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•Graduating from a remediation program is done with a structured online curriculum•The program involves weekly readings followed by focused questions•It included a faculty mentor, practice exams and faculty lead review sessions•Residents scoring above the 30thpercentile completed more assignments post ABSITE

Burn patients have numerous risk factors for multidrug-resistant organisms (MDROs) and altered pharmacokinetics, which both independently increase the risk of treatment failure. Data on appropriate antimicrobial dosing are limited in this population and therapeutic drug monitoring (TDM) for beta-lactams is impractical at most facilities. Technology is available that can detect genetic markers of resistance, but they are not all encompassing, and often require specialized facilities that can detect less common genetic markers. Newer antimicrobials can help combat MDROs, but additional resistance patterns may evolve during treatment. Considering drug shortages and antimicrobial formularies, clinicians must remain vigilant when treating infections. This case report describes the development of resistance to ceftazidime-avibactam in a burn patient. The patient was a 54-year-old burn victim with a 58% total body surface area (TBSA) thermal burn who underwent multiple courses of antibiotics for various Pseudomonalinfections. The initial Pseudomonalwound infection was sensitive to cefepime, aminoglycosides, and meropenem. A subsequent resistant pseudomonal pneumonia was treated with ceftazidime-avibactam 2.5 g every 6 hours due to the elevated MIC to cefepime (16 mcg/mL) and meropenem (>8 mcg/mL). Although the patient improved over 7 days, the patient again spiked fevers and had increased white blood counts (WBC). Repeat blood cultures demonstrated a multidrug-resistant (MDR) Pseudomonaswith a minimum inhibitory concentration (MIC) to ceftazidime-avibactam of 16 mcg/mL, which is above the Clinical and Laboratory Standards Institute (CLSI) breakpoint of 8 mcg/mL. At first, resistance was thought to have occurred due to inadequate dosing, but genetic work demonstrated multiple genes encoding beta-lactamases.

Toxic epidermal necrolysis (TEN) is a severe cutaneous reaction that can be life-threatening. In the United States, there are no established guidelines for the treatment of TEN. Supportive care including fluids and supportive therapies are the current recommendations. Research surrounding TEN involves mostly case studies or small, uncontrolled studies. Recent literature describes the use of tumor necrosis factor blockers in the treatment of TEN with positive results. These case reports describe decreased time to reepithelization, hospital length of stay, and minimal side effects. Conversely, we present three fatalities after the administration of etanercept.

A major gap in the Plasmodium vivaxelimination toolkit is the identification of individuals carrying clinically silent and undetectable liver-stage parasites, called hypnozoites. This study developed a panel of serological exposure markers capable of classifying individuals with recent P. vivaxinfections who have a high likelihood of harboring hypnozoites. We measured IgG antibody responses to 342 P. vivaxproteins in longitudinal clinical cohorts conducted in Thailand and Brazil and identified candidate serological markers of exposure. Candidate markers were validated using samples from year-long observational cohorts conducted in Thailand, Brazil and the Solomon Islands and antibody responses to eight P. vivaxproteins classified P. vivaxinfections in the previous 9 months with 80% sensitivity and specificity. Mathematical models demonstrate that a serological testing and treatment strategy could reduce P. vivaxprevalence by 59–69%. These eight antibody responses can serve as a biomarker, identifying individuals who should be targeted with anti-hypnozoite therapy.

The phase 3 trial of the RTS,S/AS01 malaria vaccine candidate showed modest efficacy of the vaccine against Plasmodium falciparummalaria, but was not powered to assess mortality endpoints. Impact projections and cost-effectiveness estimates for longer timeframes than the trial follow-up and across a range of settings are needed to inform policy recommendations. We aimed to assess the public health impact and cost-effectiveness of routine use of the RTS,S/AS01 vaccine in African settings.

Serological markers are a promising tool for surveillance and targeted interventions for Plasmodium vivaxmalaria. P. vivaxis closely related to the zoonotic parasite P. knowlesi, which also infects humans. P. vivaxand P. knowlesiare co-endemic across much of South East Asia, making it important to design serological markers that minimize cross-reactivity in this region. To determine the degree of IgG cross-reactivity against a panel of P. vivaxserological markers, we assayed samples from human patients with P. knowlesimalaria. IgG antibody reactivity is high against P. vivaxproteins with high sequence identity with their P. knowlesiortholog. IgG reactivity peaks at 7 days post-P. knowlesiinfection and is short-lived, with minimal responses 1 year post-infection. We designed a panel of eight P. vivaxproteins with low levels of cross-reactivity with P. knowlesi. This panel can accurately classify recent P. vivaxinfections while reducing misclassification of recent P. knowlesiinfections.

Toxic epidermal necrolysis (TEN) is a rare complication after allogeneic hematopoietic stem-cell transplantation and carries high mortality rates. Graft-vs-host disease (GVHD) is also a life-threatening complication, and potentially indistinguishable from TEN because of similar clinical symptoms. However, current therapeutic recommendations differ between these two conditions, thereby posing a diagnostic dilemma. The authors, herein, present a complicated postoperative course after bone marrow transplantation with concurrent gastrointestinal and hepatic GVHD, and extensive epidermolytic disease compatible with both severe cutaneous GVHD and TEN. An early consult to a specialized burn service, and prompt transfer to a burn intensive care unit with extensive supportive care and nursing are of paramount importance in the management of immunosuppressed patients with TEN. Better understanding of the pathogenesis of TEN and GVHD after hematopoietic stem-cell transplantation, further treatment strategies, and more advanced diagnostic techniques are still needed to achieve acceptable mortality rates.

Most current analyses of multiple organ failure after injury use the serum creatinine (SCr) as a surrogate for defining renal insufficiency (RI) or renal failure (RF). This study correlates SCrwith glomerular filtration rate, renal perfusion, and renal excretion in injured and septic patients.

Some physicians feel gastric injury is not a significant contributing factor to the adverse outcome of trauma patients, but rather a marker of epigastric injury. We hypothesized the addition of a gastric injury to multiple injured trauma patients would increase infection rate. We conducted a retrospective study comparing 450 consecutive patients with full-thickness gastric injury with 983 patients without gastric injury during the same time period. Infection rate in patients with gastric injury was 44 per cent (200 of 455) and significantly higher than 36 per cent (357 of 983) seen without gastric injury (P = 0.006). Logistic regression revealed gastric injury was an independent risk factor for infection controlling for age, Injury Severity Scale, gender, mechanism of injury, shock, and associated injuries (P = 0.047). Requiring a transfusion, Injury Severity Scale, colon injury, age, pancreas injury, and emergency department shock were also independent risk factors for developing an infection. The addition of a gastric injury to a trauma patient appears to increase the risk for infection.

Adequate nutritional support after thermal burn injury is essential for achieving successful patient outcomes. Dysphagia is common in burn patients. Our objective was to analyze hospitalized burn patients referred to speech pathology for swallowing evaluation. A retrospective study of burn patients admitted to our center and evaluated by speech pathology from December 2001 through July 2006 was performed. Of the 16 patients, 5 (31%) had a normal bedside swallow examination, did not undergo a modified barium swallow study (MBSS), and were excluded. Six (55%) of the 11 included patients were men. The average age was 44 ± 18 years. All 11 patients had a thermal burn with an average total body surface area burn of 36% ± 16%. Facial burns were present in 91% (10 of 11) of the patients, and inhalation injury was confirmed by bronchoscopy in 55% (6 of 11) of the patients. The average length of stay was 84 ± 45 days. Of the 11 abnormal bedside assessments performed, 10 (91%) were associated with an abnormal MBSS. One patient had evidence of oral dysphagia only and one patient had evidence of pharyngeal dysphagia only. Six patients had oral and pharyngeal dysphagia, and two patients had pharyngeal and esophageal dysphagia. One tracheal-esophageal fistula was identified. A bedside assessment of swallowing performed by a speech pathologist is predictive of an abnormal modified barium swallow in burn patients. Burn patients with facial burns, inhalation injury, pneumonia, and a prolonged ICU stay are at increased risk for dysphagia. Prospective studies are necessary to determine in which patients an MBSS adds additional relevant clinical information.

Patients who continue to smoke while on home oxygen therapy endanger themselves, family members, neighbors, and firefighters and create an expense to society for their medical care. This phenomenon was studied in our burn center. Fourteen patients were identified prospectively during the last 2 years. All were smoking while on nasal oxygen. The 14 patients (10 males) were 45 to 87 years of age. All suffered facial burns. Only one patient had a significant burn (30% TBSA, 20% 3rd degree), but all suffered from an exacerbation of chronic obstructive pulmonary disease. Two patients gave a history of stage IV lung cancer and four patients had newly found squamous cell cancer seen on bronchoscopy. All six patients with lung cancer and one with severe chronic obstructive pulmonary disease died. Of the seven survivors, only one patient quit smoking. Total charges were $2,861,526 and total costs were $938,311. All patients had Medicare or Medicaid on admission. Hospital loss ($432,561) was incurred in those patients admitted more than 4 days whereas a profit ($33,285) was realized in patients admitted less than 4 days. These deaths and financial loss could be reduced by better testing and more precise guidelines as to which patients can safely receive home oxygen. Patients can have their saliva tested for the nicotine breakdown product of cotinine; the test takes 10 minutes. The American Burn Association, in conjunction with the American College of Chest Physicians, should address this issue and develop guidelines for physicians who order home oxygen therapy and for state departments of public health who should regulate the companies that deliver home oxygen.

We sought to evaluate the incidence, morbidity, and mortality of pneumonia among inhalation injury patients requiring admission to our burn unit. We undertook a retrospective study of 228 consecutive patients with inhalation injury who were admitted to the burn unit of a level one trauma center between 2001 and 2004. Of the remaining 117 patients with inhalation injury and requiring hospitalization for at least 48 hours, 32 (27%) developed pneumonia. The average patient with inhalation injury and pneumonia developed their infiltrate on day 6 ± 5 days and required 3 ± 4 burn operations. There was no difference seen in age, sex, or carboxyhemoglobin level between inhalation injury patients with and without pneumonia (P> .05). The inhalation injury patients that had an associated TBSA burn of at least 20% had a 60% (12/20) pneumonia rate, which was significantly higher then the 21% (20/97) pneumonia rate observed in patients with an association burn less then 20%. The overall mortality of patients with inhalation injury and pneumonia was 19% (6/32), double the mortality rate of 9% (8/85) found in patients with inhalation injury and no pneumonia. The average length of stay of inhalation injury patients with pneumonia was significantly longer (47 ± 44 days) then inhalation injury patients without pneumonia (26 ± 54 days; P< .05). The presence of pneumonia among inhalation injury patients significantly increased length of stay and doubled mortality rates. Admission carboxyhemoglobin levels, age, and sex had no relationship to the development of pneumonia. An increase in TBSA burn was associated with a higher pneumonia rate.

It is generally accepted that patients with a systolic blood pressure (SBP) <90 mmHg are in "shock" and have a worse prognosis than patients with a higher SBP. Our objective was to determine if patients with a SBP of 90-109 mmHg have a worse outcome than patients with a higher SBP following trauma. Patients with gastric, small bowel, and/or diaphragm injuries were identified retrospectively through the trauma database from 1980-2003. All 2071 patients underwent emergent laparotomy at an urban, level one trauma center. The mortality rate of patients with a SBP of 90-109 mmHg in the ED or OR was 5% (17/354) and significantly higher than the 1% (12/1020) mortality seen in patients with a SBP of 110 mmHg or greater (P< 0.001). The average length of stay of patients with a SBP of 90-109 mmHg was 15 ± 14 days and was significantly longer than the 11 ± 11 days seen in patients with a higher SBP. If the SBP was 90-109 mmHg, the infection rate was 39% (131/340), and this was significantly higher than the 22% (219/1016) infection rate seen in patients with higher SBP (P< 0.001). Trauma patients with a systolic blood pressure of 109 mmHg or below are at increased risk for morbidity and mortality following trauma. Patients with a systolic blood pressure of 90-109 mmHg following trauma should be considered as a special group requiring aggressive resuscitation and surgery. Early operative control of hemorrhage in these patients can reduce mortality and infection.

Morbidity and mortality after gastric injury is usually the result of associated injuries. The authors conducted a retrospective study of 544 consecutive patients with gastric trauma requiring emergency surgery. Blunt injuries had the highest mortality and length of stay. The mortality of a proximal stomach injury was 43 per cent (9 of 21) and was significantly higher than the 19 per cent mortality seen in patients with more distal injuries (P< 0.01). The majority of gastric injuries were closed primarily (492 of 544 or 90%). The patients requiring more than a primary repair had a higher mortality (22 of 52 or 42% vs.87 of 492 or 18%; P< 0.001), required more blood (16 ± 16 U vs.6 ± 11 U; P< 0.001), had an increased rate of surgical site infections (17 of 52 or 33% vs.75 of 492 or 15%; P =0.001), and had an increased length of stay (20 ± 30 days vs.13 ± 18 days; P =0.024). There were 22 patients with an isolated gastric injury, and all of these patients survived. Patients with an associated arterial injury had the highest mortality (49%) and highest incidence of shock (64%). Patients with colon and gastric injuries had the highest (48 of 176 or 52%) surgical site infection rate. Isolated gastric injury is rare, but is associated with low morbidity and mortality. The mechanism of injury, location of injury, and type of repair used all affect patient outcomes with gastric injury.

As care for burn injuries continue to improve, inhalation injuries have become a more significant cause of death. The purpose of this study was to evaluate factors affecting prognosis in patients with inhalation injuries. We undertook a retrospective chart review of all 829 consecutive patients admitted to our burn unit from January 2000 to September 2004. The 600 patients with thermal injury and no inhalation injury had a mortality of 3% (20/600). The 229 (28%) patients with an inhalation injury had an overall mortality of 16% (36/229; P< .001). Of these patients, 22 (10%) died in the first 48 hours, 90 (39%) were discharged in the first 48 hours, and 117 (51%) required hospitalization of at least 48 hours. Of the remaining 117 patients with inhalation injury the mortality was 12%. No difference in mortality (5% vs 3%) or length of stay (18 days vs 14 days) was seen between patients with an isolated inhalation injury and those with an inhalation injury plus an associated burn of less than 10% (P> .05). A significant difference was noted after the associated burn was larger then 10% (P< .05). The mortality rate and length of stay appear to be increased primarily by the severity of the associated burn in patients with inhalation injury andburns.

The Kraske procedure offers a sphincter-saving alternative for surgical correction of rectal disease. This study was performed to investigate the complication rate with the traditional (transsacral) Kraske procedure versusan abdominal-assisted Kraske approach (laparoscopic or open). We conducted a retrospective review of all patients undergoing the Kraske procedure at Harper University Hospital over a 10-year period. A total of 54 patients were identified. Indications for surgery included rectal carcinoma (43), large villous adenomas (6), and other (5). Average postoperative follow-up was 40 ± 25 months (mean ± SD). Complications included rectocutaneous fistulae (9), perineal infections (13), and incontinence (8). In patients requiring an abdominal-assisted approach for colorectal mobilization, the fistula rate was significantly higher (33% vs3%; P= 0.007), as were the rates of perineal infections (33% vs17%) and of initial incontinence (25% vs7%). The laparoscopic-assisted approach significantly reduced the operating time (272 ± 72 minutes) compared to the open-assisted approach (498 ± 138 minutes) (P< 0.001). The traditional Kraske procedure can be utilized in a safe, effective manner for treatment of rectal disease. Knowledge of the increased rate of complications with the abdominal-assisted Kraske approach can guide the patient and physician considering sphincter salvage.

Development of an effective vaccine against the pathogenic blood-stage infection of human malaria has proved challenging, and no candidate vaccine has affected blood-stage parasitemia following controlled human malaria infection (CHMI) with blood-stage Plasmodium falciparum.

Most deaths from severe falciparum malaria occur within 24 h of presentation to a hospital. Intravenous (i.v.) artesunate is the first-line treatment for severe falciparum malaria, but its efficacy may be compromised by delayed parasitological responses.

Pelvic ventral hernia repair in a surviving conjoint twin with multiple congenital anomalies that make surgery a challenge. Conjoint twins are a rare. The incidence is reported to be in the range of 150 000 to 1100 000 live births. Of the conjoint twins, 40 are stillborn and an additional one-third die within 24 h of birth. Those who survive through birth and surgical separation may present later in life with a wide range of complex congenital malformations. There are no reports on hernia incidence or hernia repair in surviving conjoint twins.

Opinion. Comments on various aspects of tax increment financing and Chapter 353 of the Revised Statutes of Missouri, as economic development incentives. Requirements in the responsible use of tax incentives; Proposal to amend use of term `blight' in tax increment statute; Concern by legislators that developable pieces of vacant land were declared blighted.