Delayed Pneumoperitoneum After Percutaneous Endoscopic Gastrostomy (PEG) Tube Placement: A Case Report.

When used for a selected patient population, percutaneous endoscopic gastrostomy (PEG) can provide enteral nutrition percutaneous endoscopic gastrostomy (PEG) safely. PEG tubes generally possess a very low chance of life-threatening complications but due to the patient population that requires PEG tubes, a delayed diagnosis of minor complications could be fatal. In this study, we present a case of delayed pneumoperitoneum, discovered weeks after our patient underwent PEG placement for enteral nutritional needs. The patient recovered without the need for operative intervention. The development of a pneumoperitoneum in the setting of recent PEG needs a thorough clinical evaluation, and caution must be taken before immediately proceeding to operative exploration.

Assessing the mental health and psychosocial wellbeing of Ukrainian pediatric trauma and burn patients and their caregivers amidst the war: insights from a surgical medical mission in Poland.

On a recent surgical medical mission caring for Ukrainian pediatric burn and trauma patients in Poland, an assessment of the mental health and well-being of children and their caregivers was completed. Children living in war zones frequently experience significant distress and mental health problems, but little is known about the impact of co-existing related or unrelated burn injuries or physical disabilities. 19 Ukrainian children and their caregivers were interviewed utilizing validated questionnaires Child Behavioral Checklist (CBCL) and Youth Self-Report (YSR) to assess their risk for developing or for the presence of clinically-significant mental health problems. We found a high percentage of children at risk for developing mental health disorders and an unexpectedly high number of children meeting criteria for mental health disorders. As a result of interviewing the caregivers, agreement was seen between the self-assessment in children and the perception of parents about their children's wellbeing. Further study is needed to better understand the complex interactions between pre-existing burn and traumatic injuries and their impact on the psychosocial wellbeing of children living in war-torn environments.

Acquired Bronchobiliary Fistula in a Young Adult Patient With Sepsis: A Case Report.

Bronchobiliary fistula (BBF) is a rare, highly morbid condition that results from an abnormal connection between biliary channels and the bronchial tree. In the past, this condition has been known to be caused by untreated hydatid cysts or hepatic abscesses that can erode through the diaphragm into the pleural cavity and bronchial tree, creating fistulation. However, the condition's spectrum has changed in recent years, and BBFs have also become associated with neoplasm, iatrogenic causes, and trauma. Cases of BBF are treated differently, either with simple conservative management or invasive surgery. We present a case of a 46-year-old male initially presenting with sepsis, who was found to have a BBF. The diagnosis was made after a hepatobiliary iminodiacetic acid scan showed the flow of a tracer in the lung fields. The condition was likely due to acute cholecystitis and prior biliary instrumentation. The patient was treated successfully with percutaneous cholecystostomy tube insertion followed by elective laparoscopic cholecystectomy several weeks after hospital discharge.

Toothpick: An Unusual Cause of Small Bowel Perforation in an Adult.

Foreign body ingestion is a common complaint in the pediatric population; however, in adults, this entity remains quite rare. Most cases are managed conservatively with serial examinations and imaging. Rarely, foreign body ingestion may cause small bowel perforation and peritonitis in adults. Perforation often warrants operative management, and assessment of bowel viability is crucial. Here, we present a case of foreign body ingestion requiring exploration, without the need for bowel resection or repair. Although the need for operative intervention in adults after foreign body ingestion remains rare, it is crucial to recognize those patients who are both at risk for foreign body ingestion and have underlying small bowel narrowing that puts them at risk for perforation. A high index of suspicion in these instances is mandatory as early recognition and appropriate treatment will improve outcomes.

Global Burn Prevention: Ukraine.

Burn injury accounts for a large proportion of surgically treatable disease. It is estimated that over 180 000 flame burn deaths occur annually across the globe, with roughly 95% occurring in low- or middle-income countries (LMIC). Within these countries, children account for a disproportionately high number of burn injuries. As such, the WHO has identified burn prevention as a topic of interest, with an increased need in LMIC. Here, we describe the creation and implementation of a burn prevention program in Ukraine. We instituted a 5-step burn prevention initiative consisting of; data gathering, program design, implementation, outcome evaluation, program maintenance, and expansion. The burn prevention initiative has been adopted nationally leading to policy change. Active education and an information campaign were used to target pediatric scald injuries and improve first-aid care. The authors have successfully implemented a targeted multifaceted, national, burn prevention program within Ukraine. The described approach may be used as a guide and adapted to create similar prevention programs within other countries or regions. At this time, the Russo-Ukrainian War has caused an abrupt hold on our role in the prevention program and left the healthcare system in havoc. Moving forward, our team is prepared to re-evaluate the impact of the war on social life and the medical system and aid in redesigning the prevention program when appropriate.

Pulmonary Vein Thrombosis in the Setting of COVID-19 Infection: A Case Report.

The novel coronavirus SARS-CoV-2 (COVID-19) affects all three branches of Virchow's triad. It increases the risk of thrombosis and thromboembolic events. Pulmonary embolism and stroke are most commonly reported. However, there is an increasing number of cases demonstrating thrombosis in otherwise uncommon anatomical areas. In this presentation, we will explore the potential causes of pulmonary vein thrombosis secondary to COVID-19.

Management of a Bronchopleural Fistula After Right-Sided Lobectomy Using a Delayed Random Flap Under Guidance of Indocyanine Green (ICG) Angiography: A Case Report.

Bronchopleural fistula (BPF) following lung resection and thoracic surgery is associated with high rates of morbidity and mortality. Various methods are available for the closure of BPF and thoracic dead space, including flap procedures and thoracoplasty. While delayed random flaps have been used for the treatment of BPF and closure of thoracic dead space, no previous reports have described the concurrent use of laser-assisted indocyanine green angiography (ICG-A). We report a case of successful BPF closure with a random delayed fasciocutaneous flap using laser-assisted ICG-A guidance for flap delay.

Resumption of Short-term Burn Reconstruction Missions to Ukraine in Light of COVID-19: A Paradigm Shift.

The COVID-19 pandemic has disrupted the lives of billions of people globally. Some medical systems continue to be overburdened due to the viral illness leading to incredible public health challenges domestically as well as abroad. However, with vaccination distribution increasing globally, many are pushing for a return to some form of normalcy. In the medical community, some are weighing the risks of returning to global health missions and considering protective strategies to minimize risk of viral spread. Here, we describe our experience in returning to an annual burn reconstruction mission in a low- and middle-income country. We have successfully carried out a return surgical mission trip. Our team of 10 individuals was able to perform over 75 procedures on 25 pediatric patients in 4 operative days. We applied a variety of protective strategies and altered mission protocol to limit exposure and transmission risk while focusing heavily on education and training. Additionally, we increased the use of telemedicine and eliminated typical in-person clinic visits. We increased operative complexity to increase impact while limiting patient exposure. Rigorous perioperative safety and follow-up protocols were implemented. The increased use of telemedicine, reduction of in-person visits, emphasis on education, and implementation of safety and follow-up protocols have led to an improvement in efficiency, safety, and accountability. Our adaptations have provided guidance on responsibly resuming surgical outreach missions, with changes that are likely to endure beyond the COVID-19 pandemic.

Pedicled Soleus Muscle Flap for Salvage Therapy of Chronic Limb-Threatening Tibial Osteomyelitis: A Case Report.

The resurgence of opiate and intravenous drugs abuse in the United States has presented a renewed challenge to surgeons in community-based hospital settings. Patients often present with complex wounds, and when complicated by concomitant osteomyelitis, these wounds require special attention and diligent care. Local rotational flaps have been used in the salvage therapy of limb-threatening lower extremity trauma for years, and have been adapted in part for the use in patients with chronic, limb-threatening osteomyelitis. The use of local rotational flaps for coverage of chronic osteomyelitis is a viable, proven, and well-founded surgical technique with excellent results. Within our hospital setting, we have seen an explosion of patients presenting with chronic, limb-threatening wounds related to intravenous and subcutaneous injection of a variety of illicit drugs. Here, we describe a case of a 24-year-old female with a history of intravenous drug abuse (IVDA) who presented with an extensive left lower extremity wound which had been progressing for several years. The patient was acutely intoxicated but otherwise healthy. Due to extensive tissue loss and osteomyelitis, initial evaluation deemed her leg unsalvageable. However, given the immense morbidity associated with lower extremity amputation the plastic surgery team felt that salvage should be attempted in this young woman. She underwent numerous tissue debridements, washouts, cadaveric skin grafting, and a pedicled soleus muscle flap with eventual autologous skin grafting. The patient was kept in the hospital during this time to allow her to detox and undergo psychiatric evaluation and therapy. This approach allowed her to regain nearly full use of her limb, gain employment, as well as abstain from further drug use. As the opioid epidemic continues in inner cities throughout the United States, the increased burden on local medical centers to care for chronic limb-threatening wounds will continue to rise. Locoregional flaps provide good results but may not be suitable for unreliable patients struggling with addiction. However, in motivated patients, our approach of inpatient detox and delayed reconstruction has shown promising results.

Inflammatory and infectious complications of laser therapy in treatment of hypertrophic burn scars: Correlations in literature review & case reports.

INTRODUCTION: Hypertrophic burn scars contribute to morbidity through secondary symptoms of pain, pruritus, and scar contracture. Traditional treatment methods are now augmented by the use of monochromatic light therapies, which are generally accepted as safe and effective. However, little literature is available regarding the complications of laser treatments of hypertrophic burn scars and even less regarding inflammatory and infectious complications. METHODS: A literature search using PubMed was performed to identify literature pertaining to infectious and inflammatory complications of cutaneous laser treatments. Additionally, we reviewed cases of inflammatory and infectious complications occurring at our institution after laser treatment of hypertrophic burn scars. RESULTS: We identified 1 publication related to complications of laser therapy in the treatment of burn scars. In this series of 163 laser sessions, the reported incidence of adverse events was 25.1%, of which 6 cases 3.7% were related to inflammatory and infectious processes. In the 391 laser sessions performed at our institution (December, 2015 and July, 2016) 9 cases of inflammatory and infectious complications were noted yielding an incidence of 2.3%. Cases included 3 each of cellulitis, Systemic Inflammatory Response Syndrome (SIRS), and complicated SIRS. CONCLUSION: We found the most common inflammatory complication was SIRS with MSSA positive wound cultures. Three cases underwent hospitalization along with fluids and vasopressors, despite negative blood cultures. In light of the high prevalence of MSSA in the natural skin flora and negative blood cultures, the inability to establish a true source of infection lead to declaring these cases "complicated SIRS" and not sepsis. Correlative factors that may have led to complications reported in our cases were: preoperative evidence of infection, no preoperative antibiotics administered, no postoperative antibiotic dressings, combined procedures, and large treatment areas. The true mechanism of inflammatory and infectious complication is yet to be determined, but we postulate that these factors place a greater challenge on an already burdened immune system. Determining whether this is a true causal mechanism, leading to an aggravated inflammatory response, benefits from further investigation. APPLICABILITY OF RESEARCH TO PRACTICE: We urge institutions preforming such procedures to advise patients on preoperative wound preparation. We recommend that each individual with a preexisting history of infection and/or preoperative culture evidence of infection receive antibiotics, particularly when undergoing combined procedures or procedures involving higher surface areas. Although complications are rare, the benefits of these precautionary measures outweigh the risks when it comes to prevention and management.

Evaluation of liposomal bupivacaine infiltration at reconstructive skin graft donor sites in adolescent and young adult burn patients: A retrospective analysis.

BACKGROUND: Postoperative pain at skin graft donor sites is frequently undertreated in burn patients, which can impair reconstructive outcomes and result in harmful psychological consequences. We find a critical need to explore and promote non-opioid, multimodal analgesics. Donor site infiltration of the local anesthetic liposomal bupivacaine in adolescent and young adult burn patients has not been previously investigated. Therefore, the goal of this study was to evaluate intraoperative liposomal bupivacaine infiltration for postoperative donor site pain control in adolescent and young adult burn patients undergoing reconstructive skin graft procedures. METHODS: This retrospective analysis included patients aged 14-25 years, who underwent at least two reconstructive skin graft procedures, one that received donor site infiltration of the standard treatment (bupivacaine hydrochloride) and one that received donor site infiltration of liposomal bupivacaine. The final sample included 30 patients with a total of 44 liposomal bupivacaine cases and 53 standard treatment cases analyzed. RESULTS: In the authors' five-year experience, the use of liposomal bupivacaine compared to standard treatment was associated with statistically significant decreases in 0-4 h postoperative pain scores (mean 1.4/10 versus 2.3/10, p = 0.04) and 0-24 h postoperative pain scores (mean 1.7/10 versus 2.4/10, p = 0.02). Neither analgesic was associated with adverse events. Differences in length of stay and inpatient postoperative opioid usage were not regarded as significant. CONCLUSION: In this retrospective analysis, the authors report the first results that suggest intraoperative liposomal bupivacaine donor site infiltration may be associated with statistically improved patient outcomes in adolescent and young adult burn patients. However, the reported differences are most likely not clinically significant, establishing the necessity for further evaluation of using liposomal bupivacaine in this unique patient population.

A Case Report of Delayed Post-operative Angioedema Associated With Angiotensin-Converting Enzyme Inhibitor Use.

Angiotensin-converting enzyme inhibitors are known to precipitate angioedema. Drug-induced angioedema is rare in the perioperative setting. Even fewer cases described hours following a minor procedure. In this case report, we present a 45-year-old female who developed drug-induced angioedema hours following an obstetric procedure.

Experience of outreach in a resource-constrained environment: 10 years of outcomes in burn care.

OBJECTIVE: The objective of this work was to describe an efficient and sustainable outreach model in a resource-constrained environment, with a multifaceted approach focusing on national policy change, telemedicine, injury prevention, education and treatment of burns. SUMMARY BACKGROUND DATA: Burn injury constitutes a significant portion of morbidity and mortality worldwide, particularly in children, and in low- and middle-income countries. METHODS: We reviewed the impact of ten-years of a burn outreach program. Our focus was on clinical data on burn care within one region of Ukraine. We assessed knowledge of burn prevention/first aid utilizing a large survey, analyzed clinical data from our outreach clinic and telemedicine program, and analyzed data within a newly created burn repository within Ukraine. RESULTS: A national burn prevention policy has been implemented through our efforts along with a burn prevention program. Educational efforts have led to improvements of major complication rates (wound infection [7% vs. 16%], pneumonia [2.4% vs. 0.3%], sepsis [1.6% vs. 0.6%], UTI [2% vs. 0.6%], and cellulitis [11% vs. 3.4%]), respiratory support of acutely ill patients [1.3% vs. 0.4%], and blood transfusion triggers. CONCLUSIONS: Broadly, our model could be an example of building sustainable outreach programs in resource-constrained environments. Through collaboration with local healthcare providers, we have developed and implemented an outreach program in a resource-constrained environment.

Antegrade Foreheadplasty: A Novel Surgical Approach for Upper Eyelid Contracture Deformities in Pediatric Patients.

The intricate and delicate structure of the periorbital region, particularly in pediatric patients, presents challenges to eyelid reconstruction. Much like the more common lower eyelid ectropion, upper eyelid ectropion can result from lack of tissue, scar contracture, or over-resection as in blepharoplasty. In burns and trauma, the cause of cicatricial ectropion is typically direct scar contracture from injuries to the eyelid. However, in some cases, extrinsic wounds involving contracture to the forehead or eyebrow can result in upper eyelid cicatricial ectropion. Direct reconstruction and skin grafting of the eyelid present complex challenges, especially in the acute inflammatory phase of traumatic injury and burn care. Furthermore, in many of these cases the periorbital and lamellae anatomy is preserved, but rather severely displaced due to scar contracture forces. The authors discuss our experience with treatment of extrinsic upper eyelid cicatricial ectropion in a series of 4 pediatric patients with burns or trauma to the forehead and periorbital regions. In all 4 cases, the antegrade foreheadplasty procedure helped to provide globe coverage, while avoiding skin matching difficulties and the intrinsic risks of operating on the eyelid during the acute phase of recovery. There is currently very limited data for the use of this technique to correct such defects. With this study, the authors hope to establish the antegrade foreheadplasty as a reconstructive option for a select patient population.

Squamous Cell Carcinoma of the Tonsil Causing Small Bowel Perforation in the Setting of Metastasis and Treatment With Programmed Death-1 Inhibitors: A Case Report.

Metastasis of extra-intestinal carcinoma to the gastrointestinal tract (GIT) is a rare event, most commonly occurring with malignant melanoma. Anti-PD-1 (programmed death-1) immunotherapeutic agents are immune checkpoint inhibitors with proven benefit across multiple cancer types, including squamous cell carcinoma of the head and neck (SCCHN). Here we describe a case of small bowel perforation attributed to a primary SCCHN metastasizing to the GIT in the setting of treatment with PD-1 inhibitors.

Fractional Laser-assisted Hair Regrowth and Microneedling for the Treatment of Alopecia Areata: A Review.

Alopecia areata (AA) affects approximately 2.1% of the population, with women being affected more often than men. Current therapies consisting of topical corticosteroids or intralesional injections are often the first choices for treatment, but are limited by unsatisfactory outcomes or risks to patients. Recently, fractional lasers and microneedling, with or without the addition of topical agents, have been examined as treatment options. A literature review was performed to evaluate the efficacy of fractional lasers in the treatment of AA. A total of six fractional lasers and two microneedling studies consisting of small prospective and retrospective studies, and case reports were reviewed. The number of trials and participants are limited, but evidence suggests that fractional lasers and microneedling may be effective therapeutic approaches when coupled with topical agents. Larger studies are required to better understand the effects of these treatment modalities for AA.