Delay In Definitive Treatment Research Articles

Cervical Cancer in Pregnancy

Cervical cancer is one of the most common malignancies in pregnancy and one percent of women diagnosed with cervical cancer are pregnant or postpartum at the time of the diagnosis. We discuss how pregnancy will affect the management of cancer, and cancer will affect the management of the pregnancy. Three case reports. We report three cases, with three different approaches of pregnant patient with cervical carcinoma stage IB1, diagnosed below-20 weeks gestation. In two cases, the patients decided to continue the pregnancy. Cervical cancer in pregnancy is a clinical challenge. Once the diagnosis, the stage and the extent of invasive cervical cancer have been established, a multidisciplinary approach is required. Decisions regarding timing of treatment and delivery require careful considerations, as well as the trimester in which the diagnosis is made. Delaying definitive treatment to improve fetal outcome, may carry an additional risk of tumor progression, although a delay in definitive treatment is regarded as feasible. Delayed treatment is safe in patients with small sized, early stage disease, if there is no evidence of disease progression. Neoadjuvant chemotherapy during pregnancy is still controversial. Cesarean delivery followed by radical hysterectomy is recommended. The effect of cervical cancer on pregnancy outcome is still not clear.

Arthroscopy-Associated Complications in Osteosarcoma: A Case Report and Review of the Literature.

Iatrogenic seeding of sarcoma cells into a joint is a feared, although uncommon, phenomenon. In 1983, Joyce and Mankin described twelve patients who had undergone arthroscopy for suspected intra-articular pathology and were later determined to have extra-articular malignancies. Failure to appreciate the extra-articular lesion in eight of these patients led to delays in definitive treatment as well as the introduction of diseased tissue into the joint space1. In 2003, Musculo et al. reported a similar series of twenty-five patients with suspected athletic injuries who were operated on first and only later diagnosed with benign or malignant bone tumors2. Microscopic seeding of a joint with tumor cells from an undiagnosed malignancy is a risk in treating bone and soft-tissue tumors3-5. Iatrogenic spread of a tumor by arthroscopy is a rare complication that can substantially alter surgical outcomes for patients, leading to more aggressive surgical treatment when conservative therapy may have initially been possible6-8. In a busy clinical practice, orthopaedic surgeons must remain vigilant in assessing all patients with musculoskeletal pain, particularly patients with an equivocal etiology. We report the case of a young man with osteosarcoma who had arthroscopy-related complications. The patient’s family was informed that data concerning this case would be submitted for publication, and they provided consent. A previously healthy nineteen-year-old man presented to his primary physician with knee pain, swelling, and limited weight-bearing. The patient offered a reportedly “vague” history of trauma to the knee, sustained while playing with the family dog. After evaluation, the physician decided on empiric treatment with rest and nonsteroidal anti-inflammatory drugs. Despite the medication, the pain continued to worsen, and the patient was subsequently referred for orthopaedic evaluation. The patient presented to the orthopaedist with poorly localized pain about the knee …

Intrinsic Endobronchial Obstructions in Children from Turkey: Evaluation of 2,555 Flexible Bronchoscopic Procedures

Background: Endobronchial obstructions are rarely seen in children and are often misdiagnosed resulting in delay of definitive treatment. A variety of diseases can cause endobronchial obstructions in childhood, but data is limited as to the frequency, distribution and clinical characteristics of endobronchial obstructions diagnosed with flexible bronchoscopy (FB). Objective: To document endobronchial obstructions detected by FB. Methods: FB results from three pediatric pulmonology centers in Istanbul were evaluated. Results: A total of 2,555 children underwent an FB procedure during the study period. Endobronchial obstructions were detected in 10% (n = 256) of the patients. Among FB in patients who had endobronchial obstructions, the four most common indications for bronchoscopy were persistent infiltrations (30%, n = 72), persistent wheezing (28%, n = 70), chronic cough (26%, n = 66) and atelectasis (23%, n = 59). The most common endobronchial obstructions detected in the patients were aspirated foreign bodies (35.9%, n = 92), endobronchial tuberculosis (31.6%, n = 81), mucous plugs occluding airway (16.7%, n = 43) and granulation scars (6%, n = 16). Other pathologies included hydatid cysts (n = 5), hemangiomas (n = 5), tumors (n = 5), submucosal nodules (n = 5) and polyps (n = 4). Endobronchial obstructions were most commonly located in the right bronchus (51%, n = 130) followed by the left bronchus (33%, n = 85), bilaterally (8%, n = 21) and trachea (8%, n = 20). Conclusions: Endobronchial obstructions can be caused by a number of different diseases which require various medical or surgical treatments. In the presence of clinical or radiological findings suggesting an endobronchial obstruction, FB should be performed promptly.

1462 IS ACTIVE SURVEILLANCE ASSOCIATED WITH ADVERSE PATHOLOGIC OR SURGICAL OUTCOMES IN MEN EVENTUALLY CHOOSING DEFINITIVE TREATMENT WITH ROBOTIC RADICAL PROSTATECTOMY?

You have accessJournal of UrologyProstate Cancer: Localized VII1 Apr 20121462 IS ACTIVE SURVEILLANCE ASSOCIATED WITH ADVERSE PATHOLOGIC OR SURGICAL OUTCOMES IN MEN EVENTUALLY CHOOSING DEFINITIVE TREATMENT WITH ROBOTIC RADICAL PROSTATECTOMY? Rachael Sussman, Ilene Staff, Alison Champagne, Jamie Fish-Furhman, Joseph Tortora, Stuart Kesler, and Joseph Wagner Rachael SussmanRachael Sussman Farmington, CT More articles by this author , Ilene StaffIlene Staff Hartford, CT More articles by this author , Alison ChampagneAlison Champagne Hartford, CT More articles by this author , Jamie Fish-FurhmanJamie Fish-Furhman Hartford, CT More articles by this author , Joseph TortoraJoseph Tortora Hartford, CT More articles by this author , Stuart KeslerStuart Kesler Hartford, CT More articles by this author , and Joseph WagnerJoseph Wagner Hartford, CT More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.1983AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Many men with low risk prostate cancer choose active surveillance (AS) as opposed to definitive treatment such as initial robotic prostatectomy (RP) with the hope that opportunity for surgical cure will not be lost and in an effort to avoid the morbidity associated with definitive treatment. We evaluate whether a delay in definitive treatment with RP secondary to an initial treatment decision of AS was associated with adverse pathologic features, inability to perform nerve sparing surgery and biochemical recurrence. METHODS From our RP database we identified men with low risk prostate cancer (prostate-specific antigen (PSA) < 10 ng/mL, biopsy Gleason sum ≤ 6, cancer involvement of < 33% of biopsy cores, and clinical stage T1/T2a tumor) who were managed with initial AS, all of whom eventually underwent RP. Two control groups were selected: Control 1 was based on biopsy data at the time of diagnosis and Control 2 was based on biopsy data just prior to surgery. All unique patients fitting matching criteria (year of engagement +/1 year, PSA Partin Table Category (0-2.5, 2.6-4.0, etc), percent positive cores +/− 10%, clinical stage and Gleason score) were included. Ability to perform nerve sparing surgery, adverse pathologic features, and biochemical recurrence were compared between the study group and each control group. RESULTS See Table 1. Table 1. Study Group (n=41) Control Group 1 (n=164) p value % Gleason upgrading 81.1 46.3 .001 % pT3 24.4 12.8 n.s.(p.=.1) % bilateral nerve sparing 75.6 93.9 .001 % positive margins 31.7 19.5 n.s.(p.=.1) % biochemical recurrence 11.4 1.3 .012 Study Group (n=41) Control Group 2 (n=123) p value % Gleason upgrading 31.7 35.0 n.s. % pT3 24.4 20.2 n.s. % bilateral nerve sparing 75.6 84.2 n.s. % positive margins 31.7 27.6 n.s. % biochemical recurrence 11.4 5.7 n.s. CONCLUSIONS For men with low risk prostate cancer, treatment with AS followed by delayed RP impacted the incidence of bilateral nerve sparing surgery. There was an association between delayed RP and adverse pathologic features when comparing our cohort to a group of men with similar parameters at the time of diagnosis who chose treatment with initial RP. Since many men went on to surgery due toupgrading on surveillance biopsies, this was not unexpected. We hypothesized thatclose monitoring and multiple surveillance biopsies would correlate with improvedpathologic outcomes compared to patients who had undergone one set of biopsies and immediately underwent surgery, This was not the case as our cohort had the sameoutcomes when comparing them to men with similar parameters just prior to surgerywho were not an on AS protocol. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e592-e593 Peer Review Report Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Rachael Sussman Farmington, CT More articles by this author Ilene Staff Hartford, CT More articles by this author Alison Champagne Hartford, CT More articles by this author Jamie Fish-Furhman Hartford, CT More articles by this author Joseph Tortora Hartford, CT More articles by this author Stuart Kesler Hartford, CT More articles by this author Joseph Wagner Hartford, CT More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Total colonic aganglionosis with skip lesions: report of a rare case and management

We present an unusual case of total colonic aganglionosis with well-documented skip lesions and discuss our staged approach for diagnosis and surgical management. To date, there have been few reported cases of total colonic aganglionosis with skip areas. This type of presentation challenges the accepted theory regarding the etiology of colonic aganglionosis. Although skip lesions in Hirschsprung disease are extremely rare, their existence must be appreciated especially when a patient's clinical and pathologic findings do not support classic Hirschsprung disease. If not considered, additional areas of aganglionosis can be missed at initial presentation, leading to a delay in definitive treatment. This case illustrates how careful mapping of bowel via multiple biopsies can identify and thereby preserve intervening segments of bowel with normal ganglions cells to yield the maximal amount of bowel possible.

Acute intrathecal haematoma following neuraxial anaesthesia: diagnostic delay after apparently normal radiological imaging

We describe a case of intrathecal haematoma following combined spinal-epidural anaesthesia for caesarean section. The parturient was previously well with no risk factors for haematoma development. Surgical intervention was delayed, resulting in permanent neurological injury. Incorrect interpretation of clinical findings and magnetic resonance imaging contributed to the delay in definitive treatment. We discuss the difficulties in diagnosis, image interpretation and the need for a specialist opinion when abnormal neurological symptoms persist despite apparently normal imaging.

Unmet medical needs in systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is an autoimmune disease of diverse manifestations, with onset usually in young women in the third to fourth decade of life. The chronic nature of this relapsing remitting disease leads to organ damage accrual over time. Mortality and morbidity are increased in patients with SLE compared with the general population. Therapeutic advances over the last few decades have led to significant improvements in patient outcomes. Five-year survival has improved to over 90% from a low of 50% in the 1950s. However, multiple aspects of the management of SLE patients are still far from optimal. Early diagnosis remains a challenge; diagnostic delays leading to delay in definitive treatment are common. Monitoring treatment remains problematic due to the paucity of sensitive biomarkers. Current treatment regimens rely heavily on corticosteroids, even though corticosteroids are well known to cause organ damage. Treatment of refractory disease manifestations such as nephritis, recalcitrant cutaneous lesions and neurological involvement require new approaches with greater efficacy. Cognitive dysfunction is common in SLE patients, but early recognition and adequate treatment are yet to be established. Premature accelerated atherosclerosis remains a leading cause of morbidity and mortality. Fatigue is one of the most disabling symptoms, and contributes to the poor quality of life in patients with SLE. Ongoing research in SLE faces many challenges, including enrollment of homogeneous patient populations, use of reliable outcome measures and a standard control arm. The current review will highlight some of the outstanding unmet challenges in the management of this complex disease.

Break a Sweat in the Diagnosis and Management of a Flesh‐Colored Nodule

Eccrine porocarcinoma (EPC), which is a tumor of the sweat ducts, most commonly affects older adults, with an average age of 68, but may occur at any age.1 It may arise originally in malignant form2 but most often develops from a long-standing benign eccrine poroma as a form of degenerative progression.3 It is not uncommon for the lesion to be misdiagnosed. Because the tumor has the capacity to metastasize, with consequent poor prognosis, it is imperative for accurate diagnosis and management. A 63-year-old man presented with a 4-month history of a flesh-colored nodule over the left upper cutaneous lip that had been enlarging gradually and was asymptomatic. There had been no preexisting lesion at the site before onset. His past medical history included hypertension for which he was taking antihypertensives. Clinical examination revealed a flesh-colored 15- × 10-mm nodule over the left upper cutaneous lip extending to the vermillion. There was telangiectasia over the surface. There was no pearly margin (Figure 1). A punch biopsy was performed that revealed a dermal-based tumor with nests of tumor cells with ductal structures showing numerous mitotic figures at low magnification. Polyclonal carcinoembryonic antigen (CEA) highlighted ducts, confirming their eccrine differentiation. A diagnosis of EPC was made, and the lesion was excised in one stage with two blocks using Mohs micrographic surgery (MMS) and the defect closed with mucosal advancement of the lip. EPC has a propensity to arise on the lower limbs (44%), trunk (24%), or head and neck (24%).4-6 One problem with EPC is delay in definitive treatment because of the tumor's indolent behavior or misleading clinical diagnosis.7 The tumor is typically formed of cohesive basaloid epithelial cells and may be misdiagnosed as basal cell carcinoma. Foci of squamous differentiation that can resemble well-differentiated squamous cell carcinoma are often observed within EPC. The presence of ductal structures and use of immunostains help in making the histological diagnosis. Regional lymph node metastases are found in approximately 20% of patients, and distant metastases arise in approximately 10% of patients. There is an approximately 67% mortality in individuals with lymph node metastases.8 Its metastatic potential and poor outlook in the event of metastasis dictates the need for early identification and complete excision as the best chance of a cure. EPC has been treated using a variety of methods, including electrosurgery, simple and wide excision, MMS, and radiation. Curative rates of 70% to 80% have been reported for excision, with recurrence rates as high as 20% being reported.1, 5 Recurrences had been reported to occur 4 months to 12 years after treatment.9 One study7 reported that three of eight individuals had recurrences after wide excision (≥10-mm margins). Thus simple or wide excision is not the optimal treatment for EPC. MMS appears most promising. Another study10 reported a series of five cases of primary EPC treated using MMS without recurrence after 2 to 4 years of follow-up. The current patient was treated using MMS. Tumor extirpation was achieved in one stage with two blocks. One year after treatment, no recurrence was noted. primary and metastatic EPC have shown poor response to radiation therapy. Chemotherapy also has a poor response and is generally reserved for treatment of documented metastatic EPC. EPC is challenging for surgeons and medical and radiation oncologists. Because of its rarity and lack of consensus and guidelines for its management, EPC is a challenge to treat. MMS, which allows for full evaluation of the tumor margins, may be the ideal treatment for this rare tumor. Because tumor recurrence had been reported 12 years after treatment, monitoring is essential after treatment. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Both authors were involved in the analysis and interpretation of data and preparation of manuscript. Sponsor's Role: None.

Imaging Techniques in Acute Coronary Syndromes: A Review

Coronary heart disease (CHD) remains the leading cause of death in the United States. National review of Emergency Department (ED) visits from 2007 to 2008 reveals that 9% are for chest pain. Of these patients, 13% had acute coronary syndromes (ACSs) (Antman et al., 2004). Plaque rupture with thrombus formation is the most frequent cause of ACS, and identifying patients prior to this event remains important for any clinician caring for these patients. There has been an increasing amount of research and technological advancement in improving the diagnosis of patients presenting with ACS. Low-to-intermediate risk patients are the subgroup that has a delay in definitive treatment for ACS, and a push for methods to more easily and accurately identify the patients within this group that would benefit from an early invasive strategy has arisen. Multiple imaging modalities have been studied regarding the ability to detect ischemia or wall motion abnormalities (WMAs), and an understanding of some of the currently available noninvasive and invasive imaging techniques is important for any clinician caring for ACS patients.

Popliteal Artery Injuries in an Urban Trauma Center with a Rural Catchment Area: Do Delays in Definitive Treatment Affect Amputation?

Extended length of time from injury to definitive vascular repair is considered to be a predictor of amputation in patients with popliteal artery injuries. In an urban trauma center with a rural catchment area, logistical issues frequently result in treatment delays, which may affect limb salvage after vascular trauma. We examined how known risk factors for amputation after popliteal trauma are affected in a more rural environment, where patients often experience delays in definitive surgical treatment. All adult patients admitted to the Level I trauma center, the University of Mississippi Medical Center, with a popliteal artery injury between January 2000 and December of 2007 were identified. Demographic information management and outcome data were collected. Body mass index, mangled extremity severity score (MESS), Guistilo open fracture score, injury severity score, and time from injury to vascular repair were examined. Fifty-one patients with popliteal artery injuries (53% blunt and 47% penetrating) were identified, all undergoing operative repair. There were nine amputations (17.6%) and one death. Patients requiring amputation had a higher MESS, 7.8 versus 5.3 (P < 0.01), and length of stay, 43 versus 15 days (P < 0.01), compared with those with successful limb salvage. Body mass index, injury severity score, Guistilo open fracture score, or time from injury to repair were not different between the two groups. Patients with a blunt mechanism of injury had a slightly higher amputation rate compared with those with penetrating trauma, 25.9 per cent versus 8.3 per cent (P = non significant). MESS, though not perfect, is the best predictor of amputation in patients with popliteal artery injuries. Morbid obesity is not a significant predictor for amputation in patients with popliteal artery injuries. Time from injury to repair of greater than 6 hours was not predictive of amputation. This study further demonstrates that a single scoring system should be used with caution when determining the need for lower extremity amputation.

Delayed presentation of IIIB tibial fractures: outcome following management in a specialist centre

The aim of this study was to assess whether the outcome of delayed presentation of open tibial fractures from neighbouring orthopaedic units can be salvaged in a specialist ortho-plastic centre. All grade IIIB tibial fractures treated in a specialist unit over an 18-month period were retrospectively reviewed. Time to definitive soft tissue coverage, complications, number of operations and method of skeletal and soft tissue reconstruction were also reviewed. The functional outcome was assessed using the Enneking score. Forty-five consecutive patients (27 male and 18 female; mean age, 42.3 years) were treated using strict surgical protocols. Seventeen patients were referred locally, and 28 from seven neighbouring orthopaedic units. The mean time from injury to definitive surgery was 3.9 and 7.7 days for patients referred locally and those referred from neighbouring units, respectively. Definitive surgery, from the time of initial plastic surgery assessment, was performed at a mean of 2.4 days for patients referred locally and 2.8 days for patients referred from neighbouring units. One patient developed a deep soft tissue wound infection. There were no delayed amputations or any cases of infected non-union. Patients from neighbouring units underwent, on average, one extra operation. There was a delay from the time of injury in achieving soft tissue coverage in these patients (7.7 vs. 3.9 days). No significant difference in return of limb function between the two groups was detected. Referral to a specialist centre may produce equivalent functional return even if there is a delay in definitive treatment, at the expense of further risky surgery.

Delays in Transfer Times for Patients with Extradural Haematomas in Greater Manchester

Decompression surgery for acute extradural haematoma (EDH) should be completed within 240 minutes of the onset of significant symptoms. Previous studies have shown that this time target is rarely met. We investigated all EDH patients requiring surgical intervention who were referred to Salford Royal Foundation Trust in a six-month period to establish the causes of delay in definitive treatment. The study showed a median time of 384 minutes (range 198–704) from admission to the recipient emergency department to the commencement of surgical decompression. Analysis of the timeline of treatment showed that the attainment of initial CT scan and preparation for transfer were the primary factors delaying definitive treatment. We recommend altering the approach to certain key processes, namely attainment of CT, the referral process and the preparation for transfer, in order to achieve the 240-minute target.

Kawasaki Disease in A Nigerian Child- a case report

We report a three year old child who appeared to have a drug-induced muco-cutaneous hypersensitivity reaction during treatment for a febrile illness, but eventually manifested all the diagnostic criteria for Kawasaki Disease (KD) while on admission. Although an initial diagnosis of Steven-Johnson's Syndrome was made, the emerging clinical features, presence of thrombocytosis, low plasma proteins and high ESR, prompted a change of diagnosis to Kawasaki Disease. She received bed rest and steroid therapy due to the absence of Intravenous ImmunoglobulinGand our reluctance to use aspirin. Although she did not manifest any echocardiographic cardiac features while on admission, a verbal autopsy report of her sudden death two days after discharge against medical advice, suggested possible cardiac involvement. In view of the high mortality risk asscociated with non-institution or delay of definitive treatment, it is important to add KD to the list of differential diagnoses in febrile children with muco-cutaneous lesions. Key words; Atypical measles, Kawasaki Disease, Nigeria, Verbal Autopsy

Appendicitis in northern aboriginal children: does delay in definitive treatment affect outcome?

Background The treatment of northern aboriginal children (NAC) is often complicated by distance from a treating facility. We sought to compare outcomes of NAC requiring transfer with appendicitis to those who presented locally. We hypothesized that NAC with appendicitis experienced higher rates of perforation and increased length of stay (LOS). Methods A retrospective chart review of 210 appendectomies was performed. Charts were reviewed for age, sex, weight, days of symptoms before presentation, time of transfer, leukocyte count (white blood cell count), usage of antibiotics prior to transfer, time to operation, type of procedure and findings, pathology, postoperative outcomes, and LOS. Results Sixty-eight children were NAC, whereas 142 were local. The average transfer times for NAC was 10 hours (range, 4-20 hours). The two groups had similar ages (11.1 vs 10.7 years), time to presentation (1.64 vs 1.85 days), and LOS (2.91 vs 2.90 days). Significantly higher perforation rates (44 vs 28%; P = .02), higher white blood cell count (17.9 vs 16.0; P = .02), and longer times to operation after arrival (10.3 vs 7.0 hours; P = .0002) were noted in NAC. Postoperative complications were similar between groups. Forty-seven (69%) NAC received antibiotics prior to transfer, which did not affect rate of rupture. Conclusion NAC with appendicitis experience longer transfer times and higher perforation rates than local children without a difference in length of stay or complications. Pretransfer antibiotics do not reduce perforation rates but may impact complications. We endorse their use if a delay in transfer is anticipated.

Use of Medical Simulation to Explore Equipment Failures and Human-Machine Interactions in Anesthesia Machine Pipeline Supply Crossover

High-fidelity medical simulation can be used to explore failure modes of technology and equipment and human-machine interactions. We present the use of an equipment malfunction simulation scenario, oxygen (O(2))/nitrous oxide (N(2)O) pipeline crossover, to probe residents' knowledge and their use of anesthetic equipment in a rapidly escalating crisis. In this descriptive study, 20 third-year anesthesia residents were paired into 10 two-member teams. The scenario involved an Ohmeda Modulus SE 7500 anesthetic machine with a Datex AS/3 monitor that provided vital signs and gas monitoring. Before the scenario started, we switched pipeline connections so that N(2)O entered through the O(2) pipeline and vice versa. Because of the switched pipeline, the auxiliary O(2) flowmeter delivered N(2)O instead of O(2). Two expert, independent raters reviewed videotaped scenarios and recorded the alarms explicitly noted by participants and methods of ventilation. Nine pairs became aware of the low fraction of inspired O(2) (Fio(2)) alarm. Only 3 pairs recognized the high fraction of inspired N(2)O (Fin(2)o) alarm. One group failed to recognize both the low Fio(2) and the high Fin(2)o alarms. Nine groups took 3 or more steps before instigating a definitive route of oxygenation. Seven groups used the auxiliary O(2) flowmeter at some point during the management steps. The fact that so many participants used the auxiliary O(2) flowmeter may expose machine factors and related human-machine interactions during an equipment crisis. Use of the auxiliary O(2) flowmeter as a presumed external source of O(2) contributed to delays in definitive treatment. Many participants also failed to notice the presence of high N(2)O. This may have been, in part, attributable to 2 facts that we uncovered during our video review: (a) the transitory nature of the "high N(2)O" alert, and (b) the dominance of the low Fio(2) alarm, which many chose to mute. We suggest that the use of high-fidelity simulations may be a promising avenue to further examine hypotheses related to failure modes of equipment and possible management response strategies of clinicians.

Time Delays in Definitive Treatment for Polytrauma Patients Treated in the Royal Victoria Hospital, Belfast, N. IRELAND

Time Delays in Definitive Treatment for Polytrauma Patients Treated in the Royal Victoria Hospital, Belfast, N. IRELAND

Management of Non-Spinal Injury Pressure Sore Referrals

Management of Non-Spinal Injury Pressure Sore Referrals

Transfer delay and in-hospital mortality of trauma patients in Pakistan

Background Mortality and morbidity in trauma remain a major problem in developing countries. Organized emergency response systems for transfer of trauma patients to hospitals are absent and the consequent delays could cause significant complications. Aims This study assessed the outcomes as a result of hospital transfer and delays in trauma patients. Methods The study was based on trauma patients presenting to the Aga Khan University Hospital (AKUH), Karachi, Pakistan from 1998 to 2005, meeting the trauma team activation criteria. Data were collected and entered in a Trauma Registry. The study focused on analyzing the outcomes of injury to delay in definitive treatment and survival. Results Out of 978 patients, only 303 (30.9%) patients reached the emergency room (ER) within an hour. The mean time from injury occurrence to arrival in the ER was 4.7 h. There was no significant difference in mortality between all patients presenting early and those with more than 1 h delay (OR = 0.9, 95% CI: 0.6, 1.5). Conclusions Transfer and delay in admission to a tertiary care center does not affect in-hospital mortality of trauma patients in a setting with no emergency response system. This may be due to self selection of patients who survive long enough to reach the hospital.

Effect of Intramedullary Nails in Tibial Shaft Fractures as a Factor in Raised Intracompartmental Pressures: a Clinical Study.

Tibial shaft fractures are the commonest cause of compartment syndrome. Intramedullary nails have been the most common treatment for such fractures. Raised pressures after nailing do not necessarily imply compartment syndrome, but are an important factor to consider when deciding on the appropriate treatment. A clinical study was performed that included 80 cases diagnosed with tibial shaft fractures and treated with reamed intramedullary nails. Compartment pressure was measured with a slit catheter. The pressure was calculated before and just after surgery. Delta P values were also calculated. Patients with overpressure but no clinical suspicion of compartment syndrome were monitored for 24 h. Patients diagnosed with compartment syndrome were treated via fasciotomy. A descriptive and statistical study was performed with 95% confidence intervals and significant difference p < 0.05. A statistically significant increase in pressure was observed after surgery. Delta P values only decreased after nailing in the anterior compartment, although the decrease was not significant (p ≥ 0.05). Four cases required monitoring for 24 h. Eleven patients were diagnosed with compartment syndrome after surgery, with absolute pressures of over 30 mmHg and delta P values of less than 40 mmHg. Reamed intramedullary nails can increase compartment pressures in tibial shaft fractures. The delta P value can influence the decision about whether to perform a fasciotomy. The diagnosis of compartment syndrome must be based on clinical findings. If there is any doubt, we recommend measuring the pressure and using a cut-off value for fasciotomy of delta P ≤ 40 mmHg. A delay in definitive treatment is suggested until pressure values are secure.

Squamous cell carcinoma of tongue in a 19-year-old female

Squamous cell carcinoma is the most common malignant neoplasm of the Oral Cavity, usually affecting individuals over 50 years of age. It rarely occurs in patients who are less than 40 years old (0.4-5.5%). However, since it is so rare, when cases occur they are often misdiagnosed and inappropriately treated leading to delay in definitive treatment. This report describes a case of squamous cell carcinoma, involving the posterolateral border of the tongue of a 19-year-old female patient, with no deleterious habits usually associated with oral cancer. This report focuses on the etiological factors and prognosis related to the case. Additionally, a brief literature review regarding squamous cell carcinoma in young patients is also included.