M. Elamin

Influence of nebulized unfractionated heparin and N-acetylcysteine in acute lung injury after smoke inhalation injury.

To determine whether the combination of aerosolized unfractionated heparin and N-acetylcystine reduces 28-days mortality and lung injury scores (LISs) in adult patients with smoke inhalation injury requiring mechanical ventilation. The study was a single-center retrospective study with historical control. The authors included 30 mechanically ventilated adult subjects who were admitted within 48 hours of their bronchoscopy confirmed smoke inhalation injury over a 5-year period. The experimental group was treated with nebulized heparin sulfate, N-acetylcystine, and albuterol sulfate. Controls received ventilation support and albuterol sulfate. The authors calculated acute physiology and chronic health evaluation (APACHE)-III scores on admission in addition to daily LIS for 7 days. The experimental group was divided into five APACHE-III subgroups and matched with inhalation lung injury patients in the historical control group. There was no significant difference in initial APACHE-III scores or LISs between groups (&agr; = 0.05) upon entry to the study. The experimental group showed significant improvement in LISs, respiratory resistance and compliance measurements, and hypoxia scores as compared with controls throughout the duration of the study. There was a statistically significant survival benefit in the experimental group that was most pronounced in patients with APACHE-III scores >35. Survival for the control vs experimental group was 0.5714 ± 0.1497 vs 0.9375 ± 0.0605, respectively, (risk ratio −0.0055; 95% confidence interval −0.0314-0.0204; hazard ratio 1.003; number needed to treat 2.7). The use of aerosolized unfractionated heparin and N−acetylcystine attenuates lung injury and the progression of acute respiratory distress syndrome in ventilated adult patients with acute lung injury following smoke inhalation.

The "T" in trauma: the helper T-cell response and the role of immunomodulation in trauma and burn patients.

BACKGROUND The immune system undergoes numerous changes after traumatic and burn injuries, including a down-regulation of the TH1 response and up-regulation of the TH2 response. METHODS The PubMed, Medline, and Ovid search engines were queried for relevant human studies. Bibliographies were also meticulously reviewed. RESULTS An interesting and potentially clinically relevant pattern of immune dysregulation exists after injury. The type 1 T-helper cell (TH1) response is suppressed as illustrated by diminished interleukin (IL)-2, interferon (IFN)-gamma, and IL-12 levels after major injury. The enhancement of the TH2 response is marked by elevated IL-10 and IL-4. Certain cytokine profiles, ratios, and polymorphisms may help identify patients at increased risk of systemic inflammatory response syndrome (SIRS), sepsis, multiple organ failure (MOF), and deep venous thrombosis. The most promising prognostic indicators to date are decreased production of the IL-12, elevated IL-10, soluble IL-2 receptor-a (sIL-2Ra), and IL-18 levels, IL-18 promoter polymorphisms, the IL-6:IL-10 ratio, and the degree of TH1 suppression as measured by diminished IL-2 and IFN-gamma. The Cytokine sections are subdivided into basic science, human studies, animal studies (when necessary), and directed therapeutics. The outcomes of sepsis, SIRS, or MOF are generally discussed together. CONCLUSIONS T-cell-specific immunologic changes occur after major injury. Identification of those TH1/TH2 cytokine profiles associated with worse prognosis may one day allow clinicians to risk stratify injured patients and identify those at increased risk of developing SIRS, sepsis, MOF, and deep venous thrombosis. Immune-targeted therapies may eventually serve as effective treatments in the acute setting to decrease morbidity and mortality, and to improve the management and prognosis of those patients at risk for developing postinjury complications.

Inhaled anticoagulation regimens for the treatment of smoke inhalation-associated acute lung injury: a systematic review.

Objective:Inhaled anticoagulation regimens are increasingly being used to manage smoke inhalation–associated acute lung injury. We systematically reviewed published and unpublished preclinical and clinical trial data to elucidate the effects of these regimens on lung injury severity, airway obstruction, ventilation, oxygenation, pulmonary infections, bleeding complications, and survival. Data Sources:PubMed, Scopus, EMBASE, and Web of Science were searched to identify relevant published studies. Relevant unpublished studies were identified by searching the Australian and New Zealand Clinical Trials Registry, World Health Organization International Clinical Trials Registry Platform, Cochrane Library, ClinicalTrials.gov, MINDCULL.com, Current Controlled Trials, and Google. Study Selection:Inclusion criteria were any preclinical or clinical study in which 1) animals or subjects experienced smoke inhalation exposure, 2) they were treated with nebulized or aerosolized anticoagulation regimens, including heparin, heparinoids, antithrombins, or fibrinolytics (e.g., tissue plasminogen activator), 3) a control and/or sham group was described for preclinical studies, and 4) a concurrent or historical control group described for clinical studies. Exclusion criteria were 1) the absence of a group treated with a nebulized or aerosolized anticoagulation regimen, 2) the absence of a control or sham group, and 3) case reports. Data Extraction:Ninety-nine potentially relevant references were identified. Twenty-seven references met inclusion criteria including 19 preclinical references reporting 18 studies and eight clinical references reporting five clinical studies. Data Synthesis:A systematic review of the literature is provided. Both clinical and methodological diversity precluded combining these studies in a meta-analysis. Conclusions:The high mortality associated with smoke inhalation–associated acute lung injury results from airway damage, mucosal dysfunction, neutrophil infiltration, airway coagulopathy with cast formation, ventilation-perfusion mismatching with shunt, and barotrauma. Inhaled anticoagulation regimens in both preclinical and clinical studies improve survival and decrease morbidity without altering systemic markers of clotting and anticoagulation. In some preclinical and clinical studies, inhaled anticoagulants were associated with a favorable effect on survival. This approach appears sufficiently promising to merit a well-designed prospective study to validate its use in patients with severe smoke inhalation–associated acute lung injury requiring mechanical ventilation.

Novel Influenza A(H1N1) Virus Among Gravid Admissions

BACKGROUND Pandemic novel influenza A(H1N1) is a substantial threat and cause of morbidity and mortality in the pregnant population. METHODS We conducted an observational analysis of 18 gravid patients with H1N1 in 2 academic medical centers. Cases were identified based on direct antigen testing (DAT) of nasopharyngeal swabs followed by real-time reverse-transcriptase polymerase chain reaction analysis (rRT-PCR) or viral culture. Patient demographics, symptoms, hospital course, laboratory and radiographic results, pregnancy outcome, and placental pathologic information were recorded. Results were then compared with published reports of the H1N1 outbreak and reports of flu pandemics of 1918 and 1957. RESULTS Eighteen pregnant patients were admitted with H1N1 during the study period. All patients were treated with oseltamivir phosphate beginning on the day of admission. Mean (SD) age was 27 (6.6) years (age range, 18-40 years); median length of hospital stay was 4 days. Intensive care unit admission rate was 17% (n = 3). Demographically, 2 patients were health care workers (11%); 15 were black (83%); 2, Hispanic (11%); and 1, white (6%). None reported recent travel. Half of the patients presented with gastrointestinal or abdominal complaints; 13 patients met sepsis criteria (72%). The most common comorbidities were asthma, sickle cell disease, and diabetes. Fourteen patients tested positive for H1N1 on DAT (initial or repeated) (78%); in the other 4 cases, H1N1 was identified by viral culture or rRT-PCR (22%). Seven patients delivered during hospitalization (39%), 6 prematurely and 4 via emergency cesarean delivery. There were 2 fetal deaths (11%). No maternal mortality was recorded. CONCLUSIONS Admitted pregnant patients with H1N1 are at risk for obstetrical complications including fetal distress, premature delivery, emergency cesarean delivery, and fetal death. A high number of patients presented with gastrointestinal and abdominal complaints. Early antiviral treatment may improve maternal outcomes.

Silver sulfadiazine for the treatment of partial-thickness burns and venous stasis ulcers

BACKGROUND For decades silver-containing antibiotics such as silver sulfadiazine (SSD) have been applied as standard topical therapy for patients with partial-thickness burns and venous stasis ulcers. This evidence-based review intends to answer the following research question: in ambulatory patients with partial-thickness burns or stasis dermatitis ulcers, does the use of topical SSD compared with nonantibiotic dressings improve mortality, wound healing, re-epithelialization, or infection rates? METHODS MEDLINE, EMBASE, Cochrane Library, and other databases were searched. We considered trials that enrolled patients of any age with partial-thickness burns or venous stasis ulcers and randomized them to either topical SSD or placebo, saline-soaked gauze, paraffin gauze, sterile dry dressing, or nonantibiotic moist dressing. Outcomes included mortality, wound healing, speed of re-epithelialization, and infection rates. RESULTS For burns, our search revealed 400 potential articles. No human studies met the inclusion criteria. Only 7 animal studies (1 mouse, 4 rat, and 2 pig) were relevant to the proposed question. These animal studies provided conflicting results. Whereas some support the use of SSD for treatment of partial-thickness burns, others question its effectiveness. For stasis dermatitis ulcer, the search identified 50 articles for review, of which 20 abstracts were reviewed, and one article met the inclusion criteria. This study did not show any significant improvement in the rate of complete healing in SSD group compared with placebo either at 4 weeks (relative risk 6.2, 95% confidence interval 0.8-48) or at 1 year (relative risk 5.2, 95% confidence interval 0.6-41.6) of follow-up. CONCLUSION There is insufficient evidence to either support or refute the routine use of SSD for ambulatory patients with either partial-thickness burns or stasis dermatitis ulcers to decrease mortality, prevent infection, or augment wound healing in human beings.

Influenza A 2009 (H1N1) Virus in Admitted and Critically Ill Patients

Introduction: The influenza A 2009 (H1N1) virus is a pandemic respiratory infection commanding international attention. More information is needed on patient demographics, illness severity, and risk indicators. Methods: A total of 43 patients with H1N1 influenza A 2009 presenting to 2 urban academic medical centers during the first wave were assessed for demographics, triage vital signs, hemograms, and serum chemistries including lactate. Chest X-rays were assessed for infiltrate or effusion. Illness severity markers were recorded including anion gap (AG), strong ion gap (SIG), systemic inflammatory response syndrome score, shock index, confusion, uremia, respiratory rate, blood pressure, and age >= 65 years (CURB-65) score, and pneumonia severity index. Subgroup analysis was performed on asthmatic, pregnant, and intensive care unit (ICU) versus non-ICU patients. Results: Eighty-one percent of patients were women. Pregnancy (34.8%), asthma (39.5%), diabetes mellitus (18.6%), and sickle cell (6.98%) were the most frequent comorbidities. In all, 91% had positive influenza nasopharyngeal direct antigen test, while 9% tested positive only by viral culture or real-time reverse transcriptase polymerase chain reaction (rRT-PCR); 14% required ICU admission; and 20.8% had infiltrate on chest X-ray. A trend toward greater incidence of ICU admission existed among patients with elevated SIG (P = .08), however contrary to our prior studies in noninfluenza patients, an elevated SIG in the presence of normal AG and lactate measurements did not correlate with ICU admission. Conclusion: A high percentage of patients with H1N1 presented with underlying comorbid conditions including asthma and pregnancy. Traditional markers of pneumonia severity including CURB-65 score, Pneumonia Severity Index (PSI), serum lactate, and AG did not correlate with ICU admission in patients with H1N1. Strong ion gap effectively identified significant acid−base disturbances not identified by lactate or AG, however the trend of greater ICU admission rates among patients with elevated SIG did not reach statistical significance. Further study is needed to identify clinical tools to aid in risk-stratifying H1N1 patients.

Brain Death and Islam: The Interface of Religion, Culture, History, Law, and Modern Medicine

How one defines death may vary. It is important for clinicians to recognize those aspects of a patients religious beliefs that may directly influence medical care and how such practices may interface with local laws governing the determination of death. Debate continues about the validity and certainty of brain death criteria within Islamic traditions. A search of PubMed, Scopus, EMBASE, Web of Science, PsycNet, Sociological Abstracts, DIALOGUE ProQuest, Lexus Nexus, Google, and applicable religious texts was conducted to address the question of whether brain death is accepted as true death among Islamic scholars and clinicians and to discuss how divergent opinions may affect clinical care. The results of the literature review inform this discussion. Brain death has been acknowledged as representing true death by many Muslim scholars and medical organizations, including the Islamic Fiqh Academies of the Organization of the Islamic Conference and the Muslim World League, the Islamic Medical Association of North America, and other faith-based medical organizations as well as legal rulings by multiple Islamic nations. However, consensus in the Muslim world is not unanimous, and a sizable minority accepts death by cardiopulmonary criteria only.

Immune Enteral Nutrition Can Improve Outcomes in Medical-Surgical Patients with ARDS: A Prospective Randomized Controlled Trial

Objective To determine if early continuous enteral feeding of a diet containing eicosapentaenoic acid (EPA), gamma-linolenic acid (GLA), docosahexaenoic acid, and antioxidants in surgical-medical patients with ARDS improves Lung Injury Score (LIS), gas exchange, Multiple Organ Dysfunction (MOD) Score, ICU length of stay, and days on mechanical ventilation. Methods Prospective randomized 2-center double-blind controlled trial of 17 ARDS patients whom continuously tube-fed the experimental diet (n=9) or an isonitrogenous, isocaloric standard diet (n=8) at a minimum caloric delivery of 90% of basal energy expenditure. Results In the experimental group, there was a decrease in lung injury score (p < 0.003) and lower ventilation variables (p < 0.001). Patients in the experimental group had a statistically significant decrease in 28-day MOD score (p < 0.05). The length of ICU stay was significantly decreased in the experimental group (12.8 vs. 17.5 days; p = 0.01). The study was underpowered to detect any survival benefits between the two groups. Conclusion An EPA and GLA supplemented diet contributes to improved gas exchange in addition to decrease LIS, MOD scores and length of ICU stay in patients with ARDS. An EPA+GLA-enriched enteral diet may be an effective tool in the medical management of ARDS.

Transient Ischemic Attack and Nephrotic Syndrome: Case Report and Review of Literature

Thrombotic complications in patients with nephrotic syndrome are attributed to a hypercoagulable state. Venous thrombosis is common, but arterial thrombosis occurs less frequently in adult nephrotic patients. We report a case of recurrent transient ischemic attacks as an initial manifestation of nephrotic syndrome due to early-stage membranous glomerulonephritis, review the literature for similar cases, and briefly discuss this potentially life-threatening condition. We observed that transient ischemic attack or ischemic stroke could be the initial manifestation of nephrotic syndrome. Our observation may serve as reminder to consider nephrotic syndrome as a possible contributor when evaluating patients with transient ischemic attacks with no other discernable clues. A high index of suspicion alone avoids the unnecessary withholding of prophylaxis or treatment that can be life saving.

Clinical and Prognostic Features of Erionite-Induced Malignant Mesothelioma

This review analytically examines the published data for erionite-related malignant pleural mesothelioma (E-MPM) and any data to support a genetically predisposed mechanism to erionite fiber carcinogenesis. Adult patients of age ≥18 years with erionite-related pleural diseases and genetically predisposed mechanisms to erionite carcinogenesis were included, while exclusion criteria included asbestos- or tremolite-related pleural diseases. The search was limited to human studies though not limited to a specific timeframe. A total of 33 studies (31042 patients) including 22 retrospective studies, 6 prospective studies, and 5 case reports were reviewed. E-MPM developed in some subjects with high exposures to erionite, though not all. Chest CT was more reliable in detecting various pleural changes in E-MPM than chest X-ray, and pleural effusion was the most common finding in E-MPM cases, by both tests. Bronchoalveolar lavage remains a reliable and relatively less invasive technique. Chemotherapy with cisplatin and mitomycin can be administered either alone or following surgery. Erionite has been the culprit of numerous malignant mesothelioma cases in Europe and even in North America. Erionite has a higher degree of carcinogenicity with possible genetic transmission of erionite susceptibility in an autosomal dominant fashion. Therapeutic management for E-MPM remains very limited, and cure of the disease is extremely rare.