Medicine and Health Sciences Commons^™

Outcome After Decompressive Craniectomy For The Treatment Of Severe Traumatic Brain Injury., Jerry Lee Howard, Mark D Cipolle, Meredith Anderson, Victoria Sabella, Daniele Shollenberger, P Mark Li, Michael D. Pasquale Md, Facs, Fccm

Michael D Pasquale MD, FACS, FCCM

BACKGROUND: Using decompressive craniectomy as part of the treatment regimen for severe traumatic brain injury (STBI) has become more common at our Level I trauma center. This study was designed to examine this practice with particular attention to long-term functional outcome.

METHODS: A retrospective review of prospectively collected data was performed for patients with STBI admitted from January 1, 2003 to December 31, 2005. Our institution manages patients using the Brain Trauma Foundation Guidelines. Data collected from patients undergoing decompressive craniectomy included: age, Injury Severity Score, admission and follow-up Glasgow Coma Score, timing of, and indication for decompressive craniectomy, and …

Multicenter Study Of Noninvasive Monitoring Systems As Alternatives To Invasive Monitoring Of Acutely Ill Emergency Patients., W C Shoemaker, H Belzberg, C C Wo, D P Milzman, Michael D. Pasquale Md, Facs, Fccm, L Baga, M A Fuss, G J Fulda, K Yarbrough, J P Van Dewater, P J Ferraro, D Thangathurai, P Roffey, G Velmahos, J A Murray, J A Asensio, K Eltawil, W R Dougherty, M J Sullivan, R S Patil, J Adibi, C B James, D Demetriades

Michael D Pasquale MD, FACS, FCCM

BACKGROUND: Recent reports showed lack of effectiveness of pulmonary artery catheterization in critically ill medical patients and relatively late-stage surgical patients with organ failure. Since invasive monitoring requires critical care environments, the early hemodynamic patterns may have been missed. Ideally, early noninvasive hemodynamic monitoring systems, if reliable, could be used as the "front end" of invasive monitoring to supply more complete descriptions of circulatory pathophysiology.

OBJECTIVES: To evaluate the accuracy and reliability of noninvasive hemodynamic monitoring consisting of a new bioimpedance method for estimating cardiac output combined with arterial BP, pulse oximetry, and transcutaneous PO2 and PCO2; we compared this …

Elective Colostomy Closure In An Aids Patient., Michael D. Pasquale Md, Facs, Fccm, J M Kenkel, R W Holt

Michael D Pasquale MD, FACS, FCCM

This article describes a 27-year-old patient with acquired immunodeficiency syndrome (AIDS) who underwent emergency sigmoid colostomy, Hartmann's pouch, and presacral drainage for rectal perforation. Three months later, he underwent uneventful elective colostomy closure, a procedure previously unreported in an AIDS patient. He remained without gastrointestinal symptoms for 14 months after colostomy closure until he died from central nervous system toxoplasmosis. A diagnosis of AIDS alone should not preclude colostomy closure in AIDS patients.

Outcome Of Blunt Thoracic Aortic Injury In A Level I Trauma Center: An 8-Year Review., E J Frick, M D Cipolle, Michael D. Pasquale Md, Facs, Fccm, T E Wasser, M Rhodes, Raymond L. Singer Md, S A Nastasee

Michael D Pasquale MD, FACS, FCCM

BACKGROUND: The purpose of this study was to evaluate our experience with blunt thoracic aortic injury and identify factors predictive of outcome.

METHODS: Hospital charts, trauma registry data, and autopsies of 64 patients with blunt thoracic aortic injury from 1988 to 1995 were reviewed.

RESULTS: Patients were identified and segregated based on admission physiology. Group 1 patients (n = 19) arrived in arrest. Group 2 patients (n = 10) arrived in shock with systolic BP 90. Group 3 patients (n = 35) arrived with systolic BP>90. All patients in groups 1 and 2 expired. Injury Severity Scores for nonsurvivors …

Extra-Anatomic Redo Of Midcab And Opcab: An Early Experience., M C Sinclair, M Leboutillier, W Gee, Theodore Phillips, Raymond Singer

Raymond L Singer MD

BACKGROUND: Eighteen patients with unstable angina underwent repeat myocardial revascularization without cardiopulmonary bypass using saphenous vein grafts from either the left (13) or right (2) axillary arteries or the descending thoracic aorta (3). Patients' ages ranged from 53 to 85 years. Left ventricular ejection fractions ranged from 15% to 60%. METHODS: In 14 patients, the heart was exposed through an anterior thoracotomy, a minimally invasive direct coronary artery bypass (MIDCAB) technique. In 3 patients a left posterolateral thoractomy (lateral MIDCAB) was performed. One patient underwent repeat sternotomy (off-pump coronary artery bypass: OPCAB). In MIDCAB and lateral MIDCAB patients, the "target" …

Outcome Of Blunt Thoracic Aortic Injury In A Level I Trauma Center: An 8-Year Review., E J Frick, M D Cipolle, Michael Pasquale, T E Wasser, M Rhodes, Raymond Singer, S A Nastasee

Raymond L Singer MD

BACKGROUND: The purpose of this study was to evaluate our experience with blunt thoracic aortic injury and identify factors predictive of outcome. METHODS: Hospital charts, trauma registry data, and autopsies of 64 patients with blunt thoracic aortic injury from 1988 to 1995 were reviewed. RESULTS: Patients were identified and segregated based on admission physiology. Group 1 patients (n = 19) arrived in arrest. Group 2 patients (n = 10) arrived in shock with systolic BP 90. Group 3 patients (n = 35) arrived with systolic BP>90. All patients in groups 1 and 2 expired. Injury Severity Scores for nonsurvivors …

Male Gender Is Associated With Increased Risk For Postinjury Pneumonia., Christopher J Gannon, Michael Pasquale, J Kathleen Tracy, Robert J Mccarter, Lena M Napolitano

Michael D Pasquale MD, FACS, FCCM

Nosocomial pneumonia in trauma patients is a significant source of resource utilization and mortality. We have previously described increased rates of pneumonia in male trauma patients in a single institution study. In that study, female trauma patients had a lower incidence of postinjury pneumonia but a higher relative risk for mortality when they did develop pneumonia. We sought to investigate the hypothesis that male trauma patients have an increased incidence of postinjury pneumonia in a separate population-based dataset. Prospective data were collected on 30,288 trauma patients (26,231 blunt injuries, 4057 penetrating injuries) admitted to all trauma centers (n = 26) …

Is Extended Volume External Beam Radiation Therapy Covering The Anastomotic Site Beneficial In Post-Esophagectomy High Risk Patients?, Edward Yu, Rashid Dar, George Rodrigues, Larry Stitt, Gregory Videtic, Pauline Truong, Anna Tomiak, Robert Ash, Ed Brecevic, Richard Inculet, Richard Malthaner, Mark Vincent, Ian Craig, Walter Kocha, Michael Lefcoe

Richard A. Malthaner

Background and purpose: To assess the impact of extended volume radiation therapy (RT) with anastomotic coverage on local control in high risk post-operative esophageal cancer patients.

Patients and methods: This is a retrospective study of high risk (T(3), T(4), nodes positive, with or without margin involvement) post-operative esophageal cancer patients treated at London Regional Cancer Centre from 1989 to 1999. After esophagectomy, all patients received adjuvant combined modality therapy consisting of four cycles of fluorouracil-based chemotherapy, and loco-regional RT with or without coverage of the anastomotic site. RT dose ranged from 45 to 60 Gy at 1.8-2.0 Gy/fraction with treatment …

Is Extended Volume External Beam Radiation Therapy Covering The Anastomotic Site Beneficial In Post-Esophagectomy High Risk Patients?, Edward Yu, Rashid Dar, George Rodrigues, Larry Stitt, Gregory Videtic, Pauline Truong, Anna Tomiak, Robert Ash, Ed Brecevic, Richard Inculet, Richard Malthaner, Mark Vincent, Ian Craig, Walter Kocha, Michael Lefcoe

Richard A. Malthaner

Background and purpose: To assess the impact of extended volume radiation therapy (RT) with anastomotic coverage on local control in high risk post-operative esophageal cancer patients.

Patients and methods: This is a retrospective study of high risk (T(3), T(4), nodes positive, with or without margin involvement) post-operative esophageal cancer patients treated at London Regional Cancer Centre from 1989 to 1999. After esophagectomy, all patients received adjuvant combined modality therapy consisting of four cycles of fluorouracil-based chemotherapy, and loco-regional RT with or without coverage of the anastomotic site. RT dose ranged from 45 to 60 Gy at 1.8-2.0 Gy/fraction with treatment …

Brother, Have You Got A Light? Assessing The Need For Intubation In Patients Sustaining Burn Injury Secondary To Home Oxygen Therapy., Hamed Amani, Daniel Lozano, Sigrid Blome-Eberwein

Sigrid A Blome-Eberwein MD

Home oxygen therapy use has steadily increased for the past 30 years. A majority of these patients suffer from chronic obstructive pulmonary disease secondary to smoking. Although warned of the danger of smoking while on oxygen, patients continue to do so, potentially resulting in cutaneous burns and suspected inhalation injury. Those suspected of inhalation injury are intubated for airway control. In the English literature, there is a paucity of data discussing the need for intubation. To date, this is the largest study to determine whether intubated patients had inhalation injury as observed by bronchoscopy and whether intubation was necessary. All …

Odontoid Fractures In The Elderly: Should We Operate?, Alice Fagin, Mark Cipolle, Robert Barraco, Sherrine Eid, James Reed, P. Mark Li, Michael Pasquale

Robert D Barraco MD, MPH

BACKGROUND: : Treatment of odontoid fractures remains controversial. There are conflicting data in the literature with regard to timing of operative fixation (OP), as well as whether OP should be performed. Within our own institution, treatment is variable depending largely on surgeon preference. This study was undertaken in an attempt to develop management consensus by examining outcomes in elderly patients with odontoid fractures and comparing OP to a nonoperative (non-OP) approach.

METHODS: : The trauma registry of our level I trauma center was queried for elderly (age > or = 60) patients with odontoid fractures from January 2000 to May 2006. …

Diabetic Lisfranc Fracture-Dislocations And Charcot Neuroarthropathy., Bradley A Levitt, John Stapleton, Thomas Zgonis

John J Stapleton DPM, FACFAS

The goal with Lisfranc fracture-dislocations is to regain joint congruity and reestablish midfoot stability to avoid debilitating posttraumatic arthrosis and chronic pain in the sensate patient. In the diabetic population, dense peripheral neuropathy and/or vascular disease are equally important and may alter the surgical approach to traumatic tarsometatarsal injuries. The initial diagnosis in the diabetic population may be delayed due to subtle radiographic findings and/or patient unawareness of trauma in the insensate foot. Failure to initiate treatment in the early stages of acute diabetic neuropathic Lisfranc injuries can predispose the patient to midfoot instability, potential ulceration, infection, and Charcot neuroarthropathy.

Combined Lateral Column Arthrodesis, Medial Plantar Arteryflap, And Circular External Fixation For Charcot Midfoot Collapse With Chronic Plantar Ulceration., Thomas Zgonis, Thomas S Roukis, John Stapleton, Douglas T Cromack

John J Stapleton DPM, FACFAS

No abstract provided.

Surgically Induced Charcot Neuroarthropathy Following Partial Forefoot Amputation In Diabetes., T Zgonis, John Stapleton, N Shibuya, T S Roukis

John J Stapleton DPM, FACFAS

No abstract provided.

A Stepwise Approach To The Surgical Management Of Severe Diabetic Foot Infections., Thomas Zgonis, John Stapleton, Thomas S Roukis

John J Stapleton DPM, FACFAS

Foot infections are common among diabetic patients with ulceration and are a major cause of hospitalization and lower extremity amputation. Aggressive and emergent surgical intervention is essential in the face of life- or limb-threatening infection to achieve limb salvage and survival. Critical limb ischemia, neuropathy, and an impaired host complicate the treatment of a severe diabetic foot infection. A severe diabetic foot infection carries a 25% risk of major amputation. For this reason, surgery should be coordinated with a well-functioning multidisciplinary team that specializes in diabetic limb preservation. Timing of surgery and strategies employed should be understood and agreed on …

Revisional Charcot Foot And Ankle Surgery., John Stapleton, Ronald Belczyk, Thomas Zgonis

John J Stapleton DPM, FACFAS

Charcot neuroarthropathy is often a devastating diabetic foot complication that poses a great risk for limb loss and can have a significant impact on a patient's quality of life in the presence of multiple existing comorbidities. It is a progressive and debilitating condition characterized by joint dislocation, pathologic fracture(s), and extensive destruction of the foot or ankle architecture secondary to dense peripheral neuropathy. This pathologic process can be idiopathic, secondary to acute trauma or previous surgery, or attributable to repetitive "microinjury." Once the Charcot process has been initiated, continued ambulation results in progressive collapse and deformity. Severe deformities can have …

Surgical Reconstruction Of The Diabetic Charcot Foot: Internal, External Or Combined Fixation?, John Stapleton, Thomas Zgonis

John J Stapleton DPM, FACFAS

Charcot neuroarthropathy of the foot and ankle is a devastating neuropathic complication that can eventually lead to a lower extremity amputation in the presence of an ulceration or infection. Current surgical approaches for the management of the diabetic Charcot foot and ankle deformities are largely based on expert opinions in various fixation methods attempting to avoid major postoperative complications. The goal of this article is to discuss the advantages and disadvantages of various internal, external, or combined fixation methods as they relate to the inherent challenges in the management of the diabetic Charcot foot.

Combined Medial Displacement Calcaneal Osteotomy, Subtalar Joint Arthrodesis, And Ankle Arthrodiastasis For End-Stage Posterior Tibial Tendon Dysfunction., John Stapleton, Ronald Belczyk, Thomas Zgonis, Vasilios D Polyzois

John J Stapleton DPM, FACFAS

Combining an ankle arthrodiastasis with a medial displacement calcaneal osteotomy and a subtalar joint arthrodesis offers surgeons a joint-sparing procedure for young and active patients who have end-stage posterior tibial tendon dysfunction and ankle joint involvement. An isolated subtalar joint arthrodesis or triple arthrodesis combined with an ankle arthrodiastasis is an option that can be used in certain case scenarios. Delaying the need for a joint destructive procedure through an ankle arthrodiastasis, however, may have a great impact in the near future, as advancements are underway to improve the use of ankle endoprosthesis.

Concomitant Osteomyelitis And Avascular Necrosis Of The Talus Treated With Talectomy And Tibiocalcaneal Arthrodesis, John Stapleton, Thomas Zgonis

John J Stapleton DPM, FACFAS

The goal with Lisfranc fracture-dislocations is to regain joint congruity and reestablish midfoot stability to avoid debilitating posttraumatic arthrosis and chronic pain in the sensate patient. In the diabetic population, dense peripheral neuropathy and/or vascular disease are equally important and may alter the surgical approach to traumatic tarsometatarsal injuries. The initial diagnosis in the diabetic population may be delayed due to subtle radiographic findings and/or patient unawareness of trauma in the insensate foot. Failure to initiate treatment in the early stages of acute diabetic neuropathic Lisfranc injuries can predispose the patient to midfoot instability, potential ulceration, infection, and Charcot neuroarthropathy.

Treatment Of Adult Obesity With Bariatric Surgery, Robin Schroeder, Jordan Garrison, Mark Johnson

Robin S. Schroeder MD

Bariatric surgery procedures, including laparoscopic adjustable gastric banding, laparoscopic sleeve gastrectomy, and Roux-en-Y gastric bypass, result in an average weight loss of 50 percent of excess body weight. Remission of diabetes mellitus occurs in approximately 80 percent of patients after Roux-en-Y gastric bypass. Other obesity-related comorbidities are greatly reduced, and health-related quality of life improves. The Obesity Surgery Mortality Risk Score can help identify patients with increased mortality risk from bariatric surgery. Complications and adverse effects are lowest with laparoscopic surgery, and vary by procedure and presurgical risk. The Roux-en-Y procedure carries an increased risk of malabsorption sequelae, which can …

Odontoid Fractures In The Elderly: Should We Operate?, Alice Fagin, Mark Cipolle, Robert Barraco, Sherrine Eid, James Reed, P. Mark Li, Michael Pasquale

Michael D Pasquale MD, FACS, FCCM

BACKGROUND: : Treatment of odontoid fractures remains controversial. There are conflicting data in the literature with regard to timing of operative fixation (OP), as well as whether OP should be performed. Within our own institution, treatment is variable depending largely on surgeon preference. This study was undertaken in an attempt to develop management consensus by examining outcomes in elderly patients with odontoid fractures and comparing OP to a nonoperative (non-OP) approach.

METHODS: : The trauma registry of our level I trauma center was queried for elderly (age > or = 60) patients with odontoid fractures from January 2000 to May 2006. …

A Randomized, Double-Blind, Placebo-Controlled Study To Assess The Effect Of Recombinant Human Erythropoietin On Functional Outcomes In Anemic, Critically Ill, Trauma Subjects: The Long Term Trauma Outcomes Study, Fred Luchette, Michael Pasquale, Timothy Fabian, Wayne Langholff, Marsha Wolfson

Michael D Pasquale MD, FACS, FCCM

BACKGROUND: Achieving a higher hemoglobin (Hb) level might allow the anemic, critically ill, trauma patient to have an improved outcome during rehabilitation therapy. METHODS: Patients with major blunt trauma orthopedic injuries were administered epoetin alfa or placebo weekly both in hospital and for up to 12 weeks after discharge or until the Hb level was >12.0 g/dL, whichever occurred first. The 36-question Short Form Health Assessment questionnaire (SF-36) was used to evaluate physical function (PF) outcomes at baseline, at hospital discharge, and at several time points posthospital discharge. RESULTS: One hundred ninety-two patients were enrolled (epoetin alfa [n = 97], …

Adult Ecmo And Gastrointestinal Bleeding From Small Bowel Arteriovenous Malformations: A Novel Treatment Using Spiral Enteroscopy., Konrad Sarosiek, Hitoshi Hirose, Harrison T Pitcher, Nicholas Cavarocchi

Nicholas C Cavarocchi MDJ

Hemorrhagic complications on extracorporeal membrane oxygenation (ECMO) are common because of the need for anticoagulation to maintain the oxygenator and circuitry. Gastrointestinal bleeding (GIB) is reported to occur in 3-6% of ECMO patients, 1 requiring frequent transfusions as well as multiple diagnostic and therapeutic interventions. Multiple transfusions can result in volume overload, coagulopathies and infections leading to significant morbidity and mortality. We present the first published case of GIB from an arteriovenous malformation (AVM) treated with a novel therapy termed spiral enteroscopy while the patient remained on venoarterial (VA) ECMO.

Surgical Outcome In Pet-Positive, Mri-Negative Patients With Temporal Lobe Epilepsy, Carla Lopinto-Khoury, Michael R. Sperling, Christopher Skidmore, Maromi Nei, James Evans, Ashwini Sharan, Scott Mintzer

maromi nei

PURPOSE: Fluorodeoxyglucose positron emission computed tomography (FDG-PET) hypometabolism is important for surgical planning in patients with temporal lobe epilepsy (TLE), but its significance remains unclear in patients who do not have evidence of mesial temporal sclerosis (MTS) on magnetic resonance imaging (MRI). We examined surgical outcomes in a group of PET-positive, MRI-negative patients and compared them with those of patients with MTS. METHODS: We queried the Thomas Jefferson University Surgical Epilepsy Database for patients who underwent anterior temporal lobectomy (ATL) from 1991 to 2009 and who had unilateral temporal PET hypometabolism without an epileptogenic lesion on MRI (PET+/MRI-). We compared …

Is Extended Volume External Beam Radiation Therapy Covering The Anastomotic Site Beneficial In Post-Esophagectomy High Risk Patients?, Edward Yu, Rashid Dar, George Rodrigues, Larry Stitt, Gregory Videtic, Pauline Truong, Anna Tomiak, Robert Ash, Ed Brecevic, Richard Inculet, Richard Malthaner, Mark Vincent, Ian Craig, Walter Kocha, Michael Lefcoe

Edward Yu

Background and purpose: To assess the impact of extended volume radiation therapy (RT) with anastomotic coverage on local control in high risk post-operative esophageal cancer patients. Patients and methods: This is a retrospective study of high risk (T(3), T(4), nodes positive, with or without margin involvement) post-operative esophageal cancer patients treated at London Regional Cancer Centre from 1989 to 1999. After esophagectomy, all patients received adjuvant combined modality therapy consisting of four cycles of fluorouracil-based chemotherapy, and loco-regional RT with or without coverage of the anastomotic site. RT dose ranged from 45 to 60 Gy at 1.8-2.0 Gy/fraction with treatment …