The traditional classification of neck injuries uses an anatomic description of Zones I through III. The objective of this article was to characterize the association between external wounds and the corresponding internal injuries after penetrating neck trauma to identify the clinical use of the anatomic zones of the neck. Patients who sustained penetrating neck trauma from December 2008 to March 2011 were analyzed. All patients underwent structured clinical examination documenting the external zone where the wound(s) were located. All internal injuries were then correlated with the external wounds. An internal injury was defined as “unexpected” if it was located outside the borders of the neck zone corresponding to the external wound. In total, 146 patients sustaining a penetrating neck injury were analyzed; 126 (86%) male. The mechanism of injury was stab wounds in 74 (51%) and gunshot wounds in 69 (47%). Mean age was 31 years (range, nine to 62 years). Thirty-seven (25%) patients sustained had a total of 50 internal injuries. There was a high incidence of noncorrelation between the location of the external injury and the internal structures that were damaged in patients with hard signs of vascular or aerodigestive injury. The use of the anatomic zones and their role in the workup of penetrating neck injury are questionable.

NA Laryngoscope, 127:110-115, 2017.

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IntroductionPatients with ST elevation myocardial infarction (STEMI) require rapid identification and triage to initiate reperfusion therapy. Walk-in STEMI patients have longer treatment times compared to emergency medical service (EMS) transported patients. While effective triage of large numbers of critically ill patients in the emergency department is often cited as the reason for treatment delays, additional factors have not been explored. The purpose of this study was to evaluate baseline demographic and clinical differences between walk-in and EMS-transported STEMI patients and identify factors associated with prolonged door to balloon (D2B) time in walk-in STEMI patients.MethodsWe performed a retrospective review of 136 STEMI patients presenting to an urban academic teaching center from January 2009 through December 2010. Baseline demographics, mode of hospital entry (walk-in versus EMS transport), treatment times, angiographic findings, procedures performed and in-hospital clinical events were collected. We compared walk-in and EMS-transported STEMI patients and identified independent factors of prolonged D2B time for walk-in patients using stepwise logistic regression analysis.ResultsWalk-in patients (n=51) were more likely to be Latino and presented with a higher heart rate, higher systolic blood pressure, prior history of diabetes mellitus and were more likely to have an elevated initial troponin value, compared to EMS-transported patients. EMS-transported patients (n=64) were more likely to be white and had a higher prevalence of left main coronary artery disease, compared to walk-in patients. Door to electrocardiogram (ECG), ECG to catheterization laboratory (CL) activation and D2B times were significantly longer for walk-in patients. Walk-in patients were more likely to have D2B time >90 minutes, compared to EMS- transported patients; odds ratio 3.53 (95% CI 1.03, 12.07), p=0.04. Stepwise logistic regression identified hospital entry mode as the only independent predictor for prolonged D2B time.ConclusionBaseline differences exist between walk-in and EMS-transported STEMI patients undergoing primary percutaneous coronary intervention (PCI). Hospital entry mode was the most important predictor for prolonged treatment times for primary PCI, independent of age, Latino ethnicity, heart rate, systolic blood pressure and initial troponin value. Prolonged door to ECG and ECG to CL activation times are modifiable factors associated with prolonged treatment times in walk-in STEMI patients. In addition to promoting the use of EMS transport, efforts are needed to rapidly identify and expedite the triage of walk-in STEMI patients.

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Peer review of the quality of care of the medical staff in a healthcare delivery system, properly executed and utilized, can bring about changes that improve the quality and safety of patient care, enhance clinical performance, and augment physician education. Although all healthcare facilities are mandated to conduct peer reviews, the process of how it is conducted, reported, and utilized varies widely. In 2007, our institution, a large public teaching acute care facility, developed and implemented an electronic Medical Staff Peer Review System (MS-PRS) that replaced the existing paper-based system and created a centralized database for all peer review activities. Despite limited resources and mounting known challenges, we have developed and implemented a system that includes 100% mortality reviews, an ongoing random review for reappointment and operative procedures, and morbidity peer reviews. Parallel to the 4-year implementation of the system, we observed a steady, significant downward trend in the medical malpractice claim rate, which can be attributable in part to the implementation of MS-PRS. In this paper, we share our experiences in the development, outcomes, challenges encountered, and lessons learned from MS-PRS and provide our recommendations to similar institutions for the development of such a system.

Subtotal cholecystectomy (SC) is an alternative to open total cholecystectomy (OTC) when variable anatomy or other intraoperative findings preclude safe dissection of Calot's triangle. The objective of this study was to compare the outcomes between SC and OTC in patients with complicated cholecystitis, cases that could not be completed with the original surgical approach and required intraoperative conversion to either SC or OTC. All cases of cholecystectomy converted to SC or OTC from January 2008 to December 2012 were retrospectively identified. Preoperative laboratory values, imaging studies, and clinical demographics were compared between the two groups. The outcome variables analyzed included hospital and intensive care unit length of stay as well as intraoperative complications. In this study, 214 cases of complicated cholecystitis were analyzed; 63 SC and 151 laparoscopic converted to OTC. From the SC group, 46 (73%) were converted to open, 12 (19%) were primary open, and five (8%) were done laparoscopically. There were no statistically significant differences in demographics, preoperative serologic markers, or intraoperative findings ( P > 0.05). Five (3.3%) common bile duct (CBD) injuries occurred in the OTC group, whereas none occurred in the SC group. Overall there were 23 (15.2%) complications in the OTC group and nine (14.3%) in the SC group. The aggregate severe complication rate (CBD injury, vascular injury, gastrointestinal injury) was significantly higher in the OTC group (0.0 to 7.9%, P = 0.036). In conclusion, SC may be considered as a safe alternative in complicated cholecystitis.

Introduction:Human papillomavirus (HPV)-positive and HPV-negative oropharyngeal squamous cell carcinomas (OPSCCs) are 2 distinct cancers, with HPV-positivity conferring a better prognosis. Smoking status is a complicating factor for both patient populations. There have been scattered literature that have reported on incomplete information regarding the profiles of their patient population. Details including age and sex distributions, TNM staging, histology grading, recurrence time and types, death rates, and the direct causes of deaths have been reported incompletely in the literature. Here, based on the experience at our university medical centers, we explored all the details of the important clinical profiles of HPV-negative OPSCC, HPV-positive OPSCC in smokers and nonsmokers.Objective:In this article, we compare detailed clinical profiles of HPV-negative OPSCC and HPV-positive OPSCC in both smokers and nonsmokers. The clinical profiles we elucidated here include patients’ age and sex distribution, general health conditions, histology grading, TNM staging, perineural invasion (PNI), and lymphovascular invasion (LVI), extracapsular extension (ECE), recurrence rate and types, death rate, and direct causes. Specifically, we divided HPV-positive OPSCC into smokers and nonsmokers and compared the different clinical profiles between these groups to give a better idea of the complicating role of smoking in the development of HPV-positive OPSCC.Method:All patients with OPSCC at a tertiary care publicly funded county hospital and a tertiary care university hospital from June 2009-July 2015 were retrospectively reviewed. The attending physicians were the same at both hospitals. The primary outcome measure was posttreatment 2-year follow-up status (locoregional recurrence, distant recurrence, death rate). Other measures included HPV status based on p16 staining, smoking history, age, sex, comorbidities, tumor size, nodal and distant metastasis information, LVI, PNI, ECE, and tumor histology grade.Results:A total of 202 patients with OPSCC were identified. They were categorized into 3 groups: HPV-negative OPSCC group (HPV−), HPV-positive smoker group (HPV+SMK+), and HPV-positive nonsmoker group (HPV+SMK−). Patients of HPV− group are older (61.1 ± 11.6 years) than the other groups on average. The HPV− group has the highest percentage of women (22.7%). The HPV− patients with OPSCC have more comorbidities than the HPV+SMK+ group and the HPV+SMK− group, although there is no statistical difference. Grade 2 tumor is the most common histology grade for HPV− patients with OPSCC, whereas grade 3 is the most common grade for HPV+SMK+ and HPV+SMK− groups. Both PNI and LVI are positive at around 40% for all groups without any significant difference, but ECE is very common for HPV− OPSCC, at 86.7%, which is significantly higher than that of the HPV+SMK+ and HPV+SMK− groups. There was no difference of bilateral neck metastases noticed among different groups. For T staging and N staging, although HPV+SMK− and HPV+SMK+ patients have relat...