Neurological Examination Frequency and Time-to-Delirium After Traumatic Brain Injury

BACKGROUND

Frequent neurological examinations in patients with traumatic brain injury (TBI) disrupt sleep-wake cycles and potentially contribute to the development of delirium.

OBJECTIVE

To evaluate the risk of delirium among patients with TBI with respect to their neuro-check frequencies.

METHODS

A retrospective study of patients presenting with TBI at a single level I trauma center between January 2018 and December 2019. The primary exposure was the frequency of neurological examinations (neuro-checks) assigned at the time of admission. Patients admitted with hourly (Q1) neuro-check frequencies were compared with those who received examinations every 2 (Q2) or 4 (Q4) hours. The primary outcomes were delirium and time-to-delirium. The onset of delirium was defined as the first documented positive Confusion Assessment Method for the Intensive Care Unit score.

RESULTS

Of 1552 patients with TBI, 458 (29.5%) patients experienced delirium during their hospital stay. The median time-to-delirium was 1.8 days (IQR: 1.1, 2.9). Kaplan-Meier analysis demonstrated that patients assigned Q1 neuro-checks had the greatest rate of delirium compared with the patients with Q2 and Q4 neuro-checks ( P < .001). Multivariable Cox regression modeling demonstrated that Q2 neuro-checks (hazard ratio: 0.439, 95% CI: 0.33-0.58) and Q4 neuro-checks (hazard ratio: 0.48, 95% CI: 0.34-0.68) were protective against the development of delirium compared with Q1. Other risk factors for developing delirium included pre-existing dementia, tobacco use, lower Glasgow Coma Scale score, higher injury severity score, and certain hemorrhage patterns.

CONCLUSION

Patients with more frequent neuro-checks had a higher risk of developing delirium compared with those with less frequent neuro-checks.

Decision Support Tool to Judiciously Assign High-Frequency Neurologic Examinations in Traumatic Brain Injury

INTRODUCTION

Traumatic brain injury (TBI) management includes serial neurologic examinations to assess for changes dictating neurosurgical interventions. We hypothesized hourly examinations are overassigned. We conducted a decision tree analysis to determine an algorithm to judiciously assign hourly examinations.

METHODS

A retrospective cohort study of 1022 patients with TBI admitted to a Level 1 trauma center from January 1, 2019, to December 31, 2019, was conducted. Patients with penetrating TBI or immediate or planned interventions and those with nonsurvivable injuries were excluded. Patients were stratified by whether they underwent an unplanned intervention (e.g., craniotomy or invasive intracranial monitoring). Univariate analysis identified factors for inclusion in chi-square automatic interaction detection technique, classifying those at risk for unplanned procedures.

RESULTS

A total of 830 patients were included, 287 (35%) were assigned hourly (Q1) examinations, and 17 (2%) had unplanned procedures, with 16 of 17 (94%) on Q1 examinations. Patients requiring unplanned procedures were more likely to have mixed intracranial hemorrhage pattern (82% versus 39%; P = 0.001), midline shift (35% versus 14%; P = 0.023), an initial poor neurologic examination (Glasgow Comas Scale ≤8, 77% versus 14%; P < 0.001), and be intubated (88% versus 17%; P < 0.001). Using chi-square automatic interaction detection, the decision tree demonstrated low-risk (2% misclassification) and excellent discrimination (area under the curve = 0.915, 95% confidence interval 0.844-0.986; P < 0.001) of patients at risk of an unplanned procedure. By following the algorithm, 167 fewer patients could have been assigned Q1 examinations, resulting in an estimated 6012 fewer examinations.

CONCLUSIONS

Using a 4-factor algorithm can optimize the assignment of neuro examinations and substantially reduce neuro examination burden without sacrificing patient safety.

Time is domain: factors affecting primary fascial closure after trauma and non-trauma damage control laparotomy (data from the EAST SLEEP-TIME multicenter registry)

PURPOSE

Damage control laparotomy (DCL) is used for both traumatic and non-traumatic indications. Failure to achieve primary fascial closure (PFC) in a timely fashion has been associated with complications including sepsis, fistula, and mortality. We sought to identify factors associated with time to PFC in a multicenter retrospective cohort.

METHODS

We reviewed retrospective data from 15 centers in the EAST SLEEP-TIME registry, including age, comorbidities (Charlson Comorbidity Index [CCI]), small and large bowel resection, bowel discontinuity, vascular procedures, retained packs, number of re-laparotomies, net fluid balance after 24 h, trauma, and time to first takeback in 12-h increments to identify key factors associated with time to PFC.

RESULTS

In total, 368 patients (71.2% trauma, of which 50.6% were penetrating, median ISS 25 [16, 34], with median Apache II score 15 [11, 22] in non-trauma) were in the cohort. Of these, 92.9% of patients achieved PFC at 60.8 ± 72.0 h after 1.6 ± 1.2 re-laparotomies. Each additional re-laparotomy reduced the odds of PFC by 91.5% (95%CI 88.2-93.9%, p < 0.001). Time to first re-laparotomy was highly significant (p < 0.001) in terms of odds of achieving PFC, with no difference between 12 and 24 h to first re-laparotomy (ref), and decreases in odds of PFC of 78.4% (65.8-86.4%, p < 0.001) for first re-laparotomy after 24.1-36 h, 90.8% (84.7-94.4%, p < 0.001) for 36.1-48 h, and 98.1% (96.4-99.0%, p < 0.001) for > 48 h. Trauma patients had increased likelihood of PFC in two separate analyses (p = 0.022 and 0.002).

CONCLUSION

Time to re-laparotomy ≤ 24 h and minimizing number of re-laparotomies are highly predictive of rapid achievement of PFC in patients after trauma- and non-trauma DCL.

LEVEL OF EVIDENCE

2B.

The Efficacy and Safety of Methylnaltrexone for the Treatment of Postoperative Ileus

BACKGROUND

Postoperative ileus (POI) is a surgical complication resulting in increased morbidity and length of stay (LOS). Usual care for POI includes bowel rest and gastric decompression. It has been questioned if methylnaltrexone (MNTX), a peripheral opioid antagonist, could be used as treatment for POI. The purpose of this study was to determine if MNTX is effective and safe for POI treatment.

METHODS

This single-center, retrospective cohort study included patients ⩾ 18 years with a POI. Patients with acute colonic pseudo-obstruction, small bowel obstruction, and gastrointestinal malignancy were excluded. The intervention was MNTX administration. The primary outcome was time to ileus resolution. Secondary outcomes included LOS, duration of nasogastric tube, total parenteral nutrition requirement, and incidence of gastrointestinal perforations.

RESULTS

110 patients were included in the analysis; 28 received MNTX. Time to ileus resolution was 9.9 days for the MNTX group and 11.4 days for the control group (P = .38). Duration of gastric decompression was 4.6 days for the MNTX group and 4.2 days for the control group (P = .71). Length of stay was 19.9 days for the MNTX group and 19.7 days for the control group (P = .96). The percentage of TPN requirement was 17.9% in the MNTX group and 22.0% in the control group (P = .65). No gastrointestinal perforations were observed in either group.

CONCLUSION

For the treatment of POI, MNTX did not significantly reduce time to resolution of ileus, LOS, duration of gastric decompression, or TPN requirements. However, no gastrointestinal perforations were seen, indicating that MNTX may be safely used in these patients.

Continuous Intrathecal Morphine Infusion for Pain Management in a Polytrauma Patient: A Case Report

Polytrauma patients are at high risk for neurologic complications as a result of the primary mechanism of their trauma and/or delirium caused by subsequent pain, sedatives and analgesic exposure, sleep disturbances, infections, metabolic derangements, organ dysfunctions, withdrawal syndromes, or other factors. The high prevalence of delirium within trauma intensive care units increases risks for both patients and providers and is associated with worsened patient outcomes. This case report explains the rationale and utilization of continuous intrathecal morphine administration to improve pain control while reducing and eliminating intravenous (IV) analgesics and sedatives to enable wakefulness in a polytrauma patient with refractory agitated delirium.

Complication to consider: delayed traumatic hemothorax in older adults

Background

Emerging evidence suggests older adults may experience subtle hemothoraces that progress over several days. Delayed progression and delayed development of traumatic hemothorax (dHTX) have not been well characterized. We hypothesized dHTX would be infrequent but associated with factors that may aid prediction.

Methods

We retrospectively reviewed adults aged ≥50 years diagnosed with dHTX after rib fractures at two level 1 trauma centers (March 2018 to September 2019). dHTX was defined as HTX discovered ≥48 hours after admission chest CT showed either no or ‘minimal/trace’ HTX. Two blinded, board-certified radiologists reviewed inpatient chest imaging and classified injury patterns according to Chest Wall Injury Society (CWIS) taxonomy. Descriptive analysis was performed for demographic and hospitalization characteristics.

Results

We identified 14 patients with pooled dHTX rate of 1.3%. After initial chest CT negative for concerning hemothoraces, the patients did not undergo follow-up imaging until new symptoms (shortness of breath, chest pain) developed: eight (57%) were not diagnosed until after discharge from initial hospitalization (mean (range): 9 (2–20) days after discharge). Aspirin and/or anticoagulants were involved in fewer than half of cases (43%). According to CWIS taxonomy, all patients had a series of posterolateral fractures with at least one offset or displaced fracture, and an average of six consecutive rib fractures. All patients underwent tube thoracostomy and six patients (42%)—all aged <65—underwent operative interventions.

Discussion

Preliminary data suggest older adults with rib fractures may be at risk of experiencing delayed progression of trace hemothoraces or a delayed presentation of hemothoraces. Asymptomatic progression or readmission to other services/hospitals likely occurs and true dHTX rates are likely higher. Our preliminary findings suggest a possible anatomic explanation for severe chest wall injury patterns’ association with dHTX. Further characterization and capturing the true incidence of dHTX first requires wider recognition of this complication.

Association of Coworker Reports About Unprofessional Behavior by Surgeons With Surgical Complications in Their Patients

Importance

For surgical teams, high reliability and optimal performance depend on effective communication, mutual respect, and continuous situational awareness. Surgeons who model unprofessional behaviors may undermine a culture of safety, threaten teamwork, and thereby increase the risk for medical errors and surgical complications.

Objective

To test the hypothesis that patients of surgeons with higher numbers of reports from coworkers about unprofessional behaviors are at greater risk for postoperative complications than patients whose surgeons generate fewer coworker reports.

Design, Setting, and Participants

This retrospective cohort study assessed data from 2 geographically diverse academic medical centers that participated in the National Surgical Quality Improvement Program (NSQIP) and recorded and acted on electronic reports of safety events from coworkers describing unprofessional behavior by surgeons. Patients included in the NSQIP database who underwent inpatient or outpatient operations at 1 of the 2 participating sites from January 1, 2012, through December 31, 2016, were eligible. Patients were excluded if they were younger than 18 years on the date of the operation or if the attending surgeon had less than 36 months of monitoring for coworker reports preceding the date of the operation. Data were analyzed from August 8, 2018, through April 9, 2019.

Exposures

Coworker reports about unprofessional behavior by the surgeon in the 36 months preceding the date of the operation.

Main Outcomes and Measures

Postoperative surgical or medical complications, as defined by the NSQIP, within 30 days of the operation.

Results

Among 13 653 patients in the cohort (54.0% [7368 ] female; mean [SD] age, 57 [16] years) who underwent operations performed by 202 surgeons (70.8% [143] male), 1583 (11.6%) experienced a complication, including 825 surgical (6.0%) and 1070 medical (7.8%) complications. Patients whose surgeons had more coworker reports were significantly more likely to experience any complication (0 reports, 954 of 8916 [10.7%]; ≥4 reports, 294 of 2087 [14.1%]; P < .001), any surgical complication (0 reports, 516 of 8916 [5.8%]; ≥4 reports, 159 of 2087 [7.6%]; P < .01), or any medical complication (0 reports, 634 of 8916 [7.1%]; ≥4 reports, 196 of 2087 [9.4%]; P < .001). The adjusted complication rate was 14.3% higher for patients whose surgeons had 1 to 3 reports and 11.9% higher for patients whose surgeons had 4 or more reports compared with patients whose surgeons had no coworker reports (P = .05).

Conclusions and Relevance

Patients whose surgeons had higher numbers of coworker reports about unprofessional behavior in the 36 months before the patient's operation appeared to be at increased risk of surgical and medical complications. These findings suggest that organizations interested in ensuring optimal patient outcomes should focus on addressing surgeons whose behavior toward other medical professionals may increase patients' risk for adverse outcomes.

Transfusion rates in emergency general surgery: high but modifiable

BACKGROUND

Transfusion of red blood cells (RBC) increases morbidity and mortality, and emergency general surgery (EGS) cases have increased risk for transfusion and complication given case complexity and patient acuity. Transfusion reduction strategies and blood-conservation technology have been developed to decrease transfusions. This study explores whether transfusion rates in EGS have decreased as these new strategies have been implemented.

METHODS

This is a retrospective review of the American College of Surgeons' National Surgical Quality Improvement Program (ACS NSQIP) data from three academic medical centers. Operations performed by general surgeons on adults (aged ≥18 years) were selected. Data were analyzed from two periods: 2011-2013 and 2014-2016. Cases were grouped by the first four digits of the primary procedure Current Procedural Terminology code. Transfusion was defined as any RBC transfusion during or within 72 hours following the operation. Composite morbidity was defined as any NSQIP complication within 30 days following the operation.

RESULTS

Overall general surgery transfusion rates decreased from 6.4% to 4.8% from period 1 to period 2 (emergent: 16.6%-11.5%; non-emergent 4.9%-3.7%; Fisher's exact p values <0.001). Among patients transfused, the number of units received decreased slightly (median 2 U (IQR 2-3) to median 2 U (IQR 1-3), Mann-Whitney U test p=0.005). Morbidity decreased (overall: 13.8%-12.3%, p=0.001; emergent: 26.3%-20.6%, p<0.001) while mortality did not change.

DISCUSSION

Rates of RBC transfusion decreased in both emergent and non-emergent cases. Efforts to reduce transfusion may have been successful in the EGS population. Morbidity improved over the time periods while mortality was unchanged.

LEVEL OF EVIDENCE

Level III.

Use of Unsolicited Patient Observations to Identify Surgeons With Increased Risk for Postoperative Complications

Importance

Unsolicited patient observations are associated with risk of medical malpractice claims. Because lawsuits may be triggered by an unexpected adverse outcome superimposed on a strained patient-physician relationship, a question remains as to whether behaviors that generate patient dissatisfaction might also contribute to the genesis of adverse outcomes themselves.

Objective

To examine whether patients of surgeons with a history of higher numbers of unsolicited patient observations are at greater risk for postoperative complications than patients whose surgeons generate fewer such unsolicited patient observations.

Design, Setting, and Participants

This retrospective cohort study used data from 7 academic medical centers participating in the National Surgical Quality Improvement Program and the Vanderbilt Patient Advocacy Reporting System from January 1, 2011, to December 31, 2013. Patients older than 18 years included in the National Surgical Quality Improvement Program who underwent inpatient or outpatient operations at 1 of the participating sites during the study period were included. Patients were excluded if the attending surgeon had less than 24 months of data in the Vanderbilt Patient Advocacy Reporting System preceding the date of the operation. Data analysis was conducted from June 1, 2015, to October 20, 2016.

Exposures

Unsolicited patient observations for the patient's surgeon in the 24 months preceding the date of the operation.

Main Outcomes and Measures

Postoperative surgical or medical complications as defined by the National Surgical Quality Improvement Program within 30 days of the operation of interest.

Results

Among the 32 125 patients in the cohort (13 230 men, 18 895 women; mean [SD] age, 55.8 [15.8] years), 3501 (10.9%) experienced a complication, including 1754 (5.5%) surgical and 2422 (7.5%) medical complications. Prior unsolicited patient observations for a surgeon were significantly associated with the risk of a patient having any complication (odds ratio, 1.0063; 95% CI, 1.0004-1.0123; P = .03), any surgical complication (odds ratio, 1.0104; 95% CI, 1.0022-1.0186; P = .01), any medical complication (odds ratio, 1.0079; 95% CI, 1.0009-1.0148; P = .03), and being readmitted (odds ratio, 1.0088, 95% CI, 1.0024-1.0151; P = .007). The adjusted rate of complications was 13.9% higher for patients whose surgeon was in the highest quartile of unsolicited patient observations compared with patients whose surgeon was in the lowest quartile.

Conclusions and Relevance

Patients whose surgeons have large numbers of unsolicited patient observations in the 24 months prior to the patient's operation are at increased risk of surgical and medical complications. Efforts to promote patient safety and address risk of malpractice claims should continue to focus on surgeons' ability to communicate respectfully and effectively with patients and other medical professionals.

Feeding the Open Abdomen

BACKGROUND

The purpose of this study was to determine if early enteral nutrition improves outcome for trauma patients with an open abdomen (OA).

METHODS

Retrospective review was used to identify 78 patients who required an OA for >or=4 hospital days, survived, and had available nutrition data. Demographic data and nutrition data comprising enteral nutrition initiation day and daily % target goal were collected. Patients were divided into 2 groups: early enteral feeding (EEN), initiated <or=4 days within celiotomy; and late enteral feeding (LEN; >4 days). Outcomes included infectious complications, early closure of the abdominal cavity (<8 days from original celiotomy), and fistula formation.

RESULTS

Fifty-three of 78 (68%) patients were men, with a mean age of 35 years; 74% had blunt trauma. Forty-three of 78 (55%) patients had EEN, whereas 35 of 78 (45%) had LEN. There was no difference with respect to demographics, injury severity, or infectious complication rates. Thirty-two of 43 (74%) patients with EEN had early closure of the abdominal cavity, whereas 17 of 35 (49%) patients with late feeding had early closure (p = .02). Four of 43 (9%) patients with EEN demonstrated fistula formation, whereas 9 of 35 (26%) patients with late feeding formed fistulae (p = .05). The EEN group had lower hospital charges (p = .04) by more than $50,000.

CONCLUSIONS

EEN in the OA was associated with (1) earlier primary abdominal closure, (2) lower fistula rate, (3) lower hospital charges.

Safety and Efficacy of Thoracostomy in the Air Medical Environment

OBJECTIVE

The use of thoracostomy to treat tension pneumothorax is a core skill for prehospital providers. Tension pneumothoraces are potentially lethal and are often encountered in the prehospital environment.

METHODS

The authors reviewed the prehospital electronic medical records of patients who had undergone finger thoracostomy (FT) or tube thoracostomy (TT) while under the care of air medical crewmembers. Demographic data were obtained along with survival and complications.

RESULTS

During the 90-month data period, 250 patients (18 years of age or older) underwent FT/TT, with a total of 421 procedures performed. The mean age of patients was 44.8 years, with 78.4% being male and 21.6% being female; 98.4% of patients had traumatic injuries. Cardiopulmonary resuscitation was required in 65.2% of patients undergoing FT/TT; 34.8% did not require cardiopulmonary resuscitation. Thirty percent of patients exhibited clinical improvement such as increasing systolic blood pressure, oxygen saturation, improved lung compliance, or a release of blood or air under tension. Patients who experienced complications such as tube dislodgement or empyema made up 3.4% of the cohort.

CONCLUSION

The results of this study suggest that flight crews can use FT/TT in their practice on patients with actual or potential pneumothoraces with limited complications and generate clinical improvement in a subset of patients.

Up Close and Personal: A Statewide Collaborative's Effort to Get Individual Surgeon Quality Improvement Data to the Practitioner

Ranking of surgeons and hospitals focuses on procedure volume and hospitality. The National Surgical Quality Improvement Program provides vetted outcomes of surgical quality and therefore can direct improvement. Our statewide collaborative's analysis creates personalized surgeon data to drive quality improvement. Statewide National Surgical Quality Improvement Program data generated specific measures from 103,656 general/vascular cases and identified individual surgeon's outcome of occurrences and length of procedure. We assumed a normal distribution and called the top 2.5 per cent as exemplars and the bottom 2.5 per cent as outliers. For length of operation, a standard duration was calculated, and identified outliers as longer than the 95th percentile of the upper confidence interval/procedure. Since 2009, sharing best practice reduced statewide mortality rate by 31.5 per cent and postoperative morbidity by 33.3 per cent. For length of surgery, long outliers have more complications (urinary tract infection, organ space/surgical site infection, sepsis, septic shock, prolonged intubation, pneumonia, deep venous thrombosis, deep incisional infection, and wound disruption). No significant trends in surgeon performance were seen over 24 months. A statewide collaborative has resulted in substantial risk-adjusted reductions in surgical morbidity and mortality. These results of the individual surgeon demonstrate best practices are shared, a proven tool for improvement in our collaborative.

Up Close and Personal: A Statewide Collaborative's Effort to Get Individual Surgeon Quality Improvement Data to the Practitioner

Ranking of surgeons and hospitals focuses on procedure volume and hospitality. The National Surgical Quality Improvement Program provides vetted outcomes of surgical quality and therefore can direct improvement. Our statewide collaborative's analysis creates personalized surgeon data to drive quality improvement. Statewide National Surgical Quality Improvement Program data generated specific measures from 103,656 general/vascular cases and identified individual surgeon's outcome of occurrences and length of procedure. We assumed a normal distribution and called the top 2.5 per cent as exemplars and the bottom 2.5 per cent as outliers. For length of operation, a standard duration was calculated, and identified outliers as longer than the 95th percentile of the upper confidence interval/procedure. Since 2009, sharing best practice reduced statewide mortality rate by 31.5 per cent and postoperative morbidity by 33.3 per cent. For length of surgery, long outliers have more complications (urinary tract infection, organ space/surgical site infection, sepsis, septic shock, prolonged intubation, pneumonia, deep venous thrombosis, deep incisional infection, and wound disruption). No significant trends in surgeon performance were seen over 24 months. A statewide collaborative has resulted in substantial risk-adjusted reductions in surgical morbidity and mortality. These results of the individual surgeon demonstrate best practices are shared, a proven tool for improvement in our collaborative.

Traumatic brain injury-related attention deficits: treatment outcomes with lisdexamfetamine dimesylate (Vyvanse)

BACKGROUND AND OBJECTIVES

Attention deficits are often among the most persistent and debilitating impairments resulting from traumatic brain injury (TBI). This study examined the effects of lisdexamfetamine dimesylate (Vyvanse) in treating attention deficits due to moderate-to-severe TBI. It was the first study of lisdexamfetamine dimesylate with this population and, in fact, was the first controlled trial in this area examining a stimulant medication option other than methylphenidate.

METHODS

This was a 12-week, randomized, double-blind, placebo-controlled, cross-over trial. A total of 22 rigorously selected cases were enrolled, 13 of whom completed the trial. They were 16-42 years of age and had newly acquired attention deficits persisting for 6-34 months post-injury. They were assessed on a broad range of neuropsychological and behavioural measures at baseline, 6-weeks and at 12-weeks.

RESULTS AND CONCLUSIONS

Positive treatment effects were found involving selective measures of sustained attention, working memory, response speed stability and endurance and in aspects of executive functioning. No major problems with safety or tolerability were observed. Some moderating treatment effects were found from a broad range of pre-treatment subject characteristics and injury variables examined. Avenues for further research and treatment applications in this area are discussed.

The success of traumatic brain injury registry outreach

BACKGROUND

Traumatic brain injury (TBI) affects a large percentage of the US population. Survivors are under-served and recognized. The current mechanisms to contact patients and provide access to needed services appear ineffective.

OBJECTIVE

To review the effectiveness of current TBI outreach using registries.

METHODS

This study reviewed practices of the local TBI programme containing a registry utilized for outreach. Then, using a standardized questionnaire focusing on the TBI registry structure and its follow-up techniques, self-proclaimed registries were contacted and compared across the nation.

RESULTS

Twelve additional TBI programmes were contacted. Eight others had actual registries used for follow-up. The principal mechanism was postal mail. Mail response rates varied from 0.54-25%. Programmes were limited by funding, staffing and access to contact information.

CONCLUSION

Postal mail has not been a successful follow-up method for TBI registries. New structuring of letters and alternative contact techniques are needed. Improved access to those individuals with TBI's contact information and funding would likely also aid programmes managing this public health epidemic.

Tennessee emergency hand care distributions and disparities: Emergent hand care disparities

BACKGROUND

Hand trauma is the most frequently treated injury in emergency departments, but presently there is a crisis of insufficient emergency coverage. This study evaluates the discrepancy of emergent and elective hand care trends based on socioeconomic factors in the state of Tennessee.

METHODS

We identified 119 hospitals in Tennessee that contained operating and emergency room facilities. Of these, 111 hospitals participated in a survey to determine the availability of elective and emergency hand surgery. Wilcoxon rank-sum test or permutation chi-square test and logistic regression were used to analyze reported measures.

RESULTS

Our results revealed that hospitals in counties with the lowest per capita income and median household income are less likely to have hand specialists or offer hand call. There are also significantly fewer hospitals that have hand specialists and offer hand call that are located in medically underserved areas. In the state of TN, level 1 trauma facilities are required by the Tennessee Department of Health to have staffed hand specialists and 24/7 hand call. Our study revealed that while 7/8 (87.5 %) level 1 trauma facilities have hand specialists, only 2/8 (25 %) provide 24/7 hand specialist call.

CONCLUSION

Our results strongly suggest the presence of a health care disparity for hand trauma in counties with a low income and in medically underserved areas.

Acellular dermal allograft for ventral hernia repair in the compromised surgical field

A ventral hernia and a contaminated surgical field are a difficult surgical combination. We hypothesize that acellular human dermis (AHD) can be a suitable biological tissue alternative in the repair of a ventral hernia. The study involved a retrospective review of the use of AHD in the repair of ventral hernia from 2001-2004. Inclusion criteria included a ventral hernia repair in a clean-contaminated (CC) or contaminated-dirty (CD) surgical field. The primary outcome of the study was wound infection and mesh removal. Patients were stratified into CC and CD, and management of a wound infection [medically managed (MM) or surgically managed (SM)]. Seventy-five patients met the study criteria. The most common comorbidity was hypertension (45.3%). There was one death in the study (from multiple organ dysfunction syndrome). The overall wound infection rate was 33.3 per cent: 11 MM (14.7%) and 14 SM (18.7%). The average length of stay was 16.7 days (+/-20.8) with a mean follow-up of 275 (+/-209) days. Subgroup analysis: CC (n = 64) had 9 wound infections that were MM (14.1%) and 12 wound infections that were SM (18.8%); CD (n = 11) had 2 wound infections that were MM (18.2%) and 2 wound infections that were SM (18.2%). Five of 14 SM (35.7%) wound infections required removal of the mesh. Wound infection in the contaminated surgical field occurred 33.3 per cent of the time. Some (18.7%) of the cases required SM management, and 35.7 per cent of these required removal of the AHD.

Acellular Dermal Allograft for Ventral Hernia Repair in the Compromised Surgical Field

A ventral hernia and a contaminated surgical field are a difficult surgical combination. We hypothesize that acellular human dermis (AHD) can be a suitable biological tissue alternative in the repair of a ventral hernia. The study involved a retrospective review of the use of AHD in the repair of ventral hernia from 2001–2004. Inclusion criteria included a ventral hernia repair in a clean-contaminated (CC) or contaminated-dirty (CD) surgical field. The primary outcome of the study was wound infection and mesh removal. Patients were stratified into CC and CD, and management of a wound infection [medically managed (MM) or surgically managed (SM)]. Seventy-five patients met the study criteria. The most common comorbidity was hypertension (45.3%). There was one death in the study (from multiple organ dysfunction syndrome). The overall wound infection rate was 33.3 per cent: 11 MM (14.7%) and 14 SM (18.7%). The average length of stay was 16.7 days (±20.8) with a mean follow-up of 275 (±209) days. Subgroup analysis: CC (n = 64) had 9 wound infections that were MM (14.1%) and 12 wound infections that were SM (18.8%); CD (n = 11) had 2 wound infections that were MM (18.2%) and 2 wound infections that were SM (18.2%). Five of 14 SM (35.7%) wound infections required removal of the mesh. Wound infection in the contaminated surgical field occurred 33.3 per cent of the time. Some (18.7%) of the cases required SM management, and 35.7 per cent of these required removal of the AHD.

The early work-up for isolated ligamentous injury of the cervical spine: does computed tomography scan have a role?

BACKGROUND

Helical computed tomography (HCT) scan is the preferred modality for diagnosing fractures of the cervical spine in blunt trauma. We hypothesize that HCT can be used as a screening tool for isolated ligamentous injury (LI) in blunt trauma.

METHODS

A prospective, consecutive series study design was used to include patients that could not have their cervical spine cleared clinically. All patients underwent HCT (occiput-T1) and plain radiographs (PR) with five views of the cervical spine. Patients with clinical or radiographic abnormalities without fracture underwent cervical magnetic resonance imaging (MRI). Demographic and outcome data were collected. The attending radiologist's interpretation was used for clinical management. Three neuroradiologists in a blinded fashion re-reviewed the studies (HCT, PR, and MRI) of the MRI subgroup.

RESULTS

One thousand five hundred seventy-seven patients met the study criteria. Two hundred seventy-eight had 416 cervical spine fractures. PR failed to identify 299 of 416 (72%) cervical spine fractures in 208 of 278 (74.8%) patients. Of the 1,299 (82%) patients who had no fracture, 85 (6.5%) required an MRI. The mean time from admission to MRI was 3 days for the LI subgroup. Of these, 21 of 85 (25%) had LI by MRI. Seven of 21 (33.3%) patients had an abnormal HCT versus 3 of 21 (14.3%) patients who had an abnormal PR. Four of 85 (4.7%) patients had spinal cord injury without radiographic abnormality. One (1.2%) patient required surgical stabilization of LI, as seen on all studies performed (PR, HCT, and MRI). Sensitivities for PR and HCT for LI were 16% and 32%, respectively. Negative predictive values for PR and HCT for LI were 74% and 78%, respectively. Measurements of interrater reliability for MRI, HCT, and PR had kappa values of 0.60, 0.14, and 0.41, respectively.

CONCLUSION

HCT is the most sensitive, specific, and cost-effective modality for screening the cervical spine bony injuries, but it is not an effective modality for screening for cervical LI. MRI is clearly superior to HCT for LI. The indications for MRI include abnormalities on HCT, neurologic deficits, cervical pain or tenderness on examination, or the inability to clear the cervical spine in the obtunded patient. With the current state of the art technology, we have redefined the definition of spinal cord injury without radiographic abnormality to include spinal cord injuries without boney injuries or LI.

Reduced mortality rate in patients with severe traumatic brain injury treated with brain tissue oxygen monitoring

Object. An intracranial pressure (ICP) monitor, from which cerebral perfusion pressure (CPP) is estimated, is recommended in the care of severe traumatic brain injury (TBI). Nevertheless, optimal ICP and CPP management may not always prevent cerebral ischemia, which adversely influences patient outcome. The authors therefore determined whether the addition of a brain tissue oxygen tension (PO2) monitor in the treatment of TBI was associated with an improved patient outcome.

Methods. Patients with severe TBI (Glasgow Coma Scale [GCS] score < 8) who had been admitted to a Level I trauma center were evaluated as part of a prospective observational database. Patients treated with ICP and brain tissue PO2 monitoring were compared with historical controls matched for age, pathological features, admission GCS score, and Injury Severity Score who had undergone ICP monitoring alone. Therapy in both patient groups was aimed at maintaining an ICP less than 20 mm Hg and a CPP greater than 60 mm Hg. Among patients whose brain tissue PO2 was monitored, oxygenation was maintained at levels greater than 25 mm Hg. Twenty-five patients with a mean age of 44 ± 14 years were treated using an ICP monitor alone. Twenty-eight patients with a mean age of 38 ± 18 years underwent brain tissue PO2-directed care. The mean daily ICP and CPP levels were similar in each group. The mortality rate in patients treated using conventional ICP and CPP management was 44%. Patients who also underwent brain tissue PO2 monitoring had a significantly reduced mortality rate of 25% (p < 0.05).

Conclusions. The use of both ICP and brain tissue PO2 monitors and therapy directed at brain tissue PO2 is associated with reduced patient death following severe TBI.

Hepatic angiography in patients undergoing damage control laparotomy

OBJECTIVE

Patients undergoing damage control (DC) laparotomy require intensive and aggressive resuscitation, and may require additional maneuvers to control parenchymal bleeding. Those patients suffering significant liver injury are at high risk for arterial bleeding deep within the liver, and many require hepatic angiography in addition to hepatic packing. We reviewed our experience with hepatic angiography, and sought to determine its safety in the DC population of penetrating and blunt trauma patients.

METHODS

A 3-year (June 1997-May 2000) retrospective review generated 37 DC patients. Patients sustaining hepatic trauma constituted the study group. Patients undergoing angiography in addition to DC laparotomy were compared with the group of patients not undergoing angiography. Data regarding mechanism of injury, patient demographics, extent of hepatic injury, and presence of associated injuries were collected. Physiologic parameters including vital signs at admission, lowest pH and base excess in the operating room, and lactate levels in the intensive care unit, as well as volumes of fluid resuscitation throughout all phases of DC were examined. Complications including death, intra-abdominal processes, acute respiratory distress syndrome and/or multiple organ dysfunction syndrome, and acute renal failure were reviewed.

RESULTS

Nineteen patients (51%) had hepatic trauma and underwent perihepatic packing as a part of DC laparotomy. Eleven had sustained penetrating injury and 8 had blunt injury. There was 1 American Association for the Surgery of Trauma grade I, 5 grade II, 3 grade III, and 10 grade IV injuries. Nine patients in the study population underwent angiography, and eight of these were hepatic artery angiograms. One hepatic angiogram was obtained before operation and seven were obtained in the immediate postoperative period. Six underwent embolization of bleeding hepatic vessels, for a therapeutic liver angiography rate of 75%. There was no statistical difference in physiologic parameters or fluid requirements between the patients who underwent angiography and those who did not. There were no mishaps or complications from angiography or while in the angiography suite.

CONCLUSION

Hepatic angiography is a safe adjunct to the principles of damage control. It has a high therapeutic ratio, with no significant untoward effect in this small study population.

Pattern of invasion and margin assessment in patients with oral tongue cancer

BACKGROUND

Involvement of resection margins and the pattern of tumor invasion are reported to be important predictors of local recurrence and survival in surgically treated patients. In this study we have retrospectively assessed the significance of these two prognostic factors in a relatively homogeneous patient population. Patients and Methods This study was confined to 150 previously untreated patients who had surgery for squamous carcinoma of the oral tongue between 1987 and 1993. There were 82 men and 68 women who ranged in age from 25 to 89 years (median 60 years). Glossectomy was peroral in 129, whereas 8 and 13, respectively, had a cheek flap or mandibulotomy approach. Some form of lymphadenectomy was performed in 109 (73%), and 51 patients (34%) received postoperative radiotherapy. Histologic slides from each primary tumor were reviewed to verify the margin status. In addition, the pattern of invasion was evaluated and graded from 1 to 4, varying from a consistently well-defined, "pushing" border (Grade 1) to diffuse infiltration and cellular dissociation (Grade 4).

RESULTS

Intraoperative frozen section assessment of margins was accurate, whether positive or negative, in 118 of 133 patients (89%). Positive or close margins (within one high-power field) and an endophytic growth pattern were associated with a significant increase in local recurrence (p <0.003 and <0.04, respectively). With higher grades of infiltration (Grade 3 or 4; 82 patients), the tumors tended to be larger and the patients younger. Although the likelihood of nodal involvement and subsequent distant metastasis was significantly greater in those with Grade 3 or grade 4 patterns (p <0.0003 and <0. 01, respectively), there was no impact on local recurrence. Cumulative survival was similar whether or not the surgical margins were involved, but was significantly reduced when the pattern of tumor invasion was of higher grade (p <0.01).

SUMMARY

Frozen section provided reasonably accurate information about margins in our patients, whether taken from the patient or the surgical specimen. Positive margins increased the likelihood of local recurrence, but did not impact on survival because subsequent surgery and/or irradiation controlled tumor recurrence in some patients. Grade 3 or 4 patterns at the tumor/host interface were associated with an increased incidence of nodal and distant metastasis, as well as a significant decrease in survival.

Laryngeal preservation for advanced laryngeal and hypopharyngeal cancers

OBJECTIVE

To compare a single institutional experience with combination chemotherapy and radiation for laryngeal preservation with historical age-, sex-, stage-, and site-matched controls who underwent laryngectomy for cancer of the larynx or hypopharynx.

DESIGN

Fifty-five patients with stage III or IV laryngeal and hypopharyngeal squamous carcinoma were prospectively entered into a protocol to receive three cycles of cisplatin (+/- bleomycin sulfate) and fluorouracil and radiation therapy from 1986 to 1991 (group 1). Following two cycles of chemotherapy, the clinical tumor response was assessed and responders received a third cycle of chemotherapy followed by definitive radiation therapy. Nonresponders underwent surgical salvage. Two patients in the surgical control group were matched to each protocol patient (n = 110, group 2) regarding site, stage, sex, and age (+/- 7 years) without knowledge of patient outcome.

SETTING

A tertiary cancer referral center, The University of Texas M. D. Anderson Cancer Center, Houston.

RESULTS

Following chemotherapy, the tumor response rate for group 1 was complete in 38% and partial in 31%. With a median follow-up of 24 months (group 1) and 37 months (group 2), the Kaplan-Meier 2-year disease-specific survival for group 1 and 2 was 63% and 74%, respectively (P = .251). Among group 1 patients, 67% retained their larynges. Local recurrences were more frequent among the laryngeal preservation group (P = .001), whereas distant metastasis was more frequent among controls (P = .35). Thirty-three percent (18/55) of group 1 patients required total laryngectomy. Examining these subsets of patients showed that of the 67% (n = 37) of patients who retained their larynges, their 2-year survival was 56%, not significantly different from their respective controls (n = 74), 71%. Additionally, 2-year survival among the 18 group 1 patients who required salvage laryngectomy was 75% as compared with 80% for their matched controls (n = 36).

CONCLUSIONS

These results document the results of chemotherapy and radiation therapy in the treatment of patients with advanced laryngeal and hypopharyngeal cancers in preserving the larynx. Although local control is significantly compromised among these patients, there is no compromise in overall survival when combined with prompt surgical salvage.

Evaluation of the dose for postoperative radiation therapy of head and neck cancer: first report of a prospective randomized trial

PURPOSE

This study was designed to determine in a prospective randomized trial the optimal dose of conventionally fractionated postoperative radiotherapy for advanced head and neck cancer in relation to clinical and pathologic risk factors.

METHODS AND MATERIALS

Between January 1983 and March 1991, 302 patients were enrolled on the study. This analysis is based on the first 240 patients entered through September 1989, of whom 221 (92%) had AJC Stage III or IV cancers of the oral cavity, oropharynx, hypopharynx, or larynx. The patients were stratified by postulated risk factors and randomized to one of three dose levels ranging between 52.2 Gy and 68.4 Gy, all given in daily doses of 1.8 Gy. Patients receiving > 57.6 Gy had a field reduction at this dose level such that boosts were only given to sites of increased risk.

RESULTS

The overall crude and actuarial 2-year local-regional recurrence rates were 25.4% and 26%, respectively. Patients who received a dose of < or = 54 Gy had a significantly higher primary failure rate than those receiving > or = 57.6 Gy (p = 0.02). No significant dose response could be demonstrated above 57.6 Gy except for patients with extracapsular nodal disease in the neck in whom the recurrence rate was significantly higher at 57.6 Gy than at > or = 63 Gy. Analysis of prognostic factors predictive of local-regional recurrence showed that the only variable of independent significance was extracapsular nodal disease. However, clusters of two or more of the following risk factors were associated with a progressively increased risk of recurrence: oral cavity primary, mucosal margins close or positive, nerve invasion, > or = 2 positive lymph nodes, largest node > 3 cm, treatment delay greater than 6 weeks, and Zubrod performance status > or = 2. Moderate to severe complications of combined treatment occurred in 7.1% of patients; these were more frequent in patients who received > or = 63 Gy.

CONCLUSION

With daily fractions of 1.7 Gy, a minimum tumor dose of 57.6 Gy to the whole operative bed should be delivered with a boost of 63 Gy being given to sites of increased risk, especially regions of the neck where extracapsular nodal disease is present. Treatment should be started as soon as possible after surgery. Dose escalation above 63 Gy at 1.8 Gy per day does not appear to improve the therapeutic ratio.

Ampicillin-sulbactam vs clindamycin in head and neck oncologic surgery. The need for gram-negative coverage

This study was undertaken to assess whether gram-negative antimicrobial coverage is required in patients undergoing head and neck oncologic surgery. Ampicillin sodium-sulbactam sodium and clindamycin phosphate were compared in a prospective, randomized, parallel, double-blind trial of 212 patients undergoing head and neck procedures involving clean-contaminated wounds. Both antibiotics were given up to 1 hour before surgery and continued at 6-hour intervals after surgery for an additional eight doses. Fourteen infections occurred in the ampicillin-sulbactam-treated group (13.3%) and 29 infections in the clindamycin-treated group (27.1%). From patients receiving clindamycin, 29 gram-negative organisms were isolated, compared with six from those patients receiving ampicillin-sulbactam. This finding supports the need for gram-negative coverage in patients undergoing clean-contaminated head and neck oncologic surgery.

Intraoral soft tissue reconstruction after cancer ablation: a comparison of the pectoralis major flap and the free radial forearm flap

We compared, by retrospective chart review, the free radial forearm flap and the pectoralis major flap in repairing intraoral soft tissue defects resulting from tumor ablation. Statistical significance of differences was determined using Fisher's exact test and chi-square analysis. Fifty-one free flap and 126 musculocutaneous flap transfers were analyzed. The former were used more often for defects in the anterior part of the oral cavity, whereas the latter were used more frequently in the posterior part. Significantly more patients with pectoralis major flap transfers had late-stage (T3 and T4) disease than did those in the free radial forearm flap group (p = 0.004). Also, the complication rate was significantly higher in the pectoralis major flap group (p = 0.01); this was due to differences in the rates of dehiscence, fistula formation, and flap loss. We thus conclude that, despite the need for microsurgery, the free radial forearm flap is at least as reliable as the pectoralis major flap and that the choice of flap should be based on defect considerations rather than on the perceived reliability of the reconstructive method.

Do neuropeptides in the dorsal horn change if the dorsal root ganglion cell death that normally accompanies peripheral nerve transection is prevented?

Peripheral nerve section causes the death of dorsal root ganglion cells and changes in neuroactive peptides in the dorsal horn of the spinal cord. The relationship between these 2 events has not been previously studied, however. One approach would be to prevent sensory cell death and then determine changes in peptide immunoreactivity. To do this, transected rat sciatic nerve stumps were placed in an impermeable silicone tube for one month. The tube was then removed and after 30 additional days the cells were counted. The data indicate that no cell death occurred. We conclude that the sensory cells are first saved due to some factor present in the tube, and then after 30 days, the cells become independent of the tube and its contents. In these same animals, all of the peptides we examined were significantly changed. Four of the peptides, calcitonin gene-related peptide (CGRP), substance P (SP), cholecystokinin octapeptide (CCK) and galanin (GAL) were significantly depleted in the medial L4-L5 superficial dorsal horn, and vasoactive intestinal polypeptide (VIP) was significantly increased. We conclude that there are major changes in spinal peptide systems following peripheral nerve transection even if there is no accompanying death of sensory neurons. Thus we suggest that dramatic central changes in peptide immunoreactivity following peripheral nerve transection are independent of the sensory cell death that usually occurs in response to this injury.

Treatment selection for carcinoma of the base of the tongue

Between 1974 and 1984, 173 patients were treated for squamous cell carcinoma of the tongue base. Fifty-four patients had T1 or T2 primaries, while 115 patients had T3 or T4 tumors (4 were not staged). Lymph node metastasis was present in 120 patients. Early primary tumors treated with surgery or radiotherapy had a control rate of 83% (5 of 6 tumors) and 89% (40 of 45 tumors), respectively. For advanced primary tumors, definitive radiotherapy produced a local control rate of 55% (42 of 76 tumors), compared with 79% (23 of 29 tumors) for surgery and postoperative radiotherapy. If primary control was obtained, the regional failure rate was less than 10%. Tumor growth patterns were predictive of the response to radiotherapy. The primary control rate at 2 years for 21 patients with exophytic tumors was 84% as opposed to 58% for 62 patients with ulcerative-infiltrative tumors (p = 0.04). Radiotherapy is effective for early stage or exophytic tumors, whereas for advanced or deeply invasive tumors combined therapy enhances local control.

Prognostic factors in patients dying of well-differentiated thyroid cancer

While some well-differentiated cancers of the thyroid gland are unusually aggressive, most have a more benign clinical behavior, making it difficult to evaluate factors possibly influencing patient survival such as initial surgical treatment. By studying 135 patients who received their initial surgical therapy at our institution, we have defined the prognostically significant factors. Sixteen patients (11.9%) died of disease during a ten- to 20-year follow-up period. Significant factors associated with death from disease were aged 40 years or older, primary lesion size of 2.5 cm or greater, presence of invasive characteristics, and presence of distant metastases. We recommend total thyroidectomy and postoperative sodium iodide I 131 therapy in patients 40 years of age or older, while suggesting a less aggressive approach may be appropriate in the younger patients.

Squamous cell carcinoma of the soft palate, uvula, and anterior faucial pillar

This retrospective study concerns 188 patients with squamous cell carcinoma of the soft palate, uvula, and anterior faucial pillar treated for cure between 1970 and 1983. Men predominated in the group (1.9:1) and 55% of the patients were between 60 and 70 years old. Mean duration of followup was 56.7 months. TNM stage distribution was 29, 67, 37, and 49 patients for stages I, II, III, and IV respectively; six patients were unstaged because of previous excisional biopsy. Treatment to the primary site consisted of radiotherapy for 150 patients, surgery alone for 28 patients, and combined therapy for 10 patients. Primary control for T stages 1 through 4 was: 91% (31 of 34), 77% (71 of 92), 77% (30 of 39), and 35% (6 of 17), respectively. One hundred twenty-eight patients were N0 at presentation, as compared to 60 patients with regional nodal metastasis. Regional control was obtained in 87.5% of patients with N0 necks and in 76.7% of those with nodal involvement. In patients with primary control, these figures were 89% and 81%. Overall determinant survival was 80% at 2 years, but fell to 67% at 5 years. In addition to advanced tumor stage, the survival rate was reduced by regional lymph node metastasis. Tumor extension to the tongue base diminished survival. Survival was poorer among patients with midline tumors or tumors that extended across the palatine arch (37 patients) than for those with unilateral primary tumors (151 patients) (p less than 0.05). Despite similar T-stage distribution, the incidence of regional nodal metastasis was 49% in the former group, compared with 28% in the latter.(ABSTRACT TRUNCATED AT 250 WORDS)

Salivary epithelial-myoepithelial carcinomas of intercalated ducts: a clinical, electron microscopic, and immunocytochemical study

The salivary epithelial-myoepithelial carcinoma of intercalated duct origin is a distinctive, biologically low-grade carcinoma with a predilection for the parotid gland. Nine examples from the M.D. Anderson Hospital in Houston, Texas, bring the number of published cases to 33. Immunocytochemical (S-100 protein, myosin, and keratin) and electron-optic studies strongly support an active myoepithelial cell participation in the histogenesis of these carcinomas.

Mucinous adenocarcinomas of nose and paranasal sinuses

This study concerns the Clinicopathologic findings for 18 patients with mucinous adenocarcinomas of nose and/or paranasal sinuses. Males in the 5th decade of life predominated in the series. Nasal obstruction, a growing mass in a sinus, or epistaxis were the most frequent complaints. Ten patients had tumors in the maxillary antrum, and the nasal cavity was the site in 5 patients. Histopathologically, the tumors were moderately to well differentiated, with a few poorly differentiated types. Tumor with the solid pattern of growth were anaplastic; these patients had poorer prognoses. For most patients, treatment consisted of radical surgery alone or in combination with radiotherapy. Of 13 patients for whom survival could be adequately evaluated, 7 died from the tumors, 5 are alive and free of disease more than 4 years, and 1 is living with recurrent tumor 14 months after diagnosis.

Intravenous hyperalimentation in patients with head and neck cancer

Intravenous hyperalimentation was utilized to support nutritionally 23 malnourished patients with major head and neck tumors during surgical treatment, radiotherapy, or the convalescent period. Fifteen patients were treated during the perioperative period and 12 survived. Six patients received convalescent nutritional support successfully 4 to 24 months following operation or radiation treatment. Two patients received treatment with hyperalimentation throughout a protracted course of radiation therapy. Weight gain, wound healing, and recovery were achieved in all but 3 patients. Subclavian vein thrombosis occurred in 1 patient, and catheter-related sepsis occurred in 2 patients. Otherwise, hyperalimentation was safe and efficacious in the debilitated patients. These patients may now become acceptable risks for surgical treatment or radiation therapy by nutritional repletion with intravenous hyperalimentation.