Global epidemiology of childhood bone and joint infection: a systematic review.

PURPOSE: Childhood bone and joint infection (BJI) is a potentially severe disease that may have permanent sequelae, including growth impairment and limb deformity. It has been characterised in the literature with a focus on Western epidemiology; there are currently no reports detailing global epidemiology and bacteriology. This omits key data from determining temporal trends, appropriate antibiotic therapy, and resource allocation. This review aims to identify studies that characterise the incidence of childhood bone and joint infection or provide detailed bacteriology within their region. METHODS: A systematic review of the literature was performed from 01/01/1980 to 31/12/2020. Data has been analysed to give incidence of disease per 100,000 children, primary pathogen by country where available, and risk ratio (RR) for disease by ethnicity. This is applicable for areas that experience race-related inequitable burden of disease. RESULTS: Forty-four articles met the inclusion area; of these, seven were population-wide studies, primarily from Europe or the United States, and the remainder were cohort studies. Incidence could be derived from 26 studies compromising over 34, 000 children. Information on bacteriology was available from 39 publications (10, 957 cases). Methicillin-sensitive Staphylococcus aureus is the most common pathogen in the West. Recently, disease secondary to Kingella kingae and methicillin-resistant S. aureus has increased. Salmonella remains a dominant pathogen in African regions. Increased risk of disease is observed in Aboriginal, New Zealand Maori, Pacific, Indigenous Fijian, and Bedouin children. CONCLUSION: The current state of the literature detailing incidence of childhood BJI focuses on disease patterns from the West. There is a paucity of high-quality publications in the developing world. Despite these limitations, global trends in burden of disease show race-related inequitable risk of BJI. Temporal and regional variation in bacteriology can be demonstrated. LEVEL OF EVIDENCE: III.

Impact of a Daily Huddle on Safety in Perioperative Services.

BACKGROUND: Communication failures contribute to quality gaps and may lead to serious safety events (SSEs) in the operating room (OR). Our perioperative services team experienced an increased rate of SSEs in 2020. Event analysis revealed clustered causes: communication failures and lack of timely information to prepare for cases. Consequently, the team implemented a daily morning OR safety huddle conducted before bringing patients into the OR to reduce quality gaps and improve communication. METHODS: The attending surgeon and anesthesiologist, circulating nurse, and scrub staff are required to be present. Cases are discussed using a standard format designed by the OR team with built-in time for questions and clarifications. The surgeon initiates the huddle; the circulating nurse leads and records the discussion. OR leadership initially performed daily audits but gradually reduced them when huddles became standard operating procedure (SOP). SSEs were recorded from December 2015 to September 2020 preintervention and October 2020 to July 2023 postintervention. RESULTS: Following the implementation of huddles, there were no SSEs for more than 900 days (2.0 SSEs/year preintervention vs. 0.0 SSEs/year postintervention). The first SSE during the postintervention period occurred in March 2023. Huddle compliance was consistently > 95%. No delays were observed in first-case on-time starts postintervention. The huddle is now SOP for all general OR teams and interventional radiology. CONCLUSION: Implementing the morning safety huddle contributed to a reduction in the rate of SSEs without introducing delays to first-case start-times.

Skin decontamination: principles and perspectives.

Skin decontamination is the primary intervention needed in chemical, biological and radiological exposures, involving immediate removal of the contaminant from the skin performed in the most efficient way. The most readily available decontamination system on a practical basis is washing with soap and water or water only. Timely use of flushing with copious amounts of water may physically remove the contaminant. However, this traditional method may not be completely effective, and contaminants left on the skin after traditional washing procedures can have toxic consequences. This article focuses on the principles and practices of skin decontamination.

Movement disorders in adult surviving patients with maple syrup urine disease.

Maple syrup urine disease is a rare metabolic disorder caused by mutations in the branched-chain α-keto acid dehydrogenase complex gene. Patients generally present early in life with a toxic encephalopathy because of the accumulation of the branched-chain amino acids leucine, isoleucine, and valine and the corresponding ketoacids. Movement disorders in maple syrup urine disease have typically been described during decompensation episodes or at presentation in the context of a toxic encephalopathy, with complete resolution after appropriate dietary treatment. Movement disorders in patients surviving childhood are not well documented. We assessed 17 adult patients with maple syrup urine disease (mean age, 27.5 years) with a special focus on movement disorders. Twelve (70.6%) had a movement disorder on clinical examination, mainly tremor and dystonia or a combination of both. Parkinsonism and simple motor tics were also observed. Pyramidal signs were present in 11 patients (64.7%), and a spastic-dystonic gait was observed in 6 patients (35.2%). In summary, movement disorders are common in treated adult patients with maple syrup urine disease, and careful neurological examination is advisable to identify those who may benefit from specific therapy. © 2011 Movement Disorder Society.

Dietary treatment of phenylketonuria: the effect of phenylalanine on reaction time.

There is no evidence that high phenylalanine (Phe) levels have irreversible effects on the adult brain. Many adults with phenylketonuria (PKU) no longer follow a protein-restricted diet. Neuropsychological studies have shown that reaction time in adults with PKU is slower than controls. There are no data to show that this is directly related to Phe levels. Another way to assess reaction time is to measure saccadic latency. We have used a portable, head-mounted saccadometer to measure latency in the outpatient setting. Patients with PKU were split into three groups: off-diet (Phe >1,200 µmol/l), on-diet (Phe < 800 µmol/l) and maternal diet (Phe 100-400 µmol/l ). Reciprocal median latency (RML) was compared between groups. Latency was significantly slower in patients who were off-diet than in patients on-diet, on a maternal diet or in normal controls. Reaction times in both diet-treated groups were not significantly different from normal controls. In 16 women planning pregnancy we obtained values before and after they commenced the maternal diet. Stricter control of Phe levels resulted in a significant improvement in reaction times. We conclude that saccadometry is useful in monitoring PKU patients. Adult patients with PKU not on a protein-restricted diet have significantly slower reaction times than controls. In addition, off-diet patients have significantly slower reaction times than on-diet. Paired data show that effects of Phe levels on reaction time are reversible.

Correlation of transepidermal water loss with skin barrier properties in vitro: comparison of three evaporimeters.

AIM: This study investigates the relationship between transepidermal water loss (TEWL) and skin permeability to tritiated water as a rapid assessment of the integrity of the barrier properties of skin as part of in vitro skin permeation studies. METHODS: TEWL values before and during the experimental period were measured using three evaporimeters (A, B, and C) representing different measuring principles and technologies. Single application of tritiated water was dosed on dermatomed human skin samples in a flow-through diffusion cell system. Radioactivity of the absorbed dose and the removable dose residues was counted to determine percent dose and flux rate. These data were further combined with TEWL values to analyze the correlation. RESULTS: Evaporimeter C, a closed chamber-condenser technology, had higher measurement capacity than other instruments, evaporimeter A, an open chamber, and evaporimeter B, a closed chamber (P<0.001). The baseline TEWL value correlated with tritiated water flux (r=0.34, P=0.04). The pattern of tritiated water expressed as percent dose permeated into receptor fluid was similar to that of TEWL values. CONCLUSION: These data indicate that TEWL can be ascribed to be a measure of skin water barrier function. Further work should be conducted to interpret the significance of measuring TEWL by evaporimetry.

Hair highlights and severe acute irritant dermatitis ("burn") of the scalp.

CONTEXT: These days, most celebrities--young and old--have their hair highlighted. That is why it is not surprising that even the youth have their hair highlighted as they emulate their favorite actors, unaware of the harmful consequences of this unsafe procedure. Hair highlighting involves decolorizing melanin pigments of select hair strands through an oxidation reaction under alkaline conditions by the active ingredients of the highlighting mixture--hydrogen peroxide, persulfates, and metasilicate. Hydrogen peroxide and the persulfates are flammable, necessitating that regulatory bodies (namely, the U.S. Food and Drug Administration [FDA] and the Cosmetic Ingredient Review [CIR] Expert Panel, the European Union's (EU), European Economic Community [EEC] directives, the Australian government's National Industrial Chemicals Notification and Assessment Scheme [NICNAS], and the Association of Southeast Asian Nations [ASEAN]) to regulate the permissible amounts of these chemicals in hair highlighting products. OBJECTIVES: To review published case reports of resulting in severe acute irritant dermatitis ("burns") of the scalp caused by hair highlighting, to explain why these scalp burns happen, to identify preventive measures to avoid such occurrences, and to discuss the implications for society. MATERIALS AND METHODS: We searched medical and scientific search engines and used keywords such as hair highlights, scalp burn, and other related terms.. RESULTS: Six articles were obtained, yielding 8 reported cases (2 of the 6 articles had 2 cases each) of hair highlighting resulting in scalp burns; these 8 cases were reviewed and analyzed. Five of the 8 patients belonged to the pediatric age group. DISCUSSION: The causes of scalp burn were classified into 2 categories: chemical (caustic nature of the highlighting mixture, spillage of the hot mixture, toxic reaction to the dyes) and thermal (by contact of the scalp with overheated aluminum foil and by the blow dryer). The 5 pediatric patients in the group unnecessarily suffered pain and embarrassment caused by this procedure, as well as the risk of developing malignancy in the future. CONCLUSIONS: Hairstylists play a large role in the occurrence of scalp burns. Thus, they need to be careful and knowledgeable of the caustic nature of the highlighting mixture and the potential harm these chemicals may cause. The authors strongly propose that the relevant regulatory bodies review the permissible levels of the caustic chemicals, and that this unsafe procedure should be performed only on adults.

Dietary practices in methylmalonic acidaemia: a European survey.

Background The dietary management of methylmalonic acidaemia (MMA) is a low-protein diet providing sufficient energy to avoid catabolism and to limit production of methylmalonic acid. The goal is to achieve normal growth, good nutritional status and the maintenance of metabolic stability. Aim To describe the dietary management of patients with MMA across Europe. Methods A cross-sectional questionnaire was sent to European colleagues managing inherited metabolic disorders (IMDs) (n=53) with 27 questions about the nutritional management of organic acidaemias. Data were analysed by different age ranges (0-6 months; 7-12 months; 1-10 years; 11-16 years; >16 years). Results Questionnaires were returned from 53 centres. Twenty-five centres cared for 80 patients with MMA vitamin B12 responsive (MMAB12r) and 43 centres managed 215 patients with MMA vitamin B12 non-responsive (MMAB12nr). For MMAB12r patients, 44% of centres (n=11/25) prescribed natural protein below the World Health Organization/Food and Agriculture Organization/United Nations University (WHO/FAO/UNU) 2007 safe levels of protein intake in at least one age range. Precursor-free amino acids (PFAA) were prescribed by 40% of centres (10/25) caring for 36% (29/80) of all the patients. For MMAB12nr patients, 72% of centres (n=31/43) prescribed natural protein below the safe levels of protein intake (WHO/FAO/UNU 2007) in at least one age range. PFAA were prescribed by 77% of centres (n=33/43) managing 81% (n=174/215) of patients. In MMAB12nr patients, 90 (42%) required tube feeding: 25 via a nasogastric tube and 65 via a gastrostomy. Conclusions A high percentage of centres used PFAA in MMA patients together with a protein prescription that provided less than the safe levels of natural protein intake. However, there was inconsistent practices across Europe. Long-term efficacy studies are needed to study patient outcome when using PFAA with different severities of natural protein restrictions in patients with MMA to guide future practice.

Measuring human skin buffering capacity: an in vitro model.

BACKGROUND/PURPOSE: It has been thought that skin possesses buffering capacity. This study measured the skin buffering capacity against two model solutions of acid and base at three concentrations with an in vitro system. METHODS: Ten microliters of model base (sodium hydroxide--NaOH) and acid (hydrochloric acid--HCl) solutions at concentrations of 0.025, 0.05, and 0.1 N was applied to human cadaver skin (3.18 microL/cm(2)) placed onto glass diffusion cells. Phosphate-buffered saline (PBS) was used as a standard buffer solution. Deionized water served as the negative control, whereas untreated skin served as the blank control. Skin pH was read and recorded immediately following dosing (0 time), and at 10 and 30 min of post-dosing. After the 30 min of dosing, each skin, except untreated skin (blank control), was then washed by applying 1 cm(3) of deionized water. The pH on each washed skin was measured immediately following washing, and the pH measurement was repeated at 10 and 30 min of post-washing. Six replicates were conducted. RESULTS: The pH values sharply significantly increased (P<0.05) immediately following dosing with NaOH at all concentrations (the highest concentration, caused the highest pH), and then decreased closely to baselines within 30 min post-application but still remained at significantly (P<0.05) higher values when compared with the blank control (untreated skin). HCl (acid) significantly (P<0.05) decreased skin pH immediately following dosing with all concentrations (the highest concentration, caused the lowest pH) and then restored rapidly to baseline. There was no significant difference in post-washing procedures on the skins that were pre-treated with the acid (HCI) solutions. However, with all base solutions (NaOH) pre-treated skin, pH values were significantly higher (P<0.05) at all time points post-washing. Furthermore, both PBS and water controls significantly elevated (P<0.05) the pH values following washing. CONCLUSION: Skin pH and its buffering capacity can be measured on human cadaver skin in vitro, which may partially replicate the response of in vivo skin. Dose-response was noted; i.e. the higher concentration caused larger changes in skin pH. In addition, the restoration of skin pH is relatively faster with acid when compared with base treatment. Clinical implications are offered.

Cutaneous bioengineering instrumentation standardization: the Tissue Viability Imager.

BACKGROUND: Tissue Viability Imaging (TiVi) is a new bioengineering technology intended for remote two-dimensional mapping of skin red blood cell concentration (RBC(conc)). Before use in the laboratory, work-site and dermatology clinic, critical performance parameters of this emerging technology require careful evaluation. OBJECTIVE: To assess short- and long-term stability, image uniformity, distance and image size dependence, ambient light and curvature influence in a production batch of Tissue Viability Imagers. METHODS: Four Tissue Viability Imagers from the same production batch were evaluated at two laboratories (one industrial and one dermatological) with respect to critical parameter performance. RESULTS: The average systematic drift in sensitivity over time was 0.27% and <1.02% for all four units tested. Difference in sensitivity between units was limited to 4.1% and was due to offset rather than gain deviation. Spatial variation in image uniformity was below 3.08% and 1.93% in the corners and centre of an individual image, respectively. This spatial variation could be further reduced to 0.25% and 0.13%, respectively by image normalization. Ambient light from a 40 W bulb or a 11 W fluorescent light source at a distance of 50-60 cm above the object, reduced the recorded values by about 10%, while the camera to object distance and image size had no detectable influence on sensitivity. Curved objects, such as human forearm, demonstrated an edge effect limited to below 10%. CONCLUSION: The critical TiVi performance parameters evaluated proved stable in relation to expected variations in skin RBC(conc) over time. Calibration by way of a two-point method may reduce differences in sensitivity between instruments to further facilitate inter-laboratory comparison of results.

Tissue viability imaging: mapping skin erythema.

BACKGROUND: Tissue Viability Imaging (TiVi) is an emerging bioengineering technology intended for two-dimensional mapping of skin erythema and blanching. Before TiVi can be effectively used in studies of diseased or damaged skin, the variability in normal skin red blood cell concentration (RBC(conc)) requires evaluation. OBJECTIVE: To demonstrate how TiVi maps spatial and temporal variations in normal skin RBC(conc) at the dorsal side of the hand at rest and during post-occlusive hyperemia. METHODS: Short-term and day-to-day variations in skin RBC(conc) were quantified at the dorsal side of the hand in four healthy volunteers at rest. In a separate study, the increase in skin RBC(conc) was recorded during post-occlusive hyperemia. RESULTS: A lower skin RBC(conc) (179-184 TiVi units) was observed at the back of the hand and base of the thumb compared with areas adjacent to the nailfoldfold region of the fingers (190-213 TiVi units). The short-term variation (within 70 s) was <2% in all areas of the dorsal side of the hand, while day-to-day variations were in the range 5-7% in the back of the hand and up to 10% in areas adjacent to the nailfold region. In the post-occlusive hyperemia phase, up to a 60% increase in skin RBC(conc) was observed in the early part of the reactive hyperemia phase. This increase in skin RBC(conc) successively decreased but remained about 18% above the pre-occlusion level after 30 min. CONCLUSION: Establishment of healthy skin RBC(conc) reference values is important for the design of versatile test procedures for assessment of skin damage caused by vibration tools, chemical exposure or peripheral vascular disease.

Comparison of tissue viability imaging and colorimetry: skin blanching.

BACKGROUND: Operator-independent assessment of skin blanching is important in the development and evaluation of topically applied steroids. Spectroscopic instruments based on hand-held probes, however, include elements of operator dependence such as difference in applied pressure and probe misalignment, while laser Doppler-based methods are better suited for demonstration of skin vasodilatation than for vasoconstriction. OBJECTIVE: To demonstrate the potential of the emerging technology of Tissue Viability Imaging (TiVi) in the objective and operator-independent assessment of skin blanching. METHODS: The WheelsBridge TiVi600 Tissue Viability Imager was used for quantification of human skin blanching with the Minolta chromameter CR 200 as an independent colorimeter reference method. Desoximetasone gel 0.05% was applied topically on the volar side of the forearm under occlusion for 6 h in four healthy adults. In a separate study, the induction of blanching in the occlusion phase was mapped using a transparent occlusion cover. RESULTS: The relative uncertainty in the blanching estimate produced by the Tissue Viability Imager was about 5% and similar to that of the chromameter operated by a single user and taking the a(*) parameter as a measure of blanching. Estimation of skin blanching could also be performed in the presence of a transient paradoxical erythema, using the integrated TiVi software. The successive induction of skin blanching during the occlusion phase could readily be mapped by the Tissue Viability Imager. CONCLUSION: TiVi seems to be suitable for operator-independent and remote mapping of human skin blanching, eliminating the main disadvantages of methods based on hand-held probes.

Nutritional and Metabolic Characteristics of UK Adult Phenylketonuria Patients with Varying Dietary Adherence.

The nutritional and metabolic characteristics of adult phenylketonuria (PKU) patients in the UK with varying dietary adherence is unknown. In other countries, nutritional and metabolic abnormalities have been reported in nonadherent patients compared to adherent counterparts. A pooled analysis of primary baseline data from two UK multi-centre studies was therefore performed to establish whether this is true from a UK perspective. Adult PKU patients who had provided 3-day food records and amino acid blood samples were included and grouped according to dietary adherence (adherent; n = 16 vs. nonadherent; n = 14). Nonadherent patients consumed greater amounts of natural protein compared to adherent patients (61.6 ± 30.7 vs. 18.3 ± 7.7 g/day; q < 0.001). In contrast, the contribution of protein substitutes to total protein intake was lower in nonadherent compared to adherent patients (3.9 ± 9.2 g/day vs. 58.6 ± 10.2 g/day; q < 0.001). Intakes of iron, zinc, vitamin D3, magnesium, calcium, selenium, iodine, vitamin C, vitamin A and copper were significantly lower in nonadherent compared to adherent patients and were below UK Reference Nutrient Intakes. Similarly, intakes of thiamin, riboflavin, niacin, vitamin B6 and phosphorus were significantly lower in nonadherent compared to adherent patients but met the UK Reference Nutrient Intakes. Phenylalanine concentrations in nonadherent patients were significantly higher than adherent patients (861 ± 348 vs. 464 ± 196 µmol/L; q=0.040) and fell outside of European treatment target ranges. This study shows the nutritional and metabolic consequences of deviation from phenylalanine restriction and intake of PKU protein substitutes in nonadherent adult PKU patients. Collectively, these data further underlie the importance of life-long adherence to the PKU diet.

Hydrogen peroxide, blanching, and skin: an overview.

For more than a century, hydrogen peroxide (H(2)O(2)) has been known as an antiseptic. Three percent H(2)O(2) is used in minor wound irrigations, producing oxygen bubbles and transient skin blanching. Many people who use H(2)O(2) as an antiseptic are alarmed at this phenomenon. This concise report provides probable mechanisms on how H(2)O(2)-induced skin blanching is produced.

A randomized, double-blind, placebo-controlled trial to determine the efficacy and safety of lactoferrin with vitamin E and zinc as an oral therapy for mild to moderate acne vulgaris.

Lactoferrin is an iron-binding milk-derived protein that has shown antibacterial and anti-inflammatory effects in vitro and in vivo. The objective of this study was to determine the efficacy and safety of lactoferrin, combined with vitamin E and zinc, for mild to moderate acne vulgaris. In this randomized, double-blind, placebo-controlled trial, 168 subjects aged 13-40 years old were randomly assigned to take either a capsule formulation containing lactoferrin with vitamin E and zinc or placebo twice a day for 3 months. The primary outcome measure was a reduction in the number of acne lesions compared to placebo. A total of 164 subjects completed the study per protocol. The lactoferrin group (n = 82) showed a significant median percent reduction in total lesions as early as 2 weeks (14.5%, P = 0.0120), with the maximum reduction occurring at week 10 (28.5%, P < 0.0001) compared to placebo group (n = 82). Maximum reduction in comedones (32.5%, P < 0.0001) and inflammatory lesions (44%, P < 0.0001) was also seen at week 10 compared to placebo. Sebum scores were improved by week 12. No adverse events were observed during the trial. A twice daily regimen of lactoferrin with vitamin E and zinc significantly reduced acne lesions in people with mild to moderate acne vulgaris.

A rare cause of pulmonary tuberculosis.

We present a case of bovine tuberculosis in a 50-year-old Maori female. She had worked for approximately 7 years at a local freezing works where animal organs were cleaned and packed. The diagnosis was established 4 weeks after commencement of first-line anti-TB therapy. While human zoonotic tuberculosis may be uncommon in developed countries, its diagnosis still has important public health and treatment implications.

Low mercury levels in marine fish from estuarine and coastal environments in southern China.

This study is the first comprehensive evaluation of total Hg and methylmercury (MeHg) concentrations in wild marine fish from an estuarine and a coastal ecosystem in southern China. A total of 571 fish from 54 different species were examined. Our results showed that the Hg levels were generally low in the fish, and the Hg levels were below 30 ng g(-1) (wet weight) for 82% of the samples, which may be related to the reduced size of the fish and altered food web structure due to overfishing. Decreased coastal wetland coverage and different carbon sources may be responsible for the habitat-specific Hg concentrations. The degree of biomagnification was relatively low in the two systems.