Burn size estimation in children: Still a problem

Background: Accurate determination of burn size and depth forms an integral part of the initial assessment of any burn injury. Errors might lead to inaccurate fluid resuscitation and inappropriate transfer of patients to specialized burns units (BUs). Although recent data suggest some improvement in the estimation of burn injury in adults, this has not been shown in children. Methods: A retrospective review of children with burn injuries referred to the BU of our institution was performed. Data were collected from all patients presenting to the BU during the calendar year 2009. The total body surface area burned (TBSA‐B) estimated by the referring centre was compared with the actual TBSA determined measured on arrival at the BU. Results: Of the 71 paediatric patients referred during the study period, 10 did not have any TBSA‐B estimation documented by the referring hospital. Inaccurate estimation of burn area was noted in 48 out of 61 patients (79%). Burn size was more likely to be overestimated than underestimated by a ratio of 2.2 to 1, especially in burns >10% TBSA‐B (P= 0.002). Conclusions: Inaccurate estimation of burn size remains a problem in children. The persistent miscalculation of burn size might be a result of the various methods employed in assessing burn area, the inclusion of simple erythema and inadequate training or exposure of first responders. Accurate assessment of TBSA‐B and burn depth in children remains elusive and would appear to require additional training and education.     

Percutaneous tibial nerve stimulation (pTNS): success rate and the role of rectal capacity

Purpose

Percutaneous tibial nerve stimulation (pTNS) was originally developed to treat urinary incontinence. Recently, some case series have also documented its success in the treatment of fecal incontinence. Nevertheless, the mechanism underlying this effect remains unknown but may be related to changes in rectal capacity. The aim of this study was to investigate the success of pTNS for the treatment of fecal urge incontinence and assess the influence of rectal capacity on treatment efficacy.

Methods

All patients undergoing pTNS for fecal incontinence between July 2009 and March 2014 were enrolled in a prospective, observational study consisting of a therapeutic regimen that lasted 9 months. Therapy success was defined as a reduction in the CCI (Cleveland Clinic incontinence) score of ≥50% and patient-reported success. Furthermore, quality of life (Rockwood’s scale) and changes in anorectal physiology were recorded.

Results

Fifty-seven patients with fecal urge incontinence were eligible, nine of whom were excluded. The success rate was 72.5%. Incontinence events and urge symptoms were significantly reduced after 3 months and at the end of therapy. The median CCI score decreased from 12 to 4 (P < 0.0001), and the quality of life was significantly improved. However, rectal capacity was not significantly related to treatment success before or after therapy. No adverse events were observed.

Conclusions

These results demonstrate that pTNS can improve the symptoms and quality of life of patients with fecal urge incontinence. However, the study fails to demonstrate a correlation between treatment success and changes in rectal capacity.

     

Endoplasmic reticulum stress and inflammation

Endoplasmic reticulum (ER) stress due to the presence of misfolded or unfolded proteins in the ER invokes a fundamental biological response, termed the unfolded protein response (UPR). The UPR is orchestrated by three main proximal effectors, of which the IRE1/XBP1 pathway represents the evolutionarily most conserved one. Due to its high secretory burden, the intestinal epithelium is highly susceptible to perturbations in the UPR as has been revealed by functional investigations such as in mice that lack Xbp1 expression, specifically in the intestinal epithelial cells. Genetic studies have revealed several ER stress/UPR-associated genes, including XBP1, ORMDL3, AGR2 and MUC19 as risk factors for IBD, and specific functional, rare variants have been described for XBP1. Xbp1(Δ)(IEC) mice spontaneously develop small intestinal enteritis with crypt abscesses reminiscent of human IBD, while Agr2(-/-) mice develop granulomatous ileocolitis. Mechanistic studies into Xbp1(Δ)(IEC) mice revealed a major effect on Paneth cells associated with alterations in host-microbe interactions in the intestine, and the activation of key proinflammatory pathways in the host directly associated with unresolved ER stress and hypomorphic Xbp1 function. Remarkably, the intestinal epithelium of IBD patients commonly exhibits evidence of marked ER stress, which cannot easily be attributed to these genetic risk factors alone and indicates that the paradigm of ER stress-related inflammation might be both a primary originator as well as a potent perpetuator of intestinal inflammation in IBD.     

Assessment of serum visfatin levels in girls with anorexia nervosa

Objective Visfatin (VISF) is a recently described peptide regulating the process of adipocyte differentiation. Only one pilot study of VISF expression in the fat tissue and its circulating concentrations in a small group of patients with anorexia nervosa (AN) have been published, yet. Design and patients Cross‐sectional assessment of VISF serum concentrations in 195 girls aged 11–18·9 years with AN (n = 87), eating disorders not otherwise specified (NOS; n = 17), simple obesity (OB; n = 30), and healthy controls (H; n = 61). Measurements Blood samples were collected during the fasting state between 7:00 am–8:30 am. VISF serum concentrations were determined using enzyme immunoassay. Comparisons of VISF levels between groups were performed. Results Mean serum VISF concentrations in girls with AN and NOS were significantly lower than those in the H and OB groups. Serum VISF concentrations were higher in the OB than in the H groups. When were calculated per body mass index (BMI), VISF concentrations were significantly lower in the AN, NOS, and OB groups than in healthy controls. Among participants with a normal BMI, serum VISF concentrations correlated positively with BMI (r = 0·27; P < 0·05). In the OB group, a significant, negative correlation between BMI and VISF levels (r = ?0·38; P = 0·04) was observed. Conclusions Compared with healthy girls, serum VISF concentrations are decreased in girls with AN. Conversely, obese girls have elevated VISF levels. When calculated per BMI (VISF/BMI), the results in AN and OB groups were lower than in healthy participants.     

Cyanosis when head turned to left in an infant with primary ciliary dyskinesia

A 19‐month‐old boy with primary ciliary dyskinesia (PCD), mirror‐image dextrocardia, situs inversus (SI) totalis suffered from persistent hypoxia. Cyanosis became clinically evident when the child turned the head to the left and resolved after turning the head to the right. Echocardiography demonstrated two superior caval veins; the left sided superior vena cava (SVC) entering the left sided right atrium (RA) and the right sided into the right sided left atrium (LA). Surgical redirection of the right sided caval vein into RA was performed. Pediatr Pulmonol. 2013; 48:88–90. © 2012 Wiley Periodicals, Inc.     

Prevalence of Sexually Transmitted Infections Among Men Who Have Sex with Men in Zagreb, Croatia

We used respondent-driven sampling among men who have sex with men (MSM) in Zagreb, Croatia in 2006 to investigate the prevalence of HIV, other sexually transmitted infections and sexual behaviours. We recruited 360 MSM. HIV infection was diagnosed in 4.5%. The seroprevalence of antibodies to viral pathogens was: herpes simplex virus type-2, 9.4%; hepatitis A, 14.2%; hepatitis C, 3.0%. Eighty percent of participants were susceptible to HBV infection (HBs antigen negative, and no antibodies to HBs and HBc antigen). Syphilis seroprevalence was 10.6%. Prevalence of Chlamydia and gonorrhoea was 9.0%, and 13.2%, respectively. Results indicate the need for interventions to diagnose, treat and prevent sexually transmitted infections among this population.     

Deletion of the c-kit protooncogene in the human developmental defect piebald trait.

The protooncogene c-kit is critical for development of hematopoietic stem cells, germ cells, and melanoblasts in the mouse. Homozygous mutations of this gene in the mouse cause anemia, infertility, and albinism, whereas heterozygous mutant mice usually exhibit only a white forehead blaze and depigmentation of the ventral body, tail, and feet. The heterozygous mouse phenotype is very similar to human piebald trait, which is characterized by a congenital white hair forelock and ventral and extremity depigmentation. To investigate the possibility that alterations in the human c-kit gene may be a cause of piebald trait, DNA from seven unrelated affected individuals was examined by Southern blot analysis. One subject, although cytogenetically normal, has a heterozygous deletion of the c-kit protooncogene. This deletion encompasses the entire coding region for c-kit and also involves the closely linked gene for platelet-derived growth factor receptor alpha. Fluorescence in situ hybridization of genomic c-kit probes to metaphase chromosomes independently confirmed the deletion in this case. These findings provide molecular evidence mapping piebald trait to the c-kit locus on chromosome 4. Although we cannot exclude the involvement of other closely linked genes, the demonstration of a genomic c-kit deletion in one subject with piebald trait and the marked concordance of the human and mouse phenotypes provide strong evidence for the role of c-kit in the development of human melanocytes and in the pathogenesis of piebald trait.