A closed surgical intensive care unit organization improves cardiac surgical patient outcomes.

Background: Intensive care unit (ICU) organization is a critical factor in optimizing patient outcomes. ICU organization can be divided into "OPEN" (O) and "CLOSED" (C) models, where the specialist or intensivist, respectively, assumes the role of primary physician. Recent studies support improved outcomes in closed ICUs, however, most of the available data is centered on ICUs generally or on subspecialty surgical patients in the setting of a subspecialized surgical intensive care unit (SICU). We examined the impact of closing a general SICU on patient outcomes following cardiac and ascending aortic surgery. Methods: A retrospective cohort of patients following cardiac or ascending aortic surgery by median sternotomy was examined at a single academic medical center one year prior and one year after implementation of a closed SICU model. Patients were divided into "OPEN" (O; n=53) and "CLOSED" (C; n=73) cohorts. Results: Cohorts were comparable in terms of age, race, and number of comorbid conditions. A significant difference in male gender (O: 60.4% vs. C: 76.7%, P=0.049), multiple procedure performed (O: 13.21% vs. C: 35.62%, P=0.019), and hospital readmission rates was detected (O: 39.6% vs. C: 9.6%, P=0.0003). Using a linear regression model, a closed model SICU organization decreased SICU length of stay (LOS). Using a multivariate logistic regression, being treated in a closed ICU decreased a patient's likelihood of having an ICU LOS greater than 48 hours. Conclusions: Our study identified a decreased ICU LOS and hospital readmission in cardiac and ascending aortic patients in a closed general SICU despite increased procedure complexity. Further study is needed to clarify the effects on surgical complications and hospital charges.

Weight-Based Dosing for Low-Molecular-Weight Heparin (Enoxaparin) Administration to Achieve Optimal VTE Prophylaxis in Trauma Patients.

INTRODUCTION: Patients admitted after traumatic injuries are at high risk for developing venous thromboembolism (VTE). Low-molecular-weight heparin (LMWH) is commonly used to prevent VTE in this patient population; however, the optimal dosing strategy has yet to be determined. To address this question, a fixed-dosing strategy of LMWH was compared to a weight-based dosing strategy of LMWH for VTE prophylaxis. METHODS: A retrospective, pre-post implementation cohort study compared a fixed vs a weight-based dosing strategy of LMWH for VTE prophylaxis. Patients admitted to our level 1 trauma center were included if they had an estimated glomerular filtration rate >30 mL/min/1.73 m2, received at least 3 doses of LMWH, and had an appropriately drawn anti-Xa level on their initial dosing regimen. Patients in the pre-cohort received 30 mg LMWH subcutaneously twice daily as the initial dosing regimen. Patients in the post-cohort received .5 mg/kg (max 60 mg) LMWH subcutaneously every 12 h as the initial dosing regimen. A goal anti-Xa of .2-.4 IU/mL was targeted for prophylaxis. RESULTS: There were 817 patients in the fixed-dosing group (FDG) and 874 patients in the weight-based dosing group (WBDG). In the FDG, 42.8% of the patients achieved the goal initial anti-Xa level, with 54.1% and 3.1% reaching sub- and supratherapeutic doses, respectively. In the WBDG, 66.5% of patients reached goal initial anti-Xa levels, with 23.5% and 10.1% at sub- and supratherapeutic levels. The distribution of dose ranges was significantly different between the dosing strategies (P-value <.001). There was no difference in the number of patients who received blood products (39.1% vs 41.7%. P-value = .299). CONCLUSIONS: In our study, weight-based dosing of LMWH yielded a significantly higher proportion of patients who achieved goal prophylactic anti-Xa levels than fixed-dosing of LMWH. Larger-scale studies are needed to assess the risk of VTE events and bleeding with these dosing strategies.

Weight-Based Dosing for Venous Thromboembolism Prophylaxis in Spinal Trauma Patients Appears Safe.

INTRODUCTION: Venous thromboembolism (VTE) is a substantial cause of morbidity and mortality in trauma patients. VTE prophylaxis (VTEP) initiation is often delayed in certain patients due to the perceived risk of bleeding complications. Our VTEP guideline was changed from fixed-dosing to a weight-based dosing strategy using enoxaparin in June 2019. We investigated the rate of postoperative bleeding complications with a weight-based and a standard dosing protocol in traumatic spine injury patients requiring surgical stabilization. METHODS: A retrospective pre-post cohort study using an institutional trauma database was conducted, comparing bleeding complications between fixed and weight-based VTEP protocols. Patients undergoing surgical stabilization of a spine injury were included. The preintervention cohort received fixed-dose thromboprophylaxis (30 mg twice daily or 40 mg daily); the postcohort received weight-based thromboprophylaxis (0.5 mg/kg q12 h with anti-factor Xa monitoring). All patients received VTEP 24-48 h after surgery. International Classification of Diseases codes were used to identify bleeding complications. RESULTS: There were 68 patients in the pregroup and 68 in the postgroup with comparable demographics. Incidence of bleeding complications in the pre- and postgroups were 2.94% and 0% respectively. CONCLUSIONS: VTEP initiated 24-48 h after surgical stabilization of a spine fracture using a weight-based dosing strategy and has a similar rate of bleeding complications as a standard dose protocol. Our study is limited by the low overall incidence of bleeding complications and small sample size. These findings could be validated by a larger multicenter trial.

Are Chest Radiographs or Ultrasound More Accurate in Predicting a Pneumothorax or Need for a Thoracostomy Tube in Trauma Patients?

BACKGROUND: Historically, chest radiographs (CXR) have been used to quickly diagnose pneumothorax (PTX) and hemothorax in trauma patients. Over the last 2 decades, chest ultrasound (CUS) as part of Extended Focused Assessment with Sonography in Trauma (eFAST) has also become accepted as a modality for the early diagnosis of PTX in trauma patients. METHODS: We queried our institution's trauma databases for all trauma team activations from 2021 for patients with eFAST results. Demographics, injury variables, and the following were collected: initial eFAST CUS, CXR, computed tomography (CT) scan, and thoracostomy tube procedure notes. We then compared PTX detection rates on initial CXR and CUS to those on thoracic CT scans. RESULTS: 580 patients were included in the analysis after excluding patients without a chest CT scan within 2 hours of arrival. Extended Focused Assessment with Sonography in Trauma was 68.4% sensitive and 87.5% specific for detecting a moderate-to-large PTX on chest CT, while CXR was 23.5% sensitive and 86.3% specific. Extended Focused Assessment with Sonography in Trauma was 69.8% sensitive for predicting the need for tube thoracostomy, while CXR was 40.0% sensitive. DISCUSSION: At our institution, eFAST CUS was superior to CXR for diagnosing the presence of a PTX and predicting the need for a thoracostomy tube. However, neither test is accurate enough to diagnose a PTX nor predict if the patient will require a thoracostomy tube. Based on the specificity of both tests, a negative CXR or eFAST means there is a high probability that the patient does not have a PTX and will not need a chest tube.

Closed Collaborative Surgical Intensive Care Unit Modeling and Its Association With Trauma Patient Outcomes.

INTRODUCTION: The optimization of intensive care unit (ICU) care impacts clinical outcomes and resource utilization. In 2017, our surgical ICU (SICU) adopted a "closed-collaborative" model. The aim of this study is to compare patient outcomes in the closed-collaborative model versus the previous open model in a cohort of trauma surgical patients admitted to our adult level 1 trauma center. METHODS: A retrospective review of trauma patients in the SICU from August 1, 2015 to July 31, 2019 was performed. Patients were divided into those admitted prior to August 1, 2017 (the "open" cohort) and those admitted after August 1, 2017 (the "closed-collaborative" cohort). Demographic variables and clinical outcomes were analyzed. Trauma severity was assessed using injury severity score (ISS). RESULTS: We identified 1669 patients (O: 895; C: 774). While no differences in demographics were observed, the closed-collaborative cohort had a higher overall ISS (O: 21.5 ± 12.14; C: 25.10 ± 2.72; P < 0.0001). There were no significant differences between the two cohorts in the incidence of strokes (O: 1.90%; C: 2.58%, P = 0.3435), pulmonary embolism (O: 0.78%; C: 0.65%; P = 0.7427), sepsis (O: 5.25%; C: 7.49%; P = 0.0599), median ICU charges (O: $7784.50; C: $8986.53; P = 0.5286), mortality (O: 11.40%; C: 13.18%; P = 0.2678), or ICU length of stay (LOS) (O: 4.85 ± 6.23; C: 4.37 ± 4.94; P = 0.0795). CONCLUSIONS: Patients in the closed-collaborative cohort had similar clinical outcomes despite having a sicker cohort of patients. We hypothesize that the closed-collaborative ICU model was able to maintain equivalent outcomes due to the dedicated multidisciplinary critical care team caring for these patients. Further research is warranted to determine the optimal model of ICU care for trauma patients.

Prophylactic Antibiotics in Patients with Traumatic Pneumocephalus or Cerebrospinal Fluid Leak.

INTRODUCTION: Pneumocephalus and cerebrospinal fluid (CSF) leaks are uncommon after trauma, but they expose the sterile CSF to environmental pathogens and create theoretical risk of central nervous system infection (CNSI). Prophylactic antibiotics are commonly given to these patients, but there is a paucity of evidence to guide this practice. We aim to quantify the incidences of these entities and analyze the efficacy of prophylactic antibiotics in preventing CNSIs. METHODS: A retrospective cohort study was conducted using our institutional trauma registry. All patients admitted from January 2014 to July 2020 with traumatic pneumocephalus (TP) or basilar skull fracture with CSF leak (BSF-CSF) were included. ICD-9 and ICD-10 codes were used to identify CNSIs. CNSI rates among defined prophylactic antibiotic regimens, no antibiotics, and other antibiotic regimens were evaluated. ANOVA was used to analyze differences between the groups. RESULTS: 365 patients met inclusion criteria: 360 with TP; 5 with BSF-CSF. 1.1% (4/365) of patients developed CNSI, all with isolated traumatic pneumocephalus. 1.4% of patients (1/72) without antibiotics; 1.2% (3/249) receiving IV antibiotics outside of a defined regimen; and 1.1% (1/88) on a designated prophylactic regimen developed CNSIs. ANOVA indicated the incidence of CNSI was not significantly different among patients who received antibiotics or not, regardless of the regimen (p-value 0.958). CONCLUSION: TP and BSF-CSF are rare diagnoses among trauma patients. The rate of CNSI is marginal and antibiotics do not appear to confer a protective advantage. A larger trial is needed to elucidate the true effect of antibiotics on preventing CNSIs in patients with these uncommon diagnoses.

Incidence of Red Cell Antibody Formation Following Massive Transfusion Protocol: Experience of a Single Institution.

BACKGROUND: Injured patients in hemorrhagic shock have a survival benefit with massive transfusion protocol (MTP). While there are many published studies on the transfusion management of massively bleeding patients, the risk of alloimmunization in patients that have received products during an MTP activation is relatively unknown. Therefore, we sought to determine the frequency of new antibody formation in MTP patients that received blood products from an uncrossmatched megapack. MATERIALS AND METHODS: We conducted a retrospective data review of patients who underwent an MTP activation for trauma resuscitation between May 2014 and July 2020. Data were collected from patients who met the following criteria: MTP was activated, the patients received at least one unit of packed red blood cells, one unit of fresh frozen plasma, one unit of platelets, and had a repeat type and screen within 6 weeks of transfusion. These inclusion criteria resulted in 28 patients over the 6-year timeframe. RESULTS: Overall, the risk of alloimmunization secondary to MTP is 3.6% in our trauma patient population. The newly developed antibodies post-MTP are considered clinically significant, meaning they can cause hemolysis if exposed to donor red blood cells containing those antigens. DISCUSSION: Blood products should be given preferentially over crystalloids to acutely bleeding patients to prevent ischemic injury during an MTP activation despite the risk of alloimmunization. In our single-institution study, the alloimmunization rate in massive transfusions where patients receive uncrossmatched red blood cells is similar to those receiving crossmatched red blood cells.

Rapid Standardized CT-Based Method to Determine Lean Body Mass SUV for PET-A Significant Improvement Over Prediction Equations.

In 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography (PET) studies, maximum standardized uptake value (SUVmax) is the parameter commonly used to provide a measurement of the metabolic activity of a tumor. SUV normalized by body mass is affected by the proportions of body fat and lean tissue, which present high variability in patients with cancer. SUV corrected by lean body mass (LBM), denoted as SUL, is recommended to provide more accurate, consistent, and reproducible SUV results; however, LBM is frequently estimated rather than measured. Given the increasing importance of a quantitative PET parameter, especially when comparing PET studies over time to evaluate disease response clinically, and its use in oncological clinical trials, we set out to evaluate the commonly used equations originally derived by James (1976) and Janmahasatian et al. (2005) against computerized tomography (CT)-derived measures of LBM. Methods: Whole-body 18F-FDG PET images of 195 adult patients with cancer were analyzed retrospectively. Representative liver SUVmean was normalized by total body mass. SUL was calculated using a quantitative determination of LBM based on the CT component of the PET/CT study (LBMCT) and compared against the equation-estimated SUL. Bland and Altman plots were generated for SUV-SUL differences. Results: This consecutive sample of patients undergoing usual care (men, n = 96; women, n = 99) varied in body mass (38-127 kg) and in Body Mass Index (BMI) (14.7-47.2 kg/m2). LBMCT weakly correlated with body mass (men, r2 = 0.32; women, r2 = 0.22), and thus SUV and SULCT were also weakly correlated (men, r2 = 0.24; women, r2 = 0.11). Equations proved inadequate for the assessment of LBM. LBM estimated by James' equation showed a mean bias (overestimation of LBM compared with LBMCT) in men (+6.13 kg; 95% CI 4.61-7.65) and in women (+6.32 kg; 95% CI 5.26-7.39). Janmahasatian's equation provided similarly poor performance. Conclusions: CT-based LBM determinations incorporate the patient's current body composition at the time of a PET/CT study, and the information garnered can provide care teams with information with which to more accurately determine FDG uptake values, allowing comparability over multiple scans and treatment courses and will provide a robust basis for the use of PET Response Criteria in Solid Tumors (PERCIST) in clinical trials.

Preoperative nutritional counselling in patients undergoing oesophagectomy.

BACKGROUND: Patients undergoing surgery for oesophageal cancer are at high risk of malnutrition due to pathology and neoadjuvent therapy. This study sought to determine if oesophageal cancer patients undergoing oesophagectomy achieve superior clinical outcomes when preoperative nutritional counselling is performed. METHODS: Oesophageal cancer patients undergoing oesophagectomy were retrospectively divided into cohorts based on those who received (n = 48) and did not receive (n = 58) preoperative nutritional counselling. We compared weight loss, length of stay, 30-day readmission related to nutrition or feeding tube problems, and 90-day mortality. RESULTS: Per cent weight loss was less in patients who received preoperative nutritional counselling. There was a trend toward decreased mean length of stay and there were fewer readmissions for feeding tube-related complications in patients who received counselling. CONCLUSIONS: Nutritional counselling before surgery may lead to decreased weight loss and reduced readmissions for feeding tube-related complications in patients with oesophageal cancer undergoing oesophagectomy.

Anatomy Scholars Program for Medical Students Entering a Surgical Residency.

A near-peer teaching experience for upper-level medical students could help prepare them for surgical residency by providing specific education opportunities and exposure to the field of surgery. Five medical students were selected to be near-peer teachers (NPTs) in gross anatomy, and then they reflected on their experiences. The NPTs spent the majority of effort in a teaching role, and reported improved NTS, anatomy knowledge, and dissection skills. MS1s and faculty also reported on the value of the ASP. Further development and evaluation of the ASP may be an excellent opportunity for future surgeons.

Myosteatosis is prognostic in metastatic melanoma treated with nivolumab.

BACKGROUND: While immunotherapy agents have improved outcomes in metastatic melanoma (MM), predictive biomarkers in these patients are lacking. Parameters identified from body composition analysis, such as low SMD (also termed myosteatosis), may prognosticate MM patients on immunotherapy. METHODS: In this retrospective study, 44 MM patients received nivolumab, either as monotherapy or in combination with ipilimumab. Pre-treatment computed tomography (CT) scans were analyzed to determine skeletal muscle density (SMD) in Hounsfield units (HU) and muscle surface area (MSA) in cm2 at L3. MSA was used to determine nivolumab dosing in mg/cm2. RESULTS: Low SMD was associated with worse overall survival (OS) by log rank test (median 12.03 vs. 34.96 months, p = 0.001) and in multivariate analysis when accounting for age, sex, performance status, and number of prior lines of therapy (HR 4.40, 95% CI 1.44-13.42, p = 0.009). Lower nivolumab dosing by MSA was significantly associated with improved OS (median 42.9 vs. 12.3 months, p < 0.001). This association remained significant in multivariate analysis with age, sex, performance status, and number of prior lines of therapy (HR 0.05, 95% CI 0.01-0.30, p = 0.001). Neither SMD nor higher nivolumab dose per MSA were associated with increased incidence of treatment toxicity. CONCLUSIONS: Low SMD is prognostic in MM treated with nivolumab immunotherapy. Presence of myosteatosis or higher nivolumab dose based on body composition did not predict treatment toxicity.

Demographics, Treatment, and Cost of Periprosthetic Femur Fractures: Fixation Versus Revision.

INTRODUCTION: Periprosthetic femur fractures (PPFX) are complications of both total hip and knee arthroplasty and may be treated with open reduction and internal fixation (ORIF) or revision arthroplasty. Differences in treatment and fracture location may be related to patient demographics and lead to differences in cost. Our study examined the effects of demographics and treatment of knee and hip PPFXs on length of stay (LOS) and cost. METHODS: Of all, 932 patients were identified with hip or knee PPFXs in the National Inpatient Sample from January 2013 to September 2015. Age, gender, race, mortality, comorbidity level, LOS, total cost, procedure type, geographic region, and hospital type were recorded. A generalized linear regression model was conducted to analyze the effect of fracture type on LOS and cost. RESULTS: Differences in gender (66% vs 83.7% female, P < .01), comorbidities (fewer in hips, P < .01), and costs (US$30 979 vs US$27 944, P < .01) were found between the hip and knee groups. Knees had significantly higher rates of ORIF treatment (80.7% vs 39.1%) and lower rates of revision arthroplasties (19.3% vs 60.9%) than hip PPFXs (P < .01). Within both groups, patients with more comorbidities, revision surgery, and blood transfusions were more likely to have a longer LOS and higher cost. CONCLUSION: Periprosthetic femur fractures patients are not homogenous and treatment varies between hip and knee locations. For knee patients, those treated with ORIF were younger, with fewer comorbidities than those treated with revision. Conversely, hip patients treated with ORIF were older, with more comorbidities than those treated with revision. Hips had higher costs than knees, and cost correlated with revision arthroplasty and more comorbidities. In both hip and knee groups, longer LOS was associated with more comorbidities and being treated in urban teaching hospitals. Total cost had the strongest associations with revision procedures as well as number of comorbidities and blood product use.

ROTEM as a Predictor of Mortality in Patients With Severe Trauma.

BACKGROUND: Hemorrhage, especially when complicated by coagulopathy, is the most preventable cause of death in trauma patients. We hypothesized that assessing hemostatic function using rotational thromboelastometry (ROTEM) or conventional coagulation tests can predict the risk of mortality in patients with severe trauma indicated by an injury severity score greater than 15. METHODS: We retrospectively reviewed trauma patients with an injury severity score >15 who were admitted to the emergency department between November 2015 and August 2017 in a single level I trauma center. Patients with available ROTEM and conventional coagulation data (partial thromboplastin time [PTT], prothrombin time [PT], and international normalized ratio) were included in the study cohort. Logistic regression was performed to assess the relationship between coagulation status and mortality. RESULTS: The study cohort included 301 patients with an average age of 47 y, and 75% of the patients were males. Mortality was 23% (n = 68). Significant predictors of mortality included abnormal APTEM (thromboelastometry (TEM) assay in which fibrinolysis is inhibited by aprotinin (AP) in the reagent) parameters, specifically a low APTEM alpha angle, a high APTEM clot formation time, and a high APTEM clotting time. In addition, an abnormal international normalized ratio significantly predicted mortality, whereas abnormal PT and PTT did not. CONCLUSIONS: A low APTEM alpha angle, an elevated APTEM clot formation time, and a high APTEM clotting time significantly predicted mortality, whereas abnormal PT and PTT did not appear to be associated with increased mortality in this patient population. Viscoelastic testing such as ROTEM appears to have indications in the management and stabilization of trauma patients.

Change in Skeletal Muscle Following Resection of Stage I-III Colorectal Cancer is Predictive of Poor Survival: A Cohort Study.

BACKGROUND: Sarcopenia at time of diagnosis predicts worse survival outcomes. It is currently unknown how changes in muscle mass over time interact with sarcopenia in colorectal patients treated with curative intent. Objectives of this study were to quantify sarcopenia and skeletal muscle loss from time of diagnosis to end of surveillance and determine its effect on survival outcomes after completion of 2 years of surveillance. METHODS: Retrospective cohort study of stage I-III colorectal cancer patients from 2007-2009, who underwent resection and had preoperative and 2-year surveillance computed tomography scans, without recurrence during that time. Body composition analysis was done at both time points to determine lumbar skeletal muscle index, radiodensity and adiposity. Change over time was standardized as a percentage per year. Cox proportional hazard regression modeling was used for survival analysis. RESULTS: Of 667 patients included, median survival from surgery was 7.96 years, with 75 recurrences occurring after 2 years. On average patients lost muscle mass (-0.415%/year; CI -0.789, -0.042) and radiodensity (-5.76 HU/year; CI -6.74, -4.80), but gained total adipose tissue (7.06%/year; CI 4.34, 9.79). Patients with sarcopenia at diagnosis (HR 1.80; CI 1.13, 2.85) or muscle loss over time (HR 1.55; CI 1.01, 2.37) had worse overall survival, with significantly worse joint effect (HR 2.73; CI 1.32, 5.65). CONCLUSIONS: Sarcopenia at diagnosis combined with ongoing skeletal muscle loss over time resulted in significantly worse survival. Patients with these features who are recurrence-free at 2 years are more likely to have a non-colorectal cancer cause of death.

The Impact of Muscle and Adipose Tissue on Long-term Survival in Patients With Stage I to III Colorectal Cancer.

BACKGROUND: Computed tomography-derived body composition parameters are emerging prognostic factors in colorectal cancer. OBJECTIVE: This study aimed to determine the roles of sarcopenia, myosteatosis, and obesity as independent and overlapping parameters in stage I to III colorectal cancer. DESIGN: This is a retrospective cohort study from a prospectively collected database. Multivariate Cox proportional hazards models were performed to assess the associations between body composition parameters and survival. SETTINGS: All patients were seen in a tertiary care cancer center. PATIENTS: Adult patients with stage I to III colorectal cancer, undergoing curative resection from 2007 to 2009, were included. INTERVENTION: Computed tomography-derived quantification of skeletal muscle and adipose tissues was used to determine population-specific cutoffs for sarcopenia, myosteatosis, and total adiposity. MAIN OUTCOME MEASURES: Primary outcome measures were overall, recurrence-free, and cancer-specific survival. RESULTS: In the 968 patients included, there were a total of 254 disease recurrences and 350 deaths. Body mass index and CT-derived measures of adiposity did not result in worse survival outcomes. Sarcopenia was independently predictive of worse overall (HR, 1.45; 95% CI, 1.16-1.84), recurrence-free (HR, 1.32; 95% CI, 1.00-1.75), and cancer-specific survival (HR, 1.46; 95% CI, 1.09-1.94) in a multivariate model. Myosteatosis was also independently predictive of overall survival (HR, 1.53; 95% CI, 1.19-1.97). In a model considering joint effects of sarcopenia and myosteatosis, the presence of both predicted the worst overall (HR, 2.23; 95% CI, 1.62-3.06), recurrence-free (HR, 1.53; 95% CI, 1.06-2.21), and cancer-specific survival (HR, 2.40; 95% CI, 1.69-3.42) in a multivariate model. LIMITATIONS: The limitations of this study are inherent in retrospective observational studies. CONCLUSIONS: Sarcopenia and myosteatosis are independent predictors of worse survival in stage I to III colorectal cancer, and their joint effect is highly predictive of reduced overall, recurrence-free, and cancer-specific survival. See Video Abstract at http://links.lww.com/DCR/A923.

Is It Safe to Fly Patients with Penetrating Trauma in a Rural State?

BACKGROUND: There is limited data pertaining to the triage and transportation of patients with penetrating trauma in rural states. Large urban trauma centers have found rapid transport to be beneficial even when done by nonemergency medical staff. However, there is limited application to a rural state with only a single level 1 trauma center. MATERIALS AND METHODS: This a retrospective observational study of 854 trauma patients transported by helicopter emergency services between 2009 and 2015 to the state's only level 1 trauma center. RESULTS: After excluding patients with other injuries or lack of data, 854 patients underwent final analysis. Compared with penetrating trauma, blunt trauma had a significantly different chance of survival (92.0% versus 81.2%, P = 0.002) and a significantly different injury severity score (17 ± 12 versus 12 ± 9, P = 0.002). After controlling for blunt injuries, age, gender, injury severity score, tachycardia, tachypnea, hypotension, glasgow coma scale, and dispatch to hospital arrival time in multivariate analysis, blunt trauma had higher odds of survival than penetrating trauma (OR, 5.97; 95% CI, 2.52-14.12; P = <0.001 = 1). Gender, tachycardia, tachypnea, and dispatch to arrival time did not impact a patient's likelihood of survival. CONCLUSIONS: Penetrating trauma has a higher mortality when compared with blunt trauma in Helicopter Emergency Services transported patients in a rural state. Perhaps a new algorithm in the management of penetrating trauma would include hemorrhage control at a locoregional hospital before definitive care. Further study is required to understand the exact variables that lead to a higher mortality in penetrating trauma in a rural state.

Comparison of 30 mCi and 50 mCi I-131 doses for ablation of thyroid remnant in papillary thyroid cancer patients.

PURPOSE OF THE STUDY: To compare efficacy of thyroid remnant ablation using 30 mCi or 50 mCi 131-I in papillary thyroid cancer patients. MATERIALS AND METHODS: Five hundred and fifteen consecutive patients with Tumor-Node-Metastasis (TNM) stages T1-T3 N1/N0/NX receiving either 30 mCi or 50 mCi I-131 were analyzed for the effectiveness of remnant ablation using rhTSH-stimulated serum thyroglobulin. One hundred and five consecutive patients receiving 100 mCi I-131 were analyzed for the incidence of radiation thyroiditis and sialadenitis. RESULTS AND CONCLUSIONS: Doses of 30 mCi and 50 mCi were equally effective for low- and moderate-risk disease but 30 mCi was less effective for T1T2NX disease, and 50 mCi was less effective for T3 compared to T1T2 disease. Low dose radiation hypersensitivity or unknown more extensive disease may have accounted for observed differences. Radiation thyroiditis and sialadenitis were more common in a comparison series of 100 mCi dose compared to 30 mCi, but not more common than in 50 mCi doses.