Presentation and Management of Staphylococcal Scalded Skin Syndrome in a Child After a Burn Injury: A Case Report.

This case report describes the clinical course of a child who developed staphylococcal scalded skin syndrome (SSSS) after a burn injury. The intent is to aid other units in recognizing the presentation of SSSS after a pediatric burn and to optimize subsequent management. The main clinical finding was of rapid, progressive, superficial epidermal loss at sites separate from the original burn, involving 55% of the total body surface area, 13 days after a 6% scald burn to the face, neck, and chest. Diagnosis was confirmed by multidisciplinary team clinical assessment and histopathology of an intraoperative skin biopsy. This confirmed epidermal cleavage at the granular cell layer. These findings were later supported by Staphylococcus aureus cultured from the burn wound, and a positive epidermolytic toxin A assay. Management was with general medical supportive care, clindamycin and flucloxacillin intravenous antibiotic therapy, and cleansing and dressing of the areas of epidermal loss. Key learning points from this case were that SSSS presented after a burn injury and that 13 days elapsed between the burn and SSSS. Factors differentiating it from toxic epidermal necrolysis are described, including the value of histopathology in confirming the diagnosis. The prompt use of antibiotics and attentive wound care are advocated as an effective management strategy.

Thromboprophylaxis in adult and paediatric burn patients: A survey of practice in the United Kingdom.

INTRODUCTION: Patients with burn injuries are at an increased risk of venous thromboembolism (VTE). This predisposition is secondary to the endothelial injury, hyper-coagulable state and stasis (Virchow's triad) associated with burn injury. Although the true incidence of VTE in burn patients has not been adequately quantified, symptomatic VTE occurs in 0.2-7% of this population. VTE prophylaxis has proven clinical effectiveness and affords a reduction in the morbidity associated with such events, but the benefits and risk of complications need to be balanced in order to provide the best quality of care. Owing to the lack of prospective data on VTE in burns, practice varies greatly, not only internationally, but also between local burns services. Our aim was to better understand current VTE practice within United Kingdom (UK) burn care services by performing a comprehensive survey. METHODS: We contacted all the inpatient burn care services in the UK and collected data on current VTE practice via a standardised questionnaire. Services were given the choice to complete the survey by telephone or email and a follow-up plan was formulated. RESULTS: Twenty-five burn care services were contacted and 23 agreed to participate (92% response rate). Responding services treated adults, children or both and lead burn nurses or senior medical staff familiar with current VTE practice were interviewed. Routine VTE prophylaxis was provided in 84% of burn services and the majority utilised a combination of chemoprophylaxis and thromboembolic deterrent stockings (TEDS). All used low molecular weight heparin (LMWH) as their choice of chemoprophylaxis. Of those treating adults, all used a VTE prophylaxis protocol, but none of these applied to children. Only 56% of services treating children had such a protocol. The majority discontinued prophylaxis once patients were mobile. DISCUSSION AND CONCLUSION: Although the true burden of VTE in burn patients is unknown, we recognise that they are a population at risk. In addition to changes in the inflammatory and clotting pathways associated with thermal injury, prolonged hospital stay, ventilatory support, multiple surgeries, numerous central venous cannulations and reduced mobility all multiply this risk. The risk associated with the administration of heparin (bleeding complications and heparin-induced thrombocytopaenia) is low and can be reduced even further to 0.1% by the use of LMWH. The risk of symptomatic VTE is far greater, therefore the benefits of VTE prophylaxis would seem to outweigh the risks of not undertaking prophylactic measures. A higher LMWH dose and routine monitoring of anti-factor Xa levels are useful for acute burn patients. Two previous surveys, performed in Canada and the United States of America (USA), found routine administration of VTE prophylaxis to be 50% and 76% respectively. Of the 71 centres in the USA participating in the survey, 30% used a combination of sequential compression devices (SCD) and heparin and 24% did not provide VTE prophylaxis at all. A lack of prospective data on VTE in burn patients appears to be associated with diverse practice, and consensus on this topic could ensure that the potential morbidity caused by VTE is reduced. A clinical tool for identifying patients at risk and guidelines for management will standardise practice, which in turn should allow us to improve and maintain high quality care for burn patients.

"SIMBurns": A high-fidelity simulation program in emergency burn management developed through international collaboration.

Acute management of a severely burned patient is an infrequent and stressful situation that requires medical knowledge as well as immediate coordinated action. Many adverse events in health care result from issues related to the application of 'non-technical' skills such as communication, teamwork, leadership and decision making rather than lack of medical knowledge. Training in these skills is known as Crisis Resource Management (CRM) training. In order to create well-prepared burn teams, it is critical to teach CRM principles through high-fidelity simulation (HFS). While CRM teaches foundational non-technical skills, HFS incorporates lifelike, whole-body, fully-responsive mannequins in order to provide a realistic emergency situation. The aim of the study is to describe the development of a novel high-fidelity simulation course called "SIMBurns: High Fidelity Simulation Program for Emergency Burn Management" that uses CRM as its foundation and is focused on management of burn injuries. The course was designed by a panel of simulation and burns experts from Meyer Children's Hospital in Italy and Birmingham Children's Hospital in the U.K. Simulation Program experts were certified by Boston Children's Hospital's Simulation Program. In this paper, we describe the course's design, development, structure, and participant's assessment of the course. Since the creation of the SIMBurns course in 2013, 9 courses have been conducted and 101 participants have attended the course. The course was well-received and its "Overall Satisfaction" was rated at 4.8/5. The primary objective in the SIMBurns course - to teach teamwork and CRM skills to medical staff involved in emergency burn care - was also met at 4.8/5. Participants felt that the course developed their ability to interact with other team members, further improved their understanding of how to appropriately use resources, emphasized the importance of role clarity and developed their communication skills. Additional quantitative and qualitative analyses obtained from participants were also reviewed after each course. The SIMBurns course aims to contribute to the education of those in healthcare in order to improve patient safety and to continue advancing the education of our emergency burn care teams.

The contribution of leucocytes to the antimicrobial activity of platelet-rich plasma preparations: A systematic review.

The infection of a wound is one of the major contributors to delays in healing and tissue regeneration. As multi-drug resistance to antibiotics is becoming a serious threat, research in this field has focused on finding new agents and strategies to fight infection and additionally to reduce healing times. The topical use of autologous Platelet Rich Plasma (PRP) as a biological accelerator of the healing process, has been safely used as a form of treatment for wounds since the 1990s. Although the presence or absence of leucocytes in PRP preparation was previously neglected, in the last decade more attention has been paid to their role and several studies have been conducted to explore both their immuno-metabolic effects and their antimicrobial properties. In this review, we aim to summarise the literature on the contribution of leucocytes included in PRP preparations in terms of their antimicrobial properties. This should help to inform clinical practice and additional research in this promising field.

Does Overestimation of Burn Size in Children Requiring Fluid Resuscitation Cause Any Harm?

Overestimation of burn size especially in children is common. It is unclear if this may cause harm. This study was designed to assess the accuracy of burn size estimation by referring non-burn clinicians and investigate whether inaccurate estimates caused any harm. Three and a half years retrospective review of pediatric resuscitation burns (ie, ≥10% TBSA) referred to a tertiary burns center from other hospitals was performed. This included basic demographics, data from referring emergency departments (initial TBSA estimations and fluid volumes prescribed), and data on arrival to the burn center (actual burn TBSA sustained, fluid volumes given prior to arrival, and actual fluid volumes required). Clinical parameters at 8 and 24 hr after injury were also examined. Forty-six patients were identified. Mean age was 3.9 years and weight 18 kg. Mean time to arrival from initial burn injury to our tertiary center was 5 hr. Thirty-two children (70%) had their burns overestimated, seven (15%) underestimated, and another seven (15%) were correctly estimated. After accurate calculations of the burn size and the required resuscitation fluids on arrival to the burns center, only five children of the entire cohort of 46 patients (11%) had received more fluids than required. These five children were in the overestimated burn size group. Only three children received the appropriate amount of fluid prior to arrival to the burns center. There were no mortalities or significant clinical adverse events in any of the children. Overestimation led to overprescription of fluid volumes, but this did not translate into over-resuscitation, and in most cases was in fact associated with inadequate fluid administration. Although 70% of the children in our cohort had the burn size overestimated, only 11% had actually received more fluids than required before arrival. None of these children went on to have any significant complications as a result of overestimation. Training and education is essential for clinicians in emergency departments. However, estimation of size in pediatric burns, in particular scalds, is challenging and the importance of early transfer to a specialist service cannot be overemphasized.

Epidemiology of U.K. Military Burns 2008-2013.

After sustaining burn injuries overseas, U.K. Armed Forces personnel are evacuated to the Royal Centre for Defence Medicine. The objective was to review the etiology of U.K. Military burns managed at the center between 2008 and 2013. Analysis will aid provision planning and assist in the prevention of burn injuries for future tours. The International Burn Injury Database database of all U.K. Armed Forces burn injured patients evacuated to the Queen Elizabeth University Hospital Birmingham between 2008 and 2013 were reviewed retrospectively. Analysis included patient demographics, injury mechanism, burn severity, management, and mortality. There were 65 military personnel with burn injuries requiring repatriation to the United Kingdom. Percentage of 78.5 were sustained in Afghanistan. The mean age was 25 (18-46) years. Percentage of 70.8 were considered noncombat burn injuries. Of the noncombat burns, the mechanism of injury most commonly involved burning waste and misuse of fuels and scalds. The mean TBSA for all patients was 6% (0.05-51%). Areas most commonly affected included arms, legs, and face. The length of hospital stay for combat vs noncombat burn injury patients was 10 vs 7 days. There were no fatalities. In conclusion, substantially fewer military personnel sustained combat burns between 2008 and 2013 than in preceding study period (19 vs 79). The number of accidental noncombat burns remained constant. The decrease in combat burns may reflect a relative decrease in military intensity and effective protective equipment and safety measures. Further education may allow for an additional decrease in preventable burn injuries.

MSCs seeded on bioengineered scaffolds improve skin wound healing in rats.

Growing evidence has shown the promise of mesenchymal stromal cells (MSCs) for the treatment of cutaneous wound healing. We have previously demonstrated that MSCs seeded on an artificial dermal matrix, Integra (Integra Lifesciences Corp., Plainsboro, NJ) enriched with platelet-rich plasma (Ematrix) have enhanced proliferative potential in vitro as compared with those cultured on the scaffold alone. In this study, we extended the experimentation by evaluating the efficacy of the MSCs seeded scaffolds in the healing of skin wounds in an animal model in vivo. It was found that the presence of MSCs within the scaffolds greatly ameliorated the quality of regenerated skin, reduced collagen deposition, enhanced reepithelization, increased neo-angiogenesis, and promoted a greater return of hair follicles and sebaceous glands. The mechanisms involved in these beneficial effects were likely related to the ability of MSCs to release paracrine factors modulating the wound healing response. MSC-seeded scaffolds, in fact, up-regulated matrix metalloproteinase 9 expression in the extracellular matrix and enhanced the recruitment of endogenous progenitors during tissue repair. In conclusion, the results of this study provide evidence that the treatment with MSC-seeded scaffolds of cutaneous wounds contributes to the recreation of a suitable microenvironment for promoting tissue repair/regeneration at the implantation sites.

Pharmacological management of osteogenesis.

Osteogenesis and bone remodeling are complex biological processes that are essential for the formation of new bone tissue and its correct functioning. When the balance between bone resorption and formation is disrupted, bone diseases and disorders such as Paget's disease, fibrous dysplasia, osteoporosis and fragility fractures may result. Recent advances in bone cell biology have revealed new specific targets for the treatment of bone loss that are based on the inhibition of bone resorption by osteoclasts or the stimulation of bone formation by osteoblasts. Bisphosphonates, antiresorptive agents that reduce bone resorption, are usually recommended as first-line therapy in women with postmenopausal osteoporosis. Numerous studies have shown that bisphosphonates are able to significantly reduce the risk of femoral and vertebral fractures. Other antiresorptive agents indicated for the treatment of osteoporosis include selective estrogen receptor modulators, such as raloxifene. Denosumab, a human monoclonal antibody, is another antiresorptive agent that has been approved in Europe and the USA. This agent blocks the RANK/RANKL/OPG system, which is responsible for osteoclastic activation, thus reducing bone resorption. Other approved agents include bone anabolic agents, such as teriparatide, a recombinant parathyroid hormone that improves bone microarchitecture and strength, and strontium ranelate, considered to be a dual-action drug that acts by both osteoclastic inhibition and osteoblastic stimulation. Currently, anti-catabolic drugs that act through the Wnt-ß catenin signaling pathway, serving as Dickkopf-related protein 1 inhibitors and sclerostin antagonists, are also in development. This concise review provides an overview of the drugs most commonly used for the control of osteogenesis in bone diseases.

Pharmacological management of osteogenesis

Osteogenesis and bone remodeling are complex biological processes that are essential for the formation of new bone tissue and its correct functioning. When the balance between bone resorption and formation is disrupted, bone diseases and disorders such as Paget's disease, fibrous dysplasia, osteoporosis and fragility fractures may result. Recent advances in bone cell biology have revealed new specific targets for the treatment of bone loss that are based on the inhibition of bone resorption by osteoclasts or the stimulation of bone formation by osteoblasts. Bisphosphonates, antiresorptive agents that reduce bone resorption, are usually recommended as first-line therapy in women with postmenopausal osteoporosis. Numerous studies have shown that bisphosphonates are able to significantly reduce the risk of femoral and vertebral fractures. Other antiresorptive agents indicated for the treatment of osteoporosis include selective estrogen receptor modulators, such as raloxifene. Denosumab, a human monoclonal antibody, is another antiresorptive agent that has been approved in Europe and the USA. This agent blocks the RANK/RANKL/OPG system, which is responsible for osteoclastic activation, thus reducing bone resorption. Other approved agents include bone anabolic agents, such as teriparatide, a recombinant parathyroid hormone that improves bone microarchitecture and strength, and strontium ranelate, considered to be a dual-action drug that acts by both osteoclastic inhibition and osteoblastic stimulation. Currently, anti-catabolic drugs that act through the Wnt-β catenin signaling pathway, serving as Dickkopf-related protein 1 inhibitors and sclerostin antagonists, are also in development. This concise review provides an overview of the drugs most commonly used for the control of osteogenesis in bone diseases.

The endocrine response to severe burn trauma.

The endocrine system is frequently altered after a major burn trauma. Besides the endocrine response to stress characterized by hypercortisolism, several hypothalamus-hypophysis-target gland axes are rapidly perturbed within a few days. These alterations can persist in the long term and deserve an appropriate treatment. Disturbances in water clearance and glucidic metabolism are also common and need to be diagnosed and corrected to decrease morbidity in such patients. Bone and mineral metabolism is deeply compromised and requires correction of mineral abnormalities in order to improve symptoms and prevent bone loss. No large prospective and/or intervention trials are available to date to elaborate age-related, evidence-based recommendations to monitor and treat burn-related endocrine alterations.

A review on strontium ranelate long-term antifracture efficacy in the treatment of postmenopausal osteoporosis.

Osteoporotic fractures are one of the major causes of increased morbidity and mortality in postmenopausal women and the overall aging population. One of the major issues in the management of postmenopausal osteoporosis is to find a safe and effective treatment in the long term (>3 years) to achieve and maintain a reduction in the risk of fracture. Strontium ranelate (PROTELOS(®)) is a relatively novel drug, currently approved in Europe for the treatment of postmenopausal osteoporosis. Strontium ranelate is the first agent of a new therapeutic class in osteoporosis, capable of both promoting bone formation and, to a lesser extent, inhibiting bone resorption. This uncoupling in bone turnover results in a net gain in bone mineral density (BMD), bone quality improvement and reduction in risk of vertebral and nonvertebral fractures, as initially demonstrated in the preplanned long-term registrative trials SOTI (Spinal Osteoporosis Therapeutic Intervention) and TROPOS (Treatment of Peripheral Osteoporosis) at 5 years. Recently, open-label extensions of the SOTI and TROPOS trials up to 8 and, recently, 10 years have confirmed the sustained efficacy of strontium ranelate in increasing BMD, the long-term safety profile and the high compliance to treatment, independently from baseline BMD or other risk factors for osteoporotic fractures. Recent economic impact analyses have proved that long-term treatment with strontium ranelate is highly cost effective, especially in women older than 70 years of age. Histomorphometric analyses in animals and humans participating in the phase III trials have proved that the quality of mineralization is preserved in the long term and bone microarchitecture is ameliorated, with increased bone strength. Thus, strontium ranelate has been confirmed to be an effective compound for the long-term, chronic treatment of postmenopausal osteoporosis.

Drug delivery using composite scaffolds in the context of bone tissue engineering.

INTRODUCTION: Due to the disadvantages of the current bone autograft and allograft in many clinical condition in which bone regeneration is required in large quantity, engineered biomaterials combined with growth factors, such as bone morphogenetic protein-2 (BMP-2), have been demonstrated to be an effective approach in bone tissue engineering, since they can act both as a scaffold and as a drug delivery system to promote bone repair and regeneration. AREA COVERED: Recent advantages in the field of engineered scaffolds have been obtained from the investigation of composite scaffolds designed by the combination of bioceramics, especially hydroxyapatite (HA), and biodegradable polymers, such as poly (D,L-lactide-co-glycolide) (PLGA) and chitosan, in order to realize osteoconductive structures that can mimic the natural properties of bone tissue. Herein it is demonstrated that the incorporation of BMP-2 into different composite scaffolds, by encapsulation, absorption or entrapment, could be advantageous in terms of osteoinduction for new bone tissue engineered scaffolds as drug delivery systems and some of them should be further analyzed to optimized the drug release for future therapeutic applications. EXPERT OPINION: New design concepts and fabrication techniques represent novel challenges for further investigations about the development of scaffolds as a drug delivery system for bone tissue regeneration.

Incidence of febrile urinary tract infections in children after successful endoscopic treatment of vesicoureteral reflux: a long-term follow-up.

OBJECTIVE: To evaluate the incidence of febrile urinary tract infection (UTI) after successful endoscopic correction of intermediate and high-grade vesicoureteral reflux (VUR). STUDY DESIGN: Medical records of 1271 consecutive children (male, 411; female, 903) who underwent successful endoscopic correction of VUR were reviewed. Factors potentially influencing postoperative UTIs, such as history of presentation, age, sex, grade of VUR, renal scarring, and agent used for the endoscopic injection, were analyzed. RESULTS: Febrile UTI developed in 73 children (5.7%) after successful endoscopic correction of VUR. Thirty-nine children had a single episode of UTI, and 34 children had two or more episodes at 1 month to 5.9 years (median, 1 year) after correction of VUR. With multivariate analysis, female sex (P < .001), history of preoperative bladder/bowel dysfunction (BBD; P = .005), and BBD after endoscopic correction (P = .001) were revealed to be the most important independent risk factors for a febrile UTI after successful correction of VUR. CONCLUSIONS: The incidence of febrile UTIs after successful correction of intermediate and high grade VUR is low. Female sex and BBD were the most important risk factors in the development of febrile UTI. Our data supports the importance of assessing bladder and bowel habits in older children with febrile UTIs after endoscopic correction of VUR.

Urinary tract anomalies associated with high grade primary vesicoureteral reflux.

BACKGROUND: Few studies have evaluated the significance of associated urological anomalies in vesicoureteral reflux (VUR). The aim of our study was to determine the incidence of associated urological anomalies in patients with high grade VUR and to assess their impact on renal parenchymal scarring. METHODS: We retrospectively reviewed the hospital records of 1,765 consecutive cases diagnosed with high grade VUR (Grade III-V) at our hospital between 1998 and 2010. The diagnosis of VUR was made by a voiding cystourethrogram (VCUG). Renal scarring was evaluated by dimercapto-succinic acid (DMSA) scintigraphy and classified into three groups: mild (focal defects in uptake between 40 and 45%), moderate (uptake of renal radionuclide between 20 and 40%), and severe (shrunken kidney with relative uptake <20%). All associated urological anomalies were diagnosed by ultrasound or VCUG or DMSA scan. RESULTS: Associated urological anomalies were present in 229 (13%) children. There were 87 boys and 142 girls. Duplex kidney was the main associated anomaly occurring in 148 (64.6%) of the 229 patients. Other anomalies were: bladder diverticulum in 29, solitary kidney in 12, ureterocele in 13, hypospadiasis in 11, pelviureteric junction obstruction in 9, malrotated kidney in 3, horseshoe kidney in 2, crossed fused ectopia in 1 and renal cyst in 1. DMSA scan revealed renal scarring in 105 (47.7%) of the 220 children who had a DMSA scan. 75 (50.7%) children with duplex kidneys showed renal scarring. CONCLUSION: Associated urological anomalies occur commonly in patients with high grade VUR. Our data shows that nearly half of the patients with VUR and associated urological anomalies have renal scarring. Early recognition and treatment of VUR patients with associated urological anomalies may decrease the risk of renal parenchymal damage.

Endoscopic treatment of primary grade V vesicoureteral reflux using hyaluronic acid copolymer (DX/HA).

PURPOSE: Since DX/HA was approved by the Food and Drug Administration in 2001 as an acceptable tissue-augmenting substance for subureteral injection, endoscopic treatment has become increasingly popular for treating vesicoureteral reflux (VUR). However, most paediatric urologists still continue to recommend ureteral reimplantation as the treatment of choice in the management of grade V VUR. The purpose of this study was to prospectively evaluate the effectiveness of endoscopic subureteral injection of DX/HA in the treatment of grade V reflux. MATERIALS AND METHODS: During 2001-2009, 56 children (35 males, 21 females) with primary grade V VUR underwent endoscopic treatment using DX/HA. Their ages ranged from 4 months to 11 years. Forty-nine patients had unilateral grade V VUR, and seven had bilateral grade V (63 refluxing ureters including 17 duplex systems). Renal scarring on dimercaptosuccinic acid was observed in 39 kidneys (mild scarring 13, moderate scarring 14 and severe scarring 12). In all patients, endoscopic injection was made after inserting the needle within the wide ureteral orifice. Renal ultrasound and voiding cystourethrogram was performed 3 months after the endoscopic treatment. If VUR had not resolved, the patient was considered for further endoscopic treatment. After the VUR was resolved, children were followed with renal ultrasound at 1 year and every 2 years thereafter. RESULTS: The VUR completely resolved after first injection of DX/HA in 33 (52.4%) ureters and downgraded to grade I VUR in 7 (11.1%) ureters. 19 (30.2%) ureters required a second injection, and 4 (6.3%) ureters required a third injection to resolve VUR. No children in this series needed reimplantation of ureters or presented with ureteral obstruction during follow-up. CONCLUSION: Endoscopic treatment with DX/HA is effective in eradicating grade V primary reflux. This simple and minimally invasive treatment should be offered to all parents of children with grade V VUR as an alternative to ureteral reimplantation.

The importance of patient selection in the treatment of distal hypospadias using modified Koff procedure.

OBJECTIVE: We present our experience in the treatment of distal hypospadias using a modified Koff procedure, emphasizing the importance of patient selection for a good outcome. MATERIALS AND METHODS: In 2003-2008, 90 patients, mean age 52.1 months, underwent surgical repair of distal hypospadias using urethral advancement according to Koff, modified with a Ψ incision on the tip of the glans. Meatal defect was glanular in six (8%), subglanular in 24 (26%) and coronal in 60 (66%) cases. Mild chordee was present in 19 patients (21%). Follow-up was 8-66 months. All patients were evaluated in terms of cosmetic results, and early and late postoperative complications. RESULTS: All patients showed excellent cosmetic results with urethral meatus on the tip. There was only one postoperative fistula due to extensive use of electrocautery during urethral mobilization that was surgically corrected 8 months after appearance. One patient had a postoperative meatal stenosis treated conservatively. No cases of residual chordee were detected. CONCLUSIONS: Successful use of the modified Koff procedure depends on careful selection of patients. Good candidates are those with distal or mid-shaft hypospadias, presenting with: (1) absence or low degree of ventral chordee; (2) distal plate of urethra well developed; (3) distance between meatus and tip of glans at most 10-12 mm; and (4) glanular morphology preserved.