Robert T. Stovall

Long-term Follow-up and Survival of Patients Following a Recurrence of Melanoma After a Negative Sentinel Lymph Node Biopsy Result

OBJECTIVE To analyze the predictors and patterns of recurrence of melanoma in patients with a negative sentinel lymph node biopsy result. DESIGN Retrospective chart review of a prospectively created database of patients with cutaneous melanoma. SETTING Tertiary university hospital. PATIENTS A total of 515 patients with melanoma underwent a sentinel lymph node biopsy without evidence of metastatic disease between 1996 and 2008. MAIN OUTCOME MEASURES Time to recurrence and overall survival. RESULTS Of 515 patients, 83 (16%) had a recurrence of melanoma at a median of 23 months during a median follow-up of 61 months (range, 1-154 months). Of these 83 patients, 21 had melanoma that metastasized in the studied nodal basin for an in-basin false-negative rate of 4.0%. Patients with recurrence had deeper primary lesions (mean thickness, 2.7 vs 1.8 mm; P < .01) that were more likely to be ulcerated (32.5% vs 13.5%; P < .001) than those without recurrence. The primary melanoma of patients with recurrence was more likely to be located in the head and neck region compared with all other locations combined (31.8% vs 11.7%; P < .001). Median survival following a recurrence was 21 months (range, 1-106 months). Favorable characteristics associated with lower risk of recurrence included younger age at diagnosis (mean, 49 vs 57 years) and female sex (9% vs 21% for males; P < .001). CONCLUSION Overall, recurrence of melanoma (16%) after a negative sentinel lymph node biopsy result was similar to that in previously reported studies with an in-basin false-negative rate of 4.0%. Lesions of the head and neck, the presence of ulceration, increasing Breslow thickness, older age, and male sex are associated with increased risk of recurrence, despite a negative sentinel lymph node biopsy result.

A multicenter, randomized clinical trial of IV iron supplementation for anemia of traumatic critical illness

Objective:To evaluate the efficacy of IV iron supplementation of anemic, critically ill trauma patients. Design:Multicenter, randomized, single-blind, placebo-controlled trial. Setting:Four trauma ICUs. Patients:Anemic (hemoglobin < 12 g/dL) trauma patients enrolled within 72 hours of ICU admission and with an expected ICU length of stay of more than or equal to 5 days. Interventions:Randomization to iron sucrose 100 mg IV or placebo thrice weekly for up to 2 weeks. Measurements and Main Results:A total of 150 patients were enrolled. Baseline iron markers were consistent with functional iron deficiency: 134 patients (89.3%) were hypoferremic, 51 (34.0%) were hyperferritinemic, and 64 (42.7%) demonstrated iron-deficient erythropoiesis as evidenced by an elevated erythrocyte zinc protoporphyrin concentration. The median baseline transferrin saturation was 8% (range, 2–58%). In the subgroup of patients who received all six doses of study drug (n = 57), the serum ferritin concentration increased significantly for the iron as compared with placebo group on both day 7 (808.0 ng/mL vs 457.0 ng/mL, respectively, p < 0.01) and day 14 (1,046.0 ng/mL vs 551.5 ng/mL, respectively, p < 0.01). There was no significant difference between groups in transferrin saturation, erythrocyte zinc protoporphyrin concentration, hemoglobin concentration, or packed RBC transfusion requirement. There was no significant difference between groups in the risk of infection, length of stay, or mortality. Conclusions:Iron supplementation increased the serum ferritin concentration significantly, but it had no discernible effect on transferrin saturation, iron-deficient erythropoiesis, hemoglobin concentration, or packed RBC transfusion requirement. Based on these data, routine IV iron supplementation of anemic, critically ill trauma patients cannot be recommended (NCT 01180894).

Surgical stabilization of severe rib fractures.

R ib fractures are common and lead to prolonged pain, dyspnea, and health care expenditures. Traditionally, even the most severe fracture patterns have beenmanaged nonoperatively. However, an improved understanding of rib biomechanics, advancements in fixation systems, the development of musclesparring techniques, and favorable outcomes research have led to a renewed interest in surgical stabilization of rib fractures (SSRF). Furthermore, because SSRF lies at the confluence of trauma, orthopedic, and thoracic surgery, it is a well-suited procedure for the acute care surgeon to master. Many trauma centers now routinely perform SSRF, and expert panels have recognized the utility of this procedure. However, there remains a lack of consensus regarding both indications and technique. The following is a description of our approach to patients with severe rib fractures; we are currently collecting prospectively outcomes data related to this management protocol and would encourage other centers considering adoption of SSRF to do the same.

Intra-abdominal injury following blunt trauma becomes clinically apparent within 9 hours

BACKGROUND The diagnosis of blunt abdominal trauma can be challenging and resource intensive. Observation with serial clinical assessments plays a major role in the evaluation of these patients, but the time required for intra-abdominal injury to become clinically apparent is unknown. The purpose of this study was to determine the amount of time required for an intra-abdominal injury to become clinically apparent after blunt abdominal trauma via physical examination or commonly followed clinical values. METHODS A retrospective review of patients who sustained blunt trauma resulting in intra-abdominal injury between June 2010 and June 2012 at a Level 1 academic trauma center was performed. Patient demographics, injuries, and the amount of time from emergency department admission to sign or symptom development and subsequent diagnosis were recorded. All diagnoses were made by computed tomography or at the time of surgery. Patient transfers from other hospitals were excluded. RESULTS Of 3,574 blunt trauma patients admitted to the hospital, 285 (8%) experienced intra-abdominal injuries. The mean (SD) age was 36 (17) years, the majority were male (194 patients, 68%) and the mean (SD) Injury Severity Score (ISS) was 21 (14). The mean (SD) time from admission to diagnosis via computed tomography or surgery was 74 (55) minutes. Eighty patients (28%) required either surgery (78 patients, 17%) or radiographic embolization (2 patients, 0.7%) for their injury. All patients who required intervention demonstrated a sign or symptom of their intra-abdominal injury within 60 minutes of arrival, although two patients were intervened upon in a delayed fashion. All patients with a blunt intra-abdominal injury manifested a clinical sign or symptom of their intra-abdominal injury, resulting in their diagnosis within 8 hours 25 minutes of arrival to the hospital. CONCLUSION All diagnosed intra-abdominal injuries from blunt trauma manifested clinical signs or symptoms that could prompt imaging or intervention, leading to their diagnosis within 8 hours 25 minutes of arrival to the hospital. All patients who required an intervention for their injury manifested a sign or symptom of their injury within 60 minutes of arrival. LEVEL OF EVIDENCE Therapeutic study, level IV. Epidemiologic study, level III.

Endovascular Stenting Is Rarely Necessary for the Management of Blunt Cerebrovascular Injuries

BACKGROUND The role of stenting for blunt cerebrovascular injuries (BCVI) continues to be debated, with a trend toward more endovascular stenting. With the recent intracranial stenting trial halted in favor of medical therapy, however, management of BCVI warrants reassessment. The study purpose was to determine if antithrombotic therapy, rather than stenting, was effective in post-injury patients with high-grade vascular dissections and pseudoaneurysms. STUDY DESIGN In 1996, we began screening for BCVI. After the 2005 report on the risks of carotid stenting for BCVI, a virtual moratorium was placed on stenting at our institution; our primary therapy for BCVI has been antithrombotics. Patients with grade II (luminal narrowing >25%) and grade III (pseudoaneurysms) injuries were included in the analysis. RESULTS Grade II or III BCVIs were diagnosed in 195 patients. Before 2005, 25% (21 of 86) of patients underwent stent placement, with 2 patients suffering stroke. Of patients treated with antithrombotics, 1 had a stroke. After 2005, only 2% (2 of 109) of patients with high-grade injuries had stents placed. After 2005, no patient treated with antithrombotics suffered a stroke and there was no rupture of a pseudoaneurysm. CONCLUSIONS Antithrombotic treatment for BCVI is effective for stroke prevention. Routine stenting entails increased costs and potential risk for stroke, and does not appear to provide additional benefit. Intravascular stents should be reserved for the rare patient with symptomatology or a markedly enlarging pseudoaneurysm.

RibScore: A novel radiographic score based on fracture pattern that predicts pneumonia, respiratory failure, and tracheostomy.

BACKGROUND There is currently no scoring system for rib fractures that relates detailed anatomic variables to patient outcomes. Our objective was to develop and validate a radiographic rib fracture scoring system based on computed tomographic chest findings. METHODS We reviewed our trauma registry from September 2012 to April 2014 for all blunt trauma patients with one or more rib fractures visualized on chest computed tomography. We identified the following six candidate radiographic variables and tested their individual associations with pneumonia, respiratory failure, and tracheostomy: (1) six or more rib fractures, (2) bilateral fractures, (3) flail chest, (4) three or more severely (bicortical) displaced fractures, (5) first rib fracture, and (6) at least one fracture in all three anatomic areas (anterior, lateral, and posterior). We developed the “RibScore” by assigning 1 point for each variable, which was validated among the sample using univariate analyses, test performance characteristics, and the receiver operating characteristic area under the curve c statistic. RESULTS A total of 385 patients with one or more rib fractures were identified; 274 (71.2%) were males, median age was 48 years, and median Injury Severity Score (ISS) was 17. Of these patients, 156 had six or more rib fractures, 120 had bilateral fractures, 46 had flail chest, 32 had three or more severely displaced fractures, 91 had a first rib fracture, and 58 had fractures in all three anatomic areas. Each RibScore component variable was associated with the three pulmonary outcomes by univariate analysis (p < 0.05). The median RibScore was 1 (range, 0–6). The distribution of the RibScore was as follows: score of 0, 41.9%); score of 1, 23.9%; score of 2, 15.4%; score of 3, 9.9%; score of 4, 7.6%; and score of five, 1.3%. RibScore was linearly associated with pneumonia (p < 0.01), acute respiratory failure (p < 0.01), and tracheostomy (p < 0.01). The receiver operating characteristic areas under the curve for the outcomes were 0.71, 0.71, and 0.75, respectively. CONCLUSION The RibScore predicts adverse pulmonary outcomes and represents a standardized assessment of fracture severity that may be used for communication and prognostication of the severely injured trauma patient. LEVEL OF EVIDENCE Prognostic study, level III.

Hypercoagulability following blunt solid abdominal organ injury: when to initiate anticoagulation

BACKGROUND The optimal time to initiate venous thromboembolism pharmacoprophylaxis after blunt abdominal solid organ injury is unknown. METHODS Postinjury coagulation status was characterized using thromboelastography (TEG) in trauma patients with blunt abdominal solid organ injuries; TEG was divided into 12-hour intervals up to 72 hours. RESULTS Forty-two of 304 patients (13.8%) identified underwent multiple postinjury thromboelastographic studies. Age (P = .45), gender (P = .45), and solid organ injury grade (P = .71) were similar between TEG and non-TEG patients. TEG patients had higher Injury Severity Scores compared with non-TEG patients (33.2 vs 18.3, respectively, P < .01). Among the TEG patients, the shear elastic modulus strength and maximum amplitude values began in the normal range within the first 12-hour interval after injury, increased linearly, and crossed into the hypercoagulable range at 48 hours (15.1 ± 1.9 Kd/cs and 57.6 ± 1.6 mm, respectively; P < .01, analysis of variance). CONCLUSIONS Patients sustaining blunt abdominal solid organ injuries transition to a hypercoagulable state approximately 48 hours after injury. In the absence of contraindications, pharmacoprophylaxis should be considered before this time for effective venous thromboembolism prevention.

Clinical Utility of Chest Computed Tomography in Patients with Rib Fractures CT Chest and Rib Fractures

Background Chest CT is more sensitive than a chest X-ray (CXR) in diagnosing rib fractures; however, the clinical significance of these fractures remains unclear. Objectives The purpose of this study was to determine the added diagnostic use of chest CT performed after CXR in patients with either known or suspected rib fractures secondary to blunt trauma. Methods Retrospective cohort study of blunt trauma patients with rib fractures at a level I trauma center that had both a CXR and a CT chest. The CT finding of ≥ 3 additional fractures in patients with ≤ 3 rib fractures on CXR was considered clinically meaningful. Student’s t-test and chi-square analysis were used for comparison. Results We identified 499 patients with rib fractures: 93 (18.6%) had CXR only, 7 (1.4%) had chest CT only, and 399 (79.9%) had both CXR and chest CT. Among these 399 patients, a total of 1,969 rib fractures were identified: 1,467 (74.5%) were missed by CXR. The median number of additional fractures identified by CT was 3 (range, 4 - 15). Of 212 (53.1%) patients with a clinically meaningful increase in the number of fractures, 68 patients underwent one or more clinical interventions: 36 SICU admissions, 20 pain catheter placements, 23 epidural placements, and 3 SSRF. Additionally, 70 patients had a chest tube placed for retained hemothorax or occult pneumothorax. Overall, 138 patients (34.5%) had a change in clinical management based upon CT chest. Conclusions The chest X-ray missed ~75% of rib fractures seen on chest CT. Although patients with a clinical meaningful increase in the number of rib fractures were more likely to be admitted to the intensive care unit, there was no associated improvement in pulmonary outcomes.

Early repeat imaging is not warranted for high-grade blunt cerebrovascular injuries.

BACKGROUND The current management for blunt cerebrovascular injuries (BCVIs) includes repeat imaging 7 days to 10 days after initial diagnosis. This recommendation, however, has not been systematically evaluated. The purpose of this study was to evaluate the impact of early repeat imaging on treatment course. We hypothesized that a minority of patients with high-grade injuries (Grades III and IV) have complete resolution of their injuries early in their treatment course and hence repeat imaging does not alter their therapy. METHODS Our prospective BCVI database was queried from January 1, 1997, to January 1, 2013. Injuries were graded according to the Denver scale. Injuries, treatment, and imaging results were analyzed. BCVI healing was defined as a complete resolution of the injury. RESULTS During the 16-year study, 582 patients sustained 829 BCVIs; there were 420 carotid artery injuries and 409 vertebral artery injuries. The majority (78%) received antithrombotic therapy. For the 296 carotid artery injuries (70%) with repeat imaging, there was complete healing of the injury in 56% of Grade I, 20% of Grade II, 5% of Grade III, and 0% of Grade IV injuries. For the 255 vertebral artery injuries (62%) with repeat imaging, there was a resolution of the injury in 56% of Grade I, 17% of Grade II, 14% of Grade III, and 3% of Grade IV injuries. For BCVIs overall, there was healing documented in 56% of Grade I, 18% of Grade II, 8% of Grade III, and 2% of Grade IV injuries. CONCLUSION Injury grade of BCVIs is associated with the healing rate of the injury. While approximately half of Grade I BCVIs resolved, only 7% of all high-grade injuries healed. Early repeat imaging may not be warranted in high-grade BCVI; the vast majority of injuries do not resolve. The cost, radiation, and transport risk of early repeat imaging should be weighed against the potential treatment impact for individual patients. LEVEL OF EVIDENCE Therapeutic/care management study, level IV.

Completely thoracoscopic, intra-pleural reduction and fixation of severe rib fractures

Despite favourable outcome data [1], surgical stabilisation of severe rib fractures (SSRF) is employed in only the minority of cases of chest wall injuries [2]. One barrier to widespread adoption of this procedure is concern about the operativemorbidity [3].We recently reported our technique for open SSRF, which employs minimal incisions and muscle splitting whenever possible [4]. However, this technique (and any open technique) remains limited by 1) the need for longer skin incisions; 2) the need for partial division of the lattisimus dorsi and trapezius muscles at the extremes of exposure in some fracture patterns; 3) the need for scapular retraction to gain exposure to subscapular fractures; 4) plate placement on the outer cortex of the ribs, which may be palpable by thinner patients; 5) risk of pulmonary or cardiac injury from drilling and screwing in an internal direction; and 6) the inability to routinely visualise the pleural space (unless a thoracotomy is performed). Herein we describe a case of totally thoracoscopic, intra-pleural SSRF, including fixation to the inner rib cortex, a technique which addresses each of the aforementioned limitations of the open approach.