Luke's Hospital Research Articles

HMGB1 guides cytokines in early carbon nanoparticle lung exposure

An initial effect of carbon nanoparticle (CN) lung exposure is the cellular release of damage‐associated molecular pattern recognition molecules (DAMPs). One of the earliest is the high mobility group box 1 (HMGB1) protein, which, extracellularly, exerts its actions as a ligand for pattern recognition receptor (PRR) target cell activation. This work studies HMGB1's role in damage recognition and activation of cellular processes. CN (0.025 mg, endotoxin free in 0.050 mL Survanta) was intratracheally instilled into rat airways (n=45). At necropsy 0.5hr to 4 wks later, bronchoalveolar lavage fluid (BAL), lungs and sera were measured (ELISA, cytology) for HMGB1 and 3 cytokines. BALs were also used to activate PRRs in RAW Blue cells, stably transfected lung macrophages expressing the SEAP gene inducible by NF‐kB and AP‐1. HMGB1‐containing BALs induced significant expression of SEAP in the RAW blue cells, highest at 24 hr, which was compared to purified HMGB1 dose‐dependent activation. Histopathology described Inflammation of lung parenchyma and translocation of CN from airways to the mesothelial lining. IL‐10 and IL‐6 in lung related in timing to HMGB1‐receptor complexes (p=0.04). The results show that sterile CN exposure releases lung cell HMGB1, and BAL from this exposure activates raw blue cells at times when HMGB1 is elevated, with related receptors and cytokines.Sponsor: Saint Luke's Hospital Foundation

Survival Trends Promising in Geriatric Trauma Patients

CHICAGO – Long-term survival in severely injured geriatric trauma patients may not be as poor as once thought, according to a study at a level 1 trauma center in Pennsylvania that followed these patients for up to 10 years after discharge. The retrospective study presented at the annual meeting of the American Association for the Surgery of Trauma showed an overall death rate of 33% in elderly patients with brain injury, according to Dr. Ulunna Ofurum of St. Luke's Hospital in Bethlehem, Pa. Trauma patients aged 65 and older with an Injury Severity Score of 30 or higher were assigned to two groups based on the presence or absence of brain injury, with an Abbreviated Injury Scale score of 3 or higher as the cutoff. The Social Security Death Index database was used to determine survival status. “The initial drop in survivorship was most pronounced in the patients with severe head injury,” Dr. Ofurum said. Overall, 97 of the 145 patients survived hospital discharge, but nearly a third died after hospital discharge. That left 65 for analysis of current living status. Of those, 52 patients in the head-injured group had a median survival of 33 months, and 13 of the patients without head injury had a median survival of 49 months. Of the 65 who were still alive when the study ended, 47 were contacted by phone to determine their living arrangements. Overall, 31 (65%) were at home, 11 (23%) were in skilled nursing facilities, four (8%) were in assisted living, and one (2%) was in a rehabilitation center. “The most significant finding of this study is that severely injured geriatric trauma patients who survive their hospitalization have appreciable long-term survival and that a surprising number return home,” Dr. Ofurum said. “This study showed that the 5-year survival is almost 20%, which is similar to that of many cancer diagnoses.” Dr. Ofurum acknowledged some limitations of the study, including its retrospective nature, the small sample size, and no data on cause of death, comorbidities, or survivors' functional status. “However, in our practice, it's been noted that about one-third of deaths that occur in geriatric trauma patients are associated with immediate withdrawal of care,” she said. This makes managing complications critical in this patient group. With the exponential growth of the elderly population, this and similar studies are notable, said discussion leader Dr. Roxie Albrecht, of the University of Oklahoma in Oklahoma City. “Studies such as this do give us a glimmer of hope that not every patient over the age of 65 has the Grim Reaper standing over them predicting that they will either die in the hospital or never return to their prehospital living status,” she said. She noted that the St. Luke's study is consistent with other reports on elderly trauma (J. Trauma 1998;44:618-23; J. Trauma 2002;52:242-6). Dr. Ofurum had no conflict of interest to disclose.

DOES ULTRAFILTRATION FOR ACUTE DECOMPENSATED HEART FAILURE BY AQUAPHERESIS INCREASE BLEEDING RISK?

Heart Failure Society of America and American College of Cardiology/American Heart Association guidelines support use of ultrafiltration therapy (UF) for acute decompensated heart failure (ADHF) with volume overload. At St Luke's Hospital, UF is prescribed by the Heart Failure Management

Delivering the infection control message: a communication challenge

Hospital infection control teams (ICTs) worldwide face a constant challenge to deliver timely information to audiences with specific and diverse information needs. Our study investigated the communication flow between the ICT and healthcare workers (HCWs) at St Luke's Hospital, Malta, using an exploratory descriptive research design. Using a self-administered questionnaire, data were collected from a stratified random sample of nurses (N=143) and doctors (N=63) working within inpatient wards; a response rate of 97% was achieved. HCWs felt most comfortable receiving information from members of their same profession. Information transfer was mainly vertically up and down the hierarchy. Respondents preferred to receive information through educational activities (35%, N=69) and through face-to-face contact (31%, N=62). Electronic channels (e-mail and intranet) were ranked least preferable; however, only 41% (N=81) had regular access to a computer system at work. The majority of respondents 91% (N=181) trusted the information by the ICT and 60% (N=118) regarded it as being consistent. Nevertheless, this did not guarantee constant compliance; 54% (N=106) of respondents implemented IC measures only when they perceived a risk for their health. Greater presence of the ICT on the wards was recommended. Notwithstanding the electronic age, the study confirms that face-to-face contact between ICTs and HCWs remains the most effective way of disseminating IC information.

Abstract 96: CTP-Mismatch Maps Improve Interobserver Agreement

Introduction: The use of mismatch between the ischemic core and penumbra to select patients who are likely to benefit from acute stroke therapy has gained popularity. Interpretation of the ischemic core and penumbra on standard CT-perfusion (CTP) maps is subjective. This may lead to variability among physicians in the decision if a patient is a good candidate for acute stroke therapy. A CTP-Mismatch map with outlines of the ischemic core and penumbra could limit this variability. The goal of this study was to determine if inter-observer agreement regarding a patient’s suitability for acute stroke therapy improves with the use of a CTP-Mismatch map. The figure shows a typical CTP-Mismatch map. Methods: Ninety-six consecutive patients evaluated with CTP prior to intra-arterial therapy at St. Lukes Hospital in 2008-09 were included. 79 patients had adequate quality CTP for this analysis. Standard CTP maps (CBV, CBF, MTT, and Tmax) and a CTP-Mismatch map were generated with a fully automated program for processing of CTP source images (RAPID). RAPID assessed the ischemic core using a CBF threshold <30% of the contralateral hemisphere (rCBF<30%). The ischemic penumbra was defined by a Tmax threshold of >6 sec (Tmax>6s). The standard CTP maps and the CTP-Mismatch map were independently analyzed by two vascular neurologists in a blinded fashion. The raters assessed a patient's suitability for intra-arterial therapy based on the following mismatch criteria: (1) a ratio between (Tmax>6s) and (rCBF<30%) volumes >1.8 and (2) an absolute difference between (Tmax>6s) and (CBF<30%) volumes >15ml. Interobserver reliability was assessed with Cohen’s kappa. Results: When assessment of suitability for intra-arterial therapy was based on interpretation of standard CTP maps, the two raters agreed in 58 of 79 patients (kappa=0.46; 95% CI=0.24-0.60). The agreement between observers improved when suitability was determined using CTP-Mismatch maps (agreement in 76 of 79 cases; kappa=0.92; 95% CI=0.75-0.92; p<0.001 for difference between kappa values). The 3 cases with inter-observer disagreement had artifact on the CTP-Mismatch map. Following concensus adjudication of these 3 cases, 40 of the 79 patients (51%) were deemed suitable candidates for acute stroke therapy. Conclusion: CTP-Mismatch maps with estimates of ischemic core and penumbra volumes markedly improve inter-observer agreement regarding assessment of suitability for acute stroke therapy. Such maps, which can be generated automatically, may help standardize decision making algorithms for evaluation of potential intra-arterial therapy candidates.

The use of hyperbaric oxygen for treating delayed radiation injuries in gynecologic malignancies: a review of literature and report of radiation injury incidence

The purposes of this paper are to review the best evidence supporting the use of hyperbaric oxygen therapy (HBOT) in delayed radiation injuries in gynecologic malignancies and report the incidence of radiation injuries at two large medical centers in southeastern Wisconsin. A literature search was performed on Google Scholar, PubMed, and Ovid for studies evaluating the use of HBOT radiation cystitis, proctitis, and necrosis. The studies were then reviewed for the highest quality evidence using American Academy of Neurology guidelines. To evaluate radiation injuries, cancer databases at Froedtert Memorial Lutheran Hospital (FMLH) and Aurora St. Luke's Hospital (ASLH) were accessed. Several studies support the use of HBOT in treating radiation cystitis, proctitis, and necrosis, with proctitis having the strongest evidence in its favor. The average annual incidence of radiation injury at FMLH was 13.8%. Patients with cervical cancer and vulvar cancer had rates of 23% each. The average annual incidence of radiation injury among gynecologic cancer patients at ASLH was 5.5%. There is level A evidence for using HBOT to treat radiation proctitis. There is level B evidence for using HBOT to treat radiation cystitis and necrosis. The incidence delayed radiation injuries can be as high as 23%. This has relevance in practice guidelines for the treatment of delayed radiation injuries in gynecologic malignancies.

Utility of the tourniquet test and the white blood cell count to differentiate dengue among acute febrile illnesses in the emergency room.

Dengue often presents with non-specific clinical signs, and given the current paucity of accurate, rapid diagnostic laboratory tests, identifying easily obtainable bedside markers of dengue remains a priority. Previous studies in febrile Asian children have suggested that the combination of a positive tourniquet test (TT) and leucopenia can distinguish dengue from other febrile illnesses, but little data exists on the usefulness of these tests in adults or in the Americas. We evaluated the diagnostic accuracy of the TT and leucopenia (white blood cell count <5000/mm3) in identifying dengue as part of an acute febrile illness (AFI) surveillance study conducted in the Emergency Department of Saint Luke's Hospital in Ponce, Puerto Rico. From September to December 2009, 284 patients presenting to the ED with fever for 2–7 days and no identified source were enrolled. Participants were tested for influenza, dengue, leptospirosis and enteroviruses. Thirty-three (12%) patients were confirmed as having dengue; 2 had dengue co-infection with influenza and leptospirosis, respectively. An infectious etiology was determined for 141 others (136 influenza, 3 enterovirus, 2 urinary tract infections), and 110 patients had no infectious etiology identified. Fifty-two percent of laboratory-positive dengue cases had a positive TT versus 18% of patients without dengue (P<0.001), 87% of dengue cases compared to 28% of non-dengue cases had leucopenia (P<0.001). The presence of either a positive TT or leucopenia correctly identified 94% of dengue patients. The specificity and positive predictive values of these tests was significantly higher in the subset of patients without pandemic influenza A H1N1, suggesting improved discriminatory performance of these tests in the absence of concurrent dengue and influenza outbreaks. However, even during simultaneous AFI outbreaks, the absence of leucopenia combined with a negative tourniquet test may be useful to rule out dengue.

Initial experience of a nationwide ruthenium‐106 and iodine‐125 ocular brachytherapy service in Ireland

AbstractPurpose St. Lukes Hospital, Rathgar, Dublin 6, Ireland has recently implemented an Ocular Brachytherapy Service using both Ruthenium‐106 and Iodine‐125 plaques. This work will summarize the initial experience of the hospital in these treatment modalities and provide information on some of the challenges experienced by a new centre performing this technique. Outline plans for the future of the service will also be presented.Methods Between September 2010 and June 2011, twenty six patients received a plaque treatment at St. Lukes Hospital. Six of these were Iodine‐125 cases, while twenty used Ruthenium‐106. A multi‐disciplinary pre‐planning procedure using BEBIGs "Plaque Simulator" software identifies treatment durations. This group consists of a Physicist, Consultant Ophthalmologist and a Consultant Radiation Oncologist with the goal of fitting both plaque insertions &amp; removals into designated weekly theatre slots. Following this, a comprehensive plancheck analysis is performed. Post‐treatment, a delivered plan is generated by a Physicist and signed by the clinical team. A yearly delivery of Ruthenium plaques is scheduled; information is given on plaque types, number of uses and plans for Year Two. NPL calibrations were used as a second‐check in Year One with an in‐house method involving a stereotactic diode proposed for Year Two.Results Nine months into the program, tumour regression in the initial patients is already being observed. Procedures have been streamlined to satisfy designated theatre slots where possible and to maximise throughput of patients. A second‐check calculation procedure for Ruthenium plaques has been devised; however the long‐term plan proposes a greater proportion of Iodine treatments due to the timing flexibility this provides. The in‐house method of calibration shows promise, however further investigations are required before it is suitable for clinical use. This work is ongoing.Conclusion An Ocular Brachytherapy service has been successfully implemented in St Lukes Hospital that is providing both Ruthenium‐106 and Iodine‐125 treatments to patients across the Republic of Ireland. As the service matures and further intra‐departmental training takes place, the facility will be well prepared to handle both an increase in capacity and complexity while performing treatments to a high standard.

The Oncogenic Potential of Endometrial Polyps: A Systematic Review and Meta-Analysis

Obstetrics and Gynecology, The Family Birth Place at St Luke's Hospital, Jacksonville, Florida Financial Disclosure: The author did not report any potential conflicts of interest. Editor's Note:Readers may refer to a Correction about this reply on p. 364.

Early Ultrafiltration May Reduce Length of Hospital Stay for Decompensated Heart Failure

Heart Failure Society of America and American College of Cardiology/American Heart Association (ACC/AHA) guidelines support use of ultrafiltration (UF) as a treatment for patients with heart failure who present with volume overload [1] [2]. Studies have shown reduced length of hospital stay [3] and reduced readmission rates [4] with ultrafiltration in comparison to standard therapy. Early initiation of UF therapy may reduce length of hospital stay. Data were extracted by retrospective chart review of admissions with primary diagnosis of decompensated heart failure including right and left ventricular failure and requiring UF. Institutional Review Board exemption was granted. All UF treatments were prescribed and managed by the Heart Failure Management Program practitioners at St Luke's Hospital and Health Network, Bethlehem, PA, using Aquapheresis by the Aquadex system between December 2008 and November 2010. One hundred eighty UF therapies provided data, mean age ± standard deviation [SD] was 73.7 ± 11.1 years); 124 (68.9%) were aged >70 years and 103 (57.2%) were male. Among the 180 UF therapies, data was compared between those initiated within the first 24 hours of admission (101) vs. those initiated between 24 and 72 hours (34). UF therapies initiated after 72 hours were excluded. Both groups were demographically similar with 61% males and mean age of 74 years. Multiple parameters including serum creatinine, BUN, electrolytes, UF duration, UF volume, change in weight, length of hospital stay and readmission rates were compared. The mean length of stay ± standard deviation [SD] for early UF (within 24 hours) was 5.5 +/- 5.0 days in comparison to 12.2 +/- 11.4 days for later UF (24 to 72 hours). Statistical analysis using Welch's unpaired t test showed the difference to be statistically significant (P=0.002). Among patients who qualify for ultrafiltration therapy, early initiation reduces length of hospital stay.

Clark H. Millikan, MD, FAAN (1915–2011)

Clark Harold Millikan was born in Freeport, Illinois, on March 2, 1915, the only child of William Millikan and Louise (Chamberlain) Millikan. His father, a Methodist minister who served in 7 different communities, passed away in 1931, when Clark was 16. Clark H. Millikan, MD, FAAN. Clark attended high school and junior college in Parsons, Kansas. He then attended medical school at the University of Kansas. While in medical school, Clark worked for the National Youth Administration and still had high academic achievement, graduating in 1939. He was an intern and resident in internal medicine at St. Luke's Hospital in Cleveland, Ohio, and a neurology resident at the University of Iowa, where his training was directed by Dr. Clarence Van Epps. He was the mentor who most …

Optimal Recovery from Cardiac Arrest: Implementation of a Therapeutic Hypothermia Program

Optimal Recovery from Cardiac Arrest: Implementation of a Therapeutic Hypothermia Program

Sero – prevalence of Human Immunodeficency Virus (HIV) infection among antenatal clinic attendees in St Luke's Hospital, Uyo, Akwa Ibom State, Nigeria

The prevalence of human immunodeficiency virus (HIV) infection was estimated among pregnant women attending clinic at St. Luke’s Hospital, Anua – Uyo in Akwa Ibom State. A total of 281 samples were tested serologically by the serial algorithm method using three standard kits namely Abbott Determine HIV1/2, the Chembio HIV1/2 STATPAK assay and the Trinity Biotech UniGold HIV tests. Results indicated that 24(12.1%) were infected with HIV. The percentage prevalence by educational status was: women with no formal education 37.5%; those with secondary education, 11.3% and women with tertiary education 5.7%. Estimates of HIV prevalence by age indicated that the age range of 15-29 was the most affected with a prevalence of 37.8%, followed by 30-40 with a prevalence of 17.7% and 41- 49 with O%. HIV prevalence by parity showed 15.5% in the first pregnancy, 8.5% in the second and 10.5% in those with two or more pregnancies. Analysis also revealed that the unmarried and unemployed were more affected than the married and employed. It is evident that HIV infection prevailed most in the least educated, most tender in age, unmarried and unemployed. Therefore, periodic survey and targeted intervention programmes should be harnessed to help control and mitigate the impact of HIV/AIDS among pregnant women. KEY WORDS: HIV, sero- prevalence, Antenatal attendees

The History of Neurological Surgery at Rush University Medical Center

The history of neurosurgery at Rush University is tightly linked to the emergence of neurological surgery in the city of Chicago. Rush Medical College (RMC) was chartered in 1837 and in 1898 began an affiliation with the newly founded University of Chicago (UC), which proceeded to full union in 1923 as the Rush Medical College of the University of Chicago (RMC/UC). Percival Bailey founded neurosurgery at the RMC/UC and started a neurosurgery training program at the South Side campus in 1928. In 1935, Adrien Ver Brugghen started the first neurosurgical training program at the West Side campus at the Presbyterian Hospital/RMC. The major alliances with RMC have involved the Cook County Hospital, the Presbyterian Hospital, the UC, the University of Illinois, and St. Luke's Hospital. Those affiliations significantly shaped Rush neurosurgery. The RMC/UC union was dissolved in 1941, and an affiliation was formed with the University of Illinois in Chicago (UI). In 1959, Eric Oldberg, the founder and Chairman of Neurosurgery at the UI, became the next chairman of neurosurgery at Presbyterian-St. Luke's Hospital, incorporating it into the UI program. He was succeeded in 1970 by Walter Whisler, who founded the first independent and board-approved neurosurgery residency program in 1972 at the newly reactivated Rush Medical College. Whisler was chairman until 1999, when Leonard Cerullo, founder of the Chicago Institute of Neurosurgery and Neuroresearch, became chairman at Rush. Richard Byrne, appointed in 2007, is the current chairman of the Rush University neurosurgery department.

University of Missouri—Kansas City School of Medicine

University of Missouri—Kansas City School of Medicine

Invited Commentary

*Professor of Orthopaedic Surgery, Anatomy and Cell Biology, Temple School of Medicine, Chief of Orthopaedics SLHN; †Director, Research Institute, St. Luke's Hospital and Health Network.

Ralph Sacco: putting the heart into neurology

Ralph Sacco: putting the heart into neurology

SU-FF-BRA-01: Special Symposium on Patient Safety

SU-FF-BRA-01: Special Symposium on Patient Safety

A decade of experience with an inpatient pneumococcal vaccination program

A hospital's experience with an inpatient pneumococcal vaccination program is described. Saint Luke's Hospital (SLH) is a 625-bed, tertiary care, referral hospital in Kansas City, Missouri. In a retrospective analysis conducted in 1995 of pneumococcal vaccination rates in patients with community-acquired pneumonia (CAP) at the hospital, only 1 of 84 patients had documented pneumococcal vaccination. These results led to efforts to improve assessment of vaccination status, documentation of vaccination, and pneumococcal vaccination rates. In 1998, the pharmacy department at SLH conducted a study to examine the impact of pharmacists on pneumococcal vaccination rates through incorporation of vaccination assessment into selected critical pathways. Pharmacists were assigned to screen and educate patients on chosen pathways. When eligible patients were identified in the intervention group, the pharmacist would then contact their physician for authorization to vaccinate. The success of the study led to several notable changes to the pneumococcal vaccination program in 2001. First, the vaccination assessment was moved from selected critical pathways to the admission database of all patients. Second, a collaborative practice agreement was developed to authorize pharmacists to write pneumococcal and influenza vaccine orders for eligible patients per the program's protocol. These two changes led to a dramatic improvement in overall screening and documentation rates of pneumococcal vaccination for patients with CAP and for other at-risk patients. A pneumococcal vaccination program helped a hospital meet regulatory expectations for vaccination of patients with CAP and vaccinated many other at-risk patients.

Commentary: Comparison of current flow cytometry methods for monoclonal B cell lymphocytosis detection

Monoclonal B cell lymphocytosis (MBL) is now recognized as the B-lymphocyte analogue of a monoclonal gammopathy of unknown significance. MBL can be the precursor of chronic lymphocytic leukemia or associated with non-Hodgkin's lymphoma. It may be associated with an autoimmune abnormality or be related to aging (immunosenescence). The combination of available new fluorochrome-conjugated monoclonal antibody reagents, multilaser instrumentation, and improved software tools have led to a new level of multicolor analysis of MBL. Presently, several centers, including the University of Salamanca (Spain), Duke University (Durham, NC), Mayo Clinic (Rochester, MN), and the National Cancer Institute (Bethesda, MD) in conjunction with the Genetics and Epidemiology of Familial chronic lymphocytic leukemia Consortium, the Food and Drug Administration (Bethesda, MD), and the Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry (Atlanta, GA) in collaboration with Saint Luke's Hospital (Kansas City, MO), the Università Vita-Salute San Raffaele in Milan (Italy), and Leeds Teaching Hospital (UK) are all actively conducting studies on MBL. This commentary is an updated summary of the current methods used in these centers. It is important to note the diversity of use in reagents, instruments, and methods of analysis. Despite this diversity, there is a consensus in what constitutes the diagnosis of MBL and its subtypes. There is also an emerging consensus on what the next investigative steps should be.