Accuracy and Clinical Utility of Reports from Outside Hospitals for CT of the Cervical Spine in Blunt Trauma.

BACKGROUND AND PURPOSE: Multidetector CT is the workhorse for detecting blunt cervical spine injury. There is no standard of care for re-interpretation of radiology images for patients with blunt trauma transferred to a higher level of care. The clinical impact of discrepancies of cervical spine CT reads remains unclear. We evaluated the discordance between primary (from referring hospitals) and secondary radiology interpretations (from a receiving level I tertiary trauma center) of cervical spine CT scans in patients with blunt trauma and assessed the clinical implications of missed cervical spine fractures. MATERIALS AND METHODS: Medical records of patients with blunt trauma transferred to our institution between 2008 and 2015 were reviewed. Primary and secondary interpretations were compared and categorized as concordant and discordant. Two senior neuroradiologists adjudicated discordant reports. The benefit of re-interpretation was determined. For discordant cases, outcomes at discharge, injury severity pattern, treatment, and arrival in a cervical collar were assessed. RESULTS: Six hundred fifty patients were included; 608 (94%) presented with concordant reports: 401 (61.7%) with fractures and 207 (31.8%) with no fractures. There were 42 (6.5%) discordant reports; 18 (2.8%) were cervical spine injuries undetected on the primary interpretation. Following adjudication, the secondary interpretation improved the sensitivity (99.3% versus 95.7%) and specificity (99.1% versus 91.7%) in detecting cervical spine fractures compared with the primary interpretation alone (P < .001). CONCLUSIONS: There was an overall 6.5% discordance rate between primary and secondary interpretations of cervical spine CT scans. The secondary interpretation of the cervical spine CT increased the sensitivity and specificity of detecting cervical spine fractures in patients with blunt trauma transferred to higher-level care.

Feature mining and predictive model construction from severe trauma patient's data.

In management of severe trauma patients, trauma surgeons need to decide which patients are eligible for damage control. Such decision may be supported by utilizing models that predict the patient's outcome. The study described in this paper investigates the possibility to construct patient outcome prediction models from retrospective patient's data at the end of initial damage control surgery by using feature mining and machine learning techniques. As the data used comprises rather excessive number of features, special attention was paid to the problem of selecting only the most relevant features. We show that a small subset of features may carry enough information to construct reasonably accurate prognostic models. Furthermore, the techniques used in our study identified two factors, namely the pH value when admitted to ICU and the worst partial active thromboplastin time, to be of highest importance for prediction. This finding is pathophysiologically reasonable and represents two of three major problems with severe trauma patients, metabolic acidosis, hypothermia, and coagulopathy.

Treatment of metastatic breast cancer with somatostatin analogues--a meta-analysis.

BACKGROUND: Somatostatin analogues appear to have antiproliferative effects in breast cancer by inhibiting various hormones. Several small phase 1 and 2 clinical trails have evaluated the efficacy of somatostatin analogues, but the results are varied. The purpose of this study was to use the technique of meta-analysis to determine the effect of somatostatin analogues on tumor response, toxicity, and serum hormone levels in women with metastatic breast cancer. METHODS: All published and unpublished trials were reviewed. Meta-analysis was preformed by best linear unbiased estimate regression with observations weighted inversely to their variance. Significance was considered at P < .05. RESULTS: Fourteen studies (N = 210) were included. Positive tumor response was reported in 87 patients (41.4%). Mean duration of response was 3.9 months. Response was best when somatostatin analogues were given as first-line therapy (69.5% versus 28.5%, P < .006) and in patients with < or =2 metastases (45.0% versus 5.6%, P = .3). Mild side effects occurred in 47 of 185 patients (25.4%). Therapy was associated with a decrease in serum insulin-like growth factor (IGF-1) and an increase in growth hormone. CONCLUSIONS: In patients with metastatic breast cancer, treatment with somatostatin analogues was associated with a tumor response of over 40% with few side effects. Best results were achieved when somatostatin analogues were given as first-line therapy.

Prolonged use of intraluminal arterial shunts without systemic anticoagulation.

BACKGROUND: Temporary arterial shunts maintain perfusion while surgeons postpone arterial repairs. The common indications are combined orthopedic and vascular injuries and damage control. The duration of patency and the need for systemic anticoagulation remain in question. We examined our experience for answers. METHODS: We searched for patients who had temporary arterial shunts and collected the following: mechanism, artery injured, shunt time, blood loss and transfusions, injury severity score (ISS,) mangled extremity severity score (MESS,) and anticoagulation. RESULTS: Of 19 patients, 10 had shunts for damage control (group 1,) and 9, for orthopedic/vascular injuries (group 2.) group 1 had significantly higher shunt time, mortality, ISS, and MESS. Shunt time ranged from 47 to 3,130 minutes (52 hours.) Two patients, 1 in each group, required amputations. CONCLUSION: Temporary arterial shunts can be use for combined orthopedic and vascular injuries and for damage control. Shunts can stay open for 52 hours without systemic anticoagulation.

Predictive model for survival at the conclusion of a damage control laparotomy.

BACKGROUND: We employed modern statistical and data mining methods to model survival based on preoperative and intraoperative parameters for patients undergoing damage control surgery. METHODS: One hundred seventy-four parameters were collected from 68 damage control patients in prehospital, emergency center, operating room, and intensive care unit (ICU) settings. Data were analyzed with logistic regression and data mining. Outcomes were survival and death after the initial operation. RESULTS: Overall mortality was 66.2%. Logistic regression identified pH at initial ICU admission (odds ratio: 4.4) and worst partial thromboplastin time from hospital admission to ICU admission (odds ratio: 9.4) as significant. Data mining selected the same factors, and generated a simple algorithm for patient classification. Model accuracy was 83%. CONCLUSION: Inability to correct pH at the conclusion of initial damage-control laparotomy and the worst PTT can be predictive of death. These factors may be useful to identify patients with a high risk of mortality.

Is regionalization of trauma care using telemedicine feasible and desirable?

BACKGROUND: The judgement and skill of an experienced surgeon are crucial ingredients during trauma resuscitation, so that errors of omission, commission, and misprioritization can be avoided. Trauma represents a potential paradigm application for telemedicine owing to its ubiquitous and urgent nature and the limited availability of specialized care. METHODS: A two-phase project was performed, using an Advanced Trauma Life Support (ATLS)-based evaluation tool. In phase I, we reviewed 24 videotaped trauma resuscitations on a single pass. Clinical data thus observed were compared with the clinical chart for agreement. In phase II, we performed real time, remote, initial evaluations of 17 trauma victims. RESULTS: In phase I, 19 of 44 variables had agreement rates >90%, 10 had agreement rates between 70% and 90%. In phase II, agreement rates were similar to those in phase I, with improved accuracy in documenting initial and secondary vital signs and the secondary physical examination. CONCLUSION: Remote evaluation of trauma victims is feasible. Accurate clinical data can be recorded, tasks delegated, and therapeutic measures advised using telemedicine. This can make expert trauma care available to hospitals without advanced trauma systems and potentially reduce cost, prevent unnecessary transfers, and promote early transfer when indicated.

Low use of breast conservation surgery in medically indigent populations.

BACKGROUND: Breast conservation surgery (BCS) with radiation is an acceptable treatment for early-stage breast cancer. METHODS: Data were obtained from hospital cancer registries on women surgically treated for Stage 0 to II breast cancer from 1993 to 1997. Data on 1,747 patients were analyzed for surgical treatment, hospital type (private versus public), disease stage, and ethnic origin. RESULTS: In this study, 34% of women received BCS. Women treated in private hospitals received BCS more often than women treated in public hospitals. Women with stage II disease received BCS less often than women with earlier stage disease. Hospital type (public versus private) and disease stage were strong, independent predictors for use of BCS. When hospital type and disease stage were statistically controlled, no treatment differences across ethnic groups were identified. CONCLUSIONS: Use of BCS in this study was low compared with National Cancer Database statistics. Women treated in publicly funded hospitals and those with stage II disease were significantly less likely to receive BCS.

Pulmonary tractotomy as an abbreviated thoracotomy technique.

BACKGROUND: Operative abbreviated thoracotomy techniques in thoracic trauma include emergency center thoracotomy, ligation of major arterial branches, packing the thoracic cavity for diffuse bleeding, towel clip or Bogota bag closure of the chest, and pulmonary tractotomy. Pulmonary tractotomy with selective vascular ligation was originally described for deep through-and-through lung injuries that did not involve hilar vessels or airways. Pulmonary tractotomy has evolved into use as an abbreviated thoracotomy technique in patients with severe thoracic or multivisceral trauma. As with any operative technique in high-risk patients, specific procedure-related complications may occur and are analyzed herein. The objective of this manuscript is to review the indications, techniques, and results for pulmonary tractotomy in trauma patients requiring abbreviated thoracotomy. METHODS: Medical records were retrospectively reviewed for 30 of 32 consecutive tractotomy patients treated at Ben Taub General Hospital, during a 3-year period. By using a model for logistic regression analysis, the characteristics of each patient and their clinical course were tested for impact on mortality. RESULTS: Seventy percent of patients had at least one intraoperative parameter indicative of acidosis (pH < 7.2), coagulopathy (prothrombin time > 13.8 or partial thromboplastin time > 38.0 seconds), or hypothermia (core temperature < 34 degrees C), and 50% of patients manifested two of these three parameters. The mortality rate among the 30 patients was 17%. Three of the five patients who died were noted to be acidotic, coagulopathic, and hypothermic. Twelve of 25 patients who survived more than 1 day had at least one thoracic complication. There were no late deaths. There was one failed tractotomy and one missed injury. A second thoracotomy was not required for control of a lung injury in any patient. Logistic regression analysis showed that intraoperative blood loss was the only predictive factor for mortality. CONCLUSION: Pulmonary tractotomy is a simple and effective technique in injured patients who require an abbreviated thoracotomy and has an acceptable mortality and complication rate. This follow-up report notes that as definitive therapy, tractotomy continues to allow for direct control of bleeding and air leak and obviates the need for formal resection.

Remote clinical assessment for acute trauma: an initial experience.

Optimal care of the injured patient requires an organized approach, dedicated resources and clinical expertise. Victims of major trauma, however, frequently present to rural and suburban hospitals regardless of whether a dedicated trauma system in place. Immediate consultation by a trauma expert could potentially expedite effective evaluation and management of trauma victims, reducing the occurrence of unnecessary transport and leading to efficient stabilization and transport when needed. Remote assessment of trauma patients must be assesses for feasibility, safety and efficacy before widespread implementation. This project represents the initial steps towards the development of a functional telemedicine system for trauma care.

Low rate of breast conservation surgery in large urban hospital serving the medically indigent.

BACKGROUND: Breast conservation surgery (BCS) with radiation therapy is an acceptable treatment for stage I and II breast carcinoma. The purpose of this study was to measure the use of BCS in a large, urban, university-affiliated hospital serving primarily medically indigent patients. METHODS: A chart review of patients receiving operative treatment for breast carcinoma during 1995 and 1996 was done. Patients with stage I or II disease were selected. Data were analyzed for clinical stage, surgical treatment, age, and ethnic origin. RESULTS: Of patients eligible, only 16% received BCS. There were slight trends for younger women to receive BCS and for decreased use of BCS with stage II disease. No differences in surgical treatment were seen across ethnic groups. CONCLUSIONS: We suggest that poverty, poor education, and cultural differences may play a role in selection of surgical treatment for breast carcinoma. Further investigation is needed to facilitate best treatment.

Prolonged abdominal packing for trauma is associated with increased morbidity and mortality.

Abdominal packing and planned reoperation is a lifesaving technique for temporary control of hemorrhage in severely injured patients. Morbidity and mortality in this group of patients, however, remain significant. It is unclear whether the duration of packing impacts upon outcome. The purpose of this study is to evaluate the abscess, sepsis, and mortality rates associated with duration of abdominal packing. The records of 35 patients treated with abdominal packing between July 1994 and December 1995 who survived to reoperation were retrospectively reviewed. Evaluation included age; sex; mechanism; injuries; Abdominal Trauma Index; duration of packing; survival; and presence of abscess, sepsis or other infections. Patients packed for a total of 72 hours or less had lower abscess, sepsis, and mortality rates than those packed for more than 72 hours. The differences in abscess rate and mortality were statistically significant (P < 0.05). The Abdominal Trauma Index and mechanism of injury were similar for the two groups. Based on these results, we conclude that although abdominal packing is a useful technique in the severely injured patient, it is associated with greater morbidity and mortality when the duration of packing exceeds 72 hours.

The logistics of damage control.

Damage control surgery is labor intensive and consumes extensive materials. The unusual logistic effort surrounding the critically injured patient is an integral part of the challenge of damage control surgery. This article is based on data gleaned from the major series in the literature and on the ongoing experience of the Ben Taub General Hospital with patients undergoing damage control surgery.

Penetrating thoracic vascular injuries.

1. Known injuries to the ascending aorta and arch are exposed by median sternotomy. Known injuries to the descending thoracic aorta can be exposed through a posterolateral thoracotomy. These injuries are more commonly diagnosed through emergent exploration by means of anterolateral thoracotomies. 2. Preoperative arteriography is extremely useful in managing penetrating injuries to the thoracic outlet, as it allows the choice of appropriate incisions for exposure and control. 3. Innominate artery, right common carotid or subclavian artery, as well as left intrathoracic common carotid artery injuries are best managed via median sternotomy with appropriate extension. 4. Left subclavian arteries are managed with high left anterolateral thoracotomy for proximal control combined with supraclavicular incision. 5. Distal subclavian arteries are managed with proximal control by a supraclavicular incision and distal control by an infraclavicular incision. 6. The bypass principle is useful for managing innominate or left carotid artery injuries. Ligation with brachiocephalic bypass can be a simple solution to a complex problem. 7. Soft grafts, fine sutures, and minimal mobilization are the techniques of choice. 8. Adjuncts such as Fogarty balloon catheters, Foley catheters, autotransfusion, shunts, and pulmonary tractotomy can be useful in managing these injuries. 9. Documentation of the preoperative neurovascular status of the patient should be performed, as well as discussion with the patient and the family, if available, of the potential outcome with appropriate documentation in the chart. 10. Rehabilitation services should be involved as appropriate to care for these patients. 11. Ligation is always an option to save the patient's life.

Delayed tension pneumopericardium after thoracotomy for penetrating chest trauma.

Tension pneumopericardium is a rare entity typically described in premature infants requiring positive-pressure ventilation. However, recent reports suggest an increase in its occurrence in adults. A case of delayed postoperative tension pneumopericardium in an adult patient is presented with a review of the history, pathophysiology, presentation, and treatment of this entity.