Analyzing Mortality And The Effect Of Early Excision As A Preliminary Treatment Of Acute Burn Patients In A Limited Resource Setting Using LA50 As An Outcome Measurement.

Advances in burn care have led to an overall improvement in mortality in high-income countries, but in low-middle income countries mortality remains relatively high. In a limited resource setting where temporary wound closure options were unavailable, it was determined whether early excision as a preliminary treatment could improve prognosis. A retrospective cohort study was conducted in Cipto Mangunkusumo Hospital Burn Unit to evaluate the outcomes of acute burn patients admitted from January 2013 to December 2018 using mortality and lethal area 50 (LA50), and to compare the outcomes between groups who underwent early excision without skin graft (EEWG), early excision with skin graft (EESG), delayed excision without skin graft (DEWG), or delayed excision with skin graft (DESG). Out of 390 patients available for screening, 256 were eligible for further study. The overall mortality was 17.9% with an increase linear with age and total body surface area (TBSA). The overall LA50 was 49%. Preliminary data showed the highest percentage of deaths in the no treatment group, with no deaths seen in treatment groups EESG and DESG. The odds ratio for mortality in the EEWG group was 2.11 (p-value 0.201, CI95% = 0.65-6.80) compared to the DEWG group. LA50 is more objective compared to crude mortality and enables future internal and external comparison. The highest mortality was in the no treatment group with mortality in the EEWG group higher than in the DEWG, but not statistically different. Early excision without skin grafting as a preliminary procedure may still be considered in a limited resource setting.

Si les progrès dans leur traitement ont permis de réduire la moralité des brûlures dans les pays à revenus élevés, elle reste relativement élevée dans les pays aux revenus moyens et bas. Dans ceux- ci, où les couvertures cutanées temporaires ne sont pas disponibles, l'amélioration du pronostic grâce à l'excision précoce reste à évaluer. Nous avons effectué une étude rétrospective à partir des dossiers de 256 patients hospitalisés dans le CTB de l'hôpital Cipto Mangunkusumo entre janvier 2013 et décembre 2018. Nous avons comparé l'évolution des groupes ayant subi uniquement une excision précoce, sans greffe (EP), une excision-greffe précoce (EGP), une excision tardive sans greffe (ET) et une excision-greffe tardive (EGT). La mortalité globale était de 17,9%, augmentant linéairement avec l'âge et la surface brûlée. La Surface Létale 50 (SL50), qui est probablement l'indice le plus objectif pour comparer les mortalités entre groupes comme entre CTB, était de 49%. Les patients non traités meurent le plus, il n'y a aucun mort, les patients greffés (précocement ou non) ne meurent pas. Si l'on compare les groupes EP et ET, l'odds- ratio est de 2,11 (p = 0,201; IC95 0,65- 6,8) en faveur de EP. Bien que la différence entre EP et EP n'atteigne pas la significativité statistique, l'excision précoce doit être évoquée dans les pays à ressources limitées.

HIV prevalence and associated risk factors among female sex workers in Dar es Salaam, Tanzania: tracking the epidemic.

Since 2014, HIV care and treatment services among key populations including female sex workers (FSWs) have intensified in Tanzania. We sought to track the epidemic among FSWs in Dar es Salaam, Tanzania. We conducted a cross-sectional integrated bio-behavioral survey using respondent-driven sampling and a structured questionnaire. Blood was drawn for HIV testing. Modified Poisson regression was used to determine factors associated with HIV infection. We recruited 958 FSWs (median age 26 years) of whom 952 consented to HIV testing. The HIV prevalence was 15.3% (95%CI: 12.5-18.6). Factors associated with higher HIV prevalence included old age (25-34 years: aPR 2.38; 95%CI: 1.23, 4.60 and over 35 years: aPR = 6.08; 95%CI: 3.19, 11.58) and having experienced sexual violence in the past year (aPR = 1.94; 95%CI: 1.34, 2.82). Attaining higher education level was associated with lower HIV prevalence (aPR = 0.51; 95%CI: 0.36, 0.73 for primary school level and aPR = 0.20; 95%CI: 0.08, 0.46 for secondary school level and/or above). The HIV prevalence among FSWs in Dar es Salaam has decreased by half since 2013. Prevention strategies should target older FSWs, aim to educate young girls, and institute approaches to mitigate violence among FSWs.

Biofilm formation and esp gene carriage in enterococci.

AIMS: To investigate biofilm production and esp carriage in enterococci. METHODS: Biofilm production in vancomycin resistant enterococci (VRE) and vancomycin susceptible enterococci (VSE) was tested on a microtitre plate method, using both brain heart infusion (BHI) broth and human serum as media. Isolates were screened for the esp gene, which has been reported to be essential for biofilm formation in enterococci, by means of the polymerase chain reaction. RESULTS: None of seven VRE and nine of 28 VSE tested formed a biofilm. One initially negative VRE Enterococcus faecium isolate produced a strong biofilm after 21 weeks of dry starvation on a cotton swab. By Fisher's exact test, there was no significant difference in biofilm formation between VRE and VSE, E faecalis and E faecium, or isolates from different sites. Biofilm formation was independent of possession of the esp gene. One isolate produced a strong biofilm in human serum but only a weak biofilm in BHI, whereas another produced a moderate biofilm in human serum but a weak biofilm in BHI. CONCLUSIONS: The acquisition of vancomycin resistance may result in a lower ability to form biofilms, but a larger study using clinical isolates is needed to test this hypothesis. That one initially negative VRE isolate produced a strong biofilm after prolonged dry starvation suggests that biofilm formation may be an adaptive response. The esp gene does not appear to be necessary or sufficient for production of biofilms in enterococci.

Survivability of vancomycin resistant enterococci and fitness cost of vancomycin resistance acquisition.

AIMS: To investigate the survivability of vancomycin resistant enterococci (VRE) under dry starvation conditions and the fitness cost of vancomycin resistance. METHODS: VRE colonies on cotton swabs were incubated at room temperature in a sterile box and cultured weekly until cultures no longer showed growth. Negative swabs inoculated into brain heart infusion (BHI) broth were subcultured to blood agar after 24, 48, and 72 hours of incubation to resuscitate viable but non-culturable cells. Stability of the vancomycin resistance determinant and of the DNA fingerprint pattern was determined by multiplex polymerase chain reaction (PCR) and repetitive PCR, respectively. Tests for fitness cost were carried out on the same VRE isolates and 28 hospital vancomycin sensitive enterococci (VSE) isolates by incubation and measurement of optical density using a microplate reader and comparing maximum growth rate and lag phase duration between VRE and VSE, using independent samples t tests. RESULTS: Mean maximum time of recovery by primary culture was 8.5 weeks for Enterococcus faecalis VRE and 21.8 weeks for E. faecium VRE. Two of two E. faecalis isolates were resuscitated after 24 hours in BHI broth, and two of five E. faecium isolates after 72 hours. No fitness cost of vancomycin resistance was demonstrated. CONCLUSIONS: VRE can survive for prolonged periods in a dry starvation state, retaining their genetic complement, including vancomycin resistance determinants, and show little or no fitness cost of vancomycin resistance. Thus, the rate of entry required for VRE to become, and remain, endemic in the community is relatively small.