Sherrine Eid

Odontoid fractures in the elderly: should we operate?

BACKGROUND : Treatment of odontoid fractures remains controversial. There are conflicting data in the literature with regard to timing of operative fixation (OP), as well as whether OP should be performed. Within our own institution, treatment is variable depending largely on surgeon preference. This study was undertaken in an attempt to develop management consensus by examining outcomes in elderly patients with odontoid fractures and comparing OP to a nonoperative (non-OP) approach. METHODS : The trauma registry of our level I trauma center was queried for elderly (age > or = 60) patients with odontoid fractures from January 2000 to May 2006. Patients were then grouped according to treatment, early-OP (< or =3 days posttrauma), late-OP (>3 days), or non-OP treatment. Patient characteristics that were evaluated and compared among the three groups included age, Injury Severity Score, preexisting conditions, and the type of odontoid fracture. Outcomes evaluated included in-hospital mortality, ventilator days, hospital length of stay (HLOS), need for tracheostomy and percutaneous endoscopic gastrostomy (PEG), and the complications of urinary tract infection (UTI), deep vein thrombosis (DVT), and pneumonia. Differences among groups were tested using analysis of variance, Students t test, chi, and Fishers exact test. RESULTS : The non-OP patients were significantly older than either operative group (mean, 82.4 for non-OP; 77.4 for early-OP; and 76.4 for late-OP; p = 0.006 non-OP compared with either operative group). Injury Severity Score, number of preexisting conditions, mechanism of injury, and distribution of type of odontoid fractures were similar among all three groups. There was no statistically significant difference in mortality among the three groups (11.7% early-OP, 8.7% late-OP, and 17.6% non-OP). There was also no difference among all three groups with respect for the need for tracheostomy and PEG and the development of UTI or pneumonia. However, there were significantly less DVTs in the non-OP group compared with the early-OP group (2.9% vs. 17.6%, p = 0.02). The percentage of patients discharged to a skilled nursing facility was similar among all three groups. The non-OP group had a significant decrease in both ventilator days and HLOS when compared with the operative groups. Only 2.9% of non-OP patients returned for OP for nonunion of the odontoid fracture. CONCLUSIONS : Despite being an older population, elderly patients with odontoid fracture who were managed non-OP had similar mortality, UTI, and pneumonia rates compared with their younger counterparts who underwent OP. The need for tracheostomy and PEG and discharge disposition was similar among all three groups. Elderly patients with odontoid fracture managed non-OP had a reduction in HLOS and ventilator days compared with either operative group and less DVT compared with the early operative group. Based on these results, non-OP management should be given strong consideration in elderly patients with traumatic odontoid fractures.

Family Presence During Trauma Resuscitation: Ready for Primetime?

BACKGROUND The concept of family presence during trauma resuscitation (FPTR) remains controversial. Healthcare providers have expressed concern that resuscitation of severely injured trauma patients is inappropriate for family members as they may have psychologic distress, disrupt resuscitative efforts, or misinterpret provider actions, which can ultimately impact satisfaction with care. The minimal evidence that exists is descriptive or anecdotal. METHODS Using a previously developed FPTR protocol, a prospective, comparative study assessing 50 adult family members, who were present (n = 25) or not present (n = 25) with their severely injured adult family member during resuscitation, was conducted. Family member anxiety was assessed using State-Trait Anxiety Inventory, satisfaction using a Revised-Critical Care Family Needs Inventory, and well-being using Family Member Well-being Index within 48 hours of intensive care unit admission. Mean total scores were compared for both groups with independent t tests. Significance was set at p < 0.05. RESULTS Age and Injury Severity Score were statistically equivalent in all patients. Anxiety, satisfaction, and well-being were not statistically different in family members present compared with those not present during resuscitation. There were no untoward events during resuscitation efforts. Family members present felt they benefited the patient and gained a better understanding of the situation. Conversely, family members not present commented that they would have preferred to have been present during resuscitation. CONCLUSIONS Family members present during trauma resuscitation suffered no ill psychologic effects and scored equivalent to those family members who were not present on anxiety, satisfaction, and well-being measures. Quality of care during trauma resuscitation was maintained. The fact that all the family members would repeat experience again supports the idea that FPTR was not too traumatic for those who chose to be present.

Oxytocin Discontinuation During Active Labor in Women Who Undergo Labor Induction

OBJECTIVE The purpose of this study was to determine whether there is an increase in the cesarean delivery rate in women who undergo induction when oxytocin is discontinued in the active phase of labor. STUDY DESIGN We conducted a prospective randomized controlled trial of women who underwent induction of labor at term; they were assigned randomly to either routine oxytocin use (routine) or oxytocin discontinuation (DC) once in active labor. Analysis was by intention to treat. RESULTS Two hundred fifty-two patients were eligible for study analysis: 127 patients were assigned randomly to the routine group and 125 patients were assigned randomly to the DC group. Cesarean delivery rate was similar between the groups (routine, 25.2% [n = 32] vs the DC group, 19.2% [n = 24]; P = .25). There was a higher chorioamnionitis rate and slightly longer active phase in those women who were assigned to the DC group. In adjusted analysis, the rate of chorioamnionitis was not different by randomization group but was explained by the duration of membrane rupture and intrauterine pressure catheter placement. CONCLUSION Discontinuation of oxytocin in active labor after labor induction does not increase the cesarean delivery rate significantly.

Demographic determinants and effect of pre-operative angiotensin converting enzyme inhibitors and angiotensin receptor blockers on the occurrence of atrial fibrillation after CABG surgery

BackgroundAtrial fibrillation (AF) occurs in about 27% to 40% of post cardiac surgery patients. AF following coronary artery bypass graft surgery (CABG) is associated with a two-fold increase in morbidity and mortality. Various demographic risk factors and medications have been studied to predict the occurrence of this arrhythmia. The role of angiotensin related medications on the occurrence of AF in CABG patients is not determined.MethodsRetrospective clinical and statistical analysis was made of all the patients who had undergone CABG surgery at Lehigh Valley Hospital during the years 2005 and 2006. Patients with chronic AF and those undergoing valvular surgery with CABG were excluded. Statistic analysis included chi-square test for categorical and student t-test for continuous variables.Results757 patients (560 males and 197 females) were studied. AF occurred in 19% of the patients. Age (70.5 vs. 65.1, p < 0.005. OR per year of age: 1.02, 95%CI: 1.018-1.023) and presence of hypertension (OR: 1.92, 95%CI: 1.086-3.140, p = 0.025) were significantly associated with occurrence of AF. Neither ARBs (OR: 0.78, 95%CI: 0.431-1.410, p = 0.41) nor ACE inhibitors (OR: 1.01, 95%CI: 0.753-1.608, p = 0.63) reduced the occurrence of post operative AF. Patients with post operative AF had a significantly longer hospital stay (9.5 +/- 5.4 days vs. 6.9 +/- 4.3 days, p = 0.001).ConclusionsAdvanced age and presence of hypertension were independent predictors of post-CABG AF. Patients with post operative AF had significantly longer hospital stay. Neither ARBs nor ACE inhibitors were associated with reduction of post-surgical AF. Further studies are needed to better delineate the role of angiotensin related medications on reduction of post-surgical AF.

Prevalence of peripheral artery disease varies significantly depending upon the method of calculating ankle brachial index

Objective Peripheral artery disease (PAD) identifies individuals at high risk for future cardiovascular disease (CVD) warranting aggressive risk reduction therapies. PAD can be diagnosed noninvasively by calculating the ankle brachial index (ABI), a ratio of ankle and arm blood pressures. We examined the existing various methods of calculating ABI and the resulting estimates of PAD prevalence. Methods We analyzed data from three National Health and Nutrition Examination Surveys. PAD prevalence using three different methods of calculating ABI was determined in 5376 participants, aged ≥ 40 years without prior history of CVD. ABI was defined as an ankle brachial index of less than 0.9. Statistical analysis was performed using SPSS V15.0. Results PAD prevalence among asymptomatic adults without CVD increased significantly during the 6-year time period (1999-2004), regardless of the method used for determining ABI. However, across the National Health and Nutrition Examination Survey assessments, ABI method significantly affected calculated PAD prevalence. Differences in calculated PAD prevalence correspond to approximately 2.2 million persons who would be reclassified as having or not having PAD. Conclusion The calculated prevalence of asymptomatic PAD varies significantly by the ABI method used. Further study is required to determine the most accurate method of performing ABI.

Effect of subcutaneous epinephrine/saline/local anesthetic versus saline-only injection on split-thickness skin graft donor site perfusion, healing, and pain.

The technique for split-thickness skin graft harvest varies among surgeons. Even though there is scientific evidence that the subcutaneous injection of modified tumescent solution reduces blood loss during burn surgery, the technique has not been unanimously adapted because of, in part, fear of healing retardation. This study prospectively examines the effect of tumescent injection on donor site perfusion, healing, and pain. Ten burn patients in need of grafting with a need for two distinctly different donor sites were included. During the grafting procedure, the two donor areas were randomly assigned to receive either modified tumescent solution or warm sterile saline solution subcutaneously before skin graft harvest with a dermatome. Perfusion, pain, pruritus, and donor site healing were measured, and a follow-up evaluation on scar quality was performed. Baseline perfusion on day 1 was significantly less in the donor site injected with modified tumescent solution (62.26 vs 95.71 perfusion units; P = .031), whereas the response to heat was similar in both sites. The physiologic response to injury (hyperemia) on days 2 and 3 was not suppressed in the modified tumescent group. Pain reported on day 1 was 2.38/10 in the tumescent site and 3.38/10 in the saline site (P = .21). On all other days, measurements showed no difference between the two sites. Donor sites healed in an average of 16.1 days with modified tumescent solution and in 16.4 days with saline. Late follow-up showed no difference in scar quality. The subcutaneous injection of modified tumescent solution before split-thickness donor site harvest has no adverse effect on donor site perfusion past day 1 or donor site healing. The addition of a local anesthetic may decrease pain for 24 hours postoperatively, but the difference in this study group was not significant. This technique should be universally recommended.

Tissue Expander Complications Predict Permanent Implant Complications and Failure of Breast Reconstruction.

BackgroundTwo-stage tissue expander–based breast reconstruction is the most commonly used reconstructive modality following mastectomy. We sought to determine if patients who experienced complications during the expansion phase were at increased risk for complications or reconstructive failure after the exchange procedure. MethodsA retrospective review of tissue expander–based breast reconstructions was performed from January 2007 through December 2011. Variables evaluated included age, presence of cancer, tobacco use, body mass index, comorbidities, use of acellular dermal matrix, chemotherapy, radiation, timing of reconstruction (delayed/immediate), intraoperative tissue expander fill, complications, and explantation or salvage of the reconstruction by means of debridement and closure or myocutaneous flap. ResultsA total of 196 patients underwent mastectomy with 304 tissue expander reconstructions. Tobacco use (active and remote), hypertension, and radiation were associated with complications. Patients with a salvaged tissue expander complication were 3 times more likely to have a complication after placement of a permanent implant and 9 times more likely to fail permanent implant reconstruction (ie, require explantation). ConclusionsWomen with complications after placement of a tissue expander are at significantly increased risk for both complications and reconstructive failure after placement of a permanent implant. Consideration for earlier autologous reconstruction as a salvage should be strongly considered in patients with a tissue expander complication, particularly in smokers and those undergoing radiation therapy.

Surgical and Financial Implications of Genetic Counseling and Requests for Concurrent Prophylactic Mastectomy.

Risk assessment evaluation and breast cancer (BRCA) testing can occur in situations where a woman considers herself to be at increased risk for developing breast cancer or her physicians, either during routine evaluation or after diagnosis of unilateral breast cancer, consider her to be at risk for harboring a genetic predisposition to breast malignancy. This study examined the impact of risk assessment counseling on trends in breast surgery and cost of care.A retrospective chart review was performed from January 1, 1999 to December 31, 2008 for women older than 18 years who underwent breast surgery for malignancy or prophylaxis, had at least 1-year follow-up, and underwent genetic counseling. From the total number of women treated at our institution who underwent unilateral or bilateral mastectomy, we identified 102 women who underwent genetic counseling and selected 199 patients who did not undergo counseling to create a 4:1 retrospective case–control study. Patients who underwent BRCA gene testing and/or counseling were compared with patients who did not (controls). The study was powered at 70%, and &agr; was set at 0.05.Counseled patients were >9 times more likely to undergo bilateral mastectomies (odds ratio = 9.18). They were younger (46.4 vs. 61.8) and incurred higher total costs (

Impact of Injury Mechanisms on Patterns and Management of Facial Fractures.

10,810 vs.

Delayed diagnosis of hand injuries in polytrauma patients.

7,266) (P < 0.002). The same trend was observed in each group. In counseled and control groups, younger women chose bilateral mastectomies (mean 44.4; 55.5), whereas older women chose unilateral procedures (mean 49.8; 63.02) (P < 0.014). Total cost for bilateral mastectomies was greater than unilateral mastectomies for both groups. Of 55 counseled patients undergoing mastectomies (85 breasts), 78 (92%) breasts were reconstructed, whereas 113 (49%) of 230 breasts were reconstructed in the control group.There was a statistically significant association between counseling with BRCA testing and decision to undergo bilateral as opposed to unilateral mastectomies. Younger women were also more likely to choose bilateral mastectomies whether or not they underwent counseling. Furthermore, a greater proportion of counseled women who underwent reconstruction opted to have bilateral implants. At our institution, younger women tend to choose costlier options.