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Dave RV, Kim B, Courtney A, O'Connell R, Rattay T, Taxiarchi VP, Kirkham JJ, Camacho EM, Fairbrother P, Sharma N, Cartlidge CWJ, Horgan K, McIntosh SA, Leff DR, Vidya R, Potter S, Holcombe C, Copson E, Coles CE, Cutress RI, Gandhi A, Kirwan CC. Publisher Correction: Breast cancer management pathways during the COVID-19 pandemic: outcomes from the UK 'Alert Level 4' phase of the B-MaP-C study. Br J Cancer 2021; 125:905. [PMID: 34163004 PMCID: PMC8220421 DOI: 10.1038/s41416-021-01465-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Rajiv V Dave
- The Nightingale Breast Cancer Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, M23 9LT, UK.
| | - Baek Kim
- Department of Breast Surgery, St. James's University Hospital, Leeds, LS9 7TF, UK
| | - Alona Courtney
- Department of Surgery and Cancer, Imperial College, London, UK
| | - Rachel O'Connell
- Department of Breast Surgery, The Royal Marsden NHS Foundation Trust, Downs Road, Sutton, Surrey, SM2 5PT, UK
| | - Tim Rattay
- Leicester Cancer Research Centre, Clinical Sciences Building, University of Leicester, Leicester, LE2 2LX, UK
| | - Vicky P Taxiarchi
- Division of Population Health, Health Services Research, and Primary Care, School of Health Sciences, University of Manchester, Manchester, M13 9PL, UK
| | - Jamie J Kirkham
- Division of Population Health, Health Services Research, and Primary Care, School of Health Sciences, University of Manchester, Manchester, M13 9PL, UK
| | - Elizabeth M Camacho
- Division of Population Health, Health Services Research, and Primary Care, School of Health Sciences, University of Manchester, Manchester, M13 9PL, UK
| | | | - Nisha Sharma
- Breast unit, Level 1 Chancellor wing, St James's Hospital, Leeds, LS9 7TF, UK
| | | | - Kieran Horgan
- Department of Breast Surgery, St. James's University Hospital, Leeds, LS9 7TF, UK
| | - Stuart A McIntosh
- Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, 97 Lisburn Road, Belfast, BT9 7AE, UK
| | - Daniel R Leff
- Department of Surgery and Cancer, Imperial College, London, UK
| | - Raghavan Vidya
- The Royal Wolverhampton NHS Trust, Wolverhampton Road, Wolverhampton, WV10 0QP, UK
| | - Shelley Potter
- Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Canynge Hall, Whatley Road, Bristol, BS8 2PS, UK.,Bristol Breast Care Centre, North Bristol NHS Trust, Southmead Road, Bristol, BS10 5NB, UK
| | - Chris Holcombe
- Linda McCartney Centre, Royal Liverpool and Broadgreen University Hospital, Prescot Street, Liverpool, L7 8XP, UK
| | - Ellen Copson
- Cancer Sciences Academic Unit, University of Southampton and University Hospital Southampton, Tremona Road, Southampton, SO16 6YD, UK
| | | | - Ramsey I Cutress
- Cancer Sciences Academic Unit, University of Southampton and University Hospital Southampton, Tremona Road, Southampton, SO16 6YD, UK
| | - Ashu Gandhi
- The Nightingale Breast Cancer Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, M23 9LT, UK.,Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Oglesby Cancer Research Building, Manchester Cancer Research Centre, Wilmslow Road, Manchester, M20 4BX, UK
| | - Cliona C Kirwan
- The Nightingale Breast Cancer Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, M23 9LT, UK. .,Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Oglesby Cancer Research Building, Manchester Cancer Research Centre, Wilmslow Road, Manchester, M20 4BX, UK.
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Dave RV, Kim B, Courtney A, O'Connell R, Rattay T, Taxiarchi VP, Kirkham JJ, Camacho EM, Fairbrother P, Sharma N, Cartlidge CWJ, Horgan K, McIntosh SA, Leff DR, Vidya R, Potter S, Holcombe C, Copson E, Coles CE, Cutress RI, Gandhi A, Kirwan CC. Breast cancer management pathways during the COVID-19 pandemic: outcomes from the UK 'Alert Level 4' phase of the B-MaP-C study. Br J Cancer 2021; 124:1785-1794. [PMID: 33767422 PMCID: PMC7993073 DOI: 10.1038/s41416-020-01234-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 12/04/2020] [Accepted: 12/10/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The B-MaP-C study aimed to determine alterations to breast cancer (BC) management during the peak transmission period of the UK COVID-19 pandemic and the potential impact of these treatment decisions. METHODS This was a national cohort study of patients with early BC undergoing multidisciplinary team (MDT)-guided treatment recommendations during the pandemic, designated 'standard' or 'COVID-altered', in the preoperative, operative and post-operative setting. FINDINGS Of 3776 patients (from 64 UK units) in the study, 2246 (59%) had 'COVID-altered' management. 'Bridging' endocrine therapy was used (n = 951) where theatre capacity was reduced. There was increasing access to COVID-19 low-risk theatres during the study period (59%). In line with national guidance, immediate breast reconstruction was avoided (n = 299). Where adjuvant chemotherapy was omitted (n = 81), the median benefit was only 3% (IQR 2-9%) using 'NHS Predict'. There was the rapid adoption of new evidence-based hypofractionated radiotherapy (n = 781, from 46 units). Only 14 patients (1%) tested positive for SARS-CoV-2 during their treatment journey. CONCLUSIONS The majority of 'COVID-altered' management decisions were largely in line with pre-COVID evidence-based guidelines, implying that breast cancer survival outcomes are unlikely to be negatively impacted by the pandemic. However, in this study, the potential impact of delays to BC presentation or diagnosis remains unknown.
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Affiliation(s)
- Rajiv V Dave
- The Nightingale Breast Cancer Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, M23 9LT, UK.
| | - Baek Kim
- Department of Breast Surgery, St. James's University Hospital, Leeds, LS9 7TF, UK
| | - Alona Courtney
- Department of Surgery and Cancer, Imperial College, London, UK
| | - Rachel O'Connell
- Department of Breast Surgery, The Royal Marsden NHS Foundation Trust, Downs Road, Sutton, Surrey, SM2 5PT, UK
| | - Tim Rattay
- Leicester Cancer Research Centre, Clinical Sciences Building, University of Leicester, Leicester, LE2 2LX, UK
| | - Vicky P Taxiarchi
- Division of Population Health, Health Services Research, and Primary Care, School of Health Sciences, University of Manchester, Manchester, M13 9PL, UK
| | - Jamie J Kirkham
- Division of Population Health, Health Services Research, and Primary Care, School of Health Sciences, University of Manchester, Manchester, M13 9PL, UK
| | - Elizabeth M Camacho
- Division of Population Health, Health Services Research, and Primary Care, School of Health Sciences, University of Manchester, Manchester, M13 9PL, UK
| | | | - Nisha Sharma
- Breast unit, Level 1 Chancellor wing, St James's Hospital, Leeds, LS9 7TF, UK
| | | | - Kieran Horgan
- Department of Breast Surgery, St. James's University Hospital, Leeds, LS9 7TF, UK
| | - Stuart A McIntosh
- Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, 97 Lisburn Road, Belfast, BT9 7AE, UK
| | - Daniel R Leff
- Department of Surgery and Cancer, Imperial College, London, UK
| | - Raghavan Vidya
- The Royal Wolverhampton NHS Trust, Wolverhampton Road, Wolverhampton, WV10 0QP, UK
| | - Shelley Potter
- Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Canynge Hall, Whatley Road, Bristol, BS8 2PS, UK
- Bristol Breast Care Centre, North Bristol NHS Trust, Southmead Road, Bristol, BS10 5NB, UK
| | - Chris Holcombe
- Linda McCartney Centre, Royal Liverpool and Broadgreen University Hospital, Prescot Street, Liverpool, L7 8XP, UK
| | - Ellen Copson
- Cancer Sciences Academic Unit, University of Southampton and University Hospital Southampton, Tremona Road, Southampton, SO16 6YD, UK
| | | | - Ramsey I Cutress
- Cancer Sciences Academic Unit, University of Southampton and University Hospital Southampton, Tremona Road, Southampton, SO16 6YD, UK
| | - Ashu Gandhi
- The Nightingale Breast Cancer Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, M23 9LT, UK
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Oglesby Cancer Research Building, Manchester Cancer Research Centre, Wilmslow Road, Manchester, M20 4BX, UK
| | - Cliona C Kirwan
- The Nightingale Breast Cancer Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, M23 9LT, UK.
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Oglesby Cancer Research Building, Manchester Cancer Research Centre, Wilmslow Road, Manchester, M20 4BX, UK.
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Courtney A, O'Connell R, Rattay T, Kim B, Cutress RI, Kirwan CC, Gandhi A, Fairbrother P, Sharma N, Cartlidge CWJ, Horgan K, McIntosh SA, Leff DR, Vidya R, Potter S, Holcombe C, Copson E, Coles CE, Dave RV. The B-MaP-C study: Breast cancer management pathways during the COVID-19 pandemic. Study protocol. Int J Surg Protoc 2020; 24:1-5. [PMID: 32838092 PMCID: PMC7388760 DOI: 10.1016/j.isjp.2020.07.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 07/14/2020] [Accepted: 07/15/2020] [Indexed: 01/15/2023] Open
Abstract
Introduction Approximately 55,000 women in the United Kingdom are diagnosed with new breast cancer annually. Since emerging in December 2019, SARS-CoV-2 (coronavirus disease 2019, COVID-19) has become a global pandemic, affecting healthcare delivery worldwide. In response to the pandemic, multiple guidelines were issued to assist with rationalising breast cancer care. The primary aim of the B-MaP-C study is to audit and describe breast cancer management of patients newly diagnosed with breast cancer during the COVID-19 pandemic against pre-COVID-19 management practice in the UK. The implications of changes to management will be determined and the impact of a COVID-19 diagnosis on the patient’s breast cancer management will be determined. Methods and analysis This is a multi-centre collaborative audit of consecutive breast cancer patients undergoing treatment decisions during the acute and recovery phases of the COVID-19 pandemic. All patients with newly diagnosed primary breast cancer, whose treatment was decided in a multidisciplinary meeting from the 16th March 2020, are eligible for inclusion. Ethics and dissemination As this is an audit ethical approval is not required. Each participating centre is required to register the study locally and obtain local governance approvals prior to commencement of data collection. Local audit data will be available to individual participating units for governance purposes. The results of the data analysis will be submitted for publication, as well as disseminated via the ABS newsletter and a webinar. All data will be presented at national and international conferences, circumstances permitting. Registration details Each participating centre received local governance audit registration.
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Affiliation(s)
- Alona Courtney
- Department of Surgery and Cancer, Imperial College London, UK
| | - Rachel O'Connell
- Department of Breast Surgery, The Royal Marsden NHS Foundation Trust, Downs Road, Sutton, Surrey SM2 5PT, UK
| | - Tim Rattay
- Department of Cancer Studies, Clinical Sciences Building, University of Leicester, Leicester LE2 2LX, UK
| | - Baek Kim
- Department of Breast Surgery, St. James's University Hospital, Leeds LS9 7TF, UK
| | - Ramsey I Cutress
- University of Southampton and University Hospital Southampton, Tremona Road, Southampton SO16 6YD UK
| | - Cliona C Kirwan
- The Nightingale Breast Cancer Centre, Wythenshawe Hospital, Manchester M23 9LT, UK.,Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Oglesby Cancer Research Building, Manchester Cancer Research Centre, Wilmslow Road, Manchester M20 4BX, UK
| | - Ashu Gandhi
- The Nightingale Breast Cancer Centre, Wythenshawe Hospital, Manchester M23 9LT, UK.,Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Oglesby Cancer Research Building, Manchester Cancer Research Centre, Wilmslow Road, Manchester M20 4BX, UK
| | | | - Nisha Sharma
- Breast Unit, Level 1 Chancellor Wing, St James's Hospital, Leeds LS9 7TF, UK
| | | | - Kieran Horgan
- Department of Breast Surgery, St. James's University Hospital, Leeds LS9 7TF, UK
| | - Stuart A McIntosh
- Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, 97 Lisburn Road, Belfast BT9 7AE, UK
| | - Daniel R Leff
- Department of Surgery and Cancer, Imperial College London, UK
| | - Raghavan Vidya
- The Royal Wolverhampton NHS Trust, Wolverhampton Road, Wolverhampton WV10 0QP, UK
| | - Shelley Potter
- Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Canynge Hall, Whatley Road, Bristol BS8 2PS UK
| | - Chris Holcombe
- Linda McCartney Centre, Royal Liverpool and Broadgreen University Hospital, Prescot Street, Liverpool L7 8XP, UK
| | - Ellen Copson
- University of Southampton and University Hospital Southampton, Tremona Road, Southampton SO16 6YD UK
| | | | - Rajiv V Dave
- The Nightingale Breast Cancer Centre, Wythenshawe Hospital, Manchester M23 9LT, UK
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Dixon JM, Cartlidge CWJ. Twenty-five years of change in the management of the axilla in breast cancer. Breast J 2019; 26:22-26. [PMID: 31854498 DOI: 10.1111/tbj.13720] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 10/01/2019] [Indexed: 12/18/2022]
Abstract
Sentinel lymph node (SLN) biopsy is now used worldwide. It has led to many changes in how we manage the axilla in patients with breast cancer. This review covers four areas of management of the axilla in breast cancer: assessing the clinically node-negative axilla, managing the clinically negative axilla found to be involved at SLN biopsy, management of the clinically positive axilla in the context of neo-adjuvant chemotherapy, and treatment of the diseased axilla when radical therapy is required. We suggest that the evidence supports an optimum number of 3 nodes to be removed for accurate SLN biopsy. Breast cancer departments that have not adopted Z0011 patient management cannot continue to avoid change. The evidence is clear: Not all patients with limited axillary nodal disease on sentinel node biopsy need axillary lymph node dissection. For patients who do need axillary treatment, axillary radiotherapy continues to be under-used. Patients undergoing neo-adjuvant chemotherapy can be safely assessed by post-therapy SLN biopsy, with retrieval of any previously biopsied involved nodes by targeted axillary dissection. There is much to support the trend to doing less in the axilla. We are obliged to act based on the available robust clinical trial data in a way that limits morbidity while at the same time does not increase the risk of disease recurrence.
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Affiliation(s)
- J Michael Dixon
- Edinburgh Breast Unit, Western General Hospital, Edinburgh, UK
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Alshurbasi N, Cartlidge CWJ, Kohlhardt SR, Hadad SM. Predicting Patients Found to Have Malignancy at Nipple Duct Surgery. Breast Care (Basel) 2019; 15:491-497. [PMID: 33223992 DOI: 10.1159/000504528] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 11/02/2019] [Indexed: 01/03/2023] Open
Abstract
Introduction The unexpected diagnosis of breast cancer following total duct excision is distressing for patients. Despite advances in radiology and the description of suspicious nipple discharge, pre-operative diagnosis of malignancy still evades us. The aim of this study was to review the pathological findings of total duct excision and microdochectomy with reference to pre-operative symptoms, ultrasound, or mammographic findings and identify features associated with increased likelihood of malignant disease. Methods Data were collected retrospectively of all patients who underwent total duct excision surgery in a single centre (2011-2017). Pre-operative demographics, symptoms, and imaging findings were recorded and correlated with subsequent pathology. Results 214 patients underwent total duct excision; data were available for 211. Median age was 53 years. 175/211 (82.9%) patients had benign pathology (duct ectasia, papilloma without atypia, fibrocystic change) on final histological examination, 21/211 (10%) had "risk" lesions (papilloma with atypia, atypical ductal hyperplasia), and 15/211 (7.1%) had malignancy (ductal carcinoma in situ). Of the 15 patients with malignant lesions, 6/15 (40%) had normal imaging (M1, U1). 71/211 (33.6%) had normal imaging (M1, U1): 60/71 (84.5%) had benign disease, 5/71 (7%) had "risk" lesions, and 6/71 (8.5%) had malignant lesions. 83/211 (39.3%) patients presented with bloody discharge: 64/83 (77.1%) had benign pathology, 9/83 (10.8%) risk, and 10/83 (12%) malignancy. 38/211 (18%) patients presented with non-bloody discharge: 32/38 (84.2%) had benign disease, 4/38 (10.5%) risk, and 2/38 (5.3%) malignant lesions. Conclusion Neither imaging nor presenting symptoms correlate with the likelihood of malignant disease being present at final pathology. Even with advances in pre-operative diagnosis, total duct excision remains an essential diagnostic and therapeutic procedure.
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Affiliation(s)
- Nour Alshurbasi
- Department of Breast and Plastic Surgery, Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, United Kingdom
| | - Christopher W J Cartlidge
- Department of Breast and Plastic Surgery, Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, United Kingdom
| | - Stanley R Kohlhardt
- Department of Breast and Plastic Surgery, Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, United Kingdom
| | - Sirwan M Hadad
- Department of Breast and Plastic Surgery, Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, United Kingdom
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Cartlidge CWJ, Stewart GD, de Beaux AC, Paterson-Brown S. The evolution of laparoscopic antireflux surgery and its influence on postoperative stay. Scott Med J 2011; 56:64-8. [PMID: 21670129 DOI: 10.1258/smj.2010.010014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Laparoscopic fundoplication is an established treatment for refractory gastro-oesophageal reflux disease. This study aims to compare the outcome of two laparoscopic antireflux techniques in a regional specialist unit. A sequential audit was carried out on patients undergoing laparoscopic Nissen (LN: performed May 1994 to November 2000) or laparoscopic anterior (LA: performed March 2001 to December 2004) fundoplication. Patient satisfaction was assessed by postal questionnaire. The cohorts undergoing each operation were also divided into two chronological groups of 51 patients, to study the effect of possible learning curve progression on the number of nights spent in the hospital postoperatively. In all, 142/204 (70%) questionnaires were returned from patients with follow-up ranging from 5 to 40 months postoperation. Overall, 102/142 (72%) reported a good or excellent outcome. Patients who underwent LA had a higher rate of antacid medication use (LN 17.4% versus LA 34.2%, P = 0.036) but there was a higher score for inability to belch following LN (LN 2.03 versus LA 1.53, P = 0.034). When comparing the chronologically divided cohorts, LN was associated with a significantly longer hospital stay than LA (P < 0.001, Mann-Whitney U test). There was a significant decrease in hospital stay from the first to second group of 51 LNs (P < 0.001, Mann-Whitney U test) and a further significant reduction in hospital stay from the first 51 to second 51 LAs (P < 0.001, Mann-Whitney U test). In conclusion, both procedures provide good symptom control. Increased requirement for acid suppression following LA and inability to belch following LN, may suggest more long-term durability of the LN wrap. The decrease in the number of nights spent in hospital may be related to the procedure performed but seems more likely to be an effect of increasing volume of surgical experience.
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Affiliation(s)
- C W J Cartlidge
- Department of Clinical and Surgical Sciences (Surgery), University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK.
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Abstract
BACKGROUND Although adult respiratory distress syndrome is an important early complication of blunt trauma, the epidemiology and risk factors for its development remain poorly defined. The aims of this study were to determine the prevalence and demographics of this complication in a prospective cohort series of patients admitted to the hospital following injury. We also assessed the contribution of the severity and pattern of the injury to the risk of this complication developing. By identifying factors associated with the highest risk of the development of adult respiratory distress syndrome, we aimed to produce guidelines to facilitate earlier detection. METHODS We prospectively studied 7192 patients admitted to a single university hospital, over an eight-year period, for treatment of a traumatic injury. With the exception of patients who had sustained a hip fracture or who had been discharged within seventy-two hours after admission, all patients who required hospital admission following trauma, were older than thirteen years of age, and were a resident within the catchment area were included in the analysis. The prevalence and demographics of posttraumatic adult respiratory distress syndrome were identified for patients who had sustained musculoskeletal, thoracic, abdominal, and head injuries, either in isolation or in combination. The relative risks of this condition developing were calculated according to the injury pattern. Multiple logistic regression analysis was performed to identify the most highly significant predictors of the development of adult respiratory distress syndrome. RESULTS Adult respiratory distress syndrome developed in thirty-six (0.5%) of the patients. The prevalence was significantly higher among younger patients (p = 0.002), and 83% of the cases followed high-energy trauma. The prevalence of adult respiratory distress syndrome after isolated thoracic, head, abdominal, or extremity injury was <1%. Patients with injuries to two anatomical regions had a higher prevalence (up to 2.9%), and those with injuries to three anatomical regions had an even higher prevalence (up to 10.2%). Multiple logistic regression analysis showed the Injury Severity Score, the presence of a femoral fracture, the combination of abdominal and extremity injuries, and observations of compromised physiological function on admission each to be an independent predictor of the later development of adult respiratory distress syndrome. CONCLUSIONS The prevalence of adult respiratory distress syndrome increases with injury severity and combinations of injuries to more than one anatomical region. We have been able to quantify the importance and relative risks associated with these injuries. The implications of our findings with regard to facilitating early detection of this complication are discussed.
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Affiliation(s)
- Timothy O White
- Orthopaedic Trauma Unit, Royal Infirmary of Edinburgh, Little France, Scotland EH16 4SU, United Kingdom
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