General Surgery, Department of

The Most Commonly Occurring Papillary Thyroid Cancer in the United States Is Now a Microcarcinoma in a Patient Older than 45 Years

Tue, 01 Mar 2011 00:00:00 GMT

The Most Commonly Occurring Papillary Thyroid Cancer in the United States Is Now a Microcarcinoma in a Patient Older than 45 Years Hughes, David T.; Haymart, Megan R.; Miller, Barbra S.; Gauger, Paul G.; Doherty, Gerard M. Background: The incidence of papillary thyroid cancer (PTC) is growing at a faster rate than any other malignancy. However, it is unknown what effect age is having on the changing PTC incidence rates. With the goal of understanding the role of age in thyroid cancer incidence, this study analyzes the changing demographics of patients with PTC over the past three decades. Methods: This was a retrospective evaluation of the incidence rates of PTC from 1973 to 2006 reported by the National Cancer Institute's Surveillance, Epidemiology, and End Results database. Results: From 1973-2006 the age group most commonly found to have PTC has shifted from patients in their 30s to patients in the 40-50-year-old age group. In 1973 60% of PTC cases were found in patients younger than 45, and the majority of cases continued to occur in younger patients until 1999. After 1999 PTC became more common in patients older than 45 years, and in 2006, 61% of PTC cases were in patients older than 45 years. From 1988 to 2003 there has been an increasing incidence of all sizes of PTC in all age groups with the largest increase in tumors <1-cm in patients older than 45. Forty-three percent of tumors in patients older than 45 are now <1-cm, whereas only 34% are <1-cm in patients younger than 45. Of the nearly 20,000 thyroid cancer cases in 2003, 24% were microcarcinomas in patients over the age of 45. Conclusions: The incidence of PTC is increasing disproportionally in patients older than 45 years. The number of PTC tumors smaller than 1-cm is increasing in all age groups, and now the most commonly found PTC tumor in the United States is a microcarcinoma in a patient older than 45 years. These changing patterns relating age and incidence have important prognostic and treatment implications for patients with PTC.

Extracorporeal Membrane Oxygenation in the Context of the 2009 H1N1 Influenza A Pandemic

Fri, 01 Apr 2011 00:00:00 GMT

Extracorporeal Membrane Oxygenation in the Context of the 2009 H1N1 Influenza A Pandemic Sihler, Kristen C.; Park, Pauline K. Background: Extracorporeal membrane oxygenation (ECMO) incorporates surgical techniques as adjuncts in the management of refractory respiratory dysfunction. For many years, its primary application was for support of neonatal infants in cardiorespiratory failure. As the 2009 H1N1 influenza A pandemic developed, more reports came in of severe respiratory dysfunction and even death that seemed to be occurring preferentially in younger adults. Centers with the capability began to use ECMO to salvage these patients. Results: The H1N1 virus is a subtype of influenza A. The hemagglutinin receptor binding is similar to that of the seasonal influenza virus, but 2009 H1N1 also binds to •2,3-linked receptors, which are found in the conjunctivae, distal airways, and alveolar pneumocytes. Influenza viruses elude host immune responses through drift and shift in the hemagglutinin (HA) and neuraminidase (NA) proteins. The incubation period ranges from 1-7 days. The majority of patients present with fever and cough, but a broad spectrum of clinical syndromes has been reported, and laboratory testing remains the mainstay of diagnosis. Most patients recover within a week without treatment. The H1N1 virus remains largely sensitive to the NA inhibitors but is resistant to the matrix protein-2 inhibitors. Extracorporeal membrane oxygenation provides continuous pulmonary (and sometimes cardiac) support and minimizes ventilator-induced lung injury. The potential for life-threatening complications is high. In 2009, in the Conventional Ventilation or ECMO for Severe Adult Respiratory Failure (CESAR) randomized trial of ECMO, the overall survival rate was 63% in the ECMO group compared with 47% in the control group (p = 0.03). Similar studies have been reported from Australia and New Zealand, Canada, and France. Conclusions: Supportive management is continued along with ECMO. Antiviral drugs and antimicrobial agents should be given as appropriate, as should nutritional support. Volume management should be used. Ventilator settings should be reduced as ECMO support allows, with a goal of reducing airway pressures, ventilator rate, and FiO2. Complications of ECMO are common. Bleeding, the most common, can result in death, especially if it occurs intracranially.

Aeromonas Pneumonia in a Trauma Patient Requiring Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome: Case Report and Literature Review

Wed, 01 Jun 2011 00:00:00 GMT

Aeromonas Pneumonia in a Trauma Patient Requiring Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome: Case Report and Literature Review Issa, Nabil; Napolitano, Lena M. Background: Aeromonas species, particularly Aeromonas hydrophila, cause a wide spectrum of diseases in human being such as gastroenteritis; soft tissue infections including necrotizing fasciitis, meningitis, peritonitis, and bacteremia; but pneumonia and respiratory tract infections are uncommon. Methods: Case report and literature review. Results: A 30-year-old victim of a motor vehicle crash sustained pelvic fractures and splenic injury. Delayed splenic rupture caused sudden cardiorespiratory arrest. The patient was resuscitated but suffered septic shock and severe hypoxemia refractory to advanced mechanical ventilatory strategies. Aeromonas hydrophila was isolated as the causative pathogen of severe bilateral pneumonia. Venovenous extracorporeal membrane oxygenation (ECMO) was used temporarily. The patient recovered uneventfully. Conclusion: This is the first case, to our knowledge, of the use of ECMO in a trauma patient with severe fulminant A. hydrophila pneumonia. Clinicians should be aware of the characteristics of this pathogen and associated clinical infections.

Prevention of Catheter-Related Blood Stream Infection: Back to Basics?

Tue, 01 Feb 2011 00:00:00 GMT

Prevention of Catheter-Related Blood Stream Infection: Back to Basics? Cherry-Bukowiec, Jill R.; Denchev, Krassimir; Dickinson, Sharon; Chenoweth, Carol E.; Zalewski, Christy; Meldrum, Craig; Sihler, Kristen C.; Brunsvold, Melissa E.; Papadimos, Thomas J.; Park, Pauline K.; Napolitano, Lena M. Background: Central venous catheter (CVC)-related infections are a substantial problem in the intensive care unit (ICU). Our infection control team initiated the routine use of antiseptic-coated (chlorhexidine-silver sulfadiazine; Chx-SS) CVCs in our adult ICUs to reduce catheter-associated (CA) and catheter-related (CR) blood stream infection (BSI) as we implemented other educational and best practice standardization strategies. Prior randomized studies documented that the use of Chx-SS catheters reduces microbial colonization of the catheter compared with an uncoated standard (Std) CVC but does not reduce CR-BSI. We therefore implemented the routine use of uncoated Std CVCs in our surgical ICU (SICU) and examined the impact of this change. Hypothesis: The use of uncoated Std CVCs does not increase CR-BSI rate in an SICU. Methods: Prospective evaluation of universal use of uncoated Std CVCs, implemented November 2007 in the SICU. The incidences of CA-BSI and CR-BSI were compared during November 2006-October 2007 (universal use of Chx-SS CVCs) and November 2007-October 2008 (universal use of Std CVCs) by t-test. The definitions of the U.S. Centers for Disease Control and Prevention were used for CA-BSI and CR-BSI. Patient data were collected via a dedicated Acute Physiology and Chronic Health Evaluation (APACHE) III coordinator for the SICU. Results: Annual use of CVCs increased significantly in the last six years, from 3,543 (2001) to 5,799 (2006) total days. The APACHE III scores on day 1 increased from a mean of 54.4 in 2004 to 55.6 in 2008 (p = 0.0010; 95% confidence interval [CI] 1.29-5.13). The mean age of the patients was unchanged over this period, ranging from 58.2 to 59.6 years. The Chx-SS catheters were implemented in the SICU in 2002. Data regarding the specific incidence of CR-BSI were collected beginning at the end of 2005, with mandatory catheter tip cultures when CVCs were removed. Little difference was identified in the incidence of BSI between the interval with universal Chx-SS use and that with Std CVC use. (Total BSI 0.7 vs. 0.8 per 1,000 catheter days; CA-BSI 0.5 vs. 0.8 per 1,000 catheter days; CR-BSI 0.2 vs. 0 per 1,000 catheter days.) No difference was seen in the causative pathogens of CA-BSI or CR-BSI. Conclusion: Eliminating the universal use of Chx-SS-coated CVCs in an SICU with a low background incidence of CR-BSIs did not result in an increase in the rate of CR-BSIs. This study documents the greater importance of adherence to standardization of the processes of care related to CVC placement than of coated CVC use in the reduction of CR-BSI.