Clinical management of occult hemothorax: a prospective study of 81 patients

Background

Intrapleural blood detected by computed tomography scan, but not evident on plain chest radiograph, defines occult hemothorax. This study determined the role for tube thoracostomy.

Methods

Hemothorax was quantified on computed tomography by measuring the deepest lamellar fluid stripe at the most dependent portion. Data were collected prospectively on demographics, injury mechanism/severity, chest injuries, mechanical ventilation, hospital length of stay, complications, and outcome. Indications for tube thoracostomy were recorded.

Results

Tube thoracostomy was avoided in 67 patients (83%). Indications for chest tube placement included progression of hemothorax (8), desaturation (4), and delayed hemothorax (2). Patients with intrapleural fluid thickness greater than 1.5 cm were 4 times more likely to require tube thoracostomy.

Conclusions

Occult hemothorax can be managed successfully without tube thoracostomy in most cases. Mechanical ventilation is not an indication for chest tube placement. Accompanying occult pneumothorax may be expected in 50% of cases, but did not affect clinical management.     

Clinical characteristics and short to mid term functional outcomes of surgically treated occult hip fractures in the elderly

BackgroundOccult hip fractures in the elderly are challenging to diagnose and often result in surgical delays which may worsen outcomes. However, the minimally displaced nature of these fractures may conversely lead to better outcomes. The aim of this study was to determine if surgically treated occult hip fractures have better short to mid term functional outcomes when compared to non-occult fractures. The secondary aim was to determine if there are any differences in clinical characteristics of patients who present with occult hip fractures.MethodsThis was a retrospective cohort study of all elderly patients aged 65 years and above who presented with hip fractures in a single institution from January 2012 to December 2013. Elderly patients who presented with hip fractures were enrolled into an Ortho-geriatric carepath and were eligible for recruitment. The exclusion criteria included patients with pathological fractures and multiple injuries. Demographic and pre-injury variables were collected. The functional outcome measurement was the Modified Barthel’s Index (MBI). Patients were divided into non-occult hip fractures (Group 1) and occult hip fractures (Group 2).ResultsA total of 1017 patients were admitted during this period into the hip fracture carepath, of which 49 (4.8%) were diagnosed to have occult hip fractures. There was no significant difference between the demographics, Charlson co-morbidity index, abbreviated mental test scores or pre-morbid patient dependence between the groups. There was a significant delay to surgery for occult hip fractures when compared to non-occult fractures. (p = 0.03) Subgroup analysis showed that pre-morbidly, patients with occult inter-trochanteric fractures were significantly more independent than patients with non-occult inter-trochanteric fractures. (p = 0.03) There was no significant difference between the length of stay, surgical complications and 1-year mortality between the 2 groups. Occult inter-trochanteric fractures had better MBI scores at all time points when compared to non-occult inter-trochanteric fractures.ConclusionsDespite the significant delay to surgical intervention for patients with occult hip fractures, the short to mid term functional outcomes for this group of patients are comparable to surgically treated non-occult hip fractures. There are no distinctive clinical characteristics of elderly patients who are more likely to suffer occult hip fractures.     

Occult pneumothorax in the blunt trauma patient: Tube thoracostomy or observation?

Background

The term occult pneumothorax (OP) describes a pneumothorax that is not suspected on the basis of either clinical examination or initial chest radiography, but is subsequently detected on computed tomography (CT) scan. The optimal management of OP in the blunt trauma setting remains controversial. Some physicians favour placement of a thoracostomy tube for patients with OP, particularly those undergoing positive pressure ventilation (PPV), while others favour close observation without chest drainage. This study was conducted both to determine the incidence of OP and to describe its current treatment status in the blunt trauma population at a Canadian tertiary trauma centre. Of interest were the rates of tube thoracostomy vs. observation without chest drainage and their respective outcomes.

Methods

A retrospective review was conducted of the Nova Scotia Trauma Registry. The data on all consecutive blunt trauma patients between October 1994 and March 2003 was reviewed. Outcome measures evaluated include length of stay, discharge status—dead vs. alive, intervention and time to intervention (tube thoracostomy and its relation to institution of PPV). Direct comparison was made between the OP with tube thoracostomy group and OP without tube thoracostomy group (observation or control group). They were compared in terms of their baseline characteristics and outcome measures.

Results

In 1881 consecutive blunt trauma patients over a 102-month period there were 307 pneumothoraces of which 68 were occult. Thirty five patients with OP underwent tube thoracostomy, 33 did not. Twenty nine (82.8%) with tube thoracostomy received positive pressure ventilation (PPV), as did 16 (48.4%) in the observation group. Mean injury severity score (ISS) for tube thoracostomy and observation groups were similar (25.80 and 22.39, p = 0.101) whereas length of stay (LOS) was different (17.4 and 10.0 days, p = 0.026). Mortality was similar (11.4% and 9.1%). There were no tension pneumothoraces.

Conclusion

The natural history of OP in blunt trauma patients at our institution appears to be one of uneventful resolution irrespective of ISS, need for PPV, or placement of tube thoracostomy. This study suggests an interesting hypothesis that observation of the blunt trauma patient with OP, without tube thoracostomy, may be safe and contribute to a shorter hospital stay. These are observations that would benefit from further study in a large, prospective randomised controlled trial.     

隐匿性乳腺癌的诊断与治疗

目的探讨隐匿性乳腺癌(OBC)的诊断与治疗经验。方法回顾性分析13例隐匿性乳腺癌的诊断与治疗方法。结果 10例腋窝肿块免疫组化,7例雌激素受体(ER);病理切片淋巴结转移性腺癌。乳腺癌根治或改良根治术后标本全乳房多次连续病理切片,3例未见原发灶,10例找到直径0.15 cm～0.90 cm肿瘤。5 a生存率46.15%。结论腋窝淋巴结活检、免疫组化分析及MRI检查对隐匿性乳腺癌的诊断具有重要意义,治疗首选改良根治术并辅以化疗、放疗及内分泌治疗等综合治疗。     

切开复位内固定治疗隐匿性跖跗关节损伤

目的探讨切开复位内固定治疗隐匿性跖跗关节损伤的临床疗效。方法 2002年7月-2009年7月,收治47例隐匿性跖跗关节损伤患者。男31例,女16例;年龄19～66岁,平均35.6岁。交通事故伤27例,高处坠落伤11例,运动伤6例,压砸伤3例。左足18例,右足29例。单纯内侧柱损伤6例,内侧柱伴中间柱损伤24例,中间柱伴外侧柱损伤13例,三柱损伤4例。患者均存在跖骨基底部骨折。受伤至手术时间为4～21 d,平均8.6 d。手术采用1～2个足背侧纵形切口,复位后用小钢板、螺钉、骑缝钉、克氏针固定内侧柱及中间柱,外侧柱均用克氏针固定。结果 1例术后切口感染,经封闭式负压引流2周后采用腓肠神经营养血管皮瓣移位修复创面;其余患者切口均Ⅰ期愈合。术后32例获随访,随访时间12～75个月,平均28.3个月。骨折于术后9～15周愈合,平均12.3周。末次随访时,15例出现中足骨关节炎表现,但无需行关节融合术。采用美国矫形足踝协会(AOFAS)的中足评分标准评价疗效,获优9例,良16例,一般4例,差3例,优良率为78.1%。随访期间均未出现跖跗关节再脱位。结论对跖骨基底部骨折应给予足够重视,术中探查有助于发现隐匿性跖跗关节损伤,应根据不同损伤类型及伴发损伤,采用合理的固定方式,尽量做到解剖复位、可靠固定,重建中足内在稳定是获得满意疗效的关键。     

Omission of routine chest x-ray after chest tube removal is safe in selected trauma patients

Background

Definitive practice guidelines regarding the utility of chest x-ray (CXR) following chest tube removal in trauma patients have not been established. The authors hypothesized that the selective use of CXR following chest tube removal is safe and cost effective.

Methods

A retrospective review of chest tube insertions performed at a level I trauma center was conducted.

Results

Patients who underwent chest tube removal without subsequent CXR had a lower mean Injury Severity Score and were less likely to have suffered penetrating thoracic injuries. These patients received fewer total CXRs and had shorter durations of chest tube therapy and shorter lengths of stay following tube removal. Subsequent reinterventions were performed more frequently in the CXR group. The annual decrease in hospital charges by foregoing a CXR was $16,280.

Conclusions

The selective omission of CXR following chest tube removal in less severely injured, nonventilated patients does not adversely affect outcomes or increase reintervention rates. Avoiding unnecessary routine CXR after chest tube removal could provide a significant reduction in total hospital charges.     

Angiographically occult arteriovenous malformations

Angiographically occult arteriovenous malformations not associated with clinically recognizable intracranial hemorrhage appear to be rare. We are reporting three cases of histologically proven arteriovenous malformations of the brain that were angiographically occult. These cases presented with seizures or attacks of dizziness, and were detected by computed tomography scan, radionuclide scan, or both. The preoperative diagnosis was granuloma in the first case and meningioma in the other two. After surgical exploration, biopsy revealed an arteriovenous malformation in each case. A review of 47 cases in the literature is tabulated and etiologies of the angiographically occult arteriovenous malformations are discussed. The routine use of computed tomography scan and timely, appropriate surgical intervention with the operating microscope for the removal of these deeply situated lesions is necessary for the diagnosis and therapy.     

Therapeutic options for occult breast cancer: a survey of the American Society of Breast Surgeons and review of the literature

BACKGROUND: Axillary presentation of occult breast cancer (OBC) is uncommon, and continues to be a diagnostic and therapeutic challenge to physicians. After our recent experience with a similar patient, a survey of the American Society of Breast Surgeons (ASBS) was conducted to assess the Society's member's opinions on treatment. METHODS: A survey was sent by mail to 1837 members of the ASBS. The survey consisted of a brief case presentation after which the surgeon's preference for management of the breast was sought. The choices included "mastectomy," "whole breast radiation" or "other." RESULTS: A total of 776 (42%) responses were received. The majority of respondents, 338 or 43%, preferred "mastectomy," while 285 or 37% opted for "whole breast radiation." Twenty percent of respondents (153 responses) chose "other," of which 46 physicians (6% of total) indicated they would observe the patient. CONCLUSIONS: Although recent literature supports the use of whole breast radiation, these results demonstrate that a small majority of physicians still prefer mastectomy. The appropriate treatment of the breast after an axillary presentation of OBC continues to be a controversial issue.     

Surgery for metastatic neuroendocrine tumors with occult primaries

Introduction

Neuroendocrine tumors (NETs) frequently metastasize prior to diagnosis. Although metastases are often identifiable on conventional imaging studies, primary tumors, particularly those in the midgut, are frequently difficult to localize preoperatively.

Materials and methods

Patients with metastatic NETs with intact primaries were identified. Clinical and pathologic data were extracted from medical records. Primary tumors were classified as localized or occult based on preoperative imaging. The sensitivities and specificities of preoperative imaging modalities for identifying the primary tumors were calculated. Patient characteristics, tumor features, and survival in localized and occult cases were compared.

Results

Sixty-one patients with an intact primary tumor and metastatic disease were identified. In 28 of these patients (46%), the primary tumor could not be localized preoperatively. A median of three different preoperative imaging studies were utilized. Patients with occult primaries were more likely to have a delay (>6 mo) in surgical referral from time of onset of symptoms (57% versus 27%, P = 0.02). Among the 28 patients with occult primary tumors, 18 (64%) were found to have radiographic evidence of mesenteric lymphadenopathy corresponding, in all but one case, to a small bowel primary. In all but three patients (89%), the primary tumor could be identified intraoperatively.

Conclusion

The primary tumor can be identified intraoperatively in a majority of patients with metastatic NETs, irrespective of preoperative localization status. Referral for surgical management should not, therefore, be influenced by the inability to localize the primary tumor.     

Incidence and risk factors of occult posterior malleolar fracture in patients with spiral distal tibial fracture: Reexamination and analysis

ObjectiveTo evaluate the incidence and risk factors for posterior malleolar fractures (PMFs) in patients with spiral distal tibial fractures (SDTFs).MethodsIn a retrospective study, 248 adults with SDTFs who underwent treatment were enrolled between November 2017 and May 2020. In a prospective study, we recruited 113 consecutive, skeletally mature patients with SDTFs who were identified from the trauma clinic of our hospital between June 2020 and May 2021. Radiographs and CT scans of the ankle region on the affected side were obtained to determine the presence of PMFs. If the CT scan was negative, additional MRI examination of the ankle was performed as a supplementary protocol in the prospective study. Univariate analysis and multivariate analysis were conducted to analyze the risk factors.ResultsIn the retrospective study, the incidence of PMFs associated with simple SDTFs was 74.0% (105/142), which was significantly lower than 90.8% (69/76) in the prospective study. Independent predictors of PMFs in patients with simple SDTFs identified by multivariate analysis in the retrospective study were age (OR = 1.07; P = 0.001) and external rotation of the proximal tibia (OR = 3.36; P = 0.027) and those in the prospective study were osteoporosis (OR = 0.04; P = 0.007) and spiral fibula fractures (OR = 16.05; P = 0.046).ConclusionThis study reexamined the high incidence of concurrent PMFs. Additionally, ankle radiographs and CT scans were recommended for all simple SDTF patients. For simple SDTF patients with negative CT scans, especially those caused by external rotation of the proximal tibia, combined with nonosteoporotic or spiral fibula fractures, additional MRI examinations are recommended.     

Clinical characteristics and long-term mortality of occult hip fracture elderly patients

Background and objective

Occult hip fractures (OHF) occur in a minute population of patients. Diagnosis is made via magnetic resonance imaging (MRI) or alternatively via bone scan. Very little is known about the clinical characteristics of OHF patients. Our aim was to characterize the clinical and long-term survival of OHF in elderly patients and to determine if a certain subgroup of patients would benefit from an MRI investigation following normal or equivocal radiography.

Methods

Twenty-nine OHF patients diagnosed by a bone scan during 1995-2004 were compared with a control group of 94 randomly chosen hip fractured patients diagnosed by plain radiography in the same hospital and during the same period.

Results

Mean age, women/men ratio, place of residence, comorbidities, cognitive and functional status were similar in the OHF and control group. Twenty-two (75.9%) and 4 (13.8%) patients in the OHF group had had subcapital and intertrochanteric fractures respectively, vs. 41 (43.6%) and 47 (50%) in the control group (p = 0.003). Diagnosis delay in the OHF group was 16.8 ± 26.5 days vs. 2.5 ± 2.9 days (p < 0.001) in the control group. There were fewer operations and complications in the OHF group compared to the control group (p < 0.001 and p = 0.017, respectively). During a 13-year follow-up, no differences in survival were found between the two groups nor any differences between those operated on and those who were not.

Conclusions

OHF patients have no distinctive clinical characteristics or long-term survival. The delay in diagnosing OHF is too much long and is probably related to the high prevalence of conservative treatment. MRI investigation is recommended whenever OHF are suspected and surgical treatment is considered, in order to improve diagnosis and treatment.     

胆囊上皮不典型增生与隐性胰胆反流

目的 评价隐性胰胆反流与胆囊癌变的关系.方法 检测340例择期胆囊切除术病人血液和胆囊胆汁淀粉酶确定隐性胰胆反流.组织病理学观察隐性胰胆反流胆囊标本的不典型增生发生率以及免疫组化观察胆囊黏膜上皮的增殖活性.结果 340例择期胆囊切除标本中隐性胰胆反流发生率为9.4%(32/340).32例隐性胰胆反流标本中发生胆囊癌1例.不典型增生11例.胆囊癌和不典型增生发生率为37.5%(12/32).对照组发生不典型增生发生率8.4%(26/308),两组差异有显著意义(P=0.006).隐性胰胆反流的胆囊上皮的Ki67指数平均为24.4%,高于对照组13.2%(P=0.014).结论 隐性胰胆反流是胆囊癌发生重要的诱因.     

Is routine chest radiograph necessary after chest tube removal?

Background

Obtaining a chest radiograph (CXR) after chest tube (CT) removal to rule out a pneumothorax is a universal practice. However, the yield of this CXR has not been well documented. Additionally, most iatrogenic pneumothoraces resulting from CT removal are atmospheric in origin, asymptomatic, and can be observed. Recently, we have begun to discontinue routine CXR for CT removal. We evaluated our experience with CT removal to clarify the usefulness of routine post CT removal CXR.

Methods

After IRB approval, a retrospective study was conducted on patients who had a CT placed in the past decade. Cardiac patients requiring a CT were excluded. Patient demographics, diagnosis, treatments, and outcomes were collected. Patients were divided into two groups, those with a CXR after CT removal (Group 1) and those without (Group 2). Percentages were compared with Chi square with Yates correction.

Results

462 patients were identified (group 1 = 327, group 2 = 135). Indications for CT included; empyema (n = 176), lung resection (n = 146), pneumothorax (n = 71), pleural effusion (n = 26), spinal fusion (n = 20), trauma (n = 16), and miscellaneous (n = 7). Seven patients (2.1%) in group 1 required reinsertion for pneumothorax (n = 4), empyema (n = 2), and pleural effusion (n = 1) compared to 1 patient (0.7%) in group 2 who required reinsertion for pleural effusion. This difference was not significant (P = 0.2).

Conclusions

In non-cardiac patients with a CT, tube reinsertion is uncommon and tube replacement is secondary to symptoms. Therefore, routine post CT removal CXR is not necessary. CXR in these patients should be obtained based upon clinical indications after CT removal.     

Clinically occult breast carcinoma: Diagnostic approaches and role of axillary node dissection

Background: Nonpalpable breast lesions are being detected with increasing frequency with the advent of improved mammographic techniques. Although only 20–30% of these lesions are malignant, definitive diagnosis has usually required a needle-localization excisional biopsy, which is costly and increases the psychological stress on the patient. The purpose of this retrospective study was to determine the sensitivity of ultrasound-guided fine-needle aspiration (FNA) biopsy of nonpalpable breast masses and the incidence of axillary nodal metastases in these subclinical lesions. Methods: Seventy-one patients treated for clinically occult malignant breast tumors between 1985 and 1992 were identified. Charts were reviewed to determine the accuracy of breast ultrasonography in detecting occult mass lesions and whether ultrasound guidance improved the accuracy of FNA biopsy. In addition, the incidence of axillary lymph node involvement was noted. Results: Of the 71 malignant tumors, 35 were in situ and 36 were invasive. The median diameter was 0.5 cm for noninvasive lesions and 0.8 cm for invasive tumors. A mass was seen on mammography in 32 (45%) patients, microcalcifications were seen in 36 (51%), and both a mass and microcalcifications were seen in three (4%). Of the 30 patients who underwent an axillary node dissection, 4 (13%) had disease-positive nodes. Ultrasound-guided FNA was performed in 15 patients with a mass lesion, with a sensitivity of 93%. Conclusions: These results indicate that ultrasound-guided FNA cytologic analysis is an accurate diagnostic technique even in small (<1 cm), mammographically detected breast masses. In addition, the incidence of axillary nodal metastases indicates that an axillary lymph node dissection should be performed in invasive lesions, even those <1 cm in diameter.     

腹腔镜治疗成年人隐匿性腹股沟疝的临床研究

目的:分析腹腔镜一侧疝修补术患者对侧隐匿性腹股沟疝的存在概率及其危险因素评估,以判断需行双侧腹股沟区探查的患者范围。方法:回顾分析2014年至2015年因腹股沟疝就诊且行腹腔镜疝修补术的174例患者的临床资料,其中160例行单侧疝修补术的同时探查对侧腹股沟区,术后随访24~36个月,记录隐匿性疝、异时性对侧疝及手术并发症发生率。结果:完成双侧腹股沟区探查的患者中15例合并隐匿性对侧腹股沟疝,1例失访,余者中位随访29个月,6例(6/144)术中确认"健康"的对侧出现了腹股沟疝。术后发生血清肿2例、复发1例、网片移位1例、慢性疼痛5例,1例中转开放手术,未发生手术部位感染、肠管损伤、输精管与血管损伤。结论:对于高龄、男性、左侧、疝环缺损较大者,出现隐匿性对侧腹股沟疝的概率较高,建议术中行双侧腹股沟区探查,并根据患者具体情况决定是否行预防性对侧疝修补术。双侧预防性修补是安全的。     

Early diagnosis of occult hip fractures MRI versus CT scan

OBJECTIVE: We compared Computerised Tomography (CT) and Magnetic Resonance Imaging (MRI) in diagnosis of a painful hip in elderly patients after trauma. We report on accuracy, efficiency and benefits. DESIGN: We assessed 13 patients, average age 73 years, after fall with plain X-rays showing no evidence of fracture. There were two groups: Group A (six patients) underwent CT and MRI; Group B underwent MRI only. RESULTS: In Group A where all of the six patients underwent CT and MRI, four of the CT images resulted in misdiagnosis due to inaccuracy. In Group B where all the seven patients underwent only MRI, all the results were accurate and enabled a precise and fast diagnosis. CONCLUSIONS: MRI was found to be a more accurate modality than CT scan for obtaining early diagnosis of occult hip fractures. These results point out the advantage of immediate MRI imaging in patients with occult hip fracture enabling a more effective treatment, a shorter hospitalisation period entailing decreased medical costs.     

膝关节隐匿性骨折的MRI诊断价值探讨

目的 探讨膝关节隐匿性骨折的MRI特征和临床应用价值．方法 选择35例膝关节外伤后X线检查阴性但有明显疼痛等症状的患者进行研究，所有患者全部进行MRI检查．重点观察股骨下端、胫腓骨上端及髌骨的骨质信号．前后交叉韧带、内外侧副韧带、内外侧半月板的完整性和信号异常情况。结果 隐匿性骨折的好发部位为：胫骨内外侧平台(14／35)、股骨内外侧髁(I3／35），35例患者中X线检查全部阴性，其中CT检查11例，3例阳性(27％)，MRI检查全部阳性(100％)。结论 MRI是检查隐匿性骨折的最佳影像学方法，对于X线或CT显示正常但又有明显症状的膝关节外伤患者，应做MRI检查，以防漏诊和误诊。