Comparison of Isolated and Concomitant Liver Injuries: is Hepatic Trauma Entirely Responsible for the Outcome ?

Objective: This study was undertaken to examine both isolated and concomitant liver injuries to clarify the role of liver trauma on outcome.

Patients and methods: This retrospective study was a review of all abdominal trauma patients who presented with liver injuries, with or without concomitant injury at Ege University School of Medicine over a 3-year period. Presentation, injury grade, management, and outcomes were analyzed. Patients with isolated hepatic injury (Group A) were compared with patients who had concomitant hepatic injury (liver and spleen/small bowel) (Group B). Significance was set at 95% confidence intervals.

Results: Of 368 patients, 80 (21%) presented with liver injury. Of these, the aetiology was as follows: 53 (66.2%) blunt injury, 19 (23%) penetrating injury, and 8 (10%) gun shot trauma. There were 38 patients in Group A and 42 in Group B. Of these 42 patients, 19 were diagnosed with serious types of injury; eight thoracic, three open long bone fracture, one intra-cardiac, one intracranial. Six additional patients were observed with injuries to large abdominal vessels. Eleven patients (28.9%) with isolated hepatic injury were managed non-operatively. Mortality, intensive care unit and hospital length of stay, and transfusion requirements were significantly higher in Group B. Only the number of transfused blood units and the grade of liver injury were found to be effective on outcome whereas stepwise regression analysis revealed that injury type (penetrating) and blood transfusion were predictive for mortality.

Conclusion: This study highlighted that although isolated liver injury results in good outcome with non-operative management, concomitant injuries to the liver lead to a higher failure and mortality rate. However, liver injury itself is rarely responsible for death.     

Do Psychological Factors Predict Poor Outcome in Patients Undergoing TKA? A Systematic Review

Background

A subgroup of patients undergoing TKA is unhappy with the outcome of surgery and preoperative psychological factors may play a role in their dissatisfaction.

Questions/purposes

We asked whether (1) psychological factors, as measured by preoperative self-reported questionnaires, predicted poor outcome after TKA, and (2) whether certain psychological factors examined predicted poor outcome better than others.

Methods

We performed a systematic review and meta-analysis of prospective observational studies published in MEDLINE, CINAHL^®, EMBASE™, and PsycINFO^® databases from their date of inception to October 2013, augmented with a manual search of bibliographies. Study eligibility was performed according to an a priori protocol. Included studies were assessed for quality according to the Newcastle-Ottawa scale. Two reviewers independently performed the search, identified eligible studies, assessed their methodologic quality, and extracted data. Outcomes of interest included postoperative dissatisfaction, pain, or limited function of the patients.

Results

A total of 19 studies (17 cohort studies and two cross-sectional surveys) containing data on 9046 TKAs performed in 8704 adult patients were included in the review. Mean patient age was 68 years and followup ranged from 6 to 60 months (mean study followup, 14 months). Clinical and methodologic heterogeneity in study design prevented the statistical pooling of data and subsequent meta-analysis. Dissatisfaction rates with TKA ranged from 7.5% to 28.3%. Psychological health was deemed a significant predictor of satisfaction, pain, or function at a minimum of 6 months after TKA in 16 studies. The remaining three studies did not find this relationship. Baseline mental health factors may affect patient satisfaction, their long-term perception of pain, and their motivation to return to the desired level of function. We were unable to determine the most relevant psychological states or the most appropriate way to assess them with our systematic review.

Conclusions

The preoperative psychological state of a patient may affect the outcome after a TKA. A comprehensive psychological assessment of patients is required to examine the long-term effect of such psychological factors on the eventual outcomes of TKA once the recovery phase is complete and to assess the effect that treatment for these psychological conditions may have on decreasing the dissatisfaction rate with TKA in this population.

Electronic supplementary material

The online version of this article (doi:10.1007/s11999-015-4234-9) contains supplementary material, which is available to authorized users.     

Trauma Whipple: Do or Don’t After Severe Pancreaticoduodenal Injuries? An Analysis of the National Trauma Data Bank (NTDB)

Background

Pancreaticoduodenectomy for trauma (PDT) is a rare procedure, reserved for severe pancreaticoduodenal injuries. Using the National Trauma Data Bank (NTDB), our aim was to compare outcomes of PDT patients to similarly injured patients who did not undergo a PDT.

Methods

Patients with pancreatic or duodenal injuries treated with PDT (ICD-9-CM 52.7) were identified in the NTDB 2008–2010 Research Data Sets. We excluded those who underwent delayed PDT (>4 days). The PDT group (n = 39) was compared to patients with severe combined pancreaticoduodenal injuries (grade 4 or 5) who did not undergo PDT (non-PDT group, n = 38). Patients who died in the emergency department or did not undergo a laparotomy were excluded. Our primary outcome was death. Secondary outcomes were intensive care unit length of stay (LOS), hospital LOS, and total ventilator days. A multivariate model was used to determine predictors of in-hospital mortality within each group and in the overall cohort.

Results

The non-PDT group had a significantly lower systolic blood pressure and Glasgow Coma Scale values at baseline and more severe duodenal, pancreatic, and liver injuries. There were no significant differences in outcomes between the two groups. The Injury Severity Score was the only independent predictor of mortality among PDT patients [odds ratio (OR) 1.12, 95 % confidence interval (CI) 1.01–1.24] and in the entire cohort (OR 1.06, 95 % CI 1.01–1.12). The operative technique did not influence any of the outcomes.

Conclusions

Compared to non-PDT, PDT did not result in improved outcomes despite a lower physiologic burden among PDT patients. More conservative procedures for high-grade injuries of the pancreaticoduodenal complex may be appropriate.     

How Common Are Civilian Blast Injuries in the National Trauma Databank,and What Are the Most Common Mechanisms and Characteristics of Associated Injuries?

BackgroundRecent military conflicts have produced substantial improvements in the care of service members who experience blast injuries. As conflicts draw down, it is important to preserve and improve skills gained in combat. It is unknown whether civilian blast injuries can serve as a surrogate for military blast trauma. To guide further research, it is crucial to understand the volume, severity, and distribution of civilian blast injury in the civilian population.Questions/purposes(1) What proportion of US trauma admissions are a result of blast injury? (2) What are the common mechanisms, and what is the demographic breakdown of civilian patients presenting to trauma centers after blast injuries? (3) What is the severity, and what are the characteristics of injuries sustained by civilian patients after blast injuries?MethodsWe queried the American College of Surgeons National Trauma Databank (NTDB), a national aggregation of trauma registry data which captures robust mechanism of injury and wounding pattern information, for any patient admitted for trauma and an initial mechanism of injury corresponding to a predefined list of ICD-9 and ICD-10 external cause of injury codes related to blast injuries and reported as a proportion of all trauma-related admissions. Mechanisms were categorized into similar groups, and data were collected regarding demographics as well as location and intentionality of blast (that is, unintentional, the result of assault, or self-inflicted). Patient injuries were characterized by ICD-9 or ICD-10 diagnosis codes and sorted according to the body area affected and severity of injury, measured via the Injury Severity Score (ISS). The ISS is a measure of trauma severity, with scores ranging from 1 to 75 points based on injury severity, which is calculated according to injury scores in six separate body domains (head or neck, face, chest, abdomen or pelvis, extremities, external). A score of 1 represents a minor trauma to one region, while a score of 75 indicates injuries deemed nonsurvivable in one or more domains. Data were limited to trauma admissions in 2016.ResultsPatients injured by blast mechanisms represented 0.3% (2682 of 968,843) of patients in NTDB-participating trauma centers who were treated after a blast injury in the year 2016; 86% (2315 of 2682) of these patients were men, and the mean ± SD age was 38 ± 21 years. Blast injuries most commonly occurred after detonation of fireworks (29% [773 of 2682]) or explosion of gas or pressurized containers (27% [732 of 2682]). The most commonly injured area of the body was the upper extremity (33% [894 of 2682]), followed by the face (28% [747 of 2682]), lower extremity (11% [285 of 2682]), thorax (10% [280 of 2682]), and head (10% [259 of 2682]). Fifty-eight percent (1564 of 2682) of patients had at least one burn injury. A total of 2% (51 of 2682) of the injuries were fatal, with a mean ISS score of 6 ± 8; 23% (608 of 2682) of patients presented with injuries classified as severe (ISS > 8).ConclusionCivilian blast-associated injuries are not common, but they can be severe, and in many (though not all) respects they seem similar to those described in published case series of military blast victims. Key differences include age and gender (civilian injuries more commonly involve women and older patients than do those in military studies). The potential of civilian blast patient care as a surrogate for study and clinical experience for military surgeons in the interwar period—as recommended by the National Academies of Sciences, Engineering, and Medicine report—is supported by our preliminary results. Future interventions or training programs would likely need to rely on multisite or targeted partnerships to encounter appropriate numbers of patients with blast injuries.Level of EvidenceLevel IV, prognostic study.     

Is Same-Day Discharge After Roux-en-Y Gastric Bypass Safe? A Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Database Analysis

Obesity Surgery - Same-day discharge (SDD) after bariatric surgery is gaining popularity. We aimed to analyze the safety of SDD after Roux-en-Y gastric bypass (RYGB) and compare its outcomes to...     

Do Reexcisions Impair Aesthetic Outcome in Breast Conservation Surgery? Exploratory Analysis of a Prospective Cohort Study

Purpose  

Reexcision is a clinically relevant aspect of oncological breast conservation surgery. The influence of reexcision on aesthetic outcome is described differently in the literature. Our aim was to analyze this question in a well-defined cohort with standardized study instruments.     

Do SIRS Criteria Predict Clinical Outcomes in Diabetic Skin and Soft Tissue Infections?

The aim of this study was to assess whether systemic inflammatory response syndrome (SIRS) is correlated with outcomes in diabetic foot infections (DFIs). We retrospectively reviewed 137 diabetic patients admitted to the hospital with Infectious Diseases Society of America moderate and severe DFIs. We used SIRS criteria to define severe infection based on the presence of at least 2 of the following: heart rate >90 bpm, temperature >38°C or <36°C, respiratory rate >20 breaths per minute, and white blood cell count >12,000/mm³ or <4,000/mm³. Patients with severe DFI were significantly younger (median 49.6 versus 53.6 years, p = .04), less often had type 2 diabetes (88.6% versus 98.9%, p = .01), and less often had a history of previous amputation (15.9% versus 40.9%, p < .01). There were no differences in patients with severe infections defined by SIRS versus moderate infections in the need for surgery (47.7% versus 59.1%, p = .27), any amputation (20.5% versus 29.0%, p = .29), leg amputations (6.8% versus 7.5%, p = .88), duration of antibiotics (median ± standard deviation 34.1 ± 46.5 versus 31.9 ± 47.2 days, p = .47), or healing within 1 year (68.2% versus 66.7%, p = 1.00). Length of hospital stay was the only outcome variable that was significantly different in severe infections (median 12.7 ± 11.9 versus 7.8 ± 5.8 days, p = .02). Foot-related readmission was more common in moderate infections (46.2% versus 25.0%, p = .02). In conclusion, SIRS criteria for severe infections in diabetic patients with skin and soft tissue infections were not associated with a difference in outcomes other than longer hospital stay.     

Acute Median Neuropathy and Carpal Tunnel Release in Perilunate Injuries Can We Predict Who Gets a Median Neuropathy?

This study addressed the following null hypotheses: 1) There are no demographic differences between patients with perilunate dislocation (PLD) or fracture-dislocation (PLFD); 2) There are no factors associated with the development of median nerve symptoms in the setting of a PLD or PLFD; and 3) There are no factors associated with carpal tunnel release. Using a retrospective search of a prospective trauma database, we identified all patients who had sustained a radiologically confirmed PLD or PLFD over a 10-year period at two trauma centers. From the medical records we identified median nerve symptoms and carpal tunnel release in addition to demographic and injury characteristics. Among the 71 patients treated for PLD or PLFD, acute median neuropathy was diagnosed in 33 patients (47 %). The only significant difference between PLD and PLFD was a younger age with PLFD. No demographic or injury factors were associated with symptoms of median neuropathy. Carpal tunnel release surgery during the initial operative management was related to the presence of median nerve symptoms and the trauma center. We report a high incidence of acute median neuropathy accompanying perilunate injuries. As there are no demographic or injury factors associated with symptoms of median neuropathy; all patients with PLD/PLFD merit equally high vigilance for acute median neuropathy.Level of Evidence: Level III, prognostic study     

Do Surgeon Expectations Predict Clinically Important Improvements in WOMAC Scores After THA and TKA?

Background

Failure of THA or TKA to meet a patient’s expectations may result in patient disappointment and litigation. However, there is little evidence to suggest that surgeons can consistently anticipate which patients will benefit from those interventions.

Questions/purposes

To determine the ability of surgeons to identify, in advance of surgery, patients who will benefit from THA or TKA and those who will not, where ‘benefit’ is defined as a clinically important improvement in a validated patient-reported outcomes score.

Methods

In this prospective study, eight high-volume orthopaedic surgeons completed validated THA and TKA expectations questionnaires (score 0–100, 100 being the highest expectation) as part of preoperative assessment of all their patients scheduled for a THA or TKA and enrolled in the Hospital for Special Surgery institutional registry. Enrolled patients completed the WOMAC preoperatively and at 2 years. Successful outcomes were defined as achieving the minimum clinically important difference (MCID) in WOMAC pain and function subscales. Sensitivity, specificity, and receiver operating characteristic (ROC) curves were used to evaluate the ability of surgeons’ expectation scores to identify patients likely to achieve the MCID on the WOMAC scale. Analyses were run separately for patients having THA and TKA. We enrolled 259 patients undergoing THA and 247 undergoing TKA, of whom 77% (n = 200) and 77% (n = 191) completed followup surveys 2 years after their procedures, respectively.

Results

Surgeons’ expectation scores effectively anticipated patients who would improve after THA, but they were no better than chance in identifying patients who would achieve the MCID on the WOMAC score 2 years after TKA. For patients having THA, the areas under the ROC curve were 0.67 (95% CI, 0.53–0.82; p = 0.02) and 0.74 (95% CI, 0.63–0.85; p < 0.01) for WOMAC function and pain outcomes, respectively, indicating good accuracy. Sensitivity and specificity were maximized on WOMAC pain and function scores (sensitivity = 0.69, specificity = 0.72, both for pain and function) at an expectations score of 83 or greater of 100. Surgeons’ expectations were more accurate for patients who were men, who had a BMI less than 30 kg/m², who had more than one comorbidity, and who were older than 65 years. For patients having TKA, surgeons’ expectation scores were not better than chance for identifying those who would experience a clinically important improvement on the WOMAC scale (area under ROC curve: Function = 0.51, [95% CI, 0.42–0.61], p = 0.78; Pain = 0.51, [95% CI, 0.40–0.61], p = 0.92).

Conclusions

Most patients having THA and TKA achieved the MCID improvement after surgery. However, the inability of surgeons’ expectation scores to discriminate accurately between patients who benefit and those who do not among patients scheduled for THA who are young, with no comorbidities, and with elevated BMIs, and among all patients scheduled for TKA, calls for surgeons to spend more time with these patients to fully understand and address their needs and expectations. Using standardized assessment tools to compare surgeons’ expectations and those of their patients may help focus the surgeon-patient discussion further, and address patients’ expectations more effectively.

Level of Evidence

Level II, therapeutic study.