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Biomedical subjects

D M Heimbach

Publications and source records attributed to D M Heimbach.

At least 19 recordsLinked to original sources
PubMed2001

The utility of a burn specific measure of pain anxiety to prospectively predict pain and function: a comparative analysis.

Patients treated for burn injuries commonly experience high levels of acute pain and anxiety during hospitalization, particularly as it relates to their dressing changes and other medical procedures. A new instrument, the burn specific pain anxiety scale (BSPAS), was designed to characterize patient's anxiety in this setting, but its predictive validity in relation to other measures of anxiety has yet to be demonstrated. In this study, 27 patients with acute burn injuries completed three measures of anxiety upon admission to a major medical burn trauma center. Scores on the anxiety measures were compared with regard to their ability to predict subsequent ratings of procedural and background pain levels, pain medication usage, and physical and emotional functioning upon discharge. In support of criterion-related validity, the BSPAS was the best predictor of procedural pain levels as rated later the same day relative to the other global anxiety measures; moreover, the BSPAS did not predict later-day background pain levels as hypothesized. Both the BSPAS and the global anxiety measures were found to significantly predict total number of pain medications over a 24-h period. Finally, the BSPAS was the only significant predictor of decreased physical role functioning at discharge whereas the other more global measures of anxiety were better predictors of emotional functioning. These results provide preliminary evidence that the BSPAS is a unique and valid indicator of pain-related anxiety surrounding burn care in hospitalized patients and may be useful in identifying those patients at risk for decreased functional capacity at the time of discharge.

Adolescent↗
PubMed2000

Current status of burn wound pathophysiology.

Healing is a continuum that can be unpredictable. Despite many advances and understanding of the multiple cellular processes and molecules involved in burn wound healing, physicians and patients have yet to reap the full benefit of this knowledge. The advances have occurred in a very short period, and with the exponential growth of molecular biology techniques and transgenic animal models, our understanding and treatment of burn wound healing could change exponentially over the next 10 years. The goal must be to continue to improve functional outcomes for burn survivors just as we have conquered critical care management for acutely injured burn patients.

Angiogenesis Inducing Agents↗
PubMed2000

Modern techniques for wound coverage of the thermally injured upper extremity.

The use of flaps; synthetic, dermal analogues; cultured skin substitutes; or a combination of these may one day help return severely burned arms to normal function and appearance. The complexity and expense of these alternatives limits their use in commonplace burns. As the techniques are refined with increased experience, so also will the roles for each of these options. Fortunately, an excellent result is still possible in most situations using simple autograft. The availability of these numerous choices to acutely cover the thermally injured upper extremity should not distract us from the gold standard of split-thickness skin graft (Fig. 7).

Burns↗
PubMed1999

Methemoglobinemia secondary to topical silver nitrate therapy--a case report.

Methemoglobinemia is a rare complication in individuals exposed to nitrates or nitrites. Whereas methemoglobinemia is a recognized potential complication in burn patients treated with topical 0.5% silver nitrate solution, no report of methemoglobinemia in burn patients has been present in the literature for more than 15 years. We raise consciousness about this complication with a case report of a 12-month-old child with necrotizing fasciitis resulting from a cutaneous flank infection. The patient developed cyanosis 20 days after initiation of topical treatment with 0.5% silver nitrate solution. Intravenous injection of methylene blue can restore normal blood oxygenation.

Administration, Topical↗
PubMed1997

Monocyte chemoattractant protein-1 mRNA expression in the human burn wound.

The inflammatory response following a thermal insult begins with the skin itself. Langerhan's cells, tissue macrophages, keratinocytes, fibroblasts, and endothelial cells contribute to the initial events of wound healing with active and passive release of cell mediators. One of the mediators potentially important to the repair process is monocyte chemoattractant protein-1 (MCP-1). Macrophages, fibroblasts, endothelial cells, and keratinocytes can produce MCP-1 in response to inflammatory stimuli. Therefore, we evaluated 10 human burn wound specimens for MCP-1 mRNA using in situ hybridization. Selected specimens of different ages were examined using combined in situ hybridization and immunocytochemistry to identify cell types that expressed MCP-1 mRNA. Antibodies to HAM56 for macrophages, CD45 for bone marrow-derived cells, Factor VIII for endothelial cells, and Factor XIIIa for dermal antigen-presenting cells were included in these experiments. By Postburn Day 2, basal layer keratinocytes at the edges of the wound had upregulated MCP-1 message; the increased signal persisted in the rate pegs deep in the dermal wound bed through 49 days postinjury. Occasional FXIIIa+ immunostained dermal cells expressed MCP-1 mRNA. Islands of granulation tissue throughout the wound bed were positive for increased expression of MCP-1; endothelial cells and inflammatory cells both contributed to this upregulated signal. Our data support the theory that the skin itself is a component of the immune system and that noninflammatory cells contribute to the initiation and maintenance of the inflammation at a wound site. Failure to produce MCP-1 or other related mediators by indigenous cutaneous cells may delay the inflammatory response to injury and potentially disrupt other essential phases of wound repair.

Antibodies↗
PubMed1995

Immunolocalization of FXIIIa+ dendritic cells in human burn wounds.

Dermal dendrocytes constitute a population of indigenous antigen-presenting cells that have been implicated in dermal inflammation and may have a role in wound healing. They are identified by expression of the transglutaminase coagulation Factor XIIIa (FXIIIa) and a perivascular distribution in the papillary dermis. In this study, we used immunohistochemistry to localize and characterize FXIIIa+ cells in healing burn wounds. Wound specimens from Postburn Days 2, 3, 4, 5, 6, 8, 9, 10, 11, 15, 30, and 49 were collected from 18 patients at the time of excision and grafting, processed for immunolabeling, and labeled with an antibody to FXIIIa. Tissue sections were also double-labeled with the anti-FXIIIa and with antibodies to CD68, specific for macrophages, CD45, specific for bone marrow-derived cells, and proliferating cell nuclear antigen (PCNA) for proliferation. Antigen-presenting status was evaluated using an antibody to the major histocompatibility complex HLA-DR. The dermis subjacent to the tongue of proliferating epithelium at the wound edge had increased numbers of FXIIIa+ dendritic cells compared to the cellular distribution in uninjured skin. FXIIIa+ dendritic cells were absent from the burned dermis on all postburn days examined in this study. However, capillaries in the deep dermis had a FXIIIa+ granular staining pattern. CD68+ cells and CD45+ cells were present throughout the wound bed at all stages of healing, indicating an inflammatory cell response in the injured dermis. Antibodies to PCNA did not colocalize to FXIIIa+ cells, suggesting that the dermal dendrocytes were not proliferating. The antibody to HLA-DR localized to some, but not all of the FXIIIa+ dendritic cells.(ABSTRACT TRUNCATED AT 250 WORDS)

Biomarkers↗
PubMed1995

Pain, coping, and adjustment in patients with burns: preliminary findings from a prospective study.

We prospectively examined the associations between procedural pain during hospitalization and coping and adjustment 1 month postdischarge in 43 patients treated at a major regional burn center for burns extensive enough to require at least 5 days of daily wound debridement procedures. Both patients and nurses provided ratings of patient pain, which were summarized and aggregated across a 5-day period. Results indicated that those subjects with higher pain scores also reported poorer adjustment as measured by scores on the Brief Symptoms Inventory and the Sickness Impact Profile. Moreover, these associations remained significant after partialling out the effects of preburn adjustment. Hierarchical regression analyses revealed evidence that seeking social support had a moderating effect on the association between pain and scores on a measure of posttraumatic stress disorder.

Adaptation, Psychological↗
PubMed1994

Basic fibroblast growth factor in the early human burn wound.

The role of endogenous growth factors in normal wound healing is not clear. Most of the data on growth factors in healing wounds have been obtained from the application of recombinant exogenous growth factors to animal and human wounds. We describe the immunolocalization of basic fibroblast growth factor (bFGF) in the injured dermis of skin from patients with partial and full-thickness burns. Three antibodies demonstrate an extracellular staining pattern of bFGF corresponding to areas of tissue injury that was most intense in specimens collected between 4 and 11 days post-burn injury. In contrast, bFGF staining appeared markedly decreased by Postburn Day 17 and was more consistent with uninjured tissue in a 30-day-old burn that had virtually reepithelialized. Basic FGF staining in the non-burned skin from the same patients was restricted to the dermal capillary basement membranes and the sweat glands, which is consistent with other reports of immunoreactive bFGF localization in normal adult skin. The immunohistochemical results were confirmed with Western immunoblots of the same tissue. The major band at 16.5 kDa, which is within the recognized range of the bFGF molecule's several forms, was detected in both burned and unburned tissue from the same patient. These findings support the hypothesis that bFGF is a presynthesized mediator that is stored in either the cells or extracellular matrix, is released locally from sites of direct injury, and may be important in early wound healing.

Blotting, Western↗
PubMed1994

Changes in transfusion practices in burn patients.

In 1980 patients with burns greater than 10% of total body surface area (TBSA) received a mean of 8 units of blood (range, 0-42 units) during hospitalization in our burn center. Concern about the risks of blood transfusion caused us to reassess our transfusion practices and to question the need to maintain hematocrits above 30%. We compared the quantity of blood given to burn patients at Harborview Medical Center in 1980 with that given in 1990. Available records were reviewed from all patients with greater than 10% TBSA burns who required at least one operation (1980; n = 41; 1990: n = 38). There were no differences between groups for patients' ages, timing of first excision, or length of hospital stay. There were no differences in extent of burn excision per operation, but surgical times were significantly shorter in 1990 than in 1980. In 1980, 1.2 +/- 1.2 mL of blood was transfused per square centimeter surface area excised, compared with 0.23 +/- 0.49 mL in 1990 (p < 0.0001). In 1980, 133 +/- 153 mL blood was transfused per patient per percent burn during the acute hospitalization, compared with 20 +/- 34 mL in 1990 (p < 0.0001). There have been no instances of myocardial infarction or congestive heart failure related to the maintenance of lower hematocrits. We now permit hematocrits to fall to 15%-20% in healthy patients who need limited operations. In healthy patients with more extensive burns we accept hematocrits of 25%, and only critically ill patients and those with pre-existing cardiovascular disease are transfused to hematocrits of 30% or higher.

Adolescent↗
PubMed1994

Engine block burns: Dupuytren's fourth-, fifth-, and sixth-degree burns.

We recently treated two patients with engine block-muffler contact burns and greatly underestimated the devastating injuries to bone, deep fascia, and muscle. As a result, each patient required multiple procedures to close their burn wounds. Ten-year data from the University of Washington Burn Unit confirmed our observation that these burns tend to be considerably deeper than suspected. Eighteen patients with contact burns from engine parts were identified from 1980 through 1990. Nine (50%) of these were initially recognized to be fourth-degree and five (28%) were third-degree thermal injuries, showing that these are deep burns. Eight patients required fascial excisions and four required debridement of devascularized bone. The mean burn size was only 6% total body surface area; however, the patients with fourth-degree burns had an average graft take of only 56% and required a mean hospital stay of 44 days. Patients with third-degree burns also had suboptimal graft take and some required prolonged hospitalization. Thirty-six percent of patients required flaps either as the initial procedure or as a second procedure following an autograft. The four patients with partial-thickness burns healed without surgery and their average length of hospital stay was 3 days. Of the entire group, only four healed without surgery and only five healed with a single operation. Our 10-year data indicate that engine block contact burns are usually small, but most are deceptively deep, involving tendon, muscle, or bone. If the burn appears full thickness, suspicion must be very high at the initial surgical procedure that there is deep tissue destruction.(ABSTRACT TRUNCATED AT 250 WORDS)

Accidents, Traffic↗
PubMed1993

Mediators in thermal injury.

The combined goal of each of the mediators discussed here is homeostasis in a stressful situation. The associated immunosuppression and immunohyperactivity are unfortunate sequelae of massive upregulation of mediators normally produced in miniscule quantities. Perhaps they were once necessary to regulate survival of severely injured patients. However, Stoner's question about whether these mediators are beneficial for modern medical practices is very relevant. Our significant challenge is now to counteract the body's own efforts to heal itself. Understanding the interactions initiates this task; discovering therapeutic control mechanisms must be the next step.

Arachidonic Acid↗
PubMed1992

Early ambulation and discharge in 100 patients with burns of the foot treated by grafts.

Traditional treatment after grafting of foot, ankle, and lower leg burns is bedrest, limb elevation, and gradual ambulation only after 5 to 10 days. In 1982 we suggested that aggressive surgical treatment and early ambulation could shorten hospital stay and decrease morbidity. Our treatment of these burns is excision and grafting, application of an Unna (dome paste) boot immediately in the operating room or the next morning, with normal ambulation 4 hours later and discharge of the patient if there are no other reasons for continued hospitalization. This paper reports the continuation of this plan in 100 patients treated since 1982 with a mean age of 28.8 +/- 16.9 (SD) years and burn size of 3.7% +/- 4.4%. Sheet grafts were applied to 64% with a 96% take and narrowly meshed grafts to 36% with a 97% take. Results were excellent in 85 patients, satisfactory in ten, and poor in three who required another graft. Return to work was in 4.7 +/- 3 weeks. Unna boot application permits immediate ambulation, avoids frequent dressing changes, permits a brief or no hospital stay, and provides excellent graft take with prompt return to work.

Administration, Topical↗
PubMed1992

Iliofemoral venous thrombosis following fascial excision of a deep burn of the lower extremity: case report.

Burned patients with deep venous thrombosis present a particularly perplexing challenge. They frequently require central venous catheters. Their altered skin integrity does not permit correlation with the typical changes described by the classic terminology for thrombophlebitis or its most severe forms, phlegmasia cerulea dolens or phlegmasia alba dolens. They are at risk of exsanguination or massive graft loss with lytic therapy or anticoagulation. Venous thrombectomy may be a necessary limb-saving surgical option.

Adult↗
PubMed1992

Laboratory monitoring of nutritional status in burn patients.

Most nutrition laboratory testing relies on serum concentrations of ingested nutrients, their coenzymes, proteins, or lipids. Alternatively, functional tests measure a specific physiological process or biochemical reaction. We compared these two approaches to nutritional assessment in intensive-care burn patients, in whom the serum concentrations of transthyretin (prealbumin), albumin, transferrin, carotene, retinol, ascorbic acid, copper, cholesterol, iron, and calcium were all below established reference ranges. In contrast, serum triglyceride concentrations were often above the reference range. Functional tests for thiamin, riboflavin, pyridoxine, and iron (by zinc protoporphyrin/heme ratio) in these patients all showed normal values. Dietary intake, weight trends, and nitrogen balances all indicated that these patients' estimated caloric and protein needs had been met. These findings suggest that static measurements of serum concentrations may be unreliable indicators of nutritional status in burn patients.

Adolescent↗
PubMed1991

Tap water burn prevention: the effect of legislation.

Five years after a 1983 Washington State law required new water heaters to be preset at 49 degrees C (120 degrees F), 77% of homes (84% of homes with postlaw and 70% of homes with prelaw water heaters) had tap water temperatures of less than 54 degrees C. In 1977, 80% of homes had tap water temperatures greater than 54 degrees C. Mean temperature in 1988 was 50 degrees C compared with 61 degrees C in 1977. Both changes were significant compared with 1977 temperatures. Few people increased their heater temperature after installation. Eighteen burn victims were identified from July 1979 through May 1988, for an average admission rate of 2.4 per year, compared with 5.5 per year in the 1970s. Compared with the 1970s, total body surface area burned, mortality, grafting, scarring, and length of hospital stay were all reduced, while the likelihood that scald burns were the result of child abuse increased to 50%. Both education campaigns and legislation have resulted in significantly safer water temperatures. Further, this change seems to have resulted in a reduction in frequency, morbidity, and mortality of tap water burn injuries in children. Lower water heater settings proved acceptable to the consumer.

Adolescent↗