Acute Intermittent Porphyria in a Burn Patient: Case Study and Review of the Literature.

Healthcare providers evaluating patients presenting with neurological, visceral, or cutaneous symptoms that are disproportionate to the expected severity may need to consider porphyria in the differential. Porphyria is an inherited condition in which toxic metabolites of the heme pathway are increased. Carriers of porphyrias are asymptomatic and will not present with classical symptoms, nor will levels be elevated, until the disease is induced by certain drugs, hormones, or idiopathic causes such as the stress of trauma. Acute intermittent porphyria, a form of acute porphyria, is a rare autosomal dominant disease that results in a dysfunctional porphobilinogen deaminase. This consequently increases neurotoxic porphobilinogen and subsequent increase in δ-aminolevulinic acid. Both of these metabolites cause neurovisceral symptoms that afflict the patient in acute attacks. We present a rare case of acute intermittent porphyria manifested in a burn patient suffering a burn injury. The patient presented with symptoms indicative of acute intermittent porphyria, including altered mental status and abdominal pain accompanied with a chronic history of alcoholism and smoking. A negative work-up, including imaging and findings of associated manifestations consistent with Acute Intermittent Porphyria led to a discovery of elevated porphyrins. The patient's course and death due to his injuries gives insight into the presentation of acute intermittent porphyria in a burn patient.

Analysis of online materials regarding DIEP and TRAM flap autologous breast reconstruction.

Online resources have become a mainstay for health information, and it is vital that such resources maintain accessible literacy levels to empower informed decision making. Previous studies have shown that the online resources regarding post-mastectomy breast reconstruction are of low readability; however, none have evaluated specific online resources regarding the most common procedures within autologous breast reconstruction, limiting analysis to the results of generic searches. This study sought to discover the readability of online, patient-directed resources regarding the Deep Inferior Epigastric Perforator (DIEP) and Transverse Rectus Abdominis Muscle (TRAM) flaps, the most utilized autologous flaps in breast reconstruction, using health literacy analysis. We hypothesized that the online materials regarding DIEP and TRAM flaps would yield literacy scores above the 6th-grade reading level, as recommended by the American Medical Association, despite previous literature and readability recommendations. Google searches for "DIEP breast reconstruction" and "TRAM breast reconstruction" were conducted. All patient-directed, non-sponsored websites found within the first three pages of the search underwent analysis using a variety of readability formulae. Both DIEP and TRAM resources were well above the 6th-grade reading level according to every metric used, and there was no significant difference in the reading level between the two procedures. Based on these results, significant work was needed to simplify the online resources to be more understandable for patients; these authors propose one method for such. In addition, the low readability of online resources suggests added emphasis on the need for surgeons to ensure that patients understand the medical information discussed during the presurgical consultations.

Charge capture in the BICU: Increasing revenue by improving documentation behaviors.

Documentation by a healthcare provider is the key to capturing appropriate reimbursement for effort, expertize, and time given to patients. However, patient encounters are known to be under-coded; often describing a level of service that does not reflect the physician's labor. If there is deficient medical decision making (MDM) documentation, this will ultimately lead to a loss of revenue, as coders can only evaluate service levels from the documentation during the encounter. Physicians at the Timothy J. Harnar Regional Burn Center at Texas Tech University Health Sciences Center were experiencing below-average reimbursement for work performed in the burn center and theorized that deficiencies in documentation (particularly in the area of MDM) were the cause. They hypothesized that poor documentation by physicians was resulting in a substantial proportion of encounters being compulsorily coded at inadequate and imprecise levels of service. To improve the service levels of MDM in physician documentation at the Burn Center and consequently, increase the numbers and levels of billable encounters in the unit with an accompanying increase in revenue, two resources were created and employed with the purpose of providing increased documentation recall and thoroughness. These resources included a pocket card, designed to prevent missed details when documenting patient encounters, and a standardized EMR template that was mandated to be used by all BICU medical professionals rotating through the unit. After completion of the intervention period (July - October 2021), a comparison was made between the 4-month periods of July-October 2019 and 2021. Based on the encounters provided by residents and one fellow assigned to the BICU medical director, inpatient subsequent visit codes showed an average increase in billable encounters of 1500% amid the compared periods. Upon implementation of the intervention, subsequent visit codes 99231, 99232, and 99233 (higher-numbered codes indicating an increased level of service and accompanying reimbursement) raised by 142%, 2158%, and 2200%, respectively. An additional finding since the implementation of the pocket card and revised template, billable encounters have replaced the once-dominate global encounter, 99024 (associated with no reimbursement); realizing an increase in billable inpatient services due to complete and thorough documentation of non-global issues patients experienced throughout their hospital stays. Obtaining buy-in from physicians proved a significant challenge; consistent training and feedback allowed for an improved understanding of billing and coding processes within the BICU. The described findings indicate that a focused effort to improve documentation offers a promising method to yield potentially significant improvements in a unit's profitability.

Synergistic Use of Novel Technological Advances in Burn Care Significantly Reduces Hospital Length of Stay Below Predicted: A Case Series.

Length of stay is an important metric in healthcare systems, primarily because it reflects the cost of care provided. In the United States, as in many countries, inpatient hospital stays are significantly more expensive than outpatient care across all healthcare conditions,1 so earlier discharge and transition to outpatient care is crucial to help control the ever-increasing cost of healthcare. In burn patients, length of stay has traditionally been estimated at 1 day per 1% total body surface area of burn. This estimation was first described in a round table discussion in 1986.2 However, since that time there has been significant evolution in the quality of care available to burn patients, in both the operating room and ICU. The use of new harvesting techniques, synthetic dermal substitution, and autologous epidermal skin cell suspension are allowing large, deep burns to be excised and covered in much quicker time frames than historically were possible. Examples include the skin harvesting and wound debridement device for grafting and excision, biodegradable temporizing matrix as a fully synthetic dermal template, and regenerative epidermal suspension concerning cell harvesting. Although these modalities can all be used separately, we believe that using them in conjunction has allowed us to shorten the length of stay in patients with severe partial and full-thickness burns. We present an initial case series of three patients with anticipated hospital lengths of stay of 54.5, 55, and 51 days, who were ready for discharge in 37, 35, and 43 days, respectively.

Vitamin A-Induced Hypercalcemia in Burn Patients: A Case Study.

Vitamin and steroid supplementation such as oxandrolone are commonly given to speed the recovery process in severe burn injuries. Vitamin A is administered concurrently with steroids because of its pro-inflammatory and positive effects on wound healing. However, vitamin A supplementation warrants caution as hypercalcemia can result from vitamin A overdose. Our case involves an 18-year-old male injured in an oil field explosion who presented with 55% total body surface area (TBSA) partial- and full-thickness burns. Following successful resuscitation, he was given vitamin A, oxandrolone, vitamin C, and zinc sulfate as part of the standard vitamin supplementation. On hospital day (HD) 33, serum calcium levels were noted to be elevated and increased to 13 mg/dL a few days later. Parathyroid hormone and vitamin D levels were found to be within normal range, and urine analysis showed normal calcium excretion. Subsequent assessment of vitamin A levels revealed significantly elevated levels at 93 mcg/dL. Vitamin A supplementation was discontinued, and the patient was discharged on HD 42. At the 1-month follow-up, serum calcium levels were normal, which links the hypercalcemia to vitamin A overdose. This case highlights the importance of considering vitamin A overdose as a cause for asymptomatic hypercalcemia with a normal parathyroid and vitamin D workup. While routine, vitamin A supplementation in burn patients calls for assessment of both serum calcium and vitamin A levels throughout the hospital stay to prevent hypercalcemia and its negative effects.

Autologous Cell Harvesting System as Adjunct for Soft-tissue Reconstruction of Necrotizing Soft Tissue Infection.

Necrotizing soft tissue infections (NSTIs) cause rapidly progressing destruction of skin and soft tissue, leaving large soft tissue defects and necessitating complex reconstruction. RECELL, an autologous cell harvesting device, provides a regenerative epidermal suspension (RES) from a small split-thickness skin biopsy for the substitution of (or in addition to) split-thickness skin grafting (STSG). We present a case of a 56-year-old man with extensive NSTI managed by serial debridement, leading to a degloving injury to the right upper extremity, axilla, flank and back, which was later reconstructed using RES application in conjunction with STSG and Integra placement. At his 2-week hospital follow-up, the patient was healing well with limited right upper extremity range of motion, but continued improvement seen with physical and occupational therapy. Due to the patient's significant soft tissue defect, a unique reconstructive plan was required using both Integra and RECELL in conjunction with STSG. RECELL, in conjunction with STSG, should be considered for the treatment of significant soft tissue defects such as those found in NSTI.

Preventing Rectourethral Fistula Recurrence With Gracilis Flap.

BACKGROUND: Rectourethral fistula (RUF) is an uncommon serious condition with various etiologies including neoplasm, radiation therapy, and surgery. Treatment for RUF remains problematic with a high recurrence rate. Although studies have suggested the recurrence rate of RUF is lower after surgical repair using a gracilis flap, outcomes have varied and the studies were small and inadequately controlled. Here, we compare outcomes of RUF repair with and without gracilis flap to evaluate its efficacy in preventing fistula recurrence and identify risk factors for recurrence. METHODS: We retrospectively reviewed patients who had undergone surgical repair for RUF between 2007 and 2018 at our institution and had at least 30 days of follow-up. Patient demographics, comorbidities, and surgical outcomes were recorded and compared for patients who had gracilis flap repair and those who did not (controls). Single variable logistic regression analysis was used to identify risk factors for recurrence. RESULTS: The gracilis group (n = 24) and control group (n = 12) had similar demographics and comorbidities. Fistula recurrence was far less frequent in the gracilis group (8% vs 50%, P = 0.009). There were no significant differences in other outcomes including length of hospitalization and surgical complications. When recurrent RUF was treated with a muscle flap (gracilis or inferior gluteus), 83% of the group had no additional fistula recurrence. In the control group, history of radiation ( P = 0.04) and urinary incontinence ( P = 0.015) were associated with fistula recurrence. CONCLUSIONS: We recommend using a gracilis flap for RUF repair given its association with lower recurrence without increased surgical complications.

Autologous Skin Cell Suspension Application for Toxic Epidermal Necrolysis: A Case Report.

Toxic epidermal necrolysis (TEN) is a drug-mediated disease process that mimics a partial-thickness thermal injury. It has long been treated with frequent wound dressing changes and supportive care. There has been minimal efficacious systemic therapy. The pathophysiology is poorly understood but causes necrosis of keratinocytes at the dermal-epidermal junction leading to sloughing of the epidermis. The disease is rare with high mortality rates associated with long hospital stays. This case report describes the application of autologous skin cell suspension to a patient with TEN after antihypertensive and hyperglycemic therapy. This was associated with minimal wound care and efficacious arrest of patient disease process and timely closure of wound.

Use of a novel chitosan-based dressing on split-thickness skin graft donor sites: a pilot study.

OBJECTIVE: Split-thickness skin graft (STSG) donor site dressings can play an integral role in reducing donor site morbidity. This study tested a novel, chitosan-based wound dressing, Opticell Ag, as an STSG donor site dressing for wounds <10% total body surface area (TBSA). METHOD: Between January and December 2016, the chitosan-based dressing was placed on participating patients' donor sites immediately following graft harvest and covered with a transparent occlusive dressing. Pain was evaluated on postoperative day one, before dressing change between days 5-7, and before and after dressing removal between days 10-14 using the Visual Analog Scale (VAS). The extent of re-epithelialisation was determined between day 10-14 and at one month, and healing quality was also evaluated at one month post-operatively using the Vancouver Scar Scale (VSS). RESULTS: A total of 19 patients were recruited, of which 16 completed the study. Patients experienced mild-to-moderate pain in their donor sites when the chitosan-based dressing was used. Pain decreased significantly between postoperative day one and days 10-14, as well as between days 5-7 and 10-14. The mean percentage of re-epithelialisation on days 10-14 was 92% and by one month was 99%. The mean VSS at one month was 3.2±1.4. There were no statistically significant differences between patients' re-epithelialisation rates or VSS scores. There were unplanned dressing changes in four patients. No donor site infections or other adverse events were identified. CONCLUSION: The chitosan-based dressing tested in this study is safe, effective, and associated with reasonable pain control and acceptable healing quality. The results suggest that it is a promising STSG donor site dressing.

Role of Facial Vascularized Composite Allotransplantation in Burn Patients.

Face transplantation can provide improved quality of life to patients with extensive burn injuries. Facial vascularized composite allotransplantation (VCA) offers a new paradigm of treatment options, serving as a powerful reconstructive tool to restore facial form and function. Although currently facial VCA patients must follow a lifelong regimen of immunosuppression medications and suffer a risk of rejection, in properly selected patients, facial VCA can be a transformative operation and can improve quality of life. Research efforts continue to optimize immunosuppression and surgical technique and serve as evidence of the procedure's growing role in reconstructive surgery for critically injured patients.

Intraoperative Feeding Improves Calorie and Protein Delivery in Acute Burn Patients.

Enteral nutrition support is a critical component of modern burn care for severely burned patients. However, tube feeds are frequently withheld during the perioperative period because of aspiration concerns. As a result, patients requiring multiple operative procedures risk accumulating significant protein-calorie deficits. The objective of this study was to describe our American Burn Association-certified burn center's experience implementing an intraoperative feeding protocol in severely burned patients defined as a cutaneous burn ≥20% TBSA. A retrospective review of patients with major thermal injuries (2008-2013). Thirty-three patients with an average of seven operating room trips (range, 2-21 trips) were evaluated. Seventeen patients received intraoperative enteral feeds (protocol group) and 16 patients did not (standard group). Feeding was performed using an enteral feeding tube placed postpylorically and was continued intraoperatively, regardless of operative positioning. There was no statistically significant difference in mortality between the groups (P = .62). No intraoperative aspiration or regurgitation events were recorded. The protocol group received significantly more calculated protein and caloric requirements, 98.06 and 98.4%, respectively, compared with 70.6 and 73.2% in the standard group (P < .001). Time to goal tube feed infusion rate was achieved on average 3 days sooner in the protocol group compared with the standard group (3.35 vs 6.18 days, P = .008). Early initiation and continuation of enteral feeds in severely burned patients led to higher percentages received of prescribed goal protein and caloric needs without increased rates of aspiration, regurgitation, or mortality.

Extended V-Y Advancement Flap Reconstruction of a Large Posterior Upper Midline Trunk Defect.

Large posterior upper trunk defects can be challenging to reconstruct. Trapezius or latissimus dorsi myocutaneous flaps are principally utilized for reconstruction; however, some defects may not be amenable to this standard approach. Here, we describe a patient with a full-thickness skin and subcutaneous tissue loss of the upper back and inferior cervical region after dermatofibrosarcoma protuberans resection. A large, extended V-Y flap was used for closure of this wound secondary to its location, size, and orientation. This approach preserves shoulder function, allows for readvancement of the flap as needed, and is a reconstructive option for patients with large upper back defects.