Background. An occult pneumothorax is identified by computed tomography but not visualized by a plain film chest X-ray. The optimal management remains unclear. Methods. A retrospective review of an urban level I trauma center’s trauma registry was conducted to identify patients with occult pneumothorax over a 2-year period. Factors predictive of chest tube placement were identified using univariate and multivariate logistic regression analysis. Results. A total of 131 patients were identified, of whom 100 were managed expectantly with an initial period of observation. Ultimately, 42 (32.0%) patients received chest tubes and 89 did not. The patients who received chest tubes had larger pneumothoraces at initial assessment, a higher incidence of rib fractures, and an increased average number of rib fractures, of which significantly more were displaced. Conclusions. Displaced rib fractures and moderate-sized pneumothoraces are significant factors associated with chest tube placement in a victim of blunt trauma with occult pneumothorax. The optimal timing for the first follow-up chest X-ray remains unclear.

BackgroundWe sought to compare the safety profile of prepectoral breast reconstruction with total submuscular tissue expander reconstruction, previously our standard. Primary outcomes of interest in this retrospective cohort study were incidence of infection, hematoma, seroma, mastectomy flap necrosis, and reconstruction loss.MethodsTotal submuscular and prepectoral with acellular dermal matrix reconstructions consecutively performed by a single surgeon (P.D.S.) between January 1, 2016, and December 31, 2019, were compared. Demographic and clinical characteristics, as well as complications and complication types, were extracted for all patients. A t test was used to assess differences in continuous variables. Multivariate logistics regression was used to assess the association between type of reconstruction and complication rate. The statistical significance was set at 0.05 for all comparisons.ResultsA total of 133 patients (234 breasts) were included. There was a significantly greater incidence of infection (16.5% vs 5.5%, P < 0.01) in the prepectoral/acellular dermal matrix cohort. However, reconstructive loss was low in both cohorts (2.5% and 3.0%, P = 0.83). Adjusted odds ratio for complications in the prepectoral cohort was 2.26, but this was not statistically significant (adjusted P = 0.24).ConclusionsPrepectoral breast reconstruction shares an overall complication profile that is not greater than that of total submuscular reconstruction. It is associated with a greater risk of infection; however, the ability to salvage the reconstruction with early, aggressive intervention results in low rates of reconstructive loss, comparable with those of total submuscular reconstruction.

Introduction In light of the opioid crisis, there is an increased interest in the acute pain management of patients with history of drug addiction. There is no consensus on pain management among different burn centers and the amount of narcotic prescription reportedly doubled over a seven year period according to Tully in 20191. Our aim was to study the association of previous drug addiction history and the treatment of acute burn patients with special interest on the daily morphine equivalent requirements. Methods A prospectively maintained database was queried to study acute burn patients admitted in a reference burn center from 2013 to 2018. Patients with a previous history of drug addiction (group 1) were compared to patients without it (group 2). Drug abuse was defined as patients with history of opioids abuse, heroin, cocaine, cannabis, inhalants, and alcoholism, specifically those with diagnostic codes on file. The expected mortality was calculated using the Premier® database. A p0.05 was considered significant. Results A total of 3046 patients were studied, 502 (16.5%) had previous history of drug abuse on file. Compared to group 2, group 1 had: more males - 343 (68.3%) vs 1456 (57.2%) p0.001; was younger - 45.7914.65 vs 52.0219.57 p0.001; required intubation at a higher rate - 100 (19.9%) vs 329 (12.9%) p0.001; longer intubation period - 2.4310.05 vs 1.377.71 p0.001; had a prolonged admission - 13.8728.82 vs 8.4816.58 p0.001; more surgeries - 1.213.30 vs 0.71.58 p=0.002, and a higher daily morphine milligram equivalent requirement - 148.34320.56 vs 56.0297.81 p0.001. The groups had similar expected mortality rates: 3.03% vs 3.56%p=0.483; which may be partly explained by the fact that the drug use history is not accounted for on the formula. No significant difference was seen on the burned area between the groups. Conclusions Drug addiction was associated with increased need for intubation and length of intubation, prolonged admission, increased surgery rate and a higher daily morphine equivalent usage. Further studies are necessary guide the treatment of the specific needs of these increasingly common burn patients subgroup and also to define the need of including the history of drug use on the expected mortality rate formula. Applicability of Research to Practice This study adds to the literature differences in the treatment of burn patients with history of drug addiction and highlights the need for specific protocols for improved care.

Burn scar contracture greatly limits function for burn survivors, particularly when the scarring crosses multiple joints. Previous research has identified fields of skin recruited during single joint motion, called cutaneous functional units (CFU), indicating that impairments may be seen distal to the injured tissue. This case report connects the principles of CFU and yoga-inspired therapy modalities in improving clinical outcomes for a burn survivor. The patient is a 38-year-old male who sustained deep partial-thickness electrical burns to his neck, chest, and bilateral upper extremities, presenting with significantly decreased range of motion. The patient attended physical therapy 4 days a week, where he performed a specific yoga asana program during each session. Outcomes including standard range of motion measures, the Vancouver Scar Scale (VSS), and the Neck Disability Index (NDI), which were recorded every 10 sessions. CFUs of cervical extension and shoulder flexion were analyzed via photographs comparing cutaneous position during specified yoga poses and resting anatomical position in standing. Over 30 visits, cervical and shoulder range of motion increased, although the VSS and NDI did not show significant improvement. Yoga poses showed overall cutaneous recruitment distal to the targeted joints, and burned skin was recruited similarly to nonburned skin in positions of stretch. Incorporating multijoint approaches for stretching, like yoga, appears to contribute to improved clinical range-of-motion outcomes when paired with traditional burn-rehabilitation interventions. Yoga poses involving multiple joints align with the principle of CFUs, warranting continued investigation.