The epidemiology of cytomegalovirus infection among patients with burns.

To determine the epidemiology of cytomegalovirus (CMV) infections among patients with burns, we prospectively studied 120 burn patients admitted to the University of Iowa Burn Center over a two-and-one-half year period. At the time of their admission, 44% of the patients had serologic evidence of prior CMV infection. Among 44 seropositive patients, 23 (52%) had four-fold or greater rises in CMV antibody titers. These patients had more severe burns (mean body surface area burn [BSAB] 26.8%) than those who did not exhibit titer rises (mean BSAB 16.2%, p = .04). Among 43 seronegative patients observed for at least 65 days after discharge from the center, eight (18.6%) seroconverted. Patients who seroconverted had longer hospital stays (p = .03), trends toward more severe burns (p = .08) and a younger age (p = .15) than patients who remained seronegative. Despite frequent serologic evidence of CMV infection, CMV did not contribute, either directly or indirectly, to the morbidity or mortality of burns in these patients.

Fournier's gangrene with an unusual urologic etiology.

Fournier's gangrene is a necrotizing infection affecting the male genitalia and perineum, caused by synergistic aerobic and anaerobic organisms. We report on a previously undescribed upper urinary tract etiology for this life-threatening infection.

Cadaver skin allografts and transmission of human cytomegalovirus to burn patients.

BACKGROUND: The potential role of cadaver skin as a vehicle for CMV transmission to burn patients has never been clearly defined. We sought to determine if a cytomegalovirus (CMV)-positive cadaver allograft transmits CMV infections to CMV-seronegative burn patients. STUDY DESIGN: All patients in this study were CMV seronegative on admission. They received CMV-seronegative blood products, and cadaver allografts for temporary wound closure and management without regard to the donor's CMV serum status (positive or negative). RESULTS: Of 493 patients admitted from 1989 to 1993, 22 were CMV seronegative on admission and required cadaver allografts for their burn wounds. Five (22.7 percent) of 22 patients seroconverted during hospitalization: one of five had CMV pneumonia develop, two had CMV viruria develop, and three had persistent fever, abnormal liver enzymes, and diarrhea not ascribable to bacterial or other viral agents. CONCLUSIONS: Cytomegalovirus infections result from using CMV-seropositive cadaver allografts on seronegative burn patients.

Effect of gastric bypass on gastric secretion.

Gastric bypass as a 90 per cent gastric exclusion operation was used in 393 patients with massive obesity to limit food intake. Stomal ulcer has occurred in 1.8 per cent of such patients or one ulcer per 140 man years of observation. The studies of indwelling fundic pH and of gastric acid secretion from the excluded stomach indicate that acid secretion is reduced after gastric bypass but that the acid, unbuffered by food in the excluded stomach, results in a lowered gastrin secretion after a meal. Thus, gastric bypass in inhibitory to acid secretion in most morbidly obese patients who do not have known acid peptic disease.

Lobar collapse in the surgical intensive care unit.

The chest X rays of 200 consecutive patients in the surgical Intensive Care Unit were reviewed. Eighteen cases of lobar collapse were diagnosed in 17 patients (8.5%) with a high degree of certainty. Most cases involved the left lower lobe (12/18, 66%), but collapse of the right lower lobe (4/18, 22%) and the right upper lobe (2/18, 11%) was also noted. Although theories have been postulated to account for the high incidence of left lower lobe collapse following cardiac surgery, the predominance of left lower lobe collapse generally amongst ICU patients is not fully explained.

Cushing's syndrome secondary to bronchial carcinoid secretion of ACTH: a review.

Cushing's syndrome as a result of the ectopic production of adrenocorticotrophic hormone by bronchial carcinoids is a rare phenomena. The clinical course of two patients is presented in depth, and a review of the literature is provided. A discussion of various forms of therapy and an algorithm for the evaluation and management of the patients is presented.

An in vitro model for studying the effects of slime and nonslime-forming Staphylococcus epidermidis contamination of intravenous catheters.

An in vitro model was developed to study the relationship between intravenous catheters, bacteria, and the subcutaneous tunnel. Studies of both slime-forming and nonslime-forming coagulase negative Staphylococcus epidermidis show that slime formation enhances capillary action of coagulase negative S. epidermidis. This offers a possible explanation of the increased virulence associated with slime-forming coagulase negative S. epidermidis in the clinical situation.

Aggressive approach to physical therapy management of the burned hand. A clinical report.

Hand burn care requires physical therapy involvement from the earliest stage of wound management. Hand burns may cause loss of sensation, decreased range of motion, loss of tissue and digits, or a combination of these conditions. The initial evaluation must include careful analysis of the extent and depth of the hand burn and concomitant injuries. Proper-positioning splints and active and passive range-of-motion exercises are vital to the preservation and restoration of function of the burned hand. This clinical report describes an aggressive physical therapy hand burn management program that is initiated early in patient care and continued throughout patient hospitalization and outpatient follow-up.

Long-term neuropsychological sequelae of severe burns.

Eight patients who suffered severe burns and protracted periods of amnesia following those burns were evaluated for neuropsychological and neuropsychiatric problems between 6 months and 4 years following their accidents. All were found to have significant problems as evidenced in neuropsychological testing, activities of daily living, and reports from relatives. Findings on these burn patients with postburn amnesia were quite different from those of five burn patients who did not develop amnesia. Problems observed and reported in the burn-amnesia patients appeared to reflect clear neuropathological etiologies, which was not unexpected because their initial amnestic syndromes must also have been the result of significant central nervous system dysfunction. It is recommended that severe burn patients have neuropsychological, psychiatric, and neurological exams as part of routine postburn care.

Analysis of changes in coagulation factors after postoperative blood loss in burn and non-burn patients.

A prospective study of the postoperative kinetics of coagulation factors was undertaken in 23 burn patients and in six non-burn patients. All procedures resulted in a large volume blood loss. Fibrinogen, platelets and factors V, VIII and IX were measured serially. Burn patients returned all parameters to preoperative levels by 48 h postoperation, while non-burn patients showed a slower rate of return of platelets and factor V. This study suggests that burn patients may safely undergo re-operation at 48 h intervals for successive wound debridements if clinically necessary.

Predicting survival in an elderly burn patient population.

The purpose of this study was to analyze the outcome of elderly burn victims and to determine an instrument to predict survival in this population. Charts of three hundred and eight burn patients > or =60 yr of age who were admitted to a university-based hospital between the years of 1977-1996 were retrospectively analyzed. The mean age of the population was 71.5+/-8.6, with a male predominance (1.8 to 1, P < 0.001). The majority of the burns were secondary to flame injuries (210, 68.6%). The median body surface area (BSAB) was 13.0% with an in-hospital mortality rate of 30.2%. We demonstrated improved survival in patients aged 60-74 yr as compared to 1965-1971 national burn survival data. A similar trend could not be shown in the very old (> 75 yr of age). Only age and BSAB were related to death by multiple stepwise forward linear regression. The Baux score, which adds age and BSAB, was predictive of outcome in 87.0% of our population. In conclusion, this study reinforces the high mortality associated with burn injuries in the elderly and the superior ability of the Baux score (age + percent burn) in predicting outcome in this population.

Carbon monoxide poisoning and myocardial ischemia in patients with burns.

Carbon monoxide poisoning is a well-known problem in patients with burns. A retrospective 11-year chart review was undertaken to determine the incidence of myocardial injury after carbon monoxide poisoning. Of the 1533 consecutive admissions from July 1, 1979 to June 30, 1990, 18 patients had carboxyhemoglobin levels of greater than or equal to 10% on admission. Five of these patients were found to have electrocardiographic changes that were indicative of myocardial injury. (Three also had elevated levels of creative kinase-MB). Four of five patients with electrocardiographic changes were operated on successfully with the use of perioperative invasive monitoring. None of the 18 patients had congestive heart failure or cardiac dysrhythmias during their hospital course. These data suggest that myocardial damage can result from acute carbon monoxide poisoning, and appropriate screening is indicated for the detection of such injuries.

Continuous enteral feeding and short fasting periods enhance perioperative nutrition in patients with burns.

Both retrospective and prospective analyses of the effects of various fasting regimens were carried out on the achievement of calculated caloric needs of patients with severe burns. The records of patients who received enteral feedings while undergoing burn debridements were divided into three groups and retrospectively analyzed to determine the effect that duration of fasting had an achievement of caloric needs and on the risks of aspiration. Patients in two other groups were prospectively studied to determine the safety and efficacy of stopping continuous enteral feedings 1 and 4 hours before surgery, respectively. Techniques of airway management and anesthetic induction were left to the discretion of the attending anesthesiologist. In the retrospective analysis, patients in group I, who fasted for 2 hours achieved 28% of their calculated 24-hour caloric goals compared with 11% in those who fasted for 2 to 8 hours (group II) and 6% in those who fasted for more than 8 hours (group III) before surgery (p less than 0.001). In the prospective portion of the study, patients who fasted for 1 hour before anesthesia was induced achieved 30% of their caloric needs, whereas those who fasted for 4 hours achieved 15% of their target nutritional needs (p = 0.0001). No patient had evidence of pulmonary aspiration. We conclude that controlled enteral feedings and shortened preoperative fasting periods can safely enhance nutritional support in patients with burns.

An in vitro model for studying the effect of the subcutaneous tunnel and the skin exit site on the accuracy of central venous catheter tip cultures.

The diagnosis of central venous catheter-related sepsis depends on a positive culture obtained from the distal intravascular portion of the catheter. The effects of the subcutaneous tunnel and the skin exit site on the accuracy of cultures obtained from the catheter are unknown. We have developed an in vitro model to study the effect of these variables. By inoculating polyethylene catheters embedded in agar with Pseudomonas aeruginosa, we were able to show that: (1) capillary action occurs along catheters in an agar tunnel, (2) organisms that are growing on the distal segment (tip) of the catheter can be dislodged from the surface of the catheter when it is pulled through the agar tunnel, and (3) pulling a catheter through a contaminated area results in distal contamination.

A study of functional viability and metabolic degeneration of human skin stored at 4 degrees C.

We sought to ascertain whether an in vitro assay could be as reliable as an in vivo assay in determining the viability of human skin stored at 4 degrees C. Allografts from six human donors were stored in RPMI 1640 tissue culture medium at 4 degrees C. At fixed intervals during the storage period, all skin specimens were tested concurrently by two different viability assays: (1) transplantation onto surgically created defects on nude mice, and (2) intracellular enzyme activity with use of a 4-hour semiquantitative micromethod system activity (API ZYM; Biomerieux Vitek Inc., Hazelwood, Mo.). Human graft survival on the nude mice was 100% for the first 15 days of storage, and then declined to 50% on storage day 30. The API ZYM assay showed a comparable progressive decrease in enzyme activity over skin storage time. The API ZYM assay is a simple, rapid system that produces reproducible results and is cost-effective when compared to the biologic model.

Changes in coagulation factors in patients with burns during acute blood loss.

A prospective study was undertaken to determine the change in coagulation factors in patients undergoing tangential excisions of burn wounds when red blood cells preserved with ADSOL (adenine, dextrose, saline, and mannitol) and crystalloid solution were used for volume replacement. Nine patients with burns were studied, three on two separate occasions. No patient had a history of a bleeding disorder or had taken aspirin within 10 days of surgery. Results of preoperative coagulation studies were all within normal limits. The initial levels of coagulation factor and rates of removal were compared with those of 12 patients without burns who were undergoing elective surgery and who also had massive intraoperative blood loss. Coagulation factor levels measured included the platelet count, fibrinogen, factors V, VIII, and IX. These were determined before blood loss and each time loss and replacement of one third of a patient's calculated blood volume occurred during a tangential excision of a burn wound. The data showed that patients with burns have significantly higher baseline levels of platelets, fibrinogen, and factor VIII than patients without burns do. The removal rates of platelet and factor IX are significantly lower among patients with burns than among patients without burns. No patient in the study group developed a coagulopathy or received fresh frozen plasma or platelet supplementation. These findings suggest that the intraoperative blood losses that occurred during tangential excisions of burn wounds were made safe by the higher than normal preoperative levels of platelets, fibrinogen, and factor VIII and by the slow wash-out curve for platelets and factor IX. Prophylactic use of either fresh frozen plasma or platelet concentrates is not indicated unless a specific deficit or coagulopathy has been identified.

Short-term skin preservation at 4 degrees C: skin storage configuration and tissue-to-volume medium ratio.

This study was designed to examine the effect of the storage configuration of skin and the ratio of tissue-to-storage medium on the viability of skin stored under refrigeration. Human skin specimens were stored in four physical configurations in RPMI 1640 tissue culture media at 4 degrees C. Skin was transferred to surgically created defects on nude mice after specific storage intervals. Grafts were examined grossly and microscopically after ten days. In the rolled configuration, on storage day 15, the viability of the outside of the roll was significantly better than the inside (P less than 0.01). The graft viability of the outside of the skin rolls was similar for both tissue-to-media ratios as well as for both free-floating configurations (P = 0.27). These findings suggest the optimum cold storage configuration is free floating, and 300 cm2/100 mL is an appropriate skin surface area to volume media ratio. This proportion of tissue to media is in agreement with the minimum ratio currently recommended by the Skin Council of the American Association of Tissue Banks.

A prospective comparison of a new, synthetic donor site dressing versus an impregnated gauze dressing.

Three institutions enrolled 38 patients who required bilateral skin graft donor sites into a safety and efficacy study of a new synthetic donor site dressing. Bilateral donor sites were randomized to receive either a new, synthetic donor site dressing or an impregnated gauze dressing. Wounds were assessed by time to healing, pain, and patient preference. Synthetic dressing wounds were treated 7.9 days compared with 10.2 days for gauze dressing wounds (p < 0.001), and synthetic dressing wounds were more completely epithelialized. Visual analogue pain analysis revealed significantly less donor site pain with synthetic dressing (2.94) versus gauze dressing (4.64) (p < 0.001). Synthetic dressing had fewer treatment-related adverse experiences than gauze dressing (2 vs 7) and was judged by recipients to be superior to gauze dressing in comfort, pain relief, cosmetic appeal, ease of ambulation, and overall acceptance.

Trash and brush burning: an underappreciated mechanism of thermal injury in a rural community.

Open-fire injuries associated with burning trash or brush result in a significant number of burn admissions annually. Trash- and brush-burning injuries are more prevalent in rural environments where open burning is an acceptable practice of waste disposal. These injuries are not "unavoidable accidents" but follow a predictable injury pattern. Understanding this injury pattern is paramount to effective prevention. The purpose of this work is to describe the epidemiology of burn injuries associated with burning trash or brush. Charts were retrospectively reviewed for all trash and brush burning injuries from July 1989 to December 2000. One hundred ninety-four injuries were identified, accounting for one fifth of all flame admissions for the study period. Persons most at risk for these burn injuries were males between the ages of 25 to 45, followed by males ages 16 to 24. Accelerant use was identified in over 80% of these injuries. The median cost for admission was $9,363.00 US dollars. Cost was significantly related to age, percent body surface area burned, and operative intervention. Brush and trash burning can lead to costly injuries especially when accelerants are used. Additional research is needed to explore the cultural and social influences associated with these injuries to target effective prevention.

Cytomegalovirus infection in burn patients.

We studied the seroepidemiology of cytomegalovirus (CMV) infection in 59 patients with thermal injuries. Among the 31 patients who were initially CMV seronegative, seven (22.5%) seroconverted. Patients who seroconverted had longer hospital stays (mean, 27 +/- 23.9 days v 14.9 +/- 8.8 days in seronegative patients [P = 0.03]) and they received more blood products (mean, 10.7 +/- 17.9 units v 1.8 +/- 2.8 units [P = 0.02]) than patients who remained seronegative. Among 18 patients who were initially seropositive for CMV, 10 (56%) had a fourfold or greater rise in CMV antibodies, evidence of CMV reactivation. Patients who had reactivated CMV infection tended to be younger, to have a larger burn area, and to have a longer hospital stay. No patient who experienced CMV infection, whether primary or reactivated, had serious complications attributable to CMV.