ABSTRACT
INTRODUCTION: Approximately 300 000 hip fractures occur annually in the USA in patients >65 years old. Early intervention is key in reducing morbidity and mortality. Our institution implemented a collaborative hip fracture protocol, streamlining existing processes to reduce time to OR (TTO) and hospital length of stay (LOS). Our aim was to determine if this protocol improved these outcomes. STUDY DESIGN: We conducted a retrospective cohort study using our level-1 trauma center's trauma registry, comparing outcomes for patients >60 years old with isolated hip fractures pre-and post-hip protocol implementation in May 2018. Our primary outcomes were TTO and in-hospital mortality. Secondary outcomes included LOS and postoperative complications. Univariate analysis was done using chi-square and T-test. RESULTS: We identified 176 patients with isolated hip fractures: 69 post- and 107 pre-protocol. Comparing post- to pre-protocol, TTO decreased by 18hrs (39 vs 57h; P = .013) and patients had fewer postoperative complications (9 vs 23%; P = .016) despite post-protocol patients being more likely to have diabetes (42 vs 27%, P < .05), elevated BMI (22 vs 25; P < .001), and to be current smokers (9 vs 2%; P < .05). LOS and in-hospital mortality also decreased (11 vs 20d; P = .312, 4.3 vs 7.5%; P = .402). Post-protocol patients were more likely to go to the OR within 24hrs of presentation (39 vs 16%; P < .001) and to go straight from ED to OR (32 vs 4%; P < .001). CONCLUSION: TTO, LOS, and postoperative complications for isolated hip fracture patients were lower post-protocol. Though not all statistically significant, this trend indicates that the protocol was helpful in improving hip fracture outcomes but may require further improvement and institution-wide education.
ABSTRACT
INTRODUCTION: Glomus tumors (GTs) are rare neoplasms that originate from the modified smooth muscle cells of glomus bodies and occasionally arise from visceral primary sites. All previously reported primary hepatic GTs were benign. Here we report the first malignant primary hepatic GT. PRESENTATION OF CASE: Our patient is a 60-year-old male who presented with weight loss, early satiety, night sweats, and abdominal distention. Imaging demonstrated a large mass abutting the stomach, duodenum, and head of the pancreas, exerting mass effect on the portal vein and inferior vena cava. Biopsy results were deemed nondiagnostic after extensive review at multiple academic institutions. We performed a caudate lobe resection, antrectomy, and Bilroth II gastrojejunostomy that required skeletonization of much of the periportal vascular anatomy and the repair of multiple venotomies due to the tumor's adherence to the inferior vena cava. Histopathologic evaluation revealed morphologic and immunohistochemical findings consistent with a malignant GT, and next-generation sequencing using a targeted panel revealed an inactivating TP53 mutation. DISCUSSION: This case presented both a surgical and histopathologic challenge, requiring meticulous operative technique for resection in conjunction with a combination of characteristic morphologic features and immunohistochemical staining for diagnosis. Sequencing results using a targeted panel add to the limited GT genomic literature. CONCLUSION: While rare, it is important to consider malignant GTs in the differential diagnosis for heterogeneous liver masses. Close follow-up will be essential to monitor our patient's clinical course and expeditiously pursue any further interventions.
