Long-term follow-up of prophylactic greenfield filters in multisystem trauma patients.

PURPOSE: The efficacy of prophylactic Greenfield filter (PGF) placement in multisystem trauma patients at high risk for venous thromboembolism has been established. The objective of this study is to demonstrate the long-term safety and durability of PGFs placed in young, active trauma patients. METHODS: Starting January 1992, all trauma patients at high risk for development of venous thromboembolism were identified for placement of PGFs. These included patients with ISS > 9 and severe closed head injury, spinal injury, pelvic fracture, multiple long bone fracture, or direct iliofemoral venous injury. Four patients with PGFs placed before the study protocol in 1992 were also included. Follow-up was attempted in all patients with at least 5 years' duration since placement of PGF using physical examination, duplex ultrasound (US), and plain abdominal radiograph. RESULTS: There were 108 patients who had a PGF placement during the period of January 1992 to June 1994 that were eligible for the study. Eighteen of these 108 (17%) patients died. Twelve of them (67%) had autopsies and medical records available to determine the cause of death, none from a pulmonary embolism. The average time of death was 2.7 months after injury. The remaining 90 patients and the 4 patients with PGFs placed before 1992 were sought for follow-up, but only 36 patients could be contacted, 33 of which returned for evaluation (35%). The mean time of follow-up from the time of injury to the time of examination was 67.7 months, and the mean age at follow-up was 38.1 years. Although six patients had mild to moderate lower extremity edema on physical examination, none of them had a deep venous thrombosis by US. Radiographs obtained in 19 of the 33 patients showed no migration or breakdown of the Greenfield filters in place. CONCLUSION: Prophylactic Greenfield filters in high-risk trauma patients are safe and durable. There appears to be no significant consequence in over 5 years of follow-up.

Contribution of age and gender to outcome of blunt splenic injury in adults: multicenter study of the eastern association for the surgery of trauma.

BACKGROUND: The purpose of this study was to examine the contribution of age and gender to outcome after treatment of blunt splenic injury in adults. METHODS: Through the Multi-Institutional Trials Committee of the Eastern Association for the Surgery of Trauma (EAST), 1488 adult patients from 27 trauma centers who suffered blunt splenic injury in 1997 were examined retrospectively. RESULTS: Fifteen percent of patients were 55 years of age or older. A similar proportion of patients > or = 55 went directly to the operating room compared with patients < 55 (41% vs. 38%) but the mortality for patients > or = 55 was significantly greater than patients < 55 (43% vs. 23%). Patients > or = 55 failed nonoperative management (NOM) more frequently than patients < 55 (19% vs. 10%) and had increased mortality for both successful NOM (8% vs. 4%, p < 0.05) and failed NOM (29% vs. 12%, p = 0.054). There were no differences in immediate operative treatment, successful NOM, and failed NOM between men and women. However, women > or = 55 failed NOM more frequently than women < 55 (20% vs. 7%) and this was associated with increased mortality (36% vs. 5%) (both p < 0.05). CONCLUSION: Patients > or = 55 had a greater mortality for all forms of treatment of their blunt splenic injury and failed NOM more frequently than patients < 55. Women > or = 55 had significantly greater mortality and failure of NOM than women < 55.

Blunt splenic injury in adults: Multi-institutional Study of the Eastern Association for the Surgery of Trauma.

BACKGROUND: Nonoperative management of blunt injury to the spleen in adults has been applied with increasing frequency. However, the criteria for nonoperative management are controversial. The purpose of this multi-institutional study was to determine which factors predict successful observation of blunt splenic injury in adults. METHODS: A total of 1,488 adults (>15 years of age) with blunt splenic injury from 27 trauma centers in 1997 were studied through the Multi-institutional Trials Committee of the Eastern Association for the Surgery of Trauma. Statistical analysis was performed with analysis of variance and extended chi2 test. Data are expressed as mean +/- SD; a value of p < 0.05 was considered significant. RESULTS: A total of 38.5 % of patients went directly to the operating room (group I); 61.5% of patients were admitted with planned nonoperative management. Of the patients admitted with planned observation, 10.8% failed and required laparotomy; 82.1% of patients with an Injury Severity Score (ISS) < 15 and 46.6% of patients with ISS > 15 were successfully observed. Frequency of immediate operation correlated with American Association for the Surgery of Trauma (AAST) grades of splenic injury: I (23.9%), II (22.4%), III (38.1%), IV (73.7%), and V (94.9%) (p < 0.05). Of patients initially managed nonoperatively, the failure rate increased significantly by AAST grade of splenic injury: I (4.8%), II (9.5%), III (19.6%), IV (33.3%), and V (75.0%) (p < 0.05). A total of 60.9% of the patients failed nonoperative management within 24 hours of admission; 8% failed 9 days or later after injury. Laparotomy was ultimately performed in 19.9% of patients with small hemoperitoneum, 49.4% of patients with moderate hemoperitoneum, and 72.6% of patients with large hemoperitoneum. CONCLUSION: In this multicenter study, 38.5% of adults with blunt splenic injury went directly to laparotomy. Ultimately, 54.8% of patients were successfully managed nonoperatively; the failure rate of planned observation was 10.8%, with 60.9% of failures occurring in the first 24 hours. Successful nonoperative management was associated with higher blood pressure and hematocrit, and less severe injury based on ISS, Glasgow Coma Scale, grade of splenic injury, and quantity of hemoperitoneum.

Continued experience with physical examination alone for evaluation and management of penetrating zone 2 neck injuries: results of 145 cases.

PURPOSE: Our preliminary experience with physical examination alone in the evaluation of penetrating zone 2 neck injuries for vascular trauma was previously reported in 28 patients over a 2-year period (1991-1993). The purpose of the current study was to examine the results of this approach in a much larger group of patients over an 8-year period. METHODS: The medical records for all patients admitted to our level I trauma center (all of them entered into our prospective protocol) between December 1991 and April 1999 with penetrating zone 2 neck trauma were reviewed for their initial presentation and any documented vascular injury. RESULTS: A total of 145 patients made up the study group; in 30 of these patients, the penetrating trajectory also traversed zone 1 or 3. Thirty-one patients (21%) had hard signs of vascular injury (active bleeding, expanding hematoma, bruit/thrill, pulse deficit, central neurologic deficit) and were taken immediately to the operating room; 28 (90%) of these 30 patients had either major arterial or venous injuries requiring operative repair (the false-positive rate for physical examination thus being 10%). Of the 114 patients with no hard signs, 23 underwent arteriography because of proximity of the injury to the vertebral arteries or because the trajectory included another zone. Of these 23 arteriograms, three showed abnormalities, but only one required operative repair. This case had no complications relating to the initial delay. The remaining 91 patients with no hard signs were observed without imaging or surgery for a minimum of 23 hours, and none had any evidence of vascular injury during hospitalization or during the initial 2-week follow-up period (1/114; false-negative rate for physical examination, 0.9%). CONCLUSIONS: This series confirms the earlier report indicating that patients with zone 2 penetrating neck wounds can be safely and accurately evaluated by physical examination alone to confirm or exclude vascular injury. The missed-injury rate is 0.7% (1/145) with this approach, which is comparable to arteriography in accuracy but less costly and noninvasive. Long-term follow-up is needed to confirm this management option.

A surgical Internet discussion list (Surginet): a novel venue for international communication among surgeons.

BACKGROUND: Internet discussion lists, also known as mailing lists, are subject-specific groups that are participated in and distributed by e-mail. Medical mailing lists have not been warmly received by the peer-reviewed medical literature. OBJECTIVE: To demonstrate the potential value of medical discussion lists on the Internet through a description of Surginet, the largest such mailing list dealing with general surgery, and a survey of its participants. Our hypothesis is that Internet discussion lists fill a unique niche in dissemination of medical information. DESIGN: A retrospective review of the electronic activities of one medical mailing list, and an e-mail questionnaire survey of its membership's demographics and practice patterns. PARTICIPANTS: Four hundred eighty-nine subscribers to Surginet from 46 countries. MAIN OUTCOME MEASURES: Electronic activity of the list, subscribers' demographics, and subscribers' perceptions concerning the list's activities and its value. RESULTS: Surginet currently has 489 subscribers from 46 countries. During 1997 an average of 12.5 messages per day and 375 per month were posted, all dealing with topics in general surgery. Completed questionnaires were received from 190 subscribers (39%), of which 93% are men and 73% are between the ages of 30 and 50 years practicing in 38 countries; 84% are practicing surgeons and 13% are surgical residents. Most (59%) are "passive" members who read, but do not actively participate in, the discussions. Improving knowledge base, interaction with other surgeons, and obtaining consults were the most common reasons given for list subscription. CONCLUSIONS: Groups such as Surginet fill a niche involving the free exchange of ideas, methods, and attitudes relevant to the current practice of general surgery, which is different from the way medical information is disseminated by published literature and organized medical meetings. There is a perception among list subscribers that this is a valuable and useful modality for continuing education.

Trends in surgical treatment of breast cancer at an urban teaching hospital: a six-year review.

The treatment of breast cancer at an urban teaching hospital from 1990 to 1995 was analyzed according to age, stage, race, and funding status. Two hundred thirty-eight patients (mean age, 55 years) with newly diagnosed breast cancers were retrospectively identified and reviewed. A larger proportion of all funded patients (F; n = 131) presented with early-stage cancers (ductal carcinoma in situ, stage I) compared to nonfunded (NF, n = 107) (41 vs 25%; P = 0.03). Additionally, there was an increasing rate of early cancers occurring in F over the study interval (40% in 1990 to 69% in 1995), but there was no such increase in NF. There was an increasing trend in the overall use of breast conservation therapy (BCT) over this interval (11.6% of all cancers in 1990, 50.8% in 1994 and 1995). Although F were overall more likely to undergo BCT than NF (40% vs 29%, P = 0.04), there was no statistical difference in the use of BCT for nonadvanced (ductal carcinoma in situ, stage I and II) cancers (44% of F, 46% of NF). Age did not affect the overall use of BCT (36% of patients 55 or older, 35% younger than 55). Mean age was significantly greater in F than in NF (60 vs 49, P < 0.000001), but racial composition did not differ between these two groups. In conclusion, funded status of our patients corresponded with earlier diagnosis, perhaps due to better access to screening. Additionally, neither funding status nor age affected the use of BCT in our patients with nonadvanced cancers. Our rate of BCT far exceeds that seen nationally, perhaps reflecting a trend at academic institutions.

Validation of nonoperative management of occult vascular injuries and accuracy of physical examination alone in penetrating extremity trauma: 5- to 10-year follow-up.

PURPOSE: To establish by long-term follow-up the safety and efficacy of nonoperative management of clinically occult arterial injuries and the use of physical examination (PE) alone in determining treatment of penetrating extremity trauma (PET). METHODS: Two groups of patients were studied: (1) all patients with PET, arterial abnormalities on arteriograms, and no hard signs of vascular injury treated nonoperatively from 1986 to 1989; and (2) all patients with PET to the extremities managed by PE alone from 1989 to 1991. Telephone contact, PE, and duplex ultrasonography (US) were attempted in all group 1 patients, and telephone interviews were attempted in all group 2 patients. RESULTS: Group 1 had 43 patients with 44 clinically occult penetrating injuries to extremity arteries. Arteriography identified 21 intimal flaps/irregularities, 19 narrowings, 2 pseudoaneurysms, and 1 arteriovenous fistula. Four patients (9%) had clinical deterioration within 1 month and required surgery, with good results. Twenty-three of the other 39 patients (58%) were able to be contacted, and 17 (43%) with 18 injuries underwent PE and US. All were asymptomatic and had normal PE, and one had mild residual narrowing on US. The other 6 patients (four in prison, two out of state) reported no symptoms of vascular insufficiency and never sought medical attention for vascular problems. Mean follow-up was 9.1 years (range, 8.6-11.1 years). Group 2 had 287 patients (309 injuries) with PET treated by observation based on PE alone. Four patients (1.3%) required delayed surgery within the first week, and 78 with 90 injuries (29%) were able to be contacted. No patient reported any vascular symptoms or ever saw a physician for vascular problems. Mean follow-up was 5.4 years (range, 2.2-6.0 years). CONCLUSION: This is the first long-term follow-up of nonoperative management of clinically occult arterial injuries of the extremities and the use of PE alone in the initial management of PET. The results show these approaches to be safe, effective, and now a proven standard of care.

The impact of selective laboratory evaluation on utilization of laboratory resources and patient care in a level-I trauma center.

BACKGROUND: Routine laboratory evaluation of preoperative patients has not been shown to be cost effective when a detailed history and physical examination are performed. However, since such a detailed history is not possible in trauma patients, the time-honored approach has been for laboratory evaluation to be protocol driven. The cost-benefit ratio of this practice has never been evaluated. METHODS: Trauma patients who underwent routine laboratory evaluation (n = 552; group I) were compared with patients who had laboratory evaluation based on clinical need (n = 603; group II). A concurrent review of each case in group II was conducted every day while a retrospective review of charts was conducted for patients in group I to determine patient care issues and identify abnormal trauma center test results. RESULTS: The number of patients with laboratory tests decreased from 97% in group I to 27% in group II (P < 0.0001). Positive chemistry profiles increased (55% versus 92%; P < 0.0001) as did coagulation profiles (8% versus 33%; P < 0.0001). There were no differences in the percentage of patients receiving intervention based on laboratory data (7% in group I versus 8% in group II). No adverse effect on patient care was identified as a result of absent laboratory information in group II. Mortality, length of stay, and intensive care unit days were statistically unchanged. There was an annualized savings of $1.5 million in billed trauma center laboratory charges in group II. CONCLUSION: Selective laboratory evaluation of trauma patients can greatly reduce medical cost and does not adversely affect care.

Changing patterns of arterial injuries associated with fractures and dislocations.

BACKGROUND: Significant changes occurred over a 4.5-year period in the causes, diagnosis, and treatment of arterial injuries associated with skeletal fractures of the extremities. STUDY DESIGN: The trauma registry data of 1,091 consecutive patients with fractures, dislocations, or both, were reviewed for the diagnosis of associated arterial injury documented by arteriography or an exploratory operation. The decision to perform a vascular repair was based solely on the presence of definitive signs of arterial injury found during physical examination. RESULTS: Arterial injuries occurred in 41 patients (3.8 percent). Of these, 29 (71 percent) had penetrating injuries, and 12 (29 percent) had blunt trauma. Twenty-six patients (63 percent) had definitive signs of arterial injury and all required arterial repairs. Only three patients (7.3 percent), all with blunt injuries, required amputations because of massive soft tissue trauma. Fifteen patients had intimal flaps, irregularities, or localized narrowings shown on the arteriogram. No patient's condition had deteriorated by the time of a repeat arteriogram (n = 6) or physical examination (n = 9), and no injury required delayed repair (mean follow-up of 6.5 months). No patient without definitive signs of vascular injury at the time of initial examination required surgical repair. CONCLUSIONS: Arterial injuries associated with fractures increasingly result from penetrating trauma and carry a much lower risk of amputation than injuries from blunt trauma. Physical examination can accurately detect 100 percent of the arterial injuries requiring repair. Minimal arterial abnormalities seen on arteriograms may be safely followed up by observation.

Advances in the diagnosis and treatment of extremity vascular trauma.

Extremity vascular trauma poses several difficult dilemmas in diagnosis and treatment. The still evolving trend in management of these injuries is toward more rapid, less costly, and less invasive diagnostic modalities, an improved understanding of the therapeutic implications of the clinical presentation, prompt repair of significant vascular injuries, and a liberal use of adjunctive techniques such as fasciotomy. Many issues remain to be resolved by further experience and investigation, in order to achieve optimal limb salvage in this setting.

Physical examination alone is safe and accurate for evaluation of vascular injuries in penetrating Zone II neck trauma.

BACKGROUND: Optimal management of patients with Zone II penetrating neck trauma for vascular injury remains controversial. Retrospective studies have demonstrated that physical examination alone may be as accurate as arteriography in detecting significant cervical vascular injuries requiring operative repair. This study was undertaken to evaluate prospectively the safety and accuracy of physical examination in determining the management of patients with penetrating Zone II neck trauma. STUDY DESIGN: During a 22 month period, 66 consecutive patients presented to our Level I trauma center with penetrating neck trauma. Determination of the vascular status of these patients was based on physical examination alone if the injury was located in Zone II and there was no definite sign of vascular injury. Patients were observed for at least 23 hours. Patients admitted during the first year of the study underwent ultrasound examination of the carotid artery within 48 hours to assess for injuries. RESULTS: Thirty-six patients met admission criteria. Two patients had large lacerations requiring operative debridement and closure. Six patients underwent arteriography because of the proximity of the vertebral arteries to the injury tract, the trajectory also included Zone I or III, or there were equivocal signs of vascular injury. Each arteriogram was negative. Of the remaining 28 patients, none had any evidence of a vascular injury during hospitalization or follow-up period (mean of 1.8 months). Eighteen of the 28 patients had carotid ultrasounds, none of which showed injuries requiring operative intervention. CONCLUSIONS: Patients with Zone II penetrating neck injuries and no definite signs of vascular injury can be safely and accurately managed on the basis of physical examination alone. Arteriography or ultrasonography are not needed to identify vascular injuries.

Overview of the biology and management of ductal carcinoma in situ of the breast.

Ductal carcinoma in situ of the breast (DCIS) is an early, noninvasive stage of breast malignancy that arises from ductal epithelium and has an especially favorable prognosis. Its biologic characteristics are consistent with a direct precursor to invasive carcinoma, which develops in the majority of cases if left untreated, generally within 10 years of diagnosis. Mammography has resulted in a substantial increase in its diagnosis, as well as a change in its presentation from large, palpable masses to nonpalpable lesions manifested primarily as microcalcifications. The same treatment options are available for DCIS as for invasive breast carcinoma, and there is also a limited role for wide local excision alone in incidental lesions. Most cases of DCIS currently are treated effectively by lumpectomy and radiation therapy, although the fact that 50% of all local breast recurrences are invasive lesions may affect survival adversely. Mastectomy is associated with the best survival rates and should be performed on any patient with factors known to pose a high risk of locoregional recurrence. There are still many outstanding issues to be resolved by further study before the intriguing potential of this disease can be realized fully.

Management of in situ and minimally invasive breast carcinoma.

In situ breast carcinoma represents an early localized stage in the transition to invasive breast carcinoma and has an especially favorable prognosis with appropriate management. The widespread use of mammography has contributed to its increased rate of diagnosis. The two histologic forms of this entity have distinct pathologic and biologic characteristics, with different therapeutic implications. Lobular carcinoma in situ is considered a marker of increased risk for subsequent invasive carcinoma and is most commonly managed by nonoperative surveillance. Ductal carcinoma in situ behaves more as a true anatomic precursor of invasive disease and has the same therapeutic options as invasive breast carcinoma. Minimally invasive breast carcinoma should be considered a fundamentally different entity, primarily because of its potential for systemic metastasis that in situ lesions do not theoretically have. There are still many outstanding issues and dilemmas to be resolved by scientific investigation before the intriguing potential of these early forms of breast malignancy are fully understood.

Reassessing the role of arteriograms in the management of posterior knee dislocations.

Vascular injury has been reported in up to one third of patients with posterior knee dislocations, which has led to the routine use of arteriograms in the management of these injuries. Recent studies have shown physical examination (PE) is reliable in detecting significant vascular injuries requiring surgery from other mechanisms. We hypothesized that PE would be similarly sufficient to assess popliteal injury in patients with posterior knee dislocations. To test this, we reviewed the records of all 37 patients with 38 such injuries at our institution over the past 5 years. The average age was 29.5 years, and 31 patients (81.5%) had other associated injuries. All dislocations were the result of blunt trauma. Two patients (5.3%) had hard signs (distal ischemia and no pulses) that clearly indicated vascular injury. Total occlusions of the popliteal artery were seen on arteriograms in both cases and these were successfully treated surgically with reversed saphenous vein bypass grafts. The remaining 36 dislocations manifested no hard signs of vascular injury (absent pulses, distal ischemia, active bleeding, bruit/thrill). Nineteen patients (50.0%) had normal vascular examination results, did not receive arteriograms, and had no adverse sequelae, with a mean follow-up of 9.3 months (range 1 day-43 months). Sixteen patients with 17 dislocations (44.7%) underwent arteriography and the findings appeared normal in ten extremities; nine of these extremities had normal pulses and one had a diminished but palpable pulse. A minimal injury (intimal defect, 3; narrowing, 4) was demonstrated in seven extremities, five with normal pulses and two with diminished pulses.(ABSTRACT TRUNCATED AT 250 WORDS)

Ductal carcinoma in situ of the breast.

DCIS is an early localized stage of mammary malignancy that has an especially favorable prognosis with appropriate management. It seems to be a direct precursor to invasive carcinoma of the breast and has the same therapeutic options. There are still many outstanding issues to be resolved before the intriguing potential of this disease can be fully realized. Any physician involved in the management of diseases of the breast must be committed to a thorough understanding of all aspects of the biologic factors of this entity, so as to be able to rationally provide appropriate advice and treatment. Ongoing investigations should advance the knowledge and experience with this disease in future years.