Charles E. Wade

The purpose of this study was to evaluate glucose control and clinical outcomes in diabetic burn intensive care unit (ICU) patients. The authors revie

Some studies have reported an increased incidence of thromboembolic complications following trauma. We performed a literature review and queried the National Trauma Data Bank to more closely examine the incidence of a variety of thromboembolic complications following injury. Thromboembolic events are rare, but occur at a greater rate in more severely injured patients. It is unclear, however, whether the incidence of thromboembolic complications in trauma patients is on the rise overall. Differences in study populations, particularly injury severity scores, as well as different methods of screening, diagnosis, prophylaxis, and treatment have led to extreme differences in reported rates. While recent research has added to the body of knowledge, continued efforts focusing on risk stratification, diagnosis, screening, prophylaxis, and treatment are necessary to rationally understand the spectrum of thrombotic complications.

Background: Tympanic membrane perforation is the most common primary blast injury in the current conflicts and occurs in approximately one tenth of service members wounded by combat explosions. We wanted to determine the severity of perforation and its effect on hearing and combat readiness. Methods: This analysis is a retrospective study of US service members injured in combat explosions in Afghanistan or Iraq and treated at our institution between March 2003 and July 2006. Data captured included location and grade of perforation, symptoms, healing rates, audiogram results, need for hearing aids, and loss of eligibility for military service. Results: Of 436 explosion-wounded patients admitted to our facility, 65 (15%) patients had tympanic membrane perforation diagnosed by the otolaryngology service. A total of 97 tympanic membrane perforations occurred among 65 patients. The average surface area involved was 41% ± 32% (right) and 35% ± 34% (left). More than one third of perforations were grade 4. The most common locations were central and anterior-inferior. Most (83%) patients reported symptoms, most commonly diminished hearing (77%) and tinnitus (50%). Outcome data were available for 77% of perforations. Spontaneous healing occurred in 48%. The remainder (52%) had surgical intervention. The most common audiogram abnormality was mild high frequency hearing loss. Ultimately, three patients (5%) required hearing aids and one discharge from military service. Conclusions: Tympanic membrane perforation occurs in 16% of explosion-injured patients. Most patients are symptomatic and many have large perforations requiring operative intervention. Long-term hearing loss is uncommon but does impact ability to continue military service.

In the previous issue of Critical Care, Otto and colleagues used in vitro studies to explore the theory that immunomodulation, by correction of hyperglycemia, may be a contributing factor to the reported efficacy of intensive insulin therapy (IIT) in critically ill patients. They suggested that hyperglycemia via hyperosmolarity at supra-physiological levels potentiates the production of cytokines by peripheral blood mononuclear cells in response to lipopolysaccharide (LPS) stimulation and that it also reduces the responses of phagocytosis and oxidative burst in human granulocytes. The efficacy of IIT, they concluded, may be partially due to the correction of hyperosmolality. Other studies, however, have suggested that immunological responses to LPS in the presence of hyperglycemia are mediated by a mechanism other than hyperosmolality.

Spaceflight and prolonged bed rest (BR) alter plasma hormone levels inconsistently. This may be due, in part, to prescription of heavy exercise as a countermeasure for ameliorating the adverse effects of disuse. The initial project was to assess exercise programs to maintain aerobic performance and leg strength during BR. The present study evaluates the effect of BR and the performance of the prescribed exercise countermeasures on plasma steroid levels. In a 30-day BR study of male subjects, the efficacy of isotonic (ITE, n = 7) or isokinetic exercise (IKE, n = 7) training was evaluated in contrast to no exercise (n = 5). These exercise countermeasures protected aerobic performance and leg strength successfully. BR alone (no-exercise group) did not change steroidogenesis, as assessed by the plasma concentrations of cortisol, progesterone, aldosterone, and free (FT) and total testosterone (TT). In the exercise groups, both FT and TT were decreased (P < 0.05): FT during IKE from 24 ± 1.7 to 18 ± 2.0 pg/ml and during ITE from 21 ± 1.5 to 18 ± 1 pg/ml, and TT during IKE from 748 ± 68 to 534 ± 46 ng/dl and during ITE from 565 ± 36 to 496 ± 38 ng/dl. The effect of intensive exercise countermeasures on plasma testosterone was not associated with indexes of overtraining. The reduction in plasma testosterone associated with both the IKE and ITE countermeasures during BR supports our hypothesis that intensive exercise countermeasures may, in part, contribute to changes in plasma steroid concentrations during spaceflight.