Browse Health
Surgical Specialist
29 years of experience
Accepting new patients

Education ?

Medical School Score
Creighton University (1981)
  • Currently 2 of 4 apples

Awards & Distinctions ?

Awards  
Castle Connolly America's Top Doctors® (2002 - 2008, 2010 - 2014)
Associations
American Board of Surgery
American College of Surgeons

Affiliations ?

Dr. Griswold is affiliated with 6 hospitals.

Hospital Affilations

Score

Rankings

  • University Medical Center - Lubbock
    602 Indiana Ave, Lubbock, TX 79415
    • Currently 2 of 4 crosses
  • University Medical Center
  • Lincoln County Medical Center
  • University Medical Center Health System
  • TX Tech Physicians Associates
  • University Associates
  • Publications & Research

    Dr. Griswold has contributed to 58 publications.
    Title Future Directions in Training Surgical Residents to Perform Endoscopic Examinations.
    Date April 2008
    Journal The American Surgeon
    Title Pseudomonas Aeruginosa Forms Biofilms in Acute Infection Independent of Cell-to-cell Signaling.
    Date September 2007
    Journal Infection and Immunity
    Excerpt

    Biofilms are bacterial communities residing within a polysaccharide matrix that are associated with persistence and antibiotic resistance in chronic infections. We show that the opportunistic pathogen Pseudomonas aeruginosa forms biofilms within 8 h of infection in thermally injured mice, demonstrating that biofilms contribute to bacterial colonization in acute infections as well. Using light, electron, and confocal scanning laser microscopy, P. aeruginosa biofilms were visualized within burned tissue surrounding blood vessels and adipose cells. Although quorum sensing (QS), a bacterial signaling mechanism, coordinates differentiation of biofilms in vitro, wild-type and QS-deficient P. aeruginosa strains formed similar biofilms in vivo. Our findings demonstrate that P. aeruginosa forms biofilms on specific host tissues independently of QS.

    Title Diversity of Biofilms Produced by Quorum-sensing-deficient Clinical Isolates of Pseudomonas Aeruginosa.
    Date July 2007
    Journal Journal of Medical Microbiology
    Excerpt

    The quorum-sensing (QS) systems control several virulence attributes of Pseudomonas aeruginosa. Five QS-deficient P. aeruginosa clinical isolates (CI) that were obtained from wound (CI-1), tracheal (CI-2, CI-3, CI-4) and urinary tract (CI-5) infections had previously been characterized. In this study, a flow-through continuous-culture system was utilized to examine in detail the biofilms formed by these isolates in comparison with the P. aeruginosa prototrophic strain PAO1. Analysis of the biofilms by confocal laser scanning microscopy and COMSTAT image analysis at 1 and 7 days post-inoculation showed that the isolates produced diverse biofilms. In comparison with PAO1, the CI produced biofilms that scarcely or partially covered the surface at day 1, although CI-1 produced larger microcolonies. At day 7, CI-2 and CI-4 produced mature biofilms denser than that produced by PAO1, while the biofilm formed by CI-1 changed very little from day 1. CI-1 was defective in both swarming and twitching motilities, and immunoblotting analysis confirmed that it produced a reduced level of PilA protein. The twitching-motility defect of CI-1 was not complemented by a plasmid carrying intact pilA. In the 48 h colony biofilm assay, the CI varied in susceptibility to imipenem, gentamicin and piperacillin/tazobactam. These results suggest that: (1) the isolates produced biofilms with different structures and densities from that of PAO1; (2) biofilm formation by the isolates was not influenced by either the isolation site or the QS deficiencies of the isolates; (3) the behaviour of CI-1 in the different biofilm systems may be due to its lack of swarming motility and type IV pilus-related twitching motility.

    Title Role of Free Hemoglobin in 8-iso Prostaglandin F2-alpha Synthesis in Chronic Renal Failure and Its Impact on Cd163-hb Scavenger Receptor and on Coronary Artery Endothelium.
    Date January 2007
    Journal Asaio Journal (american Society for Artificial Internal Organs : 1992)
    Excerpt

    Free hemoglobin (Hb) during autoxidation increases 8-iso-prostaglandin-F2-alpha (8-isoprostane) formation in vitro. Because 8-isoprostane and plasma Hb are elevated in chronic renal failure (CRF), we evaluated the role of Hb in this isoprostane synthesis in vivo. By monitoring correlations between Hb, haptoglobin (Hp), CD163-Hb-scavenger receptor, and 8-isoprostane that is known to induce CD163 shedding, we examined whether 8-isoprostane blocks Hb catabolism in CRF. Additionally, by studying the effect of 8-isoprostane on human coronary artery endothelium (HCAEC) in vitro and its impact on intercellular adhesion molecule-1 (ICAM-1) in vivo, we tested its role in promotion of cardiovascular events in CRF. Twenty-two never-dialyzed CRF patients and 18 control patients were screened for renal function, plasma and urine 8-isoprostane, and plasma Hb, Hp, thiobarbituric-acid-reactants (TBARS), C-reactive-protein (CRP), and soluble (s) ICAM-1 and sCD163. HCAEC exposed to 8-isoprostane were tested for ICAM-1 and apoptosis. In CRF, urine 8-isoprostane was significantly elevated and correlated with free-Hb and TBARS. The increased free-Hb, Hp, and sCD163 in CRF suggested 8-isoprostane-mediated suppression of Hb catabolism through CD163 receptor shedding. 8-Isoprostane enhanced ICAM-1 expression and apoptosis in HCAEC. CRF patients showed elevated sICAM-1. In conclusion, free-Hb, via 8-isoprostane, paradoxically blocks its own catabolism. Free-Hb and/or 8-isoprostane may intensify cardiovascular events in CRF.

    Title A Comparison of Anterior and Posterior Approaches for the Surgical Treatment of Pancreatic Pseudocyst Using Laparoscopic Cystogastrostomy.
    Date June 2006
    Journal Journal of Laparoendoscopic & Advanced Surgical Techniques. Part A
    Excerpt

    BACKGROUND: Laparoscopic treatment of pancreatic pseudocyst allows for definitive drainage with faster recovery. Although many groups have reported their experience with an anterior approach, only a few have done so with a posterior approach. This paper compares the approaches, analyzing their potential benefits and pitfalls. MATERIALS AND METHODS: Seven females and one male underwent laparoscopic cystgastrostomy to treat pancreatic pseudocysts. The anterior approach was performed by opening the stomach anteriorly, localizing the pseudocyst ultrasonographically, draining the cyst with a needle and, via the same opening, using a stapler to form a cystgastrostomy. The posterior approach was performed by directly visualizing the posterior gastric wall and the pseudocyst, opening and draining the cyst with a needle, and using a stapler and running sutures for closure. RESULTS: All patients had gallstone pancreatitis. Cystgastrostomy via the anterior approach was used in 4 patients and via the posterior approach in 4 patients. Dense adhesions required one attempted posterior cystgastrostomy to be converted to an anterior approach. The mean age of the anterior group was 38 years (range, 18-58 years) and hospital stay was 6 days (range, 4-8 days): for the posterior group, mean age was 42 years (range, 40-44 years) and length of stay was 3 days (range, 2-4 days). CONCLUSION: Although both approaches had good results with no complications and short hospital stays, the posterior approach is safer, with a more precise cyst visualization and dissection that permits more tissue to be sent for histopathologic examination. Furthermore, the posterior approach?s larger anastomosis would seem to yield fewer occlusions, which are commonly seen with the anterior approach. The anterior approach is easier to learn, but it requires the opening of the anterior stomach and the use of ultrasound.

    Title Toward the Improvement of Image-guided Interventions for Minimally Invasive Surgery: Three Factors That Affect Performance.
    Date June 2006
    Journal Human Factors
    Excerpt

    OBJECTIVES: The objectives were to measure the impact of specific features of imaging devices on tasks relevant to minimally invasive surgery (MIS) and to investigate cognitive and perceptual factors in such tasks. BACKGROUND: Although image-guided interventions used in MIS provide benefits for patients, they pose drawbacks for surgeons, including degraded depth perception and reduced field of view (FOV). It is important to identify design factors that affect performance. METHOD: In two navigation experiments, observers fed a borescope through an object until it reached a target. Task completion time and object shape judgments were measured. In a motion perception experiment, observers reported the direction of a line that moved behind an aperture. A motion illusion associated with reduced FOV was measured. RESULTS: Navigation through an object was faster when a preview of the object's exterior was provided. Judgments about the object's shape were more accurate with a preview (compared with none) and with active viewing (compared with passive viewing). The motion illusion decreased with a rectangular or rotating octagonal viewing aperture (compared with circular). CONCLUSIONS: Navigation performance may be enhanced when surgeons develop a mental model of the surgical environment, when surgeons (rather than assistants) control the camera, and when the shape of the image is designed to reduce visual illusions. APPLICATION: Unintentional contact between surgical tools and healthy tissues may be reduced during MIS when (a) visual aids permit surgeons to maintain a mental model of the surgical environment, (b) images are bound by noncircular apertures, and (c) surgeons manually control the camera.

    Title Isolated Chyle Duct Injury in Blunt Trauma.
    Date March 2006
    Journal The American Surgeon
    Excerpt

    We present a case of a patient sustaining an isolated injury to the right main branch of the cysterna chyli due to a high-speed motor vehicle accident. A 42-year-old man presented after a high-speed collision. CT revealed a collection of hypodense fluid in the gallbladder fossa, which was the clue to take him to the OR. We proceeded to laparoscopic exploration, and based on the milky white color of the fluid, identified a chyle leak. In an open fashion, the retroperitoneum was explored and the injury was identified as disruption of the right lumbar branch entering the cisterna chyli, and this was ligated with silk ties. Chyle duct injury secondary to blunt trauma is a rare finding. The use of CT imaging can identify this injury. Laparoscopy can confirm the injury. Open ligation of the injured duct is the best treatment.

    Title Syndecan 1 Shedding Contributes to Pseudomonas Aeruginosa Sepsis.
    Date January 2006
    Journal Infection and Immunity
    Excerpt

    The innate immune system is comprised of many components that function coordinately to prevent bacterial sepsis. However, thermal injury suppresses many of these factors, and the opportunistic pathogen Pseudomonas aeruginosa takes advantage of this condition, making it one of the leading causes of morbidity and mortality in the setting of thermal injury. P. aeruginosa is extremely efficient at colonizing burn wounds, spreading systemically, and causing sepsis, which often results in a systemic inflammatory response, multiple-organ failure, and death. The pathogenicity of P. aeruginosa is due to the arsenal of virulence factors produced by the pathogen and the immunocompromised state of the host. Syndecan 1 is a major heparan sulfate proteoglycan present on many host cells involved in thermal injury. Syndecan 1 anchored to the cell surface can be cleaved in a process termed ectodomain shedding. Syndecan 1 shedding results in the release of intact, soluble proteoglycan ectodomains that have diverse roles in innate immunity. Here we show for the first time that thermal injury results in shedding of syndecan 1 from host tissue. Our data show that syndecan 1 null mice are significantly less susceptible to P. aeruginosa infection than their wild-type counterparts, as demonstrated by (i) significantly lower mortality; (ii) absence of systemic spread of P. aeruginosa; and (iii) significant reductions in some proinflammatory cytokines. These results suggest that shed syndecan 1 plays an important role in the pathogenesis of P. aeruginosa infection of thermal injury and that syndecan 1-neutralizing agents may be effective supplements to current P. aeruginosa treatments.

    Title Treatment of Isolated Penetrating Flank Trauma.
    Date August 2005
    Journal The American Surgeon
    Excerpt

    We present our experience during the past 5 years with isolated penetrating flank trauma. We examined the evaluation process, treatment plan, length of stay, outcome, and complications of patients with isolated penetrating injuries to the flank. There were four patient groups: 1) laparotomy (n = 5); 2) local wound exploration (n = 1); 3) laparoscopy (n = 8); and 4) observation and triple contrast CT scan (n = 9). All patients were male. The mean length of stay was 15 days for group 1, one day for group 2, two days in group 3, and 1.5 days in group 4. Three patients had diaphragmatic injuries, which were repaired laparoscopically. One patient with local wound exploration re-presented with a diaphragm hernia. A negative triple contrast CT scan resulted in no subsequent intervention. There were no missed injuries or complications from CT scan + observation or from diagnostic laparoscopy. We believe that laparoscopy may emerge as a useful adjunct in the treatment of patients with flank trauma. We present an algorithm for the management of penetrating flank trauma.

    Title The Association Between Chance Fractures and Intra-abdominal Injuries Revisited: a Multicenter Review.
    Date July 2005
    Journal The American Surgeon
    Excerpt

    The association between Chance fractures and intra-abdominal injuries is reported to be as high as 89 per cent. Because prior studies were small series or case reports, we conducted a multicenter review to learn the true association between Chance fractures and intra-abdominal injuries as well as diagnostic trends. Trauma registry data, medical records, and radiology reports from 7 trauma centers were used to characterize 79 trauma patients with Chance fractures. Initial methods of abdominal assessment were computed tomography (CT) scan (79%), clinical examination (16%), and diagnostic peritoneal lavage (DPL) (5%). Twenty-six (33%) patients had intraabdominal injuries of which hollow viscus injuries predominated (22%). Twenty patients (25%) underwent laparotomy. The presence of an abdominal wall contusion and automobile restraint use were highly predictive of intra-abdominal injury and the need for laparotomy. The association between a Chance fracture and intra-abdominal injury is not as high as previously reported. CT scan has become the primary modality to assess the abdominal cavity of patients with Chance fractures, whereas the role of DPL has diminished.

    Title Protamine Sulfate Reduces the Susceptibility of Thermally Injured Mice to Pseudomonas Aeruginosa Infection.
    Date February 2005
    Journal The Journal of Surgical Research
    Excerpt

    BACKGROUND: In this study, we investigated the ability of protamine sulfate, at sub-bactericidal dosing, to interfere with the in vivo virulence of Pseudomonas aeruginosa (PAO1) during burn wound infection. MATERIALS AND METHODS: The study was conducted using the murine model of thermal injury. Preliminary experiments determined a protocol for administration of protamine sulfate that had no in vivo bactericidal effects. Based on this, the effect of local injection of protamine sulfate on the in vivo virulence of PAO1 was assessed using these parameters: (1) the percent mortality among PAO1-infected, thermally injured mice; (2) the local proliferation and spread of PAO1 within the infected burned tissue; (3) the systemic spread of PAO1 within thermally injured/infected mice; and (4) the local cytokine response elicited by PAO1 thermally injured/infected mice. RESULTS: Injection of protamine sulfate into the thermally injured tissue of PAO1-infected/thermally injured mice significantly decreased the percent mortality and inhibited the systemic dissemination of PAO1 microorganisms to the liver and spleen. It had no effect, however, on the ability of the bacteria to proliferate and spread within the thermally injured tissue. It also was determined that protamine sulfate was ineffective at preventing mouse death at the dose administered if injected intramuscularly instead of directly into burned tissue. Protamine sulfate reduced the expression of the proinflammatory cytokines IL-6 and LIF in the injured/infected tissue. Heparan sulfate given in conjunction with protamine sulfate returned mortality levels to those of untreated mice. CONCLUSIONS: Our results suggest that: (1) local injection of sub-bactericidal doses of protamine sulfate reduces the virulence of P. aeruginosa; (2) this effect is due to interference with the systemic rather than local spread of P. aeruginosa; and (3) local application of protamine sulfate may have potential as supportive therapy for prevention of systemic P. aeruginosa infection in severely burned patients.

    Title Heuristic Haptic Texture for Surgical Simulations.
    Date November 2004
    Journal Studies in Health Technology and Informatics
    Excerpt

    Generation of credible force feedback renderings adds the sense of touch crucial for the development of a realistic virtual surgical environment. However, a number of difficulties must be overcome before this can be achieved. One of the problems is the paucity of data on the in-vivo tissue compliance properties needed to generate acceptable output forces. Without this "haptic texture," the sense of touch component remains relatively primitive and unrealistic. Current research in the quantitative analysis of biomechanics of living tissue, including collection of in-vivo tissue compliance data using specialized sensors, has made tremendous progress. However, integration of all facets of biomechanical data in order to transfer them into haptic texture remains a very difficult problem. For this reason, we are attempting to create a library of heuristic haptic textures of anatomical structures. The library of heuristic haptic textures will capture the expert's sense of feel for selected anatomical structures and will be used to convey the sense of touch for surgical training simulations. Once the techniques for converting biomechanical data into haptic texture become more robust, this library can be used as a benchmark to verify theoretical computational models used for generating output forces in haptic devices.

    Title Volumetric Virtual Body Structures.
    Date November 2004
    Journal Studies in Health Technology and Informatics
    Excerpt

    Understanding the visuospatial aspects of anatomic structures is one of the most important goals of gross anatomy. Creation of realistic three-dimensional structures of human anatomy has thus been a goal of medical doctors and computer scientists. In this paper, we describe a PC/NT based system in which a user can easily select anatomical structures to be created, along with the chosen connected structures. The system then constructs a three-dimensional volumetric model, a virtual body structure, slice-by-slide. Once the virtual structure is assembled it is possible to "walk" through the volume with coronal, sagittal, and transverse views, or at any angle. The dynamic nature of the system is unique in that it allows for real time choice of volumetric body structures to be created, their rapid generation, and the ability to manipulate the resulting visualization.

    Title Analysis of Quorum Sensing-deficient Clinical Isolates of Pseudomonas Aeruginosa.
    Date October 2004
    Journal Journal of Medical Microbiology
    Excerpt

    Pseudomonas aeruginosa produces multiple virulence factors and causes different types of infections. Previous clinical studies identified P. aeruginosa isolates that lack individual virulence factors. However, the impact of losing several virulence factors simultaneously on the in vivo virulence of P. aeruginosa is not completely understood. The P. aeruginosa cell-to-cell communication system, or quorum sensing (QS), controls the production of several virulence factors. Animal studies using constructed QS mutants indicated that loss of the QS system severely impacts the virulence of P. aeruginosa. In this study, we tried to determine if deficiency within the QS system compromises the ability of P. aeruginosa to establish infections in humans. We have identified five QS-deficient strains through screening 200 isolates from patients with urinary tract, lower respiratory tract and wound infections. These strains lacked LasB and LasA activities and produced either no or very low levels of the autoinducers N-(3-oxododecanoyl) homoserine lactone and N-butyryl homoserine lactone. PCR analysis revealed that three isolates contained all four QS genes (lasI, lasR, rhlI and rhlR) while two isolates lacked both the lasR and rhlR genes. We also examined the five isolates for other virulence factors. The isolates produced variable levels of exotoxin A and, with one exception, were deficient in pyocyanin production. One isolate produced the type III secretion system (TTSS) effector proteins ExoS and ExoT, two isolates produced ExoT only and two isolates produced no TTSS proteins. The isolates produced weak to moderate biofilms on abiotic surfaces. Analysis of the patients' data revealed that two of the isolates represented a single strain that was isolated twice from the same patient within a 1 month interval. One QS-deficient clinical isolate (CI-1) lacked all tested virulence factors and produced a weak biofilm. These results suggest that naturally occurring QS-deficient strains of P. aeruginosa do occur and are capable of causing infections; and, that besides the known virulence factors, additional factors may contribute to the ability of certain strains such as CI-1 to establish an infection.

    Title Pseudomonas Aeruginosa Autoinducer Enters and Functions in Mammalian Cells.
    Date May 2004
    Journal Journal of Bacteriology
    Excerpt

    Quorum sensing (QS) is a cell density-dependent signaling mechanism used by many bacteria to control gene expression. Several recent reports indicate that the signaling molecules (autoinducers) that mediate QS in Pseudomonas aeruginosa may also modulate gene expression in host cells; however, the mechanisms are largely unknown. Here we show that two P. aeruginosa autoinducers, N-3-oxododecanoyl-homoserine lactone and N-butyryl-homoserine lactone, can both enter eukaryotic cells and activate artificial chimeric transcription factors based on their cognate transcriptional activators, LasR and RhlR, respectively. The autoinducers promoted nuclear localization of chimeric proteins containing the full LasR or RhlR coding region, and the LasR-based proteins were capable of activating transcription of a LasR-dependent luciferase gene. Responsiveness to autoinducer required the N-terminal autoinducer-binding domains of LasR and RhlR. Truncated proteins consisting of only the C-terminal helix-turn-helix DNA-binding domains of both proteins attached to a nuclear localization signal efficiently translocated to the nucleus in the absence of autoinducer, and truncated LasR-based proteins functioned as constitutively active transcription factors. Chimeric LasR proteins were only activated by their cognate autoinducer ligand and not by N-butyryl-L-homoserine lactone. These data provide evidence that autoinducer molecules from human pathogens can enter mammalian cells and suggest that autoinducers may influence gene expression in host cells by interacting with and activating as-yet-unidentified endogenous proteins.

    Title Heterogeneity in the Effect of Albumin and Other Resuscitation Fluids on Intracellular Oxygen Free Radical Production.
    Date May 2004
    Journal The Journal of Trauma
    Excerpt

    BACKGROUND: We hypothesized that by studying a suspension of a single cell type in various resuscitation fluids, we could compare their effects on parameters associated with cell death. METHODS: Jurkat cells were suspended in resuscitation fluids. Using flow cytometry, light scatter, phosphatidylserine translocation, propidium iodide uptake, and intracellular H2O2 production were measured. RESULTS: Buffer (pH, 7.4) and albumin added to Ringer's lactate inhibited the adverse changes, including intracellular oxygen free radical production. Oxygen free radical production was variable within the cell population and inhibited by albumin but not other colloids or crystalloids. This correlated well with the ability of albumin to enhance metabolic activity. A flavoprotein inhibitor blocked H2O2 production, suggesting that mitochondria are the source of the H2O2 and the variability. CONCLUSION: Oxygen free radical inhibition by albumin could explain both its beneficial and its harmful effects.

    Title Cytokine Induction by the P. Aeruginosa Quorum Sensing System During Thermal Injury.
    Date February 2004
    Journal The Journal of Surgical Research
    Excerpt

    INTRODUCTION: Pseudomonas aeruginosa causes serious infections in severely burned patients due to its ability to produce numerous virulence factors. The production of most of these factors is controlled by the cell-to-cell communication system called quorum sensing (QS). We have recently shown that several proinflammatory and hematopoietic cytokines are produced during infection of the burn wound with P. aeruginosa strain PAO1. Most of these cytokines were not produced during either thermal injury or P. aeruginosa infection alone. MATERIALS AND METHODS AND RESULTS: In this study, we tried to determine if the QS systems play a role in the production of cytokines during P. aeruginosa infection of burn wounds. This was accomplished using the murine model of thermal injury, the P. aeruginosa strain PAO1 and its QS defective mutant (PAO-JP2), and the Multi-probe RNase protection assay. The mRNA for TNF-alpha, IL-6, TGF-beta, and G-CSF was detected within the skin of PAO1 infected/thermally injured mice. In contrast, the expression of these cytokines was not detected in PAO-JP2 infected/thermally injured mice. In comparison with the parent strain, PAO-JP2 was not defective either in its growth or in its spread within the thermally injured skin. A complementation experiment, using a plasmid that carries the intact QS gene, was conducted to confirm these results. In the presence of the complementing plasmid, PAO-JP2 produced the mRNA for the above cytokines. CONCLUSIONS: These results suggest that: 1) the QS system is involved in the induction of cytokine expression during P. aeruginosa infection of burn wounds; and 2) this effect may be caused by either a component of the QS system or a QS-controlled virulence factor.

    Title Anti-eta Igg Neutralizes the Effects of Pseudomonas Aeruginosa Exotoxin A.
    Date August 2002
    Journal The Journal of Surgical Research
    Excerpt

    BACKGROUND: The opportunistic pathogen Pseudomonas aeruginosa causes severe infections in immunocompromised hosts. Among P. aeruginosa-infected burn patients, mortality may reach as high as 50%. Due to their immunocompromised status, burn patients may benefit from passive immunotherapy against infection. As a potential multivalent immunoglobulin therapy, specific polyclonal antibodies against four P. aeruginosa virulence factors, including exotoxin A (ETA), were prepared. MATERIALS AND METHODS AND RESULTS: In this study, we analyzed the ability of ETA antibody (ETA-Ab) to neutralize the in vivo effects of ETA. Adult mice injected with purified ETA suffered 100% mortality. The cytosolic DNA of their hepatocytes was fragmented, indicating ETA induction of apoptosis. In addition, multiprobe RNase protection assays showed that ETA upregulates the expression of the genes for proinflammatory cytokines as well as apoptosis genes in the livers of ETA-injected mice. Treatment with ETA-Ab prior to ETA injection prevented mortality, ETA-induced hepatocyte DNA fragmentation, and upregulation of the cytokine and apoptosis-related genes. The role of ETA during P. aeruginosa infection of the burn wound was examined by determining the in vivo virulence of P. aeruginosa PA103 and its isogenic, ETA-deficient mutant PA103Omega::toxA using the thermally injured mouse model. The lethality, local spread, and systemic spread of PA103Omega::toxA were significantly reduced compared to PA103. CONCLUSION: These results suggest that (1) ETA induces apoptosis in hepatocytes, (2) specific cytokines are produced in response to ETA, (3) ETA-Ab neutralizes these effects, and (4) ETA contributes to the spread of P. aeruginosa during burn wound infection.

    Title The Effects of Infection of Thermal Injury by Pseudomonas Aeruginosa Pao1 on the Murine Cytokine Response.
    Date April 2002
    Journal Cytokine
    Excerpt

    Pseudomonas aeruginosa infection, one of the major complications of burn wounds, may lead to sepsis and death. Using the Multi-Probe Template/RNase protection assay, we have compared the expression of different cytokine genes within the skin and livers of thermally injured mice infected with P. aeruginosa PAO1. Thermal injury alone enhanced or up-regulated certain cytokines, including macrophage colony-stimulating factor (M-CSF), interleukin 1 (IL-1)RI, IL-1 beta, macrophage inflammatory protein (MIP)-1 beta and MIP-2; while PAO1 challenge alone up-regulated tumour necrosis factor alpha (TNF-alpha) and transforming growth factor beta (TGF-beta) expression. The combination of thermal injury plus PAO1 infection enhanced the expression of several pro-inflammatory and haematopoietic cytokines [stem cell factor (SCF), leukocyte inhibitory factor (LIF), IL-6 and TNF-alpha]; induced the expression of granulocyte-macrophage colony-stimulating factor (GM-CSF) and G-CSF by 5 h and the expression of additional cytokines, including TGF-beta, TNF-beta, lymphotoxin beta (LT-beta), interferon gamma (IFN-gamma), and IFN-beta by 40 h post-burn/infection. While the most intense cytokine expression occurred in the skin, the majority of cytokines tested were also expressed in the liver by 40 h post-burn/infection. These results suggest that in P. aeruginosa infection of burn wounds: (1) up-regulation of the expression of different cytokines, locally and within the livers of burned mice, is an indication of P. aeruginosa -induced sepsis; and (2) IL-6 and G-CSF play an important role in the host response mechanism.

    Title Adrenal Hemorrhage in a Pediatric Burn Patient.
    Date October 2001
    Journal Burns : Journal of the International Society for Burn Injuries
    Excerpt

    Adrenal hemorrhage with subsequent insufficiency is a rare complication in the burn patient. The case of a previously healthy 3-year-old Latin American male who was a victim of child abuse is presented. He suffered a submersion injury in hot water leading to a 45% total body surface area burn. An acute deterioration on the 7th post burn day was unresponsive to standard inotropic support and cardiopulmonary resuscitation. Post mortem examination revealed bilateral adrenal hemorrhage that had not been present 2 days earlier. To the authors' knowledge, this is the first reported case in a pediatric burn patient. The clinical manifestations of adrenal insufficiency vary widely and can be easily confused with sepsis. High index of suspicion is necessary for early diagnosis and treatment. Serum cortisol level should be checked and steroid therapy implemented if sepsis syndrome is unresponsive to standard therapy in this setting. This early intervention may be the key to improved survival of the burn patient with a sudden unexplained deterioration resistant to well established resuscitation methods.

    Title A Novel Hemoglobin-adenosine-glutathione Based Blood Substitute: Evaluation of Its Effects on Human Blood Ex Vivo.
    Date April 2001
    Journal Asaio Journal (american Society for Artificial Internal Organs : 1992)
    Excerpt

    Chemically modified hemoglobin (Hb) solutions are under current investigation as potential red cell substitutes. Researchers at Texas Tech University have developed a novel free Hb based blood substitute product. This blood substitute is composed of purified bovine Hb cross-linked intramolecularly with o-adenosine-5'-triphosphate and intermolecularly with o-adenosine, and conjugated with reduced glutathione (GSH). In this study, we compared the effects of our novel blood substitute and unmodified (U) Hb, by using allogenic plasma as the control, on human blood components: red blood cells (RBCs), platelets, monocytes (Mo), and low-density lipoproteins (LDLs). The pro-oxidant potential of both Hb solutions on RBCs was examined by the measurement of osmotic and mechanical fragility, conjugated dienes (CD), lipid hydroperoxides (LOOH), thiobarbituric acid reactants (TBAR-S), isoprostanes (8-iso PGF2alpha) and intracellular GSH. The oxidative modification of LDLs was assessed by CD, LOOH, and TBAR-S, and the degree of apolipoprotein (apo) B cross-linking. The effects of Hb on platelets have been studied by monitoring their responses to the aggregation agonists: collagen, ADP, epinephrine, and arachidonic acid. Monocytes were cultured with Hb solutions or plasma and tested for TNF-alpha and IL-1beta release, then examined by electron microscopy. Results indicate that native UHb initiates oxidative stress of many blood components and aggravates inflammatory responses of Mo. It also caused an increase in RBC osmotic and mechanical fragility (p < 0.001). While the level of GSH was slightly changed, the lipid peroxidation of RBC increased (p < 0.001). UHb was found to be a stimulator of 8-iso PGF2alpha synthesis, a potent modulator of LDLs, and an effective potentiator of agonist induced platelet aggregation. Contrarily, our novel blood substitute did not seem to induce oxidative stress nor to increase Mo inflammatory reactions. The osmotic and mechanical fragility of RBCs was similar to that of the control. Such modified Hb failed to alter LDLs, increase the production of 8-iso PGF2alpha, but markedly inhibited platelet aggregation. The effect of this novel blood substitute can be linked with the cytoprotective and anti-inflammatory properties of adenosine, which is used as a cross-linker and surface modifier, and a modification procedure that lowers the hemoglobin pro-oxidant potential.

    Title The Role of Quorum Sensing in the in Vivo Virulence of Pseudomonas Aeruginosa.
    Date February 2001
    Journal Microbes and Infection / Institut Pasteur
    Excerpt

    Pseudomonas aeruginosa is an opportunistic pathogen that causes a wide variety of infections. The cell-density-dependent signaling mechanisms known as quorum sensing play a role in several of these infections including corneal, lung and burn wound infections. In addition, the quorum-sensing systems contribute to the ability of P. aeruginosa to form biofilms on medically important devices. The quorum-sensing systems accomplish their effect by controlling the production of different virulence factors and by manipulating the host immune response.

    Title Pseudomonas Aeruginosa Strains Obtained from Patients with Tracheal, Urinary Tract and Wound Infection: Variations in Virulence Factors and Virulence Genes.
    Date January 2000
    Journal The Journal of Hospital Infection
    Excerpt

    Pseudomonas aeruginosa produces several virulence factors including exotoxin A, exoenzyme S and elastase. In previous reports we have analysed several clinical isolates for the production of these three virulence factors and for possible heterogeneity within the genes that code for these factors (toxA, lasB and the exoS genes). The isolates were obtained from three specific sites (trachea, urinary tract and wounds). Although the isolates produced variable levels of these factors, isolates that were obtained specifically from urinary tract and wound infections produced increased levels of exotoxin A and exoenzyme S. In addition, a prolonged infection with P. aeruginosa appears to enhance exoenzyme S production. Restriction site polymorphism was very limited within the toxA, lasB, and exoS structural genes; however, the upstream region of toxA showed restriction site polymorphisms between the different isolates. The observed polymorphisms did not correlate with any variations in the levels of the virulence factors. In this article, we provide a short review of these studies.

    Title Contribution of Quorum Sensing to the Virulence of Pseudomonas Aeruginosa in Burn Wound Infections.
    Date November 1999
    Journal Infection and Immunity
    Excerpt

    The Pseudomonas aeruginosa quorum-sensing systems, las and rhl, control the production of numerous virulence factors. In this study, we have used the burned-mouse model to examine the contribution of quorum-sensing systems to the pathogenesis of P. aeruginosa infections in burn wounds. Different quorum-sensing mutants of P. aeruginosa PAO1 that were defective in the lasR, lasI, or rhlI gene or both the lasI and rhlI genes were utilized. The following parameters of the P. aeruginosa infection were examined: (i) lethality to the burned mouse, (ii) dissemination of the P. aeruginosa strain within the body of the infected mouse (by determining the numbers of CFU of P. aeruginosa within the liver and spleen), and (iii) spread of the P. aeruginosa strain within the burned skin (by determining the numbers of CFU of P. aeruginosa at the inoculation site and at a site about 15 mm from the inoculation site [distant site]). In comparison with that of PAO1, the in vivo virulence of lasI, lasR, and rhlI mutants was significantly reduced. However, the most significant reduction in in vivo virulence was seen with the lasI rhlI mutant. The numbers of CFU that were recovered from the livers, spleens, and skin of mice infected with different mutants were significantly lower than those of PAO1. At 8 and 16 h post burn infection, comparable numbers of CFU of PAO1 and lasI and rhlI mutants were obtained from both the inoculation and distant sites of the burned skin of infected mice. In contrast, CFU of the lasR mutant and the lasI rhlI double mutant were recovered only from the inoculation site of infected mice at 8 and 16 h post burn infection. The ability of a plasmid carrying either the lasI or rhlI gene or the lasI and rhlI genes to complement the defect of the lasI rhlI double mutant was also examined. The presence of any of these plasmids within the lasI rhlI double mutant significantly enhanced its in vivo virulence, as well as its ability to spread within the burned skin. These results suggest that the quorum-sensing systems play an important role in the horizontal spread of P. aeruginosa within burned skin and in the dissemination of P. aeruginosa within the bodies of burned-and-infected mice and contributed to the overall virulence of P. aeruginosa in this animal model.

    Title Bradykinin Metabolism in Perfused Rat Kidney.
    Date August 1999
    Journal Shock (augusta, Ga.)
    Excerpt

    The purpose of this study was to assess the capacity of perfused rat kidney to inactivate bradykinin (BK), and to compare the BK degrading capacity of rat kidney with the BK degrading capacities of rat lung, liver, and skeletal muscle, which was approximated by perfusion of rat hind limbs. Radioactively labeled BK, with the Pro2 and Pro3 residues having been tritiated, in an asanguinous salt solution was perfused through the kidney of the rat, over a concentration range of .0028-33 microM. Rat kidney had a large capacity to degrade BK and the system did not appear to approach saturation until perfusate BK concentrations reached 24 microM. A least-squares linear regression analysis and extrapolation to zero concentration was used to obtain values for amounts of BK degraded and BK fragments formed. The amount of BK cleaved was 99.9% of the administered dose. The major tritiated BK fragments formed, and the amount of each expressed as a percentage of the amount of BK degraded during transrenal passage, were the amino acid proline derived from the Pro2 and/or Pro3 residues of BK (Pro2,3), 60%; Pro-Pro (BK 2-3), 12%; Arg-Pro-Pro-Gly-Phe (BK 1-5), 14%; and Arg-Pro-Pro-Gly-Phe-Ser-Pro (BK 1-7), 14%. The formation of BK 2-3 is indicative of initial aminopeptidase-P cleavage of BK to yield Arg, and des-Arg1-BK. Thus in rat kidney the aminopeptidase-P pathway is the major route for BK degradation, as is the case in rat liver.

    Title Contribution of the Regulatory Gene Lasr to the Pathogenesis of Pseudomonas Aeruginosa Infection of Burned Mice.
    Date April 1999
    Journal The Journal of Burn Care & Rehabilitation
    Excerpt

    Pseudomonas aeruginosa is a gram-negative opportunistic pathogen that causes severe infections in patients with burns. The P aeruginosa regulatory gene, lasR, regulates the expression of several virulence factors. The specific lasR isogenic mutant, PAO-R1, is defective in the synthesis of the 2 elastases (LasB and LasA) and produces low levels of exotoxin A and alkaline proteases. In this study, we used a burned mouse model to examine the role of lasR in the pathogenesis of P aeruginosa infections. We have examined the following aspects of P aeruginosa infections: 1) lethality to the burned mouse, 2) the dissemination within the body of the burned mouse, and 3) the local spread within the burned skin. In comparison with its parent strain, PAO1, PAO-R1 was less lethal. In addition, the numbers of PAO-R1 microorganisms recovered from the livers and spleens of the burned mice were less than those of PAO1. Furthermore, at 8 hours postinfection, equivalent numbers of PAO1 and PAO-R1 were detected at the inoculation site of the burned skin. However, only PAO1 microorganisms were detected at other sites of the burned skin. These results suggest that the lasR gene contributes (directly and indirectly) to the dissemination of P aeruginosa within the body of burned mice and its horizontal spread within the burned skin.

    Title Analysis of Pseudomonas Aeruginosa Clinical Isolates for Possible Variations Within the Virulence Genes Exotoxin A and Exoenzyme S.
    Date March 1999
    Journal The Journal of Surgical Research
    Excerpt

    We have previously characterized several Pseudomonas aeruginosa isolates that were obtained from patients with tracheal, urinary tract, or wound infections (A. H. Hamood, J. A. Griswold, and C. M. Duhan, 1996, J. Surg. Res. 61: 425). Analysis of additional isolates showed that regardless of the isolation site, some isolates produced significantly higher or significantly lower levels of either exotoxin A or exoenzyme S proteins. These variations did not correlate with the mucoid phenotype of the isolates. One aim of this study was to determine if the variations in the level of exotoxin A or exoenzyme S are due to DNA rearrangements within either the toxA or the exoS gene. This was accomplished by Southern blot hybridization experiments using a toxA internal probe, a toxA upstream probe, or an exoS internal probe. Hybridization with the toxA internal probe produced a 0.8-kb hybridizing fragment, whereas hybridization with the exoS internal probe produced either a 2.0- or a 2.3-kb hybridizing fragment. Hybridization with the toxA upstream probe, however, produced hybridizing fragments of varying sizes, regardless of their isolation site. Isolates that showed a similar hybridization fragment with either the toxA upstream probe or the exoS internal probe produced variable levels of exotoxin A or exoenzyme S. These results suggest that: [1] specific location within the host has no effect on either the mucoid phenotype of the isolate or the level of exotoxin A or exoenzyme S produced by the isolates; [2] although restriction polymorphism exists within the toxA upstream region, both the toxA and the exoS structural genes are relatively conserved; and [3] variations in the level of exoenzyme S and exotoxin A produced by different isolates do not correlate with either the observed heterogeneity within the toxA upstream region or the mucoid phenotype of the isolates.

    Title Bradykinin Metabolism in Rat Hind Limbs.
    Date November 1998
    Journal Shock (augusta, Ga.)
    Excerpt

    The purpose of this study was to assess the capacity of perfused rat hind limbs, the majority of which is skeletal muscle, to inactivate bradykinin (BK), and to compare the BK degrading capacity of rat hind limbs with the BK degrading capacities of rat lung and liver. BK, with tritiated Pro2 and Pro3 residues, in an asanguinous salt solution was perfused for a single passage through skeletal muscle and other tissues in the hind legs of the rat over a concentration range of .0029 to 49.3 microM. Rat hind limbs had a large capacity to degrade BK and the system did not approach saturation, even at 49.3 microM. A least-squares linear regression analysis and extrapolation to zero concentration was used to obtain values for amounts of BK degraded and BK fragments formed. The amount of BK cleaved was 95% of the administered dose. The major BK fragments formed, and the amount of each expressed as a percentage of the amount of BK degraded were Pro-Pro (BK 2-3), 8.6%; Arg-Pro-Pro-Gly-Phe (BK 1-5), 82%; and Arg-Pro-Pro-Gly-Phe-Ser-Pro (BK 1-7), 6%. The BK 1-5 yield was reduced from 82% to one-fourth of that by angiotensin converting enzyme (ACE) inhibitors. BK 2-3 formation is indicative of initial aminopeptidase-P cleavage of BK to yield Arg, and des-Arg1-BK. ACE inhibitor sensitive formation of BK 1-5 is indicative of initial kininase-II, also known as ACE, cleavage of BK. Thus in rat hind limbs, the ACE pathway is the preponderant mechanism for BK degradation, which is in contrast to our previously published reports that in rat liver the amino-peptidase-P pathway predominates, and that in rat lung both the aminopeptidase-P pathway and the ACE pathway exhibit nearly equal capacities to degrade BK.

    Title Modulation of Immune Response in Thermal Injury by Essential Fatty Acid-deficient Diet.
    Date February 1997
    Journal The Journal of Burn Care & Rehabilitation
    Excerpt

    This study was performed to determine the effects of essential fatty acid-deficient diet (EFAD) on immune parameters at 24 hours and 1 week after burn injury. Sprague Dawley rats were fed an EFAD diet or chow diet for 14 days. Twenty percent of the animals were put to death before the burn treatment (day 0), and the remainder were selected randomly to receive a scald or sham injury. Elevation in natural killer cell activity for EFAD-fed animals compared with rats fed the control diet was demonstrated at 100:1 effector:target (E:T) ratio on postburn day 1, and 25:1 E:T ratio on postburn day 7. EFAD-fed animals had significantly higher T-cell proliferation for all doses of phytohemagglutinin than did control animals before the burn injury. One week after the injury, EFAD-fed animals' T-cell activity was reduced to a level equivalent to that of control chow animals, whereas burned chow rats' lymphocyte activity was diminished significantly. EFAD diets enhanced T-cell proliferation and modestly improved natural killer cell response in both burned and control animals.

    Title Bradykinin Metabolism in the Liver and Lung of the Rat.
    Date January 1997
    Journal The Journal of Surgical Research
    Excerpt

    Bradykinin (BK) in an asanguinous salt solution was perfused through intact rat liver. The perfusate was delivered through the portal vein and was collected from the inferior vena cava. BK concentrations varied from 0.0030 to 38.0 microm. The liver had a large capacity to degrade BK and the system did not approach saturation until perfusate BK concentrations reached 60 microm. The quantitatively predominant BK fragments formed and the amount of each formed, expressed as a percentage of the BK degraded during a single transhepatic passage, were Pro-Pro, 74%; Arg-Pro-Pro-Gly-Phe, 15%; and Arg-Pro-Pro-Gly-Phe-Ser-Pro, 7%; the first is indicative of initial aminopeptidase-P cleavage of BK to yield Arg and des-Arg1-BK and the latter two are indicative of initial angiotension converting enzyme (ACE) cleavage of BK. On the other hand, while the perfused rat lung also had a large capacity to degrade BK, the quantitatively predominant BK fragments formed and the amount of each formed, again expressed as a percentage of BK metabolized during a single transpulmonary passage, were Pro-Pro, 47%; Arg-Pro-Pro-Gly-Phe, 35%; and Arg-Pro-Pro-Gly-Phe-Ser-Pro, 7%. Thus in rat liver the aminopeptidase-P pathway is the major route for BK degradation, whereas in rat lung the aminopeptidase-P and the ACE pathways exhibit nearly equal capacities to degrade BK.

    Title Trauma in Pregnancy: the Role of Interpersonal Violence.
    Date August 1996
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: Our purpose was to determine what role interpersonal violence as intentional injury plays in the pregnant trauma victim. STUDY DESIGN: We performed a retrospective review of medical records. RESULTS: During a 9-year period in a single university medical and trauma center, 203 pregnant women were treated for a physically traumatic event. Sixty-four women (31.5%) were victims of intentional injury, in most cases by the husband or boyfriend. Although the mean Injury Severity Score was higher in women with fetal death than in women with successful pregnancy outcomes (7.25 vs 1.74, respectively; p < 0.01), 5 of the 8 women with fetal losses incurred these despite an apparent absence of physical injury (maternal Injury Severity Score = 0). CONCLUSIONS: Interpersonal violence during pregnancy is a frequent and increasingly common cause of maternal injury. The inconsistent relationship between Injury Severity Score and serious fetal injury or death is underscored by the loss of 5 fetuses despite an Injury Severity Score of 0.

    Title Production of Extracellular Virulence Factors by Pseudomonas Aeruginosa Isolates Obtained from Tracheal, Urinary Tract, and Wound Infections.
    Date July 1996
    Journal The Journal of Surgical Research
    Excerpt

    This study was conducted to determine the effect of the local environment within the host on the ability of P. aeruginosa to produce different extracellular virulence factors (elastase, phospholipase C, toxin A, and exoenzyme S). A total of 105 P. aeruginosa isolates was obtained from patients with tracheal, urinary tract, and wound infections. Quantitative analysis of the virulence factors was done by growing the isolates in vitro in different defined media. Single colonies of each isolate were inoculated from the primary isolation plates into the defined medium. All four virulence factors were produced by most isolates. However, depending on the location of their isolation, the isolates varied in the level of virulence factors they produced. High levels of elastase and phospholipase C were produced by most isolates obtained from trachea, urinary tract, and wounds. A significantly higher level of toxin A was produced by wound isolates, while a significantly higher level of exoenzyme S was produced by wound and urinary tract isolates. Some P. aeruginosa strains were frequently isolated from the same site of infection (persistent infection isolates). Comparative analysis of virulence factors produced by these isolates showed that, regardless of the isolation site, subsequent isolates produced higher levels of exoenzyme S. These results suggest that: (1) elastase, phospholipase C, toxin A, and exoenzyme S are produced by P. aeruginosa isolates from different sites of infection; (2) the production of higher levels of elastase and phospholipase C is important in all types of infections, while the production of toxin A and exoenzyme S is important in wound infection; (3) persistent infection with P.aeruginosa may enhance exoenzyme S production.

    Title The Effect of Smoke Inhalation on Bradykinin Metabolism by the Perfused and Ventilated Rat Lung.
    Date February 1996
    Journal The Journal of Burn Care & Rehabilitation
    Excerpt

    The effect of smoke inhalation on bradykinin metabolism was studied in the rat lung perfused with Ringer's bicarbonate solution. After smoke (from cotton, polyester, or seat cushion material) inhalation, tritium-labeled bradykinin was added to the Ringer's bicarbonate solution, and then the lung perfusion effluent aliquots containing bradykinin and its metabolic fragments were collected after a single transpulmonary passage. For the 20 control rats without smoke inhalation, 91% of the bradykinin dose was metabolized, with Pro-Pro (I), 49%, and Arg-Pro-Pro-Gly-Phe (II), 32%, being the predominant bradykinin cleavage fragments. For 12 rats with smoke inhalation, 89% of the bradykinin dose was metabolized, with I (28%) and II (36%) being the major bradykinin cleavage fragments. The type of smoke did not significantly alter the capacity of the rat lung to metabolize bradykinin. Exposure to smoke from seat cushion material for more than 3 minutes caused pulmonary edema and thickening, and smoke exposure for more than 5 minutes caused loss of integrity at the lung alveolar-capillary interface. In contrast, exposure to cotton or polyester smoke did not cause any observable gross changes of the lung. Electron microscopic examination of lung exposed to seat cushion material smoke revealed considerable damage, with the type I epithelium existing as patches on the alveolar surface and capillary endothelium separated from the basement lamina. Thus in our model acute, short-term inhalation of smoke did not significantly alter the amount of bradykinin metabolized by the pulmonary endothelium so long as the integrity of the lung alveolar-capillary interface was maintained, although there seemed to be a moderate shift in the amount of major cleavage fragments from I to II.

    Title A Comparison of Xeroform and Skintemp Dressings in the Healing of Skin Graft Donor Sites.
    Date July 1995
    Journal The Journal of Burn Care & Rehabilitation
    Excerpt

    The best donor site dressing would minimize pain while it increased the rate of healing. This study compares a standard fine-mesh gauze dressing, Xeroform (Sherwood Medical Industries Ltd., Markham, Ontario, Canada), to a new collagen-based dressing, SkinTemp (BioCore Inc., Topeka, Kan.). Eight patients requiring two donor sites of equal size received Xeroform gauze on one site and SkinTemp on the other. The Xeroform was covered for 24 hours and was then allowed to air-dry. Healing was determined to be complete once the gauze peeled off and complete epithelialization was observed. The SkinTemp was covered for 7 days and inspected on days 3, 5, and 7. Pain was measured daily with a standard visual analog scale. Mean Xeroform donor site size was 224.75 cm2, and SkinTemp size was 319.87 cm2. Donor site thickness was 0.012 to 0.014 inches for both. Mean length of healing was 10.62 days for Xeroform and 7.75 days for SkinTemp. Mean pain rating was 22.28 mm for Xeroform and 15.29 mm for SkinTemp. The overall preference of the eight subjects yielded five choosing SkinTemp and three choosing Xeroform, and seven reported SkinTemp as less painful. SkinTemp dressing appears to be less painful and has a better healing rate compared with Xeroform.

    Title The Mangled Lower Extremity: Can Salvage Be Predicted?
    Date January 1994
    Journal The American Surgeon
    Excerpt

    The ability to predict amputation following combined orthopedic, vascular and soft tissue trauma to an extremity could eliminate prolonged attempts at salvage of a doomed limb. We reviewed our experience with 48 mangled lower extremities in 46 patients. Twenty-one penetrating wounds and 25 blunt injuries occurred in 37 men and nine women ranging in age from 3 to 59 years. Severity of injuries to muscle, skin, and major nerves were strongly interrelated (r = 0.49 to 0.74, P < 0.001), but there were no correlations between injuries to these tissues and severity of bone injury (r < 0.19, P > 0.20). Twenty-four limbs were salvaged, and 24 were amputated. Increased severity of soft tissue injury was associated with a greater probability of limb loss (P < 0.001), but limb salvage or amputation could not be predicted accurately by any variable or group of variables such as age, mechanism of injury, Injury Severity Score, presence of shock, level of injury, venous injury or repair, sequence of repair (vascular vs skeletal), time of fasciotomy, arteriography, blood requirement, or duration of ischemia. Amputation was best predicted by severity of injury to the sciatic or tibial nerves (P < 0.001), and by failure of arterial repair (P < 0.01). Severe extremity injuries require a coordinated approach and decisions regarding amputation require careful judgement. These decisions cannot always be made at the time of presentation or during the initial operation. If after revascularization and skeletal stabilization the extremity is clearly nonviable or remains insensate, then delayed amputation can be performed under more controlled circumstances.

    Title The Role of Infection in Outcome of Multiple Organ Failure.
    Date December 1993
    Journal The American Surgeon
    Excerpt

    It is widely assumed that infections are the principal cause and primary outcome determinant of the syndrome of Multiple Organ Failure (MOF) in critically ill patients. Infections are frequent in these patients, but the prevention and treatment of infections may not influence the course of MOF. This study tested the hypothesis that infections play a decisive role in the outcome of MOF. Data were gathered concurrently on all adult patients admitted over an 18-month period to a non-cardiac surgical ICU at a university hospital and recorded in a computer database. Sepsis was defined as a state characterized by at least three of the following: fever, tachycardia, leukocytosis or leukopenia, increased cardiac index, reduced systemic vascular resistance, and hypercatabolism manifested by nitrogen-wasting. The presence of an infection was not required for the diagnosis of sepsis. Mild sepsis was defined as the presence of three or four parameters. Severe sepsis was defined as the presence of five or six parameters. MOF was defined as the development of dysfunction of at least two of the following major organ systems: cardiac, gut, pulmonary, renal, cerebral, and hepatic. Of 749 admissions, 73 patients developed MOF. Thirty four (47%) had a documented source of infection, 37 (51%) had positive blood cultures, and all had sepsis. Hospital mortality was 66 percent (48 of 73 patients). Death could not be predicted by bacteremia (P > 0.25), nor by the presence of an infectious source (P = 1.0), but was strongly associated with severe sepsis (P < 0.0005).(ABSTRACT TRUNCATED AT 250 WORDS)

    Title Outpatient Skin Grafting of Extremity Burn Wounds with the Use of Unna Boot Compression Dressings.
    Date November 1993
    Journal The Journal of Burn Care & Rehabilitation
    Excerpt

    Thirty-one patients underwent split-thickness skin grafting for burn injuries of an extremity, after which Unna Boot compression dressings were applied for fixation of the graft. Three patients required hospitalization of 2 to 4 days, and 28 patients were treated strictly on an outpatient basis. The lower extremity was involved in 25 patients, and the upper extremity was involved in six. Average wound size was 284 cm2. Eighteen patients were treated with sheet grafts, and 13 received meshed grafts. Nine wounds extended across a joint. Patients were allowed immediate ambulation after surgery. All grafts resulted in 95% to 100% wound coverage, and no regrafting was required. Application of Unna boot compression dressings to extremity skin grafts provides excellent protection of both meshed and nonmeshed grafts and allows immediate ambulation and range of motion. Many patients with burn injuries may be treated on an outpatient basis with the use of this technique.

    Title Computed Tomography in the Management of Blunt Thoracic Trauma.
    Date September 1993
    Journal The Journal of Trauma
    Excerpt

    Computed tomographic (CT) scanning has proved to be valuable in evaluating the head and abdomen of victims of blunt trauma; CT scans of the thorax often are obtained on patients with blunt torso trauma, but their value for this purpose is unclear. We conducted a prospective study to evaluate the role of chest CT scanning in thoracic trauma. Hemodynamically stable patients at least 18 years old with an estimated Abbreviated Injury Scale--Thorax score of 2 or greater underwent a contrast-enhanced CT scan of the chest, usually in conjunction with CT scans of the head, abdomen, or both. Thirteen patients were dead on arrival, 14 required emergency surgical procedures, and 13 were too unstable to undergo chest CT scan. Thirty-three patients were not included because they refused to participate or the protocol was not followed. Forty-six men (69%) and 21 women with a mean age of 42.7 years completed the study. Sixty-one were injured in motor vehicle crashes, four were injured in falls, and one each was injured by assault and by crushing forces. Injury Severity Scores ranged from 4 to 45, with a mean of 20.5. Four patients died (6%), three from head injury and one from multiple organ dysfunction. Chest roentgenography (CXR) was superior to CT scanning in identifying rib fractures, but CT scanning was more sensitive than CXR for pneumothorax, fluid collections, and infiltrates (p < 0.001); CT scanning also was more specific for aortic injury. Despite this quantitative superiority, the abnormalities missed by CXR but identified by CT scanning infrequently led to a change in management.(ABSTRACT TRUNCATED AT 250 WORDS)

    Title White Blood Cell Response to Burn Injury.
    Date September 1993
    Journal Seminars in Nephrology
    Excerpt

    Multiple sites of decreased immune response have been discovered, but the instigation of this diffuse immunosuppression remains a matter of much debate. Several investigators have observed immunosuppressive affects of low-molecular weight peptides found in the serum of burn and trauma patients. These substances have been termed suppressive active peptides (SAP). Current research is also focusing on the intricate connection between stress hormones and neurotransmitters, in which there exist a complex information channel between the immune, endocrine, and central nervous systems. It is becoming clear that immune homeostasis may require regulatory influence via immunocompetent cells, along with influences from the central nervous system and a balanced endocrine environment. In fact, macrophages, lymphocytes, and neutrophils contain receptors for many hormones including corticosteroids, insulin, growth hormone, catecholamines, acetylcholine, and endorphins. The dramatic alteration in the hormonal milieu after injury may play a significant role in immunocompetence. Attempts to modulate specific defects in the immune system have been unsuccessful to date. Our goal, to decrease the risk of infection in burn patients, therefore, is meticulous supportive care. This includes not only reducing the risk of invading bacteria, but also increasing the patient's resistance to overall infection. The cornerstone of this support is to restore mechanical barrier function to as near normal as possible. Immediately after injury, vigorous wound management includes several daily debridements combined with wound protection using an appropriate topical antimicrobial substance.(ABSTRACT TRUNCATED AT 250 WORDS)

    Title Essential Fatty Acids Influence Survival in Sepsis.
    Date August 1993
    Journal The Journal of Trauma
    Excerpt

    Metabolites of arachidonic acid, formed from omega-6 essential fatty acids (n-6), play a pathologic role in mortality from sepsis. Metabolites of eicosapentaenoic acid, formed from omega-3 essential fatty acids (n-3), are less potent inflammatory mediators. Dietary restriction of n-6 fatty acids or supplementation with n-3 fatty acids in the form of fish oil have been shown to decrease the production of n-6 metabolites. Male Sprague-Dawley rats (350-400 g) were divided to receive either rat chow (CHOW) or essential-fatty-acid-deficient chow (EFAD) and subdivided to receive 1 mL daily of either fish oil (N3), linoleic acid (N6), or normal saline (NS), via gastric gavage. Two weeks later, half of the animals in each group underwent cecal ligation and puncture (CLP) to induce peritonitis or sham (SHAM) celiotomy. Survival was tabulated for 7 days. Survival was significantly decreased for animals undergoing CLP for both the N6 and NS groups but not for the N3 group. Omega-3 fatty acids as the sole essential fatty acids or as a supplement to a "routine" diet, when fed to rats for 2 weeks before a septic challenge, improved survival in this peritonitis model.

    Title Trauma is a Recurrent Disease.
    Date July 1993
    Journal Surgery
    Excerpt

    BACKGROUND. Many victims of trauma have a history of repetitive accidental or violent injuries, which implies that trauma is not necessarily a random event. Recurrent trauma is thought to be a problem of urban areas, associated with criminal activities, but there are few data from rural areas that include the victims of nonintentional injuries. METHODS. The prior trauma experience of 200 consecutive patients admitted for trauma was compared with that of 100 consecutive emergency nontrauma surgical admissions and 100 elective surgical admissions to a university hospital and level I trauma center. RESULTS. Trauma patients were younger than emergency patients and elective surgery patients. They were more likely to be male than either emergency or elective surgery patients and, along with emergency nontrauma patients, were more likely to be from a racial minority than were elective admissions. Trauma patients were more likely to have had a previous hospitalization for an injury than either emergency patients or elective surgery patients, and a greater proportion of their prior trauma admissions had been within the past 5 years than in the other two groups. There was no difference in the probability of a prior trauma admission between patients admitted with an intentional injury or an accidental injury, but patients whose current admission was for an intentional injury were three times more likely to have had a prior hospitalization as a result of an intentional injury than were patients admitted because of an accidental injury. CONCLUSIONS. Trauma is a disease with a high risk of recurrence. This may be related to chronic high-risk behaviors such as alcohol or drug abuse, preexisting psychopathology, and cultural acceptance of violent resolution of personal conflicts, all of which adversely affect patients' lives. The role of intensive preventive measures after an initial injury, and directed toward specific high-risk behavior, should be evaluated.

    Title Injury Severity Dictates Individualized Antibiotic Therapy in Penetrating Abdominal Trauma.
    Date May 1993
    Journal The American Surgeon
    Excerpt

    Antibiotics play a crucial role in reducing the risk of postoperative infection in patients suffering penetrating abdominal trauma. The infection rate for patients with these injuries ranges from 7% to 16%. Single agents with broad-spectrum activity have proven efficacy, but dosage and duration are still controversial. A prospective, double-blinded study was performed on 102 patients randomized to receive one of three antibiotics for a total of 12 hours: cefoxitin (3 doses, 31 patients); ceftizoxime (2 doses, 36 patients); or mezlocillin (3 doses, 35 patients). Two distinct groups at risk for postoperative infection were evident depending on the severity of injury: Group A were those with no colon injury or a colon injury that could be repaired, no evidence of shock, or fewer than 3 organs injured; Group B were those requiring a colostomy, evidence of shock on presentation, or three or more organs injured. All comparisons of the patient populations receiving the different antibiotics showed the two groups to be equivalent. The mean penetrating abdominal trauma index for Group A was 8.8 and 28.2 for Group B. The overall infection rate for Group A was 10.3% and 42.3% for Group B. There was a significant increase in infection rate for all antibiotics except ceftizoxime in Group B compared with group A. The penetrating abdominal trauma index was significantly higher in all patients who developed infection for all antibiotics. In addition, if the surgical wound was closed primarily, patients with colon injuries developed wound infections 71% of the time, and those with small-bowel injuries did so 30% of the time.(ABSTRACT TRUNCATED AT 250 WORDS)

    Title Sepsis and Infection in the Intensive Care Unit: Are They Related?
    Date May 1993
    Journal The American Surgeon
    Excerpt

    Sepsis is a clinical syndrome characterized by fever, leukocytosis or leukopenia, tachycardia, increased cardiac index, reduced systemic vascular resistance, and hypercatabolism. It is generally believed to be a response to invasive infections, although an infectious source cannot always be identified in patients with sepsis. Over an 18-month period 287 patients were admitted for more than 48 hours to a noncardiac adult surgical intensive care unit. Data were collected concurrently and recorded in a computer database. Seventy-three patients (25%) developed sepsis, and 50 (68% of those with sepsis) had bacteremia, with a mean of 1.5 organisms and 3.5 positive blood cultures per patient. Only 22 of 50 patients with bacteremia had a potential infectious source, and there was a concordance of cultures from the putative source and the blood stream in only 10 patients. Forty-one patients with sepsis (56%) had no apparent infectious source, but 28 of these (68%) had bacteremia, often with multiple organisms. Forty of the 73 patients with sepsis died in the hospital. Mortality in sepsis could not be predicted by the presence of an infectious source (P > 0.35) and was not related to bacteremia (P > 0.75). Mortality was strongly associated with the development of multiple organ failure (P < 0.0001). Sepsis is a generic response to a number of physiologic insults and does not require infection for expression. This inflammatory response may have survival value by increasing oxygen delivery to sites of injury, but uncontrolled inflammation may cause dysfunction in several vital organ systems. The associated immunosuppression results in bacterial colonization of sites from which bacteria ordinarily are excluded.(ABSTRACT TRUNCATED AT 250 WORDS)

    Title Surgical Approach of Choice for Penetrating Cardiac Wounds.
    Date March 1993
    Journal The Journal of Trauma
    Excerpt

    One hundred nineteen patients suffered penetrating cardiac trauma over a 15-year period: 59 had gunshot wounds, 49 had stab wounds, and 11 had shotgun wounds. The overall survival rate was 58%. The most commonly injured structures were the ventricles. Twenty-seven patients had injuries to more than one cardiac chamber. Thirty patients had associated pulmonary injuries. Emergency thoracotomy was performed in 47 patients with 15% survival. Median sternotomy was used in 30 patients with 90% survival. Seventeen of the 83 patients with thoracotomies required extension across the sternum for improved cardiac exposure or access to the contralateral hemithorax. Only one patient with sternotomy also required a thoracotomy. All pulmonary injuries were easily managed when sternotomy was used. We conclude that sternotomy provides superior exposure for cardiac repair in patients with penetrating anterior chest trauma. We feel it is the incision of choice in hemodynamically stable patients. Thoracotomy should be reserved for unstable patients requiring aortic cross-clamping, or when posterior mediastinal injury is highly suspected.

    Title Grossly Positive Peritoneal Lavage and Nontherapeutic Laparotomy After Abdominal Stab Wound.
    Date December 1992
    Journal Journal of the Mississippi State Medical Association
    Excerpt

    Diagnostic peritoneal lavage is often employed in the evaluation of stab wounds of the anterior abdomen and lower chest. This technique is perhaps too sensitive, however, in detecting self-limited solid visceral and abdominal wall injuries. We report five cases of nontherapeutic laparotomies in abdominal stab wound victims who had a grossly positive peritoneal lavage prior to surgery. Previous retrospective data indicate that such "false positive" lavages most commonly result from blood entering the abdominal cavity from the wound, although nonoperative injuries to solid viscera and iatrogenic trauma are sometimes implicated. We review these studies and suggest caution in relying too much on lavage results in determining the need for exploration after abdominal stab wounds. Rather, they must be considered alongside other findings in assessing each individual case.

    Title Two Crack Cocaine Body Stuffers.
    Date November 1992
    Journal Annals of Emergency Medicine
    Title Intracranial Complications of Mucormycosis: an Experimental Model and Clinical Review.
    Date July 1992
    Journal The Laryngoscope
    Excerpt

    The clinical course of patients with mucormycosis of the paranasal sinuses can be unpredictable and is often determined by intrinsic host factors. The degree to and mechanism(s) by which these factors influence a patient's ability to survive the disease are poorly understood. Extensions to orbital and intracranial structures occur in some patients with paranasal sinus mucormycosis despite aggressive treatment. Controversies persist over adequate antifungal regimen, the precise role of hyperbaric oxygenation, and the appropriate extent of surgical debridement. We have developed an alloxan-induced immunocompromised murine model of mucormycosis in mice. Deferoxamine iron chelation produced rhinocerebral mucormycosis in these animals when challenged intraethmoidally with Rhizopus spores. The implications of our experimental studies in the content of our clinical experience in managing patients with intracranial extensions of paranasal sinus mucormycosis are discussed.

    Title Lower Extremity Fracture Fixation in Head-injured Patients.
    Date June 1992
    Journal The Journal of Trauma
    Excerpt

    Compared with nonsurgical management or delayed repair, early fracture fixation can reduce the incidence of pulmonary complications in patients with long-bone fractures of the lower extremities. Blunt trauma victims often have multiple nonskeletal injuries that might influence the risk of pulmonary complications, and when head injuries are present it has been a common practice to delay nonemergent operations for several days to protect the injured brain. We conducted a retrospective review of 114 patients with multiple trauma whose injuries included head trauma and a fracture of the neck or shaft of the femur or shaft of the tibia to determine if delayed stabilization of lower extremity fractures increased the risk of pulmonary complications or reduced the risk of cerebral complications. Forty-six patients underwent surgical fixation of their fractures within 24 hours of injury (early fixation), 26 patients had their fractures repaired more than 24 hours after injury (late fixation), and 42 patients did not undergo surgical fracture fixation. The risk of pulmonary complications was not related to the timing of surgical fracture fixation but was strongly influenced by the severity of injuries to the head and to the chest (p less than 0.001). Furthermore, a delay in fracture fixation did not protect the injured brain; the risk of CNS events was determined by the severity of the head injury (p less than 0.0001). Early fracture fixation in patients with head injury may be appropriate because it simplifies patient care and does not seem to worsen the head injury, but it does not prevent pulmonary complications in these high-risk patients.

    Title Complications of Pelvic Fractures from Blunt Trauma.
    Date June 1992
    Journal The American Surgeon
    Excerpt

    Significant external forces are required to fracture a normal pelvis. These forces usually result from rapid deceleration or crushing injuries, and energy often is delivered to multiple anatomic sites in addition to the pelvis. Associated injuries are common, and numerous complications can occur in patients with pelvic fractures. During 4 years, the authors treated 144 men and 92 women with pelvic fractures from blunt trauma who were admitted directly to the University of Mississippi Medical Center. They had a mean age of 31.5 years, a mean Injury Severity Score of 21.3, and an average hospital stay of 16.8 days. Seventy-seven of the 236 patients (32.6%) had 137 complications, including 18 deaths. Most of these were infections such as pneumonia (6), urinary tract infections (8), wound infections (8), or sepsis without a defined source (10). There was a high incidence of pulmonary complications including Adult Respiratory Distress Syndrome (12), significant atelectasis (7), and fat emboli (3). Musculoskeletal complications (13) and coagulopathy (12) also occurred frequently. Eight patients had thromboembolic events, but prophylactic, subcutaneous heparin was not beneficial in preventing these complications. Patients with complications had higher Injury Severity Scores, lower Trauma Scores, increased transfusion requirements, longer hospital stays, and greater hospital charges compared to those without complications (P less than 0.01 for all variables). There was no association of complications with patient age, sex, mechanism of injury, anatomic site or amount of displacement of the pelvic fracture, or vector of injury. Patients with unstable pelvic fractures were much more likely to have complications than were those with stable pelvic fractures (P = 0.013).(ABSTRACT TRUNCATED AT 250 WORDS)

    Title Peritoneal Neutrophil Chemotaxis is Impaired in Biliary Obstruction.
    Date March 1992
    Journal The American Surgeon
    Excerpt

    Previous studies have shown impaired reticuloendothelial function in biliary obstruction. The chemotactic response of polymorphonuclear leukocytes from peripheral blood and peritoneal fluid of jaundiced rats (Group 1) was compared to that of sham operated controls (Group 2) and normal rats (Group 3). Male Sprague-Dawley rats underwent bile duct ligation or sham celiotomy. Studies were performed from 1 to 3 weeks after surgery. Mean serum bilirubin was 6.8 mg percent in Group 1 and normal in Groups 2 and 3. Peritoneal neutrophils were induced by intraperitoneal injection of 10 ml of 10 percent peptone broth 16 hours before the study, harvested from peritoneal fluid and peripheral blood, and isolated on Ficoll-Hypaque. F-met-leu-phe (FMLP) chemoattractant (10(-7) M) was used to induce migration of neutrophils across 3 mu filters. The filters were removed, mounted on slides, stained, and counts averaged for five oil immersion fields for each of three wells. Data were expressed as number of neutrophils per oil immersion field. Peritoneal neutrophil chemotaxis was significantly decreased in Group 1 (10.3 +/- 8.1) compared with Groups 2 (17.0 +/- 7.3) and 3 (20.2 +/- 6.4). A similar trend was noted in polymorphonuclear leukocytes from peripheral blood (Group 1: 13.1 +/- 7.8, Group 2: 18.2 +/- 6.7, Group 3: 17.4 +/- 5.9; P = 0.1). This impairment in neutrophil chemotaxis may contribute to the high rate of septic complications observed in the jaundiced host.

    Title Pneumonia, Selective Decontamination, and Multiple Organ Failure.
    Date January 1992
    Journal Surgery
    Title Current Therapy of Hand Burn Injuries.
    Date January 1992
    Journal Journal of the Mississippi State Medical Association
    Title Oral Decontamination and Ventilator-associated Pneumonia.
    Date September 1991
    Journal Jama : the Journal of the American Medical Association
    Title Hypertonic Saline Resuscitation: Efficacy in a Community-based Burn Unit.
    Date July 1991
    Journal Southern Medical Journal
    Excerpt

    Many have discussed hypertonic saline for resuscitation in burned patients only to discourage its use or to emphasize it only as a research tool and not as standard resuscitation. We reviewed the records of 47 adults with burns over 20% or more of the total body surface area (TBSA) in whom hypertonic saline was used as standard resuscitation fluid in a large community burn unit. The solution consisted of sodium, 300 mEq/L, acetate, 200 mEq/L, and chloride, 100 mEq/L, with an osmolality of 600 mOsm/L. The mean TBSA burned was 37% and the mean patient age was 44.8 years. Eighteen patients (mean age 39.7 years, mean TBSA burned 27%) received hypertonic saline alone. They required an average of 75% of the Parkland calculated volume to achieve a urinary output of 1 mL/kg/hr. The mean hematocrit value over the first 48 hours was 44.2% and the mean serum sodium level was 141.6 mEq/L. Twenty-nine patients (mean age 51.8 years, mean TBSA burned 47.8%) received hypertonic saline plus colloid (albumin or fresh frozen plasma). Colloid was used in older patients with more serious burns. This group required 57% of the Parkland calculated volume to achieve a urinary output of 1 mL/kg/hr. The mean hematocrit value was 45.1% and mean sodium level was 143.8 mEq/L. The mean weight gain for both groups was 7.3% of the admission weight. None of the patients had changes in pH or renal function. All patients survived the resuscitation phase of their injury; the overall death rate was 49%. We conclude that hypertonic saline is a safe, effective means of resuscitation even in a community-based unit. It allows less fluid to be delivered for adequate resuscitation. The usual hyponatremia, hemoconcentration, and significant weight gain associated with administration of isotonic solutions was avoided. Colloid may further improve the resuscitation capabilities of hypertonic saline.

    Title Pelvic Fracture from Major Blunt Trauma. Outcome is Determined by Associated Injuries.
    Date July 1991
    Journal Annals of Surgery
    Excerpt

    Pelvic hemorrhage has been implicated as the cause of death in 50% of patients who die following pelvic fractures. To establish correlates of morbidity and mortality from pelvic fractures due to blunt trauma, we reviewed 236 patients treated during 4 years. The average age of the 144 men and 92 women was 31.5 years, the average Injury Severity Score was 21.3, the average blood requirement was 5 units, and the average hospital stay was 16.8 days. One hundred fifty-two patients (64.4%) were injured in motor vehicle accidents, 33 (14%) had motor vehicle-pedestrian accidents, 16 (6.8%) had crush injuries, 12 (5.1%) each had either motorcycle accidents or falls, and 11 (4.6%) had miscellaneous accidents. Eighteen patients (7.6%) died, with seven (38.9%) deaths due to hemorrhage. Only one death was caused by pelvic hemorrhage. Other deaths were due to hemorrhage from other sites (6), head injury (5), sepsis or multiple-organ failure (4), pulmonary injury (1), and pulmonary embolus (1). None of the septic deaths was related to a pelvic hematoma. Multivariate multiple regression analysis showed that the severity of injury was correlated with indices of severity of pelvic fractures such as fracture site (p less than 0.0001), fracture displacement (p less than 0.005), pelvic stability (p less than 0.0001), and vector of injury (p less than 0.01). However death could not be predicted on the basis of these indices of severity (p greater than 0.28). Of the nine patients who underwent pelvic arteriography, three required embolization of actively bleeding pelvic vessels, but seven had intra-abdominal hemorrhage that required laparotomy, and eight developed a coagulopathy. Massive bleeding from pelvic fractures was uncommon, and the major threat of hemorrhage was from nonpelvic sites. Furthermore, although injury severity was correlated with the severity of the pelvic fracture, hospital outcome was determined by associated injuries and not by the pelvic fracture.

    Title High Bifurcation of the Brachial Artery.
    Date June 1991
    Journal Injury
    Title Chylous Drainage from a Stab Wound to the Neck.
    Date December 1990
    Journal Annals of Emergency Medicine
    Excerpt

    A 24-year-old man was assaulted and sustained a stab wound to the left lower neck. When he arrived at the emergency department, he was hemodynamically stable. Although the wound had penetrated the platysma, on initial evaluation the patient did not appear to have sustained significant injury. Closer examination of the wound revealed chylous drainage, indicating injury to the cervical portion of the thoracic duct. The patient was taken to the operating room for exploration of the wound, during which an injury to the left internal jugular vein was identified and repaired. The thoracic duct, which had been severed, was ligated. The remainder of the patient's hospital course was unremarkable. The consistent association between penetrating injury to the cervical portion of the thoracic duct and injury to neighboring vascular structures is discussed.

    Title Determinants of Donor Site Infections in Small Burn Grafts.
    Date February 1990
    Journal The Journal of Burn Care & Rehabilitation
    Excerpt

    Studies indicate no advantage to the early use of systemic antibiotics in patients with burns, but the use of prophylactic antibiotics during excision is still being questioned. The records of 213 patients who required excision and who had less than 20% total body surface area burned were reviewed. We investigated risk factors associated with donor- and graft-site infections and whether or not perioperative antibiotics influenced the incidence of infections. Statistically significant increases in donor-site infections occurred when patients did not receive perioperative antibiotics, when the excision was large, and when the time between injury and excision was prolonged. Age, burn size, or type of dressing did not influence the development of infections. A risk of graft infections in those patients who were not receiving perioperative antibiotics existed, but it was not significant. The time between injury and excision and the actual size of the excision influence the development of donor-site infections. However, perioperative antibiotics seem to decrease the risk of these infections.

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