Recent Publications by CFE Educators

BACKGROUND

Computed tomographic angiography (CTA) has been established as a valid modality for the assessment of extremity vascular injury. Over the last several years at our institution, CTA has evolved as the primary diagnostic modality for penetrating extremity injuries, largely replacing diagnostic angiography. The purpose of this study was to evaluate the outcomes with this imaging modality at a high-volume Level I trauma center.

METHODS

A retrospective review was conducted of all patients presenting with penetrating lower extremity trauma between 2008 and 2009. Patient factors collected included demographics, mechanism of injury, injury severity, presence of hard signs of vascular injury, radiologic studies, operative intervention, and outcomes.

RESULTS

There were 132 patients with penetrating lower extremity trauma. The average age of the patients was 25 years, with an average injury severity score of 10. The injuries were primarily gunshot wounds (89%). In all, 59 patients (45%) underwent CTA. CTA of the extremity was performed as a continuation of a computed tomography of the chest/abdomen/pelvis in 28 (47%) versus a targeted CTA of the extremity in 31 (53%) patients. In all, 34 (58%) CTAs were negative for vascular injury, 19 (32%) were positive, and six (10%) were indeterminate. Of the 34 patients with a normal CTA, none went to the operating room for repair of a major vascular injury; similarly, of the 19 patients with an abnormal CTA, there were no negative operative explorations. A total of 28 (21%) patients required operative intervention for the injured extremity; procedures performed included fasciotomy, venous and arterial ligation, primary repair, and interposition grafting. There were no amputations and no mortalities.

CONCLUSIONS

Our results support the use of CTA as the primary imaging modality in evaluating penetrating lower extremity injury. Because of its proven accuracy in detecting major vascular injury, cost-effectiveness, and ease and rapidity of administration and interpretation, CTA should supplant conventional angiography in initial evaluation of the patient presenting with penetrating trauma.

To develop a practical informant-based screening tool that reliably identifies patients with mild cognitive impairment (MCI) and dementia, we analyzed data from a sample of patients and normal controls seen in a memory clinic. All patients were evaluated with the Clinical Dementia Rating scale. Individual Clinical Dementia Rating responses were dichotomized and entered into a forward stepwise multivariable logistic regression model. Four independent predictors of MCI and dementia thus identified were combined into a prediction rule that was validated in a separate cohort drawn from the same clinic. Using a cut point of 2 or more positive responses to the 4 questions, the final prediction rule had sensitivity of 95% (95% confidence interval (CI): 92-97%) for MCI or dementia, and a specificity of 91% (95% CI: 86-95%). When applied to the validation cohort, the sensitivity for MCI or dementia was 96% (95% CI: 94-98%), and the specificity was 96% (95% CI: 92-98%). Using both cohorts, the positive likelihood ratio for MCI or dementia was 15.6 (95% CI: 14.0-17.3) and the negative likelihood ratio was 0.05 (95% CI: 0.04-0.07). This tool has the potential to identify patients who warrant further cognitive evaluation in busy outpatient or emergency department settings.

African American and Hispanic women develop more triple negative breast cancer at younger ages than Caucasian women. The frequently observed association between race and socioeconomic status (SES) has confounded our understanding of the outcomes disparities seen in these groups. Given the association between inflammatory cells and high-grade, triple negative tumors, we sought to investigate whether differences in the presence of these cells varies by race. We evaluated breast tumor specimens for the presence PCNA+ tumor-associated macrophages (TAMs) in consecutive cases from a county hospital serving primarily un- or under-insured patients. All patients in this cohort had elevated PCNA + TAM levels. Higher PCNA + TAM counts were associated with hormone receptor (HR) negative tumors and non-Caucasian ethnicity. Hispanic women specifically had significantly higher PCNA + TAM counts than Caucasian patients and shorter disease-free survival. These findings implicate immune function in the development of aggressive breast cancer and suggest a possible link between SES and the inflammatory response.

BACKGROUND

Medullary thyroid microcarcinomas (microMTCs) are medullary thyroid carcinomas (MTCs) that measure ≤1 cm in size for which there is a paucity of data on incidence, characteristics, and clinical significance.

METHODS

Patients who had a diagnosis of microMTC were abstracted from the Surveillance, Epidemiology, and End Results database (1988-2007). The data were analyzed using chi-square tests, t tests, and log-rank tests; multivariate logistic regression was used to identify factors that were associated independently with lymph node metastases. Tests for diagnostic accuracy, including likelihood ratio tests and post-test probability tests, were computed to evaluate the size-specific likelihood of developing lymph node metastases among patients with microMTC.

RESULTS

In total, 310 patients had microMTC; its incidence increased during the study period (P(trend) = .033), and microMTC as a proportion of all MTCs increased by 39%. The mean tumor size was 5.7 mm. Thirty-one percent of tumors were multifocal, and 7.8% had extrathyroid extension. Lymph node metastases occurred in nearly 37% of patients who had any lymph nodes removed (65 of 176 patients). Nearly 20% of patients had regional disease, and 5% had distant metastases. The overall 10-year survival rates for patients with localized, regional, and distant disease stages were 96%, 87%, and 50%, respectively (P .001). After adjustment, extrathyroid extension (odds ratio [OR], 41.9; P .001) and tumor size (OR, 1.2; P = .008) retained an independent association with lymph node metastases. MTCs that measured ≤5 mm were associated with a probability of lymph node metastases of approximately 23%, and the probability increased for patients who had tumors >5 mm.

CONCLUSIONS

The current results indicated that microMTCs have significant rates of poor prognostic features known to impact the survival of patients with MTC. These microcarcinomas are an important clinical entity that requires comprehensive evaluation and surgical management.

BACKGROUND

Reported accuracy of preoperative localization imaging for primary hyperparathyroidism (pHPT) varies. The purpose of this study is to determine the accuracy of ultrasound, sestamibi-single photon emission computed tomography (SPECT), and four-dimensional computed tomography (4D-CT) as preoperative localization strategies.

METHODS

A meta-analysis was performed of studies investigating the accuracy of ultrasound, sestamibi-SPECT, and 4D-CT for preoperative localization in pHPT. Electronic databases were systematically searched, and two independent reviewers reviewed results using specific criteria. Study quality was assessed using a validated measure for diagnostic imaging studies. Study heterogeneity and pooled results were calculated.

RESULTS

43 studies met criteria for inclusion, and data were available for extraction in 19 ultrasound, 9 sestamibi-SPECT, and 4 4D-CT studies. Ultrasound had pooled sensitivity and positive predictive value (PPV) of 76.1% (95% CI 70.4-81.4%) and 93.2% (90.7-95.3%), respectively. Sestamibi-SPECT had pooled sensitivity and PPV of 78.9% (64-90.6%) and 90.7% (83.5-96.0%), respectively. Only two 4D-CT studies investigated patients undergoing initial parathyroidectomy. Results suggested sensitivity and PPV of 89.4% and 93.5%, respectively.

CONCLUSIONS

Ultrasound and sestamibi-SPECT are similar in ability to preoperatively localize abnormal parathyroid glands in pHPT. Accuracy may be improved with 4D-CT; however, further investigation is required. Choice of preoperative imaging strategy depends on numerous patient, institutional, and economic factors of which the surgeon must be aware.

OBJECTIVE

The objective of this study was to localize impacted canines in 3 dimensions and determine the most common location of impaction using cone beam computed tomography (CBCT). We also assessed root resorption of adjacent teeth. The cusp tip of each impacted canine was located and digitized using Dolphin 3D imaging, after viewing sagittal, coronal, and axial views. The position on the occlusal plane where the normally erupted canine cusp tip should be located was used as a control reference point. The degree of impaction was defined by the difference between the impacted canine cusp tip and reference cusp tip positions.

MATERIALS AND METHODS

CBCT scans of 29 consecutive individuals with impacted canines undergoing orthodontic treatment at the UCSF Orthodontic Clinic were included in this study.

RESULTS

The average degree of mesial impactions was 10.1 mm, of distal impactions was 4.2 mm, of facial impactions was 4.16 mm, of palatal impactions was 1.8 mm, and of gingival impactions was 10 mm; 40.4% had no root resorption, 35.7% showed slight root resorption, 14.2% showed moderate resorption, and 4% showed severe root resorption of the adjacent lateral incisor.

CONCLUSION

We reliably assessed the position of impacted canines in 3 dimensions using CBCT, thereby improving accuracy of location and facilitating precise surgical and orthodontic management. In our study 40.4% had no root resorption, 35.7% showed slight root resorption, 14.2% showed moderate resorption, and 4% showed severe root resorption of the adjacent lateral incisor. The most frequent location of impacted canines was palatal, mesial, and gingival.

OBJECTIVE

To analyze our experience with delayed repair of pediatric urethral trauma.

MATERIALS AND METHODS

From 1978 to 2007, 26 boys 18 years old (mean age 15.0) presented for delayed repair of urethral stricture after blunt trauma. Anterior and posterior urethral injuries were separately stratified.

RESULTS

There were 8 anterior and 18 posterior urethral strictures. All patients presented in a delayed fashion. Mean follow up of the anterior cohort was 2.9 years. All repairs were performed via a ventral onlay buccal graft or anastomotic approach. The mean follow up of the posterior cohort was 1.1 years, and all posterior urethral injuries were repaired via an anastomotic approach. Overall success for anterior stricture disease was 88.9% and for posterior stricture disease was 89.5%. All three urethroplasty failures responded favorably to internal urethrotomy; however, one failed anterior repair and one of the two failed posterior repairs required two internal urethrotomy operations for success. No secondary urethroplasty operations were required and ultimately all patients were voiding per urethra without need for urethral dilation.

CONCLUSION

Delayed, definitive repair of pediatric urethral trauma via open urethroplasty has a high success rate.

BACKGROUND

Most women diagnosed with a fetal anomaly terminate the pregnancy. Little is known about utilization of two procedures: dilation and evacuation (D&E) and induction termination.

STUDY DESIGN

This retrospective cohort study included all women seen at the University of California, San Francisco (UCSF) Prenatal Diagnosis Center (PDC) who underwent a second-trimester abortion for an anomalous pregnancy from 2005 to 2008. We abstracted variables from the PDC database and medical charts to identify predictors associated with undergoing D&E.

RESULTS

Three quarters of the 192 women underwent D&E (n=148). Higher maternal age, proximity to UCSF, earlier gestational age, singleton gestation and genetic anomaly were associated with undergoing D&E. In adjusted analysis, earlier gestational age and singleton gestation were associated with undergoing D&E.

CONCLUSIONS

The D&E procedure was more commonly utilized for terminating an anomalous pregnancy at UCSF than medical induction. Further inquiry is needed to explore how provider counseling influences the choice of D&E vs. induction.