Vance Y. Sohn

Functional and survival outcomes in traumatic blunt thoracic aortic injuries: An analysis of the National Trauma Databank.

OBJECTIVE Blunt thoracic aortic injury (BAI) remains a leading cause of trauma deaths, and off-label use of endovascular devices has been increasingly utilized in an effort to reduce the morbidity and mortality in this population. Utilizing a nationwide database, we determined the incidence of BAI, and analyzed both functional and survival outcomes at discharge compared with matched controls. METHODS Patients with BAI were identified by International Classification of Disease-9 codes from the National Trauma Data Bank (Version 6.2), 2000-2005. Patients were analyzed based on aortic repair, associated physiologic burden, and coexisting injuries. Control groups were matched by age, mechanism, major thoracic Abbreviated Injury Scale score (AIS >/= 3), major head AIS, and major abdominal AIS. Outcomes were assessed using the functional independence measure (FIM) score and overall mortality. FIM scores were scored from 1 (full assistance required) to 4 (fully independent) for three categories: feeding, locomotion, and expression. RESULTS During the study period, 3,114 patients with BAI were identified among 1.1 million trauma admissions for an overall incidence of 0.3%. One hundred thirteen (4%) were dead on arrival, and 599 (19%) died during triage. Of the patients surviving transport and triage (n = 2402), 29% had a concomitant major abdominal injury and 31% had a major head injury. Sixty-eight percent (1,642) underwent no repair, 28% (665) open aortic repair, and 4% (95) endovascular repair with associated mortality rates of 65%, 19%, and 18%, respectively (P < .05). Aortic repair independently improved survival when controlling for associated injuries and physiologic burden (odds ratio (OR) = 0.36; 95% confidence interval (CI), 0.24-0.54, P < .05). Compared with matched controls, BAI resulted in a higher mortality (55% vs. 15%, P < .05), and independently contributed to mortality (OR = 4.04; 95% CI, 3.53-4.63, P < .05). In addition, BAI patients were less likely to be fully independent for feeding (72% vs. 82%, P < .05), locomotion (33% vs. 55%, P < .05), and expression (80% vs 88%, P < .05). CONCLUSION This manuscript is the first to define the incidence of BAI utilizing the NTDB. Remarkably, two-thirds of patients are unable to undergo attempts at aortic repair, which portends a poor prognosis. When controlling for associated injuries, blunt aortic injury independently impacts survival and results in poor function in those surviving to discharge.

Colonic ischemia complicating open vs endovascular abdominal aortic aneurysm repair

OBJECTIVE Colonic ischemia (CI) is a known complication of both open abdominal aortic aneurysm (AAA) repair and endovascular aneurysm repair (EVAR). Despite a relatively low incidence of 1% to 6%, the associated morbidity and mortality are high. We sought to analyze factors that affect the development of CI on the basis of type of repair as well as associated outcomes from a large nationwide database. METHODS All admissions undergoing AAA repair were selected from the 2003 and 2004 Nationwide Inpatient Sample. Univariate and logistic regression analyses were used to compare outcome measures and identify independent predictors of development of colonic ischemic complications. RESULTS We identified 89,967 admissions for AAA repair (mean age, 69.9 years). Open elective repair was performed in 49% of cases, elective EVAR in 41%, and ruptured aneurysm repair in 9%. The overall incidence of CI was 2.2% (1941 cases); however, the incidence for specific procedures was significantly higher after repair of ruptured aneurysm (8.9%) and open elective repair (1.9%) than after EVAR (0.5%; both P < .001). Patients who developed CI were at increased risk for mortality (37.8% vs 6.7%), had longer hospital stays (21.5 vs 8.1 days), incurred higher hospital charges (

Breast Papillomas in the Era of Percutaneous Needle Biopsy

182,000 vs

Ultrasound-Guided Access Improves Rate of Access-Related Complications for Totally Percutaneous Aortic Aneurysm Repair

77,000), and were less likely to be discharged home from hospital (36% vs 71%; all P < .001). Independent predictors of development of CI included ruptured aneurysm (odds ratio [OR] = 6.4), female gender (OR = 1.6) and, in the setting of elective repair, open operation (OR = 3.1). CI was found to be a strong independent predictor of mortality in evaluations of both the entire cohort (OR = 4.5) and the elective open repair and EVAR (OR = 2.4) subgroups. CONCLUSIONS CI is significantly more common after open AAA repair and is associated with increased morbidity and a two- to fourfold increase in mortality.

Atypical Ductal Hyperplasia: Improved Accuracy with the 11-Gauge Vacuum-Assisted versus the 14-Gauge Core Biopsy Needle

BackgroundThe significance of breast papillomas detected on core needle biopsy (CNB) remains unclear. While those associated with malignancy or atypia are excised, no clear solution exists for benign papillomas. We sought to determine the indication for surgical excision, incidence of malignancy, significance, and natural history.MethodsIn this retrospective review, patients were divided into benign, atypical, or malignant cohorts based on initial results. While patients with malignant or atypical features were encouraged to undergo surgical excision, no standard recommendation was given for benign papillomas. Mammographic features, method of initial diagnosis, pathology results, and follow-up data were analyzed.ResultsBetween January 1994 to December 2005, 5,257 CNBs were performed at our tertiary level medical center. 206 patients were diagnosed with 215 breast papillomas. 174 (81%) papillomas were benign, 26 (12%) were associated with atypia, and 15 (7%) were associated with malignancy. Two benign papillomas (1.1%) developed into cancer over an average of 53 months. Average follow-up of those patients not undergoing excision for benign papilloma was 41 months; we had 92 patients with greater than two year follow-up and 57 patients with greater than four year follow-up. Of patients with atypia or malignancy associated with papilloma, there was a 26% and 87% associated rate of malignancy, respectively.ConclusionsBenign breast papillomas diagnosed by CNB have a low risk of malignancy and do not need excision. However, they should be considered high risk lesions which require serial radiographic monitoring. Papillomas associated with atypia or malignancy should continue to be excised.

Demographics, Treatment, and Early Outcomes in Penetrating Vascular Combat Trauma

Previous experience with totally percutaneous aortic aneurysm repair has identified morbid obesity and larger sheath sizes (> or =20F) as complicating factors for percutaneous access closure. We sought to evaluate the impact of ultrasound-guided femoral access on rates of technical success, conversion to open femoral repair, and access-related complications. A retrospective review of a prospectively maintained database was performed. All consecutive patients undergoing totally percutaneous closure of large-bore-sheath (>12F) access sites with a suture-mediated closure device were included. The cohort was stratified into two groups by access technique, standard percutaneous femoral access, and ultrasound-guided femoral access. Patient variables were evaluated, and outcome measures included technical success, requirement for conversion to open repair, and access-related complications. Recorded conversions only included those related to access closure technique. During the study period, 88 consecutive patients underwent percutaneous closure of 152 large-bore access sites after endovascular aneurysm repair. There was no difference in the proportion of morbidly obese patients (body mass index >35 kg/m(2)) between the two cohorts. Access-related complications were significantly reduced in the group undergoing ultrasound-guided access. Despite the lower complication profile with ultrasound guidance, 24 sites (41%) had sheath sizes > or =20F compared to only 21 sites (24%) in the standard access group (p<0.05). Evaluating conversions and technical success of percutaneous closure, a significant benefit was identified for sheath sizes > or =20F (p<0.05). Upon comparing the two cohorts, operative time continued to decrease from 154 (+/-64) to 101 (+/-56) min after the addition of ultrasound guidance for access (p<0.05). The addition of ultrasound-guided femoral access to totally percutaneous aortic aneurysm repair continues to increase the technical success rate for vessel closure and has a clinically profound impact on access-related complications. This technical adjunct appears to have the largest impact on patients requiring larger sheath sizes.

Efficacy of Three Topical Hemostatic Agents Applied by Medics in a Lethal Groin Injury Model

BackgroundPercutaneous stereotactic core needle biopsy (CNB) has become the primary diagnostic modality for evaluating nonpalpable, mammographically detected breast lesions. Atypical ductal hyperplasia (ADH) uncovered by CNB confers a significant risk of harboring an occult malignancy in the excisional biopsy specimen; therefore, we sought to determine the benefits of upsizing biopsy needles from 14- to 11-gauge.MethodsPatients with isolated ADH diagnosed by CNB were included for analysis in this retrospective review. Mammographic description, number of needle passes, pathology results, and follow-up data were analyzed and compared to our previously published institutional results with the 14-gauge needle.ResultsFrom June 1996 until July 2006, 4,579 CNBs were performed at our tertiary level medical facility. Seventy eight of 88 patients (89%) diagnosed with ADH on CNB with an 11-gauge vacuum-assisted needle underwent open surgical excision. Of these patients, nine (11%) were upgraded to ductal carcinoma in-situ (DCIS) while five (6%) had invasive cancer (IC), giving a total underestimation rate of 17%. These results differ from our previously published series of 14-gauge CNB which revealed an underestimation rate of 36%. Mean number of passes obtained at time of biopsy, mean age of patients, and characteristic radiographic abnormalities were similar for malignant and benign diagnoses.Conclusion11-gauge CNB technique reduces sampling error and improves accuracy, but does not eliminate the risk of missing an underlying malignancy. Surgical excision of ADH identified by CNB is required for definitive diagnosis.

Primary tumor location impacts breast cancer survival

OBJECTIVES To describe arterial and venous injuries and their management and short-term outcomes in a wartime hospital. DESIGN Retrospective review of patients with vascular injuries. Mechanism, location, method of repair, and outcomes were analyzed with descriptive and inferential statistics. SETTING The 31st Combat Support Hospital, Operation Iraqi Freedom. PATIENTS A total of 153 patients with 218 vascular injuries from January 1, 2004, to December 30, 2004. MAIN OUTCOME MEASURES Limb salvage and mortality rates. RESULTS The overall limb salvage rate was 80%, while all-cause mortality was 6%. Most vascular injuries were sustained by blast and fragmentation mechanisms. Not surprisingly, most vascular injuries were in lower extremity vessels (57% arterial, 50% venous), with a high predominance of superficial femoral vessel injuries. Vascular injuries to the upper extremities were associated with a higher limb salvage rate (95%) than injuries to the lower extremities (71%). Variable follow-up data for 63 (41%) patients revealed that 32 underwent further procedures outside the combat theater, 12 of which were delayed amputations. Of all arterial injuries, 36% were primarily repaired, 34% were repaired with a vein interposition graft, 29% were ligated, and 2% were repaired with a prosthetic graft. A majority of venous injuries (56%) were ligated. CONCLUSIONS There is an acceptable early patency and limb salvage rate in combat vascular repairs. A majority of penetrating vascular injuries occur in the lower extremities. Overall, penetrating vascular trauma is often a survivable injury.

Incidence of low vitamin A levels and ocular symptoms after Roux-en-Y gastric bypass

BACKGROUND Advanced topical hemostatic agents are increasingly utilized to control traumatic hemorrhage. We sought to determine the efficacy of three chitosan based hemostatic agents in a lethal groin injury model when applied by combat medic first responders. METHODS After creation of a standardized femoral artery injury in a goat model, medics attempted hemorrhage control with standard gauze dressing followed by randomization to one of three hemostatic agents in this two tiered study. In the first tier, medics were randomized to either a chitosan based one-sided wafer (OS) or a dual-sided, flexible, roll (DS). In the second tier, medics were randomized to the flexible DS dressing or a chitosan powder (CP). Efficacy of gauze, each chitosan agent, proper application, and participant surveys were obtained and included for analysis using univariate techniques. RESULTS From January 2007 to June 2007, 55 (45%) DS, 36 (29%) OS, and 32 (26%) CP agents were used to treat 123 actively bleeding arterial injuries in 62 animals. Standard gauze failed to stop hemorrhage in 122 (99%) groins. Although all three chitosan agents were marginally effective at 2 min, the recommended time for application, hemostasis improved after 4 min. The DS dressing was the most effective, controlling hemorrhage 76% at 4 min. Of the failures, 3 (23%) DS and 9 (53%) OS were due to improper application. End-user survey results demonstrated that medics preferred the DS dressing 77% and 60% over the OS and CP, respectively. CONCLUSIONS Chitosan based bandages are significantly more effective at hemorrhage control compared to standard gauze field dressings. The dual-sided chitosan dressing demonstrated better hemorrhage control than the one-sided dressing and the chitosan powder, and was less likely to fail despite application errors.

A prospective evaluation of C-reactive protein in the progression of carotid artery stenosis.

BACKGROUND The prognostic significance of tumor location in breast cancer remains unclear. To better understand this relationship, we evaluated the Department of Defense tumor registry. METHODS Patients with infiltrating ductal adenocarcinoma or lobular carcinoma over a 10-year period were identified and analyzed. RESULTS Of the 13,984 tumors, 7,871 (58%) originated from the upper-outer quadrant or axillary tail, whereas the remainder were found at the nipple complex (9%), upper-inner quadrant (14%), lower-inner quadrant (9%), and lower-outer quadrant (10%). Univariate analysis of cancer-specific survival revealed a significant difference based on location of the primary breast cancer. Upper-outer quadrant lesions were associated with an independent contribution toward a survival benefit. CONCLUSIONS Upper-outer quadrant breast cancers have a more favorable survival advantage when compared with tumors in other locations. Factors that negatively impacted survival included high-grade tumors, advanced stage, and race.