Heterotopic ossification in high-grade open fractures sustained in combat: risk factors and prevalence.

OBJECTIVES: To determine the prevalence and identify the risk factors for heterotopic ossification (HO) formation in high-grade open fractures sustained during combat and to report on the results of HO excision. DESIGN: Retrospective. SETTING: United States Army level-1 trauma center. PATIENTS/PARTICIPANTS: Seventy-six consecutive patients with 91 combat-related open Gustilo and Anderson type II and higher fractures were identified from March 1, 2003, through January 30, 2005. Fifty-nine patients with 71 fractures met criteria for study inclusion. MAIN OUTCOME MEASUREMENTS: Fractures were categorized into HO-present and HO-absent groups based on radiographic imaging. Risk factors such as injury mechanism, injury severity score (ISS), Gustilo and Anderson type, injury location, closed head injury, burn, and infection were compared between the groups. RESULTS: HO was present in 27 of 71 open fractures (38.1%). Variables associated with HO formation included ISS (p = 0.02) and injury location although infection and use of negative pressure therapy were not. Ten of 27 fractures with HO underwent excision. HO did not occur or was mild in 25 tibiae. CONCLUSIONS: HO is a common sequela of high-grade open fractures sustained in combat. High ISS and injury location to the shoulder, hip, and femur are risk factors for HO formation. The most common regions for HO excision were the elbow, forearm, and hip with mixed results. Importantly, HO did not seem to be a complication of open high-grade tibia fractures. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Evaluation of the Patient-Generated Subjective Global Assessment (PG-SGA) as a predictor of febrile neutropenia in gynecologic cancer patients receiving combination chemotherapy: a pilot study.

OBJECTIVE: Determine if pre-treatment Patient-Generated Subjective Global Assessment (PG-SGA) predicts febrile neutropenia (FN) in gynecologic cancer patients receiving primary combination chemotherapy. METHODS: Following IRB approval, clinicopathologic variables, pre-treatment laboratory values and PG-SGA were recorded from eligible patients. Bone marrow toxicity (CTC 3.0) divided groups of patients: (1) No grade 3 or 4 neutropenia, (2) grade 3 or 4 neutropenia, (3) FN. Statistical analysis with Kruskal-Wallis one-way analysis of variance and a receiver operating characteristic (ROC) curve were performed. RESULTS: 58 patients met study inclusion: 25 in group 1, 28 in group 2, and 5 in group 3. Mean age was 61 and the majority, 42 (72%), had ovarian cancer. Median PG-SGA scores were: 6 (group 1) vs. 7 (group 2) vs. 14 (group 3) (p=0.019). Both median albumin: (1) 4.2 vs. (2) 4.0 vs. (3) 3.4 g/dl (p=0.041), and hemoglobin: (1) 12.1 vs. (2) 11.75 vs. (3) 10.6g/dl (p=0.05) differed between the groups. The overall AUC of the ROC curve for PG-SGA was 0.831 ± 0.064 (95% CI=0.706 to 0.956, p=0.015). Using the ROC, selecting a PG-SGA score of 7.5 to be predictive of febrile neutropenia yields a sensitivity of 100% and a specificity of 60%. When the cutoff value is set at 12.5, the specificity improves to 81% while decreasing sensitivity to 80%. CONCLUSIONS: PG-SGA scores were higher for patients experiencing FN and may be a reasonably predictive marker of FN in patients receiving multi-agent primary chemotherapy and likely benefactors of prophylactic GCSF.

Surgically managed stage I endometrial cancer in a low-volume center: outcomes and complications in a military residency program.

OBJECTIVE: The purpose of this study was to compare operative outcomes and complications for patients with endometrial cancer who underwent staging by laparoscopy vs laparotomy in a low-volume facility. STUDY DESIGN: Research was conducted with a retrospective cohort of surgical patients with clinical stage I endometrial cancer from 2004-2009. RESULTS: Eighty-six demographically similar patients (50 laparotomy and 36 laparoscopy) were identified. Laparoscopy had less estimated blood loss (339 vs 558 mL; P = .013) and lower rates of transfusion (5.6% vs 24%; P = .02). Laparoscopy was longer (281 vs 202 minutes; P < .0005) but required a shorter hospital stay (2.2 vs 5.5 days; P < .0005). Laparoscopy patients had fewer overall complications (16.7% vs 32%; P = .11). No differences in final surgical stage or lymph node yields between the groups were present. CONCLUSION: Although a longer procedure, laparoscopy had fewer complications and shorter hospital stays. Prolonged operative time, compared with published experience, is potentially the result of unique factors in our center.

Prevalence of nonalcoholic fatty liver disease and nonalcoholic steatohepatitis among a largely middle-aged population utilizing ultrasound and liver biopsy: a prospective study.

BACKGROUND & AIMS: Prevalence of nonalcoholic fatty liver disease (NAFLD) has not been well established. The purpose of this study was to prospectively define the prevalence of both NAFLD and nonalcoholic steatohepatitis (NASH). METHODS: Outpatients 18 to 70 years old were recruited from Brooke Army Medical Center. All patients completed a baseline questionnaire and ultrasound. If fatty liver was identified, then laboratory data and a liver biopsy were obtained. RESULTS: Four hundred patients were enrolled. Three hundred and twenty-eight patients completed the questionnaire and ultrasound. Mean age (range, 28-70 years) was 54.6 years (7.35); 62.5% Caucasian, 22% Hispanic, and 11.3% African American; 50.9% female; mean body mass index (BMI) (calculated as kg/m(2)) was 29.8 (5.64); and diabetes and hypertension prevalence 16.5% and 49.7%, respectively. Prevalence of NAFLD was 46%. NASH was confirmed in 40 patients (12.2% of total cohort, 29.9% of ultrasound positive patients). Hispanics had the highest prevalence of NAFLD (58.3%), then Caucasians (44.4%) and African Americans (35.1%). NAFLD patients were more likely to be male (58.9%), older (P = .004), hypertensive (P < .00005), and diabetic (P < .00005). They had a higher BMI (P < .0005), ate fast food more often (P = .049), and exercised less (P = 0.02) than their non-NAFLD counterparts. Hispanics had a higher prevalence of NASH compared with Caucasians (19.4% vs 9.8%; P = .03). Alanine aminotransferase, aspartate aminotransferase, BMI, insulin, Quantitative Insulin-Sensitivity Check Index, and cytokeratin-18 correlated with NASH. Among the 54 diabetic patients, NAFLD was found in 74% and NASH in 22.2%. CONCLUSION: Prevalence of NAFLD and NASH is higher than estimated previously. Hispanics and patients with diabetes are at greatest risk for both NAFLD and NASH.

External validation of a virtual reality transurethral resection of the prostate simulator.

PURPOSE: Virtual reality surgical simulation is an emerging technology that may eventually fill the gaps in surgical education created by changes in our medical system. We assessed the construct validity of a commercially available, virtual reality transurethral prostate resection simulator. MATERIALS AND METHODS: Participants performed 2, 5-minute transurethral prostate resection exercises on a standardized virtual reality prostate. Data from the first exercise were discarded. Simulator based metrics from the second exercise were tabulated, including tissue resected in gm, number of cuts, coagulation time, number of coagulation attempts, tissue per cut in gm and blood loss. Complications were recorded. Performance metrics were compared between groups based on urological training level and prior real-world experience with transurethral prostate resection. RESULTS: A total of 35 participants with varied levels of transurethral prostate resection experience completed the exercise. Several performance metrics had statistically significant correlations with urology training level and prior experience with transurethral prostate resection. There was a positive correlation of all measures of experience with mass resected, mass resected per cut and blood loss. Number of cuts correlated significantly with transurethral prostate resection experience in the previous year. Complications were present in most groups with medical students more likely to encounter external urethral sphincter and rectal injuries. CONCLUSIONS: We report the construct validity of a commercially available, virtual reality transurethral prostate resection simulator. The more experienced participants resected more tissue in a more efficient manner but with increased blood loss. Further investigations are needed before the widespread application of transurethral prostate resection simulators for training, certification and accreditation.