Parent vs burn-injured child self-report: contributions to a better understanding of anxiety levels.

Anxiety disorders are the most commonly reported form of mental health problem among youth, but they often go undiagnosed and untreated. This study examined the relationship between burn-injured youths' self-reported anxiety levels, as compared with their parent's perceptions of their child's emotional well-being. Burn-injured children were invited to voluntarily complete the Child Version of the 41-item survey, Screen for Child Anxiety Related Disorders, which consists of five anxiety subscales as well as a Total Anxiety Score. Parents were invited to complete the Parent Version. Sixty-three parent-child dyads, with girls (57%) and boys (43%), completed surveys. Mothers (73%) fathers (16%), and other caregivers (11%) participated. Youth mean age was 12.63 years and 60% reported visible burn scars. Matched-pairs t-tests were used to compare parent and child reports. Significantly lower mean scores were found between Screen for Child Anxiety Related Disorders Total Anxiety Score--Parent mean score of 10.52 vs the Youth mean score 21.06 (P<.001), as well as on all subscales including; panic disorder/somatic symptoms (P<.001), generalized anxiety disorder (P=.004), social anxiety disorder (separation anxiety (P<.001), and school avoidance (P<0.001). Results indicate that parents may be severely underestimating the psychological well-being of burn-injured youth. Findings emphasize the importance of a comprehensive approach in assessment for anxiety, involving the collection of feedback from both child and parent. Asking children for input into their psychological well-being is important. This study reinforces the need for a course of ongoing patient and parent education.

Hydrofiber dressing with silver for the management of split-thickness donor sites: a randomized evaluation of two protocols of care.

BACKGROUND: This randomized, open-label study evaluated Aquacel Ag Hydrofiber dressing with silver (HDS; ConvaTec, Skillman, NJ, USA) with an adherent or gelled protocol in the management of split-thickness donor sites. METHODS: HDS was the primary dressing in the adherent group (gauze as secondary covering) and gelled group (transparent film as secondary covering). Dressings were changed on study day 1 or 2 and study days 5 (optional), 10 (optional), and 14. The primary outcome was healing (>or=90% re-epithelialization) at study day 14. RESULTS: Seventy subjects were treated (36 adherent, 34 gelled). By study day 14, 77% of donor sites had healed (67% adherent, 88% gelled). Pain scores decreased over time in both treatment groups. Investigators were "very satisfied" or "satisfied" with (adherent, gelled) time required to manage dressing change (89%, 79% of subjects), minimization of donor-site pain (64%, 82%), ease of application (97%, 94%), management of drainage (92%, 82%), ease of removal (77%, 85%), and ability of dressing to remain in place (69%, 76%). Thirty-nine (56%) subjects had adverse events, most commonly non-donor-site infection (11%) and gastrointestinal events (11%). CONCLUSION: In this randomized, open-label study, HDS was well-tolerated, versatile, and effective in the management of split-thickness donor sites.

Food allergy is associated with an increased risk of asthma.

BACKGROUND: The atopic march is well documented, but the interrelationship of food allergy (FA) and asthma is not well understood. OBJECTIVE: The aim of this study was to examine the strength of the association and temporal relationships between FA and asthma. METHODS: This analysis included 271 children >or=6 years (older group) and 296 children <6 years (younger group) from a family-based FA cohort in Chicago, IL. Asthma was determined by parental report of physician diagnosis. FA status was determined based on the type and timing of clinical symptoms after ingestion of a specific food, and results of prick skin test (Multi-Test II) and allergen-specific IgE (Phadia ImmunoCAP). Analyses were carried out using logistic regression accounting for important covariates and auto-correlations among siblings. Kaplan-Meier curves were used to compare the time to onset of asthma with the FA status. RESULTS: Symptomatic FA was associated with asthma in both older [odds ratio (OR)=4.9, 95% confidence interval (CI): 2.5-9.5] and younger children (OR=5.3, 95% CI: 1.7-16.2). The association was stronger among children with multiple or severe food allergies, especially in older children. Children with FA developed asthma earlier and at higher prevalence than children without FA (Cox proportional hazard ratio=3.7, 95% CI: 2.2-6.3 for children >or=6 years, and hazard ratio=3.3, 95% CI: 1.1-10 for children <6 years of age). No associations were seen between asymptomatic food sensitization and asthma. CONCLUSIONS: Independent of markers of atopy such as aeroallergen sensitization and family history of asthma, there was a significant association between FA and asthma. This association was even stronger in subjects with multiple food allergies or severe FA.

A multicenter review of toxic epidermal necrolysis treated in U.S. burn centers at the end of the twentieth century.

Toxic epidermal necrolysis (TEN) is a potentially fatal disorder that involves large areas of skin desquamation. Patients with TEN are often referred to burn centers for expert wound management and comprehensive care. The purpose of this study was to define the presenting characteristics and treatment of TEN before and after admission to regional burn centers and to evaluate the efficacy of burn center treatment for this disorder. A retrospective multicenter chart review was completed for patients admitted with TEN to 15 burn centers from 1995 to 2000. Charts were reviewed for patient characteristics, non-burn hospital and burn center treatment, and outcome. A total of 199 patients were admitted. Patients had a mean age of 47 years, mean 67.7% total body surface area skin slough, and mean Acute Physiology and Chronic Health Evaluation (APACHE II) score of 10. Sixty-four patients died, for a mortality rate of 32%. Mortality increased to 51% for patients transferred to a burn center more than one week after onset of disease. Burn centers and non-burn hospitals differed in their use of enteral nutrition (70 vs 12%, respectively, P < 0.05), prophylactic antibiotics (22 vs 37.9%, P < 0.05), corticosteroid use (22 vs 51%, P < 0.05), and wound management. Age, body surface area involvement, APACHE II score, complications, and parenteral nutrition before transfer correlated with increased mortality. The treatment of TEN differs markedly between burn centers and non-burn centers. Early transport to a burn unit is warranted to improve patient outcome.

Anhydrous ammonia burns case report and review of the literature.

Chemical burns are associated with significant morbidity, especially anhydrous ammonia burns. Anhydrous ammonia is a colorless, pungent gas that is stored and transported under pressure in liquid form. A 28 year-old patient suffered 45% total body surface area of second and third degree burns as well as inhalational injury from an anhydrous ammonia explosion. Along with fluid resuscitation, the patient's body was scrubbed every 6 h with sterile water for the first 48 h to decrease the skin pH from 10 to 6-8. He subsequently underwent a total of seven wound debridements; initially with allograft and then autograft. On post burn day 45, he was discharged. The injuries associated with anhydrous ammonia burns are specific to the effects of ammonium hydroxide. Severity of symptoms and tissue damage produced is directly related to the concentration of hydroxyl ions. Liquefactive necrosis results in superficial to full-thickness tissue loss. The affinity of anhydrous ammonia and its byproducts for mucous membranes can result in hemoptysis, pharyngitis, pulmonary edema, and bronchiectasis. Ocular sequelae include iritis, glaucoma, cataracts, and retinal atrophy. The desirability of treating anhydrous ammonia burns immediately cannot be overemphasized. Clothing must be removed quickly, and irrigation with water initiated at the scene and continued for the first 24 h. Resuscitative measures should be started as well as early debridement of nonviable skin. Patients with significant facial or pharyngeal burns should be intubated, and the eyes irrigated until a conjunctivae sac pH below 8.5 is achieved. Although health care professionals need to be prepared to treat chemical burns, educating the public, especially those workers in the agricultural and industrial setting, should be the first line of prevention.

Vietnamese "coining": a burn case report and literature review.

"Coining," "coin rubbing," or çao gio, is an ancient Vietnamese folk remedy that is practiced by many Vietnamese-Americans to treat minor ailments. There are few reported cases of serious complications of çao gio; most of the complications have been minor burns. We present a case report of a 45-year-old woman who sustained 22% partial-thickness and full-thickness burns after she caught on fire during a coining treatment. She underwent fluid resuscitation, wound care management, and, eventually, burn debridement and autografting. She was discharged 10 days after the operation, with excellent take of all of her grafts. However, a contracture of her right axilla did develop and will require surgical release. This case represents a serious injury that can result from traditional cultural forms of medicine.

Ventral hernia synthetic mesh repair infected by Mycobacterium fortuitum.

We report the occurrence of a refractory infection caused by the "rapidly growing" nontuberculous mycobacterium, Mycobacterium fortuitum, after incisional hernia repair using synthetic mesh. The patient had previously undergone three herniorrhaphies incorporating polypropylene mesh. Multiple surgical debridements were required, along with complete removal of all the mesh, to eradicate the infection. Prolonged antimicrobial therapy with sulfamethoxazole, an agent active against the patient's isolate, was also used. Although this atypical mycobacterium has been reported to cause a variety of infections, including many types of periprosthetic infections, this case represents successful treatment of M. fortuitum infecting abdominal wall mesh.

Acute cholecystitis secondary to hemobilia.

Invasive diagnostic and therapeutic techniques such as percutaneous transhepatic cholangiography, endoscopic retrograde cholangiopancreatography (ERCP), transjugular intrahepatic portosystemic shunting, and laparoscopic cholecystectomy have led to a rise in hemobilia. Most complications from hemobilia are attributable to acute blood loss; other complications are secondary to thrombus formation in the biliary tree. We present a case report of acute cholecystitis secondary to hemobilia after percutaneous liver biopsy. The role of ERCP in the diagnosis and treatment of this exceedingly rare event is discussed.

Perihepatic packing of major liver injuries: complications and mortality.

HYPOTHESIS: Perihepatic packs used to control hemorrhage after liver injury increase the risk of complications and this risk increases the longer packs are left in place. DESIGN: Retrospective case series. SETTING: University level I trauma center. PATIENTS: Consecutive patients with hepatic injury. MAIN OUTCOME MEASURES: Liver-related complications (biliary leak and abscess), rebleeding, and mortality. RESULTS: One hundred twenty-nine of 804 patients with liver injuries were treated with perihepatic packing. Of the 69 who survived more than 24 hours, 75% lived to hospital discharge. Mortality rates were 14% and 30% in patients with and without liver complications, respectively (P = .23). Liver complication rates were similar (P = .83) when packs were removed within 36 hours (early [33%]) or between 36 and 72 hours (late [29%]) after they were placed; the rebleeding rate was greater in the early group (21% vs 4%; P<.001). CONCLUSIONS: Liver complications associated with perihepatic packing did not affect survival. Removing liver packs 36 to 72 hours after placement reduced the risk of rebleeding without increasing the risk of liver-related complications.

Development of a colocutaneous fistula in a patient with a large surface area burn.

A 61 year old female sustained a large surface area burn, complicated by inhalation injury. One month before the incident, she had undergone a left hemicolectomy with colorectal anastomosis for diverticular disease. Due to the severity of her burns, multiple surgical debridement and skin grafting procedures were required, including a large fascial debridement of her flank and back. Her hospital course was complicated by recurrent episodes of pulmonary and systemic infection, as well as pre-existing malnutrition. Prior to her discharge to a rehabilitation center, stool began to drain from her left posterior flank. This complication represented a colonic fistula arising from the recent colon anastomosis. The fistula was managed nonoperatively and gradually closed. To our knowledge, this is the first report of a colocutaneous fistula spontaneously draining from the abdomen via the retroperitoneum in a burn victim, not related to direct thermal injury to the peritoneal cavity.

Cultured composite autografts as coverage for an extensive body surface area burn: case report and review of the technology.

Cultured epithelial autografts (CEA) have been used as an adjunct in the surgical management of extensive thermal burns. Unfortunately, the lack of a dermal matrix makes CEA susceptible to infection, shearing forces and limits their incorporation into the burn wound. A cultured composite autograft (CCA) has been developed in which autologous keratinocytes and fibroblasts are surgically harvested from the burn patient's normal skin. These components are proliferated and then combined to form an epidermal and dermal matrix, grown to confluence then applied. Standard wound coverage techniques as well as CCA technology were utilized for successful wound closure in a 12 yr-old female with an 81% third degree burn. After fascial excision and allograft coverage, autografts were placed on her posterior burns and then 7500 cm2 of CCA was placed onto her anterior thorax, abdomen and lower extremities. Sixty percent of the burn was covered with CCA resulting in a success rate of 40%. No evidence of infection was noted, even in areas where CCA failed, although in those areas random epithelialization appeared to occur which then seemed to facilitate autograft placement. Early debridement and allografting followed by conventional autografts and CCA placement may provide an effective skin coverage strategy in patients with extensive deep burns.

Continuous hemodialysis for the management of acute renal failure in the presence of cerebellar hemorrhage. Case report.

In this report the authors describe the use of continuous venovenous hemodialysis (CVVHD) in a medically unstable patient who suffered from a spontaneous cerebellar hemorrhage. Conventional dialysis techniques carry the risk of developing the dialysis disequilibrium syndrome (DDS) when performed in the presence of a variety of intracranial diseases. The CVVHD technique was used successfully in a morbidly obese, short-statured woman with a spontaneous hypertensive intraparenchymal cerebellar hemorrhage. The woman experienced acute renal failure several days after her hemorrhage and her general medical condition prevented her from undergoing surgical evacuation. The CVVHD did not result in elevations in intracranial pressure (ICP) and the patient made a full recovery from both acute renal failure and life-threatening posterior fossa hemorrhage. This case is noteworthy because of the absence of abnormally high ICP elevations or development of DDS in a patient with a large acute posterior fossa intraparenchymal brain hemorrhage and acute renal failure whose case was managed with CVVHD in the acute period.

Rationale for 'early' percutaneous dilatational tracheostomy in patients with burn injuries.

Several investigators have cited the numerous complications that occur with conventional tracheostomies in patients with burn injuries. However, none of these studies included the technique of percutaneous dilatational tracheostomy, which has been shown to significantly decrease operative time, cost, perioperative, and long-term sequelae as compared to conventional tracheostomy. A retrospective analysis of 36 patients with burn injuries, from 1400 burn admissions, was conducted to compare conventional tracheostomy versus percutaneous dilatational tracheostomy. In this study, percutaneous dilatational tracheostomy resulted in significantly decreased operative times and cost compared to conventional tracheostomy. There were no major operative complications in either group, and alveolar-arterial oxygen gradients were improved in 71% of the patients with a tracheostomy. Percutaneous dilatational tracheostomy is an efficacious technique for airway management in patients with burn injuries. It can be safely performed at the bedside, at one fourth the cost of a conventional tracheostomy. Percutaneous dilatational tracheostomy may also benefit the patient with severe burns by decreasing alveolar-arterial oxygen gradients. Improved ventilatory mechanics might allow for a shorter duration of mechanical ventilation, thereby decreasing patient morbidity, hospital stay, and cost.

How managed care may choose hospitals for contracts for laparoscopic cholecystectomy.

BACKGROUND AND OBJECTIVES: Maricopa Medical Center (MMC) was found to have higher charges and length-of-stays than 16 other regional hospitals in an analysis of DRG categories for gallbladder disease. These comparative figures identified MMC as being inefficient and demanded review to determine the reasons for the inefficiencies. METHODS: In an attempt to determine the reason for inefficiency of charges and length-of-stay for the laparoscopic portion of laparoscopic cholecystectomy, matched pairs of open cholecystectomy and converted laparoscopic cholecystectomy from a data base of 633 patients with cholecystectomies were reviewed. Thirty-five matches for age, sex and similar diagnosis were successful. RESULTS: Matched pair evaluation disclosed a $6,880 difference in charges, which was attributed solely to the charge for laparoscopy. Subsequent chart analysis showed a high charge for instrumentation, prolonged anesthesia and operative times and longer preoperative delays before surgery. Moreover, no matter what the conversion rate is, open cholecystectomy was more cost effective. However, if there is a conversion rate of 5%, total hospital charges for laparoscopic cholecystectomy would have to be reduced to $12,679 (a reduction of $3,332 from $16,011) to make laparoscopic cholecystectomy cost-effective. CONCLUSIONS: Cost-effective decision tree analysis of matched pair comparisons and sensitivity analysis proves to be an effective technique in evaluating the cost-effectiveness of laparoscopic cholecystectomy in a hospital population.

Using delta/DRG diagrams and decision tree analysis to select a cost-effective surgery for cholecystitis.

BACKGROUND AND OBJECTIVES: Many studies have attempted cost analysis of laparoscopic cholecystectomy as compared to open cholecystectomy. However, these analyses have included costs, charges, expenses, etc., and at times they have been used interchangeably. This paper demonstrates how DRG diagrams containing charges and length-of-stay, preoperative prediction of conversion rates, decision-tree construction and sensitivity analysis can be used to select the most cost-efficient operation for a given patient with cholecystitis. METHODS: A Delta DRG analysis for complicated cholecystectomy (DRG 195) showed the hospital to be an extreme outlier in both charges and length of stay. Record review indicated that 55% of the cases were converted laparoscopic cholecystectomies and the remainder were aged or younger patients with advanced disease. Chart and literature review determined the causes and the probability of conversion. Data were then placed into decision-tree and sensitivity analyses. The most cost-effective operation for a given probability of conversion was demonstrated. RESULTS: Three preoperative findings and combinations of each predicted conversion rates and analysis showed that the charge of laparoscopic cholecystectomy must be held below the range of $5,361-$13,084 to make routine laparoscopic cholecystectomy cost-effective. CONCLUSIONS: This method demonstrated that using Delta/DRG, decision-tree and sensitivity analysis offers physicians, hospitals and other health-care providers a method of evaluating the treatment of DRG categories to determine the most cost-effective management.