Improving radiology: a whole-system opportunity

In this article, we set out the current context and case for change in radiology in England and how quality-improvement approaches can support the development of sustainable Imaging services and networks to meet the challenges faced now and in the future.

Non-Invasive Prenatal Testing (NIPT) - We Need a National Programme

Aims The provision of non-invasive prenatal testing (NIPT), a blood test screening for aneuploidy during pregnancy, varies widely internationally. In Ireland, NIPT is available privately, costing over €400. Gobal research on the patient perspective on NIPT shows a strong desire for the test to be provided for free. Attitudes towards NIPT amongst pregnant women in Ireland have not previously been studied. We assessed this in women attending maternity services in our unit. Methods This was a cross-sectional observational study involving a telephone survey. Women were asked about their prior knowledge of NIPT. Women with no prior knowledge were given information about NIPT and asked about their opinion of the test. Results One hundred and twelve (n=112) women participated. Of these, 60% (n=67) had not heard of NIPT, 86% (n=96) believe it should be freely available, and 80% (n=90) said they would avail of the test if it were free. Cost was the main prohibitive factor for those choosing not to have the test. All women wished to be more informed about NIPT. Conclusion Awareness of NIPT amongst women attending maternity services in Ireland may be low, but there is a desire for more information and a more equitable provision of the test.

The role of anatomic pelvic dissection in the successful closure of bladder exstrophy: an aid to success

INTRODUCTION

Classic bladder exstrophy is one of the rarest congenital anomalies compatible with life. Surgical treatment of bladder exstrophy has progressed, but the goal of surgery remains a successful primary bladder closure. Several factors have been identified to decrease the risk of failed closure, including appropriate use of osteotomy and adequate postoperative immobilization and analgesia. However, the role of the radical anatomic pelvic dissection, including dissection of the urogenital diaphragm fibers, in a successful closure has not yet been extensively explored.

OBJECTIVE

The objective of this study was go examine the role of radical anatomic pelvic dissection, including dissection of the urogenital diaphragm fibers, in patients with classic bladder exstrophy.

STUDY DESIGN

This was a retrospective study based on an institutional database.

METHODS

A retrospective review from an institutional approved database of more than 1,300 patients with epispadias-exstrophy complex was performed. The inclusion criteria included patients with classic bladder exstrophy with at least one failed bladder closure and a reclosure at the authors' institution with a single senior surgeon. Data collection included demographics, clinical variables, and status of urogenital diaphragm fibers. Magnetic resonance imaging (MRI) scans, if available, were reviewed with a pediatric radiologist to identify urogenital diaphragm fibers.

RESULTS

From the database, 93 patients met inclusion criteria. Of these patients, 74 had urogenital diaphragm fibers completely intact at the time of repeat closure, whereas 19 patients did not. There was no association with age or gender and status of urogenital diaphragm fibers. There was no association with osteotomy, the type of primary bladder closure, surgeon subspecialty, and the status of the urogenital fibers. Fourteen patients had at least two prior closures; surprisingly, 11 of these repeat closure patients still had intact urogenital fibers even after two prior closures.

DISCUSSION

The recent development and application of 3D MRI-guided pelvic dissection in a large group of patients led the authors to investigate whether adequate pelvic floor dissection had been accomplished at primary or secondary closure. Several patients had MRI scans performed before repeat closure in which the urogenital diaphragm fibers were identified to be intact on imaging; this was corroborated with surgical findings. Approximately 80% of patients had their urogenital diaphragm fibers completely intact and, therefore, did not have an adequate pelvic dissection during their primary or secondary bladder closure, putting the success of their previous closures at risk.

CONCLUSION

Inadequate pelvic diaphragm dissection, defined as intact urogenital diaphragm fibers, demonstrated in a large group of patients with failed exstrophy closure, may be a decisive factor in bladder closure failure. The use of 3D intra-operative image guidance may aid in a safer and more successful pelvic dissection.

The pregnant female surgical resident

BACKGROUND

Surgery continues to be an intense, time-consuming residency. Many medical students decide against surgery as a profession due to the long work hours and family strain. The pregnant female surgical resident has an added stress factor compared to her male counterpart.

METHODS

We distributed an electronic, online 26-question survey to 32 general surgery programs in the southwestern region of the United States. Each program distributed our survey to the female surgical residents who had been pregnant during residency in the last 5 years. Each program was re-contacted 6 weeks after the initial contact. Most questions were in a 5-point Likert scale format. The responses were collected and analyzed using the Survey Monkey website.

RESULTS

An unvalidated survey was sent to 32 general surgery programs and 26 programs responded (81%). Each program was asked for the total number of possible responses from female residents that met our criteria (60 female residents). Seven of the programs (27%) stated that they have had zero residents pregnant. We had 22 residents respond (37%). Over half of the residents (55%) were pregnant during their 2nd or 3rd year of residency, with only 18% pregnant during a research year. Thirty-one percent had a lower American Board of Surgery In-Training Exam (ABSITE) score. Ninety percent of the residents were able to take 4 weeks or more for maternity leave. Most of the residents (95%) stated that they would do this again during residency given the opportunity, but many of the residents felt that returning back to work with a child at home was the most difficult part.

CONCLUSION

Our preliminary study shows that the programs surveyed were accommodating to the female surgical resident. Nevertheless, despite adequate support from their program and an overall positive experience, many residents indicated that they had a decline in their education and performance.

Harlequin Ichthyosis - A Case Report

Harlequin Ichthyosis is a very rare genetic disorder affecting mainly the skin with severe morbidity and mortality. It affects both sexes with incidence of about 1 in 300,000 live births. Autosomal recessive inheritance has been inferred with mutation in ABCA 12 gene identified. Hence, genetic counseling and mutation screening of this gene should be considered in at-risk patients. Death usually occurred in the first 3 months of life due to sepsis, feeding problems and respiratory distress. With improved neonatal care and early introduction of retinoids, its survival rate has increased.

Skip and save: utility of pelvic x-rays in the initial evaluation of blunt trauma patients

BACKGROUND

The cost of medical care is an area of major emphasis in the current healthcare environment. Medical providers have a significant role in reducing costs. One way to achieve this goal is to eliminate practices that add little value to patient care. The pelvic x-ray (PXR) obtained during the initial evaluation of blunt trauma may be an example. The objective of this study was to explore the utility of the pelvic x-ray in the initial evaluation of blunt trauma patients.

METHODS

Blunt trauma patients with pelvic fractures of any type admitted to our urban trauma center from January 2012 to December 2013 were reviewed. Demographics including age, sex, race, mechanism of injury, and outcomes were collected. Findings on PXR and computed tomography (CT) were compared for correlation. Patients requiring surgery for their pelvic fractures were identified.

RESULTS

Of the 3,217 trauma admissions over the 2-year period, 153 patients sustained a pelvic fracture. Mean age was 50 years (15 to 97), male 54%, and Caucasian 46%, Hispanic 31%, African American 22%, and Asian 1%. The average injury severity score was 12.9. The main mechanism of injury was motor vehicle collisions 45%, followed by fall from standing 22% and auto and/or pedestrian accidents 12%. There were 22 patients that did not have both CT and pelvic imaging for comparison. Of the 131 patients with both CT and pelvic films, findings were the same in 43 (33%). CT identified one or more additional pelvic fractures in 88 (67%) patients compared with the PXR. In 29 patients (22%), pelvic fractures were not evident on PXR with fractures only identified by CT. The most common missed fractures on PXR were sacral and iliac injuries. Of the 153 patients with pelvic fractures, 24% required surgery for their pelvic injuries. Mortality was 4% for nonpelvic fracture-related causes. The PXR findings did not change management provided by trauma team in the emergency department.

CONCLUSIONS

As expected, CT is more sensitive in identifying pelvic fractures compared with PXR. Most blunt trauma patients are undergoing further evaluation with CT. We therefore propose that in patients that are normotensive with no pelvic instability or hip dislocation on physical examination who are to undergo further imaging with CT, the pelvic film should be avoided as it adds little value to patient management. The Advanced Trauma Life Support (ATLS) guidelines should be revised to reflect a diminishing role of the PXR in blunt trauma patients.

10-year outcome study of an early intervention program for psychosis compared with standard care service

BACKGROUND

Despite evidence on the short-term benefits of early intervention (EI) service for psychosis, long-term outcome studies are limited by inconsistent results. This study examined the 10-year outcomes of patients with first-episode psychosis who received 2-year territory-wide EI service compared to those who received standard care (SC) in Hong Kong using an historical control design.

METHOD

Consecutive patients who received the EI service between 1 July 2001 and 30 June 2002, and with diagnosis of schizophrenia-spectrum disorders, were identified and matched with patients who received SC first presented to the public psychiatric service from 1 July 2000 to 30 June 2001. In total, 148 matched pairs of patients were identified. Cross-sectional information on symptomatology and functioning was obtained through semi-structured interview; longitudinal information on hospitalization, functioning, suicide attempts, mortality and relapse over 10 years was obtained from clinical database. There were 70.3% (N = 104) of SC and 74.3% (N = 110) of EI patients interviewed.

RESULTS

Results suggested that EI patients had reduced suicide rate (χ2 (1) = 4.35, p = 0.037), fewer number [odds ratio (OR) 1.56, χ2 = 15.64, p < 0.0001] and shorter duration of hospitalization (OR 1.29, χ2 = 4.06, p = 0.04), longer employment periods (OR -0.28, χ2 = 14.64, p < 0.0001) and fewer suicide attempts (χ2 = 11.47, df = 1, p = 0.001) over 10 years. At 10 years, no difference was found in psychotic symptoms, symptomatic remission and functional recovery.

CONCLUSIONS

The short-term benefits of the EI service on number of hospitalizations and employment was sustained after service termination, but the differences narrowed down. This suggests the need to evaluate the optimal duration of the EI service.

Current approaches to journal club by general surgery programs within the Southwestern surgical congress

BACKGROUND

Journal club (JC) is a well-recognized education tool for many postgraduate medical education programs. Journal club helps residents learn critical analytic skills and keep up to date with current medical practices. To our knowledge, there is minimal evidence in the current literature detailing modern JC practices of general surgery training programs. Our study attempts to define how general surgery residency programs are implementing JC in their training process.

METHOD

We distributed by mail a 14-question survey to general surgery program directors within the Southwestern Surgical Congress. These surveys were redistributed 1 month after the initial attempt. The responses were collected and analyzed. Survey questions aimed to define JC practice characteristics, such as where JC is held, when JC is held, who directs JC, what journals are used, the perceived importance of JC, and average attendance.

RESULTS

The surveys were sent to 32 program directors (PDs), which included 26 university and 6 community-based programs. We received responses from 26 (81%) PDs. Ninety-two percent of the programs have a consistent journal club (JC). Most JCs meet monthly (64%) or weekly (16%). The meeting places ranged from conference rooms (60%), faculty homes (20%), restaurants (8%), or in the hospital (12%). The meeting times were divided between morning (29%), midday (29%), and evening (42%). Most JCs lasted between 1 and 2 hours (88%), reviewed 1-4 articles (88%), and are attended by more than 60% of residents routinely (75%). Half of the programs (50%) had 3-4 faculty members present during discussion; 29% of the programs had only 1-2 faculty present. The articles were selected from more than 10 different journals. Seventy-five percent of the programs used the American Journal of Surgery and Annals of Surgery to find articles; only 13% of the programs used evidence-based reviews in surgery. PDs believe JC is very beneficial (42%), moderately beneficial (42%), or only fairly beneficial (16%). According to PDs, JC is most beneficial because it improves clinical knowledge (88%), initiates additional reading (62%), and improves American Board of Surgery In-Training Examination (ABSITE) scores (15%).

CONCLUSION

Journal club has historically been an integral part of general surgery training. Our research indicates that journal club is still used widely as a beneficial educational resource and helps meet core competency requirements.

Annual mammography screening: is it necessary?

Recent recommendations from the U.S. Preventative Services Task Force suggest that screening mammography for women should be biennial starting at age 50 years and continue to age 74 years. With these recommendations in mind, we proposed a study to evaluate women at our institution in whom breast cancer is diagnosed within 1 year of a previously benign mammogram. A retrospective chart review was performed over a 4-year period. Only patients who had both diagnostic mammograms and previous mammograms performed at our institution and a pathologic diagnosis of breast cancer were included. Benign mammograms were defined as either Breast Imaging Reporting And Data System 1 or 2. Analysis of the time elapse between benign mammogram and subsequent mammogram indicative of the diagnosis of breast cancer was performed. A total of 205 patients were included. The average age was 64 years. From our results, 48 patients, 23 per cent of the total, had a documented benign mammogram at 12 months or less before a breast cancer diagnosis. One hundred forty-three (70%) patients had a benign mammogram at 18 months or less prior. This study raises concern that 2 years between screening mammograms may delay diagnosis and possible treatment options for many women.

Annual Mammography Screening: Is it Necessary?

Recent recommendations from the U.S. Preventative Services Task Force suggest that screening mammography for women should be biennial starting at age 50 years and continue to age 74 years. With these recommendations in mind, we proposed a study to evaluate women at our institution in whom breast cancer is diagnosed within 1 year of a previously benign mammogram. A retrospective chart review was performed over a 4-year period. Only patients who had both diagnostic mammograms and previous mammograms performed at our institution and a pathologic diagnosis of breast cancer were included. Benign mammograms were defined as either Breast Imaging Reporting And Data System 1 or 2. Analysis of the time elapse between benign mammogram and subsequent mammogram indicative of the diagnosis of breast cancer was performed. A total of 205 patients were included. The average age was 64 years. From our results, 48 patients, 23 per cent of the total, had a documented benign mammogram at 12 months or less before a breast cancer diagnosis. One hundred forty-three (70%) patients had a benign mammogram at 18 months or less prior. This study raises concern that 2 years between screening mammograms may delay diagnosis and possible treatment options for many women.

Spanish as a primary language and its effect on breast cancer presentation

PURPOSE

It is well documented that patients without health insurance tend to present at more advanced cancer stages than those with insurance. What has not been well documented is the effect that primary language has on cancer stage presentation. Given the significant number uninsured patients and patients not fluent in English who are treated at our institution, we sought to identify how these parameters affect cancer staging at presentation using breast cancer as a model.

METHODS

We conducted a retrospective chart review over a 36-month period at an urban community hospital. Patients who received their initial surgical treatment at this facility were included. One hundred seventy patients were identified. Definitive breast cancer surgery, breast cancer stage, and type were recorded for all subjects. We analyzed patient demographics including ethnicity, primary language spoken, and insurance status.

RESULTS

All patients were female. Patient populations were evenly distributed among three major ethnicities: 39% were African American, 36% were white, 23% were Hispanic, and 2% were listed as "other." Seventy percent of Hispanic patients noted that English was not their primary language. Ten percent of the white population presented at stage III or greater compared with 16% of African Americans and 22% of Hispanics. Twenty-seven percent of non-English-speaking Hispanics presented with advanced-stage disease.

CONCLUSION

Non-English-speaking Hispanic patients presented at more advanced stages than their English-speaking counterparts. Health care reform must address the non-English-speaking Hispanic to effectively improve the health of all groups in the United States.

Civilian and military trauma: does civilian training prepare surgeons for the battlefield?

The management of trauma patients continues to be a major focus of resident training. The purpose of this review is to compare the mechanism and distribution of injuries in civilian and military trauma and to ascertain whether we are optimally preparing surgeons for the injuries seen on the battlefield. We performed a retrospective 5-year review of all trauma admissions to our urban trauma center (TC). We then compared this data with that recently acquired from Operation Iraqi Freedom (OIF). There were 7732 trauma patients seen during that time at our TC with 9.8 per cent sustaining gunshot wounds. Of those, 26 per cent sustained a gunshot wound to the thorax, and injuries to the abdomen and pelvis were sustained in 28.5 per cent. In total, truncal trauma accounted for 55 per cent of the injuries. Extremity injuries occurred in just 31 per cent. Data from OIF show the mechanism and distribution of injuries to be quite different. Improvised explosive devices accounted for greater than 50 per cent of the injuries in OIF. Truncal injuries accounted for just 14 per cent of the injuries seen and extremity injuries accounted for, a significant, 56 per cent of all the injuries observed. The civilian experience with gunshot wounds often focuses on truncal trauma, yet the military data show a need for knowledge of devastating injuries to the extremity. This divergent experience may be even more salient in the future as the battlefield is brought closer to home through domestic terrorism and the line is blurred between military and civilian trauma.

Civilian and Military Trauma: Does Civilian Training Prepare Surgeons for the Battlefield?

The management of trauma patients continues to be a major focus of resident training. The purpose of this review is to compare the mechanism and distribution of injuries in civilian and military trauma and to ascertain whether we are optimally preparing surgeons for the injuries seen on the battlefield. We performed a retrospective 5-year review of all trauma admissions to our urban trauma center (TC). We then compared this data with that recently acquired from Operation Iraqi Freedom (OIF). There were 7732 trauma patients seen during that time at our TC with 9.8 per cent sustaining gunshot wounds. Of those, 26 per cent sustained a gunshot wound to the thorax, and injuries to the abdomen and pelvis were sustained in 28.5 per cent. In total, truncal trauma accounted for 55 per cent of the injuries. Extremity injuries occurred in just 31 per cent. Data from OIF show the mechanism and distribution of injuries to be quite different. Improvised explosive devices accounted for greater than 50 per cent of the injuries in OIF. Truncal injuries accounted for just 14 per cent of the injuries seen and extremity injuries accounted for, a significant, 56 per cent of all the injuries observed. The civilian experience with gunshot wounds often focuses on truncal trauma, yet the military data show a need for knowledge of devastating injuries to the extremity. This divergent experience may be even more salient in the future as the battlefield is brought closer to home through domestic terrorism and the line is blurred between military and civilian trauma.

Is there a benefit to multidisciplinary rounds in an open trauma intensive care unit regarding ventilator-associated pneumonia?

Multidisciplinary rounds (MDRs) have been instituted for patient care since June 2005. Before June 2005, all care was provided by individual practitioners. MDRs include the surgical intensivist, surgical resident, patient's nurse, case manager, pharmacist, chaplain, nutritionist, and respiratory therapist. Our study examined the effect of MDRs on ventilator-associated pneumonia in trauma patients in open intensive care units (ICUs). Group 1 included patients from June 2003 to May 2005 before the implementation of MDRs, and Group 2 included patients after the institution of MDRs from June 2005 to May 2007. In Group 1, there were 83 ventilator-associated pneumonias (VAPs) during 2414 ventilator days. In Group 2, there were 49 VAPs during 2094 ventilator days. The ratio of VAPs per thousand ventilator days decreased from 34.4 to 23.4 between the two groups (P = 0.04). When comparing trauma patients in our open ICU with similar mean Injury Severity Score and mean Abbreviated Injury Score for chest and for head and neck, implementing MDRs significantly decreased our incidence of VAP.

Is There a Benefit to Multidisciplinary Rounds in an Open Trauma Intensive Care Unit regarding Ventilator-Associated Pneumonia?

Multidisciplinary rounds (MDRs) have been instituted for patient care since June 2005. Before June 2005, all care was provided by individual practitioners. MDRs include the surgical intensivist, surgical resident, patient's nurse, case manager, pharmacist, chaplain, nutritionist, and respiratory therapist. Our study examined the effect of MDRs on ventilator-associated pneumonia in trauma patients in open intensive care units (ICUs). Group 1 included patients from June 2003 to May 2005 before the implementation of MDRs, and Group 2 included patients after the institution of MDRs from June 2005 to May 2007. In Group 1, there were 83 ventilator-associated pneumonias (VAPs) during 2414 ventilator days. In Group 2, there were 49 VAPs during 2094 ventilator days. The ratio of VAPs per thousand ventilator days decreased from 34.4 to 23.4 between the two groups ( P = 0.04). When comparing trauma patients in our open ICU with similar mean Injury Severity Score and mean Abbreviated Injury Score for chest and for head and neck, implementing MDRs significantly decreased our incidence of VAP.

Study rationale and design of the CIMT trial: the Copenhagen Insulin and Metformin Therapy trial

BACKGROUND

Patients with type 2 diabetes (T2DM) have an increased mortality rate primarily because of macrovascular disease. Where T2DM patients cannot be managed sufficiently through diet, exercise and peroral antidiabetic drugs, that is when haemoglobin A1c (HbA1c) is above 7.0%, it is yet unknown whether a combination of metformin and insulin analogues is superior to insulin analogues alone. Nor is it known which insulin analogue regimen is the optimal.

OBJECTIVE

The primary objective of this trial is to evaluate the effect of an 18-month treatment with metformin vs. placebo in combination with one of three insulin analogue regimens, the primary outcome measure being carotid intima-media thickness (CIMT) in T2DM patients.

DESIGN

A randomized, stratified, multicentre trial having a 2 x 3 factorial design. The metformin part is double masked and placebo controlled. The insulin treatment is open. The intervention period is 18 months.

PATIENT POPULATION

Nine hundred and fifty patients with T2DM and HbA1c > or = 7.5% on treatment with oral hypoglycaemic agents or on insulin treatment and deemed able, by the investigator, to manage once-daily insulin therapy with a long-acting insulin analogue.

RANDOMIZATION

Central randomization stratified for age (above 65 years), previous insulin treatment and treatment centre.

INTERVENTIONS

Metformin 1 g x two times daily vs. placebo (approximately 475 patients vs. 475 patients) in combination with insulin detemir before bedtime (approximately 315 patients) or biphasic insulin aspart 30 before dinner with the possibility to increase to two or three injections daily (approximately 315 patients) or insulin aspart before the main meals (three times daily) and insulin detemir before bedtime (approximately 315 patients). Intervention follows a treat-to-target principle in all six arms aiming for an HbA1c < or = 7.0%.

OUTCOME MEASURES

Primary outcome measure is the change in CIMT from baseline to 18 months. Secondary outcome measures comprises the composite outcome of death, acute myocardial infarction, stroke or amputation assessed by an adjudication committee blinded to intervention, other cardiovascular clinical outcomes, average postprandial glucose increment from 0 to 18 months, hypoglycaemia and any inadvertent medical episodes. In addition, change in plaque formation in the carotids, HbA1c, cardiovascular biomarkers, body composition, progression of microvascular complications and quality of life will be assessed as tertiary outcome measures. TIME SCHEDULE: Patient enrolment started May 2008. Follow-up is expected to finish in March 2011.

CONCLUSION

CIMT is designed to provide evidence as to whether metformin is advantageous even during insulin treatment and to provide evidence regarding which insulin analogue regimen is most advantageous with regard to cardiovascular disease.

Expanding the indications for laparoscopic gastric resection for gastrointestinal stromal tumors

OBJECTIVE

Laparoscopic resection of large gastric gastrointestinal stromal tumors (GIST) has been controversial. This generally has been limited to small lesions. We hypothesize that laparoscopic mobilization and resection using, in some cases, extracorporeal anastomosis of the gastrointestinal (GI) tract is an oncologically safe alternative to open surgery even when tumors are large.

METHODS

Four patients underwent a laparoscopic approach for gastric GIST tumors >2 cm at Methodist Dallas Medical Center over a 6-month period. Patient demographics, operative findings, postoperative course, and pathologic characteristics were examined.

RESULTS

The mean age in this patient group was 58 years (range, 36 to 77). Gastrointestinal bleeding and dyspepsia were the most common symptoms. Seventy-five percent of the patients were females. Mean tumor size was 10 cm (range, 2.5 to 20) with distribution in the stomach as follows: 75% greater curvature and 25% antrum. Tumors were removed by wedge, sleeve, and partial gastrectomies. Two of these tumors showed a high grade and the other 2 a moderate grade of differentiation. The number of mitoses was <5/50 HPF in all the tumors. No intraoperative spillage occurred in any patients, even with the largest tumor (20 cm). Importantly, all tumors were excised with a negative gross and microscopic margin. Average length of stay was 4 days. No patients required reoperation, and there were no complications postoperatively.

CONCLUSION

Minimally invasive assisted approaches may be an option to treat large GIST tumors. Obeying principles of minimal touch, no spillage, and obtaining a negative margin, a safe operation with a laparoscopic approach is feasible, even in giant tumors. The large size of diagnosed GIST tumors should not preclude a minimally invasive approach.

Retroperitoneal leiomyosarcoma of the inferior vena cava mimicking a liver tumor

Leiomyosarcoma of the inferior vena cava (IVC) is a rare sarcoma, but it is the most common primary malignancy of the IVC. It has an extremely poor prognosis. We describe a 60-year-old white female complaining of abdominal fullness for 7 weeks before she sought medical assistance. Initial work-up including sonography, computed tomography, and magnetic resonance showed a tumor in the right upper quadrant of the abdominal cavity originating from the liver with compression of the IVC and displacement of the right kidney. The patient underwent surgical resection of the tumor with clear margins and reconstruction of the IVC using a Dacron tubular graft. Postoperatively, she was placed on Coumadin and adjuvant chemotherapy was started. Subsequently, the patient developed metastasis into the liver and peripancreatic nodes during the follow-up period. Considering the aggressiveness of this tumor, early radical en block resection with clear margins is still the only chance for long-term survival.

Retroperitoneal Leiomyosarcoma of the Inferior Vena Cava Mimicking a Liver Tumor

Leiomyosarcoma of the inferior vena cava (IVC) is a rare sarcoma, but it is the most common primary malignancy of the IVC. It has an extremely poor prognosis. We describe a 60-year-old white female complaining of abdominal fullness for 7 weeks before she sought medical assistance. Initial work-up including sonography, computed tomography, and magnetic resonance showed a tumor in the right upper quadrant of the abdominal cavity originating from the liver with compression of the IVC and displacement of the right kidney. The patient underwent surgical resection of the tumor with clear margins and reconstruction of the IVC using a Dacron tubular graft. Postoperatively, she was placed on Coumadin® and adjuvant chemotherapy was started. Subsequently, the patient developed metastasis into the liver and peripancreatic nodes during the follow-up period. Considering the aggressiveness of this tumor, early radical en block resection with clear margins is still the only chance for long-term survival.

Car Surfing: Case Studies of a Growing Dangerous Phenomenon

Car surfing is a dangerous new pastime for American youth. Car surfing is an activity that is defined as standing (or lying) on a vehicle while it is being driven. This activity frequently results in severe injuries that often require significant surgical intervention. Despite its destructive nature, however, there are many Internet sites that encourage this behavior and view it as amusing. As a result, car surfing is becoming increasingly popular. We conducted a retrospective chart review of all patients injured as a result of car surfing over the last 4 years at our Urban Level II trauma center. Data collected included Injury Severity Score (ISS), Revised Trauma Score (RTS), age, gender, injury pattern, surgical intervention, and length of stay. Eight car surfers were identified. The average age was 17. The average Revised Trauma Score was 6.8 with an average Injury Severity Score of 16.9. Five patients were admitted to the intensive care unit. Four of these five patients needed to be intubated for ventilatory support. Five of the eight patients had significant intracranial injuries. Two patients had epidural hematomas that required evacuation. Two other patients had subdural hematomas that were treated nonoperatively, and one patient had a subarachnoid hemorrhage that was also treated nonoperatively. Four of the eight patients required surgical intervention. There were no deaths in this study. Car surfing leads to severe injuries that can result in significant morbidity. American youth have access to Internet sites that project this activity as an acceptable behavior. Five of our eight patients had a significant intra-cranial injury. Trauma surgeons need to be more aware of this injury phenomenon.

Car surfing: case studies of a growing dangerous phenomenon

Car surfing is a dangerous new pastime for American youth. Car surfing is an activity that is defined as standing (or lying) on a vehicle while it is being driven. This activity frequently results in severe injuries that often require significant surgical intervention. Despite its destructive nature, however, there are many Internet sites that encourage this behavior and view it as amusing. As a result, car surfing is becoming increasingly popular. We conducted a retrospective chart review of all patients injured as a result of car surfing over the last 4 years at our Urban Level II trauma center. Data collected included Injury Severity Score (ISS), Revised Trauma Score (RTS), age, gender, injury pattern, surgical intervention, and length of stay. Eight car surfers were identified. The average age was 17. The average Revised Trauma Score was 6.8 with an average Injury Severity Score of 16.9. Five patients were admitted to the intensive care unit. Four of these five patients needed to be intubated for ventilatory support. Five of the eight patients had significant intracranial injuries. Two patients had epidural hematomas that required evacuation. Two other patients had subdural hematomas that were treated nonoperatively, and one patient had a subarachnoid hemorrhage that was also treated nonoperatively. Four of the eight patients required surgical intervention. There were no deaths in this study. Car surfing leads to severe injuries that can result in significant morbidity. American youth have access to Internet sites that project this activity as an acceptable behavior. Five of our eight patients had a significant intracranial injury. Trauma surgeons need to be more aware of this injury phenomenon.

Wandering spleen presenting as recurrent pancreatitis

INTRODUCTION

A wandering spleen occurs when there is a laxity of the ligaments that fix the spleen in its normal anatomical position.

CASE REPORT

We present the case of a wandering spleen in a 20-year-old female who presented with recurrent pancreatitis and underwent a laparoscopic splenectomy.

DISCUSSION

The presentation of a wandering spleen varies from an asymptomatic mass to splenic infarct with an acute abdomen. Its correct diagnosis relies mostly on imaging studies. Treatment consists of performing either splenectomy or splenopexy.

CONCLUSION

The diagnosis of wandering spleen can often be difficult due to the intermittent nature of the torsion. Computed tomography studies for diagnosis and laparoscopic surgery have changed the management of this interesting disease.

Medical Admission of Elderly Trauma Patients with Isolated Injuries

We sought to evaluate the outcomes of trauma patients admitted to medical services rather than to the general trauma team, particularly those elderly patients with isolated injuries of a specialty nature. Over the 2-year retrospective study period, 3017 trauma patients were admitted. The trauma service directed care in 2740 (90.8%) of this group versus the 277 (9.2%) admitted to medical services (MS). The patients in each group were then classified according to age younger than 55 years or older than 55 years (elderly). Of the 277 patients admitted to the MS, 177 (63.8%) were elderly compared with only 13 per cent of the trauma service group. Smaller proportions (16.9%) of the elderly medical patients were admitted to the intensive care unit as compared with the trauma group (22.1%). There was a higher morbidity rate, 41.9 per cent, in the trauma service group as compared with the MS group, 20 per cent. No patients on the MS underwent a laparotomy for intraabdominal injuries nor were there any missed injuries of a general surgical nature. Allowing elderly trauma patients with isolated specialty injuries to be managed by the MS is not associated with increased morbidity or mortality.

Medical admission of elderly trauma patients with isolated injuries

We sought to evaluate the outcomes of trauma patients admitted to medical services rather than to the general trauma team, particularly those elderly patients with isolated injuries of a specialty nature. Over the 2-year retrospective study period, 3017 trauma patients were admitted. The trauma service directed care in 2740 (90.8%) of this group versus the 277 (9.2%) admitted to medical services (MS). The patients in each group were then classified according to age younger than 55 years or older than 55 years (elderly). Of the 277 patients admitted to the MS, 177 (63.8%) were elderly compared with only 13 per cent of the trauma service group. Smaller proportions (16.9%) of the elderly medical patients were admitted to the intensive care unit as compared with the trauma group (22.1%). There was a higher morbidity rate, 41.9 per cent, in the trauma service group as compared with the MS group, 20 per cent. No patients on the MS underwent a laparotomy for intraabdominal injuries nor were there any missed injuries of a general surgical nature. Allowing elderly trauma patients with isolated specialty injuries to be managed by the MS is not associated with increased morbidity or mortality.

Review of tracheo-esophageal fistula associated with endotracheal intubation

Tracheo-esophageal fistula (TEF) formation is a rare complication of either endotracheal intubation or tracheostomy. This complication is generally thought to be iatrogenic and occurs in less than 1% of patients. High-volume, low-pressure cuffs have made TEFs an infrequent occurrence; however, it still poses as a potential life-threatening condition. Evaluation and close monitoring of endotracheal tube (ETT) cuff pressures is an area of significance commonly overlooked and/or underemphasized by surgical residents. To illustrate and review this clinical problem, a case of an iatrogenic TEF as a consequence of excessive endotracheal cuff pressures is reported.