Effects of a caspase and a calpain inhibitor on resting energy expenditures in normal and hypermetabolic rats: a pilot study.

Several diseases induce hypermetabolism, which is characterized by increases in resting energy expenditures (REE) and whole body protein loss. Exaggerated protein degradation is thought to be the driving force underlying this response. The effects of caspase and calpain inhibitors on REE in physiological and hypermetabolic conditions, however, are unknown. Thus, we studied whether MDL28170 (calpain inhibitor) or z-VAD-fmk (caspase inhibitor) affect REE under physiological conditions and during hypermetabolism post-burn. Rats were treated five times weekly and observed for 6 weeks. Treatment was started 2 h (early) or 48 h (late) after burn. In normal rats, MDL28170 transiently increased REE to 130 % of normal during week 2-4. z-VAD-fmk reduced REE by 20-25 % throughout the observation period. Within 14 days after burns, REE increased to 130+/-5 %. Whereas MDL28170/early treatment did not affect REE, MDL28170/late transiently increased REE to 180+/-10 % of normal by week 4 post-burn. In contrast, with z-VAD-fmk/early REE remained between 90-110 % of normal post-burn. z-VAD-fmk/late did not affect burn-induced increases in REE. These data suggest that caspase cascades contribute to the development of hypermetabolism and that burn-induced hypermetabolism can be pharmacologically modulated. Our data point towards caspase cascades as possible therapeutic targets to attenuate hypermetabolism after burns, and possibly in other catabolic disease processes.

Burn Education Awareness Recognition and Support (BEARS): a community-based juvenile firesetters assessment and treatment program.

In response to the continued staggering statistics of fires set by juveniles and the devastating personal and property costs that are associated with these fires, the Burn and Shock Trauma Institute of Loyola University Medical Center, in collaboration with the State Fire Marshal's Office; the Illinois Fire Safety Alliance; and representatives from the firefighting community, law enforcement, emergency medicine and mental health, came together to create the Burn Education Awareness Recognition and Support Program. Through financial grant support from the International Association of Firefighters, the Illinois Fire Safety Alliance, and other private donations, the Burn Education Awareness Recognition and Support Program is able to provide a free resource to anyone who is concerned about a child playing with fire. Specially trained firefighters assess each child using the tool developed by the Federal Emergency Management Agency. In 2002, we assessed 42 children; 29 of those children were referred through the courts. So far, none of the children treated in our program have returned to fire-setting behaviors.

Cost reduction strategies in burn nutrition services: adjustments in dietary treatment of patients with hyponatremia and hypophosphatemia.

Two clinically effective adjustments in diet therapy were tested at a burn center as strategies to lower clinical care costs. The use of adult enteral formulas for pediatric burn patients reduced the incidence of hyponatremia and the need for costly sodium supplements. The prophylactic administration of oral phosphate during the first days of hospitalization may lessen the decline in serum phosphate and save costs for the treatment of hypophosphatemia of severely burned patients.

Trauma care fellowships: current status and future survival.

BACKGROUND AND METHODS: To determine the current status and future direction of trauma care fellowships, a phone survey was conducted with the 45 program directors reporting information to the American Association for the Surgery of Trauma and the Eastern Association for the Surgery of Trauma. RESULTS: Forty programs (89%) were operational, with 86 positions. The duration of the fellowship was 1 year for 16 (40%) and 2 or more years for 24 (60%). Accreditation Council for Graduate Medical Education accreditation (ACGME) (for surgical critical care) was held by 28 (70%). Mean salary was $39,600 at the first-year level. A funding shift from institutional to practice revenue sources is foreseen. Thirteen directors (32.5%) saw future recruitment potential as increasing and 11 (27.5%) saw it as decreasing. CONCLUSION: The essence, structure, and funding of trauma fellowships are changing. One-year exclusive trauma fellowships are being replaced by 1- to 2-year trauma or surgical critical care fellowships with Accreditation Council for Graduate Medical Education accreditation increasingly seen as essential. The challenge for fellowships in an era of budgetary constraints will be to provide adequate training in the full spectrum of tramatology within a reasonable time frame supported by a predictable funding mechanism.

A burn center cost-reduction program.

A concerted effort to decrease resource usage and length of stay without sacrificing quality of care was undertaken over a 2-year period in a high-census Burn Center. Through a series of changes in practice, substantial decreases in the costs of several high-usage items were tracked. During this period the average length of stay also was decreased. The average hospital charge decreased from $46,628 per patient in fiscal year 1993 to $33,159 per patient in fiscal year 1994. During this period there was no significant change in the patient population as measured by total body surface area percentage burn and acuity level. With the exception of significant improvement in the infection rate, there was no substantial change in indicators of quality care as measured by readmission, morbidity, and posthospital would healing progression. This cost-reduction program showed that costs can be reduced without diminishing quality of care; in some respects quality of care improved due to the practice changes that were implemented.

Why activity-based costing works.

With advancing technology and the quest for delineating the true cost of a procedure or diagnostic test, cost accounting techniques are being re-explored in the health care setting. Activity-based costing (ABC), adopted from other businesses, is one such example that has applications in the health industry. The purpose of this paper is to enhance the understanding of health care costs among physician providers, emphasizing a new approach--activity-based costing.

Comparative analysis of bedside and operating room tracheostomies in critically ill patients with burns.

The objective of this study was to demonstrate that bedside burn intensive care unit tracheostomy is a safe and cost-effective procedure and has advantages over operating room tracheostomy. The charts of all patients who underwent tracheostomies in the burn unit between January 1990 and September 1993 were reviewed retrospectively. All tracheostomies were performed by residents in their second to fourth postgraduate years. The identical operating room technique was used for all bedside procedures including complete instrument tray, electrocautery, and adequate lighting. Standard tracheostomies were routinely performed at the bedside instead of the operating room in an attempt to deal with an increasing number of critically ill patients with burns requiring operating room surgical procedures. No patient-specific criteria were used to determine whether bedside or operating room tracheostomy would be performed. Charges for bedside intensive care unit and operating room tracheostomy were compared. Group t test and chi-square analysis were used with significance set at p < 0.05. Forty-three tracheostomies were performed in the 45-month period reviewed. Twenty-five tracheostomies performed in the operating room were compared with the 18 tracheostomies performed at the bedside in the burn intensive care unit. No statistical difference existed in age, sex, mean total body surface area percent burned, mean inspired oxygen, mean positive end expiratory pressure, mean pretracheostomy intubated days, presence of inhalation injury, or complication rate between groups. The average combined cost for operating room and anesthesia was $1740 per tracheostomy performed in the operating room. No charge was given to the patient for a bedside tracheostomy apart from the surgeon's fee and tracheostomy tube.(ABSTRACT TRUNCATED AT 250 WORDS)

Perception of differences between trauma care and other surgical emergencies: results from a national survey of surgeons.

A national sample of 2500 surgeons was surveyed. Thirteen variables were analyzed to ascertain perceived differences between trauma care and other surgical emergencies, as well as to identify factors contributing to a preferential reluctance to treat trauma. The response rate was 60%. Trauma was perceived as most likely to occur at inconvenient times by 67% of respondents, more often complex (44%), and more demanding of specialized knowledge (39%). Trauma was viewed as less likely to be reimbursed by 35% and most often litigious by 30%. Fewer respondents perceived differences for risk of exposure to lethal pathogens and violence (26% and 9%) and personal or professional rewards (25%). Surgeons who prefer to treat trauma view it as more often demanding of specialized knowledge and more complex than other surgical emergencies. Surgeons who prefer not to treat trauma or take trauma call perceive it as never personally or professionally rewarding, more often disruptive to personal life, emotionally taxing, litigious, and inconvenient compared with other emergencies. Perception of dissimilar reimbursement and personal health risk are less often associated factors. Perceived differences in the litigious nature of cases are not based on fact. We conclude that the individual degree of reluctance or enthusiasm for trauma care in comparison with other emergencies is influenced by perception, personality, and myth rather than by logic and facts.

The role of diagnostic laparoscopy in the management of trauma patients: a preliminary assessment.

This study evaluated the role and advantages of diagnostic laparoscopy (DL) compared with diagnostic peritoneal lavage (DPL) in 75 trauma patients who were prospectively studied with DL followed by DPL. Of these, 59 patients had blunt injuries and 16 stab wounds. Seventy patients (93%) had the procedures performed in the emergency department (ED); 41 (59%) of these were awake and under local anesthesia. Forty-two patients had negative DPL and DL results with no subsequent sequelae. Twenty-three patients had negative DPL results and abnormal DL results. Of these, 20 were managed nonsurgically, and three (DPL < 10,000 RBC) underwent surgery based solely on DL findings of diaphragmatic lacerations from stab wounds. These were repaired. All 23 had an uneventful course. Three patients had positive DPL and insignificant DL findings. Laparotomy and DL findings correlated. A splenectomy for iatrogenic injury unrelated to DL and two nontherapeutic laparotomies were performed. Seven patients demonstrated both positive DPL and significant DL findings, and all had therapeutic laparotomies. Management based on DL rather than DPL would potentially have improved care in 8% of cases (6 of 75). Reliance on DL improved care in 19% (3 of 16) of patients with stab wounds and possibly could have in 3% (2 of 59) of those with blunt injuries. Management using DL would have potentially improved care in 30% (3 of 10) of patients with positive DPL findings and 5% (3 of 65) with negative DPL findings. Diagnostic laparoscopy can be performed safely in stable patients under local anesthesia in the ED. It offers no advantage over DPL as a primary assessment tool in blunt trauma. It does have advantages in the management of stab wounds. Diagnostic laparoscopy has a role in redefining DPL criteria for laparotomy and, in selected patients, as an adjunct to DPL, allowing further diagnosis and potentially the treatment of injuries without laparotomy.

Routine pelvic x-ray studies in awake blunt trauma patients: a sensible policy?

To evaluate the usefulness of routine pelvic x-ray films in the resuscitation of blunt trauma victims, 1395 patients were prospectively evaluated over a 13-month period. Of these, 810 (58%) were awake with Glasgow Coma Scale scores greater than or equal to 13 and were enrolled into the study. A history, with directed questions regarding pelvic pain, a clinical examination of the pelvis, and an anterior-posterior pelvic x-ray film (APPX) were obtained for each patient. Thirty-nine patients (5%) had fractures identified on the x-ray films. Of these patients with radiographically identified fractures, 34 (87%) complained of pain and had positive results on clinical examination, two (5%) either complained of pain or had positive results on examination and three (8%) had neither complaint of pain nor positive examination results. Of the 771 patients without fractures 743 (96%) lacked pain complaints or positive examination results. The likelihood of fracture was greatest in patients with complaints of pain and positive examination results (65%) followed by patients with either complaint of pain or positive examination results (16%). Only three (0.4%) of the 743 patients having no complaints of pain and a negative clinical examination had fractures diagnosed roentgenographically. These were minor fractures that did not affect the clinical course. Total charges incurred to diagnose pelvic fractures in this low-yield patient group were $88,028. We conclude that the practice of obtaining a screening APPX is not necessary or cost-effective in the management of awake blunt trauma patients who do not complain of pain and who have normal pelvic physical examination results.

Intoxication and injury.

The relationship between alcohol use and injury severity was investigated in trauma patients admitted to a tertiary referral hospital during a 23-month period. Admission blood alcohol levels (BALs) were obtained on 427 trauma patients, who were stratified into three groups: those with no measurable blood alcohol, those within the legal limit of 100 mg/dL, and those over the legal limit or intoxicated. The no-alcohol group had significantly lower injury severity than the other two groups (p less than 0.001). Even when the BAL was well within the legal limit, injuries suffered by those in the alcohol-positive groups were more severe than those in the no-alcohol group. Confirmatory evidence of the effect of alcohol on injury severity was reflected by a 2.3% mortality in alcohol-negative patients compared with a 13.3% death rate in alcohol-positive patients (p less than 0.0001). To assess the potentially confounding effect of alcohol on injury scoring accuracy, we examined the change in Glasgow Coma Scale (GCS) scores following admission. No significant differences were found when admission GCS values were compared with GCS determinations made 24 hours following admission by separate observers. To correct for any potential bias as a tertiary referral center, repeat analysis with exclusion of transferred patients was done with essentially no change in results. Our data revealed a highly significant relationship between alcohol use, degree of injury, and resource consumption.

Predicting hospital charges for trauma care.

Diagnosis related groups (DRGs) have sharply decreased the amount of compensation hospitals can expect for providing trauma care. A total of 637 patients admitted for acute traumatic injuries between Oct 1, 1985, and July 30, 1986, had their DRG classifications, Injury Severity Scores, trauma scores, and ages compared with hospital charges in an attempt to identify factors that could be used to accurately predict hospital charges. The best prediction of charges was obtained when DRG assignment was combined with Injury Severity Scores and age. When the equation obtained by this approach was applied to a separate population of 301 patients, the average difference between the actual charge and that predicted was $38 and would have led to a 33-fold decrease in money lost by the hospital. Altering the DRG payment schedule as proposed would allow hospitals to be fairly compensated for the care of trauma patients.