Current expectations for survival in pediatric burns.

BACKGROUND: Conventional wisdom and published reports suggest that children, particularly those younger than 48 months, have higher mortality rates after burns than young adults. However, coincident with refinements in resuscitation, operative techniques, and critical care, survival rates for children with burns seem to have improved. To document this change and to define current expectations, a review of deaths during two 7-year intervals separated by a decade was done. DESIGN: We examined the clinical course of children who died after admission for care of acute thermal burns during two 7-year intervals: calendar years 1974 to 1980 inclusive (group 1) and 1991 to 1997 inclusive (group 2). Dying children were stratified by total body surface area (TBSA) burned: small (0%-39%), midsize (40%-59%), and large (60%-100%) TBSA burns. Children who arrived with anoxic brain injury or in a moribund state with refractory shock were excluded from analysis (4 children in group 1 and 5 in group 2); 2 of these children in group 2 died and became solid organ donors. SETTING: Regional pediatric burn center. PATIENTS: Six hundred seventy-eight children in group 1 and 1150 children in group 2. MAIN OUTCOME MEASURE: Survival. RESULTS: In children with 0% to 39% TBSA burns, mortality was 0.6% in group 1 and 0% in group 2 (Fisher exact test, P = .04; chi2 test, P = .02). In children with 40% to 59% TBSA burns, mortality was 7.7% in group 1 and 0% in group 2 (Fisher exact test, P = .07; chi2 test, P = .047). In children with 60% to 100% TBSA bums, mortality was 33.3% ingroup 1 and 14.3% in group 2 (Fisher exact test, P = .04; chi2 test, P = .02). Although 59% of the children in group 2 were younger than 48 months, including 55% of those with 40% to 59% TBSA burns and 41% of those with 60% to 100% TBSA burns, there were no deaths in this age group. CONCLUSION: Survival rates after burns have improved significantly for children. At present, most children, even young children and children with large burns, should survive.

Management strategy in purpura fulminans with multiple organ failure in children.

Purpura fulminans (PF), which describes the necrosis of soft tissue secondary to diffuse microvascular thrombosis induced by transient protein C deficiency associated with meningococcal sepsis, is unusual despite the approximately 15000 cases of bacterial meningitis which occur annually in the USA. PF has a reported mortality of 50 per cent secondary to multiple organ failure which commonly accompanies the syndrome and is associated with major long-term morbidity in those who survive. Children who develop multiple organ failure in association with purpura fulminans are difficult management problems and benefit from the unique surgical and critical care resources available in burn centres. We describe our recent experience with three such patients and suggest a management strategy, the key components of which include early excision and closure of deep wounds, aggressive critical care management and long-term follow-up should delayed epiphyseal growth occur.

Progress in a Moscow children's burn unit: a joint Russian-American collaboration.

A joint Russian-American paediatric burn programme involving Childrens Hospital No. 9 in Moscow and Project HOPE in Millwood, Virginia emerged from the efforts of burn professionals from both countries in caring for a group of children seriously burned as a result of the train-pipeline catastrophe that occurred in June 1989 in the Ural Mountains. This paper describes the burn unit and its activities during the years 1985-93 and includes: (1) a general description of the physical and administrative structure of the unit; (2) the demography of burn admissions; (3) clinical activities; (4) a comparison of the clinical results of the years before the institution of the combined programme (1985-89) with those achieved during the first 4 years of the combined collaboration (1990-93). Among the important changes that have occurred since the onset of the combined programme are: (1) overall reduction in the crude burn mortality rate; (2) decrease in burn deaths in all burn size groups; (3) dramatic reduction in the length of stay of children with the deepest burns; (4) marked improvement in the take of skin grafts applied to burn wounds and an almost total elimination of complete skin graft failures.

The burn unit as a resource for the management of acute nonburn conditions in children.

Burn units bring together resources to manage large complex wounds, organ failures, and the hypermetabolic response to injury. These resources can also facilitate management of other problems such as purpura fulminans, toxic epidermal necrolysis, staphylococcal scalded skin syndrome, and major mechanical soft-tissue injuries. During a recent 10-year interval 2.4% of all acute admissions to a regional pediatric burn facility were in this category and form the basis for this review.

Comparison of the effects of interleukin-1 beta on proteoglycan synthesis by human skin and post-burn normal scar explant cultures.

The effect of interleukin (IL)-1 beta on proteoglycan (PG) synthesis and secretion, into culture medium by normal human skin and post-burn human normal scar using tissue explants in culture, was investigated. Following exposure of different tissues to labeling with Na2[35SO4] in the presence and absence of IL-1 beta, the extractable [35SO4]PG (isolated from 0.15 M NaCl and 4 M Gdm. Cl extracts), non-extractable [35SO4]PG (isolated after papain treatment of residual tissue), and [35SO4]PG secreted into culture medium were analyzed for contents and distribution. The contents of [35SO4]PG as measured by [35SO4] incorporation indicate differences in [35SO4]PG production of extractable and non-extractable PGs and also in the PGs released into the culture medium. Examination of the sizes of [35SO4]PGs on Sepharose CL-6 beta columns with and without treatment of IL-1 beta shows that the size of non-extractable [35SO4]PG decreases after IL-1 beta treatment. Cellulose acetate plate electrophoresis of these [35SO4]PG fractions shows that the distribution of PGs alters after treatment with IL-1 beta. These results indicate that burn wound healing abnormalities (scarring) is related to a change in the level of PGs, and may be modified by IL-1 beta treatment.

Proteoglycan synthesis in human skin and burn scar explant cultures.

The synthesis of proteoglycans (PG) by normal human skin, and normal and hypertrophic scars were compared using tissue explants in culture. Newly synthesized PG were labelled with [35S]Na2SO4. Significant differences were found in the proportion of [35S]-radio-labelled incorporation of PG in the tissue and accumulation of [35S]PG in culture medium in the different tissues. The rate of PG biosynthesis in all three tissue types occurred in two phases. There was an initial phase of PG synthesis occurring at 0-3 h and a later phase that occurred at 3-18 h [35S]-labelled PG were isolated and characterized by Sepharose CL-6B chromatography and cellulose acetate electrophoresis. The results showed that the hypertrophic scar tissue and its culture medium contained higher proportions of dermatan sulphate (DS), chondroitin sulphate (CS) and DS' PG than the normal skin fractions. These results suggest that abnormal scarring is related to a change in the level of PG synthesis during the burn injury repair process.

Initial experiences with surgical treatment of deep burns at a USSR children's burn unit.

Thirty-eight consecutive children with deep burns who underwent early burn wound excision and grafting are reported from the 6th Surgical Department and the All-Union Pediatric Burn Center, Children's Hospital no.9, Moscow, USSR. Early excision represents a radical departure from previously employed expectant treatment. Infection rate fell from 25-48 per cent to 15 per cent. Two children died during a time period when, based on prior experience, seven to eight children would have been expected to succumb. With additional experience with this technique, results should improve even further.

Burned children from the Bashkir train-gas pipeline disaster. I. Acute management at Children's Hospital 9, Moscow.

Following the Bashkir train-gas pipeline disaster of 4 June 1989, US surgeons and nurses had an opportunity to join their Soviet counterparts at the Burn Unit at Children's Hospital 9 in Moscow in caring for the children. As a result of the joint effort, both the Soviet and US professionals came to understand the strengths and limits of each system of burn care. Joining strengths through mutual willingness to listen and cooperate left an elevated level of burn care at Children's Hospital 9.

Burned children from the Bashkir train-gas pipeline disaster. II. Follow-up experience at Children's Hospital 9, Moscow.

A group of US surgeons and nurses was invited by the Soviet surgeons and nurses of the Burn Unit of Childrens Hospital 9 to return to Moscow to participate in the evaluation and treatment of a group of 25 children burned in the Bashkir train-gas pipeline accident of 4 June 1989. The US group had participated in the acute care of the children 7 months before. Major sequelae observed were hepatitis, cardiomyopathy and severe emotional disorders. Reconstructive surgery for burn scars was jointly planned and carried out during a 2-week period of mutually instructive cooperation.

Cultured epithelial autografts for giant congenital nevi.

Eight pediatric patients with giant congenital nevi confluent over 21 to 51 percent body surface area were treated by excision and grafting. The nevus was excised to the muscle fascia, and the open wound was grafted with cultured epithelial autografts and split-thickness skin grafts. The patients have been followed from 17 to 56 months. Seventeen operations were performed in the eight patients, excising a mean of 6.9 percent body surface area at each procedure. The mean duration of anesthesia was 3.7 hours, and the mean operative blood loss was 12.3 percent estimated blood volume. The mean "take" for the cultured epithelial autografts was 68 percent, and for the split-thickness skin grafts, 84 percent. Epithelialization of open wound areas adjacent to the grafts was somewhat slower for the cultured epithelial autografts than for the split-thickness skin grafts, but it led to a healed wound in all patients except one. Ten of the 17 areas grafted with cultured epithelial autografts resulted in small open wounds that required regrafting. Wound contraction under the cultured epithelial autografts and under split-thickness skin grafts was similar and depended more on the anatomic site grafted than on the type of graft employed. in 16 of 17 operations, the cultured epithelium remained as a permanent, durable skin coverage. The use of cultured epithelial autografts allowed a larger area of excision than would have been possible with split-thickness skin grafts alone and, therefore, a more rapid removal of nevus. Cultured epithelial autograft are an important new technique in the care of patients with giant congenital nevi.

A multivariate analysis of determinants of survival for patients with squamous cell carcinoma of the head and neck.

The prognosis for patients with squamous cell carcinoma of the head and neck remains poor, despite refinements in conventional therapy and experimental protocols using alternative treatment modalities. Clinical characteristics reported to influence survival have included age and sex of the patient, the therapy used, location of the primary tumor, and stage at initial presentation. However, such variables are highly correlated, and previous reports have lacked sufficient statistical analysis to assess the independent influence of these competing variables on survival. To better define the principal determinants of survival, we used a Cox multivariate regression analysis of 542 patients with invasive squamous cell carcinoma of the head and neck treated exclusively at our institution from 1962 to 1976. All patients were followed for a minimum of 5 years after diagnosis, with 98% complete follow-up achieved. Stage at initial presentation was the single-most important factor influencing survival for all tumor locations (p less than 0.0001). Advanced age (p = 0.001) and location of the primary tumor in the tonsillar area (p = 0.01) were also independently associated with an inferior survival. The type of therapy used and sex of the patient did not significantly influence survival after controlling for stage. These data emphasize the need for early diagnosis and treatment of squamous cell carcinoma of the head and neck and underscore the limitations of current therapeutic approaches. Future investigations should incorporate multivariate statistical techniques whenever possible, and additional efforts must be directed at basic research into the biology and immunologic characteristics of these tumors in an attempt to identify innovative therapeutic modalities.

Significant reductions in mortality for children with burn injuries through the use of prompt eschar excision.

During the past 19 years, mortality due to burn injuries has markedly declined for children at the Boston Unit of the Shriners Burns Institute (SBI), dropping from an average of 9% of SBI admissions during 1968-1970 to an average of 1% during 1981-1986. Detailed statistical analysis using logistic regression was necessary for determining whether this decline in mortality was explained by changes in patient characteristics, such as age or burn size, which are known to strongly influence the outcome of burn injuries. This dramatic decline in mortality during the past 19 years was not the result of change in the age of the patients or their burn sizes; rather, it may be attributed to improvements in burn care. Results of this statistical analysis indicated that, for burn injury patients whose ages ranged from 11 days to 19 years, age had no demonstrable effect on survival from a burn injury. Children survived burn injuries at least as well if not better than the young adult (20-29 years of age). Also, infants (less than 1 year old) survived as well as other children (2-19 years old). Dramatic improvement in survival occurred in patients with burns covering more than 50% of the body surface area. Since 1979, mortality has been essentially eliminated for patients with burn sizes less than 70% of the total body surface area (of 296 patients with burns covering 15-69% of the total body surface area, only two patients died). During the period 1979-1986, 29 of 37 patients (78%) survived an 80% or greater total body surface area thermal injury.

Squamous cell carcinoma of the head and neck at the Massachusetts General Hospital: a comparison of biologic characteristics in men and women.

Little is known about the biologic behavior of squamous cell carcinoma of the head and neck in women. A few recent reports for selected sites have suggested that these tumors may be becoming more common in women. To evaluate potential differences between males and females with squamous cell carcinoma of the oral cavity, oropharynx, and hypopharynx and to assess whether the proportion of females with this disease is increasing, the authors have undertaken a retrospective review of 542 consecutive patients treated at our institution from 1962 through 1976. We report here the first detailed comparison of males and females with squamous cell carcinoma of the head and neck, with attention directed to stage at initial presentation, choice of therapy, response to therapy, age distribution, survival, and prevalence of second primary malignancies. It has been widely published that survival for women with squamous cell carcinoma of the head and neck is superior to that for men, and this has been attributed to a difference in the biologic characteristics of the disease between the two sexes. Although overall survival calculations in our series suggested a significantly better survival rate for women than for men, these rates were strongly influenced by the larger proportion of women (64%) who had stage I or II disease, compared with only 50% of men. When survival was compared stage by stage, there was no significant difference in survival between the two sexes. The proportion of females in the combined study population was 35%, increasing from 33% in the first 5 years of the study period to 40% in the last 5 years. Among patients born before 1920, 34% were female compared with 43% of patients born after 1920. Of the 13 patients less than 40 years of age at diagnosis, 62% were female. The rising proportion of women during the 15-year study period, particularly among young patients and those in more recent birth cohorts, strongly suggests that squamous cell carcinoma of the head and neck is increasing among women in this referral population. A review of the literature indicates that this trend began more than 40 years ago.

Management of toxic epidermal necrolysis in a pediatric burn center.

Toxic epidermal necrolysis (TEN) is an acute severe exfoliative skin and mucosal membrane disorder with a clinical picture similar to a total-body scald injury. Toxic epidermal necrolysis shares features with severe erythema multiforme seen in Stevens-Johnson syndrome, and is thought by some to be a maximal expression of this syndrome. Drug-related TEN is uncommon in children. Mortalities of 70% have been reported, and death is usually secondary to the bacterial and metabolic consequences of a large open wound. Over the past two years, four children with probable drug-induced TEN were treated successfully. Since the problems of infection, wound care, fluid balance, nutrition, and pain control are similar in TEN and major burn patients, treatment using the principles of burn care may improve survival.

Clinical behavior and results of current therapeutic modalities for squamous cell carcinoma of the buccal mucosa.

A retrospective analysis of 28 patients who received therapy for squamous cell carcinoma of the buccal mucosa at the Massachusetts General Hospital from January 1962 through December 1976 is presented. The patients ranged in age from 42 to 78 years; the majority of patients presented with disease at 50 years or more. The proportion of females in this series (43 per cent) represented a dramatic increase compared with previous reports from other large centers. The 29 per cent rate of metachronous or synchronous second primary malignant disease is increased significantly over that expected for the general population. Uncontrolled disease above the clavicle continues to be the major site of therapeutic failure. The development of co-operative multicenter randomized prospective protocols to evaluate the efficacy of various combinations of current therapy methods in order to improve patient survival from this devastating disease are encouraged.

Squamous cell carcinoma of the alveolar ridge and palate. A 15-year survey.

A retrospective review of 82 patients treated at the Massachusetts General Hospital from 1962 through 1976 for squamous cell carcinoma of the maxillary and mandibular alveolar ridge and soft and hard palates is presented. Stage at first presentation, clinical features of the disease, analysis of current therapeutic modalities, survival statistics, and prevalence of second primary malignancies are analyzed and compared with reports from other large centers.

Squamous cell carcinoma of the tongue: a comparison of the anterior two thirds of the tongue with its base.

A retrospective analysis of 176 patients with squamous cell carcinoma of the tongue has been reported. The tongue base and mobile tongue, believed to behave as two clinically distinct anatomic areas, have been compared and contrasted. Women comprised 25 percent of the patients with tumors of the base of the tongue and 45 percent of those with mobile tongue lesions, an increase over previous reports for both locations. The majority of patients with squamous cell carcinoma of the tongue base (77 percent) presented with advanced (stage III or IV) lesions at time of initial clinical and diagnostic staging, compared with only 33 percent of those with cancer of the mobile tongue. There was no significant difference in survival between the two locations when survival rates were compared stage by stage. The decreased overall survival frequently reported for patients with squamous cell carcinoma of the tongue base compared with the survival for patients with tumors of the mobile tongue may be due to the disproportionately high number of patients with cancer of the tongue base who present with advanced disease. Survival rates have not significantly improved when compared with other retrospective series reported in the past 40 years. We strongly urge the development of intercenter, multidisciplinary, cooperative, prospective, protocols to assess combinations of currently accepted therapeutic modalities in the hope of improving treatment of this devastating disease.

Squamous cell carcinoma of the mobile tongue. Clinical behavior and results of current therapeutic modalities.

A retrospective review of 122 patients who received therapy at the Massachusetts General Hospital for squamous cell carcinoma of the mobile tongue from January 1962 through December 1976 was analyzed for clinical patterns of behavior and results of current therapeutic modalities. The results were compared with a previously reported series from our surgical service. Our series showed a dramatic increase in the proportion of women with carcinoma of the tongue from the 10 to 30 percent distribution reported 20 to 30 years ago to the 45 percent female to male ratio we observed. Only 38 percent of patients who had a regional recurrence of disease after initial therapy responded to secondary therapeutic measures. We therefore encourage that initial treatment offer the patient the optimal chance for cure. No significant increase in survival with the current therapeutic modalities of surgery, radiation, or combined therapy was noted; we observed 55 percent 2 year and a 34 percent 5 year overall survival rates. It is our belief that randomized, prospective, therapeutic protocols are essential for further progression of treatment success for patients with this devastating disease.

Intra-oral cancer at the Massachusetts General Hospital. Squamous cell carcinoma of the floor of the mouth.

A retrospective review of 163 consecutive patients with biopsy-proven, invasive squamous cell carcinoma of the floor of the mouth who underwent inpatient treatment at the Massachusetts General Hospital during the 15-year period from January 1962 through December 1976 is presented. The stage at first presentation, clinical features of the disease, incidence of second primary tumors, analysis of therapeutic modalities, and survival statistics are compared with reports from other large centers. Floor of mouth tumors comprised 28%, (163/592) of oral squamous cell carcinomas seen at the Massachusetts General Hospital during that time period. Seventy-one per cent of floor of mouth tumors were in men and 29% in women; women tended to present earlier in the course of their disease. Thirty-seven patients (23%) developed a secondary primary malignancy, and four of these 37 patients developed two second primaries. Distant metastatic disease appeared in 6% of patients with Stage I, II, or III disease and 26% of patients with Stage IV disease. Radiation therapy alone and surgery alone resulted in equivalent long-term survival rates for early stage disease. In more advanced stages (III and IV), a combined approach utilizing surgery and radiation therapy obtained superior results for short-term survival than either modality alone. The importance of early diagnosis and treatment and suggestions for development of cooperative protocols in an attempt to improve salvage of patients with this disease is discussed.