Illicit Cosmetic Silicone Injection: A Recent Reiteration of History.

The injection of liquid silicone for cosmetic augmentation has a history of both legal as well as illicit practice in the United States and worldwide. Recently, the American Society of Plastic Surgeons has launched a public awareness campaign through patient stories and various statements in response to the rise in deaths related to this illicit practice. A articular segment of the population that has become a target is the transgender patient group. A brief review is provided of the history of industrial liquid silicone injection, including the pathophysiology to fully describe and review silicone injection injury. Three cases of soft tissue cellulitis and wound necrosis treated at our institution are summarized and a treatment algorithm proposed based on literature review of treatment options and our own experience.

American College of Surgeons National Surgical Quality Improvement Program as a quality improvement tool: a single institution's experience with vascular surgical site infections.

Vascular surgical site infections (VSSIs) result in significant patient morbidity and hospital cost. The objective of this study is to report a single hospital's experience using the National Surgical Quality Improvement Program (NSQIP) as an instrument to decrease VSSIs. After review of initial NSQIP data, changes in antibiotic dosage and timing, surgical preparation, patient warming, and oxygenation were put into practice. Records of all patients undergoing vascular surgical operations during a two-year period were reviewed and VSSIs were identified. Statistical comparisons were made between groups before and after implementation of these changes. A total of 478 cases met our criteria. Practice changes were introduced in October 2009 and fully implemented by January 2010. Two hundred forty-three cases were performed in 2009 and 235 in 2010. When operations during the two time periods were compared, significantly fewer VSSIs were identified in 2010 than in 2009 (P = 0.036). NSQIP enabled our institution to identify an unacceptably high level of VSSIs. By implementing changes in our clinical practice, we were able to significantly lower our rate of VSSI.

Famotidine use and thrombocytopenia in the trauma patient.

The purpose of this study was to assess the incidence and clinical significance of famotidine-associated thrombocytopenia in the trauma patient population. A retrospective cohort study was performed between January 2003 and May 2009 comparing the consecutive platelet counts of trauma patients treated with intravenous famotidine with a similar group of trauma patients who were not. Patients were excluded if: 1) daily platelets counts for 48 hours were not drawn; 2) if platelet counts were less than 150 × 103/µL on admission or before initiation of famotidine treatment; 3) if patients received heparin or enoxaparin before or during the study period; and 4) if patients were taking famotidine before admission. Platelet counts were then recorded for the day of admission, the day famotidine was started if not on admission, and 24 hours and 48 hours during treatment. Seventy-two of 181 (39.8%) patients treated with famotidine developed thrombocytopenia compared with 23 of 126 (18.3%) untreated patients (P < 0.001). Patients who developed thrombocytopenia were also more likely to have a longer length of stay and higher Injury Severity Scores. Intravenous famotidine therapy was the only variable found to be statistically significant after both univariate and multivariate analysis (P < 0.001 and P = 0.003, respectively). Thrombocytopenia became clinically significant in eight of 181 (4.4%) famotidine-treated patients or 11.1 per cent of those who developed thrombocytopenia. Given these findings, we recommend the use of alternative medications for peptic ulcer prophylaxis in the critically ill trauma patient, especially those who are coagulopathic.

CT imaging in motorcycle collision victims: routine or selective?

With improving accuracy and efficiency of CT, some trauma centers have used a low threshold for the use of CT scans in the evaluation and assessment of trauma patients. The purpose of this study was to evaluate the diagnostic benefits of liberal CT scanning in multisystem blunt trauma motorcycle accident victims. The trauma registry at our community-based Level II center was accessed to identify consecutive motorcycle accident victims within a 55-month period who: 1) were evaluated on presentation by an attending trauma surgeon; and 2) underwent a head, cervical spine, chest, abdomen, or pelvis CT scan or any combination as part of their initial assessment. For those patients with clinically significant findings identified on CT, the percentage of those with negative clinical examinations was calculated. We found that 48, 77, 47, and 69 per cent of patients with clinically significant findings on head, cervical spine, thoracic, and abdominal CT, respectively, had normal clinical examinations. Our data suggest lower thresholds for CT use in the evaluation of patients sustaining multisystem blunt trauma should be adopted, even in the face of normal clinical examinations. This is especially true for the neck and abdominal regions.

Primary stenting of the superficial femoral and popliteal artery.

OBJECTIVES: Over the last decade, the number of endovascular procedures performed on the superficial femoral (SFA) and popliteal arteries (PA) has significantly increased. There is no consensus on the optimal form of intervention used in this arterial segment. While some have advocated balloon angioplasty alone, others have championed either selective or primary stenting of these lesions. It is the purpose of this study to determine the efficacy and durability of primary stenting of the superficial femoral and popliteal artery. METHODS: All patients undergoing peripheral angioplasty by a single vascular surgeon were prospectively enrolled in an Institutional Review Board-approved, primary-stenting protocol. During a 44-month period, all patients undergoing percutaneous transluminal angioplasty of the SFA or PA also received primary arterial stenting with bare, self-expanding nitinol stents. Patient demographics and risk factors were identified. TransAtlantic InterSociety Consensus (TASC) classifications were determined for all lesions. Loss of primary patency was said to have occurred when an occlusion or a 50% or greater stenosis in any treated arterial segment was diagnosed by arterial duplex or angiography. Only time to loss of primary patency was recorded. Kaplan-Meier survival curves were plotted and differences between groups tested by log rank method. RESULTS: Between January 16, 2004 and August 13, 2007, 201 angioplasties with primary stenting were performed on 161 patients. One hundred twenty-three stents were placed for claudication, and 78 for critical limb ischemia. Forty-six segments treated were TASC A, 82 were TASC B, 38 were TASC C, and 35 were TASC D. Patient follow-up ranged from three to 1329 days (mean: 426 days). Primary patency rates for TASC A and B lesions were 79%, 67%, and 57% at 12, 24, and 36 months. For TASC C and D lesions, primary patency rates were 52.7%, 36%, and 19% at the same time intervals. Primary patency rates for TASC A and B lesions were significantly higher than for C and D lesions (P < .001). The limb salvage rate was 88.5% in patients with critical limb ischemia. Distal runoff did not influence patency (P = .827). CONCLUSIONS: Primary stenting of the SFA and PA provides durable results in patients with TASC A and B lesions and may be an effective treatment strategy. This approach is significantly less effective when used in treating those with TASC C and D disease. Based on the results in this series, the use of primary stenting does not extend the anatomic limits of the current treatment recommendations for catheter-based intervention in patients with infrainguinal occlusive disease.

Placement of an implantable drug delivery system under the breast.

OBJECTIVE: Our case will demonstrate a safe and practical alternative location for an implantable drug delivery system (IDDS) pump. Traditionally, these pumps have been placed subcutaneously in the lower abdomen. We will describe the technique used for under the breast placement. PATIENT: The patient was a 52-year-old female with metastatic colon cancer and chronic flank pain. RESULTS: The pump was placed in the retromammary location with no complications or problems with patient discomfort. Adequate pain control was achieved. CONCLUSION: The retromammary location for the IDDS pump is a safe and aesthetically pleasing option for some patients. This location is a useful alternative for female cachectic patients, or patients with abdominal ostomies.