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1.
Ann Surg ; 266(4): 595-602, 2017 10.
Artículo en Inglés | MEDLINE | ID: mdl-28697050

RESUMEN

OBJECTIVE: Our objective was to compare outcomes of a restrictive to a liberal red cell transfusion strategy in 20% or more total body surface area (TBSA) burn patients. We hypothesized that the restrictive group would have less blood stream infection (BSI), organ dysfunction, and mortality. BACKGROUND: Patients with major burns have major (>1 blood volume) transfusion requirements. Studies suggest that a restrictive blood transfusion strategy is equivalent to a liberal strategy. However, major burn injury is precluded from these studies. The optimal transfusion strategy in major burn injury is thus needed but remains unknown. METHODS: This prospective randomized multicenter trial block randomized patients to a restrictive (hemoglobin 7-8 g/dL) or liberal (hemoglobin 10-11 g/dL) transfusion strategy throughout hospitalization. Data collected included demographics, infections, transfusions, and outcomes. RESULTS: Eighteen burn centers enrolled 345 patients with 20% or more TBSA burn similar in age, TBSA burn, and inhalation injury. A total of 7054 units blood were transfused. The restrictive group received fewer blood transfusions: mean 20.3 ±â€Š32.7 units, median = 8 (interquartile range: 3, 24) versus mean 31.8 ±â€Š44.3 units, median = 16 (interquartile range: 7, 40) in the liberal group (P < 0.0001, Wilcoxon rank sum). BSI incidence, organ dysfunction, ventilator days, and time to wound healing (P > 0.05) were similar. In addition, there was no 30-day mortality difference: 9.5% restrictive versus 8.5% liberal (P = 0.892, χ test). CONCLUSIONS: A restrictive transfusion strategy halved blood product utilization. Although the restrictive strategy did not decrease BSI, mortality, or organ dysfunction in major burn injury, these outcomes were no worse than the liberal strategy (Clinicaltrials.gov identifier NCT01079247).


Asunto(s)
Transfusión Sanguínea/métodos , Quemaduras/terapia , Adolescente , Adulto , Bacteriemia/epidemiología , Quemaduras/complicaciones , Quemaduras/mortalidad , Humanos , Incidencia , Infecciones/epidemiología , Tiempo de Internación , Persona de Mediana Edad , Insuficiencia Multiorgánica/epidemiología , Estudios Prospectivos , Respiración Artificial , Factores de Tiempo , Resultado del Tratamiento , Cicatrización de Heridas , Adulto Joven
2.
Surg Infect (Larchmt) ; 25(7): 499-504, 2024 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-38973692

RESUMEN

Introduction: Surgical site infections (SSIs) are an important quality measure. Identifying SSIs often relies upon a time-intensive manual review of a sample of common surgical cases. In this study, we sought to develop a predictive model for SSI identification using antibiotic pharmacy data extracted from the electronic medical record (EMR). Methods: A retrospective analysis was performed on all surgeries at a Veteran Affair's Medical Center between January 9, 2020 and January 9, 2022. Patients receiving outpatient antibiotics within 30 days of their surgery were identified, and chart review was performed to detect instances of SSI as defined by VA Surgery Quality Improvement Program criteria. Binomial logistic regression was used to select variables to include in the model, which was trained using k-fold cross validation. Results: Of the 8,253 surgeries performed during the study period, patients in 793 (9.6%) cases were prescribed outpatient antibiotics within 30 days of their procedure; SSI was diagnosed in 128 (1.6%) patients. Logistic regression identified time from surgery to antibiotic prescription, ordering location of the prescription, length of prescription, type of antibiotic, and operating service as important variables to include in the model. On testing, the final model demonstrated good predictive value with c-statistic of 0.81 (confidence interval: 0.71-0.90). Hosmer-Lemeshow testing demonstrated good fit of the model with p value of 0.97. Conclusion: We propose a model that uses readily attainable data from the EMR to identify SSI occurrences. In conjunction with local case-by-case reporting, this tool can improve the accuracy and efficiency of SSI identification.


Asunto(s)
Antibacterianos , Infección de la Herida Quirúrgica , Veteranos , Humanos , Infección de la Herida Quirúrgica/epidemiología , Infección de la Herida Quirúrgica/diagnóstico , Estudios Retrospectivos , Masculino , Veteranos/estadística & datos numéricos , Femenino , Persona de Mediana Edad , Anciano , Antibacterianos/uso terapéutico , Mejoramiento de la Calidad , Registros Electrónicos de Salud/estadística & datos numéricos
3.
Trauma Case Rep ; 42: 100711, 2022 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-36210921

RESUMEN

Bronchial disruption is a catastrophic consequence of blunt thoracic trauma with high pre-hospital lethality. This injury is classically managed through a large thoracotomy incision to facilitate adequate exposure for open repair. Here, we describe a case of complete bronchus intermedius disruption following a motor vehicle accident that was repaired via robotic thoracoscopy. The patient sustained multi-system trauma, including a grade III liver laceration, an innominate artery pseudoaneurysm, and femoral condyle fracture, all of which required systematic intervention and multi-disciplinary coordination to best facilitate this patient's care. This patient recovered well from his multiple injuries and was discharged after an uneventful post-operative course.

4.
J Trauma ; 70(1): 65-9; discussion 69-70, 2011 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-21217483

RESUMEN

INTRODUCTION: An increasing proportion of trauma patients are on anticoagulation or antiplatelet therapy. Unlike warfarin, where measuring international normalized ratio can help direct management, measuring platelet inhibition from clopidogrel (Plavix) is not standardized. We report the use of a new P2Y12 point-of-care assay (VerifyNow; Accumetrics, San Diego, CA) to determine the magnitude of platelet inhibition in trauma patients using clopidogrel. METHODS: Trauma patients in 2009 were queried for clopidogrel use by prehospital personnel and the trauma team. Blood was obtained on admission for patients reportedly taking clopidogrel and was assayed for platelet inhibition using the VerfiyNow-P2Y12 device that measures P2Y12 reaction units and photometrically determines platelet inhibition percentage within 30 minutes. Patient demographics including age, Injury Severity Score, mechanism of injury, and complications from hemorrhage were also analyzed. RESULTS: In the time studied, 46 patients taking clopidogrel were assayed for platelet inhibition. The mean age was 75.9 years±11.8 years, and the most common mechanism of injury was fall (86.9%). Platelet inhibition ranged from 0% to 89%. There were no deaths, and only two patients, from the 0% and>30% inhibition group, had hemorrhagic complications (increased intracranial hemorrhage). CONCLUSIONS: The P2Y12 point-of-care assay determined that a large percentage of patients had undetectable or low platelet inhibition despite reportedly being on clopidogrel therapy. These patients may be clopidogrel nonresponders or noncompliant. It is unlikely that clopidogrel reversal therapies, such as platelet transfusions or Desmopressin, would be beneficial in this group. Further studies stratifying the percent platelet inhibition needed to increase bleeding complications is warranted to optimize management strategies.


Asunto(s)
Inhibidores de Agregación Plaquetaria/sangre , Sistemas de Atención de Punto , Ticlopidina/análogos & derivados , Heridas y Lesiones/sangre , Anciano , Clopidogrel , Femenino , Hemorragia/sangre , Hemorragia/líquido cefalorraquídeo , Humanos , Puntaje de Gravedad del Traumatismo , Masculino , Estudios Retrospectivos , Ticlopidina/sangre
5.
J Trauma ; 70(4): 923-30, 2011 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-21610397

RESUMEN

BACKGROUND: Little is known about the impact of postinjury depression after major trauma in adolescents. A prospective epidemiologic study was conducted to examine depression in injured adolescents. Specific objectives of this report are to identify risk factors for depression onset and the impact of depression on quality of life (QoL) outcomes. METHODS: Four hundred one trauma patients were enrolled in this study (age, 12-19 years; injury severity score [ISS] ≥4). Depression diagnosis was based on the Children's Depression Inventory. QoL outcomes were measured using the Quality of Well-being Scale at 3-, 6-, 12-, 18-, and 24-month follow-up. RESULTS: Depression at discharge was diagnosed in 41% of 399 adolescent trauma survivors with complete Children's Depression Inventory data. Multivariate logistic regression identified ISS, >3 body regions injured, low socioeconomic status, family members injured at the scene, and suicidal ideology or attempted suicide before injury as strong and independent predictors of depression risk. ISS and three or more body regions injured predicted depression risk. Patients with severe injury (ISS ≥17) were twice more likely to have depressive symptoms than patients with moderate injury (ISS <17; odds ratio [OR] = 2.0; p < 0.01). Patients with three or more body regions injured were more likely to have depressive symptoms than patients with less than three body regions injured (OR = 2.1; p < 0.01). Adolescents from low socioeconomic status families were more likely to be depressed (OR = 2.2; p < 0.05). Adolescent patients who witnessed family injured at the trauma event were also more likely to be depressed (OR = 2.4; p < 0.01). Patients who experienced suicidal ideology or attempted suicide preinjury were more likely to be depressed than adolescent patients who did not (OR = 2.87; p < 0.05). Quality of well-being scores were significantly and markedly lesser for patients with depression across the 24-month follow-up (3-18 months follow-up, p < 0.0001; 24 months: with depression = 0.738 vs. without depression = 0.784, p < 0.0001). Patients with depression were also significantly more likely to develop acute stress disorder and long-term posttraumatic stress disorder (OR = 1.8, p < 0.001). CONCLUSIONS: Postinjury depression is a major and an important complication in seriously injured adolescents. Adolescent trauma survivors have high rates of predischarge depression. Depression severely impacts QoL outcomes and is associated with injury severity, injury event-related factors, social factors, acute stress disorder, and posttraumatic stress disorder. Early recognition and treatment of DEPR in seriously injured adolescents will improve acute trauma care and long-term QoL outcomes.


Asunto(s)
Depresión/epidemiología , Calidad de Vida , Heridas y Lesiones/complicaciones , Adolescente , Niño , Depresión/etiología , Femenino , Humanos , Incidencia , Puntaje de Gravedad del Traumatismo , Masculino , Oportunidad Relativa , Pronóstico , Estudios Prospectivos , Factores de Riesgo , Estados Unidos/epidemiología , Heridas y Lesiones/diagnóstico , Heridas y Lesiones/epidemiología
6.
J Trauma ; 70(5): 1241-7, 2011 May.
Artículo en Inglés | MEDLINE | ID: mdl-21610438

RESUMEN

BACKGROUND: This study compares open tibia fractures in US Navy and US Marine Corps casualties from the current conflicts with those from a civilian Level I trauma center to analyze the effect of blast mechanism on limb-salvage rates. METHODS: Data from the 28,646 records in the University of California San Diego Trauma Registry from 1985 to 2006 was compared with 2,282 records from the US Navy and US Marine Corps Combat Trauma Registry Expeditionary Medical Encounter Database for the period of March 2004 to August 2007. Injuries were categorized by Gustilo-Anderson (G-A) open fracture classification. Independent variables included age, gender, mechanism of injury including blast mechanisms, shock, blood loss, prehospital time, procedures, Injury Severity Score, length of stay, and Mangled Extremity Severity Score (MESS). Dependent variables included early or late amputation and mortality. RESULTS: The civilian group had 850 open tibia fractures with 45 amputations; the military group had 21 amputation patients (3 bilateral) in 115 open tibia fractures. Military group patients were more severely injured, more likely have hypotension, and had a higher amputation rate for G-A IIIB and IIIC fractures then civilian group patients. Blast mechanism was seen in the majority of military group patients and was rare in the civilian group. MESS scores had poor sensitivity (0.46, 95% confidence interval: 0.29-0.64) in predicting the need for amputation in the civilian group; in the military group sensitivity was better (0.67, 95% confidence interval: 0.43-0.85), but successful limb salvage was still possible in most cases with an MESS score of ≥7 when attempted. CONCLUSION: Despite current therapy, limb salvage for G-A IIIB and IIIC grades are significantly worse for open tibia fractures as a result of blast injury when compared with typical civilian mechanisms. MESS scores do not adequately predict likelihood of limb salvage in combat or civilian open tibia fractures.


Asunto(s)
Traumatismos por Explosión/cirugía , Explosiones , Fracturas Abiertas/cirugía , Recuperación del Miembro/métodos , Personal Militar , Fracturas de la Tibia/cirugía , Guerra , Adulto , Traumatismos por Explosión/diagnóstico , Traumatismos por Explosión/etiología , Femenino , Estudios de Seguimiento , Fracturas Abiertas/diagnóstico , Humanos , Puntaje de Gravedad del Traumatismo , Pierna/cirugía , Masculino , Estudios Retrospectivos , Fracturas de la Tibia/diagnóstico , Fracturas de la Tibia/etiología , Centros Traumatológicos , Adulto Joven
7.
Ann Vasc Surg ; 24(6): 825.e1-5, 2010 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-20472384

RESUMEN

High-voltage electrical burns are rare but cause devastating injuries, resulting in potential limb loss and major morbidity and mortality. These injuries are more insidious than flame burns in that the extent of the injury is not obvious at first glance. Damage to underlying muscle, nerve, and vessels may occur, resulting in limb-threatening ischemia and delayed hemorrhage. The management of such injuries remains controversial and can be challenging for the vascular and reconstructive surgeon. We present a case of high-voltage electrical injury to bilateral upper extremities resulting in limb-threatening ischemia, review the literature on the management of such injuries, and propose an algorithm to guide the management of these devastating injuries.


Asunto(s)
Arteriopatías Oclusivas/etiología , Quemaduras por Electricidad/complicaciones , Isquemia/etiología , Trombosis/etiología , Extremidad Superior/irrigación sanguínea , Adulto , Amputación Quirúrgica , Arteriopatías Oclusivas/diagnóstico , Arteriopatías Oclusivas/fisiopatología , Arteriopatías Oclusivas/cirugía , Arterias/lesiones , Arterias/cirugía , Hemodinámica , Humanos , Isquemia/diagnóstico , Isquemia/fisiopatología , Isquemia/cirugía , Ligadura , Masculino , Flujo Sanguíneo Regional , Reoperación , Vena Safena/trasplante , Trasplante de Piel , Trombectomía , Trombosis/diagnóstico , Trombosis/fisiopatología , Trombosis/cirugía , Resultado del Tratamiento , Procedimientos Quirúrgicos Vasculares
8.
Am J Crit Care ; 18(3 Suppl): S2-14: quiz S15, 2009 May.
Artículo en Inglés | MEDLINE | ID: mdl-19623696

RESUMEN

BACKGROUND: Fecal contamination is a major challenge in patients in acute/critical care settings that is associated with increased cost of care and supplies and with development of pressure ulcers, incontinence dermatitis, skin and soft tissue infections, and urinary tract infections. OBJECTIVES: To assess the economic impact of fecal containment in bedridden patients using 2 different indwelling bowel catheters and to compare infection rates between groups. METHODS: A multicenter, observational study was done at 12 US sites (7 that use catheter A, 5 that use catheter B). Patients were followed from insertion of an indwelling bowel catheter system until the patient left the acute/critical care unit or until 29 days after enrollment, whichever came first. Demographic data, frequency of bedding/dressing changes, incidence of infection, and Braden scores (risk of pressure ulcers) were recorded. RESULTS: The study included 146 bedridden patients (76 with catheter A, 70 with catheter B) who had similar Braden scores at enrollment. The rate of bedding/dressing changes per day differed significantly between groups (1.20 for catheter A vs 1.71 for catheter B; P = .004). According to a formula that accounted for personnel resources and laundry cycle costs, catheter A cost $13.94 less per patient per day to use than did catheter B. Catheter A was less likely than was catheter B to be removed during the observational period (P = .03). Observed infection rates were low. CONCLUSION: Catheter A may be more cost-effective than catheter B because it requires fewer unscheduled linen changes per patient day.


Asunto(s)
Cateterismo/instrumentación , Infección Hospitalaria/prevención & control , Incontinencia Fecal/terapia , Úlcera por Presión/prevención & control , Anciano , Cateterismo/economía , Análisis Costo-Beneficio , Cuidados Críticos , Infección Hospitalaria/economía , Incontinencia Fecal/economía , Humanos , Proyectos Piloto , Infecciones Urinarias/prevención & control
9.
Am J Prev Med ; 33(3): 219-21, 2007 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-17826583

RESUMEN

BACKGROUND: The attention placed on cruise ship infectious epidemics has helped create important preventive strategies in improving food handling, sanitation, and overall cruise ship medical care. However, the incidence of serious injury in cruise ship passengers has never been fully described. In 2006, there was an increase in the number of cruise ship passengers receiving medical care at a Level I trauma center. This report provides a case series analysis of eight patients identified as suffering from significant cruise ship-related injuries. METHODS: A retrospective, descriptive study design was used. Data on trauma patients transported directly from cruise ships and admitted to a university Level I trauma center in 2003-2006 were reviewed. RESULTS: A total of 2,132 patients were admitted as major trauma resuscitations in 2006. Eight were identified as being injured on a major cruise ship compared to an average of 1.7 patients/year in the preceding 3 years. All but one patient was female. Three patients had significant medical comorbidities. All eight patients suffered injuries from falls, five of which were in stairwells. Concussions were the most common injury. Five patients were discharged to home, two to extended rehabilitation facilities, and one died. CONCLUSIONS: In this case series, falls were the sole cause of major injury among cruise ship passengers. Improved surveillance and characterization of injuries among cruise ship passengers is needed to inform safety policies and develop programs to prevent passenger injury.


Asunto(s)
Accidentes por Caídas , Conmoción Encefálica/etiología , Navíos , Heridas y Lesiones/etiología , Accidentes por Caídas/mortalidad , Adulto , Anciano , Anciano de 80 o más Años , Conmoción Encefálica/terapia , Comorbilidad , Servicio de Urgencia en Hospital , Femenino , Humanos , Masculino , Persona de Mediana Edad , Resucitación , Estudios Retrospectivos , Centros Traumatológicos , Heridas y Lesiones/terapia
10.
J Burn Care Res ; 38(4): 220-224, 2017.
Artículo en Inglés | MEDLINE | ID: mdl-28644205

RESUMEN

Electronic cigarettes (e-cigarettes) are novel battery-operated devices that deliver nicotine as an inhaled aerosol. They originated from China in 2007 and their use has rapidly increased worldwide in the past decade, yet they remain largely unregulated. Reports of injuries associated with their use have appeared as unusual events in the news media and as case reports in the medical literature. This study was undertaken to explore e-cigarettes as a mechanism of burn injury. Referral records to three burn centers from January 2007 to July 2016 were searched to identify patients with injuries caused by e-cigarettes. Data were gathered from the electronic medical records (EMRs) of patients referred within the most recent 18 months. Thirty patients with burns resulting from e-cigarettes were identified. Twenty-nine were referred within the most recent 18 months. Only one was referred in the preceding 8 years. An explosion was identified by the patient as the inciting event in 26 of the 30 injuries (87%). Explosion of an isolated battery while it was carried on personal attire was reported in 10 cases. Explosion of a fully assembled e-cigarette was described in 16 cases. In seven of these 16 cases, the explosion occurred while the device was idle and carried on personal attire. In the other nine cases, the explosion occurred while the device was being operated. No injury occurred while batteries were charging. The mean age of injured patients was 30 years. The mean size of burn was 4% TBSA. The thighs, hands, and genitalia were the most common sites of injury. Twenty-six patients required hospital admission and nine required surgery. Serious burn injuries from e-cigarettes have recently occurred with greatly increased frequency. The increase in injuries appears out of proportion to the increased popularity of e-cigarettes. The most common pattern of injury is explosion when either the idle device or its batteries are carried on personal attire.


Asunto(s)
Quemaduras/epidemiología , Sistemas Electrónicos de Liberación de Nicotina/instrumentación , Explosiones/estadística & datos numéricos , Adulto , Unidades de Quemados , California , Femenino , Humanos , Masculino , Estudios Retrospectivos
11.
Surg Infect (Larchmt) ; 16(6): 669-74, 2015 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-26460850

RESUMEN

BACKGROUND: We identified recently esophageal cancer related gene-4 (ECRG4) as a candidate cytokine that is expressed on the surface of quiescent polymorphonuclear leukocytes (PMNs) and shed in response to ex vivo treatment with lipopolysaccharide. To investigate the potential biologic relevance of changes in cell surface ECRG4 in human samples, we performed a pilot study to examine a population of burn patients in whom blood could be analyzed prospectively. We hypothesized that cutaneous burn injury would alter cell surface expression of ECRG4 on PMNs. METHODS: Patients admitted with more than 20% total burn surface area (TBSA) (n = 10) had blood collected at the time of admission and weekly thereafter. For comparison, blood was obtained from a control group of healthy human volunteers (n = 4). We used flow cytometry to measure changes in ECRG4(+) PMNs from patients during recovery from injury. Esophageal cancer related gene-4 expression at each time point was compared with the patient's clinical status based on a Multiple Organ Dysfunction (MOD) score. RESULTS: Esophageal cancer related gene-4 was detected on the PMN surface of cells collected from healthy volunteers, however, within 48 h of admission after burn injury (n = 10 patients), the number of PMNs with cell surface ECRG4 was decreased. Esophageal cancer related gene-4 expression in PMNs was re-established over the course of patient recovery, unless complications occurred. In this case, the decrease in cell surface ECRG4(+) PMNs preceded the clinical diagnosis of infectious complications and was reflected by increased organ injury scores. CONCLUSION: From a small sample set, we were able to determine that PMN cell surface ECRG4 expression was decreased after burn injury and returned to baseline during recovery from injury. Although larger studies are needed to define the role of ECRG4 in human PMNs further, this report is the first assessment of cell surface ECRG4 protein in a patient population to support analogous findings in animal studies.


Asunto(s)
Quemaduras/patología , Proteínas de la Membrana/análisis , Proteínas de Neoplasias/análisis , Neutrófilos/metabolismo , Adulto , Animales , Citometría de Flujo , Humanos , Masculino , Persona de Mediana Edad , Proyectos Piloto , Estudios Prospectivos , Proteínas Supresoras de Tumor , Adulto Joven
12.
J Burn Care Res ; 33(3): e114-9, 2012.
Artículo en Inglés | MEDLINE | ID: mdl-22079904

RESUMEN

Glucose control has repeatedly been shown to influence favorable outcomes in the surgical intensive care unit (ICU). Intensive insulin therapy has recently been associated with reduced infections complications in burn patients. However, traditional protocols are associated with rates of severe hypoglycemia as high as 19%. Two commercial computer glucose control programs have reported rates of severe hypoglycemia (glucose <50 mg/dl) of 0.6 and 0.4%. Recently, the authors' burn ICU adopted an intensive insulin computer-based protocol created at their institution and already successfully in use in their surgical ICU. The authors hypothesized that their protocol can be used effectively in the burn patient population without an increase risk of severe hypoglycemia. All patients admitted to the burn ICU have blood glucose (BG) values checked routinely. With two consecutive hyperglycemic values >200 mg/dl, patients are placed on a computer-based protocol intravenous insulin drip. Once initiated, BGs are tested hourly with adjustments made according to the computer protocol. Values recorded from January to December 2008 were abstracted from the database and analyzed. Thirty-one patients were treated using the computer glucose control protocol and 12,699 measurements were performed. There were eight measurements <50 mg/dl (0.07%). Seventy-six percent of values were within the target range of 90 to 150 mg/dl. Few patients had severe hyperglycemia with BG >300 mg/dl (0.2%). There were no adverse events associated with the hypoglycemic episode. The computer-based protocol is more effective than those previously used at the institution and provides safe, reliable results in the burn patients.


Asunto(s)
Quemaduras/tratamiento farmacológico , Quimioterapia Asistida por Computador/métodos , Hiperglucemia/tratamiento farmacológico , Insulina/administración & dosificación , Unidades de Cuidados Intensivos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Glucemia/análisis , Unidades de Quemados , Quemaduras/complicaciones , Quemaduras/diagnóstico , Estudios de Cohortes , Cuidados Críticos/métodos , Enfermedad Crítica/terapia , Femenino , Estudios de Seguimiento , Humanos , Hiperglucemia/sangre , Hiperglucemia/etiología , Hipoglucemia/prevención & control , Insulina/efectos adversos , Sistemas de Infusión de Insulina , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Medición de Riesgo , Resultado del Tratamiento , Adulto Joven
13.
J Leukoc Biol ; 91(5): 773-81, 2012 May.
Artículo en Inglés | MEDLINE | ID: mdl-22396620

RESUMEN

We identified fresh human leukocytes as an abundant source of the candidate epithelial tumor suppressor gene, Ecrg4, an epigenetically regulated gene, which unlike other tumor suppressor genes, encodes an orphan-secreted, ligand-like protein. In human cell lines, Ecrg4 gene expression was low, Ecrg4 protein undetectable, and Ecrg4 promoter hypermethylation high (45-90%) and reversible by the methylation inhibitor 5-AzaC. In contrast, Ecrg4 gene expression in fresh, normal human PBMCs and PMNs was 600-800 times higher than in cultured cell lines, methylation of the Ecrg4 promoter was low (<3%), and protein levels were readily detectable in lysates and on the cell surface. Flow cytometry, immunofluorescent staining, and cell surface biotinylation established that full-length, 14-kDa Ecrg4 was localized on PMN and monocyte cell surfaces, establishing that Ecrg4 is a membrane-anchored protein. LPS treatment induced processing and release of Ecrg4, as detected by flow and immunoblotting, whereas an effect of fMLF treatment on Ecrg4 on the PMN cell surface was detected on the polarized R2 subpopulation of cells. This loss of cell surface Ecrg4 was associated with the detection of intact and processed Ecrg4 in the conditioned media of fresh leukocytes and was shown to be associated with the inflammatory response that follows severe, cutaneous burn injury. Furthermore, incubation of macrophages with a soluble Ecrg4-derived peptide increased the P-p65, suggesting that processing of an intact sentinel Ecrg4 on quiescent circulating leukocytes leads to processing from the cell surface following injury and macrophage activation.


Asunto(s)
Quemaduras/metabolismo , Genes Supresores de Tumor , Leucocitos/metabolismo , Macrófagos Peritoneales/metabolismo , Monocitos/metabolismo , Proteínas de Neoplasias/metabolismo , Animales , Células 3T3 BALB , Western Blotting , Estudios de Casos y Controles , Células Cultivadas , Metilación de ADN , Citometría de Flujo , Humanos , Leucocitos/citología , Activación de Macrófagos , Ratones , Proteínas de Neoplasias/genética , Neutrófilos/citología , Neutrófilos/metabolismo , ARN Mensajero/genética , Reacción en Cadena en Tiempo Real de la Polimerasa , Proteínas Supresoras de Tumor
14.
Fibrogenesis Tissue Repair ; 4: 7, 2011 Feb 17.
Artículo en Inglés | MEDLINE | ID: mdl-21329515

RESUMEN

BACKGROUND: The natural response to injury is dynamic and normally consists of complex temporal and spatial cellular changes in gene expression, which, when acting in synchrony, result in patent tissue repair and, in some instances, regeneration. However, current therapeutic regiments are static and most rely on matrices, gels and engineered skin tissue. Accordingly, there is a need to design next-generation grafting materials to enable biotherapeutic spatiotemporal targeting from clinically approved matrices. To this end, rather then focus on developing completely new grafting materials, we investigated whether phage display could be deployed onto clinically approved synthetic grafts to identify peptide motifs capable of linking pharmaceutical drugs with differential affinities and eventually, control drug delivery from matrices over both space and time. METHODS: To test this hypothesis, we biopanned combinatorial peptide libraries onto different formulations of a wound-healing matrix (Integra®) and eluted the bound peptides with 1) high salt, 2) collagen and glycosaminoglycan or 3) low pH. After three to six rounds of biopanning, phage recovery and phage amplification of the bound particles, any phage that had acquired a capacity to bind the matrix was sequenced. RESULTS: In this first report, we identify distinct classes of matrix-binding peptides which elute differently from the screened matrix and demonstrate that they can be applied in a spatially relevant manner. CONCLUSIONS: We suggest that further applications of these combinatorial techniques to wound-healing matrices may offer a new way to improve the performance of clinically approved matrices so as to introduce temporal and spatial control over drug delivery.

15.
J Safety Res ; 42(2): 131-5, 2011 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-21569895

RESUMEN

OBJECTIVE: Pedicabs are a new and controversial transportation innovation for tourists in congested areas in several U.S. cities. Scant literature on this trauma mechanism exists. The purpose of this study is to identify the incidence, demographics, morbidity, mortality, and potential for injury prevention of pedicab incidents amongst major trauma admissions at an urban, academic Level I Trauma Center. PATIENTS & METHODS: Researchers conducted a retrospective review of the Trauma Registry from 2000 to 2009. All patients identified as being injured in a pedicab incident were reviewed. Demographics, diagnoses, toxicology, treatments, and injury severity scale (ISS) were collected. Outcomes included mortality, ICU, and hospital length of stay (LOS), discharge disposition, and hospital charges. A photographic survey of 50 local pedicabs was examined for the presence and use of safety equipment. RESULTS: During the period of January 2000 to July 2009 there were 15 major trauma victims from identified pedicab incidents. Falling from the pedicab was the mechanism of injury in 14 of 15 cases. There were two fatalities in victims following severe traumatic brain injury. Traumatic brain injury, skull fracture, or loss of consciousness was seen in 11/15 victims. Ethanol ingestion was detected in blood tests of 10 of the 14 adult victims. Median charges of hospitalization due to a pedicab related injury was US$29,956 ± 77,482. A photographic survey of 50 local pedicabs reveals very limited use of safety belts by passengers despite existing city ordinances. CONCLUSIONS: Major trauma victims of pedicab incidents in the United States suffer significant injuries and death. Most cases occurred in passengers falling from the pedicab at night after alcohol ingestion. There is an opportunity for implementation of strategies toward improved injury prevention with this new form of transport.


Asunto(s)
Transportes/métodos , Heridas y Lesiones/etiología , Adulto , California/epidemiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Sistema de Registros , Estudios Retrospectivos , Heridas y Lesiones/epidemiología , Heridas y Lesiones/mortalidad , Heridas y Lesiones/fisiopatología , Adulto Joven
16.
J Burn Care Res ; 31(1): 184-9, 2010.
Artículo en Inglés | MEDLINE | ID: mdl-20061854

RESUMEN

Seasonal use of campground bonfires and beach fire pits is a common practice. A sense of fellowship is derived from this experience. Unfortunately, many people are injured by these fires. It was the objective of this study to quantify and better identify those factors that lead to these injuries. A retrospective review of patients injured from a beach or campground, fire pits, or bonfires was conducted using data from a regional burn registry (1999-2007). Patients sustaining burns serious enough to merit admission were included in this study. Demographic information, circumstances surrounding the injury events, size and location of burn, operative procedures, length of stay, and outcomes were analyzed. There were 3083 patients admitted to the burn center of which 241 met criteria for inclusion in this study. Each year, between 12 and 39 patients were injured by this mechanism; 84% were men. Ages fell into two discrete groups; young age (2-9 years) and adults (18-64 years). Alcohol was a contributing factor in 60.6% of adult burns. The areas of burn, by location and rank order include upper extremities (35.3% of patients), thorax/abdomen/buttocks (32.8%), lower extremities (30.7%), and hands (29.5%). The mean TBSA was 6.1% (1-100%). Approximately 80.7% of the patients sustained combination partial- and full-thickness burns whereas, 4.2% were only partial and 5.1% only full-thickness burns; 36.6% of the patients required skin grafting. The mean length of stay was 8.6 days. There were four fatalities including one suicide. Burn injuries from recreational bonfires remain a problem in our community. Beaches were the most common location for these injuries. Universal safeguards to prevent burn injury should be implemented, including designated areas for fires, protective mechanical barriers to keep children and adults from inadvertently walking or falling into the fire pit. Disposal areas for hot coals from fires or charcoal grills must be furnished and usage strictly enforced. Consideration of the elimination of free-standing beach bonfires should be considered.


Asunto(s)
Accidentes/estadística & datos numéricos , Playas , Quemaduras/epidemiología , Acampada , Incendios , Adolescente , Adulto , Quemaduras/patología , Quemaduras/terapia , Niño , Preescolar , Estudios de Cohortes , Femenino , Humanos , Lactante , Tiempo de Internación , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Resultado del Tratamiento , Adulto Joven
18.
Eplasty ; 10: e1, 2009 Dec 11.
Artículo en Inglés | MEDLINE | ID: mdl-20076783

RESUMEN

Complex early and late neuropathies resulting from direct and conductive electrical patterns of injury are disabling and extremely challenging to manage. We report a patient who suffered acute onset of right-hand weakness and decreased sensation following a radar equipment-related electrical injury. He received a carpal and Guyon tunnel release, regaining sensation and strength to his right hand by the first postoperative day.

19.
Eur J Trauma Emerg Surg ; 35(1): 26-30, 2009 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-26814527

RESUMEN

INTRODUCTION: Under the trimodal distribution, most trauma deaths occur within the first hour. Determination of cause of death without autopsy review is inaccurate. The goal of this study is to determine cause of death, in hourly intervals, in trauma patients who died in the first 24 h, as determined by autopsy. MATERIALS AND METHODS: Trauma deaths that occurred within 24 h at a Level I trauma center were reviewed over a six-year period ending December 2005. Timing of death was separated into 0-1, 1-3, 3-6, 6-12 and 12-24 h intervals. Cause of death was determined by clinical course and AIS scores, and was confirmed by autopsy results. RESULTS: Overall, 9,388 trauma patients were admitted, of which 185 deaths occurred within 24 h, with 167 available autopsies. Blunt and penetrating were the injury mechanisms in 122 (73%) and 45 (27%) patients, respectively. Of 167 deaths, 73 (43.7%) occurred within the first hour. Brain injury, when compared to other body areas, was the most likely cause of death in all hourly intervals, but hemorrhage was as or more important than brain injury as the cause of death during the first 3 h and up to 6 h. No deaths were attributable to hemorrhage after 12 h. CONCLUSIONS: The temporal distribution of the cause of death varies in the first 24 h after admission. Hemorrhage should not be overlooked as the cause of death, even after survival beyond 1 h. Understanding the temporal relationship of causes of early death can aid in the targeting of management and surgical training to optimize patient outcome.

20.
Burns ; 35(6): 811-7, 2009 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-19423227

RESUMEN

The use of engineered tissue for the treatment of a variety of acute to chronic wounds has become a clinical standard, and a better understanding of the cellular mechanisms of re-vascularization and barrier integrity could enhance clinical outcomes. Here, we focus on the characterization of the re-vascularization of acellular grafts such as Integra in an animal model to better understand the physiological properties of blood vessels growing in the collagen-glycosaminoglycan matrix vs. wound margins. While Integra has been extensively studied in pre-clinical models, the re-modeling mechanisms of the capillary bed under these matrices are not well understood. Therefore, our first objective was to quantify the kinetics of re-vascularization. The second objective was to assess changes in vascular permeability (VP) of the wound bed compared to normal adjacent skin. The third objective was to establish a non-invasive and quantitative assay for the measurement of VP to facilitate the rapid and reproducible characterization of vascular integrity. Using an excisional wound model in mice, we characterize the appearance, growth, and maturation of blood vessels in an Integra graft over 28 days after surgery. Initial appearance of blood vessels in the graft was observed at 7 days, with angiogenesis peaking between 7 and 14 days. The onset of VP coincided with the increase in re-vascularization of the wound bed and there was a sustained elevation of VP that declined to baseline by 28 days. We propose a non-invasive strategy to assess VP of the wound capillary bed will facilitate a better understanding of the cell and molecular basis of angiogenesis in wound healing.


Asunto(s)
Permeabilidad Capilar/fisiología , Sulfatos de Condroitina/uso terapéutico , Colágeno/uso terapéutico , Neovascularización Fisiológica/fisiología , Piel/irrigación sanguínea , Cicatrización de Heridas/fisiología , Animales , Modelos Animales de Enfermedad , Supervivencia de Injerto/fisiología , Tejido de Granulación/fisiología , Masculino , Ratones , Ratones Endogámicos C57BL , Periodo Posoperatorio , Piel/lesiones , Trasplante de Piel/métodos , Trasplante de Piel/patología , Trasplante de Piel/fisiología , Piel Artificial
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