Kimberly Lumpkins

Glial fibrillary acidic protein is highly correlated with brain injury.

BACKGROUND Glial fibrillary acidic protein (GFAP) is an intermediate filament protein found in the cytoskeleton of astroglia. Recent work has indicated that GFAP may serve as a serum marker of traumatic brain injury (TBI) that is released after central nervous system cell damage. METHODS Serum from 51 critically injured trauma patients was prospectively collected on admission and on hospital day 2. All patients underwent an admission head computed tomography (CT) scan as a part of their clinical evaluation. Patients with facial fractures in the absence of documented TBI and patients with spinal cord injury were excluded. Demographic and outcome data were collected prospectively. Serum GFAP was measured in duplicate using enzyme-linked immunosorbent assay techniques. RESULTS Thirty-nine (76%) of the 51 patients had CT-documented TBI. The study cohort was 72.5% men with a mean age of 43 years and mean Injury Severity Score (ISS) of 30.2. There were no statistically significant demographic differences between the two groups. At admission day, the mean GFAP level in non-TBI patients was 0.07 pg/mL compared with 6.77 pg/mL in TBI patients (p = 0.002). On day 2 the mean GFAP level was 0.02 in non-TBI patients compared with 2.17 in TBI patients (p = 0.003). Using regression analysis to control for age, sex, and ISS, the Head Abbreviated Injury Scale was predictive of the level of GFAP on both days 1 and 2 (p values 0.006 and 0.026, respectively). Although GFAP levels were not predictive of increased hospital length of stay, intensive care unit length of stay, or ventilator days, high GFAP levels on hospital day 2 were predictive of mortality when controlling for age, sex, and ISS (odds ratio 1.45, p value 0.028). The area under the receiver operating characteristic curve for GFAP was 0.90 for day 1 and 0.88 for day 2. A GFAP cutoff point of 1 pg/mL yielded 100% specificity and 50% to 60% sensitivity for TBI. CONCLUSIONS GFAP is a serum marker of TBI, and persistent elevation on day 2 is predictive of increased mortality. Excellent specificity for CT-documented brain injury was found using a cutoff point of 1 pg/mL.

Plasma Levels of the Beta Chemokine Regulated Upon Activation, Normal T Cell Expressed, and Secreted (RANTES) Correlate With Severe Brain Injury

BACKGROUND The expression of the beta chemokine RANTES (regulated upon activation, normal T cell expressed, and secreted) has previously been shown to be elevated after traumatic brain injury (TBI) in animal models, but it was unknown whether the plasma level of RANTES was predictive of TBI in critically injured trauma patients. METHODS A prospective study was conducted on 108 critically ill trauma patients. Patients were stratified by radiologic diagnosis of TBI. Severe TBI was classified as the presence of diffuse axonal injury, midline shift, or herniation based on admission head computed tomography findings. Serum levels were evaluated at admission and hospital day 7. RANTES was measured using Luminex multiplex assays. RESULTS Fifty-four patients with and without TBI were compared. Severe TBI was diagnosed in 23 of the 54 TBI patients (43%) and mild/moderate TBI was found in 31 (57%) patients. The mean age of the study population was 43 +/- 20 years with a mean Injury Severity Score of 29 +/- 14. There was no significant difference between groups in age, sex, and Injury Severity Score. At admission, RANTES was significantly higher in patients with severe brain injury than in non-TBI patients (mean 1,339 pg/mL vs. 708 pg/mL, p = 0.046), and there was a trend toward significance when comparing patients with severe versus mild/moderate brain injury (mean 1,339 pg/mL vs. 752 pg/mL, p = 0.069). There was no statistically significant difference on day 7. CONCLUSIONS RANTES was a significant early marker of severe TBI in critically injured trauma patients, consistent with animal models. Future research on the role of RANTES in the pathogenesis of human TBI is warranted.

Significant predictors of complications after sternal wound reconstruction: a 21-year experience.

BackgroundWe sought to identify patient comorbidities that predict complications after tissue flap sternal reconstruction. MethodsA retrospective study, December 1989 to December 2010, analyzed numerous comorbidities, including diabetes mellitus (DM), hypertension (HTN), coronary artery disease, congestive heart failure (CHF), and renal insufficiency, as independent risk factors for postoperative complications. Pearson &khgr;2 test, Fisher exact test, 2-sample t test, and median-unbiased estimation were used for data analysis. Significance was P ⩽ 0.05. ResultsIn all, 106 patients received 161 sternal tissue flap repairs. Nineteen patients (18%) required reoperation because of complications, including recurrent wound infection, tissue necrosis, wound dehiscence, mediastinitis, and hematoma formation. Our analysis found DM, HTN, and CHF as significant predictors of complications after sternal reconstruction (P = 0.014, 0.012, and 0.006). ConclusionsResults suggest DM, HTN, and CHF may contribute to complications after tissue flap repair of sternal wounds, possibly through impaired perfusion and healing of repairs.

Clostridium difficile Infection in Critically Injured Trauma Patients

BACKGROUND Clostridium difficile infection (CDI) is an increasing problem worldwide. To our knowledge, there are no studies evaluating specifically the incidence of CDI in the critically injured trauma population. METHODS Five hundred eighty-one consecutive critically injured trauma patients were followed prospectively for development of CDI, diagnosed by toxin assay. Testing was ordered on the basis of symptoms. Antibiotic usage was classified as surgical prophylaxis or therapeutic. RESULTS Nineteen cases of CDI were diagnosed in 581 patients (3.3%). Age, sex, race, and injury severity score (ISS) were similar in patients with and without CDI (p > 0.2); the mean ISS in patients with CDI was 29 points. Intensive care unit length of stay (ICU LOS), ventilator days, and hospital length of stay (HLOS) were significantly higher in the CDI patients. The diagnosis was made a mean of 17 days after admission; however, in four patients (21%), the infections were diagnosed within six days of admission. Fourteen patients (74%) had received therapeutic antibiotics for confirmed or suspected infection prior to the appearance of colitis; four patients (21%) received only intraoperative prophylaxis, and one patient had no antibiotic exposure. These five patients were significantly younger than those who developed CDI after therapeutic antibiotic usage and had significantly shorter HLOS and ICU LOS (p < 0.05). This result persisted after controlling for age using multiple linear regression analysis. CONCLUSIONS Clostridium difficile infection occurred in 3.3% of patients and was diagnosed as early as the fourth hospital day. We have identified a unique subgroup of younger patients who developed CDI after minimal or no antibiotic exposure. Further study is needed to characterize this population.

Intraductal papillary mucinous neoplasm in a neonate with congenital hyperinsulinism and a de novo germline SKIL gene mutation

A 3 day old infant with persistent severe hypoglycemia was found to have a cystic pancreatic tumor. Cessation of glucose infusion led to severe hypoglycemia. Pancreaticoduodenectomy was performed and revealed an intraductal papillary mucinous neoplasm (IPMN) with high-grade dysplasia. Sequencing of the IPMN revealed a KRAS gene mutation not present in surrounding normal tissues. Deep sequencing of the patients blood for KRAS mutations showed no evidence of mosaicism. Whole exome sequencing of the blood of the patient and both parents revealed a de novo germline SKIL mutation in the child that was not present in either parent. This suggests a possible role for SKIL in the pathogenesis of pancreatic tumors.

Pectoralis major turnover versus advancement technique for sternal wound reconstruction.

BackgroundWe compared the efficacy of pectoralis turnover versus advancement technique for sternal wound reconstruction. MethodsA retrospective chart review was performed, December 1989 to December 2010, to compare postoperative complication rates between pectoralis major turnover versus pectoralis major advancement reconstruction techniques. Complications included hematomas, wound infections, tissue necrosis, dehiscence, and need for reoperation. Pearson &khgr;2 and logistic regression were used and significance was P < 0.05. ResultsSixty-seven patients received 91 tissue flaps. Eleven patients (16%) required reoperation due to complications, including recurrent wound infection, tissue necrosis, wound dehiscence, mediastinitis, and hematoma formation. Four patients (6%) were treated conservatively for minor complications. Overall, complication rates were significantly higher after pectoralis major advancement reconstruction (32.5% vs. 3.7%, P = 0.004). ConclusionsWhen feasible, pectoralis major turnover flap offers a superior reconstructive technique for complex sternal wounds, with diminished complications compared with the pectoralis advancement flap.

Emergency pediatric surgery: Comparing the economic burden in specialized versus nonspecialized children's centers

BACKGROUND The American College of Surgeons has developed a verification program for childrens surgery centers. Highly specialized hospitals may be verified as Level I, while those with fewer dedicated resources as Level II or Level III, respectively. We hypothesized that more specialized childrens centers would utilize more resources. STUDY DESIGN We performed a retrospective study of the Maryland Health Services Cost Review Commission (HSCRC) database from 2009 to 2013. We assessed total charge, length of stay (LOS), and charge per day for all inpatients with an emergency pediatric surgery diagnosis, controlling for severity of illness (SOI). Using published resources, we assigned theoretical level designations to each hospital. RESULTS Two hospitals would qualify as Level 1 hospitals, with 4593 total emergency pediatric surgery admissions (38.5%) over the five-year study period. Charges were significantly higher for children treated at Level I hospitals (all P<0.0001). Across all SOI, children at Level I hospitals had significantly longer LOS (all P<0.0001). CONCLUSION Hospitals defined as Level II and Level III provided the majority of care and were able to do so with shorter hospitalizations and lower charges, regardless of SOI. As care shifts towards specialized centers, this charge differential may have significant impact on future health care costs. LEVEL OF EVIDENCE Level III Cost Effectiveness Study.

Surgical treatment of a type IV cystic sacrococcygeal teratoma with intraspinal extension utilizing a posterior-anterior-posterior approach: a case report

Type IV sacrococcygeal teratoma with intraspinal involvement is rare and to our knowledge has not been reported previously in the literature. The authors present the case of a 2-month-old infant with a type IV sacrococcygeal teratoma diagnosed on prenatal ultrasound. Postnatal MRI revealed intraspinal extension through an enlarged sacral neuroforamina on the right side. On surgical exploration, the authors discovered a dorsal cystic tumor involving the sacral spine that extended through an enlarged S4 foramen to a large presacral component. The tumor was successfully removed to achieve a complete en bloc surgical resection. The authors review the epidemiology, pathophysiology, and treatment of sacrococcygeal teratomas with intraspinal extension.

Anomalous mesenteric vessel—a rare etiology of intermittent partial small bowel obstruction

Abstract We report a case of an 11-year with recurrent episodes of abdominal pain and vomiting. Diagnostic laparoscopy during a severe episode demonstrated an anomalous blood vessel incompletely encircling the bowel, leading to transient partial small bowel obstruction. This likely represents a remnant vessel from the omphalomesenteric duct. Recurrent abdominal pain and vomiting in the pediatric population requires careful history and physical exam, and a willingness to entertain unusual diagnoses.

Pectoralis Major Turnover Versus Advancement Flap for Sternal Wound Reconstruction: A 21-Year Experience

concluSIon: DIEP flaps appear to be as profitable as pTRAM flaps with lower morbidity. The transition from pTRAM to perforator flaps can be done successfully with well-trained microsurgeons, an already established breast reconstruction practice, and support from leadership and hospital staff. We believe that the development of a perforator flap practice represents an opportunity cost in optimizing patient care, and should be an option available to patients seeking autologous breast reconstruction. Pectoralis Major Turnover Versus Advancement Flap for Sternal Wound reconstruction: A 21-year Experience