Allograft of Primary Cutaneous Mucormycosis in a Preterm Neonate: A Case Report.

INTRODUCTION: Primary cutaneous mucormycosis (PCM) is a fungal infection of the skin that can affect compromised hosts. Skin lesions evolve from an indurated area to a necrotic ulcer. Preterm neonates are at increased risk due to poorly developed skin, immature immune function, and invasive devices. Antifungals and debridement with grafting have been reported as primary treatments. CASE REPORT: The authors report allografting in addition to systemic antifungals as an option for critically ill preterm neonates to decrease blood loss and risk of donor site infection. A female triplet was born to a 35-year-old G1P0211 mother; the triplet developed PCM (Rhizopus genus) and was treated with systemic liposomal amphotericin B in addition to debridement and allografting. Surgery was delayed initially, given concerns over the depth of invasion into the chest. As the wound began to contract and separate over the next few weeks, the decision was made to excise the lesion and reconstruct the chest wall with an allograft. The graft had good take and remained in place for 11 weeks until the patient succumbed to a third recurrence of bacterial sepsis. CONCLUSIONS: While PCM can be fatal for many preterm infants, debridement with allografting may serve as a valuable treatment option with fewer associated complications for neonates as they are stabilizing clinically.

Ramadan-Associated Circadian Census Variation In A Busy Middle Eastern Emergency Department.

BACKGROUND: An important goal for the Emergency Department operations is planning for changes in patient volume and assuring staffing accordingly. We hypothesized that understanding the Emergency Department census changes during the month-long Ramadan holiday each year could facilitate operations planning for Emergency Department's serving a largely Muslim population. METHODS: This was an observational study conducted at an academic centre, over 83 weeks of analysis that included two Ramadan months (those occurring during 2016 and 2017). The data was from an electronic medical record that records presentation time as well as age, sex, nationality, and acuity. Chi-square and mediandifferences testing (p<.05 defining significance) were used to compare overall patient characteristics between cases seen during Ramadan vs. non-Ramadan. RESULTS: For the 83 study weeks, the Emergency Department volume was 689,140 (annualized volume 431,750). Graphic depiction of weekly census showed Ramadan-associated census impact varied markedly over the course of a day's 24 hours. Statistically significant hourly census increase (of up to 83%) or decrease (of as much as 50%) were identified for 21 of 24 hours of the day. Ramadan was not associated with change in patient age or proportion of high-acuity cases. However, it was associated with increase in proportion of males, paediatrics, and Qatari national's patient visits. CONCLUSIONS: As compared to non-Ramadan baseline, Ramadan was associated with substantial changes in overall census and in proportions of various patient subgroups. Therefore, Emergency Department's serving large Muslim population should undertake studying major operations changes that can be expected for the month.

Restrictive Transfusion Strategy Is More Effective in Massive Burns: Results of the TRIBE Multicenter Prospective Randomized Trial.

OBJECTIVES: Studies suggest that a restrictive transfusion strategy is safe in burns, yet the efficacy of a restrictive transfusion policy in massive burn injury is uncertain. Our objective: compare outcomes between massive burn (≥60% total body surface area (TBSA) burn) and major (20-59% TBSA) burn using a restrictive or a liberal blood transfusion strategy. METHODS: Patients with burns ≥20% were block randomized by age and TBSA to a restrictive (transfuse hemoglobin <7 g/dL) or liberal (transfuse hemoglobin <10 g/dL) strategy throughout hospitalization. Data collected included demographics, infections, transfusions, and outcomes. RESULTS: Three hundred and forty-five patients received 7,054 units blood, 2,886 in massive and 4,168 in restrictive. Patients were similar in age, TBSA, and inhalation injury. The restrictive group received less blood (45.57 ± 47.63 vs. 77.16 ± 55.0, p < 0.03 massive; 11.0 ± 16.70 vs. 16.78 ± 17.39, p < 0.001) major). In massive burn, the restrictive group had fewer ventilator days (p < 0.05). Median ICU days and LOS were lower in the restrictive group; wound healing, mortality, and infection did not differ. No significant outcome differences occurred in the major (20-59%) group (p > 0.05). CONCLUSIONS: A restrictive transfusion strategy may be beneficial in massive burns in reducing ventilator days, ICU days and blood utilization, but does not decrease infection, mortality, hospital LOS or wound healing.

Transfusion Requirement in Burn Care Evaluation (TRIBE): A Multicenter Randomized Prospective Trial of Blood Transfusion in Major Burn Injury.

OBJECTIVE: Our objective was to compare outcomes of a restrictive to a liberal red cell transfusion strategy in 20% or more total body surface area (TBSA) burn patients. We hypothesized that the restrictive group would have less blood stream infection (BSI), organ dysfunction, and mortality. BACKGROUND: Patients with major burns have major (>1 blood volume) transfusion requirements. Studies suggest that a restrictive blood transfusion strategy is equivalent to a liberal strategy. However, major burn injury is precluded from these studies. The optimal transfusion strategy in major burn injury is thus needed but remains unknown. METHODS: This prospective randomized multicenter trial block randomized patients to a restrictive (hemoglobin 7-8 g/dL) or liberal (hemoglobin 10-11 g/dL) transfusion strategy throughout hospitalization. Data collected included demographics, infections, transfusions, and outcomes. RESULTS: Eighteen burn centers enrolled 345 patients with 20% or more TBSA burn similar in age, TBSA burn, and inhalation injury. A total of 7054 units blood were transfused. The restrictive group received fewer blood transfusions: mean 20.3 ±â€Š32.7 units, median = 8 (interquartile range: 3, 24) versus mean 31.8 ±â€Š44.3 units, median = 16 (interquartile range: 7, 40) in the liberal group (P < 0.0001, Wilcoxon rank sum). BSI incidence, organ dysfunction, ventilator days, and time to wound healing (P > 0.05) were similar. In addition, there was no 30-day mortality difference: 9.5% restrictive versus 8.5% liberal (P = 0.892, χ test). CONCLUSIONS: A restrictive transfusion strategy halved blood product utilization. Although the restrictive strategy did not decrease BSI, mortality, or organ dysfunction in major burn injury, these outcomes were no worse than the liberal strategy (Clinicaltrials.gov identifier NCT01079247).

An unusual tale of rat-bite fever endocarditis.

A 49-year-old man presented to our department with an acute history of right leg tenderness, rash, swelling and fever. CT of the chest, abdomen and pelvis and a transoesophageal echocardiogram confirmed the diagnosis of mitral valve infective endocarditis with distal splenic emboli. Positive blood cultures revealed the causative organism to be Streptobacillus moniliformis. The patient was treated with high-dose antibiotics and had mitral valve replacement surgery.

Results of a focused scald-prevention program.

Scalds are a leading cause of burn injury for young children. A focused prevention program was developed in the zip code accounting for the majority of scald burns. This study investigated the effect of the program. Families in the high-risk area were identified at clinics, community centers, and schools. Parent workshops and home visits were the interventions used. A pretest was administered at the workshop to measure baseline knowledge. A post-test was administered at either the home visit or by telephone to measure change in knowledge. A survey was used to measure baseline scald risks in the home. Home visits were used to reinforce information from workshops, evaluate the home environment, and assist parents to make environmental changes. Changes to the home environments were made, with antiscald devices installed in the shower, sink, or bathtub depending on parent preference. The survey was repeated on a follow-up home visit to determine whether parents adhered to environmental changes and safety practices. The postmeasurements were performed from 6 to 12 months after the initial measurement. More than 900 parents attended the initial workshops, and 173 consented to participate in the follow-up study and took the pretest. Of these, 62 completed the post-test, and 48 participated in a home visit. The mean pretest score was 72 +/- 1%, and mean post-test score was 85 +/- 1% (P < .01). The initial home visit surveys revealed an average of 7 +/- 2 scald risks per household, whereas follow-up surveys showed an average of 2 +/- 1 risks (P < .01). Antiscald devices were installed in 37 households on the initial visit and remained in place and functioning in 22 households (60%) on the follow-up visit. Before the focused prevention program, the admission rate from the target zip code was 137 per 100,000 children ages 0 to 5 years. After the intervention, there was a greater than 2-fold reduction, to 59 per 100,000 (P < .01). In addition, there were no new scald burns in the homes in which the focused prevention program took place. This study demonstrates that a focused burn-prevention program can identify high-risk groups, decrease the number of scald risks per home, and decrease the rate of scald burns in the population. This straightforward program could be used to intervene in high-risk groups in other communities.

Developing a focused scald-prevention program.

Scalds account for a high percentage of burn injuries in young children. The purpose of this project was to use a formative evaluation process to design a pilot scald-prevention program for a high-risk population. The burn registry and U.S. Census were used to define a high-risk population. A total of 53 children younger than age 6 were admitted to a local burn center with scalds during a 4-year period. Cooking or food accounted for 84% of these injuries. A total of 21% of the patients resided in one zip code, representing an incidence rate of 23 per 100,000, which was statistically significant. Focus group meetings were conducted with parents in this zip code. They were queried about scald injury knowledge, prevention practices, and attitudes toward interventions. A prevention program was designed based on the findings. Workshops are conducted with high-risk groups in the zip code. Attendees consent to a home visit where prevention practices are assessed and taught. A pre/post test and home risk assessment survey is used to measure change. The Burn Registry, U.S. Census, and focus groups were complimentary formative evaluation measures that assisted in developing a targeted scald prevention project.