Autologous Blood-Derived Products (ABDPs) for the Treatment of Chronic Wounds.

Autologous blood-derived therapies have emerged as a unique and promising treatment option for chronic wounds. From whole blood clots to spun-down clot constituents, these therapies are highly versatile and tend to have a lower cost profile, allow for point-of-service preparation, and inherently carry minimal to no risk of rejection or allergic reaction when compared to many alternative cellular and matrix-like products. Subsequently, a diversity of processing systems, devices, and kits have surfaced on the market for preparing autologous blood-derived products (ABDPs) and many have demonstrated preclinical and clinical efficacy in facilitating chronic wound healing. However, not all ABDPs are created equal, and the lack of standardization among product formulations and cell concentrations as well as varying complexities in preparation protocols has led to unreliable substrate viabilities and overall inconsistent conclusions on efficacy. Additionally, external factors, such as the ease of drawing blood, the health of a patient's blood, and the reimbursement landscape have dissuaded some practitioners from incorporating ABDPs into an algorithm of care for recalcitrant wounds. Here, we attempt to categorize ABDPs into "classes" and examine their efficacy, advantages, and limitations when used as both a primary therapy and an adjunct for treating chronic wounds as well as comment on some potential considerations that may help gear future product development and application.

Avoiding the Use of Halogenated Anesthetic Agents for Uterine Relaxation in Open Mid-Gestation Fetal Surgery: A Case Report.

INTRODUCTION: Profound uterine relaxation is required for open fetal surgery. This is typically achieved by the administration of high-dose halogenated anesthetic agents. However, this anesthetic technique is associated with adverse cardiovascular effects in the fetus and may have long-term neurocognitive effects as well. CASE PRESENTATION: We pre-sent reports for 2 patients in whom uterine relaxation was maintained with nitroglycerin and magnesium infusions without any exposure to halogenated anesthetic agents. There were no adverse fetal or maternal effects from this technique. DISCUSSION/CONCLUSION: To the best of our knowledge, these are the first reports of open fetal surgery being performed without the use of halogenated anesthetic agents. This has potential short- and long-term benefits for the fetus, particularly as more complex and longer duration minimally invasive procedures are developed.

Age and gender differences in substance screening may underestimate injury severity: a study of 9793 patients at level 1 trauma center from 2006 to 2010.

BACKGROUND: Although the relationship between psychoactive substance use and injury is known, evidence remains conflicting on the impact of substance use on clinical outcomes after injury. We hypothesized that preinjury substance use would negatively impact clinical outcomes. METHODS: National Trauma Registry American College of Surgeons identified patients (n = 9793) presenting to Duke Hospital from 2006 to 2010. Logistic regression models assessed potential predictors of receiving substance screening, mortality, length of stay, ventilator requirement, intensive care admission, or emergency department disposition. RESULTS: Forty-seven percent (4607/9793) of patients received blood alcohol screen (BAS) and 31% (3017/9793) received urine drug screen (UDS). Men were more likely to receive both BASs (P < 0.001) and UDSs (P = 0.001) than women after controlling for potential confounders. There was no significant difference between men and women over the legal limit for alcohol (OLLA; 27.2%, 95% confidence interval [CI]: 25.7%-28.8% versus 24.8%, 95% CI: 22.3%-27.5%). Similarly, younger patients more likely received both BASs (P < 0.001) and UDSs (P < 0.001) compared with older patients. The proportion of patients aged ≤45 y OLLA (26.5 %, 95% CI: 24.9%-28.2%) was similar to those aged >45 y OLLA (26.8%, 95% CI: 24.5%-29.3%). After controlling for potential confounders neither alcohol, nor tetrahydrocannabinol, nor cocaine was predictive of mortality, ventilator requirement, length of stay, or emergency department disposition, but a higher alcohol level (P = 0.0174) predicted intensive care admission. CONCLUSIONS: Females and those aged >45 y are less likely to receive BASs and UDSs. Differential screening that is biased may place patients at risk for receiving inadequate care.

Nutritional Wellness for the Busy Health Care Provider: Small Everyday Wins.

When describing health care provider wellness, diet and nutrition are typically not addressed. This, in combination with the lack of decent food and diet resources typically available to the typically busy health care provider, exposes a significant gap in the road to advancing clinician wellness. This article aims to describe the relationship between nutrition and well-being, and potential barriers to optimal nutrition encountered by health care providers in the workplace. Readily available and practical strategies to improve physician diet and nutrition include: mindful eating practices, home meal preparation, food journaling, and mobile applications. From an organizational level, once physicians are making more informed food choices it is the hospital's responsibility to make nutritional options available in the workplace.

Case report: Pulmonary hypertensive crisis leading to cardiac arrest during endoscopic evaluation in a 6-year-old boy with autism, severe malnutrition, and undiagnosed scurvy.

Pediatric gastroenterologists are often responsible for the evaluation of malnutrition in the setting of selective eating. Endoscopic evaluation for conditions including eosinophilic esophagitis and celiac disease can help to identify and treat mucosal disease contributing to food selectivity. However, undiagnosed micronutrient deficiencies can cause cardiovascular derangements that significantly increase a patient's anesthetic risk. Vitamin C deficiency in particular, alone or in combination with severe malnutrition, is associated with a severe but reversible form of pulmonary arterial hypertension that, while life threatening in the acute phase, may significantly improve within days of starting ascorbic acid replacement therapy. Here we present a case of a 6-year-old boy with autism spectrum disorder (ASD), severe malnutrition, and undiagnosed chronic vitamin C deficiency who developed a pulmonary hypertensive crisis after induction of general anesthesia leading to cardiac arrest during endoscopic evaluation. While the association between food selectivity among youth with neurodevelopmental differences and vitamin C deficiency is well-described, and pulmonary hypertension is a recognized rare complication of scurvy, extant literature has not addressed next steps to improve patient outcomes. Using this case report as a foundation, we discuss specific patient populations to screen and treat for micronutrient deficiencies prior to anesthesia and propose a novel clinical algorithm for pre-anesthesia risk stratification and mitigation in patients specifically at risk for scurvy and associated pulmonary hypertension.

A meta-analysis of the effects of exposure to microplastics on fish and aquatic invertebrates.

Microplastics are present in aquatic ecosystems the world over and may influence the feeding, growth, reproduction, and survival of freshwater and marine biota; however, the extent and magnitude of potential effects of microplastics on aquatic organisms is poorly understood. In the current study, we conducted a meta-analysis of published literature to examine impacts of exposure to microplastics on consumption (and feeding), growth, reproduction, and survival of fish and aquatic invertebrates. While we did observe within-taxa negative effects for all four categories of responses, many of the effects summarized in our study were neutral, indicating that the effects of exposure to microplastics are highly variable across taxa. The most consistent effect was a reduction in consumption of natural prey when microplastics were present. For some taxa, negative effects on growth, reproduction and even survival were also evident. Organisms that serve as prey to larger predators, e.g., zooplankton, may be particularly susceptible to negative impacts of exposure to microplastic pollution, with potential for ramifications throughout the food web. Future work should focus on whether microplastics may be affecting aquatic organisms more subtly, e.g., by influencing exposure to contaminants and pathogens, or by acting at a molecular level.

Species identity matters when interpreting trophic markers in aquatic food webs.

In aquatic systems, food web linkages are often assessed using diet contents, stable isotope ratios, and, increasingly, fatty acid composition of organisms. Some correlations between different trophic metrics are assumed to be well-supported; for example, particular stable isotope ratios and fatty acids seem to reflect reliance on benthic or pelagic energy pathways. However, understanding whether the assumed correlations between different trophic metrics are coherent and consistent across species represents a key step toward their effective use in food web studies. To assess links among trophic markers, we compared relationships between major diet components, fatty acids, and stable isotope ratios in three fishes: yellow perch (Perca flavescens), round goby (Neogobius melanostomus), and spottail shiner (Notropis hudsonius) collected from nearshore Lake Michigan. Yellow perch and spottail shiner are native in this system, while round goby are a relatively recent invader. We found some evidence for agreement between different trophic metrics, especially between diet components, n-3:n-6 fatty acid ratios, and stable isotope ratios (δ13C and δ15N). However, we also observed significant variation in observed relationships among markers and species, potentially due to taxonomic variation in the specific diet items consumed (e.g., chydorid microcrustaceans and Dreissena mussels) and species-specific biochemical processes. In many of these latter cases, the invasive species differed from the native species. Understanding the effects of taxonomic variation on prey and predator signatures could significantly improve the usefulness of fatty acids in food web studies, whereas diet contents and stable isotopes appear to be reliable indicators of trophic niche in aquatic food webs.

Systematic review of the benefits and risks of metformin in treating obesity in children aged 18 years and younger.

IMPORTANCE: Childhood obesity is an important public health problem with increasing prevalence. Because treatment often has limited success, new approaches must be identified. OBJECTIVE: To evaluate the effectiveness and safety of metformin for treating obesity in children aged 18 years and younger without a diagnosis of diabetes mellitus. EVIDENCE REVIEW: We included randomized clinical trials identified through searches of MEDLINE, the Cochrane Library, and ClinicalTrials.gov. Our primary outcome measure was change in body mass index (BMI, calculated as weight in kilograms divided by height in meters squared). We assessed study quality, pooled data using a random-effects model, and performed subgroup and sensitivity analyses. FINDINGS: Fourteen randomized clinical trials were eligible. For BMI, moderate-strength evidence indicated a reduction of -1.38 (95% CI, -1.93 to -0.82) from baseline compared with control at 6 months. A similar, if less dramatic, effect was observed in studies less than 6 months, but the pooled estimate from studies of 1 year of treatment was not statistically significant. Subgroup analyses indicated smaller, but significant, effects for those with baseline BMI below 35, those of Hispanic ethnicity, those with acanthosis nigricans, those who had tried and failed diet and exercise programs, and in studies with more girls or higher mean age (adolescents). Moderate-strength evidence indicated that with metformin, 26% reported a gastrointestinal event compared with 13% in control groups (relative risk, 2.05; 95% CI, 1.19-3.54), although there was no difference in discontinuations due to adverse events. No serious adverse events were reported. CONCLUSIONS AND RELEVANCE: Metformin provides a statistically significant, but very modest reduction in BMI when combined with lifestyle interventions over the short term. A large trial is needed to determine the benefits to subgroups or impacts of confounders. In the context of other options for treating childhood obesity, metformin has not been shown to be clinically superior.

Comparison of helicopter versus ground transport for the interfacility transport of isolated spinal injury.

BACKGROUND CONTEXT: The use and need of helicopter aeromedical transport systems (HEMSs) in health care today is based on the basic belief that early definitive care improves outcomes. Helicopter aeromedical transport system is perceived to be safer than ground transport (GT) for the interfacility transfer of patients who have sustained spinal injury because of the concern for deterioration of neurologic function if there is a delay in reaching a higher level of care. However, the use of HEMS is facing increasing public scrutiny because of its significantly greater cost and unique risk profile. PURPOSE: The aim of the study was to determine whether GT for interfacility transfer of patients with spinal injury resulted in less favorable clinical outcomes compared with HEMS. STUDY DESIGN/SETTING: Retrospective review of all patients transferred to a Level 1 trauma center. PATIENT SAMPLE: Patients identified from the State Trauma Registry who were initially seen at another hospital with an isolated diagnosis of injury to the spine and then transferred to a Level 1 trauma center over a 2-year period. OUTCOME MEASURES: Neurologic deterioration, disposition from the emergency department, in-hospital mortality, interfacility transfer time, hospital length of stay, nonroutine discharge, and radiographic evidence of worsening spinal injury. METHODS: Patients with International Classification of Diseases, Ninth Revision (ICD-9) codes for injury to the spine were selected and records were reviewed for demographics and injury details. All available spine radiographs were reviewed by an orthopedic surgeon blinded to clinical data and transport type. Chi-square and t tests and multivariate linear and logistic regression models were done using STATA version 10. RESULTS: A total of 274 spine injury patients were included in our analysis, 84 (31%) of whom were transported by HEMS and 190 (69%) by GT. None of the GT patients had any deterioration in neurologic examination nor any detectable alteration in the radiographic appearance of their spine injury attributable to the transportation process. Helicopter aeromedical transport system resulted in significantly less transfer time with an average time of 80 minutes compared with 112 minutes with GT (p<.001). Ultimate disposition included 175 (64%) patients discharged to home, 15 (5%) expired patients, and 84 (31%) discharged to extended care facilities. After adjusting for patient age and Injury Severity Score, the use of GT was not a significant predictor of in-hospital mortality (odds ratio, 1.4; 95% confidence interval, 0.3-5), hospital length of stay (11.2+1.3 vs. 9.5+0.8 days, p=.3), or nonroutine discharge (odds ratio, 1.1; 95% confidence interval, 0.5-2.2). CONCLUSIONS: Ground transport for interfacility transfer of patients with spinal injury appears to be safe and suitable for patients who lack other compelling reasons for HEMS. A prospective analysis of transportation mode in a larger cohort of patients is needed to verify our findings.

Pediatric injury patterns by year of age.

PURPOSE: Since trauma is the leading cause of death and disability among children, understanding injury patterns may reduce morbidity and mortality through targeted prevention efforts. The purpose of this study was to identify pediatric injury patterns by year of age using a large national database. METHODS: We searched the National Trauma Database (NTDB) Research Data Set 7.0 for patients aged 0-18 years with the following relevant ICD-9 external-cause-of-injury codes (e-codes). We also reviewed our institutional trauma registry data (1999-2009). Data were analyzed using χ(2) analysis and ANOVA with significance defined as p<0.05. RESULTS: We identified 354,196 pediatric trauma patients. The leading MOI were motor-vehicle collisions (MVC) for ages 10-18 years and falls for ages 0-9 years. Fire was the second leading MOI among 1-year-olds, but not a major MOI in other age groups. Penetrating trauma was the MOI for 21% of injuries among adolescents with public or no insurance (versus 7.5% adolescents with private insurance). Injury severity scores were highest for children <1 year old and children 14-18 years old. Our review of 1209 patients from our institution yielded additional detail. CONCLUSION: MVC and falls remain leading pediatric MOI. In our year-of-age analysis, we found several interesting trends, including a higher-than-expected rate of penetrating trauma. Our findings may support targeted injury prevention efforts.

Population structure and spatial influence of agricultural variables on Hessian fly populations in the southeastern United States.

Population structure dictates the evolution of each population, and thus, the species as a whole. Incorporating spatial variables with population genetic statistics allows for greater discovery beyond traditional population genetics alone and can inform management decisions. The understanding of population structure in Hessian fly, Mayetiola destructor (Say), a pest of wheat, has been limited in the past. We scored 14 microsatellite loci from 12 collections of Hessian fly in the southeastern United States. Through Bayesian clustering analysis, we found two major populations of Hessian fly covering the entire southeastern United States. We evaluated correlations between agriculturally significant spatial variables and population genetic differentiation to test if genetic structure has an ecological component in a wheat agro-ecosystem. Our results suggest the total amount of alternative host plants in the county may be driving some genetic differentiation. Although planting date may also be influential, geographic distance, mean annual temperature, and harvested wheat for grain do not seem to be contributing factors. The ecological or spatial component to population structure, however, may be minimal compared to factors such as genetic drift.