2024 Focused Update: Guidelines on Use of Corticosteroids in Sepsis, Acute Respiratory Distress Syndrome, and Community-Acquired Pneumonia

RATIONALE

New evidence is available examining the use of corticosteroids in sepsis, acute respiratory distress syndrome (ARDS) and community-acquired pneumonia (CAP), warranting a focused update of the 2017 guideline on critical illness-related corticosteroid insufficiency.

OBJECTIVES

To develop evidence-based recommendations for use of corticosteroids in hospitalized adults and children with sepsis, ARDS, and CAP.

PANEL DESIGN

The 22-member panel included diverse representation from medicine, including adult and pediatric intensivists, pulmonologists, endocrinologists, nurses, pharmacists, and clinician-methodologists with expertise in developing evidence-based Clinical Practice Guidelines. We followed Society of Critical Care Medicine conflict of interest policies in all phases of the guideline development, including task force selection and voting.

METHODS

After development of five focused Population, Intervention, Control, and Outcomes (PICO) questions, we conducted systematic reviews to identify the best available evidence addressing each question. We evaluated the certainty of evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach and formulated recommendations using the evidence-to-decision framework.

RESULTS

In response to the five PICOs, the panel issued four recommendations addressing the use of corticosteroids in patients with sepsis, ARDS, and CAP. These included a conditional recommendation to administer corticosteroids for patients with septic shock and critically ill patients with ARDS and a strong recommendation for use in hospitalized patients with severe CAP. The panel also recommended against high dose/short duration administration of corticosteroids for septic shock. In response to the final PICO regarding type of corticosteroid molecule in ARDS, the panel was unable to provide specific recommendations addressing corticosteroid molecule, dose, and duration of therapy, based on currently available evidence.

CONCLUSIONS

The panel provided updated recommendations based on current evidence to inform clinicians, patients, and other stakeholders on the use of corticosteroids for sepsis, ARDS, and CAP.

To close or not to close? Wound management in emergent colorectal surgery, an EAST Multicenter prospective cohort study

BACKGROUND

To determine the clinical impact of wound management technique on surgical site infection (SSI), hospital length of stay (LOS) and mortality in emergent colorectal surgery.

METHODS

A prospective observational study (2021-2023) of urgent or emergent colorectal surgery patients at 15 institutions was conducted. Pediatric patients and traumatic colorectal injuries were excluded. Patients were classified by wound closure technique: skin closed (SC), skin loosely closed (SLC), or skin open (SO). Primary outcomes were SSI, hospital LOS and in-hospital mortality rates. Multivariable regression was used to assess the effect of wound closure on outcomes after controlling for demographics, patient characteristics, ICU admission, vasopressor use, procedure details and wound class. A priori power analysis indicated that 138 patients per group were required to detect a 10% difference in mortality rates.

RESULTS

In total, 557 patients were included (SC n = 262, SLC n = 124, SO n = 171). Statistically significant differences in BMI, race/ethnicity, ASA scores, EBL, ICU admission, vasopressor therapy, procedure details, and wound class were observed across groups (Table 1). Overall, average LOS was 16.9 ± 16.4 days, and rates of in-hospital mortality and SSI were 7.9% and 18.5%, respectively, with the lowest rates observed in the SC group (Table 2). After risk adjustment, SO was associated with increased risk of mortality (OR = 3.003, p = 0.028 in comparison to the SC group. SLC was associated with increased risk of superficial SSI (OR = 3.439, p = 0.014), after risk adjustment.

CONCLUSION

When compared to the SC group, the SO group was associated with mortality, but comparable when considering all other outcomes, while the SLC was associated with increased superficial SSI. Complete skin closure may be a viable wound management technique in emergent colorectal surgery.

STUDY TYPE

Level III Therapeutic/Care Management.

Optimizing Transitions of Care and Enhancing Surgical Education on Acute Care Surgery: A Multi-Institutional Survey Study

OBJECTIVE

Critically ill and injured patients are routinely managed on the Trauma and Acute Care Surgery (ACS) service and receive care from numerous residents during hospital admission. The Clinical Learning Environment Review (CLER) program established by the ACGME identified variability in resident transitions of care (TC) while observing quality care and patient safety concerns. The aim of our multi-institutional study was to review surgical trainees' impressions of a specialty-specific handoff format in order to optimize patient care and enhance surgical education on the ACS service.

DESIGN

A survey study was conducted with a voluntary electronic 20-item questionnaire that utilized a 5 point Likert scale regarding TC among resident peers, supervised handoffs by trauma attendings, and surgical education. It also allowed for open-ended responses regarding perceived advantages and disadvantages of handoffs.

SETTING

Ten American College of Surgeons-verified Level 1 adult trauma centers.

PARTICIPANTS

All general surgery residents and trauma/acute/surgical critical care fellows were surveyed.

RESULTS

The study task was completed by 147 postgraduate trainees (125 residents, 14 ACS fellows, and 8 surgical critical care fellows) with a response rate of 61%. Institutional responses included: university hospital (67%), community hospital-university affiliate (16%), and private hospital-university affiliate (17%). A majority of respondents were satisfied with morning TC (62.6%) while approximately half were satisfied with evening TC (52.4%). Respondees believe supervised handoffs improved TC and prevented patient care delays (80.9% and 74.8%, respectively). A total of 35% of trainees utilized the open-ended response field to highlight specific best practices of their home institutions.

CONCLUSIONS

Surgical trainees view ACS morning handoff as an effective standard to provide the highest level of clinical care and an opportunity to enhance surgical knowledge. As TC continue to be a focus of certifying bodies, identifying best practices and opportunities for improvement are critical to optimizing quality patient care and surgical education.

Does lower extremity fracture fixation technique influence neurologic outcomes in patients with traumatic brain injury? The EAST Brain vs. Bone multicenter trial

OBJECTIVE

This study aimed to determine whether lower extremity fracture fixation technique and timing (≤24 vs. >24 hours) impact neurologic outcomes in TBI patients.

METHODS

A prospective observational study was conducted across 30 trauma centers. Inclusion criteria were age 18 years and older, head Abbreviated Injury Scale (AIS) score of >2, and a diaphyseal femur or tibia fracture requiring external fixation (Ex-Fix), intramedullary nailing (IMN), or open reduction and internal fixation (ORIF). The analysis was conducted using analysis of variamce, Kruskal-Wallis, and multivariable regression models. Neurologic outcomes were measured by discharge Ranchos Los Amigos Revised Scale (RLAS-R).

RESULTS

Of the 520 patients enrolled, 358 underwent Ex-Fix, IMN, or ORIF as definitive management. Head AIS was similar among cohorts. The Ex-Fix group experienced more severe lower extremity injuries (AIS score, 4-5) compared with the IMN group (16% vs. 3%, p = 0.01) but not the ORIF group (16% vs. 6%, p = 0.1). Time to operative intervention varied between the cohorts with the longest time to intervention for the IMN group (median hours: Ex-Fix, 15 [8-24] vs. ORIF, 26 [12-85] vs. IMN, 31 [12-70]; p < 0.001). The discharge RLAS-R score distribution was similar across the groups. After adjusting for confounders, neither method nor timing of lower extremity fixation influenced the discharge RLAS-R. Instead, increasing age and head AIS score were associated with a lower discharge RLAS-R score (odds ratio [OR], 1.02; 95% confidence interval [CI], 1.002-1.03 and OR, 2.37; 95% CI, 1.75-3.22), and a higher Glasgow Coma Scale motor score on admission (OR, 0.84; 95% CI, 0.73-0.97) was associated with higher RLAS-R score at discharge.

CONCLUSION

Neurologic outcomes in TBI are impacted by severity of the head injury and not the fracture fixation technique or timing. Therefore, the strategy of definitive fixation of lower extremity fractures should be dictated by patient physiology and the anatomy of the injured extremity and not by the concern for worsening neurologic outcomes in TBI patients.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

Creation of standardized tools to evaluate reporting in health research: Population Reporting Of Gender, Race, Ethnicity & Sex (PROGRES)

Despite increasing diversity in research recruitment, research finding reporting by gender, race, ethnicity, and sex has remained up to the discretion of authors. This study developped and piloted tools to standardize the inclusive reporting of gender, race, ethnicity, and sex in health research. A modified Delphi approach was used to develop standardized tools for the inclusive reporting of gender, race, ethnicity, and sex in health research. Health research, social epidemiology, sociology, and medical anthropology experts from 11 different universities participated in the Delphi process. The tools were pilot tested on 85 health research manuscripts in top health research journals to determine inter-rater reliability of the tools. The tools each spanned five dimensions for both sex and gender as well as race and ethnicity: Author inclusiveness, Participant inclusiveness, Nomenclature reporting, Descriptive reporting, and Outcomes reporting for each subpopulation. The sex and gender tool had a median score of 6 and a range of 1-15 out of 16 possible points. The percent agreement between reviewers piloting the sex and gender tool was 82%. The interrater reliability or average Cohen's Kappa was 0.54 with a standard deviation of 0.33 demonstrating moderate agreement. The race and ethnicity tool had a median score of 1 and a range of 0-15 out of 16 possible points. Race and ethnicity were both reported in only 25.8% of studies evaluated. Most studies that reported race reported only the largest subgroups; White, Black, and Latinx. The percent agreement between reviewers piloting the race and ethnicity tool was 84 and average Cohen's Kappa was 0.61 with a standard deviation of 0.38 demonstrating substantial agreement. While the overall dimension scores were low (indicating low inclusivity), the interrater reliability measures indicated moderate to substantial agreement for the respective tools. Efforts in recruitment alone will not provide more inclusive literature without improving reporting.

Impact of COVID-19 pandemic at a level 1 trauma center

Introduction

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic commonly called COVID-19 brought new changes to healthcare delivery in the US. The purpose of this study is to identify the impact of COVID-19 on the delivery of acute surgical care for patients at a Level 1 trauma center during the lockdown period of the pandemic from March 13-May 1 2020.

Methods

All trauma admission to the University Medical Center Level 1 Trauma Center from March 13 to May 13, 2020, were retrospectively abstracted and compared to the same period during 2019. Analysis focused on the lockdown period of March 13-May 1, 2020, and compared to the same dates in 2019. Abstracted data included demographics, care timeframes, length of stay, and mortality. The data were analyzed using Chi-Square, Fisher Exact, and the Mann-Whitney U test.

Results

A total of 305 (2019) vs. 220 (2020) procedures were analyzed. No significant differences were seen in mean BMI, Injury Severity Score, American Society of Anesthesia Score, and Charlson Comorbidity Index between the two groups. Diagnosis time, interval to surgery, anesthesia time, surgical preparation time, operation time, transit time, mean hospital stay, and mortality were similar.

Conclusion

The results of this study demonstrate that the lockdown period of the COVID-19 pandemic did not significantly affect the trauma surgery service line, aside from case volume, at a Level 1 trauma center in West Texas during the lockdown period. Despite changes to healthcare delivery during the pandemic, care of surgical patients was conserved as timely and of high quality.

Laparoscopic management of combined cholecystogastric and cholecystocolonic fistulae

Cholecystogastric and cholecystocolonic fistulae are rare sequelae of longstanding cholelithiasis and can complicate surgical management. Our case involves a male patient in his early 40s with a history of chronic cholelithiasis who presented to the emergency department with severe abdominal pain. Findings on imaging were consistent with acute calculous cholecystitis. During laparoscopic cholecystectomy, the presence of both cholecystogastric and cholecystocolonic fistulae was discovered. Fistula resection with cholecystectomy in a one-step approach using indocyanine green (ICG) angiography was performed. The patient improved and was discharged 3 days later. Laparoscopic management complemented by ICG angiography is a viable surgical approach in patients with cholecystogastric and cholecystocolonic fistulae.

And Miles to Go Before We Sleep: EAST Diversity and Inclusivity Progress and Remaining Challenges

OBJECTIVE

The aim of this study was to examine the diversity, equity, and inclusion landscape in academic trauma surgery and the EAST organization.

SUMMARY BACKGROUND DATA

In 2019, the Eastern Association for the Surgery of Trauma (EAST) surveyed its members on equity and inclusion in the #EAST4ALL survey and assessed leadership representation. We hypothesized that women and surgeons of color (SOC) are underrepresented as EAST members and leaders.

METHODS

Survey responses were analyzed post-hoc for representation of females and SOC in academic appointments and leadership, EAST committees, and the EAST board, and compared to the overall respondent cohort. EAST membership and board demographics were compared to demographic data from the Association of American Medical Colleges.

RESULTS

Of 306 respondents, 37.4% identified as female and 23.5% as SOC. There were no significant differences in female and SOC representation in academic appointments and EAST committees compared to their male and white counterparts. In academic leadership, females were underrepresented ( P < 0.0001), whereas SOC were not ( P = 0.08). Both females and SOC were underrepresented in EAST board membership ( P = 0.002 and P = 0.043, respectively). Of EAST's 33 presidents, 3 have been white women (9%), 2 have been Black, non-African American men (6%), and 28 (85%) have been white men. When compared to 2017 AAMC data, women are well-represented in EAST's 2020 membership ( P < 0.0001) and proportionally represented on EAST's 2019-2020 board ( P > 0.05).

CONCLUSIONS

The #EAST4ALL survey suggests that women and SOC may be underrepresented as leaders in academic trauma surgery. However, lack of high-quality demographic data makes evaluating representation of structurally marginalized groups challenging. National trauma organizations should elicit data from their members to re-assess and promote the diversity landscape in trauma surgery.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Alternative management of delayed spontaneous oesophageal perforation by endoscopic stenting

Boerhaave's syndrome or spontaneous perforation of the oesophagus is a life-threatening condition that carries high mortality. Delayed diagnosis has a mortality rate of 20%-50%. While surgical intervention has been the mainstay of treatment, advancements in endoscopy and oesophageal stenting have allowed for alternative management. Our case involves a 33-year-old man with self-induced emesis and DKA. After 10 days in the ICU, he developed a large right pleural effusion, which was treated with chest tube placement. Upper GI study confirmed delayed Boerhaave's syndrome. A self-expanding stent was inserted followed by percutaneous endoscopic gastrostomy (PEG) for decompression and jejunal extension for nutrition. He developed empyema and underwent right thoracotomy for washout and lung decortication. Stent was exchanged once due to recurrent leak following migration and removed after 40 days. Endoscopic stent placement with PEG with jejunal extension followed by thoracotomy is a viable alternative to primary repair of delayed oesophageal perforation.

Granular packings with sliding, rolling, and twisting friction

Intuition tells us that a rolling or spinning sphere will eventually stop due to the presence of friction and other dissipative interactions. The resistance to rolling and spinning or twisting torque that stops a sphere also changes the microstructure of a granular packing of frictional spheres by increasing the number of constraints on the degrees of freedom of motion. We perform discrete element modeling simulations to construct sphere packings implementing a range of frictional constraints under a pressure-controlled protocol. Mechanically stable packings are achievable at volume fractions and average coordination numbers as low as 0.53 and 2.5, respectively, when the particles experience high resistance to sliding, rolling, and twisting. Only when the particle model includes rolling and twisting friction were experimental volume fractions reproduced.

Apixaban-induced haematoma causing small bowel intussusception

Apixaban (Eliquis) is a direct acting oral anticoagulant (DOAC) indicated for treatment of deep vein thrombosis, non-valvular atrial fibrillation, pulmonary embolism and postoperative venous thromboprophylaxis following hip or knee replacement. Complications are minimal and include, but are not limited to, bleeding and intracranial haemorrhage, and haematoma formation. Our patient is a 73-year-old woman who presented with clinical and radiographic findings of small bowel obstruction. She was found to be taking apixaban for atrial fibrillation. CT scan showed small bowel intussusception. She underwent an exploratory laparotomy and resection of the small bowel intussusception with primary side-to-side anastomosis. Histopathological examination showed that the intussusception was caused by an intramural haematoma. This case presents a rare instance of adult intussusception caused by a DOAC. To our knowledge, no case of intussusception caused by apixaban has yet been found in literature.

Laparoscopic removal of migrated intrauterine device

Intrauterine device (IUD) is a popular long-acting reversible contraceptive device with an estimated rate of use of about 5.3%. It is highly effective but not without complications, one of which is uterine perforation. The patient was a 32-year-old female who presented with nausea, vomiting and right upper quadrant abdominal pain that was tender on palpation. CT scan was performed and they found signs of acute calculous cholecystitis with incidental finding of a migrated IUD in the left lateral mid-abdomen within the peritoneal cavity. She underwent a laparoscopic cholecystectomy followed by a successful IUD retrieval. Most uterine perforations occur at the time of insertion; however, partial perforation with subsequent delayed complete perforation may also occur. This case emphasises the importance of a full workup for a missing IUD and that, if incidentally found, IUDs can be removed safely laparoscopically in conjunction with another procedure.

Evolution of Socioeconomic Conditions and Its Relation to Spatial-Temporal Changes of Giardiasis and Helminthiasis in Amazonian Children

This study analyzed the evolution of socioeconomic, sanitary, and personal factors as well as spatiotemporal changes in the prevalence of helminthiasis and giardiasis in urban Amazonian children between 2003 and 2011. Child age, lack of sanitation, and lack of access to bottled water were identified as significant associated factors for helminthiasis and giardiasis. There was an overall improvement in socioeconomic and sanitary conditions in the city resulting in decreased helminth prevalences from 12.42 to 9.63% between 2003 and 2010, but the prevalence increased to 15.03% in 2011 due to migratory movement and unstable sanitary conditions. As for Giardiasis, socioeconomic and environmental changes were not enough to reduce prevalence (16% in 2003 and 23% in 2011). Spatial analysis identified a significant cluster for helminthiasis in an area of poor housing conditions. Control programs in the Amazon need to target high-risk areas focusing changes in sanitation, water usage, and health education.

Successful operative rib fixation of traumatic flail chest in a patient with osteogenesis imperfecta

Increasing attention has been directed towards operative rib fixation of traumatic flail chest; reported benefits include more rapid weaning from the ventilator, decreased intensive care unit stays, decreased complications and improved functional results. The outcomes of this surgical intervention in patients with osteogenesis imperfecta, a rare condition characterized by low bone density and bone fragility, are unknown. This case demonstrates that, in the management of traumatic flail chest in a patient with osteogenesis imperfecta, surgical fixation can be successful and should be considered early.

A quantitative TaqMan PCR assay for the detection of Mycoplasma suis

AIM

To develop a TaqMan probe-based, highly sensitive and specific quantitative PCR (qPCR) assay for the detection and quantification of Mycoplasma suis in the blood of pigs.

METHODS AND RESULTS

Primers and probes specific to Myc. suis 16S rRNA gene were designed. The qPCR assay's specificity, detection limit, intra- and inter-assay variability were evaluated and its performance was compared with a Myc. suis conventional PCR assay (cPCR). Blood of two experimentally infected pigs, 40 Indiana pigs, 40 Brazilian sows and 28 peccaries were tested. The assay detected as few as ten copies of Myc. suis plasmids and was 100-fold more sensitive than the cPCR. No cross-reactivity with nontarget pig mycoplasmas was observed. An average of 1·62 × 10(11) and 2·75 × 10(8) target copies ml(-1) of blood were detected in the acutely and chronically infected pigs, respectively. Three (7·5%) pigs and 32 (80·0%) sows were positive while all peccaries were negative for Myc. suis.

CONCLUSION

The developed qPCR assay is highly sensitive and specific for Myc. suis detection and quantification.

SIGNIFICANCE AND IMPACT OF THE STUDY

TaqMan qPCR is an accurate and quick test for detection of Myc. suis infected pigs, which can be used on varied instrumentation platforms.

The influence of oxygen-containing functional groups on the dispersion of single-walled carbon nanotubes in amide solvents

Surface composition plays an important role in carbon nanotube dispersibility in different environments. Indeed, it determines the choice of dispersion medium. In this paper the effect of oxidation on the dispersion of HiPCO single-walled carbon nanotubes (SWNTs) in N-methyl-pyrrolidinone (NMP), N,N-dimethylformamide (DMF), N,N-dimethylacetamide (DMA), N-dodecyl-pyrrolidinone (N12P) and cyclohexyl-pyrrolidinone (CHP) was systematically studied. During the oxidation process, similar amounts of carboxylic acid and phenolic groups were introduced to mostly already existing defects. For each solvent the dispersion limits and the absorption coefficients were estimated by optical absorption analysis over a range of SWNT concentrations. The presence of acid oxygenated groups increased SWNT dispersibility in NMP, DMF and DMA, but decreased in N12P and CHP. The absorption coefficients, however, decreased for all solvents after oxidation, reflecting the weakening of the effective transition dipole of the π-π transition with even limited extension functionalization and solvent interaction. The analysis of the results in terms of Hansen and Flory-Huggins solubility parameters evidenced the influence of dipolar interactions and hydrogen bonding on the dispersibility of oxidized SWNTs.

Optimization of donor management goals yields increased organ use

Multiple strategies have been used in an effort to increase the pool of organs for transplantation. Standardizing donor management has produced promising results. Donor management goals (DMGs) are now being used as end points of intensive care unit care during the prerecovery phase but no prospective results have been reported. Data from the United Network for Organ Sharing Region 11 were collected for successful achievement of eight common donor management goals (mean airway pressure [MAP], central venous pressure [CVP], pH, PaO2, sodium, glucose, single pressor use, and urine output) before organ recovery. Two time periods were studied with different panels of DMGs. The analysis identified the success rate of transplantation. Goals were stratified by their statistical correlation with the number of organs transplanted per donor (OTPD) in an effort to identify the most important parameter(s). Eight hundred five organ donors were studied with 2685 organs transplanted. DMGs were assessed through two phases of the study. Achieving DMGs rose from 18 to 66 per cent associated with significant improvement in OTPD (range, 2.96 to 3.45). The success of transplantation was primarily associated with limitations in vasopressor use and PaO2. Tight glucose control did affect the rate of pancreatic transplants. Thoracic organs were the most sensitive to DMGs with a 10- to 15-fold increase in lung transplantation when PaO2 rose above 100 mmHg. MAP, CVP, pH, sodium, and urine output had little effect on transplantation. Standardization of end points of donor management was associated with increased rates of transplantation. Surprisingly, not all standard goals are necessary for optimal organ use. The most significant parameters were the low use of vasopressor agents and oxygenation. Donor management strategies should strive to optimize these goals.

An analysis of risk-taking behavior among adolescent blunt trauma patients

INTRODUCTION

The impact of risk-taking behavior among adolescent blunt trauma patients is not fully appreciated. This study examined the relationship between adolescent risk-taking behaviors, the resultant injury severity, and outcome for blunt trauma.

METHODS

Between January 2000 and December 2005, data were collected on adolescent blunt trauma patients (12-18 years) admitted to either a Level I adult trauma center or large urban pediatric hospital. Five groups of risk-taking behavior were examined: ATV riders, drug and alcohol users, unhelmeted motorcyclists, unhelmeted extreme sports participants and unrestrained motor vehicle occupants. Demographic data, mechanism of injury, injury severity, hospital course and outcomes were evaluated for each group.

RESULTS

A total of 2030 adolescents were admitted following blunt trauma; 723 adolescents (36%) were engaged in risk-taking behavior at the time of their injury. Most patients were male (68%). Unrestrained MVA occupants were the most frequently encountered risk takers (37%); among this subset, most were unrestrained passengers (74%). Head injuries were frequent (22%) among risk takers. When compared to non-risk-takers, there were no significant age, race, gender, or ISS differences. However, a significantly higher number of positive head CT scans were found among risk-taking adolescents (22%, p < 0.05). Mortality was low (3%).

CONCLUSIONS

Risk-taking behavior is prevalent among adolescent blunt trauma patients. Improved injury prevention strategies are needed to discourage these behaviors during adolescence.

Detection of Th1/Th2 cytokine signatures in yellow fever 17DD first-time vaccinees through ELISpot assay

Immunity to yellow fever (YF) is conferred by the interplay of humoral and cellular immune response. Despite the extensive literature on the humoral immune response to the YF vaccine virus, little is known about its cellular immune response to vaccination. The analysis of cytokine production by ex-vivo antigen-stimulated T cells has been considered as a valuable tool for understanding cellular immune response. Thus, we have analyzed two T(H)1/T(H)2 signature cytokines (IFN-gamma and IL-4) from 12 healthy first-time adults vaccinated with YF17DD virus. The cells, harvested on day 0 (before vaccination) and 7, 15 and 30 days after immunization were antigen-stimulated and analyzed by ELISpot. A significant increase in the number of spot-forming cells during the response to YF 17DD live virus stimulation by ELISpot assay was observed. IFN-gamma-and IL-4-producing cells were significantly increased on the 15th day after vaccination in all volunteers. These results presented herein are important for understanding the role of cytokines in the immune response to YF 17DD virus.

Drug and alcohol use among adolescent blunt trauma patients: dying to get high?

PURPOSE

We compared injury severity, hospital course, and outcomes between adolescent blunt trauma patients with and without positive toxicology screens.

METHODS

Trauma registry data were used to identify adolescent blunt trauma victims between 2000 and 2005. Demographics, injury severity, hospital course, and outcomes were evaluated. Patients with and without positive toxicology results were compared.

RESULTS

There were 9.3% that had positive toxicology results. The mean age of toxicology-positive patients was 17.2 years. The most commonly detected drugs were cannabinoids (40%), alcohol (30%), and polysubstances (23%). Toxicology-positive patients had significantly lower Glasgow Coma Scale (11.8 +/- 4.6 vs 13.7 +/- 3.3; P < .001), higher Injury Severity Score (16.7 +/- 11.2 vs 10.4 +/- 9.1; P < .001), and required more emergent operations (20.7% vs 12.8%; P < .001). Length of stay was longer (7.3 +/- 8.1 vs 4.8 +/- 7.2 days; P < .001). Functional Independence Measure scores were lower (10.5 +/- 2.2 vs 11.2 +/- 1.7; P < .001); mortality was higher (6.4% vs 2.6%; P < .001).

CONCLUSIONS

A significant number of adolescents had positive toxicology screens. Our data suggest that toxicology-positive patients were more severely injured, required more hospital care, and had worse outcomes than other adolescent blunt trauma victims.

Decarboxylation of oxidized single-wall carbon nanotubes

A classical protocol widely used in organic chemistry of aromatic and polyaromatic molecules has been successfully applied in this work for the decarboxylation of oxidized single-wall carbon nanotube (SWNT) to rend C-H SWNT derivatives. SWNT produced by arc discharge method have been oxidized during a purification process using strongly oxidant agents, such as hydrogen peroxide and nitric acid. The decarboxylation of oxidized SWNT has been conduced with copper(I) oxide in a 50:50 solution of N-methylpyrrolidone and quinoline. Fourier transform infrared spectroscopy, X-ray photoelectron spectroscopy and acid-base potentiometric titration analyses were carried out to characterize quali and quantitatively the changes in the chemical environment on the SWNT surface in each step of the purification and the decarboxylation process. Those techniques showed the appearance of mainly carboxylic and phenolic groups after the purification process and the disappearance of the carboxylic groups after the decarboxylation reaction. Fourier transform infrared spectroscopy analysis indicated also the formation of aliphatic and aromatic C-H groups. X-ray photoelectron spectroscopy and potentiometric titration results determined an efficiency higher than 90% for our decarboxylation procedure. The purity and structural quality of the SWNT sample used in the decarboxylation process were evaluated by thermogravimetry and Raman spectroscopy. Thermogravimetric analysis identified a purified sample with approximately 80 wt% of SWNT, in fractions distributed in highly structured SWNTs (25 wt%), with distribution in composition, length and structural quality (35 wt%) and with very defective and short tubes (25 wt%). The damages on the purified SWNT walls were characterized by the Raman scattering analysis.

Prevention of postoperative tooth sensitivity: a preliminary clinical trial

The purpose of this study was to evaluate clinically the effects of pre-treatments with a 35% hydroxyethyl metacrylate/5% glutaraldehyde dentine desensitizer (Gluma Desensitizer) and a 2% chlorexidine-based cavity disinfectant (Cav-Clean) on postoperative sensitivity. Three premolar teeth with no pain symptoms were selected from each one of 17 patients, totalling 51 teeth, for which Class II restoration using a composite was indicated. Each one of the three premolar teeth of the same patient was submitted to a different treatment. After acid etching, only a dental adhesive was applied to the first tooth, which served as the control. Gluma Desensitizer dentinal desensitizer was applied to the second premolar tooth prior to applying the dental adhesive. Cav-Clean cavity disinfectant was used on the third premolar tooth before applying the dental adhesive. Only one tooth was restored per session, and all premolar teeth were restored with a condensable composite, according to current restoration technique guidelines. Sensitivity to different stimuli (cold, heat, sweet and dental floss) was assessed on Day 1, Day 4 and Day 7 by questionnaire following restorative procedures. The results of this clinical research showed that, as far as the investigated stimuli and postoperative course are concerned, there was no statistically significant difference in the three different treatments (P>0.05). Postoperative sensitivity resulting from Class II restorations using composite resin cannot be completely eliminated with the prior use of a dentinal desensitizer or a cavity disinfectant. In day-to-day clinical treatment, postoperative sensitivity may possibly be related to the technique employed.

Methamphetamine laboratory explosions: a new and emerging burn injury

The proliferation of clandestine methamphetamine laboratories (meth labs) as a result of the growing popularity of the drug has resulted in an increasing incidence of burn injuries associated with laboratory accidents. We undertook this study to characterize these injuries. Fifteen consecutive patients were identified and case-matched by age and TBSA to 45 control subjects. Most meth lab patients were men, Caucasian, unemployed, and positive for polysubstance abuse. Resuscitation requirements were 1.8 times greater in these patients. There was a higher incidence of inhalational injury corresponding to higher intubation and tracheostomy rate and longer ventilator days among meth lab patients. The rate of nosocomial pneumonia, skin graft loss, and mortality were not different between the two groups. Meth lab injury is unique and requires more critical care resources. It also is associated with lack of insurance coverage and poor follow-up after injury. This injury has a significant impact not only on patients but also on the healthcare system.

Phonon-assisted excitonic recombination channels observed in DNA-wrapped carbon nanotubes using photoluminescence spectroscopy

By using a sample of DNA-wrapped single-wall carbon nanotubes strongly enriched in the (6,5) nanotube, photoluminescence emissions observed at special excitation energy values were identified with specific mechanisms of phonon-assisted excitonic absorption and recombination processes associated with (6,5) nanotubes, including one-phonon, two-phonon, and some continuous-luminescence processes. Such detailed processes are not separately identified in three-dimensional semiconducting materials. A general theoretical framework is presented to interpret the experimentally observed phonon-assisted processes in terms of excitonic states.

Resonance Raman spectroscopy characterization of single-wall carbon nanotube separation by their metallicity and diameter

Several techniques were recently reported for the bulk separation of metallic (M) and semiconducting (S) single wall carbon nanotubes (SWNTs), using optical absorption and resonance Raman spectroscopy (RRS) as a proof of the separation. In the present work, we develop a method for the quantitative evaluation of the M to S separation ratio, and also for the SWNT diameter selectivity of the separation process, based on RRS. The relative changes in the integrated intensities of the radial-breathing mode (RBM) features, with respect to the starting material, yield the diameter probability distribution functions for M and S SWNTs in the separated fractions, accounting for the different resonance conditions of individual SWNTs, while the diameter distribution of the starting material is obtained following the fitting procedure developed by Kuzmany and coworkers. Features other than the RBM are generally less effective for characterization of the separation process for SWNTs.

Interphase chromosomes and the Rabl configuration: does genome size matter?

Summary It is now well established that the cereals share a common gene order or gene synteny. However, the cereal species encompass an enormous range of genome size, with wheat being one of the largest and rice one of the smallest. Here we describe the current state of knowledge of interphase chromosome structure within the cereal species. In wheat and its close relatives, the interphase chromosomes adopt a highly regular Rabl configuration, with the two chromosome arms lying next to each other and the centromeres and telomeres located at opposite poles of the nuclei. By contrast, the chromosomes in most rice nuclei clearly do not show a Rabl configuration. Surprisingly, the chromosomes in the endoreduplicated xylem vessel cells of rice do adopt a Rabl configuration. To explain this observation, we propose that endoreduplication may occur immediately after chromosome segregation in these cells, and that the new chromatin interactions, particularly at the centromeres, in the endoreduplicated chromosomes may stabilize the anaphase chromosome configuration.

[Predictive factors of hospital and 6-month morbidity and mortality in hospitalized elderly patients]

This article presents the results of a prospective multivariable study of elderly patients aged over 70 years, hospitalized in an Internal Medicine Department of a Central Lisbon Hospital. The study aimed to identify, at the beginning of hospital admission (HA), predictive factors of hospital mortality (HM) and mortality at 6 months, of duration of HA, of admission to a nursing home at the time of discharge and during a period of 6 months thereafter and of hospital readmission during the 6 months following discharge. The study included 158 patients with a mean hospital stay of 15 days and a hospital mortality of 12%. The main pathologies responsible for hospital admission were cerebrovascular accident (22%), heart failure (20%) and pneumonia (16%). Mortality at 6 months was 29% and hospital readmission in the 6 months thereafter was 24%. When the patient was cared for by the spouse there was a statistically significant correlation with a shorter duration of admission (p = 0.006). Mean hospital stay was not significantly associated with any other variable. A subjective medical evaluation (SME) at the start of HA (p = 0.001), a low Barthel score prior to and at the time of HA, low serum albumin (p = 0.001) and a high leucocyte count (p = 0.005) were correlated with a higher HM. Nursing home admission was only positively correlated with cerebrovascular pathology. Mortality at 6 months was significantly correlated with the SME (p = 0.001), a low Barthel score prior to admission (p < 0.008) and at the time of HA (p < 0.001), nursing home residency (p < 0.005) and a low mental test score (p < 0.01). Hospital readmission at 6 months was influenced by the SME (p < 0.04) and by the reduction in the Barthel score caused by the illness and HA (p = 0.004). These correlations enabled the development of mathematical models that predict HM and mortality at 6 months and admission to a nursing home at the time of discharge and during a period of 6 months thereafter. They could be important in identifying elderly patients' needs early in the hospital admission and in the improvement of the strategy necessary for a successful and dignified hospital discharge.

Widely separated multiple transgene integration sites in wheat chromosomes are brought together at interphase

We have investigated the organization of transgenes delivered by particle bombardment into the wheat genome, combining conventional molecular analysis with fluorescence in situ hybridization (FISH) and three-dimensional confocal microscopy. We selected a representative population of transformed wheat lines and carried out molecular and expression analysis. FISH on metaphase chromosomes showed that transgene integration sites were often separated by considerable lengths of genomic DNA (>1 Mbp), or could even be on opposite chromosome arms. Plants showing multiple integration sites on a single chromosome were selected for three-dimensional confocal analysis of interphase nuclei in root and embryo tissue sections. Confocal microscopy revealed that these sites lay in close physical proximity in the interphase nuclei. Our results clearly show that multiple transgenes physically separated by large intervening regions of endogenous DNA at metaphase can be brought together at interphase. This may reflect the original physical organization of the endogenous DNA at the moment of transformation, with DNA strand breaks introduced into several co-localized DNA loops by the intruding gold particles. Alternatively, the transgenes may be brought together after transformation, either by an ectopic homologous pairing mechanism, or by recruitment to a common transcription site.

Evidence for zinc protection against 2,5-hexanedione toxicity by co-exposure of rats to zinc chloride

The protective role of zinc against the toxic effects of 2, 5-hexanedione (2,5-HD), the main neurotoxic metabolite of n-hexane, was investigated by studying the interference of zinc on the toxicokinetics of 2,5-HD. Six groups of Wistar rats were exposed for 3 days to diets containing 2,5-HD, zinc chloride and 2,5-HD+zinc chloride. The amounts of pyrroles and free and total 2,5-HD in urine were determined using Ehrlichs's reagent and gas chromatography/flame ionization detection, respectively. The results show that after the first day of co-exposure (ZnCl(2)+2,5-HD) there was a significant decrease in the excretion of pyrroles and free 2, 5-HD in rats exposed to the chemical mixture when compared to the pyrroles and free 2,5-HD excreted in rats exposed to 2,5-HD alone. However, no significant decrease was observed in the urinary excretion of total 2,5-HD (free 2,5-HD + preformed 2,5-HD). Suggestions are made about the role played by this metal ion in inhibiting pyrrole formation.

[Comparative study of the coronary circulation pattern of anatomic specimens and surgical patients]

The recent improvement in the cardiac surgery requires a continuous study of the great anatomy of the heart. In this paper, we compare the anatomic pattern of the coronary artery between normal individuals and individuals with sintomatic ischemic disease of the heart. The anatomic pattern of circulation was carried out in two different groups: group I formed by 119 anatomical specimens taken from individuals whose cause of death was non-cardiac and group II formed by 150 live individuals with sintomatic coronary disease, on pre-operative management. In the former was performed epicardiectomy and in the latter, radiologic study. In group I was found 68% of right predominance, 13% of left predominance and 19% of balanced type of circulation. In group II was found 59%, 17% and 24%, respectively. When considering the number of branches that trespass the crux cordis in group I, there was 48% with only one branch, 28% with two, 17% with three, 4% with four and 3% with five branches. Performing the same study for group II, we found 47%, 29%, 14.6%, 3.4% and 6% respectively. Both groups were compared by Chi-square test and by Fisher's Exact test and no considerable difference was pointed out.

Intratypic differentiation of polioviruses isolated from suspected cases of poliomyelitis in Brazil during the period of 1990 to 1993

This study analyzed 3129 fecal samples derived from 1626 patients with sudden onset acute flaccid paralysis clinically compatible with poliomyelitis. The samples were collected in the period ranging from January 1990 to September 1993 in all regions of Brazil. Among the 1626 cases studied, 196 had isolation of poliovirus. Nevertheless, it was observed that some factors influenced the isolation rate and the intratypic characterization of these polioviruses. No cases of acute flaccid paralysis has been found to be etiologically related with wild polioviruses.

Metabolic differences between whole blood and isolated lymphocyte cultures for micronucleus (MN) induction by cyclophosphamide and benzo[a]pyrene

In order to study the metabolic differences between whole blood and isolated lymphocyte cultures, two indirectly acting mutagens cyclophosphamide (CP) and benzo[a]pyrene (B[a]P) were assessed for their potential to induce micronuclei (MN) in the presence and absence of S9 microsomal fractions. In isolated lymphocyte cultures supplemented with S9, CP and B[a]P induced a statistically significant increase in MN which was not observed in whole blood cultures. However, the direct-acting agent methyl methanesulphonate (which was used as a positive control) showed an increase in MN frequency in a dose-dependent manner in both culture methods. The effect of erythrocytes was then investigated by treating isolated lymphocyte cultures simultaneously with CP and S9 mix in the presence of purified erythrocyte concentrate (PEC). A clear reduction in the MN frequency was observed compared to the frequencies of MN induced in isolated lymphocyte cultures treated with CP and S9 mix in the absence of PEC. Thus, isolated lymphocyte cultures may represent a more sensitive test system for the evaluation of potential indirect-acting mutagens. However, whole blood cultures may reflect the 'real life' situation more accurately as a consequence of the presence of erythrocytes.

Misoprostol and illegal abortion in Fortaleza, Brazil

Misoprostol, a prostaglandin E1 analogue indicated for ulcer treatment, has been widely used as an abortifacient by women in Brazil, where abortion is legal only in cases of rape or incest, or to save the woman's life. Because misoprostol is an inefficient abortifacient, many women who use it have incomplete abortions and need uterine evacuation. We reviewed the records of women admitted to the main obstetric hospital of Fortaleza, capital of Ceará state, Brazil, between January, 1990, and July, 1992, for uterine evacuation after induced abortion. The number of incomplete abortions induced by misoprostol increased substantially during the first half of 1990, and declined thereafter. Of the 593 cases in 1991, 75% were related to misoprostol, 10% to the use of other specified drugs, and 6% to unspecified drugs. For the remaining 9% the procedure used was not recorded; these included 3% in whom abortion had been induced by a clandestine abortionist. The number of uterine evacuations per month fell from 89 in August, 1990, to 62 in July, 1991, when sales of misoprostol in Ceará state were suspended. The fall continued after the sale of misoprostol ceased, to about 20 cases in December, 1991; numbers remained around this level until June, 1992, sustained by clandestine sales. The lack of access to contraception is the main reason for the large numbers of unplanned pregnancies and is a major public health issue for Brazilian women. The prohibition of abortion creates a void in which misuse of medicines is one extra complication, mainly because of the poor control of drug marketing.

Prediction of steroid responsiveness in the idiopathic nephrotic syndrome using urinary retinol-binding protein and beta-2-microglobulin

OBJECTIVES

To determine the prevalence of early proximal tubular dysfunction, measured by urinary excretion of retinol-binding protein (RBP) and beta-2-microglobulin (B2M), in patients with the idiopathic nephrotic syndrome and to investigate the value of these tests in predicting steroid responsiveness.

DESIGN

Before-after trial with 8-week treatment period.

SETTING

Tertiary referral center.

PATIENTS

Sequential sample of 37 patients with the idiopathic nephrotic syndrome caused by minimal change disease, focal segmental glomerulosclerosis, or mesangial proliferative glomerulonephritis.

INTERVENTION

All patients were treated with prednisone as one dose of 1 to 1.5 mg/kg body weight per day for 8 weeks.

MEASUREMENTS

Urinary RBP was measured by an immunoenzymometric assay and B2M, by an enzyme-linked immunosorbent assay. Remission of the nephrotic syndrome after steroid treatment was the main outcome variable.

RESULTS

Elevated levels of urinary RBP and B2M before treatment were detected in 65% and 75% of the patients, respectively. Median urinary RBP and B2M, before treatment, were significantly higher in the steroid-unresponsive group than in the responsive group (P less than 0.01). In the steroid-responsive group, urinary RBP and B2M levels decreased significantly after remission (P less than 0.01). In the steroid-unresponsive group, the likelihood ratios for urinary RBP greater than 4000 micrograms/g creatinine and for B2M greater than 3000 micrograms/g creatinine were 3.8 and 3.0, respectively. The probability was 100% that values of RBP of less than 1300 micrograms/g creatinine and B2M of less than 130 micrograms/g creatinine were from steroid-responsive patients. Multivariate analysis confirmed that higher urinary levels of RBP and B2M were associated with a lower likelihood of steroid responsiveness, independent of age and histologic diagnosis.

CONCLUSIONS

Proximal tubular dysfunction is frequent in patients with the idiopathic nephrotic syndrome. Pretreatment urinary RBP and B2M levels may be helpful in identifying nephrotic patients who are more likely to be responsive to steroids.

Replication of hepatitis B virus in adult carriers in an endemic area

We have examined serological markers of replicative and nonreplicative infection in 124 adult, black South African carriers of hepatitis B virus (HBV), in whom this infection is predominantly acquired in early childhood. The mean age of the group was 36 years. Antibody to hepatitis B e antigen (anti-HBe) was present in the serum of 93.5% of these carriers. Only 25.8% of the carriers were positive for HBV DNA in serum, and in the majority of these only trace amounts were detectable. IgM antibody to hepatitis B core antigen (IgM anti-HBc) was negative in 54% of the carriers, and only 26% had IgM anti-HBc in high titer. A significantly greater proportion of carriers who were positive for anti-HBe were positive for IgM anti-HBc (43.1%) than were positive for HBV DNA (24.5%). Serum aminotransferases were less than twofold elevated in 90.3% of the carriers. Only one carrier has thus far developed hepatocellular carcinoma. These results suggest that there is an inexorable progression to predominantly nonreplicative infection in the majority of southern African adult, black carriers, an occurrence that may take several decades. In areas endemic for HBV infection, antiviral agents effective against replicative HBV will have to be administered in childhood.