Should esophageal resections for cancer be performed in high-volume centers only?

Esophageal resection remains the only curative option for esophageal cancer, and therefore, improving the outcome of surgery is the best method of reducing mortality. Several studies have evaluated the postoperative morbidity and mortality after esophageal resection, analyzing the relationship between volume or surgical experience and operative mortality. In this article, the evidence supporting the referral of esophageal surgery to centers with a greater experience (i.e., high-volume centers) is reviewed in order to establish the best practice.     

Should patients with isolated hip fractures be included in trauma registries?

BACKGROUND: Patients with isolated hip fractures are frequently excluded from trauma registries. The goal of this study was to show that patients with these injuries have higher resource use and poorer outcomes than the rest of the trauma population. METHODS: The Quebec Trauma Registry was used to identify all trauma patients from April 1, 1998, to March 31, 2003. Patients who were dead on arrival at the emergency room were excluded. Isolated hip fracture (HIP) was defined as a diagnosis of a single fracture to the neck of the femur (Abbreviated Injury Scale 1990 codes 851808.3, 851810.3, 851812.3, and 851818.3) secondary to a fall and for which the Injury Severity Score was 9 or 10 (no other Abbreviated Injury Scale code higher than 1). Patients with all other trauma diagnosis (OT) were used for comparison. Outcome variables were length of hospital stay, length of intensive care unit (ICU) stay, in-hospital complications, and status and orientation at discharge. Chi-square and Wilcoxon rank-sum tests were used. RESULTS: There were 68,422 patients: 14,426 (21.1%) HIP patients and 53,996 (78.9%) OT patients. The median Injury Severity Score was 9 for HIP (range, 9-10) and 9 for OT (range, 1-75). Mean length of hospital stay was 18.4 days for HIP compared with 11.7 days for OT (p < 0.0001). HIP patients represented 29.5% of the total hospital stay. ICU stay was required for 1,353 HIP patients (9.4%) and for 12,395 (23.0%) OT patients (p < 0.0001). Mean ICU stay was 3.9 days for HIP compared with 5.5 days for OT (p = 0.0006). In-hospital mortality was 8.5% in HIP compared with 3.7% in OT (p < 0.0001). HIP represented 62.7% of patients referred for long-term care and 39.3% of patients referred to a rehabilitation center. CONCLUSION: Patients with HIP represented 21.1% of admissions while accounting for 42% of total days of hospitalization and 38% of deaths. Patients with hip fractures have a significantly higher risk of death, prolonged hospital stay, and complication rate, and are more often transferred to a rehabilitation center or to a long-term nursing home than the rest of the trauma population despite lower severity. They require multidisciplinary care typical of the rest of the trauma population and should be included in the trauma registry if the registry is to document the full outcome and resource use of the trauma population.     

Are all level I trauma centers created equal? A comparison of American College of Surgeons and state-verified centers

Scant literature investigates potential outcome differences between Level I trauma centers. We compared overall survival and survival after acute respiratory distress syndrome (ARDS) in patients admitted to American College of Surgeons (ACS)-verified versus state-verified Level I trauma centers. Using the National Trauma Data Bank Version 7.0, incident codes associated with admission to an ACS-verified facility were extracted and compared with the group admitted to state-verified centers. Overall, there were 382,801 (73.7%) patients admitted to ACS and 136,601 (26.3%) admitted to state centers. There was no adjusted survival advantage after admission to either type (4.9% for ACS vs 4.8% for state centers; 1.014 [95% CI, 0.987 to 1.042], P = 0.311). However, in the 3,088 cases of ARDS, mortality for admission to the ACS centers was 20.3 per cent (451 of 2,220) versus 27.1 per cent (235 of 868) for state centers. Adjusting for injury severity and facility size, admission to an ACS center was associated with a significantly greater survival after ARDS (0.75 [0.654 to 0.860]; P < 0.001). Level I verification does not necessarily imply similar outcomes in all subgroups. Federal oversight may become necessary to ensure uniformity of care, maximizing outcomes across all United States trauma systems. Further study is needed.     

Should normothermia be restored and maintained during resuscitation after trauma and hemorrhage?

BACKGROUND: Although hypothermia often occurs after trauma and has protective effects during ischemia and organ preservation, it remains unknown whether maintenance of hypothermia or restoring the body temperature to normothermia during resuscitation has any deleterious or beneficial effects on heart performance and organ blood flow after trauma-hemorrhage. METHODS: Male rats underwent laparotomy (i.e., induced trauma) and were exsanguinated to and maintained at a mean arterial pressure of 40 mm Hg until 40% of the maximum shed volume was returned in the form of Ringer's lactate. Body temperature decreased from approximately 36.5 degrees C to below 32 degrees C. The animals were then resuscitated with four times the volume of maximal bleedout with Ringer's lactate. In one group, body temperature was rewarmed to 37 degrees C during resuscitation. In another group, body temperature was maintained at hypothermia (32 degrees C) for 4 hours after resuscitation. In an additional group, the body temperature was kept at 37 degrees C during hemorrhage as well as during resuscitation. Left ventricle performance parameters such as maximal rate of left ventricular pressure increase and decrease (+/-dP/dt(max)) were measured up to 4 hours. Cardiac output and regional blood flow were determined by radioactive microspheres at 4 hours after the completion of resuscitation. RESULTS: The maintenance of normothermia during hemor. rhage or prolonged hypothermia after resuscitation depressed the left ventricular performance parameters, cardiac output, and regional blood flow in various organs. Rewarming the body to normothermia during resuscitation, however, significantly increased heart performance, cardiac output (from hypothermia 16.2 +/- 1.4 to 22.3 +/- 1.4 mL/min per 100 g body weight,p < 0.05) and total hepatic blood flow (from hypothermia 117.5 +/- 5.3 to 166.0 +/- 9.3 mL/min per 100 g tissue, p < .05). CONCLUSION: Our data indicate that restoration of normothermia during resuscitation improves cardiac function and hepatic blood flow compared with hypothermia.     

Should blunt arterial trauma to the extremities be treated with endovascular techniques?

Endovascular techniques are making progress in most aspects of vascular disease. Penetrating or blunt trauma to large arteries can in many cases be managed elegantly with endovascular techniques. However when it comes to arterial trauma of the extremities things are more complicated. There are no reports hitherto in the literature on endovascular treatment of blunt injuries to the arteries of the extremities. In the present report we describe two cases of blunt trauma to the brachial artery treated with balloon angioplasty (PTA) to fixate the dissected intima to the vessel wall. The "glueing" was effective in giving a long lasting patency.We anticipate that there may be a role, though limited, for using PTA as a means of "glueing" the intima. More advanced techniques such as insertion of stents or stent-grafts in traumatized extremity arteries would rarely be indicated.     

Should older patients be selectively referred to high-volume centers for abdominal aortic surgery?

The objective of the current study was to determine the effect of hospital volume on outcomes of abdominal aortic surgery for patients older than and younger than 65 years. In order to perform this investigation, information on all adult patients who underwent abdominal aortic surgery in Maryland from 1994 to 1996 (N = 2,987 patients) in 45 acute care hospitals was obtained. Hospitals were designated as low (< 20/year), medium (20 to 36/year), or high (> 36/year) volume according to the annual number of procedures performed. The relationship of hospital volume and mortality was determined for patients less than or greater than 65 years old. Two separate multiple logistic regression models were used to adjust for patient case-mix in each age category. Of the 2,987 patients, 2,067 (69%) were older than 65 years and 920 (31%) were younger. The crude in-hospital mortality rates according to hospital volume were 2.7% (low), 2.1% (medium), and 2.7% (high) for patients younger than 65 years old (p = .8). For patients older than 65 years, in-hospital mortality rates were 11.9% (low), 9.9% (medium), and 6.9% (high) (p = .005). After adjusting for patient case-mix in a multivariate analysis, high hospital volume was associated with a decreased risk of in-hospital mortality for patients older than 65 years (OR 0.57; 95% CI 0.37 to 0.86; p = .008) but not for patients under 65 years old. In conclusion, hospital volume was associated with decreased in-hospital mortality after abdominal aortic surgery only for patients greater than 65 years old. Because of this differential effect, targeting elderly patients for regionalization would achieve most potentially avoidable deaths for this common high-risk surgical procedure.     

Do trauma centers improve functional outcomes: a national trauma databank analysis?

BACKGROUND: The development of a tiered trauma care system has lead to improved survival for the critically injured. The question as to whether the increased survival associated with the establishment of tiered levels of trauma care is paralleled by an improved functional outcome has not, however, been addressed. METHODS: Multivariate logistic regression analysis of the National Trauma Data Bank from 1994 to 2001 was performed with functional independence measure (FIM) as the primary outcome. Trauma centers were dichotomized as Level II or above versus Level III or below. Blunt and penetrating trauma patients were analyzed separately. Other covariates included age, gender, shock, comorbidities, alcohol, drugs, as well as head, chest, abdominal, spine, and lower extremity injury. Confidence intervals were set at an alpha of 0.05. RESULTS: A total of 474,024 patients were analyzed. Among minimally injured penetrating trauma patients, those receiving care at a higher tiered center had a higher likelihood of total independence (odds ratio [OR] = 1.4, 95% confidence interval [CI] = 1.0, 2.0). Among minimal, moderate and severely injured blunt trauma patients those receiving care at a higher tiered center had a higher likelihood of total independence (OR = 1.2, 95% CI = 1.0, 1.4, OR = 1.3, 95% CI = 1.1, 1.6, OR = 1.3, 95% CI = 1.3, 1.5, respectively). CONCLUSIONS: These data indicate that the complex care delivered by advanced level trauma centers is associated with improved functional outcomes. Further investigations to identify the reasons for differences in these outcomes are necessary to improve care at lower tiered hospitals particularly for minimally injured patients.     

Should airguns be banned?

In this article, we express concerns regarding the availability of airguns, the injuries that they cause and their abuse as weapons of assault. We wish to stimulate debate on this topic and report a 5-year retrospective analysis of all airgun injuries to the head and neck, presenting to Alder Hey Children's Hospital, Liverpool, from June 1998 to June 2003. We identified 16 patients who suffered such injuries with ages ranging from 5 to 15 years. The majority of cases were violent assaults, which is not in accordance with previous published reports. All of these occurred in public places outside the home. Most incidents occurred through the spring and summer period. Six patients required overnight stay in hospital. Nine patients required operative procedures to remove the airgun pellets. Two patients had serious eye injuries resulting in loss of vision. Two patients had penetrating neck injuries requiring exploration of the wound. The remaining group had either skin-penetrating injuries with lodgement of fragments in subcutaneous tissues or non-skin penetrating injuries. This study highlights serious injuries arising from the abuse of airguns as weapons of assault. Airguns are readily available to people without license. Recent legislation has increased the minimum age at which airguns can be carried in a public place, but we believe that stricter legislation is required to produce a reduction in the number of airgun-related injuries.     

Should plain X-rays be routinely performed after blunt knee trauma? A prospective analysis

BACKGROUND: We tested the hypothesis that it was possible to decrease the number of performed x-rays after a knee trauma without delayed fracture diagnosis by using the Ottawa knee rules. METHODS: Patients had routine x-rays of the injured knee during the first stage of the study and selective x-rays during the second stage. All patients were followed up to 6 months after the trauma. RESULTS: 138 patients were included in the first stage; 57 had negative Ottawa criteria: no fracture was observed; following the Ottawa rules, 41% of the x-rays could have been avoided. 178 patients were included in the second stage; 63 patients had negative Ottawa criteria: no fracture was diagnosed during the whole follow-up; 35% of the x-rays have been avoided. CONCLUSIONS: Ottawa rules allowed decreasing the number of x-rays performed after a knee trauma by 35% with a sensitivity for a knee fracture detection of 100%.     

Should soft tissue sarcomas be treated at high-volume centers? An analysis of 4205 patients

OBJECTIVE:: To define the prognostic significance of surgical center case volume on outcome for soft tissue sarcoma (STS). METHODS:: STS cases registered in the Florida Cancer Data System (FCDS) between 1981 and 2001 were analyzed. Medical facilities were ranked by STS operative volume. Facilities above the 67th percentile for volume were defined as high-volume centers (HVCs). RESULTS:: Of the 4205 operative cases of STS identified, 68.1% were treated at low-volume centers (LVCs) and 31.9% at HVCs. A larger proportion of high-grade tumors (53.8% vs. 44.3%) and lesions over 10 cm (40.7% vs. 28.7%) were resected at HVC (P < 0.001). The 30-day mortality was 0.7% for HVC and 1.5% for LVC (P = 0.028), and mortality rates at 90 days were 1.6% and 3.6%, respectively (P = 0.001). Median survival was 40 months at HVC and 37 months at LVC (P = 0.002). Univariate analysis demonstrated significantly improved survival at HVC for high-grade tumors (median 30 months vs. 24 months, P = 0.001), lesions over 10 cm (28 months vs. 19 months, P = 0.001) and truncal or retroperitoneal sarcomas (39 months vs. 31 months, P = 0.011). Limb amputation rate was lower (9.4% vs. 13.8%, P = 0.048) and radiation and chemotherapy were more frequently administered at HVC (OR = 1.54). On multivariate analysis, treatment at a HVC was a significant independent predictor of improved survival (OR = 1.292, P = 0.047). CONCLUSIONS:: STS patients treated at HVC have significantly better survival and functional outcomes. Patients with either large (>10 cm), high-grade or truncal/retroperitoneal tumors should be treated exclusively at a high-volume center.     

Should aminoglycoside antibiotics be abandoned?

BACKGROUND: Aminoglycosides can cause nephrotoxicity and ototoxicity. Alternatives are available. METHODS: Surgical service antibiotic use, aminoglycoside toxicity, and perioperative culture/sensitivity results from July 1998 to June 1999 were reviewed. RESULTS: Of 289 positive cultures in 243 patients, 92 cultures (32%) grew 151 Gram-negative rods (GNRs). Aminoglycosides were used in 26 patients and 4 of 26 (15%) suffered nephrotoxicity. Of the 112 GNRs tested against ceftazidime, 111 (99%) were sensitive to it which was significantly better than amikacin (56 of 61, 92%, P = 0.038), gentamicin (116 of 134, 87%, P <0.001), and tobramycin (67 of 81, 83%, P <0.001). The proportion sensitive to cefuroxime (26 of 30, 87%) was equivalent to the proportions sensitive to gentamicin (87%, P = NS) and tobramycin (83%, P = NS). Of the 35 GNRs that were resistant to gentamicin and/or tobramycin, 15 (43%) were Pseudomonas aeruginosa. CONCLUSION: Aminoglycosides produce a significant rate of nephrotoxicity. There are antibiotics with equal or better sensitivity profiles than aminoglycosides against GNRs and Pseudomonas. Aminoglycoside use is rarely, if ever, indicated.