderness (27%). Diagnosis was confirmed by CT scan of the neck (66% blunt, 33% penetrating) or bronchoscopy (44% blunt, 66% penetrating). Injury location, patient disposition, and associated injures were the same for both groups. The most frequent operative intervention performed for both groups consisted of a primary airway repair via a collar incision within 8 hours of injury. Only patients with a laryngeal injury required concomitant tracheostomy regardless of mechanism. Blunt and penetrating neck injuries resulted in similar types of tracheal and laryngeal injuries. Anatomic location of the injury determined the need for tracheostomy. Regardless of mechanism, the overall outcome for patients with laryngotracheal injuries is good when injuries are recognized and treated expeditiously. A high level of suspicion must be maintained when evaluating all potential laryngotracheal injury patients irrespective of the mechanism of injury.

Adult↗
PubMed2003

Trauma alters alveolar effector cell apoptosis.

BACKGROUND: The lung's immune response to trauma is biphasic with an initial proinflammatory and a subsequent anti-inflammatory cytokine response that alters cell function. Apoptosis, programmed cell death, is regulated by cytokines, and alteration of this important cellular function has been associated with end-organ dysfunction. We hypothesize that the lung's immune response to trauma alters alveolar inflammatory cell apoptosis and may contribute to posttrauma pulmonary dysfunction. METHODS: Bronchoalveolar lavage specimens were obtained from trauma patients with an injury severity score of 16 or more compared with patients who underwent elective surgery. Interleukin (IL)-8 and IL-10 were measured in the supernatant. Apoptosis and HLA-DR expression were measured in the cellular content, and Pao(2)/Fio(2) ratios were calculated as a measure of pulmonary function. RESULTS: After trauma, the alveolar inflammatory cell population was composed primarily of neutrophils. Apoptosis was suppressed initially after injury but increased to control levels by 72 hours after injury in parallel to alveolar concentrations of IL-10. Levels of IL-8 remained elevated, and HLA-DR expression remained suppressed throughout the study period. Pao(2)/Fio(2) ratios demonstrated pulmonary dysfunction by 72 hours. CONCLUSION: The lung's biphasic cytokine response to injury significantly alters both alveolar inflammatory cell apoptosis and HLA-DR expression. The alteration of alveolar inflammatory cell apoptosis may be dependent on the local production of IL-10. A reduction in apoptosis immediately preceded the onset of clinically significant pulmonary dysfunction.

Adult↗
PubMed2003

Tertiary care centers: a strategy for fiscal survival.

BACKGROUND: Managed care organizations use a variety of payment strategies to contract for high-end tertiary services with academic healthcare centers. We assessed the financial outcome of these strategies and attempted to identify those that maintain a balance between cost and reimbursement. METHODS: Patients admitted with an Injury Severity Score > or =16, hospital charges > or =$100,000, and a managed care organization as the payer were evaluated. RESULTS: A fixed reimbursement contract decreased reimbursement by 28% and negatively impacted the margin by 215%. The addition of a stop-loss provision to a fixed reimbursement contract is the best strategy to share the risk between payer and provider. If the fixed reimbursement strategy continued, the negative impact to the margin would have been $36,984 per patient. CONCLUSIONS: Fixed reimbursement strategies shift all the risk to the academic healthcare center. If volume, severity of illness, or cost is not controlled, they negatively affect the financial outcomes. The addition of a stop loss at $100,000 of charges paid at 40% of the entire claim most equitably distributes risk between the academic healthcare center and the managed care organization. It also excludes the negative impact of increasing severity of illness and volume and should induce cost control.

Academic Medical Centers↗
PubMed2003

Prophylactic antibiotics adversely affect nosocomial pneumonia in trauma patients.

BACKGROUND: Little data are available regarding the impact that prolonged prophylactic antibiotic use (>48 hours) has on the development of nosocomial pneumonia. This retrospective study was conducted to assess the effect that prolonged prophylactic antibiotic use has on the development of nosocomial pneumonia and antibiotic use complications. METHODS: The records of patients who contracted nosocomial pneumonia during mechanical ventilation were retrospectively reviewed. These patients then were classified into two groups: those who received prolonged prophylactic antibiotics before the diagnosis of pneumonia and those who did not receive antibiotics. RESULTS: For the patients who received prolonged prophylactic antibiotics, the first pneumonia was diagnosed later, the causative organisms were more likely to be resistant or Gram-negative bacteria, and the incidence of antibiotic complications were two times greater than for patients who did not receive extended antibiotic prophylaxis. CONCLUSION: Justification for the use and duration of prolonged (>48 hours) prophylactic antibiotics requires careful reevaluation because this practice is associated with significant clinical complications that lead to increased use of patient resources, lengthened hospital stay, and higher cost.

Adult↗
PubMed2002

Is laparoscopic umbilical hernia repair with mesh a reasonable alternative to conventional repair?

BACKGROUND: Laparoscopic mesh repair has been advocated as treatment of choice for ventral hernias. The term "ventral hernia" refers to a variety of abdominal wall defects and laparoscopic papers have not reported defect specific analysis. The purpose of this study was to determine any advantages to laparoscopic mesh repair of umbilical hernias. METHODS: A retrospective review (January 1998 to April 2001) was made of patients undergoing umbilical hernia repair. Patients were categorized into three groups: laparoscopic repair with mesh, open repair with mesh, and open repair without mesh. Comparative analysis was performed. RESULTS: One-hundred and sixteen umbilical hernia repairs were performed in 112 patients: 30 laparoscopic mesh repairs, 20 open mesh repairs, and 66 open nonmesh repairs. The laparoscopic technique was used for larger defects and took more time with a trend toward fewer postoperative complications and recurrences. CONCLUSIONS: Laparoscopic umbilical hernia repair with mesh presents a reasonable alternative to conventional methods of repair.

Adolescent↗
PubMed2002

Systemic and pulmonary effector cell function after injury.

OBJECTIVE: Traumatic injury initiates a complex inflammatory response that is associated with end-organ dysfunction, immunosuppression, and the development of nosocomial infection. We hypothesize that the lungs of injured patients experience a unique inflammatory response to traumatic injury in which the ability of alveolar effector cells to respond to a bacterial challenge is impaired. DESIGN: Prospective, longitudinal comparative study. SETTING: The surgical intensive care unit of an ACS level I trauma center. PATIENTS: Forty consecutive multiple trauma patients requiring mechanical ventilation. MEASUREMENT: Blood and bronchoalveolar lavage fluid were collected on admission, 24, and 48 hrs postinjury. Interleukin (IL)-6, IL-8, and IL-10 were measured in each sample initially and after lipopolysaccharide stimulation by using an ex vivo model of whole blood and bronchoalveolar lavage fluid cellular contents. Five patients who underwent elective surgery formed a control group. MAIN RESULTS: Systemic and alveolar levels of IL-6, IL-8, and IL-10 increase dramatically after severe injury. Levels of IL-6 and IL-8 in trauma bronchoalveolar lavage fluid are significantly greater than those of the systemic circulation. Whereas whole blood up-regulates production of IL-6 and IL-8 in response to lipopolysaccharide, bronchoalveolar lavage fluid cellular contents do not. In contrast, bronchoalveolar lavage fluid and whole blood from injured patients contain similar amounts of IL-10 and both up-regulate IL-10 production in response to lipopolysaccharide. CONCLUSION: The lungs of injured patients experience a profound proinflammatory response to injury more severe than that of the systemic circulation. Within this setting, the ability of alveolar effector cells to respond to a bacterial challenge is diminished compared with that of systemic cells. As such, alveolar effector cell function after injury seems to be impaired, possibly explaining the high frequency of pulmonary infection among these patients.

Adult↗
PubMed2002

Increased IL-10 production and HLA-DR suppression in the lungs of injured patients precede the development of nosocomial pneumonia.

The incidence of nosocomial pneumonia (NP) among injured patients is substantial. We hypothesize that traumatic injury induces alterations in local organ effector cell function that may predispose the lungs of injured patients to infection. It is the objective of this study to compare the systemic and alveolar effector cell response to injury and assess the relationship these have to the development of NP. Peripheral blood and bronchoalveolar lavage fluid (BAL) were collected from 10 elective surgery patients (controls) and 16 multitrauma patients at 12, 36, and 60 h post-injury. Systemic and alveolar levels of IL-8 and IL-10 were measured. CD11b expression on peripheral blood neutrophils (PBN) and alveolar neutrophils (AN) and HLA-DR expression on peripheral blood monocytes (PBM) and alveolar macrophages (AM) were measured. Alveolar levels of IL-8 and IL-10 were significantly higher than systemic levels after injury. HLA-DR expression was reduced on both PBM and AM after injury but was lowest on the AM. Six of 16 patients (38%) developed NP (NP+). There were no differences in cytokine levels (IL-8 and IL-10) or effector cell phenotype (CD11b and HLA-DR expression) within the systemic circulation of NP+ and NP- patients. In contrast, NP+ and NP- patients differed significantly in alveolar cytokine levels and alveolar effector cell phenotype. IL-8 was significantly higher in BAL form NP+ patients at all time points after injury. Furthermore, alveolar levels of IL-10 decreased in NP- patients but increased in NP+ patients. In all patients, AM HLA-DR expression was significantly reduced from normal controls 12 h post-injury. In NP-patients, AM HLA-DR expression returned to normal 60 h post-injury, whereas in NP+ patients, expression remained suppressed. These findings identify distinct trends in local organ cytokine production and alterations in effector cell phenotype that precede NP. The persistence of reduced HLA-DR expression amidst increasing levels of IL-10 in NP+ patients suggest that cell-mediated immune function is being suppressed. As such, local organ immunosuppression may be responsible for the development of nosocomial pneumonia in injured patients.

Adult↗
PubMed2002

Epinephrine as a mediator of pulmonary neutrophil sequestration.

Neutrophil-mediated lung injury is a potential complication of trauma and sepsis. Concomitant with trauma and sepsis, there is an immediate and sustained systemic elevation of catecholamines including epinephrine. In the absence of trauma or sepsis, we examined whether epinephrine contributes to the accumulation of neutrophils in the lung. Eight- to 12-week-old male CF-1 mice were injected i.p. with 0.2 mL of normal saline or epinephrine (0.1-5.0 mg/kg). An unmanipulated control group was included to examine the stress of i.p. injection. Animals were sacrificed at predetermined time points, and lung and spleen were harvested. PMN accumulation was assessed by using a myeloperoxidase (MPO) assay, which is an indirect marker for neutrophil presence. Morphometric analysis of lung tissue was performed by a pathologist blinded to the groups. Increasing epinephrine doses resulted in a significantly increased accumulation of pulmonary neutrophils compared with normal saline. The stress of normal saline injection also resulted in a significantly greater pulmonary neutrophil accumulation than unmanipulated controls. The effects of epinephrine on pulmonary neutrophil accumulation were greatest at 2 h, but they were not significantly different from saline-injected controls by 12 h. These results correlated with histological analysis. There were no significant differences in spleen MPO activity between groups, suggesting an organ-specific mechanism of epinephrine-induced pulmonary neutrophil sequestration. In the absence of trauma, shock, or infection, epinephrine results in the accumulation of neutrophils in murine lungs. The finding that "injection stress" increased lung neutrophil sequestration suggests the possibility that this mechanism may be physiologically relevant. Thus, epinephrine release in trauma may set the stage for development of neutrophil-mediated acute lung injury.

Animals↗
PubMed2002

Laparoscopic ventral hernia repair: are there comparative advantages over traditional methods of repair?

Recent studies have noted advantages of laparoscopic over open repair of ventral hernias. Because few reports have involved comparison with traditional repair we report a comparison between laparoscopic and open approaches. We retrospectively reviewed the records of patients undergoing ventral hernia repair over a 28-month period. Patients were grouped into three categories: laparoscopic repair with mesh, open repair with mesh, and open repair without mesh. There were 295 ventral hernia repairs and there was no difference in age, gender, operative complications, or hospital stay between the groups. Mesh and defect size was greater in the laparoscopic group. The overall postoperative complication rate was greater in the open group with mesh. Yet when specific wound complications were analyzed there was no difference between the groups. Furthermore a death occurred in the laparoscopic group from an unrecognized bowel injury. The recurrence rate was greatest in the open repair without mesh group. Finally hospital cost was greatest in the laparoscopic group and third-party reimbursement was better for the open techniques. We were unable to demonstrate a significant advantage to laparoscopic ventral hernia repair. Although many patients with large fascial defects were well served with this approach it may not be a better option for these patients.

Adult↗
PubMedDate not supplied

Methamphetamine laboratory explosions: a new and emerging burn injury.

The proliferation of clandestine methamphetamine laboratories (meth labs) as a result of the growing popularity of the drug has resulted in an increasing incidence of burn injuries associated with laboratory accidents. We undertook this study to characterize these injuries. Fifteen consecutive patients were identified and case-matched by age and TBSA to 45 control subjects. Most meth lab patients were men, Caucasian, unemployed, and positive for polysubstance abuse. Resuscitation requirements were 1.8 times greater in these patients. There was a higher incidence of inhalational injury corresponding to higher intubation and tracheostomy rate and longer ventilator days among meth lab patients. The rate of nosocomial pneumonia, skin graft loss, and mortality were not different between the two groups. Meth lab injury is unique and requires more critical care resources. It also is associated with lack of insurance coverage and poor follow-up after injury. This injury has a significant impact not only on patients but also on the healthcare system.

Accidents↗