Caitlin A. Smith

Predicting Survival for Well-Differentiated Liposarcoma: The Importance of Tumor Location

BACKGROUND Although well-differentiated liposarcoma (WD Lipo) is a low grade neoplasm with a negligible risk of metastatic disease, it can be locally aggressive. We hypothesized that survival for WD Lipo varies significantly based on tumor location. METHODS We identified 1266 patients with WD Lipo in the Surveillance, Epidemiology, and End Results database from 1988-2004. After excluding patients diagnosed by autopsy only, those lacking histologic confirmation, those lacking data on tumor location, and those with metastatic disease or unknown staging information, we arrived at a final study cohort of 1130 patients. Clinical, pathologic, and treatment variables were analyzed for their association with overall survival (OS) and disease-specific survival (DSS) using Kaplan-Meier analysis and Cox proportional hazards multivariate models. RESULTS Mean age was 61 y (± 14.6), 72.2% were white, and 60.4% were male. Eighty-one percent of patients were treated with surgical therapy alone, 4.6% were treated with radiotherapy (RT) alone, and 12.9% were treated with both surgery and RT. Extremity location was most common (41.6%), followed by trunk (29%), retroperitoneal/intra-abdominal (RIA, 21.6%), thorax (4.2%), and head/neck (3.6%). With a median follow-up of 45 mo, median OS was 115 mo (95% confidence interval [CI] 92-138 mo) for RIA tumors compared to not reached for other tumor locations (P = 0.002). On multivariate analysis, increasing age and RIA location both predicted worse OS and DSS while tumor size, race, sex, receipt of RT, and Surveillance, Epidemiology, and End Results (SEER) stage did not. Tumor size became a significant predictor of worse DSS, but not OS, only when site, SEER stage, and extent of resection were removed from the multivariate model. Non-RIA locations, including extremity, experienced statistically similar OS, but 5-y DSS for trunk location was intermediate [92.3%, (95% CI 88.5%-96.1%) compared with 98.0% (95% CI, 96.2%-99.8%) for extremity and 86.6 (95% CI 81.1%-92.1%) for RIA, P < 0.001]. CONCLUSIONS Among patients with WD Lipo, RIA location is associated with significantly worse outcomes independent of tumor size. Future studies should focus on the anatomic and biologic reasons for these differences.

Cost-minimization analysis of two fluid products for resuscitation of critically injured trauma patients

PURPOSE Results of a study to determine potential cost benefits of substituting an alternative electrolyte solution for 0.9% sodium chloride injection for the initial fluid resuscitation of trauma patients are presented. METHODS Using data from a randomized clinical trial that compared 24-hour fluid resuscitation outcomes in critically injured trauma patients treated with 0.9% sodium chloride injection and those who received a balanced electrolyte solution (Plasma-Lyte A, Baxter Healthcare), a cost-minimization analysis was performed at a large medical center. The outcomes evaluated included fluid and drug acquisition costs, materials and nurse labor costs, and costs associated with electrolyte replacement. RESULTS The use of Plasma-Lyte A was associated with a relatively higher fluid acquisition cost but a reduced need for magnesium replacement. During the first 24 hours of hospitalization, 4 of 24 patients (17%) treated with 0.9% sodium chloride injection and none of the patients who received the comparator product (n = 22) required supplemental magnesium. Patients treated with 0.9% sodium chloride injection received a median of 4 g of magnesium (interquartile range [IQR], 2.5-4.0 g), compared with a median of 0 g (IQR 0-2 g) in the comparator group. Taking into account the costs of consumable supplies and nursing labor, the cost-minimization analysis indicated a 24-hour cost differential of

The surgical residency baby boom: changing patterns of childbearing during residency over a 30-year span.

12.35 in favor of Plasma-Lyte A. CONCLUSION Substitution of Plasma-Lyte A for 0.9% sodium chloride injection for fluid resuscitation during the first 24 hours after traumatic injury was associated with decreased magnesium replacement requirements and a net cost benefit to the institution.

Extremity soft tissue tumor surgery by surgical specialty: A comparison of case volume among oncology and non-oncology-designated surgeons

BACKGROUND Birthrates during surgical residency appear to be rising. One assumption is that this is due to changes in the structure of surgical residencies. OBJECTIVE The purpose of our study was to explore whether an increase in birthrates has occurred and the reasons for this. METHODS We conducted an anonymous survey of current residents and alumni from 1976 to 2009 at a single university-based surgery training program. RESULTS Alumni (46 of 116) and current residents (38 of 51) were surveyed, and our response rate was approximately 50% (84 of 167). Respondents were grouped into cohorts based on their residency start year. The early cohort consisted of residents starting residency between 1976 and 1999, and the late cohort consisted of residents starting residency between 2000 and 2009. The percentage of male residents with children during residency training was similar for the early and late cohorts (34% [10 of 29] versus 41% [9 of 22]). For female residents, there was a substantial increase in childbearing for the late cohort (7% [1 of 15] versus 35% [6 of 18]). Fifty-two percent (44 of 84) of the respondents who had children during residency reported that work hours and schedule had a negative effect on their decision to have children. Most respondents reported that availability or cost of child care, impact on residency, support from the program, increased length of training, or availability of family leave did not factor as concerns. CONCLUSIONS Childbearing during residency has increased in female residents in our study. Surgical residency programs may need to accommodate this change if they want to continue to recruit and retain talented residents.

Influence of Physician Specialty on Treatment Recommendations in the Multidisciplinary Management of Soft Tissue Sarcoma of the Extremities

We sought to characterize the extent of extremity soft tissue tumor (ESTT) resections among surgical specialties, hypothesizing that substantial variation exists in the number of ESTT resections performed by specialty.

Does saline resuscitation affect mechanisms of coagulopathy in critically ill trauma patients? An exploratory analysis.

IMPORTANCE Although prospective randomized data are available to guide the multidisciplinary management of soft tissue sarcoma (STS) of the extremities, controversy exists regarding adjuvant chemotherapy and radiation therapy. OBJECTIVE To determine if clinical specialty introduces bias in recommendations for multimodality treatment of STS. DESIGN Electronic survey. SETTING Database of active members of the American Society of Clinical Oncology, the Society of Surgical Oncology, and the Connective Tissue Oncology Society. PARTICIPANTS Members of specialty oncology societies with an active interest in STS. EXPOSURE Physician specialty. MAIN OUTCOMES AND MEASURES Survey responses regarding the multidisciplinary management of STS were scored on a 5-point Likert scale and analyzed using analysis of variance. RESULTS The questionnaire was completed by 320 of 490 potential respondents (65%), including medical (18%), radiation (8%), orthopedic (22%), and surgical oncologists (45%). Respondents concurred on the use of radiation therapy for margins positive for tumor, for high-grade tumors, for improvement in local control, for tumors larger than 10 cm, and for tumors in close proximity to a neurovascular bundle. Respondents diverged on the use of radiation therapy for tumors 5 to 10 cm in size, for low-grade tumors, for radiation-associated STS, and for survival benefit. Only radiation oncologists felt that radiation therapy was underutilized as a treatment modality (mean [SEM] Likert scale score, 2.44 [0.12]; P < .001). There was agreement on the use of chemotherapy for synovial sarcoma, for high-grade tumors, for tumors larger than 10 cm, for patients younger than 50 years of age, and for survival benefit. Medical oncologists were more likely to recommend chemotherapy for margins positive for tumor (mean [SEM] score, 3.12 [0.12]; P = .03) and for improvement in local control (mean [SEM] score, 2.91 [0.12] P = .08). Surgical oncologists placed the least emphasis on chemotherapy in the overall treatment plan (mean [SEM] score, 2.60 [0.07]; P = .001). CONCLUSIONS AND RELEVANCE Specialty bias exists in adjuvant treatment recommendations for STS. This highlights the importance of multidisciplinary STS tumor boards and interdisciplinary care to facilitate consensus decision making for individual patients.

Identification of Barriers to Adaptation of Battlefield Technologies into Civilian Trauma in California

Metabolic acidosis has been implicated in the development of coagulopathy, although the specific mechanisms have not been well characterized. We sought to explore whether resuscitation of injured patients with a balanced crystalloid solution affects coagulation, as measured by endogenous thrombin potential (ETP) and thromboelastography (TEG). We performed an exploratory analysis of a subset of subjects enrolled in a randomized trial comparing the effect of resuscitation with isotonic saline versus Plasma-Lyte A (PLA) on acidosis and electrolyte abnormalities. We collected plasma at admission and 6 h later for subsequent ETP and TEG analysis and compared subjects receiving isotonic saline to those receiving PLA. Among 18 evaluated subjects, baseline characteristics, including ETP and TEG parameters, were similar between the two arms. At 6 h, subjects receiving isotonic saline were more acidemic. At 6 h, there were no differences in ETP parameters between groups; however, TEG results showed the time from initial clot formation to an amplitude of 20 mm (K) was shorter (3.8 ± 2.1 vs. 7.2 ± 2.8 s) and the rapidity of fibrin build-up and cross-linking (&agr; angle) was significantly greater (41 ± 8 vs. 24 ± 15 deg) for the PLA group than in the isotonic saline group. Relative to PLA, isotonic saline does not alter thrombin generation, but isotonic saline and PLA may differentially impact clotting factor availability. The shorter time to reach prespecified clot amplitude and the increased rate of fibrin generation imply faster amplification of clotting factors with PLA without effect on latency time or clot strength.

Laparoscopic Transdiaphragmatic Pericardial Window: Getting to the Heart of the Matter

OBJECTIVE To characterize the adoption of routine battlefield medical techniques (tourniquets, hemostatic agents, and tactical combat casualty care into civilian prehospital trauma care and to identify the barriers to their use in the state of California through anonymous electronic survey of local emergency medical services agency (LEMSA) directors. RESULTS The response rate for this survey was 50% (14/28). The majority of LEMSA directors (86%) were emergency medicine physicians. Tourniquets were used by 57% of respondents. The top three reasons cited for not using tourniquets included different injury patterns in civilian trauma, no proven benefit of use, and increased risk of complications. Hemostatic agents were used even less frequently in civilian practice (7%) but had similar barriers to use. Only 36% of LEMSA directors use tactical combat casualty care with tactical emergency medical services, but when used, respondents had higher usage of tourniquets. Overall lack of training, no proven benefit, and expense were the reasons cited for not incorporating military medical techniques. CONCLUSIONS Tourniquets, hemostatic agents, and tactical medical care are the integral components of battlefield medicine and have been lifesaving in these settings. The barriers to this transition are multifactorial. Physicians familiar with these technologies should become advocates for their integration in civilian trauma patient care.

Octogenarians Develop Infrapopliteal Arterial Occlusive Disease in the Absence of Traditional Risk Factors

BACKGROUND Penetrating wounds to the upper abdomen and lower precordium mandate exclusion of intra-abdominal and cardiac injuries. The most sensitive test to exclude cardiac injury is direct visualization of the pericardial fluid. Since 2001, we have examined the abdomen and performed transdiaphragmatic (central tendon) pericardial window via laparoscopy in stable patients at risk for both cardiac and peritoneal injuries. STUDY DESIGN At our Level I trauma center we reviewed consecutive patients who underwent evaluation of pericardial fluid after trauma between 2001 and 2008 and identified those patients in whom laparoscopic pericardial window was performed. We collected data on demographics, technique, findings, complications, and follow-up. RESULTS There were 393 patients who underwent diagnostic laparoscopy. Of those, 38 patients received laparoscopic transdiaphragmatic pericardial window. Six cardiac injuries (15.8%) were identified with 5 penetrating injuries to the right ventricle and 1 myocardial contusion. All 5 right ventricular injuries required median sternotomy for injury repair. None of the patients had significant hemodynamic compromise during operation. The pericardial window was left open in all patients, with no morbidity. The average length of stay for patients without chest tubes and a negative window was less than 24 hours. For patients with chest tubes, length of stay was 4.6 days. The interquartile range for follow-up was 21.5 to 315 days. CONCLUSIONS Diagnostic laparoscopy with transdiaphragmatic pericardial window allows for thorough evaluation of both abdominal and cardiac injuries with a resultant short length of stay and no morbidity or mortality. In this, the largest series in the literature, laparoscopic pericardial window was a safe and effective modality to evaluate hemodynamically stable patients who are at risk for both cardiac and abdominal injuries.