Open-to-Air Is a Viable Option for Initial Wound Care in Necrotizing Soft Tissue Infection that Allows Early Detection of Recurrence without Need for Painful Dressing Changes or Return to Operating Room.

BACKGROUND: The standard treatment of necrotizing soft tissue infection (NSTI) includes extensive surgical debridement. Care of these debridements is challenging because of the size of the wound and associated pain. A potential solution is to leave the wounds open-to-air in the period after the initial debridement, allowing for regular inspection at bedside while reducing pain associated with frequent dressing changes. We evaluated the feasibility of this approach from a pain control standpoint. PATIENTS AND METHODS: An audit of wound care modalities used on adult patients with NSTI admitted to a regional burn center between January 2009 and May 2014 was performed. Patients with at least one operation were included. Those opting for palliative care were excluded. Wound care was divided into four categories: open-to-air (OTA), negative-pressure wound therapy (NPWT), packing, and ointment. Wound care, pain score, pain medication use, and number of operations were collected for the first seven days after initial debridement. Pain management was assessed by pain scores. Analgesic use was measured and compared using conversion to morphine milligram equivalents (MME). RESULTS: Ninety-six patients were included; 67% were men with average age of 50 years, resulting in a total of 672 days of wound care evaluated: 69 days of OTA, 127 days of NPWT, 200 days of packing, and 126 days of ointment (150 days were undocumented). Average daily pain score from all wound care modalities was 2.00. Negative pressure wound therapy had the highest reported daily pain score (2.18, p = 0.034), whereas OTA had the lowest pain score (1.63, p < 0.05). Mortality was lower in the OTA cohort but was not statistically significant; there were no other differences in long-term outcome. CONCLUSION: Leaving wounds OTA is a safe and viable option in the immediate post-debridement period of NSTI to reduce pain, while permitting frequent re-evaluation for quick recognition of disease progression and repeat operative debridement if necessary.

Incidence of Non-Melanoma Skin Cancer in the Uninsured.

Non-melanoma skin cancer (NMSC) is a common reason for outpatient primary care visits. Uninsured patients may be at a higher risk for NMSC due to lack of access to health care and a possible increased risk of sun exposure due to insecure housing. The true incidence of NMSC in this population is unknown. In order to determine the population's incidence of NMSC we performed a retrospective chart review on all patients (n = 656) seen at the Lubbock Impact Free Clinic from July 1, 2014 through July 30, 2015. This highlighted an increased incidence of NMSC in our uninsured population (1.4% [9/656]), particularly in the 50-64 age range (2.8% [7/250]) when compared with the general United States population (0.65%-1.05%). We believe that skin care education and routine skin cancer screening should be emphasized in the care of these patients due to their increased risk.

Blood loss and transfusion requirements with epsilon-aminocaproic acid use during cranial vault reconstruction surgery.

OBJECTIVE: To determine whether epsilon-aminocaproic acid (EACA) load of 50 mg∙kg-1 before skin incision, and infusion of 25 mg∙kg-1∙h-1 until skin closure during cranial vault reconstruction (CVR) were associated with decreased estimated blood loss and transfusion requirements. BACKGROUND: Antifibrinolytic medications decrease bleeding and transfusion requirements during cardiothoracic and orthopedic surgeries with high blood loss, but practical reductions in blood loss and transfusion requirements have not been consistently realized in children undergoing CVR. Current dosing recommendations are derived from adult extrapolations, and may or may not have clinical relevance. METHOD: Retrospective case-controlled study of 45 consecutive infants and children undergoing primary craniosynostosis surgery at Covenant Children's Hospital during years 2010-2014. Exclusion criteria included revision surgery, and chromosomal abnormalities associated with bleeding disorders. Blood loss and blood transfusion volumes as a percent of estimated blood volume were compared in the presence of EACA while controlling for age, suture phenotype, use of bone grafting, and length of surgery. Secondary outcomes measures included volume of crystalloid infused, length of hospital stay, and any postoperative intubation requirement. RESULTS: When analyzed based on length of surgery, EACA did reduce blood loss and blood transfusion (R2=0.19, P=.005 and R2=0.18, P=.010, respectively) with shorter surgeries. CONCLUSIONS AND RELEVANCE: Using a standardized dosing regimen of EACA during craniosynostosis surgery, we found statistical significance in blood loss and transfusion requirements in surgeries of the shortest duration. We suspect this may be due to our selected dosing regimen, which may be lower than recently recommended. This study contributes to the growing body of evidence supporting EACA in CVR for craniosynostosis.

Necrotizing Fasciitis Among Patients With Liver Cirrhosis in Texas, 2001 - 2010: A Population-Based Cohort Study.

BACKGROUND: Liver cirrhosis is a risk factor for necrotizing fasciitis (NF), and is associated with markedly worse outcomes than for NF among non-cirrhosis patients. Only limited, mostly single-center, data were reported to date on the epidemiology, clinical features, resource utilization and outcomes of NF among patients with cirrhosis. METHODS: We studied a population-based cohort of adult hospitalizations associated with cirrhosis, who had a diagnosis of NF during the years 2001 - 2010, using the Texas Inpatient Public Use Data File. The annual volume of NF hospitalizations was benchmarked against all annual hospitalizations with a diagnosis of cirrhosis. The patterns of demographics, chronic comorbidities, evolving organ failure, resource utilization and outcomes were examined. RESULTS: There were 371,745 hospitalizations associated with liver cirrhosis, with 381 NF hospitalizations during study period. The annual volume of NF hospitalizations rose 7.9%/year (P = 0.0287), while its incidence among cirrhosis-associated hospitalizations remained unchanged (P = 0.2955). Non-cirrhosis comorbidities were reported in 69.6% and ICU care was required in 67.2% of NF hospitalization. The key changes noted between 2001 - 2003 and 2008 - 2010 among NF hospitalizations included rising mean (SD) Deyo-Charlson index 2.4 (1.5) vs. 3.9 (2.4) (P < 0.0001), development of ≥ 3 organ failures in 9.1% vs. 39.8% (P < 0.0001), and discharge to long-term care facilities 7.8% vs. 21.1% (P = 0.0204). Hospital mortality was unchanged (26% vs. 33.1%; P = 0.3659). Inflation-adjusted total hospital charges did not change (P = 0.1025) during study period. CONCLUSIONS: The present cohort of NF associated with liver cirrhosis is the largest reported to date. A rising annual volume of NF events matched a corresponding increase in cirrhosis-associated hospitalizations. There was increasing burden of chronic comorbidity and rising severity of illness, with a majority of patients requiring ICU care. Case fatality was high and there has been increasing residual morbidity among hospital survivors. The observed findings warrant further study in other populations.

Socioeconomic Status and Outcomes After Burn Injury.

The objective of this article is to explore the impact of socioeconomic status on outcome metrics in post-burn injury patients. Retrospective review of patients with TBSA >15% between 2005 and 2012. Demographics and clinical course were recorded. Socioeconomics were approximated using census data of percent below poverty level at patient zip code, which was also used for calculating distance to regional burn center. Statistical analysis was performed using Statistical Analysis Software. Odds ratios and 95% confidence intervals were calculated followed by regression models for factors associated with graft loss and readmission. Two hundred and fifty subjects survived to discharge: 33% were of upper socioeconomic status, 32% were of middle status, and 35% were of lower status. Fourteen percentage of patients lived <99 miles from the burn center, 60% 100 to 249 miles away, and 26% >240 miles away. Eighty readmissions occurred among 39 patients; 43% were unplanned. Each percent increase in TBSA was associated with a 5% increase in likelihood of being readmitted. Thirty six percentage of readmission patients were covered under worker's compensation. Patients with worker's compensation were four times more likely to be readmitted than private insurance. Only worker's compensation had a majority of unplanned readmissions (58%). Graft loss occurred in 12% of patients. Those in the low socioeconomic group had five times the odds of having graft loss than those in the high socioeconomics. There was no correlation between graft loss and insurance status or distance. Findings indicate strong and statistically significant correlations between type of insurance and likelihood of readmission and between graft loss and poverty.

Interactions between benign prostatic hyperplasia (BPH) and prostate cancer in large prostates: a retrospective data review.

PURPOSE: To study the interaction between benign prostatic hyperplasia (BPH) and prostate cancer (PCa). METHODS: In this study, we performed a chart review of a cohort of 448 biopsy naive men. These men received a multi-core biopsy at our institution due to increased prostate-specific antigen (PSA) serum levels (>4 ng/ml) and/or suspicious findings on digital rectal examination in the years between 2008 and 2013. Utilizing PSA and transrectal ultrasound (TRUS) prostate volume, we obtained the PSA density (PSAD) for each individual. PSAD was calculated by dividing serum PSA concentration by TRUS prostate volume. RESULTS: Large prostates >65 g may secrete enough PSA to have a PSAD above the suggested cutoff of 0.15, yet 50 % patients have no histologic evidence of PCa, whereas prostates <35 g and an elevated PSAD of above 0.15 will have histologic evidence of PCa 70 % of the time. CONCLUSIONS: These results suggest that BPH in large prostates may be protective of PCa. The interaction of the different prostate zones, in particular the transition zone and peripheral zone, may play a significant role in the phenomenon observed in this study. However, sampling error may introduce bias that 12-16 core biopsies in larger prostates may be more likely missing the cancer lesion.

Critical Thinking and Disposition Toward Critical Thinking Among Physical Therapy Students.

PURPOSE: Students who enter a physical therapist (PT) entry-level program with weak critical thinking skills may not be prepared to benefit from the educational training program or successfully engage in the future as a competent healthcare provider. Therefore, assessing PT students' entry-level critical thinking skills and/or disposition toward critical thinking may be beneficial to identifying students with poor, fair, or good critical thinking ability as one of the criteria used in the admissions process into a professional program. PARTICIPANTS/METHODS: First-year students (n=71) from the Doctor of Physical Therapy (DPT) program at Texas Tech University Health Sciences Center completed the California Critical Thinking Skills Test (CCTST), the California Critical Thinking Dispositions Inventory (CCTDI), and demographic survey during orientation to the DPT program. Three students were lost from the CCTST (n=68), and none lost from the CCTDI (n=71). OUTCOMES: Analysis indicated that the majority of students had a positive disposition toward critical thinking, yet the overall CCTST suggested that these students were somewhat below the national average. Also, individuals taking math and science prerequisites at the community-college level tended to have lower overall CCTST scores. CONCLUSION: The entering DPT class demonstrated moderate or middle range scores in critical thinking and disposition toward critical thinking. This result does not indicate, but might suggest, the potential for learning challenges. Assessing critical thinking skills as part of the admissions process may prove advantageous.

Low Starch/Low Dairy Diet Results in Successful Treatment of Obesity and Co-Morbidities Linked to Polycystic Ovary Syndrome (PCOS).

BACKGROUND: Polycystic Ovary Syndrome (PCOS) affects approximately 15% of reproductive-age women and increases risk of insulin resistance, type 2 diabetes mellitus, cardiovascular disease, cancer and infertility. Hyperinsulinemia is believed to contribute to or worsen all of these conditions, and increases androgens in women with PCOS. Carbohydrates are the main stimulators of insulin release, but research shows that dairy products and starches elicit greater postprandial insulin secretion than non-starchy vegetables and fruits. The purpose of this study was to determine whether an 8-week low-starch/low-dairy diet results in weight loss, increased insulin sensitivity, and reduced testosterone in women with PCOS. METHODS: Prospective 8-week dietary intervention using an ad libitum low starch/low dairy diet in 24 overweight and obese women (BMI ≥ 25 kg/m2 and ≤ 45 kg/m2) with PCOS. Diagnosis of PCOS was based on the Rotterdam criteria. Weight, BMI, Waist Circumference (WC), Waist-to-Height Ratio (WHtR), fasting and 2-hour glucose and insulin, homeostasis model assessment of Insulin Resistance (HOMA-IR), HbA1c, total and free testosterone, and Ferriman-Gallwey scores were measured before and after the 8-week intervention. RESULTS: There was a reduction in weight (-8.61 ± 2.34 kg, p<0.001), BMI (-3.25 ± 0.88 kg/m2, p<0.001), WC (-8.4 ± 3.1 cm, p<0.001), WHtR (-0.05 ± 0.02 inches, p<0.001), fasting insulin (-17.0 ± 13.6 µg/mL, p<0.001) and 2-hour insulin (-82.8 ± 177.7 µg/mL, p=0.03), and HOMA-IR (-1.9 ± 1.2, p<0.001) after diet intervention. Total testosterone (-10.0 ± 17.0 ng/dL, p=0.008), free testosterone (-1.8 pg/dL, p=0.043) and Ferriman-Gallwey scores (-2.1 ± 2.7 points (p=0.001) were also reduced from pre- to post-intervention. CONCLUSION: An 8-week low-starch/low-dairy diet resulted in weight loss, improved insulin sensitivity and reduced testosterone in women with PCOS.

Evolving trends in the epidemiology, resource utilization, and outcomes of pregnancy-associated severe sepsis: a population-based cohort study.

BACKGROUND: Infections are a well-known complication of pregnancy. However, pregnancy-associated severe sepsis (PASS) has not been as well-characterized, with limited population-level data reported to date. We performed a population-based study of the evolving patterns of the epidemiology, clinical characteristics, resource utilization, and outcomes of PASS in Texas over the past decade. METHODS: The Texas Inpatient Public Use Data File was used to identify pregnancy-associated hospitalizations and PASS hospitalizations for the years 2001 - 2010. The Texas Center for Health Statistics reports of live births, abortions and fetal deaths, and a previously reported population-based, age-specific linkage study on miscarriage were used to derive the annual total estimated pregnancies (TEPs). The incidence, demographics, clinical characteristics, resource utilization and outcomes of PASS were examined. Logistic regression modeling was used to explore the predictors of PASS and its associated mortality. RESULTS: There were 4,060,201 pregnancy-associated hospitalizations and 1,007 PASS hospitalizations during study period. The incidence of PASS was increased by 236% over the past decade, rising from 11 to 26 hospitalizations per 100,000 TEPs. The key changes between 2001 - 2002 and 2009 - 2010 within PASS hospitalizations included: admission to ICU 78% vs. 90% (P = 0.002); development of ≥ 3 organ failures 9% vs. 35% (P < 0.0001); and inflation-adjusted median hospital charges (2,010 dollars) $64,034 vs. $89,895 (P = 0.0141). Hospital mortality (11%) remained unchanged during study period. Chronic liver disease (adjusted odds ratio (aOR) 41.4) and congestive heart failure (CHF) (aOR 20.5) were associated with the highest risk of PASS, in addition to black race, poverty, drug abuse, and lack of health insurance. The highest risk of death was among women with HIV infection (aOR 45.5), need for mechanical ventilation (aOR 4.5), drug abuse (aOR 3.0), and lacking health insurance (aOR 2.9). CONCLUSIONS: The incidence, severity, and fiscal burden of PASS rose substantially over the past decade. Case fatality was lower than that for severe sepsis in the general population. Chronic liver disease and CHF pose especially high risk of PASS. Pregnant women with history of drug abuse and lacking health insurance are at high risk of both developing and dying with PASS, requiring extra vigilance for early diagnosis and targeted intervention.

Contemporary trends of the epidemiology, clinical characteristics, and resource utilization of necrotizing fasciitis in Texas: a population-based cohort study.

Introduction. There are limited population-level reports on the contemporary trends of the epidemiology, clinical features, resource utilization, and outcomes of necrotizing fasciitis (NF). Methods. We conducted a cohort study of Texas inpatient population, identifying hospitalizations with a diagnosis of NF during the years 2001-2010. The incidence, clinical features, resource utilization, and outcomes of NF hospitalizations were examined. Results. There were 12,172 NF hospitalizations during study period, with ICU admission in 50.3%. The incidence of NF rose 2.7%/year (P = 0.0001). Key changes between 2001-2002 and 2009-2010 included rising incidence of NF (5.9 versus 7.6 per 100,000 [P < 0.0001]), chronic comorbidities (69.4% versus 76.7% [P < 0.0001]), and development of ≥1 organ failure (28.5% versus 51.7% [P < 0.0001]). Inflation-adjusted hospital charges rose 37% (P < 0.0001). Hospital mortality (9.3%) remained unchanged during study period. Discharges to long-term care facilities rose from 12.2 to 30% (P < 0.0001). Conclusions. The present cohort of NF is the largest reported to date. There has been increasing incidence, chronic illness, and severity of illness of NF over the past decade, with half of NF hospitalizations admitted to ICU. Hospital mortality remained unchanged, while need for long-term care rose nearly 2.5-fold among survivors, suggesting increasing residual morbidity. The sources of the observed findings require further study.

Effect of a low-starch/low-dairy diet on fat oxidation in overweight and obese women with polycystic ovary syndrome.

Polycystic ovary syndrome (PCOS) affects between 4%-18% of reproductive-aged women and is associated with increased risk of obesity and obesity-related disease. PCOS is associated with hyperinsulinemia, which is known to impair fat oxidation. Research shows that carbohydrates from dairy and starch-based foods cause greater postprandial insulin secretion than carbohydrates from nonstarchy vegetables and fruits. The purpose of this study was to determine whether an ad libitum 8-week low-starch/low-dairy diet would improve fasting and postprandial fat oxidation after a high saturated fat liquid meal (HSFLM) in overweight and obese women with PCOS. Prospective 8-week dietary intervention using a low-starch/low-dairy diet in 10 women (body mass index ≥25 kg/m(2) and ≤45 kg/m(2)) with PCOS. Indirect calorimetry was used at fasting and for 5 h following consumption of the HSFLM to determine respiratory exchange ratio (RER), macronutrient oxidation, and energy expenditure (EE) at week 0 and week 8. Participants had a reduction in body weight (-8.1 ± 1.8 kg, p < 0.05) and fasting insulin (-19.5 ± 8.9 µg/mL, p < 0.05) after dietary intervention; however, these were not significantly correlated with improved fat oxidation. There was a reduction in fasting RER, and fasting and postprandial carbohydrate oxidation, and an increase in fasting and postprandial fat oxidation after adjusting for body weight. There was also significant difference in incremental area under the curve from pre- to post-diet for fat (0.06 ± 0.00 g/kg per 5 h; p < 0.001) and carbohydrate oxidation (-0.29 ± 0.06 g/kg per 5 h; p < 0.001), but not for RER or EE. In conclusion, an 8-week low-starch/low-dairy diet increased fat oxidation in overweight and obese women with PCOS.

Necrotizing Fasciitis Associated with Pregnancy: a Population-Based Cohort Study.

INTRODUCTION: Necrotizing fasciitis (NF) is a rare complication in pregnant women. There have been no population-level data reported to date on its epidemiology, clinical features, resource utilization, and outcomes. METHODS: This was a retrospective, population-based cohort study, using the Texas Inpatient Public Use Data File to identify pregnancy-associated hospitalizations for the years 2001-2010. Hospitalizations with a diagnosis of NF were then identified using the International Classification of Diseases, Ninth Revision, Clinical Modification code 728.86. Denominator data for incidence estimates were derived from the Texas Center for Health Statistics reports of live births, abortions and fetal deaths, and previously reported population-based, age-specific linkage data on miscarriage, and were used to estimate the annual total number of pregnancies (TEP). The incidence of pregnancy-associated NF (PANF), hospitalization type, clinical features, resource utilization and outcomes were examined. RESULTS: There were 4,060,201 pregnancy-associated hospitalizations and 148 PANF hospitalizations during study period. Postpartum hospitalizations accounted for 82.4% of all PANF events, and intensive care unit care was required in 61.5%. The key trends noted between 2001-2002 and 2009-2010 included rising incidence of PANF from 1.1 vs. 3.8 per 100,000 TEP-years (P = 0.0001), chronic comorbidities 0% vs. 31.7% (P = 0.0777), and development of organ failure in 9.1% vs. 31.7% (P = 0.0302). There was no significant change in total hospital charges or hospital length of stay. Three patients (2%) died in the hospital and 55% of survivors had routine home discharge. CONCLUSIONS: The present cohort of PANF is the largest reported to date. The incidence of PANF rose nearly 3.5-fold over the past decade, with most events developing following delivery hospitalization. Chronic illness has been increasingly present, along with rising severity of illness. The majority of patients required ICU care. Hospital mortality was lower than that reported for NF in the general population. The sources of the observed findings require further study.