Prehospital emergency trauma care and management

Prehospital care of the trauma patient is continuing to evolve; however, the principles of airway maintenance, hemorrhage control, and appropriate resuscitative maneuvers remain central to the role of the emergency medical care provider. Recent changes in the regulations for research in emergency settings will allow randomized trials to proceed to test new devices, drugs, and resuscitative strategies in the prehospital environment. The creation of prehospital research networks will provide the appropriate infrastructure to greatly facilitate the development of new protocols and the execution of large-scale randomized trials with the potential to change current prehospital practice.     

Repair of medial collateral ligament injury during total knee arthoplasty

Intraoperative midsubstance lacerations of the medial collateral ligament (MCL) must be addressed during surgery, and failure to obtain coronal plane stability could affect patient outcomes and satisfaction. This article reports our results of a series of patients who sustained an intraoperative MCL injury during a primary total knee arthroplasty and were treated by direct primary repair and no change in implant constraint or postoperative protocol. Over a 5-year period, 9 patients sustained this complication. We reviewed their subjective satisfaction and stability, as well as objective measures such as functional scores, physical examinations, and radiographs. Average patient age was 58 years, and mean patient body mass index was 43.3. All patients were satisfied with the procedure and demonstrated no instability on physical examination. Average Knee Society pain score was 91.5 and functional score was 73.3. No radiographic changes or signs of loosening were noted. This novel approach for intraoperative midsubstance lacerations of the MCL does not involve altering implants or postoperative protocols and has encouraging results.     

Application of a rules-based natural language parser to critical value reporting in anatomic pathology

Critical values in anatomic pathology are rare occurrences and difficult to define with precision. Nevertheless, accrediting institutions require effective and timely communication of all critical values generated by clinical and anatomic laboratories. Provisional gating criteria for potentially critical anatomic diagnoses have been proposed, with some success in their implementation reported in the literature. Ensuring effective communication is challenging, however, making the case for programmatic implementation of a turnkey-style integrated information technology solution. To address this need, we developed a generically deployable laboratory information system-based tool, using a tiered natural language processing predicate calculus inference engine to identify qualifying cases that meet criteria for critical diagnoses but lack an indication in the electronic medical record for an appropriate clinical discussion with the ordering physician of record. Using this tool, we identified an initial cohort of 13,790 cases over a 49-month period, which were further explored by reviewing the available electronic medical record for each patient. Of these cases, 35 (0.3%) were judged to require intervention in the form of direct communication between the attending pathologist and the clinical physician of record. In 8 of the 35 cases, this intervention resulted in the conveyance of new information to the requesting physician and/or a change in the patient's clinical plan. The very low percentage of such cases (0.058%) illustrates their rarity in daily practice, making it unlikely that manual identification/notification approaches alone can reliably manage them. The automated turnkey system was useful in avoiding missed handoffs of significant, clinically actionable diagnoses.     

Diagnostic utility of CD10 in benign and malignant extrahepatic bile duct lesions

CD10, a cell surface enzyme with neutral metalloendopeptidase activity, is a marker for intestinal epithelial brush border. It is also present in normal bile ducts and gallbladder epithelia but is absent in cholangiocarcinomas. However, the expression profile of CD10 in benign and malignant extrahepatic biliary lesions has not been studied. In this study, 69 biopsies, 9 resections, and 9 cell blocks prepared from fine-needle aspirations of the extrahepatic bile ducts from 86 patients were studied immunohistochemically for CD10 expression. The majority of cases contained normal biliary epithelium (NL, n=64), along with foci of benign or malignant lesions in various combinations. Benign lesions included reactive atypia (n=35), low-grade dysplasia of unknown significance (n=21), and bile duct adenoma (BDA, n=1). Malignant lesions included high-grade dysplasia (HGD, n=45) and invasive adenocarcinoma (IC, n=30). As expected, the NL showed strong continuous staining at the apical surface in all cases. Benign lesions were also CD10 positive in all but 3 cases; however, the staining pattern was discontinuous, with positive cells varying from 20% to 80%. None of the malignant lesions showed CD10 immunoreactivity, except for 2 HGD cases and 1 IC case, which exhibited focal staining. The Pearson χ2 and Fisher exact tests showed significant statistical difference in CD10 expression among the study groups (P<0.001). Our findings suggest that absence of CD10 expression in strips of atypical biliary epithelial cells may be a phenotype associated with malignant transformation and may serve as a useful marker to aid in the evaluation of bile duct biopsies, in which distinction between benign and malignant lesions on biopsies or cytology specimens can be extremely challenging because of limited sampling, crush artifact, and frequent inflammatory/reactive changes.     

Perineural and intraneural invasion in posttherapy pancreaticoduodenectomy specimens predicts poor prognosis in patients with pancreatic ductal adenocarcinoma

Perineural invasion (PNI) is one of the established prognostic factors in pancreatic ductal adenocarcinoma (PDAC). However, the prognostic significance of PNI in patients with PDAC who received neoadjuvant therapy and pancreaticoduodenectomy is not clear. In this study, we performed a detailed examination of neural invasion in pancreaticoduodenectomy specimens from 212 patients with PDAC who received neoadjuvant chemoradiation (treated group) and in 60 untreated patients at our institution between January 1999 and December 2007. The frequency of PNI was higher in the untreated group (80%, 48/60) than in the treated group (58%, 123/212). For the 123 treated cases that were positive for PNI, extratumoral PNI, intratumoral PNI, intrapancreatic PNI only, extrapancreatic PNI, and intraneural invasion were identified in 86 (69.9%), 37 (30.1%), 11 (8.9%), 112 (91.1%), and 35 cases (28.5%), respectively. The presence of PNI correlated with tumor size, margin status, lymph node metastasis, pathologic tumor, and American Joint Committee on Cancer stages in the treated group. Tumor involvement of nerves >0.8 mm correlated with higher frequency of positive margin compared with tumors with PNI involving nerves ≤0.8 mm but not with other clinicopathologic parameters and survival. In the treated group, the presence of PNI or intraneural invasion correlated significantly with shorter disease-free survival and overall survival compared with no PNI or PNI only, respectively. PNI was an independent prognostic factor for both disease-free survival and overall survival in multivariate analysis. Our results showed that PNI plays an important role in the progression of PDAC and in predicting prognosis in this group of patients.