Axillary lymph node recurrence following wire-directed sentinel lymph node dissection for breast cancer patients with biopsy-proven axillary metastases prior to neoadjuvant chemotherapy at a safety net medical center.

BACKGROUND: Although sentinel lymph node dissection (SLND) after neoadjuvant chemotherapy (NAC) is feasible, axillary management for patients with pretreatment biopsy-proven axillary metastases and who are clinically node-negative after NAC (ycN0) remains unclear. This retrospective study was performed to determine the rate of axillary lymph node recurrence for such patients who had wire-directed (WD) SLND. METHODS: Patients treated with NAC from 2015 to 2020 had axillary nodes evaluated by pretreatment ultrasound. Core biopsies were done on abnormal nodes, and microclips were placed in nodes during biopsy. For patients with biopsy-proven node metastases who received NAC and were ycN0 by clinical exam, WD SLND was done. Patients with negative nodes on frozen section had WD SLND alone; those with positive nodes had WD SLND plus axillary lymph node dissection (ALND). RESULTS: Of 179 patients receiving NAC, 62 were biopsy-proven node-positive pre-NAC and ycN0 post-NAC. Thirty-five (56%) patients were node-negative on frozen section and had WD SLND alone. Twenty-seven (43%) patients had WD SLND + ALND. Forty-seven patients had postoperative regional node irradiation. With median follow-up of 40 months, there were recurrences in 4 (11%) of 35 patients having WD SLND and 5 (19%) of 27 having WD SLND + ALND, but there was only one axillary lymph node recurrence, identified by CT scan. CONCLUSIONS: Axillary node recurrence was very uncommon after WD SLND for patients who had pretreatment biopsy-proven node metastases and were ypN0 after NAC. These patients would be unlikely to derive clinical benefit from the addition of completion ALND to SLND.

Is the "Death Triad" a Casualty of Modern Damage Control Resuscitation.

BACKGROUND: Principles of damage control laparotomy (DCL) focus on early surgical control of hemorrhage and contamination in addition to damage control resuscitation (DCR) to combat the significant mortality associated with the "death triad" of hypothermia, acidosis, and coagulopathy. We hypothesized that DCL patients managed with DCR would have lower mortality from the death triad than historical studies. METHODS: A 5-y retrospective chart review of all consecutive adult trauma patients presenting to a Level I trauma center who underwent DCL was conducted. Parameters associated with the death triad were evaluated on admission and 24 h after the presentation. Kaplan Meier survival plots were used to compare the components of the death triad. Univariate and multivariate analyses were performed. RESULTS: A total of 149 adult patients were identified. The overall incidence of death triad was 20.8% (n = 31/149). 24-h mortality for all patients was 5.4% (n = 8/149). Kaplan Meier plots showed that 24-h mortality was significantly increased if 3/3 components of the death triad were present (P < 0.05). At 24-h after admission, mortality occurred in 16.6% (n = 5/30) of patients with the death triad. CONCLUSIONS: This study confirms that the 24-h mortality of trauma patients increased with the addition of all three death triad components. The death triad predicted death in 16.6% of patients treated with DCL and DCR at 24 h. Results suggest that the death triad might not be as applicable in the modern era of DCL in combination with DCR. Other factors contributing to in-hospital mortality need to be further elucidated.

Correlation of ride sharing service availability and decreased alcohol-related motor vehicle collision incidence and fatality.

BACKGROUND: Alcohol-related motor vehicle collisions (AR-MVCs) account for ~30% of all US traffic fatalities. Ride-sharing services (RSS) have existed since 2010, but few studies to date have investigated their impact on AR-MVCs. We hypothesized that the availability of RSS would be correlated with a decrease in AR-MVCs at an urban Level I trauma center. METHODS: A retrospective chart review was conducted of all AR-MVC trauma activations at a Level I trauma center from 2012 to 2018. Additional data were gathered from regional governmental traffic and law enforcement databases, including crash incidence, fatalities, and demographics. Data were compared pre- and post-RSS and analyzed using an unpaired t test with p less than 0.05 considered significant. RESULTS: There were 1,474 patients in AR-MVCs during the study period. There was a significant decrease in the annual average proportion of MVCs that were AR-MVCs pre- vs. post-RSS (39% vs. 29%, p = 0.02) as well as a decrease in the average annual incidence of fatal AR-MVCs (11.6 vs. 5, p = 0.02). Subset analysis showed a decrease in AR-MVC incidence in 18- to 29-year-olds (12.7% vs. 7.5%; p = 0.03), which was also demonstrated by data from a local law enforcement database. Availability of RSS was also correlated with a decreased proportion of nighttime AR-MVCs (14.7% vs. 7.6%, p = 0.03) and decreased number of driving while intoxicated (1198.0 ± 78.5 vs. 612.8 ± 137.6, p = <0.01). CONCLUSION: We found that the incidence of both total AR-MVCs and fatal AR-MVCs presenting to our trauma center decreased after the introduction of RSS. Ride-sharing services may play a role in preventing AR-MVCs. Further research is needed to correlate AR-MVC incidence with granular proprietary RSS usage data and to account for any confounding factors. Future studies may identify ways to better utilize RSS availability as a targeted intervention for certain demographic groups to prevent AR-MVCs. LEVEL OF EVIDENCE: Therapeutic/Care Management, Level IV.