Carbohydrate antigen 19-9 plus carcinoembryonic antigen for prognosis in colorectal cancer: An observational study.

AIM: Carcinoembryonic antigen (CEA) is a primary prognostic marker and can detect colorectal cancer (CRC) recurrence; however, it has low sensitivity. Carbohydrate antigen 19-9 (CA 19-9) can be used as a supplemental tumour marker along with CEA. The purpose of this study was to determine whether preoperative CA 19-9 added to CEA helped predict long-term prognosis and whether follow-up CA 19-9 added to CEA had additional benefits in diagnosing the recurrence of CRC. METHOD: We retrospectively assessed patients who underwent surgery for primary CRC between January 2004 and December 2015 at Seoul National University Hospital. Data on demographics, preoperative and follow-up CEA and CA 19-9 levels, recurrence and survival were obtained and analysed with respect to tumour marker levels to ascertain their prognostic and diagnostic values. RESULTS: A total of 4972 and 1530 patients were included to analyse preoperative and follow-up tumour marker levels, respectively. The 5-year relapse-free survival rates were 72.2% ± 0.8%, 52.5% ± 2.2%, 55.5% ± 3.2% and 32.1% ± 2.3% in the normal CEA and CA 19-9, high CEA, high CA 19-9, and high CEA and high CA 19-9 groups, respectively (all P < 0.001). Patients whose elevated CEA or CA 19-9 levels reduced to normal levels had better survival outcomes than those with postoperatively elevated levels. Elevated follow-up CA 19-9 and CEA levels were related to higher incidences of distant metastasis (CA 19-9, 14.0% vs. 23.1%, P = 0.004; CEA, 12.6% vs. 30.1%, P < 0.001) but not to local recurrence. Combined follow-up CEA and CA 19-9 increased the sensitivity for recurrence to 31.4%, with a 5% difference from the sensitivity of CEA alone. In the subgroup with high preoperative CA 19-9 levels, sensitivity increased by 18.2% overall. CONCLUSION: CA 19-9 is a valuable prognostic and diagnostic marker for CRC when used adjunctively with CEA and can be a supplementary marker with CEA to improve sensitivity, especially with elevated preoperative CA 19-9.

The effects of short bouts of ergometric exercise for severely burned children in intensive care: A randomized controlled trial.

OBJECTIVE: To determine the effects of short bouts of ergometric exercises on the number of days in the burn intensive care unit (ICU), body mass, and functional ambulation. DESIGN: Multi-center, randomized controlled trial. SETTING: Burn intensive care unit. PARTICIPANTS: Children ages 7-17 with severe burns covering over 30% total body surface area (TBSA). INTERVENTION: All patients received standard of care (Control) with the experimental group receiving additional exercise with a cycle ergometer (Exercise). MAIN MEASURES: The number of days in the ICU, total weight, lean body mass (LBM), and functional ambulation were taken shortly after randomization and again within one week of the scheduled hospital discharge. Results of outcomes are expressed as median ± interquartile range (IQR), unless otherwise noted (e.g. demographics). RESULTS: Fifty-four severely burned children (n = 18 Control, n = 36 Exercise) were included. The average ± standard deviation for age was 12 ± 3 years and TBSA was 48 ± 16%. The median ± IQR ICU days for Control was 46 ± 51 days vs 31 ± 29 days for Exercise. The median total weight loss for Control was 2.2 ± 1.2 kg vs 1.8 ± 1.4 kg in Exercise. Control lost 0.75 ± 0.8 kg of LBM vs 0.46 ± 0.43 kg in Exercise. Both groups showed significant improvement in functional ambulation (p < 0.01). However, exercise did not add additional benefits. CONCLUSION: Short bouts of ergometric exercises are feasible for severely burned patients while receiving care in the ICU but did not add additional benefits.

Inhalation Injury in the Burned Patient.

Inhalation injury causes a heterogeneous cascade of insults that increase morbidity and mortality among the burn population. Despite major advancements in burn care for the past several decades, there remains a significant burden of disease attributable to inhalation injury. For this reason, effort has been devoted to finding new therapeutic approaches to improve outcomes for patients who sustain inhalation injuries.The three major injury classes are the following: supraglottic, subglottic, and systemic. Treatment options for these three subtypes differ based on the pathophysiologic changes that each one elicits.Currently, no consensus exists for diagnosis or grading of the injury, and there are large variations in treatment worldwide, ranging from observation and conservative management to advanced therapies with nebulization of different pharmacologic agents.The main pathophysiologic change after a subglottic inhalation injury is an increase in the bronchial blood flow. An induced mucosal hyperemia leads to edema, increases mucus secretion and plasma transudation into the airways, disables the mucociliary escalator, and inactivates hypoxic vasocontriction. Collectively, these insults potentiate airway obstruction with casts formed from epithelial debris, fibrin clots, and inspissated mucus, resulting in impaired ventilation. Prompt bronchoscopic diagnosis and multimodal treatment improve outcomes. Despite the lack of globally accepted standard treatments, data exist to support the use of bronchoscopy and suctioning to remove debris, nebulized heparin for fibrin casts, nebulized N-acetylcysteine for mucus casts, and bronchodilators.Systemic effects of inhalation injury occur both indirectly from hypoxia or hypercapnia resulting from loss of pulmonary function and systemic effects of proinflammatory cytokines, as well as directly from metabolic poisons such as carbon monoxide and cyanide. Both present with nonspecific clinical symptoms including cardiovascular collapse. Carbon monoxide intoxication should be treated with oxygen and cyanide with hydroxocobalamin.Inhalation injury remains a great challenge for clinicians and an area of opportunity for scientists. Management of this concomitant injury lags behind other aspects of burn care. More clinical research is required to improve the outcome of inhalation injury.The goal of this review is to comprehensively summarize the diagnoses, treatment options, and current research.

Macrophage polarization and MRSA infection in burned mice.

Mortality associated with Staphylococcus aureus infection remains high during the sub-acute phase of burn injury. In this study, we aimed to improve antibacterial resistance of sub-acutely burned mice through macrophage polarization. Sepsis did not develop in mice at the sub-acute phase of 5% total body surface area (TBSA) burn after being infected with methicillin-resistant S. aureus (MRSA), and M1 macrophages (interleukin (IL)-10-IL-12+ inducible nitric oxide synthase+ Mφ) were isolated from these mice. In contrast, predominantly M2b macrophages (C-C motif chemokine ligand 1 (CCL1)+IL-10+IL-12- Mφ) were isolated from mice with >15% TBSA burn, and all of these mice died after the same MRSA infection. Comparing NOD scid gamma mice inoculated with Mφ with 25% TBSA burns, all mice treated with CCL1 antisense oligodeoxynucleotide (ODN) survived after MRSA infection, whereas all untreated mice given the same infection died within 4 days. CCL1 antisense ODN has been characterized as a specific polarizer of M2bMφ. M1Mφ were isolated from MRSA-infected mice with 25% TBSA burn after treatment with CCL1 antisense ODN, and these mice were shown to be resistant against a lethal dose of MRSA infection. M1Mφ were also isolated from 25% TBSA-burned mice infected with MRSA when the ODN was administered therapeutically, and subsequent sepsis was effectively controlled in these mice. These results indicate that the M2bMφ polarizer is beneficial for controlling MRSA infection in mice at the sub-acute phase of severe burn injury.

Effect of Exercise Training on the Frequency of Contracture-Release Surgeries in Burned Children.

BACKGROUND: Intensive physical exercise (IPE) increases strength, lean body mass, aerobic capacity, and range of motion in children with extensive burns. However, whether IPE decreases the frequency of burn scar contracture-releasing procedures in children with extensive burns is unknown. MATERIALS AND METHODS: Prospectively collected surgical records of 184 children who had undergone axilla, elbow, and/or wrist contracture-releasing procedures were reviewed. All children were 7 years or older and had sustained burns of at least 40% of the total body surface area. Eighty-two children completed an IPE program, and 102 children did not. For both groups, the axilla, elbow, and wrist were examined for tightness and restricted movement. Children with contractural difficulty were prescribed a releasing procedure. Logistic regression was used to model the relationship between multiple release surgeries and group. RESULTS: Patients in both groups had comparable injury severity. A total of 120 releases were carried out in the 82 IPE patients. In contrast, 211 releases were needed in the 102 non-IPE patients. An approximately 60% decrease in the frequency of rerelease operations was noted in IPE patients (12.5% for the IPE group and 31.8% for non-IPE group; P < 0.05). CONCLUSIONS: When used as an adjunct therapy in postburn rehabilitation, IPE may be useful for reducing the need for contracture release. The mechanisms underlying the beneficial effects of exercise remain undefined and should be investigated.

Satellite cell activation and apoptosis in skeletal muscle from severely burned children.

KEY POINTS: Severe burns result in profound skeletal muscle atrophy that hampers recovery. The activity of skeletal muscle stem cells, satellite cells, acutely following a severe burn is unknown and may contribute to the recovery of lean muscle. Severe burn injury induces skeletal muscle regeneration and myonuclear apoptosis. Satellite cells undergo concurrent apoptosis and activation acutely following a burn, with a net reduction in satellite cell content compared to healthy controls. The activation and apoptosis of satellite cells probably impacts the recovery of lean tissue following a severe burn, contributing to prolonged frailty in burn survivors. ABSTRACT: Severe burns result in profound skeletal muscle atrophy; persistent muscle loss and weakness are major complications that hamper recovery from burn injury. Many factors contribute to the erosion of muscle mass following burn trauma and we propose that an impaired muscle satellite cell response is key in the aetiology of burn-induced cachexia. Muscle biopsies from the m. vastus lateralis were obtained from 12 male pediatric burn patients (>30% total body surface area burn) and 12 young, healthy male subjects. Satellite cell content, activation and apoptosis were determined via immunohistochemistry, as were muscle fibre regeneration and myonuclear apoptosis. Embryonic myosin heavy chain expression and central nucleation, indices of skeletal muscle regeneration, were elevated in burn patients (P < 0.05). Myonuclear apoptosis, quantified by TUNEL positive myonuclei and cleaved caspase-3 positive myonuclei, was also elevated in burn patients (P < 0.05). Satellite cell content was reduced in burn patients, with approximately 20% of satellite cells positive for TUNEL staining, indicating DNA damage associated with apoptosis (P < 0.05). Additionally, a significant percentage of satellite cells in burn patients expressed Ki67, a marker for cellular proliferation (P < 0.05). Satellite cell activation was also observed in burn patients with increased expression of MyoD compared to healthy controls (P < 0.05). Robust skeletal muscle atrophy occurs after burn injury, even in muscles located distally to the site of injury. The activation and apoptosis of satellite cells probably impacts the recovery of lean tissue following a severe burn, contributing to prolonged frailty in burn survivors.

Propranolol attenuates hemorrhage and accelerates wound healing in severely burned adults.

INTRODUCTION: Propranolol, a nonselective ß-blocker, exerts an indirect effect on the vasculature by leaving α-adrenergic receptors unopposed, resulting in peripheral vasoconstriction. We have previously shown that propranolol diminishes peripheral blood following burn injury by increasing vascular resistance. The purpose of this study was to investigate whether wound healing and perioperative hemodynamics are affected by propranolol administration in severely burned adults. METHODS: Sixty-nine adult patients with burns covering ≥ 30% of the total body surface area (TBSA) were enrolled in this IRB-approved study. Patients received standard burn care with (n = 35) or without (control, n = 34) propranolol. Propranolol was administered within 48 hours of burns and given throughout hospital discharge to decrease heart rate by approximately 20% from admission levels. Wound healing was determined by comparing the time between grafting procedures. Blood loss was determined by comparing pre- and postoperative hematocrit while factoring in operative graft area. Data were collected between first admission and first discharge. RESULTS: Demographics, burn size, and mortality were comparable in the control and propranolol groups. Patients in the propranolol group received an average propranolol dose of 3.3 ± 3.0 mg/kg/day. Daily average heart rate over the first 30 days was significantly lower in the propranolol group (P < 0.05). The average number of days between skin grafting procedures was also lower in propranolol patients (10 ± 5 days) than in control patients (17 ± 12 days; P = 0.02), indicative of a faster donor site healing time in the propranolol group. Packed red blood cell infusion was similar between groups (control 5.3 ± 5.4 units vs. propranolol 4.4 ± 3.1 units, P = 0.89). Propranolol was associated with a 5 to 7% improvement in perioperative hematocrit during grafting procedures of 4,000 to 16,000 cm(2) compared to control (P = 0.002). CONCLUSIONS: Administration of propranolol during the acute hospitalization period diminishes blood loss during skin grafting procedures and markedly improves wound healing in severely burned adults. As burn patients require serial surgical interventions for motor and cosmetic repair, restricting blood loss during operative intervention is optimal.

Nutrition in Pediatric Burns.

Nutrition and modulation of the hypermetabolic response to acute burns are reviewed in this article. Methods to determine caloric requirements are evaluated, including indirect calorimetry and predictive equations. Individual nutritional components of carbohydrates, fat, protein, vitamins, and trace elements are discussed specifically in relation to acute burn care. Selection of formula and route of administration are outlined, with an enteral high-carbohydrate, low-fat diet being preferable. Awareness and recognition of the signs and symptoms of malnutrition is critical in the management of variable caloric needs throughout hospitalization. Lastly, the catabolic state of acute burns is addressed through early excision and grafting and implementation of various pharmacologic agents, including growth hormone, insulin-like growth factor-1, insulin-like growth factor-binding protein-3, insulin, propranolol, and oxandrolone. Through a multipronged approach to nutrition, pediatric burn patients are provided the substrates for successful recovery and rehabilitation.

Inhalation Injury.

Inhalation injury is a critical component of thermal injury that can significantly increase mortality in burn survivors. This poses significant challenges to managing these patients and profoundly impacts patient outcomes. This comprehensive literature review delves into the epidemiology, pathophysiology, diagnosis, classification, management, and outcomes of inhalation injury with burns.

Global Surgery: Burn Outreach by Shriners Children's Texas.

Global surgery describes a rapidly developing field that seeks to improve surgical treatment internationally, specifically in those specialized treatments that are not readily accessible, considered complex and expensive. Burns cause 300,000 deaths annually, 90% of which occur in low- and middle-income countries (LMICs). Burns are a public health problem since they can cause disability and death. Shriners Children's Texas is a unique model of global surgery for an important number of countries in Central and South Americas and Mexico, providing specialized acute burn care with low mortality for burned children. Survivors of severe burns may face devastating sequelae due to burn scar contractures and hypertrophic burn scars that may limit the social reintegration. Burn reconstruction is not easily accessible to patients in LMICs. After discharge from acute burn treatment at our hospital, patients may return every 6 months for in-person follow-up to assess any surgical, psychological, or rehabilitative needs. Telemedicine allows for monitoring of postoperative results and evaluation for new surgical procedures. Follow-up clinic visits called outreach clinics held in international hospitals or international Shriners Temples allow for evaluation of follow-up patients and new patients with reconstructive needs that may benefit from a treatment in Shriners Children's Texas in Galveston, Texas.

Update on Hypermetabolism in Pediatric Burn Patients.

Despite advancements in pediatric burn care, the profound hypermetabolic response associated with severe burns remains a multifaceted challenge throughout the continuum of care. Understanding the various physiologic disturbances that constitute hypermetabolism is crucial for a thorough evaluation and for implementing appropriate surgical and nonsurgical interventions. In this article, we describe the pathophysiology and treatment of hypermetabolism in pediatric burn patients with a focus on reducing resting energy requirements, minimizing infection, and optimizing nutrition for patients undergoing frequent surgical intervention.

Benefits and Process of Providing Peer Support for Pediatric Burn Survivors and Caregivers during Inpatient and Outpatient Phases of Recovery.

The World Health Organization reveals that pediatric burns represent a large portion of burns globally (61). Increases in survival rates have guided clinical and research focus on physical, psychological, and social outcomes. Research on other childhood illnesses has shown the efficacy of social support throughout recovery. In the pediatric burn literature, studies have shown the efficacy of burn camps for promoting positive interactions among survivors, learning coping skills, and facilitating socialization and reintegration. However, few studies have focused on the benefits of peer support for pediatric burn survivors and their caregivers in the inpatient and outpatient phases of recovery. This descriptive paper identifies options for building resilience for pediatric burn survivors through peer support in the inpatient and outpatient phases of recovery. The authors discuss options for providing peer support during the coronavirus disease 2019 pandemic on the pediatric intensive care unit, general pediatric floor, and outpatient setting.

Effects of nebulized adipose-derived mesenchymal stem cells on acute lung injury following smoke inhalation in sheep.

INTRODUCTION: Treatment of ARDS caused by smoke inhalation is challenging with no specific therapies available. The aim of this study was to test the efficacy of nebulized adipose-derived mesenchymal stem cells (ASCs) in a well-characterized, clinically relevant ovine model of smoke inhalation injury. MATERIAL AND METHODS: Fourteen female Merino sheep were surgically instrumented 5-7 days prior to study. After induction of acute lung injury (ALI) by cooled cotton smoke insufflation into the lungs (under anesthesia and analgesia), sheep were placed on a mechanical ventilator for 48 hrs and monitored for cardiopulmonary hemodynamics in a conscious state. ASCs were isolated from ovine adipose tissue. Sheep were randomly allocated to two groups after smoke injury: 1) ASCs group (n = 6): 10 million ASCs were nebulized into the airway at 1 hr post-injury; and 2) Control group (n = 8): Nebulized with saline into the airways at 1 hr post-injury. ASCs were labeled with green fluorescent protein (GFP) to trace cells within the lung. ASCs viability was determined in bronchoalveolar lavage fluid (BALF). RESULTS: PaO2/FiO2 in the ASCs group was significantly higher than in the control group (p = 0.001) at 24 hrs. Oxygenation index: (mean airway pressure × FiO2/PaO2) was significantly lower in the ASCs group at 36 hr (p = 0.003). Pulmonary shunt fraction tended to be lower in the ASCs group as compared to the control group. GFP-labelled ASCs were found on the surface of trachea epithelium 48 hrs after injury. The viability of ASCs in BALF was significantly lower than those exposed to the control vehicle solution. CONCLUSION: Nebulized ASCs moderately improved pulmonary function and delayed the onset of ARDS.

Use of Isokinetic Dynamometry To Assess Muscle Function In Burned Patients Is A Reliable Tool To Assist Progressive Resistance Exercise Prescription.

Isokinetic dynamometry is used during exercise testing and rehabilitation to obtain a quantitative strength measurement on which progressive strength training programs can be based. This study assesses the test-retest reliability of isokinetic leg function in the knee flexors and extensors at 150°/s in children and young adults with severe burns to be used for rehabilitation exercise program prescription. In 39 severely burned patients (49 ± 14% total body surface area burn [TBSA], mean ± SD; 34 ± 21% TBSA 3rd degree; 14 ± 5 years, 153.3 ± 16.5 cm height; 53.8 ± 17.9 kg) knee flexion/extension isokinetic dynamometry at 150°/s was performed on each patient's dominant leg in two sessions. The patient was acquainted with the test and performed 1 set of 10 repetitions at 150°/s. A second session of 1 set of 10 repetitions at 150°/ was performed within 24 h of the first. Muscle function outcomes were knee flexion/extension peak torque, average peak torque, and average power. One-sample paired t tests were performed for all muscle function outcomes; intraclass correlation coefficients and r2 values with session two as a function of session one were calculated. Sessions did not differ significantly in knee extension or flexion for any muscle function outcome or the hamstrings to quadriceps ratio. All intraclass correlation coefficients were >0.89 and r2 > 0.79. Test-retest isokinetic dynamometry functional measurements in the knee flexors and extensors at 150°/s are reliable in the burn population and may aid resistance rehabilitation program prescriptions.

Effects of Aerobic Exercise in the Intensive Care Unit on Patient-Reported Physical Function and Mental Health Outcomes in Severely Burned Children-A Multicenter Prospective Randomized Trial.

Severe burns are life-altering and can have lasting effects on patients' physical and mental health. Alterations in physical function, changes in appearance, and psychological disturbances resulting from severe burns are especially concerning in children, as they are still in the early stages of identity formation. Exercise in the nonburn population has been shown to improve quality of life and result in better physical and mental status. However, the effect of early exercise on the quality of life in pediatric burn patients requires more research. METHODS: Forty-eight children between the ages of seven and seventeen with ≥30% total body surface area (TBSA) burn were randomized in a 1:2 fashion to receive treatment with standard-of-care (SOC) or standard-of-care plus exercise (SOC+Ex). Surveys administered at admission and discharge collected patient-reported information regarding physical and mental health outcomes. The results are given as means +/- standard deviation. Significance was set at p < 0.05. RESULTS: The average age of the SOC and SOC+Ex groups were 12 ± 3 and 13 ± 4 years, respectively. The average %TBSA burned in the SOC and SOC+Ex groups were 54 ± 17 and 48 ± 14, respectively. The SOC+Ex group averaged 10 ± 9 exercise sessions (range of 1 to 38 sessions) with an attendance rate of 25% (10 sessions out of 40 BICU days). Both groups demonstrated significant improvement in patient-reported physical and mental outcomes during hospital admission (p < 0.05) However, additional exercise did not exhibit any additional benefits for measured levels. CONCLUSIONS: Our recommendation is for all pediatric patients in the BICU to continue with the SOC and consult with their physician over the benefits of additional aerobic exercise. This study suggests that perhaps there is potential for increasing the amount of exercise that can be administered to pediatric burn survivors beyond SOC as we did not find aerobic exercise to be of any harm to any patients if it is performed properly and under supervision.

Long-term propranolol use in severely burned pediatric patients: a randomized controlled study.

OBJECTIVE: To determine the safety and efficacy of propranolol given for 1 year on cardiac function, resting energy expenditure, and body composition in a prospective, randomized, single-center, controlled study in pediatric patients with large burns. BACKGROUND: Severe burns trigger a hypermetabolic response that persists for up to 2 years postburn. Propranolol given for 1 month postburn blunts this response. Whether propranolol administration for 1 year after injury provides a continued benefit is currently unclear. METHODS: One-hundred seventy-nine pediatric patients with more than 30% total body surface area burns were randomized to control (n = 89) or 4 mg/kg/d propranolol (n = 90) for 12 months postburn. Changes in resting energy expenditure, cardiac function, and body composition were measured acutely at 3, 6, 9, and 12 months postburn. Statistical analyses included techniques that adjusted for non-normality, repeated-measures, and regression analyses. P < 0.05 was considered significant. RESULTS: Long-term propranolol treatment significantly reduced the percentage of the predicted heart rate and percentage of the predicted resting energy expenditure, decreased accumulation of central mass and central fat, prevented bone loss, and improved lean body mass accretion. There were very few adverse effects from the dose of propranolol used. CONCLUSIONS: Propranolol treatment for 12 months after thermal injury, ameliorates the hyperdynamic, hypermetabolic, hypercatabolic, and osteopenic responses in pediatric patients. This study is registered at clinicaltrials.gov: NCT00675714.

Kidney Injury in Critically Ill Patients Treated with Vancomycin and Zosyn or an Alternative: A Systematic Review and Meta-Analysis.

Background: Zosyn® (piperacillin-tazobactam; Pfizer Medical, New York, NY), a valuable antibiotic against gram-negative bacteria, combined with vancomycin (Z+V) is known for its high incidence of acute kidney injury (AKI), particularly in the intensive care unit (ICU), leading to the frequent use of alternatives for gram-negative coverage (Alt+V). Because there are limited data describing AKI on these alternative antibiotic agents, a systematic review and meta-analysis was conducted to determine if these regimens were indeed associated with decreased rates of AKI. Patients and Methods: A literature review was performed electronically from its inception to November 1, 2018, screening for relevant literature by title, abstract and full text according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines within the following databases: PubMed/Medline, CINAHL, Scopus, and Cochrane Central Register of Controlled Trials. Studies were included if they contained adults who had been admitted to the ICU for treatment and had received a combination of intravenous Z + V or Alt+V as well as had AKI measured during administration of these antibiotic agents. Studies were excluded if they represented pediatric populations, did not receive care in an ICU during their hospital admission, only received monotherapy for antibiotic treatment or received antibiotic treatment for less than 48 hours. Independent extraction was performed by two reviewers. Risk of bias was assessed using the Risk of Bias in Non-randomised Studies of Interventions (ROBINS-I) methodology for retrospective studies. Random-effects models were used to calculate any differences between rates of AKI after Z + V or Alt + V. Results: Fourteen articles (totaling 30,399 patients) were included. All studies available were retrospective in design. Compared with Alt + V, Z + V was associated with a higher risk ratio of AKI (1.79; 95% confidence interval [CI], 1.46-2.19; p < 0.001). Cefepime (C + V) was the most common alternative to Zosyn, and Z + V was associated with higher rates of kidney injury compared with C + V (1.70; 95% CI, 1.36-2.12; p < 0.00001). However, there was substantial heterogeneity in the data collected as well as high risk of bias. Conclusions: Zosyn plus vancomycin is associated with more risk of AKI compared with Alt+V coverage in ICU adult populations. However, the conclusions were limited by the retrospective nature of the studies, high bias of included articles, and heterogeneity of the included studies.

Comparison of Six-Minute Walk Test and Modified Bruce Treadmill Test in Paediatric Patients With Severe Burns: A Cross-Over Study.

OBJECTIVE: To compare the six-minute walk test and the Modified Bruce treadmill test in paediatric patients with severe burns. SUBJECTS: A total of 67 children, aged 7-17 years, with severe burns. METHODS: Participants were assigned to perform the six-minute walk test and the Modified Bruce treadmill test in randomized order on discharge from acute burn care. Primary outcome measure was heart rate. Secondary outcome measures were distance walked, Borg's CR-10 rate of perceived exertion, and maximal oxygen uptake (VO2). RESULTS: A total of 67 participants were enrolled. Thirty-eight patients completed both tests. The mean six-minute walk test maximum heart rate was 135 ± 19 bpm (range 97-180 bpm) and the mean Modified Bruce treadmill test maximum heart rate was 148 ± 24 bpm (range 100-197 bpm; p ≤ 0.05), with a weak positive correlation of R² = 0.14. The mean six-minute walk test maximum distance was 294 ± 124 m (range 55 to 522 m) while the mean Modified Bruce treadmill test maximum distance was 439 ± 181 m (range 53 to 976 m; p ≤ 0.05), with no correlation of R² = 0.006. The mean RPE CR-10 score for the six-minute walk test was 3 ± 2.5 (range 0-10) vs a mean RPE CR-10 score of 10 ± 0 for the Modified Bruce treadmill test. CONCLUSION: The Modified Bruce treadmill test challenges the cardiorespiratory system significantly more than the six-minute walk test, as reflected by maximum heart rate measurements, and the perception of effort (i.e. rate of perceived exertion) by the patient. When possible, the Modified Bruce treadmill test should be used to assess cardiovascular functional capacity. However, the six-minute walk test may be more clinically feasible for use with paediatric patients with burns, and provides information about submaximal functional exercise capacity.

Reproductive experience alters prolactin receptor expression in mammary and hepatic tissues in female rats.

Recent studies have reported that reproductive experience in female rats alters prolactin (PRL) receptor gene expression in the brain as well as neural sensitivity to PRL. Given PRL's actions in nonneural tissues, that is, mammary tissue and liver, it was asked whether reproductive experience may also alter prolactin receptor (Prlr) gene expression in these tissues. Groups of age-matched female rats were generated with varying reproductive histories. Separate groups of primiparous (first lactation) and multiparous (second lactation) had mammary tissue and liver samples collected on Day 3 or 10 of lactation. A fifth group raised one litter to weaning and then resumed estrous cyclicity. This group and a final group of age-matched, virgin controls were killed on diestrus. Tissue was processed by quantitative PCR for expression rates of the long and short forms of Prlr mRNA as well as casein beta mRNA (mammary tissue only). Western blots were performed to quantify receptor protein content. Multiple lactations as well as lactation itself resulted in alterations in Prlr expression. Prlr gene expression in mammary tissue was increased in primiparous mothers compared with that in multiparous dams, whereas in the liver, Prlr expression was reduced during an initial lactation. In contrast, PRLR protein levels declined during lactation in mammary, but not hepatic, tissues. Overall, the results demonstrate that the prolactin receptor system is altered in nonneural tissues as a result of the female's reproductive history. The findings are discussed in the context of milk and bile production and PRL's possible role in breast cancer.

Association between dietary fat content and outcomes in pediatric burn patients.

BACKGROUND: The aim of the study was to compare a low fat/high-carbohydrate diet and a high-fat diet on clinical outcomes by a retrospective cohort study. METHODS: Nine hundred forty-four children with burns ≥ 40% of their total body surface area (TBSA) were divided into two groups: patients receiving Vivonex T.E.N. (low-fat/high-carbohydrate diet; n = 518) and patients receiving milk (high-fat diet; n = 426). Patient demographics, caloric intake, length of hospital stay, and incidence of sepsis, mortality, hepatic steatosis, and organomegaly at autopsy were determined. RESULTS: Demographics and caloric intake were similar in both groups. Patients receiving Vivonex T.E.N. had shorter (intensive care unit) ICU stays (Vivonex T.E.N.: 31 ± 2 d; milk: 47 ± 2 d; P < 0.01), shorter ICU stay per % TBSA burn (Vivonex T.E.N.: 0.51 ± 0.02 d/%; milk: 0.77 ± 0.03 d/%; P < 0.01), lower incidence of sepsis (Vivonex T.E.N.: 11%; milk: 20%; P < 0.01), and lived significantly longer until death than those receiving milk (Vivonex T.E.N.: 20 ± 3 d; milk: 10 ± 2 d; P < 0.01). There was no difference in overall mortality between the two groups (Vivonex T.E.N.:15% versus milk: 13%; P < 0.9). Autopsies revealed decreased hepatic steatosis and decreased enlargement of kidney and spleen in patients receiving Vivonex T.E.N. CONCLUSIONS: The period with a low-fat/high-carbohydrate diet was associated with lower LOS, decreased incidence of organomegaly, infection, and hepatic steatosis post-burn compared with the period when a high-fat diet was used. These associations indicate the benefit of high carbohydrate/low fat nutrition; however, the findings in these time periods can also be likely due to the multifactorial effects of advances in burn care. We believe that these results have some relevance because high fat is associated with poorer outcomes compared with low fat.