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1.
Am J Otolaryngol ; 41(2): 102376, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31924414

RESUMO

PURPOSE: Develop a model for quality improvement in tracheostomy care and decrease tracheostomy-related complications. METHODS: This study was a prospective quality improvement project at an academic tertiary care hospital. A multidisciplinary team was assembled to create institutional guidelines for clinical care during the pre-operative, intra-operative, and post-operative periods. Baseline data was compiled by retrospective chart review of 160 patients, and prospective tracking of select points over 8 months in 73 patients allowed for analysis of complications and clinical parameters. RESULTS: Implementation of a quality improvement team was successful in creating guidelines, setting baseline parameters, and tracking data with run charts. Comparison of pre- and post-guideline data showed a trend toward decreased rate of major complications from 4.38% to 2.74% (p = 0.096). Variables including time to tracheotomy for prolonged intubation, surgical technique, day of first tracheostomy tube change, and specialty performing surgery did not show increased risk of complications. There were increased tracheostomy-related complications in cold months (p = 0.04). CONCLUSIONS: An interdisciplinary quality improvement team can improve tracheostomy care by identifying system factors, standardizing care among specialties, and providing continuous monitoring of select data points.

3.
Transfus Apher Sci ; 57(6): 785-789, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30455154

RESUMO

Massive transfusion protocols (MTP) vary at different institutions. We implemented an algorithm in the transfusion service to support our Level I trauma center in 2007 and periodically monitor MTP utilization as part of ongoing quality management. At the last review in 2013, median plasma: RBC ratio was 1:1.8. We undertook a retrospective 3-year review of MTP activations stratifying by trauma versus non-trauma indications, and blood component utilization of the massive transfusion (MT) cases, adding a review of tranexamic acid (TXA) administration to the audit. The median transfused plasma: RBC ratio was 1:1.9 in trauma MT, and 1:1.6 in the non-trauma MT cases. Non-trauma MT patients at our institution were significantly older and more coagulopathic at MTP initiation compared to trauma MT patients, received fewer RBC units (15.5 versus 20.2), and had higher mortality. TXA adherence increased over the 3-year period to 60% of all trauma MTP activations in 2017.


Assuntos
Transfusão de Sangue/normas , Adesão à Medicação , Ácido Tranexâmico/administração & dosagem , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Tempo
4.
J Trauma Acute Care Surg ; 82(5): 877-886, 2017 05.
Artigo em Inglês | MEDLINE | ID: mdl-28240673

RESUMO

BACKGROUND: In the United States, there is a perceived divide regarding the benefits and risks of firearm ownership. The American College of Surgeons Committee on Trauma Injury Prevention and Control Committee designed a survey to evaluate Committee on Trauma (COT) member attitudes about firearm ownership, freedom, responsibility, physician-patient freedom and policy, with the objective of using survey results to inform firearm injury prevention policy development. METHODS: A 32-question survey was sent to 254 current U.S. COT members by email using Qualtrics. SPSS was used for χ exact tests and nonparametric tests, with statistical significance being less than 0.05. RESULTS: Our response rate was 93%, 43% of COT members have firearm(s) in their home, 88% believe that the American College of Surgeons should give the highest or a high priority to reducing firearm-related injuries, 86% believe health care professionals should be allowed to counsel patients on firearms safety, 94% support federal funding for firearms injury prevention research. The COT participants were asked to provide their opinion on the American College of Surgeons initiating advocacy efforts and there was 90% or greater agreement on 7 of 15 and 80% or greater on 10 of 15 initiatives. CONCLUSION: The COT surgeons agree on: (1) the importance of formally addressing firearm injury prevention, (2) allowing federal funds to support research on firearms injury prevention, (3) retaining the ability of health care professionals to counsel patients on firearms-related injury prevention, and (4) the majority of policy initiatives targeted to reduce interpersonal violence and firearm injury. It is incumbent on trauma and injury prevention organizations to leverage these consensus-based results to initiate prevention, advocacy, and other efforts to decrease firearms injury and death. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level I; therapeutic care, level II.


Assuntos
Ferimentos por Arma de Fogo/prevenção & controle , Consenso , Feminino , Armas de Fogo/estatística & dados numéricos , Humanos , Masculino , Propriedade/estatística & dados numéricos , Política Pública , Segurança , Sociedades Médicas , Inquéritos e Questionários , Traumatologia/estatística & dados numéricos , Estados Unidos
5.
J Trauma Acute Care Surg ; 82(4): 758-765, 2017 04.
Artigo em Inglês | MEDLINE | ID: mdl-28099388

RESUMO

BACKGROUND: Histone deacetylase inhibitors (HDACI) are members of a family of epigenetic modifying agents with broad anti-inflammatory properties. These anti-inflammatory properties may have important therapeutic implications in acute respiratory distress syndrome (ARDS). However, administration of HDACI may create an immunosuppressive environment conducive to bacterial growth. Accordingly, the aim of the current study is to investigate the effect of HDACI valproic acid (VPA) on host inflammatory response and bacterial burden in a murine model of Escherichia coli pneumonia-induced ARDS. METHODS: ARDS was induced in male C57BL6 mice (n = 24) by endotracheal instillation of 3 × 10 E. coli. VPA (250 mg/kg) was administered 30 minutes after E. coli instillation in the intervention group. Blood samples were collected at 3 and 6 hours, and animals were sacrificed at 6 hours. Bronchoalveolar lavage (BAL) was performed, and tissue specimens were harvested. Cytokine levels were measured in blood and BAL, and so was transalveolar protein transit. Cell counts and colony forming units were quantified in BAL fluid. RESULTS: VPA reduced neutrophil influx into the lungs and local tissue destruction through decreased myeloperoxidase activity. It also ameliorated the pulmonary and systemic inflammatory response. This led to greater bacterial proliferation in the pulmonary parenchyma. CONCLUSION: Administration of VPA in a clinically relevant bacterial model of murine ARDS mitigates the host inflammatory response, essentially preventing ARDS, but creates an immunosuppressive environment that favors bacterial overgrowth.


Assuntos
Pneumonia Bacteriana/tratamento farmacológico , Pneumonia Bacteriana/microbiologia , Síndrome do Desconforto Respiratório do Adulto/prevenção & controle , Ácido Valproico/farmacologia , Animais , Líquido da Lavagem Broncoalveolar/química , Citocinas/metabolismo , Ensaio de Imunoadsorção Enzimática , Escherichia coli/crescimento & desenvolvimento , Inflamação/tratamento farmacológico , Masculino , Camundongos , Camundongos Endogâmicos C57BL , Peroxidase/metabolismo , Síndrome do Desconforto Respiratório do Adulto/sangue
6.
JAMA Surg ; 152(1): 75-81, 2017 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-27682367

RESUMO

Importance: Trauma patients admitted to the hospital are at increased risk of bleeding and thrombosis. The use of inferior vena cava (IVC) filters in this population has been increasing, despite a lack of high-quality evidence to demonstrate their efficacy. Objective: To determine if IVC filter insertion in trauma patients affects overall mortality. Design, Setting, and Participants: This retrospective cohort study used stratified 3:1 propensity matching to select a control population similar to patients who underwent IVC filter insertion at Boston Medical Center (a level I trauma center at Boston University School of Medicine) between August 1, 2003, and December 31, 2012. Among patients with an IVC filter and matched controls, age, sex, race/ethnicity, and Injury Severity Score were entered into a multivariable logistic regression model to calculate a propensity score. Matching was stratified by the date of injury. Main Outcomes and Measures: Multivariable logistic regression was used to compare hospital mortality across both groups, adjusting for age, sex, race/ethnicity, Injury Severity Score, and brain injury severity using the head and neck Abbreviated Injury Score. To determine any significant difference in mortality, patient characteristics and mortality data from the National Death Index were analyzed in all patients and in those who survived 24, 48, and 72 hours after injury, as well as at hospital discharge. Results: Among 451 trauma patients with an IVC filter and 1343 matched controls without an IVC filter, the mean (SD) age was 47.4 (21.5) years. The median Injury Severity Score overall was 24 (range, 1-75). Based on a mean follow-up of 3.8 years (range, 0-9.4 years), there was no significant difference in overall mortality or cause of mortality in patients with vs without an IVC filter who survived more than 24 hours from the time of injury, independent of the presence or absence of deep vein thrombosis or pulmonary embolism at the time of IVC filter placement. Additional analyses at shorter intervals of 6 months and 1 year after discharge also showed no significant difference between the 2 groups of patients. Eight percent (38 of 451) of the IVC filters were removed at Boston Medical Center during the follow-up period. Conclusions and Relevance: The research herein demonstrates no significant difference in survival in trauma patients with vs without placement of an IVC filter, whether in the presence or absence of venous thrombosis. The use of IVC filters in this population should be reexamined because filter removal rates are low and there is increased risk of morbidity in patients with filters that remain in place.


Assuntos
Mortalidade Hospitalar , Implantação de Prótese , Filtros de Veia Cava , Ferimentos e Lesões/mortalidade , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Causas de Morte , Criança , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Embolia Pulmonar/prevenção & controle , Estudos Retrospectivos , Taxa de Sobrevida , Fatores de Tempo , Tromboembolia Venosa/complicações , Adulto Jovem
7.
Emerg Radiol ; 23(3): 213-9, 2016 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-26873603

RESUMO

The objective of this study was to determine the incidence and interobserver agreement of individual CT findings as well as the bowel injury prediction score (BIPS) in surgically proven bowel injury after blunt abdominal trauma. This HIPAA-compliant retrospective study was IRB approved and consent was waived. All patients 14 years or older who sustained surgically proven bowel injury after blunt abdominal trauma between 1/1/2004 and 6/30/2015 were included. Admission trauma MDCT scans were independently interpreted by two abdominal fellowship-trained radiologists who recorded the following CT findings: intraperitoneal fluid, mesenteric hematoma/fat stranding, bowel wall thickening/hematoma, active intravenous contrast extravasation, free intraperitoneal air, bowel wall discontinuity, and focal bowel hypoenhancement. Subsequently, the electronic medical records of the included patients, admission abdominal physical exam results, admission white blood cell count, and findings at exploratory laparotomy of the included patients were recorded. Thirty-three patients met the inclusion criteria. The incidence and interobserver agreement of the CT findings were as follows: intraperitoneal fluid 93.9 %, kappa = 0.784 (good); mesenteric hematoma/fat stranding 84.8 %, kappa = 0.718 (good); bowel wall thickening/hematoma 42.4 %, kappa = 0.491 (moderate); active IV contrast extravasation 36.3 %, kappa = 1.00 (perfect); free intraperitoneal air 21.2 %, kappa = 0.904 (very good), bowel wall discontinuity 6.1 %, kappa = 1.00 (perfect); and focal bowel hypoenhancement 6.1 %, kappa = 0.468 (moderate). An absence of the specified CT findings was encountered in 9.1 % with surgically proven bowel injuries (kappa = 1.00, perfect). In our study, 9/16 patients or 56.3 % had a bowel injury prediction score (BIPS) of 2 or more as defined by McNutt et al. (J Trauma Acute Care Surg 78(1):105-111, 2014). The presence of intraperitoneal fluid and mesenteric hematoma/fat stranding are the most common CT findings in bowel injuries proven at laparotomy. A small percentage of patients have no abnormal CT findings. This grading system did not prove to be useful in our study likely due to our inherently small patient population; however, the use of BIPS deserves further investigation as it may help in identifying blunt bowel and mesenteric injury patients with often subtle or nonspecific CT findings.


Assuntos
Traumatismos Abdominais/diagnóstico por imagem , Intestinos/diagnóstico por imagem , Intestinos/lesões , Tomografia Computadorizada por Raios X , Traumatismos Abdominais/classificação , Traumatismos Abdominais/cirurgia , Adolescente , Idoso de 80 Anos ou mais , Feminino , Humanos , Intestinos/cirurgia , Masculino , Pessoa de Meia-Idade , Variações Dependentes do Observador , Estudos Retrospectivos
8.
Am J Prev Med ; 50(6): 719-726, 2016 06.
Artigo em Inglês | MEDLINE | ID: mdl-26853845

RESUMO

INTRODUCTION: Among people aged ≥65 years, falling is the leading cause of emergency department visits. Emergency medical services (EMS) are often called to help older adults who have fallen, with some requiring hospital transport. Chief aims were to determine where falls occurred and the circumstances under which patients were transported by EMS, and to identify future fall prevention opportunities. METHODS: In 2012, a total of 42 states contributed ambulatory data to the National EMS Information System, which were analyzed in 2014 and 2015. Using EMS records from 911 call events, logistic regression examined patient and environmental factors associated with older adult transport. RESULTS: Among people aged ≥65 years, falls accounted for 17% of all EMS calls. More than one in five (21%) of these emergency 911 calls did not result in a transport. Most falls occurred at home (60.2%) and residential institutions such as nursing homes (21.7%). Logistic regression showed AORs for transport were greatest among people aged ≥85 years (AOR=1.14, 95% CI=1.13, 1.16) and women (AOR=1.30, 95% CI=1.29, 1.32); for falls at residential institutions or nursing homes (AOR=3.52, 95% CI=3.46, 3.58) and in rural environments (AOR=1.15, 95% CI=1.13, 1.17); and where the EMS impression was a stroke (AOR=2.96, 95% CI=2.11, 4.10), followed by hypothermia (AOR=2.36, 95% CI=1.33, 4.43). CONCLUSIONS: This study provides unique insight into fall circumstances and EMS transport activity. EMS personnel are in a prime position to provide interventions that can prevent future falls, or referrals to community-based fall prevention programs and services.


Assuntos
Acidentes por Quedas/prevenção & controle , Acidentes por Quedas/estatística & dados numéricos , Serviços Médicos de Emergência/estatística & dados numéricos , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Serviço Hospitalar de Emergência , Feminino , Humanos , Masculino , Fatores Sexuais
9.
Appl Environ Microbiol ; 82(4): 1035-1039, 2016 02 15.
Artigo em Inglês | MEDLINE | ID: mdl-26637595

RESUMO

There is still great interest in controlling bacterial endospores. The use of chemical disinfectants and, notably, oxidizing agents to sterilize medical devices is increasing. With this in mind, hydrogen peroxide (H2O2) and peracetic acid (PAA) have been used in combination, but until now there has been no explanation for the observed increase in sporicidal activity. This study provides information on the mechanism of synergistic interaction of PAA and H2O2 against bacterial spores. We performed investigations of the efficacies of different combinations, including pretreatments with the two oxidizers, against wild-type spores and a range of spore mutants deficient in the spore coat or small acid-soluble spore proteins. The concentrations of the two biocides were also measured in the reaction vessels, enabling the assessment of any shift from H2O2 to PAA formation. This study confirmed the synergistic activity of the combination of H2O2 and PAA. However, we observed that the sporicidal activity of the combination is largely due to PAA and not H2O2. Furthermore, we observed that the synergistic combination was based on H2O2 compromising the spore coat, which was the main spore resistance factor, likely allowing better penetration of PAA and resulting in the increased sporicidal activity.


Assuntos
Antibacterianos/farmacologia , Sinergismo Farmacológico , Peróxido de Hidrogênio/farmacologia , Viabilidade Microbiana/efeitos dos fármacos , Ácido Peracético/farmacologia , Esporos Bacterianos/efeitos dos fármacos , Esporos Bacterianos/fisiologia
11.
J Am Osteopath Assoc ; 115(7): 444-50, 2015 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-26111132

RESUMO

BACKGROUND: The Joint Commission requires hospitals to develop systems in which a team of clinicians can rapidly recognize and respond to changes in a patient's condition. The rapid response team (RRT) concept has been widely adopted as the solution to this mandate. The role of house staff in RRTs and the impact on resident education has been controversial. At Christiana Care Health System, eligible residents in their second through final years lead the RRTs. OBJECTIVE: To evaluate the use of a team-based, interdisciplinary RRT training program for educating and training first-year residents in an effort to improve global RRT performance before residents start their second year. METHODS: This pilot study was administered in 3 phases. Phase 1 provided residents with classroom-based didactic sessions using case-based RRT scenarios. Multiple choice examinations were administered, as well as a confidence survey based on a Likert scale before and after phase 1 of the program. Phase 2 involved experiential training in which residents engaged as mentored participants in actual RRT calls. A qualitative survey was used to measure perceived program effectiveness after phase 2. In phase 3, led by senior residents, simulated RRTs using medical mannequins were conducted. Participants were divided into 5 teams, in which each resident would rotate in the roles of leader, nurse, and respiratory therapist. This phase measured resident performance with regard to medical decision making, data gathering, and team behaviors during the simulated RRT scenarios. Performance was scored by an attending and a senior resident. RESULTS: A total of 18 residents were eligible (N=18) for participation. The average multiple choice test score improved by 20% after didactic training. The average confidence survey score before training was 3.44 out of 5 (69%) and after training was 4.13 (83%), indicating a 14% improvement. High-quality team behaviors correlated with medical decision making (0.92) more closely than did high-quality data gathering (0.11). This difference narrowed during high-pressure scenarios (0.84 and 0.72, respectively). CONCLUSION: Our data suggest that resident training using a team-based, interdisciplinary RRT training program may improve resident education, interdisciplinary team-based dynamics, and global RRT performance. In turn, data gathering and medical decision making may be enhanced, which may result in better patient outcomes during RRT scenarios.


Assuntos
Serviços Médicos de Emergência/normas , Internato e Residência/normas , Equipe de Assistência ao Paciente/organização & administração , Avaliação de Programas e Projetos de Saúde , Ensino/normas , Competência Clínica , Educação Médica Continuada/normas , Avaliação Educacional , Humanos , Projetos Piloto
12.
J Trauma Acute Care Surg ; 79(1): 125-31, 2015 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-26091325

RESUMO

BACKGROUND: Fourteen percent (43.1 million) of the population in the United States was 65 years and older in 2012. This population is projected to reach 20% (88.5 million) by 2050. Older adults accounted for 17% of all traffic fatalities and 9% of all vehicle occupant injuries in 2012. We explored the effectiveness of three interventions to help older adults assess their current driving behaviors at a Level 1 trauma center. METHODS: During 2010 to 2012, 1,216 inpatients 70 years and older admitted for surgical and medical services were screened for eligibility, and 120 were enrolled. Participants completed a driving assessment and preintervention questionnaires and were subsequently randomized to one of the following interventions: (1) brief negotiated interview plus an educational kit by the American Automobile Association about older driving plus an accompanying list of Web-based resources for older adult drivers; (2) American Automobile Association document and a list of Web-based resources; (3) online referral sheet of the list of Web-based resources only. A 3-month postintervention follow-up questionnaire was administered over the telephone to measure changes in (1) driving-related knowledge, attitudes, and beliefs as well as (2) driving-related behaviors and intended behaviors. RESULTS: A total of 113 randomized patients were included in the analysis. The mean (SD) age was 76.8 (5.23) years; majority of patients were white (64%), followed by black African American (33%); and 51% were males and 49% were females. Multivariate analysis showed that older adults' driving knowledge, attitudes, and beliefs (p < 0.0001, R = 0.37) as well as behaviors and intentions (p < 0.0001, R = 0.27) toward driving were positively correlated, controlling for other predictors in the model. Intervention assignment did not affect changes in outcomes, although outcomes improved across experimental conditions. CONCLUSION: Our pilot study suggests that older adults are likely to make changes in their driving behavior on the basis of minimal hospital-based intervention.


Assuntos
Condução de Veículo , Entrevista Motivacional , Educação de Pacientes como Assunto/métodos , Acidentes de Trânsito/prevenção & controle , Acidentes de Trânsito/psicologia , Acidentes de Trânsito/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Condução de Veículo/psicologia , Feminino , Comportamentos Relacionados com a Saúde , Humanos , Masculino , Análise Multivariada , Medição de Risco
13.
Am J Health Syst Pharm ; 72(12): 1059-64, 2015 Jun 15.
Artigo em Inglês | MEDLINE | ID: mdl-26025998

RESUMO

PURPOSE: The development of eligibility criteria and use of tranexamic acid in conjunction with a massive transfusion protocol (MTP) are described. SUMMARY: The trauma surgery and pharmacy departments collaborated to operationalize tranexamic acid administration in trauma patients for whom an MTP was activated. The MTP at Boston Medical Center, an urban, tertiary, academic medical center, is activated by the attending physician when the patient is expected to require at least 10 units of packed red blood cells in 24 hours. Tranexamic acid was considered in MTP trauma patients who arrived at the medical center within 8 hours of traumatic injury, were 15 years of age or older, and weighed at least 40 kg. Eligible patients were to receive a loading dose of tranexamic acid 1 g i.v. over 10 minutes followed by a maintenance dose of 1 g infused over 8 hours. To ensure that tranexamic acid use was limited to trauma patients, both its location of use and physician-ordering privileges were restricted by the pharmacy department. A 16-month assessment revealed that 16 patients received tranexamic acid, 13 (81%) of whom met all criteria for use. Tranexamic acid was used in 13 (38%) of 34 eligible MTP patients. Barriers to the use of tranexamic acid include a lack of familiarity with the medication among staff, drug availability, the complexity of administration, and the critical setting of MTP activation. CONCLUSION: Multidisciplinary collaboration and standardization of tranexamic acid use in conjunction with an MTP promoted use of the drug within a trauma population.


Assuntos
Antifibrinolíticos/administração & dosagem , Transfusão de Eritrócitos/métodos , Ácido Tranexâmico/administração & dosagem , Ferimentos e Lesões/terapia , Centros Médicos Acadêmicos , Adolescente , Adulto , Boston , Comportamento Cooperativo , Feminino , Humanos , Infusões Intravenosas , Masculino , Pessoa de Meia-Idade , Adulto Jovem
14.
J Antimicrob Chemother ; 70(3): 773-9, 2015 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-25428922

RESUMO

OBJECTIVES: To elucidate the mechanisms of spore resistance to and killing by the oxidizing microbicide peracetic acid (PAA). METHODS: Mutants of Bacillus subtilis lacking specific spore structures were used to identify resistance properties in spores and to understand the mechanism of action of PAA. We also assessed the effect of PAA treatment on a number of spore properties including heat tolerance, membrane integrity and germination. RESULTS: The spore coat is essential for spore PAA resistance as spores with defective coats were greatly sensitized to PAA treatment. Small acid-soluble spore proteins apparently provide no protection against PAA. Defects in spore germination, specifically in germination via the GerB and GerK but not the GerA germination receptors, as well as leakage of internal components suggest that PAA is active at the spore inner membrane. It is therefore likely that the inner membrane is the major site of PAA's sporicidal activity. CONCLUSIONS: PAA treatment targets the spore membrane, with some of its activity directed specifically against the GerB and GerK germination receptors.


Assuntos
Anti-Infecciosos/farmacologia , Bacillus subtilis/efeitos dos fármacos , Viabilidade Microbiana/efeitos dos fármacos , Ácido Peracético/farmacologia , Esporos Bacterianos/efeitos dos fármacos , Bacillus subtilis/genética , Proteínas de Bactérias/genética , Proteínas de Bactérias/metabolismo , Proteínas de Membrana/genética , Proteínas de Membrana/metabolismo , Membranas/efeitos dos fármacos , Oxidantes/farmacologia , Esporos Bacterianos/genética
15.
Keio J Med ; 63(2): 23-33, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-24965876

RESUMO

Penetrating neck injuries are commonly related to stab wounds and gunshot wounds in the United States. The injuries are classified by penetration site in terms of the three anatomical zones of the neck. Based on this zonal classification system, penetrating injuries to the head and neck have traditionally been evaluated by conventional angiography and/or surgical exploration. In recent years, multidetector-row computed tomography (CT) angiography has significantly improved detectability of vascular injuries and extravascular injuries in the setting of penetrating injuries. CT angiography is a fast and minimally invasive imaging modality to evaluate penetrating injuries of the head and neck for stable patients. The spectrum of penetrating neck injuries includes vascular injury (extravasation, pseudoaneurysm, dissection, occlusion, and arteriovenous fistula), aerodigestive injury (esophageal and tracheal injuries), salivary gland injury, neurologic injury (spinal canal and cerebral injuries), and osseous injury, all of which can be evaluated using CT angiography. Familiarity with the complications and imaging characteristics of penetrating injuries of the head and neck is essential for accurate diagnosis and optimal treatment.


Assuntos
Traumatismos Cranianos Penetrantes/diagnóstico por imagem , Lesões do Pescoço/diagnóstico por imagem , Lesões do Sistema Vascular/diagnóstico por imagem , Ferimentos por Arma de Fogo/diagnóstico por imagem , Ferimentos Perfurantes/diagnóstico por imagem , Angiografia , Humanos , Tomografia Computadorizada Multidetectores , Centros de Traumatologia , Estados Unidos
16.
J Oral Maxillofac Surg ; 71(11): 1853-60, 2013 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-23845698

RESUMO

PURPOSE: Approximately 35% to 60% of all patients with head and neck cancer are malnourished at the time of their diagnosis because of tumor burden and obstruction of intake or the anorexia and cachexia associated with their cancer. The purpose of this article is to provide a contemporary review of the nutritional aspects of care for patients with head and neck cancer. MATERIALS AND METHODS: A literature search was performed in Medline, Cochrane, and other available databases from 1990 through 2012 for the clinical effectiveness of nutritional support, treatment modalities, and methods of delivery in relation to patients with head and neck malignancies. Human studies published in English and having nutritional status and head and neck cancer as a predictor variable were included. Randomized controlled trials, meta-analyses, prospective clinical studies, and systemic reviews were selected based on their relevance to the abovementioned subtitles. The resultant articles were analyzed and summarized into the definition, impact, assessment, treatment, and modes of administration of nutrition on the outcome of patients with head and neck cancer. RESULTS: Articles were reviewed that focused on the etiology and assessment of malnutrition and current nutritional treatments for cancer-induced anorexia and cachexia. Two hundred forty-eight articles were found: 2 clinical trials, 10 meta-analyses, 210 review studies, and 26 systematic reviews. Because of the lack of prospective data, a summative review of the conclusions of the studies is presented. CONCLUSION: Nutritional interventions should be initiated before cancer treatment begins and these interventions need to be ongoing after completion of treatment to ensure optimal outcomes for patients. A nutritional assessment must be part of all comprehensive treatment plans for patients with head and neck cancer. Alternative medical interventions, such as immune-enhancing nutrients or anticytokine pharmaceutical agents, also may be effective as adjuvant therapies, but more research is needed to quantify their clinical effect.


Assuntos
Neoplasias de Cabeça e Pescoço/fisiopatologia , Fenômenos Fisiológicos da Nutrição/fisiologia , Anorexia/prevenção & controle , Caquexia/prevenção & controle , Humanos , Desnutrição/prevenção & controle , Avaliação Nutricional , Apoio Nutricional , Planejamento de Assistência ao Paciente
17.
Biochim Biophys Acta ; 1829(5): 436-42, 2013 May.
Artigo em Inglês | MEDLINE | ID: mdl-23298640

RESUMO

Hepatocyte nuclear factor (HNF)-4α is a key member of the transcription factor network regulating hepatocyte differentiation and function. Genetic and molecular evidence suggests that expression of HNF-4α is mainly regulated at the transcriptional level. Activation of HNF-4A gene involves the interaction of distinct sets of transcription factors and co-transcription factors within enhancer and promoter regions. Here we study the inhibitory effect of microRNAs (miRNAs) on the 3'-untranslated region (3'-UTR) of HNF-4A mRNA. The potential recognition elements of a set of miRNAs were identified utilizing bioinformatics analysis. The family members of miR-34 and miR-449, including miR-34a, miR-34c-5p and miR-449a, share the same target elements located at two distinct locations within the 3'-UTR of HNF-4A. The over-expression of miR-34a, miR-34c-5p or miR-449a in HepG2 cells led to a significant decrease in the activity of luciferase reporter carrying 3'-UTR of HNF-4A. The repressive effect on reporter activity was partially or fully eliminated when one or two of the binding site(s) for miR-34a/miR-34c-5p/miR-449a were deleted within the 3'-UTR. The protein level of HNF-4α was dramatically reduced by over-expression of miR-34a, miR-34c-5p and miR-449a, which correlates with a decrease in the binding activity of HNF-4α and transactivation of HNF-4α target genes. These results suggest that the recognition sites of miR-34a, miR-34c-5p and miR-449a within 3'-UTR of HNF-4A are functional. The mechanism of down-regulation of the binding activity and transactivation of HNF-4α by the miRNAs involves the decrease in HNF-4α protein level via miRNAs selectively targeting HNF-4A 3'-UTR, leading to the translational repression of HNF-4α expression.


Assuntos
Regulação da Expressão Gênica , Fator 4 Nuclear de Hepatócito/genética , MicroRNAs/metabolismo , Regiões 3' não Traduzidas , Sítios de Ligação , Linhagem Celular Tumoral , Fator 4 Nuclear de Hepatócito/metabolismo , Humanos , Ativação Transcricional
18.
Am J Clin Pathol ; 137(4): 566-71, 2012 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-22431532

RESUMO

We implemented a protocol incorporating a higher fresh frozen plasma (FFP)/RBC ratio for the management of trauma patients requiring massive transfusion in 2007. This study aims to identify issues that affected the effective deployment of the massive transfusion protocol (MTP) and compare outcome variables with a historic cohort. Data from 49 trauma patients who received at least 10 units of packed RBCs within 24 hours were analyzed and compared with a historic massively transfused cohort who had received recombinant activated factor VII (rFVIIa). Of the patients, 28 received an FFP/RBC ratio of 1:1 to 1:2; 12 received a lower ratio of 1:2 to 1:4; 3 received more than 1:1 and 6 had less than 1:4. Compared with the historic cohort, the 1:1-1:2 group received significantly fewer blood components and did not require rescue rFVIIa. An MTP incorporating a higher FFP/RBC ratio of 1:1 to 1:2 is associated with decreased use of blood components and may obviate the need for rFVII.


Assuntos
Transfusão de Sangue/métodos , Fator VIIa/administração & dosagem , Plasma , Ferimentos e Lesões/terapia , Adulto , Fator VIIa/uso terapêutico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento
19.
World J Surg ; 36(2): 266-9, 2012 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-22167261

RESUMO

BACKGROUND: Chest radiography is routinely used post-tracheostomy to evaluate for complications. Often, the chest X-ray findings do not change clinical management. The present study was conducted to evaluate the utility of post-tracheostomy X-rays. METHOD: This retrospective review of 255 patients was performed at a single-center, university, level I trauma center. All patients underwent tracheostomy and were evaluated for postprocedure complications. RESULTS: Of the 255 patients, 95.7% had no change in postprocedure chest X-ray findings. New significant chest X-ray findings were found in 4.3% of patients, including subcutaneous emphysema, pneumothorax, and new significant consolidation. Only three of these patients required change in clinical management, and all changes were based on clinical presentation alone. CONCLUSIONS: Routine chest X-ray following tracheostomy fails to provide additional information beyond clinical examination. Therefore radiographic examination should be performed only after technically difficult procedures or if the patient experiences clinical deterioration. Significant cost savings and minimization of radiation exposure can be achieved when chest radiography after tracheostomy is performed exclusively for clinical indications.


Assuntos
Pneumotórax/diagnóstico por imagem , Complicações Pós-Operatórias/diagnóstico por imagem , Radiografia Torácica , Enfisema Subcutâneo/diagnóstico por imagem , Traqueostomia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Custos Hospitalares , Humanos , Massachusetts , Pessoa de Meia-Idade , Pneumotórax/economia , Pneumotórax/etiologia , Complicações Pós-Operatórias/economia , Radiografia Torácica/economia , Estudos Retrospectivos , Enfisema Subcutâneo/economia , Enfisema Subcutâneo/etiologia , Adulto Jovem
20.
J Surg Res ; 175(2): 298-304, 2012 Jun 15.
Artigo em Inglês | MEDLINE | ID: mdl-21737100

RESUMO

BACKGROUND: The hepatic acute phase response(APR) is an organ-specific response to a diverse array of insults and is largely under transcriptional control. Liver-specific transcription factors, hepatic nuclear factors (HNFs)-1α and 4α play important roles in maintenance of liver phenotype and function and their binding activity changes early after injury. However, their roles in modulation of the liver's response over time are not defined. MATERIALS AND METHODS: C57/BL6 mice were anesthetized and exposed to 95°C water for 10 s to create a 15% body surface area full-thickness burn. At specific time points, the mice were sacrificed. An ELISA for IL-6 was performed on serum and hepatic mRNA levels for fibrinogen-γ and serum amyloid A(SAA)-3 were obtained through polymerase chain reaction (PCR). Transcriptional factor binding activity was assessed with electrophoretic mobility shift assays. RESULTS: Serum IL-6 levels peaked at 3 h and fibrinogen-γ and SAA mRNA levels increased more than 6-fold at 12 h before returning to control levels at 48 h. The binding activity of HNF-4α and HNF-1α rapidly declined after injury (1.5 h) but recovered to near control level at 24 and 6 h, respectively. CONCLUSIONS: Changes in HNF-4α and HNF-1α binding occurred before changes in acute phase protein mRNA levels and were preceded by the peak in IL-6 levels. The rapid suppression and reconstitution of liver-specific transcription factor binding after injury may represent a mechanism that allows the normal liver phenotype to change and an injury-response phenotype to prevail. This mechanism in the liver's adaptive response to injury suggests a central role for both HNF-4α and HNF-1α in transcriptional regulation of the hepatic APR.


Assuntos
Reação de Fase Aguda/etiologia , Reação de Fase Aguda/metabolismo , Queimaduras/complicações , Fator 1-alfa Nuclear de Hepatócito/metabolismo , Fator 4 Nuclear de Hepatócito/metabolismo , Fígado/metabolismo , Animais , Fibrinogênio/metabolismo , Regulação da Expressão Gênica , Interleucina-6/sangue , Masculino , Camundongos , Camundongos Endogâmicos C57BL , Modelos Animais , RNA Mensageiro/metabolismo , Proteína Amiloide A Sérica/metabolismo
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