BACKGROUND:Prospective studies of surgical stabilization of rib fractures (SSRF) have excluded elderly patients, and no study has exclusively addressed the ≥80-year-old subgroup. We hypothesized that SSRF is associated with decreased mortality in trauma patients 80 years or older. METHODS:Multicenter retrospective cohort study involving eight centers. Patients who underwent SSRF from 2015 to 2020 were matched to controls by study center, age, injury severity score, and presence of intracranial hemorrhage. Patients with chest Abbreviated Injury Scale score less than 3, head Abbreviated Injury Scale score greater than 2, death within 24 hours, and desire for no escalation of care were excluded. A subgroup analysis compared early (0-2 days postinjury) to late (3-7 days postinjury) SSRF. Poisson regression accounting for clustered data by center calculated the relative risk (RR) of the primary outcome of mortality for SSRF versus nonoperative management. RESULTS:Of 360 patients, 133 (36.9%) underwent SSRF. Compared with nonoperative patients, SSRF patients were more severely injured and more likely to receive locoregional analgesia. There were 31 hospital deaths among the entire sample (8.6%). Multivariable regression demonstrated a decreased risk of mortality for the SSRF group, as compared with the nonoperative group (RR, 0.41; 95% confidence interval, 0.24-0.69; p < 0.01). However, SSRF patients were more likely to develop pneumonia, and had an increased duration of both mechanical ventilation and intensive care unit stay. There were no differences in discharge destination, although the SSRF group was less likely to be discharged on narcotics (RR, 0.66; 95% confidence interval, 0.48-0.90; p = 0.01). There was no difference in adjusted mortality between the early and late SSRF subgroups. CONCLUSION:Patients selected for SSRF were substantially more injured versus those managed nonoperatively. Despite this, SSRF was independently associated with decreased mortality. With careful patient selection, SSRF may be considered a viable treatment option in octogenarian/ nonagenarians.
BACKGROUND:Chest computed tomography (CT) scans are important for the management of rib fracture patients, especially when determining indications for surgical stabilization of rib fractures (SSRFs). Chest CTs describe the number, patterns, and severity of rib fracture displacement, driving patient management and SSRF indications. Literature is scarce comparing radiologist versus surgeon rib fracture description. We hypothesize there is significant discrepancy between how radiologists and surgeons describe rib fractures. METHODS:This was an institutional review board-approved, retrospective study conducted at a Level I academic center from December 2016 to December 2017. Adult patients (≥18 years of age) suffering rib fractures with a CT chest where included. Basic demographics were obtained. Outcomes included the difference between radiologist versus surgeon description of rib fractures and differences in the number of fractures identified. Rib fracture description was based on current literature: 1, nondisplaced; 2, minimally displaced (<50% rib width); 3, severely displaced (≥50% rib width); 4, bicortically displaced; 5, other. Descriptive analysis was used for demographics and paired t test for statistical analysis. Significance was set at p = 0.05. RESULTS:Four hundred and ten patients and 2,337 rib fractures were analyzed. Average age was 55.6(±20.6); 70.5% were male; median Injury Severity Score was 16 (interquartile range, 9-22) and chest Abbreviated Injury Scale score was 3 (interquartile range, 3-3). For all descriptive categories, radiologists consistently underappreciated the severity of rib fracture displacement compared with surgeon assessment and severity of displacement was not mentioned for 35% of rib fractures. The mean score provided by the radiologist was 1.58 (±0.63) versus 1.78 (±0.51) by the surgeon (p < 0.001). Radiologists missed 138 (5.9%) rib fractures on initial CT. The sensitivity of the radiologist to identify a severely displaced rib fracture was 54.9% with specificity of 79.9%. CONCLUSION:Discrepancy exists between radiologist and surgeon regarding rib fracture description on chest CT as radiologists routinely underappreciate fracture severity. Surgeons need to evaluate CT scans themselves to appropriately decide management strategies and SSRF indications.
Ipsilateral breast tumor recurrence (IBTR) is a risk after breast conserving surgery, and is traditionally treated with mastectomy. Given the limited literature on outcome after mastectomy for IBTR, we evaluated our long-term data for this group. A retrospective review was conducted using a database of 2101 breast cancer patients at a single institution. Fifty-nine patients underwent breast conserving surgery and experienced an IBTR. Exclusion criteria included repeat lumpectomy or metastatic disease before mastectomy. Patients presented with invasive ductal (58%), invasive lobular (7%), other invasive (11%), or ductal carcinoma in situ (24%). Initial tumors were Tis (24%), T1 (42%), T2 (20%), T3 (2%), or not recorded (12%). IBTR lesions were Tis (20%), T1 (46%), T2 (25%), or T3 (9%). Median follow-up after mastectomy was 4.6 years. Thirteen patients (22%) had post-mastectomy recurrence (PMR), which decreased overall survival ( P = 0.002). PMR was more common with larger IBTR tumors ( P = 0.03), specifically IBTR ≥ T2 ( P = 0.003). Eighty-five per cent of PMR occurred within 2 years of mastectomy. Mastectomy for IBTR remains effective treatment for most patients, but the risk of PMR remains. Patients with IBTR tumors >2 cm have an increased risk of PMR. Strict follow-up should be routine, especially during the first 24 months.
Introduction: Identification of occult hypovolemia in trauma patients at admission can be difficult without additional laboratory evaluation or advanced imaging. We hypothesized that in acute trauma patients, the response of ultrasound-measured minimum inferior vena cava diameter (IVCD MIN ), IVC Collapsibility Index (IVCCI) or minimum internal jugular diameter (IJVD MIN ) or IJV Collapsibility Index (IJVCI) in repeated ultrasound examinations (USA-IVC) during up to 1 hour of standard-of-care intravenous fluid resuscitation would predict 24hour resuscitation intravenous fluid requirements (24FR). Methods: An NTI funded, AAST-MITC group prospective, multi-institutional cohort trial was conducted at 4 Level I Trauma Centers. Major trauma patients were screened in the supine position for an IVCD of 12 mm or IVCCI of 50% or less on the initial FAST examination for enrollment. A second IVCD was obtained 40-60 minutes later, after the patient received standard-of-care fluid resuscitation. Patients whose second measurement IVCD was less than 10mm were deemed Non-Responders (NON-RESP), those at or greater than 10mm were Responders (RESP). Prehospital fluid, initial resuscitation fluid and 24FR were recorded. Demographics, ISS, arterial blood gasses, ICU admission, length-of-stay, interventions and complications were recorded. Means were compared by ANOVA and categorical variables were compared via Chi-square. Receiver-operator characteristic (ROC) curves and gray area analysis were used to compare the IVC and IJV measures and to Base Excess (BE), ISS and other 24FR predictors.Results: There were 4798 patients screened by FAST-IVC, 196 were identified with admission IVCD of 12 mm or IVCCI of 50% or less, 144 were enrolled and had useable Abstract imagery. After 1 hour of standard of care resuscitation, there were 86 RESP and 58 NON-RESP. There were no significant differences between groups in demographics. initial hemodynamics or laboratory measures. NON-RESP had smaller IVCD (6.0mm ± 3.7 vs.14.2mm ± 4.3, p< 0.001) and higher IVCCI 41.7% ± 30.0 vs. 13.2% ± 12.7, p< 0.001) but no significant difference in IJVD or IJVCCI. RESP had significantly greater 24FR than NON-RESP (2503ml ± 1751 vs. 1243ml ± 1130 0.003). ROC analysis indicates IVCD MIN predicted 24FR (AUC= 0.74, C.I.: 0.64-0.84, p<0.001) as did IVCCI (AUC= 0.75, C.I.: 0.65-0.85, p<0.001) not IJVD (AUC= 0.48, C.I.: 0.24-0.60, p=N.S.) or IVCCI (AUC= 0.54, C.I.: 0.42-0.67, p=N.S.) and more predictive than ISS (AUC=0.65, C.I.:0.54-0.76, p=0.007) in predicting 24FR. Conclusion: Ultrasound assessed IVCD MIN and IVCCI but not IJ diameter response to initial major trauma patient resuscitation predicts 24-hour fluid resuscitation requirements.
Introduction Isolated hip fractures (IHF) are common injuries in the elderly. Controversy exists about which hospital service is best suited to manage these patients. We hypothesize that baseline patient severity of illness (SOI) score drives patient outcomes, not the hospital service managing these patients. Methods Retrospective review of all IHF patients from 2014 to 2018 at our Level 1 trauma center. Basic demographics were obtained. Patients were divided into service line they were admitted; surgical vs non-surgical. Primary outcomes included hospital length of stay (HLOS), time to OR, time to VTE prophylaxis, complication rate (defined by the Trauma Quality Improvement Program), 30-day mortality, and readmissions. SOI score (which is DRG-based) was controlled to see if any differences in primary outcomes occurred between cohorts. Chi-square was used for categorical variables and regression analysis for continuous variables. Significance was p \ 0.05. Results A total of 366 total patients were analyzed with the same ISS. A total of 102 were admitted to a surgical service and 264 to a non-surgical service. Average overall age was 80 year, 66.9% were female, and 86% were Caucasian. There was no statistical difference between outcomes when comparing admitting services. Controlling for SOI score, there was no difference between admitting service for outcomes as well. SOI score was a significant predictor for increased HLOS and complication occurrence (p \ 0.001) via regression analysis, with a 6.06-fold increase in complication rate from mild to moderate SOI score (p = 0.001). Conclusion There is no difference in outcomes based on admitting service and process measures. However, the SOI score is perhaps a better predictor of outcomes for isolated hip fracture patients.
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