New onset squamous cell carcinoma in previous split-thickness skin graft donor site.

INTRODUCTION: Marjolin' s ulcer, an aggressive ulcerating squamous cell carcinoma, is a well-known phenomenon that occurs in chronically inflamed or scarred tissue; however, squamous cell carcinoma arising in the acute setting after tissue trauma - specifically autograft donor harvest sites for burns - is a rare, but notable event. METHODS: This case series describes three instances of squamous cell carcinoma diagnosed in split-thickness skin graft donor sites in the immediate post-operative period. Charts were reviewed in detail after at least 9 months follow-up from identification of the tumor. Detailed descriptions of each case are included. A discussion of the literature on this rare entity is included as well. RESULTS: In the three cases discussed, all were characterized clinically as painful masses arising in a recently healed donor site. Two were managed surgically with adherence to oncologic principals. One lesion regressed or fell off spontaneously. With at least 9 months follow-up, there was no evidence of recurrence. CONCLUSIONS: Very few cases of acute neoplasm in donor sites have been described in the literature. Presently, there is no dominant theory as to how these lesions arise; however, this is an entity that burn care providers, world wide should be aware of, with a low threshold for oncologic evaluation if suspected.

Is Pre-Hospital CPR a Risk Factor for Early Death in Patients Transferred to an Adult Burn Center?

BACKGROUND: Burn patients who require CPR before admission to a burn center are anecdotally known to suffer higher mortality than those who do not require pre-hospital CPR. STUDY DESIGN: A retrospective chart review identified adult patients admitted to our burn center between 2013 and 2015. Included patients met 1 or both of the following criteria: 20% or more total body surface area burned and need for intubation before admission to our facility. We sought to identify predictors of early death, late death, and survival among burn patients who underwent CPR before admission. RESULTS: Of the 80 patients meeting inclusion criteria, 17.5% underwent CPR before arrival at our facility. Seventy-nine percent of these died, compared with 29% of the patients who did not require CPR (p = 0.0005). Seventy-one percent of CPR patients died within 48 hours of admission, compared with 8% of non-CPR patients (p < 0.0001). The major predictor of death vs survival after CPR was lower initial arterial pH. CONCLUSIONS: Patients who undergo CPR before transfer to a burn center are at high risk for early death. Predictors of death and early death after CPR may include elevated initial lactate and lower initial arterial pH.

Is Medical Student Interest in Cardiothoracic Surgery Maintained After Receiving Scholarship Awards?

BACKGROUND: Medical student exposure to cardiothoracic surgery has been facilitated by many scholarship opportunities. This study reviews the long-term interest of students at our institution who have received such support. METHODS: After the first or second year of medical school, participants were selected to receive scholarships for clinical or research activities in cardiothoracic surgery ranging from 4 to 8 weeks in duration. These were funded by the American Association for Thoracic Surgery, Society of Thoracic Surgeons, Southern Thoracic Surgical Association, or a private family donor. Over time, each student's scholarship type, current interest in cardiothoracic surgery, and current education or career status was prospectively monitored in an institutional database. RESULTS: Since 1999, 45 students received scholarships. Eight (18%) were funded by the American Association for Thoracic Surgery, two (4%) by The Society of Thoracic Surgeons one (2%) by the Southern Thoracic Surgical Association, and 34 (76%) by private donors. The median follow-up of graduated students is 7 years. Of the 20 (44%) with an active current interest in cardiothoracic surgery, 2 are faculty, 1 is a fellow, 1 is in an integrated 6-year program, 11 are in general surgery residency and are planning to apply to cardiothoracic surgery fellowship, and the remaining 5 are in medical school and planning a cardiothoracic surgery career. Of all former medical students who received cardiothoracic surgery research scholarships and who have now made a career choice, 17.4% chose cardiothoracic surgery. CONCLUSIONS: More than one-third of medical students who received scholarships in cardiothoracic surgery maintained their interest over time, and more than half maintained interest in a surgical field. Although long-term data are scarce, it remains critical to foster mentoring relationships with students over time to guide their career choices.

Lung gene therapy with highly compacted DNA nanoparticles that overcome the mucus barrier.

Inhaled gene carriers must penetrate the highly viscoelastic and adhesive mucus barrier in the airway in order to overcome rapid mucociliary clearance and reach the underlying epithelium; however, even the most widely used viral gene carriers are unable to efficiently do so. We developed two polymeric gene carriers that compact plasmid DNA into small and highly stable nanoparticles with dense polyethylene glycol (PEG) surface coatings. These highly compacted, densely PEG-coated DNA nanoparticles rapidly penetrate human cystic fibrosis (CF) mucus ex vivo and mouse airway mucus ex situ. Intranasal administration of the mucus penetrating DNA nanoparticles greatly enhanced particle distribution, retention and gene transfer in the mouse lung airways compared to conventional gene carriers. Successful delivery of a full-length plasmid encoding the cystic fibrosis transmembrane conductance regulator protein was achieved in the mouse lungs and airway cells, including a primary culture of mucus-covered human airway epithelium grown at air-liquid interface, without causing acute inflammation or toxicity. Highly compacted mucus penetrating DNA nanoparticles hold promise for lung gene therapy.

Simulation in cardiothoracic surgical training: where do we stand?

OBJECTIVES: Simulation may reduce the risks associated with the complex operations of cardiothoracic surgery and help create a more efficient, thorough, and uniform curriculum for cardiothoracic surgery fellowship. Here, we review the current status of simulation in cardiothoracic surgical training and provide an overview of all simulation models applicable to cardiothoracic surgery that have been published to date. METHODS: We completed a comprehensive search of all publications pertaining to simulation of cardiothoracic surgical procedures by using PubMed. RESULTS: Numerous cardiothoracic surgical simulators at various stages of development, assessment, and commercial manufacturing have been published to date. There is currently a predominance of models simulating coronary artery bypass grafting and bronchoscopy and a relative paucity of simulators of open pulmonary and esophageal procedures. Despite the wide range of simulators available, few models have been formally assessed for validity and educational value. CONCLUSIONS: Surgical simulation is becoming an increasingly important educational tool in training cardiothoracic surgeons. Our next steps forward will be to develop an objective, standardized way to assess surgical simulation training compared with the current apprenticeship model.

N-acetylcysteine enhances cystic fibrosis sputum penetration and airway gene transfer by highly compacted DNA nanoparticles.

For effective airway gene therapy of cystic fibrosis (CF), inhaled gene carriers must first penetrate the hyperviscoelastic sputum covering the epithelium. Whether clinically studied gene carriers can penetrate CF sputum remains unknown. Here, we measured the diffusion of a clinically tested nonviral gene carrier, composed of poly-l-lysine conjugated with a 10 kDa polyethylene glycol segment (CK(30)PEG(10k)). We found that CK(30)PEG(10k)/DNA nanoparticles were trapped in CF sputum. To improve gene carrier diffusion across sputum, we tested adjuvant regimens consisting of N-acetylcysteine (NAC), recombinant human DNase (rhDNase) or NAC together with rhDNase. While rhDNase alone did not enhance gene carrier diffusion, NAC and NAC + rhDNase increased average effective diffusivities by 6-fold and 13-fold, respectively, leading to markedly greater fractions of gene carriers that may penetrate sputum layers. We further tested the adjuvant effects of NAC in the airways of mice with Pseudomonas aeruginosa lipopolysaccharide (LPS)-induced mucus hypersecretion. Intranasal dosing of NAC prior to CK(30)PEG(10k)/DNA nanoparticles enhanced gene expression by up to ~12-fold compared to saline control, reaching levels observed in the lungs of mice without LPS challenge. Our findings suggest that a promising synthetic nanoparticle gene carrier may transfer genes substantially more effectively to lungs of CF patients if administered following adjuvant mucolytic therapy with NAC or NAC + rhDNase.