Human skin processing affects clinical outcome in allograft recipients.

Skin allografts represent a milestone in burn patient treatment. However, skin procurement is still burdened by high rates of contamination, and validation procedures have not yet been standardized. In addition, it is not clear if tissue viability affects allograft skin outcomes. In 2120 skin samples from 610 donors, a retrospective analysis was performed to identify donor and procurement variables associated with bacterial contamination and tissue viability. Post-processing contamination was associated significantly with the donor type, cause of death, length of hospitalization, procurement site, surgeon, interval between procurement and banking, and decontamination method. Tissue viability appeared to be negatively associated with freezing. In two series of skin allograft recipients (155 and 195 patients), we evaluated the role of skin characteristics and procurement variables on clinical outcomes. We found that the length of hospitalization was associated significantly with donor age. Procalcitonin and PCR values in allograft recipients were correlated with the decontamination method. No significant associations were observed between tissue viability and clinical outcomes (length of hospitalization, cause of donor death, or inflammatory parameters) after allograft transplantation. In these large case series, we identified donor and procurement variables that may affect allograft skin recipients. The decontamination method appeared to be a critical step for skin allograft requiring better standardization.

Mechanical chest compression and extracorporeal life support for out-of-hospital cardiac arrest. A 30-month observational study in the metropolitan area of Milan, Italy.

BACKGROUND: Return of spontaneous circulation (ROSC) is achieved in 25% of out-of-hospital cardiac arrest (OHCA) patients. Mechanical chest compression (mechCPR) may maintain better perfusion during transport, allowing hospital treatments like extracorporeal circulation life support (ECLS). We aim to assess the effectiveness of a pre-hospital protocol introduction. METHODS: Observational, retrospective study assessing all OHCA patients aged 12-75, with no-flow time <20 min in a metropolitan area (Milan, Italy, 2013-2016). PRIMARY OUTCOMES: ROSC and Cerebral Performance Category score (CPC) ≤2 at hospital discharge. Logistic regressions with multiple comparison adjustments balanced with propensity scores calculated with inverse probability of treatment weighting were performed. RESULTS: 1366 OHCA were analysed; 305 received mechCPR, 1061 manual chest compressions (manCPR), and 108 ECLS. ROSC and CPC ≤2 were associated with low-flow minutes (odds ratio [95% confidence interval] 0.90 [0.88-0.91] and 0.90 [0.87-0.93]), shockable rhythm (2.52 [1.71-3.72] and 10.68 [5.63-20.28]), defibrillations number (1.15 [1.07-1.23] and 1.15 [1.04-1.26]), and mechCPR (1.86 [1.17-2.96] and 2.06 [1.11-3.81]). With resuscitation times >13 min, mechCPR achieved more frequently ROSC compared to manCPR. Among ECLS patients, 70% had time exceeding protocol: 8 (7.5%) had CPC ≤2 (half of them with low-flow times between 45 and 90 min), 2 (1.9%) survived with severe neurological disabilities, and 13 brain-dead (12.0%) became organ donors. CONCLUSIONS: MechCPR patients achieved ROSC more frequently than manual CPR patients; mechCPR was a crucial factor in an ECLS protocol for refractory OHCA. ECLS offered a chance of survival to patients who would otherwise die.

Negative Pressure Wound Therapy for the Treatment of Fournier's Gangrene: A Rare Case with Rectal Fistula and Systematic Review of the Literature.

Fournier's gangrene (FG) is a Necrotizing Soft Tissue Infection (NSTI) of the perineal region characterized by high morbidity and mortality even if appropriately treated. The main treatment strategies are surgical debridement, broad-spectrum antibiotics, hyperbaric oxygen therapy, NPWT (Negative Pressure Wound Therapy), and plastic surgery reconstruction. We present the case of a 50-year-old woman with an NSTI of the abdomen, pelvis, and perineal region associated with a rectal fistula referred to our department. After surgical debridement and a diverting blow-out colostomy, an NPWT system composed of two sponges connected by a bridge through a rectal fistula was performed. Our target was to obtain healing in a lateral-to-medial direction instead of depth-to-surface to prevent the enlargement of the rectal fistula, promoting granulation tissue growth towards the rectum. This eso-endo-NPWT technique allowed for the primary suture of the perineal wounds bilaterally, simultaneously treating the rectal fistula and the perineum lesions. A systematic review of the literature underlines the spreading of NPWT and its effects.

Regenerative Medicine to Improve Outcomes of Ventral Hernia Reconstruction (REPAIR Study) Phase 1: Find the Best Decellularization Protocol for the Human Dermis.

Background: Tissue regeneration is a complex process that allows wounds to heal. Many options are currently available to help human skin repair and to reduce the recurrence of hernias. The aim of this study is to analyze the best decellularization protocol for allogenic human dermal tissues. Methods: Dermal flaps from donors were used and compared with a control group. Each flap was subjected to seven different decellularization protocols and washed with a sequence of five solutions. The samples were then subjected to four control tests (such as Nile Red), and long-term contacts were analyzed to assess whether the decellularized dermis samples could support the growth of human fibroblasts. Results: All the samples had an average residual viability of 60%. Except for one sample, the decellularization treatments were able to reduce cell viability significantly. The Nile Red test showed a significant reduction in phospholipid content (mean 90%, p-value < 0.05) in all treatments. The cell growth increased in a linear manner. As described in the literature, sodium-dodecyl-sulfate (SDS) caused an interference between the test and the detergent. Conclusions: This paper shows the first step to finding the best decellularization protocol for allografting human dermal tissues. Further biocompatibility tests and DNA quantification are necessary.

Open issues in management of carbon monoxide poisoning in pregnancy: practical suggestions.

Carbon monoxide (CO) poisoning during pregnancy may cause deleterious effects to the fetus. Hyperbaric oxygen therapy (HBO) in pregnancy is proven to be safe and it is considered to be beneficial, reducing the severity of the fetal injuries. However, a number of issues are still to be discussed, among them the question of the carboxyhemoglobin (COHb) levels that trigger HBO therapy in pregnant CO poisoned patients. In this letter we report some practical suggestions for organizations wishing to develop their own protocols.

Impact of Point-of-Care Ultrasound on Secondary Triage: A Pilot Study.

OBJECTIVES: In mass casualty scenarios, patients with apparent hemodynamic and respiratory stability might have occult life-threatening injuries. These patients could benefit from more accurate triage methods. This study assessed the impact of point-of-care ultrasound on the accuracy of secondary triage conducted at an advanced medical post to enhance the detection of patients who, despite their apparent clinically stable condition, could benefit from earlier evacuation to definitive care or immediate life-saving treatment. METHODS: A mass casualty simulated event consisting of a bomb blast in a remote area was conducted with 10 simulated casualties classified as YELLOW at the primary triage scene; patients were evaluated by 4 physicians at an advanced medical post. Three patients had, respectively, hemoperitoneum, pneumothorax, and hemothorax. Only 2 physicians had sonographic information. RESULTS: All 4 physicians were able to suspect hemoperitoneum as a possible critical condition to be managed first, but only physicians with additional sonographic information accurately detected pneumothorax and hemothorax, thus deciding to immediately evacuate or treat.

Nonoperative Management of a Recurrent Postoperative Inguinal Lymphatic Leak via Negative-Pressure Wound Therapy: A Case Report.

ABSTRACT: Lymphatic leaks are common following common femoral vessel exposure for cardiac surgical procedures. The management of this complication can be difficult and is often uncomfortable for the patient. This case report describes the successful nonoperative treatment of a recurrent lymphatic leak from an inguinal surgical wound via negative-pressure wound therapy. Negative pressure may be considered a minimally invasive, effective, and acceptable way to treat postoperative lymphatic leaks at the groin.

GMP-compliant sponge-like dressing containing MSC lyo-secretome: Proteomic network of healing in a murine wound model.

Chronic wounds account for 3% of total healthcare expenditure of developed countries; thus, innovative therapies, including Mesenchymal Stem Cells (MSCs) end their exosomes are increasingly considered, even if the activity depends on the whole secretome, made of both soluble proteins and extracellular vesicles. In this work, we prove for the first time the in vivo activity of the whole secretome formulated in a sponge-like alginate wound dressing to obtain the controlled release of bioactive substances. The product has been prepared in a public GMP-compliant facility by a scalable process; based on the murine model, treated wounds healed faster than controls without complications or infections. The treatment induced a higher acute inflammatory process in a short time and sustained the proliferative phase by accelerating fibroblast migration, granulation tissue formation, neovascularization and collagen deposition. The efficacy was substantially supported by the agreement between histological and proteomic findings. In addition to functional modules related to proteolysis, complement and coagulation cascades, protein folding and ECM remodeling, in treated skin, emerged the role of specific wound healing related proteins, including Tenascin (Tnc), Decorin (Dcn) and Epidermal growth factor receptor (EGFR). Of note, Decorin and Tenascin were also components of secretome, and network analysis suggests a potential role in regulating EGFR. Although further experiments will be necessary to characterize better the molecular keys induced by treatment, overall, our results confirm the whole secretome efficacy as novel "cell-free therapy". Also, sponge-like topical dressing containing the whole secretome, GMP- compliant and "ready-off-the-shelf", may represent a relevant point to facilitate its translation into the clinic.

Out-of-hospital cardiac arrests in a large metropolitan area: synergistic effect of exposure to air particulates and high temperature.

AIMS: Air pollution and climate change are intrinsically linked to emerging hazards for global health. High air particulate matter (PM) levels may trigger out-of-hospital cardiac arrest (OHCA). High temperature could act synergistically with PM in determining OHCA. The aim of the present study was to investigate the effect of PM exposure alone, and in combination with temperature, on the risk of OHCA, in a large European metropolitan area with population >4 million. METHODS: We evaluated the association between short-term PM exposure, temperature, and the risk of OHCA over a two-year study period, allowing us to investigate 5761 events using a time-stratified case-crossover design combined with a distributed lag non-linear model. RESULTS: Higher risk of OHCA was associated with short-term exposure to PM10. The strongest association was experienced three days before the cardiac event where the estimated change in risk was 1.70% (0.48-2.93%) per 10 µg/m3 of PM. The cumulative exposure risk over the lags 0-6 was 8.5% (0.0-17.9%). We observed a joint effect of PM and temperature in triggering cardiac arrests, with a maximum effect of 14.9% (10.0-20.0%) increase, for high levels of PM before the cardiac event, in the presence of high temperature. CONCLUSION: The present study helps to clarify the controversial role of PM as OHCA determinant. It also highlights the role of increased temperature as a key factor in triggering cardiac events. This evidence suggests that tackling both air pollution and climate change might have a relevant impact in terms of public health.

Hospital Surge Capacity during Expo 2015 in Milano, Italy.

IntroductionHospital Acute Care Surge Capacity (HACSC), Hospital Acute Care Surge Threshold (HACST), and Total Hospital Capacity (THC) are scales that were developed to quantify surge capacity in the event of a multiple-casualty incident (MCI). These scales take into consideration the need for adequate care for both critical (T1) and moderate (T2) trauma patients. The objective of this study was to verify the validity of these scales in nine hospitals of the Milano (Italy) metropolitan area that prepared for a possible MCI during EXPO 2015. METHODS: Both HACSC and HACST were computed for individual hospitals. These were compared to surge capacities declared by individual hospitals during EXPO 2015, and also to surge capacity evaluated during a simulation organized on August 23, 2016. RESULTS: Both HACSC and HACST were smaller compared to capacities measured and reported by the hospitals, as well as those found during the simulation. This resulted in significant differences in THC when this was computed from the different methods of calculation. CONCLUSIONS: Surge capacity is dependent on the method of measurement. Each method has its inherent deficiencies. Until more reliable methodologies are developed, there is a benefit to analyze surge capacity using several methods rather than just one. Emergency committee members should be aware of the importance of critical resources when looking to the hospital capacity to respond to an MCI, and to the possibility to effectively increase it with a good preparedness plan. Since hospital capacity during real events is not static but dynamic, largely depending on occupation of the available resources, it is important that the regional command center and the hospitals receiving casualties constantly communicate on specific agreed upon critical resources, in order for the regional command center to timely evaluate the overall regional capacity and guarantee the appropriate distribution of the patients. FaccincaniR, Della CorteF, SesanaG, StucchiR, WeinsteinE, AshkenaziI, IngrassiaP. Hospital surge capacity during Expo 2015 in Milano, Italy. Prehosp Disaster Med. 2018;33(5):459-465.

Mortality and ST resolution in patients admitted with STEMI: the MOMI survey of emergency service experience in a complex urban area.

BACKGROUND: Since 2001, the urban area of Milan has been operating a network among 23 cardiac care units, the 118 dispatch centre (national free number for medical emergencies), and the county government health agency called Group for Prehospital Cardiac Emergency. METHODS AND RESULTS: In order to monitor the network activity, time to treatment, and clinical outcome, a periodic survey, called MOMI(2), was repeated two or three times a year. Each survey lasted 30 days and was repeated in comparable periods. Data were stratified for hospital admission mode. We collected data concerning 708 consecutive ST-elevation myocardial infarction (STEMI) patients (male 72.6%; mean age 64.4 years). In these six surveys, we observed a high rate of primary percutaneous coronary intervention (73.2%) and a mortality rate of 6.3%. Using advanced statistical models, we identified age, Killip class, and the symptom onset-to-balloon time as most relevant prognostic factors. Nonparametric test showed that the modality of hospital admittance was the most critical determinant of door-to-balloon time. 12-lead ECG tele-transmission and activation of a fast track directly to the catheterization laboratory are easy action to reduce time to treatment. CONCLUSIONS: The experience of the Milan network for cardiac emergency shows how a network coordinating the community, rescue units, and hospitals in a complex urban area and making use of medical technology contributes to the health care of patients with STEMI.

Cardiac deatH prevention by aUtomated defibrillatoRs in ChurcHes: rationale and design of the CHURCH trial.

Early defibrillation programs by the use of automated external defibrillators (AEDs) located in high-attendance public places may improve survival and neurologic outcome of patients undergoing sudden cardiac arrest (SCA). We planned a prospective cohort study to assess the effectiveness of a public-access defibrillation program based on positioning of AEDs in churches and training of lay volunteers in Basic Life Support Defibrillation during a single-day 5-hour training session. The CHURCH project aims to promote a widespread diffusion of AEDs, to train a large number of lay volunteers in Basic Life Support Defibrillation, and to increase population awareness on the opportunities for sudden death prevention. The rationale of the study rests on a survey commissioned by the Diocese of Milan that found a high prevalence of elderly subjects (44.5% were >60 years old) attending holy services in the morning hours, when sudden death incidence peaks. The catchment areas of the 12 parishes included in the trial as of June 2008 include a population of 140,000. The projected incidence of AED-treatable SCA, based on the presence of trained volunteers in the churches during day hours, at the CHURCH participating sites was estimated at 8 episodes per year. To estimate an overall 30% mortality reduction from SCA after AED placement at the study sites with respect to conventional SCA management by the Emergency Medical Service, 25 SCA episodes will have to be treated during the 4-year study period. The CHURCH project might be of interest and applicable in every country where high-attendance worship places are present.

Emergency Medical System response to out-of-hospital cardiac arrest in Milan, Italy.

The objective of this study was to investigate how rapidly the Emergency Medical System provides life support to patients suffering out-of-hospital cardiac arrest in Milan, Italy. The study population included 1426 consecutive participants with out-of-hospital cardiac arrest between January 2007 and October 2008. The mean age was 72.7 years. The incidence of ventricular tachycardia/ventricular fibrillation as the presenting rhythm was 12.7%. Eighty percent of out-of-hospital cardiac arrests occurred at home and bystander cardiopulmonary resuscitation (CPR) was in progress in 11.1% of all cases. The mean time interval from collapse-to-first shock was 18.67+/-5.37 min. The mean Emergency Medical System unit response time interval was 7.07+/-3.14 min; time elapsed from arrival-to-first CPR was 7.75+/-4.32 min. In conclusions, the dispatch to arrival and dispatch to CPR intervals are comparable with those reported in other large urban areas, but the time from arrival-to-first CPR was longer than recommended by current guidelines.

How to reduce the time windows for primary percutaneous coronary intervention.

Percutaneous coronary intervention (PCI) is an effective procedure for re-establishing coronary artery perfusion in ST-segment elevation myocardial infarction. PCI is the preferred therapeutic option when it can be performed by an experienced team within 90-120 min of the first medical contact. Time from the onset of symptoms to balloon inflation seems to correlate directly with mortality rates. We discuss both hospital strategies and territorial system networks aimed at reducing the time windows for primary PCI, thereby improving clinical outcome and survival rates.

[Cardiological emergency network in Lombardy]. / Le reti dell'emergenza in Cardiologia: i'esperienza lombarda.

AIMS: To achieve a reduction of time to reperfusion through the organization of an interhospital network and the involvement of the Regional Health Authority. METHODS: Four major endpoints were identified: institutional governance action, clinical management of acute ST-elevation myocardial infarction (STEMI), priority actions for cardiac arrest and early defibrillation, actions to avoid the delay related to decision-making, and logistic factors. Since 2001 in the urban area of Milan a network has been operating among 23 coronary care units, the 118 Dispatch Center (national free number for medical emergencies) and the Health Country Government Agency named Group for Prehospital Cardiac Emergency. In order to monitor the network activity and time to treatment and clinical outcomes a periodic monthly survey, called MOMI (One Month Monitoring Myocardial Infarction), was undertaken and repeated twice yearly. Data were evaluated according to hospital admission modality. RESULTS: Global times are: symptom onset to first medical contact 116 min (interquartile range [IQR] 189), time to first ECG 7 min (IQR 12), door-to-balloon time 77 min (IQR 81.7). Non-parametric test showed that the modality of hospital admittance was the most critical determinant of door-to-balloon time. The shortest one (49.5 min) was that of patients transported by means of advanced rescue units with 12-lead ECG teletransmission and activation of a fast track directly to the cath lab. CONCLUSIONS: Our data show how in a complex urban area the organization of an interhospital network and the availability of ECG teletransmission are effective in reducing time to reperfusion, in the treatment of major arrhythmias and in pre-alert of coronary care units and cath labs in case of confirmed STEMI. This experience also stimulated an improvement in technological equipment of rescue units with extension of 12-lead teletransmission to basic life support units. Through the Health Country Government Agency and the Scientific Societies we carry on with our job to create a regional network for cardiac emergency involving all the hospitals.