The impact of nosocomially-acquired resistant Pseudomonas aeruginosa infection in a burn unit.

BACKGROUND: Nosocomially-acquired Pseudomonas aeruginosa remains a serious cause of infection and septic mortality in burn patients. This study was conducted to quantify the impact of nosocomially-transmitted resistant P. aeruginosa in a burn population. METHODS: Using a TRACS burn database, 48 patients with P. aeruginosa resistant to gentamicin were identified (Pseudomonas group). Thirty-nine were case-matched to controls without resistant P. aeruginosa cultures (control group) for age, total body surface area, admission year, and presence of inhalation injury. Mortality and various morbidity endpoints were examined, as well as antibiotic costs. RESULTS: There was a significantly higher mortality rate in the Pseudomonas group (33% vs. 8%, p < 0.001) compared with in the control group. Length of stay was increased in the Pseudomonas group (73.4 +/- 11.6 vs. 58.3 +/- 8.3 days). Ventilatory days (23.9 +/- 5.4 vs. 10.8 +/- 2.4, p < 0.05), number of surgical procedures (5.2 +/- 0.6 vs. 3.4 +/- 0.4, p < 0.05), and amount of blood products used (packed cells 51.1 +/- 8.0 vs. 21.1 +/- 3.4, p < 0.01; platelets 11.9 +/- 3.0 vs. 1.4 +/- 0.7, p < 0.01) were all significantly higher in the Pseudomonas group. Cost of antibiotics was also significantly higher ($2,658.52 +/- $647.93 vs. $829.22 +/- $152.82, p < 0.01). CONCLUSIONS: Nosocomial colonization or infection, or both, of burn patients with aminoglycoside-resistant P. aeruginosa is associated with significantly higher morbidity, mortality, and cost of care. Increased resource consumption did not prevent significantly higher mortality rates when compared with that of control patients. Thus, prevention, identification, and eradication of nosocomial Pseudomonas contamination are critical for cost-effective, successful burn care.

Fluorescein diacetate for determination of cell viability in 3D fibroblast-collagen-GAG constructs.

Quantification of cell viability and distribution within engineered tissues currently relies on representative histology, phenotypic assays, and destructive assays of viability. To evaluate uniformity of cell density throughout 3D collagen scaffolds prior to in vivo use, a nondestructive, field assessment of cell viability is advantageous. Here, we describe a field measure of cell viability in lyophilized collagen-glycosaminoglycan (C-GAG) scaffolds in vitro using fluorescein diacetate (FdA). Fibroblast-C-GAG constructs are stained 1 day after cellular inoculation using 0.04 mg/ml FdA followed by exposure to 366 nm UV light. Construct fluorescence quantified using Metamorph image analysis is correlated with inoculation density, MTT values, and histology of corresponding biopsies. Construct fluorescence correlates significantly with inoculation density (p < 0.001) and MTT values (p < 0.001) of biopsies collected immediately after FdA staining. No toxicity is detected in the constructs, as measured by MTT assay before and after the FdA assay at different time points; normal in vitro histology is demonstrated for the FdA-exposed constructs. In conclusion, measurement of intracellular fluorescence with FdA allows for the early, comprehensive measurement of cellular distributions and viability in engineered tissue.

Clinical assessment of sleep among pediatric burn patients does not correlate with polysomnography.

A vast amount of sleep research relies on subjective, observational assessments of wakefulness and sleep. The authors had the unique opportunity to compare observational and polysomnographic (PSG) determinations of sleep in a randomized crossover study of sleep-inducing medication in a group of pediatric burn patients. Pediatric burn patients were randomized to one of two regimens with sleep-inducing agents over a 2-week period. PSG was conducted for three consecutive nights each week, between 7-13 and 14-20 days postburn. The first night of monitoring each week was conducted without medication to serve as a baseline. Observational sleep assessments (awake, drowsy, or asleep) were simultaneously recorded every 15 minutes. PSG concordance with observation was based on the PSG sleep stages identified during the 2 minutes before the observations. If all 30-second epochs in the two minutes were designated as sleep stage 1 or above, then the PSG record was categorized as asleep. If all epochs demonstrated wakefulness, an awake status was recorded. Otherwise, the corresponding PSG finding was classified as mixed. Forty patients were enrolled into the study, with a mean age of 9.4 ± 0.6 years, TBSA burn of 50.1 ± 2.9%, and third-degree burn surface area of 43.2 ± 3.6%. Patients were judged according to observational criteria to be awake 9% of the nocturnal study period compared with PSG recordings indicating that the patients were awake 52.3% of the time. The correlation between observation and PSG was poor regardless of sleep agent administration. In conclusion, observational determination of wakefulness in pediatric burn patients correlates poorly with PSG; therefore, PSG is vital in the accurate evaluation of sleep-inducing medications among burn patients.

Pediatric thermal injury: acute care and reconstruction update.

BACKGROUND: The acute and reconstructive care of each pediatric burn patient presents unique challenges to the plastic surgeon and the burn care team. METHODS: : The purpose of this review article is to highlight the interdependence between the acute and reconstructive needs of pediatric burn patients as it pertains to each anatomical site. Relevant principles of acute pediatric burn care and burn reconstruction are outlined, based on the authors' experience and review of the literature. RESULTS: The need for late reconstruction in pediatric burn survivors is significantly influenced by the acute surgical and rehabilitative treatments. With their vulnerability to airway swelling, hypothermia, pulmonary edema, and ischemia-reperfusion injury, pediatric patients with large burns require precise, life-saving treatment in the acute phase. Decision-making in pediatric burn reconstruction must take into account the patient's future growth, maturity, and often lack of suitable donor sites. CONCLUSION: Appropriately selected reconstructive techniques are essential to optimize function, appearance, and quality of life in pediatric burn survivors.

Fluorescein diacetate for determination of cell viability in tissue-engineered skin.

Assurance of the quality of cultured skin substitutes (CSSs) currently relies on representative histology and determination of surface hydration, which provide limited sampling at selected points. To evaluate uniformity of cell density on the collagen matrices before clinical use, a field assessment of cell viability is advantageous. This study aimed to develop a field measure of cell viability in CSSs in vitro using fluorescein diacetate (FdA). CSSs were stained 3 days after keratinocyte inoculation using 0.04 mg/mL FdA followed by exposure to 366 nm of ultraviolet light. CSS fluorescence quantified using Metamorph image analysis was correlated with inoculation density, 3-(4,5-dimethylthiazol-2-Yl)-2,5-diphenyltetrazolium bromide (MTT) values and histology of corresponding biopsies. CSS fluorescence correlated significantly with inoculation density (p < 0.001) and MTT values (p < 0.001) of biopsies collected immediately after FdA staining. Fluorescence at day 3 also predicted day 10 MTT values. No toxicity was detected in CSSs, and normal in vitro and in vivo histology was demonstrated after FdA exposure. In conclusion, measurement of intracellular fluorescence with FdA allows for the early, comprehensive measurement of cellular distributions and viability in engineered skin and may therefore facilitate quality assurance.

A comparison of human and porcine acellularized dermis: interactions with human fibroblasts in vitro.

BACKGROUND: Dermal substitutes derived from xenograft materials require elaborate processing at a considerable cost. Acellularized porcine dermis is a readily available material associated with minimal immunogenicity. The objective of this study was to evaluate acellularized pig dermis as a scaffold for human fibroblasts. METHODS: In vitro methods were used to evaluate fibroblast adherence, proliferation, and migration on pig acellularized dermal matrix. Acellular human dermis was used as a control. RESULTS: Pig acellularized dermal matrix was found to be inferior to human acellularized dermal matrix as a scaffold for human fibroblasts. Significantly more samples of human acellularized dermal matrix (83 percent, n = 24; p < 0.05) demonstrated fibroblast infiltration below the cell-seeded surface than pig acellularized dermal matrix (31 percent, n = 49). Significantly more (p < 0.05) fibroblasts infiltrated below the surface of human acellularized dermal matrix (mean, 1072 +/- 80 cells per section; n = 16 samples) than pig acellularized dermal matrix (mean, 301 +/- 48 cells per section; n = 16 samples). Fibroblasts migrated significantly less (p < 0.05) distance from the cell-seeded pig acellularized dermal matrix surface than in the human acellularized dermal matrix (78.8 percent versus 38.3 percent cells within 150 mum from the surface, respectively; n = 5). Fibroblasts proliferated more rapidly (p < 0.05) on pig acellularized dermal matrix (n = 9) than on the human acellularized dermal matrix (7.4-fold increase in cell number versus 1.8-fold increase, respectively; n = 9 for human acellularized dermal matrix). There was no difference between the two materials with respect to fibroblast adherence (8120 versus 7436 average adherent cells per section, for pig and human acellularized dermal matrix, respectively; n = 20 in each group; p > 0.05). CONCLUSION: Preliminary findings suggest that substantial differences may exist between human fibroblast behavior in cell-matrix interactions of porcine and human acellularized dermis.