Congenital Appendiceal Diverticulum: An Incidental Finding During an Appendectomy.

Diverticula are small outpouchings that form at weak points in the wall of the digestive tract. They are commonly found in the colon, and while they can occur anywhere in the digestive tract, occurrence in the appendix is rare. Here, we report the case of a young woman presenting with complaints of right lower quadrant abdominal pain. The patient's physical examination, laboratory values, and computed tomography (CT) result supported the presumptive diagnosis of uncomplicated appendicitis. The patient underwent a laparoscopic appendectomy, where an appendiceal diverticulum was appreciated. A postoperative pathology report supported the diagnosis of a true appendiceal diverticulum. The patient's symptoms improved postoperatively, and her recovery has been unremarkable. We conclude that appendiceal diverticula are often incidental findings that should be removed along with the appendix to reduce the risk of malignancy and perforation.

Efficacy of a pneumonia prevention protocol in the reduction of ventilator-associated pneumonia in trauma patients.

BACKGROUND: We hypothesized that implementing evidence-based ventilator-associated pneumonia (VAP) prevention (VAPP) strategies would decrease the incidence of VAP, and that VAP affects patient outcomes. METHODS: A prospective study was performed with 331 consecutive ventilated trauma patients in a level one university teaching hospital. The VAPP protocol was modified to include elevation of the head of the bed more than 30 degrees , twice-daily chlorhexidine oral cleansing, a once-daily respiratory therapy-driven weaning attempt, and conversion from a nasogastric to an orogastric tube whenever possible. Ventilator days were compared with occurrences of nosocomial pneumonia, as defined by the U.S. Centers for Disease Control National Nosocomial Infection Surveillance criteria. Patients with and without VAP were compared to discern the effect VAP has on outcome. RESULTS: In 2003, there were 1,600 days of ventilator support with 11 occurrences of VAP (6.9/1,000 ventilator days). In 2004, there were two occurrences of VAP in 703 days of ventilation (2.8/1,000 ventilator days). In the analysis of outcomes of the patients with and without VAP, there was a statistically significant difference in total hospital days (38.7 +/- 26.2 vs. 13.3 +/- 15.5), ICU days (27.8 +/- 12.6 vs. 7.5 +/- 9.7), ventilator days (21.1 +/- 9.8 vs. 6.0 +/- 10.3), Functional Independence Measures (7.25 +/- 2.3 vs. 10.8 +/- 1.8), and hospital charges ($371,416.70 +/- $227,774.31 vs. $138,317.39 +/- $208,346.64)(p < 0.05 for all). The mortality rate did not decrease significantly (20% vs. 7.5%; p = NS). The difference in the mean Injury Severity Score in the two groups was not significant (21.9 +/- 9.6 vs. 16.7 +/- 11.4 points) and thus could not account for the differences in outcomes. CONCLUSION: These data suggest that a VAPP protocol may reduce VAP in trauma patients. Ventilator-associated pneumonia may result in more hospital, ICU, and ventilator days and higher patient charges.

Methamphetamine-associated burn injuries: a retrospective analysis.

Methamphetamine production and use has increased dramatically during the past 10 years. Methamphetamine production requires combining hazardous and volatile chemicals that expose the manufacturer to burn injuries from explosions and chemical spills. We sought to review the epidemiology of burn injuries in a rural burn center secondary to the use of amphetamine or methamphetamine and/or the manufacture of methamphetamine. Review of the records of 507 patients who were admitted to our burn unit from December 1, 1998, to December 31, 2001, revealed 34 patients who were involved in the use of amphetamines or methamphetamines and/or the manufacture of methamphetamine. Thirty-one patients tested positive for either amphetamine (n = 2) or methamphetamine (n = 29) on routine admission urine drug screens. Twenty of these patients were involved in the manufacture of methamphetamines. Three additional patients were identified as methamphetamine manufacturers but tested negative for the use of methamphetamines. The mean age of the study population was 31.88 +/- 7.65 years, with a male:female ratio of 10.3:1. The average burn size was 18.86 +/- 20.72, with the majority secondary to flame (n = 26). Patient burn admission histories were vague, and the patient's involvement in the manufacture of methamphetamine was often only later confirmed by media, the fire marshal, family members, or the patient. Fifteen patients showed the usual withdrawal pattern of agitation and hypersomnolence, with seven patients requiring detoxification with benzodiazepines. Two were admitted acutely to the psychiatric ward for uncontrollable agitation. Eighteen patients were offered chemical dependency treatment, and two completed therapy. There was one mortality. The mean cost per person was US 77,580 dollars (range, US 112 dollars - US 426,386 dollars). The increasing use of and manufacture of methamphetamine presents new challenges for the burn team because these patients can become violent and frequently need assistance with detoxification. Routine drug screens are mandatory in identifying methamphetamine use to alert burn unit personnel to particular management problems and target individuals who may be receptive to drug rehabilitation.

Innovations in caring for a large burn in the Iraq war zone.

The authors report on a single case of a large, civilian burn cared for at a U.S. military hospital during Operation Iraqi Freedom. The management of the patient, using a large negative pressure wound therapy device and the Meek grafting technique, is reviewed. This is a case report. The patient survived his injury. In Iraq, most patients with this severity of injury succumb to the injury. By using two innovative techniques, the authors found that the patient was able to survive his injury and return to his home.

Massive Marjolin's ulcer in a burn graft site 46 years later.

Marjolin's ulcers, or malignancy originating from burn scars, have been recorded in the literature since the first century AD (Ozek et al. Marjolin's ulcers arising in burn scars. J Burn Care Rehabil 2001;22:384-9). The majority of cases of Marjolin's ulcers occur in primary burn scar sites with few reported cases following secondary graft placement. We report a case of Marjolin's ulcer that developed in a 57-year-old man, 46 years after initial skin graft placement following a left lower extremity burn. The patient presented to us following diagnosis of squamous cell carcinoma of the verucous type lesion. Wide surgical excision was performed and a split thickness skin graft was applied. The postoperative course was uneventful and no recurrences have occurred. To our knowledge, this is the largest reported Marjolin's case recorded in the literature.

Prospective analysis of nosocomial infection rates, antibiotic use, and patterns of resistance in a burn population.

Despite significant advances in burn care, infection remains a major cause of morbidity and mortality in burn patients. We sought to determine accurate infection rates, risk factors for infection, and the percentage of infections caused by resistant organisms. In addition, we attempted to identify interventions to decrease the use of antimicrobial drugs. Data were collected prospectively from 157 burn patients admitted to the University of Iowa Carver College of Medicine burn treatment center from October 2001 to October 2002. A research assistant reviewed the medical record for each patient identified by burn surgeons as being infected to determine whether these episodes met the infection control criteria for nosocomial infections. The infection control assessment agreed with the surgeon's assessment for 16.7% of the pneumonias, 70.0% of the burn wound infections, 57.1% of the urinary tract infections, and 70.0% of the bloodstream infections. By multiple logistic regression analysis, body surface area burned, comorbidities, and use of invasive devices were significantly related to acquisition of nosocomial infections as identified by both the burn surgeons and the infection control criteria. Staphylococcus aureus and Pseudomonas were the most common resistant organisms identified. In our population, surgeons could decrease antimicrobial use by using explicit criteria for identifying patients with hospital-acquired infections, limiting perioperative prophylaxis to patients at highest risk of infection, and decreasing the incidence of nosocomial infection with reduced use of devices and strict adherence to aseptic technique.