Junlin Liao

Determinants of survival in patients with calciphylaxis: a multivariate analysis.

BACKGROUND Our study aims to assess the factors affecting survival in patients with calciphylaxis. METHODS We identified 26 patients with biopsy-proven calciphylaxis treated between 1995 and 2007. Clinical and follow-up data were obtained from medical records. Cox proportional hazards models were used to assess the factors affecting survival. RESULTS The study group consisted of 23 women and 3 men with a mean age of 56.4 +/- 12.9 years. All patients had multiple comorbidities/risk factors including coronary artery disease (58%), diabetes mellitus (58%), and peripheral vascular disease (23%). Mean laboratory values were: calcium, 9.0 mg/dL (range, 6.8-11.6); albumin, 2.8 mg/dL; phosphate, 4.5 mg/dL (range, 2.5-7.5); Ca *phosphate, 35.9; and parathyroid hormone, 320.9 pg/mL (range, 4.6-2,419). Parathyroidectomy was performed in 9 of 26 patients (35%). Of our patients, 19% underwent revascularization procedures and 58% underwent debridement. In multivariate analyses, factors associated with poor survival were female gender ( P = .01), increased weight ( P = .01), and need for vascular procedures ( P = .06). Improved survival was associated with operative debridement ( P = .01). Parathyroidectomy alone did not emerge as a determinant of patient survival, although there was a trend to improved survival when debridement and parathyroidectomy were combined ( P = .09). CONCLUSION Rather than a single intervention such as parathyroidectomy, a multidisciplinary approach involving early diagnosis, aggressive medical management, operative debridement, and parathyroidectomy may improve survival in calciphylaxis.

Risk Factors for Development and Recurrence of Primary Breast Abscesses

BACKGROUND We investigated risk factors that predispose to the development of primary breast abscesses and subsequent recurrence. STUDY DESIGN This was a case control study of patients with a primary or recurrent breast abscess, with recurrence defined by the need for repeated drainage within 6 months. RESULTS Sixty-eight patients with a primary breast abscess were identified. Univariate analysis indicated that smoking (odds ratio [OR] 8.0 [95% CI 3.4 to 19.4]), obesity (OR 3.6 [95% CI 1.5 to 9.2]), diabetes mellitus (OR 5.7 [95% CI 1.1 to 54.9]), and nipple piercing (OR 10.2 [95% CI 1.3 to 454.4]) were significant risk factors for development of primary breast abscess. Multivariate logistic regression analysis confirmed smoking as a significant risk factor for the development of primary breast abscess (OR 6.15 [95% CI 2.65 to 14.29]) and in the subtype of subareolar breast abscess, nipple piercing was identified as a risk factor (OR 20.26 [95% CI 2.01 to 204.28]) in addition to smoking (OR 11.49 [95% CI 4.41 to 29.94]). Recurrent breast abscess occurred in 36 (53%) patients. Multivariate logistic regression identified significant OR for an increase in recurrence related to age (OR 1.08 [95% CI 1.01 to 1.15] per year), smoking (OR 14.73 [95% CI 3.18 to 68.22]), surgical treatment (11.94 [95% CI 1.08 to 131.72]), and a decrease in recurrence after MRSA infections (OR 0.02 [95% CI 0.00 to 0.72]). CONCLUSIONS Our results strongly suggest that tobacco smoking is significantly associated with primary breast abscess and its recurrence. Nipple piercing is associated with increased risk of developing subareolar breast abscess. Recurrence is associated with smoking, surgical treatment, and increased age and is less likely with MRSA infections.

Trends in 393 necrotizing acute soft tissue infection patients 2000–2008 ☆

OBJECTIVE To determine the outcomes effect of changing trends in patients with necrotizing acute soft tissue infections (NASTI) 2000-2008. METHODS A single institution retrospective chart review of all patients treated for NASTI. RESULTS There were 393 patients with mean age 50 years, diabetes 53%, % body surface area excised 3.5. Wounds were located on: extremity 57%, perineum 40%, trunk 26%. Wound cultures %: polymicrobial=62, Staphylococci=48, Streptococci=31. Patients developing complications %: Pulmonary=23, renal insufficiency/failure=27. During the study period, overall mortality rate remained unchanged: 30/393=7.6% (5.5% for patients first admitted by burn/trauma/acute care surgery vs. 29% for all other services, p=0.003). Significant annual increases were found in number of patients, p=0.03, male sex, p=0.000, transfer from outside hospital, p<0.001, BMI p=0.003, ventilator requirement >24h, p=0.0005, APACHE II p=0.002, and number of patients developing any complication, p=0.04. Statistically significant decreases annually were found in: days of antibiotic use, p=0.008, number of operations required for excision, p=0.02, development of non-wound infections, p=0.002, and length of stay in days (LOS), p=0.03. CONCLUSIONS This is the largest cohort of NASTI patients from a single institution to date, demonstrating significantly shorter LOS and decreased non-wound infection rates in the face of increasing BMI and APACHE II scores. The increasing number of patients and BMI suggests a causal relationship between NASTI and obesity. Initial care by surgeons experienced in caring for these patients provides mortality rates well below the national average.

The response to neoadjuvant chemotherapy predicts clinical outcome and increases breast conservation in advanced breast cancer

BACKGROUND The aim of this study was to determine outcomes in patients with breast cancer treated with neoadjuvant chemotherapy. METHODS Seventy-two consecutive patients receiving neoadjuvant chemotherapy for breast cancer were enrolled. RESULTS Mastectomy was avoided in 46% of patients, and 42% converted to negative nodes after neoadjuvant chemotherapy. Thirteen patients (18%) achieved a pathologic complete response, which was associated with the estrogen receptor (ER)-negative/human epidermal growth factor receptor 2 (Her2)-negative subtype (58%) and was significantly less likely to occur in the ER+/Her2- subtype (2%) (P < .01). Patients with the ER+/Her2+ subtype were most likely to have no response or progression during chemotherapy, compared with those with the ER-/Her2- subtype (50% vs 0%, P = .01). Five-year survival for patients achieving a pathologic complete response was 100%, compared with 74% in the group with partial response and 48% in the group with no response or progression (P = .01). CONCLUSIONS Neoadjuvant chemotherapy for patients with advanced breast cancer provided prognostic information, allowed evaluation of response to chemotherapy, decreased the mastectomy rate, and potentially reduced the need for axillary lymph node dissection.

Outcomes of plastic closure in gastroschisis.

BACKGROUND Gastroschisis is a congenital abdominal wall defect in which the intestines develop outside the abdomen and are exposed to amniotic fluid. When the defect is small, lymphatic, venous, and intestinal obstruction may occur and contribute to the formation of intestinal edema, atresia, ischemia, and a thick inflammatory peel. Treatment requires early coverage of abdominal contents either by primary closure or by the placement of temporary Silastic silo followed by abdominal wall closure. Currently, both traditional suture closure and the sutureless plastic closure are being employed to repair the gastroschisis defect. The goal of the current study is to evaluate plastic closure. We predict no difference will be found in clinical outcomes between plastic closure and traditional suture closure. METHODS A retrospective review of 80 patients treated between 2000 and 2009 was performed. Plastic closure was used in 52 (65%) and traditional suture closure in 28 (35%) babies. The surgical procedure was determined by surgeon preference. Of the 31(39%) babies who required silos, 15 (19%) were treated with plastic closure and 16 (20%) underwent traditional closure. We collected the following demographic data and clinical progression data. Using SAS 9.2 (SAS Institute Inc, Cary, NC), we conducted linear regression, logistic regression, and time to event models to compare the following outcomes: days on ventilator, days to start enteral feeds, days to reach goal enteral feeds, days on total parenteral nutrition, hospital charges, duration of stay, mortality, and complications. RESULTS The mean duration of follow-up was 11.4 months. Patients spent an average of 6 days on the ventilator. There were 2 mortalities. A multivariate analysis demonstrated that no differences were found between the 2 closures with most of the outcomes; however, when compared with traditional suture closure, those babies treated with plastic closure spent 4 days fewer days on the ventilator (P < .01). Those babies who underwent suture closure were more likely to have an infection or sepsis (odds ratio, 5.15; P < .001). When the entire cohort was considered, no significant difference was found between plastic and suture closure in time to start feeds, time to reach goal feeds, time on parenteral nutrition, hospital charges, duration of stay, or complications. Ventral hernias were noted in 46 (58%) patients, 32 (62%) after plastic closure and 14 (50%) after suture closure (P = .32). Hernia repair was required in 16 (20%) patients, 11 (21%) after plastic closure, and 5 (18%) after traditional repair (P = .32). In the silo cohort, children treated with plastic closure required 7.5(P < .01) fewer days to start enteral feeds than those treated with suture closure. CONCLUSION Plastic closure of abdominal wall defects in gastroschisis is effective both as a primary procedure and after silo placement. A multivariate analysis shows plastic closure to be associated with fewer days of mechanical ventilation and less likelihood of developing infection or sepsis.

Complications and survival associated with operative procedures in patients with unresectable pancreatic head adenocarcinoma.

Unresectable tumors of the pancreatic head are encountered in up to 20% of patients taken for resection. The objective of this study was to evaluate the complications and outcome associated with palliative surgical procedures to help guide management decisions in these patients.

Helmets Prevent Motorcycle Injuries with Significant Economic Benefits

Objective: The number of registered motorcycles in the United States has been steadily increasing, as have the number of motorcycle injuries and fatalities. The Midwest has the lowest incidence of helmet use in the country. Iowa in particular has no helmet law. Materials and Methods: We conducted a retrospective study of the motorcycle crash victims treated at our level 1 trauma center between 2002 and 2008. Data from 713 motorcycle trauma victims were analyzed for correlations between helmet use and multiple outcome measures. Results: The helmeted cases were similar to the unhelmeted cases in demographic and most crash characteristics. Unhelmeted patients suffered more severe injuries as measured by the Injury Severity Score (P < .01) and Glasgow Coma Score (P < .01) and they had lower survival probability (P = .01). The unhelmeted patients were more likely to be smokers (P < .01), to drink alcohol (P < .01), to use drugs (P < .01), and to be involved in crashes at night (P = .03). Helmeted cases suffered fewer injuries (P < .01). Helmets reduced the risk of injury to the head by at least two thirds (P < .01) and to the cervical spine by at least half (P = .03). Helmeted patients were less likely to require mechanical ventilation or intensive care or to have infections. They were discharged an average of 3 days earlier (P < .01) and were less likely to be discharged to a care facility for additional institutional care (P = .02). Total hospital cost savings exceeded

A pediatric cervical spine clearance protocol to reduce radiation exposure in children

20,000 (P = .02) per helmeted patient. Conclusion: Helmets protect patients from head and neck injuries, which results in less severe injuries and a more benign hospital course. Helmet use results in significant inpatient cost savings plus additional care and social cost savings by reducing the need for further institutional care. We recommend legal and social measures to induce and encourage helmet use. Supplemental materials are available for this article. Go to the publishers online edition of Traffic Injury Prevention to view the supplemental file.

Gabapentin is Ineffective as an Analgesic Adjunct in the Immediate Postburn Period

BACKGROUND To minimize radiation exposure in children and reduce resource use, we implemented an age-specific algorithm to evaluate cervical spine injuries at a Level 1 trauma center. The effects of protocol implementation on computed tomography (CT) use in children (≤ 10 y) were determined. METHODS With institutional review board approval, we conducted a retrospective review using the institutional trauma registry. All pediatric patients (≤ 10 y) (n = 324) between January 2007 and present were reviewed. We excluded cases in which no imaging or outside imaging was performed. Patients were evaluated by physical exam alone, with the aid of plain radiograms or with cervical spine CT. All patients who required head CT also had CT of cervical spine to C3. We analyzed demographic, injury, and outcome data using STATA to perform chi-square and t-test, and to determine P value. P < 0.05 was defined as significant. We used the WinDose program to calculate the radiation-effective dose used in cervical spine CT. RESULTS There were 123 and 124 patients in the pre-protocol and post-protocol groups, respectively. Demographics, GCS, and injury analysis, specifically head-neck and face Injury Severity Scores showed no significant difference between groups. There was a 60% (P < 0.001) decrease in the use of full CTs after protocol implementation. We estimated that the protocol reduced the exposed area by 50% and decreased the radiation dose to the thyroid by > 80%. We extrapolated the combined effect results in a threefold reduction in radiation exposure. CONCLUSIONS Implementation of a cervical spine protocol led to a significant reduction in radiation exposure among children.

The impact of opioid administration on resuscitation volumes in thermally injured patients.

Successful treatment of burn pain requires a multimodality approach. Although opioid agents are the mainstay, other nonopioid agents, such as anticonvulsants, are frequently employed for pain control, with unknown benefits. The authors sought to determine the efficacy of gabapentin in acute burn pain management. Patients admitted to the burn center with burns more than 5% total body surface area and expected length of stay more than 48 hours were randomized and prospectively enrolled in this double-blind, placebo-controlled study from February 2010 to September 2011. Drug escalation and titration were done by protocol. Pain was assessed by unit protocol with the Numeric Rating Scale. Neuropathic pain and anxiety were recorded at least biweekly. Psychosocial adjustment was assessed at follow-up. Opioid medications were converted to morphine equivalents. Differences between pain levels and opioid consumption were analyzed between groups with the Student’s t-test and &khgr;2 test, respectively. The study was designed to detect a difference of 22% in opioid use between the two study groups with an enrollment of 50 patients with &agr; of 0.05 and &bgr; of 80%. P < .5 was considered significant. Fifty-three patients consented for the study and received the loading dose. Four patients withdrew. Both an intention-to-treat and actual treatment analysis were performed on all 53 patients. The placebo and drug populations were well matched for demographic variables, body surface area burned, and need for surgical intervention. The average length of stay was 11 ± 6.8 days and did not vary between groups. The study drug group received 10.8 ± 0.67 days of study drug, with eight patients receiving a dosage of 300 mg thrice daily (TID), 24 receiving 600 mg TID, 14 receiving 800 mg TID, and seven receiving 1200 mg TID. The incidence of neuropathic pain was 39% in the study drug arm and 38% in the placebo group. Neither pain scores (rest and procedural) nor opioid consumption differed between the groups. Forty-three patients (81.1%) were assessed at their first clinic visit. There was no difference in psychosocial functioning in either treatment group. In this randomized, double-blind, placebo-controlled study, the use of gabapentin in acute burn pain management did not decrease pain scores or lessen opioid requirements. Further research into nonopioid alternatives for burn pain analgesia is needed.