Utility of the Severity-of-Illness Score for Toxic Epidermal Necrolysis (SCORTEN) in Pediatric Stevens-Johnson Syndrome Patients.

The Severity-of-Illness Score for Toxic Epidermal Necrolysis (SCORTEN) is a system that predicts in-hospital mortality for Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis (SJS/TEN). The system is widely utilized in adults but not pediatrics. We aim to determine the accuracy of the SCORTEN in pediatrics. A retrospective review of pediatric patients admitted to a verified pediatric burn center with SJS/TEN from 2008 to 2022 was performed. Twenty-four patients were analyzed. Ten patients had 0-1 SCORTEN risk factor, thirteen had 2 risk factors, and one had three risk factors. There was no relationship between initial BUN, bicarbonate, glucose, or initial heart rate on the length of intensive care unit (ICU) stay or ventilator days. Hospital length of stay and feeding tube days were positively related (p<0.001) along with length of stay and maximum total body surface areas (TBSA) (p<0.05 Hospital length of stay, ICU length of stay, and ventilator days were not statistically significant between those having 0-1 and 2 risk factors. This study suggests that the SCORTEN system is not useful for pediatrics and a different scoring system is needed, as SCORTEN overestimates mortality and does not have a relationship to outcome measures.

Factors associated with an extended length of stay in the pediatric burn patient.

BACKGROUND: The Center for Medicaid and Medicare Services predicts the length of stay for pediatric burn patients based on several variables. However, many patients exceed their anticipated length. This study looks to identify aspects of patient presentation, wound characteristics, treatment, and discharge that are associated with a longer-than-predicted length of stay to identify strategies to safely reduce it. METHODS: We conducted a retrospective chart review of 535 pediatric burn patients admitted to our academic hospital from January 2018 to December 2020. 405 patients met inclusion criteria. Data were collected and analyzed. RESULTS: Average patient age was 3.36 years. 72.3% were treated for scald burns. Average length of stay was 13.5 days. 20.5% (n = 83) of patients exceeded their predicted length of stay. In comparing patients who exceeded their predicted length of stay to those who did not, the former had significant differences in burn causes, percent total body surface area burned (12.80% vs 4.24% [P = .000]), and body areas involved. Patients who exceeded length of stay had a higher incidence of endotracheal intubation (15.7% vs 1.3%), surgical intervention (85.5% vs 29.2%), need for tube-feeding (48.2% vs 4.3%), and intensive care unit admissions (22.9% vs 2.2% [P = .00 all]). They also averaged more operations, autografting (31.3% vs 1.6% [P = .00]), total operating room time (250 vs 31 minutes [P = .00]), and time to the first operation (2.32 vs 1.64 days [P = .00]). Tube-feeding averaged 9.52 vs 0.72 days (P = .00) extending patient stay after wound stability (43.9% vs 4.3% [P = .00]). These patients also required more discharge planning, with higher rates of Child Protective Services involvement (39.8% vs 10.9% [P = .00]), services consulted (1.06 vs 0.24 [P = .00]), and discharges to inpatient rehabilitation (8.6% vs 0.6% [P = .00]). 89.6% of all patients followed up in clinic. CONCLUSIONS: Twenty percent of pediatric burn patients had a longer length of stay than predicted by the Center for Medicaid and Medicare Services. Many factors were strongly associated with a longer-than-predicted length of stay. Identifying these early on might help reduce length of stay and meet the targets of the Center for Medicaid and Medicare Services.

Initial blood cultures in pediatric patients with central line infections and short bowel syndrome can direct a treatment plan that can reduce hospital length of stay.

BACKGROUND: Children with short bowel syndrome requiring parenteral nutrition are at high risk of recurrent central line-associated bloodstream infections requiring inpatient admission. Predicting responses to treatment at admission could help revise our current treatment algorithm and reduce the length of stay. METHODS: We conducted a retrospective study of all intestinal rehabilitation clinic patients admitted for central line-associated bloodstream infections at our academic hospital between January 2018 and June 2021. Demographic, blood culture, and treatment response data were analyzed. RESULTS: There were 180 separate admissions for central line-associated bloodstream infections, involving 24 patients who met the inclusion and exclusion criteria. The average length of stay was 9.4 days, and 77.1% of the admissions exceeded the predicted length of stay. All patients were treated according to the standard protocols. In the initial blood cultures, 64.4%, 10.6%, and 25% grew a single bacterium, a single fungus, and multiple organisms, respectively. After treatment initiation, 73.3% of single bacterial infections did not show additional positive cultures. However, 78.9% and 48.9% of fungal and multiple organism infections, respectively, had multiple positive cultures, even after initiating treatment. All positive repeat cultures were treated with an ethanol lock for 24 hours in addition to continued treatment. The treatment preserved 90.5% of the catheters. CONCLUSION: Patients experiencing short bowel syndrome admitted for central line-associated bloodstream infections with initial cultures growing fungi or multiple organisms frequently had multiple positive cultures, whereas those with a single bacterial organism did not. Discharging patients who grew a single bacterial organism and placing an initial ethanol lock on those with multiple or fungal organisms could reduce the average length of stay, even if some of these patients would require readmission for line removal.

Factors affecting length and complexity of hospital stay in pediatric dog bite patients.

Background: Dog bite injuries are a source of significant morbidity and expense in the USA, and rates of hospitalization have been rising. Children are at increased risk of dog bites compared with adults, yet there is a lack of published material on factors affecting hospital course. The objective of this study is to explore factors associated with increased length of stay (LOS), more complex course of care and post-discharge return rates in this population. Methods: A retrospective review was conducted of all patients presenting to our urban, academic children's hospital for dog bite injuries between January 2016 and May 2021. Only those patients admitted for inpatient care were included, as identified through our institution's trauma registry, and variables were examined prior to, during, and after hospital stay. Results: 739 pediatric patients in total were treated for dog bites during the study period, of which 349 were admitted. Analysis revealed two pre-admission predictors of increased LOS: bone fracture (mean LOS=5.3 days vs. 2.5 days, p=0.013) and prior medical comorbidity (4.3 days vs. 2.8 days, p=0.042). After admission, fractures were associated with a higher rate of postoperative complications (16% vs. 5.6%, p=0.014) and return (13% vs. 2.0%, p<0.001), primarily due to wound infection. Although the facial region represented the largest proportion of fractures, long bone fractures of the arm and leg were noted to have comparatively higher LOS and complication rates. Postoperative complications were not associated with any documented infection at admission. Conclusions: Our findings suggest that long bone fractures in pediatric dog bites can be an underappreciated source of latent wound infection associated with late-presenting negative outcomes. Increased awareness of these relationships could lead to earlier detection of infection in this vulnerable population. Level of evidence: Level III, Prognostic / Epidemiological.

Ocular Complications of Facial Burns in the Pediatric Population.

Pediatric ocular burns carry a risk of permanent vision impairment. This study identifies risk factors that place these patients at high risk of permanent visual complications. A retrospective review was conducted in our academic urban pediatric burn center. All 300 patients under 18 years of age admitted from January 2010 to December 2020 with periorbital or ocular thermal injuries were included. Variables analyzed included patient demographics, burn characteristics, ophthalmology consultation, ocular exam findings, follow up time period, and early and late ocular complications. Etiologies of burn injuries were as follows: 112 (37.5%) scald, 80 (26.8%) flame, 35 (11.7%) contact, 31 (10.4%) chemical, 28 (9.4%) grease, and 13 (4.3%) friction. Overall, 207 (70.9%) patients with ocular burns received an ophthalmology consult. Of these patients, 61.5% had periorbital cutaneous burns and 39.8% had corneal injuries, and only 61 (29.5%) presented for a follow-up visit. Ultimately, six had serious ocular sequelae, including ectropion, entropion, symblepharon, and corneal decompensation. While thermal burns involving the ocular surface and eyelid margins are relatively infrequent overall, they carry a small risk of serious to long-term sequelae. Recognizing those at greatest risk, and initiating appropriate early intervention is critical.

Weight-based vs body surface area-based fluid resuscitation predictions in pediatric burn patients.

Treatment for pediatric burns includes fluid resuscitation with formulas estimating fluid requirements based on weight and/or body surface area (BSA) with percent total body surface area burn (%TBSA burn). This study evaluates the risk of complications using weight-based resuscitation in children following burn injuries and compares fluid estimates with those that incorporate BSA. A retrospective review was conducted on 110 children admitted to an ABA-verified urban pediatric burn center over 12 years. Patients had ≥ 15% TBSA burn and were resuscitated with the weight-based Parkland formula. BSA-based Galveston and BSA-incorporated Cincinnati formula predictions were calculated. Complications were collected throughout hospital stay. Patients were classified into weight groups based on percentile. This study included 11 underweight, 60 normal weight, 18 overweight, and 21 obese children. Total fluid administered was higher as percentile increased; however, overweight children received more fluid than the obese (p = 0.023). The Galveston formula underpredicted fluid given over the first 24 h post-injury (p = 0.042); the Parkland and Cincinnati formula predictions did not significantly differ from fluids given. Further research is needed to determine the value of weight-based vs BSA-based or incorporated formulas in reducing risk of complications.

Outcomes of Early Surgical vs Nonsurgical Management of Pediatric Hand Friction Injuries Caused by Treadmills.

Pediatric hand friction injuries caused by running treadmills are ever more prevalent due to the increasing presence of home exercise equipment. These and other related injuries have received recent attention in the media, leading to mass product recalls in some cases. These friction injuries are similar to deep thermal burns, and these patients are usually cared for in the pediatric burn unit at our institution. We sought to describe our recent experience managing 22 patients with these injuries. Patients were queried from our urban pediatric burn center database. After Institutional Review Board approval, a retrospective chart review of all patients admitted for a treadmill-related hand injury over a 5-year period was performed. Data collected included patient demographics, initial treatment methods (surgical vs nonoperative), type of dressing used, hospital length of stay (LOS), and compliance with follow-up. We collected patient-centered outcomes included the time to healing and the need for subsequent surgical and/or nonsurgical interventions to treat the sequelae of these injuries. Our center treated 22 hand friction injuries caused by treadmills over the 5-year period. Five patients (23%) underwent early surgical intervention (<30 days from injury), with a median time from injury of 7 days (interquartile range 1.75-13.5). This cohort required additional interventions to treat postoperative sequelae with 2 (40%) requiring additional surgery and 3 (60%) managed nonsurgically. Of the 17 (77%) who were initially treated nonoperatively, 5 (29%) healed completely with dressing changes only and required no further treatment. Eleven (65%) had injury-related sequelae and were managed successfully with nonsurgical interventions. Only 1 patient (6%) required scar modification by Z-plasty. Average LOS was 14 hours and the median number of weekly follow-up visits was 4 until complete healing. Given the excellent outcomes observed in patients treated without acute surgical intervention in this case series, nonoperative management appears to be feasible, safe, and may reduce the need for operative intervention. These injuries, although small, are deep and require a prolonged period of dressing changes and aggressive therapy including posthealing time commitment to scar management in order to achieve best outcomes. Our study supports the need for increased community awareness of this type of injury.

A Retrospective Study of Touchless Spray for Pediatric Perineal Burns Treatment.

Silver-based topical treatments have seen widespread use for the management of burns due to silver's antimicrobial activity. Recent studies suggest that silver nanoparticles could negatively affect healing time due to their toxic effect on keratinocytes and fibroblasts at higher concentrations. Zinc oxide antimicrobial activity has been demonstrated in vitro, and results from animal studies are promising for burn management. At our ABA-verified pediatric burn center, the use of silver sulfadiazine cream ("Silvadene") has been slowly replaced by a zinc oxide/dimethicone spray-on solution ("Touchless Spray"). The dimethicone allows the spray to be occlusive without interfering with clothing, yet easily removed as opposed to Silvadene cream which requires wound scrubbing to remove and replace; potentially improving patient adherence with at-home treatments. This is the first study of zinc oxide's efficacy as a burn wound management agent in humans. We sought to compare the efficacy of silver sulfadiazine and that of zinc oxide/dimethicone to determine whether zinc oxide/dimethicone, in its easy-to-use form, is a viable alternative to silver sulfadiazine. We conducted a retrospective review of the electronic medical records of all patients treated for perineal, genital, perianal, suprapubic, or buttocks burn wounds at a large pediatric-verified burn center from January 1, 2014 to October 28, 2019. Only patients with superficial second-degree scald burns that arrived at our institution less than 24 hours after injury were included. Of a total 52 patients identified, 27 patients received silver sulfadiazine while 25 received zinc oxide/dimethicone. After initial evaluation and treatment by the burn team, all patients were followed up at our weekly burn clinic until complete healing was achieved. We retrospectively extracted demographic data, wound size, depth, and location, management strategies, time to complete healing, and incidence of infectious and noninfectious complications. The control group contained patients with total body surface area burns significantly greater than the zinc oxide/dimethicone group likely due to selective treatment when zinc oxide/dimethicone was first introduced at our facility. Time to healing was significantly lower in the zinc oxide/dimethicone intervention group (12.16 ± 8.644 days) than the silver sulfadiazine control group (16.89 ± 11.342 days). No infections were observed. Limitations include the relatively small sample sizes and differences in the size of burn wounds that confounded our results and likely negatively affected healing time in the control group. The zinc oxide/dimethicone group had a significantly lower healing time than the silver sulfadiazine group in the treatment of pediatric burns to the perineum, genitalia, suprapubis, and buttocks. Zinc oxide/dimethicone may prove to be a useful tool for treating burn wounds, and further study is needed to determine its efficacy and safety.

The Unconventional Role for Gastric Volume in the Response to Bariatric Surgery for Both Weight Loss and Glucose Lowering.

OBJECTIVE: To study the relationship between the amount of surgery-induced gastric volume reduction and long-term weight loss and glucose tolerance. BACKGROUND DATA: Vertical sleeve gastrectomy (VSG) has recently surpassed gastric bypass to become the most popular surgical intervention to induce sustained weight loss. Besides inducing significant weight loss, VSG also improves glucose tolerance. Although no clear correlation has been observed between the size of the residual stomach and sustained weight loss, this begs the question whether less aggressive gastric volume reduction may provide sufficient efficacy when weight loss is not the major goal of the surgical intervention. METHODS: A series of strategies to reduce gastric volume were developed and tested in Long Evans male rats, namely: VSG, Fundal (F)-Resection, Gastric Sleeve Plication (GSP), Fundal-Plication, and Fundal-Constrained. RESULTS: All surgical interventions resulted in a reduction of gastric volume relative to sham, but none of the interventions were as effective as the VSG. Gastric volume was linearly correlated to increased gastric emptying rate as well as increased GLP-1 response. Overall, cumulative food intake was the strongest correlate to weight loss and was logarithmically related to gastric volume. Regression modeling revealed a nonlinear inverse relation between body weight reduction and gastric volume, confirming that VSG is the only effective long-term weight loss strategy among the experimental operations tested. CONCLUSIONS: The data suggest a minimum threshold volume of the residual stomach that is necessary to induce sustained weight loss. Although all gastric volume interventions increased the GLP-1 response, none of the interventions, except VSG, significantly improved glucose tolerance. In conclusion, if weight loss is the primary goal of surgical intervention, significant volume reduction is required, and this most likely requires excising gastric tissue.

Assessment of mammographic breast density after sleeve gastrectomy.

BACKGROUND: Mammographic breast density (BD) is an independent risk factor for breast cancer. The effects of bariatric surgery on BD are unknown. OBJECTIVES: To investigate BD changes after sleeve gastrectomy (SG). SETTING: University hospital, United States. METHODS: Fifty women with mammograms before and after SG performed from 2009 to 2015 were identified after excluding patients with a history of breast cancer, hormone replacement, and/or breast surgery. Patient age, menopausal status, co-morbidities, hemoglobin A1C, and body mass index were collected. Craniocaudal mammographic views before and after SG were interpreted by a blinded radiologist and analyzed by software to obtain breast imaging reporting and data system density categories, breast area, BD, and absolute dense breast area (ADA). Analyses were performed using χ2, McNemar's test, t test, and linear regressions. RESULTS: Radiologist interpretation revealed a significant increase in breast imaging reporting and data system B+C category (68% versus 54%; P = .0095) and BD (9.8 ± 7.4% versus 8.3 ± 6.4%; P = .0006) after SG. Software analyses showed a postoperative decrease in breast area (75,398.9 ± 22,941.2 versus 90,655.9 ± 25,621.0 pixels; P < .0001) and ADA (7287.1 ± 3951.3 versus 8204.6 ± 4769.9 pixels; P = .0314) with no significant change in BD. Reduction in ADA was accentuated in postmenopausal patients. Declining breast area was directly correlated with body mass index reduction (R2 = .4495; P < 0.0001). Changes in breast rather than whole body adiposity better explained ADA reduction. Neither diabetes status nor changes in hemoglobin A1C correlated with changes in ADA. CONCLUSIONS: ADA decreases after SG, particularly in postmenopausal patients. Software-generated ADA may be more accurate than radiologist-estimated BD or breast imaging reporting and data system for capturing changes in dense breast tissue after SG.