Biomedical subjects

Richard L Gamelli

Publications and source records attributed to Richard L Gamelli.

At least 19 recordsLinked to original sources

PubMed2016

Early leukocyte gene expression associated with age, burn size, and inhalation injury in severely burned adults.

BACKGROUND: In the patient with burn injury, older age, larger percentage of total body surface area (TBS) burned, and inhalation injury are established risk factors for death, which typically results from multisystem organ failure and sepsis, implicating burn-induced immune dysregulation as a contributory mechanism. We sought to identify early transcriptomic changes in circulating leukocytes underlying increased mortality associated with these three risk factors. METHODS: We performed a retrospective analysis of the Glue Grant database. From 2003 to 2010, 324 adults with 20% or greater TBS burned were prospectively enrolled at five US burn centers, and 112 provided blood samples within 1 week after burn. RNA was extracted from pooled leukocytes for hybridization onto Affymetrix HU133 Plus 2.0 GeneChips. A multivariate regression model was constructed to determine risk factors for mortality. Testing for differential gene association associated with age, burn size, and inhalation injury was based on linear models using a fold change threshold of 1.5 and false discovery rate of 0.05. RESULTS: After adjusting for potential confounders, age greater than 60 years (relative risk [RR], 4.53; 95% confidence interval [CI], 2.93-6.99), burn size greater than 40% TBS (RR, 4.24; 95% CI, 2.61-6.91), and inhalation injury (RR, 2.08; 95% CI, 1.35-3.21) were independently associated with mortality. No genes were differentially expressed in association with age greater than 60 years or inhalation injury. Fifty-one probe sets representing 39 unique genes were differentially expressed in leukocytes from patients with burn size greater than 40% TBS; these genes were associated with platelet activation and degranulation/exocytosis, and gene-set enrichment analysis suggested increased cellular proliferation and down-regulation of proinflammatory cytokines. CONCLUSION: Among adults with large burns, older age, increasing burn size, and inhalation injury have a modest effect on the leukocyte transcriptome in the context of the "genomic storm" induced by a 20% or greater than TBS burned. The 39-gene signature we identified may provide novel targets for the development of therapies to reduce morbidity and mortality associated with burns greater than 40% TBS. LEVEL OF EVIDENCE: Epidemiologic study, level III.

Adult↗

PubMed2006

Intraabdominal complications after lung transplantation.

BACKGROUND: Because more lung transplant recipients survive the perioperative period, nonpulmonary complications become a major source of morbidity and mortality. Of these, intraabdominal complications are of particular concern because of the potential need for surgical intervention. So appropriate management of these complications becomes paramount. STUDY DESIGN: We retrospectively reviewed 229 lung transplant recipients in a university medical center, between January 1997 and December 2004 developed in forty-seven patients. Abdominal complications. Detailed reviews of these patients' hospital charts were performed. Complications were categorized as early or late depending on if they occurred within 30 days of transplantation or later. The primary outcomes variable studied was mortality. RESULTS: Fifty-three surgical consultations for abdominal symptoms were requested in these 47 patients. Twenty-two of the 47 patients (47%) with intraabdominal complications required 24 operative interventions. Overall 5-year survival was substantially worse in patients with intraabdominal complications (34%) than in those without (62%, p=0.01). There was no marked difference in the 30-day mortality for patients experiencing early (27%, 4 of 15) versus late (24%, 9 of 38) complications. Mortality in patients with intraabdominal complications was lower among those treated operatively (n=2, 9%) compared with those treated nonoperatively (n=11, 44%, p=0.02). CONCLUSIONS: Mortality for patients with intraabdominal complications is high after lung transplantation. Operative intervention is well tolerated and associated with lower mortality. A high index of suspicion and timely operative intervention are necessary for the treatment of intraabdominal complications in lung transplant recipients.

Adolescent↗

PubMed2006

Application of rehabilitation ethics to a selected burn patient population's perspective.

BACKGROUND: Flame injury confers significant physical and psychologic stress on burn patients. Because most patients and their surrogates lack an understanding of burn injury, and these injuries preclude the meaningful exercise of patient autonomy, informed consent is a challenge for physicians. To better promote patient autonomy, this project collected patient perspectives on the proper duties of patients and physicians after severe burn injury and throughout the recovery phases. STUDY DESIGN: Ten survivors of severe burn injury were prospectively identified to represent different causes of injury, support systems, and socioeconomic backgrounds. Six persons participated (4 men, 2 women). Personal interviews with these individuals discussed their perspective and experience regarding physician and patient duties after severe burn injury as they relate to patient autonomy. RESULTS: All participants thought that informed consent was unrealistic at the time of their injury, but that this capacity developed over time as their understanding and level of functioning improved. In addition, all believed that the burn physicians' role was to do whatever was medically best for their patients in an emergency situation, but that this duty included the physician educating the patient or surrogates about what these treatments entail. CONCLUSIONS: Patient autonomy may be an unrealistic goal acutely for patients with severe burn injuries. Educational approaches to consent may facilitate patient autonomy, participation in decision making, and adherence to care plan over time. The ethical framework for this approach has been accepted in rehabilitation literature, but this is the first demonstration that relevant patient populations agree with this approach.

Adult↗

PubMed2006

Exogenous pro-angiogenic stimuli cannot prevent physiologic vessel regression.

BACKGROUND: In healing wounds, rising levels of vascular endothelial growth factor (VEGF) induce a period of robust angiogenesis. The levels of pro-angiogenic factors in the wound begin to decline just before a period of vascular regression, suggesting that these mediators are necessary to sustain vessel density. The purpose of this study was to determine if the maintenance of pro-angiogenic stimuli in the wound would prevent physiological vessel regression. MATERIALS AND METHODS: A standard subcutaneous sponge wound model was modified by the addition of a mini-osmotic pump, allowing manipulation of the wound milieu by the addition of exogenous growth factors. After initial characterization of this model, exogenous VEGF (10 microg/mL), FGF (10 microg/mL), PDGF (10 microg/mL), or VEGF (10 microg/mL) plus FGF (10 microg/mL) were delivered to wounds and blood vessel density analyzed by immunohistochemistry. RESULTS: VEGF administration resulted in a transient increase in wound vessel density (P < 0.05). None of the pro-angiogenic growth factors (VEGF, FGF, PDGF, VEGF/FGF) were able to prevent vascular regression (P = NS). CONCLUSIONS: These findings suggest that the anti-angiogenic signals that mediate physiological vascular regression in wounds are strongly dominant over pro-angiogenic stimuli during the later phases of wound healing. Clinical manipulation of anti-angiogenic signals in addition to the currently used pro-angiogenic targets may be needed to achieve therapeutic modulation of blood vessel density.

Analysis of Variance↗

PubMed2006

Injury-induced suppression of effector T cell immunity requires CD1d-positive APCs and CD1d-restricted NKT cells.

Overwhelming infection remains the leading cause of death from serious burn injury despite recent advances in the care of burn patients and a better understanding of immune and inflammatory consequences of injury. In this study, we report a critical requirement for CD1d-restricted NKT cells and CD1d expression by APCs in the immune dysfunction that occurs early after burn injury. Using a well-established murine scald injury model with BALB/c and BALB/c CD1d knockout mice, we investigated whether peripheral T cell immunity was affected by the presence or absence of CD1d-restricted NKT cells in the early stages after injury. Using Ag-specific delayed-type hypersensitivity, T cell proliferation, and cytokine production as indices of immune responsiveness, we observed that both CD1d expression by APCs and CD1d-restricted NKT cells are required for immune suppression after injury. Via adoptive transfer of splenocytes from injured mice to uninjured recipients, we found injury-induced suppression of immunity to be Ag specific, long lasting, and critically dependent on cell surface expression of CD1d by APCs. Together, our results suggest that the defects in T cell responsiveness that occur subsequent to severe burn injury are not merely the result of global or passive suppression, but instead represent an active form of CD1d/NKT cell-dependent immunologic tolerance.

Adoptive Transfer↗

PubMed2006

Effect of blood transfusion on outcome after major burn injury: a multicenter study.

OBJECTIVE: To delineate blood transfusion practices and outcomes in patients with major burn injury. CONTEXT: Patients with major burn injury frequently require multiple blood transfusions; however, the effect of blood transfusion after major burn injury has had limited study. DESIGN: Multicenter retrospective cohort analysis. SETTING: Regional burn centers throughout the United States and Canada. PATIENT POPULATION: Patients admitted to a participating burn center from January 1 through December 31, 2002, with acute burn injuries of >or=20% total body surface area. OUTCOMES MEASURED: Outcome measurements included mortality, number of infections, length of stay, units of blood transfused in and out of the operating room, number of operations, and anticoagulant use. RESULTS: A total of 21 burn centers contributed data on 666 patients; 79% of patients survived and received a mean of 14 units of packed red blood cells during their hospitalization. Mortality was related to patient age, total body surface area burn, inhalation injury, number of units of blood transfused outside the operating room, and total number of transfusions. The number of infections per patient increased with each unit of blood transfused (odds ratio, 1.13; p<.001). Patients on anticoagulation during hospitalization received more blood than patients not on anticoagulation (16.3+/-1.5 vs. 12.3+/-1.5, p<.001). CONCLUSIONS: The number of transfusions received was associated with mortality and infectious episodes in patients with major burns even after factoring for indices of burn severity. The utilization of blood products in the treatment of major burn injury should be reserved for patients with a demonstrated physiologic need.

Adult↗

PubMed2006

Norepinephrine modulates the inflammatory and proliferative phases of wound healing.

BACKGROUND: Injury results in the massive release of norepinephrine (NE) into the peripheral circulation. Recent investigations have demonstrated functional adrenoreceptors on the cellular mediators of cutaneous wound healing and NE-induced phenotypic alterations in immune cells have been demonstrated in vitro. Despite this, there is little description of how NE might alter the phases of wound healing in vivo. The purpose of this study was to compare cutaneous wound healing in norepinephrine-intact and norepinephrine-depleted mice. METHODS: Norepinephrine-depleted (NED) mice were generated by chemical axotomy with 6-hydroxydopamine and compared with norepinephrine-intact (NEI) animals (n = 6-12 per group, per time point). Using an excisional wound model, neutrophil recruitment was measured by myeloperoxidase assay. Macrophage recruitment and angiogenesis were measured by immunohistochemistry and re-epithelialization was determined histologically. The development of incisional wound disruption strength was determined over time. Finally, macrophage scavenger function was assessed by an in vitro latex bead phagocytosis assay. RESULTS: Wounds from NEI mice demonstrated greater neutrophil infiltration than NED wounds (24, 72 hours; p < 0.05). Wound macrophage recruitment was initially higher in NEI animals (24 hours, p < 0.05), but was eventually surpassed by that of NED animals (120 hours, p < 0.05). Angiogenesis was decreased while re-epithelialization was accelerated in NEI animals (p < 0.05). Wound disruption strength and macrophage scavenger function were unaltered between NED and NEI mice. CONCLUSIONS: Norepinephrine modulates the inflammatory and proliferative phases of wound healing in a temporally defined, cell-specific manner. By increasing recruitment of innate immune cells and expediting wound closure, norepinephrine appears to play a protective role in defense against infection.

Animals↗

PubMed2006

Ventilator-associated pneumonia, like real estate: location really matters.

INTRODUCTION: Previous work has demonstrated an increased risk of ventilator-associated pneumonia (VAP) in trauma patients after prehospital (field) intubation as compared with emergency department (ED) intubations. However, this population was not compared with patients intubated as inpatients, making data interpretation difficult. We sought to further examine predictors for the development of VAP after trauma. METHODS: A 10-year retrospective review of all patients mechanically ventilated greater than 24 hours after injury was performed. RESULTS: In all, 1,628 patients were identified, of which 1,213 (75%) were intubated as inpatients and 415 were emergently intubated (353 ED, 62 field). Overall, those intubated emergently were younger (p = 0.03) and less injured as seen by higher Glasgow Coma Scale scores (p = 0.0002), lower Injury Severity Scores (p = 0.01) and higher Revised Trauma Scores (p < 0.0001). Despite a lower injury severity, those patients emergently intubated were more likely to develop pneumonia as 22% of ED intubations and 15% of field intubations developed pneumonia, as compared with the inpatient rate of 6.5%. Pneumonia after field intubation was more likely to be community-acquired (p < 0.0001) with a significantly lower percentage of infecting enteric gram-negative rods (p < 0.0001) as compared with the inpatient and ED groups. Forward logistic regression analysis (with VAP = 1) identified inpatient intubation as protective against VAP (odds ratio 0.28, 95% CI = 0.2-0.4). Backwards logistic regression analysis further identified both field airway (odds ratio 2.29, 95% CI = 1.1-4.9) and ED airway (odds ratio 3.61, 95% CI = 2.5-5.2) as predictive of VAP. CONCLUSIONS: Compared with a population of trauma patients as inpatients, and excluding those patients mechanically ventilated less than 24 hours, patients intubated in the ED or field have a higher incidence of pneumonia, despite equivalent or lower injury severity.

Adolescent↗

PubMed2005

Reversibility of caspase activation and its role during glycochenodeoxycholate-induced hepatocyte apoptosis.

The accumulation of glycochenodeoxycholate (GCDC) induced hepatocyte apoptosis in cholestasis. However, many hepatocytes still survived GCDC-induced apoptosis. The molecular mechanism for the survival of hepatocytes remains unclear. In the present study, isolated rat hepatocytes were cultured in William's E medium and treated with 50 microM GCDC. DNA, RNA, cell lysate, and nuclear proteins were collected at different intervals for DNA fragmentation assay, reverse transcription PCR, Western blotting, and gel mobility shift assay, respectively. GCDC-induced active caspases were detected as early as 2 h by Western blotting and kinetic caspase assay, whereas hepatocyte apoptosis was found at 4 h by DNA fragmentation and terminal deoxynucleotidyl transferase-mediated dUPT nick-end labeling assay. When GCDC was removed, the increased caspases as well as NF-kappaB could be restored to control level. A1/Bfl-1 and inducible nitric oxide synthase (iNOS) were up-regulated in 2 h of GCDC stimulation. After GCDC was removed, hepatocytes decreased expression of A1/Bfl-1, but not iNOS, to the control level. NF-kappaB activation coincided with the change of A1/Bfl-1. Survivin, cIAP1, cIAP2, XIAP, and A1/Bfl-1, but not iNOS, were down-regulated by pan-caspase inhibitor benzyloxycarbonyl-VAD-fluoromethyl ketone. In addition, benzyloxycarbonyl-VAD-fluoromethyl ketone inhibited release of cytochrome c and suppressed NF-kappaB activation. Our data suggested that caspase pathway is an important regulatory factor during hepatocyte apoptosis. GCDC-induced caspase response is reversible, which may activate anti-apoptotic genes to protect hepatocytes from apoptosis.

Amino Acid Chloromethyl Ketones↗

PubMed2005

Corticosterone suppresses mesenteric lymph node T cells by inhibiting p38/ERK pathway and promotes bacterial translocation after alcohol and burn injury.

Previous studies showed that alcohol (EtOH) intoxication before burn injury suppresses mesenteric lymph node (MLN) T cell functions and increases gut bacterial translocation. In this study, we examined whether corticosterone (Cort) plays any role in suppressing MLN T cell function and bacterial accumulation after EtOH intoxication and burn injury. Rats were gavaged with EtOH to achieve a blood EtOH level of approximately 100 mg/dl before receiving 25% total body surface area burn or sham injury. A group of rats was treated with the Cort synthesis inhibitor metyrapone (25 mg/kg) at the time of injury and on day 1 after injury. Two days after injury, a significant increase in blood Cort levels and suppression of MLN T cell proliferation and IL-2 production was observed in rats receiving combined insult of EtOH intoxication and burn injury compared with rats receiving EtOH intoxication or burn injury alone. There was no change in T cell apoptosis after combined insult of EtOH and burn injury. Furthermore, T cell suppression was accompanied by a significant decrease in p38 and ERK1/2 activation (phosphorylation). There was no difference in JNK activation after EtOH and burn injury. Treatment of rats with metyrapone prevented the suppression of MLN T cell proliferation, IL-2 production, and p38 and ERK1/2 phosphorylation. Restoration of T cell function in metyrapone-treated animals was also associated with the decrease in bacterial accumulation in MLN. These findings suggest that EtOH intoxication before burn injury augments Cort release, which suppresses MLN T cell function by inhibiting p38 and ERK1/2 activation and promotes bacterial accumulation in MLN after EtOH and burn injury.

Alcoholic Intoxication↗

PubMed2005

Effect of acute alcohol ingestion prior to burn injury on intestinal bacterial growth and barrier function.

Previous studies from our laboratory have shown that acute alcohol (EtOH) ingestion prior to burn injury enhances intestinal bacterial translocation. This study tested if increased intestinal bacterial translocation in alcohol and burn injured rats is due to an overgrowth in intestinal bacteria. We determined if the translocation was accompanied with alterations in intestinal permeability and immune cell population. Rats (225-250 g) were gavaged with alcohol to achieve a blood EtOH level in the range of 100 mg/dl prior to burn or sham injury (25% total body surface area). Two days after injury, we found that acute alcohol ingestions prior to burn injury results in a significant increase in bacterial counts in small intestine. The increase in intestinal bacterial counts accompanied a significant increase in intestinal permeability. Finally, immunohistochemical analysis revealed a substantial (p<0.05) loss of both T cell and dendritic cells in intestine of alcohol and burn injured rats compared with intestine of rats receiving either burn or sham injury. Altogether, results presented in this manuscript suggest that increase in intestinal bacterial growth along with alterations in intestinal permeability and immune status contribute to the increase in bacterial translocation observed in alcohol and burn injured rats.

Animals↗

PubMed2005

The evolving characteristics and care of necrotizing soft-tissue infections.

BACKGROUND: Necrotizing soft-tissue infections such as necrotizing fasciitis and Fournier's gangrene are a source of high morbidity and mortality. These difficult cases are increasingly being referred to burn centers for specialized wound and critical care issues. In this study, we examine our institution's recent experience with a large series of necrotizing soft-tissue infections. STUDY DESIGN: A retrospective chart review was performed of 65 consecutive patients over a 5-year period with necrotizing soft-tissue infections that required radical surgical debridement. RESULTS: Overall survival was 83%, with an average length of stay of 32.4+/-3.32 days for survivors and for the entire group of 29.5+/-3 days. Time from onset of symptoms to initial presentation to our institution averaged 6.9+/-1.19 days. Patients averaged 2.9+/-0.22 surgical procedures, and 46% of patients required skin grafting with an average graft area of 1554+/-248 cm(2). Of the survivors, only 54% were able to return home, with 46% needing further hospitalization or transfer to an inpatient rehabilitation facility. CONCLUSIONS: There were frequent delays in diagnosis and referrals to and from within our institution, and progress can be made in educating the medical community to identify these patients. Advancements in wound care and critical care have made inroads into the treatment of patients with necrotizing soft-tissue infections. However, these infections continue to be a source of high morbidity and mortality and significant healthcare resource consumption. These challenging patients are best served with prompt diagnosis, immediate radical surgical debridement, and aggressive critical care management. Referral to a major burn center may help provide optimal surgical intervention, wound care, and critical care management.

Adult↗

PubMed2005

Establishing transfusion needs in burn patients.

BACKGROUND: Despite blood-conservation techniques, hemorrhage during burn excision remains substantial. It is difficult to predict the blood loss that will occur per operation and how many units the patient will require during surgery. This may result in high cross-match-to-transfusion ratios (CMTRs). METHODS: A retrospective chart review from 2001 to 2003 was performed. All adult patients with >20% total body surface area burns who underwent surgery were included in the study. Variables examined were centimeters excised, estimated blood loss, packed red blood cells transfused during surgery, preoperative and postoperative hematocrit, and CMTR. RESULTS: There were 273 operations. The average estimated blood loss was 820 mL, and; the median posttransfusion hematocrit was 27. Based on the area excised and units transfused, a ratio of packed red blood cells/cm excised was determined. A total of 1.78 U blood were transfused/1000 cm(2) excised to keep hematocrit between 25 and 31; P = 0.02. CONCLUSIONS: Estimation of excision area can predict transfusion need, which at our institution yields a low CMTR.

Adolescent↗

PubMed2005

Half-a-dozen ribs: the breakpoint for mortality.

BACKGROUND: We hypothesized that the number of rib fractures independently impacted patient pulmonary morbidity and mortality. METHODS: The National Trauma Data Bank (NTDB, v. 3.0 American College of Surgeons, Chicago, IL) was queried for patients sustaining 1 or more rib fractures. Data abstracted included the number of rib fractures by International Classification of Diseases-9 code, Injury Severity Score, the occurrence of pneumonia, acute respiratory distress syndrome, pulmonary embolus, pneumothorax, aspiration pneumonia, empyema, and associated injuries by abbreviated injury score, the need for mechanical ventilation, number of ventilator days, intensive care unit (ICU) length of stay (LOS), hospital LOS, mortality, and use of epidural analgesia. Statistical analysis was performed using the Student t test and linear regression analysis. Statistical significance was defined as a P value of less than .05. RESULTS: The NTDB included 731,823 patients. Of these, 64,750 (9%) had a diagnosis of 1 or more fractured ribs. Thirteen percent (n = 8,473) of those with rib fractures developed 13,086 complications, of which 6,292 (48%) were related to a chest-wall injury. Mechanical ventilation was required in 60% of patients for an average of 13 days. Hospital LOS averaged 7 days and ICU LOS averaged 4 days. The overall mortality rate for patients with rib fractures was 10%. The mortality rate increased (P < .02) for each additional rib fracture. The same pattern was seen for the following morbidities: pneumonia (P < .01), acute respiratory distress syndrome (P < .01), pneumothorax (P < .01), aspiration pneumonia (P < .01), empyema (P < .04), ICU LOS (P < .01), and hospital LOS for up to 7 rib fractures (P < .01). An association between increasing hospital LOS and number of rib fractures was not shown (P = .19). Pulmonary embolism also was not related to the number of rib fractures (P = .06). Epidural analgesia was used in 2.2% (n = 1,295) of patients with rib fractures. A reduction in mortality with epidural analgesia was shown at 2, 4, and 6 through 8 rib fractures. The use of epidural analgesia had no impact on the frequency of pulmonary complications. When stratifying data by Injury Severity Score and the presence or absence of rib fractures the mortality rates were similar. CONCLUSIONS: Increasing the number of rib fractures correlated directly with increasing pulmonary morbidity and mortality. Patients sustaining fractures of 6 or more ribs are at significant risk for death from causes unrelated to the rib fractures. Epidural analgesia was associated with a reduction in mortality for all patients sustaining rib fractures, particularly those with more than 4 fractures, but this modality of treatment appears to be underused.

Anesthesia, Epidural↗

PubMed2005

Neurosurgical coverage: essential, desired, or irrelevant for good patient care and trauma center status.

SUMMARY AND BACKGROUND DATA: As a result of many factors, the availability of neurosurgeons (NS) to care for trauma patients (TP) is increasingly sparse. This has precipitated a crisis in access to neurosurgical support in many trauma systems, often placing undue burden on level I centers. This study examines the profile of head-injured (HI) trauma patients and their actual need for the specific expertise of a neurosurgeon. METHODS: The National Trauma Data Bank (NTDB) was queried for specific information relating to the volume, nature, timeliness, and outcome of HI TP. Study patients were identified by reported International Classification of Diseases, 9th Edition (ICD-9) codes denoting open (OHI) or closed head injury (CHI) in isolation or in combination with other injuries. RESULTS: Total number of NTDB patients studied was 731,823, of which 213,357 (29%) had a reported HI. CHI represented 22% of all TP and 74% of HI. OHI was reported in 8% of all TP and was 26% of HI. Craniotomy (crani) was performed in 3.6% of all HI (1% of all TP). This was in 2.8% of OHI and 2.6% of CHI. Mean Glasgow Coma Scale score (GCS) of crani patients was 9, and 13 for the noncrani group. Subdural hematoma occurred in 18% of HI (5% of TP), with 13% undergoing crani. Epidural hematoma occurred in 10% of HI (3% of all TP), with 17% undergoing crani. Median time to OR for all cranis was 195 minutes (195 for CHI; 183 for OHI). Of all cranis, 6.5% were performed within 1 hour of hospital admission. Intracranial pressure (ICP) monitoring was reportedly used in 0.7% of TP and 2.2% of HI. CONCLUSIONS: Care of TP with HI rarely requires the explicit expertise and immediate presence of a neurosurgeon due to volume and nature of care. HI was diagnosed in <30% of TP reported to the NTDB. Over 95% required nonoperative management alone, with only 1% of all TP and 2%-4% of HI TP requiring crani and/or ICP monitoring. Immediate availability of NS is not essential if a properly trained and credentialed trauma surgeon or other health care provider can appropriately monitor patients for neurologic demise and effect early transfer to a center capable of, and committed to, operative and postoperative neurosurgical care. A subgroup of patients known to have a high propensity for the specific expertise of a neurosurgeon may be able to be identified for direct transport to these committed centers.

Craniocerebral Trauma↗

PubMed2005

A low blood ethanol level is associated with improved cytokine production in aged mice after traumatic injury.

BACKGROUND: Many trauma patients have been consuming alcohol at the time of injury. Although high concentrations of alcohol are correlated with poor outcome, few studies have examined the effects of low levels of alcohol. We examined the effects of low alcohol exposure after burn injury using a murine model. METHODS: Three- and 18-month-old mice were given ethanol or saline 30 minutes before a 15% total body surface area burn injury. Twenty-four hours after injury, cellular immune responses, including delayed-type hypersensitivity response and splenocyte proliferation were examined, along with production of interferon-gamma, interleukin (IL)-2, and IL-4. RESULTS: Alcohol administration resulted in a significant increase in interferon-gamma in the aged, but not young, burn-injured mice. Likewise, slight increases in IL-2, IL-4, and the delayed-type hypersensitivity response were observed. CONCLUSION: Low levels of ethanol at the time of injury are associated with partial restoration of immune responses in aged mice.

Aging↗

PubMed2005

Old fashion clinical judgment in the era of protocols: is mandatory chest X-ray necessary in injured patients?

BACKGROUND: The ATLS Course advocates that injured patients have a chest x-ray (CXR) to identify potential injuries. The purpose of this study was to correlate clinical indications and clinician judgment with CXR results to ascertain if a selective policy would be beneficial. METHODS: Patients treated at a Level I trauma center over 12 months were prospectively evaluated. Before obtaining a CXR, signs, symptoms, and history suggestive of thoracic injury were identified. Additionally, a trauma surgeon (TS) recorded whether in their judgment a CXR was clinically indicated. These findings were compared with final CXR diagnoses. The sensitivity of individual clinical indicators, combinations of clinical indicators, and TS judgment for CXR abnormalities were calculated with a 95% confidence interval. RESULTS: During the twelve-month study period, data were acquired on 772 patients (age 0-102 years). Seventy percent were male and 86.0% were injured by blunt force. Only 29% (N = 222) of the patients manifested one or more of the clinical indicators (signs and symptoms). The negative predictive value for the TS judgment was 98.2% which was superior to the clinical indicators. Reliance on the opinion of the TS to determine the need for a CXR would have eliminated 49.9% of CXRs and avoided hospital and radiologist reading charges totaling $100,078.22. CONCLUSION: Mandatory CXR for all trauma patients has a low yield for abnormal findings. A selective policy relying on surgical judgment guided by clinical indicators is safe and efficacious while reducing cost and conserving resources.

Accidental Falls↗

PubMed2005

Reasons to omit digital rectal exam in trauma patients: no fingers, no rectum, no useful additional information.

BACKGROUND: Performance of digital rectal examination (DRE) on all trauma patients during the secondary survey has been advocated by the Advanced Trauma Life Support course. However, there is no clear evidence of its efficacy as a diagnostic test for traumatic injury. The purpose of this study is to analyze the value of a policy mandating DRE on all trauma patients as part of the initial evaluation process and to discern whether it can routinely be omitted. METHODS: Prospective study of patients treated at a Level I trauma center. Clinical indicators other than DRE (OCI) denoting gastrointestinal bleeding (GIB), urethral disruption (UD), or spinal cord injury (SCI) were sought and correlated with DRE findings suggesting the same. Impression of the examining physician as to the need and value of DRE was also studied. Patients with a Glasgow Coma Scale Score (GCS) of 3 and pharmacologically paralyzed were excluded from the SCI analyses. UD analysis included only males. RESULTS: In all, 512 cases were studied (72% male, 28% female) ranging in age from 2 months to 102 years. Thirty index injuries were identified in 29 patients (6%), 17 SCI (3%), 11 GIB (2%), and 2 UD (0.4%). DRE findings agreed positively or negatively with one or more OCI of index injuries in 93% of all cases (92% seeking SCI, 90% seeking GIB, 96% seeking UD). Overall, negative predictive value of DRE was the same as that of OCI, 99% (SCI 98% versus 99%, GIB, 97% versus 99%, UD both 100%). Positive predictive value for DRE was 27% and for OCI 24% (SCI 47% versus 44%, GIB 15% versus 18%, UD 33% versus 6%). Efficiency of DRE was 94% and OCI was 93%. For confirmed index injuries, indicative DRE findings were associated with 41% and OCI 73% (SCI 36% versus 79%, GIB 36% versus 73%, UD 50% versus 100%). OCIs were present in 81% of index injury cases. In all index injury cases where OCIs were absent, positive DRE findings were also absent. DRE was felt to give additional information in 5% of all cases and change management in 4%. In cases where the clinician felt DRE was definitely indicated (29%) it reportedly gave no additional information in 85% and changed management in 11%. CONCLUSION: DRE is equivalent to OCI for confirming or excluding the presence of index injuries. When index injuries are demonstrated, OCI is more likely to be associated with their presence. DRE rarely provides additional accurate or useful information that changes management. Omission of DRE in virtually all trauma patients appears permissible, safe, and advantageous. Elimination of routine DRE from the secondary survey will presumably conserve time and resources, minimize unpleasant encounters, and protect patients and staff from the potential for further harm without any significant negative impact on care and outcome.

Adolescent↗