Bruce Ham

Management and outcome of pneumatosis intestinalis.

BACKGROUND Pneumatosis intestinalis (PI), infiltration of gas into the bowel wall, has traditionally been associated with immediate operative intervention and a high mortality rate. METHODS We retrospectively reviewed the diagnosis and management of pneumatosis in an attempt to characterize the disease, and examined management strategies. RESULTS Ninety-seven patients had a computed tomography (CT) diagnosis of pneumatosis. The location of pneumatosis was as follows: 46% colon, 27% small bowel, 5% stomach, and 7% both small and large bowel. Fourteen patients also had portal venous gas and 6 (43%) of these patients died. Management strategy was non-operative in 52%, operative in 33%, and futile care in 15%. The overall mortality rate was 22% (16% operative, 6% non-operative, and 87% futile). Patients who died had a higher mean APACHE II score (25 vs 11, P <.001). CONCLUSIONS Approximately 50% of patients with pneumatosis can be successfully managed non-operatively. The combination of PI and portal venous gas may confer a higher mortality rate.

Prolonged pain and disability are common after rib fractures

BACKGROUND The contribution of rib fractures to prolonged pain and disability may be underappreciated and undertreated. Clinicians are traditionally taught that the pain and disability of rib fractures resolves in 6 to 8 weeks. METHODS This study was a prospective observation of 203 patients with rib fractures at a level 1 trauma center. Chest wall pain was evaluated by the McGill Pain Questionnaire (MPQ) pain rating index (PRI) and present pain intensity (PPI). Prolonged pain was defined as a PRI of 8 or more at 2 months after injury. Prolonged disability was defined as a decrease in 1 or more levels of work or functional status at 2 months after injury. Predictors of prolonged pain and disability were determined by multivariate analysis. RESULTS One hundred forty-five male patients and 58 female patients with a mean injury severity score (ISS) of 20 (range, 1 to 59) had a mean of 5.4 rib fractures (range, 1 to 29). Forty-four (22%) patients had bilateral fractures, 15 (7%) had flail chest, and 92 (45%) had associated injury. One hundred eighty-seven patients were followed 2 months or more. One hundred ten (59%) patients had prolonged chest wall pain and 142 (76%) had prolonged disability. Among 111 patients with isolated rib fractures, 67 (64%) had prolonged chest wall pain and 69 (66%) had prolonged disability. MPQ PPI was predictive of prolonged pain (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.4 to 2.5), and prolonged disability (OR, 2.2; 95% CI, 1.5 to 3.4). The presence of significant associated injuries was predictive of prolonged disability (OR, 5.9; 95% CI, 1.4 to 29). CONCLUSIONS Prolonged chest wall pain is common, and the contribution of rib fractures to disability is greater than traditionally expected. Further investigation into more effective therapies that prevent prolonged pain and disability after rib fractures is needed.

Biomechanical testing of a novel, minimally invasive rib fracture plating system.

BACKGROUND A novel rib fracture repair plating system was developed to provide durable fixation with a shorter length than standard systems and thus facilitate minimally invasive repair. We hypothesized that U-plate fixation would be at least equivalent in durability to standard anterior fixation. STUDY Twenty fresh frozen ribs (10 pairs) from two human cadavers were first tested for intact stiffness (force or deformation). A gap of 5 mm was then created in the middle of each rib with a saw. Each rib was reconstructed with either the U-plate (4.6 cm length, Acute Innovations, LLC, Hillsboro, OR) with four screws or a 2.4-mm anterior locking plate (9.5 cm length, Synthes, Paoli, PA) with six screws. The U-plates were placed on one rib and the anterior plates on the contralateral rib of the paired levels. The reconstructed ribs were cycled 50,000 times with a load of +/-2N at 1 Hz in a simulation of the repetitive loading of deep breathing. The stiffness of the construct was measured throughout the test. RESULTS Stiffness decreased from the intact rib to the transected/plated rib for both types of fixation; however, a significant decrease in stiffness was observed only with the anterior repair (p = 0.03). After 50,000 cycles, the U-plated ribs lost 0.12 +/- 0.03 N/mm (1.9%) stiffness, whereas the anterior-plated ribs lost 0.72 +/- 0.13 N/mm (9.9%) stiffness (p = 0.001). CONCLUSIONS In this simulation of an unstable rib fracture with a small bony gap, U-plate fixation was more durable than standard anterior fixation. The greatly diminished size of the U-plate compared with the standard may facilitate minimally invasive rib fracture repair.

A novel drug for treatment of necrotizing soft-tissue infections: A randomized clinical trial

IMPORTANCE Necrotizing soft-tissue infections (NSTI) have high morbidity and mortality rates despite aggressive surgical debridement and antibiotic therapy. AB103 is a peptide mimetic of the T-lymphocyte receptor, CD28. We hypothesized that AB103 will limit inflammatory responses to bacterial toxins and decrease the incidence of organ failure. OBJECTIVES To establish the safety of AB103 in patients with NSTI and evaluate the potential effects on clinically meaningful parameters related to the disease. DESIGN, SETTING, AND PARTICIPANTS A prospective, randomized, placebo-controlled, double-blinded study was performed in 6 academic medical centers in the United States. Participants included adults with NSTI. Of 345 patients screened, 43 were enrolled for the intent-to-treat analysis, and 40 met criteria for the modified intent-to-treat analysis; 15 patients each were included in the high-dose and low-dose treatment arms, and 10 in the placebo arm. INTERVENTION Single intravenous dose of AB103 (0.5 or 0.25 mg/kg) within 6 hours after diagnosis of NSTI. MAIN OUTCOMES AND MEASURES Change in the Sequential Organ Failure Assessment score within 28 days, intensive care unit-free and ventilator-free days, number and timing of debridements, plasma and tissue cytokine levels at 0 to 72 hours, and adverse events. RESULTS Baseline characteristics were comparable in the treatment groups. The Sequential Organ Failure Assessment score improved from baseline in both treatment groups compared with the placebo group at 14 days (change from baseline score, -2.8 in the high-dose, -2 in the low-dose, and +1.3 in the placebo groups; P = .04). AB103-treated patients had a similar number of debridements (mean [SD], 2.2 [1.1] for the high-dose, 2.3 [1.2] for the low-dose, and 2.8 [2.1] for the placebo groups; P = .56). There were no statistically significant differences in intensive care unit-free and ventilator-free days or in plasma and tissue cytokine levels. No drug-related adverse events were detected. CONCLUSIONS AND RELEVANCE AB103 is a safe, promising new agent for modulation of inflammation after NSTI. Further study is warranted to establish efficacy. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01417780.

Novel management of closed degloving injuries

Degloving injuries result from a shearing force applied to the skin surface, which causes separation of the skin and subcutaneous tissue from the underlying muscle and fascia. These injuries create a potential space allowing accumulation of fluid. Extensive injuries frequently require surgical drainage and prolonged use of closed suction drains. Most of the degloving injuries seen today involve the torso or lower extremities and are caused by entrapment between a fixed surface and a moving object such as a spinning automobile tire. Others occur when patients are thrown across a fixed surface or injured during extrication.1 The shearing forces applied during injury disrupt perforating vessels at the fascial level, which may lead to skin necrosis if the blood supply is not adequate. These injuries are frequently associated with fractures and other life-threatening injuries. Vacuum-assisted closure (VAC) has been well described in treating both acute and chronic wounds. Since its introduction, the indications for wound VAC therapy have greatly expanded. It is now applied to contaminated wounds, burns, envenomations, infiltrations, and wound complications from failed operations.2 This therapy has also been applied to open degloving injuries, both as a primary treatment and as a dressing over skin grafts.3,4 We present the initial report of a novel use for wound VAC therapy in an extensive closed degloving injury.

Breast cancer severity score is an innovative system for prognosis

BACKGROUND Survival in breast cancer maybe more accurately predicted by a scoring system based on the biologic characteristics of the tumor such as diameter, number of involved nodes, and hormone receptor status than by conventional staging. METHODS Medical records of 419 patients with a diagnosis of breast cancer from a university hospital between 1997 and 2002 were reviewed. Tumor characteristics were given a value reflecting the impact on survival. Tumor diameter was assigned 1 point per cm, specifically: 1 point for 0.1 to 1 cm, 2 points for 1.1 to 2 cm, 3 points for 2.1 to 5 cm, and 4 points for 5.1 cm and over. Nodal status was assigned 1 point if the patient had 1 to 3 positive nodes, 5 points if 4 to 10 positive nodes were found, and 10 points if more than 10 nodes were identified. Hormone receptor status was given 1 point if either estrogen or progesterone receptors were not present or 2 points if both were absent. The breast cancer severity score (BCSS) was used to analyze overall and disease-free survival by Kaplan-Meier analysis. Significance of differences in survival was determined by log-rank analysis. RESULTS An increased severity score was inversely proportional to overall and disease-free survivals. A BCSS of greater than 7 was most predictive of outcome with 5-year survival of 68%; and a BCSS of less than 7 had a 5-year survival of 98% (P = 0.0028). A BCSS of greater than 7 also discriminated disease-free survival within stage II (P = 0.02) and stage III (P = 0.01). CONCLUSIONS The BCSS provides a better resolution of outcome than traditional staging, and works both for overall survival and within specific stages. Using the BCSS, management and follow-up can be specifically tailored for low- and high-risk patients.

DNA Fingerprints Provide a Patient-Specific Breast Cancer Marker

BackgroundDetection of systemic breast cancer recurrence is limited by lack of universally expressed tumor cell markers. We hypothesized that a test that detects genetic alterations specific to breast cancer cells of an individual patient would provide a superior cancer marker.MethodsDNA was extracted from blood, primary tumor, and axillary lymph nodes of 33 breast cancer patients and normal breast tissue of 12 control patients. A patient’s genome was scanned by PCR amplification between Alu sequences. A DNA fingerprint of approximately 17–40 bands was produced for comparison between normal blood and sampled tissues.ResultsThere were 7 stage I, 18 stage II, 7 stage III, and 1 stage IV breast cancer cases; 33 of 33 cancer cases showed DNA fingerprint differences between blood and primary tumor (P < .0001).This test predicted 100% of positive nodes. No false-negatives occurred, and in two cases malignancy was detected in histologically negative nodes. Three of the 12 controls showed a single similar band change.ConclusionsDNA fingerprinting is a method for detecting and characterizing genetic alterations specific to an individual patient’s primary tumor in 100% of cases tested. These specific changes were also identified in 100% of positive nodes, proving the capacity of the test to detect metastases.