Burn center management of necrotizing soft-tissue surgical infections in unburned patients

BACKGROUND

Patients with necrotizing soft-tissue infections present great challenges in management from initial presentation through definitive care. Because burn centers concentrate expertise in critical care, wound management, and rehabilitation, we examined the effectiveness of burn center care for patients with necrotizing infections.

METHODS

We reviewed our burn center's experience with all patients admitted from 1990 through 1999 with a primary diagnosis of necrotizing fasciitis (NF) or Fournier's gangrene (FG).

RESULTS

Fifty-seven patients were identified, 18 with FG and 39 with NF. Patients had a high incidence of preexisting medical problems, including diabetes (37%), obesity defined as greater than 20% above ideal body weight (33%), and hypertension (33%). Seven of 57 (12%) patients died. Patients required a mean of 4.1 operative procedures (range 1 to 15) for definitive wound closure. The mean length of stay (survivors only) was 28.5 days, (range 3 to 70). Although costs increased throughout this period, a formal program of cost-containment resulted in no increase in actual charges per day, from a mean of $4,735 in 1991 to $5,202 in 1999.

CONCLUSIONS

Burn centers can provide successful and cost-effective acute care, definitive wound closure, and rehabilitation for patients with NF and FG.

The use of contingency management in the treatment of a geriatric nursing home patient with psychogenic vomiting

A substantial percentage of nursing home residents evidence psychosocial and behavioral problems. However, surprisingly little is known about how effectively to treat geriatric patients with behavioral problems. The present study reports the behavioral treatment of a patient with psychogenic vomiting. The patient was successfully treated by changing the contingencies of her illness behavior and of behavior associated with rehabilitation goals. This indicates the importance of nursing home staff attending to the operants of illness behavior. Specifically, independent behavior should be rewarded by praise and attention and illness behavior should be ignored in terms of attention.