What is the prevalence of hypertrophic scarring following burns?

Hypertrophic scarring after burns remains a major problem and is considered to be "common". Pressure garments are commonly used as treatment even though there is little sound data that they reduce the prevalence or magnitude of the scarring. In 1999 we began a study of the efficacy of pressure garments on forearm burns. After studying 30 patients, mainly white adults, we found no hypertrophic scar in either those treated with pressure or without. This prompted us to review the literature on the prevalence of hypertrophic scarring after burns and found only four articles with a relatively small number of patients and only three geographical locations. It became clear that the prevalence of hypertrophic scarring is really unknown. We then did a retrospective study of 110 burn survivors and counted all hypertrophic scars of all sizes and locations in all races and found the prevalence hypertrophic scarring to be 67% which conflicts with the published reports and our prospective study and suggests that further research is necessary. We concluded that a worldwide, prospective survey is necessary to establish the prevalence of hypertrophic scarring after burns. In this article we are calling for and offering to organize this survey.     

Patient outcomes in academic medical centers: influence of fellowship programs and in-house on-call attending surgeon

BACKGROUND: There are very few data on characteristics or policies that improve patient outcomes in academic medical institutions. We were interested in 2 such policies or characteristics that are commonly implemented in academic centers: an in-house on-call attending physician policy and the existence of postgraduate medical education. HYPOTHESIS: An in-house attending surgeon on-call policy and the presence of trauma and critical care fellowship programs improve outcomes of critically injured patients. DESIGN: Multicenter cohort study. Two cohorts were analyzed: blunt trauma (n = 601; mortality, 16.0%) and penetrating abdominal trauma (n = 503; mortality, 7.5%). SETTING: Thirty-one academic level I trauma centers, 10 (32.3%) with in-house on-call policy and 11 (35.5%) with fellowship programs. MAIN OUTCOME MEASURES: Mortality, hospital length of stay, and intensive care unit length of stay. RESULTS: In-house on-call surgeon policy had no impact on mortality or length of hospital or intensive care unit stay for either the blunt or penetrating trauma cohort. However, the presence of fellowship programs was associated with a significant decrease in blunt trauma mortality (odds ratio, 0.4; 95% confidence interval [CI], 0.1-0.8) and a decrease in length of intensive care unit stay (mean difference, 4.7 days; 95% CI, 0.6-8.8 days) and hospital stay (mean difference, 3.2 days; 95% CI, 0.6-5.9 days). There were no significant effects of fellowship programs on penetrating trauma outcomes. CONCLUSIONS: An in-house on-call attending surgeon policy is not associated with improved outcomes. In contrast, presence of a trauma and surgical critical care fellowship program, a potential surrogate marker for an institution that is committed to this specialty interest, is associated with improved outcomes for critically injured patients. An investment in advanced postgraduate medical education has potential benefits in patient care and outcomes.     

Assessment of volume of hemorrhage and outcome from pelvic fracture

HYPOTHESIS: Measurement of pelvic hemorrhage on computed tomographic (CT) scans can estimate the pelvic fracture component of total patient blood loss and predict the need for angiography. DESIGN: Retrospective cohort study. SETTING: Large level 1 trauma center. PATIENTS: We examined data from 759 consecutive, nonreferral blunt trauma patients who sustained pelvic fracture. MAIN OUTCOME MEASURES: Pelvic-fracture-specific outcomes included estimation of extraperitoneal pelvic hemorrhage volume from emergency department CT scans and determination of arterial injury from angiograms. General patient outcomes determined from medical record review included transfusion requirement, estimated blood loss, and mortality. Subanalysis was performed on subjects with only pelvic fracture as a source of major hemorrhage (derived from discharge International Classification of Diseases, Ninth Revision, Clinical Modification codes). RESULTS: Overall mortality was 96 (13%) of 759 patients. Blood transfusion was given to 418 (55%) patients, and 258 (34%) received 6 or more units in the first 72 hours. Pelvic-fracture-related hemorrhage averaged 149 mL (range, 0-1423 mL). Angiography was performed on 163 patients, of whom 113 had arterial injury. Higher pelvic hemorrhage volumes on CT scans were seen in subjects with pelvic arterial injury demonstrated on angiograms (P<.001). In subjects without another source of major hemorrhage, pelvic CT hemorrhage volumes were strongly associated with transfusion requirement (P<.001). Subjects with large pelvic hemorrhage volumes (>500 mL) were more likely to have pelvic arterial injury (risk ratio, 4.8; 95% confidence interval, 3.0-7.8; P<.001) and require large-volume (>/=6 U) transfusions (risk ratio, 4.7; 95% confidence interval, 1.8-12.3; P<.001) than patients with smaller pelvic hemorrhage volumes. CONCLUSION: Pelvic hemorrhage volumes derived from pelvic CT scans were predictors of the need for pelvic arteriography and transfusions.     

Renal injury and operative management in the United States: results of a population-based study

BACKGROUND: To evaluate the extent to which nonoperative renal trauma management has been adopted, we determined the incidence of renal injury and the rate of operative management across the United States. METHODS: International Classification of Diseases, Ninth Revision diagnosis and procedure codes identified patients with renal injuries in an 18-state administrative database representing 62% of the U.S. population. RESULTS: Of 523,870 patients hospitalized for trauma in 1997 or 1998, 6,231 (1.2%) had renal injuries (4.89 per 100,000 population). Sixty-four percent of patients with injuries that were classified had contusions/hematomas, 26.3% had lacerations, 5.3% had parenchymal disruption, and 4% had vascular injuries. Eleven percent of renal trauma patients required surgical management of their kidney injuries, of whom 61%, or 7% of patients with renal injuries overall, underwent nephrectomy. Injury Severity Score, mechanism, and renal injury severity were independent predictors of nephrectomy. CONCLUSION: The nephrectomy rate in community and academic centers reflects renal and global injury severity. Prospective trials are indicated to determine whether, in the traumatized patient with severe kidney injury, renal preservation could lead to improved outcomes compared with nephrectomy.     

Synthesis and biological assays of new H3-antagonists with imidazole and imidazoline polar groups

New histamine H3-receptor antagonists were synthesised and tested on rat brain membranes and on electrically stimulated guinea-pig ileum. The new compounds have a central polar group represented by a 2-alkylimidazole or a 2-thioimidazoline nucleus. The effect of the polar group basicity on the optimal length of the alkyl chain, connecting this group to a 4(5)-imidazolyl ring, was investigated. The best affinity values, obtained by displacement of [3H]-RAMHA from rat brain, were obtained for the 2-alkylimidazole derivatives (2a-f) with tetramethylene chain (pKi 8.03-8.97), having an intermediate basicity between that of the previously reported 2-thioimidazoles (1a-i) and that of 2-alkylthioimidazolines (3a-h). In contrast, a general lowering of affinity (pKi 5.90-7.63) was observed for compounds of the last series (3a-h), with a complex dependence on the terminal lipophilic group and chain length.     

Solitary bronchioloalveolar carcinoma: CT criteria

The computed tomographic (CT) scans of 30 patients with solitary bronchioloalveolar carcinoma were reviewed. Common features at CT included the peripheral or subpleural location of a pulmonary mass (25 cases), pseudocavitation (18 cases), heterogeneous attenuation (17 cases), irregular margins forming a star pattern (22 cases), and pleural tags (21 cases). Using these CT criteria, four independent observers attempted to identify cases of bronchioloalveolar carcinoma from a larger sample of lung cancers and benign lesions by categorizing a series of test cases into four probability categories. Although the bronchioloalveolar carcinomas were correctly ranked in the two highest probability categories 75% of the time (in 45 of 60 cases), there was considerable overlap with other lung lesions, particularly with adenocarcinoma and large cell undifferentiated carcinoma. However, even though the typical features of bronchioloalveolar carcinoma are not invariable or highly specific, they are characteristic enough to suggest the diagnosis.     

Risk of injury to children less than 5 years of age in day care versus home care settings

Recent studies have suggested that day care may be a relatively unsafe environment. In this population-based study, the incidence of injuries in day care and home care were evaluated based on the number of hours children were exposed to each environment. In this population, 43.6% of children less than 5 years of age spent part of the year in day care. The rate of injuries in day care was 2.50 per 100,000 child-hours of exposure compared with a rate of 4.88 per 100,000 child-hours of exposure in the home environment. There were no differences in overall severity of injuries in the two groups. It was concluded that children are at no greater risk of injury in day-care settings than in the home environment.