Combined CD25, CD64, and CD69 Biomarker in 3D-Printed Multizone Millifluidic Device for Sepsis Detection in Clinical Samples.

Sepsis is a serious medical condition that arises from a runaway response to an infection, which triggers the immune system to release chemicals into the bloodstream. This immune response can result in widespread inflammation throughout the body, which may cause harm to vital organs and, in more severe cases, lead to organ failure and death. Timely and accurate diagnosis of sepsis remains a challenge in analytical diagnostics. In this work, we have developed and validated a sepsis detection device, utilizing 3D printing technology, which incorporates multiple affinity separation zones. Our device requires minimal operator intervention and utilizes CD64, CD69, and CD25 as the biomarker targets for detecting sepsis in liquid biopsies. We assessed the effectiveness of our 3D-printed multizone cell separation device by testing it on clinical samples obtained from both septic patients (n = 35) and healthy volunteers (n = 8) and validated its performance accordingly. Unlike previous devices using poly(dimethyl siloxane), the 3D-printed device had reduced nonspecific binding for anti-CD25 capture, allowing this biomarker to be assayed for the first time in cell separations. Our results showed a statistically significant difference in cell capture between septic and healthy samples (with p values of 0.0001 for CD64, CD69, and CD25), suggesting that 3D-printed multizone cell capture is a reliable method for distinguishing sepsis. A receiver operator characteristic (ROC) analysis was performed to determine the accuracy of the captured cell counts for each antigen in detecting sepsis. The ROC area under the curve (AUC) values for on-chip detection of CD64+, CD69+, and CD25+ leukocytes were 0.96, 0.92, and 0.88, respectively, indicating our diagnostic test matches clinical outcomes. When combined for sepsis diagnosis, the AUC value for CD64, CD69, and CD25 was 0.99, indicating an improved diagnostic performance due to the use of multiple biomarkers.

A simulation study on the association of HRO communication patterns and surgical team performance.

BACKGROUND: The hallmarks of high-reliability organizations (HROs) have been broadly embraced by health-care organizations as a path to achieve greater reliability in patient care. A simulation study was conducted to investigate the hypothesis that surgical teams whose intraoperative communication displayed the HRO hallmarks had a greater capacity to detect and resolve surgical complications in less time. METHODS: The study consisted of presenting four simulations to five surgical teams using a within-subject experimental design. In each simulation, the patient would manifest a complication in which the detection and/or resolution was either obscure or obvious. Communication patterns related to the frequency and sustained duration of HRO content were extracted from coded transcripts using recurrence quantification analysis (RQA), which were paired with the teams' elapsed time to detect or resolve a surgical complication. Spearman's rank-order statistics was then used to test for a monotonically decreasing association between these variables. RESULTS: Data consisting of the RQA metrics and elapsed times are reported for each surgical team in each simulation in addition to statistical tests for association between these variables and inter-rater reliability statistics of the coded communication. CONCLUSIONS: The study suggests that surgical teams whose communication espouses the HRO hallmarks of commitment to resilience and deference to expertise in both frequency and duration are able to resolve surgical complications with an obscure corrective action in less time. The study did not provide confirming evidence that these are associated with their ability to resolve a complication with an obvious corrective action in less time or that patterns of sensitivity to operations are associated with their ability to detect an obscure surgical complication in less time.

Inhalation Injury Grading Using Transfer Learning Based on Bronchoscopy Images and Mechanical Ventilation Period.

The abbreviated injury score (AIS) is commonly used as a grading system for inhalation injuries. While inhalation injury grades have inconsistently been shown to correlate positively with the time mechanical ventilation is needed, grading is subjective and relies heavily on the clinicians' experience and expertise. Additionally, no correlation has been shown between these patients' inhalation injury grades and outcomes. In this paper, we propose a novel inhalation injury grading method which uses deep learning algorithms in bronchoscopy images to determine the injury grade from the carbonaceous deposits, blistering, and fibrin casts in the bronchoscopy images. The proposed method adopts transfer learning and data augmentation concepts to enhance the accuracy performance to avoid overfitting. We tested our proposed model on the bronchoscopy images acquired from eighteen patients who had suffered inhalation injuries, with the degree of severity 1, 2, 3, 4, 5, or 6. As performance metrics, we consider accuracy, sensitivity, specificity, F-1 score, and precision. Experimental results show that our proposed method, with both transfer learning and data augmentation components, provides an overall 86.11% accuracy. Moreover, the experimental results also show that the performance of the proposed method outperforms the method without transfer learning or data augmentation.

A Reappraisal of Oxandrolone in Burn Management.

Objective: Burn injuries remain among the most severe traumatic injuries globally. With the discovery of cortisol, the use of steroids has become an essential therapy for the management of inflammatory and metabolic conditions. Several studies have shown the steroid oxandrolone improves burn injuries through stimulating anabolic and reducing catabolic processes. In this review, we examine the efficacy and applications of oxandrolone with regard to burn management and treatment. Data Sources: A literature search was performed using the PubMed database from January 1990 to May 2020 to identify articles on oxandrolone and burn management. A total of 18 studies were included in our review. Study Selection and Criteria: The keywords used in our search strategy for PubMed included "oxandrolone" and "burns." Data Synthesis: The main benefit of oxandrolone is the improved long-term lean body, protein, and bone mineral mass of burn patients. In addition, 3 separate meta-analyses showed oxandrolone shortened length of hospital stay, donor-site healing time, reduced weight loss, and net protein loss. However, oxandrolone therapy did not affect mortality, infection, or liver function. Conclusion: Oxandrolone remains an effective therapy for reducing the hypermetabolic response and comorbidities from burn injuries. Future clinical trials are needed using larger sample sizes and long-term follow-up to determine whether oxandrolone in the context of rehabilitation programs can reduce mortality, lower treatment costs, and improve function outcomes among burn patients.

New markers for sepsis caused by Pseudomonas aeruginosa during burn infection.

INTRODUCTION: Sepsis is a leading cause of mortality in burn patients. One of the major causes of sepsis in burn patients is Pseudomonas aeruginosa. We hypothesized that during dissemination from infected burn wounds and subsequent sepsis, P. aeruginosa affects the metabolome of the blood resulting in changes to specific metabolites that would serve as biomarkers for early diagnosis of sepsis caused by P. aeruginosa. OBJECTIVES: To identify specific biomarkers in the blood after sepsis caused by P. aeruginosa infection of burns. METHODS: Gas chromatography with time-of-flight mass spectrometry was used to compare the serum metabolome of mice that were thermally injured and infected with P. aeruginosa (B-I) to that of mice that were neither injured nor infected, mice that were injured but not infected, and mice that were infected but not injured. RESULTS: Serum levels of 19 metabolites were significantly increased in the B-I group compared to controls while levels of eight metabolites were significantly decreased. Thymidine, thymine, uridine, and uracil (related to pyrimidine metabolism), malate and succinate (a possible sign of imbalance in the tricarboxylic acid cycle), 5-oxoproline (related to glutamine and glutathione metabolism), and trans-4-hydroxyproline (a major component of the protein collagen) were increased. Products of amino acid metabolism were significantly decreased in the B-I group, including methionine, tyrosine, indole-3-acetate, and indole-3-propionate. CONCLUSION: In all, 26 metabolites were identified, including a unique combination of five metabolites (trans-4-hydroxyproline, 5-oxoproline, glycerol-3-galactoside, indole-3-acetate, and indole-3-propionate) that could serve as a set of biomarkers for early diagnosis of sepsis caused by P. aeruginosa in burn patients.

Heparinase Is Essential for Pseudomonas aeruginosa Virulence during Thermal Injury and Infection.

The opportunistic pathogen Pseudomonas aeruginosa is a major cause of sepsis in severely burned patients. If it is not eradicated from the wound, it translocates to the bloodstream, causing sepsis, multiorgan failure, and death. We recently described the P. aeruginosa heparinase-encoding gene, hepP, whose expression was significantly enhanced when P. aeruginosa strain UCBPP_PA14 (PA14) was grown in whole blood from severely burned patients. Further analysis demonstrated that hepP contributed to the in vivo virulence of PA14 in the Caenorhabditis elegans model. In this study, we utilized the murine model of thermal injury to examine the contribution of hepP to the pathogenesis of P. aeruginosa during burn wound infection. Mutation of hepP reduced the rate of mortality from 100% for mice infected with PA14 to 7% for mice infected with PA14::hepP While comparable numbers of PA14 and PA14::hepP bacteria were recovered from infected skin, only PA14 was recovered from the livers and spleens of infected mice. Despite its inability to spread systemically, PA14::hepP formed perivascular cuffs around the blood vessels within the skin of the thermally injured/infected mice. Intraperitoneal inoculation of the thermally injured mice, bypassing the need for translocation, produced similar results. The rate of mortality for mice infected with PA14::hepP was 0%, whereas it was 66% for mice infected with PA14. As before, only PA14 was recovered from the livers and spleens of infected mice. These results suggest that hepP plays a crucial role in the pathogenesis of PA14 during burn wound infection, most likely by contributing to PA14 survival in the bloodstream of the thermally injured mouse during sepsis.

Multiparameter Affinity Microchip for Early Sepsis Diagnosis Based on CD64 and CD69 Expression and Cell Capture.

Sepsis is a leading cause of death worldwide. In this work, a multiparameter affinity microchip was developed for faster sepsis diagnosis, which can reduce the mortality caused by late validation. The separation device captured cells expressing CD25, CD64, and CD69 into discrete antibody regions. The performance of multiparameter cell separation microchips was compared with flow cytometry analysis and validated with samples of septic patients ( n = 15) and healthy volunteers ( n = 10). The total analysis time was 2 h. Results showed that total on-chip cell counts for both CD64 and CD69 regions were linear with antigen expression levels. The difference between cell capture for septic and healthy samples was statistically significant (CD64: p = 0.0033; CD69: p = 0.0221, 95% confidence interval), indicating that sepsis is distinguishable based on microfluidic cell capture. For on-chip detection of CD64+ and CD69+ leukocytes, the AUC was 0.95 and 0.78, respectively. The combination of CD64 and CD69 for sepsis diagnosis had the AUC of 0.98, indicating the improved and excellent diagnostic performance of multiple parameters.

Spectral imaging of FRET-based sensors reveals sustained cAMP gradients in three spatial dimensions.

Cyclic AMP is a ubiquitous second messenger that orchestrates a variety of cellular functions over different timescales. The mechanisms underlying specificity within this signaling pathway are still not well understood. Several lines of evidence suggest the existence of spatial cAMP gradients within cells, and that compartmentalization underlies specificity within the cAMP signaling pathway. However, to date, no studies have visualized cAMP gradients in three spatial dimensions (3D: x, y, z).This is in part due to the limitations of FRET-based cAMP sensors, specifically the low signal-to-noise ratio intrinsic to all intracellular FRET probes. Here, we overcome this limitation, at least in part, by implementing spectral imaging approaches to estimate FRET efficiency when multiple fluorescent labels are used and when signals are measured from weakly expressed fluorescent proteins in the presence of background autofluorescence and stray light. Analysis of spectral image stacks in two spatial dimensions (2D) from single confocal slices indicates little or no cAMP gradients formed within pulmonary microvascular endothelial cells (PMVECs) under baseline conditions or following 10 min treatment with the adenylyl cyclase activator forskolin. However, analysis of spectral image stacks in 3D demonstrates marked cAMP gradients from the apical to basolateral face of PMVECs. Results demonstrate that spectral imaging approaches can be used to assess cAMP gradients-and in general gradients in fluorescence and FRET-within intact cells. Results also demonstrate that 2D imaging studies of localized fluorescence signals and, in particular, cAMP signals, whether using epifluorescence or confocal microscopy, may lead to erroneous conclusions about the existence and/or magnitude of gradients in either FRET or the underlying cAMP signals. Thus, with the exception of cellular structures that can be considered in one spatial dimension, such as neuronal processes, 3D measurements are required to assess mechanisms underlying compartmentalization and specificity within intracellular signaling pathways.

Isolation and characterization of HepP: a virulence-related Pseudomonas aeruginosa heparinase.

BACKGROUND: Pseudomonas aeruginosa is an opportunistic pathogen that causes serious infections in immunocompromised hosts including severely burned patients. In burn patients, P. aeruginosa infection often leads to septic shock and death. Despite numerous studies, the influence of severe thermal injuries on the pathogenesis of P. aeruginosa during systemic infection is not known. Through RNA-seq analysis, we recently showed that the growth of P. aeruginosa strain UCBPP-PA14 (PA14) in whole blood obtained from severely burned patients significantly altered the expression of the PA14 transcriptome when compared with its growth in blood from healthy volunteers. The expression of PA14_23430 and the adjacent gene, PA14_23420, was enhanced by seven- to eightfold under these conditions. RESULTS: Quantitative real-time PCR analysis confirmed the enhancement of expression of both PA14_23420 and PA14_23430 by growth of PA14 in blood from severely burned patients. Computer analysis revealed that PA14_23430 (hepP) encodes a potential heparinase while PA14_23420 (zbdP) codes for a putative zinc-binding dehydrogenase. This analysis further suggested that the two genes form an operon with zbdP first. Presence of the operon was confirmed by RT-PCR experiments. We characterized hepP and its protein product HepP. hepP was cloned from PA14 by PCR and overexpressed in E. coli. The recombinant protein (rHepP) was purified using nickel column chromatography. Heparinase assays using commercially available heparinase as a positive control, revealed that rHepP exhibits heparinase activity. Mutation of hepP resulted in delay of pellicle formation at the air-liquid interface by PA14 under static growth conditions. Biofilm formation by PA14ΔhepP was also significantly reduced. In the Caenorhabditis elegans model of slow killing, mutation of hepP resulted in a significantly lower rate of killing than that of the parent strain PA14. CONCLUSIONS: Changes within the blood of severely burned patients significantly induced expression of hepP in PA14. The heparinase encoded by hepP is a potential virulence factor for PA14 as HepP influences pellicle formation as well as biofilm development by PA14 and the protein is required for full virulence in the C. elegans model of slow killing.

Detection of sepsis in patient blood samples using CD64 expression in a microfluidic cell separation device.

A microfluidic affinity separation device was developed for the detection of sepsis in critical care patients. An affinity capture method was developed to capture cells based on changes in CD64 expression in a single, simple microfluidic chip for sepsis detection. Both sepsis patient samples and a laboratory CD64+ expression model were used to validate the microfluidic assay. Flow cytometry analysis showed that the chip cell capture had a linear relationship with CD64 expression in laboratory models. The Sepsis Chip detected an increase in upregulated neutrophil-like cells when the upregulated cell population is as low as 10% of total cells spiked into commercially available aseptic blood samples. In a proof of concept study, blood samples obtained from sepsis patients within 24 hours of diagnosis were tested on the chip to further validate its performance. On-chip CD64+ cell capture from 10 patient samples (619 ± 340 cells per chip) was significantly different from control samples (32 ± 11 cells per chip) and healthy volunteer samples (228 ± 95 cells per chip). In addition, the on-chip cell capture has a linear relationship with CD64 expression indicating our approach can be used to measure CD64 expression based on total cell capture on Sepsis Chip. Our method has proven to be sensitive, accurate, rapid, and cost-effective. Therefore, this device is a promising detection platform for neutrophil activation and sepsis diagnosis.

Serial envenomation in a snake handler with severe coaguloapathy.

We present a rare case study of a 37-year-old man with a history of multiple prior snake bites who presented to the emergency department for treatment of a rattlesnake bite to his right hand. Upon examination, he was found to be mildly hypertensive and exhibited significant coagulation abnormalities. Initial treatment included six vials of Crotalidae polyvalent immune fab; however, his coagulopathy was so severe that he required an additional eight vials. Continuous monitoring and calculations of Snakebite Severity Score demonstrated resolution of coagulopathy within 36 hours of admission. We believe the patient's unusual recovery was likely due to an innate immune response, specifically an activated memory B-cell cascade. This case should lead researchers to consider that the resolution of severe coagulopathy might result from a memory-driven immune response in instances of multiple envenomations.

Assessing resuscitation in burn patients with varying degrees of liver disease.

We find minimal literature and lack of consensus among burn practitioners over how to resuscitate thermally injured patients with pre-existing liver disease. Our objective was to assess burn severity in patients with a previous history of liver disease. We attempted to stratify resuscitation therapy utilised, using it as an indicator of burn shock severity. We hypothesized that as severity of liver disease increased, more fluid therapy is needed. We retrospectively studied adult patients with a total body surface area (TBSA) of burn greater than or equal to 20% (n = 314). We determined the severity of liver disease by calculating admission Model for End-Stage Liver Disease (MELD) scores and measured resuscitation adequacy via urine output within the first 24 h. We performed stepwise, multivariable linear regression with backward selection to test our hypothesis with α = 0.05 defined a priori. After controlling for important confounders including age, TBSA, baseline serum albumin, total crystalloids, colloids, blood products, diuretics, and steroids given in first 24 h, we found a statistically significant reduction in urine output as MELD score increased (p < 0.000). In our study, severity of liver disease correlated with declining urine output during first 24-hour resuscitation more so than burn size or burn depth. While resuscitation is standardized for all patients, lack of urine output with increased liver disease suggests a new strategy is of benefit. This may involve investigation of alternate markers of adequacy of resuscitation, or developing modified resuscitation protocols for use in patients with liver disease. More investigation is necessary into how resuscitation protocols may best be modified.

Pseudomonas aeruginosa biofilms perturb wound resolution and antibiotic tolerance in diabetic mice.

Diabetic patients are more susceptible to the development of chronic wounds than non-diabetics. The impaired healing properties of these wounds, which often develop debilitating bacterial infections, significantly increase the rate of lower extremity amputation in diabetic patients. We hypothesize that bacterial biofilms, or sessile communities of bacteria that reside in a complex matrix of exopolymeric material, contribute to the severity of diabetic wounds. To test this hypothesis, we developed an in vivo chronic wound, diabetic mouse model to determine the ability of the opportunistic pathogen, Pseudomonas aeruginosa, to cause biofilm-associated infections. Utilizing this model, we observed that diabetic mice with P. aeruginosa-infected chronic wounds displayed impaired bacterial clearing and wound closure in comparison with their non-diabetic littermates. While treating diabetic mice with insulin improved their overall health, it did not restore their ability to resolve P. aeruginosa wound infections or speed healing. In fact, the prevalence of biofilms and the tolerance of P. aeruginosa to gentamicin treatment increased when diabetic mice were treated with insulin. Insulin treatment was observed to directly affect the ability of P. aeruginosa to form biofilms in vitro. These data demonstrate that the chronically wounded diabetic mouse appears to be a useful model to study wound healing and biofilm infection dynamics, and suggest that the diabetic wound environment may promote the formation of biofilms. Further, this model provides for the elucidation of mechanistic factors, such as the ability of insulin to influence antimicrobial effectiveness, which may be relevant to the formation of biofilms in diabetic wounds.

Treatment of Severe Road Rash with ReCell® Autologous Skin Cell Suspension.

Road rash injuries are often variable in severity, with injuries ranging from simple scrapes to full-thickness burns. Autologous skin cell suspension devices, such as ReCell®, have shown increased promise by creating results comparable to the current standard of care, split-thickness skin grafting with significantly less donor skin required. We present a case of a 29-year-old male with significant road rash after a motorcycle accident at highway speeds, who was successfully treated solely with ReCell application. After surgery, he reported decreased pain with wound care and showed overall wound improvement with no changes in range of motion at 2-week follow-up. This case demonstrates the potential of ReCell as an independent treatment modality for pain and skin injury secondary to severe road rash.

Autologous Skin Cell Suspension in Toxic Epidermal Necrolysis: A Case Series.

Toxic epidermal necrolysis (TEN) is a dermatological process which has lacked both clear pathophysiological definition and efficacious medical treatment. This leads to metabolic dysfunction due to the inability to regulate fluid and electrolytes after the loss of skin. It is a deadly and costly disease which is associated with long lengths of stay and high-mortality rates. The depth of TEN mimics that of a partial-thickness burn. There has been documentation of successful usage of autologous skin cell suspension (ASCS) in TEN. This study expands upon our previous experience using ASCS in TEN to a series of three. Dermatology is consulted for biopsy along with the burn surgery team for wound care, where a Score for TEN is performed for risk stratification. Aggressive operative debridement is performed in the operative suite and a healthy, uninvolved donor site is harvested and processed per standard protocol. Dressings are taken down at postoperative day 4 for evaluation. The average length of stay when compared to historical data in literature is a reduction by 48%. ICU days were reduced by 64%. Cost was reduced by 54%. There was no mortality in our population of three. ASCS is both therapeutically and cost effective at treating TEN. The question of type of dressing and decision to operate is mitigated by this intervention. As an efficacious intervention, it reduces hospital stay, reduces wound cares, speeds healing, and provides a cosmetically acceptable outcome.

A Rare Mechanism of Inhalation Injury: Direct Thermal Damage to the Lower Airway.

In patients with inhalation injury associated with major burns, the primary mechanism of tissue harm depends on the location within the respiratory tract. Proximal to the trachea, the upper respiratory tract epithelium is classically injured via direct thermal injury. Such injury occurs due to the inhalation of high-temperature air. These upper airway structures and the tracheobronchial tree's dense vasculature protect the lower airways and lung parenchyma from direct thermal damage. The lower respiratory tract epithelium and lung parenchyma typically become injured secondary to the cytotoxic effects of chemical irritants inhaled in smoke as well as delayed inflammatory host responses. This paper documents a rare case in which a patient demonstrated evidence of direct thermal injury to the lower respiratory tract epithelium. A 26-year-old Caucasian male presented to the emergency room with 66% total body surface area thermal burns and grade 4 inhalation injury after a kitchen fire. Instead of visualizing carbonaceous deposits in the bronchi, a finding common in inhalation injury, initial bronchoscopy revealed bronchial mucosa carpeted with hundreds of bullae. Despite the maximum grade of inhalation injury per the abbreviated injury score and a 100% chance of mortality predicted with the revised Baux score, as well as a clinical course complicated by pneumonia development, bacteremia, and polymicrobial external wound infection, this patient survived. This dissonance between his expected and observed clinical outcome suggests that the applicability of current inhalation injury classification systems depends on the precise mechanism of injury to the respiratory tract. The flaws of these grading scales and prognostic indicators may be rooted in their failure to account for other pathophysiologic processes involved in inhalation injury. It may be necessary to develop new grading and prognostic systems for inhalation injury that acknowledge and better account for unusual pathophysiologic mechanisms of tissue damage.

Acute Intermittent Porphyria in a Burn Patient: Case Study and Review of the Literature.

Healthcare providers evaluating patients presenting with neurological, visceral, or cutaneous symptoms that are disproportionate to the expected severity may need to consider porphyria in the differential. Porphyria is an inherited condition in which toxic metabolites of the heme pathway are increased. Carriers of porphyrias are asymptomatic and will not present with classical symptoms, nor will levels be elevated, until the disease is induced by certain drugs, hormones, or idiopathic causes such as the stress of trauma. Acute intermittent porphyria, a form of acute porphyria, is a rare autosomal dominant disease that results in a dysfunctional porphobilinogen deaminase. This consequently increases neurotoxic porphobilinogen and subsequent increase in δ-aminolevulinic acid. Both of these metabolites cause neurovisceral symptoms that afflict the patient in acute attacks. We present a rare case of acute intermittent porphyria manifested in a burn patient suffering a burn injury. The patient presented with symptoms indicative of acute intermittent porphyria, including altered mental status and abdominal pain accompanied with a chronic history of alcoholism and smoking. A negative work-up, including imaging and findings of associated manifestations consistent with Acute Intermittent Porphyria led to a discovery of elevated porphyrins. The patient's course and death due to his injuries gives insight into the presentation of acute intermittent porphyria in a burn patient.

Burn Management in a Patient With Acute Exacerbation of Comorbid Systemic Lupus Erythematosus.

A 28-year-old female presented to the burn unit with 2% total body surface area second-degree burns to the right flank and right breast after accidentally spilling coffee on herself while hospitalized for an acute exacerbation of systemic lupus erythematosus (SLE) in the form of neuromyelitis optica spectrum disorder. We document her inpatient management, which was challenging because of the contradictory relationship between typical management of SLE exacerbations (i.e., immunosuppressive medication regimens) and the body's post-burn healing process, which is inherently inflammatory in nature. Even with a high-dose immunosuppressive medication regimen, our patient's second-degree burns healed with non-operative management without significant adverse events. Adding to a small yet growing body of literature addressing the clinical presentation and management of burn wounds in the setting of an acute SLE exacerbation, our case suggests that clinicians must carefully weigh the risks of surgical intervention with those of non-operative management when approaching burn care during an acute rheumatologic disease flare up.

Charge capture in the BICU: Increasing revenue by improving documentation behaviors.

Documentation by a healthcare provider is the key to capturing appropriate reimbursement for effort, expertize, and time given to patients. However, patient encounters are known to be under-coded; often describing a level of service that does not reflect the physician's labor. If there is deficient medical decision making (MDM) documentation, this will ultimately lead to a loss of revenue, as coders can only evaluate service levels from the documentation during the encounter. Physicians at the Timothy J. Harnar Regional Burn Center at Texas Tech University Health Sciences Center were experiencing below-average reimbursement for work performed in the burn center and theorized that deficiencies in documentation (particularly in the area of MDM) were the cause. They hypothesized that poor documentation by physicians was resulting in a substantial proportion of encounters being compulsorily coded at inadequate and imprecise levels of service. To improve the service levels of MDM in physician documentation at the Burn Center and consequently, increase the numbers and levels of billable encounters in the unit with an accompanying increase in revenue, two resources were created and employed with the purpose of providing increased documentation recall and thoroughness. These resources included a pocket card, designed to prevent missed details when documenting patient encounters, and a standardized EMR template that was mandated to be used by all BICU medical professionals rotating through the unit. After completion of the intervention period (July - October 2021), a comparison was made between the 4-month periods of July-October 2019 and 2021. Based on the encounters provided by residents and one fellow assigned to the BICU medical director, inpatient subsequent visit codes showed an average increase in billable encounters of 1500% amid the compared periods. Upon implementation of the intervention, subsequent visit codes 99231, 99232, and 99233 (higher-numbered codes indicating an increased level of service and accompanying reimbursement) raised by 142%, 2158%, and 2200%, respectively. An additional finding since the implementation of the pocket card and revised template, billable encounters have replaced the once-dominate global encounter, 99024 (associated with no reimbursement); realizing an increase in billable inpatient services due to complete and thorough documentation of non-global issues patients experienced throughout their hospital stays. Obtaining buy-in from physicians proved a significant challenge; consistent training and feedback allowed for an improved understanding of billing and coding processes within the BICU. The described findings indicate that a focused effort to improve documentation offers a promising method to yield potentially significant improvements in a unit's profitability.

Adenosine-5'-triphosphate-adenosine-glutathione cross-linked hemoglobin as erythropoiesis-stimulating agent.

An effective hemoglobin (Hb)-based blood substitute that acts as a physiological oxygen carrier and volume expander ought to stimulate erythropoiesis. A speedy replacement of blood loss with endogenous red blood cells should be an essential feature of any blood substitute product because of its relatively short circulatory retention time and high autoxidation rate. Erythropoiesis is a complex process controlled by oxygen and redox-regulated transcription factors and their target genes that can be affected by Hb physicochemical properties. Using an in vitro cellular model, we investigated the molecular mechanisms of erythropoietic action of unmodified tetrameric Hb (UHb) and Hb cross-linked with adenosine-5'-triphosphate (ATP), adenosine, and reduced glutathione (GSH). These effects were studied under normoxic and hypoxic conditions. Results indicate that these Hb solutions have different effects on stabilization and nuclear translocation of hypoxia-inducible factor (HIF)-1 alpha, induction of the erythropoietin (EPO) gene, activation of nuclear factor (NF)-kappa B, and expression of the anti-erythropoietic agents-tumor necrosis factor-alpha and transforming growth factor-beta 1. UHb suppresses erythropoiesis by increasing the cytoplasmic degradation of HIF-1 alpha and decreasing binding to the EPO gene while inducing NF-kappa B-dependent anti-erythropoietic genes. Cross-linked Hb accelerates erythropoiesis by downregulating NF-kappa B, stabilizing and facilitating HIF-1 alpha binding to the EPO gene, under both oxygen conditions. ATP and adenosine contribute to normoxic stabilization of HIF-1 and, with GSH, inhibit the NF-kappa B pathway that is involved in the suppression of erythroid-specific genes. Proper chemical/pharmacological modification is required to consider acellular Hb as an erythropoiesis-stimulating agent.