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Background: Sleep deprivation is reported in 80% of patients in the intensive care unit (ICU) and is associated with delirium. Guidelines recommend implementing a sleep-promoting protocol in critically ill patients which may increase the quantity and quality of sleep and may decrease delirium. Our objective was to implement a pharmacist-led interdisciplinary sleep-promoting protocol and analyze its impact on delirium in ICU patients receiving mechanical ventilation (MV). Methods: The study involved pre-implementation education, protocol development, and post-implementation analysis. ICU pharmacists completed prospective patient chart reviews to reduce exposure to deliriogenic medications and assess the need for a pharmacologic sleep aid. The primary outcome was the incidence of delirium and delirium-free days. Secondary outcomes included ICU length of stay (LOS), incidence of MV, and pharmacist medication interventions. Results: Post-protocol patients (n = 185) had a higher incidence of delirium compared to pre-protocol patients (n = 237) (51.3% vs 39.0%; P = .01). Post-protocol patients had a higher average APACHE III score (P = <.001). Delirium-free days were not significantly different between groups (P = .97). Difference in ICU LOS was not significant (P = .80). More patients received MV post-protocol implementation (55.7% vs 36.1%; P < .001). Pharmacists documented a total of 113 medication interventions. Conclusion and Relevance: A pharmacist-led, ICU sleep-promoting protocol was successfully implemented but did not reduce the incidence of delirium or the administration of insomnia agents. Post-protocol patients had higher disease severity and were more likely to receive MV. Incidence of delirium was consistent with the national reported prevalence of ICU delirium. ICU pharmacists on all shifts had an active role in optimizing sleep.
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Emergent ventral hernia repair (eVHR) is associated with significant morbidity, yet there is no consensus regarding optimal surgical approach. We hypothesized that eVHR with synthetic mesh would have a higher readmission rate compared to primary eVHR or biologic mesh repair. Retrospective analysis of the Nationwide Readmissions Database (NRD) was conducted for patient entries between 2016 and 2018. Adult patients who underwent eVHR were included. Patient demographics, comorbidities, and surgical techniques were compared between readmitted and non-readmitted patients. Predictors of readmission were assessed using multivariate analysis with propensity weighting for various eVHR techniques. Secondary outcomes included hospital length of stay and readmission diagnoses. 43,819 patients underwent eVHR; of the 22,732 with 6 months of follow-up, 6382 (28.1%) were readmitted. The majority of readmissions occurred within the first 30 days (51.8%). Over half of the readmissions were related to surgical complications (50.6%), the most common being superficial surgical site infection (30.1%) and bowel obstruction/ileus (12.2%). In the multivariate analysis, predictors of 30-day readmission included use of synthetic mesh (OR 1.07, 95% CI 1.00-1.14), biologic mesh (OR 1.26, 95% CI 1.06-1.49), and need for concomitant large bowel resection (OR 1.46, 95% CI 1.30-1.65). eVHR is associated with high rates of readmission. Primary repair had favorable odds for readmission and lower risk of surgical complications compared to synthetic and biologic mesh repairs. Synthetic repair had lower odds of readmission than biologic repair. Given the inherent limitations of the NRD, further institutional prospective studies are required to confirm these findings.
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Produtos Biológicos , Hérnia Ventral , Hérnia Incisional , Adulto , Humanos , Estudos Retrospectivos , Readmissão do Paciente , Recidiva Local de Neoplasia/cirurgia , Hérnia Ventral/cirurgia , Hérnia Incisional/cirurgia , Herniorrafia/efeitos adversos , Herniorrafia/métodos , Telas Cirúrgicas , Resultado do Tratamento , RecidivaRESUMO
BACKGROUND: Post-intensive care unit (ICU) syndrome (PICS) occurs at an exorbitant rate in surgical ICU (SICU) survivors. It remains unknown if critical illness due to trauma versus acute care surgery (ACS) may represent different pathophysiologic entities. In this longitudinal study, we determined if admission criteria in a cohort of trauma and ACS patients were associated with differences in the occurrence of PICS. METHODS: Patients were 18 years or older, admitted to a Level I trauma center to the trauma or ACS services, remained in the SICU for ≥72 hours, and were seen in an ICU Recovery Center at 2 weeks, 12 weeks, and 24 weeks after hospital discharge. Post-ICU syndrome sequelae were diagnosed by dedicated specialist staffing using clinical criteria and screening questionnaires. The PICS symptoms were distilled into physical, cognitive, and psychiatric categories. Preadmission histories, hospital courses, and recovery data were collected via retrospective chart review. RESULTS: One hundred twenty-six patients were included: 74 (57.3%) trauma patients and 55 (42.6%) ACS patients. Prehospital psychosocial histories were similar between groups. Acute care surgery patients had a significantly longer hospital course, higher APACHE II and III scores, were intubated for longer, and had higher rates of sepsis, acute renal failure, open abdomen, and hospital readmissions. At the 2-week follow-up visit, ACS patients had higher rates of PICS sequelae (ACS, 97.8% vs. trauma 85.3%; p = 0.03), particularly in the physical (ACS, 95.6% vs. trauma 82.0%, p = 0.04), and psychiatric domains (ACS, 55.6% vs. trauma 35.0%, p = 0.04). At the 12-week and 24-week visits, rates of PICS symptoms were comparable between groups. CONCLUSION: The occurrence of PICS is extraordinarily high in both trauma and ACS SICU survivors. Despite entering the SICU with similar psychosocial histories, the two cohorts have different pathophysiologic experiences, which are associated with a higher rate of impairment in the ACS patients during early follow-up. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.
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Cuidados Críticos , Unidades de Terapia Intensiva , Humanos , Estudos Longitudinais , Estudos Retrospectivos , Progressão da Doença , SobreviventesRESUMO
BACKGROUND: The occurrence of adult intussusception from colorectal cancer in a 27-year-old man is quite uncommon. OBJECTIVES: To raise awareness of the incidence of intussusception in adults, to educate others about the protean manifestations and high association with malignancy of the disease, and to provide treatment recommendations. CASE REPORT: We present a case of a 27-year-old man with a non-contributory family history who presented to the Emergency Department multiple times over a 10-month period with vague abdominal complaints. Clinical symptoms ultimately included a 75-lb weight loss, fatigue, mild right-sided abdominal pain, and anemia. Computed tomography scan of the abdomen revealed right-sided colocolic intussusception with a lead point. The patient underwent a right hemicolectomy with ileocolic anastomosis. Pathologic evaluation and staging revealed a stage IIIB poorly differentiated adenocarcinoma. Molecular analysis was negative for genetic causes. CONCLUSION: This case demonstrates how intussusception and possible colorectal cancer must be included in the differential diagnosis even in young adults who have persistent abdominal complaints.
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Adenocarcinoma/complicações , Doenças do Colo/etiologia , Neoplasias Colorretais/complicações , Intussuscepção/etiologia , Adenocarcinoma/diagnóstico , Adulto , Neoplasias Colorretais/diagnóstico , Humanos , MasculinoRESUMO
Tumoral calcinosis involves focal calcium deposits in the soft tissues surrounding a joint and most commonly occurs in the hips and elbows, rarely in the cervical spine. Furthermore, it has not been known to be associated with pathologic fractures. To the best of our knowledge, our case report highlights the first case of a pathologic type II odontoid fracture associated with adjacent tumoral calcinosis, resulting in pain, dysphagia, and severe spinal stenosis. The patient underwent a posterior occipitocervical fusion and C1 laminectomy, along with planned tracheostomy and gastrostomy to avoid expected difficulty with postoperative extubation and dysphagia. Additionally, we present a review of existing literature on tumoral calcinosis in the upper cervical spine.
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BACKGROUND: Multiple techniques describe the management of the open abdomen (OA) and restoration of abdominal wall integrity after damage-control laparotomy (DCL). It is unclear which operative technique provides the best method of achieving primary myofascial closure at the index hospitalization. METHODS: A writing group from the Eastern Association for the Surgery of Trauma performed a systematic review and meta-analysis of the current literature regarding OA management strategies in the adult population after DCL. The group sought to understand if fascial traction techniques or techniques to reduce visceral edema improved the outcomes in these patients. The Grading of Recommendations Assessment, Development and Evaluation methodology was utilized, meta-analyses were performed, and an evidence profile was generated. RESULTS: Nineteen studies met inclusion criteria. Overall, the use of fascial traction techniques was associated with improved primary myofascial closure during the index admission (relative risk, 0.32) and fewer hernias (relative risk, 0.11.) The use of fascial traction techniques did not increase the risk of enterocutaneous fistula formation nor mortality. Techniques to reduce visceral edema may improve the rate of closure; however, these studies were very limited and suffered significant heterogeneity. CONCLUSION: We conditionally recommend the use of a fascial traction system over routine care when treating a patient with an OA after DCL. This recommendation is based on the benefit of improved primary myofascial closure without worsening mortality or enterocutaneous fistula formation. We are unable to make any recommendations regarding techniques to reduce visceral edema. LEVEL OF EVIDENCE: Systematic Review and Meta-Analysis; Level IV.
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Traumatismos Abdominais , Parede Abdominal , Técnicas de Fechamento de Ferimentos Abdominais , Fístula Intestinal , Gerenciamento da Prática Profissional , Abdome/cirurgia , Traumatismos Abdominais/etiologia , Traumatismos Abdominais/cirurgia , Parede Abdominal/cirurgia , Adulto , Fasciotomia , Humanos , Fístula Intestinal/cirurgia , Laparotomia/métodosRESUMO
The multifaceted long-term impairments resulting from critical illness and COVID-19 require interdisciplinary management approaches in the recovery phase of illness. Operational insights into the structure and process of recovery clinics (RCs) from heterogeneous health systems are needed. This study describes the structure and process characteristics of existing and newly implemented ICU-RCs and COVID-RCs in a subset of large health systems in the United States. DESIGN: Cross-sectional survey. SETTING: Thirty-nine RCs, representing a combined 156 hospitals within 29 health systems participated. PATIENTS: None. INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: RC demographics, referral criteria, and operating characteristics were collected, including measures used to assess physical, psychologic, and cognitive recoveries. Thirty-nine RC surveys were completed (94% response rate). ICU-RC teams included physicians, pharmacists, social workers, physical therapists, and advanced practice providers. Funding sources for ICU-RCs included clinical billing (n = 20, 77%), volunteer staff support (n = 15, 58%), institutional staff/space support (n = 13, 46%), and grant or foundation funding (n = 3, 12%). Forty-six percent of RCs report patient visit durations of 1 hour or longer. ICU-RC teams reported use of validated scales to assess psychologic recovery (93%), physical recovery (89%), and cognitive recovery (86%) more often in standard visits compared with COVID-RC teams (psychologic, 54%; physical, 69%; and cognitive, 46%). CONCLUSIONS: Operating structures of RCs vary, though almost all describe modest capacity and reliance on volunteerism and discretionary institutional support. ICU- and COVID-RCs in the United States employ varied funding sources and endorse different assessment measures during visits to guide care coordination. Common features include integration of ICU clinicians, interdisciplinary approach, and focus on severe critical illness. The heterogeneity in RC structures and processes contributes to future research on the optimal structure and process to achieve the best postintensive care syndrome and postacute sequelae of COVID outcomes.
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BACKGROUND: Surgical stabilization of rib fractures (SSRF) has become increasingly common for the treatment of traumatic rib fractures; however, little is known about related postoperative readmissions. The aims of this study were to determine the rate and cost of readmissions and to identify patient, hospital, and injury characteristics that are associated with risk of readmission in patients who underwent SSRF. The null hypotheses were that readmissions following rib fixation were rare and unrelated to the SSRF complications. METHODS: This is a retrospective analysis of the 2015 to 2017 Nationwide Readmission Database. Adult patients with rib fractures treated by SSRF were included. Univariate and multivariate analyses were used to compare patients readmitted within 30 days with those who were not, based on demographics, comorbidities, and hospital characteristics. Financial information examined included average visit costs and national extrapolations. RESULTS: A total of 2,522 patients who underwent SSRF were included, of whom 276 (10.9%) were readmitted within 30 days. In 36.2% of patients, the reasons for readmissions were related to complications of rib fractures or SSRF. The rest of the patients (63.8%) were readmitted because of mostly nontrauma reasons (32.2%) and new traumatic injuries (21.1%) among other reasons. Multivariate analysis demonstrated that ventilator use, discharge other than home, hospital size, and medical comorbidities were significantly associated with risk of readmission. Nationally, an estimated 2,498 patients undergo SSRF each year, with costs of US $176 million for initial admissions and US $5.9 million for readmissions. CONCLUSION: Readmissions after SSRF are rare and mostly attributed to the reasons not directly related to sequelae of rib fractures or SSRF complications. Interventions aimed at optimizing patients' preexisting medical conditions before discharge should be further investigated as a potential way to decrease rates of readmission after SSRF. LEVEL OF EVIDENCE: Epidemiological study, level III.
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Readmissão do Paciente/estatística & dados numéricos , Fraturas das Costelas/cirurgia , Idoso , Análise Custo-Benefício , Bases de Dados Factuais , Feminino , Humanos , Incidência , Escala de Gravidade do Ferimento , Tempo de Internação , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fraturas das Costelas/economia , Fatores de Risco , Estados UnidosRESUMO
Background: Comparative morbidity after either sternotomy or non-resuscitative thoracotomy in penetrating cardiac injuries (PCI) is unknown. Methods: Retrospective review of adults with PCI who underwent either sternotomy or non-resuscitative thoracotomy using the National Trauma Data Bank 2007-2015. Since there is no unique International Classification of Diseases Procedure Coding System (ICD-PCS) codes assigned for resuscitative vs. non-resuscitative thoracotomy, and both procedures were coded as "thoracotomy", propensity score (PS) methods were applied to avoid inclusion of resuscitative thoracotomy. Results: Despite well PS matching on injury severity score the non-thoracotomy group compared to the sternotomy group had a significantly increased risk of mortality (30 percent vs 8 percent, p<0.0001). The morbidity differed as well-25 percent vs. 12 percent, p=0.0007. Conclusions: The differences in mortality in PCI patients who underwent non-resuscitative thoracotomy vs. sternotomy may be biased by unintentional inclusion of resuscitative thoracotomy. To accurately capture thoracotomy type, separate unique resuscitative and non-resuscitative thoracotomy procedure codes should be created in future revisions of the ICD PCS.
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Traumatismos Cardíacos/cirurgia , Classificação Internacional de Doenças/normas , Esternotomia/mortalidade , Toracotomia/mortalidade , Ferimentos Penetrantes/cirurgia , Adulto , Feminino , Traumatismos Cardíacos/mortalidade , Mortalidade Hospitalar , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Ferimentos Penetrantes/mortalidadeRESUMO
BACKGROUND: The American College of Surgeons Committee on Trauma requires that all level I trauma centers have cardiopulmonary bypass (CPB) capabilities immediately available. Despite this mandate, there are limited data on the utilization and clinical outcomes among trauma patients requiring CPB in the management of injuries. The aim of this study was to evaluate the current use of CPB in the care of trauma patients. METHODS: This is a retrospective analysis of the National Trauma Data Bank from 2010 to 2015. Adult patients sustaining cardiothoracic injuries who underwent surgical repair within the first 24 hours of admission were included. Propensity score matching was used to compare outcomes (in-hospital mortality, hospital length of stay (LOS), intensive care unit LOS, and complications) between patients who underwent CPB within the first 24 hours of admission and those with similar injuries who did not receive CPB. RESULTS: A total of 28,481 patients who met the inclusion criteria were identified, of whom 319 underwent CPB. Three-hundred three CPB patients were matched to 895 comparison patients who did not undergo CPB. Overall in-hospital mortality was 35%. Patients who were not treated with CPB had a significantly higher in-hospital mortality compared with those treated with CBP (odds ratio, 1.57; 95% confidence interval, 1.16-2.12; p = 0.003); however, complications were significantly lower in those who did not receive CPB (odds ratio, 0.63; 95% confidence interval, 0.47-0.86; p = 0.003). Hospital LOS (non-CPB: mean, 13.4 ± 16.3 days; CPB: mean, 14.7 ± 15.1 days; p = 0.23) and intensive care unit LOS (non-CPB: mean, 9.9 ± 10.7 days; CPB: mean, 10.1 ± 9.7 days; p = 0.08) did not differ significantly between groups. CONCLUSION: The use of CPB in the initial management of select cardiothoracic injuries is associated with a survival benefit. Further investigation is required to delineate which specific injuries would benefit the most from the use of CPB. LEVEL OF EVIDENCE: Therapeutic, level IV.
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Ponte Cardiopulmonar/estatística & dados numéricos , Traumatismos Torácicos/cirurgia , Lesões do Sistema Vascular/cirurgia , Adulto , Bases de Dados Factuais , Feminino , Mortalidade Hospitalar , Humanos , Escala de Gravidade do Ferimento , Unidades de Terapia Intensiva , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Pontuação de Propensão , Estudos Retrospectivos , Taxa de Sobrevida , Traumatismos Torácicos/mortalidade , Resultado do Tratamento , Estados Unidos/epidemiologia , Lesões do Sistema Vascular/mortalidade , Ferimentos não Penetrantes/mortalidade , Ferimentos não Penetrantes/cirurgia , Ferimentos Penetrantes/mortalidade , Ferimentos Penetrantes/cirurgia , Adulto JovemRESUMO
ABO blood groups are associated with genetically predisposed variations in von Willebrand factor (VWF) resulting in higher risks of thrombotic events in non-O blood types and bleeding complications in blood type O. The role of ABO blood groups in progression of traumatic intracranial hemorrhage (TICH) is unknown. Given statistically lower VWF levels in blood type O in the general population, we hypothesized that blood type O patients have a higher risk of such progression. A retrospective review of adult trauma patients with isolated TICH admitted to a Level 1 trauma center over eight years was conducted. Patients were categorized with blood type O and non-O (types A, B, AB) delineation. The primary outcome was radiological progression of TICH during the first 24â¯h. Secondary outcomes included surgical intervention after follow-up computed tomography (CT), complications, days on mechanical ventilation (DMV), intensive care unit (ICU) length of stay (LOS), hospital LOS, and mortality. Of 949 patients, 432 (45.5%) had blood type O. When comparing O and non-O groups, no significant differences were found in gender, age, race, admission vital signs, Glasgow Coma Scale, coagulation profile, TICH type, or Injury Severity Score. No difference in TICH progression was found between O and non-O groups: 73 (17%) vs 80 (15%), respectively, pâ¯=â¯0.55. Blood type O mortality was 12 (3% vs. 23 (4%), pâ¯=â¯0.174). Rate of TICH surgical intervention after follow-up CT, DMV, complications, and ICU and hospital LOS did not differ. No association between ABO blood types and radiological progression of TICH was identified.
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Sistema ABO de Grupos Sanguíneos , Hemorragia Intracraniana Traumática/sangue , Adulto , Idoso , Cuidados Críticos , Progressão da Doença , Feminino , Escala de Coma de Glasgow , Mortalidade Hospitalar , Humanos , Escala de Gravidade do Ferimento , Hemorragia Intracraniana Traumática/diagnóstico por imagem , Hemorragia Intracraniana Traumática/terapia , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Respiração Artificial , Estudos Retrospectivos , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Fator de von WillebrandRESUMO
BACKGROUND: Postintensive care syndrome (PICS) has been identified in a large proportion of medical intensive care unit survivors; however, the occurrence surgical intensive care unit (SICU) survivors is unknown. We implemented a multidisciplinary critical care outpatient clinic (CCOC) to identify the occurrence of PICS in SICU survivors. METHODS: Seventy acute care surgery and trauma patients, 18 years or older, who remained in the SICU for 72 hours or longer at a Level I trauma center were seen in CCOC at 2 weeks, 12 weeks, and 24 weeks after hospital discharge. The CCOC staffing included a nurse coordinator, social worker, critical care pharmacist, physical therapist, and acute care surgeon who identified PICS sequelae in their respective specialties by clinical criteria and screening questionnaires. RESULTS: Of 82 eligible patients, 70 (85.4%) were seen at least once for 116 total visits. Forty-three (61.4%) patients suffered traumatic injuries and 27 (38.6%) underwent emergent general surgery. Sixty-seven (95.7%) demonstrated at least one PICS criterion. Over all visits, 26 (37.1%) patients presented with one PICS criterion, 24 (34.3%) patients with two, and 17 (24.3%) with three. Cognitive impairment was observed in 29 (41.4%) patients, psychiatric in 30 (42.9%), and physical symptoms in 65 (92.9%). Activity Measure for Post-Acute Care scores improved from severe impairment at admission to full function by 12 weeks postdischarge, yet 6 Minute Walk Test scores remained below age-matched references through all visits. Patients expressed mild to moderate depression based on Patient Health Questionnaire-9 scores. A medication reconciliation was completed at 96.5% (112/116) of the visits with 116 total medication recommendations. By 24 weeks following discharge, only 26.4% (14/53) of previously employed patients had resumed work. CONCLUSION: Through the successful implementation of a multidisciplinary CCOC, this study identifies an exorbitant rate of PICS among SICU survivors. LEVEL OF EVIDENCE: Therapeutic/epidemiological, level III.
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Estado Terminal , Unidades de Terapia Intensiva/estatística & dados numéricos , Reconciliação de Medicamentos/estatística & dados numéricos , Ferimentos e Lesões/cirurgia , Adulto , Idoso , Instituições de Assistência Ambulatorial , Disfunção Cognitiva/epidemiologia , Disfunção Cognitiva/etiologia , Cuidados Críticos , Estudos de Viabilidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Sobreviventes/psicologia , Ferimentos e Lesões/epidemiologiaRESUMO
BACKGROUND: Assessment of the immediate need for specific blood product transfusions in acutely bleeding patients is challenging. Clinical assessment and commonly used coagulation tests are inaccurate and time-consuming. The goal of this practice management guideline was to evaluate the role of the viscoelasticity tests, which are thromboelastography (TEG) and rotational thromboelastometry (ROTEM), in the management of acutely bleeding trauma, surgical, and critically ill patients. METHODS: Systematic review and meta-analyses of manuscripts comparing TEG/ROTEM with non-TEG/ROTEM-guided blood products transfusions strategies were performed. The Grading of Recommendations Assessment, Development and Evaluation methodology was applied to assess the level of evidence and create recommendations for TEG/ROTEM-guided blood product transfusions in adult trauma, surgical, and critically ill patients. RESULTS: Using TEG/ROTEM-guided blood transfusions in acutely bleeding trauma, surgical, and critically ill patients was associated with a tendency to fewer blood product transfusions in all populations. Thromboelastography/ROTEM-guided transfusions were associated with a reduced number of additional invasive hemostatic interventions (angioembolic, endoscopic, or surgical) in surgical patients. Thromboelastography/ROTEM-guided transfusions were associated with a reduction in mortality in trauma patients. CONCLUSION: In patients with ongoing hemorrhage and concern for coagulopathy, we conditionally recommend using TEG/ROTEM-guided transfusions, compared with traditional coagulation parameters, to guide blood component transfusions in each of the following three groups: adult trauma patients, adult surgical patients, and adult patients with critical illness. LEVEL OF EVIDENCE: Systematic Review/Meta-Analysis, level III.
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Transtornos da Coagulação Sanguínea/sangue , Transfusão de Sangue/normas , Hemorragia/terapia , Guias de Prática Clínica como Assunto , Tromboelastografia/métodos , Adulto , Transtornos da Coagulação Sanguínea/diagnóstico , Testes de Coagulação Sanguínea , Transfusão de Sangue/métodos , Estado Terminal , Hemorragia/sangue , Hemorragia/etiologia , Hemorragia/mortalidade , Humanos , Avaliação de Resultados em Cuidados de Saúde , Sociedades Médicas , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Tromboelastografia/efeitos adversos , Ferimentos e Lesões/complicações , Ferimentos e Lesões/mortalidadeRESUMO
INTRODUCTION: Acute hemorrhage remains the leading cause of death in potentially survivable injuries. The use of topical hemostatic agents has increased over the last two decades with the evolution of damage control surgery. By 2008, the military widely adopted Combat Gauze as the hemostatic dressing of choice for compressible hemorrhage. The goal of this study was to compare the performance of a novel fibrin sealant patch to Combat Gauze in two clinically relevant models of hemorrhage. MATERIALS AND METHODS: Yorkshire swine underwent unilateral femoral artery puncture or a grade V liver laceration with timed free bleeding then received either the fibrin patch or Combat Gauze packing with 3 minutes of standardized pressure. Animals were then resuscitated to maintain a mean arterial pressure of 60 mmHg for 4 hours. Hemostasis, blood loss, resuscitation volume, survival, vessel patency, and hematologic parameters were evaluated. RESULTS: Hemostasis was equivalent in both groups after hepatic and vascular injury. Survival was 80% in the fibrin patch vascular injury group and 100% in all other groups. Hematologic parameters were not significantly different between treatment groups. Femoral artery patency was 80% in both groups after vascular injury. With simulated ambulation after vessel injury, 60% of the Combat Gauze group and 80% of the fibrin patch group remained hemostatic (p > 0.05). In simulated re-exploration with packing removal, all animals rebled after hemostatic product removal. CONCLUSION: There was no significant difference in hemostasis between a novel fibrin patch and Combat Gauze after extremity arterial or hepatic injury. This novel fibrin patch may have a clinical advantage over the Combat Gauze, as it can be left in the body, thereby limiting the potential need for reoperation.
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Adesivo Tecidual de Fibrina/normas , Hemorragia/terapia , Animais , Bandagens/normas , Bandagens/estatística & dados numéricos , Modelos Animais de Doenças , Adesivo Tecidual de Fibrina/uso terapêutico , Hemorragia/prevenção & controle , Hemostáticos/normas , Hemostáticos/uso terapêutico , Fígado/lesões , Fígado/cirurgia , Hepatopatias/prevenção & controle , Hepatopatias/terapia , Suínos/lesões , Suínos/cirurgia , Lesões do Sistema Vascular/prevenção & controle , Lesões do Sistema Vascular/terapiaRESUMO
Three-dimensional electrodes that are controllable over multiple lengthscales are very important for use in bioanalytical systems that integrate solid-phase devices with solution-phase samples. Here we present a fabrication method based on all-solution-processing and thin film wrinkling using smart polymers that is ideal for rapid prototyping of tunable three-dimensional electrodes and is extendable to large volume manufacturing. Although all-solution-processing is an attractive alternative to vapor-based techniques for low-cost manufacturing of electrodes, it often results in films suffering from low conductivity and poor substrate adhesion. These limitations are addressed here by using a smart polymer to create a conformal layer of overlapping wrinkles on the substrate to shorten the current path and embed the conductor onto the polymer layer. The structural evolution of these wrinkled electrodes, deposited by electroless deposition onto a nanoparticle seed layer, is studied at varying deposition times to understand its effects on structural parameters such as porosity, wrinkle wavelength and height. Furthermore, the effect of structural parameters on functional properties such as electro-active surface area and surface-enhanced Raman scattering is investigated. It is found that wrinkling of electroless-deposited thin films can be used to reduce sheet resistance, increase surface area, and enhance the surface-enhanced Raman scattering signal.
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OBJECTIVE: To describe a patient with severe hypercalcemia and elevated intact parathyroid hormone (iPTH) levels associated with a hepatocellular carcinoma. METHODS: We present a case report, detailing the laboratory, surgical, and sestamibi scanning findings. Moreover, the literature relating to paraneoplastic ectopic production of iPTH is reviewed. RESULTS: A 72-year-old man had the following laboratory results at the time of initial assessment: serum calcium of 14.5 mg/dL, ionized calcium of 6.8 mg/dL, serum iPTH of 92 pg/mL, and a PTH-related peptide of <0.7 pg/mL. Findings on preoperative sestamibi scanning were suggestive of a parathyroid adenoma, with additional uptake in the dome of the liver. He was diagnosed as having primary hyperparathyroidism, and a neck exploration was undertaken. The right superior, right inferior, and left superior parathyroid glands were mildly enlarged and were excised. The left inferior parathyroid gland could not be identified, despite an extensive neck exploration. Bilateral internal jugular vein sampling demonstrated elevated iPTH levels, an indication of a systemic origin of the hormone. Postoperatively, a repeated sestamibi scan confirmed hyperactivity in the liver, and a subsequent computed tomographic scan revealed masses in segments IV, VII, and VIII of the liver in conjunction with portal vein involvement. Tissue biopsy confirmed the presence of hepatocellular carcinoma, and the fluid obtained with the biopsy specimen was strongly positive for iPTH. The patient was treated with transarterial chemoembolization but subsequently died. CONCLUSION: This case demonstrates the rare occurrence of hepatocellular carcinoma producing iPTH as the cause of life-threatening hypercalcemia. Sestamibi scans were accurate in detecting focal hyperactivity that correlated with the malignant involvement.
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Carcinoma Hepatocelular/metabolismo , Hipercalcemia/complicações , Hipercalcemia/etiologia , Neoplasias Hepáticas/metabolismo , Hormônio Paratireóideo/sangue , Idoso , Carcinoma Hepatocelular/complicações , Carcinoma Hepatocelular/diagnóstico por imagem , Carcinoma Hepatocelular/terapia , Quimioembolização Terapêutica , Evolução Fatal , Hormônios Ectópicos/sangue , Humanos , Hiperparatireoidismo/etiologia , Neoplasias Hepáticas/complicações , Masculino , Glândulas Paratireoides/cirurgia , Recidiva , Tecnécio Tc 99m Sestamibi , Tomografia Computadorizada de EmissãoRESUMO
Arginase activity is expressed by macrophages in healing wounds and other sites of inflammation and has been shown to modulate the synthesis of nitric oxide, polyamines, and collagen. The role of CCAAT/enhancer-binding protein beta (C/EBPbeta) in the regulation of macrophage arginase by different agonists was investigated using C/EBPbeta-/- and +/+ macrophage cell lines. 8-Bromo-cyclic adenosine monophosphate (8-Br-cAMP, 0.5 mM), recombinant murine interleukin 4 (rmIL-4, 20 U/mL), Escherichia coli lipopolysaccharide (100 ng/mL), and hypoxia (1% O2) induced arginase activity in C/EBPbeta+/+ macrophages, where enzyme activity correlated with arginase I protein. Only rmIL-4 increased arginase activity in C/EBPbeta-/- cells. Arginase II protein was expressed constitutively in wild-type and C/EBPbeta-/- cell lines and was unaltered by 8-Br-cAMP or rmIL-4. rmIL-4-stimulated immortalized C/EBPbeta-/- macrophages demonstrated higher nuclear signal transducer and activator of transcription-6 (STAT6) and phospho-STAT6 content than their +/+ counterparts. Validating the biological relevance of findings with the cell lines, additional experiments examined wound fluids and peritoneal macrophages from C/EBPbeta-/- mice and demonstrated that both contained less arginase activity than those from wild-type controls. Wounds in C/EBPbeta-/- animals showed signs of delayed maturation, as manifested by the persistence of neutrophils in the inflammatory infiltrate. Peritoneal macrophages from C/EBPbeta+/+ animals responded to 8-Br-cAMP and rmIL-4 with increased arginase activity, whereas those from C/EBPbeta-/- mice did not respond to cAMP. Results demonstrate a key mechanistic role for C/EBPbeta in the modulation of macrophage arginase I expression in vivo and in vitro.