Shiara Ortiz-Pujols

The Employed Surgeon: A Changing Professional Paradigm

OBJECTIVE To identify trends and characteristics of surgeon employment in the United States. Surgeons are increasingly choosing hospital or large group employment as their practice environment. DESIGN American Medical Association Physician Masterfile data were analyzed for the years 2001 to 2009. SETTING Surgeons identified within the American Medical Association Masterfile. PARTICIPANTS Surgeons were defined using definitions from the American Medical Association specialty data and the American Board of Medical Specialties certification data and included active, nonfederal, and nonresident physicians younger than 80 years of age. MAIN OUTCOME MEASURES Employment status and trends. RESULTS The number of surgeons who reported having their own self-employed practice decreased from 48% to 33% between 2001 and 2009, and this decrease corresponded with an increase in the number of employed surgeons. Sixty-eight percent of surgeons in the United States now self-identify their practice environment as employed. Between 2006 and 2011, there was a 32% increase in the number of surgeon in a full-time hospital employment arrangement. Younger surgeons and female surgeons increasingly favor employment in large group practices. Employment trends were similar for both urban and rural practices. CONCLUSIONS General surgeons and surgical subspecialists are choosing hospital employment instead of independent practice. The trend is especially notable among younger surgeons and among female surgeons. The trend denotes a professional paradigm shift of major importance.

Bronchoscopy-Derived Correlates of Lung Injury following Inhalational Injuries: A Prospective Observational Study

Background Acute lung injury (ALI) is a major factor determining morbidity following burns and inhalational injury. In experimental models, factors potentially contributing to ALI risk include inhalation of toxins directly causing cell damage; inflammation; and infection. However, few studies have been done in humans. Methods We carried out a prospective observational study of patients admitted to the NC Jaycees Burn Center who were intubated and on mechanical ventilation for burns and suspected inhalational injury. Subjects were enrolled over an 8-month period and followed till discharge or death. Serial bronchial washings from clinically-indicated bronchoscopies were collected and analyzed for markers of cell injury and inflammation. These markers were compared with clinical markers of ALI. Results Forty-three consecutive patients were studied, with a spectrum of burn and inhalation injury severity. Visible soot at initial bronchoscopy and gram negative bacteria in the lower respiratory tract were associated with ALI in univariate analyses. Subsequent multivariate analysis also controlled for % body surface area burns, infection, and inhalation severity. Elevated IL-10 and reduced IL-12p70 in bronchial washings were statistically significantly associated with ALI. Conclusions Independently of several factors including initial inhalational injury severity, infection, and extent of surface burns, high early levels of IL-10 and low levels of IL-12p70 in the central airways are associated with ALI in patients intubated after acute burn/inhalation injury. Lower airway secretions can be collected serially in critically ill burn/inhalation injury patients and may yield important clues to specific pathophysiologic pathways.

Blood utilization in patients with burn injury and association with clinical outcomes (CME)

Uncontrolled bleeding is an important cause of increased transfusion in burn victims; however, description of blood utilization patterns in the burn population is lacking.

Major Burn Injury is not Associated with Acute Traumatic Coagulopathy

BACKGROUND The pathophysiology and time course of coagulopathy after major burns are inadequately understood. Our study objectives were to determine whether acute traumatic coagulopathy (ATC) is seen in burn patients at admission and to determine the changes in international normalized ratio (INR), activated partial thromboplastin time (aPTT), platelet count (PLT), and hemoglobin (Hgb) in the first 7 days after injury. METHODS We conducted a retrospective study of patients with burn injury of at least 15% total body surface area who presented to the University of North Carolina. Data on patient demographics, injury characteristics, and laboratory data (INR, aPTT, PLT, and Hgb) at admission and within the first 7 days after injury were recorded. We defined ATC as INR of 1.3 or greater, aPTT of 1.5 or greater times the mean normal limit, and normal PLT at admission. RESULTS We studied the hematologic profile of 102 patients with burn injury of 15% to 100% total body surface area but did not identify a single patient with ATC at admission. The screening hematologic profile at admission was not influenced by burn severity. In the first 7 days after injury, the INR and aPTT were relatively preserved, while the PLT quickly recovered to baseline after an early decline and the Hgb remained stable at around 10 g/dL; all these changes occurred during the time when the burn patients had received large amounts of fluid resuscitation. CONCLUSION The screening hematologic profile of burn patients at admission is normal, and the standard screening assays do not suggest the existence of ATC at admission. While this is a relatively small study, it provides evidence to suggest that ATC is unique to trauma patients. LEVEL OF EVIDENCE Prognostic study, level III.

DNA and Inflammatory Mediators in Bronchoalveolar Lavage Fluid From Children With Acute Inhalational Injuries

The aim of this study was to assess the feasibility of using serial bronchoalveolar lavage fluids (BALFs) to characterize the course of cell damage and inflammation in the airways of pediatric patients with acute burn or inhalation injury. This was a prospective, longitudinal, descriptive pilot study conducted at the Burn and Pediatric Intensive Care Units in a tertiary care medical center. Six consecutively intubated and mechanically ventilated pediatric patients with acute inhalational injuries were studied. Serial BALF specimens from clinically indicated bronchoscopies were used to measure DNA and cytokine levels. BALF DNA levels for the six pediatric burn subjects were the highest within the first 72 hours after burn injury and declined thereafter. At the early stages after injury, BALF DNA levels (median [min, max] 3789 [1170, 11,917] ng/ml) were similar to those in adult burn patients and pediatric cystic fibrosis or bronchiectasis patients and was higher than those in pediatric recurrent pneumonia patients. BALF DNA levels in children and adults with inhalation injury correlated significantly with BALF interleukin-6, interleukin-8, and transforming growth factor-&bgr;1 levels. The patient with the most severe early visible airway mucosal damage and soot pattern at bronchoscopy, as well as the most extensive burns, also had the highest average early BALF DNA level (11,917ng/ml) and the longest ventilator course and hospital stay. Procedures were well tolerated. In children with acute burn and inhalational injury, airway cellular damage and inflammation (reflected in high BALF DNA levels) appear to peak during the first 72 hours after burn or inhalation injury followed by a slow decline. Serial analysis of factors in airway secretions is feasible and has the potential to reveal important pathophyisiologic pathways and therapeutic targets for the treatment of acute inhalational injuries.

Management and sequelae of a 41-year-old Jehovah's Witness with severe anhydrous ammonia inhalation injury

Anhydrous ammonia is a commonly used chemicals that are found in fertilizer, refrigeration, and in other occupational environments. Lung damage because of inhalation of ammonia can be devastating, producing debilitating lung disease and can ultimately lead to death. This is the case of a 41-year-old male, previously healthy, Jehovahs Witness, who was working at a poultry plant facility when an explosion occurred exposing him to toxic levels of anhydrous ammonia. Our patient developed end-stage lung disease after sustaining a severe ammonia inhalation injury. Despite aggressive pulmonary rehabilitation, the patient continued to deteriorate, and his only option for a chance at improved quality of life was a double-lung transplant. To our knowledge, this is the first report of a bloodless lung transplantation for inhalational lung injury in the literature. Further study is needed to better understand the effects of ammonia on lung physiology in order to better manage and treat patients who develop acute and chronic lung complications after exposure.

Chest high-frequency oscillatory treatment for severe atelectasis in a patient with toxic epidermal necrolysis.

Atelectasis is a significant risk factor for the development of pneumonia, especially in pediatric populations more prone to alveolar collapse or those who may have weakened muscular tone. The Metaneb system is a pneumatic, noninvasive physiotherapy technique that delivers chest high-frequency oscillations. Chest high-frequency oscillations have been shown to enhance mucociliary clearance of secretions and help resolve patchy atelectasis. This report describes the case of a 17-year-old female patient who developed significant left-sided atelectasis after extubation and was effectively managed with complete resolution of her atelectasis with the Metaneb system, obviating the need for reintubation.

Differential regulation of innate immune cytokine production through pharmacological activation of Nuclear Factor-Erythroid-2-Related Factor 2 (NRF2) in burn patient immune cells and monocytes

Burn patients suffer from immunological dysfunction for which there are currently no successful interventions. Similar to previous observations, we find that burn shock patients (≥15% Total Burn Surface Area (TBSA) injury) have elevated levels of the innate immune cytokines Interleukin-6 (IL-6) and Monocyte Chemoattractant Protein-1 (MCP-1)/CC-motif Chemokine Ligand 2(CCL2) early after hospital admission (0–48 Hours Post-hospital Admission (HPA). Functional immune assays with patient Peripheral Blood Mononuclear Cells (PBMCs) revealed that burn shock patients (≥15% TBSA) produced elevated levels of MCP-1/CCL2 after innate immune stimulation ex vivo relative to mild burn patients. Interestingly, treatment of patient PBMCs with the Nuclear Factor-Erythroid-2-Related Factor 2 (NRF2) agonist, CDDO-Me(bardoxolone methyl), reduced MCP-1 production but not IL-6 or Interleukin-10 (IL-10) secretion. In enriched monocytes from healthy donors, CDDO-Me(bardoxolone methyl) also reduced LPS-induced MCP1/CCL2 production but did not alter IL-6 or IL-10 secretion. Similar immunomodulatory effects were observed with Compound 7, which activates the NRF2 pathway through a different and non-covalent Mechanism Of Action (MOA). Hence, our findings with CDDO-Me(bardoxolone methyl) and Compound 7 are likely to reflect a generalizable aspect of NRF2 activation. These observed effects were not specific to LPS-induced immune responses, as NRF2 activation also reduced MCP-1/CCL2 production after stimulation with IL-6. Pharmacological NRF2 activation reduced Mcp-1/Ccl2 transcript accumulation without inhibiting either Il-6 or Il-10 transcript levels. Hence, we describe a novel aspect of NRF2 activation that may contribute to the beneficial effects of NRF2 agonists during disease. Our work also demonstrates that the NRF2 pathway is retained and can be modulated to regulate important immunomodulatory functions in burn patient immune cells.

Life-threatening Skin Disorders Treated in the Burn Center: Impact of Health care–associated Infections on Length of Stay, Survival, and Hospital Charges

This article reviews a single burn center experience with life-threatening skin disorders, over a 10-year period. It explores the incidence of health care-associated infections and the impact on length of stay, hospital charges, and mortality.

Acalculous Cholecystitis in Burn Patients: Is There a Role for Percutaneous Cholecystostomy?

Although acute acalculous cholecystitis is uncommon in burn patients, this condition can be rapidly fatal due to delays in diagnosis and treatment and should always be considered in the differential diagnosis when burn patients become septic, develop abdominal pain, or have hemodynamic instability. This article reviews the use of percutaneous cholecystostomy in burn patients as both a diagnostic and therapeutic intervention.