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Steven J Lawrence

Publications and source records attributed to Steven J Lawrence.

13 recordsLinked to original sources
PubMed2006

Surveillance for vancomycin-resistant enterococci: type, rates, costs, and implications.

OBJECTIVE: To evaluate 2 active surveillance strategies for detection of enteric vancomycin-resistant enterococci (VRE) in an intensive care unit (ICU). DESIGN: Thirty-month prospective observational study. SETTING: ICU at a university-affiliated referral center. PATIENTS: All patients with an ICU stay of 24 hours or more were eligible for the study. INTERVENTION: Clinical active surveillance (CAS), involving culture of a rectal swab specimen for detection of VRE, was performed on admission, weekly while the patient was in the ICU, and at discharge. Laboratory-based active surveillance (LAS), involving culture of a stool specimen for detection of VRE, was performed on stool samples submitted for Clostridium difficile toxin detection. RESULTS: Enteric colonization with VRE was detected in 309 (17%) of 1,872 patients. The CAS method initially detected 280 (91%) of the 309 patients colonized with VRE, compared with 25 patients (8%) detected by LAS; colonization in 4 patients (1%) was initially detected by analysis of other clinical specimens. Most patients with colonization (76%) would have gone undetected by LAS alone, whereas use of the CAS method exclusively would have missed only 3 patients (1%) who were colonized. CAS cost Dollars 1,913 per month, or Dollars 57,395 for the 30-month study period. Cost savings of CAS from preventing cases of VRE colonization and bacteremia were estimated to range from Dollars 56,258 to Dollars 303,334 per month. CONCLUSIONS: A patient-based CAS strategy for detection of enteric colonization with VRE was superior to LAS. In this high-risk setting, CAS appeared to be the most efficient and cost-effective surveillance method. The modest costs of CAS were offset by the averted costs associated with the prevention of VRE colonization and bacteremia.

Cost-Benefit Analysis↗
PubMed2005

Open calcaneal fractures: assessment and management.

Open calcaneal fractures are obscure fractures. Typically, these injuries result in a high-energy, polytraumatized patient population. Initial management consists of irrigation and debridement. Secondary forms of management continue to evolve. High-energy fracture subtypes and severe soft tissue injuries portend an unsatisfactory outcome, despite appropriate management. Standards for the type and timing of treatment have not been established.

Calcaneus↗
PubMed2004

Free tissue transfer to a difficult wound of the lower extremity.

Amputation is still recommended to patients with a difficult wound of the lower extremity because limb salvage after free tissue transfer in these patients remains uncertain. During the past 3 years, the authors studied 15 patients (11 men, 4 women; age range, 17-71 years) with difficult wounds of the lower extremities who had free tissue transfers for limb salvage. Eleven patients had an extensive soft-tissue defect (nearly the entire length) of the legs or feet, and 4 had a composite-tissue defect of the legs or feet that required bony reconstruction. A total of 16 free tissue transfers (13 free muscle flaps, 2 osteomusculocutaneous flaps, and 1 adipofascial flap) were performed in 15 patients (1 patient had bilateral transfers). A saphenous vein loop or graft was used in 3 patients and a subsequent bone graft was done in 2 patients. Free tissue transfer was accomplished successfully in 14 patients (93%). Limb salvage was achieved ultimately in 12 patients (80%) who were able to ambulate during a 36-month follow-up. The authors believe that free tissue transfer for limb salvage in any patient with a difficult wound of the lower extremity is still a worthwhile procedure and should be attempted if possible. Meticulous preoperative preparation and intraoperative execution combined with the use of innovative microsurgical techniques are the keys for success.

Adolescent↗
PubMed2004

Open calcaneal fractures.

Open calcaneal fractures can be managed with an array of treatment techniques and result in a wide range of outcomes. Due to the fracture's relative obscurity, the optimal form of intervention remains controversial. Consequently, treatment for these hindfoot fracture-disruptions continues to evolve. Timing of intervention may be a key factor in decreasing complication rates. The goals of open calcaneal fracture management include timely healing of the soft-tissue envelope without infection and maintenance of bony alignment. Unfortunately, restoration of joint congruence may be impossible. Unsatisfactory outcomes may result from neurogenic pain, infection, malunion, arthrosis, and bony impingement. Future advancements in treatment are anticipated and will depend on an improved understanding of this devastating orthopedic injury.

Calcaneus↗
PubMed2003

Reconstruction of through-and-through gunshot wounds to the feet with free gracilis muscle flaps.

Reconstruction of a through-and-through gunshot wound (GSW) to the foot remains a challenging problem for plastic and orthopedic surgeons, because it is difficult to achieve reliable soft tissue coverage of the foot while at the same time optimizing foot contour and weightbearing. In the past year, four patients with such an injury were treated with initial wound debridement and stabilization of the metatarsals, followed by a free gracilis muscle transfer with a split-thickness skin graft. One patient also had a secondary iliac bone graft to the first metatarsal. All patients have completely healed wounds, are free of osteomyelitis, and have achieved an excellent contour and good ambulation of the foot without donor site problems. Thus, a free gracilis muscle transfer should be considered first for reconstruction of a through-and-through GSW to the foot, because it can provide reliable soft tissue coverage with excellent contour and minimal donor site morbidity.

Adolescent↗
PubMed2003

Evaluation and treatment of open calcaneal fractures: a retrospective analysis.

The primary evaluation and management of 47 consecutive patients with 48 open calcaneal fractures was retrospectively analyzed. The fractures were treated over a 7-year period. Forty-two fractures resulted from blunt trauma, and 6 followed penetrating trauma. The predominant mechanism of injury was a motor vehicle accident. Initial treatment consisted of emergent irrigation and debridement of the open wound with intravenous antibiotic prophylaxis. Most patients underwent a second debridement. More than two thirds of the wounds were >5 cm in length, degloving-type injuries, associated with a significant neurovascular deficit and/or required a free-tissue transfer. Internal fixation of the os calcis was undertaken in 40% of patients. In addition, >40% of patients sustained concomitant foot and ankle fractures. Two patients underwent below-the-knee amputations as primary treatment. Five patients required a free-tissue transfer. Complications included two infections and one below-the-knee amputation. Two deaths occurred due to unrelated causes. Treatment standards for the optimal management of open calcaneal fractures remain controversial. A better understanding of this complex injury will help determine suitable treatment strategies.

Adolescent↗
PubMed2002

An intervention to improve antibiotic delivery and sputum procurement in patients hospitalized with community-acquired pneumonia.

STUDY OBJECTIVES: To determine if an educational intervention targeting emergency department (ED) and medicine staff could successfully decrease the time to antibiotic delivery (door-to-drug delivery time [DDD]) for patients admitted through the ED with community-acquired pneumonia (CAP). DESIGN: Prospective, multidisciplinary team-based educational project. Demographics, outcomes, and processes of care including DDD and sputum procurement for patients with CAP were determined during a baseline period and compared to the same parameters for patients with CAP presenting after the educational intervention was administered to ED and medicine staff. SETTING: Barnes-Jewish Hospital, a large Midwest teaching institution affiliated with the Washington University School of Medicine. PATIENTS: Consecutive adult patients admitted through the ED with CAP. INTERVENTION: Multidisciplinary in-service education administered to ED physicians and nurses, and medicine housestaff, which emphasized the importance of rapid antibiotic delivery and procurement of preantibiotic expectorated sputum. RESULTS: Mean DDD improved from 413 to 291 min (p = 0.02), with more patients receiving antibiotics in the ED (46% vs 69%; adjusted odds ratio [OR], 2.3; 95% confidence interval [CI], 1.0 to 4.9). Sputum procurement improved from 11.5 to 25.4% (adjusted OR, 3.3; 95% CI, 1.1 to 9.9). There were no observed differences for inpatient mortality or length of stay. CONCLUSION: This multidisciplinary team intervention significantly improved the time to initiation of antibiotics and procurement of sputum for patients with CAP.

Adult↗
PubMedDate not supplied

Bioterrorism risk perceptions and educational needs of public health professionals before and after September 11, 2001: a national needs assessment survey.

The study objectives were to compare local public health professionals' bioterrorism risk perceptions, the extent of bioterrorism preparedness training, and to describe preferred methods for delivery of preparedness education in the United States. National needs assessments were conducted via a mailed survey to 3,074 local public health departments in October 2000 and November 2001. Compared to a survey conducted in October 2000, the perceived risk of a bioterrorism attack in the United States increased dramatically after September 11 (p < 0.0001); however, 57% of respondents believed one was unlikely to occur within their own community. Public health professionals perceive their own communities to be at low risk for a bioterrorism event. Ongoing, updated, standardized bioterrorism preparedness education is needed.

Bioterrorism↗