James A. Sebesta

Prehospital tourniquet use in Operation Iraqi Freedom: effect on hemorrhage control and outcomes.

BACKGROUND Up to 9% of casualties killed in action during the Vietnam War died from exsanguination from extremity injuries. Retrospective reviews of prehospital tourniquet use in World War II and by the Israeli Defense Forces revealed improvements in extremity hemorrhage control and very few adverse limb outcomes when tourniquet times are less than 6 hours. HYPOTHESIS We hypothesized that prehospital tourniquet use decreased hemorrhage from extremity injuries and saved lives, and was not associated with a substantial increase in adverse limb outcomes. METHODS This was an institutional review board-approved, retrospective review of the 31st combat support hospital for 1 year during Operation Iraqi Freedom. Inclusion criteria were any patient with a traumatic amputation, major extremity vascular injury, or documented prehospital tourniquet. RESULTS Among 3,444 total admissions, 165 patients met inclusion criteria. Sixty-seven patients had prehospital tourniquets (TK); 98 patients had severe extremity injuries but no prehospital tourniquet (No TK). Extremity Acute Injury Scores were the same (3.5 TK vs. 3.4 No TK) in both groups. Differences (p < 0.05) were noted in the numbers of patients with arm injuries (16.2% TK vs. 30.6% No TK), injuries requiring vascular reconstruction (29.9% TK vs. 52.5% No TK), traumatic amputations (41.8% TK vs. 26.3% No TK), and in those patients with adequate bleeding control on arrival (83% TK vs. 60% No TK). Secondary amputation rates (4 (6.0%) TK vs. 9 (9.1%) No TK); and mortality (3 (4.4%) TK vs. 4 (4.1%) No TK) did not differ. Tourniquet use was not deemed responsible for subsequent amputation in severely mangled extremities. Analysis revealed that four of seven deaths were potentially preventable with functional prehospital tourniquet placement. CONCLUSIONS Prehospital tourniquet use was associated with improved hemorrhage control, particularly in the worse injured (Injury Severity Score >15) subset of patients. Fifty-seven percent of the deaths might have been prevented by earlier tourniquet use. There were no early adverse outcomes related to tourniquet use.

Socioeconomic disparities in eligibility and access to bariatric surgery: a national population-based analysis

BACKGROUND To analyze the socioeconomics of the morbidly obese patient population and the impact on access to bariatric surgery using 2 nationally representative databases. Bariatric surgery is a life-changing and potentially life-saving intervention for morbid obesity. Access to bariatric surgical care among eligible patients might be adversely affected by a variety of socioeconomic factors. METHODS The national bariatric eligible population was identified from the 2005-2006 National Health and Nutrition Examination Survey and compared with the adult noneligible population. The eligible cohort was then compared with patients who had undergone bariatric surgery in the 2006 Nationwide Inpatient Sample, and key socioeconomic disparities were identified and analyzed. RESULTS A total of 22,151,116 people were identified as eligible for bariatric surgery using the National Institutes of Health criteria. Compared with the noneligible group, the bariatric eligible group had significantly lower family incomes, lower education levels, less access to healthcare, and a greater proportion of nonwhite race (all P <.001). Bariatric eligibility was associated with significant adverse economic and health-related markers, including days of work lost (5 versus 8 days, P <.001). More than one third (35%) of bariatric eligible patients were either uninsured or underinsured, and 15% had incomes less than the poverty level. A total of 87,749 in-patient bariatric surgical procedures were performed in 2006. Most were performed in white patients (75%) with greater median incomes (80%) and private insurance (82%). Significant disparities associated with a decreased likelihood of undergoing bariatric surgery were noted by race, income, insurance type, and gender. CONCLUSION Socioeconomic factors play a major role in determining who does and does not undergo bariatric surgery, despite medical eligibility. Significant disparities according to race, income, education level, and insurance type continue to exist and should prompt focused public health efforts aimed at equalizing and expanding access.

An Evaluation of the Impact of Apheresis Platelets Used in the Setting of Massively Transfused Trauma Patients

INTRODUCTION Trauma is a major cause of morbidity and mortality worldwide. Of patients arriving to trauma centers, patients requiring massive transfusion (MT, >or=10 units in 24 hours) are a small patient subset but are at the highest risk of mortality. Transfusion of appropriate ratios of blood products to such patients has recently been an area of interest to both the civilian and military medical community. Plasma is increasingly recognized as a critical component, though less is known about appropriate ratios of platelets. Combat casualties managed at the busiest combat hospital in Iraq provided an opportunity to examine this question. METHODS In-patient records for 8,618 trauma casualties treated at the military hospital in Baghdad more than a 3-year interval between January 2004 and December 2006 were retrospectively reviewed and patients requiring MT (n = 694) were identified. Patients who required MT in the first 24 hours and did not receive fresh whole blood were divided into study groups defined by source of platelets: (1) patient receiving a low ratio of platelets (<1:16 apheresis platelets per stored red cell unit, aPLT:RBC) (n = 214), (2) patients receiving a medium ratio of platelets (1:16 to <1:8 aPLT:RBC) (n = 154), and (3) patients receiving a high ratio of platelets (>or=1:8 aPLT:RBC) (n = 96). The primary endpoint was survival at 24 hours and at 30 days. RESULTS At 24 hours, patients receiving a high ratio of platelets had higher survival (95%) as compared with patients receiving a medium ratio (87%) and patients receiving the lowest ratio of platelets (64%) (log-rank p = 0.04 and p < 0.001, respectively). The survival benefit for the high and medium ratio groups remained at 30 days as compared with those receiving the lowest ratio of platelets (75% and 60% vs. 43%, p < 0.001 for both comparisons). On multivariate regression, plasma:RBC ratios and aPLT:RBC were both independently associated with improved survival at 24 hours and at 30 days. CONCLUSION Transfusion of a ratio of >or=1:8 aPLT:RBC is associated with improved survival at 24 hours and at 30 days in combat casualties requiring a MT within 24 hours of injury. Although prospective study is needed to confirm this finding, MT protocols outside of investigational research should consider incorporation of appropriate ratios of both plasma and platelets.

Risks associated with fresh whole blood and red blood cell transfusions in a combat support hospital

Objective:Fresh whole blood (FWB) and red blood cells (RBCs) are transfused to injured casualties in combat support hospitals. We evaluated the risks of FWB and RBCs transfused to combat-related casualties. Design:Retrospective chart review. Setting:Deployed U.S. Army combat support hospitals. Subjects:Donors of FWB and recipients of FWB and RBCs. Measurements and Results:The storage age of RBCs at transfusion was measured as an indicator of overall risk associated with the storage lesion of RBCs between January 2004 and December 2004 at one combat support hospital. Between April 2004 and December 2004, FWB was prescreened only at one combat support hospital for human immunodeficiency virus, hepatitis C virus, and hepatitis B surface antigen before transfusion. To estimate the general incidence of infectious agent contamination in FWB units, samples collected between May 2003 and February 2006 were tested retrospectively for human immunodeficiency virus, hepatitis B surface antigen, hepatitis C virus, and human lymphotropic virus. Results were compared between FWB samples prescreened and not prescreened for infectious agents before transfusion. At one combat support hospital in 2004, 87 patients were transfused 545 units of FWB and 685 patients were transfused 5,294 units of RBCs with a mean age at transfusion of 33 days (±6 days). Retrospective testing of 2,831 samples from FWB donor units transfused in Iraq and Afghanistan between May 2003 and February 2006 indicated that three of 2,831 (0.11%) were positive for hepatitis C virus recombinant immunoblot assay, two of 2,831 (0.07%) were positive for human lymphotropic virus enzyme immunoassay, and none of 2,831 were positive for both human immunodeficiency virus 1/2 and hepatitis B surface antigen by Western blot and neutralization methods, respectively. The differences in the incidence of hepatitis C virus contamination of FWB donor units between those prescreened for hepatitis C virus (zero of 406; 0%) and not prescreened (three of 2,425; 0.12%) were not significant (p = .48). Conclusions:The risk of infectious disease transmission with FWB transfusion can be minimized by rapid screening tests before transfusion. Because of the potential adverse outcomes of transfusing RBCs of increased storage age to combat-related trauma patients, the risks and benefits of FWB transfusions must be balanced with those of transfusing old RBCs in patients with life-threatening traumatic injuries.

Colon and Rectal Injuries During Operation Iraqi Freedom: Are There Any Changing Trends in Management or Outcome?

PurposeDespite the evolution in the management of traumatic colorectal injuries in both civilian and military settings during the previous few decades, they continue to be a source of significant morbidity and mortality. The purpose of this study was to analyze management and clinical outcomes from a cohort of patients suffering colorectal injuries.MethodsThis was a retrospective analysis of prospectively collected data from all patients injured and treated at the 31st Combat Support Hospital during Operation Iraqi Freedom from September 2003 to December 2004.ResultsFrom the 3,442 patients treated, 175 (5.1 percent) had colorectal injuries. Patients were predominately male (95 percent), suffered penetrating injuries (96 percent), and had a mean age of 29 (range, 4–70) years. Ninety-one percent of patients had associated injuries. Initial management included primary repair (34 percent), stoma (33 percent), resection with anastomosis (19 percent), and damage control only (14 percent). By injury location, stomas were placed more frequently with rectal or sphincter injuries 65 percent (25/40) vs. other sites (right, 19 percent (8/42); transverse, 25 percent (8/32); left, 36 percent (20/55); P < 0.01). Thirteen percent of patients eventually received stomas for failure of initial in-continuity management. Patients with colorectal injuries had a significantly increased mortality rate than those without (18 percent (31/175) vs. 8 percent (269/3267); P < 0.001) but not the subset without colorectal injuries undergoing celiotomy (18 vs.14.4 percent; P = 0.41). Rectal (odds radio, 22; P = 0.03) and transverse colon (odds radio, 17; P = 0.04) injuries were independently associated with increased mortality in multivariate regression analysis. Initial placement of stoma had an independent association with lower leak rates (odds radio, 0.06; P = 0.04).ConclusionsInjury to the rectum or transverse colon is an independent predictor of mortality. The use of a diverting stoma varied by injury site and was associated with a decreased leak rate but demonstrated no impact on the incidence of sepsis or mortality.

Selective nonoperative management of penetrating torso injury from combat fragmentation wounds.

BACKGROUND Historically, military surgical doctrine has mandated exploratory laparotomy for all penetrating fragmentation wounds. We hypothesized that stable patients with abdominal fragmentation injuries whose computerized tomography (CT) scans for intraperitoneal or retroperitoneal penetration disclosed nothing abnormal, can be safely observed without therapeutic laparotomy. METHODS We retrospectively studied all hemodynamically stable patients with penetrating fragmentation wounds to the back, flank, lower chest, abdomen, and pelvis evaluated by abdominal physical examination (PE), CT, or ultrasound treated during a 6-month period at one combat support hospital. Sensitivity, specificity, and positive and negative predictive values were calculated comparing each positive test to laparotomy and each negative test to successful nonoperative management. RESULTS One hundred forty-five patients met study criteria. Based on CT scans, 85 (59%) patients were managed nonoperatively; 60 (41%) underwent laparotomy. Forty-five of 60 (75%) of laparotomies were therapeutic. CT scan for intraperitoneal or retroperitoneal penetration that disclosed nothing abnormal was 99% predictive of successful nonoperative management. In detecting intra-abdominal injury requiring laparotomy, sensitivity for each method was 30.2% (PE), 11.7% (ultrasound), and 97.8% (CT) (p < 0.05). Specificity was 94.8% (PE), 100% (ultrasound), and 84.8% (CT). The areas under the receiver operating characteristic (ROC) curves were 0.565 (PE), 0.543 (ultrasound), and 0.929 (CT) (p < 0.0001). All patients with a positive ultrasound (n = 4) underwent therapeutic laparotomy. CONCLUSION PE alone was unreliable in stable patients with abdominal fragmentation injuries. The clinical value of ultrasound results was limited, likely because the majority of these stable patients did not have injuries associated with the large accumulation of peritoneal fluid. CT scan safely and effectively analyzed nonoperative management of penetrating abdominal fragmentation injuries and should be the diagnostic study of choice in all stable patients without peritonitis with abdominal, flank, back, or pelvic combat fragmentation wounds.

Demographics, Treatment, and Early Outcomes in Penetrating Vascular Combat Trauma

OBJECTIVES To describe arterial and venous injuries and their management and short-term outcomes in a wartime hospital. DESIGN Retrospective review of patients with vascular injuries. Mechanism, location, method of repair, and outcomes were analyzed with descriptive and inferential statistics. SETTING The 31st Combat Support Hospital, Operation Iraqi Freedom. PATIENTS A total of 153 patients with 218 vascular injuries from January 1, 2004, to December 30, 2004. MAIN OUTCOME MEASURES Limb salvage and mortality rates. RESULTS The overall limb salvage rate was 80%, while all-cause mortality was 6%. Most vascular injuries were sustained by blast and fragmentation mechanisms. Not surprisingly, most vascular injuries were in lower extremity vessels (57% arterial, 50% venous), with a high predominance of superficial femoral vessel injuries. Vascular injuries to the upper extremities were associated with a higher limb salvage rate (95%) than injuries to the lower extremities (71%). Variable follow-up data for 63 (41%) patients revealed that 32 underwent further procedures outside the combat theater, 12 of which were delayed amputations. Of all arterial injuries, 36% were primarily repaired, 34% were repaired with a vein interposition graft, 29% were ligated, and 2% were repaired with a prosthetic graft. A majority of venous injuries (56%) were ligated. CONCLUSIONS There is an acceptable early patency and limb salvage rate in combat vascular repairs. A majority of penetrating vascular injuries occur in the lower extremities. Overall, penetrating vascular trauma is often a survivable injury.

Primary tumor location impacts breast cancer survival

BACKGROUND The prognostic significance of tumor location in breast cancer remains unclear. To better understand this relationship, we evaluated the Department of Defense tumor registry. METHODS Patients with infiltrating ductal adenocarcinoma or lobular carcinoma over a 10-year period were identified and analyzed. RESULTS Of the 13,984 tumors, 7,871 (58%) originated from the upper-outer quadrant or axillary tail, whereas the remainder were found at the nipple complex (9%), upper-inner quadrant (14%), lower-inner quadrant (9%), and lower-outer quadrant (10%). Univariate analysis of cancer-specific survival revealed a significant difference based on location of the primary breast cancer. Upper-outer quadrant lesions were associated with an independent contribution toward a survival benefit. CONCLUSIONS Upper-outer quadrant breast cancers have a more favorable survival advantage when compared with tumors in other locations. Factors that negatively impacted survival included high-grade tumors, advanced stage, and race.

Does telomerase activity add to the value of fine needle aspirations in evaluating thyroid nodules

BACKGROUND Telomerase replaces DNA sequences that are lost with cell division. Increased activity has been documented in malignant cells. Fine needle aspiration (FNA) has a 90% sensitivity for diagnosis of papillary carcinomas, but a specificity of 52%. This often leads to unnecessary surgery. METHODS Telomeric repeat amplification protocol assays were performed on FNA specimens of thyroid nodules in 19 patients. These results were compared with the surgical pathology using chi-square analysis. RESULTS There were 5 malignant and 14 benign nodules. Telomerase activity was found in 3 of 5 malignant (60%) and 9 of 14 benign (64%): sensitivity was 60%, specificity was 36%. CONCLUSION Telomerase assays did not add any additional information to FNA alone. Inflammatory changes associated with benign and malignant lesions can possess telomerase activity independent of the malignant state.

Training Surgeons and the Informed Consent Process: Routine Disclosure of Trainee Participation and Its Effect on Patient Willingness and Consent Rates

OBJECTIVES To examine patient perceptions and willingness to participate in resident education and to assess the effect on patient willingness and consent rates. DESIGN Anonymous questionnaire designed to capture demographics, overall opinions of teaching programs, and willingness to consent to various scenarios of trainee participation. Descriptive and univariate analyses were performed. SETTING Tertiary-level referral center. PATIENTS Three hundred sixteen individuals scheduled for elective surgery. MAIN OUTCOME MEASURES Consent rates for various scenarios. RESULTS Of the 316 patients who completed the questionnaire, most expressed overall support of resident training: 91.2% opined that their care would be equivalent to or better than that of a private hospital, 68.3% believed they derived benefit from participation, and most consented to having an intern (85.0%) or a resident (94.0%) participate in their surgical procedure. However, when given specific, realistic scenarios involving trainee participation, major variations in the consent rate were observed. Affirmative consent rates decreased from 94.0% to 18.2% as the level of resident participation increased. Patients also were more willing to consent to the participation of a senior resident (83.1%) vs a junior resident (57.6%) or an intern (54.5%). Patients overwhelmingly opined that they should be informed of the level of resident participation and that this information could change their decision of whether to consent. CONCLUSIONS Most patients expressed approval of teaching facilities and resident education. However, consent rates were significantly altered when more detailed information was provided and they declined with increasing levels of resident participation. Providing detailed informed consent is preferred by patients but it could adversely affect resident participation and training.