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We examined the interactive effects of copper (Cu) and overweight (overweight) and obesity on outcomes of burn patients. We posited that higher baseline Cu among burn patients with overweight or obesity will be associated with poor clinical outcomes vs. patients with a normal weight.A retrospective review was conducted on patients with ≥20% total burn surface area (TBSA) with an initial measurement of Cu. Patients were grouped by body mass index (BMI). The interactions between baseline Cu and BMI groups on multiple burn patient outcomes were examined in a series of multiple regression models.One-hundred-and-sixty patients met eligibility (age 43.9 ± 17.5, males 86.3%, normal weight:overweight:obesity = 53:38:69). BMI groups did not differ significantly on demographics, burn severity, or baseline biochemistry. Normal weight patients with higher baseline Cu had shorter ICU stay (ICUS), shorter length of stay (LOS), and had fewer operations (Ps0.05). In contrast, overweight and obese patients with higher baseline Cu had longer ICU stay (p = 0.001 and p = 0.034), LOS (p = 0.005 and p = 0.066), and increased operations (p = 0.001 and p = 0.067).Higher baseline Cu seems associated with adverse outcomes in overweight and obese burn patients. Further research is needed to confirm this association and explore the direction of causality.

Background Hidradenitis suppurativa (HS) is a debilitating skin condition; in severe forms it requires excision and skin grafting for cure. This is commonly performed as a multi-stage procedure; we explored single-stage operation as a more efficient alternative. Methods Retrospective review 2007–2018 evaluating outcomes of patients undergoing single-stage surgery. Results 139 one-stage procedures were performed: 35 excision and primary closure, 104 split-thickness skin grafting (STSG). Success rate was higher for STSG at 75% versus 60% with primary closure. Of failed primary closures, 57% required revision by grafting due to recurrence. Axilla procedures were most successful at 91% compared to 70%, 54%, and 50% for inguinal, gluteal, and perineal areas, respectively. Infection was the most common complication (17%), with 38% requiring readmission. Conclusion Compared to prior literature on multi-stage HS treatment, one-stage operations are a feasible, cost-effective alternative. STSG should remain the procedure of choice, even when primary closure appears feasible.

Laparoscopic cholecystectomy is a common operation; approximately 20 million Americans have gallstones, the most common indication. Surgeons who operate on the biliary tree must be familiar with the presentations and treatment options for acute and chronic biliary pathology. We focus on the difficult "bad" gallbladder. We explore the available evidence as to what to do when a gallbladder is too inflamed, too technically challenging, or a patient is too sick to undergo standard laparoscopic cholecystectomy. We discuss whether or not open cholecystectomy is a relevant tool and what can be done to manage common bile duct stones found unexpectedly intraoperatively.

Necrotizing soft tissue infections (NSTIs) are highly aggressive and may be lethal if untreated. Polymicrobial infections of the groin and lower limb have been documented secondary to invasive colorectal cancer (CRC). We present a case of CRC diagnosed more than 4 years after the development of NSTI. There are documented cases of NSTIs concomitant with a preexisting CRC. In this case, however, the patient’s initial presentation was an NSTI followed by later diagnosis of CRC. A previously treated NSTI that is not healing appropriately may be an early indicator for CRC.

RCTs showed benefits in Lap repair of perforated peptic ulcer (PPU). The SWSC Multi-Center Trials Group sought to evaluate whether Lap omental patch repairs compared to Open improved outcomes in PPU in general practice. Data was collected from 9 SWSC Trial Group centers. Demographics, operative time, 30-day complications, length of stay and mortality were included. 461 PATIENTS: Open in 311(67%) patients, Lap in 132(28%) with 20(5%) patients converted from Lap to Open. Groups were similar at baseline. Significant variability was found between centers in their utilization of Lap (0-67%). Complications at 30 days were lower in Lap (18.5% vs. 27.5%, p 0.05) as was unplanned re-operation (4.7% vs 14%, p 0.05). Lap reduced LOS (6 vs 8 days, p 0.001). Ileus was more in Lap (42% vs 18 p 0.001) operative time was 14 min higher in Lap(p 0.01) and admission to OR time was 4 h higher in Lap(0.05). No significant difference readmission or mortality. Our results suggest Lap should be considered a first-line option in suitable PPU patients requiring omental patch repair in centers that have the capacity and resources 24/7.

The COVID-19 pandemic resulted in a statewide stay-at-home (SAH) order in California beginning March 19, 2020, forcing large-scale behavioral changes and taking an emotional and economic toll. The effects of SAH orders on the trauma population remain unknown. We hypothesized an increase in rates of penetrating trauma, gunshot wounds, suicide attempts, and domestic violence in the Southern California trauma population after the SAH order.A multicenter retrospective analysis of all trauma patients presenting to 11 American College of Surgeons levels I and II trauma centers spanning seven counties in California was performed. Demographic data, injury characteristics, clinical data, and outcomes were collected. Patients were divided into three groups based on injury date: before SAH from January 1, 2020, to March 18, 2020 (PRE), after SAH from March 19, 2020, to June 30, 2020 (POST), and a historical control from March 19, 2019, to June 30, 2019 (CONTROL). POST was compared with both PRE and CONTROL in two separate analyses.Across all periods, 20,448 trauma patients were identified (CONTROL, 7,707; PRE, 6,022; POST, 6,719). POST had a significantly increased rate of penetrating trauma (13.0% vs. 10.3%, p0.001 and 13.0% vs. 9.9%, p0.001) and gunshot wounds (4.5% vs. 2.4%, p = 0.002 and 4.5% vs. 3.7%, p = 0.025) compared with PRE and CONTROL, respectively. POST had a suicide attempt rate of 1.9% and a domestic violence rate of 0.7%, which were similar to PRE (p = 0.478, p = 0.514) and CONTROL (p = 0.160, p = 0.618).This multicenter Southern California study demonstrated an increased rate of penetrating trauma and gunshot wounds after the COVID-19 SAH orders but no difference in attempted suicide or domestic violence rates. These findings may provide useful information regarding resource utilization and a target for societal intervention during the current or future pandemic(s).Epidemiological, level IV.

Introduction A >25% increase in daily insulin dosing is suggestive of possible sepsis in burn patients, however, no conclusive evidence is available regarding the time point at which insulin dosing begins to increase. The purpose of this study is to determine the exact time point at which the insulin requirement increases among non-diabetic burn patients with sepsis. Methods A retrospective chart review in non-diabetic burn patients with ≥20% total body surface area burned (TBSA) during 2010–2018 who received a blood culture for suspected sepsis. Absolute insulin dosing at intervals (0, 24, 48, 72, and 96 h prior to blood culture) were Box–Cox transformed and compared vs.−96 h reference using mixed-effects models accounting for within-patient dependencies. Results Fifty-eight patients (84% males, age 44 ± 17 years, TBSA% 49 ± 17.5) were included. When cube root of daily insulin dosing was regressed on each time point in a mixed-effects model, statistically significant increase in insulin dosing compared to baseline was observed for −48 (p = 0.018), −24 (p = 0.011), and 0 h (p = 0.008). Conclusion Daily insulin dosing increases 48 h prior to development of other clinical signs of sepsis and can be used as a sensitive early marker.

Background: Necrotizing soft tissue infections (NSTIs) are a group of rapidly progressive infections of the skin and its underlying tissue. These infections result in substantial morbidity and mort...

Introduction Sepsis is a leading cause of mortality in burn patients. One of the major causes of sepsis in burn patients is Pseudomonas aeruginosa. We hypothesized that during dissemination from infected burn wounds and subsequent sepsis, P. aeruginosa affects the metabolome of the blood resulting in changes to specific metabolites that would serve as biomarkers for early diagnosis of sepsis caused by P. aeruginosa. Objectives To identify specific biomarkers in the blood after sepsis caused by P. aeruginosa infection of burns. Methods Gas chromatography with time-of-flight mass spectrometry was used to compare the serum metabolome of mice that were thermally injured and infected with P. aeruginosa (B–I) to that of mice that were neither injured nor infected, mice that were injured but not infected, and mice that were infected but not injured. Results Serum levels of 19 metabolites were significantly increased in the B–I group compared to controls while levels of eight metabolites were significantly decreased. Thymidine, thymine, uridine, and uracil (related to pyrimidine metabolism), malate and succinate (a possible sign of imbalance in the tricarboxylic acid cycle), 5-oxoproline (related to glutamine and glutathione metabolism), and trans-4-hydroxyproline (a major component of the protein collagen) were increased. Products of amino acid metabolism were significantly decreased in the B–I group, including methionine, tyrosine, indole-3-acetate, and indole-3-propionate. Conclusion In all, 26 metabolites were identified, including a unique combination of five metabolites (trans-4-hydroxyproline, 5-oxoproline, glycerol-3-galactoside, indole-3-acetate, and indole-3-propionate) that could serve as a set of biomarkers for early diagnosis of sepsis caused by P. aeruginosa in burn patients. Electronic supplementary material The online version of this article (10.1007/s11306-020-01658-2) contains supplementary material, which is available to authorized users.

Introduction While copper (Cu) has been shown to be beneficial in wound healing, high levels of circulating Cu are also associated with increased oxidative stress. Interestingly, elevated baseline Cu levels have been seen in obese patients, and theoretically, this is associated with higher baseline oxidative stress. Overweight (OW) and Obesity (OB) are common conditions in the US; therefore, a significant proportion of burn patients will be potentially affected. We examined the interactive effects of Cu and obesity on outcomes of burn patients; specifically, we hypothesized that higher baseline Cu levels in OW and OB burn patients are associated with worse clinical outcomes. Methods A retrospective review of patients with burns ≥20% TBSA between 2015–2019. Patients were grouped according to body mass index (BMI) (i.e., NW:18–24.9; OW:25–29.9; and OB: ≥ 30 kg/m2). Baseline characteristics were compared using ANOVA and χ 2 tests. The interactions between baseline Cu and BMI groups on 1) lengths of ICU stay (ICUS), 2) overall hospital stay (LOS), and 3) the number of operative procedures, were examined in a series of multiple regression models in R. Results Data of 160 patients met eligibility (NW: OW: OB = 53: 38: 69). BMI groups did not differ significantly on demographics, TBSA, degree of burn, inhalational injury, or mortality. Regression models revealed that NW patients with high baseline Cu levels had shorter ICUS (p< 0.001) and LOS (p=0.003) and also had fewer operations (p = 0.001). While OW and OB were protective at low Cu levels, patients with OW or OB who had high baseline Cu levels had longer ICUS (p< 0.001 and p=0.033), LOS (p=0.001 and p=0.063), and a greater number of operations (p< 0.001 and p=0.066) (Table 1). Conclusions High baseline Cu seems to be beneficial for NW burn patients, yet associated with adverse outcomes in burn patients with OW and OB. While further evidence is needed to confirm this notion, caution is advised when supplementing Cu for burn patients with OW and OB.

Introduction The literature regarding outcomes in patients on irreversible antithrombotic therapy (IAT) undergoing urgent laparoscopic appendectomy is limited. The aim of this multicenter retrospective study was to examine the impact of prehospital IAT on outcomes in this population. Methods From 2010 to 2014, seven institutions from the Southwest Surgical Multicenter Trials (SWSC MCT) group conducted a retrospective study to evaluate the clinical course of all patients on IAT who underwent urgent/emergent laparoscopic appendectomy. The IAT+ group was subdivided into IAT+ (Aspirin only) and IAT+ (Aspirin-Plavix). These groups were matched 1:1 to controls. The primary outcomes were estimated blood loss (EBL) and transfusion requirement. Secondary outcomes included infections (SSI – Surgical Site Infection, DSI – Deep Space Infection, and OSI – Organ Space Infection), hospital length of stay (HLOS), complications, 30-day readmissions, and mortality. Results Out of the 2903 patients included in the study, 287 IAT+ patients were identified and matched in a 1:1 ratio to 287 IAT-patients. In the IAT+ vs IAT-analysis, no significant differences in EBL (p = 1.0), transfusion requirement during the preoperative (p = 0.5), intraoperative (p = 0.3) or postoperative periods (p = 0.5), infectious complications (SSI; p = 1.0, DSI; p = 1.0, and OSI; p = 0.1), overall complications (p = 0.3), HLOS (p = 0.7), 30-day readmission (p = 0.3), or mortality (p = 0.1) were noted. Similarly, outcomes in the IAT+ (Aspirin only) and IAT+ (Aspirin-Plavix) subgroups failed to demonstrate any significant differences when compared to controls. Conclusions Our analysis suggests that IAT is not associated with worse outcomes in urgent/emergent laparoscopic appendectomy. Prehospital use of IAT should not be used to delay laparoscopic appendectomy.

While a considerable body of knowledge regarding sepsis in trauma patients is available, the potential influence of trauma-induced changes in the blood of these patients on the pathogenesis of Pseudomonas aeruginosa is basically an unexplored area. Rather than using standard laboratory media, we grew P. aeruginosa in whole blood from either healthy volunteers or trauma patients. The specific changes in the P. aeruginosa transcriptome in response to growth in blood from trauma patients reflect the adaptation of this organism to the bloodstream environment. This knowledge is vital for understanding the strategies this pathogen uses to adapt and survive within the host during systemic infection. Such information will help researchers and clinicians to develop new approaches for treatment of sepsis caused by P. aeruginosa in trauma patients, especially in terms of recognizing the effects of specific therapies (e.g., iron, zinc, or mannitol) on the organism. Further, this information can most likely be extrapolated to all patients with P. aeruginosa septicemia., Trauma patients (TPs) are highly susceptible to infections, which often lead to sepsis. Among the numerous causative agents, Pseudomonas aeruginosa is especially important, as P. aeruginosa sepsis is often fatal. Understanding the mechanism of its pathogenesis in bloodstream infections is imperative; however, this mechanism has not been previously described. To examine the effect of trauma-induced changes in blood on the expression of P. aeruginosa genes, we grew strain UCBPP-PA14 (PA14) in blood samples from eight TPs and seven healthy volunteers (HVs). Compared with its growth in blood from HVs, the growth of PA14 in blood from TPs significantly altered the expression of 285 genes. Genes whose expression was significantly increased were related to carbon metabolism, especially malonate utilization and mannitol uptake, and efflux of heavy metals. Genes whose expression was significantly reduced included genes of the type VI secretion system, genes related to uptake and metabolism of amino acids, and genes related to biosynthesis and transport of the siderophores pyoverdine and pyochelin. These results suggest that during systemic infection in trauma patients, and to adapt to the trauma-induced changes in blood, P. aeruginosa adjusts positively and negatively the expression of numerous genes related to carbon metabolism and virulence, respectively. IMPORTANCE While a considerable body of knowledge regarding sepsis in trauma patients is available, the potential influence of trauma-induced changes in the blood of these patients on the pathogenesis of Pseudomonas aeruginosa is basically an unexplored area. Rather than using standard laboratory media, we grew P. aeruginosa in whole blood from either healthy volunteers or trauma patients. The specific changes in the P. aeruginosa transcriptome in response to growth in blood from trauma patients reflect the adaptation of this organism to the bloodstream environment. This knowledge is vital for understanding the strategies this pathogen uses to adapt and survive within the host during systemic infection. Such information will help researchers and clinicians to develop new approaches for treatment of sepsis caused by P. aeruginosa in trauma patients, especially in terms of recognizing the effects of specific therapies (e.g., iron, zinc, or mannitol) on the organism. Further, this information can most likely be extrapolated to all patients with P. aeruginosa septicemia.

Controversy exists regarding how quickly an adult with appendicitis requires surgery to prevent perforation, and recent literature on antibiotic use as definitive treatment has complicated this question further. Since perforation is associated with worse outcomes, particularly in the elderly, efforts to prevent this complication are warranted. We studied risk factors for in-hospital perforation in patients diagnosed by admission CT with non-perforated acute appendicitis.We evaluated baseline demographics, symptom duration, and time from admission to antibiotics and surgery. Outcome measure was perforation diagnosed intra-operatively by attending surgeon.Of 700 patients, 84 (12%) sustained in-hospital perforation; time from admission to operation or antibiotics were not associated. Duration of symptoms24 h (aOR = 2.23, 95% CI = 1.33-3.72, p 0.001) increased perforation risk. Patient age over 46 years (aOR = 4.54, 95% CI = 2.04-10.06, p 0.001) was also associated with higher risk that increased with increasing age.Time to operation and antibiotic timing were not associated with in-hospital perforation in a general adult population. However, these findings suggest a possible benefit to expedient surgery in older patients.

Objective: Alcohol Withdrawal Syndrome (AWS) remains a common problem, especially in trauma and surgical patients. An intravenous ethanol infusion protocol was developed at this institution and previously validated for AWS prophylaxis. One concern with intravenous ethanol has been potential for intoxication and/or side effects. This study was performed on patients receiving AWS prophylaxis with an intravenous ethanol protocol to evaluate for intoxication and the occurrence of any adverse effects. Methods: We did a retrospective review of all patients in our hospital who received AWS prophylaxis by ethanol infusion between 2008 and 2013. Information collected specific to ethanol infusion included rate of administration, serum ethanol levels, serum sodium level, use of benzodiazepines and anti-emetics, and development of AWS. Intoxication was defined using the Texas limit for blood alcohol content in a driver of .08% (80mg/dL). The study period began at admission and lasted 7 days. Results: Ninety-seven patient charts were reviewed. Average serum ethanol level on admission was 137 mg/dL. Serum ethanol levels increased in 12% of patients after administration of ethanol infusion, and levels generally decreased over time. Asymptomatic hyponatremia (serum sodium

Smoke inhalation and carbon monoxide poisoning are a significant cause of mortality and neurologic morbidity. We present the unusual case of complete neurologic survival after prolonged hypoxia, severe acidosis, out of hospital cardiac arrest, and exposure to high levels of carbon monoxide poisoning in a patient with sickle cell disease. The hypothesis that there might be a potential protective effect from the type of hemoglobin seen in patients with sickle cell disease in carbon monoxide poisoning is discussed.

The USA is currently going through an opioid crisis, associated with tremendous economic and societal impacts. In response to this crisis, healthcare professionals are looking for alternative pain management methods, and non-steroidal anti-inflammatory drugs (NSAIDs) are a sensible choice because of their effectiveness after surgical procedures. However, before surgeons start prescribing NSAIDs in place of opioids, it is crucial to first understand their potential post-surgical complications. The goal of this review is to summarize the data obtained through both animal and human studies, which suggest how a dramatic increase in NSAID use may affect these post-surgical complications. We first provide a short review outlining the mechanisms of action of NSAIDs, followed by a summary of animal studies, which show a trend towards the negative effects of NSAIDs on wound healing and an association between NSAID use and wound infections. Lastly, we present evidence from human studies on the association of NSAIDs with the following complications: anastomotic leaks, necrotizing soft tissue infections, bleeding complications, orthopedic injuries, wound healing, and cancer care. The human studies are much more variable in their conclusions as to whether NSAIDs are beneficial or not, with the only strong evidence showing that NSAIDs inhibit bone healing. This may partially be explained by male and female differences in response to NSAIDs as many animal studies showing the inhibitory effects of NSAIDs were performed on females, while all the human studies were performed with both sexes. We conclude that strong caution should be used in the prescription of NSAIDs, especially in female patients, but larger scale studies are warranted before solid recommendations can be made.

Objective: Necrotising soft tissue infections (NSTIs) progress rapidly and mortality remains high, ranging from 10% to 30%, representing a significant challenge for health professionals. Early accurate diagnosis is crucial because timely and aggressive surgical intervention remains the number one indicator for a better clinical outcome. Understanding the microbial background of NSTIs would aid early diagnosis. Presentation: We present a case of NSTI, in a seemingly healthy adult male, originating from a tooth abscess. The NSTI progressed rapidly, and eventually covered the patient's chest and abdominal skin and underlying soft tissue. Results: Traditional blood and tissue culture only found Group C Streptococcus where 16S sequencing detected abundant Prevotella spp., a more likely causal organisms of the NSTI. The use of antibiotics with the approriate anaerobe coverage, in combination with timely surgical intervention, contributed to the ultimate successful clinical outcome. Complete wound healing and successful graft was achieved within one month of diagnosis of the microbes present. Conclusion: While surgical intervention remains the most important consideration in treatment of NSTI, correct identifcation of the microbial flora could also contribute to successful treatment.

Introduction Venous thromboembolism (VTE) remains one of the principal causes of morbidity and death in trauma patients that survive the first 24 h. Recent literature on VTE prevention focuses on choice of chemoprophylaxis, specifically unfractionated heparin (UFH) versus low molecular weight heparin (LMWH). This singular focus on a multifactorial process may be inadequate to fully understand the optimal approach to VTE prevention. We hypothesized that variations in care between trauma centers could be used to identify key components of VTE prevention associated with better outcomes. Methods A 50 question survey of VTE management for years 2014–2016 was sent to 15 trauma centers. The survey included: demographics of the trauma centers, type and timing of chemoprophylaxis, ambulation expectations, and complementary services (geriatric trauma service (GTS), mobility teams, physical and occupational therapy (PT/OT)). Each center submitted their American College of Surgeons Trauma Quality Improvement Program (TQIP) Benchmark Report for Spring 2017. TQIP data included: mortality, observed rates of deep vein thrombosis (DVT) and pulmonary embolus (PE), and time to VTE prophylaxis. The survey and TQIP reports were blinded for analysis; descriptive statistics were utilized. The top DVT & PE TQIP performers were used to identify potential aspects of better care on the survey responses. The institutions’ DVT and PE rates were then compared for these responses using Wilcoxon-Rank-Sum test. Results Fifteen trauma centers (13 Level-1, 2 Level-2) completed the survey; the centers admitted 1050–7200 trauma patients per year (median 3000). The majority of centers were University-affiliated (11 of 15) with general surgery residencies (14 of 15), Acute Care Surgery or Surgical Critical Care Fellowships, (9 of 15) and critical care boarded-surgeons only on-call (9 of 15). Few have geriatric trauma services (3 of 15) or mobility teams (1 of 15). Half the trauma centers have dedicated PT/OT teams for trauma or weekend coverage. With a total of 20,878 TQIP patients analyzed, the average observed DVT and PE rates were 1.27% (range 0.1–5.2%) and 0.68% (range 0–1.6%), respectively. Weekly lower extremity surveillance duplex (2 of 15) increased DVT detection (4.15% vs 0.80%, p = 0.034) but did not decrease PE rates (1.05% vs 0.62%, p = 0.229). Great variance was seen in choice, dosing and timing of chemoprophylaxis: UFH,4 LMWH daily,1 LMWH twice-daily,5 LMWH weight-based dosing,4 and LMWH anti-Xa dosing.1 The top 3 performers for DVT and PE all used different types of chemoprophylaxis. These top performers had a prominent culture of mobility: dedicated PT/OT teams for trauma or weekends and an expectation to ambulate 3-times per day. Weekend PT/OT teams were associated with lower DVT rates (median 0.40%, range 0.10–1.10% vs 1.30%, 0.60–5.20%, p = 0.018), and ambulation 3-times per day was associated with lower PE rates (median 0.20%, range 0.00–0.20% vs 0.80%, 0.40–1.60%, p Conclusions Considerable variation in VTE chemoprophylaxis exists among trauma centers. “Best practices” in this area requires further investigation. An expectation of mobility and investment in mobility resources may serve to decrease VTE rates in trauma patients compared to a singular focus on type of chemoprophylaxis administered.

Highlights • Large defects following giant scalp melanoma resection pose a challenge to surgeon. • Excision beyond galea difficult to close with skin grafts & flaps. • INTEGRA® following split-thickness-skin-graft may be used to cover the wound., Introduction Surgical defect left following excision of a large and neglected scalp melanoma of can pose a significant challenge for the surgeon. Scalp reconstruction encompasses options such as skin flaps, grafts, and various mechanical techniques. In scalp excision that involves dissection beyond the galea, skin grafts and flaps may not take well and not enough tissue may be available for a skin flap. Presentation of case We present the case of a 64 year-old male with a giant scalp melanoma. The patient underwent excisional surgery of the tumor that left behind a large, galeal scalp wound defect. We used a dermal regeneration template (INTEGRA®) followed by negative pressure wound therapy (wound V.A.C.®), followed by split-thickness-skin-graft (STSG) to cover the wound. The patient was operated on and discharged home the same day and home health wound care was utilized for wound V.A.C.® maintenance. The patient underwent same day surgery for STSG two weeks later with great results. His one-month follow-up visit showed 100% graft take and a well-healing wound. Discussion The combination of INTEGRA®, negative pressure dressing, and skin graft proved to be a safe and effective solution to dealing with large wound defects following surgical excision of the tumor. This is likely secondary to neovascularization and regeneration of a dermal template that is achieved with the dermal regeneration matrix INTEGRA®. Other studies have shown that combination of negative pressure wound therapy with INTEGRA® promotes faster integration of the matrix and decreases wound complications such as infection. Conclusion The excellent results for this case present a very effective, time-expedient operative approach to surgical challenges in treating giant scalp melanomas. A four-week follow-up visit after INTEGRA® and wound V.A.C.® application indicated that Integra was well integrated to the calvarium with good neovascularization and granulation tissue evident. Skin grafting not only covered the defect completely, but also took to the scalp 100% with no wound breakdown or wound-healing issues.

This is a case report of foreign body ingestion in a 55-year-old intellectually disabled man with a history of pica and previous removal of ten plastic gloves from his rectum four months prior to this presentation. The patient presented after ingesting plastic gloves which formed large, rigid esophageal and gastric bezoars that were not amenable to endoscopic removal. An exploratory laparotomy and gastrostomy was performed, and a 10 × 4.5 × 2 cm gastric bezoar consisting of rigid plastic gloves was removed without complication. Special considerations must be taken when considering the ingestion of nonfood items in the intellectually disabled population as these cases may not present classically with symptoms of a gastric bezoar.

Removal is the standard treatment for mesh infection following prosthetic hernia repair. However, certain types of mesh may be less amenable to removal even in the setting of active infection; we present four such cases, all involving the same composite mesh. Four high-risk patients underwent Parietex mesh implantation for large ventral wall hernias and developed subsequent Staphylococcus infections with attempted explantation of infected mesh and wound care. There was inability to completely explant mesh in all four cases, leading to chronic purulent wounds and long-term complications. While mesh infection is a recognized complication of prosthetic hernia repair, many synthetic meshes form a slimy biofilm and thus can be removed relatively easily. However, the structural qualities of certain types of mesh create ingrowth into tissues even in the setting of infection, resulting in inability to explant with subsequent long-term chronic wound complications.

Aims: The aim of this study was to characterize positive blood alcohol among patients injured at work, and to compare the severity of injury and outcome of blood alcohol concentration (BAC) positive and negative patients. Settings and Design: A retrospective cohort study was performed at a Level 1 academic trauma center. Patients injured at work between 01/01/07 and 01/01/12 and admitted with positive (BAC+) vs negative (BAC-) blood alcohol were compared using bivariate analysis. Results: Out of 823, 319 subjects were tested for BAC (38.8%), of whom 37 were BAC+ (mean 0.151 g/dL, range 0.015-0.371 g/dL). Age (41 years), sex (97.2% men), race, intensive care unit (ICU) and hospital length of stay (LOS), and mortality were similar between groups. Nearly half of BAC+ cases were farming injuries (18, 48.6%): Eight involved livestock, five involved all-terrain vehicles (ATVs), three involved heavy equipment, one fell, and one had a firearm injury. Eight (21.6%) were construction site injuries involving falls from a roof or scaffolding, five (13.5%) were semi-truck collisions, four (10.8%) involved falls from a vehicle in various settings, and two (5.4%) were crush injuries at an oilfield. BAC+ subjects were less likely to be injured in construction sites and oilfields, including vehicle-related falls (2.3 vs 33.9%, P < 0.0001). Over half of BAC+ (n = 20, 54%) subjects were alcohol dependent; three (8.1%) also tested positive for cocaine on admission. No BAC+ subjects were admitted to rehabilitation compared to 33 (11.7%) of BAC- subjects. Workers' compensation covered a significantly smaller proportion of BAC+ patients (16.2 vs 61.0%, P < 0.0001). Conclusions: Alcohol use in the workplace is more prevalent than commonly suspected, especially in farming and other less regulated industries. BAC+ is associated with less insurance coverage, which probably affects resources available for post-discharge rehabilitation and hospital reimbursement.

INTRODUCTIONAn unusual cause of intussusception due to small bowel obstruction secondary to dried apricot consumption was encountered. Phytobezoar small bowel obstruction is a rare, but interesting pathology that accounts for 2–4% of small bowel obstructions (18). Even rarer, is an intussusception caused by dried fruit ingestion. We present the case of a 56-year-old female that presented with an intussusception after she ingested a large amount of dried apricots.PRESENTATION OF CASEThe patient is a 56-year-old female with a small bowel obstruction secondary to intussusception in the distal ileum. She was taken to the operating room for a celiotomy where an intussusception of the distal small bowel was found. An enterotomy was performed which revealed dried apricots as the lead point. The intussusception was successfully reduced and the apricots removed.DISCUSSIONSmall bowel obstruction due to intussusception can be caused secondary to malignancy, Meckel's Diverticulum, benign neoplasm, and strictures. A less common cause for small bowel obstruction due to intussusception in adults is secondary to mechanical obstruction by bezoars. Risk factors for bezoar formation include previous gastric surgery, diabetes, and mastication problems.CONCLUSIONBezoars are an extremely rare cause of intussusception in adults. A high level of suspicion needs to exist in the presence of a history of eating dried fruit, history of gastric surgery, diabetes mellitus, and problems with mastication. Various treatment modalities exist to treat obstructions secondary to bezoars, including open reduction and removal of bezoar via enterotomy.

Introduction: Inhalation injury is a particularly lethal form of thermal burn injury, and is associated with increased morbidity and mortality. Pneumonia is a common complication of inhalation injury, due to the increased susceptibility of lungs that have been stripped of their biologic defense mechanisms, as well as the general susceptibility of the burn population to infections. While older series suggest that pneumonia is associated with worse mortality and morbidity, recent reports suggest that this may not be the case in all populations. Methods: We attempted to clarify the impact of pneumonia in terms of mortality, length of mechanical ventilation, need for tracheostomy, and discharge disposition, in patients admitted with inhalation injury by performing a retrospective review of patients admitted to a regional burn center 2002-2009. Burn registry and electronic chart review were used to obtain demographic, clinical and outcome data. Univariate and multivariate analysis was used to compare outcomes in patients who developed pneumonia versus those who did not. Results: The study cohort comprised 166 patients, of whom 21 (13%) were diagnosed with pneumonia. Development of pneumonia was not predicted by age, surface area burned or other complications such as acute respiratory distress syndrome. Surprisingly, pneumonia was associated with reduced inpatient mortality (p = 0.006). However, patients who developed pneumonia were also more likely to have prolonged ventilator dependence (19 vs 5 days, p

In this chapter, we address the battle between host and microbe in the burn patient. A multiplicity of infection types is discussed, including ventilator-associated pneumonia, central line infection, UTI, and burn wound infection. The paradigm of treatment for these infections is explained, as well as specific pathogens of concern and the agents of their coverage in modern practice. Sepsis, defined differently in the burn patient, is discussed along with the reasons behind this difference.

Pneumomediastinum (PM) is an uncommon finding after blunt trauma to the neck or chest. Motor vehicle collisions are the most common cause in adults, while falls are the most common in children. The majority of traumatic PM results from medial tracking of air from a concomitant pneumothorax. The Macklin effect, of air tracking medially along peribronchial sheaths from alveolar rupture, is responsible for most other cases. Chest pain is the most common symptom, and crepitus the most common sign. The majority of PM will resolve spontaneously, and requires no specific intervention. Only 1—6% of cases result from rupture of the larynx, trachea, bronchi or oesophagus. Hoarseness, dyspnea, persistent lung collapse or air leak should increase suspicion for aerodigestive injury. Computed tomography (CT) can help differentiate benign etiology from those that require surgical correction. High suspicion for aerodigestive injury based on clinical and/or CT findings should prompt diagnostic bronchoscopy and/or oesophagram.

Background: Pneumomediastinum occurs in up to 10% of patients with blunt thoracic and cervical trauma. Mandatory evaluation of all patients with bronchoscopy and esophageal imaging to exclude a major injury has been recommended. There is little data on the safety or efficacy of this approach. We evaluated the incidence of major injuries associated with pneumomediastinum, the accuracy of diagnostic modalities, and the results of observation versus aggressive evaluation. Methods: Medical records of all blunt trauma patients diagnosed with pneumomediastinum and/or aerodigestive tract injury between 1998 and 2005 were reviewed. The patient's hospital course was reviewed for demographic data, admission diagnoses, diagnostic imaging and procedures, operations, missed injuries, length of stay, and mortality. Results: The review identified a total of 136 patients with pneumomediastinum, and an additional 22 patients with thoracic aerodigestive tract injuries but without pneumomediastinum. Only patients with pneumomediastinum were considered in subsequent analysis. Pneumomediastinum was detected by CT scan in all 136 (100%) patients, although identified on plain radiograph in only 20 (15%) patients. Computed tomography findings were suspicious for a major aerodigestive tract injury in 27 (20%) patients. Ten (37%) of these 27 patients had an injury requiring operative intervention: five (4%) laryngeal injuries, three (2%) tracheal disruptions, and two (1%) esophageal perforations. Eighty-one patients (60%) never had endoscopic evaluation. There were no delayed diagnoses, missed injuries, or complications in the observation-only cohort. The overall sensitivity and specificity of CT scan for major aerodigestive tract injury was 100% and 85%, respectively. Conclusion: Major airway or esophageal injury is an uncommon cause of pneumomediastinum. CT scan was able to identify patients at high risk for aerodigestive injury in all cases, and should be the preferred screening tool for airway injury in patients with pneumomediastinum.

Background Damage-control laparotomy has become increasingly common after operative resuscitation of severe hemorrhagic shock after injury. Despite increased use, uncertainty exists about the safety and timing of enteral nutrition. The purpose of this study was to determine the safety and effect of immediate enteral nutrition. Study Design Data were obtained from a multicenter prospective cohort study evaluating clinical outcomes in adults with hemorrhagic shock after injury and were limited to patients with an open abdomen and no hollow viscus injury. The immediate enteral nutrition cohort was defined as initiation of enteral feeds within 36 hours after acute resuscitation completion. Multivariate stepwise logistic regression was used to evaluate factors associated with immediate enteral nutrition. Results One hundred subjects met inclusion criteria; 32 immediate enteral nutrition and 68 nonimmediate enteral nutrition. Nearly all patients underwent fascial closure (93.8% immediate enteral nutrition versus 94.1% nonimmediate enteral nutrition), with an average closure day of 6.47 ± 0.83 with immediate enteral nutrition and 8.55 ± 0.85 with nonimmediate enteral nutrition (p = 0.129). No significant difference in multiorgan dyfunction syndrome, length of ventilator days, ICU days, hospital days, or mortality was seen between groups. The rate of pneumonia was significantly different: 14 (43.8%) in immediate enteral nutrition and 49 (72.1%) in nonimmediate enteral nutrition (p = 0.008). Immediate enteral nutrition remained independently associated with a reduction in pneumonia within our stepwise regression (odds ratio=0.32; 95% CI, 0.13 to 0.79). Conclusions Immediate enteral nutrition after damage control appears safe, with no effect on abdominal closure rate. In addition, the reduction in pneumonia associated with immediate enteral nutrition suggests a tangible benefit. Immediate enteral nutrition should be considered in patients with open abdomens after severe trauma.

Purpose A decline in breast cancer incidence has been attributed to the reduction in hormone replacement therapy (HRT) prescriptions since the publication of the landmark WHIT paper in 2003. Concurrently, a relationship between HRT and cerebrovascular disease incidence has also been suggested. No generalized analysis of HRT prescription rates and breast cancer incidence rates that included more than seven years of data. We hypothesized that detailed analysis of SEER data would clarify the relationship between HRT use and breast cancer incidence. Given the large decline in HRT prescription rates uncovered, analyses of potential complications were also conducted, with the understanding that a small effect or one limited to a subpopulation, such as a single race, might not be detected. Methods Incidence rates (per 100,000 women) and standard errors for ductal and lobular breast carcinomas, and endometrioid /endometrial carcinomas in women over 50 years were obtained from the Surveillance, Epidemiology, and End Results (SEER) database 1992–2012. From the Medical Expenditure Panel Survey 1996–2012 weighted counts and standard errors of hormone replacement therapy (HRT) prescriptions for women over 50 years were obtained. Using the National Hospital Discharge Survey (NHDS), 1996–2010 weighted counts and standard errors of femoral neck fractures, total hip replacements, acute myocardial infarctions, and cerebral infarctions were obtained for 50+ year men and women. Weighted counts and standard errors were divided by US census figures and multiplied by 100,000. Joinpoint regression was used to analyze rates. Main Results Beginning 2001, HRT prescription rates dropped dramatically, 2001–2012 AAPC -14.9 (95% CI -17.4, -12.4). Breast cancer rates, which began to decline in 1999, increased after 2003; 2012 rates were similar to those seen in 2001 for both ductal, AAPC 0.1 (-0.4, 0.6) and lobular, AAPC 0.5 (-0.4, 1.5), carcinoma. Endometrial carcinoma rates increased, 2001–2012 AAPC 3.5 (3.1, 3.8), arguing against a negative effect of HRT discontinuation of endometrial carcinoma. Tests for parallelism failed to detect APC differences among genders for femoral neck fractures (P = 0.24), for total hip replacements (P = 0.11), for myocardial infarctions (P = 0.10), or for cerebral infarctions (P = 0.19), precluding any assignment of general effect on these disorders by HRT. Conclusions Using SEER data, we demonstrated that changes in breast cancer rates cannot be explained by HRT prescription rate changes.

Background Alcohol withdrawal syndrome (AWS) occurs in dependent patients during the initial period of sudden onset abstinence. It is usually manifested by mild symptoms such as disorientation, agitation, and tachycardia, but, if untreated, can lead to severe confusion, seizures, and even cardiovascular collapse. Prevention of AWS has been shown to improve morbidity and mortality and shorten hospital and ICU stays. We examined the efficacy of ethanol as a method of prophylaxis. Study Design Our patient population was divided into two groups. Group 1 consisted of surgical patients receiving alcohol prophylaxis for AWS between January 2001 and July 2004 (n=124), as identified by retrospective chart review. We then developed a protocol for the initiation, dosage, and weaning of intravenous ethanol in patients at risk for AWS, based on blood alcohol levels and clinical assessment of withdrawal symptoms and signs. Group 2 consisted of all patients treated prospectively with this protocol during the subsequent year (n=76). Patients who did not fit inclusion criteria for the protocol were excluded from analysis, resulting in 92 and 68 patients in group 1 and group 2, respectively. We compared initiation criteria, efficacy, dosage, route, duration, and referral pattern to the substance abuse clinic before and after initiation of the protocol. Results Our initial use of intravenous ethanol was very variable in dosage, duration, and indication. The protocol decreased the duration of treatment between the two groups from 7 days to a mean of 3 days. The failure rate dropped from 20% to 7%. Referral to the substance abuse clinic rose from 7.6% to 20%. The only complication was asymptomatic hyponatremia in one patient. Conclusions Intravenous ethanol is a viable option for AWS prophylaxis when administered in a systematic protocol.

We present our experience during the past 5 years with isolated penetrating flank trauma. We examined the evaluation process, treatment plan, length of stay, outcome, and complications of patients with isolated penetrating injuries to the flank. There were four patient groups: 1) laparotomy (n = 5); 2) local wound exploration (n = 1); 3) laparoscopy (n = 8); and 4) observation and triple contrast CT scan (n = 9). All patients were male. The mean length of stay was 15 days for group 1, one day for group 2, two days in group 3, and 1.5 days in group 4. Three patients had diaphragmatic injuries, which were repaired laparoscopically. One patient with local wound exploration re-presented with a diaphragm hernia. A negative triple contrast CT scan resulted in no subsequent intervention. There were no missed injuries or complications from CT scan + observation or from diagnostic laparoscopy. We believe that laparoscopy may emerge as a useful adjunct in the treatment of patients with flank trauma. We present an algorithm for the management of penetrating flank trauma.

INTRODUCTIONRectovaginal fistulas have a multitude of causes and it is well known that obstetric and gynecological problems form a large part of these causes such as our case.PRESENTATION OF CASEWe present a 45-year-old female that presented with complaints of stool per vagina and was found to have a rectal vaginal fistula near the vaginal cuff from her previous uncomplicated vaginal hysterectomy. The patient was originally scheduled for a complex open abdominal surgery based on examination but underwent a sigmoidoscopy with vaginal examination and identified a small opening with minimal inflammation. The patient was treated with Bioglue® and had complete resolution of the fistula at follow-up.DISCUSSIONThere are numerous cases presented in the literature on the use of bioglue for anal fistulas and rectovaginal fistulas with multiple cases of success. However, in looking at the literature failure appears to be due to ongoing inflammation from the previous disease process.CONCLUSIONAlthough the use of Bioglue® may not be suitable for all patients with rectovaginal fistulas, it offers yet another treatment modality for select patients.

Background The ‘Golden Hour’ emphasizes the importance of rapidly providing definitive care to trauma patients. Dispatch time, defined as the time it takes the Helicopter Emergency Medical Service (HEMS) to dispatch from their base and reach the patient, and on-scene time, defined as the time spent with the patient prior to departure to a trauma center, can impact how quickly the patient will reach definitive care. We evaluated HEMS dispatch and on-scene times by investigating the survival rates among patients transported by air to a level 1 trauma center. We hypothesize that longer HEMS dispatch and on-scene times are associated with worse patient outcomes. Methods A retrospective, single institution analysis was performed on patients transported by HEMS. Inclusion criteria were air transported patients aged 18 years and above admitted to a level 1 trauma center from January 1, 2005 to January 1, 2015. Total dispatch time and on-scene times were divided into five incremental groups and mortality data were analyzed. Mortality was defined as death during initial hospital admission. A Pearson’s correlation was used to analyze relationship between dispatch times, on-scene times, and mortality. Simple binary logistic regression was used to run a multivariate analysis on confounding variables of Injury Severity Score (ISS), gender, age, and Glasgow Coma Scale. Results There was a strong positive linear correlation between HEMS on-scene time and mortality, R=0.962, p=0.038. Additionally, there was a positive trend between HEMS dispatch time and mortality. ISS was found to be a significant confounder of mortality in our cohort with on-scene times >20 min, with mortality increasing by 7.5% for every 0.1 increase in ISS score (p=0.01). Conclusion Longer HEMS on-scene and dispatch times appeared to be associated with increased mortality in trauma patients. However, those with higher ISS require longer on-scene times, increasing mortality. Regardless, efforts should focus on reducing on-scene and dispatch times. Level of evidence and study type Level III; Therapeutic/Care Management.

Burn-injured patients have the highest metabolic demand of all critically ill patients and are vulnerable to complications of malnutrition. Many burn centers have challenges in achieving prescribed rates of nutrition, despite aggressive algorithms. One possible reason for the discrepancy is inaccurate documentation of volumes. This is a retrospective review of patients requiring tube feeding admitted to a regional burn center between June and August 2015. Demographics were abstracted including gender, type of injury, TBSA, and age. The total feeding volume was recorded from the feeding pump every 24 hours. The values were compared with the enteral nutrition volume charted by the nursing staff and rate prescribed by the physician team. Repeated measures analysis of variance was used to compare continuous variables. Twenty-five patients were observed during the study period providing a total of 105 patient days. The average age was 44 years with 42% TBSA mean burn size. The average volume prescribed by providers was 1,598 ml/d. According to documentation, the average volume given was 1,448 ml/d, a significant difference (P =

Background Lymph node positivity is a strong prognostic indicator in many cancers including gastric cancer. The extent of surgical resection directly influences the number of lymph nodes available for staging, with the lesser D1 resection that is standard practice in non-Asian countries typically providing fewer nodes for analysis. The widely used AJCC TNM staging system has been criticized for under-staging and stage migration where fewer than 15 nodes are resected, which is often the case in these populations. The ratio of positive to total nodes harvested – Lymph Node Ration (LNR) – has been proposed as an improved and more widely applicable prognostic indicator. Hypothesis The LNR is a reliable and accurate prognostic indicator of survival in a Western gastric cancer population. Methods 9357 patients were acquired via a SEER case listing session with 2004–2011 gastric adenocarcinoma diagnoses. AJCC 7th edition nodal staging (N0: 0, N1:1–2, N2:3–6, N3:≥7 positive lymph nodes) and LNR positive nodal staging (PN0: 0%, PN1: 1–20%, PN2: 21–50%, PN3: 51–100% of examined nodes positive) were compared as respects seven year survivorship. Results Adjusted survival time ratios for AJCC nodal curves were less evenly distributed than were the percent positive nodal curves. Results of multiple regression reflected that survival time ratios of the percent positive nodal schema being more evenly spaced than those of the AJCC schema. Because BIC for AJCC, 41071.48, was larger than that for percent positive nodes, 41024.25, the LNR nodal system better explained survival than the AJCC nodal classification system. Conclusion LNR produced reliable and internally consistent survival curves for this population. LNR is an effective tool to predict survival in a western gastric cancer patient population, where the majority of the patients have limited lymph node dissection.

Smoke inhalation continues to be a major source of morbidity and mortality in burn patients, increasing the likelihood of mortality by as much as 25% despite the many advances in burn care over the past decades.1 Although inhalation injury is not uncommon among patients with burns, there remains no standard for its diagnosis, scoring, and subsequent treatment, which makes it difficult to evaluate the results of studies and treatments.2 For these reasons, inhalation injury was designated a top 10 research priority at the 2007 American Burn Association (ABA) Consensus Conference.3 Smoke inhalation occurs through a variety of mechanisms, including thermal injury to the respiratory tract mucosa; however, the exact mechanism of what occurs following smoke inhalation injury is not clearly understood. Studies have shown that airway edema combined with obstructive casts produced from cellular debris, fibrin clots, polymorphonuclear leukocytes, mucus, and mucin B5 cause the airway obstruction contributing to pulmonary failure.4 Inhalation injury leads to the destruction of the ciliated epithelium that lines the tracheobronchial tree and impairs surfactant production, ultimately leading to a proinflammatory cytokine cascade, altering capillary membrane integrity and exacerbating pulmonary edema.5 Neutrophils and mucus casts can cause upper-airway obstruction, contributing to pulmonary failure. Hollingsed et al6 found that patients with inhalation injury had a 73% incidence of respiratory failure (hypoxemia, multiple pulmonary infections, or prolonged ventilator support) and a 20% incidence of acute respiratory distress syndrome (ARDS). Heparin and N-acetylcysteine nebulization treatment in combination with albuterol has potential efficacy in inhalation injury based initially on results from animal models and clinical studies in children. The primary mechanism is thought to be a combination of mucolysis by the N-acetylcysteine component, bronchodilation by the albuterol, and inhibition of fibrin clot formation within the airways by the anticoagulant heparin. Herndon and Traber’s7 laboratory reported the effects of aerosolized recombinant human antithrombin and heparin in an ovine model of acute lung injury induced by smoke inhalation and cutaneous flame burn. The results of this study strongly suggest that aerosolized recombinant human antithrombin and heparin in combination may be a novel therapeutic approach for airway management of burn victims with smoke inhalation injury. Desai et al8 have previously demonstrated that nebulized heparin/N-acetylcysteine is associated with reduced mortality in burned children with inhalation injury (n = 47), without significant side effects. The Holt9 group found no clinical benefit using a similar protocol in a treated group consisting of both children and adults (n = 62). Miller et al4 described the effect of a protocol with alternating nebulized N-acetylcysteine and 10,000 U of heparin as attenuating lung injury and the progression of ARDS in ventilated adult patients (n = 30) with acute lung injury. We therefore hypothesized that aerosolized anticoagulant may benefit adult burn patients with inhalation injury and implemented a nebulized heparin/N-acetylcysteine/albuterol (HNA) protocol at our burn center in 2011; this study details the clinical results of this protocol.

Diabetes mellitus (DM) affects 23.6 million people in the USA and approximately 20–25% of diabetic patients will develop foot ulceration during the course of their disease. Up to a quarter of these patients will develop infections that will necessitate amputation. Although many studies report that the rates of antibiotic resistant infections have increased dramatically in the DM population over the last decade, to our knowledge there have been no reports directly comparing the rates of antibiotic resistant infections in DM versus non-DM wounds. We performed a retrospective study comparing the wound infections of 41 DM patients to those of 74 non-DM patients to test the hypothesis that infections with multidrug resistant organisms (MDRO) were more prevalent in the DM population. We found that 63.4% of DM and 50% of non-DM patients had MDRO infections, which was not statistically different. However, 61% of the DM patients hadPseudomonasinfections compared to only 18.9% of non-DM patients. Furthermore, DM patients had significantly more coinfections with bothPseudomonasandStaphylococcus aureus. Though our initial hypothesis was incorrect, we demonstrated a significant correlation betweenPseudomonasandPseudomonas/S. aureuscoinfections within DM wounds.

We immunohistochemically characterised the expression of the calcium-binding protein parvalbumin in the normal human antetroventral thalamic nucleus (AVN). Two morphologically distinct neuronal populations were found to be parvalbumin-immunoreactive (PV-IR): a large population of lightly staining PV-IR neurons and a smaller population of intensely PV-IR neurons. This second type of neuron, which displayed many characteristics normally associated with GABAergic interneurons, has not previously been described in human thalamus. Thus, presumptive thalamic interneurons in the human brain can be further subtyped on the basis of immunoreactivity to parvalbumin. This may have implications for the understanding of thalamocortical function in the normal state and in dysfunctional conditions such as Wernicke-Korsakoff syndrome and schizophrenia.

Optimal nutrition is essential to the recovery of burned patients. The authors evaluated the efficacy of an aggressive nutrition delivery protocol. The following protocol was implemented: initiation of tube feeds within 4 hours, acceleration to goal rate within 8 hours, and tolerance of gastric residual volumes of 400 ml. Patients on the protocol formed the study group whereas patients admitted immediately before implementation served as controls for a study period of 7 days after admission. Outcome variables included ileus, prokinetic medication use, intensive care unit and overall length of stay, ventilator days and mortality. Variables were compared using bivariate analysis. The 42 study subjects and 34 controls were similar at baseline. Time to initiation was similar (6.8 vs 9.4 hours; P = .226), however, goal rate was achieved much sooner in the study group (11.2 vs 20.9 hours; P < .001). Number of hours spent at goal was different on days 1 and 2 (6.62 vs 2.74, P = .003 and 17.24 vs 13.18, P = .032) with no difference thereafter. Residual volumes in the study group were higher from day 2 onward, and remained increased throughout the study period (401 vs 234 ml average; P = .449). Clinical ileus was much more common in the study group (8 cases vs 1, P = .037). There was no difference in length of stay or mortality. The protocol was successfully implemented and resulted in early achievement of goal tube feed rates. However, this resulted in tube feed intolerance as manifested by more cases of clinical ileus.

Pseudomonas aeruginosa is a Gram-negative opportunistic pathogen that causes serious infections in immunocompromised hosts including severely burned patients. After multiplying within the burn wound, P. aeruginosa translocate into the bloodstream causing bacterial sepsis frequently leading to organ dysfunction and septic shock. Although the pathogenesis of P. aeruginosa infection of thermally-injured wounds has been extensively analyzed, little is known regarding the ability of P. aeruginosa to adapt and survive within the blood of severely burned patients during systemic infection. To identify such adaptations, transcriptome analyses (RNA-seq) were conducted on P. aeruginosa strain PA14 that was grown in whole blood from a healthy volunteer or three severely burned patients. Compared with growth in blood from healthy volunteers, growth of PA14 in the blood from severely burned patients significantly altered the expression of 2596 genes, with expression of 1060 genes enhanced, while that of 1536 genes was reduced. Genes whose expression was significantly reduced included genes related to quorum sensing, quorum sensing-controlled virulence factors and transport of heme, phosphate, and phosphonate. Genes whose expression was significantly enhanced were related to the type III secretion system, the pyochelin iron-acquisition system, flagellum synthesis, and pyocyanin production. We confirmed changes in expression of many of these genes using qRT-PCR. Although severe burns altered the levels of different blood components in each patient, the growth of PA14 in their blood produced similar changes in the expression of each gene. These results suggest that, in response to changes in the blood of severely burned patients and as part of its survival strategy, P. aeruginosa enhances the expression of certain virulence genes and reduces the expression of others.

Invasive lobular cancer (L) differs clinically and morphologically from invasive ductal cancer (D); differences notwithstanding, Nottingham grades are provided in both. This study compared 22,719 lobular carcinomas with 201,517 ductal carcinomas, dividing them into the grades: well differentiated (W), moderately differentiated (M), poorly differentiated (P), and ungraded to see if differences between comparable grades of lobular and ductal cancer were uniform, consistent with the notion the grading system provides similar information for both cancer subtypes.The Surveillance, Epidemiology and End Results (SEER) database was used to limn relationships among grades, as respects proportions of patients with T3 tumors and nodal metastases, as well as cancer-specific survival. Taken into account were age, estrogen and progesterone receptor status, and the administration of radiotherapy.More lobular than ductal carcinomas were T3; grades were not homogenous, with the incidence rate ratio (IRR) comparing lobular and ductal carcinomas being 8.2 for well differentiated, 4.1 for moderately differentiated, and 2.48 for poorly differentiated. With respect to nodal metastases, the 1.16 W L:W D IRR (P0.05) was not explicable by chance, but both the 0.97 M L:M D IRR (P0.05) and the 0.96 P L:P D IRR (P0.05) could have been due to chance. As respects survival, neither the 1.4 P L:P D time ratio (TR) (P0.05) nor the 1.23 M L:M D TR (P0.05) could have been explained by chance; the 1.05 W L: W D (P0.05) might have been due to chance.Grades of lobular carcinoma imply different meanings than do grades of ductal carcinoma. Studies of breast cancer should not assume commonality with respect to grade.

Burns are devastating injuries that disproportionately affect people in developing countries, including children. In addition to a high mortality rate, survivors are burdened with life-long physical and emotional scars. The etiology and nature of burn injuries varies significantly by country, and this chapter explores the predominant causes and patterns of burn injury in both the developing and industrialized worlds. Gender differences play a significant role in the risk of burn injuries, across a spectrum with a predominance of women injured in fires from cooking and heating fuels in the developing world and industrial accidents primarily affecting men in developed nations. Children are particularly vulnerable to burn injuries, accounting for almost 50% of all burn patients in some studies. A majority of pediatric burns are scald injuries usually affecting very young children below the age of 5 years, and we discuss the behavioral patterns underlying this finding. Finally, the elderly form a rapidly increasing proportion of the population in many countries, and are often burdened with comorbidities that are likely to pose significant challenges in burn care.