Optimizing the use of Aquacel Ag® for pediatric burns - When to start?

Most pediatric burns are 2nd degree partial thickness, and most will heal spontaneously by providing a good healing environment, though there is no standardized treatment protocol. Aquacel Ag® has shown good clinical results in reducing the need for frequent dressing changes in the pediatric population. This study's goal was to review our experience using this dressing for pediatric partial thickness burns in order to optimize and customize its use. A retrospective study included all pediatric patients suffering from burns, admitted to our institution between July 2013 and May 2018. We investigated a total of 705 dressing changes in our cohort of 276 patients. The most prevalent dressing material was Aquacel Ag®, used in 48% of cases. We examined the pattern of using Aquacel Ag® dressings. The average time until dressing change was required proved to be much longer when applied on the 1st day after burn and onward in comparison to the day of injury (4.85 vs. 2.21 days, p<0.001). Moreover, when it was applied on the 1st day after burn, a dressing used on a superficial 2nd degree burn needed to be changed less often than when it was applied on a deep 2nd degree burn (4.95 vs. 2.29 days, p=0.024). To optimize its use and cost effectiveness, dressing with Aquacel Ag® should be initiated on the 1st day after burn, or on the 2nd day when a deep 2nd degree burn is suspected; until then a standard topical preparation should be used.

La plupart des brûlures de l'enfant sont des brûlures du 2e degré intermédiaire et cicatriseront spontanément si les conditions locales sont favorables. Cependant il n'y a pas de protocole standardisé. Aquacel AG® a montré de bons résultats cliniques tout en réduisant la fréquence de réfection des pansements dans la population pédiatrique. Le but de cette étude est de faire le point sur notre expérience avec ce pansement pour les brûlures de 2e degré intermédiaire de l'enfant afin d'optimiser et de standardiser son utilisation. Tous les enfants admis dans notre institution pour brûlures entre juillet 2013 et mai 2018 ont été inclus de façon rétrospective. Nous avons repris un total de 705 réfections de pansement sur notre cohorte de 276 patients. Le pansement utilisé le plus souvent était Aquacel AG®, dans 48% des cas. Nous avons étudié les modalités d'utilisation du pansement Aquacel AG®. Le délai moyen dans lesquels il était nécessaire de refaire le pansement s'est révélé être bien plus long lorsque la première application d'Aquacel AG® avait lieu le lendemain de l'accident où les jours suivants comparativement à l'application le jour de l'accident (4,85 vs 2,21 jours, p< 0,001). De plus, lorsque le pansement était appliqué le lendemain de l'accident, la fréquence des changements ultérieurs était moins importante pour le 2e degré superficiel que pour le 2e degré profond (4,95 versus 2,29 jours, p< 0,024). Pour optimiser son utilisation et la balance coût/efficacité, le pansement Aquacel AG® doit être appliqué le lendemain d'une brûlure de 2e degré superficiel et le surlendemain si on craint une brûlure de 2e degré profond. Entre-temps, un pansement classique sera utilisé.

HLA-F polymorphisms in a Euro-Brazilian population from Southern Brazil.

HLA-F is a non-classical major histocompatibility complex (MHC) gene. It codes class Ib MHC molecules with restricted distribution and less nucleotide variations than MHC class Ia genes. Of the 22 alleles registered on the IMGT database only four alleles encode for proteins that differ in their primary structure. To estimate genotype and allele frequencies, this study targeted on known protein coding regions of the HLA-F gene. Genotyping was performed by Sequence Base Typing (SBT). The sample was composed by 199-unrelated bone marrow donors from the Brazilian Bone Marrow Donor Registry (REDOME), Euro-Brazilians, from Southern Brazil. About 1673 bp were analyzed. The most frequent allele was HLA-F*01:01 (87.19%), followed by HLA-F*01:03 (12.31%), HLA-F*01:02 (0.25%) and HLA-F*01:04 (0.25%). Significant linkage disequilibrium (LD) was verified between HLA-F and HLA classes I and II alleles. This is the first study regarding HLA-F polymorphisms in a Euro-Brazilian population contributing to the Southern Brazilian genetic characterization.

HLA-G 5' URR SNPs and 3' UTR 14-bp insertion/deletion polymorphism in an Afro-Brazilian population from Paraná State.

The present study investigated 23 SNPs in the 5'URR promoter region and the 14 bp ins/del polymorphism at the 3'UTR region of the HLA-G gene in 150 individuals with Afro-Brazilian ancestry. Three haplotypes were found to be the most frequent. Comparing these polymorphisms in other samples, our data suggest that Afro-Brazilians are more similar to the Euro-Brazilians than to Hutterite population.

Endometriosis and cancer: what do we know?

Endometriosis is the presence of endometriotic tissue outside of the uterus, composed of endometriotic glands and stroma. It affects between 10% to 12% of women in reproductive age. It presents with dysmenorrhea, dyspareunia, chronic pelvic pain, infertility, urinary or digestive symptoms. Diagnosis is based on clinical suspicion, clinical exam, pelvic ultrasound or pelvic magnetic resonance, and confirmed by laparoscopy with pathology studies. Its management is better understood nowadays. However, its association with neoplasia has been questioned for many years. It probably plays a role in the etiology of gynecological cancers, mainly ovarian neoplasia. In our review, we separately compared endometriosis and endometrioma to cancer, in terms of mutual causality, common risk factors, distinction based on histological findings, in addition to molecular and genetic pathways behind this association. This article reviews the English literature for studies on the association between endometriosis and gynecological cancers. Additional reports were collected by systematically reviewing all references from retrieved papers.

Identification of a new HLA-DRB1*11 variant, HLA-DRB1*11:130, by sequence-based typing in a Brazilian individual.

HLA-DRB1*11:130, detected in a Euro-Brazilian female, presents a point mutation at codon 59.3 (GAG→GAC).

Potential impacts of climate variability on dengue hemorrhagic fever in Honduras, 2010.

Climate change and variability are affecting human health and disease direct or indirectly through many mechanisms. Dengue is one of those diseases that is strongly influenced by climate variability; however its study in Central America has been poorly approached. In this study, we assessed potential associations between macroclimatic and microclimatic variation and dengue hemorrhagic fever (DHF) cases in the main hospital of Honduras during 2010. In this year, 3,353 cases of DHF were reported in the Hospital Escuela, Tegucigalpa. Climatic periods marked a difference of 158% in the mean incidence of cases, from El Niño weeks (-99% of cases below the mean incidence) to La Niña months (+59% of cases above it) (p<0.01). Linear regression showed significantly higher dengue incidence with lower values of Oceanic Niño Index (p=0.0097), higher rain probability (p=0.0149), accumulated rain (p=0.0443) and higher relative humidity (p=0.0292). At a multiple linear regression model using those variables, ONI values shown to be the most important and significant factor found to be associated with the monthly occurrence of DHF cases (r²=0.649; ßstandardized=-0.836; p=0.01). As has been shown herein, climate variability is an important element influencing the dengue epidemiology in Honduras. However, it is necessary to extend these studies in this and other countries in the Central America region, because these models can be applied for surveillance as well as for prediction of dengue.

HLA-DRB1*08:48, a novel allele identified in a Brazilian donor.

The new allele presents a point mutation at codon 67.1 (ATC→CTC) resulting in a conservative change from isoleucine to leucine.

Two novel alleles, HLA-B*40:125 and B*40:129, in the Brazilian population.

The new alleles, HLA-B*40:125 and HLA-B*40:129, present a mismatch at codon 103.1 (G → C) and three mismatches at codons 9.1 (C → T), 11.1 (T → G) and 12.1 (G → A).

A novel allele, HLA-A*66:14, identified in a Brazilian volunteer bone marrow donor.

The new allele might have arisen from HLA-A*66:01 through a point mutation at codon 182.1 (ACG→GCG) resulting in a non-conservative change from threonine to alanine.

Potential impacts of climate variability on Dengue Hemorrhagic Fever in Honduras, 2010

Climate change and variability are affecting human health and disease direct or indirectly through many mechanisms. Dengue is one of those diseases that is strongly influenced by climate variability; however its study in Central America has been poorly approached. In this study, we assessed potential associations between macroclimatic and microclimatic variation and dengue hemorrhagic fever (DHF) cases in the main hospital of Honduras during 2010. In this year, 3,353 cases of DHF were reported in the Hospital Escuela, Tegucigalpa. Climatic periods marked a difference of 158% in the mean incidence of cases, from El Niño weeks (-99% of cases below the mean incidence) to La Niña months (+59% of cases above it) (p<0.01). Linear regression showed significantly higher dengue incidence with lower values of Oceanic Niño Index (p=0.0097), higher rain probability (p=0.0149), accumulated rain (p=0.0443) and higher relative humidity (p=0.0292). At a multiple linear regression model using those variables, ONI values shown to be the most important and significant factor found to be associated with the monthly occurrence of DHF cases (r2=0.649; βstandardized=–0.836; p=0.01). As has been shown herein, climate variability is an important element influencing the dengue epidemiology in Honduras. However, it is necessary to extend these studies in this and other countries in the Central America region, because these models can be applied for surveillance as well as for prediction of dengue.

A new allele, HLA-B*4212, identified in a Brazilian volunteer bone marrow donors by sequence-based typing.

Here we report the discovery of a novel HLA-B allele, named B*4212 in a Brazilian volunteer bone marrow donor. The new sequence has nucleotide variation at position 496 (T→G) as compared with B*4201. This variation results in a conservative amino acid substitution from valine to glycine at codon 165 of exon 3.

Identification of SHV-type and CTX-M-12 extended-spectrum beta-lactamases (ESBLs) in multiresistant Enterobacteriaceae from Colombian Caribbean hospitals.

The production of extended-spectrum beta-lactamases (ESBLs) in Enterobacteriaceae is the most prevalent resistance mechanism to third-generation cephalosporins. The aim of this study was to identify the ESBLs produced in Escherichia coli and Klebsiella pneumoniae clinical isolates from two hospitals of the Colombian Caribbean Region. A total of 30 clinical isolates of K. pneumoniae (21) and E. coli (9) ESBL-producers were collected in two hospitals from January, 2001 to June, 2003. Isoelectric point values were indicative of SHV-, and CTX-M-type beta-lactamases. PCR amplification and sequencing of SHV genes revealed that SHV-12 was the most prevalent ESBL followed by SHV-5, SHV-2a, the novel SHV-86 and CTX-M-12. There was a geographic distribution of two particular PFGE subtypes in these two distant hospitals. Clonal and horizontal dissemination of resistance was observed.

HLA-B*18:35, a new HLA-B*18 allele identified by sequence-based typing in a Brazilian volunteer bone marrow donor.

A novel human leukocyte antigen-B allele named B*18:35 was identified in a Brazilian volunteer bone marrow donor.

Seroprevalencia del virus de leucemia e inmunodeficiencia felina en gatos de Montería, Córdoba / Seroprevalence immunodeficiency virus and feline leukemia in cats in Monteria, Córdoba

El incremento gradual de la población felina en Colombia y algunos países está acompañadode la aparición de enfermedades que ponen en riesgo la salud animal. El virus deinmunodeficiencia y la leucemia felina son las principales enfermedades retrovirales demayor morbilidad y mortalidad en los felinos, que requieren de un diagnóstico oportunoque permita prolongar la vida de estos animales. Se realizó un estudio descriptivo de cortetransversal que incluyó 60 gatos domésticos del área urbana de la ciudad de Montería procedentesde clínicas, consultorios veterinarios y viviendas familiares. El diagnóstico simultáneode leucemia e inmunodeficiencia felina se realizó en muestras de suero y plasma porel inmunoensayo comercial SNAP combo FeLV Ag/ FIV Ab (Laboratories Idexx Toronto,Canadá). Los animales fueron sometidos a exámenes físicos y de laboratorio. La poblaciónestuvo conformada por 30 hembras y 30 machos en su mayoría menores de dos años. Laseroprevalencia fue del 23,3% (14/60) para leucemia felina, inmunodeficiencia felina 1,6%(1/60) y la seroprevalencia de doble infección por el virus de leucemia e inmunodeficienciafelina fue del 5% (3/60). Se realizó por primera vez el serodiagnóstico del virus de inmunodeficienciay leucemia felina en la población de gatos domésticos de la ciudad de Montería;se estableció una seroprevalencia del 23,3% y 1,6% respectivamente.

The gradual increment of the feline population in Colombia and some countries is associatedwith presence of diseases that care produce animal health risk. The virus of immunodeficiencyand the feline leukemia are the main retroviales diseases with high morbility andmortality in felines and they require of a right diagnostic that extend the felines’ life. A descriptivetransversal cut study was done, 60 urban domestic cats of Montería were included,animals were from clinics, veterinarian consults and familiar houses. The simultaneousdiagnostic of leukemia and feline immunodeficiency was carried out by using inmunoensayo SNAP combo FeLV Ag/FIV Ab (laboratories Idexx Toronto, Canadá) in samples ofserum and plasma. The animals were submitted to a physical and laboratory examinationthe population studied were 30 females and 30 males most of them minor of 2 years. Felineleukemia showed a seroprevalence of 23,3% (14/60), for feline immunodeficiency a seroprevalenceof 1,6% (1/60), and the prevalence of double infection for feline leukemia andimmunodeficiency was of 5% (3/60). The immunodeficiency’s virus and feline leukemiadiagnostic was carry out for first time in the population of domestics cats in the city ofMontería and it established a seroprevalence of 23,3% and 1,6% respectively.

Bariatric surgery improves cardiac function in morbidly obese patients with severe cardiomyopathy.

BACKGROUND: Longstanding morbid obesity can be associated with severe cardiomyopathy. However, the safety and efficacy of bariatric surgery in patients with severe cardiomyopathy has not been studied, and the effect of surgical weight loss on postoperative cardiac function is also unknown. In addition, morbidly obese patients have significantly increased mortality associated with cardiac transplantation, often precluding them from becoming recipients. METHODS: A retrospective study of patients with a left ventricular ejection fraction < or =35% who underwent bariatric surgery (1998-2005) was performed. Short-term morbidity/mortality, length of stay, excess weight loss, pre- and postoperative left ventricular ejection fraction, and New York Heart Association (NYHA) functional class were assessed. RESULTS: A total of 14 patients (10 men and 4 women) with a mean preoperative body mass index of 50.8 +/- 2.04 kg/m(2) underwent bariatric surgery (10 underwent laparoscopic Roux-en-Y gastric bypass, 1 open Roux-en-Y gastric bypass, 2 sleeve gastrectomy, and 1 laparoscopic gastric banding). The complications were pulmonary edema in 1, hypotension in 1, and transient renal insufficiency in 2. The median length of stay was 3.0 days (range 2-9). The mean excess weight loss at 6 months was 50.4%, with a decrease in the mean body mass index from 50.8 +/- 2.04 kg/m(2) to 36.8 +/- 1.72 kg/m(2). The mean left ventricular ejection fraction at 6 months had significantly improved from 23% +/- 2% to 32% +/- 4% (P = .04), correlating with improved functional capacity, as measured by the NYHA classification. Preoperatively, 2 patients (14%) had an NYHA classification of IV, 6 (43%) a classification of III, and 6 (43%) a classification of II. At 6 months postoperatively, no patient had an NYHA classification of IV, 2 (14%) had a classification of III, and 12 (86%) an NYHA classification of II. Two patients had undergone cardiac transplant evaluations preoperatively and underwent successful transplantation after weight loss. CONCLUSION: The results of our study have shown that bariatric surgery for patients with cardiomyopathy is feasible and effective. Surgically induced weight loss results in both subjective and objective improvement in cardiac function. In addition, surgical weight loss can provide a bridge to transplantation in patients who were prohibited secondary to their morbid obesity.

Treatment of refractory gastroesophageal reflux disease with radiofrequency energy (Stretta) in patients after Roux-en-Y gastric bypass.

BACKGROUND: Morbid obesity is associated with gastroesophageal reflux disease (GERD), which, in most cases, completely resolves after Roux-en-Y gastric bypass (RYGB). Patients with persistent or recurrent symptoms have limited surgical options. This study sought to evaluate the application of the Stretta procedure for patients with refractory GERD. METHODS: The medical records of all patients who underwent Stretta for refractory GERD after RYGB were reviewed. Demographic, preoperative, and postoperative reflux data were collected. Data are presented as mean +/- standard error of the mean. The t-test was used for comparison purposes. RESULTS: Of 369 patients, 7 received Stretta 27 +/- 6 months after RYGB. All were women with a mean age of 49 +/- 2 years. All the patients had experienced prebypass GERD symptoms for a duration of 45 +/- 8 months. The mean prebypass body mass index was 45 +/- 2 kg/m(2), and this was reduced to 29 +/- 2 kg/m(2) after laparoscopic RYGB (p < 0.001). Before Stretta, all patients underwent a 48-h Bravo pH study, which demonstrated reflux with a mean fraction time of 7% +/- 2% for pH lower than 4. After Stretta, five patients had complete resolution of their symptoms, with normalization of pH studies (mean fraction time of 3% +/- 0% for pH < 4). The follow-up period after Stretta was 20 +/- 2 months. One patient did not have adequate relief of symptoms after Stretta, and one patient was lost to follow-up evaluation. CONCLUSION: Stretta is a valid option in the treatment of persistent GERD for patients who have undergone gastric bypass. Further study is required to evaluate the long-term efficacy of this procedure.

Laparoscopic sleeve gastrectomy as an initial weight-loss procedure for high-risk patients with morbid obesity.

BACKGROUND: The surgical treatment of obesity in the high-risk, high-body-mass-index (BMI) (>60) patient remains a challenge. Major morbidity and mortality in these patients can approach 38% and 6%, respectively. In an effort to achieve more favorable outcomes, we have employed a two-stage approach to such high-risk patients. This study evaluates our initial outcomes with this technique. METHODS: In this study, patients underwent laparoscopic sleeve gastrectomy (LSG) as a first stage during the period January 2002-February 2004. After achieving significant weight loss and reduction in co-morbidities, these patients then proceeded with the second stage, laparoscopic Roux-en-Y gastric bypass (LRYGBP). RESULTS: During this time, 126 patients underwent LSG (53% female). The mean age was 49.5 +/- 0.9 years, and the mean BMI was 65.3 +/- 0.8 (range 45-91). Operative risk assessment determined that 42% were American Society of Anesthesiologists physical status score (ASA) III and 52% were ASA IV. The mean number of co-morbid conditions per patient was 9.3 +/- 0.3 with a median of 10 (range 3-17). There was one distant mortality and the incidence of major complications was 13%. Mean excess weight after LSG at 1 year was 46%. Thirty-six patients with a mean BMI of 49.1 +/- 1.3 (excess weight loss, EWL, 38%) had the second-stage LRYGBP. The mean number of co-morbidities in this group was 6.4 +/- 0.1 (reduced from 9). The ASA class of the majority of patients had been downstaged at the time of LRYGB. The mean time interval between the first and second stages was 12.6 +/- 0.8 months. The mean and median hospital stays were 3 +/- 1.7 and 2.5 (range 2-7) days, respectively. There were no deaths, and the incidence of major complications was 8%. CONCLUSION: The staging concept of LSG followed by LRYGBP is a safe and effective surgical approach for high-risk patients seeking bariatric surgery.

The impact of laparoscopic bariatric workshops on the practice patterns of surgeons.

BACKGROUND: This study was designed to evaluate the impact of a 2-day laparoscopic bariatric workshop on the practice patterns of participating surgeons. METHODS: From October 1998 to June 2002, 18 laparoscopic bariatric workshops were attended by 300 surgeons. Questionnaires were mailed to all participants. RESULTS: Responses were received from 124 surgeons (41%), among whom were 56 bariatric surgeons (open) (45%), 30 advanced laparoscopic surgeons (24%), and 38 surgeons who performed neither bariatric nor advanced laparoscopic surgery (31%). The questionnaire responses showed that 46 surgeons (37%) currently are performing laparoscopic gastric bypass (LGB), 38 (31%) are performing open gastric bypass, and 39 (32%) are not performing bariatric surgery. Since completion of the course, 46 surgeons have performed 8,893 LGBs (mean, 193 cases/surgeon). Overall, 87 of the surgeons (70%) thought that a limited preceptorship was necessary before performance of LGB, yet only 25% underwent this additional training. According to a poll, the respondents thought that, on the average, 50 cases (range, 10-150 cases) are needed for a claim of proficiency. CONCLUSION: Laparoscopic bariatric workshops are effective educational tools for surgeons wishing to adopt bariatric surgery. Open bariatric surgeons have the highest rates of adopting laparoscopic techniques and tend to participate in more adjunctive training before performing LGB. There was consensus that the learning curve is steep, and that additional training often is necessary. The authors propose a mechanism for post-residency skill acquisition for advanced laparoscopic surgery.

What happens to the rectus abdominus fascia after laparoscopic ventral hernia repair?

BACKGROUND: One criticism of laparoscopic ventral hernia repair (LVH) is that the rectus muscles are not re-approximated to the midline, and the effect of LVH repair on the fascial edges is unclear. Progressive migration of the fascial edges toward the midline has been observed anecdotally, but objective evidence remains limited. The purpose of this study is to observe the effect of LVH repair on the rectus abdominus fascia. METHODS: Patients undergoing LVH repair with defects > 10 cm in horizontal diameter were identified prospectively and enrolled. All were repaired laparoscopically with intraperitoneal placement of mesh (DualMesh, W.L. Gore and Associates) using a standard approach. Radio-opaque clips were placed at the fascial edges intraoperatively to mark the defect, and plain abdominal films were taken postoperatively (Time 1) to establish the initial distance between clips (measured in cm). A subsequent follow-up film was taken (Time 2), and the difference in clip distance per patient was recorded. Results were analyzed using a chi-squared test. RESULTS: Twelve patients qualified for analysis and their results were compared. Mean fascial defect size was 15.1 cm (range 8.3-22.0). With respect to change in clip distance from Times 1 to 2, three events were observed: (1) Diminished (i.e. medialized), (2) Enlarged, or (3) No Change. Ten patients (83%) medialized, one patient enlarged, and one patient showed no change (chi2 (d.f. = 2) 9.17, p < 0.0023). CONCLUSIONS: Medialization of the rectus abdominus fascia occurs in the majority of patients undergoing LVH repair. Causes for this phenomenon are unclear: however eliminating intrabdominal pressure with intraperitoneal mesh placement likely plays a role.

Repair of ventral hernias in morbidly obese patients undergoing laparoscopic gastric bypass should not be deferred.

BACKGROUND: There is no consensus regarding the optimal treatment of ventral hernias in patients who present for weight loss surgery. METHODS: Medical records of consecutive morbidly obese patients who underwent laparoscopic Roux-en-Y (LRYGB) gastric bypass with a secondary diagnosis of ventral hernia were reviewed. Only patients who were beyond 6 months of follow-up were included. RESULTS: The study population was 85 patients. There were three groups of patients according to the method of repair: primary repair (59), small intestine submucosa (SIS) (12), and deferred treatment (14). Average follow-up was 26 months. There was a 22% recurrence in the primary repair group. There were no recurrences in the SIS group. Five of the patients in the deferred treatment group (37.5%) presented with small bowel obstruction due to incarceration. CONCLUSION: Biomaterial mesh (SIS) repair of ventral hernias concomitant with LRYGB resulted in the most favorable outcome albeit having short follow-up. Concomitant primary repair is associated with a high rate of recurrence. All incarcerated ventral hernias should be repaired concomitant with LRYGB, as deferment may result in small bowel obstruction.