Sheryl G. A. Gabram

A Prospective Analysis of a Two-Year Experience Using Computed Tomography as an Adjunct for Cervical Spine Clearance

The role of CT scanning as an adjunct to plain roentgenograms of the cervical spine was reviewed in acutely injured blunt trauma patients. Following institution of a protocol to evaluate the cervical spine in all blunt trauma patients, 179 patients underwent CT scanning of their cervical spine. This was performed for patients whose x-ray findings were positive, for patients with plain x-ray films suggestive of a pathologic condition, for patients with plain x-ray films that did not reveal all of the cervical vertebrae, and for patients who had persistent pain or neurologic deficits despite normal plain x-ray films. Of 123 patients not able to have their cervical spine cleared by normal roentgenograms, 93% were cleared within 24 hours of admission based on CT scans. There were no missed injuries in this setting. A false-positive rate of 28% and a false-negative rate of 1.5% were found for plain roentgenograms. Computed tomographic scans detected 98% of the injuries in our study and when combined with a three-view plain x-ray series of the cervical spine, 100% of cervical spine injuries were detected. Computed tomographic scanning as an adjunct to plain x-ray films of the cervical spine is a highly accurate and expedient modality to clear the cervical spine of blunt trauma patients.

Hypercoagulability following Multiple Trauma

Abstract. We sought evidence of hypercoagulability in 59 seriously injured trauma patients. An extended coagulation profile (consisting of tissue plasminogen activator antigen concentration, plasminogen activator inhibitor, serum antithrombin III, protein C antigen, functional protein C, protein S antigen, D-dimer, and prothrombin fragment 1.2) was compared to control values. Laboratory evidence of hypercoagulability was seen in 85% (n = 50) of the patients. Patients with an Injury Severity Score (ISS) ≥ 16 (n = 36) had significantly elevated levels of D-dimer and decreased levels of functional protein C compared to patients with an ISS ≤ 15 (n = 23). Functional protein C had a negative correlation (r =−0.44;p < 0.001) with the ISS. A hypercoagulable state exists immediately following severe trauma. Greater injury severity may increase this hypercoagulable state. Decreased levels of functional protein C best correlated with increased injury severity.

Adverse skin lesions after methylene blue injections for sentinel lymph node localization

BACKGROUND Methylene blue dye (MBD) is being used as an alternative to isosulfan blue dye in sentinel lymph node (SLN) biopsies for breast cancer patients. Complications using MBD for SLN localization have not previously been reported. METHODS A retrospective study was conducted of 24 consecutive patients who received MBD. Patients were given 3 to 5 cc of 1% MBD as peritumoral injections within the breast parenchyma and intradermally. Patients who developed local skin lesions at the injection site were queried regarding lesion appearance and when subsequent adjuvant therapy was initiated. RESULTS Five of the 24 patients (21%) developed skin lesions at the injection site. Intradermal injections were discontinued, and only deep parenchymal injections were performed. All 5 patients had improvement of their skin lesions with silver sulfadiazine cream and no patient required debridement. Each patient received adjuvant therapy after surgery without delay. CONCLUSIONS Our institution has experienced patients who developed skin lesions at the MBD injection site when using combined deep parenchymal and intradermal injections. With the increased use of MBD, caution should be used to avoid intradermal injections with SLN localization.

Evaluation of Axillary Sentinel Lymph Node Biopsy by Immunohistochemistry and Multilevel Sectioning in Patients With Breast Carcinoma

BACKGROUND Axillary lymph node dissection for evaluation of the presence or absence of metastatic disease is the single most important prognostic factor for patients with newly diagnosed primary breast cancer. Recently, sentinel lymph node (SLN) biopsy is being investigated as an alternative to the evaluation of the entire axilla. We evaluated whether the application of multilevel sectioning and immunohistochemistry in SLNs will increase the accuracy of detection of metastatic deposits. METHODS Between October 1998 and July 1999, 38 patients with breast carcinoma (25 ductal, 5 lobular, 4 tubular, and 4 mixed ductal and lobular) underwent successful SLN biopsy followed by complete axillary node dissection. Sentinel lymph nodes were localized with a combination of isosulfan blue dye and radionuclide colloid injection. Frozen sections and permanent sections of SLNs were examined. All negative SLNs were examined for micrometastases by 3 additional hematoxylin-eosin (H&E)-stained sections and immunohistochemistry with the cytokeratins AE1/AE3. RESULTS Sentinel lymph nodes were successfully identified surgically in 38 (93%) of 41 patients. There was a 97% correlation between the results of the frozen sections and the permanent H&E-stained sections. Twelve (32%) of 38 patients showed evidence of metastatic disease in their SLN by routine H&E staining. In 7 (58%) of 12 patients with positive nodes, the sentinel node was the only positive node. The 26 patients with negative SLN examination by H&E were further analyzed for micrometastases; 5 (19%) were found to have metastatic deposits by immunohistochemistry. Of these patients, 2 were also converted to node positive by detection of micrometastatic disease by examination of the additional H&E levels. CONCLUSIONS Sentinel lymph nodes can be accurately identified in the axilla of breast cancer patients. Evaluation of SLNs provides reliable information representative of the status of the axilla in these patients. Immunohistochemistry and, to a lesser degree, detailed multilevel sectioning are able to further improve our ability to detect micrometastatic disease in SLNs of breast cancer patients.

Trauma 24-Hour Observation Critical Path

BACKGROUND The 24-hour observation critical pathway for trauma is a clinical tool developed to expedite health care delivery to minimally injured patients. The use of patient care, BS, guidelines and physician-approved standing orders was implemented in a Level I trauma center. METHODS A retrospective chart review was performed of 122 patients admitted via the emergency department between December 1, 1993, and May 31, 1994. All patients were evaluated in the emergency department by emergency medicine and trauma physicians and deemed appropriate for 24-hour observation. The information collected included patient demographics, hospital charges, injuries, length of stay, diagnostic tests, consultations, and variances from the critical pathway. RESULTS During the 6-month study period, there were 600 trauma admissions. Of those admissions, 122 patients (20%) were evaluated in the emergency department and deemed appropriate for enrollment in the 24-hour observation pathway. The charts of these patients were reviewed. Fourteen admissions were determined inappropriate for the critical pathway because of the severity of injuries or discharge against medical advice. One hundred eight charts were evaluated further. Eighty-nine patients (80%) completed the critical pathway with a length of stay of 24 hours. CONCLUSION The 24-hour observation critical pathway was designed and used appropriately as exemplified by an overall 80% completion rate. The critical pathway offers a mechanism to streamline care of the minimally injured trauma patient. It also serves as a quality-improvement tool for increasing efficiency, decreasing utilization of resources, and decreasing length of stay.

Trauma care fellowships: current status and future survival.

BACKGROUND AND METHODS To determine the current status and future direction of trauma care fellowships, a phone survey was conducted with the 45 program directors reporting information to the American Association for the Surgery of Trauma and the Eastern Association for the Surgery of Trauma. RESULTS Forty programs (89%) were operational, with 86 positions. The duration of the fellowship was 1 year for 16 (40%) and 2 or more years for 24 (60%). Accreditation Council for Graduate Medical Education accreditation (ACGME) (for surgical critical care) was held by 28 (70%). Mean salary was

TRAUMATIC INTRAMYOCARDIAL DISSECTION SECONDARY TO SIGNIFICANT BLUNT CHEST TRAUMA: A CASE REPORT

39,600 at the first-year level. A funding shift from institutional to practice revenue sources is foreseen. Thirteen directors (32.5%) saw future recruitment potential as increasing and 11 (27.5%) saw it as decreasing. CONCLUSION The essence, structure, and funding of trauma fellowships are changing. One-year exclusive trauma fellowships are being replaced by 1- to 2-year trauma or surgical critical care fellowships with Accreditation Council for Graduate Medical Education accreditation increasingly seen as essential. The challenge for fellowships in an era of budgetary constraints will be to provide adequate training in the full spectrum of tramatology within a reasonable time frame supported by a predictable funding mechanism.

Short-Term Quality of Life Following Partial Breast Irradiation with Balloon Brachytherapy- Comparison with Whole Breast Irradiation

The case of a patient with delayed mitral regurgitation and right coronary artery traumatic injury in association with intramyocardial dissection without rupture or pseudoaneurysm is presented. These findings evolved secondary to blunt chest trauma and were confirmed by cardiac ultrasound scanning, magnetic resonance imaging, and cardiac catheterization. Successful surgical correction was facilitated with this combination of diagnostic testing.

Personality Types of, Flight Crew Members in a Hospital-Based Helicopter Program

To the Editor: Radiation therapy following lumpectomy for early breast cancer remains an integral part of breast conservation therapy (BCT). Standard radiation therapy is whole breast radiation therapy (WBRT) lasting for 6–6.5 weeks encompassing the entire breast and the underlying structures. There has been interest in exploring more focused forms of radiation, one of them is partial breast radiation therapy (PBRT) using a balloon catheter (Mammosite RTS applicator ; Cytyc Corporation, USA) (1). This approach is attractive because of patient convenience and the abbreviated course of radiotherapy. Although large patient cohorts have been reported (2) and mention has been made about possible improvement in quality of life (QOL)this has not been prospectively reported. The diagnosis of breast cancer as well as the treatment experience is a psychological stressor (3). Standard WBRT is a stressor and is known to be associated with physical symptoms (fatigue) as well as emotional changes (mood, anger, etc), that impact QOL (4–6). We postulated that in addition to the reduction of physical toxicity to the patient there would be a psychological QOL benefit – with that intention we assessed functional assessment of cancer therapy (FACT) QOL scores in two groups of women as described. Standard WBRT involves irradiation of a greater volume of breast and normal tissues compared to PBRT – it also involves a longer time and stress, and logically, it should cause greater reduction in QOL. We initiated a phase IV IRB approved protocol of Balloon Brachytherapy looking at QOL at Loyola University Medical Center. Women with unilateral breast cancer and age >45 years; T1 N0 invasive nonlobular or ductal carcinoma in situ (DCIS) Lesions <2 cm and not receiving adjuvant chemotherapy were eligible. At entry, baseline QOL analysis was done using the Functional Assessment of Cancer Therapy – Breast (FACT-B) scale validated for breast cancer and repeated 3 months after completion of PBRT, (n = 20). The group of 15 women that received WBRT and acted as controls had also undergone QOL assessment as part of another study for the corresponding time periods as the PBRT patients. While not being directly matched, relevant demographic information and medical history were compared for the two groups to address differences between them(these differences were not statistically significant.) The mean QOL scores of the two groups at the corresponding time points were compared using Student’s t-test. For PBRT group, QOL assessment indicated that mean scores were high and stable at 3 months suggesting no detriment in QOL (Fig. 1). By contrast for the WBRT group there is some detriment in short term QOL within the first 3 months for Physical and Emotional Well-being scales (Fig. 2). For the comparison analysis (Fig. 3), there was a significantly greater Emotional and Physical Well-Being on QOL assessment with PBRT compared to WBRT, (p < 0.03).

Delayed hemorrhagic pericardial effusion: case reports of a complication from severe blunt chest trauma.

PURPOSE To determine the personality preferences of flight crew members in a hospital-based helicopter emergency medical service (HEMS) using the Myers-Briggs Type Indicator (MBTI), and to differentiate and compare these preferences between crew specialties and a historical control population. METHODS A prospective cohort study was conducted of all active crew members (nurses, respiratory therapists and pilots) in a hospital-based flight program. Data collected included the results of the MBTI, gender, age and years of flight experience. RESULTS Crew members were represented by 14 of 16 possible MBTI personality types, with three types predominating. For each crew specialty, extroversion preferences predominated over introversion, and perceiving characteristics predominated over judging characteristics. Differences existed by crew specialty for the sensing-intuition and thinking-feeling dimensions. CONCLUSIONS A personality typology has been established for individual and group preferences within one hospital-based HEMS program. This data begins to develop a data base and an investigative protocol for understanding some of the human factors regarding flight programs. Future research should focus on expanding the data base and exploring specific crew interactions based on additional diagnostic and evaluative methodologies.