"Minimally Invasive" Skin Grafting With Enzymatic Debridement and Autologous Skin Cell Spray: A Retrospective Case Series.

Minimally invasive surgery is becoming the standard of care across surgical subspecialties. Several new "minimally invasive" options for burn debridement and autografting exist. Enzymatic bromelain-based debridement (BBD) and autologous skin cell spray (ASCS) have independently proven to reduce the rate of split-thickness skin grafting (STSG) and decrease donor site size when grafting is performed. There is a paucity in the literature regarding the combination of these two therapies. The purpose of this study is to characterize a cohort of patients treated with both BBD and ASCS and qualitatively compare data to expected outcomes without these therapies. This retrospective study of a single academic burn center's experience using BBD and ASCS together included 13 patients with a total burn surface area (TBSA) from 1-30% and all had >50% deep partial thickness. All patients received BBD and ASCS. Deeper burns additionally received STSG with ASCS overspray. Median burn size was 14% TBSA (IQR:5.45,20), donor site size was 225 sq cm (IQR:28.5,556.5), and ratio of donor site area to total treatment area of 0.082 (IQR: 0.039, 0.241) was observed. Median observed length of stay (LOS) was 19 days (IQR:10,27), expected LOS was 15.4 days, and O/E ratio 1.06. Donor sites in both groups of patients were much smaller than expected versus treatment with conventional meshed STSG alone and length of stay is lower than expected based on burn size. An emphasis on expenses and scar development will guide future studies into the patient subset and wound features that are best for this combination treatment.

La chirurgie mini-invasive devient le standard de traitement dans de nombreuses spécialités. Il y a de telles possibilités en brûlologie comme de débridement enzymatique à la bromélaïne (DEB) et la pulvérisation de cellules cutanées autologues (PCCA) qui ont chacun permis de diminuer le recours aux autogreffes et de réduire la surface de la zone donneuse. La littérature est pauvre en ce qui concerne la combinaison des 2. Cette étude rétrospective rapporte une cohorte de 13 patients traités dans notre centre par combinaison de DEB et PCCA, et compare le résultat avec celui attendu avec un traitement conventionnel. Les patients étaient brûlés sur 1 à 30% de SCT (médiane 14, IQR 5,45-20) dont au moins la moitié de 2ème profond, ayant tous reçu une combinaison de DEB et PCCA. Les atteintes plus profondes étaient greffées, avec une PCCA par dessus. Le site donneur avait une surface médiane de 225 cm2 (IQR 28,5-556,5) avec un rapport surface donneuse/surface traitée de 0,082 (IQR 0,039-0,241). La durée médiane de séjour est de 19 jours (IQR 10-27) quand elle était supposée être de 15,4 jours (rapport 1,06). Les sites donneurs étaient plus exigus que sous traitement conventionnel et la durée de séjour plus courte que supposée. Une étude plus précise sur les séquelles et les coûts permettrait de cibler plus précisément les patients susceptibles de bénéficier de ce protocole.

An Adjusted Ideal Body Weight Index Formula With Fresh Frozen Plasma (FFP) Rescue Decreases Fluid Creep During Burn Resuscitation.

Severe burn injury requires significant volume resuscitation, but over-resuscitation can be deadly. Accurate resuscitation of obese patients is challenging due to the decreased vascularity of adipose tissue. This study compares an adjusted ideal body weight index formula with fresh frozen plasma rescue to historical controls resuscitated with Parkland-based resuscitation. A retrospective review was conducted of adult patients admitted to our regional burn center with ≥ 20% total body surface area (TBSA) burns from 2010 to 2017 who survived more than 48 hours. Historical controls were resuscitated with Parkland-based resuscitation with occasional albumin. The adjusted ideal body weight (AIBW) patients were resuscitated with 2-4 mL/kg/%TBSA using an adjusted ideal body weight with fresh frozen plasma (FFP) rescue. Outcomes were compared with nonparametric statistics. A total of 161 patients met inclusion criteria: 40 patients received AIBW resuscitation and 121 patients were included as controls. The AIBW group received less fluid (3.30 vs. 4.15 mL/kg/%TBSA, p<0.001). A significant reduction in acute kidney injury requiring dialysis in the AIBW group was appreciated (5% vs. 19%, p=0.03) with improved mortality in AIBW patients as well (5% vs. 20%, p=0.03). Using an adjusted ideal body weight with FFP rescue to resuscitate patients with severe burn injury leads to a significant reduction in fluid administration without increase in acute kidney injury requiring dialysis and with improved mortality.

Les brûlés graves ont besoin d'un remplissage vasculaire majeur, pouvant toutefois être mortel s'il est exagéré. Il est particulièrement difficile chez les obèses, en raison de la faible vascularisation du tissu adipeux. Cette étude compare une formule basée sur le poids idéal (PI) et utilisant du PFC à des séries historiques utilisant la formule de Parkland. Cette étude rétrospective a revu les dossiers des patients admis dans notre CTB, ayant survécu plus de 48 h, entre 2010 et 2017. Les 121 cas historiques recevaient un remplissage selon Parkland (et de l'albumine au besoin). Les 40 patients à l'étude recevaient 2 à 4 mL/kg/% de PFC, le volume étant calculé sur le poids idéal. Ce groupe recevait significativement (p < 0,001) moins (3,3 mL/kg/%) de volume que le groupe contrôle (4,15). Ils avaient aussi moins fréquemment besoin d'épuration extra- rénale (5% VS 19%, p= 0,03) et leur mortalité était moindre (5% VS 20%, p= 0,03).

Prehospital hydroxocobalamin for inhalation injury and cyanide toxicity in the United States - analysis of a database and survey of ems providers.

Prehospital use of hydroxocobalamin as an antidote for cyanide toxicity, a serious complication of smoke inhalation, has yet to be universally adopted in the United States though its efficacy and safety have been demonstrated since 2006. The purpose of this study was to characterize practices of prehospital hydroxocobalamin administration via a survey of emergency medical services (EMS) and to report a case series from an EMS database to track use of hydroxocobalamin. The Fire Smoke Coalition Newsletter emailed a voluntary survey to EMS subscribers regarding hydroxocobalamin use. Survey responses were analyzed in addition to survival data from the Smoke Inhalation Treatment Database (SITD), a publically available, self-reported, online database for EMS regarding smoke inhalation patient outcomes. Analysis was compared to current published data from PubMed. The survey had a 14% response rate (284/2000). Only 38% reported prehospital utilization of a hydrogen cyanide antidote with 46% using hydroxocobalamin. 20% of responders reported a formal ALS protocol was in place for hydroxocobalamin use. For the SITD, 12 of 13 (92%) patients who received hydroxocobalamin for suspected inhalation survived. Other studies found a survival rate of 72% and 42% after administration of hydroxocobalamin for smoke inhalation. Prehospital administration of hydroxocobalamin for cyanide toxicity is uncommon in the United States, as evidenced by this analysis, despite well-documented safety and efficacy. Although a small sample, patients who received prehospital hydroxocobalamin had improved survival. This survival rate is significantly greater than those reported previously.

L'utilisation préhospitalière de l'hydroxocobalamine (OHB12) comme antidote du cyanure, intoxication grave compliquant les inhalations de fumées (IF), n'est toujours pas réalisée partout aux États-Unis, bien que son innocuité et son efficacité aient été démontrées dès 2006. Les buts de cette étude était de caractériser l'utilisation préhospitalière d'OHB12 à travers les données des services d'urgences (SU) et de rapporter une série de cas issus de leurs dossiers. La « Fire Smoke Coalition Newsletter ¼ a proposé par courriel aux services d'urgence abonnés un étude sur l'utilisation d'OHB12, basée sur le volontariat. En plus des réponses, nous avons analysé les données de la « Smoke Inhalation Treatment Database ¼ (STID), banque de données publique abondée par les SU, colligeant le devenir des patients victimes d'une IF et les avons comparées aux données de la littérature, retrouvée dans PubMed. Le taux de réponse au questionnaire a été de 14% (284/2 000). Trente huit pour cent des répondeurs utilisent des antidotes au cyanure en préhospitalier, qui est OHB12 dans 46% des cas. Vingt pour cent des répondeurs attestent de l'existence d'un protocole formalisé quant à l'utilisation d'OHB12. Selon STID, 92% (12/13) des patients ayant reçu OHB12 ont survécu. D'autres études retrouvent des taux de survie de 72% et 42% après administration de OHB12 dans le cadre de l'IF. Cette étude confirme que l'utilisation préhospitalière d'OHB12 dans le cadre de l'intoxication au cyanure n'est pas habituelle aux États-Unis, malgré une efficacité et une innocuité reconnues. Bien que l'échantillon soit faible, les patients ayant reçu OHB12 en préhospitalier ont un taux de survie nettement amélioré par rapport à ceux précédemment rapportés.

Feline discrete high-grade gastrointestinal lymphoma treated with surgical resection and adjuvant CHOP-based chemotherapy: retrospective study of 20 cases.

The aim of this retrospective study was to evaluate the outcome of cats treated with surgical intervention for a discrete intermediate-/high-grade gastrointestinal lymphoma prior to CHOP-based chemotherapy. Variables including sex, breed, haematocrit, white blood cell count, serum albumin concentration, clinical stage of disease, gastrointestinal obstruction and peritonitis were assessed for their effect on survival. Twenty cats met the inclusion criteria with three cats still alive at the time of data analysis. The overall median survival time (MST) was 417 days (range: 12-2962 days). The disease-free interval (DFI) was 357 days (range: 0-1585 days) with six cats still deemed in remission prior to death. Only clinical stage had a significant effect on both MST and DFI. Cats with discrete intermediate/high-grade gastrointestinal lymphoma that undergo surgical resection followed by adjuvant CHOP chemotherapy may achieve acceptable overall survival times.

Full-thickness wounds resulting from 'do-it-yourself' cryolipolysis: a case study.

This report reviews the case of a 55-year-old woman who suffered frostbite while attempting a 'do-it-yourself' version of cryolipolysis without the guidance of a medical professional. Cryolipolysis is a well-understood process through which the careful application of below-freezing temperatures is used to induce adipose cell death while sparing the skin, reducing body fat. This patient used dry ice in lieu of professional medical equipment, resulting in 4% total body surface area full- and partial-thickness wounds to her abdomen. Ultimately, the more superficial wounds healed with xenograft and a silver-impregnated dressing. The superior, deeper wound was excised and primarily closed with a fleur-de-lis panniculectomy. Her hospital course and recovery were uneventful. This case illustrates how online information of dubious quality can put the uneducated patient at risk of injury. Health-care professionals should be aware of the questionable resources available online, and should help patients become more discerning consumers of online information. Strategies to prevent such injury should be developed on a national scale.

Retinoblastoma protein regulates the crosstalk between autophagy and apoptosis, and favors glioblastoma resistance to etoposide.

Glioblastomas (GBMs) are devastating tumors of the central nervous system, with a poor prognosis of 1-year survival. This results from a high resistance of GBM tumor cells to current therapeutic options, including etoposide (VP-16). Understanding resistance mechanisms may thus open new therapeutic avenues. VP-16 is a topoisomerase inhibitor that causes replication fork stalling and, ultimately, the formation of DNA double-strand breaks and apoptotic cell death. Autophagy has been identified as a VP-16 treatment resistance mechanism in tumor cells. Retinoblastoma protein (RB) is a classical tumor suppressor owing to its role in G1/S cell cycle checkpoint, but recent data have shown RB participation in many other cellular functions, including, counterintuitively, negative regulation of apoptosis. As GBMs usually display an amplification of the EGFR signaling involving the RB protein pathway, we questioned whether RB might be involved in mechanisms of resistance of GBM cells to VP-16. We observed that RB silencing increased VP-16-induced DNA double-strand breaks and p53 activation. Moreover, RB knockdown increased VP-16-induced apoptosis in GBM cell lines and cancer stem cells, the latter being now recognized essential to resistance to treatments and recurrence. We also showed that VP-16 treatment induced autophagy, and that RB silencing impaired this process by inhibiting the fusion of autophagosomes with lysosomes. Taken together, our data suggest that RB silencing causes a blockage on the VP-16-induced autophagic flux, which is followed by apoptosis in GBM cell lines and in cancer stem cells. Therefore, we show here, for the first time, that RB represents a molecular link between autophagy and apoptosis, and a resistance marker in GBM, a discovery with potential importance for anticancer treatment.

Clinical effectiveness of new stent design: randomized single-blind comparison of tail and double-pigtail stents.

BACKGROUND AND PURPOSE: Stent morbidity appears to be secondary to lower urinary tract irritation. In an effort to decrease stent morbidity, a "one size fits all" Tail stent (Microvasive [Boston Scientific] Natick, MA) was developed with a 7F proximal pigtail and 7F shaft which tapers to a lumenless straight 3F tail. PATIENTS AND METHODS: We randomized 60 patients in a single-blind fashion to a 7F tail stent or 7F double-pigtail Percuflex stent. Patients were evaluated at the time of stent removal and 2 weeks later with a standardized questionnaire assessing: irritative lower tract symptoms individually and on a total scale of 0 (no symptoms) to 30 (worst symptoms), obstructive lower tract symptoms (on a total scale of 0-20), and upper tract irritative symptoms (on a total scale of 0-10). RESULTS: Patient age, weight, and height were similar in the two groups. Complications, including fever, urinary tract infections, emergency room visits, and the need for antispasmodics and pain medication, also demonstrated no significant difference. At the time of stent removal, patients who received a tail stent had significantly less urinary frequency and a statistically significant (21%) decrease in overall irritative voiding symptoms (12.2 v 15.4; p = 0.048). Two weeks after stent removal, the total irritative voiding symptoms was markedly decreased in both groups (7.1 in the Tail v 5.3 in the double-pigtail group; p = 0.15). Obstructive bladder and flank symptoms were not significantly different in the two stent groups, either at the time of stent removal or at 2 weeks after removal. CONCLUSION: In this randomized, single-blind study, the 7F Tail stent produced significantly less irritative symptoms than did the standard 7F double-pigtail stent. Obstructive symptoms tended to be less with the new stent, while flank symptoms were similar.

Mechanism of ureteral stent flow: a comparative in vivo study.

BACKGROUND AND OBJECTIVES: The flow characteristics of ureteral stents have yet to be clearly defined. In this study, flow mechanics were studied in several silicone-based stents including 4.8F, 7F, and 10.3F pigtail; 7F Tower; and a prototype mesh stent. MATERIALS AND METHODS: Forty-five female Yucatan minipigs underwent bilateral laparoscopic occlusion of their renal vessels to stop urine production. A nephrostomy tract was established by retrograde puncture. A stent was placed in the ureter, and three measurements were taken with flow from a bag of irrigant 20 cm above the kidney: stent occluded with a guidewire (extraluminal flow), stent unobstructed (total flow), and laparoscopically placed extraureteral ligature (luminal flow). RESULTS: Luminal flow and, to a lesser extent, total flow appeared to increase as the internal and external diameters of the stent increased. The Tower stent, which had no sideholes, had much lower flow rates in all categories, while the prototype mesh stent showed greater total flow compared with the other stents. Extraluminal flow did not increase with stent size greater than 7F. CONCLUSIONS: Luminal flow, but not extraluminal flow, increased with an increase in the internal diameter of the stent. In general, the least favorable flow occurred with a Tower stent, which had the smallest internal diameter. The greatest flow was seen with the prototype mesh stent.

An open study on the efficacy and safety of transurethral needle ablation of the prostate in treating symptomatic benign prostatic hyperplasia: the University of Florida experience.

PURPOSE: We determine the safety and efficacy of transurethral needle ablation of the prostate in patients with moderate to severe symptoms of benign prostatic hyperplasia. MATERIALS AND METHODS: Transurethral needle ablation of the prostate was performed on 45 consecutive patients. For an average prostate of 2.5 to 3 cm. long treatments were performed in 2 separate planes at 4 quadrants (2, 4, 8 and 10 o'clock positions) each. The 2 planes were 1 cm. below the bladder neck and 1 cm. proximal to the verumontanum. For prostatic urethral lengths longer than 3 cm. a treatment plane was added for each additional centimeter of prostatic urethra. The procedure was performed in 26 patients under local anesthesia using 20 cc 2% intraurethral lidocaine gel (11) or supplemented with intravenous 1.25 to 5 mg. midozolam (15). Of these patients 2 had a supplemental perineal block using a mixture of equal amounts of 15 cc 2% lidocaine without epinephrine and 0.25% bripivacaine, 10 underwent the procedure under general anesthesia, 2 had epidural and 4 had spinal anesthesia, and 3 had managed anesthesia care. Mean length of each procedure was 79 minutes (range 50 to 240). All procedures were done on an outpatient basis and patients were released on the same operative day. RESULTS: Mean prostatic volume on transrectal ultrasound was estimated at 48.1 cc (range 20 to 185). Following treatment the International Prostate Symptom Score decreased from a mean of 20.9 at baseline to 15.4 at 1 month, 16.1 at 3 months, 10.7 at 6 months and 9.9 at 1 year. The peak flow rate improved from a baseline mean of 8.3 to 13.4 at 3 months, 13.1 at 6 months and 14.9 at 1 year. The quality of life score improved from a baseline of 4.8 to 3.5, 2.2, 2.5 and 1.03 at 1, 3, 6 and 12 months, respectively. Of the 2 patients in whom the procedure failed; 1 required a bladder neck incision at 3 months and the other transurethral resection of the prostate. Foley catheters were left in place in all patients for an average of 4.85 days. CONCLUSIONS: After a followup of up to 12 months we conclude that transurethral needle ablation of the prostate is an effective treatment for symptomatic benign prostatic hyperplasia. This procedure has minimal morbidity, is less costly than conventional transurethral resection of the prostate and can be performed as an outpatient office procedure under local anesthesia in a significant number of patients.

Contribution of endothelin-1 to renal vasoconstriction in unilateral ureteral obstruction: reversal by verapamil.

PURPOSE: In unilateral ureteral obstruction (UUO) vasoconstriction occurs both during and after release of UUO. ET-1, an endogenous peptide, causes marked vasoconstriction mediated by an increase in cytosolic calcium. We measured renal output of endothelin-1 (ET-1) in dogs with UUO and examined if the renal vasoconstriction that persisted after release of UUO could be reversed by a calcium antagonist, verapamil. MATERIALS AND METHODS: Hemodynamic and clearance experiments were performed in anesthetized mongrel dogs in three groups. Group I consisted of 9 dogs with sham-operation. Group 2 consisted of 7 dogs in whom ureteral obstruction was released 1.9 hours after UUO. Group 3 consisted of 5 dogs in whom verapamil was infused into the renal artery at two doses (5 and 10 microg./min., respectively) after release of UUO of 19-hour duration. ET-1 concentrations (measured by radioimmunoassay) were determined for renal venous and arterial plasma. RESULTS: In Group 1 renal venous plasma ET-1 level was 16.7 +/- 2.2, significantly lowered than 22.8 +/- 3.2 pg./ml. in arterial plasma, indicating a net clearance of ET-1. In Group 2 and 3, renal venous plasma ET-1 levels (28.2 +/- 5.2 and 27.2 +/- 2.4 pg./ml., respectively) were significantly greater than those in arterial plasma (24.2 +/- 5.7 and 17.4 +/- 0.8 pg./ml., respectively), indicating a net output of ET-1 in the kidney, In addition, renal vasoconstriction occurred in Groups 2 and 3 as indicated by significantly lower renal blood flow and GFR than those in Group 1. In Group 3, intrarenal infusion of verapamil at two doses did not change arterial pressure but caused an ipsilateral, significant increase in RBF (from 132 +/- 4 17 to 1.84 +/- 19 and 180 +/- 16 ml./min., respectively) and dose-dependent increases in GFR (from 12 +/- 2 to 25 +/- 3 and 38 +/- 7 ml./min., respectively), associated with a profound dose-dependent ipsilateral diuresis and natriuresis. CONCLUSION: Profound renal vasoconstriction in UUO was associated with an increase in renal production of ET-1, possibly contributing to renal vasoconstriction, and was reversed by intrarenal infusion of verapamil.

Osteoporosis and genetic influence: a three-generation study.

We have studied 27 triads of mother, daughter and grandmother for possible genetic influence on distal and proximal forearm bone density, measured by single photon absorptiometry. We found a significant correlation of bone density at the proximal forearm between the mothers and grandmothers (r = 0.499, P < 0.01). There was also a weak correlation between proximal forearm bone densities of mothers and daughters (r = 0.327, P < 0.1). Significant correlations were found between the three generations for grip strength, pedometry, height and triceps skinfold thickness. There was also significant correlation between mother and grandmother for alcohol intake. There was no correlation for contraceptive pill use, smoking, dietary calcium intake, body weight or body mass index. The study concludes that, although there are similarities in bone mineral content between the three generations, genetic factors cannot be conclusively proven to be the major determinant of bone density. Lifestyle and environmental factors may have a bearing on achieving the peak bone mass and subsequent development of osteoporosis.

Hepatic disorders in the acquired immune deficiency syndrome: a clinical and pathological study.

We reviewed the clinical data, hepatic histology, and microbiological features of 21 patients with previously documented acquired immune deficiency syndrome who had liver biopsies. Diagnoses of specific infections were made on liver biopsy in 11/21 patients (57%). Granulomas were found in 10/21 patients (48%) and were most often a manifestation of infection with Mycobacterium avium-intracellulare. Elevated levels of serum alkaline phosphatase and longer duration of diagnosed illness were significantly associated with the presence of granulomatous disease.

Local area networks and the hospital.

Hospital information systems are characterized by their complexity of individual functions, heterogeneity of functions, and dependence upon integration. A distributed computerized information system is well suited to meeting the needs of hospitals. A local area communications network (LACN) removes a major impediment to the use of distributed systems. An advanced microprocessor-based LACN using fiberoptic communications has been developed by the Applied Physics Laboratory of The Johns Hopkins University and has been implemented at the University of California, San Francisco Hospital.

A prototype generalized network technology for hospitals: initial implementation.

A demonstration implementation of a distributed data-processing hospital information system using an intelligent local area communications network (LACN) technology is described. This system is operational at the UCSF Medical Center and integrates four heterogeneous, stand-alone minicomputers. The applications systems are PID/Registration, Outpatient Pharmacy, Clinical Laboratory, and Radiology/Medical Records. Functional autonomy of these systems has been maintained, and no operating system changes have been required. The LACN uses a fiber-optic communications medium and provides extensive communications protocol support within the network, based on the ISO/OSI Model. The architecture is reconfigurable and expandable. This paper describes system architectural issues, the applications environment, and the local area network.