Abstract
Intensive care for massively burn patients has increased survival and highlights the need for a solution to the problem of insufficient donor sites for autologous skin coverage. In this case ...series, we present 10 patients with average burn size of 81% TBSA and mean age of 24 years old, who underwent burn excision followed by either immediate or delayed biodegradable temporizing matrix (BTM) placement. After an integration period, the BTM was delaminated either the day before or immediately prior to placement of cultured epithelial autografts over a widely meshed (4:1 or 6:1) split thickness skin graft. One patient had cultured epithelial autografts alone, without split thickness skin graft, placed on integrated BTM and had successful take. Seven patients survived to discharge and had average 95% wound closure at 135 ± 35 days. The patients had on average 10.4 total operations and 8.7 excision and grafting operations. Five patients had complications related to the BTM requiring removal or replacement including three fungal infections, one bacterial infection and one with bleeding and a large clot burden. In conclusion, this surgical strategy is a viable option for patients with massive burns and insufficient donor for autologous skin grafting.
Burn care continues to improve and larger total body surface area (TBSA) burn survival is increasing. These survivors require more extensive care than smaller burns and are at higher risk for ...wound/scar related complications. Prior work has shown low rates of follow up for burn survivors linked to socioeconomic factors such as housing insecurity and substance use. There are limited studies that evaluate socioeconomic factors that contribute to follow up and reconstructive surgery rates in massively burned patients. Patients that survived to discharge with >50% TBSA burns and planned return to treating institution were included in the study. Univariate and multivariate analyses were performed on the data collected. Sixty-Five patients were included with an average TBSA of 63.1%. Fifty-three patients (81.5%) attended at least one follow up appointment with median of four follow-up appointments. Younger patients (33±9 vs 44±11; p=0.0006), patients with larger TBSA burns (65±13 vs 55±5%; p=0.02), those with private insurance and those without housing insecurity (1.8% vs 45.4%; p=0.003) were more likely to follow up. On multivariate regression analysis, patients with housing insecurity were independently associated with lack of follow up (OR: 0.009 CI: 0.00001-0.57). Thirty-five patients had at least one reconstructive surgery and 31 patients had reconstructive surgery after discharge. No patients with housing insecurity underwent reconstructive surgery. Follow up rates in massive burns were higher than reported for smaller TBSA burns and more than half received reconstructive surgery. Housing insecure patients should be targeted for improved follow up and access to reconstructive surgery.
Seven burn centers performed a 10-yr retrospective chart review of patients diagnosed with purpura fulminans. Patient demographics, etiology, presentation, medical and surgical treatment, and outcome ...were reviewed. A total of 70 patients were identified. Mean patient age was 13 yr. Neisseria meningitidis was the most common etiologic agent in infants and adolescents whereas Streptococcus commonly afflicted the adult population. Acute management consisted of antibiotic administration, volume resuscitation, ventilatory and inotropic support, with occasional use of corticosteroids (38%) and protein C replacement (9%). Full-thickness skin and soft-tissue necrosis was extensive, requiring skin grafting and amputations in 90% of the patients. One fourth of the patients required amputations of all extremities. Fasciotomies when performed early appeared to limit the level of amputation in 6 of 14 patients. Therefore, fasciotomies during the initial management of these patients may reduce the depth of soft-tissue involvement and the extent of amputations.
The importance of inflammation pathways to the development of many human cancers prompted us to examine the associations between single-nucleotide polymorphisms (SNP) in inflammation-related genes ...and risk of ovarian cancer. In a multisite case-control study, we genotyped SNPs in a large panel of inflammatory genes in 930 epithelial ovarian cancer cases and 1,037 controls using a custom array and analyzed by logistic regression. SNPs with P < 0.10 were evaluated among 3,143 cases and 2,102 controls from the Follow-up of Ovarian Cancer Genetic Association and Interaction Studies (FOCI) post-GWAS collaboration. Combined analysis revealed association with SNPs rs17561 and rs4848300 in the interleukin gene IL1A which varied by histologic subtype (P(heterogeneity) = 0.03). For example, IL1A rs17561, which correlates with numerous inflammatory phenotypes, was associated with decreased risk of clear cell, mucinous, and endometrioid subtype, but not with the most common serous subtype. Genotype at rs1864414 in the arachidonate 5-lipoxygenase ALOX5 was also associated with decreased risk. Thus, inherited variation in IL1A and ALOX5 seems to affect ovarian cancer risk which, for IL1A, is limited to rarer subtypes. Given the importance of inflammation in tumorigenesis and growing evidence of subtype-specific features in ovarian cancer, functional investigations will be important to help clarify the importance of inherited variation related to inflammation in ovarian carcinogenesis.
The association of invasive ovarian carcinoma risk with the functional polymorphism rs2228570 (aka rs10735810; FokI polymorphism) in the vitamin D receptor (VDR) gene was examined in 1820 white ...non‐Hispanic cases and 3479 controls in a pooled analysis of five population‐based case–control studies within the Ovarian Cancer Association Consortium. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using unconditional logistic regression. Carriers of the rare T allele were at increased risk of ovarian carcinoma compared to women with the CC genotype in all studies combined; each copy of the T allele was associated with a modest 9% increased risk (OR = 1.09; 95% CI: 1.01–1.19; p = 0.04). No significant heterogeneity among studies was observed (p = 0.37) and, after excluding the dataset from the Hawaii study, the risk association for rs2228570 among replication studies was unchanged (OR = 1.09; 95% CI: 1.00–1.19; p = 0.06). A stronger association of rs2228570 with risk was observed among younger women (aged < 50 years versus 50 years or older) (p = 0.04). In all studies combined, the increased risk per copy of the T allele among younger women was 24% (OR = 1.24; 95% CI: 1.04–1.47; p = 0.02). This association remained statistically significant after excluding the Hawaii data (OR = 1.20; 95% CI: 1.01–1.43; p = 0.04). No heterogeneity of the association was observed by stage (p = 0.46), tumor histology (p = 0.98), or time between diagnosis and interview (p = 0.94). This pooled analysis provides further evidence that the VDR rs2228570 polymorphism might influence ovarian cancer susceptibility.
159 Escape the Conference Room Nelson, M.; Calandrella, C.; Schmalbach, P. ...
Annals of emergency medicine,
October 2017, 2017-10-00, Letnik:
70, Številka:
4
Journal Article
Abstract
Introduction
Dressing changes are a significant source of pain and agitation for critically ill burn patients. Despite decades of research, prospective pain trials are limited and no ...guidelines are available. As a result, insufficient pain control is common during dressing changes. This study aims to determine if a multi-modal, tailored approach to pain management during wound care improves pain control and sedation.
Methods
This prospective, observational cross-over study enrolled patients with burns > 10% total body surface area (TBSA). A clinical pharmacist observed pain control during two consecutive dressing changes per patient; the first with standard of care and the second with a tailored pharmacist-driven pain and sedation regimen. The tailored intervention included multi-modal analgesics, pre-medications and adjusting analgesic dosing and timing during the procedure as well as changes to basal analgesic regimens. Impact was assessed using critical care pain observation tool (CPOT) and Richmond Agitation and Sedation Scale (RASS) scores every five minutes. Secondary endpoints included average analgesic (morphine equivalents-ME) and sedative requirements (lorazepam equivalents-LE) per 30 minutes and hemodynamic safety endpoints.
Results
A total of 9 patients have completed this ongoing study. Mean TBSA was 33 ±16% and mean hospital days at enrollment was 16.7 ±11.1. Average CPOT scores per patient decreased post-pharmacist intervention (3.2 (IQR 1.8, 5.0) vs. 1.5 (IQR 1.0, 2.0) p-value: 0.0005). No significant difference in RASS scores was detected between groups. Oral pre-medications (oxycodone and lorazepam) were added in 100% of patients. Similarly, gabapentin and ketorolac were added in 22% and 75% respectively. Analgesic dosing and timing were adjusted in two patients. Total opioid (110 mg-ME vs 133 mg-ME; p-value 0.37) and benzodiazepine use (1.15 mg-LE vs 1.59-LE; p-value: 0.36) over time were not statistically different between groups. There was also no difference in hemodynamic safety endpoints between groups.
Conclusions
Implementation of an individualized regimen led to significantly reduced pain scores without a change in sedation level or opioid requirements in this study. A tailored pain regimen in burn dressing changes may be helpful.
Applicability of Research to Practice
Prospectively tailoring a patient’s analgesic and sedative regimen may improve patient experience during wound care.
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