Effect of isokinetic training on muscle strength,size and gait after healed pediatric burn: A randomized controlled study

Objective

The aim of this study was to investigate the effects of isokinetic training program on muscle strength, muscle size and gait parameters after healed pediatric burn.

Design

Randomized controlled trial.

Subjects

Thirty three pediatric burned patients with circumferential lower extremity burn with total body surface area (TBSA) ranging from 36 to 45%, and ages from 10 to 15 years participated in the study and were randomized into isokinetic group and a control group. Non-burned healthy pediatric subjects were assessed similarly to burned subjects and served as matched healthy controls.

Methods

Patients in the isokinetic group (n = 16) participated in the isokinetic training program for 12 weeks for quadriceps dominant limb, 3 times per week, at angular velocity 150°/s, concentric mode of contraction, time rest between each set for 3 min, 3 sets/day and control group (n = 17) participated in home based physical therapy exercise program without isokinetic.

Main measures

Assessment of quadriceps strength by isokinetic dynamometer, quadriceps size and gait parameters were performed at baseline and at the end of the training period for both groups.

Results

Patients in isokinetic group showed a significant improvement in quadriceps strength, quadriceps size and gait parameters as compared with those in the control group. Quadriceps strength and percentage of improvement was 79.25 ± 0.93 Nm (68.40%) for isokinetic group and 51.88 ± 1.31 Nm (9.84%) for the control group. Quadriceps size and percentage of improvement was 31.50 ± 0.89 cm (7.47%) for isokinetic group and 29.26 ± 1.02 cm (1.02%) for the control group. Stride length, step length, velocity and cadence and percentage of improvement for isokinetic group was 135.50 ± 2.82 (53.97%), 63.25 ± 2.97 (63.77%), 135.94 ± 1.65 (81.42%), 137.63 ± 1.36 (66.96%) and for the control group was 94.00 ± 2.69 (6.68%), 43.76 ± 1.34 (15.15%), 81.11 ± 1.91 (8.6%), 90.35 ± 1.32 (9.01%) respectively.

Conclusions

Participation in the isokinetic training program resulted in a greater improvement in quadriceps muscle strength, size and gait parameters in pediatric burn.     

Effect of amniotic membrane on graft take in extremity burns

Background

Several studies have shown that the application of amniotic membrane as a biological dressing in the management of burns is accompanied by rapid re-epithelialisation and healing as it diminishes the oozing of plasma, bacterial count and fluid, protein and heat loss. This study evaluates the effect of amniotic membrane on graft take in split-thickness skin graft of extremity burns.

Methods

From October 2008 to January 2010, in a prospective clinical trial, 54 patients (108 limbs) with second and third degree burns, covering 4–15% of total body surface area (TBSA), were included in this study. All patients needed split-thickness skin grafts for burn-wound coverage. Selected patients had symmetric burns on two (upper or lower) extremities. Then in every patient, the extremities were randomly divided into two groups: in one limb, the skin graft was traditionally fixed with skin staples (control group) and in the other limb the skin graft was covered with an amniotic membrane (amnion group). Therefore, in every patient the graft was covered with an amniotic membrane in one extremity and fixed with skin staples in the other extremity. Finally, the duration and success rate of complete graft take was compared between the two groups.

Results

The study group was composed of 108 limbs in 54 patients (27 males and 27 females) with a mean age of 23.54 ± 4.9 years and burn 9.03 ± 2.69% TBSA. The mechanism of burn was flame (63%), scald (18.5%) and flash (18.5%). The rate of complete graft take was 96.76% and 88.79% in the amnion group and in the control group, respectively. The mean duration of graft take was 6.98 ± 1.35 days in the amnion group and 13.9 ± 1.66 days in the control group. This difference was statistically significant (P < 0.001).

Conclusions

Our results show that although the amniotic membrane has no negative impact on graft take, it significantly reduces the duration of complete graft take, which is very important for both the patient and the health-care system.     

Long-term health-related quality of life after complex and/or complicated esophageal atresia in adults and children registered in a German patient support group

Background

Health-related quality of life (HRQoL) after esophageal atresia (EA) repair is postulated to be good. However, little is known about the long-term results after repair of complex and/or complicated EA regarding HRQoL. We investigated long-term HRQoL after delayed anastomosis, esophageal replacement, major revisions, or multiple dilatations in patients registered in a support group.

Methods

Patients registered in the German patient support group database (KEKS) were enrolled and allocated to subgroups according to surgical treatment and age. HRQoL was evaluated using validated questionnaires (GIQLI, WHO-5, KIDSCREEN27).

Results

Complete follow-up (mean 14.5 ± 9.8 years) was available for 90/92 patients. Patients were allocated to subgroups delayed anastomosis (n = 28), esophageal replacement (n = 27), major revisions (n = 15), and multiple dilatations (n = 20). Adult patients presented with impaired well-being according to WHO-score and gastrointestinal function (GIQLI). In contrast, HRQoL of children was comparable to controls in most KIDSCREEN27-dimensions. Delayed anastomosis was associated with most-favourable HRQoL. Regarding physical well-being, these children scored significantly better than controls [64.01 ± 10.40 vs. 52.36 ± 8.73;p = 0.0011], children after replacement [51.40 ± 5.70;p = 0.008], revisions [52.04 ± 6.97;p = 0.026], and multiple dilatations [50.22 ± 9.67,p = 0.04].

Conclusions

HRQoL after complex and/or complicated EA is excellent in children registered in a patient support group. In adults, disease-specific symptoms negatively affect HRQoL. Our data indicate that saving the esophagus may achieve the best HRQoL.     

Patterns of recovery over 12 months following a burn injury in Australia

Objective

To describe patients’ generic health status and health-related quality of life (HRQoL) 12-months following admission to a state-wide burns service.

Methods

A total of 114 injured adults with >10% total body surface area burned (TBSA) or burns less than 10% TBSA to smaller anatomical areas such as the hands and feet participated in this study. Retrospective assessment of pre-burn injury status and prospective assessment of generic health and HRQoL were followed up at 3, 6 and 12-months after injury using the 36-item Short Form Health Survey (SF-36 v.2) and Burns Specific Health Scale-Brief (BSHS-B). The SF-36 v.2 was administered retrospectively during the initial hospital stay to assess pre-injury HRQoL. Changes in instruments scores were assessed using multilevel mixed effects regression models. Mean scores were compared over time and between severity groups as defined by <10%, 10–30% and >30% TBSA.

Results

For the overall sample, the SF-36 v.2 physical component scale (PCS) score between 3 and 12-months post-burn injury were significantly lower than pre-injury scores (p < 0.01), with no significant change over time for the mental component scale (MCS) (p = 0.36). Significant %TBSA-burden by time interactions highlighted changes from pre-burn injury in overall PCS (p = 0.02), physical functioning (p < 0.001) and role-physical (p = 0.03), with subscales worse for the TBSA >30% group. With respect to the BSHS-B, significant improvement from 3 to 12-months post-burn injury was seen for the entire sample in simple abilities (p < 0.001), hand function (p = 0.001), work (p = 0.01), and treatment regime (p = 0.004) subscales. The TBSA >30% group showed a greater rate of improvement in simple abilities (p = 0.01) and hand function (p = 0.005) between 3 and 12 months post-burn injury.

Conclusions

Whilst certain HRQoL measures improve over the 12-months, in most cases they do not reach pre-morbid levels. Patients face ongoing challenges regarding their physical and psychosocial recovery 12-months post-burn injury with respect to generic health and burn-specific health. These challenges vary at different time periods over the 12-month post-burn period, and may provide windows of opportunity in which to address ongoing issues.     

Long term outcomes of laparoscopic-assisted anorectoplasty: A comparison study with posterior sagittal anorectoplasty

Purpose

The aim of this study is to compare the long term outcomes between laparoscopic-assisted anorectoplasty (LAARP) and posterior sagittal anorectoplasty (PSARP) for children with rectobladderneck and rectoprostatic fistula anorectal malformations (ARM).

Methods

Thirty-two ARM children with rectobladderneck and rectoprostatic fistula who underwent LAARP between October 2001 and March 2012 were reviewed. The outcomes were compared with those of 34 ARM children who underwent PSARP between August 1992 and September 2001. The sacral ratio (SR), age at operation, operative time, postoperative hospital stay and complications were evaluated. Bowel functions were assessed using the Krickenbeck classification.

Results

The mean operative time of the LAARP was significantly shorter than that of PSARP group (1.62 ± 0.40 vs 2.13 ± 0.30 h). The postoperative hospital stay was significantly shorter in the LAARP group (5.8 ± 0.65 vs 8.4 ± 0.67 h). The wound infections (11.8% vs 0%) and recurrent fistula (11.8% vs 0%) were more common in PSARP patients. The overall morbidity rate of PSARP group was significantly higher than that of the LAARP group (35.3% vs 12.5%, p < 0.05). However, 7.5% of the LAARP patients developed rectal prolapse. Twenty-four of 32 patients were followed up for more than 3 years in LAARP group. The median follow up period was 7.5 years (range 4–11) in LAARP patients and 15.5 years (range 11–20) in PSARP patients. The rates of voluntary bowel movement, soiling (grade 1, 2 & 3) were similar in both groups. More patients from PSARP group developed grade 2 or 3 constipation (22.5% vs 0%, P < 0.01).

Conclusions

Compared to PSARP, LAARP is a less invasive procedure. The long term functional outcomes after LAARP were equivalent if not better than those of PSARP.     

A retrospective analysis of securing autologous split-thickness skin grafts with negative pressure wound therapy in paediatric burn patients

Background and Aim

Deep dermal and full-thickness burn wounds are excised and grafted with split-thickness skin grafts. Especially in less compliant patients such as young children, conventional fixing methods can often be ineffective due to high mobility rates in this age group.The aim of this retrospective single-centre study was to give an overview of our experience in the fixation of autologous split-thickness skin grafts (ASTSGs) on burn wounds by negative pressure wound therapy (NPWT) in paediatric patients.

Methods

A retrospective analysis describing 53 paediatric patients with burns or burn-related injuries who were treated as 60 individual cases were conducted. All patients received ASTSGs secured by NPWT.

Results

Of the individual cases, 60 cases with a mean age of 8 ± 6 years (the youngest was 3 months, the eldest was 24 years old) were treated in a single procedure with ASTSG and NPWT. Total burn surface area (TBSA) was, median (med) 4.5% (3.0–12.0%). The TBSA of deep dermal thickness to full-thickness (IIb–III°) burns was med 4.0% (2.0–6.0%). The TBSA treated with ASTSG and NPWT was med 3.5% (2.0–6.0%). Take rate was, med 96% (90–99%) with a total range of 70–100%. The only significant correlation that could be found was between the grafted TBSA and the take rate. The smaller the grafted TBSA the better the take rate resulted, as expected. In three cases, major complications were noted.

Conclusion

To sum up our experience, the NPWT system has developed itself to be a constant, well-implemented and useful tool in securing ASTSGs to the wound bed. The main advantage of the technique is a much higher mobility of the patient compared to conventional fixation methods. The high compliance rate of an often challenging group of patients such as children recompenses possible higher costs compared to conventional fixation methods.     

Estimating severity of burn in children: Pediatric Risk of Mortality (PRISM) score versus Abbreviated Burn Severity Index (ABSI)

Objective

The purpose of our study is to validate the Pediatric Risk of Mortality (PRISM) score and compare the accuracy of PRISM predicted outcomes to the Abbreviated Burn Severity Index (ABSI). We hypothesized that the PRISM score is more accurate in predicting mortality and hospital length of stay than the ABSI in children with severe burns.

Methods

All children <18 years of age admitted to a regional pediatric burn center between January 1, 2008 and July 1, 2010 were reviewed. Those with a Total Body Surface Area (TBSA) burn ≥20% who were admitted within 7 days of injury were selected for our study. Measured parameters included: demographics, burn characteristics, PRISM and ABSI scores at admission, and outcomes (mortality, hospital length of stay (LOS), ventilator days and cause of death).

Results

A total of 83 patients met criteria and had complete data sets. The mean age (±SEM) was 8.0 ± 0.6 years, mean % TBSA burn 49.9 ± 2.1%, 62.7% were male, and 45.8% had inhalation injury. Hospital LOS was 74.4 ± 7.9 days, with 31.5 ± 4.9 ventilator days. Mean PRISM score ranged from 14.2 to 16.0, with ABSI scores 7.9 to 8.5. Actual overall mortality was 18.1% compared to a PRISM predicted mortality of 19.8 ± 2.5% (p < 0.001, r = 0.570). ABSI predicted mortality varied from 10 to 20% for a score of 7.9 to 30–50% for a score of 8.5. Logistic regression showed that both PRISM (p < 0.001) and ABSI (p < 0.001) mortality predictions accurately estimated actual mortality, which remained true in a combined model. ABSI was predictive of hospital LOS (p < 0.001) and ventilator days (p < 0.001) while PRISM was not (p = 0.326 and p = 0.863).

Conclusions

Both PRISM and ABSI scores are predictive of mortality in severely burned children. Only ABSI correlates with hospital length of stay and ventilator days, and thus may also be more useful in predicting ICU resource utilization.     

Systemic absorption of amphotericin B with topical 5% mafenide acetate/amphotericin B solution for grafted burn wounds: Is it clinically relevant?

Objective

To determine if patients receiving topical amphotericin B in combination with 5% mafenide acetate solution will acquire systemically detectable levels of amphotericin B.

Methods

A prospective, observational study of consecutive patients from May 2007 to March 2008 who received 5% mafenide acetate/amphotericin B (2 mcg/ml) solution topically every 4 h to their excised and grafted burn wounds for at least 5 days. Serum amphotericin B levels were measured every 5 days during treatment. In addition, the percentage of graft take, occurrence of infection, and potential adverse reactions or toxicities were monitored and recorded.

Results

A total of 27 patients were enrolled, accumulating 420 treatment days and 72 amphotericin B levels. Sixty-nine of the amphotericin B levels were undetectable, while 3 were detectable at non-therapeutic levels (<0.5 mcg/ml). Of the patients with a detectable serum amphotericin B level, only one experienced adverse reactions that could potentially be attributed to amphotericin B. The mean TBSA burned was 32% (SD ± 14%), with a mean TBSA treated with solution of 21% (SD ± 13%). The median duration of treatment was 8 days (range 5–52 days), and the median number of amphotericin B levels drawn per patient was 1 (range 1–19). The median percentage graft take was 95%, and there were no fungal wound infections.

Conclusions

We conclude that 5% mafenide acetate/amphotericin B (2 mcg/ml) solution, applied to excised and grafted burn wounds, does not produce clinically relevant serum levels of amphotericin B. Based on our observations, this topical regimen is safe.     

Correlation between circulating proteasome activity,total protein and c-reactive protein levels following burn in children

Aim of the study

To characterize burn-induced changes following burn in children by analyzing circulating proteasome (c-proteasome) activity in the plasma in correlation with total protein and c-reactive protein levels in the plasma, and the severity of the burn.

Methods

Fifty consecutive children scalded by hot water who were managed at the Department of Pediatric Surgery after primarily presenting with burns in 4–20% TBSA were included into the study. The children were aged 9 months up to 14 years (mean age 2.5 ± 1 years). Patients were divided into groups according to the pediatric injury severity score used by American Burns Association. Plasma proteasome activity was assessed using Suc-Leu-Leu-Val-Tyr-AMC peptide substrate, 2–6 h, 12–16 h, 3 days, 5 days, and 7 days after injury. 20 healthy children consecutively admitted for planned inguinal hernia repair served as controls.

Results

Statistically significant elevation of plasma c-proteasome activity was noted in all groups of burned children 12–16 h after the injury. We found a strong negative correlation of c-proteasome activity with total protein levels, and positive correlation with CRP levels 12–16 h after burn. We also found stronger correlation between c-proteasome activity and severity of burn, than CRP level and severity of burn 12–16 h, and 3 days after the burn. Correlations were statistically significant.

Conclusions

This study characterized circulating 20S proteasome activity levels after burn. C-proteasome activity elevate after burn and correlate negatively with plasma total protein level, thus plasma 20S proteasome activity could be additional biomarker of tissue damage in burn in pediatric population.     

Hepatobiliary physiological changes after Roux-en-Y cholecysto-colonic diversion

Background

We speculated that Roux-en-Y cholecysto-colonic diversion was as effective for treating children with progressive familial intrahepatic cholestasis (PFIC) as partial biliary diversion. The feasibility of the novel approach in bypassing bile was investigated in rabbits.

Methods

Twenty-four rabbits were randomly divided into three groups: sham operated group (Group1), 30 cm limb group (Group 2), and 10 cm limb group (Group 3). Group 2 or 3 underwent a Roux-en-Y cholecystocolonic anastomoses with a 30- or 10-cm-long Roux limb. ^99mTcEHIDA dynamic biligraphy was used to detect alterations of bile flow among the three groups at 1 year postoperatively. TBA levels and histological changes were also evaluated.

Results

All animals survived and developed normally without clinical symptoms during 1 year follow-up. Bile was diverted into colon directly after cholecystocolonic anastomosis. In group 3, E20 and E35 values were (77.27 ± 6.15%) and (90.39 ± 1.49%) respectively. Gallbladder emptying was accelerated in 10 cm short limb group than in 30 cm long limb group. The ratio of bile shunt was (0.547 ± 0.182), which was also more than that in group 2 (p < 0.05). The activity-time curve for the gallbladder area in group 2 looks like a wave. A significant reduction in TBA level was observed in group 2 and 3 (p < 0.05).

Conclusions

Roux-en-Y cholecystocolonic bypass was safe and feasible. Its effectiveness is related to the length of Roux loop. Cholecystocolonic bypass led to a significant loss of bile acids in healthy rabbits and might be considered for bile diversion in pediatric patients with selected cholestatic diseases.     

Predictors of early lung function in patients with congenital diaphragmatic hernia

Purpose

Long-term pulmonary outcomes of congenital diaphragmatic hernia (CDH) have demonstrated airflow obstruction in later childhood. We examined pulmonary function data to assess what factors predict lung function in the first three years of life in children with CDH.

Methods

This was a retrospective study of patients treated for CDH who underwent infant pulmonary function testing (IPFT) between 2006 and 2012. IPFT was performed using the raised volume rapid thoracoabdominal compression technique and plethysmography.

Results

Twenty-nine neonates with CDH had IPFTs in the first 3 years of life. Their mean predicted survival using the CDH Study Group equation was 63% ± 4%. Fourteen infants (48%) required extracorporeal membrane oxygenation (ECMO). The mean age at IPFT was 85.1 ± 5 weeks. Airflow obstruction was the most common abnormality, seen in 14 subjects. 12 subjects had air trapping, and 9 demonstrated restrictive disease. ECMO (p = 0.002), days on the ventilator (p = 0.028), and days on oxygen (p = 0.023) were associated with restrictive lung disease.

Conclusion

Despite following a group of patients with severe CDH, lung function revealed mild deficits in the first three years of life. Clinical markers of increased severity (ECMO, ventilator days, and prolonged oxygen use) are correlated with reduced lung function.     

Serum phosphate level in burn patients

Introduction

Despite plasma phosphate imbalance being rare, it is a relatively common finding in certain subsets of burn patients. It may occur due to the burn itself or as a result of the treatment. Severe hypophosphataemia (<1.0 mg dl⁻¹) is associated with a significant morbidity and a fourfold increase in mortality. In this study, the relation between serum phosphate level and the total body surface area (TBSA) of the burn was compared.

Methods

According to the percentage of TBSA of the burn, the patients (n = 155) were divided into three groups: group A with 20–29% TBSA burns, group B with 30–39% and group C with more than 40% TBSA burns (62, 48 and 45 patients, respectively).Analysis of variance (ANOVA)-repeated measure was used to detect any statistically significant difference in the three post-burn time-points of 3rd, 6th and 9th days and the mean score of the serum phosphate level between the three groups.

Results

The incidence of hypophosphataemia at 9th post-burn day in the three groups was 6.1%, 32.4% and 73.5%, respectively. There were significant differences (p < 0.05) between mean serum phosphate levels of groups A and C, B and C and A and B as well. We found significant differences between the three post-burn follow-up time stages.

Discussion

We have shown that hypophosphataemia, defined as mean serum phosphate levels below 3.0 mg dl⁻¹, was very common following burn, based on 75.6% of patients with more than 40% burn at the 3rd post-burn day. As the percentage of TBSA of burn increases, the incidence of hypophosphataemia significantly increases. We suggest that phosphate level be routinely measured after a major burn, especially in patients with a complicated course, so that appropriate replacement therapy may be started in a timely manner.     

A novel rapid and selective enzymatic debridement agent for burn wound management: A multi-center RCT

Objectives

Excisional debridement followed by autografting is the standard of care (SOC) for deep burns, but is associated with serious potential complications. Conservative, non-surgical and current enzymatic debridement methods are inefficiently slow. We determined whether a non-surgical option of rapid enzymatic debridement with the debriding enzyme NexoBrid™ (NXB) would reduce need for surgery while achieving similar esthetic and functional outcomes as SOC.

Methods

We conducted a multi-center, open-label, randomized, controlled clinical trial including patients aged 4-55 years with deep partial and full thickness burns covering 5-30% of their total body surface area (TBSA). Patients were randomly assigned to burn debridement with NXB (applied for 4 h) or SOC, which included surgical excisional or non-surgical debridement.

Results

NXB significantly reduced the time from injury to complete débridement (2.2 vs. 8.7 days, P < 0.0001), need for surgery (24.5% vs. 70.0%, P < 0.0001), the area of burns excised (13.1% vs. 56.7%, P < 0.0001) and the need for autografting (17.9% vs. 34.1%, P = 0.01). Scar quality and quality of life scores were similar in both study groups as were the rates of adverse events.

Conclusions

Enzymatic débridement with NXB resulted in reduced need for and extent of surgery compared with SOC while achieving comparable long-term results in patients with deep burns.

Trial registration

: Clinical Trials.gov NCT00324311.     

Transosseous suturing of patellar fractures with braided polyester – A prospective cohort with a matched historical control study

Background

Although tension-band wiring is the most widely used technique to fix patellar fractures, metal implant-related complications including implant failure and postoperative pain are very common and additional procedures are often necessary to treat the complications. The purpose of this study is to evaluate a totally metal-free technique using a transosseous suturing method and to compare it with the traditional fixation technique.

Method

A total of 25 patients (mean age of 59.60 years) with displaced patellar fractures treated by a transosseous suturing technique were compared with a 1:1 matched historical control group that underwent modified tension-band-wire fixation. Union time, union rate, operation time, number of procedures, mean hospitalisation days and complications were compared between cases and controls.

Results

Union time (8.43 ± 2.92 vs. 8.64 ± 2.82 weeks) and operation time (69.00 ± 19.31 vs. 64.89 ± 14.27 min) were not different between the two groups. Mean hospitalisation days (4.04 ± 1.40 vs. 5.76 ± 1.50 days; P < 0.001), number of procedures and the frequency of complications were significantly lower in the transosseous suturing group.

Conclusion

The transosseous suturing technique is safe and effective in the transverse or comminuted fractures of the patella. The complication rate is significantly lower than with the tension-band-wiring technique.     

Using the parents' video camera for the follow-up of children who have undergone hypospadias surgery decreases hospital anxiety of children

Purpose

We investigated the benefits of using the parents' video camera records for the follow-up of children who had undergone hypospadias surgery in terms of reducing fear and hospital anxiety of the children and the time spent in the waiting room.

Methods

This prospective study was performed on children with proximal hypospadias. The patients were called for the follow-up appointment on the 7th postoperative day and were divided into 3 groups. The first group was the control group where parents were not given any follow-up visit direction. The parents of the second group were told to have their child drink enough fluids and come with a full bladder, while the third group of parents recorded their child's micturition using a video camera. The fear and anxiety of children at the postoperative visit were evaluated and recorded using a scoring system between 0 and 4 using the Children's Fear Scale (CFS) brochure. The time elapsed from the arrival of the parents in the outpatient clinic to their departure was also recorded for comparison of the total time spent during the follow-up visit among the groups.

Results

Thirty boys who underwent hypospadias repair were enrolled in this study. The median CFS scores at the postoperative follow-up visit were 2.99 ± 0.99 (range: 1–4) in the first group, 2.90 ± 0.87 (range: 1–4) in the second group, and 0.00 (range 0–0) in the third group. The median total time spent during the follow-up visit in the 3 groups was 61.50 ± 17.08 (range 35–88), 18.1 ± 13.01 (range 4–45), and 4.0 ± 0.81 (3–5) minutes, respectively. Both CFS and total time spent were significantly lower in the third group (p < 0.01).

Conclusion

Imaging of micturition at home by using a video camera for outpatient visits following hypospadias surgery will decrease the fear and anxiety of children and the time that the family spends at the hospital.     

Lack of precision of burn surface area calculation by UK Armed Forces medical personnel

Objective

Accurate determination of the severity of burn is essential for the care of thermally injured patients. We aimed to examine the accuracy and precision of TBSA calculation performed by specialist military burn care providers and non-specialist but experienced military clinicians.

Methods

Using a single case example with photographic montages and a modified Lund and Browder chart, the two cohorts of clinicians were each given 10 min to map and calculate the case example TBSA involvement. The accuracy and precision of results from the two cohorts were compared to a set standard %TBSA.

Results

The set standard %TBSA involvement was 64.5%. Mean %TBSA mapped by non-specialists (52.53 ± 10.03%) differed significantly from the set standard (p < 0.0001). No difference was observed when comparing results from the burn care providers (65.68 ± 10.29%; p = 0.622). However, when comparing precision of calculation of TBSA burned, there was no evidence of a difference in heterogeneity of results between the two cohorts (F test, p = 0.639; Levene's test, p = 0.448).

Conclusions

These results indicate that experienced military burn care providers overall more accurately assess %TBSA burned than relatively inexperienced clinicians. However, results demonstrate a lack of precision in both groups.     

Laparoscopic Approach for Artificial Urinary Sphincter Implantation in Women with Intrinsic Sphincter Deficiency Incontinence: A Single-Centre Preliminary Experience

Background

Implantation of an artificial urinary sphincter (AUS) is used as a last resort in women with stress urinary incontinence (SUI).

Objective

To assess the early functional outcome after laparoscopic placement of an AUS in women.

Design, setting, and participants

Twelve women with type 3 SUI underwent a laparoscopic AUS placement between 2006 and 2008. Eleven (92%) had previously undergone anti-incontinence procedures.

Intervention

The AUS was implanted with laparoscopic access either preperitoneally or intraperitoneally. The cuff was placed around the bladder neck between the periurethral fascia and the vagina.

Measurements

Perioperative complications were reviewed. To assess resolution of urinary incontinence, all patients were seen at 1, 3, 6, and 12 mo after the surgery and yearly thereafter.

Results and limitations

The mean age of subjects was 56.7 ± 12 yr (33–78). The mean body mass index was 24 ± 2.3 (20–25). The mean preoperative closure pressure was 22 ± 10.9 cmH₂O (4–35). The mean operative time was 181 ± 39 min [110–240]. Intraoperative complications occurred in three women (25%), with bladder (n = 2) and vaginal (n = 2) injuries. These complications required open conversion. AUS implantation was postponed in one case. The mean hospital stay was 7 ± 2.3 d (3–11). The bladder catheter was removed after a mean time of 10 ± 8 d (2–30). Urinary retention was observed in five cases (45%) after bladder catheter removal. AUS activation was done 4–14 wk after implantation. Mean follow-up was 12.1 ± 8 mo (5.2–27). Incontinence was completely resolved in eight women (88%) who underwent complete laparoscopic procedure. The main limitation of the study was the limited length of follow-up.

Conclusions

AUS implantation can be successfully achieved by laparoscopy. It appears to be technically feasible. These results are still preliminary, and further studies of larger populations with longer follow-up are needed to make any statement regarding surgical strategy.     

Management of pediatric snake bites: Are we doing too much?

Background

The optimal management of children with snake bite injuries is not well defined. The purpose of this study was to review the use of antivenom, diagnostic tests, and antibiotics in children bitten by venomous snakes in a specific geographic region (Southeast Texas).

Methods

This is a retrospective single-center review of all patients with snake bite injury from 1/2006 to 6/2012. An envenomated bite was defined as causing edema, discoloration of the skin, necrosis, or systemic effects. The severity of injury was scored using a novel 4-point scale based on initial physical examination alone.

Results

One hundred fifty-one children (mean age 8.4 ± 4.3 years) were treated for a snake bite. There were no mortalities. Lower extremity injuries were most common (60%). Most bites were from copperheads (43%). Envenomation was evident in 82% (average wound score: 2.61 ± 0.81). The median hospital stay for admitted patients (79%) was 2 days (range 1–7). Four patients required surgery for complications of the snake bite. Fifty-two children (34%) received CroFab, with one allergic reaction. 22/135 (16%) had evidence of coagulopathy. Seventy-two children (48%) received IV antibiotics.

Conclusion

Despite a high rate of envenomated bites in Southeast Texas, significant morbidity is rare. Children with an envenomation score of 1 or 2 are unlikely to be coagulopathic, suggesting that laboratory investigation should be reserved for patients with higher scores. The indications for the administration of CroFab deserve further prospective study.     

Developmental outcomes of children with congenital diaphragmatic hernia: A multicenter prospective study

Purpose

To determine developmental outcomes and associated factors in patients with congenital diaphragmatic hernia (CDH) at 2 years of age.

Methods

This is a multicenter prospective study of a CDH birth cohort. Clinical and socioeconomic data were collected. Bayley Scales of Infant Development (BSID-III) and Vineland Adaptive Behavior Scales (VABS-II) were performed at 2 years of age.

Results

BSID-III and VABS-II assessments were completed on 48 and 49 children, respectively. The BSID-III mean cognitive, language, and motor scores were significantly below the norm mean with average scores of 93 ± 15, 95 ± 16, and 95 ± 11. Ten percent (5/47) scored more than 2 standard deviations below the norm on one or more domains. VABS-II scores were similar to BSID-III scores with mean communication, daily living skills, social, motor, adaptive behavior scores of 97 ± 14, 94 ± 16, 93 ± 13, 97 ± 10, and 94 ± 14. For the BSID-III, supplemental oxygen at 28 days, a prenatal diagnosis, need for extracorporeal membrane oxygenation (ECMO) and exclusive tube feeds at time of discharge were associated with lower scores. At 2 years of age, history of hospital readmission and need for tube feeds were associated with lower scores. Lower socioeconomic status correlated with lower developmental scores when adjusted for significant health factors.

Conclusion

CDH patients on average have lower developmental scores at 2 years of age compared to the norm. A need for ECMO, oxygen at 28 days of life, ongoing health issues and lower socioeconomic status are factors associated with developmental delays.