Use of Split-Thickness Skin Grafts and Autologous Skin Cell Suspension in a Case of Extensive Fournier Gangrene.

Fournier gangrene (FG) is a life-threatening necrotizing soft-tissue infection of the perineum and external genitalia, which primarily occurs in obese, diabetic males. The mainstay of treatment is source control via early aggressive surgical excision. Wide surgical excision can result in significant soft tissue defects that can be disfiguring and difficult to close. The most common method of closure is split-thickness skin grafting (STSG). Recently, autologous skin cell suspension (ASCS) technology has been used in addition to STSG to provide better wound healing and closure. This patient experienced excellent wound progression, following FG, through the application of ASCS with STSG, despite challenges related to the wounds, anatomical location, comorbidities, size, and the patient's medical history.

Treatment of Necrotizing Fasciitis With NovoSorb Biodegradable Temporizing Matrix and RECELL Autologous Skin Cell Suspension: A Case Series.

This case series reviews the management of 2 patients who developed a rare, aggressive soft tissue infection, necrotizing fasciitis treated with a synthetic polyurethane dermal regenerative template, Biodegradable Temporizing Matrix (NovoSorb BTM) in conjunction with an off-label use of RECELL device applying autologous skin cell suspension and a split-thickness skin graft for reconstruction. The clinical relevance describes a non-traditional patient's course of treatment and clinical outcome using BTM and RECELL for necrotizing fasciitis. The 2 patients survived with acceptable outcomes and timely healing despite a high chance of mortality and likely amputation secondary to the extensive surface area and anatomical location of the infection.

Idiopathic pneumoperitoneum in a single case: an unusual entity.

Idiopathic pneumoperitoneum (IP) cases are rare and presents with varying symptoms, which makes propositions of standard treatments, clinically impracticable. There are limited IP therapies in the literature, necessitating a need, to continually highlight unique cases for the purpose of clinical education and training. This case describes an IP and management of a 34-year-old male who recently underwent a laparoscopic cholecystectomy. Patient presented to the emergency room with recurrent gastrointestinal (GI) symptoms. Despite two negative exploratory laparotomies without confirmatory evidence of GI perforations, the GI symptoms persisted, making it an unusual case. The surgeons elected to a multispecialty approach, detailing patient-specific symptoms, and corresponding treatments of the case. Based on the successful outcome of this patient, detailed knowledge of medical history, repeated physical assessments and patient-specific and comprehensive approach was shown to reduce unnecessary exploratory laparotomy, improved clinical outcomes and decrease in complications.

Management of Enteroatmospheric Fistula (EAF) Using a Fistula-Vacuum Assisted Closure (VAC) in a Complicated Abdominal Trauma Case.

Enteroatmospheric fistula (EAF) is a relatively rare complication of patients undergoing open abdomen (OA) for damage control surgery. Mortality rates are high due to the increased risk of peritonitis, intraabdominal abscess, sepsis, and new perforations. There are a wide range of EAF management therapies in the literature, however, there are limited options on cases involving fistula-vaccum assisted closure (VAC) therapy. This case describes the treatment course of a 57-year-old, male admitted for blunt abdominal trauma secondary to a motor vehicle accident. Upon admission the patient underwent damage control surgery. The surgeons elected to have the patient's abdomen open, applying a mesh to promote healing. After several weeks of hospitalization an EAF was discovered in the abdominal wound subsequently managed by utilizing a fistula-VAC technique. Based on the successful outcome of this patient, fistula-VAC was shown as an effective way to promote wound healing while reducing the chances of complications.

Wandering Spleen in a Patient With Significant Medical History.

The clinical presentation of a wandering spleen is characterized mainly by unspecific acute symptoms, ranging from diffuse abdominal pain to left upper/lower quadrant and referred shoulder pain to asymptomatic. This has challenged accelerated medical care and impeded the acquisition of confirmatory diagnosis; therefore, increasing morbidity and mortality risks. Splenectomy is an established operative procedure for a wandering spleen. However, there has not been enough literature emphasizing the clinical history of congenital malformations and surgical corrections as inferential tools for facilitating a decisive and informed procedure. The case presented is of a 22-year-old female who reported to the emergency department with a five-day persistent left upper quadrant and left lower quadrant (LLQ) abdominal pain, associated with nausea. According to the medical history, the patient had a significant history of vertebral defects, anal atresia, cardiac anomalies, tracheoesophageal fistula, renal anomalies, and limb abnormalities (VACTERL) associated with congenital anomalies. By the age of eight years, the patient had undergone multiple surgical interventions, including tetralogy of Fallot repair, an imperforate anal repair with rectal pull-through, Malone antegrade continence enema (MACE), and bowel vaginoplasty. Computed tomography imaging of the abdomen revealed evidence of a wandering spleen in the LLQ with associated torsion of the splenic vasculature (whirl sign). Intra-operatively, appendicostomy was identified extending from the cecum in a near mid-line position, to the umbilicus, and carefully incised distally, preventing injury to the appendicostomy. The spleen was identified in the pelvis, and the individual vessels were clamped, divided, and ligated. Blood loss was minimal with no post-operative complications. This rare case report adds valuable teaching points about the treatment of wandering spleen in individuals with VACTERL anomalies.

Biodegradable temporising matrix: use of negative pressure wound therapy shows a significantly higher success rate.

OBJECTIVE: The purpose of this case series was to evaluate the efficacy of a synthetic biodegradable temporising matrix (BTM; PolyNovo Biomaterials Pty Ltd, Australia) and compare the outcome of BTM patients with and without negative pressure wound therapy (NPWT). METHOD: A retrospective chart review was conducted on patients admitted with deep full-thickness burns, traumatic or complex wound injuries treated with BTM. Electronic medical records and images were evaluated by a team of clinical professionals. Endpoints included: the measure of successful BTM integration; and comparison between patients treated with and without NPWT. Additional measures were BTM total surface area, BTM sites, timeliness of BTM application and any complications. RESULTS: A total of 28 patients were evaluated and 23 (82.1%) demonstrated overall successful BTM integration. Patients treated with BTM in conjunction with NPWT (n=16) demonstrated a significantly higher (p=0.046) integration rate compared to patients treated without NPWT (n=12) (93.8% versus 58.3%, respectively). Patients treated with BTM with NPWT continued to successfully integrate and sustain favourable outcomes despite the presence of severe infection or the development of haematomas. CONCLUSION: A significantly higher integration rate was demonstrated when BTM was used in conjunction with NPWT. The results of this study further support the efficacy of successful integration of BTM as a replacement for tissue loss in the treatment of deep, full-thickness burns, traumatic and complex wound injuries, and particularly favourable outcomes with the use of NPWT. To the best of our knowledge, this is the first reported case series comparing the clinical outcomes of BTM with and without the use of NPWT.

Open Reduction and Internal Fixation of a Pediatric Talar Body Fracture using a Medial Malleolar Osteotomy - A Case Report.

Introduction: Talus fracture injuries are rare and most literature pertains to fractures in skeletally mature adults. It is unusual for pediatric talus fractures to be treated operatively and is normally treated with immobilization. The location of the talus fracture required a medial malleolar osteotomy to facilitate exposure and reduction, which was fixed with temporary smooth K-wires. The authors were unable to identify a previous description of this technique in the literature. Case Report: An 11-year-old female was referred to our hospital due to polytraumatic injuries sustained in a roll-over MVC. A displaced fracture of the talus body was present. Due to the fracture location, a medial malleolar osteotomy was required for exposure. An open reduction and internal fixation was performed using subchondral minifragment screws under general anesthesia. The patient healed uneventfully, regained a normal gait and full, pain-free range of motion. Conclusions: Medial malleolar osteotomy with smooth K-wire fixation appears to be a safe method for gaining access to the talus when required for reduction and/or fixation of pediatric talus fractures.

Post-burn temporal dynamics of blood plasma histamine during the initial 6 days from injury.

BACKGROUND: Burn injuries can induce distinct, systemic inflammatory and immunological responses which occur acutely up to 72 hrs or chronically after 24 hrs. Previously published literature showed a dramatic increase in whole blood histamine values within 24 hrs of a thermal injury. However, the data is limited due to infrequent monitoring, resulting in statistically insignificant findings. The goal of this study was to determine localized histamine fluctuations for 6 consecutive days in a successive group of patients admitted immediately after a burn. METHOD: Using blood plasma from 7 patients (average total burn surface area 24.7%), we examined histamine within an average 4.1 (± 0.3) hrs from burn injury, by means of a monoclonal-based competitive binding enzyme immunoassay. Histamine values were normalized to patient baselines prior to determining overall averages. Patient vitals and electrolyte values were extracted from the electronic health record. A two-tailed student t-test was used to compare values with p-value ≤ 0.05 considered statistically significant using statistical software R. RESULTS: The histamine values were significantly higher than patient baseline values up to 48 hrs (p-value ≤ 0.05), followed by a return to baseline values from approximately 3 days post-injury. Heart rates were within normal values up until 72 hrs. Hematocrit and hemoglobin began within normal values, dropped at 72 hrs, and reduced significantly from 96 hrs post-injury. The electrolyte calcium began within the normal range, and then was significantly less than the baseline value from 96 hrs post-injury. CONCLUSIONS: We have shown a distinct and significant increase in histamine plasma levels within 48 hrs after a moderate burn injury.

Treatment of a Full-Thickness Burn Injury With NovoSorb Biodegradable Temporizing Matrix and RECELL Autologous Skin Cell Suspension: A Case Series.

Dermal substitutes coupled with split thickness skin graft are the primary method of treating most severe full-thickness burns particularly when there is a lack of healthy donor skin. Although dermal replacements optimize functional and aesthetic outcomes in patients, the risk of infection and the amount of time required to process most dermal substitutes delay treatment potentially compromising graft take and the overall healing process. The purpose of this case series is to describe the treatment course of patients with severe burn injuries using a novel synthetic Biodegradable Temporizing Matrix (NovoSorb BTM) in conjunction with RECELL Autologous Cell Harvesting Device, a new methodology allowing for a timely point-of-care preparation of an autologous skin cell suspension in combination with a 3:1 split-thickness skin graft. To the best of our knowledge, this is the first reported case series to describe the treatment algorithm and clinical outcomes of deep full-thickness burns utilizing BTM in conjunction with RECELL ASCS.

Impact of duplicate CT scan rate after implementation of transfer image repository system at a level 1 trauma center.

PURPOSE: The regionalization of trauma in the USA results in frequent transfers of patients from a primary hospital ED to a higher level trauma facility. While many hospitals have a Picture Archive Communication System (PACS) which captures digital radiological images, these are often not available to the receiving institution resulting in duplicate imaging. The state of Arkansas instituted a trauma image repository (TIR) in July 2013. We examined whether implementation of this repository would impact CT scan duplication in the trauma system. METHODS: This was a retrospective analysis of trauma patients transferred from outlying hospitals in Arkansas and Missouri to a single level 1 trauma hospital in Missouri between July 2012 and June 2015. We compared the duplicate CT rate for patients transferred from Arkansas and Missouri hospitals before and after the repository was implemented for Arkansas. RESULTS: Prior to implementation (July 2012-June 2013) of Arkansas TIR, duplicate CT rates were similar for patients transferred from Arkansas (11.5% ± 2.8) or Missouri (16.3% ± 7.5). Following implementation (July 2013-June 2014), the duplicate CT rate for patients transferred from Arkansas was significantly lower (Arkansas = 10.1% vs. Missouri 16.2%; CI 95%, p = 0.02), and significance continued (Arkansas = 9.0% vs. Missouri = 17.8%; CI 95%, p = 0.02) during follow-up (July 2014-June 2015). CONCLUSION: Fewer patients received duplicated scans within the Arkansas as compared with the Missouri-based trauma referral systems regardless of Injury Severity Scores (ISS). Our findings suggest that TIR adoption coupled with PACS improved transferability of radiographic studies and could improve patient care while reducing costs in trauma transfers.

Moral distress in physicians and nurses: Impact on professional quality of life and turnover.

OBJECTIVE: The purpose of this study was to investigate moral distress (MD) and turnover intent as related to professional quality of life in physicians and nurses at a tertiary care hospital. METHOD: Health care providers from a variety of hospital departments anonymously completed 2 validated questionnaires (Moral Distress Scale-Revised and Professional Quality of Life Scale). Compassion fatigue (as measured by secondary traumatic stress [STS] and burnout [BRN]) and compassion satisfaction are subscales which make up one's professional quality of life. Relationships between these constructs and clinicians' years in health care, critical care patient load, and professional discipline were explored. RESULTS: The findings (n = 329) demonstrated significant correlations between STS, BRN, and MD. Scores associated with intentions to leave or stay in a position were indicative of high verses low MD. We report highest scoring situations of MD as well as when physicians and nurses demonstrate to be most at risk for STS, BRN and MD. Both physicians and nurses identified the events contributing to the highest level of MD as being compelled to provide care that seems ineffective and working with a critical care patient load >50%. CONCLUSION: The results from this study of physicians and nurses suggest that the presence of MD significantly impacts turnover intent and professional quality of life. Therefore implementation of emotional wellness activities (e.g., empowerment, opportunity for open dialog regarding ethical dilemmas, policy making involvement) coupled with ongoing monitoring and routine assessment of these maladaptive characteristics is warranted. (PsycINFO Database Record

Mucormycosis: a rare fungal infection in tornado victims.

This article reviews four immunocompetent patients who developed a rare fungal infection, mucormycosis, secondary to multiple traumatic injuries sustained during an EF-5 tornado in Joplin, MO. Commonly found in soil and decaying organic matter, mucorales are fungi associated with soft tissue and cutaneous infections. Onset of this fungal infection can occur without clinical signs, presenting several days to several weeks after injury, delaying diagnosis. A multidisciplinary treatment approach including aggressive antifungal therapy and aggressive surgical debridement is critical. This diagnosis should be considered in all patients presenting with injuries sustained from high-velocity embedment of debris such as natural disasters or explosions. We present four cases of mucormycosis, species Apophysomyces trapeziformis. Data reported includes predisposing factors, number of days between injury and diagnosis of mucormycosis, surgical treatment, antifungal therapy, outcomes, and potential risk factors that may have contributed to the development of mucormycosis.