High-dose intravenous versus low-dose oral vitamin C in burn care: potential protective effects in the severely burned: a retrospective cohort study.

Antioxidant therapies, such as ascorbic acid may have an important role during the acute phase of burn management. However, there are mixed results on the most effective dose and method of administration of ascorbic acid in burn patients. In this study, we compared the efficacy of intravenously and orally administered ascorbic acid in second-degree burns greater than 20% total-body-surface-area. Materials and methods: The hospital burn database was used to obtain data on all patients with second-degree or deeper burns of 20% total-body-surface-area or greater. Fourteen patients were selected at random to receive a scheduled dose of 1250 mg intravenous ascorbic acid every 6 h for 72 h. This was considered the high-dose group. During same period, 40 patients received scheduled 500 mg oral ascorbic acid every 6 h for 72 h and this was considered the low-dose group. We gathered sociodemographic and clinical variables associated with ascorbic acid dosing. Results: In our study, statistically significant variables were fluid requirements (p<0.001), hospital stay (p=0.011), length of time intubated on ventilator (p<0.001), colloids used (p=0.002), and total procedures required (p=0.014). Despite higher modified Baux predicted mortality in the high-dose group (10 patients vs. 24 patients, p=0.026) there was no noted significant association in days until the first infection and mortality rate (p=0.451 and 0.326, respectively). Conclusions: The calculated modified Baux predicted a higher mortality rate with the higher dosing group, yet this study did not find a mortality difference between the groups. We speculate that high-dose intravenous ascorbic acid may have protective effects in burn resuscitation. This finding may support some previous studies that found that high-dose ascorbic acid may improve clinical outcomes.

The Management of Traumatic Abdominal Wall Flank Hernia Along the Spigelian Aponeurosis Using Component Separation, Synthetic, and Biological Mesh.

Blunt abdominal trauma is associated with a variety of medical complications. Traumatic abdominal wall hernias (TAWHs) are a rare sequela of blunt trauma. Of the various forms of TAWH, a rare subtype described as a "spontaneous lateral ventral hernia" or flank hernia occurs in less than 1% of all blunt abdominal traumas. We present a case of a 39-year-old male with a past medical history of epilepsy who was involved in a rollover motor vehicle collision. It was reported that the patient had a seizure while driving. On physical exam, the patient had a large left lower flank contusion. Computed tomography revealed a complex TAWH with complete avulsion of the abdominal wall musculature from the iliac crest and near to total disruption of the internal oblique. To address this, we used a biological mesh inlay, reinforced with a synthetic Ventralight™ mesh secured to the iliac crest. In this article, we describe the patient's experience and management of a complex TAWH.

A Rare Case of Transitional Cell Carcinoma in an Adult Male With Neurofibromatosis Type 1.

Neurofibromatosis type 1 (NF1) is a multisystem genetic disorder characterized by café-au-lait macules on the skin, Lisch nodules of the iris, and predisposition to a wide array of tumors. These include neurofibromas, pheochromocytomas, and gastrointestinal stromal tumors (GIST). While there is documented evidence to suggest that the NF1 gene may play a role in the pathogenesis of transitional cell carcinoma (TCC) of the bladder, there is a paucity of documented cases of TCC in patients with NF1. Our patient is a 53-year-old male with a known diagnosis of NF1 and prior history of GIST who presented to the emergency department with lower abdominal pain, constipation, hematuria, and oliguria. The patient was found to have marked colonic distention prompting a decompressive cecostomy with subsequent return of bowel function. Cystoscopy was performed at this time for hematuria, which revealed a 9 cm bladder mass. Pathology showed a high-grade TCC of the bladder with nuclear pleomorphism and necrosis. The patient was treated with gemcitabine and cisplatin neoadjuvant chemotherapy, followed by cystoprostatectomy with bilateral pelvic lymphadenectomy and ileal conduit urinary diversion. Our case report is the first documented instance in the United States exhibiting an in vivo association of NF1 with the development of TCC of the bladder, an association previously identified in vitro. We hope our work inspires further investigation into this unique association.

Comparing the tracheostomy dislodgement and complication rate of non-sutured neck tie to skin sutured neck tie fixation.

INTRODUCTION: Tracheostomy management is a routine aspect of care in the critical care setting. While there are multiple complications that can arise in the post-operative setting after creation of a tracheostomy, dislodgement of a tracheostomy tube is associated with high mortality requiring rapid intervention. It is therefore important to prevent the occurrence with proper securement of the tracheostomy. In this study, we look at two methods commonly used to secure tracheostomy tubes: suturing of the lateral flanges to the skin with the use of cloth neck ties versus cloth neck ties alone. METHODS: This is a retrospective study with data collected from 1355 consecutive tracheostomy cases at a single institution. Our institution serves the County of San Bernardino, California as a level II trauma center. Patient selection occurred between 2004 and 2018, with distribution of patients to skin-sutured with neck tie tracheostomies (ST) and non-sutured neck tied only tracheostomies (NST) groups occurring by date of tracheostomy surgery. Our study investigates the dislodgement rate of percutaneous tracheostomies secured by either of these two methods. Due to a greater morbidity of tracheostomy dislodgement before a mature fistula tract is formed, we were specifically interested in the dislodgement rate within 7 days. RESULTS: In total, 328 cases of NST and 1027 cases of ST were collected. Overall, there was no statistically significant difference regarding the dislodgement and accidental decannulation rate between NST and ST (2.32% vs 4.46% for NST and ST, respectively, p = 0.1476). There was also no statistically significant difference regarding rates of dislodgement and accidental decannulation within 7 days between NST and ST (1.54% vs 1.11% for NST and ST, respectively, p = 0.5608). DISCUSSION: It takes 5-7 days for a tracheostomy tract to mature, and therefore most dislodgement occurs perioperatively within the first week after placement. Dislodgement of the tracheostomy tube can lead to devastating complications for those patients. To our knowledge, there has been no study investigating dislodgement in the early post-operative period in relation to tracheostomy securement method. CONCLUSION: Due to the emergent nature of tracheostomy dislodgement and loss of airway, prevention of this complication is critical. Our investigation found no statistically significant difference in the rate of early tracheostomy dislodgement in the skin sutured with neck tie and non-sutured neck tie only groups. This study contributes further data to the available literature regarding tracheostomy securement methods and dislodgement rate, specifically within the early post-operative period. LEVEL OF EVIDENCE: 2b.

Post-Liver Transplant Delirium Increases Mortality and Length of Stay.

BACKGROUND: Incidence of delirium after liver transplantation (LT) has been reported to occur in 10%-47% of patients and is associated with increased hospital and intensive care unit lengths of stay and poor outcomes. METHODS: Our primary objective was to evaluate the incidence and predisposing risk factors for developing delirium after LT. Our secondary objectives were to describe how delirium is managed in patients after LT, to examine the utilization of resources associated with delirium after LT, and to analyze the outcomes of patients who were treated for delirium after LT. RESULTS: In a population of 181 consecutive patients who received an LT, 38 (21.0%) developed delirium. In the multivariate analysis, delirium was associated with pretransplant use of antidepressants (odds ratio [OR] 3.34, 95% confidence interval [CI] 1.29-8.70) and pretransplant hospital admission for encephalopathy (OR 4.39, 95% CI 1.77-10.9). Patients with delirium spent more time on mechanical ventilation (2.0 vs 1.3 days, P=0.008) and had longer intensive care unit stays (4.6 vs 2.7 days, P=0.008), longer hospital stays (27.6 vs 11.2 days, P=0.003), and higher 6-month mortality (13.2% vs 1.4%, P=0.003) than patients who did not develop delirium. CONCLUSION: The presence of delirium is common after LT and is associated with high morbidity and mortality within the first 6 months posttransplant. Pretransplant factors independently associated with developing delirium after LT include prior use of antidepressants and pretransplant hospital admission for encephalopathy. Efforts should be made to identify patients at risk for delirium, as protocol-based management may improve outcomes in a cost-effective manner.