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This article discusses common bacterial skin infections, including impetigo, cellulitis and erysipelas folliculitis, staphylococcal scalded skin syndrome, blistering distal dactylitis, furuncles and carbuncles, and pseudomonal infections such as external otitis and malignant external otitis, ecthyma gangrenosum, pseudomonal folliculitis, toe web infection, and erysipeloid.
Skin regeneration is an important field of tissue engineering. Especially in larger burns and chronic wounds, present treatments are insufficient in preventing scar formation and promoting healing. Initial screening of potentially interesting products for skin substitution is usually done by in vitro tests. Before entering the clinic, however, in vivo studies in immunocompetent animals are necessary to prove efficacy and provide information on safety aspects. We have obtained extensive experience using the domestic pig as test animal for studies on skin replacement materials, including tissue engineered skin substitutes, and burn wound treatment. Two models are described: an excisional wound model for testing of dermal and epidermal substitutes and a burn wound model for contact and scald burns, which allows testing of modern wound dressings in comparison to the present gold standards in burn treatment. The results of these experiments show that in vivo testing was able to reveal (dis)advantages of the treatments which were not detected during in vitro studies.
OBJECTIVES: The purposes of this study were: (1) to ascertain the incidence and nature of severe physical child abuse in Wales; (2) to ascertain the incidence of all physical abuse in babies under 1 year of age; and (3) to determine whether child protection registers (CPR) accurately reflect the numbers of children who are physically abused. METHODS: This is a population-based incidence study based in Wales, UK, for 2 years from April 1996 through March 1998. Children studied were under the age of 14 with severe physical abuse consistent with the criminal law level of Grievous Bodily Harm. This included seven categories of injury (death; head injury including subdural hemorrhage; internal abdominal injury; physical injury in Munchausen Syndrome by Proxy including suffocation; fracture; burn or scald; adult bite). Cases were ascertained by a pediatrician surveillance reporting system (WPSU). A criterion for inclusion was multidisciplinary agreement that physical abuse had occurred (at case conference, strategy meeting, or Part 8 Review). The incidence of all babies under 1 year of age with physical abuse was also studied. Ascertainment of babies under the age of 1 year was undertaken from CPR as well as the WPSU. RESULTS: Severe abuse is six times more common in babies [54/100,000/year (95% CI +/- 17.2)] than in children from 1 year to 4 years of age [9.2/100,000 (95% CI +/- 3.6)]. It is 120 times more common than in 5- to 13-year-olds [0.47/100,000 (95% CI +/- 0.47)]. This is mainly because two types of serious abuse (brain injury including subdural hemorrhage and fractures) are more common in babies under the age of 1 year than older children. Using data from two sources (the WPSU and CPRs), the incidence of physical abuse in babies is 114/100,000 (CI 114 +/- 11.8) per year. This equates to 1 baby in 880 being abused in the first year of life. The largely rural Health Authority area in Wales had incidence figures for abuse in babies that were 50% of the three other predominantly urban Health Authority areas. Boys throughout the series were more at risk of being severely abused than girls (p < .025). Only 29% of the babies under 1 year of age on the CPR had actually been injured. Thirty percent of abused babies under the age of 1 year and 73% of severely abused children over the age of 1 year had caused previous concern to health professionals regarding abuse or neglect. CONCLUSIONS: Physical abuse is a significant problem in babies under the age of 1 year. Very young babies (under 6 months old) have the highest risk of suffering damage or death as a result of physical abuse. Severe abuse, in particular subdural hematoma and fracture, is much more common in babies than in older children. There is evidence of failure of secondary prevention of child abuse by health professionals, with a greater need to act on concerns regarding abuse and neglect. Interagency child protection work in partnership with parents should focus more on protecting babies under age 1 year from further abuse than on maintenance of the infant within an abusive home. The CPR is not intended as an accurate measure of children suffering abuse. It is a record of children requiring a child protection plan and must not be used as a measure of numbers of abused children.
The aims of the present study were: (i) to evaluate verotoxin-producing Escherichia coli (VTEC) faecal carriage of slaughtered pigs; (ii) to determine the effects of three different pig slaughtering processes on pig carcass contamination by VTEC; (iii) to characterise the VTEC strains isolated from pig and pig slaughterhouses (virulence genes and serotype); and (iv) to compare the strains isolated in the same slaughterhouse in order to identify the routes of contamination inside the slaughterhouse. Pork carcasses from three French slaughterhouses were sampled at three steps of the slaughter process and different sites in each slaughterhouse were sampled at three different times in the work day. Faecal material from each sampled carcass, potable water and scalding water were also collected. Detection of stx genes was performed by polymerase chain reaction (PCR) on a total of 1227 samples. In addition, a second PCR specific for E. coli O157:H7 detection was carried out on the stx-positive samples. VTEC strains were recovered from positive samples by colony hybridisation or immunoconcentration, then serotyped, genetically characterised (eae, ehx, stx1, stx2, stx2c, uidA genes associated with virulence) and pulsotyped. No E. coli O157:H7 was isolated from the three uidA-positive samples. VTEC faecal carriage was 31%. Global carcass contamination decreased with slaughter process (from 46% to 15%), whereas environmental contamination increased (from 7% to 29%). No VTEC isolates harboured eae, ehx, and uidA genes. VTEC contamination routes were not clearly identified.
The main elements of a descriptive epidemiological model for Salmonella spp. in Dutch pig slaughterlines, and the subsequent quantification of risk factors regarding the contamination of carcasses, are described. There is a strong correlation between the number of live animals that carry Salmonella spp. in their faeces and the number of contaminated carcasses at the end of the slaughterline. Live animals that carry Salmonella spp. are 3-4 times more likely to end up as a positive carcass than Salmonella-free animals. Currently, about 70% of all carcass contamination results from the animals themselves being carriers, and 30% because other animals were carriers (i.e. cross contamination). Furthermore, it is estimated that in general between 5-30% of the carcasses produced may contain Salmonella spp. With respect to carcass contamination with Enterobacteriaceae and Salmonella spp., inadequately cleaned polishing machines (odds ratio, OR, 6) and 'inapt procedures during evisceration' (OR 11), i.e. faulty evisceration and hygiene practices, are the most important risk factors. An estimated 5-15% of all carcass contamination with Salmonella spp. occurs during polishing after singeing. The remainder is the result of current evisceration practices (55-90%) and, to a lesser extent, further processing (5-35%), i.e dressing, splitting and meat inspection. Less likely Salmonella spp. already present on the skin of the live animals survive scalding and singeing. However, because pigs are the only important source for the Salmonella contamination of the line and the carcasses produced, it can also be concluded that if Salmonella-free pigs were produced, consumers could be provided with virtually Salmonella-free pork. As long as Salmonella-positive animals enter abattoirs, there will always be transmission of Salmonella spp. to consumers, even if the process is carried out according to stringent codes of good manufacturing practices (GMP). EU regulations should, therefore, allow for the decontamination of caracasses with a safe substance, e.g. lactic acid, on the condition that the slaughterhouse strictly adhers to GMP principles.
Toxic epidermal necrolysis is an acute exfoliation of skin simulating a scald injury. Drug-induced toxic epidermal necrolysis has a mortality of greater than 50%. We report an 8-year-old girl with drug-induced toxic epidermal necrolysis who was treated with cryopreserved cadaver skin, with good outcome. The allograft was clinically and histologically viable. Graft keratinocytes demonstrated epiboly as reepithelialization by the host occurred along the host/graft interface. Host epidermis regenerated rapidly, presumably from adnexae, and displaced the viable allograft along the plane of the host/graft interface. The new epidermis appeared normal in all respects.
A 17-month-old boy presented with 10% to 12% first- and second-degree burns secondary to scald injury. He rapidly developed hyponatremia secondary to inappropriate antidiuretic hormone secretion, manifested by the occurrence of seizures. After appropriate therapy was instituted, the child had an uneventful recovery. To the best of the authors' knowledge, this problem has not been reported previously in a child with a relatively mild burn.
Although infrequently reported, aspiration of hot liquid can occur in conjunction with upper-body scald burns, leading to acute compromise of the small pediatric airway with clinical features similar to those of acute infectious epiglottitis. This can be a very difficult problem if subtle signs of impending airway compromise are not appreciated. Reported here are four such cases managed over a 3-year period at a regional pediatric burn center, emphasizing points of history and physical examination that facilitate early recognition of this life-threatening problem. Aspiration of hot liquid should be suspected in children with burns in or around the mouth, particularly if there are any subtle signs of upper airway edema. If this complication is suspected, immediate endotracheal intubation should be performed in those with acute respiratory embarrassment, and prompt investigation by direct laryngoscopy in the operating room is appropriate in those who have not yet developed overt respiratory distress.
AIMS: To investigate the effects of diet composition and starvation on hepatic steatosis and mortality after severe burn injury in rats. METHODS: Experiment 1: rats received either normal chow (55 cent of energy carbohydrates, 14 cent fat, 31 cent protein), a high-fat (40 cent carbohydrates, 40 cent fat, 20 cent protein), or a high-carbohydrate diet (81 cent carbohydrates, 4 cent fat, 15 cent protein) ad libitum for 6 days. Another three groups received these diets ad libitum for 6 days after 48|h starvation. Experiment 2: mortality after 60 cent total body surface area scald burn was determined in a control group of rats and a group with nutritionally induced hepatic steatosis. Hepatic steatosis was induced by feeding the rats a high-fat diet (40 cent carbohydrates, 4 cent fat, 15 cent protein) ad libitum for 6 days. RESULTS: Without starvation, liver triglyceride content (mg/g liver) increased in response to the high-fat diet (25.6'6.9) compared to normal chow (9.4'3.8; P < 0. 05); the high-carbohydrate diet had no influence on liver triglyceride content (12.4'3.7). Refeeding after starvation resulted in elevated (P < 0.05) liver triglyceride content in the high-fat (18.8'8.3) and the high-carbohydrate group (28.7'14.4 vs control 6. 7'3.7). Liver triglyceride content correlated (R2=0.72; P < 0.05) to non-protein energy intake but not to total energy intake. Burn caused 33 cent mortality in the hepatic steatosis group and no deaths in the control group (P < 0.05). CONCLUSIONS: Diet composition and preceding starvation independently manipulate hepatic fat content in rats. Hepatic steatosis increases mortality after burn injury. Thus, nutritional interventions to reduce hepatic fat accumulation may be beneficial.
The present study investigated antioxidant status in lavage fluid, lung, liver, heart and kidney in a rat model to simulate an inhalation injury as might be encountered by firefighters and burn victims. Anesthetized rats received either a 20% total body surface area (TBSA) full thickness scald or a sham burn. After a 5 h recovery period, half of the animals in the burn or sham burn groups were exposed to cooled western bark (fir and pine) smoke for 16.25 min. The remaining rats in each group breathed room air. At 1, 12, 24, 48 and 96 h after exposure to the smoke, five rats from each of the four groups were euthanatized and lungs were lavaged by infusing three 5 ml aliquots of normal saline for evaluation of airway cellular content and lung wet to dry weight ratios to estimate lung water content. A second series of five rats/group per time point were euthanatized at the above times and lung, liver, kidney and heart were removed for evaluation of tissue antioxidant enzyme activities and for thiobarbituric acid reactive substances (TBARS) concentrations, as well as for lung histology. Smoke exposure resulted in average plasma carboxyhemoglobin (COHb) of 19+/-2% in the two smoke exposed groups and produced areas of erosion of the tracheal surface, resulting in loss of epithelium and exposed basement membrane. Lung water content was not significantly different among the four groups during the 96-h experimental period. Lung TBARS levels were 2-3-fold higher at 12 h in smoke exposed rats compared with controls. These levels peaked at 24 h and remained significantly elevated at 48 h compared to controls. TBARS were also elevated in liver, but not in heart or kidney in response to burn or combined injury. Minor effects on lung antioxidant enzyme activities were observed after smoke inhalation. These data suggest that smoke inhalation, independent of burn injury, induces an oxidant stress that persists for at least the first 48 h after smoke exposure.
BACKGROUND: Recent evidence suggests that timely fluid resuscitation can significantly reduce multiorgan failure and mortality in thermally injured children. In this study, children who received fluid resuscitation within 2 h of a thermal injury were compared with children in which fluid resuscitation was delayed by 2-12 h. We hypothesized that fluid resuscitation given within 2 h of a thermal injury attenuates renal failure, cardiac arrest, cardiac arrest deaths, incidence of sepsis, and overall mortality. METHODS: A retrospective chart review was made on 133 children admitted to our institute from 1982 to 1999 with scald or flame burns covering more than 50% of their body surface area. Comparisons between early (< 2 h of injury) or delayed (> or = 2 h of injury) fluid resuscitation were made in children experiencing renal failure, sepsis, non-survivors with cardiac arrest requiring pulmonary and advanced life support, and overall mortality. Comparisons were made using the chi2-test with Yates' continuity correction and joint binomial confidence intervals using the Bonferroni correction. RESULTS: The incidence of sepsis, renal failure, non-survivors with cardiac arrest, and overall mortality was significantly higher in burned children receiving fluid resuscitation that was delayed by 2 h or more compared with those receiving fluid resuscitation within 2 h of thermal injury (P < 0.001). CONCLUSIONS: Data suggest that fluid resuscitation, given within 2 h of a thermal injury, may be one of the most important steps in the prevention of multi-organ failure and mortality.
Acute burn injury is usually associated with pain in the injured and nearby areas. However, we have recently reported that a thoracic scald induces hindpaw hyperalgesia during the healing stage in rats. The present study investigated the cause of the remotely occurring hyperalgesia. Behavioral testing using the von Frey test revealed that rats developed hyperalgesia in the neck and flank as well as the hindpaw 2-3 weeks after injury. The concentration of nerve growth factor (NGF) in the skin of the chest increased markedly during the healing stage. Moreover, rats injected daily with anti-NGF serum after burn injury did not develop hyperalgesia, suggesting that increased NGF in the tissue of the healing skin is a key factor causing systemic hyperalgesia during the recovery stage.
The aim of this work was to evaluate the epidemiology of occupational burns referred to the Welsh Regional Burns Unit from 1st January 1995 to 31st December 1996. Three hundred and twenty-four patients were identified as having sustained occupational burns and the case notes of 319 were available for review. Data on age, sex, occupation, aetiology, percentage and site of burn, treatment, complications and length of hospital stay were recorded. Twenty percent of all burns referred to our unit occurred in the workplace, the majority of whom were male (male:female 11:1), with a mean age of 34 years. Patients presented late to our unit in 35% of cases, with an average delay of 5 days. Chemical burns predominated (23%), followed by flame (14%) and scald (14%). Small burns (< or =1% TBSA) were seen in 70% of all patients. Five patients had burns involving >15% TBSA. One hundred and seventy-five patients were admitted, of whom 79 required surgery. The length of stay ranged from 1-110 days (mean 8.5), with an average follow-up for all patients of 3.5 months. One patient died as a result of his burn injury. In conclusion, occupational burn injuries continue to account for a significant proportion of all burn injuries, affecting mainly young males in physical occupations. Despite Health and Safety guidance, chemical burns are the predominant cause and more needs to be done to educate those working with chemicals to prevent injury.
The authors report on a healthy 21-month-old toddler with 13% TBSA deep scald burns who was successfully grafted (take 100%). In the immediate postoperative phase, the patient developed classical aphthous stomatitis and subsequent herpes viremia leading to severe viral "graftitis". Although immediately administered intravenous acyclovir therapy appeared to be effective, one third of grafts were lost and had to be replaced. The lesson from this case is 2-fold: Herpes infection may threaten even perfectly engrafted fresh skin transplants, and, freshly grafted or soon to be grafted burn patients should be given intravenous antiviral therapy as soon as a herpes infection is diagnosed.
An increase in the gradient between core and peripheral skin temperature is a common finding during the early post burn period which is often interpreted as an indication of inadequate circulating blood volume. In this case study we monitored the pattern of rectal and skin surface (toe) temperature and skin blood flow (by laser Doppler imaging) during the first 16 h after a 34% bath scald in a child (female) of 36 months. In the absence of invasive monitoring of cardiac output, clinical assessment of the adequacy of fluid resuscitation was made from changes in hourly urine volumes and regular (4-h) monitoring of haematocrit. Peripheral vasoconstriction, leading to an increase in the temperature gradient between the inside and outside of the body, was not related to either a fall in urine volume or to haemoconcentration. We suggest that during the first 16 h after burn injury, widening of the core-to-peripheral temperature gradient cannot be used reliably as a clinical indicator of inadequate circulating blood volume.
A retrospective study was carried out based on 110 paediatric burns (0-14 years) seen at the Burn unit, Choithram Hospital & Research Centre, Indore over a period of 7 years (1993-1999). Epidemiological data included age, sex, seasonal variation, place of burn and the cause and mode of burn. Hospitalised paediatric burns constituted 13.5% of total burn accidents. These children were categorised into three groups, the infants and toddlers (0-2 years), early childhood (>2-6 years) and late childhood (>6-14 years). In the first two groups scalding was the predominant cause of injury while in late childhood there were many more flame and electric burns. Males were mainly affected. Most of the burns (53.6%) occurred in the winter season between October and February. Ninety-five percent of accidents occurred at home. The overall mortality rate was 21.8%. An intense campaign to make people aware of the risk factors and their avoidance is required to reduce the number of burn accidents in children.
Cutaneous burn trauma causes functional inhibition of the heart, but the mechanism is unclear. Using a high dissociation constant (K(D)) calcium indicator TF-BAPTA and 19F MR spectroscopy, the relationship between the changes of cytosolic free calcium and cardiac function after burn trauma was examined. Sprague-Dawley rats received scald (43% TBSA) or sham burns. Twenty-four hours later, the hearts were excised and perfused by the Langendorff method with a modified phosphate-free Krebs-Henseleit bicarbonate buffer. Left ventricular developed pressure (LVDP) was recorded through a catheter attached to an intraventricular balloon. At the same time, 31P and 19F nuclear magnetic resonance (NMR) spectroscopy was perforined before and after TF-BAPTA loading. LVDP of the heart from burned rats was 40% less than in sham burn rats (65+/-6 vs 110+/-12 mmHg, P<0.01). Cytosolic free calcium increased about four-fold in those hearts from the burn group compared to the sham burn group (0.807+/-0.192 vs 3.891+/-0.929 microM). Loading TF-BAPTA in those hearts only caused about a 15-20% decrease in LVDP. PCr/Pi ratio also decreased significantly with this loading, but ATP signals were not affected. In conclusion, the inhibition of cardiac contractility caused by burn trauma correlated with the overload of cytosolic free calcium in the heart.
Clinical assessment of burn depth is frequently inaccurate. In order to effectively plan the treatment of burn wounds, an accurate diagnosis of burn depth is desirable. A new method for evaluating the depth of burns by imaging the blood flow through the burned tissue using fluorescence from intravenously injected indocyanine green (ICG) dye illuminated with a 785-nm, near-infrared diode laser array was evaluated. Nine patients and 15 individual burn sites were studied. Five sites were classified by the ICG study as superficial second degree, four were deep-dermal second degree, and six were third degree. Etiology of the injuries included flame, contact burns, and scalds. The date postburn of the study ranged from 1 to 11 days. In all cases, the relative fluorescence levels (e.g. superficial second-degree burns yielded relatively bright fluorescence, third-degree burns appeared much darker than surrounding normal skin) were found to correlate well with actual burn depth as determined by histologic examination of biopsies and intraoperative clinical assessment.