Effects of delayed wound excision and grafting in severely burned children

HYPOTHESIS: Advances in burn treatment including early excision of the wound have increased survival in patients treated at specialized burn centers. We hypothesized that the patients with delayed wound excision and grafting would experience deleterious outcomes. METHODS: From 1995 to 1999, 157 children with acute burns covering 40% or more of total body surface area and having more than 10% of full-thickness burns were admitted to our institution within 2 weeks of injury. Among them, 86, 42, and 29 patients underwent first operation on days 0 to 2, days 3 to 6, and days 7 to 14 after burn, respectively. Outcomes observed were mortality, number of operative procedures, length of hospitalization, blood transfused, incidence of wound bacterial and fungal contamination, invasive wound infection, and sepsis. RESULTS: Demographic data for the groups showed no differences in sex or total body surface area burned. Mortality and number of operative procedures and blood transfusions were not different between groups. Hospitalizations were longer in the delayed groups, which was associated with a higher incidence of significant wound contamination (P =.008). Invasive wound infection also increased significantly with delay of excision (P<.001). An increased incidence of sepsis was seen in patients with delayed wound excision and grafting (P =.04). CONCLUSIONS: Delays in excision were associated with longer hospitalization and delayed wound closure, as well as increased rates of invasive wound infection and sepsis. Our data indicate that early excision within 48 hours is optimal for pediatric patients with massive burns.     

Roundtable on Bioterrorism Detection: Information System–based Surveillance

During the 2001 AMIA Annual Symposium, the Anesthesia, Critical Care, and Emergency Medicine Working Group hosted the Roundtable on Bioterrorism Detection. Sixty-four people attended the roundtable discussion, during which several researchers discussed public health surveillance systems designed to enhance early detection of bioterrorism events. These systems make secondary use of existing clinical, laboratory, paramedical, and pharmacy data or facilitate electronic case reporting by clinicians. This paper combines case reports of six existing systems with discussion of some common techniques and approaches. The purpose of the roundtable discussion was to foster communication among researchers and promote progress by 1) sharing information about systems, including origins, current capabilities, stages of deployment, and architectures; 2) sharing lessons learned during the development and implementation of systems; and 3) exploring cooperation projects, including the sharing of software and data. A mailing list server for these ongoing efforts may be found at http://bt.cirg.washington.edu.Bioterrorism has quickly become a new and frightening part of life in America. A host of potential agents, with varying degrees of virulence and a confusing array of nonspecific symptoms, are now household words. The field of medical and public health informatics has long concerned itself with developing methods to represent, store, and analyze data that describe the complexities of individual and population-based health.¹ Now, informatics tools such as knowledge representation, controlled vocabularies, heterogeneous databases, security and confidentiality, clinical decision support, data mining, and data visualization are being applied with a new urgency to the task of early detection of intentional outbreaks of disease.In November 2001, as part of the activities of the Anesthesia, Critical Care, and Emergency Medicine Working Group, investigators from several research groups took part in the “Roundtable on Bioterrorism Detection” at the AMIA Annual Symposium. The session was subtitled “Information System–based Sentinel Surveillance.” These researchers, and others, are developing public health surveillance systems that make secondary use of data gathered during normal clinical workflow or that facilitate electronic case reporting by clinicians. These surveillance strategies are intended to enhance early detection of changes in the health of the community. This paper combines brief case reports of a number of existing systems with a discussion of some commonly employed techniques and approaches.Several bioterrorism-related posters and papers were presented at the Symposium.^2–7 A handful of systems, all in active development, are currently deployed. The utility of these systems in detecting bioterrorism events is unproven, and it is hoped that their full capabilities will never need to be tested directly. However, the value of monitoring and aggregating disease indicators across a population is clear, if intuitive, and such surveillance has a strong precedent in public health practice.^8–10There are strategies for indirectly measuring the performance of these systems and for improving their diagnostic accuracy and timeliness, even in the absence of bioterrorism cases. These strategies include measuring the accuracy of detection of components of case definitions, as opposed to detection of outbreaks. Other strategies involve the detection of surrogate diseases, such as influenza, whose symptoms are similar to the initial symptoms of inhalational anthrax. Espino et al.⁴ showed a 44percent sensitivity and 97percent specificity in detection of cases of acute respiratory illness, a common symptom prodrome of many illnesses spread by bio-aerosol agents. A companion study³ showed that time–series analysis of such cases in a population could detect an outbreak of influenza. McClung et al.¹¹ found relatively similar sensitivity and specificity (37 and 97percent, respectively) in a system detecting asthma visits, based on chief complaint on presentation to an emergency room.A number of federal and other agencies have funded the work on these surveillance systems. These include the Centers for Disease Control and Prevention (CDC), through State Bioterrorism Preparedness grants, the Health Alert Network program, and cooperative agreements; the Agency for Healthcare Research and Quality (AHRQ); the Defense Advanced Research Projects Agency (DARPA); the National Library of Medicine (NLM), both directly though grant funding and indirectly through support of NLM Fellowships in Informatics and Integrated Advanced Information Management System sites; and by state and local public health agencies using CDC and other funds.     

Vitamin B-6 content of breast milk and neonatal behavioral functioning

OBJECTIVE: To determine if vitamin B-6 intakes of mothers influence the B-6 vitamer content of transition milk and if correlations exist between the vitamin B-6 content of the milk and the infants' neurobehavioral functioning. DESIGN: Transition milk samples were collected from mothers 8 to 11 days after delivery for B-6 vitamer analysis. Neurobehavioral functioning of the neonates was determined at that time. A 24-hour recall was used in estimating vitamin B-6 intakes of the mothers. SUBJECTS: A convenience sample of low-income, lactating women (n = 25) who had normal pregnancies. MAIN OUTCOME MEASURES: B-6 vitamers were measured in the mothers' transition milk samples. Neurobehavioral functioning was assessed using the Brazelton Neonatal Behavioral Assessment Scale (NBAS), and the Center for Epidemiologic Studies Depression Scale was used to evaluate maternal depression. STATISTICAL ANALYSES PERFORMED: Pearson correlation coefficients were used to assess if statistically significant relationships existed between variables. The Mann-Whitney test was used to determine if median group values were significantly different. RESULTS: The major B-6 vitamer in transition milk was pyridoxal. Mothers with vitamin B-6 intake greater than the median value had a significantly higher median pyridoxal level in their breast milk than did the mothers with intakes below the median value. All except one mother had a dietary vitamin B-6 intake that exceeded the Recommended Dietary Allowance. Infant scores on habituation (r = .94, P < .05) and autonomic stability (r = .34, P < .05) subscales of the NBAS were positively correlated with milk pyridoxal values. APPLICATIONS/CONCLUSIONS: Vitamin B-6 is important for normal behavioral functioning of infants. The mothers' vitamin B-6 intake affects vitamin B-6 levels of breast milk and the need for consuming recommended levels of vitamin B-6 should be emphasized to all pregnant and lactating mothers.     

“How Can They Act Like That?”: Clinicians and Patients as Characters in Each Other's Stories

When clinician‐patient relationships go wrong, the problem may not be merely that one person is knowingly mistreating the other. More likely, they are caught up in different stories, and animated by different moral visions. The task is for each to see the point of the other's story.     

Emergency medical care in developing countries: is it worthwhile?

Prevention is a core value of any health system. Nonetheless, many health problems will continue to occur despite preventive services. A significant burden of diseases in developing countries is caused by time-sensitive illnesses and injuries, such as severe infections, hypoxia caused by respiratory infections, dehydration caused by diarrhoea, intentional and unintentional injuries, postpartum bleeding, and acute myocardial infarction. The provision of timely treatment during life-threatening emergencies is not a priority for many health systems in developing countries. This paper reviews evidence indicating the need to develop and/or strengthen emergency medical care systems in these countries. An argument is made for the role of emergency medical care in improving the health of populations and meeting expectations for access to emergency care. We consider emergency medical care in the community, during transportation, and at first-contact and regional referral facilities. Obstacles to developing effective emergency medical care include a lack of structural models, inappropriate training foci, concerns about cost, and sustainability in the face of a high demand for services. A basic but effective level of emergency medical care responds to perceived and actual community needs and improves the health of populations.     

A “Health Commons” Approach to Oral Health for Low-Income Populations in a Rural State

Oral health needs are urgent in rural states. Creative, broad-based, and collaborative solutions can alleviate these needs. "Health commons" sites are enhanced, community-based, primary care safety net practices that include medical, behavioral, social, public, and oral health services. Successful intervention requires a comprehensive approach, including attention to enhancing dental service capacity, broadening the scope of the dental skills of locally available providers, expanding the pool of dental providers, creating new interdisciplinary teams in enhanced community-based sites, and developing more comprehensive oral health policy. By incorporating oral health services into the health commons primary care model, access for uninsured and underserved populations is increased. A coalition of motivated stakeholders includes community leaders, safety net providers, legislators, insurers, and medical, dental, and public health providers.     

Developmental toxicity of a commercial herbicide mixture in mice: I. Effects on embryo implantation and litter size

We investigated the developmental toxicity in mice of a common commercial formulation of herbicide containing a mixture of 2,4-dichlorophenoxyacetic acid (2,4-D), mecoprop, dicamba, and inactive ingredients. Pregnant mice were exposed to one of four different doses of the herbicide mixture diluted in their drinking water, either during preimplantation and organogenesis or only during organogenesis. Litter size, birth weight, and crown-rump length were determined at birth, and pups were allowed to lactate and grow without additional herbicide exposure so that they could be subjected to additional immune, endocrine, and behavioral studies, the results of which will be reported in a separate article. At weaning, dams were sacrificed, and the number of implantation sites was determined. The data, although apparently influenced by season, showed an inverted or U-shaped dose-response pattern for reduced litter size, with the low end of the dose range producing the greatest decrease in the number of live pups born. The decrease in litter size was associated with a decrease in the number of implantation sites, but only at very low and low environmentally relevant doses. Fetotoxicity, as evidenced by a decrease in weight and crown-rump length of the newborn pups or embryo resorption, was not significantly different in the herbicide-treated litters.     

Defining the brain systems of lust,romantic attraction,and attachment

Mammals and birds have evolved three primary, discrete, interrelated emotion–motivation systems in the brain for mating, reproduction, and parenting: lust, attraction, and male–female attachment. Each emotion–motivation system is associated with a specific constellation of neural correlates and a distinct behavioral repertoire. Lust evolved to initiate the mating process with any appropriate partner; attraction evolved to enable individuals to choose among and prefer specific mating partners, thereby conserving their mating time and energy; male–female attachment evolved to enable individuals to cooperate with a reproductive mate until species-specific parental duties have been completed. The evolution of these three emotion–motivation systems contribute to contemporary patterns of marriage, adultery, divorce, remarriage, stalking, homicide and other crimes of passion, and clinical depression due to romantic rejection. This article defines these three emotion–motivation systems. Then it discusses an ongoing project using functional magnetic resonance imaging of the brain to investigate the neural circuits associated with one of these emotion–motivation systems, romantic attraction.