Mycetoma caused by Microsporum canis in a patient with renal transplant: A case report and review of the literature.

Microsporum canis is a dermatophyte known to cause superficial skin infections. In immunocompromised patients, it can lead to invasive dermatophytosis. We present a case of biopsy-proven left knee mycetoma caused by M canis in a renal transplant patient. Identification of M canis was achieved via sequencing of the internal transcribed spacer regions. Treatment involved surgical debridement, oral posaconazole, and reduction in immunosuppression. In addition, we provide a review of current literature on invasive M canis infections.

Thrombosis incidence in major paediatric burns.

BACKGROUND: Major burns are associated with multiple risk factors for thrombosis such as decreased mobilization and systemic inflammation. It is unclear if these factors are offset by the inherent lower thrombosis risk in the paediatric patient. As such there is no consensus on thromboprophylaxis for paediatric burns patients, in contrast to this being a mainstay of treatment in the adult population. This retrospective cohort study examines the incidence of, and risk factors for, thrombotic events in major paediatric burns with a view to establish guidelines for prevention. METHOD: Review of major paediatric burns, defined as % total body surface area (%TBSA) ≥30%, at the Adelaide Women's and Children's Hospital (WCH) over a 16-year period. Coding data and the local burns database were used to identify participants with subsequent review of case files. RESULTS: Of the cohort (n = 23), six cases (26%) were complicated by thrombotic events. These patients had the most extensive burns averaging 68.5% TBSA, longer PICU admissions and associated interventions. These data points were more than doubled in the cohort diagnosed with a thrombus. Of the six events, five were secondary to central venous catheters (CVC) and one deep venous thrombosis (DVT) to the left calf. CONCLUSION: The incidence of thrombotic events in our study was significant albeit in a small population. There is a strong association between large %TBSA and thrombus, with clots mostly forming around CVCs. While further research is required, this study demonstrates screening and targeted thromboprophylaxis may be required for major paediatric burns.

Management of aplasia cutis congenita of the scalp.

BACKGROUND: Aplasia cutis congenita (ACC) is a rare condition commonly affecting the scalp in which there is a focal deficiency of cutaneous tissues of varying severity ranging from an absence of skin through to full thickness defects involving deeper elements such as bone and dura. Lesions of the scalp can be associated with complications including infection, hemorrhage, thrombosis, and seizures. Opinions in the current literature regarding management of this condition are varied with both conservative and surgical management advocated. Conservative treatment consists of regular wound dressings and systemic antibiotics, while surgical management commonly involves skin grafting and local flaps. METHODS: A retrospective case review was performed to audit the outcomes of patients with ACC of the scalp managed at the Women's and Children's Hospital (WCH) in Adelaide, Australia from 2002 to 2012. Cases were identified from admission coding diagnoses and data was retrieved from patient case notes. RESULTS: Seventeen cases of ACC were identified. The most common location involved was the scalp vertex. Thirteen patients were managed conservatively and 4 had primary surgical intervention. Of the cases that were managed with primary surgery, 2 had complications. None of the conservatively managed patients had complications in the acute setting. CONCLUSIONS: At the WCH, we advocate adopting a conservative approach to management of ACC of the scalp. Defects can be successfully managed with a combination of regular dressings and systemic antibiotics. Regular wound monitoring is essential to detect any complications early to instigate appropriate treatment and determine the need for emergency surgical management.

Antimicrobial silver dressings: a review of emerging issues for modern wound care.

Skin is an important barrier to pathogenic microorganisms and plays a critical role in a ctivation of innate immune responses. When the skin barrier is breached following wounding or burn injury, pathogens can invade and complicate healing with infection resulting in delayed healing and symptomatic scarring. Wound infection is a significant problem after burn injury and in patients with chronic wounds. Antimicrobial silver has had a significant role in wound antisepsis throughout history and, given the rise in community acquired antibiotic resistance, silver dressings are now commonly used to combat wound infection. The multi-modal mechanism of action, low potential for toxicity and formation of microbial resistance makes silver dressings suitable tools against a wide array of clinically important microbes. There are, however, a number of issues with silver dressings including a conflicting evidence base, the important environmental consideration of nanoparticle manufacture, and the significant cost of these products. One solution may be to adopt an 'opened-but-unused' means of wound care whereby bulk dressing materials are used piecemeal and stored in between dressing changes to increase the cost-effectiveness and reduced wastage. There is, however, little literature on this topic and so in vitro and clinical research must be performed to consider the efficacy of active ingredient dressings in wound care including silver dressings once opened and stored.

Practical extended use of antimicrobial silver (PExUS).

BACKGROUND: Antimicrobial silver has had a role in wound antisepsis throughout history and, with the rise in acquired antibiotic resistance, silver dressings are once again commonly used. Issues with silver dressings include the important environmental consideration of nanoparticle manufacture, and the significant financial cost of these products. One solution to these problems may be to adopt an opened-but-unused model of wound care whereby dressing materials are used in piecemeal fashion and excess stored in between dressing changes. Due to a lack of literature on the topic, this project was designed with the aim of testing the antimicrobial efficacy of available silver dressings during storage after opening. METHODS: Four commonly used silver dressings were tested for antimicrobial activity using a zone of inhibition assay against clinically important pathogens. The assay was performed on opening of dressings and repeated over 3 months in storage at 4, 25 or 37°C. Analysis was performed using repeated measures ANOVA. Swab cultures were taken at each simulated dressing change to detect microbial contamination of the dressings during storage. RESULTS: There was no effect of time or storage temperature on the zone of inhibition over the 12 week test period. No swabs taken returned culture consistent with microbial contamination of stored dressings. CONCLUSION: Opened silver dressings maintain antimicrobial activity for at least 12 weeks in storage and are resistant to contamination. An opened-but-unused model for wound care is likely to improve cost-effectiveness while preserving effectiveness and safety.

Variation in burn wound management approaches for paediatric burn patients in Australia and New Zealand.

BACKGROUND: To date, no large-scale exploration of the profile of, and variance among paediatric patients who underwent a burn wound management procedure in theatre exists in an Australian and New Zealand context. This study aims to provide a profile of paediatric burn patients who underwent a burn wound management procedure in theatre during an acute admission and highlight specific areas of practice where there is variation between burn services that may affect treatment efficacy and efficiency. METHODS: We performed a retrospective review of all paediatric patients (ages <16 years) who sustained a burn injury between July 2016 and June 2019 and underwent a burn wound management procedure in theatre, using data from the Burns Registry Australia New Zealand. RESULTS: The number of patients across burn services decreased as TBSA increased. Deep dermal burns represented the majority of cases across services. There was significant variation in time from injury to admission and the proportion of patients who received skin grafts across services. CONCLUSIONS: Significant differences in the patient profile and clinical practices were observed among burn services. A greater understanding of the factors underlying the variations at each particular service will also be helpful.

A comparison study of methods for estimation of a burn surface area: Lund and Browder, e-burn and Mersey Burns.

INTRODUCTION: One of the greatest challenges in burn care is the estimation of a total burn surface area (TBSA). It is especially challenging and needs to take into account the growing proportions and the age of a paediatric patient. The aims of this study is to: (1) assess the reliability of the three modalities (LB, MB, and EB) in calculating the extent of burn injuries and fluid resuscitation, and (2) compare the features in terms of usability and efficacy. METHODS: Participants were recruited from Women's and Children's Hospital (WCH), South Australia's surgical and emergency department. Participants were introduced to LB, MB and EB, and then commenced calculation of TBSA on two simulated paediatric (patient A: 12 months, patient B: 4 years) burns. The participants were categorized into three groups; (1) Burns-naïve, (2) Burns-experienced, and (3) Burns-expert. RESULTS: A total of 45 participants took part in this validation study: doctors (49%), nurses (33%), nursing students (11%) and medical students (7%). The burns-naïve group demonstrated higher means in both patients and has greater variance, TBSA mean 28.8%, range 14-40.5% and mean 37.4%, range 20-52.3% in patient A and B respectively. Two-way ANOVA analysis shows a statistically significant interaction between the effects of level of experience and use of applications on estimation of TBSA in larger burns. CONCLUSION: Innovative software and mobile applications demonstrate a high potential as clinical adjuncts in achieving better health outcomes in any health care system. Both Mersey Burns and e-burn reduced the risk of human error particularly from untrained or non-specialised clinicians, however, e-burn proved to be more favourable in our study. Technology-aided models are the future of burns assessment, and further studies are warranted to determine their impact on overall clinical outcome.

Mortality in paediatric burns at the Women's and Children's Hospital (WCH), Adelaide, South Australia: 1960-2017.

BACKGROUND: Burn injuries are the third leading cause of preventable death in children worldwide, resulting in over 100 000 annual hospitalisations. In the paediatric population, scalds are the commonest mechanism and burn injuries of greater than 40% total burn surface area (TBSA) are associated with a high mortality and morbidity rate. AIMS: The aim of this study was to review mortality in paediatric burns in a tertiary burns centre over a 60-year period, providing an understanding of local causes of mortality and directing future clinical research. METHODS: We reviewed data collected prospectively from patients treated for burn injuries at the WCH from 1960 to 2017. Data of age, gender, mechanism of injury and TBSA were collected. TBSA of 40% and greater were included in the study. RESULTS: All patients with total burn surface area (TBSA) less than 40% survived. There were a total of 75 patients who sustained burns of or greater than 40% TBSA. Overall mortality was 34% (26 of 75) of which 24 occurred in the 1960s. Of the 21 patients who died of flame burn injuries, 12 of them were described as clothes catching alight from being in close proximity to the source of flame. Average length of stay for patients who did not survive was 7 days (1-26). CONCLUSION: Mortality has since declined and the prognosis for survival good, even in TBSA of greater than 90%. The investigations in fabric flammability led by Dr Thomas Pressley and Mr Murray Clarke prompted the rewriting of Australian standards for production of children's clothing. This, in combination with advances in paediatric resuscitation, surgical techniques as well as wound care has improved survival rates and outcomes in extensive burn injuries. Future studies focus to see not only better survival rates, but also better aesthetic and functional outcomes in burn survivors.

Successful microsurgical penile replantation after a workplace injury.

Microsurgical techniques offer the opportunity for successful replantation of the amputated penis. We report the case of a patient who sustained a traumatic penile amputation as a result of a workplace accident. Microsurgical replantation was achieved with combined urological and plastic surgical input.