Surgical Infection Society Guidelines for Vaccination after Traumatic Injury

Background: Recommendations for vaccination of injured patients against infection are evolving. Newly-recognized infections, safety considerations, changing epidemiology, and redefinition of patient groups at risk are factors that may influence vaccine development priorities and recommendations for immunization. However, recommendations must often be formulated based on incomplete data, forcing reliance on expert opinion to address some crucial questions. These guidelines provide evidence-based recommendations for the prevention or treatment of infectious morbidity and mortality after traumatic injury, such as soft tissue wounds, human or animal bites, or after splenectomy. Methods: A panel of experts conducted a thorough review of published literature, as well as information posted on the internet at the websites of the U.S. Centers for Disease Control and Prevention, among others. MEDLINE was searched for the period 1966–2004 using relevant terms including anthrax, rabies, tetanus, tetanus toxoid, and splenectomy, in combination with vaccine and immunization. The Cochrane database was searched also. Reference lists were cross-referenced for additional relevant citations. All published reports were analyzed for quality and graded, with the strength of the recommendation proportionate to the quality of the supporting evidence. Results: Recommendations are provided for pre- and post-exposure prophylaxis of rabies and anthrax. For tetanus prophylaxis, recommendations are provided for prophylaxis of acute wounds stratified y age and prior immunization status, and for immunization of persons at high risk. After splenectomy, it is recommended that all persons ages 2–64 years receive 23- valent pneumococcal vaccine and meningococcal vaccine, with Haemophilus influenzae type B vaccine administered to high-risk patients as well (all are Grade D recommendations). Vaccination should be given two weeks before elective splenectomy (Grade C), or two weeks after emergency splenectomy (Grade D). A booster dose of pneumococcal vaccine is recommended after five years (Grade D); no re- vaccination recommendation is made for meningococcal or Haemophilus influenzae type B vaccine. Recommendations for prophylaxis of splenectomized children under the age of five years are also provided. Conclusion: There are limited data on the use of vaccines after injury. This document brings together a disparate literature of variable quality into a discussion of the infectious risks after injury relevant to vaccine administration, a summary of safety and adverse effects of vaccines, and evidence-based recommendations for vaccination

Lipopolysaccharide-reactive immunoglobulin E is associated with lower mortality and organ failure in traumatically injured patients

Antilipopolysaccharide (anti-LPS) immunoglobulin G (IgG) and IgM have been associated with protection from LPS effects in vivo. We investigated the presence of IgE and anti-LPS in 32 patients that had experienced severe traumatic injury and in 35 healthy volunteers; we also investigated whether IgE anti-LPS was associated with important clinical events. Plasma samples were collected daily from patients in the intensive care unit and on one occasion from volunteers; the samples were assayed for IgE anti-LPS. IgE anti-LPS was assayed by enzyme-linked immunosorbent assay with monoclonal anti-human IgE as the capture antibody. Detection was accomplished with biotin-labeled LPS (Escherichia coli J5 mutant) followed by streptavidin-peroxidase with 2,2\u27-azino(3-ethylbenzthiazoline)sulfonic acid as the substrate. The assay was demonstrated to be specific for IgE and LPS-biotin by nonreactivity of control sera with high-titer anti-LPS IgG and IgM and by inhibition with unlabeled LPS. IgE anti-LPS was detected in 1 of 35 healthy controls (2.9%o) and 25 of 32 traumatically injured patients (78%) (P \u3c 0.001). The presence of IgE anti-LPS was associated with a lower incidence of death (P = 0.026) and of renal failure (P = 0.0012). There was no apparent temporal relationship between detection of IgE anti-LPS and clinical events. IgG anti-LPS was detected more frequently in patients that were positive for IgE anti-LPS (P = 0.06) but was not associated with clinical events. The inability to detect IgE anti-LPS may be related to adverse clinical events through depletion of specific IgE due to LPS exposure after trauma or through saturation of the assay by IgE with other specificities. We have reported increased total IgE concentrations in these patients (J. T. DiPiro, R. G. Hamilton, T. R. Howdieshell, N. F. Adkinson, and A. R. Mansberger, Ann. Surg. 215:460-466, 1992)

Methods Of Analysis For Fermentation Science Products Using Various Analytical Techniques

Fermentation science, the study of microorganisms as they digest food sources to produce usable products for consumption, has been around since the dawn of modern civilization. Historically, the fermentation process has been utilized for the production of alcoholic beverages. More recently, however, the production of bioethanol and biodiesel as a fuel source alternative to classical fossil fuels has gained increased popularity. As with any synthetic process, derivations and optimizations for ideal production are needed. As such, analytical techniques must be implemented to ensure quality control and pinnacle efficiency. This body of work describes analytical techniques providing key qualitative and quantitative information about various steps in the fermentation process. Experiences and conclusions drawn about biofuel production are described in two quantitative projects: Storage Analysis of Sugar Saccharification using Ultrahigh Performance Liquid Chromatography using Corona Charged Aerosol Detection (UPLC-CAD), and Thermal Energy Quantitation of Residual Biomass Using Oxygen Bomb Calorimetry (OBC). The first major technique employs liquid chromatography to separate and quantitate major sugars (xylose and glucose) in the saccharification of biomass (switchgrass). Storage conditions can determine the economic viability of switchgrass as an alternative fuel source. As such, the extent of degradation of switchgrass over a course of one year, and limitations of useable sugars produced needed to be assessed. Results showed no significant loss in sugar production over the course of one year from three distinct storage conditions. From an industrial perspective, this provides low cost storage with minimal to no loss in bioethanol and biodiesel. In addition to biofuels, biomass, switchgrass for example, can be used directly as a combustion source to produce thermal energy. The energy produced (BTU/lb.) can be used mainly to power boiler systems or residential stoves to provide heat, and electricity through a steam turbine. Using OBC, the amount of thermal energy produced by biomass, was obtained and similar degradation studies were accessed. As with the sugar production, the extent of degradation was found to be insignificant. An additional preliminary study explored as an alternative to the pretreatment phase: Ionic Liquid (IL) pretreatment of lignin, characterized by Direct Analysis in Real Time Mass Spectrometry (DART-MS). The goal of these projects was the development of methods to characterize and quantitate specific products during major stages of biofuel production applied which can be easily to many fermentation studies. These methods can then be used as a template for further fermentation studies, both in biofuel and alcoholic beverage production

PROGRESS TOWARD INNOVATIONS IN CRYOGENIC ION CLUSTER SPECTROMETERS

Cryogenic Ion Vibrational Spectroscopy (CIVS) is a useful technique that yields rich information about non-covalent interactions in various systems including catalytic complexes, small biologically relevant molecules, and solvent networks. Current instrumentation demands high production costs and large laboratory facilities. We have designed an affordable and compact instrument that is capable of current CIVS experiments. This setup utilizes an ion funnel and a Linear Trap Quadrupole (LTQ) which improves the ion density and allows for spectroscopic interrogation directly in the trap. Preliminary results and future innovations will be discussed

Myocutaneous revascularization following graded ischemia in lean and obese mice

BACKGROUND: Murine models of diabetes and obesity have provided insight into the pathogenesis of impaired epithelialization of excisional skin wounds. However, knowledge of postischemic myocutaneous revascularization in these models is limited. MATERIALS AND METHODS: A myocutaneous flap was created on the dorsum of wild type (C57BL/6), genetically obese and diabetic (ob/ob, db/db), complementary heterozygous (ob(+)/ob(−), db(+)/db(−)), and diet-induced obese (DIO) mice (n=48 total; five operative mice per strain and three unoperated mice per strain as controls). Flap perfusion was documented by laser speckle contrast imaging. Local gene expression in control and postoperative flap tissue specimens was determined by quantitative reverse transcription polymerase chain reaction (RT-PCR). Image analysis of immunochemically stained histologic sections confirmed microvascular density and macrophage presence. RESULTS: Day 10 planimetric analysis revealed mean flap surface area necrosis values of 10.8%, 12.9%, 9.9%, 0.4%, 1.4%, and 23.0% for wild type, db(+)/db(−), ob(+)/ob(−), db/db, ob/ob, and DIO flaps, respectively. Over 10 days, laser speckle imaging documented increased perfusion at all time points with revascularization to supranormal perfusion in db/db and ob/ob flaps. In contrast, wild type, heterozygous, and DIO flaps displayed expected graded ischemia with failure of perfusion to return to baseline values. RT-PCR demonstrated statistically significant differences in angiogenic gene expression between lean and obese mice at baseline (unoperated) and at day 10. CONCLUSION: Unexpected increased baseline skin perfusion and augmented myocutaneous revascularization accompanied by a control proangiogenic transcriptional signature in genetically obese mice compared to DIO and lean mice are reported. In future research, laser speckle imaging has been planned to be utilized in order to correlate spatiotemporal wound reperfusion with changes in cell recruitment and gene expression to better understand the differences in wound microvascular biology in lean and obese states

Using Calibrated Peer Review⢠to Assess and Improve the Quality of Student Documentation of Clinical Encounters at the University of New Mexico School of Medicine (UNMSOM).

The UNMSOM adapted Calibrated Peer Review™, an internet based writing tool, to assist medical students in assessing the structure and content of their clinical notes. Students watch videotaped clinical encounters and write notes based on these patient visits. Students then apply faculty-established standards to assess three calibration notes, the notes of three peers, and their own note. CRR will be demonstrated and student satisfaction described

Outcome of Open Abdominal Management Following Military Trauma

BackgroundTemporary abdominal closure (TAC) is increasingly common after military and civilian major trauma. Primary fascial closure cannot be achieved after TAC in 30 per cent of civilian patients; subsequent abdominal wall reconstruction carries significant morbidity. This retrospective review aimed to determine this morbidity in a UK military cohort.MethodsA prospectively maintained database of all injured personnel from the Iraq and Afghanistan conflicts was searched from 1 January 2003 to 31 December 2014 for all patients who had undergone laparotomy in a deployed military medical treatment facility. This database, the patients' hospital notes and their primary care records were searched.ResultsLaparotomy was performed in a total of 155 patients who survived to be repatriated to the UK; records were available for 150 of these patients. Seventy‐seven patients (51·3 per cent) had fascial closure at first laparotomy, and 73 (48·7 per cent) had a period of TAC. Of the 73 who had TAC, two died before closure and two had significant abdominal wall loss from blast injury and were excluded from analysis. Of the 69 remaining patients, 65 (94 per cent) were able to undergo delayed primary fascial closure. The median duration of follow‐up from injury was 1257 (range 1–4677) days for the whole cohort. Nine (12 per cent) of the 73 patients who underwent TAC subsequently developed an incisional hernia, compared with ten (13 per cent) of the 77 patients whose abdomen was closed at the primary laparotomy (P = 1·000).ConclusionRates of delayed primary closure of abdominal fascia after temporary abdominal closure appear high. Subsequent rates of incisional hernia formation were similar in patients undergoing delayed primary closure and those who had closure at the primary laparotomy

Temporary Closure of the Open Abdomen: A Systematic Review on Delayed Primary Fascial Closure in Patients with an Open Abdomen

Background This study was designed to systematically review the literature to assess which temporary abdominal closure (TAC) technique is associated with the highest delayed primary fascial closure (FC) rate. In some cases of abdominal trauma or infection, edema or packing precludes fascial closure after laparotomy. This "open abdomen'' must then be temporarily closed. However, the FC rate varies between techniques. Methods The Cochrane Register of Controlled Trials, MEDLINE, and EMBASE databases were searched until December 2007. References were checked for additional studies. Search criteria included (synonyms of) "open abdomen,'' "fascial closure,'' "vacuum,'' "reapproximation,'' and "ventral hernia.'' Open abdomen was defined as "the inability to close the abdominal fascia after laparotomy.'' Two reviewers independently extracted data from original articles by using a predefined checklist. Results The search identified 154 abstracts of which 96 were considered relevant. No comparative studies were identified. After reading them, 51 articles, including 57 case series were included. The techniques described were vacuum-assisted closure (VAC; 8 series), vacuum pack (15 series), artificial burr (4 series), Mesh/sheet (16 series), zipper (7 series), silo (3 series), skin closure (2 series), dynamic retention sutures (DRS), and loose packing (1 series each). The highest FC rates were seen in the artificial burr (90%), DRS (85%), and VAC (60%). The lowest mortality rates were seen in the artificial burr (17%), VAC (18%), and DRS (23%). Conclusions These results suggest that the artificial burr and the VAC are associated with the highest FC rates and the lowest mortality rate