Significant knowledge gaps exist for resilience, preparedness, and response to public health emergencies (PHEs) in the United States. The 2009 H1N1 influenza pandemic and natural disasters (as ...experienced in Texas, Florida, Puerto Rico, and the Carolinas during the hurricane seasons of 2017-2018) highlight missed opportunities for clinical investigation to identify and address strategic vulnerabilities, gaps, and solutions. In response, US government leaders initiated a call to action to include research as part of PHE activities.1 Progress has been made since then, thanks to new funding that created organizations and infrastructure to lead change for knowledge acquisition and management.1-3 This progress is essential to answering key clinical questions in response to PHEs.2 Similar challenges worldwide are driving creation of unique solutions, such as the Platform for European Preparedness Against (Re)emerging Epidemics, the Australian Partnership for Preparedness Research on Infectious Disease Emergencies, the Canadian Critical Care Trials Group, the Mexican Emerging Infectious Disease Clinical Research Network (La Red), and the International Severe Acute Respiratory and Emerging Infection Consortium. In the United States, clinical and population research gaps exist in part because of the challenges of coordination and funding.4 Closer, more inclusive collaboration remains an essential strategic imperative, given that resilience, preparedness, and response require coordination across a broad range of stakeholders.4 The US Department of Health and Human Services (HHS), for example, has no single or overarching source of funding for resilience and preparedness: each HHS agency has a distinct budget that promotes funding in its lane. In addition, investigators may be unaware that funding for a similar or complementary aim is provided to colleagues in the same city by a different agency. The current process also is inefficient, requiring the building and disassembling of infrastructure with each funding cycle to answer questions and test hypotheses iteratively. Opportunities for synergy and sustained inquiry are missed. At present, a comprehensive PHE response vision can only result from piecing together separate funding sources and rapidly assembling collaborative partnerships.
Clinically, complication rates of brachial arterial catheterization appear to far exceed those of the radial or common femoral arteries. The study objective was to define the complication rate after ...brachial arterial line insertion. All patients undergoing arterial line placement to the brachial artery in the surgical intensive care units (SICUs) at our institution were retrospectively identified and included in the study (January 2016-December 2018). Demographics, complications (distal ischemia, thrombosis/dissection, brachial sheath hematoma, catheter-related sepsis, and inadvertent dislodgement), and outcomes were collected and analyzed. Over the study period, 53 patients underwent brachial arterial catheterization. Common admitting services were cardiothoracic surgery (n = 31, 58%), transplant surgery (n = 7, 13%), and neurosurgery (n = 4, 7%). The mean age was 55 ± 17 58 (24-84) years, and 58% (n = 31) were male. The hospital length of stay (LOS) was 37 ± 35 23 (1-132) days, and ICU LOS was 30 ± 27 20 (1-127) days. Mortality was 57% (n = 30). Complications of brachial arterial line placement occurred in 21 patients (40%). In summary, brachial arterial catheters were associated with high mortality and prolonged ICU length of stay. This likely reflects the critically ill nature of patients in whom conventional-site arterial line placement is not possible. Complications following brachial arterial catheterization were unacceptably high. On this basis, we recommend that the brachial artery be avoided whenever possible for arterial line placement in the SICU.
Oligonucleotide and complementary DNA microarrays are being used to subclassify histologically similar tumours, monitor disease progress, and individualize treatment regimens. However, extracting new ...biological insight from high-throughput genomic studies of human diseases is a challenge, limited by difficulties in recognizing and evaluating relevant biological processes from huge quantities of experimental data. Here we present a structured network knowledge-base approach to analyse genome-wide transcriptional responses in the context of known functional interrelationships among proteins, small molecules and phenotypes. This approach was used to analyse changes in blood leukocyte gene expression patterns in human subjects receiving an inflammatory stimulus (bacterial endotoxin). We explore the known genome-wide interaction network to identify significant functional modules perturbed in response to this stimulus. Our analysis reveals that the human blood leukocyte response to acute systemic inflammation includes the transient dysregulation of leukocyte bioenergetics and modulation of translational machinery. These findings provide insight into the regulation of global leukocyte activities as they relate to innate immune system tolerance and increased susceptibility to infection in humans.
Hospitals and health care systems with active critical care organizations (CCOs) that unified ICU units before the onset of the COVID-19 Pandemic were better positioned to adapt to the demands of the ...pandemic, due to their established standardization of care and integration of critical care within the larger structure of the hospital or health care system. CCOs should continue to make changes, based on the real experience of COVID-19 that would lead to improved care during the ongoing pandemic, and beyond.
Background
The goal of this study was to investigate factors associated with 30-day readmission in a multivariate model, including the CDC wound classes “clean,” “clean/contaminated,” “contaminated,” ...and “dirty/infected.”
Methods
The 2017–2020 American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for all patients undergoing total hip replacement, coronary artery bypass grafting, Ivor Lewis esophagectomy, pancreaticoduodenectomy, distal pancreatectomy, pneumonectomy, and colectomies. ACS-defined wound classes were concordant with CDC definitions. Multivariate linear mixed regression was used to determine risk factors for readmission while adjusting for type of surgery as a random intercept.
Results
477,964 cases were identified, with 38,734 (8.1%) patients having experienced readmission within 30 days of surgery. There were 181,243 (37.9%) cases classified as wound class “clean”, 215,729 (45.1%) cases classified as “clean/contaminated”, 40,684 cases (8.5%) classified as “contaminated”, and 40,308 (8.4%) cases classified as “dirty/infected”. In the multivariate generalized mixed linear model adjusting for type of surgery, sex, body mass index, race, American Society of Anesthesiologists class, presence of comorbidity, length of stay, urgency of surgery, and discharge destination, “clean/contaminated” (
p
< .001), “contaminated” (
p
< .001), and “dirty/infected” (
p
< .001) wound classes (when compared to “clean”) were significantly associated with 30-day readmission. Organ/space surgical site infection and sepsis were among the most common reasons for readmission in all wound classes.
Conclusions
Wound classification was strongly prognostic for readmission in multivariable models, suggesting that it may serve as a marker of readmissions. Surgical procedures that are “non-clean” are at significantly greater risk for 30-day readmission. Readmissions may be due to infectious complications; optimizing antibiotic use or source control to prevent readmission are areas of future study.
A genomic storm in critically injured humans Xiao, Wenzhong; Mindrinos, Michael N; Seok, Junhee ...
The Journal of experimental medicine,
12/2011, Volume:
208, Issue:
13
Journal Article
Peer reviewed
Open access
Human survival from injury requires an appropriate inflammatory and immune response. We describe the circulating leukocyte transcriptome after severe trauma and burn injury, as well as in healthy ...subjects receiving low-dose bacterial endotoxin, and show that these severe stresses produce a global reprioritization affecting >80% of the cellular functions and pathways, a truly unexpected "genomic storm." In severe blunt trauma, the early leukocyte genomic response is consistent with simultaneously increased expression of genes involved in the systemic inflammatory, innate immune, and compensatory antiinflammatory responses, as well as in the suppression of genes involved in adaptive immunity. Furthermore, complications like nosocomial infections and organ failure are not associated with any genomic evidence of a second hit and differ only in the magnitude and duration of this genomic reprioritization. The similarities in gene expression patterns between different injuries reveal an apparently fundamental human response to severe inflammatory stress, with genomic signatures that are surprisingly far more common than different. Based on these transcriptional data, we propose a new paradigm for the human immunological response to severe injury.
To test if the surgical intensive care unit optimal mobility score predicts mortality and intensive care unit and hospital length of stay.
Prospective single-center cohort study.
Surgical intensive ...care unit of the Massachusetts General Hospital.
One hundred thirteen consecutive patients admitted to the surgical intensive care unit.
We tested the hypotheses that the surgical intensive care unit optimal mobility score independent of comorbidity index, Acute Physiology and Chronic Health Evaluation II, creatinine, hypotension, hypernatremia, acidosis, hypoxia, and hypercarbia predicts hospital mortality, surgical intensive care unit and total hospital length of stay.
Two nurses independently predicted the patients' mobilization capacity by using the surgical intensive care unit optimal mobility score the morning after admission, whereas a third nurse recorded the achieved mobilization levels of patients at the end of the day. A multidisciplinary expert team measured patients' grip strength and assessed their predicted mobilization capacity independently. Multivariate analysis revealed that the surgical intensive care unit optimal mobility score was the only independent predictor of mortality. Surgical intensive care unit optimal mobility score, hypotension, and hypernatremia (>144 mmol/L) independently predicted intensive care unit length of stay, whereas the surgical intensive care unit optimal mobility score and hypernatremia predicted total hospital length of stay. The Acute Physiology and Chronic Health Evaluation II score was not identified in the multivariate analysis. The surgical intensive care unit optimal mobility score was also a reliable and valid instrument in predicting achieved mobilization levels of patients.
In surgical critically ill patients presenting without preexisting impairment of functional mobility, the surgical intensive care unit optimal mobility score is a reliable and valid tool to predict mortality and intensive care unit and hospital length of stay.
Background The purpose of this study was to further elucidate the role of the vascular smooth muscle cells (SMCs) in abdominal aortic aneurysm (AAA) disease. We hypothesized that that AAA SMCs are ...unique and actively participate in the process of degrading the aortic matrix. Methods Whole-genome expression profiles of SMCs from AAAs, nondilated abdominal aorta (NAA), and carotid endarterectomy (CEA) were compared. We quantified elastolytic activity by culturing SMCs in 3 Helastin-coated plates and measuring solubilized tritium in the media after 7 days. Matrix metalloproteinase (MMP)-2 and MMP-9 production was assessed using real-time polymerase chain reaction, zymography, and Western blotting. Results Each SMC type exhibited a unique gene expression pattern. AAA SMCs had greater elastolytic activity than NAA-SMCs (+68%; P < .001) and CEA-SMCs (+45%; P < .001). Zymography showed an increase of active MMP-2 (62 kD) in media from AAA SMCs. AAA SMCs demonstrated twofold greater expression of MMP-2 messenger (m)RNA ( P < .05) and 7.3-fold greater MMP-9 expression ( P < .01) than NAA-SMCs. Culture with U937 monocytes caused a synergistic increase of elastolysis by AAA SMCs (41%; P < .001) but not NAA-SMCs or CEA-SMCs ( P = .99). Coculture with U937 caused a large increase in MMP-9 mRNA in AAA-SMCs and NAA-SMCs ( P < .001). MMP-2 mRNA expression was not affected. Western blots of culture media showed a fourfold increase of MMP-9 (92 kD) protein only in AAA-SMCs/U937 but not in NAA-SMCs/U937 ( P < .001) and a large increase in active-MMP2 (62 kD), which was less apparent in NAA-SMCs/U937 media ( P < .01). Conclusions AAA-SMCs have a unique gene expression profile and a proelastolytic phenotype that is augmented by macrophages. This may occur by a failure of post-transcriptional control of MMP-9 synthesis.
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