Cerebral tumors: Specific features in children

Brain tumors are the second leading cause of cancer in children. Primary tumors predominate and are of very varied histological types. Their prognosis and treatment depend on the histological type and grade. The diagnostic approach to these includes analysis of the site of the lesion and appearances on computed tomography and MR, and taking account of the age and clinical features of the child. CT is used to diagnose the tumor in an emergency situation. Conventional MR provides a morphological approach and allows a staging assessment to be carried out before surgery. Advanced MR techniques (diffusion-weighted and perfusion imaging, MR spectroscopy) provide further information for the differential diagnosis, presumptive diagnosis of type and grade and to guide biopsy towards the most malignant areas in the lesion.     

Evaluation and objective assessment of the treatment course of burn injured children

Between 1984 and 1989 70 out of 76 children, who underwent a primary inpatient treatment for thermal injury, had predominant second degree burns affecting 3 to 25% of body surface. Data of them, concerning epidemiology, first aid, run of inpatient and following outpatient therapy, were documented and summarised. All patients were physical examined and we judged functional and cosmetic results at least half a year after the injury. A uniform score allowed us a comparison of two different concepts of local therapy: closed treatment with impregnated gauze dressings vs. application of ointment (Flammacerium). Kind of documentation and score are proved to be of advantage in estimating run and results of treatment.     

The risk factors and time course of sepsis and organ dysfunction after burn trauma

BACKGROUND: Sepsis and organ dysfunction are common and likely contribute to death after burn trauma. We sought to define relationships between sepsis, severe multiple organ dysfunction (MOD), and death after burn trauma. METHODS: Adults with > or = 20% total body surface area burns were prospectively enrolled. Information regarding infection, severity of sepsis, and organ failure was collected daily. Risk factors (e.g., age, burn size, shock) were analyzed for their association with severe MOD, complicated sepsis, and death. We characterized the temporal relationship between organ failure and sepsis. RESULTS: Of 175 patients, 27% developed severe MOD, 17% developed complicated sepsis, and 22% died. Full-thickness burn size, age, and inhalation injury were associated with MOD, sepsis, and death. Infection preceded MOD in 83% of patients with both. A base deficit of > or = 6 mEq/L at 24 hours after injury was associated with death. CONCLUSION: When it occurs, severe MOD is usually preceded by infection. In addition, an elevated base deficit at 24 hours and septic shock are the most important factors associated with and possibly contributing to death after burn trauma.     

Characteristics of sepsis in burn patients today

An analysis of lethal outcomes following thermal traumas during the recent 8 years has shown sepsis to occupy one of the leading places as a cause of death of burned people. During the recent years the incidence of early sepsis has been increased. This kind of sepsis develops in the period of shock and acute toxemia, is often of lightening character, possesses certain specific morphological features and is caused predominantly by gram-negative flora threatening to patients with critical burns of more than 40% of the body surface.     

Burn sepsis and burn toxin

The salient steps of a 20-year programme of research into the nature of burn disease are described. By burn disease we mean the late mortality and morbidity following burns. We have isolated a burn toxin which is derived from a thermal polymerization of cell membrane lipoproteins within the dermis and have studied its influence on the effects of sepsis. We have also used it in the development of active and passive immunization therapy of severe burns.     

Procalcitonin-a sepsis parameter in severe burn injuries

Procalcitonin (PCT) levels increase in patients with systemic infections; the highest levels have been found in sepsis. This study tested whether plasma procalcitonin level was related to sepsis, CRP, burn size, inhalation injury or mortality in severely burned patients over the entire clinical course.

In 27 patients with 51 (20–91)% TBSA, PCT was measured three times weekly from admission over the entire course of stay in a single ICU. Daily scoring by the “Baltimore Sepsis Scale” was performed. The patients were assigned to three groups depending on the clinical course and outcome: A=no septic complications, B=septic complications–survivors, C=septic complications–non-survivors.

PCT levels were elevated slightly at admission (mean 2.1 ng/ml) except in three patients who suffered electrical burns (mean 15.7 ng/ml). PCT peak levels correlated well with the Scoring values (r=0.84) while CRP did not (r=0.64). Peak PCT levels were significantly higher (p<0.005) in septic patients (B and C) who averaged 49.8±76.9 ng/ml, than in non-septic patients (A) who averaged peak levels of 2.3±3.7 ng/ml. The highest PCT levels were found immediately before death (86.8±97 ng/ml).

Seven patients had an inhalation injury III°. In these patients at 24 h postburn, there was no relationship between PCT levels and inhalation injury but during the later days postburn there were significant differences in PCT levels in patients with versus without inhalation injury. All patients with inhalation injury III° developed septic complications.

There was no positive correlation between the PCT-admission-levels and the TBSA, but there was a positive correlation between the TBSA and the mean peak PCT levels during the later days postburn (r=0.73; p<0.05). The cut-off value of 3 ng/ml we found reliable to indicate severe bacterial or fungal infection. PCT values over 10 ng/ml increasing over the following days were found only in life-threatening situations due to systemic infections. The individual course of PCT in one patient is more important than absolute values. PCT presented in this study as a useful diagnostic parameter in severely burned patients.     

Predicting fatal sepsis in burn patients.

The high morbidity after severe thermal insult is believed to be related partially to a resultant decrease in immunocompetence. We tested the ability of phytohemagglutinin (PHA) and Concanavalin (Con A) to stimulate lymphocyte transformation in 17 patients with moderate to severe thermal injury (greater than 25% BSA). The patients acted as their own controls and the per cent change in their mitogen response was measured over time. Eight acutely burned patients who subsequently developed severe sepsis (Group I) had decreased ability (mean, 12% of normal) to proliferate in response to PHA, and six of these died of severe sepsis. The depressed response appeared 4 to 7 days postinjury and predated clinical evidence of sepsis by 2 to 4 days. Cells from four patients who had mild infectious complications (Group II) demonstrated greatly augmented mitogen responses (mean + 243%) approximately 7 to 10 days postinjury. Five burn patients whose clinical course was sepsis free (Group III) exhibited only minimal changes in their mitogen responses (mean +30%). Although the Con A responses of the patients' cells corresponded less to their pathology, Group I patients whose cells exhibited depressed PHA responsiveness also had diminished Con A responses. Group II patients' cells also showed increases in Con A-induced stimulation. Group III patients, who had only slightly augmented PHA responses, had minimal decreases of the Con A-induced lymphocyte transformation. Many severely burned patients develop septicemia as a result of their large wound surfaces. The appearance of decreases in mitogen-induced proliferation, however, appears to characterize those patients who will be unable to handle the septic challenge.     

烧伤脓毒症的诊断标准与防治

烧伤脓毒症是大面积烧伤患者的严重并发症之一 ,也是诱发脓毒性休克、多器官功能障碍综合征(ＭＯＤＳ)的重要原因。烧伤脓毒症来势凶猛 ,病情进展快 ,病死率高 ,如何及时诊断及有效预防和治疗烧伤脓毒症 ,是提高烧伤救治成功率的关键。笔者就烧伤脓毒症的诊断标准和防治策略谈几点看法 ,供同道参考。一、烧伤脓毒症的诊断标准提出脓毒症诊断标准的目的 ,是在其发展为ＭＯＤＳ前及时发现并予以阻止。而作为诊断标准 ,首先不应太复杂 ,以免因不能开展某些检查项目而无法应用 ;其次应以客观指标为依据 ,能够真正反映烧伤患者的病情变化 ,有助于…     

烧伤脓毒症诊断与综合防治策略

Sepsis induced by invasive infection is a challenging problem and the major cause of death after severe burn.With the increasing understanding of sepsis,diagnostic criteria of sepsis were proposed and ...     

A simple method of predicting severe sepsis in burn patients

Twenty-six patients with major thermal injury were studied with sequential tests of immunocompetence. Five to 8 days after burn, 12 of 26 patients developed a marked depression in the phytohemagglutinin response (17 +/- 8 percent of baseline) and an increase in suppression of the normal mixed leukocyte response (70 +/- 13 percent suppression), which was followed by severe life-threatening sepsis 4 to 5 days later. Concomitant with this marked immunosuppression, the 12 patients developed red debris in the normally white mononuclear layer of the Ficoll-Hypaque density centrifugation gradients used to separate mononuclear cells. None of the 14 patients with minimal or no sepsis developed red debris in Ficoll-Hypaque gradients, nor did they show signs of immune depression by phytohemagglutinin or mixed leukocyte response assays. The only patients in the severe sepsis group who survived were those given aminoglycosides at the time red debris was observed on the Ficoll-Hypaque gradients. The presence of red debris on Ficoll-Hypaque separation appears to be a simple and reliable predictor of impending sepsis, which allows the use of antibiotics before the clinical onset of sepsis.     

Bacteriology of burn wound sepsis in a general surgical ward

During this study, 35 cases of burns of various percentages were studied to collect data on clinical aspects of and the prevalence of pathogenic bacteria in normal skin as well as burn areas.In these patients, 248 cultures were taken from the normal areas and 258 from the burn sites. One hundred and twenty-six cultures were positive out of the normal group and 187 were positive from the burn areas.Gram-positive cocci predominated in the upper half of the body while Gram-negative bacilli showed a preponderance in the lower half.Antibiograms showed that Pseudomonas aeruginosa was the most resistant organism. Staphylococcus pyogenes had been sensitive to chloramphenicol in 95 per cent of the sensitivity reports.Pyocine typing in 8 cases showed that both cross infection as well as auto-infection play a major role in the infection of burn wounds. Preventive measures need to be directed against both the sources.     

PCT as a diagnostic and prognostic tool in burn patients. Whether time course has a role in monitoring sepsis treatment

Objective

To evaluate the diagnostic and prognostic performance of inflammatory markers for septic and non septic (localized) bacterial infections in patients with severe burn.

Methods and results

Data of 145 patients were prospectively included in this study. Serum procalcitonin and other inflammatory markers were measured within 24 h after burn and daily thereafter. Maximum procalcitonin (p = 0.004) was independent predictors of outcome in logistic regression analysis. PCT thresholds of 1.5 ng/ml, 0.52 ng/ml and 0.56 ng/ml had adequate sensitivity and specificity to diagnose sepsis, respiratory tract and wound infections respectively. A threshold value of 7.8 ng/ml in PCT concentration on day 3 was associated with the effectiveness of the sepsis treatment with an AUC of 0.86 (95% CI 0.69–1.03, p = 0.002). C-reactive protein levels and WBCs showed no significant change over the first 3 days in the patients with successfully treated sepsis (p = 0.93).

Conclusion

The maximum procalcitonin level has prognostic value in burn patients. PCT can be used as a diagnostic tool in patients with infectious complications with or without bacteremia during ICU stay. Daily consecutive PCT measurements may be a valuable tool in monitoring the effectiveness of antibiotic therapy in burn ICU patients.