Growth and sustainability of burn practices can be impaired by irregular patterns of patient presentations, resulting in uneven utilization of facilities and staff. Burn care itself may not engage ...the full capacities of members of burn care teams. To address these problems, we organized a burn and reconstruction center to provide statewide acute care as Mississippi's only burn unit, to fully integrate reconstructive surgery into management of burn patients, and to diversify practice based on plastic surgery scope of practice. The first 10 years of this unit were reviewed to evaluate the performance of this scheme.
Burn admissions to and surgical procedures at this unit between July 2009 and June 2019 were analyzed to quantify acute burn care, secondary reconstructive burn care, and categories of practice growth.
The unit admitted 5469 acute burn patients with a mortality rate of 1.49%. Comparing year 10 to year 1 of practice, acute burn admissions increased 58%. Total operations increased 276%. Acute burn procedures increased 176%. Secondary burn procedures increased 405%. Nonburn procedures increased 352%, with the subset of nonburn hand surgery increasing 1062%.
Acute burn admissions and procedures increased over this period, but greater growth was seen in secondary burn procedures and nonburn procedures, especially hand cases. Expansion of practice into areas within the overall skill sets of burn team members was an effective growth strategy.
Abstract Background Previous studies of recombinant human thrombin (rThrombin) enrolled adult and adolescent patients. This phase 4, open-label, single-group study was conducted in pediatric patients ...undergoing synchronous burn wound excision and skin grafting to provide information regarding the safety and immunogenicity of rThrombin (primary and secondary endpoints) in this population. Methods Topical rThrombin was applied as a hemostatic aid during a surgical procedure (day 1). Adverse events and clinical laboratory abnormalities were recorded during the study. Immunogenicity samples were collected on days 1 and 29 (study end). Study results were summarized with descriptive statistics. Results Thirty patients enrolled and 28 completed the study. Mean age was 6.9 years (range, 0.9-17.8 years); 40.0% of patients were girls. Flame and scald were the most common burn types (33.3% each, n = 10/30). Mean graft size was 3.6% total body surface area. Procedural pain (50.0% patients), pruritus (43.3%), and anemia (30.0%) were the most commonly reported adverse events. All adverse events and clinical laboratory abnormalities were considered unrelated to treatment. No patients developed anti-rThrombin product antibodies at day 29. Conclusions In pediatric patients undergoing burn wound excision and skin grafting, rThrombin was well tolerated and did not lead to the formation of anti-rThrombin product antibodies.
Pain is frequently accompanied by enhanced arousal and hypervigilance to painful sensations. Here, we describe our findings in an experimental vigilance task requiring healthy participants to ...indicate when randomly timed moderately painful stimuli occur in a long train of mildly painful stimuli.
During a continuous performance task with painful laser stimuli (CPTpain), 18 participants rated pain intensity, unpleasantness, and salience. We tested for a vigilance decrement over time using classical metrics including correct targets (hits), incorrectly identified non-targets (false alarms), hit reaction time, and false alarm reaction time. We measured state anxiety and tense arousal before and after the task.
We found a vigilance decrement across four 12.5-minute blocks of painful laser stimuli in hits F
=2.91; p=0.043; time block 1>block 4 (t=2.77; p=0.035). Both self-report state anxiety (t
=3.34; p=0.0039) and tense arousal (t
=3.20; p=0.0053) increased after the task. We found a vigilance decrement during our laser pain vigilance task consistent with vigilance decrements found in other stimulus modalities. Furthermore, state anxiety positively correlated with tense arousal.
CPTpain acutely increased tense arousal and state anxiety, consistent with previous results implicating the reciprocal interaction of state anxiety and acute painful sensations and the role of pain in augmenting tense arousal. These results may indicate a psychological process which predisposes the hypervigilant to developing greater acute pain, resulting in positive feedback, greater pain and anxiety.
Conventional MR imaging findings are considered to be inadequate for reliably distinguishing radiation necrosis from tumor recurrence in patients with glioma. Despite this belief, we hypothesized ...that certain conventional MR imaging findings, alone or in combination, though not definitive, may favor one or another of these diagnoses in proton beam-treated patients with new enhancing lesions on serial scanning.
MR imaging findings (axial T1-, T2-, and post-gadolinium T1-weighted) of 27 proton beam radiation therapy patients with high-grade gliomas were retrospectively reviewed. Entry criteria included new MR imaging enhancing lesions after treatment and histologically unequivocal biopsy proof of diagnosis. Readers rated corpus callosum involvement, midline spread, subependymal spread, new discrete multiple enhancing foci, a "spreading wavefront" appearance, and septum pellucidum involvement. Statistical analysis was by the Fisher exact test.
Corpus callosum involvement in combination with multiple other findings was highly associated with progressive glioma. These combinations included involvement of the corpus callosum with multiple enhancing foci (P = .02), involvement of the corpus callosum with crossing the midline and multiple enhancing lesions (P = .04), and involvement of the corpus callosum with subependymal spread and multiple enhancing lesions (P = .01).
In proton beam-treated patients with glioma, corpus callosum involvement, in conjunction with multiple enhancing lesions with or without crossing of the midline and subependymal spread, favors predominant glioma progression. Overall, combinations of enhancement patterns were more likely than individual patterns to distinguish necrosis from predominant tumor progression. Together with clinical and functional imaging findings, these results may assist in determining the need for biopsy.
Distinguishing recurrent glial tumor from radiation necrosis can be challenging. The purpose of this pilot study was to preliminarily compare unenhanced arterial spin-labeled (ASL) imaging, dynamic ...susceptibility contrast-enhanced cerebral blood volume (DSCE-CBV) magnetic resonance imaging, and positron emission tomographic (PET) imaging in distinguishing predominant glioma recurrence or progression from predominant radiation necrosis in postoperative patients treated with proton-beam therapy.
Patients with grade II to IV glioma previously treated with surgery and proton-beam therapy were enrolled on the basis of new enhancing nodules or masses with primary differential diagnoses of predominant tumor recurrence or progression versus radiation necrosis. ASL, DSCE-CBV, and PET examinations were assessed by visual qualitative and quantitative analysis for the detection of predominant tumor recurrence. Imaging results were correlated with a clinical-pathologic reference standard.
Thirty patients were studied, resulting in 33 ASL, 32 DSCE-CBV, and 26 PET examinations. On the basis of visual inspection, the sensitivities of PET, ASL, and DSCE-CBV examinations for detecting high-grade tumor foci were 81%, 88%, and 86%, respectively. The highest sensitivity values for quantitative ASL imaging were obtained using a normalized cutoff ratio of 1.3, resulting in sensitivity of 94% for ASL imaging and 71% for DSCE-CBV imaging. When predominant high-grade tumors with superimposed regions of predominant mixed radiation necrosis were excluded, DSCE-CBV sensitivity improved to 90%, but ASL sensitivity remained unchanged.
Compared with DSCE-CBV imaging, ASL imaging may more accurately distinguish predominant recurrent high-grade glioma from radiation necrosis, especially in regions with mixed radiation necrosis, for which DSCE-CBV imaging may underestimate true blood volume because of leakage artifacts.
Early mobilization and deep venous thrombosis (DVT) prophylaxis have been shown to reduce the incidence of DVT and pulmonary embolism among hospitalized patients, yet thromboembolic complications ...remain a great concern, especially to those who remain immobilized for an extended period of time. There are many risk factors associated with the development of thromboembolism, especially DVT. The main objective of this retrospective study is to estimate the occurrence of DVT in burn patients and to investigate some burn-related risk factors. A retrospective examination of DVT cases was conducted among the acute burn patients admitted to our Regional Burn Center during 2008. The analysis included the demographic factors, preexisting medical conditions, ventilator support, number of surgeries and blood transfusions, and use of central line. There was a total of 97 diagnosed patients with DVT and among them 86 were adult acute burn patients. There were 113 diagnosed with DVTs in 86 burn patients, including 22 patients diagnosed with DVT at multiple sites either in one screening or in subsequent screenings. Incidence of DVT at the center was 5.92 per 100 adult acute burn admissions. Men had more DVT than women (6.87 vs. 3.34%, relative risk 2.05, P < .05). The average percentage of %TBSA was smaller in the patients who were more than 50 years of age compared with the patients who were 49 years or younger (21.97 vs. 34.77%, P < .05). Among the patients with DVT, 80 (93%) had a central venous catheter before DVT developed and the other six never had a central venous catheter. The most common site for DVT development was common femoral vein site 89%. The average number of procedures before DVT was 7.84 ± 8.36, and blood transfusions were 39.55 ± 108.37 units. Six patients (7%) died in the hospital within these study cohorts and there was no indication that pulmonary embolism was the cause of the deaths. The study showed that the incidence of DVT in the burn center was comparable with the incidences reported in the literature. Being of male sex, a smoker, an alcoholic, high-age group, high %TBSA, use of central line, increased number of surgeries, and increased number of blood transfusions are identified as possible predisposing factors for DVTs. Further meaningful evaluation to determine the incidence of DVT in burn patients and its associated risk factors will require large multicenter, well-controlled, prospective designed study.
We evaluated the AxSYM troponin I (cTnI) immunoassay for assisting in the detection of acute myocardial infarction (AMI). At four sites, the total imprecision (CV) over 20 days was 6.3-10.2%. The ...minimum detectable concentration was 0.14 +/- 0.05 microgram/L. Comparison of cTnI measurements between the AxSYM and Stratus (n = 406) over the dynamic range of the AxSYM assay demonstrated good correlation, r = 0.881, with a proportional bias: AxSYM cTnI = 3.50(Stratus cTnI) - 1. 10. The confidence intervals (95%) for the slope and intercept were 3.39-3.64 and -1.32 to -0.95, respectively. The expected cTnI concentration in healthy individuals was </=0.5 microgram/L, whereas the ROC curve-determined cutoff for AMI was 2.0 microgram/L. This gave a diagnostic sensitivity of 91.8% and specificity of 92.4% when tested in serial samples collected within 24 h of admission in 633 patients presenting with chest pain, of which 122 had an AMI. The concordances of the AxSYM cTnI with the Stratus cTnI, OPUS cTnI, and Access cTnI were 95.3%, 95.1%, and 94.3%, respectively, from patients with suspected AMI. The AxSYM cTnI demonstrated excellent clinical specificity, >/=96%, in skeletal muscle injury, chronic renal disease, and same-day noncardiac surgery patients.
BackgroundThe American College of Surgeons Needs Based Assessment of Trauma Systems (NBATS) tool was developed to help determine the optimal regional distribution of designated trauma centers (DTC). ...The objectives of our current study were to compare the current distribution of DTCs in Georgia with the recommended allocation as calculated by the NBATS tool and to see if the NBATS tool identified similar areas of need as defined by our previous analysis using the International Classification of Diseases, Ninth Revision, Clinical Modification Injury Severity Score (ICISS).MethodsPopulation counts were acquired from US Census publications. Transportation times were estimated using digitized roadmaps and patient zip codes. The number of severely injured patients was obtained from the Georgia Discharge Data System for 2010 to 2014. Severely injured patients were identified using two measures: ICISS<0.85 and Injury Severity Score >15.ResultsThe Georgia trauma system includes 19 level I, II, or III adult DTCs. The NBATS guidelines recommend 21; however, the distribution differs from what exists in the state. The existing DTCs exactly matched the NBATS recommended number of level I, II, or III DTCs in 2 of 10 trauma service areas (TSAs), exceeded the number recommended in 3 of 10 TSAs, and was below the number recommended in 5 of 10 TSAs. Densely populated, or urban, areas tend to be associated with a higher number of existing centers compared with the NBATS recommendation. Other less densely populated TSAs are characterized by large rural expanses with a single urban core where a DTC is located. The identified areas of need were similar to the ones identified in the previous gap analysis of the state using the ICISS methodology.DiscussionThe tool appears to underestimate the number of centers needed in extensive and densely populated areas, but recommends additional centers in geographically expansive rural areas. The tool signifies a preliminary step in assessing the need for state-wide inpatient trauma center services.Level of evidenceEconomic, level IV.
Overview of Spirit Microscopic Imager Results Herkenhoff, Ken E.; Squyres, Steve W.; Arvidson, Raymond E. ...
Journal of geophysical research. Planets,
February 2019, 2019-02-00, 20190201, Letnik:
124, Številka:
2
Journal Article
Recenzirano
Odprti dostop
This paper provides an overview of Mars Exploration Rover Spirit Microscopic Imager (MI) operations and the calibration, processing, and analysis of MI data. The focus of this overview is on the last ...five Earth years (2005–2010) of Spirit's mission in Gusev crater, supplementing the previous overview of the first 450 sols of the Spirit MI investigation. Updates to radiometric calibration using in‐flight data and improvements in high‐level processing are summarized. Released data products are described, and a table of MI observations, including target/feature names and associated data sets, is appended. The MI observed natural and disturbed exposures of rocks and soils as well as magnets and other rover hardware. These hand‐lens‐scale observations have provided key constraints on interpretations of the formation and geologic history of features, rocks, and soils examined by Spirit. MI images complement observations by other Spirit instruments, and together show that impact and volcanic processes have dominated the origin and evolution of the rocks in Gusev crater, with aqueous activity indicated by the presence of silica‐rich rocks and sulfate‐rich soils. The textures of some of the silica‐rich rocks are similar to terrestrial hot spring deposits, and observations of subsurface cemented layers indicate recent aqueous mobilization of sulfates in places. Wind action has recently modified soils and abraded many of the rocks imaged by the MI, as observed at other Mars landing sites.
Plain Language Summary
The Microscopic Imager (MI) on NASA's Spirit rover returned the highest‐resolution images of the Martian surface available at the time of the 2004–2010 mission. Designed to survive 90 Mars days (sols) and search for evidence of water in the past, Spirit returned data for 2210 sols, far exceeding all expectations. This paper summarizes the scientific insights gleaned from the thousands of MI images acquired during the last 5 years of the mission, supplementing the summary of the first 450 sols of the Spirit MI investigation published previously (Herkenhoff et al., ). Along with data from the other instruments on Spirit, MI images guided the scientific interpretation of the geologic history of the rocks and soils observed in Gusev crater on Mars. We conclude that the geologic history of the area explored by Spirit has been dominated by impacts and volcanism, and that water, perhaps very hot water, was involved in the evolution of some of the rocks and soils. More recently, winds have moved soil particles and abraded rocks, as observed elsewhere on Mars. These results have improved our understanding of Mars' history and informed planning of future missions to Mars.
Key Points
During the Mars Exploration Rover Spirit mission, the Microscopic Imager returned 5,923 full‐frame images
These images have guided interpretations of the geologic history of Gusev crater on Mars
A table summarizing the MI images chronologically is appended, including target/feature names and sequence identifiers for Pancam images that provide context
Transcatheter closure of cardiovascular defects remains a challenge. Several occlusion devices are available, but each device has limitations. The purpose of this study was to evaluate the new ...Gianturco-Grifka vascular occlusion device (GGVOD) in a canine model.
A total of 26 GGVODs were implanted as part of short- and long-term studies. In the short-term study, 1 GGVOD was implanted in each of 11 systemic arteries from 3.2 to 9.0 mm in diameter. All 11 arteries were occluded immediately. In the long-term study, an aortopulmonary shunt was placed in 10 dogs (9, Gore-tex graft; 1, subclavian artery) followed by GGVOD implantation; additionally, a GGVOD was implanted in 5 subclavian arteries. The dogs were boarded for 3 to 6 months, then recatheterized and euthanatized. Immediately after implantation, the 5 subclavian arteries and 9 Gore-tex shunts were occluded completely; the 1 subclavian artery shunt had a small residual leak. At recatheterization, all 10 shunts and 5 subclavian arteries were occluded completely. Necropsy revealed all shunts to be occluded, with the aortic and pulmonic orifices covered with a neointimal layer. The mean fluoroscopic time needed for GGVOD implantation was 9 minutes (range, 3 to 22 minutes).
(1) In a canine model, the GGVOD is effective for transcatheter occlusion of arteries and aortopulmonary shunts from 3 to 9 mm in diameter. Possible indications in children include aortopulmonary collateral vessels, long patent ductus arteriosus, systemic-pulmonary shunts, AV malformations, and arteries supplying tumors. (2) GGVOD implantation requires a short fluoroscopic time.
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