James S. Davis

Use of mobile learning module improves skills in chest tube insertion

BACKGROUND Just-In-Time Learning is a concept increasingly applied to medical education, and its efficacy must be evaluated. MATERIALS AND METHODS A 3-minute video on chest tube insertion was produced. Consenting participants were assigned to either the video group, which viewed the video on an Apple® iPod Touch immediately before chest tube insertion, or the control group, which received no instruction. Every participant filled out a questionnaire regarding prior chest tube experience. A trained clinician observed participants insert a chest tube on the TraumaMan® task simulator, and assessed performance using a 14-item skills checklist. RESULTS Overall, 128 healthcare trainees participated, with 50% in the video group. Participants included residents (34.4%, n = 44), medical students (32.8%, n = 42), and U.S. Army Forward Surgical Team members (32.8%, n = 42). Sixty-nine percent of all participants responded that they had never placed a chest tube, but 7% had placed more than 20. Only 25% of the participants had previously used TraumaMan®. Subjects who viewed the video scored better on the skills checklist than the control group (11.09 ± 3.09 versus 7.17 ± 3.56, P < 0.001, Cohens D = 1.16). Medical students (9.33 ± 2.65 versus 4.52 ± 3.64, P < 0.001), Forward Surgical Team members (10.07 ± 2.52 versus 8.57 ± 3.22, P < 0.001), anesthesia residents (8.25 ± 2.56 versus 5.9 ± 2.23, P = 0.017), and subjects who had placed fewer than 10 chest tubes (9.7 ± 3 versus 6.6 ± 3.9, P < 0.001) performed significantly better with the video. CONCLUSIONS The procedural animation video is an effective medium for teaching procedural skills. Embedding the video on a mobile device, and allowing trainees to access it immediately before chest tube insertion, may enhance and standardize surgical education for civilians and military personnel.

An analysis of prehospital deaths: Who can we save?

BACKGROUND Since their inception in the late 1970s, trauma networks have saved thousands of lives in the prehospital setting. However, few recent works have been done to evaluate the patients who die in the field. Understanding the epidemiology of these deaths is crucial for trauma system performance evaluation and improvement. We hypothesized that specific patterns of injury could be identified and targeted for intervention. METHODS Medical examiner reports in a large, urban county were reviewed including all trauma deaths during 2011 that were not transported to a hospital (i.e., died at the scene) or dead on arrival. Age, sex, date of death, mechanism, and list of injuries were recorded. An expert panel reviewed each case to determine the primary cause of death, and if the patient’s death was caused by potentially survivable injuries or nonsurvivable injuries. RESULTS A total of 512 patients were included. Patients were 80% male, died mostly of blunt (53%) and penetrating (46%) causes, and included 21% documented suicides. The leading cause of death was neurotrauma (36%), followed by hemorrhage (34%), asphyxia (15%), and combined neurotrauma/hemorrhage (15%). The anatomic regions most frequently injured were the brain (59%), chest (54%), and abdomen (35%). Finally, 29% of the patient deaths were classified as a result of potentially survivable injuries given current treatment options, mostly from hemorrhage and chest injuries. CONCLUSION More than one of every five trauma deaths in our study population had potentially survivable injuries. In this group, chest injuries and death via hemorrhage were predominant and suggest targets for future research and implementation of novel prehospital interventions. In addition, efforts targeting suicide prevention remain of great importance. LEVEL OF EVIDENCE Epidemiologic study, level V.

A review of 218 pediatric cases of hepatocellular carcinoma

PURPOSE This study evaluates the incidence trends and clinical outcomes of children with hepatocellular carcinoma (HCC) and assesses factors predictive of patient survival. METHODS The Surveillance, Epidemiology, and End Results registry was queried from 1973 to 2009 for all patients between ages 0 and 19 with primary HCC. Demographics, tumor histology, surgical intervention, and patient survival were collected. RESULTS Overall, 218 patients were identified. The annual age-adjusted incidence was 0.05 cases per 100,000 in 2009. Fibrolamellar subtype tumors were exclusive to children >5years old and exhibited greater survival compared to non-fibrolamellar subtype (57% vs. 28%, respectively, p=0.002). Tumor extirpation for patients with resectable disease significantly improved overall survival at 5years compared to no surgery (60% vs. 0%, respectively, p<0.0001). Overall 5-, 10- and 20-year survival for the entire cohort was 24%, 23%, and 8%, respectively. Independent prognostic factors of lower mortality according to multivariate analysis were surgical resection (hazard ratio (HR)=0.18), non-Hispanic ethnicity (HR=0.52), and local disease at presentation (HR=0.46). CONCLUSION Over the past four decades, the incidence of HCC has remained relatively stable. Children of Hispanic ethnicity have high mortality rates. However, HCC resection for curative intent significantly improves outcomes.

Malignant neuroendocrine tumors: incidence and outcomes in pediatric patients.

INTRODUCTION Malignant neuroendocrine tumors (NETs) are rare solid tumors infrequently seen in children. This study examines current incidence trends and outcomes for children with NETs. MATERIALS AND METHODS The Surveillance Epidemiology and End Results registry was examined for patients between birth and 19 years of age between 1973 and 2005 with NETs. RESULTS Overall, 481 patients were identified with malignant NETs. Tumors were classified as malignant carcinoid (n = 189, 39%), central nervous system tumors (n = 127, 26%), medullary thyroid carcinoma (n = 88, 18%), neuroendocrine carcinoma (n = 50, 10%), pheochromocytoma (n = 17, 3.5%), and paraganglioma (n = 7, 1.5%). Children less than 5 years of age had worse 5-year survival ( < 50 vs. > 76% if older, p = 0.009). Blacks had lower 5-year survival compared with whites (61 vs. 81%, p = 0.001). Tumor locations with favorable prognosis included the appendix, lung, and thyroid ( > 95% 5-year survival), whereas soft tissue and ovary location were associated with poor survival (p < 0.001). In multivariate analysis, distant disease at diagnosis (odds ratio [OR] 14.9; 95% confidence interval [CI], 6.9 to 32.1) and black race (OR 3.3; 95% CI, 1.4 to 7.4) were independent predictors of death. CONCLUSION Whites have the highest incidence of pediatric NETs. Colon/rectum, appendix, or thyroid tumor location portends favorable prognosis. Black children and those less than 5 years of age had poorer prognosis.

Twenty years of pediatric gunshot wounds: an urban trauma center’s experience

BACKGROUND Pediatric gunshot wounds remain an important cause of morbidity and mortality in the United States. Recent experience in the urban pediatric population has not been extensively documented. METHODS A retrospective review of the trauma registry identified all pediatric (age 0-16 y) gunshot wound injuries between October 1991 and August 2011. We evaluated demographic, injury location, disposition, and outcome data. We applied descriptive statistics and χ(2) with significance level set to P ≤ 0.05. RESULTS We treated 740 patients at our trauma center. Patients tended to be male (82%) and African American (72%), and most frequently were shot in the abdomen, back, or pelvic regions (26%). Patients with head or neck injuries experienced the highest mortality rate (35%), whereas the mortality rate overall was 12.7%. A total of 23% of patients were discharged directly, but 32% required an operation. We grouped data into five equal time periods, demonstrating that after decreasing through the 1990s, pediatric gunshot wounds presenting to our hospital are steadily increasing. CONCLUSIONS We identified certain demographic and temporal trends regarding pediatric gunshot wounds, and the overall number of injuries appears to be increasing.

Role of magnetic resonance cholangiopancreatography in diagnosing choledochal cysts: Case series and review

AIM To determine the merits of magnetic resonance cholangiopancreatography (MRCP) as the primary diagnostic test for choledochal cysts (CCs). METHODS Between 2009 and 2012, patients who underwent MRCP for perioperative diagnosis were identified. Demographic information, clinical characteristics, and radiographic findings were recorded. MRCP results were compared with intraoperative findings. A PubMed search identified studies published between 1996-2012, employing MRCP as the primary preoperative imaging and comparing results with either endoscopic retrograde cholangiopancreatography (ERCP) or operative findings. Detection rates for CCs and abnormal pancreaticobiliary junction (APBJ) were calculated. In addition detection rates for clinically related biliary pathology like choledocholithiasis and cholangiocarcinomas in patients diagnosed with CCs were also evaluated. RESULTS Eight patients were identified with CCs. Six patients out of them had type IV CCs, 1 had type I and 1 had a new variant of choledochal cyst with confluent dilatation of the common bile duct (CBD) and cystic duct. Seven patients had an APBJ and 3 of those had a long common-channel. Gallstones were found in 2 patients, 1 had a CBD stone, and 1 pancreatic-duct stone was also detected. In all cases, MRCP successfully identified the type of CCs, as well as APBJ with ductal stones. From analyzing the literature, we found that MRCP has 96%-100% detection rate for CCs. Additionally, we found that the range for sensitivity, specificity, and diagnostic accuracy was 53%-100%, 90%-100% and 56%-100% in diagnosing APBJ. MRCPs detection rate was 100% for choledocholithiasis and 87% for cholangiocarcinomas with concurrent CCs. CONCLUSION After initial ultrasound and computed tomography scan, MRCP should be the next diagnostic test in both adult and pediatric patients. ERCP should be reserved for patients where therapeutic intervention is needed.

Sticking our neck out: is magnetic resonance imaging needed to clear an obtunded patient's cervical spine?

BACKGROUND Evaluating the cervical spine in the obtunded trauma patient is a subject fraught with controversy. Some authors assert that a negative computed tomography (CT) scan is sufficient. Others argue that CT alone misses occult unstable injuries, and magnetic resonance imaging (MRI) will alter treatment. This study examines the data in an urban, county trauma center to determine if a negative cervical spine CT scan is sufficient to clear the obtunded trauma patient. METHODS Records of all consecutive patients admitted to a level 1 trauma center from January 2000 to December 2011 were retrospectively analyzed. Patients directly admitted to the intensive care unit with a Glasgow Coma Scale score ≤13, contemporaneous CT and MRI, and a negative CT reading were included. The results of the cervical spine MRI were analyzed. RESULTS A total of 309 patients had both CT and MRI, 107 (35%) of whom had negative CTs. Mean time between CT and MRI was 16 d. Of those patients, seven (7%) had positive acute traumatic findings on MRI. Findings included ligamentous injury, subluxation, and fracture. However, only two of these patients required surgical intervention. None had unstable injuries. CONCLUSIONS In the obtunded trauma patient with a negative cervical spine CT, obtaining an MRI does not appear to significantly alter management, and no unstable injuries were missed on CT scan. This should be taken into consideration given the current efforts at cost-containment in the health care system. It is one of the larger studies published to date.

Surgical and anesthetic considerations in histrelin capsule implantation for the treatment of precocious puberty

BACKGROUND Precocious puberty treatment traditionally meant anxiety-provoking monthly depot injections until the advent of the annually implanted histrelin capsule. This study is the first to evaluate the surgical and anesthetic aspects of histrelin implantation for precocious puberty. METHODS All cases from one surgeon at a tertiary pediatric hospital were reviewed for patient age, anesthetic type, technical difficulties, and complications. RESULTS From 12/2007 to 3/2013, 114 cases (49% implantations, 25% removals/re-implantations, 25% removals) were performed. Local anesthesia was employed in 100% of non-general anesthesia cases (n=109, 96%), augmented by inhaled N2O in 49%. Five patients (4%) underwent general anesthesia: three neurologically-impaired and two coordinated with scheduled MRIs. Procedural difficulties (n=18, 16%) included implant fracture during removal (n=16/58 removals, 28%). Fracture never occurred during implantation. Three children (3%) suffered complications. One infection was treated with antibiotics, and two implants were removed for systemic allergic reaction. Six children (5%) had unscheduled post-operative checks for pain (n=3, 3%), allergy to elastic dressing (n=2, 2%), or rash (n=1, 1%). Mean charges for general anesthesia were

Use of a warming catheter to achieve normothermia in large burns

10,188±1292 versus

Are burn patients really at risk for thrombotic events

528±147 for N2O or local alone (p<0.0001). CONCLUSION While histrelin implantation is straightforward, removal presents technical challenges. Local anesthesia, with possible N2O supplementation, is well-tolerated and introduces substantial resource and cost savings.