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PubMed1997

Is machine energy (4-8 MV) associated with outcome for stage I-II breast cancer patients?

PURPOSE: To assess the relationship between machine energy (4-8 MV) and treatment outcome in patients treated with conservative surgery and radiation therapy. METHODS AND MATERIALS: Between 1968 and 1985, 1624 patients were treated for clinical Stage I or II invasive breast cancer. The study population was limited to 1380 patients who underwent complete gross excision and received greater than or equal to 60 Gy to the tumor bed. Of these, 1125 were treated on a 4 MV, 153 on a 6 MV, and 102 on an 8 MV linear accelerator. Patients were selected for treatment on the 8 MV machine based on chest wall separations greater than 24 cm. Of patients treated on the 8 MV, netting was used for 42% and bolus was used for 26%. The median dose with bolus was 14 Gy in seven fractions (range: 2-34.2 Gy). Patients treated on the 8 MV accelerator were older, had a higher percentage of clinical T2 tumors, a higher percentage of pathologically positive nodes, and a lower incidence of extensive intraductal component (EIC). Median follow-up times were 130, 153, and 102 months, respectively, for survivors treated on the 4, 6, and 8 MV machines. RESULTS: We analyzed the site and 5-year crude incidence of first failure by machine energy and found the pattern of first failure site (local, nodal, or distant) to be virtually identical for each energy group. Of the local failures, 12 were in the skin of the treated breast, and these failures were evenly distributed by machine energy. We performed a multivariate analysis to adjust for factors known to predict for treatment failure. When adjusted for these other variables, machine energy was not associated with an increased (or decreased) risk of recurrence (RR for 8 MV vs. 4 MV = 0.94, p = 0.7; RR for 6 MV vs. 4 MV = 1.0, p = 0.9). We also analyzed the nature and incidence of treatment complications (rib fracture, radiation pneumonitis, soft tissue necrosis, and brachial plexopathy) and found no significant differences among the three treatment groups when stratified by treatment technique (tangents only vs. three-field). There was also no significant difference in cosmetic outcome at 5 years among the three groups. CONCLUSIONS: We conclude that machine energy over the range of 4 to 8 MV does not significantly affect treatment outcome. Specifically, it was feasible to treat patients with large chest wall separations using an 8 MV machine without an increase in skin recurrences and with the improved dose homogeneity afforded by 8 MV machines as compared with those of lower energies.

Adult↗
PubMed1997

Early-stage bilateral breast cancer treated with breast-conserving surgery and definitive irradiation: the University of Pennsylvania experience.

PURPOSE: To determine whether patients with early-stage bilateral breast cancer can be treated with definitive irradiation following breast-conserving surgery with acceptable survival, local control, complications, and cosmesis. METHODS AND MATERIALS: During the period 1977-1992, 55 women with Stage 0, I, or II concurrent (n = 12) or sequential (n = 43) bilateral breast cancer were treated with definitive irradiation following breast-conserving surgery. The records of these 55 patients with 110 treated breasts were reviewed for tumor size, histology, pathologic axillary lymph node status, first and overall site(s) of failure, and adjuvant chemotherapy or hormonal therapy. Curves for survival, local control, and regional control were determined. Cosmetic outcome, complication rates, and matching technique were analyzed. The median total radiation dose delivered was 64 Gy (range 42-72) using tangential whole-breast irradiation followed by an electron or iridium implant boost. The tangential fields were matched with no overlap in 40 patients (73%); there was overlap on skin of up to 4 cm in 14 patients (25%); and the matching technique was unknown in 1 patient (2%). The median follow-up for the 12 women with concurrent bilateral breast cancer was 4.0 years. The median follow-up for the other 43 women with sequential cancer was 9.3 and 4.9 years, respectively, after the first and second cancers. RESULTS: For the overall group of 55 patients, the 5- and 10-year overall survival rates were 96% and 94%, respectively, after treatment of the first cancer, and 96% and 92%, respectively, after treatment of the second cancer. The 5- and 10-year actuarial relapse-free survival rates were 90% and 75%, respectively, after treatment of the first cancer, and 83% and 72%, respectively, after treatment of the second cancer. For the 110 treated breast cancers, the 5- and 10-year actuarial local failure rates were 5% and 15%, respectively. Complication rates were: 28% breast edema, 8% arm edema, 4% pneumonitis, 3% cellulitis, 1% rib fracture, and 1% brachial plexopathy; no patient developed matchline fibrosis. For patients with a minimum of 3 years of relapse-free follow-up, the rate of excellent or good cosmetic outcome for 104 treated breasts was 85%. CONCLUSION: Definitive irradiation after breast-conserving surgery is technically feasible for selected patients with concurrent or sequential early-stage bilateral breast cancer. Survival, local control, complication rates, and cosmetic outcomes appear comparable to historical reports of breast conservation treatment for unilateral disease. Bilateral definitive breast irradiation after breast-conservation surgery should be considered an acceptable alternative treatment to bilateral mastectomy for selected patients with concurrent or sequential early-stage bilateral breast cancer.

Adult↗
PubMed2003

Fatal hepatic failure following accidental tramadol overdose.

A case of fatal overdose of tramadol is described, occurring in a 67-year-old man with painful rib fractures who accidentally ingested more than the recommended daily dose. The mode of death was acute liver failure due to fulminant hepatic necrosis. Post-mortem toxicology was negative apart from revealing a blood tramadol concentration well above the normal therapeutic range. This is the first report of fatal tramadol ingestion occurring in a therapeutic setting and also the first tramadol-related death where the mechanism was liver failure.

Accidents↗
PubMed1995

Tracheal collapse.

Tracheal collapse in calves usually is associated with dystocia at birth, especially breech presentations. Inspiratory dyspnea typically is seen within the first several months of life and may worsen progressively. Lateral cervical radiographs are useful in defining the affected segments as well as identifying previously fractured ribs. Surgical stenting of the trachea will improve the calf's condition, but because this procedure is done on young calves, the tracheal diameter of the affected segment is permanently limited by the size of the prosthesis.

Animals↗
PubMedDate not supplied

Rehabilitation of patient with brachial plexus lesion and break in axillary artery. Case study.

This paper describes the physiotherapy and occupational therapy used in treating a 74-year-old woman with a left brachial plexus lesion, a break in the axillary artery, dislocation of the acromioclavicular joint, a broken scapula and clavicula, serial left rib fractures, and lacerations on the upper and lower arm. After testing the patient, the following goals were set: reduce pain, soften scar tissue, and improve joint motion, muscle strength, and functionality of the hand. A 12-month outpatient program was used. Various analgesics were used to reduce pain, and a special aid was made to unweight the shoulder and elbow joints. Physiotherapy included kinesiotherapy, audiovisual biofeedback, electrical stimulation, friction massage, and lymph drainage. Occupational therapy included active functional exercises and re-education. As a result of this program, the patient no longer had pain, passive range of motion was close to normal, active motion where present was improved, swelling was reduced, and the hand became functional again. Complex physiotherapy, occupational therapy, and the patient's motivation resulted in the rehabilitation of severe trauma of the hand.

Aged↗
PubMed2003

Nutrition support for the patient with an open abdomen after major abdominal trauma.

OBJECTIVE: Nutrition support in the severely injured trauma patient is crucial to minimize the hypermetabolic stress response. Even though enteral nutrition is the preferred method of feeding, it is not always feasible after multiple trauma. We present a complex nutritional case in a patient who sustained severe abdominal trauma with a severe liver injury, rib fractures, and pulmonary contusion. METHODS: The patient required several repeat laparotomies, abdominal packing, and temporary abdominal closure. The clinical course was complicated by hypotension requiring multiple vasopressors; coagulopathy requiring more than 35 U of packed red cells, more than 50 U of fresh frozen plasma, and more than 80 U of platelets; acute renal failure requiring dialysis; and pneumonia and acute respiratory distress syndrome requiring intricate ventilator management. Nutrition intervention began on post-trauma day 4 with total parenteral nutrition due to hypotension, resuscitation, and massive bowel edema; by post-trauma day 8. the patient was receiving goal nutrients. RESULTS: On post-trauma day 27, bowel edema was significantly less, and a nasoenteric feeding tube was placed and enteral feeding initiated. By post-trauma day 31, full enteral feeds were tolerated, and total parenteral nutrition was stopped. Nutrient provision was adjusted daily to account for organ and metabolic changes including hepatic, pulmonary, and renal dysfunction. The patient did well and was eventually extubated and eating a regular diet. CONCLUSION: With careful monitoring and adjusting of the nutritional plan, a hypermetabolic complex trauma patient with an open abdomen can be fed optimally, safely, and successfully despite increased bowel edema and multiple organ dysfunction.

Abdominal Injuries↗
PubMed1995

Screening bone scintigraphy in the staging of locally advanced head and neck cancer.

A retrospective determination of the yield from screening bone scintigraphy in detecting bone metastasis when used for disease staging of 93 asymptomatic patients with locally extensive head and neck cancer was undertaken. The bone scintigraphy findings were correlated with observations from other radioimaging studies done within 1 month of head and neck cancer diagnosis. Bone scintigraphy did not reveal a single case of bone metastasis outside the head and neck region. On the other hand, 3 cases (8%) of resectable and 2 cases (5%) of non-resectable bone metastasis located within the head and neck area were observed among the 40 patients with abnormal bone scintigraphy. Old rib fracture or degenerative disease was responsible for the increased radionuclide uptake in bony areas below the clavicle in less than half of the remaining 35 cases. We conclude that the routine use of bone scintigraphy for disease staging in asymptomatic patients with locally advanced head and neck cancer is not warranted because the positive yield is low.

Adult↗
PubMed1998

Evolution of post-traumatic aortic aneurysm in the subacute phase: magnetic resonance imaging follow-up as a support of the surgical timing.

OBJECTIVES: A recent surgical series documented that in traumatic aortic rupture (TAR) a surgical repair postponed to the treatment of associated lesions reduced operative and overall mortality. Nevertheless some isolated cases may develop to free rupture. Until now, no imaging follow-up studies of post-traumatic aortic lesions have been reported in the early stage. The aim of this study is to analyze the behaviour of traumatic aortic ruptures in the subacute phase, in order to detect the morphological characteristics of unstable post-traumatic aneurysms. METHODS: Twenty-five consecutive patients affected by traumatic aortic rupture (one intimal hemorrhage, 19 partial lesions and five circumferential lesions) were admitted to the department of cardiac surgery. Magnetic resonance imaging (MRI) was the imaging method used to confirm the diagnosis. No one was operated on during the acute phase. All patients were treated with beta-blockers and vasodilators as well as limited fluid administration. Delayed surgery was carried out in 18 patients at 243 days (+/-127), after the resolution of associated lesions. A scheduled MRI follow-up was performed at 7, 15 and 30 days and immediately before the operation. The parameters examined were increase of post-traumatic aneurysm, increase of periaortic hematoma and modification of the thoracic associated lesions. RESULTS: At 30 days a 3.0 +/- 3.7 mm median increase of the aneurysm was observed, while in the subsequent period the lesions became substantially stable, resulting in a 4.4 +/- 3.6 mm increment at the end of the follow-up. The circumferential lesions presented a higher increment with respect to the partial lesions. In three cases an augmentation of 6, 7 and 12 mm was detected and surgical repair was anticipated. In 13 cases a periadventitial hematoma surrounding the aortic aneurysm decreased through the time. One case of intimal hemorrhage healed spontaneously, with no aneurysm formation. Thoracic associated lesions (pleural and pericardial effusions, rib fractures, lung focal contusions and two cases of ARDS) resolved at 30-60 days. CONCLUSIONS: Despite common knowledge, considering TAR highly evolutive in the acute and subacute phase, this study demonstrated that this pathological entity is relatively stable if a proper pharmacological treatment is administrated. MRI follow-up is recommended in order to detect isolated cases of unstable aneurysm.

Aorta, Thoracic↗
PubMed1998

MIDCAB characteristics and results: the CardioThoracic Systems (CTS) registry.

OBJECTIVE: The CardioThoracic Systems (CTS) registry of minimally invasive direct coronary artery bypass (MIDCAB) was established to examine baseline characteristics of patients undergoing this surgical procedure, document details of the procedures including grafting techniques and post-operative complication rates, and assess post-operative graft patency. METHODS: A total of 508 consecutive patients who had MIDCAB using CTS instrumentation between April 1996 and March 1997 at 35 international centers were analyzed. RESULTS: The mean age of patients, 27% of whom were women, was 63 years. Eight percent had previous coronary artery bypass surgery. While nearly all patients had significant stenoses in the left anterior descending artery, 23% had disease in two vessels and 9% in three vessels. Almost all procedures used the left internal mammary artery, with 7% employing multiple or sequential grafts. The entire surgical procedure lasted on average 135 min (median 2 h), with a mean time of 14 min to perform anastomosis. Surgical approaches, including anastomosis technique and method used to maintain bloodless field, varied widely across clinical centers. In-hospital complication rates were relatively low, with 0.6% mortality (0% perioperative), 1.2% conversion to sternotomy with cardiopulmonary bypass, 1.4% conversion to sternotomy without bypass, and 5.5% redo or reintervention. In total, 92% of patients were free from all of these events at hospital discharge; women showed a strong trend toward increased risk for major in-hospital events compared with men. Rib fracture was the most common complication, reported in 12% of patients. Post-operative angiography, performed in 83 patients at an average 2.2 days post-procedure, found full patency in 78 (94%). CONCLUSIONS: The CTS registry data indicates that in the great majority of patients, MIDCAB using CTS instrumentation was performed safely and with acute success. Comparative studies, most importantly clinical trials, are needed to determine the types of patients who benefit most from this procedure, as well as its longer-term outcome.

Coronary Artery Bypass↗
PubMed1999

Blunt diaphragmatic rupture.

OBJECTIVE: To identify (1) predictors of outcome in blunt diaphragmatic rupture (BDR), and (2) factors contributing to diagnostic delay. METHODS: We reviewed the charts and radiographs of 41 patients with BDR treated in our Hospital from 1988 to 1997. There were 35 male (85%) and six female, aged 17-71 (mean: 41) years. BDR was left-sided in 24 cases (58%), right-sided in 15 (36%) and bilateral in two (5%). RESULTS: Two groups of patients can be identified: group A (n = 36, 88%) with acute BDR, and group B (n = 5, 12%) with post-traumatic diaphragmatic hernia (TDH). In group A, immediate diagnosis was made in 35 cases (97%), but only in 26 (72%) preoperatively. In one case, a right BDR was missed on initial evaluation but became apparent 2 weeks later. Associated injuries were present in 34 patients (94%) involving: spleen (n = 18), rib fractures (n = 17), liver (n = 14), lung (n = 11), bowel (n = 7), kidney (n = 5) and other fractures (n = 21). Injury Severity Score (ISS) ranged from 9 to 66 (mean: 31). BDR repair was accomplished through a laparotomy in 22 cases, thoracotomy in 10 and laparo-thoracotomy in four. The overall mortality rate was 16.6% (6/36). Both patients with bilateral BDR died. The patients who died were older than the survivors (mean age: 54 vs. 39 years, P<0.05), were more severely injured (mean ISS: 46 vs. 28, P<0.05) and were in shock (100 vs. 23%, P<0.05). In group B with TDH, diagnosis was delayed for 7-16 months after injury. Four patients had non-specific clinical signs and one strangulation of hollow viscera. One patient had undergone surgery during acute injury but BDR was overlooked. Location of TDH was on the left in three cases and on the right in two. Delay in BDR diagnosis was 12.5% (3/24) in patients with left-sided and 20% (3/15) in patients with right-sided lesions (P>0.1). Repair of TDH was achieved through thoracotomy in all cases. No mortality or major morbidity were encountered. CONCLUSIONS: (1) Predictors of BDR mortality are: age, ISS and hemodynamic status of the patient. (2) Delay in diagnosis does not influence the outcome and is not influenced by the side of BDR location. (3) BDR can easily be missed in the absence of other indications for prompt surgery, where a thorough examination of both hemidiaphragms is mandatory. A high index of suspicion combined with repeated and selective radiologic evaluation is necessary for early diagnosis.

Adolescent↗
PubMed2002

The receiver operating characteristic curve for the standard uptake value in a group of patients with bone marrow metastasis.

PURPOSE: The aim of this work was to determine the standard uptake value (SUV) threshold for differentiating malignant from benign bone lesions. MATERIAL AND METHODS: Ninety-nine bone sites in 33 patients who had undergone a 2-deoxy-2-[18F]fluoro-D-glucose-positron emission tomography (FDG-PET) study for cancer evaluation were studied. In addition to FDG-PET, a bone scan and at least two of the following determinations: magnetic resonance imaging (MRI), computed tomography (CT), and x-ray were conducted in each patient. The bone lesions were considered positive for malignancy if confirmed by clinical follow-up or a high degree of suspicion based on the positive results of at least three (which must include bone scan) out of four other imaging modalities. By these criteria, 39 lesions were considered positive and 60 were considered negative. The SUV values were classified as positive or negative using 61 different values of threshold (range from 1.0 to 7.0). These results were compared with the positive criteria above and reclassified as true positive, true negative, false positive, and false negative. The true-positive fraction and false-positive fraction were calculated for each threshold value. The receiver operating characteristic (ROC) curve was drawn and the best value was determined by visual analysis. RESULTS: The SUV threshold was considered 2.5. Twenty-nine out of 39 bone lesions classified as positive showed a SUV > 2.5. Of the 10 false-negative lesions, seven showed a SUV between 1.1 and 2.0, and three were not detected. Fifty-six out of 60 lesions classified as negative showed a SUV < 2.5. Four lesions were false positive: one was a rib fracture and three were severe degenerative changes in the lumbar spine. Using an SUV threshold of 2.5, the sensitivity was 74.3% and the specificity was 93.3%. CONCLUSION: In our patient population, the optimal SUV to classify a bone lesion as malignant or benign is 2.5.

Journal Article↗
PubMedDate not supplied

Pedestrian intoxication and fatal traffic accident injury patterns.

INTRODUCTION: Sixteen percent of all motor-vehicle fatalities are pedestrian, and accidents involving pedestrians are associated with the highest morbidity and mortality rates. Classic pedestrian injury patterns have been described. However, it has been suggested that the pattern may differ if the pedestrian is intoxicated. The role of pedestrian intoxication on motor-vehicle accident injury patterns has not been well-delineated. HYPOTHESIS: Intoxicated pedestrian traffic victims have an injury pattern that is more serious and more rapidly fatal than is the pattern for nondrinking victims. METHODS: Autopsies of 223 consecutive pedestrian victims were reviewed and grouped according to the presence of alcohol in the blood: Group I, Negative (n = 165); Group II, Positive (n = 58). Gender, age, anatomic injuries, survival time, time of day, and year also were examined. RESULTS: Results indicated that there were more males in Group II (79%) than in Group I (64%); younger victims, younger than 40 years old, in Group II (70%) than in Group I (34%); fewer victims older than 60 years old in Group II (8%) than in Group I (38%). Group II sustained more frequent and more severe injuries--two times the frequency of the cervical spine, liver, upper and lower extremity, pelvic and rib fractures and thoracolumbar spine injuries; three times more aortic injuries; five times more heart injuries. Death occurred within 24 hours in 95% of those in Group II and in 67% of those in Group I. Accidents occurred from 1500h to 2300h in 67% of Group II and in 53% of Group I victims. CONCLUSION: Intoxicated pedestrian accident victims are predominantly young men, struck between 1500h and 0700h; they have an injury pattern that is two to five times more serious than is the pattern for the sober victims.

Accidents, Traffic↗
PubMed2003

Type of consent does not influence patient recall of serious potential radiation toxicity of adjuvant breast radiotherapy.

In a sample of 174 women who had received verbal consent (n = 35), general written consent (n = 34) or detailed toxicity-specific written consent (n = 105), no significant differences were found in recall of serious potential toxicities by consent type. Age younger than 70 years and employment outside of the home were significantly associated with better recall. Factors not significantly associated with different recall rates were work status, use of interpreters for consent, time elapsed from treatment or the extent of radiotherapy (tangents only vs other). Overall recall was poor. Twenty-eight percent of women could not correctly recall if their treatment risked any of four nominated complications (lymphoedema, pneumonitis, rib fracture or brachial plexopathy). Significant numbers of women erroneously attributed a number of 'complications' or symptoms to radiotherapy.

Adult↗
PubMed2001

Long-term survival in patients with non-small cell lung cancer treated with palliative radiotherapy.

The aim of palliative thoracic radiotherapy in patients with advanced non-small cell lung cancer (NSCLC) is to alleviate symptoms. This study was designed to determine whether any patients achieved long-term survival after this treatment. In Edinburgh, between 1974 and 1993, 4531 patients were treated with palliative radiotherapy for NSCLC, receiving ten fractions or fewer. We reviewed the case notes of the long-term survivors. Sixty-one (1.3%; 95% confidence interval (CI) 1.0-1.6) patients survived for more than 5 years; 43 (70%) had histological confirmation of cancer; 28 (46%) had stage Stage I or II, 28 (46%) Stage III and one Stage IV disease; 53 (87%) patients were treated with doses of 30-35 Gy in ten daily fractions, seven (12%) received 20 Gy in five daily fractions and one received a 10 Gy single fraction. Forty-two (69%) patients had a radiological complete response, 16 (26%) a partial response and the remainder stable disease. Clinically significant radiation pneumonitis occurred in one (2%) patient, radiation myelopathy in two (3%) and multiple rib fractures in one (2%). There did not appear to be an association between long-term survival and a radiosensitive phenotype. On univariate analysis, long-term survival was more frequent in patients receiving ten-fraction regimens than in those who underwent a shorter course of radiotherapy (chi 2 = 19.5, P < 0.001). Thirty-four (0.8%; 95% CI 0.6-1.0) patients were disease free at death or at last review (median 10 years; range 5-17). We conclude that palliative thoracic radiotherapy produces long-term survival in 1.3% and personal cure in up to 1% of patients with advanced NSCLC.

Aged↗
PubMed2004

The diagnosis and management of children with blunt injury of the chest.

Thoracic trauma remains a major source of morbidity and mortality in injured children, and is second only to brain injuries as a cause of death. The presence of a chest injury increases an injured child's mortality by 20-fold. Greater than 80% of chest injuries in children are secondary to blunt trauma. The compliant chest wall in children makes pulmonary contusions and rib fractures the most common chest injuries in children. Injuries to the great vessels, esophagus, and diaphragm are rare. Failure to promptly diagnose and treat these injuries results in increased morbidity and mortality.

Blood Vessels↗
PubMed2000

[Left ventricular aneurysm after myocardial contusion caused by blunt chest trauma].

A 30-year old male car-driver was polytraumatized after a frontal collision with another motor vehicle (left-sided rib fractures, right-sided pneumothorax, multiple lung contusions, anterior and posterior pelvic ring fracture, femoral shaft fracture, traumatic subarachnoid hemorrhage. After intubation and hemodynamic stabilization on the scene of accident, he was transported to our institution. Transesophageal echocardiography revealed a left-ventricular anteroseptal akinesia and patchy intramyocardial hyperdensities as indicator of myocardial contusion which was confirmed later by autopsy. In the further course, the patient developed an anteroseptal aneurysm with severe left ventricular dysfunction nad episodes of arrhythmias. Finally, septic shock complicated the case and the patient died 30 days of intensive care from therapy-refractory multiple organ system failure.

Accidents, Traffic↗
PubMed2001

Bronchial repair with pulmonary preservation for severe blunt trauma.

After a motorcycle accident, a 22-year-old male was diagnosed with multiple rib fractures, left-sided tension pneumothorax, hemothorax and left upper lobe bronchus rupture at its origin. An emergency left thoracotomy revealed an almost complete avulsion of the upper lobe bronchus from the main stem bronchus, a severely damaged pulmonary artery, and a concurrent deep intraparenchymal lower lobe laceration. Since the patient was hemodynamically stable, a decision was made to preserve as much lung as possible. In the event of complex pulmonary trauma, pulmonary preservation is desirable since emergency pneumonectomy is usually associated with high mortality. Early bronchoscopic assessment, careful anesthetic management, and meticulous surgical technique with liberal use of fibrin glue were crucial to successful outcome.

Adult↗