Access and reattachment of biliary tree anomaly through Roux-en-Y hepaticojejunostomy: A case report.

The right posterior segmental duct (RPSD) draining into the cystic duct is exceedingly rare. Ligation of the cystic duct in proximity to the junction of an aberrant right hepatic duct after a cholecystectomy can lead to life threatening complications. The present case study reveals a severed anomalous RPSD and subsequent Roux-en-Y hepaticojejunostomy procedure employed to fix biliary anomaly.

Quality of life assessment for patients undergoing irreversible electroporation (IRE) for treatment of locally advanced pancreatic cancer (LAPC).

BACKGROUND: IRE is a non-thermal ablative modality that has been shown to be safe and efficacious in LAPC and liver tumors, but few studies have shown its effects on patients' (QOL). The goal of this study is to evaluate quality-of-life (QOL) before and after irreversible electroporation (IRE) therapy for treatment of locally advanced pancreatic carcinoma (LAPC). METHODS: Between 11/2014 and 12/2016, patients scheduled for IRE therapy for LAPC were offered QOL questionnaires (EORTC QLQ-C30 V2.0) before surgery and 1,3 and 6-months after surgery. Descriptive statistics, one-way ANOVA and effect-size calculations were used in analysis of the 15 modules. RESULTS: Eight-four prospective patients were enrolled with a median age of 59.08 years (range 27.38-75.72) all who completed 6 months QOL surveys. Global health status scale showed lower average score at 3 and 6 months(p = 0.001). Symptoms scales constipation and insomnia showed higher averages at 3 months (p = 0.007 and p = 0.003 respectively), while dyspnea had higher average at 6 months (p < 0.001). Finally, changes were noted with worse diarrhea symptoms scale at 1 and 3 months (p < 0.001). Otherwise all QOL side effects were normalized at 3 months after IRE. CONCLUSIONS: The preponderance of symptoms at 3-6 months, symptom profile, and the use of additional therapy on majority of patients suggests other interrelated clinical factors influenced results (e.g. chemotherapy toxicity). This demonstrates that IRE therapy does not adversely affect QOL in the short term in patients with LAPC.

Evaluating the Regulatory Immunomodulation Effect of Irreversible Electroporation (IRE) in Pancreatic Adenocarcinoma.

BACKGROUND: Irreversible electroporation (IRE) has been demonstrated as an effective local method for locally advanced (stage 3) pancreatic adenocarcinoma. Immune regulatory T cells (Tregs) induce immunosuppression of tumors by inhibiting patients' anti-tumor adaptive immune response. This study aimed to evaluate the immunomodulation effect of IRE to identify an ideal time point for potential adjuvant immunotherapy. METHODS: This study prospectively evaluated an institutional review board-approved study of patients undergoing either in situ IRE or pancreatectomy. Patient blood samples were collected at different time points (before surgery [preOP] and on postoperative day [POD] 1, POD3, and POD5). Peripheral blood mononuclear cells (PBMCs) were isolated and evaluated for three different CD4 + Treg subsets (CD25 + CD4 +, CD4 + CD25 + FoxP3 +, CD4 + CD25 + FoxP3 -) by flow cytometry and analyzed for median fold change (MFC) between each two consecutive time points (MFC = log2(T2/T1)). RESULTS: The study analyzed 15 patients with in situ IRE (n = 11) or pancreatectomy (PAN) (n = 4). In both groups, CD25 + CD4 + Tregs decreased on POD1 followed by a steady increase in pancreatectomy, whereas the trend in the IRE group reversed between D3 and D5 (MFC: IRE [- 0.01], PAN [+ 0.39]). For each period, CD4 + CD25 + FoxP3 + Tregs showed the most dramatic inverse effect, with D3 to D5 showing the most change (MFC: IRE [- 0.18], PAN [+ 0.39]). Also, CD4 + CD25 + FoxP3 - Tregs showed an inverse effect between D3 and D5 (MFC: IRE [- 0.25], PAN [+ 0.49]). Altogether, the Treg trend was inversely affected by the in situ IRE procedure, with the greatest cumulative significant change for all three Treg subsets between D3 and D5 (MFC ± SEM: IRE [- 0.24 ± 0.05], PAN [+ 0.37 ± 0.02]; p = 0.016). CONCLUSIONS: The study data suggest that in situ IRE procedure-mediated Treg attenuation between POD3 and POD5 can provide a clinical window of opportunity for potentiating clinical efficacy in combination with immunotherapy.

Evaluation of Probe Angles for Synchronous Waveform 915-MHz Microwave Ablation.

BACKGROUND: The purpose of this study is to compare the ablation performance between a synchronous microwave ablation (MWA) system and a commercially available asynchronous system in ex vivo bovine liver and evaluate the efficacy of ablation at varying entrance angles. MATERIALS AND METHODS: Two 915-MHz MWA systems were used in bench top ex vivo bovine livers with various conditions (synchronous versus asynchronous). Using synchronous technology ablations to liver, kidney, or lung at angles of 0, 15, 30, and 90° were evaluated. RESULTS: Synchronous and asynchronous MWA systems created mean ablation zone volumes of 26.4 and 15.8 cm3, 62.9 and 45.4 cm3, 90.8 and 56.4, and 75.7 and 54.8 cm3 with single, double (2 microwave probes in use simultaneous) (2 cm spacing), and triple (three probes in use simultaneously) (2 cm and 3 cm spacing) antennae configurations, respectively; adjusted P-values ≤ 0.006. Ablation defects were similar across all groups when evaluated for entrance angle. Specifically, when comparing 0-degree angle to all other angles, achieved zones of ablation (ZA) were similar (mean ± standard deviation for 0-degree versus all other angles: 8.72 ± 4.84 versus 9.38 ± 4.11 cm2, P = 0.75). The use of the long-tip probe resulted in a statistically significant increase in the achieved ZA when compared to the short tip probe (10.9 ± 4.3 versus 6.5 ± 2.4, respectively; P = 0.01). CONCLUSIONS: Newly developed synchronous microwave technology creates significantly larger ablation zones when compared to an existing asynchronous commercially available system. The angle of approach does not affect the resulting ZA. This is clinically relevant as true 0-degree angle is often difficult to obtain.

Deficiency of tumor suppressor Merlin facilitates metabolic adaptation by co-operative engagement of SMAD-Hippo signaling in breast cancer.

The NF2 gene encodes the tumor and metastasis suppressor protein Merlin. Merlin exerts its tumor suppressive role by inhibiting proliferation and inducing contact-growth inhibition and apoptosis. In the current investigation, we determined that loss of Merlin in breast cancer tissues is concordant with the loss of the inhibitory SMAD, SMAD7, of the TGF-ß pathway. This was reflected as dysregulated activation of TGF-ß signaling that co-operatively engaged with effectors of the Hippo pathway (YAP/TAZ/TEAD). As a consequence, the loss of Merlin in breast cancer resulted in a significant metabolic and bioenergetic adaptation of cells characterized by increased aerobic glycolysis and decreased oxygen consumption. Mechanistically, we determined that the co-operative activity of the Hippo and TGF-ß transcription effectors caused upregulation of the long non-coding RNA Urothelial Cancer-Associated 1 (UCA1) that disengaged Merlin's check on STAT3 activity. The consequent upregulation of Hexokinase 2 (HK2) enabled a metabolic shift towards aerobic glycolysis. In fact, Merlin deficiency engendered cellular dependence on this metabolic adaptation, endorsing a critical role for Merlin in regulating cellular metabolism. This is the first report of Merlin functioning as a molecular restraint on cellular metabolism. Thus, breast cancer patients whose tumors demonstrate concordant loss of Merlin and SMAD7 may benefit from an approach of incorporating STAT3 inhibitors.

Clinical effect of enoxaparin on international normalized ratio following hepato-pancreatico-biliary and gastroesophageal resection.

BACKGROUND AND OBJECTIVES: Enoxaparin inactivates factor Xa via a complex formed after binding to circulating anti-thrombin III. This mechanism is reported not to alter hemostatic measures such as clotting time, PT, or PTT. To date, no clinical trials have shown a causal relationship between the clinical/pharmacological effects of enoxaparin on international normalized ratio (INR). The aim of our study is to show the clinical effect of enoxaparin on INR. METHODS: Patients (N = 350) were reviewed from our prospective IRB approved databases undergoing gastroesophageal or hepatobiliary surgeries. INR levels were recorded for 6 days: pre-operative to 5 days after surgery. RESULTS: Patients (N = 289) received enoxaparin daily starting post-operative day 1, while 61 patients who did not receive enoxaparin were used as controls. The mean post-operative INR in both the 30 and 40 mg groups were both significantly higher than the mean post-operative INR of the control group (P = 0.015 and P = 0.00075, respectively); however postoperative hemoglobin levels were not significantly lower in the enoxaparin versus control. CONCLUSION: This is the first clinical evidence of the effect of enoxaparin on INR in patients undergoing abdominal surgeries for malignancies. We demonstrate an increase in the INR for patients who received enoxaparin for post-operative VTE prophylaxis.

Calculation of breast volumes from mammogram: Comparison of four separate equations relative to mastectomy specimen volumes.

BACKGROUND AND OBJECTIVES: Accurately assessing breast volume (BV) relative to the volume of breast tissue to be removed could help objectively determine the optimal surgical candidates for breast conserving surgery. The objective of this study was to determine the optimal mammography-based method of BV estimation. METHODS: Mammography data was obtained for patients who underwent mastectomy for breast cancer from 2005 to 2015. This data was used to calculate BV using four previously published equations. Results were compared to mastectomy specimen volumes calculated from specimen weights and breast density. Five practitioners then independently assessed reproducibility and ease of use. RESULTS: Complete mammographic measurements were available for 65 breasts from 45 patients. Median age was 58 years (range 19-82). Mammographic breast density scores were available for 62 breasts. Of the 65 mastectomies performed, 16 (36%) were simple mastectomies. The equation BV = 1/3πRcc Rmlo Hmlo most closely approximated actual breast specimen volumes (R = 0.89, P < 0.0001). Internal correlation of calculated BV was excellent among all practitioners (lowest Pearson R = 0.963). CONCLUSIONS: Breast volumes can be reliably estimated utilizing measurements from a preoperative mammogram. This low-cost method of volumetric analysis can be employed to guide surgical decision making in treatment of patients with invasive breast cancer.

Long-term outcomes after hand-sewn versus circular-stapled (25 and 29 mm) anastomotic technique after esophagogastrectomy for esophageal cancer.

BACKGROUND: Anastomotic stricture following esophagogastrectomy (EG) can lead to significant dysphagia, necessitating interventions such as endoscopic dilatation. These post-operative complications gain importance with the increased survival rate of patients after EG. This study aimed to assess the outcomes of both circular-stapled (CS: 25 and 29 mm) and hand-sewn (HS) anastomoses after EG. METHODS: We reviewed prospectively accrued data from December 2004 to December 2014 identifying all patients undergoing EG for esophageal cancer. Immediate post-operative and long-term complications were noted. Primary outcome measures included anastomotic leak and stricture, dysphagia, and subsequent. RESULTS: A total of 142 patients were identified for analysis. The method used for reconstruction was noted: CS-EEA-25 mm (n = 30), CS-EEA-29 mm (n = 30), and HS (n = 82). Demographics, tumor pathology, and tumor locations were similar in each group. All groups experienced similar rates of anastomotic leak, stricture, and dysphagia. Furthermore, post-operative dilations for symptomatic dysphagia were required in 3 (10%), 4 (13%), and 9 (11%) patients, P = 0.91. CONCLUSION: In this cohort, the method of anastomotic construction had no bearing on the rate of complications after EG for the treatment of esophageal cancer. Furthermore, long-term need for dilations for symptomatic dysphagia was equal among all groups.

Indicators of Survival and Favorable Functional Outcomes after Decompressive Craniectomy: A Multi-Institutional Retrospective Study.

The role of decompressive craniectomy (DC) for severe traumatic brain injury (STBI) remains controversial. The purpose of this study was to identify factors that are indicators of survival and improved functional outcome in patients who undergo DC for STBI. A retrospective review of STBI patients who underwent DC was performed at four trauma centers during a 45-month period. Data collected included age, gender, mechanism of injury, Injury Severity Score (ISS), admission Glasgow Coma Scale (GCS), time from admission to DC, mortality, and extended Glasgow Outcome Score before discharge. Sixty-nine STBI patients were treated with DC during the study period. A higher initial GCS, lower ISS, and longer time to DC were all statistically significant for improved survival after DC. A younger age, higher initial GCS, and lower ISS were all statistically significant for a favorable functional outcome after DC. Patients with a higher initial GCS and lower ISS are more likely to survive DC and have a favorable functional outcome, whereas a longer time to DC was indicative of improved survival after DC.

Health-related quality of life during trans-arterial chemoembolization with drug-eluting beads loaded with doxorubicin (DEBDOX) for unresectable hepatic metastases from ocular melanoma.

BACKGROUND: We have previously reported favorable response and survival rates using drug-eluting beads loaded with doxorubicin (DEBDOX) for unresectable hepatic metastases. This study investigates the quality of life (QoL) impact of DEBDOX for the treatment of unresectable hepatic metastases from melanoma. METHODS: A multi-center, prospective, non-controlled clinical trial was reviewed. QoL was assessed at baseline and after each treatment, and doxorubicin-specific effects were assessed after each treatment. RESULTS: Twenty patients received 61 DEBDOX treatments. After each treatment, at least 83% of patients reported "little" to "none" doxorubicin-related symptoms. For the 8 FACT-Hep subscales, QoL scores were unchanged through 3 treatments for 18 of 24 total time points by ANOVA, with a small-to-moderate ES change through the last treatment in 36 of 40 time points. CONCLUSIONS: Hepatic arterial therapy with DEBDOX is safe with minimal QOL changes in treating unresectable liver-dominant melanoma metastasis. CLINICAL TRIAL: NCT01010984.

Wide versus narrow margins after partial hepatectomy for hepatocellular carcinoma: Balancing recurrence risk and liver function.

BACKGROUND: The goal of this study was to compare the outcome after partial hepatectomy for hepatocellular carcinoma (HCC) in which a margin less than or equal to 5 mm or greater than 5 mm was achieved. METHODS: A review of our 3300-patient prospective HPB database was performed from 12/2002 to 4/2015. Patients were stratified into two groups: resection margins ≤5 ("narrow") and >5 mm ("wide") as measured on final pathologic assessment. RESULTS: One-hundred thirty patients were included in the analysis (margin ≤5 mm, n = 41 and margin >5 mm, n = 89). At the time of analysis 54 patients had developed 56 recurrences, 15 (37%) in the narrow margin group and 41 (46%) in the wide margin group, p = 0.45. The pattern of recurrence was similar in the two groups: intrahepatic 11 (79%) versus 30 (75%), p = 1, and extra-hepatic 6 (43%) versus 17 (43%), p = 1. Median disease-free survival was similar in both groups, 18.1 versus 19.5 months (p = 0.85). CONCLUSIONS: A narrow resection margin (5 mm or less) does not detract from oncologic outcomes after partial hepatectomy for HCC. Tailoring resection margins may lead to greater preservation of hepatic parenchyma. Factors other than margin status represent the driving forces for local and systemic recurrence.

Image-Guided Transarterial Chemoembolization With Drug-Eluting Beads Loaded with Doxorubicin (DEBDOX) for Unresectable Hepatic Metastases from Melanoma: Technique and Outcomes.

PURPOSE: Hepatic metastasis from melanoma represents a therapeutic dilemma, with limited effective options for the 85% of cases deemed unresectable. Systemic agents confer toxicity and, along with traditional local hepatic arterial-directed therapies such as transarterial chemoembolization, have not led to a significant increase in survival. The aim of this study was to investigate the safety and dose-limiting toxicity of DEBDOX for the treatment of unresectable hepatic metastases from melanoma. METHODS: A multicenter (University of Louisville, Thomas Jefferson University, MD Anderson Cancer Center), prospective, non-controlled treatment trial (NCT01010984) of hepatic-directed therapy with DEBDOX for the treatment of melanoma liver metastasis was reviewed. Primary endpoints were response rates by modified response evaluation criteria in solid tumors, hepatic progression-free survival (PFS), and overall survival (OS). RESULTS: Twenty patients received a total of 61 DEBDOX treatments from January 2010 to March 2013. The median hepatic tumor burden was 40% (range 20-55), 18 patients (90%) had bilobar disease, and 13 patients (65%) had concomitant extrahepatic disease. At median assessment of 2.5 months, 11 patients (55%) exhibited a tumor response and 16 (80%) exhibited disease control. Median follow-up was 5 months (range 1.1-34.3 months). Median hepatic PFS was 3 months (95% CI 1.4, 3.4), and OS was 5 months (95% CI 3.3, 10.5). CONCLUSIONS: Directed arterial therapy with DEBDOX is effective in managing unresectable liver-dominant metastasis from melanoma and should be considered a therapeutic option in the multidisciplinary treatment of this disease. Concurrent systemic therapy is merited given the high rate of extrahepatic progression. CLINICAL TRIAL: NCT01010984.

Rib fractures and their association With solid organ injury: higher rib fractures have greater significance for solid organ injury screening.

BACKGROUND: The purpose of this study was to identify patients with rib injuries who were at risk for solid organ injury. METHODS: A retrospective chart review was performed of all blunt trauma patients with rib fractures during the period from July 2007 to July 2012. Data were analyzed for association of rib fractures and solid organ injury. RESULTS: In all, 1,103 rib fracture patients were identified; 142 patients had liver injuries with 109 (77%) associated right rib fractures. Right-sided rib fractures with highest sensitivity for liver injury were middle rib segment (5 to 8) and lower segment (9 to 12) with liver injury sensitivities of 68% and 43%, respectively (P < .001); 151 patients had spleen injuries with 119 (79%) associated left rib fractures. Left middle segment rib fractures and lower segment rib fractures had sensitivities of 80% and 63% for splenic injury, respectively (P < .003). CONCLUSIONS: Rib fractures higher in the thoracic cage have significant association with solid organ injury. Using rib fractures from middle plus lower segments as indication for abdominal screening will significantly improve rib fracture sensitivity for identification of solid organ injury.

Intraoperative management of renal gunshot injuries: is mandatory exploration of Gerota's fascia necessary?

BACKGROUND: Many trauma surgeons and trauma centers use routine exploration of Gerota's fascia (GE) for renal gunshot wounds (RGSW). The purpose of this study was to assess whether RGSW can be selectively explored for patients who undergo exploratory laparotomy. METHODS: Retrospective 10-year review of all patients who underwent exploratory laparotomy for abdominal gunshot wounds and had RGSW selectively explored. RESULTS: Sixty-three patients with RGSW underwent exploratory laparotomy. Twenty-eight (44%) underwent GE vs 35 (56%) who did not. Eight (29%) mortalities occurred with GE and 5 (14%) without GE (P < .05). Of GE patients, 14 (50%) had nephrectomy and 14 (50%) had renorrhaphy. Average hospital length of stay with GE was 16.7 days vs 17.9 without GE. Three (9%) renal-associated complications occurred without GE and 1 (4%) with GE. CONCLUSIONS: Most patients who suffer RGSW do not require exploration of GE during abdominal exploration. Complication rates due to nonexploration of RGSW are very low with infrequent need for surgical intervention due to renal-associated complications. High nephrectomy rates may be avoided when GE is averted.

Thoracolumbar spine clearance: Clinical examination for patients with distracting injuries.

BACKGROUND: The purpose of this study was to prospectively assess the sensitivity of clinical examination to screen for thoracolumbar spine (TLS) injury in awake and alert blunt trauma patients with distracting injuries. METHODS: From December 2012 to June 2014, all blunt trauma patients older than 13 years were prospectively evaluated as per standard TLS examination protocol at a Level 1 trauma center. Awake and alert patients with Glasgow Coma Scale (GCS) score of 14 or greater underwent clinical examination of the TLS. Clinical examination was performed regardless of distracting injuries. Patients with no complaints of pain or tenderness on examination of the TLS were considered clinically cleared of injury. Patients with distracting injuries, including those clinically cleared and those with complaints of TLS pain or tenderness, underwent computed tomographic scan of the entire TLS. Patients with minor distracting injuries were not considered to have a distracting injury. RESULTS: A total of 950 blunt trauma patients were entered, 530 (56%) of whom had at least one distracting injury. Two hundred nine patients (40%) with distracting injuries had a positive TLS clinical examination result, of whom 50 (25%) were diagnosed with TLS injury. Three hundred twenty-one patients (60%) with distracting injuries were initially clinically cleared, in whom 17 (5%) TLS injuries were diagnosed. There were no missed injuries that required surgical intervention, with only four injuries receiving TLS orthotic bracing. This yielded an overall clinical clearance sensitivity for injury of 75% and sensitivity for clinically significant injury of 89%. CONCLUSION: In awake and alert blunt trauma patients with distracting injuries, clinical examination is a sensitive screening method for significant TLS injury. Radiologic assessment may be unnecessary for safe clearance of the asymptomatic TLS in patients with distracting injuries. These findings suggest significant potential reduction of both health care cost and patient radiation exposure. LEVEL OF EVIDENCE: Diagnostic study, level IV; therapeutic/care management study, level IV.

Standard Dosing of Enoxaparin for Venous Thromboembolism Prophylaxis Is Not Sufficient for Most Patients Within a Trauma Intensive Care Unit.

Recent reports confirm that the standard dose of enoxaparin in obese patients is often subtherapeutic, leading to a higher incidence of venous thromboembolism. All patients receiving subcutaneous enoxaparin 30 mg twice a day (b.i.d.) for venous thromboembolism prophylaxis were prospectively enrolled in this study. Trough antiXa levels were obtained and any level less than 0.1 IU/mL was considered subtherapeutic and the final dosage requirement was recorded. Body mass index (BMI), abdominal wall thickness, and fluid balance were collected. Thirty-four patients were prospectively enrolled in the study, 14 (50%) of which had a BMI >30. Sixty-five per cent of obese patients were initially nontherapeutic, compared with 53 per cent of the nonobese (P = 0.73). However, elevated BMI (P < 0.05) and abdominal wall thickness (P < 0.05) correlated to an increased final dose required to attain an anti Xa ≥0.1 when not initially therapeutic, whereas fluid balance demonstrated no correlation (P = 0.232). Subcutaneous enoxaparin dosing of 30 mg b.i.d. is not sufficient for the majority adult trauma patients in the intensive care unit, regardless of BMI. When enoxaparin 30 mg b.i.d. is initially subtherapeutic, obese patients may require a larger dose necessary to achieve necessary anticoagulation.

The validity of abdominal examination in blunt trauma patients with distracting injuries.

BACKGROUND: Many trauma care providers often disregard the abdominal clinical examination in the presence of extra-abdominal distracting injuries and mandate abdominal computed tomographic scan in these patients. Ignoring the clinical examination may incur undue expense and radiation exposure. The purpose of this study was to assess the efficacy of abdominal clinical examination in patients with distracting injuries. METHODS: During a 1-year period, all awake and alert blunt trauma patients with Glasgow Coma Scale (GCS) score of 14 or 15 were entered into a prospective study. Abdominal clinical examination was performed and documented prospectively on all patients. Abdominal clinical examination included four-quadrant anterior abdominal palpation, flank palpation, lower thoracic palpation, pelvis examination, and palpation of the thoracolumbar spine. Following examination documentation, all patients underwent computed tomographic scan of the abdomen and pelvis with intravenous contrast. RESULTS: A total of 803 patients were enrolled: 451 patients had distracting injuries, and 352 patients did not. Of the 352 patients without distracting injuries, 19 (5.4%) had intra-abdominal injuries, of whom 2 (10.5%) had negative clinical examination result. Of the 451 patients with distracting injuries, 48 (10.6%) were diagnosed with intra-abdominal injury, of whom 5 (10.4%) had negative clinical examination result. All five missed injuries in patients with distracting injuries were solid organ injuries, none of which required surgical intervention or blood transfusion. The sensitivity and negative predictive value of abdominal examination for patients with distracting injuries were 90.0% and 97.0%, respectively. The sensitivity and negative predictive value of abdominal examination for surgically significant and transfusion-requiring injuries were both 100%. CONCLUSION: Distracting injuries do not seem to diminish the efficacy of clinical abdominal examination for the diagnosis of clinically significant abdominal injury. These data suggest that clinical examination of the abdomen is valid in awake and alert blunt trauma patients, regardless of the presence of other injuries. LEVEL OF EVIDENCE: Diagnostic study, level III.

The safety of low molecular-weight heparin after blunt liver and spleen injuries.

BACKGROUND: Anticoagulation is routinely administered to all trauma patients owing to the high incidence of venous thromboembolism (VTE). However, the timing of administration of anticoagulation is not clearly defined when patients have blunt spleen or liver injuries because of the perceived risk of hemorrhage with early administration. METHODS: A retrospective chart review was performed of all blunt trauma patients who sustained blunt liver and/or spleen injuries during the 5-year period from 2007 to 2011. Data were collected for all patients managed with nonoperative therapy for these injuries while also receiving routine prophylactic anticoagulation with low molecular-weight heparin. Patients were categorized based on the initiation of enoxaparin therapy after injury: early (<48 hours), intermediate (48 to 72 hours), and late (>72 hours). Primary and secondary outcomes were designated as need for operative or radiologic intervention secondary to spleen or liver hemorrhage, number of transfusions, and incidence of VTE. RESULTS: Three hundred and twenty-eight patients were included. There were no enoxaparin-related hemorrhagic complications or hemorrhage necessitating operative intervention. Patients in the early, intermediate, and late groups received an average of .9, .93, and 1.55 units of blood, respectively. There was 1 pulmonary embolism in the early group, and there were 6 VTE complications in the late group (3 deep venous thromboses and 3 pulmonary embolisms). CONCLUSIONS: There are currently no standards for the initiation of prophylactic anticoagulation in trauma patients with blunt liver and spleen injuries. Early administration may be safe and reduce the incidence of thrombotic complications in patients with blunt spleen and liver injuries. Prospective studies in this area are warranted.

Larger ATV engine size correlates with an increased rate of traumatic brain injury.

INTRODUCTION: Since the introduction of all-terrain vehicles (ATV) to the United States in 1971, injuries and mortalities related to their use have increased significantly. Furthermore, these vehicles have become larger and more powerful. As there are no helmet requirements or limitations on engine-size in the State of Alabama, we hypothesised that larger engine size would correlate with an increased incidence of traumatic brain injury (TBI) in patients following an ATV crash. METHODS: Patient and ATV data were prospectively collected on all ATV crashes presenting to a level one trauma centre from September 2010 to May 2013. Collected data included: demographics, age of driver, ATV engine size, presence of helmet, injuries, and outcomes. The data were grouped according to the ATV engine size in cubic centimetres (cc). For the purposes of this study, TBI was defined as any type of intracranial haemorrhage on the initial computed tomography scan. RESULTS: There were 61 patients identified during the study period. Two patients (3%) were wearing a helmet at the time of injury. Patients on an ATV with an engine size of 350 cc or greater had higher Injury Severity Scores (13.9 vs. 7.5, p ≤ 0.05) and an increased incidence of TBI (26% vs. 0%, p ≤ 0.05) when compared to patients on ATV's with an engine size less than 350 cc. CONCLUSIONS: Patients on an ATV with an engine size of 350 cc or greater were more likely to have a TBI. The use of a helmet was rarely present in this cohort. Legislative efforts to implement rider protection laws for ATVs are warranted.