As a result of this new classification scheme, no patient without an external aortic contour abnormality died of their BAI. ITs can be managed nonoperatively. BAI patients with rupture will die, and resources could be prioritized elsewhere. Those with LIFs do well, and currently, most at our institution are treated with a stent graft. If a pseudoaneurysm is going to rupture, it does so early. Hematoma at the arch on computed tomography scan and hypotension before or at arrival help to predict which pseudoaneurysms need urgent repair.
Despite advances in medical and surgical techniques, older adults tend to be at high risk for adverse outcomes following burn injury. The purpose of this study was to examine the relative impacts of age and medical comorbidities on outcome following injury in a cohort of older adults. This was a retrospective study of all patients age 55 and over admitted to the University of Washington Burn Center from 1999 to 2003. To examine the effect of baseline medical comorbidities on outcome, a Charlson Comorbidity Index score was calculated for each patient. Multivariate regression analyses were used to examine the impact of age and comorbidities on mortality and other complications. Patient records were also matched with the National Death Index to determine the effects of age and comorbidities on mortality within 1 year following hospital discharge. A total of 325 patients who were of 55 years and older were admitted to the burn center during the 5-year study period. The overall mortality rate was 18.5%. Mortality was independently associated with age, inhalation injury, and burn size. One-year mortality was significantly associated with those older than age 75 and the Charlson score. Longer length of stay was significantly associated with burn size, inhalation injury, and total number of in-hospital complications. This study demonstrates that patient age—independent of baseline medical comorbidities—and TBSA burn are the most significant factors impacting in-hospital mortality risk following burn injury. Higher number of medical comorbidities was associated with increased mortality risk within 1 year following discharge.
This is the largest BAAI series described in the English literature at one institution. BAAIs range from intimal tears to free rupture, with outcomes and management correlating with type and location of injury. Nonoperative management with blood pressure control using β-blockers coupled with antiplatelet therapy and close follow-up is successful in individuals with intimal tears with minimal thrombus formation because they remain stable or resolve on follow-up. Free rupture remains a devastating injury, with 100% mortality. For all other categories of aortic injury, successful repair correlates with a favorable prognosis.
MMP-9, TIMP-2, and TIMP-4 were assayed using the ELISA technique. Patients were divided into failed and matured groups, depending on clinical end points. Successful maturation was considered in patients who had at least three successful hemodialysis access episodes. MMP/TIMP ratios were calculated as an index of the MMP axis activity because MMP activity parallels alterations in their TIMPs.Results: Of the 20 patients who were enrolled, 13 had successful maturation, and 7 had failure of AVF maturation. Significantly higher serum levels of MMP-2/TIMP-2 were found in patients who had AVF that matured compared with those that failed (P ϭ .003). Similarly, a trend toward increased serum levels of MMP-9/TIMP-4 was found in patients with successful AVF (P ϭ .06; see Fig).Conclusions: These data show that serum MMPs and the associated inhibitors could potentially play a role as a biomarker for future AVF maturation. Blunt Abdominal Aortic InjuryObjective: Blunt abdominal aortic injury (BAAI) is rare, with fewer than 200 cases in the current reported world literature. It is most often seen in high-speed motor vehicle collisions, and is associated with major blunt intra-abdominal injury and thoracolumbar fractures. We report our institutional experience over the past decade.Methods: Of the 141 cases with blunt aortic injury presenting from 1999 to 2008, we retrospectively reviewed all cases with BAAI. Data collected included demographics, mechanism of injury, associated injuries, ISS, type of intervention, procedural complications, and subsequent CT imaging.Results: We identified BAAI in 17 patients (41% female). Average age was 32 years (range, 6-79), and 71% were due to motor vehicle collisions. At presentation, 40% were hypotensive. Average ISS was 49 (range, 16-75). Associated abdominal injuries were seen in 81%, and more than half had associated spinal injuries. Injury presentation ranged from intimal tears (29%), intimal flaps Ͼ10 mm (29%), and pseudoaneurysms (18%), to free rupture (24%). Treatment was nonoperative in 24%, and operative in the majority of cases: 41% open aortic repair, 29% endovascular repair, and one hybrid repair with visceral debranching. Overall mortality was 29%, with most occurring in the emergency department. Free aortic rupture mortality was 100% by hospital day 4. Procedure-related complications were one endoleak treated with another stent graft, and visceral bypass thrombosis in the hybrid repair case, leading to death. Follow-up imaging was available in 80%. All intimal tears treated nonoperatively healed, a large intimal flap treated nonoperatively remained stable, and six patients who underwent repair of their aortic injury had complete resolution and healing of their injury.Conclusions: This is one of the largest series described in the literature. BAAIs range from small intimal tears to free rupture, with outcomes correlating with injury severity. Nonoperative management was successful in patients with intimal tears. Free rupture is associated with the highest mortality risk. For all...
A 37-kb cosmid containing two complete major histocompatibility complex (MHC) class I alpha chain loci from the opossum Monodelphis domestica was isolated, fully sequenced, and characterized. This sequence represents the largest contiguous genomic sequence reported for the MHC region of a nonplacental mammal. Based on particular conserved amino acid residues, and limited expression analyses, the two MHC-I loci, designated ModoUB and ModoUC, appear to encode functional MHC-I molecules. The two coding regions are 98% identical at the nucleotide level; however, their promoter regions differ significantly. Two CpG islands present in the cosmid sequence correspond to the two coding regions. Twelve microsatellites and six retroelements were also present in the cosmid. The retroelements share highest sequence homology to the CORE-SINE family of retroelements. Due to high sequence identity, it is very likely that ModoUB and ModoUC loci are products of recent gene duplication that occurred less than 4 million years ago.
Objectives: Previous studies have focused on early outcomes of open (DTAR) and endovascular (TEVAR) repair for blunt aortic injury (BTAI). Late results remain ill-defined and are the focus of this report.Methods: 108 patients (1992-2009) underwent repair for BTAI. Mean age was 38.7 years (74.1% male). DTAR was performed in 90, with left heart bypass (85) or hypothermic arrest (5). TEVAR was used in 18 of 44 treated since 2002. Since 1997, repair was selectively delayed in 53 of 74 treated in that interval. The primary outcome was vital status (100% followup, mean 100 months).Results: Mean Injury Severity Score (ISS) was 39.5. 30-day mortality was 5.5% (6). Early morbidity included permanent spinal cord ischemia (2, 1.8%), stroke (3, 2.8%) and need for permanent dialysis (2, 1.8%). Independent predictors of a composite outcome of early mortality and these morbidities included ageϾ60 years (p ϭ 0.007) and elevated preoperative creatinine (p ϭ 0.04), but not type of repair (p ϭ 0.39) nor ISS (p ϭ 0.37). 10 yr Kaplan-Meier survival was 85.1%. Independent predictors of late mortality included ageϾ60 years (p ϭ 0.02), and the presence of diabetes (p ϭ 0.04). In a comparative analysis, the TEVAR group was older (DTAR 36.8 years vs TEVAR 48.2 years, p ϭ 0.01), more frequently had coronary artery disease (DTAR 3.3% vs TEVAR 22.2%, p ϭ 0.01), and a higher incidence of delayed repair (DTAR 69% vs TEVAR 89%, p Ͻ 0.001). When stratified by age, there was no survival difference based upon repair type (pϾ0.4). Endograft collapse occurred in 1 necessitating endovascular reintervention. Freedom from aortic reintervention at 4 years was higher after open repair (DTAR 100% vs TEVAR 94%, p ϭ 0.03).Conclusions: Repair for BTAI has excellent early and late results, regardless of therapeutic approach. Although TEVAR has an increased risk for reintervention, factors other than treatment strategy impact late survival. These data support the growing role of an endoluminal approach for BTAI in anatomically appropriate patients.
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