Prehospital Narrow Pulse Pressure Predicts Need for Resuscitative Thoracotomy and Emergent Intervention After Trauma.

BACKGROUND: The pulse pressure (PP) is the difference between systolic and diastolic blood pressures. Narrow PP in the Emergency Department (ED) has recently been shown to predict hemorrhagic shock after trauma. This study examined the impact of prehospital narrow PP on outcomes after trauma. METHODS: Patients presenting to our ACS-verified Level I trauma center (2008-2020) were retrospectively screened. Exclusions were unrecorded prehospital/ED vitals, age <16 or >60, transfers, on-scene cardiac arrest, and missing discharge disposition. Prehospital blood pressure defined study groups: Narrow PP (<30 mmHg) vs. Hypotensive (SBP<90 mmHg) vs. Others (herein referred to as Normotensive). Univariable/multivariable analyses compared outcomes and determined independent predictors of mortality; resuscitative thoracotomy; emergent intervention; and need for trauma intervention (NFTI), a contemporary measure of major trauma. RESULTS: In total, 39,144 patients met inclusion/exclusion criteria: 5% (n=1,834) Narrow PP, 3% (n=1,062) Hypotensive, and 92% (n=36,248) Normotensive. Penetrating trauma was more frequent among Narrow PP and Hypotensive patients (23% vs. 32% vs. 14%, p<0.001). ISS was higher among Narrow PP and Hypotensive patients (5[1-14] vs. 10[2-21] vs. 4[1-9], p<0.001). Mortality was highest among the Hypotensive (n=130, 12%) followed by Narrow PP (n=92, 5%) and Normotensive patients (n=502, 1%) (p<0.001). On multivariable analysis, prehospital narrow PP was independently associated with resuscitative thoracotomy (OR 1.609, p=0.009), emergent intervention (OR 1.356, p=0.001), and NFTI (OR 1.237, p=0.009). CONCLUSION: Prehospital narrow PP independently predicts severe trauma, resuscitative thoracotomy, and emergent intervention. Although prehospital narrow PP is not currently a TTA criterion, these patients have a mortality rate and ISS intermediate to those of hypotensive and normotensive patients. Prehospital narrow PP should be recognized as a proxy for major trauma in patients with heightened surgical and interventional needs so that appropriate in-hospital preparations may be made prior to patient arrival.

Firearm Injury, It's Not Just Physical: The Adverse Impact on Patient-Reported Socioeconomic, Mental Health, and Quality-of-Life Outcomes.

Background: The burden of firearm injury (FI) extends beyond hospitalization; however, literature focuses mostly on short-term physical outcomes. This study aimed to assess changes in patient-reported outcomes following firearm-related trauma. We hypothesized long-term patient-reported socioeconomic, mental health, and quality-of-life (QoL) outcomes are worse post-FI compared to pre-FI.Methods: This was a retrospective study where a phone survey was conducted with FI survivors admitted between January 2017 and August 2022 at a level 1 trauma center. Survey questions assessed demographics, socioeconomics, and mental and physical health pre-FI vs ≥ 6 months post-FI; the McNemar test was used for comparisons. The PROMIS-29 + 2v2.1 NIH validated instrument was used to assess long-term QoL. Standardized NIH PROMIS T-scores were calculated using the HealthMeasures Scoring Service.Results: Of 204 eligible FI survivors, 71 were successfully contacted and 38 surveyed. Respondents were male (86.8%), Black (76%), and aged 18-29 (55.3%), and 68.4% had high school level education. Post-FI, patients were more likely to be unemployed (55.2% vs 13.2%, P < .001) and report increased mental health needs (84.2% vs 21%, P < .001) compared to pre-FI. Most (73.7%) also reported lasting physical disability. Similarly, the PROMIS instrument demonstrated largely worse health-related QoL scores post-FI, particularly high anxiety/fear (T-score 60.2, SE 3.1, CI 54.6-66.3, Table 2), pain resulting in life interference (T-score 60.0, SE 2.3, CI 55.7-63.9), and worse physical function (T-score 42.5, SE 3.0, CI 38.2-46.9).Conclusions: Firearm injury survivors had more unemployment and worse mental health post-FI compared to pre-FI. Firearm injury survivors also reported significantly worse health-related QoL metrics including pain, anxiety, and physical function 6 months following their trauma. These long-term patient-reported outcomes are a framework to build future outpatient resources.Level of Evidence: IV.

Does the type of surgery for early-stage endometrial cancer affect the rate of reported lymphovascular space invasion in final pathology specimens?

OBJECTIVE: Laparoscopically assisted vaginal hysterectomy (LAVH), which usually involves the use of an intrauterine manipulator for optimal surgical control, has been shown to be as effective and safe as conventional total abdominal hysterectomy (TAH) for the staging of endometrial carcinoma. The purpose of this study was to determine whether the use of an intrauterine manipulator was associated with an increase in the pathologic reporting of lymphovascular space invasion (LVSI), which is an important determinant in choosing adjuvant therapy. We hypothesized that intracavitary manipulation and an increase of the intrauterine pressure could cause pseudolymphovascular invasion. STUDY DESIGN: We performed a retrospective chart review of endometrial cancer patients treated at our institution from January 1996 through January 2006. Records were reviewed for patient's age, preoperative diagnosis, procedure type, final surgical staging, and final pathology report. Using the 2009 International Federation of Gynecology and Obstetrics staging, we included all patients having stage IA or IB endometrioid-type endometrial cancer who had undergone either a TAH or LAVH with or without pelvic and paraaortic lymph node dissection. The χ2 and Fisher exact tests were used to measure the association between risk of positive lymphovascular invasion and surgical groups. RESULTS: Of 568 women identified as having endometrioid-type endometrial cancer, 486 (85.6%) met criteria for stage IA-IB endometrioid histology, grade 1, 2, or 3. LVSI was reported in 553/568 cases, with LVSI positivity in 16.9% (n = 96/568). The mean ages of the LAVH and TAH groups were significantly different (59.4 vs 62.4 years, respectively, P = .0050). Also, mean estimated blood loss and uterine weight significantly varied between TAH and LAVH groups (P = .0001 and .008, respectively). For stage IA, 17/220 (7.7%) who had been treated with LAVH had positive LVSI compared with 20/199 (10.1%) of patients receiving TAH (P = .73). For stage IB, 11/25 (44.0%) of patients treated with LAVH had positive LVSI compared with 10/31 (32.3%) of patients receiving TAH (P = .53). The stage I cancer patients were further subdivided into histological grades 1, 2, and 3, and LVSI was not significantly different between TAH and LAVH groups per grade of cancer. We found no differences between TAH and LAVH in early-stage endometrial cancer (stage IA and IB), with respect to the presence of positive peritoneal washings. CONCLUSION: In early-stage endometrial cancer (stage IA and IB), there were no differences between TAH and LAVH in the final pathologic report of LVSI. The use of an intrauterine manipulator for LAVH was not associated with an increased detection of LVSI.

Contemporary outcomes with the latest 1000 cases of multifetal pregnancy reduction (MPR).

OBJECTIVE: This study was undertaken to report on the outcome of multifetal pregnancy reduction in the most up-to-date largest single center experience with this procedure, and compare the outcome to the first 1000 cases performed at the same institution. STUDY DESIGN: 1000 consecutive cases of multifetal pregnancy reduction performed at the Mount Sinai Medical Center between the years 1999-2006 were identified. Pregnancy outcomes were retrieved from a large database as well as chart review. Differences in means and proportions were evaluated by analysis of variance, chi-square, Cochran-Armitage test for trend or 2-tailed Fisher exact test as appropriate. RESULTS: Outcomes were available on 841 cases, for a follow-up rate of 84.1%; 95.2% of patients delivered after 24 weeks, for a complete loss rate of 4.7%. There was a significant trend toward decreasing loss rates with decreasing starting numbers. Mean gestational age at delivery was later, and birthweights greater, for reduction to singletons vs twins. CONCLUSION: Loss rates after multifetal pregnancy reduction have remained stable at 4.7%. The lowest loss rate occurred in the patients reducing from twins to a singleton (2.1%). Reduction to a singleton was also associated with higher birthweights and lower rates of preterm deliveries.

Case of maternal and infantile choriocarcinoma following normal pregnancy.

► 33 years old woman diagnosed with choriocarcinoma after delivery, her newborn son with the same diagnosis. ► Case of transplasental dissemination of choriacarcinoma. ► Advanced disease both in the mother and the infant.