The association of angiographic collaterals with long-term clinical outcomes in patients with chronic stable angina.

OBJECTIVES: To determine the impact of coronary collaterals in stable angina. BACKGROUND: Whether spontaneously visible coronary collaterals are associated with long-term clinical outcomes in stable angina remains unclear. METHODS: We prospectively enrolled patients with stable angina referred for coronary angiography and followed them clinically for 1 year. RESULTS: A total of 1,134 consecutive patients were enrolled, and of these, 550 had at least single-vessel coronary artery disease (CAD) and were included. Patients with collaterals had more congestive heart failure (16% vs. 9%, P = 0.023), peripheral vascular disease (22% vs. 15%, P = 0.044), and 2-vessel (36% vs. 26%) and 3-vessel (28% vs. 10%) CAD compared to those without collaterals (P < 0.001). Patients with collaterals were less likely to undergo percutaneous intervention at the time of the index angiogram (32% vs. 61%, P < 0.001). At 1 year, there were no differences in angina (HR 0.74, 95% CI 0.50-1.10; P = 0.141), myocardial infarction (MI) (HR 1.22, 95% CI 0.46-3.21; P = 0.691), revascularization (HR 0.84, 95% CI 0.55-1.30; P = 0.431), death (HR 1.83, 95% CI 0.63-5.31; P = 0.269), or the combined end-point of death, MI, and revascularization (HR 0.87, 95% CI 0.61-1.24; P = 0.426) between patients with and without collaterals. When analyzed according to collateral grade, patients with Rentrop grade 1 had less angina (HR 0.48, 95% CI 0.26-0.89; P = 0.019). CONCLUSIONS: At 1 year, there was no difference in adverse events between patients with or without collaterals. The presence of Rentrop grade 1 collaterals, however, was associated with significantly less angina.

Occupant and crash characteristics for case occupants with cervical spine injuries sustained in motor vehicle collisions.

BACKGROUND: Motor vehicle collisions (MVCs) are the leading cause of spine and spinal cord injuries in the United States. Traumatic cervical spine injuries (CSIs) result in significant morbidity and mortality. This study was designed to evaluate both the epidemiologic and biomechanical risk factors associated with CSI in MVCs by using a population-based database and to describe occupant and crashes characteristics for a subset of severe crashes in which a CSI was sustained as represented by the Crash Injury Research Engineering Network (CIREN) database. METHODS: Prospectively collected CIREN data from the eight centers were used to identify all case occupants between 1996 and November 2009. Case occupants older than 14 years and case vehicles of the four most common vehicle types were included. The National Automotive Sampling System's Crashworthiness Data System, a probability sample of all police-reported MVCs in the United States, was queried using the same inclusion criteria between 1997 and 2008. Cervical spinal cord and spinal column injuries were identified using Abbreviated Injury Scale (AIS) score codes. Data were abstracted on all case occupants, biomechanical crash characteristics, and injuries sustained. Univariate analysis was performed using a χ analysis. Logistic regression was used to identify significant risk factors in a multivariate analysis to control for confounding associations. RESULTS: CSIs were identified in 11.5% of CIREN case occupants. Case occupants aged 65 years or older and those occupants involved in rollover crashes were more likely to sustain a CSI. In univariate analysis of the subset of severe crashes represented by CIREN, the use of airbag and seat belt together (reference) were more protective than seat belt alone (odds ratio [OR]=1.73, 95% confidence interval [CI]=1.32-2.27) or the use of neither restraint system (OR=1.45, 95% CI=1.02-2.07). The most frequent injury sources in CIREN crashes were roof and its components (24.8%) and noncontact sources (15.5%). In multivariate analysis, age, rollover impact, and airbag-only restraint systems were associated with an increased odds of CSI. Using the population-based National Automotive Sampling System's Crashworthiness Data System data, 0.35% of occupants sustained a CSI. In univariate analysis, older age was noted to be a significant risk factor for CSI. Airbag-only restraint systems and both rollover and lateral crashes were also identified as risk factors for CSI. In addition, increasing delta v was highly associated with CSIs. In multivariate analysis, similar risk factors were noted. Of all the restraint systems, seat belt use without airbag deployment was found to be the most protective restraint system (OR=0.29, 95% CI=0.16-0.50), whereas airbag-only restraint was associated with the highest risk of CSI (OR=3.54, 95% CI=2.29-5.46). CONCLUSIONS: Despite advances in automotive safety, CSIs sustained in MVC continue to occur too often. Older case occupants are at an increased risk of CSI. Rollover crashes and severe crashes led to a much higher risk of CSI than other types and severity of MVCs. Seat belt use is very effective in preventing CSI, whereas airbag deployment may increase the risk of occupants sustaining a CSI. More protection for older occupants is needed and protection in both rollover and lateral crashes should remain a focus of the automotive industry. The design of airbag restraint systems should be evaluated so that they are not causative of serious injury. In addition, engineers should continue to focus on improving automotive design to minimize the risk of spinal injury to occupants in high severity crashes.

Expected differences and unexpected commonalities in mortality, injury severity, and injury patterns between near versus far occupants of side impact crashes.

OBJECTIVE: To compare injury patterns and outcomes of near- and far-side collisions. METHODS: Near- and far-side occupants in the Crash Injury Research and Engineering Network (CIREN) were compared for mortality and the occurrence of severe injuries (maximum abbreviated injury scale [MAIS] 3+). Regression models, adjusting for confounders, examined death and MAIS 3+ injuries as outcomes and near- or far-side position as an independent variable. CIREN findings were compared with those of the Crash Outcome Data Evaluation System (CODES), and the Maryland Automated Accident Reporting System. RESULTS: Of the 380 cases, 72% were in the near and 28% in the far position. Mortality was similar between groups within CIREN. Near-side occupants experienced a higher frequency of MAIS 3+ injuries for the thorax, abdomen, and lower extremities, and fewer MAIS 3+ head injuries than far-side occupants (35% vs. 46%, p = 0.06). Regression models revealed similar risk of MAIS 3+ head injuries among near- and far-side occupants. The most common structures contacting the head in far-side crashes (N = 62) were opposite side structures (52%) and other occupants (13%). Similar risks of head injuries among near- and far-side occupants were observed for the CODES data; however, lower risks of death were present among far-side drivers involved in crashes, based on CODES and Maryland Automated Accident Reporting System. CONCLUSIONS: Despite a lower incidence of thoracic, abdominal, and lower extremity injuries, far-side occupants experienced a similar risk of head injuries to that of near-side occupants. Contact patterns suggest that restraint systems fail to keep far-side occupants' heads from striking opposite side structures or other occupants.

Risk of psychoactive substance dependence among substance users in a trauma inpatient population.

One measure of a substance's addictive risk is the proportion of users who become dependent. This study evaluates the lifetime and current risk of substance dependence among lifetime substance users' among trauma inpatients and provides a relative ranking of addictive risk among the substances. Data on use of 8 substance groups (alcohol, opiates, marijuana, cocaine, other stimulants, sedative-hypnotics, hallucinogens, other drugs) were obtained by interview (Structured Clinical Interview for the DSM-III-R) from 1,118 adult trauma inpatients. Prevalence of lifetime dependence among lifetime users ranged from 80.7% for opiates and 70.9% for cocaine to 33.3% for hallucinogens and 26.6% for sedative-hypnotics. The rank order of addictive risk was similar to that found in the general population. Trauma inpatients had a higher absolute addictive risk than the general population, comparable to the risk found in patients in treatment for substance use disorders, suggesting the importance of screening trauma inpatients for substance dependence.

Sociodemographic characteristics associated with substance use status in a trauma inpatient population.

Substance use is significantly associated with physical injury, yet relatively little is known about the prevalence of specific substance use disorders among trauma patients, or their associated sociodemographic characteristics. We evaluated these issues in an unselected sample of 1,118 adult inpatients at the University of Maryland Shock Trauma Center, Baltimore, MD, who were interviewed with the psychoactive substance use disorder section of the Structured Clinical Interview for DSM-III-R. Among trauma inpatients, lifetime alcohol users (71.8% of subjects) were more likely male; users of illegal drugs (45.3%) were also more likely to be younger, unmarried, and poor. Patients with current drug abuse/dependence (18.8%) were more likely to be non-white, less educated, and poor; those with current alcohol abuse/dependence (32.1%) were also more likely male, unmarried, and older. These findings highlight the need for screening for substance use disorders in trauma settings and referral of patients to substance abuse treatment programs.

The association between age, injury, and survival to hospital among a cohort of injured motorcyclists.

Despite the significant increase in mortality among older motorcyclists during the past decade, few studies have addressed specific injuries or mortality rates among all those injured. The purpose of this study is to describe the crash and injury characteristics among a cohort of motorcyclists injured in Maryland, and to determine the influence of age and crash type on mortality, injury patterns, and place of death (scene vs. hospital). Possible biases introduced by studying only those hospitalized are described. Based on the findings, specific injury prevention strategies for older vs. younger riders are proposed.

Corrigendum: Exposure to Parenting by Lying in Childhood: Associations with Negative Outcomes in Adulthood.

[This corrects the article on p. 1240 in vol. 8, PMID: 28824477.].

Exposure to Parenting by Lying in Childhood: Associations with Negative Outcomes in Adulthood.

Parents around the world engage in the practice of parenting by lying, which entails lying to manipulate children's emotional states and behavior. The current study is the first to examine whether exposure to parenting by lying in childhood is associated with later dishonesty and psychosocial maladjustment in adulthood. Female undergraduate adults retrospectively reported their experiences of parenting by lying during childhood, the current frequency at which they lie to their parents, and their current psychosocial functioning. We found that adults who recalled relatively high levels of parenting by lying during childhood both lie to their parents more often and experience greater psychosocial adjustments problems in adulthood than adults who recalled relatively low levels of parenting by lying during childhood. This study is the first to suggest that parenting by lying during childhood may be associated with negative moral and social outcomes later in life.

Injury patterns and severity among hospitalized motorcyclists: a comparison of younger and older riders.

In recent years there has been a significant increase in mortality among motorcyclists, especially older riders (40+ years). However, few studies have compared the nature and severity of injuries sustained by older vs. younger cyclists. The purpose of this analysis was to determine differences, if any, in injury patterns to older vs. younger motorcyclists and to explore rider, vehicle, and environmental factors associated with these differences. Older riders were found to have a significantly higher incidence of thoracic injury, especially multiple thoracic injuries, and specifically multiple rib fractures. Older motorcyclists were also more likely to ride larger motorcycles, and were more involved in collisions involving overturning or striking highway structures. Large engine sizes were associated with increased risk of head and thoracic injuries, but not abdominal injuries. The magnitude of increased risks related to 1000+ cc engine size was higher among older motorcyclists than younger motorcyclists.

Crash culpability and the role of driver blood alcohol levels.

Twenty years ago the American Medical Association reported the relationship between blood alcohol concentration (BAC) and crash causation. This study addresses culpability, age, gender and BAC in a population of drivers injured in motor vehicle crashes. Five years of hospital and crash data were linked, using probabilistic techniques. Trends in culpability were analyzed by BAC category. Given BAC level, the youngest and oldest drivers were more likely to have caused their crash. Women drivers had significantly higher odds of culpability at the highest BAC levels. Seatbelt use was also associated with culpability, perhaps as a marker for risk-taking among drinkers.

Intraperitoneal hyperthermic treatment of implanted peritoneal cancer in rats.

The feasibility and efficacy of treating peritoneal cancer implants by applying heat to the peritoneal surfaces were studied in inbred Buffalo A rats given i.p. injections of Morris hepatoma 5123TC tumor cells. Heat was delivered to the peritoneum by contact with a heated physiological salt solution (Normosol-R) in the peritoneal cavity. A treatment temperature of 43.3 +/- 0.3 degrees was maintained for 30 min by an immersed stainless steel coil through which hot liquid circulated. Rats implanted with 0.5 to 1.0 x 10(8) tumor cells were treated at 1 to 4 hr (Group I), 4 to 5 days (Group II), and 22 to 24 days (Group III) after tumor implantation to simulate treatment for the clinical conditions of surgically spilled cancer cells, established microscopic cancer implants, and macroscopic cancer implants, respectively. A statistically significant improvement in survival was observed in Groups I and II compared with sham-treated control animals; 58% of the heat-treated animals were cured. Only a slight but statistically insignificant improvement was noted in Group III. These observations indicate that i.p. surface heat treatment of peritoneal implanted cancer is feasible and effective.

Sensitivity of xenografts of human pancreatic adenocarcinoma in nude mice to heat and heat combined with chemotherapy.

The sensitivity of two human pancreatic adenocarcinomas (Capan-1 and Capan-2) to heat and heat combined with chemotherapy was studied using xenografts of the tumors in the foot of athymic nude mice. Heat was applied by immersion of the tumor in a water bath at 43.5 degrees for 1 hr. A single i.p. dose of mitomycin C, cisplatin, 5-fluorouracil, or 0.9% NaCl solution was given at 1 hr prior to treatment. Heat treatment alone significantly suppressed tumor growth (p less than 0.001), with 35% of the tumors showing complete regression. Combined treatment using heat plus chemotherapy yielded significantly greater suppression of tumor growth (p less than 0.05) with mitomycin for both tumors and with cisplatin or 5-fluorouracil for Capan-1. Combined treatment also gave higher rates of complete tumor regression: 55 and 64%, respectively, for Capan-1 and Capan-2 as compared with 18 and 47% for the respective tumors treated by heat alone. These observations suggest that human pancreatic carcinomas are sufficiently sensitive to heat combined with chemotherapeutic treatment to warrant a clinical trial of these modalities.

On equal footing: Trends in ankle/foot injuries for men vs. women.

OBJECTIVES: The objective of the current study was to examine trends in ankle/foot (A/F) injuries during the period 2001-2014, in order to determine whether the incidence of these injuries has changed and whether a previously identified difference in risk by gender still existed. In addition, other driver and crash-related risk factors were examined separately for men and women. METHODS: Passenger vehicle drivers aged 16+ were identified from NASS-CDS; weighted data were analyzed for model years 2001-2014. Model years (MY) were grouped as 2001-2004 (older) vs. 2005-2014 (newer), and drivers in frontal crashes were included. Ankle injuries included fractures and dislocations to the malleolus and distal tibia/fibula. Foot injuries included fractures and dislocations of the talus, calcaneus, and tarsal/metatarsal bones. Logistic regression models were constructed to identify risk factors, including MY, age, belt use, toepan/instrument panel intrusion, and body mass index (BMI) separately for each gender using odds ratios. RESULTS: The incidence of A/F injuries declined significantly between older and newer MY, especially for women. Whereas before MY 2005, ankle and foot injury risk was significantly higher for women than men, risks for ankle injury are now virtually the same for both genders, and women are only 1.2 times more likely than men to sustain a foot injury in a frontal crash. From multivariable regression models, however, it is apparent that there are different risk factors for A/F injuries for men vs. women. Body weight was a significant factor for both groups, but for men it was a risk only for those extremely obese, whereas for women those who were categorized as overweight were also at increased risk. Age greater than 55 was also found to be a risk factor for foot injuries among women but not men. For men and women, toepan intrusion remained the most important factor for both foot and ankle injuries, with significantly higher odds ratios noted for men. Foot pedals were a more likely injury source for women, whereas the toepan was more likely for men. In addition, belt use was protective for ankle injuries in women but not men. CONCLUSIONS: Significant declines in A/F injuries have been noted in recent years, especially for women, whose risks are now similar to those for men. However, significant risk factors remain for each gender, primarily related to body habitus (BMI) and toepan intrusion. Age was a risk factor for foot injuries among women, for whom the foot pedals were more likely to be an injury source. Toepan intrusion remains a major factor for both men and women, but, with the exception of 30+ cm of intrusion, odds ratios were primarily much higher for men in each category of intrusion.

Phase II trial of postoperative adjuvant intraperitoneal cisplatin and fluorouracil and systemic fluorouracil chemotherapy in patients with resected gastric cancer.

PURPOSE: This study was performed to assess the short- and long-term toxicities and the impact on relapse pattern and survival of postoperative intraperitoneal (IP) cisplatin and fluorouracil (FU) plus systemic intravenous (IV) FU as adjuvant therapy for gastric cancer patients who are at high risk for recurrence after potentially curative resection (T2N1-2M0 or T3-4N(any)M0). PATIENTS AND METHODS: Starting 14 to 28 days after potentially curative resection of primary gastric cancers, 35 patients were given IP cisplatin 25 mg/m2 and FU 750 mg daily for 4 days; FU 750 mg/m2 was concurrently given as a continuous 24-hour i.v. infusion. Five cycles of therapy delivered at 1-month intervals were used. RESULTS: After a median follow-up of 24 months, 51% of patients remain alive and free of disease. Sixteen patients have recurred; 13 of 16 had an intraabdominal component, whereas three had extraabdominal failure only. Two major treatment-related toxicities were noted: neutropenia and a late toxicity of peritoneal fibrosis (sclerosing encapsulating peritonitis [SEP]). There was one postoperative death. Eleven patients underwent second laparotomy: five patients had SEP, two patients had bowel obstruction from adhesions unrelated to SEP, and four patients had recurrent cancer. Potential causes of SEP included an alkaline pH of infused FU and cisplatin that possibly led to activation of cisplatin before infusion. CONCLUSION: IP cisplatin and FU and concurrent systemic FU is a tolerable adjuvant therapy in the postoperative setting for patients with resected gastric cancer. The recommended dosage schedule with this technique is cisplatin 25 mg/m2 and FU 750 mg total dose IP with FU 500 mg/m2 as a continuous 24-hour infusion daily for days 1 to 4. SEP as a late toxicity, which was observed in 15% of patients, is treatable by surgical lysis of adhesions.

Refinement of clinicopathologic staging for localized soft tissue sarcoma of the extremity: a study of 423 adults.

PURPOSE: The prognostic value of factors used in clinicopathologic staging of localized soft tissue sarcoma (STS) of the extremity were analyzed comprehensively. PATIENTS AND METHODS: Four hundred twenty-three patients with STS that was confined to the extremity were admitted to Memorial Sloan-Kettering Cancer Center from 1968 to 1978. Cox models for the hazards rates of tumor mortality, development of a distant metastasis, strictly local recurrence, and postmetastasis survival were developed. Tests of changes in the prognostic value of the important variables over time were performed, as well as an analysis of the effect of a local recurrence on the hazard rate of distant metastasis. RESULTS: Three unfavorable characteristics contained independent prognostic value for the rates of distant metastasis and tumor mortality: high grade (P less than .00001), deep location (P less than .0002), and size greater than or equal to 5 cm (P less than .007). Their Cox model coefficients did not differ significantly (P greater than or equal to .65); thus, a staging scheme based on the risk of ever developing a distant metastasis would assign equal prognostic weights to grade, depth, and size. The tumor grade effect during the initial 18 months was much larger in magnitude than those for depth and size, and its effect disappeared beyond that time (P = .0003). Thus, a staging scheme based on the risk of early metastatic spread would assign a distinctly larger prognostic weight to grade and lesser but equal weights to depth and size. There was no local recurrence effect on the rate of distant metastasis in the high-risk group (high grade, deep, and greater than or equal to 5 cm; P = .75), but there was a significant association among the remaining groups combined (P = .0039). The magnitude of this association actually increased according to the number of favorable characteristics presented (P = .0024). CONCLUSIONS: The refinement of clinicopathologic staging may depend on the choice of outcome variable: ultimate prognosis versus early metastatic spread. Additionally, the observed local recurrence effect may be explained by a tendency for some patients to acquire one or more unfavorable risk factors at the time of local recurrence.

Regional isolated limb perfusion of melanoma intransit metastases using mechlorethamine (nitrogen mustard).

Forty-two patients with intransit metastases of melanoma in a limb were treated by isolated regional perfusion chemotherapy using mechlorethamine (nitrogen mustard). Group 1 (n = 12) underwent treatment at low dose, less than 0.35 mg/kg, or low temperature, less than 38 degrees C. Group 2 (n = 30) received higher doses, 0.35 to 0.6 mg/kg, plus heat at 38 degrees C to 41 degrees C. No patient had evidence of disease outside the limb at the time of perfusion. The median follow-up time was 48 months (range, 1 to 9 years). Of the 42 patients, 29 had measurable lesions that responded as follows: group 1, complete response (CR) in two of ten and partial response (PR) in none; group 2, CR in six of 19 and PR in six of 19. The combined CR and PR rate of 12 of 19 in group 2 was significantly higher than that of group 1 (P less than .05). CR lasted only 2 months in the two patients of group 1, but persisted in the six patients of Group 2, four of whom are still alive free of disease at 16, 21, 33, and 40 months. Relapse-free control of disease in the limb was achieved in 36% of the patients in group 2 at 24 months, compared with 0% in group 1 (P less than .05). An overall survival of 74% at 48 months was observed in group 2, significantly higher than that of 64% for group 1 (P less than .05). The status of the regional lymph nodes (RLN) and the number of metastases did not affect tumor response. However, 77% of RLN-negative patients survived 48 months, in contrast to only 38% of RLN-positive patients (P less than .05). One patient died postoperatively of myocardial infarction. No serious systemic toxicity developed. Two patients who underwent repeat salvage perfusions developed a reversible peripheral neuropathy in the limb. Limb function was good after treatment, and dramatically improved in patients who had advanced satellitosis that responded to treatment. These results suggest that heated limb perfusion using mechlorethamine at an adequate dose can offer long-term control of intransit metastases in approximately one third of these patients, with preservation of good limb function and possible prolongation of survival.

Low molecular weight heparin (reviparin) in percutaneous transluminal coronary angioplasty. Results of a randomized, double-blind, unfractionated heparin and placebo-controlled, multicenter trial (REDUCE trial). Reduction of Restenosis After PTCA, Early Administration of Reviparin in a Double-Blind Unfractionated Heparin and Placebo-Controlled Evaluation.

OBJECTIVES: The specific objective of the REDUCE trial was to evaluate the effect of low molecular weight heparin on the incidence and occurrence of restenosis in patients undergoing percutaneous transluminal coronary angioplasty (PTCA). BACKGROUND: Unfractionated heparin and its low molecular weight fragments possess antiproliferative effects and have been shown to reduce neointimal smooth muscle cell migration and proliferation in response to vascular injury in experimental studies. METHODS: The REDUCE trial is an international prospective, randomized, double-blind, multicenter study. Twenty-six centers in Europe and Canada enrolled 625 patients with single-lesion coronary artery obstructions suitable for PTCA. Three hundred six patients received reviparin as a 7,000-U bolus before PTCA, followed by 10,500 U as an infusion over 24 h and then twice-daily 3,500-U subcutaneous application for 28 days. The 306 patients in the control group received a bolus of 10,000 U of unfractionated heparin followed by an infusion of 24,000 U over 24 h. These patients then underwent 28 days of subcutaneous placebo injections. The primary end points were efficacy (defined as a reduction in the incidence of major adverse events [i.e., death, myocardial infarction, need for reintervention or bypass surgery]), absolute loss of minimal lumen diameter and incidence of restenosis during the observation period of 30 weeks after PTCA. RESULTS: Using the intention to treat analysis for all patients, 102 (33.3%) in the reviparin group and 98 (32%) in the control group have reached a primary clinical end point (relative risk [RR] 1.04, 95% confidence interval [CI] 0.83 to 1.31, p = 0.707). Likewise, no difference in late loss of minimal lumen diameter was evident for both groups. Acute events within 24 h occurred in 12 patients (3.9%) in the reviparin group and 25 (8.2%) in the control group (RR 0.49, 95% CI 0.26 to 0.92, p = 0.027) during or immediately after the initial procedure. In the control group, eight major bleeding complications occurred, and in the reviparin group, seven were observed within 35 days after PTCA. CONCLUSIONS: Reviparin use during and after coronary angioplasty did not reduce the occurrence of major clinical events or the incidence of angiographic restenosis over 30 weeks.

Crash culpability relative to age and sex for injured drivers using alcohol, marijuana or cocaine.

While there is a great deal of data documenting the etiologic role alcohol use plays in crash culpability, there is a dearth of data for other drugs. The purpose of this study was to assess crash culpability for single drug use among injured drivers admitted to a regional trauma center. This study is the largest of its kind involving trauma center patients. Clinical toxicology results obtained for patient care were linked to police crash reports containing a field attributing crash culpability. Drugs studied were alcohol, cocaine, and marijuana. As expected crash culpability was strongly associated with pre-crash alcohol use. In contrast, for both men and women, this study did not find an association between crash culpability and marijuana use. The data documents a significant association between cocaine use and crash culpability for both sexes and for drivers 21 to 40 years of age. This is the first large study to assess for crash culpability among injured drivers relative to cocaine use. Each year approximately 42 to 43,000 people die annually as the result of vehicular crashes. (NHTSA, 2005) For the decade 1994 through 2003, alcohol was a factor in 40-43% fatal injury crashes - the fatally injured person being either a vehicular occupant or pedestrian. Specifically 25 to 29% of drivers of cars and light trucks involved in those crashes were alcohol positive. Further, it is estimated that 80% or more of those drivers had blood alcohol concentrations (BAC) of 80 mg/dl or greater. (NHTSA, 2005).

Limb salvage in soft tissue sarcomas involving neurovascular structures using combined surgical resection and brachytherapy.

While there is debate in the literature concerning the tolerance of neurovascular structures to external beam radiation, the tolerance of these tissues to interstitial radiation has never been established. To evaluate the dose of radiation and its effect on early and late toxicity of neurovascular structures, a retrospective review of our experience was undertaken. Between 1975 and 1987, 299 patients with extremity sarcomas underwent limb-sparing surgery and tumor bed Iridium-192 interstitial implantation at Memorial Sloan-Kettering Cancer Center. Forty-five patients (15%) of this group were found to have locally advanced tumors involving major neurovascular structures. Of these patients, 64% had high grade lesions. Eleven percent had evidence of gross residual disease on these structures, and an additional 58% had microscopic residual disease at or close to the margins of resection. After loading catheters were placed directly upon the neurovascular structures in the exposed tumor bed and a median dose of 4400 cGy was delivered to the target volume. Eight patients had previous radiation to the treated field and 13 patients received postoperative radiation. With a median follow-up of 4 years, the 5-year actuarial disease-free survival was 69% and the 5-year actuarial freedom from in-field failure was 79%. The 5-year actuarial incidence of distant metastases was 30%. Eighty-four percent of the patients maintained long-term preservation of limb function without the need for amputation. Four patients (9%) ultimately developed evidence of radiation neuritis 6-20 months post therapy. All four patients had received additional radiation with cumulative doses exceeding 9000 cGy to the neurovascular bundle. We conclude that combined surgical resection and interstitial radiation for locally advanced sarcomas with neurovascular involvement can provide excellent local control with preservation of limb and neurovascular function without significant toxicity.

Brachytherapy and function-saving resection of soft tissue sarcoma arising in the limb.

The treatment of soft tissue sarcoma of the limb by function-saving resection and brachytherapy (BRT) was systematically studied from 1975 to 1990 at the Memorial Sloan-Kettering Cancer Center, using iridium-192 temporary tumor-bed implants. Initial experiences showed an 88% local control rate in 33 patients who had locally advanced sarcomas, many of which would have required treatment by amputation. The technique also controlled 70% of tumors that abutted or invaded a major neurovascular bundle that was dissected out and preserved. A prospective randomized study (BRT vs no BRT) confirmed the highly significant efficacy of BRT in preventing local recurrence. This salutary effect is mainly seen in high-grade tumors. Major complications of wound healing occurred in the earlier years of this experience. Adoption of improved techniques of surgical wound repair, standardization of radiation dose planning, and in particular, postponing the loading of radiation sources until after the fifth postoperative day has reduced the rate of serious wound complications, to a level not significantly different from that seen after surgical resection alone. These results rival those currently achieved in centers experienced in external beam therapy of soft tissue sarcomas, and offer the advantage of completion of treatment in one relatively short hospital stay.