John Denobile

Inflammatory biomarkers in combat wound healing.

Background:Modern war ballistics and blast injuries inflict devastating extremity injuries, violating soft tissue, bone, and neurovascular structures. Despite advances in complex wound management, appropriate timing of war wound closure remains subjective. In addition, the pathophysiology of acute wound failure is poorly defined. Methods:Patients with penetrating extremity wounds sustained during combat were prospectively studied and followed for 30 days after definitive wound closure. The primary outcome was wound healing. Wound dehiscence was defined as spontaneous partial or complete wound disruption after closure. Serum, wound effluent, and wound bed tissue biopsy were collected at each surgical wound debridement. Serum and wound effluent were analyzed with a multiplex array of 22 cytokines and chemokines, and wound tissue for corresponding gene transcript expression. Results:Fifty-two penetrating extremity war wounds in 33 male patients were investigated. Nine (17%) wounds dehisced. Concomitant vascular injury, increased wound size, and higher injury severity score correlated with wound dehiscence. Both serum and wound effluent cytokine and chemokine protein profiles were statistically associated with healing outcome at various time points. Wound biopsy gene transcript expression demonstrated increased tissue inflammation associated with wound failure. Multiple protein and gene transcript biomarkers predictive of wound healing were identified. Conclusions:The cytokine and chemokine protein and gene transcript expression patterns demonstrate a condition of inflammatory dysregulation associated with war wound failure. A molecular biomarker panel may predict combat wound healing outcome and warrants prospective validation.

Effect of music therapy on state anxiety in patients undergoing flexible sigmoidoscopy

PURPOSE: Patient anxiety related to flexible sigmoidoscopy can negatively affect acceptability and compliance with screening protocol, complicate and prolong procedure time, and potentially result in prematurely aborted procedures. Music has been recognized through research as a safe, inexpensive, and effective nonpharmaceutical anxiolitic agent. METHODS: An experimental study was performed on 50 adults scheduled for outpatient sigmoidoscopy. The control group received standard sigmoidoscopy protocol. Subjects in the experimental group received the standard protocol with the addition of listening to music throughout the procedure. State-Trait Anxiety Inventory (STAI) measurements were performed on all subjects before and postsigmoidoscopy. Physiologic recordings of heart rate and mean arterial pressure were recorded before and during the procedure. RESULTS: Patients who listened to self-selected music tapes during the procedure had significantly decreased STAI scores (P<0.002), heart rates (P<0.03), and mean arterial pressures (P<0.001) in comparison to the control subjects. CONCLUSION: The results of the study indicate that music is an effective anxiolitic adjunct to flexible sigmoidoscopy.

Management of colorectal injuries during operation iraqi freedom: patterns of stoma usage.

BACKGROUND Management of penetrating colorectal injuries in the civilian trauma population has evolved away from diversionary stoma into primary repair or resection and primary anastomosis. With this in mind, we evaluated how injuries to the colon and rectum were managed in the ongoing war in Iraq. METHODS The records of Operation Iraqi Freedom patients evacuated to National Naval Medical Center (NNMC) from March 2004 until November 2005 were retrospectively reviewed. Patients with colorectal injuries were identified and characterized by the following: (1) injury type; (2) mechanism; (3) associated injuries; (4) Injury Severity Score; (5) levels of medical care involved in patient treatment; (6) time interval(s) between levels of care; (7) management; and (8) outcomes. RESULTS Twenty-three patients were identified as having either colon or rectal injury. The average ISS was 24.4 (range, 9-54; median 24). On average, patients were evaluated and treated at 2.5 levels of surgically capable medical care (range, 2-3; median 2) between time of injury and arrival at NNMC, with a median of 6 days from initial injury until presentation at NNMC (range, 3-11). Management of colorectal injuries included 7 primary repairs (30.4%), 3 resections with anastomoses (13.0%), and 13 colostomies (56.6%). There was one death (4.3%) and three anastomotic leaks (30%). Total complication rate was 48%. CONCLUSIONS Based upon injury severity, the complex nature of triage and medical evacuation, and the multiple levels of care involved for injured military personnel, temporary stoma usage should play a greater role in military casualties than in the civilian environment for penetrating colorectal injuries.

Gene Expression Patterns Distinguish Colonoscopically Isolated Human Aberrant Crypt Foci from Normal Colonic Mucosa

Aberrant crypt foci (ACF) are considered the earliest identifiable preneoplastic colonic lesions; thus, a greater understanding of the nature of genetic changes underlying the transformation of normal colonic mucosa (NM) into ACF may provide insight into the mechanisms of carcinogenesis. ACF were identified by indigo carmine spraying onto colonic mucosa during colonoscopy and isolated as standard pinch biopsies of the mucosal areas containing the ACF. RNAs isolated from ACF and matched NM biopsies from the ascending and descending colons of 13 patients were analyzed on arrays containing 9128 cDNAs. Thirty-four differentially expressed (P < 0.001) genes were found in a paired comparison of the ACF and NM samples, and 25 of 26 matched pairs of ACF and NM could be correctly classified in leave-one-out cross-validation. Differential expression for seven of eight genes was confirmed by real-time reverse transcription-PCR. Furthermore, ACF and NM samples, including six pairs of ACF and NM samples that had not previously been analyzed by array hybridization, can be correctly classified on the basis of the overexpression in ACF of three selected genes (REG4, SRPN-B5, and TRIM29) evaluated by real-time reverse transcription-PCR. In a separate analysis of 13 biopsy pairs from either ascending or descending colon, ACF and NM samples could also be correctly classified by the gene expression patterns. Analysis of gene expression differences in ACF from the ascending and descending colon versus NM samples indicates that ACF from these distinct colonic locations are converging toward similar gene expression profiles and losing differences in gene expression characteristic of NM from the ascending versus descending colon. (Cancer Epidemiol Biomarkers Prev 2006;15(11):2253–62)

Celecoxib treatment alters the gene expression profile of normal colonic mucosa.

A clinical trial was recently conducted to evaluate the safety and efficacy of a selective inhibitor of cyclooxygenase-2 (celecoxib) in hereditary nonpolyposis colon cancer patients. In a randomized, placebo-controlled phase I/II multicenter trial, hereditary nonpolyposis colon cancer patients and gene carriers received either celecoxib at one of two doses or placebo. The goal was to evaluate the effects of these treatment arms on a number of endoscopic and tissue-based biomarker end points after 12 months of treatment. As part of this trial, we analyzed gene expression by cDNA array technology in normal descending (rectal) colonic mucosa of patients before and after treatment with celecoxib or placebo. We found that treatment of patients with celecoxib at recommended clinical doses (200 and 400 mg p.o. bid), in contrast to treatment with placebo, leads to changes in expression of >1,400 genes in the healthy colon, although in general, the magnitude of changes is <2-fold. Twenty-three of 25 pairs of colon biopsies taken before and after celecoxib treatment can be classified correctly by the pattern of gene expression in a leave-one-out cross-validation. Immune response, particularly T- and B-lymphocyte activation and early steps of inflammatory reaction, cell signaling and cell adhesion, response to stress, transforming growth factor-β signaling, and regulation of apoptosis, are the main biological processes targeted by celecoxib as shown by overrepresentation analysis of the distribution of celecoxib-affected genes across Gene Ontology categories. Analysis of possible cumulative effects of celecoxib-induced changes in gene expression indicates that in healthy colon, celecoxib may suppress the immune response and early steps of inflammation, inhibit formation of focal contacts, and stimulate transforming growth factor-β signaling. (Cancer Epidemiol Biomarkers Prev 2006;15(7):1382–91)

A Pilot Feasibility Study of TNFerade™ Biologic with Capecitabine and Radiation Therapy Followed by Surgical Resection for the Treatment of Rectal Cancer

Objective: The purpose of this pilot study was to evaluate the feasibility and tolerability of weekly intratumoral TNFerade™ injections combined with concurrent capecitabine and radiotherapy in the treatment of patients with locally advanced rectal cancer. Methods: Patients with T3, T4, or N+ rectal cancer received radiotherapy to a total dose of 50.4–54 Gy in combination with capecitabine 937.5 mg/m2 p.o. b.i.d. TNFerade™ at a dose of 4 × 1010 particle units was injected into the rectal tumor on the first day of radiotherapy and weekly for a total of 5 injections. Surgery was performed 5–10 weeks after the completion of chemoradiation. Results: Nine patients were enrolled in this pilot trial. The stage was cT2 in 2 patients, cT3 in 6 patients, cT4 in 1 patient, N– in 7 patients and N+ in 2 patients. Eight patients completed all treatments. Grade 3 hematologic toxicity was observed in 2 patients. There was no toxicity directly attributable to the injection procedure. A complete pathologic response was observed in 2 of 9 patients. Conclusions: This study demonstrates the feasibility of weekly intratumoral TNFerade™ injections during chemoradiotherapy for locally advanced rectal cancer. Pathologic responses with this combination compare favorably to published rates.

CASE REPORT: Adjuvant Radiotherapy for Gastrointestinal Stromal Tumor of the Rectum

Gastrointestinal stromal tumors (GIST) have been variously described as leiomyomas and schwannomas and represent a benign histopathological entity of presumed smooth muscle origin (1). Although these tumors are considered benign, one large series reported a 16% local recurrence rate and the appearance of distant metastases following surgery (2). Several prognostic factors have been associated with determining the biologic potential of GIST to include size (2), presentation with symptoms (2), location (3), and mitotic index (2, 4, 5). Despite the possibility of local recurrence and the appearance of metastatic foci, these tumors have been treated primarily with conservative or radical excision. To date, there have been no reports of postoperative therapy in the management of GIST. Herein, we present a case report of a patient with a GIST of the rectum, and describe the rationale for postoperative therapy.

Perioperative blood transfusion in combat casualties: a pilot study.

BACKGROUND In recent studies, blood transfusion has been shown to increase the rate of wound healing disturbances in orthopedic patients. Furthermore, our group has determined a correlation between delayed wound healing and elevations in inflammatory mediators in combat casualties. Therefore, we sought to determine the effect of blood transfusion on wound healing and inflammatory mediator release in combat casualties. METHODS Prospective data were collected on 20 severely injured combat casualties sustaining extremity wounds. Patients were admitted to the National Naval Medical Center during a 13-month period from January 2007 to January 2008. Data variables included age, gender, Glasgow coma score (GCS), mechanism of injury, and transfusion history. Injury severity was assessed using the Injury Severity Score (ISS). Serum was collected initially and before each surgical wound debridement and analyzed using a panel of 21 cytokines and chemokines. The association between blood transfusion and wound healing, incidence of perioperative infection, intensive care unit (ICU) admission rate, and ICU and hospital length of stay was assessed. Differences were considered significant when p < 0.05. RESULTS The study cohort had a mean age of 22 +/- 1, a mean ISS of 15.8 +/- 2.6, and a mean GCS 13.9 +/- 0.6; all were men and suffered penetrating injuries (90% improvised explosive device [IED] and 10% gunshot wound [GSW]). The cohort was divided into two groups. Patients receiving <or=4 units of blood initially (group 1, n = 11) were compared with patients who received >4 units of blood initially (group 2, n = 9). There was no significant difference in age, ISS, GCS, or mortality between the two groups. However, group 2 patients had significant impairment in wound healing rate (54% vs. 9%, p < 0.05), higher ICU admission rate (78% vs. 9%, p < 0.01), perioperative infection rate (89% vs. 27%, p < 0.01), and a longer hospital length of stay (49.9 +/- 12.8 vs. 23.8 +/- 2.9, p < 0.05) compared with group 1 patients. In addition, there was a significant correlation between the initial mean serum cytokine/chemokine level of interleukin (IL)-10, IL-8, interferon inducible protein (IP)-10, IL-6, and IL-12p40 and the number of units of blood transfused (p < 0.05). CONCLUSION Allogeneic blood transfusions in combat casualties were associated with impaired wound healing, increased perioperative infection rate, and resource utilization. In addition, the extent of blood transfusion was associated with significant differences in inflammatory chemokine and cytokine release.

Benign Pneumoperitoneum after Colonoscopy: A Prospective Pilot Study

Benign pneumoperitoneum is asymptomatic free intraabdominal air and is reported to occur occasionally with colonoscopy. Management of benign pneumoperitoneum after colonoscopy is controversial and may depend on incidence or etiology. No previous studies prospectively investigated the incidence or inciting factors of benign pneumoperitoneum resulting from colonoscopy. In this study, 100 patients underwent colonoscopy and then radiography of the chest and abdomen to detect free air. The average age was 58 +/- 6.2 years, and 48 of the colonoscopies were therapeutic. No cases of benign pneumoperitoneum were detected, estimating the incidence at 0% to 3% for diagnostic and therapeutic colonoscopy. These data indicate that benign pneumoperitoneum attributable to colonoscopy is rare and possibly nonexistent. Given the paucity of data favoring the occurrence of benign pneumoperitoneum after colonoscopy, we advocate treating all cases of free intraabdominal air after colonoscopy as perforations.

Combat Wound Initiative Program

The Combat Wound Initiative (CWI) program is a collaborative, multidisciplinary, and interservice public-private partnership that provides personalized, state-of-the-art, and complex wound care via targeted clinical and translational research. The CWI uses a bench-to-bedside approach to translational research, including the rapid development of a human extracorporeal shock wave therapy (ESWT) study in complex wounds after establishing the potential efficacy, biologic mechanisms, and safety of this treatment modality in a murine model. Additional clinical trials include the prospective use of clinical data, serum and wound biomarkers, and wound gene expression profiles to predict wound healing/failure and additional clinical patient outcomes following combat-related trauma. These clinical research data are analyzed using machine-based learning algorithms to develop predictive treatment models to guide clinical decision-making. Future CWI directions include additional clinical trials and study centers and the refinement and deployment of our genetically driven, personalized medicine initiative to provide patient-specific care across multiple medical disciplines, with an emphasis on combat casualty care.