FACTORS ASSOCIATED WITH A HIGHER NUMBER OF ESOPHAGEAL DILATIONS IN CHILDREN WITH A HISTORY OF ALKALINE INGESTION.

BACKGROUND: Children who experience alkaline injury are at risk for the development of esophageal strictures and the need for esophageal dilations. OBJECTIVE: We aimed to assess predictors for a higher number of esophageal dilatations in children following alkali ingestion. METHODS: Single-center retrospective cohort study including children who underwent esophagogastroduodenoscopy (EGD) after alkali ingestion. Possible predictive factors for the need for esophageal dilatations were evaluated. RESULTS: A total of 34 patients were included, and 19 were female (55.9%). The median age at the time of the accidents was 20.6 months (IQR 15-30.7). All alkali ingestions were accidental, in all cases involving liquid products, and most (24/34; 70%) occurred at the child's home. Homemade liquid soap was the agent in half of the cases. The most frequently reported symptom at presentation was vomiting (22/34, 64.7%). The median follow-up time was 3.2 years (IQR 1.1-7.4). On follow-up, the median number of esophageal dilatations required for these patients was 12.5 (IQR 0-34). Among demographic factors, male gender (P=0.04), ingestion of homemade products (P<0.01), and accidents happening outside of the household environment (P=0.02) were associated with a greater number of esophageal dilations on follow-up. An endoscopic classification Zargar of 2B or higher (P=0.03), the presence of stricture at the time of the second EGD (P=0.01), and gastroesophageal reflux disease (GERD) as a late complication (P=0.01) were also associated with a greater number of esophageal dilations on long term follow-up. CONCLUSION: Beyond the endoscopic classification severity - a well-known risk factor for the strictures after alkali ingestions, we found that male gender, accidents with homemade products, and accidents occurring outside the household environment were significantly associated with a greater number of esophageal dilatations in the long-term follow-up of children following alkali ingestion.

[A case of high-pressure injection injury of hand complicated with deep chemical burn caused by industrial cement].

This article reports a patient with extensive high-pressure injection injury of the hand combined with deep chemical burn caused by high-pressure injection of industrial cement materials was diagnosed and treated in the Department of Hand Surgery, Xiaolan Hospital Affiliated to Southern Medical University in 2022. The nerves, tendons and blood vessels of the left hand were involved, and the ulnar skin of the left thumb was extensively necrosis, and a large number of extensive cement foreign bodies remained under the skin. Part of the cement was inserted into the joint capsule of the interphalangeal joint. After emergency surgical treatment, the patient was saved successfully, and the wound healed well without chemical poisoning and other related complications, which created conditions for the second stage of flap repair.

Clinical characteristics and laparoscopic surgical outcomes of ovarian dermoid cysts complicated by spontaneous rupture: nine cases and a literature review.

OBJECTIVE: To clarify the clinical characteristics and laparoscopic surgical outcomes of dermoid cysts complicated by spontaneous rupture. METHODS: This was a single-center retrospective observational study of patients with dermoid cysts treated between January 2005 and December 2021. RESULTS: Among 1205 cases of dermoid cysts, spontaneous rupture occurred in nine and torsion occurred in 83 cases. No obvious triggers for rupture were identified, except for one postpartum case with fundal uterine pressure maneuver. Rupture was identified by computed tomography (CT) in six cases. Patients with ruptured cysts had significantly higher serum C-reactive protein (CRP), cancer antigen 125 (CA125), carbohydrate antigen 19-9 (CA19-9), and squamous cell carcinoma antigen (SCC) levels compared with patients with uncomplicated dermoid cysts or cysts with torsion. Laparoscopic management was possible except for one case with severe adhesion, which required laparotomy. Two patients required prolonged postoperative administration of antibiotics due to refractory chemical peritonitis. CONCLUSION: Combined use of CT imaging and elevated levels of CRP, CA125, CA19-9, and SCC may help to differentiate cyst rupture from torsion. Laparoscopic surgery may be a feasible option; however, prompt laparotomic conversion should be considered in cases with difficult adhesiolysis. Refractory chemical peritonitis may occur after successful surgical management.

Pill Ingestion and Caustic Laryngeal Injury.

OBJECTIVE: To highlight an unusual mechanism of laryngeal injury. METHODS: Case report and literature review. RESULTS: A 66-year-old male ingested an over-the-counter preparation of bile acids as a dietary supplement. The capsule lodged in the patient's pharynx, and he sustained a caustic injury to the supraglottic and glottic larynx. His injury was managed conservatively, and his symptoms gradually resolved over a period of 8 weeks. A follow-up laryngoscopy at 8 weeks and 6 months showed no signs of injury. A barium swallow at 8 weeks was normal at that time and videostroboscopy results normalized with resolution of the injury as well. CONCLUSIONS: Caustic injury to the upper aerodigestive tract from pill ingestion is uncommon, and laryngeal injury even less so. Urgent evaluation should be undertaken, and appropriate therapies instituted promptly. Laryngeal injury can respond to conservative therapy, but there is a lack of clinical information to evaluate optimum treatment of this unusual injury.

Ocular-periocular burns in a tertiary hospital: Epidemiologic characteristics.

PURPOSE: Ocular burns are ophthalmic emergencies that can cause devastating injuries. This study aimed to analyze the epidemiology, complications, and management of ocular-periocular burns. METHODS: A total of 193 patients with ocular-periocular burns were admitted to our tertiary hospital from January 2018 to December 2020. The demographic characteristics of the patients, injury variables, complications, and treatments were evaluated. RESULTS: There were 142 male (73.6%) and 51 female (26.4%) patients with a mean age of 32.53±17.75 years. The average total body surface area was 12% (range, 1-80%). Injuries were most common at work (52.3%) and home (36.3%). Thermal burns were the most common injuries (74.6%), followed by chemical (14.5%) and electrical burns (10.9%). Alkaline agents (75.0%), mainly sodium hydroxide and lime, were common in chemical burns. Superficial lid burns were significantly higher in the thermal group (p < 0.001), and grade III-IV corneal burns were significantly higher in the chemical group (p < 0.001). Various complications were developed in 50 (13%) eyes. Medical treatment only was performed in 318 (82.4%) eyes, and additional surgical treatment was performed in 64 (17.6%) eyes; however, 54 (14.0%) underwent more than one surgery. The most common complications were corneal scars (7.3%), limbal deficiency (4.1%), and ectropion (3.9%). The most frequent procedures performed were amniotic membrane transplantation (AMT) (11.9%) and tarsorrhaphy (6.7%). CONCLUSION: Chemical burns, limbal and conjunctival ischemia, and full-thickness eyelid defects had a poor prognosis. The degree of limbal deficiency and injury of intraocular structures were found to have a great influence on the outcome of their visual acuity.

Carbide Gun-Related Ocular Injuries: A Case Series.

PURPOSE: The purpose of this study was to report a case series of sight-threatening ocular injuries caused by calcium carbide guns used as fire crackers. METHODS: Medical records of 15 eyes of 14 patients with ocular injuries caused while using carbide guns, visiting the Institute, from January 2021 to January 2022, were retrospectively reviewed. The collected data included patients' demography (age, sex), presenting ophthalmic features, management, and outcome. Grade I and II ocular injuries were managed medically. All grade III-V injuries were managed using Amniotic Membrane Transplantation. RESULTS: All patients were male. The mean age of the patients was 23.57 ± 11.76 years. According to the Dua classification, 5 eyes (33.3%) had Grade I-II ocular surface burns, 3 eyes (20%) had grade III burns, and 7 eyes (46.6%) had grade IV-VI burns. Presenting visual acuity ranged between hand movements to 20/50, and in 6 eyes (40%), the visual acuity was ≤20/200. Five eyes were managed medically alone, and 10 (66.6%) eyes needed surgical intervention (Amniotic Membrane Transplantation). After a mean follow-up of 14.23 ± 11.92 weeks, complete epithelization was seen in 10 eyes (66.6%). Partial limbal stem cell deficiency and its sequelae such as conjunctivalization of the cornea were noted in 7 eyes (46.6%). CONCLUSIONS: Calcium carbide-related ocular injuries can result in corneal blindness secondary to limbal stem cell deficiency in young individuals. Loss of vision in this age group can lead to loss of economic productivity and cosmetic disfigurement. More advocacy efforts are thus needed to prevent these injuries.

Clinical Characteristics and Severity Distribution of Tertiary Eye Center Attendance by Ocular Chemical Injury Patients.

OBJECTIVES: To report demographic characteristics, types and grades of injury, regional distribution of injury severity, clinical findings, and long-term results of acute ocular chemical burns. METHODS: Medical records of patients with chemical burns between 2010 and 2020 who were admitted to Ege University less than 72 hr after the injury were reviewed. Age, gender, cause of the burn, injury severity, initial and final best-corrected visual acuity, surgical intervention, and complications were recorded. The injury severity was graded according to Dua classification. RESULTS: A total of 104 patients (137 eyes) were included. The mean age was 42.69±17.39 (7-90) years with a male-to-female ratio of 86:18. The most common causes were home (32.6%) and industrial accidents (45.1%). The causative agent percentages for alkaline, acid, and neutral were 49.0%, 35.5%, and 5.7%, respectively. The percentages of eyes in each grade (1-6) were 16.0%, 16.0%, 15.3%, 16.7%, 17.5%, and 18.2%, respectively. Complications mostly occurred in eyes with grade 2 or higher injuries (83.7%). The relationship between injury grade and limbal stem-cell deficiency was statistically significant (P<0.001). Surgery was mostly needed in grade 4 or higher injuries (44 eyes). CONCLUSION: The severity of the burn is one of the most important prognostic factors in chemical burns. It is important to determine the spreading of the regional injury severity beside the global one to predict complication risk of the injuries. In the present study, the injury distribution was homogeneous in all grades. Limbal stem-cell deficiency development took place mostly in grade 5 and 6 burns as expected.

CEMENT BURNS.

BACKGROUND: Burns are a common condition presenting to the emergency department; the majority are thermal burns. The treatment for thermal burns and chemical burns differs greatly, and prompt recognition of a chemical burn is necessary. An often unrecognized and underestimated type of chemical burn is an alkali burn from wet cement. CASE REPORT: A 7-year-old boy was transferred from an outside facility for evaluation of burns after exposure to wet cement. The patient underwent partial decontamination at the outside facility with polyethylene glycol and, to prevent ongoing alkali burns, the patient necessitated further decontamination with irrigation. Burn surgery was consulted for additional evaluation. The patient required no further intervention and the patient was discharged to home and made a full recovery. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Serious morbidity and mortality can occur from unrecognized cement burns, and early decontamination and evaluation by a burn surgeon is necessary. It is critical that emergency physicians both recognize and appropriately treat this condition in a timely manner to prevent adverse outcomes.

Canonical NF-κB signaling maintains corneal epithelial integrity and prevents corneal aging via retinoic acid.

Disorders of the transparent cornea affect millions of people worldwide. However, how to maintain and/or regenerate this organ remains unclear. Here, we show that Rela (encoding a canonical NF-κB subunit) ablation in K14+ corneal epithelial stem cells not only disrupts corneal regeneration but also results in age-dependent epithelial deterioration, which triggers aberrant wound-healing processes including stromal remodeling, neovascularization, epithelial metaplasia, and plaque formation at the central cornea. These anomalies are largely recapitulated in normal mice that age naturally. Mechanistically, Rela deletion suppresses expression of Aldh1a1, an enzyme required for retinoic acid synthesis from vitamin A. Retinoic acid administration blocks development of ocular anomalies in Krt14-Cre; Relaf/f mice and naturally aged mice. Moreover, epithelial metaplasia and plaque formation are preventable by inhibition of angiogenesis. This study thus uncovers the major mechanisms governing corneal maintenance, regeneration, and aging and identifies the NF-κB-retinoic acid pathway as a therapeutic target for corneal disorders.

Electronic Cigarette-Related Injuries Presenting to Five Large Burn Centers, 2015-2019.

Electronic cigarettes are advertised as safer alternatives to traditional cigarettes yet cause serious injury. U.S. burn centers have witnessed a rise in both inpatient and outpatient visits to treat thermal injuries related to their use. A multicenter retrospective chart review of American Burn Association burn registry data from five large burn centers was performed from January 2015 to July 2019 to identify patients with electronic cigarette-related injuries. A total of 127 patients were identified. Most sustained less than 10% total body surface area burns (mean 3.8%). Sixty-six percent sustained second-degree burns. Most patients (78%) were injured while using their device. Eighteen percent of patients reported spontaneous device combustion. Two patients were injured while changing their device battery, and two were injured modifying their device. Three percent were injured by secondhand mechanism. Burn injury was the most common injury pattern (100%), followed by blast injury (3.93%). Flame burns were the most common (70%) type of thermal injury; however, most patients sustained a combination-type injury secondary to multiple burn mechanisms. The most injured body region was the extremities. Silver sulfadiazine was the most common agent used in the initial management of thermal injuries. Sixty-three percent of patients did not require surgery. Of the 36% requiring surgery, 43.4% required skin grafting. Multiple surgeries were uncommon. Our data recognize electronic cigarette use as a public health problem with the potential to cause thermal injury and secondary trauma. Most patients are treated on an inpatient basis although most patients treated on an outpatient basis have good outcomes.

Current practices in the management of corrosive ingestion in children: A questionnaire-based survey and recommendations.

BACKGROUND AND AIM: Corrosive ingestion causes significant morbidity in children with no standard guidelines regarding management. This survey aimed to understand practices adopted by gastroenterologists, identify lacunae in evaluation and management and suggest a practical algorithm. METHODS: Indian gastroenterologists participated in an online survey (65 questions) on managing corrosive ingestion. When ≥ 50% of respondents agreed on a management option, it was considered as 'agreement'. RESULTS: Ninety-eight gastroenterologists (72 pediatric) who had managed a total of ~ 2600 corrosive ingestions in the last 5 years responded. The commonest age group affected was 2-5 years (61%). Majority of ingestion was accidental (89%) with 80% due to improper corrosive storage. Ingestion of alkali and acid was equally common (alkali 41%, acid 39%, unknown 20%). History of inducing-vomiting after ingestion by community physicians was present in 57%. There was an agreement on 77% of questions. The respondents agreed on endoscopy (70%) and chest X-ray (67%) in all, irrespective of symptoms. Endoscopy was considered safe on days 1-5 after ingestion (91%) and relatively contraindicated thereafter. The consensus was to use acid suppression, always (59%); steroids, never (68%) and antibiotics, if indicated (59%). Feeding was based on endoscopic findings: oral in mild injuries and nasogastric (NG) in others. Eighty percent placed a NG tube under endoscopic guidance. Stricture dilatation was considered safe after 4 weeks of ingestion. Agreement on duration of acid suppression and stricture management (dilatation protocol and refractory strictures) was lacking. CONCLUSION: Corrosive ingestion mostly affects 2-5-year olds and is accidental in majority. It can be potentially prevented by proper storage and labelling of corrosives. An algorithm for management is proposed.

Guttate psoriasis: a case of unusual evolution of an occupation-related skin chemical burns.

INTRODUCTION: Chemical burns are a risk in domestic and occupational accidents due to the common use of caustic agents. Long-term sequelae are normally due to the amount of skin and underlying tissues damaged. We describe a case of work-related chemical burns with unusual evolution in guttate psoriasis. CASE REPORT: A 36 years-old man was admitted to the Emergency Department (ED) three-hours after a work accident. During the cleaning of an industrial hydraulic system, a jet of hydrochloric acid 20% injured his face and upper limbs. At ED admission, he presented first and second-degree skin burns on the frontal region, on the scalp, on the right forearm, and earlobe. Plastic surgery management consisted in wound topical dressing with silver sulfadiazine and paraffin gauze twice a week for one month. Forty-eight hours after the latter topical treatment (45-days after the work accident), in the same anatomical regions of the previous burn scars, he developed a skin reaction with itchy erythema. The application of topical products was suspended without improvement, excluding an allergic reaction. Within few days, a generalized guttate psoriasis was evident on the whole body. DISCUSSION: Despite many prevention actions, work-related burns are a relatively common cause of hospitalization and may involve up to 80% of patients admitted to a burn unit. Guttate psoriasis has not been described as a sequelae of chemical burns. In our case, the others most frequent factors causing guttate psoriasis have been ruled out. Considering the temporal link between the development of guttate psoriasis and the work accident, hydrochloric acid skin burns might have promoted the systemic inflammatory mediators' mechanism involved in the development of guttate psoriasis lesion's after the dermal injury.

Acetylsalicylic Acid Promotes Corneal Epithelium Migration by Regulating Neutrophil Extracellular Traps in Alkali Burn.

Neutrophils are the first cells to migrate into the cornea in response to alkali burns, and excessive neutrophil infiltration is associated with inflammatory injury and a poorer prognosis. In an effort to understand the mechanisms underlying the inflammation mediated by neutrophils after alkali burns, we examined the role of alkali-activated neutrophils on human corneal epithelial cells (HCEs) proliferation and migration, as well as the effects of acetylsalicylic acid (ASA) and dexamethasone (DXM) on NETosis. We stimulated human neutrophils with sodium hydroxide (NaOH) and observed dose- and time-dependent neutrophil extracellular traps (NETs) formation. We also observed that ASA, but not DXM, significantly inhibited NaOH-induced NETosis. Furthermore, the activation of nuclear factor (NF)-κB, but not the production of reactive oxygen species, was involved in ASA-regulated NETosis. Moreover, NETs were found to be involved in alkali-activated neutrophils (ANs) induced neutrophil-HCE adhesion. ANs enhanced HCEs proliferation via phagocytosis. Meanwhile, ANs inhibited HCEs migration through the release of NETs, which was partially rescued by 5 mM ASA. In conclusion, ANs may interfere with HCEs proliferation and migration by phagocytosis and NETs formation, respectively. ASA may enhance HCEs migration by decreasing NETs formation through inhibition of NF-κB activation and could be a promising strategy for improving the prognosis of corneal alkali burns.

A Retrospective Multicenter Study of 1898 Liquefied Petroleum Gas-Related Burn Patients in Eastern China From 2011 to 2015.

Liquefied petroleum gas (LPG) is a widely used environment-friendly fuel. Previous studies have shown an increasing number of LPG-related burns. Our study was designed to evaluate the epidemiologic pattern of these injuries and provide recommendations for burn prevention. This retrospective study included all patients with LPG-related burns from eight burn centers in Zhejiang Province, China between 2011 and 2015. Database variables included patient demographics, accident characteristics, and injury characteristics. The association between different categorical variables was identified using the chi-square test. And the association between two or more means of quantitative variables was analyzed by the one-way analysis of variance or t-test. A total of 1898 patients were included, 47.31% were males and 52.69% were females. The predominant age group was 31 to 70 years (74.50%), and the majority were poorly educated and the incidence peaked from June to September. The most common place of occurrence was home (74.08%) and gas leak (96.52%) was the most common cause. The four limbs (43.33%) were the most frequently affected areas; the mean burn area was 25.19 ± 20.97% of the total body surface area and most patients (46.89%) suffered from moderate burns. The mean length of hospital stay was 17.66 ± 16.55 days and the majority of patients (89.36%) recovered with a 0.84% mortality rate. Our findings reflected that the increase in incidence rate was alarming, and the causes resulting in LPG-related burns have not gained much attention yet. Therefore, this calls for simple but strict measures aiming at each hazardous step during the use of LPG to prevent these burn injuries.

Anesthesia Implications of Patient Use of Electronic Cigarettes.

Electronic cigarettes are essentially electronic nicotine delivery systems (ENDS). Use of ENDS has increased sharply in the United States in recent years, particularly among youth. We reviewed the literature on ENDS use, based on a PubMed search, with a focus on effects that could influence anesthetic and surgical outcomes. We also included a meta-analysis of articles published between 2016 and 2018 reporting injuries from exploding ENDS. These devices deliver nicotine, which is addictive and a cardiac stimulant. The nicotine in ENDS has been linked to increased risk of heart disease and myocardial infarction. Also, ENDS deliver vapors of solvents, flavorings, and other chemicals that can cause chronic and acute respiratory diseases. Furthermore, ENDS use may pose a cancer risk. However, ENDS are somewhat less dangerous than cigarettes and are used as smoking cessation devices. From the literature review, we identified 15 articles reporting injuries from ENDS fires and explosions to 93 patients. Most of these patients were young (mean age = 31.6 years) and male (91%). The most common injury sites were the thigh (62%) and hand (33%). Because the anesthetist will likely encounter increasing numbers of ENDS users in the future, it is important to identify these patients and to understand the risks of ENDS use.

Guía de práctica clínica Ibero-Latinoamericana sobre la esofagitis cáustica en Pediatría: aspectos terapéuticos (2a. Parte) / Ibero-Latinamerican Clinical Practical Guidelines on pediatric caustic esophagitis: therapeutical aspects (Part 2)

Resumen: La ingestión de cáusticos representa un grave problema médico-social por las consecuencias devastadoras e irreversibles que puede producir en el tracto digestivo superior. En Iberoamérica no se han publicado datos fidedignos sobre la incidencia o la prevalencia de lesiones inducidas por cáusticos. La información disponible sobre la presentación clínica, diagnóstico, tratamiento y pronóstico se basa en series retrospectivas de casos y, de hecho, su manejo clínico se sustenta en muchos casos fundamentalmente en la opinión de expertos. Recientemente como una iniciativa de la Sociedad Latinoamericana de Gastroenterología, Hepatología y Nutrición Pediátrica (SLAGHNP) y con la co laboración de colegas de la Sociedad Española de Gastroenterología, Hepatología y Nutrición Pediá trica (SEGHNP), hemos diseñado una Guía de Práctica Clínica (GPC) la cual incluye una serie de enunciados y recomendaciones dirigidos a optimizar la atención a los pacientes y que se basan en la revisión sistemática de la evidencia. En dos (2) manuscritos sucesivos nos hemos enfocado primero, en los aspectos fisiopatológicos y de diagnóstico clínico-endoscópico de la esofagitis cáustica en niños (1a. Parte) y en segundo lugar, en los aspectos más relevantes del tratamiento (2a. Parte). Esperamos esta guía se convierta en una herramienta útil para el clínico en el difícil proceso de toma de decisio nes a la hora de evaluar un paciente posterior a la ingesta de una sustancia cáustica.

Abstract: Caustic ingestion represents a serious social-medical problem due to the devastating and irreversible consequences it can produce in the upper digestive tract. In Ibero-America, there are no published reliable data on the incidence or prevalence of caustic-induced injuries, and most of the available information on clinical presentation, diagnosis, treatment, and prognosis is based on retrospective clinical series and, indeed, its clinical management is often based primarily on expert opinion. Re cently as an initiative of the Latin American Society for Pediatric Gastroenterology, Hepatology and Nutrition (LASPGHAN) and with the cooperation of the Spanish Society for Pediatric Gastroente rology, Hepatology and Nutrition (SEGHNP), we have designed a Clinical Practice Guideline that include a series of statements and recommendations aimed at optimizing patient medical care which is based on the systematic review of evidence. Two (2) separate papers focused on the evaluation of physiopathological and clinical-endoscopic diagnostic features of caustic esophagitis in children (1st. Paper) and, on the other hand, the most relevant therapeutic considerations (2nd. Paper). We expect this guideline to become a useful tool for the physician in the difficult decision-making process when assessing patients after caustic ingestion.