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The Epidemiology of Traumatic Hemothorax in a Level I Trauma Center: Case for Early Video-assisted Thoracoscopic Surgery. - European journal of trauma and emergency surgery : official publication of the European Trauma Society
Hemothorax is a common sequela of chest trauma. Complications after chest trauma include retained hemothorax and empyema requiring multiple interventions. We studied the epidemiology of hemothorax and its complications at a level I trauma center.The trauma registry was reviewed from Jan 1995 toMay 2005.Allpatients â‰¥16 years of agewhowere admitted with hemothorax, an AIS chest score of â‰¥ 3, and did not receive an immediate thoracotomy were entered in the study cohort. The patient demographics, details of the injury event, treatments, hospital length of stay (LOS), complications and outcome were analyzed.The study cohort of 522 patients with a hemothorax were treated with 685 chest thoracostomy tubes. Overall, the median ISS was 18 and 62% were penetrating injuries. 109 patients (21%) had a retained hemothorax and required placement of â‰¥ 2 chest tubes with a median LOS of 15 days longer than patients with no retained hemothorax (p < 0.0001). The overall complication rate was 5% (26/522). Of these, 20 patients had empyema (3.8%), 8 patients required decortication, and 6 patients received streptokinase treatment.More than 1 out of every 5 patients undergoing intervention for trauma-induced hemothorax develops a complication. The development of retained hemothorax is associated with empyema in 15.6% of cases and a 2-week median increase in length of stay. Future research into interventions such as Video-assisted thoracoscopic surgery (VATS) on the day of admission to completely evacuate hemothorax is warranted to reduce complication rates, length of stay and cost.
Developing Statistical Models to Assess Transplant Outcomes Using National Registries: The Process in the United States. - Transplantation
Created by the US National Organ Transplant Act in 1984, the Scientific Registry of Transplant Recipients (SRTR) is obligated to publicly report data on transplant program and organ procurement organization performance in the United States. These reports include risk-adjusted assessments of graft and patient survival, and programs performing worse or better than expected are identified. The SRTR currently maintains 43 risk adjustment models for assessing posttransplant patient and graft survival and, in collaboration with the SRTR Technical Advisory Committee, has developed and implemented a new systematic process for model evaluation and revision. Patient cohorts for the risk adjustment models are identified, and single-organ and multiorgan transplants are defined, then each risk adjustment model is developed following a prespecified set of steps. Model performance is assessed, the model is refit to a more recent cohort before each evaluation cycle, and then it is applied to the evaluation cohort. The field of solid organ transplantation is unique in the breadth of the standardized data that are collected. These data allow for quality assessment across all transplant providers in the United States. A standardized process of risk model development using data from national registries may enhance the field.
Prospective Study Evaluating Na18F-Positron Emission Tomography/Computed Tomography (NaF-PET/CT) in Predicting Clinical Outcomes and Survival in Advanced Prostate Cancer. - Journal of nuclear medicine : official publication, Society of Nuclear Medicine
This prospective pilot study evaluated the ability of sodium fluoride (Na(18)F) positron emission tomography/computed tomography (NaF-PET/CT) to detect and monitor bone metastases over time and its correlation with clinical outcomes and survival in advanced prostate cancer.Sixty prostate cancer patients, including 30 with and 30 without known bone metastases by conventional imaging underwent NaF-PET/CT at baseline, 6, and 12 months. Positive lesions were verified on follow-up scans. Changes in standardized uptake values (SUV) and lesion number were correlated with prostate-specific antigen (PSA) change, clinical impression, and overall survival (OS).Sixty patients underwent 170 NaF-PET/CT scans. Significant associations included SUV and PSA percent change at 6 (P = 0.014) and 12 months (P = 0.0005); SUV maximal percent change from baseline and clinical impression at 6 months (P = 0.0147) and 6-12 months (P = 0.0053); SUV change at 6 months and OS (P = 0.018); number of lesions on NaF-PET/CT and clinical impression at baseline (P < 0.0001), 6 (P = 0.0078), and 12 months (P = 0.0029); number of lesions on NaF-PET/CT per patient at baseline and OS (P = 0.017). In an exploratory analysis, paired (99m)Tc-MDP bone scans (TcBS) were available in 35 patients at baseline, 19 at 6 months, and 14 at 12 months (n = 68 scans). Malignant lesions on NaF-PET/CT (n =57) were classified on TcBS as malignant 65%; indeterminate 25%; and negative 10%. Additionally 65% of paired scans showed more lesions on NaF-PET/CT than on TcBS.Baseline number of malignant lesions and changes in SUV on follow-up NaF-PET/CT significantly correlates with clinical impression and OS. NaF-PET/CT detects more bone metastases earlier than TcBS and enhances detection of new bone disease in high-risk patients.Copyright Â© 2016 by the Society of Nuclear Medicine and Molecular Imaging, Inc.
Cell-cell communication enhances the capacity of cell ensembles to sense shallow gradients during morphogenesis. - Proceedings of the National Academy of Sciences of the United States of America
Collective cell responses to exogenous cues depend on cell-cell interactions. In principle, these can result in enhanced sensitivity to weak and noisy stimuli. However, this has not yet been shown experimentally, and little is known about how multicellular signal processing modulates single-cell sensitivity to extracellular signaling inputs, including those guiding complex changes in the tissue form and function. Here we explored whether cell-cell communication can enhance the ability of cell ensembles to sense and respond to weak gradients of chemotactic cues. Using a combination of experiments with mammary epithelial cells and mathematical modeling, we find that multicellular sensing enables detection of and response to shallow epidermal growth factor (EGF) gradients that are undetectable by single cells. However, the advantage of this type of gradient sensing is limited by the noisiness of the signaling relay, necessary to integrate spatially distributed ligand concentration information. We calculate the fundamental sensory limits imposed by this communication noise and combine them with the experimental data to estimate the effective size of multicellular sensory groups involved in gradient sensing. Functional experiments strongly implicated intercellular communication through gap junctions and calcium release from intracellular stores as mediators of collective gradient sensing. The resulting integrative analysis provides a framework for understanding the advantages and limitations of sensory information processing by relays of chemically coupled cells.
Frequency of bone mineral density testing in adult kidney transplant recipients from Ontario, Canada: a population-based cohort study. - Canadian journal of kidney health and disease
We lack consensus on the clinical value, frequency, and timing of bone mineral density (BMD) testing in kidney transplant recipients. This study sought to determine practice patterns in BMD testing across kidney transplant centres in Ontario, Canada, and to compare the frequency of testing in kidney transplant recipients to non-transplant reference groups.Using healthcare databases from Ontario, Canada we conducted a population-based cohort study of adult kidney transplant recipients who received a transplant from 1994-2009. We used logistic regression to determine if there was a statistically significant difference across transplant centres in the decision to perform at least one BMD test after transplantation, adjusting for covariates that may influence a physician's decision to order a BMD test. We used the McNemar's test to compare the number of recipients who had at least one BMD test to non-transplant reference groups (matching on age, sex, and date of cohort entry).In the first 3Â years after transplant, 4821 kidney transplant recipients underwent 4802 BMD tests (median 1 test per recipient, range 0 to 6 tests), costing $600,000 (2014 CAD equivalent dollars). Across the six centres, the proportion of recipients receiving at least one BMD test varied widely (ranging from 15.6 to 92.1Â %; Pâ€‰<â€‰0.001). Over half (58Â %) of the recipients received at least one BMD test post-transplant, a value higher than two non-transplant reference groups (general population with a previous non-vertebral fracture [hip, forearm, proximal humerus], 13.8Â %; general population with no previous non-vertebral fracture, 8.5Â %; P value <0.001 for each of the comparisons).There is substantial practice variability in BMD testing after transplant. New high-quality information is needed to inform the utility, optimal timing, and frequency of BMD testing in kidney transplant recipients.
Cancer Mortality Among Recipients of Solid-Organ Transplantation in Ontario, Canada. - JAMA oncology
Solid-organ transplant recipients (SOTRs) are at greater risk of developing some cancers than the general population; however, because they are also at increased risk of mortality from noncancer causes, the effect of transplantation on cancer mortality is unclear.To describe cancer mortality in SOTRs and to assess whether SOTRs are at increased risk of cancer mortality compared with the general population.Population-based cohort study of patients who underwent solid-organ transplantation in Ontario, Canada, between 1991 and 2010 with 85 557 person-years of follow-up through December 31, 2011. Solid-organ transplantation was identified using the national transplant register and linked to the provincial cancer registry and administrative databases. The analysis was conducted between November 2013 and February 2015.Solid-organ transplantation.Cancer mortality for SOTRs was compared with that of the general population using standardized mortality ratios (SMRs). Mortality and cause of death were ascertained by record linkage between the Canadian Organ Replacement Register, the Ontario Cancer Registry, and the Office of the Registrar General of Ontario death database.A total of 11 061 SOTRs were identified, including 6516 kidney, 2606 liver, 929 heart, and 705 lung transplantations. Recipients had a median (interquartile range) age of 49 (37-58) years, and 4004 (36.2%) were women. Of 3068 deaths, 603 (20%) were cancer related. Cancer mortality in SOTRs was significantly elevated compared with the Ontario population (SMR, 2.84 [95% CI, 2.61-3.07]). The risk remained elevated when patients with pretransplant malignant neoplasms (nâ€‰=â€‰1124) were excluded (SMR, 1.93 [95% CI, 1.75-2.13]). The increased risk was observed irrespective of transplanted organ. The SMR for cancer death after solid-organ transplantation was higher in children (SMR, 84.61 [95% CI, 52.00-128.40]) and lower in patients older than 60 years (SMR, 1.88 [95% CI, 1.62-2.18]) but remained elevated compared with the general population at all ages.Cancer death rate in SOTRs was increased compared with that expected in the general population; cancer was the second leading cause of death in these patients. Advances in prevention, clinical surveillance, and cancer treatment modalities for SOTRs are needed to reduce the burden of cancer mortality in this population.
Correction: Clonal CD8+ T Cell Persistence and Variable Gene Usage Bias in a Human Transplanted Hand. - PloS one
[This corrects the article DOI: 10.1371/journal.pone.0136235.].
Stem Cell-Based Therapies to Promote Angiogenesis in Ischemic Cardiovascular Disease. - American journal of physiology. Heart and circulatory physiology
Stem cell therapy is a promising approach for treatment of tissue ischemia associated with myocardial infarction and peripheral arterial disease. Stem and progenitor cells derived from bone marrow or from pluripotent stem cells have shown therapeutic benefit in boosting angiogenesis as well as restoring tissue function. Notably, adult stem and progenitor cells including mononuclear cells, endothelial progenitor cells, and mesenchymal stem cells have progressed into clinical trials and have shown positive benefits. In this review, we overview the major classes of stem and progenitor cells, including pluripotent stem cells, and summarize the state-of-the-art in applying these cell types for treating myocardial infarction and peripheral arterial disease.Copyright Â© 2015, American Journal of Physiology - Heart and Circulatory Physiology.
Epidemiology of Kidney Discard from Expanded Criteria Donors Undergoing Donation after Circulatory Death. - Clinical journal of the American Society of Nephrology : CJASN
The broader use of combined expanded criteria donor and donation after circulatory death (ECD/DCD) kidneys may help expand the deceased donor pool. The purpose of our study was to evaluate discard rates of kidneys from ECD/DCD donors and factors associated with discard.ECD/DCD donors and kidneys were evaluated from January 1, 2000 to March 31, 2011 using data from the Scientific Registry of Transplant Recipients. The kidney donor risk index was calculated for all ECD/DCD kidneys. Multivariable logistic regression models were used to determine risk factors for discarding both donor kidneys. The Kaplan-Meier product limit method and the log-rank statistic were used to assess the cumulative probability of graft failure for transplants from ECD/DCD donors where the mate kidney was discarded versus both kidneys were used.There were 896 ECD/DCD donors comprising 1792 kidneys. Both kidneys were discarded in 44.5% of donors, whereas 51.0% of all available kidneys were discarded. The kidney donor risk index scores were higher among donors of discarded versus transplanted kidneys (median, 1.82; interquartile range, 1.60, 2.07 versus median, 1.67; interquartile range, 1.49, 1.87, respectively; P<0.001); however, the distributions showed considerable overlap. The adjusted odds ratios for discard were higher among donors who were older, diabetic, AB blood type, and hepatitis C positive. The cumulative probabilities of total graft failure at 1, 3, and 5 years were 17.3%, 36.5%, and 55.4% versus 13.8%, 24.7%, and 40.5% among kidneys from donors where only one versus both kidneys were transplanted, respectively (log rank P=0.04).Our study shows a significantly higher discard rate for ECD/DCD kidneys versus prior reports. Some discarded ECD/DCD kidneys may be acceptable for transplantation. Additional studies are needed to evaluate the factors that influence decision making around the use of ECD/DCD kidneys.Copyright Â© 2015 by the American Society of Nephrology.
Epidermal devices for noninvasive, precise, and continuous mapping of macrovascular and microvascular blood flow. - Science advances
Continuous monitoring of variations in blood flow is vital in assessing the status of microvascular and macrovascular beds for a wide range of clinical and research scenarios. Although a variety of techniques exist, most require complete immobilization of the subject, thereby limiting their utility to hospital or clinical settings. Those that can be rendered in wearable formats suffer from limited accuracy, motion artifacts, and other shortcomings that follow from an inability to achieve intimate, noninvasive mechanical linkage of sensors with the surface of the skin. We introduce an ultrathin, soft, skin-conforming sensor technology that offers advanced capabilities in continuous and precise blood flow mapping. Systematic work establishes a set of experimental procedures and theoretical models for quantitative measurements and guidelines in design and operation. Experimental studies on human subjects, including validation with measurements performed using state-of-the-art clinical techniques, demonstrate sensitive and accurate assessment of both macrovascular and microvascular flow under a range of physiological conditions. Refined operational modes eliminate long-term drifts and reduce power consumption, thereby providing steps toward the use of this technology for continuous monitoring during daily activities.
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