Admission Circulating Cell-Free DNA Levels as a Prognostic Factor in Pediatric Burns.

Background: Burn injuries in children are a major physical and psychological trauma, often a severe condition with long-term consequences. Current methods of assessing the extent of burn injuries on admission are inaccurate. Circulating cell-free DNA (cfDNA) is a potential marker of tissue damage that may be useful in burn care. Objective: To explore the use of cfDNA admission levels as a prognostic marker of pediatric burn severity and outcome. Methods: cfDNA levels of 38 pediatric burn patients (otherwise healthy) and 12 matched pediatric controls (minor elective surgery patients) admitted to our center were quantified by a direct fluorometric assay. Results: We found significantly higher admission cfDNA levels in the patient group (median 724 ng/ml, range 44-4405), compared to the control group (median 423 ng/ml, range 206-970, Mann-Whitney, P = 0.03) and a significant difference between cfDNA levels of partial-thickness burns (median 590 ng/ml, range 44-2909) and full-thickness burns (median 2394 ng/ml, range 528-4405, Mann-Whitney, P = 0.01). We also found significant correlations between cfDNA levels and hospitalization duration (Spearman, R = 0.42, P < 0.01) and undergoing surgical procedures (Spearman, R = 0.40, P < 0.01). PICU admission did not correlate to cfDNA levels (Spearman, R = 0.14, P = NS). Discussion. Admission cfDNA levels may be a valuable objective tool for assessing the severity of pediatric burn injuries on admission, including correlations with the length of hospitalization and surgical burden. Conclusion: Admission cfDNA levels may be a promising novel pediatric burn assessment method. Further investigation of cfDNA levels in healthy children standardized to age and larger cohorts are needed to establish cfDNA as a valuable prognostic factor for pediatric burn injury.

Meconium-stained amniotic fluid as a protective factor against childhood dermatitis and skin rash-related hospitalization in the offspring - a population-based cohort analysis.

BACKGROUND: Gut microbiome influences cutaneous diseases including atopic dermatitis. Possible impact of intrauterine exposure to meconium on the occurrence of dermatitis and skin rash was proposed. OBJECTIVE: We investigated the possible influence of intrauterine exposure to meconium-stained amniotic fluid (MSAF) on the occurrence of dermatitis and skin rash-related hospitalizations throughout childhood. METHODS: Singleton deliveries occurring between 1991 and 2014 at a single medical centre were divided into two study groups based on presence or lack of MSAF during delivery. Population-based cohort analysis, Kaplan-Meier survival analysis and Cox proportional hazards model were used to study the association between MSAF and cutaneous morbidity-related hospitalizations. RESULTS: A lower rate of the total dermatitis or skin eruption-related hospitalization was documented in the MSAF-exposed group; 0.78 per 1000-person years (0.9%, n = 312), as compared to 0.98 per 1000-person years in the unexposed group (1.0%, n = 1992) with a hazard ratio of 0.86 (95% CI 0.76-0.96, P = 0.011). The survival curve showed lower cumulative hospitalization rate in the MSAF-exposed group as compared to the unexposed group (log rank P = 0.01). The Cox analysis, controlled for confounders, demonstrated MSAF exposure to be an independent protective factor for dermatitis and skin rash-related hospitalizations during childhood (adjusted HR 0.878 (95% CI 0.779-0.990, P = 0.034). CONCLUSION: Fetal exposure to MSAF appears to be an independent protective factor for dermatitis and skin rash-related hospitalizations in the offspring throughout childhood and adolescence.

Desmoid Tumor and Silicone Breast Implant Surgery: Is There Really a Connection? A Literature Review.

BACKGROUND: Desmoid tumors are borderline tumors of the connective tissue, arising in the musculo-aponeurotic stromal elements. A desmoid tumor (DT) has an infiltrative and locally aggressive growth pattern and usually does not metastasize; however, it has a high recurrence and complication rate. DT located in the breast (BDT) represents a rare extra-abdominal form. Recently, the presence of breast silicone implants was suggested by several researchers as a risk factor for developing BDT. OBJECTIVES: The goal of this review is to investigate the possible correlation between BDT and breast implant surgery. METHODS: We conducted a literature review of BDT-reported cases, associated with breast implant surgery. RESULTS: The search revealed 36 cases of BDT associated with silicone breast implants. CONCLUSIONS: Based on the reviewed data, the incidence of BDT following breast implant surgery is lower than BDT in the general population. At the moment, a possible association between breast implants and the development of breast desmoid tumors cannot be unequivocally confirmed. A world registry with accurate documentation of each case of BDT associated with breast implant surgery should be performed for future investigation. LEVEL OF EVIDENCE II: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Bromelain-based enzymatic debridement and minimal invasive modality (mim) care of deeply burned hands.

The objective was to critically review the data and assess the implications of NexoBrid [NexoBrid-NXB formerly Debrase Gel Dressing-DGD]a in the special field of deep hand burns. Detailed analysis of endpoints in the treatment of hand burn patients was conducted as part of a multi-center, open label, randomized, controlled two-arm study to evaluate the safety and efficacy of NXB enzymatic debridement, comparing it to the current standard of care (SOC). These results were compared to a large cohort of patients treated with NXB in a previous, single arm study. Thirty-one burned hands were treated with NXB and 41 hand burns were in the SOC group. In the NXB group, 4 out of 31 hand burns (12.9%) required some excisional debridement compared to 29 out of the 41 (70.7%) in the SOC group (p<0.0001). Mean percentage of burn wound area excised in the NXB group was 4.4 ± 13.1% compared to 52.0 ± 41.4% in the SOC group (p<0.0001). None of the NXB-treated hands required escharotomy compared to 4 out of the 41 (9.7%) in the SOC group. NXB enzymatic debridement demonstrated a statistically significant reduction in burn wound excision and auto-grafting compared to SOC, and seems to prevent the need for emergency escharotomy. a DGD is produced by MediWound and distributed under the name NexoBrid®.

Le but était de réaliser une révision attentive des données et d'évaluer la place de Nexobrid (Nexobrid-NXB, précédemment Debrase Gel Dressing-DGD) dans l'indication particulière des brûlures profondes de la main. Une analyse détaillée des objectifs dans le traitement des brûlures de la main a été conduite en partie par une étude multicentrique, ouverte, randomisée, contrôlée avec 2 groupes pour évaluer la sécurité et l'efficacité de ce débridement enzymatique par rapport aux soins habituels (Standard of Care ou SOC). Ces résultats ont été comparés à une vaste cohorte de patients traités par NXB dans une étude précédente sur un seul groupe. 31 mains brûlées furent traitées par NXB et 41 dans le groupe SOC. Dans le groupe NXB, 4 sur 31 mains brûlées soit 12,9 % nécessitèrent une excision partielle, alors que 29 sur 41 dans le groupe SOC (70,7 %) (p < 0,0001). La moyenne des zones brûlées excisées dans le groupe NXB était de 4,4 (+ ou - 13,1 %) comparée aux 52,0 (+ ou - 41,4 % du groupe SOC) (p <0,0001). Aucune des mains traitées par NXB ont nécessité une excision totale, comparée à 4 sur 41 du groupe SOC (9,7 % du groupe). Le débridement enzymatique NXB montre une réduction statistiquement significative de l'indication d'excision avec autogreffe par rapport au groupe traité classiquement et semble prévenir la nécessité d'une escarrotomie en urgence.

Minimally invasive burn care: a review of seven clinical studies of rapid and selective debridement using a bromelain-based debriding enzyme (Nexobrid®).

Current surgical and non-surgical eschar removal-debridement techniques are invasive or ineffective. A bromelainbased rapid and selective enzymatic debriding agent was developed to overcome these disadvantages and compared with the standard of care (SOC). The safety and efficacy of a novel Debriding Gel Dressing (DGD) was determined in patients with deep partial and full thickness burns covering up to 67% total body surface area (TBSA). This review summarizes data from seven studies, four of which were randomized clinical trials that included a SOC or control vehicle. DGD eschar debridement efficacy was >90% in all studies, comparable to the SOC and significantly greater than the control vehicle. The total area excised was less in patients treated with DGD compared with the control vehicle (22.9% vs. 73.2%, P<0.001) or the surgical/non-surgical SOC (50.5%, P=0.006). The incidence of surgical debridement in patients treated with DGD was lower than the SOC (40/163 [24.5%] vs. 119/170 [70.0%], P0.001). Less autografting was used in all studies. Long-term scar quality and function were similar in DGD- and SOCtreated. DGD is a safe and effective method of burn debridement that offers an alternative to surgical and non-surgical SOC.

Les protocoles actuels de détersion d'une brûlure, chirurgicaux et non chirurgicaux, sont soit invasifs soit inefficaces. Un enzyme détersif rapide et spécifique, dérivé de la bromélaïne, a été développé dans le but de palier à ces 2 inconvénients. Il a été comparé aux techniques usuelles (TU). L'efficacité et l'innocuité d'un Gel Topique Détersif (GTD) ont été évaluées chez des patients souffrant de brûlures intermédiaires et profondes atteignant jusqu'à 67% de la Surface Corporelle Totale (SCT). Cette revue compile les données de 7 études cliniques, dont 4, randomisées, faisaient appel aux TU ou à un groupe contrôle. La détersion obtenue avec GTD était toujours > 90%, comparable aux TU et meilleure que dans le groupe contrôle. La surface relative excisée totale était moindre après GTD que chez les contrôles (22.9% VS 73.2%, p<0,001) ou les patients sous TU (50.5%, p=0,006). Le nombre de patients ayant eu besoin de chirurgie a été inférieur dans le groupe GTD que dans le groupe TU (40/163 [24.5%] VS 119/170 [70%], p<0,001). Le recours aux greffes était moins fréquent dans toutes les études. Les qualités cicatricielle et fonctionnelle à distance étaient comparables après TU et GTD. GTD est une technique de détersion efficace et sûre qui offre une alternative au TU, chirurgical ou non.

Wound 'dechronification' with negatively-charged polystyrene microspheres: a double-blind RCT.

OBJECTIVE: To compare the efficacy and safety of negatively-charged polystyrene microspheres (NCM)with controls (saline soaks) in the treatment of hard-to-heal wounds of various aetiologies. METHOD: Patients with one or more hard-to-heal wounds, defined as refractory to healing for at least 4 weeks, or those with exposed bone, tendon or ligament, were eligible for inclusion and were randomised to either NCM (PolyHeal; MediWound Ltd.) or controls, both applied twice daily for 4 weeks. Patients were monitored bi-weekly for an additional 8 weeks, while treated by standard wound care, at the investigators' discretion, and were re-evaluated 2 years after inclusion. The primary endpoint was defined as coverage of> 75% of the wound area by light-red granulation tissue after 4 weeks of treatment. RESULTS: Fifty-eight patients completed the study, 32 in the NCM group and 26 in the control group. The two most common wound types were those with primary etiologies of venous insufficiency and postoperative/post trauma. In the NCM group 47% of patients achieved > 75% light red granulation tissue after 4 weeks compared with 15% of patients in the control group (p=O.O I). The mean wound surface area in the NCM group was reduced by 39.0% after 4 weeks compared with 14.9% in the control group (p=0.02).The achievement of> 75% light red granulation tissue and reduction of mean wound surface area was also observed in the two main sub-groups (venous insufficiency and postoperative/post trauma), although it was not statistically significant, possibly due to the small sample size in each sub-group. CONCLUSION: This study demonstrates that compared to control treatment, NCM treatment of hard to-heal and chronic wounds improves formation of healthy granulation tissue and reduces wound size thus in fact 'kick-starting' the healing process and 'dechronifying' chronic wounds.

Capsular flap: new applications.

UNLABELLED: Breast augmentation with silicone implants is one of the most commonly performed procedures for women seeking improvement in their body image. Because the number of breast augmentation operations is growing, the number of subsequent reoperations is increasing. Causes for repeated operative procedures include infection, capsular contracture, silicone implant replacement, and breast reaugmentation. As the average volume of silicone implants used is steadily growing according to patients' wishes and fashion requirements, the plastic surgeon often is asked to replace the silicone implants with larger implants. Replacing breast implants with a similar sized implant is a relatively simple operation, but insertion of larger implants may present a challenge due to insufficient soft tissue coverage of the lower pole of the larger breast implant, especially in thin subjects. Total coverage of the breast implant can be achieved by use of tissue substitutes (TS), such as acellular dermal matrices. Usage of TS, however, is prone to complications and very costly, and these factors influence the implementation of TS in a private practice setup. This report describes a capsular flap used to cover the lower pole of breast implants. The flap guarantees multilayered stable wound closure and prevents displacement of the inframammary fold. The capsular flap also was used to correct an inferiorly displaced inframammary fold as a consequence of the breast augmentation. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Utilization of Inferiorly Based Dermofat Flap in Breast Reconstruction after Simple Mastectomy due to Gigantomastia.

Gigantomastia (GM) is a rare disabling condition characterized by excessive breast tissue growth. To date, there is no universal classification and definition of GM. At present, GM is determined as weight over 1.5 kg per breast (Dancey et al., 2008) or 3% or more of the patient's total body weight (Dafydd et al., 2011). The lack of generally acknowledged approach regarding GM is expressed by the different methods of its treatment ranging from hormonal prescription to mastectomy and subsequent complex breast reconstruction (Shoma et al., 2011). We describe a treatment approach, including simple mastectomy and immediate breast reconstruction by an inferiorly based dermofat flap with silicone implants and nipple grafting.

Burn treatment framework in Israel.

The treatment and hospitalization policies in various hospitals in Israel are influenced by injury severity and by the existence or non-existence of a designated burn treatment body. Severely injured burn victims requiring designated burn treatment are referred to one of Israel's five major burn units located in the highest level trauma centres that have an advanced burn treatment infrastructure. This national distribution of burn centres ensures designated treatment availability in various areas according to Israeli demographics, geography, and security threats. Israel does not have an obligatory burn report policy. Implementation of a national burn repository such as that in the USA will be able to give burn treatment specialists in our country a basis for comparison of treatment standards and allow for better care for burn victims. The Israeli Burn Association has a major role in the processes discussed in the manuscript.

Burns at the soroka university medical center - a two-year experience.

Background. Burn trauma is a major public health concern, with increased risk for burns in children. Objectives. To characterize the profile of injured burn patients and to identify patients who are prone to burn injury. Methods. This is a cross-sectional study including all patients who were admitted to the Burns and Plastic Surgery Department, Soroka University Medical Center, Israel, between 1 January 2001 and 31 December 2002. Results. Five hundred and fifty-eight patients with a mean age of 15.4 yr (SD, 19.5 yr) were included in the study. There were 348 male patients (62.4%). The cause of the burns was scalding in 314 patients (56.3%), flame in 177 (31.7%), chemicals in 31 (5.6%), explosion in 20 (3.6%), and electricity in four (0.7%). There were 325 Bedouin patients (58.2%) and 221 Jewish patients (39.6%). In Bedouins, 235 patients (72.3%) were children below 5 yr, compared to 59 Jewish patients (26.7%) (p < 0.001). Eighteen burn patients (3.2%) expired. A multivariate analysis demonstrated that age and percentage of body surface area involved in the burn were significantly associated with mortality. Conclusions. The epidemiological characteristics of the burned population in Soroka University Medical Center are described. Burn injury has become a principal public health problem, particularly in Bedouin children.

Clinical and pathological findings in reexcision of incompletely excised basal cell carcinomas.

In common practice, patients with incompletely excised basal cell carcinomas (BCCs) are referred to elective reexcision. In previous reports, it was observed that tumor cells are found in only 50% of the reexcised specimens. The authors performed a retrospective analysis of a large series of patients to evaluate clinical and pathological findings in patients who underwent reexcision of incompletely excised BCCs. A total of 1,478 BCCs arising in 1,278 patients were excised by plastic surgeons in a plastic and reconstructive surgery department during a 4-year period. In 159 patients (10.8%), the excision was incomplete according to the pathological report. These tumors were defined as an incompletely excised BCCs. One hundred of the 159 patients with incompletely excised BCCs (62.9%) were reoperated. Residual tumor cells were found in 28 of 100 patients (28%) within the pathological specimen of the reexcised tissue (defined as positive reexcision, or +veRE). There was no correlation between +veRE and the age or sex of the patient. Location of the BCCs in the cheeks, eyelids, or ears was associated with a low percent of +veRE (10.0%, 13.3%, and 22.2% respectively). Pathological factors associated with a low percent of +veRE were dermal inflammatory infiltrate in the pathological specimen (p = 0.003) and sun damage pathological changes (p = 0.03), but there was no correlation with the pathological subtype distribution of the tumors. The authors conclude that lack of tumor cells at reexcision of incompletely excised BCCs is associated with location of the tumors in the cheeks, eyelids, and ears, and with pathological findings of dermal inflammatory infiltrates or sun damage changes. The roles of inflammatory and solar changes in the destruction of residual carcinoma cells should be investigated further.

Congenital epulis.

Epulis is a rare tumor of the newborn, also known as granular cell tumor of the newborn or Neumann's tumor. This tumor arises from the mucosa of the gingiva, most commonly from the anterior part of the maxillary alveolar ridge, and is typically seen as a mass protruding out of the newborn child's mouth, which may interfere with respiration or feeding. Epulis is seen only in the newborn and is a different entity from other granular cell tumors. The tumor has a marked female preponderance of 8:1. The recommended treatment is prompt surgical resection. Recurrences of the tumor and damage to future dentition have not been reported, suggesting that radical excision is not warranted. A newborn female with such a mass is described. The tumor was resected using a carbon dioxide laser; the postoperative course was uneventful. On histologic examination, it was composed of diffuse sheets and clusters of polygonal cells containing small round to oval nuclei and abundant coarsely granular cytoplasm. The tumor cells stained positive for vimentin, and negative for S100-protein, actin, desmin, laminin, keratin, estrogen, and progesterone receptors. Electron microscopic examination showed granular cells containing heterogeneous electron-dense granules, lysosomes, and cytoplasmic lipid droplets. The clinical and microscopic features of such tumors are reviewed.

Airway obstruction by Ascaris, roundworm in a burned child.

Ascaris lumbricoides, roundworm, is a Nematode parasite infecting about 1 billion people worldwide. We report the case of a ten-year-old Bedouin girl hospitalized with burns to 45% of her body surface area, including the face. The patient was intubated upon admission and mechanically ventilated. Four days later she was extubated but required reintubation 15 min later for severe hypoxemia. Laryngoscopy disclosed an unidentified tube which obstructed the opening of the larynx. The 'tube' was removed by Magill forceps. The object was identified as a 35 cm long Ascaris roundworm. Once the worm was removed the patients' respiratory condition dramatically improved. We review the main features of Ascaris infection and some similar cases of airway obstruction caused by this worm.

[Screening for colorectal cancer and polyps].

Screening programs for the early detection of colorectal neoplasms may prevent cancer or improve its prognosis. We screened 1101 individuals (89% of whom were asymptomatic) using 3 methods. The fecal occult blood test, done in 96% of those screened, was positive in only 1.9% and was low in both sensitivity (2.1%) and positive predictive value (6.7%). However, flexible sigmoidoscopy, performed in 48%, gave positive results in 7.8% of those screened, revealing 41 cases of polyps and 1 of cancer. Colonoscopy was performed in 8% and 37 cases of polyps and 1 of cancer were detected. Of the 3 screening methods tested, sigmoidoscopy appeared to be the best because of its high diagnostic yield. The risk of colorectal neoplasm was shown for the first time to be equal in Jews of oriental and occidental origin.