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Gregoire C.,Dalhousie University | Adler D.,Legacy Emanuel Medical Center | Madey S.,Legacy Emanuel Medical Center | Bell R.B.,Oregon Health And Science University
Journal of Oral and Maxillofacial Surgery | Year: 2011

Basosquamous carcinoma (BSC) or metatypical carcinoma is a rare and controversial form of basal cell carcinoma (BCC) that was first described by MacCormac in 1910. Numerous theories have been described in the literature regarding its origin but it is generally accepted as a variant of BCC that differentiates into squamous cell carcinoma (SCC). At present, it has an unsatisfactorily established phenotype but is considered to behave more like an SCC than a BCC. A reflection of this fact is its more aggressive nature with a significantly increased incidence of local and distant metastasis. It must be distinguished histologically from so-called "collision" tumors, which represent SCC and BCC arising as separate entities in the same area. We present a unique case of a neglected, large, and locally advanced case of BCC originating from the nose, but extending into the paranasal sinuses, orbit, and anterior skull base, that was treated with en bloc surgical resection using intraoperative navigation to assist in treatment planning and margin clearance. © 2011 American Association of Oral and Maxillofacial Surgeons.


Markiewicz M.R.,Oregon Health And Science University | Bell R.B.,Oregon Health And Science University | Bell R.B.,Providence Cancer Center | Bell R.B.,Legacy Emanuel Medical Center
Facial Plastic Surgery Clinics of North America | Year: 2011

The authors present an overview of 3D computer-aided design and computer-aided modeling tools available to the facial plastic surgeon. They describe the role of 3D tools in all phases of computer-aided surgery including: data acquisition, planning, surgery, and assessment. Applications of these tools include obtaining 3D measurements, using mirror imaging to reconstruct missing areas of the head and neck, and 3D sizing or segmentation of bone and soft tissue. They review of clinical outcomes obtained from studies reviewing 3D tools. These systems have potential value for education, reducing operating room time, and improving clinical outcomes. © 2011 Elsevier Inc.


Markiewicz M.R.,Oregon Health And Science University | Bell R.B.,Oregon Health And Science University | Bell R.B.,Providence Cancer Center | Bell R.B.,Legacy Emanuel Medical Center
Current Opinion in Otolaryngology and Head and Neck Surgery | Year: 2011

Purpose of review: To review the past year's literature regarding current computer-assisted reconstruction techniques and their outcomes. Recent findings: Current computer-assisted craniofacial reconstruction research is focused on data acquisition, planning, surgical and assessment phases. The major areas of interest among researchers include cosmetic surgery; cleft and craniofacial surgery; traumatic reconstruction, head and neck tumor reconstruction; and orthognathic surgery and distraction osteogenesis. Recent advances in the fields include facial analysis and planning in rhinoplasty, facial surface and bone graft volume analysis in cleft surgery, computer-guided tumor ablation and osteocutaneous reconstruction in tumor surgery, and preoperative planning and surgical assistance in orthognathic and distraction osteogenesis surgery. Summary: Research in computer-aided craniofacial surgery is progressing at a rapid rate. Rather than just the latest innovation, sound research studies are proving computer assistance to be invaluable in producing superior outcomes, especially in the fields of head and neck surgery, orthognathic surgery, and craniomaxillofacial trauma surgery. Further outcome studies and cost-benefit analyses are still needed to show the superiority of these methods to contemporary techniques. © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins.


Martin M.J.,Legacy Emanuel Medical Center | Martin M.J.,U.S. Army | Hatch Q.,U.S. Army | Cotton B.,University of Texas Health Science Center at Houston | Holcomb J.,University of Texas Health Science Center at Houston
Journal of Trauma and Acute Care Surgery | Year: 2012

BACKGROUND: Temporary abdominal closure (TAC) has become a widely used technique in severely injured patients. However, there is growing concern that TAC is being overutilized. We sought to identify less severely injured patients who underwent TAC and to compare their outcomes with patients managed with a single-stage laparotomy (SSL). METHODS: This is a analysis of all trauma patients who underwent immediate laparotomy from 2005 to 2009. Risk modeling identified TAC patients who met all low-risk criteria: systolic blood pressure >90, no severe head injury, no combined solid + hollow viscus injury, or vascular injury. The low-risk cohort (LR-TAC) was compared with a matched similarly injured cohort managed with SSL using univariate and multivariate regression analysis. RESULTS: Among the 282 patients undergoing TAC, 62 (22%) met low-risk criteria and were included in the LR-TAC group. There were 566 patients identified in the SSL group. There was no significant difference between groups for age, mechanism, Injury Severity Scores, associated injuries, base deficit, temperature, blood transfusion, solid organ injury, or bowel resection. The LR-TAC group had more hospital and ventilator days and increased complications rates (all p < 0.05). This included a higher rate of bowel ischemia/perforation with LR-TAC (7% vs. 0.7%). The use of TAC in the low-risk group was independently associated with increased complications (odds ratio 3.0, p = 0.01) and prolonged hospital stays (odds ratio 9.6, p < 0.01). CONCLUSIONS: TAC was associated with increased morbidity and resource utilization when applied to less severely injured patients. Further study is indicated to clarify populations that may be harmed or benefitted by TAC. Copyright © 2012 by Lippincott Williams & Wilkins.


Cook J.O.,Legacy Emanuel Medical Center
Current Respiratory Medicine Reviews | Year: 2015

Point-of-care ultrasound is an increasingly utilized technology in the management of the acutely injured patient. Ultrasonography has demonstrated utility and improved outcomes in rapidly detecting pnemothorax, intrapericardial blood and assessing cardiac function in the hemodynamically unstable patient. Examination of the thorax incorporated into the FAST exam (termed E-FAST, or extended FAST exam) enables rapid recognition of pathology within the trauma bay, permitting earlier intervention. © 2015, Bentham Science Publishers.


Hegsted D.,Legacy Emanuel Medical Center | Gritsiouk Y.,Legacy Emanuel Medical Center | Schlesinger P.,Legacy Emanuel Medical Center | Gardiner S.,Legacy Emanuel Medical Center | Dean Gubler K.,Legacy Emanuel Medical Center
American Journal of Surgery | Year: 2013

Background: Trauma patients are at risk for the development of venous thromboembolism (VTE). The purpose of this study was to validate the Risk Assessment Profile (RAP) as a tool for stratifying the risk of VTE. Methods: RAP scores were calculated in a retrospective cohort analysis for all trauma patients aged 13 years or older admitted in 2003 and 2006 and hospitalized longer than 48 hours. Association of RAP with VTE, sensitivity, specificity, and receiver operating characteristic curve were included in the analysis. Results: Of 2,281 patients, deep vein thrombosis (DVT) developed in 239 (10.5%) and pulmonary embolism (PE) developed in 34 (1.5%). In moderate- and high-risk patients, the RAP had a sensitivity of.82 and a specificity of.57. Identification of VTE for high-risk patients had a sensitivity.15 and a specificity of.97. The incidence of VTE increased significantly with risk level regardless of mechanism of injury. Conclusions: The RAP score is highly associated with VTE in trauma patients regardless of mechanism of injury and is a valid risk assessment tool. © 2013 Elsevier Inc. All rights reserved.


Michaels A.J.,Legacy Emanuel Medical Center | Hill J.G.,Legacy Emanuel Medical Center | Long W.B.,Legacy Emanuel Medical Center | Young B.P.,Legacy Emanuel Medical Center | And 3 more authors.
American Journal of Surgery | Year: 2013

Background: The investigators present a series of adults with severe acute respiratory distress syndrome (ARDS) who were treated with extracorporeal membrane oxygenation (ECMO) at a regional referral center. Methods: Patients with refractory hypoxic ARDS received ECMO until they recovered lung function or demonstrated futility. ECMO was initiated at the referring facility if necessary, and aggressive critical care was maintained throughout. Results: ARDS due to multiple etiologies was managed with ECMO in 36 adults. The pre-ECMO ratio of partial pressure of oxygen to fraction of inspired oxygen was 48.3 ± 2.2. Regional facilities referred 89% of these patients, and 69% required ECMO for transport. The mean duration of ECMO was 7.1 ±.9 days for survivors, and the mean post-ECMO ratio of partial pressure of oxygen to fraction of inspired oxygen was 281.2 ± 11. ECMO was successfully weaned in 67% of patients, and 60% survived to discharge. Conclusions: ECMO provides support that prevents ventilator-induced lung injury while the lungs heal. The investigators present a series of 36 adults with refractory hypoxemic ARDS (ratio of partial pressure of oxygen to fraction of inspired oxygen <50) from 17 different facilities who, treated with ECMO at a single referral center, had a 60% survival rate. © 2013 Elsevier Inc. All rights reserved.


Nadler O.A.,Legacy Emanuel Medical Center | Finkelstein M.J.,Childrens Hospitals and Clinics of Minnesota | Reid S.R.,Childrens Hospitals and Clinics of Minnesota
Pediatric Emergency Care | Year: 2011

Objective: The objective of the study was to determine whether serum bicarbonate (HCO 3) concentration can accurately predict venous pH in the evaluation of diabetic ketoacidosis (DKA). Methods: A retrospective review of patients who presented to a children's hospital emergency department and received an International Classification of Diseases, Ninth Revision code related to DKA or diabetes mellitus was performed. To be eligible for inclusion and data abstraction, patients had blood sampled simultaneously for venous blood gas and metabolic panel. A linear regression model was created using pH (dependent variable) and HCO 3 (predictor). The diagnostic performance and accuracy of HCO 3 to discriminate abnormal pH were evaluated using receiver operating characteristic curve analysis. Results: Three hundred patients met the inclusion criteria. The linear relationship between pH and HCO 3 using the Pearson correlation coefficient was found to be R = 0.89 (confidence interval [CI], 0.83-0.95; R 2 = 0.79). Receiver operating characteristic curve analysis that maximized sensitivity and specificity demonstrated that a HCO 3 18.5 or less predicts pH less than 7.3 (area under the curve = 0.97; CI, 0.94-0.99; sensitivity, 93%; specificity, 91%), and a HCO 3 10.5 or less predicts pH less than 7.1 (area under the curve = 0.97; CI, 0.95-0.99; sensitivity, 97%; specificity, 88%). Conclusions: Serum bicarbonate accurately predicts abnormal venous pH in children with DKA. Venous pH determination may not be necessary for all patients being evaluated for DKA. Copyright © 2011 by Lippincott Williams & Wilkins.


Miller L.D.,Pacific Northwest Transplant Bank | Gardiner S.K.,Devers Eye Institute | Gubler K.D.,Legacy Emanuel Medical Center
American Journal of Surgery | Year: 2014

Background: This study sought to determine whether early referral from the emergency department (ED) would increase the number of organ donors and the number of organs transplanted per donor (OTPD). Methods: This is a retrospective cohort analysis of all patients referred to a single organ procurement organization for a period of 60 months. Results: Patients referred for organ donation evaluation from the ED were more likely to become organ donors than patients referred from the intensive care unit (19.3% vs 5.2%, P <.001). ED referrals had a greater number of OTPD than those referred from the intensive care unit (mean 3.79 vs 3.16, P =.024), even after adjusting for the higher proportion of ED referrals who were trauma patients (P =.001). Conclusions: Referral for organ donation from the ED is associated with an increased likelihood of organ recovery and with an increased number of OTPD. © 2014 Elsevier Inc. All rights reserved.


Gritsiouk Y.,Legacy Emanuel Medical Center | Hegsted D.A.,Legacy Emanuel Medical Center | Schlesinger P.,Legacy Emanuel Medical Center | Gardiner S.K.,Legacy Emanuel Medical Center | Gubler K.D.,Legacy Emanuel Medical Center
American Journal of Surgery | Year: 2014

Background: In trauma patients, Enoxaparin (a low molecular weight heparin, LMWH) prophylaxis for venous thromboembolism (VTE) risk reduction is unproven. Methods: Cohort analysis conducted consisting of all trauma patients age >13 admitted to Level-I trauma center and hospitalized >48 hours. VTE risk determined by the Risk Assessment Profile. High risk patients received LMWH unless contraindicated, while low and moderate risk patients received LMWH at attending surgeon's discretion. Odds ratio for VTE by logistic regression. VTE incidence, relative risk (RR), and number needed to treat (NNT) to prevent deep vein thrombosis (DVT) or pulmonary embolism determined by risk category. Results: Cohort consisted of 2,281 patients (1,211 low, 979 moderate, 91 high risks). VTE occured in 254 patients (11.1%). High-risk patients had significantly higher VTE incidence, odds ratio = 31.8 (P <.001). VTE was significantly reduced in high-risk patients receiving LMWH versus those who did not (.26 vs.53, P =.02). Among moderate and high risk, prophylactic LMWH reduced the incidence of pulmonary embolism (RR =.19, NNT = 40.4, P =.01), and trended toward reduced DVT incidence (RR =.81, NNT = 27.3, P =.15). LMWH lowered DVT incidence (RR =.52, NNT = 4.1, P =.03) in high risk patients. Conclusion: Prophylactic LMWH is associated with reduction of VTE in trauma patients. © 2014 Elsevier Inc. All rights reserved.

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