Biomedical subjects

R L Gamelli

Publications and source records attributed to R L Gamelli.

135 records · Page 8Linked to original sources

PubMedDate not supplied

A burn center cost-reduction program.

A concerted effort to decrease resource usage and length of stay without sacrificing quality of care was undertaken over a 2-year period in a high-census Burn Center. Through a series of changes in practice, substantial decreases in the costs of several high-usage items were tracked. During this period the average length of stay also was decreased. The average hospital charge decreased from $46,628 per patient in fiscal year 1993 to $33,159 per patient in fiscal year 1994. During this period there was no significant change in the patient population as measured by total body surface area percentage burn and acuity level. With the exception of significant improvement in the infection rate, there was no substantial change in indicators of quality care as measured by readmission, morbidity, and posthospital would healing progression. This cost-reduction program showed that costs can be reduced without diminishing quality of care; in some respects quality of care improved due to the practice changes that were implemented.

Burn Units↗

PubMedDate not supplied

Cost reduction strategies in burn nutrition services: adjustments in dietary treatment of patients with hyponatremia and hypophosphatemia.

Two clinically effective adjustments in diet therapy were tested at a burn center as strategies to lower clinical care costs. The use of adult enteral formulas for pediatric burn patients reduced the incidence of hyponatremia and the need for costly sodium supplements. The prophylactic administration of oral phosphate during the first days of hospitalization may lessen the decline in serum phosphate and save costs for the treatment of hypophosphatemia of severely burned patients.

Adult↗

PubMedDate not supplied

Macrophage mediated suppression of granulocyte and macrophage growth after burn wound infection reversal by means of anti-PGE2.

The production and release of granulocytes and macrophages, crucial elements of the host defense system, are significantly impaired after burn injury and sepsis. Prostaglandin E2 (PGE2) is known to be myelosuppressive. We hypothesized that the macrophages contributed to myelopoietic suppression by means of increased PGE2 production, which is induced by thermal injury and sepsis. In this study, peritoneal macrophages were elicited at day 3 from normal mice and from mice who underwent a 15% total body surface area dorsal scald burn with or without Pseudomonas aeruginosa burn wound infection. The macrophages were incubated with or without endotoxin and with or without PGE2 polyclonal antiserum (anti-PGE2) for 18 hours. Macrophage supernatants were then used in co-cultures of bone marrow cells in a clonogenic assay of granulocyte-macrophage colony-forming cells (GM-CFCs) to determine the effect of burn wound infection on the alteration of the proliferative status of the GM-CFCs. Burn wound infection and endotoxin both caused marked reductions in GM-CFC growth in culture (20%-40% as compared with normal, P < .05-.01). The inhibition of GM-CFC growth induced by burn, burn plus infection, or endotoxin was significantly reversed by the addition of anti-PGE2 to the cultures (30%-40% increase in GM-CFC colony growth as compared with cultures without anti-PGE2). These results suggest that PGE2 is a key mediator in the gram-negative sepsis-induced macrophage suppression of granulocyte and macrophage production. The ability of anti-PGE2 to neutralize PGE2 activity may provide a useful means of mitigating myeloid depression that follows postburn sepsis.

Animals↗

PubMedDate not supplied

A biopsy of the use of the Baxter formula to resuscitate burns or do we do it like Charlie did it?

The Baxter formula is commonly used to calculate fluid requirements. Baxter reported that 12% of patients would require more than 4.3 mL/kg per percentage of total body surface area (%TBSA). We anecdotally observed that we frequently exceeded the predictions of the formula, and we wondered if this was unique to our practice. We studied our last 11 burn-related resuscitations and collected fluid resuscitation data from US burn centers. Twenty-eight centers were queried, and 6 centers shared data. We were therefore able to study the resuscitation data of 50 adult patients. For 29 patients (58%), 4.3 mL/kg/%TBSA was exceeded compared with the 12% reported by Baxter. These findings suggest that in actual practice, fluid volumes administered are larger than the Baxter formula predicts. This survey does not explain why. Possible reasons for the larger fluid volumes are as follows: (1) the sample is not representative; (2) the formula is used improperly; (3) burns have changed and require more fluids; (4) burn care has changed.

Adult↗

PubMedDate not supplied

Antithrombin(H) concentrate infusions are safe and effective in patients with thermal injuries.

An antithrombin (AT) deficiency develops in patients with thermal injuries as a result of the subclinical disseminated intravascular coagulation. We conducted a pilot study to assess AT(Human [H]) concentrate infusions for safety and efficacy in thermal injury. Nine patients with burns who received Thrombate (Bayer Corporation, Berkeley, Calif) AT(H) concentrate infusions every 8 hours to raise the plasma level to 175% in the first 72 hours after injury were compared with 9 control patients with burns. Admission AT plasma levels were 45%+/-10% in patients treated with AT(H) versus 49%+/-18% in control patients (normal, 100%+/-20%). Day-2 to day-4 levels were 120%+/-25% in patients treated with AT(H) patients versus 50%+/-12% in the control patients (P < .002). In the group treated with AT(H), the time to wound healing was shorter for all body regions and was significantly shorter for the hand (P < .02). Compared with control patients, patients treated with AT(H) had similar blood loss per grafted area. A trend toward fewer autografting procedures, a shorter meshed autograft healing time, and a decreased hospital stay was found for the patients treated with AT(H). AT(H) concentrate infusions are safe with thermal injury and are a viable option to shorten the length of hospitalization and to promote graft viability and survival. Clinical trials to confirm the benefit of this medication in the acute phase of thermal injury would be worthwhile.

Adolescent↗

PubMedDate not supplied

The expression of cyclooxygenase and the production of prostaglandin E2 in neutrophils after burn injury and infection.

Recent studies have demonstrated that neutrophils have the capacity to produce a variety of cytokines after stimulation. The synthesis and release of prostaglandin E2 (PGE2) via the cyclooxygenase (COX) pathway has been reported to occur in activated neutrophils. In the present study, we sought to determine the status of COX protein synthesis and PGE2 production in murine neutrophils after burn injury. The effect of burn injury on neutrophil COX and PGE2 response to infection or lipopolysaccharide (LPS) was also examined. Peritoneal neutrophils were obtained from BDF1 mice at 4, 18, 24, and 36 hours after a 15% TBSA full-thickness scald burn or sham burn. We found that neutrophils from healthy mice express a low level of COX-2 protein. Neutrophil COX-2 protein expression in burn animals was significantly increased at 4 hours and dramatically decreased at 36 hours after burn injury. Animals 36 hours after burn and topically infected with Pseudomonas Aeruginosa had neutrophil COX-2 expression almost identical to burn injury only. Neutrophils harvested from healthy mice cocultured with LPS (1 microg/ml) had a marked induction of COX-2 protein. Neutrophils 24 hours after burn were unresponsive to LPS-stimulated COX-2 enhancement. COX-1 protein was strongly expressed constitutively and not affected further by burn injury or LPS. The production of PGE2 corresponded with the changes in COX-2 expression for all groups of mice. Our data suggested that neutrophils express both COX-1 and COX-2 and produce PGE2. The effects of burn injury on neutrophil COX-2 protein synthesis and PGE2 production suggest that after burn there is a time-dependent response. Insights into not only the global cellular response to injury and infection but also temporal nature of the response are important in the development of the therapeutic treatment strategies for burn patients.

Analysis of Variance↗

PubMedDate not supplied

A multicenter clinical trial to evaluate the topical hemostatic efficacy of fibrin sealant in burn patients.

Current surgical management of deep partial-thickness and full-thickness burn wounds involves early excision and grafting. Blood loss during these procedures can be profound, thus prompting the use of topical hemostatic agents to control and minimize hemorrhage during grafting. The primary endpoint of this multicenter trial was to evaluate the efficacy of fibrin sealant as a topical hemostatic agent during skin grafting. The secondary endpoint was to obtain data to support the existing safety profile of a human fibrin sealant (FS) in participating patients as indicated by the type, severity, and frequency of any adverse events within the 24-hour postoperative period. A multicenter prospective, open label, Phase III multicenter, randomized, comparative clinical trial evaluated the use of fibrin sealant in burn patients undergoing skin graft procedures. Each patient served as his or her own control in this randomized, unblinded study of the effect on time to hemostasis in donor sites treated with the investigational FS product. At operation, 1 contiguous donor skin harvest site was bisected into 2 equal halves, 1 of which was then randomly selected and treated with fibrin sealant. At the end of the fibrin sealant application, the time to hemostasis in each of the donor site halves was identified by the operating surgeon and recorded by the research coordinator. The use of any other topical hemostatic agents was prohibited. A significant difference (P < .001) was demonstrated in the mean time to hemostasis between the fibrin sealant treated donor sites when compared painwise to the control sites. The significant difference was consistent across the 6 participating study centers. There were no adverse events associated with the use of fibrin sealant. The investigational FS product was shown to be efficacious, because it significantly decreases the time to hemostasis at the donor skin harvest site in patients undergoing skin grafting and was noted not to cause any adverse reactions.

Administration, Topical↗

PubMedDate not supplied

Burn Education Awareness Recognition and Support (BEARS): a community-based juvenile firesetters assessment and treatment program.

In response to the continued staggering statistics of fires set by juveniles and the devastating personal and property costs that are associated with these fires, the Burn and Shock Trauma Institute of Loyola University Medical Center, in collaboration with the State Fire Marshal's Office; the Illinois Fire Safety Alliance; and representatives from the firefighting community, law enforcement, emergency medicine and mental health, came together to create the Burn Education Awareness Recognition and Support Program. Through financial grant support from the International Association of Firefighters, the Illinois Fire Safety Alliance, and other private donations, the Burn Education Awareness Recognition and Support Program is able to provide a free resource to anyone who is concerned about a child playing with fire. Specially trained firefighters assess each child using the tool developed by the Federal Emergency Management Agency. In 2002, we assessed 42 children; 29 of those children were referred through the courts. So far, none of the children treated in our program have returned to fire-setting behaviors.

Adolescent↗

PubMedDate not supplied

Why activity-based costing works.

With advancing technology and the quest for delineating the true cost of a procedure or diagnostic test, cost accounting techniques are being re-explored in the health care setting. Activity-based costing (ABC), adopted from other businesses, is one such example that has applications in the health industry. The purpose of this paper is to enhance the understanding of health care costs among physician providers, emphasizing a new approach--activity-based costing.

Accounting↗