Amber Young

Differences in medical therapy goals for children with severe traumatic brain injury-an international study.

Objectives: To describe the differences in goals for their usual practice for various medical therapies from a number of international centers for children with severe traumatic brain injury. Design: A survey of the goals from representatives of the international centers. Setting: Thirty-two pediatric traumatic brain injury centers in the United States, United Kingdom, France, and Spain. Patients: None. Interventions: None. Measurements and Main Results: A survey instrument was developed that required free-form responses from the centers regarding their usual practice goals for topics of intracranial hypertension therapies, hypoxia/ischemia prevention and detection, and metabolic support. Cerebrospinal fluid diversion strategies varied both across centers and within centers, with roughly equal proportion of centers adopting a strategy of continuous cerebrospinal fluid diversion and a strategy of no cerebrospinal fluid diversion. Use of mannitol and hypertonic saline for hyperosmolar therapies was widespread among centers (90.1% and 96.9%, respectively). Of centers using hypertonic saline, 3% saline preparations were the most common but many other concentrations were in common use. Routine hyperventilation was not reported as a standard goal and 31.3% of centers currently use PbO2 monitoring for cerebral hypoxia. The time to start nutritional support and glucose administration varied widely, with nutritional support beginning before 96 hours and glucose administration being started earlier in most centers. Conclusions: There were marked differences in medical goals for children with severe traumatic brain injury across our international consortium, and these differences seemed to be greatest in areas with the weakest evidence in the literature. Future studies that determine the superiority of the various medical therapies outlined within our survey would be a significant advance for the pediatric neurotrauma field and may lead to new standards of care and improved study designs for clinical trials.

Development of a prototype wound dressing technology which can detect and report colonization by pathogenic bacteria

A new methodology for detecting the microbiological state of a wound dressing in terms of its colonization with pathogenic bacteria such as Staphylococcus aureus or Pseudomonas aeruginosa has been developed. Here we report how stabilized lipid vesicles containing self-quenched carboxyfluorescein dye are sensitive to lysis only by toxins/virulence factors from P. aeruginosa and S. aureus but not by a non-toxic Escherichia coli species. The development of the stabilized vesicles is discussed and their response to detergent (triton), bacterial toxin (α-hemolysin) and lipases (phospholipase A(2)). Finally, fabrics with stabilized vesicles attached via plasma deposited maleic anhydride coupling are shown visibly responding to S. aureus (MSSA 476) and P. aeruginosa (PAO1) but not E. coli DH5α in a prototype dressing.

Severe head injury in children: intensive care unit activity and mortality in England and Wales

Objective: To explore the relationship between volume of paediatric intensive care unit (PICU) head injury (HI) admissions, specialist paediatric neurosurgical PICU practice, and mortality in England and Wales. Methods: Analysis of HI cases (age <16 years) from the Paediatric Intensive Care Audit Network national cohort of sequential PICU admissions in 27 units in England and Wales, in the 5 years 2004–2008. Risk-adjusted mortality using the Paediatric Index of Mortality (PIM) model was compared between PICUs aggregated into quartile groups, first to fourth based on descending number of HI admissions/year: highest volume, medium–higher volume, medium–lower volume, and lowest volume. The effect of category of PICU interventions – observation only, mechanical ventilation (MV) only, and intracranial pressure (ICP) monitoring – on outcome was also examined. Observations were reported in relation to specialist paediatric neurosurgical PICU practice. Results: There were 2575 admissions following acute HI (4.4% of non-cardiac surgery PICU admissions in England and Wales). PICU mortality was 9.3%. Units in the fourth-quartile (lowest volume) group did not have significant specialist paediatric neurosurgical activity on the PICU; the other groups did. Overall, there was no effect of HI admissions by individual PICU on risk-adjusted mortality. However, there were significant effects for both intensive care intervention category (p<0.001) and HI admissions by grouping (p<0.005). Funnel plots and control charts using the PIM model showed a hierarchy in increasing performance from lowest volume (group IV), to medium–higher volume (group II), to highest volume (group I), to medium–lower volume (group III) sectors of the health care system. Conclusions: The health care system in England and Wales for critically ill HI children requiring PICU admission performs as expected in relation to the PIM model. However, the lowest-volume sector, comprising 14 PICUs with little or no paediatric neurosurgical activity on the unit, exhibits worse than expected outcome, particularly in those undergoing ICP monitoring. The best outcomes are seen in units in the mid-volume sector. These data do not support the hypothesis that there is a simple relationship between PICU volume and performance.

Toxic shock syndrome in burns: diagnosis and management

Toxic shock syndrome (TSS), a toxin-mediated disease, is the most common cause of unexpected mortality in children with small burns. It is a diagnosis that is often missed because of non-specific signs and an ability to mimic other childhood illnesses. Any child with a pyrexia greater than 38.9 degrees C, a rash, or a sudden change in clinical condition within a few days of a burn injury should be monitored closely for TSS. If there is co-incident hyponatraemia or lymphopaenia, or if there is any deterioration in clinical condition, the child should be managed with anti-staphylococcal and streptococcal antibiotics and passive immunity for toxins provided by fresh frozen plasma (FFP) or intravenous immunoglobulin (IVIG). It is essential that all paediatric and emergency departments accepting children with burns are aware of the symptoms, signs and early management of TSS.

Enhancement of the antimicrobial properties of bacteriophage-K via stabilization using oil-in-water nano-emulsions

Bacteriophage therapy is a promising new treatment that may help overcome the threat posed by antibiotic‐resistant pathogenic bacteria, which are increasingly identified in hospitalized patients. The development of biocompatible and sustainable vehicles for incorporation of viable bacterial viruses into a wound dressing is a promising alternative. This article evaluates the antimicrobial efficacy of Bacteriophage K against Staphylococcus aureus over time, when stabilized and delivered via an oil‐in‐water nano‐emulsion. Nano‐emulsions were formulated via thermal phase inversion emulsification, and then bacterial growth was challenged with either native emulsion, or emulsion combined with Bacteriophage K. Bacteriophage infectivity, and the influence of storage time of the preparation, were assessed by turbidity measurements of bacterial samples. Newly prepared Bacteriophage K/nano‐emulsion formulations have greater antimicrobial activity than freely suspended bacteriophage. The phage‐loaded emulsions caused rapid and complete bacterial death of three different strains of S. aureus. The same effect was observed for preparations that were either stored at room temperature (18–20°C), or chilled at 4°C, for up to 10 days of storage. A response surface design of experiments was used to gain insight on the relative effects of the emulsion formulation on bacterial growth and phage lytic activity. More diluted emulsions had a less significant effect on bacterial growth, and diluted bacteriophage‐emulsion preparations yielded greater antibacterial activity. The enhancement of bacteriophage activity when delivered via nano‐emulsions is yet to be reported. This prompts further investigation into the use of these formulations for the development of novel anti‐microbial wound management strategies.

Smart dressings for the prevention of infection in pediatric burns patients

. One of the primary problems in the treatment of burns is bac-terial infection, which can delay healing, increase pain, increase the risk of scarring and, in some cases, cause death. In recent years there have been great improve-ments in the treatment of burns, par-ticularly with biologically-derived dress-ings, which actively promote cell growth. However, the problem of infection has not gone away, and there is evidence that silver-treated antimicrobial dressings can delay burn healing.

When do children get burnt

Burns are a cause of more than 5000 paediatric hospital admissions per year in England and Wales. Injury prevention and service provision may be better planned with knowledge of burn timing. Prospectively collected records from 1st January 2010 to 31st December 2011 were analysed. All episodes involving patients less than 16 years of age reviewed by the South West Childrens Burns Centre were included. Data was collected from 1480 records to investigate seasonal, weekly, and daily variation. Day to day analysis showed significantly more burns occurred on Saturday and Sunday than Monday-Friday (p<0.001). Of all burns, 46% occurred within the time-period 08:00-15:59; however the mean hourly rate of burns was highest between 16:00 and 18:59. Of the larger burns (>10% body surface area), 38% occurred after 19:00. There was no statistically significant variation in the monthly (p=0.105) or seasonal (p=0.270) distribution of burns. Bank holidays did not cause a statistically significant increase in numbers. Injury prevention strategies are likely to have most volume impact by increasing awareness of the peak time for burns in children, enabling parents at home with young children to modify any risky behaviour and by targeting older children and their behaviour.

Preventing venous thrombosis in critically ill children: what is the right approach?

Background:  The incidence of venous thromboembolic (VTE) events in children has increased in recent years (J Neurosurg, 101, 2004, 32; J Thromb Haemost, 1, 2003, 1443) yet there is currently no consensus as to what VTE prophylaxis, if any, should be applied to the pediatric population.

In vitro studies of toxic shock toxin-1-secreting Staphylococcus aureus and implications for burn care in children.

Background: The main etiologic agent of toxic shock syndrome is the toxic shock syndrome toxin-1 (TSST-1) protein secreted by Staphylococcus aureus. Diagnosis of toxic shock syndrome is difficult and is significantly underdiagnosed in young children with burns due to the nonspecific presentation coupled with a rapid deterioration in patient condition. Methods: The lytic and cytolytic activity of a number of clinical and laboratory TSST-1–positive strains of methicillin-susceptible S. aureus (101, 253, 279 and RN4282, respectively) and Pseudomonas aeruginosa PAO1 strain were tested in vitro using an assay designed to assess the relative exotoxin activity of bacteria using phospholipid vesicles and a T cell toxicity assay. In addition, the activity of lytic exotoxins such as &dgr; -toxin and the secretion of nonlytic TSST-1 toxin from S. aureus was measured using the vesicle assay and Western blotting over the 20-hour growth of TSST-1–positive S. aureus culture. Results: Both the vesicle and T cell assays suggest a lytic exotoxin-mediated mechanism of vesicle rupture and T cell death, with high levels of vesicle lysis and T cell toxicity. It is important to note that the clinical TSST-1–positive methicillin-susceptible S. aureus strains exhibited lytic exotoxin production as well as TSST-1 expression as confirmed by Western blot. Conclusion: We suggest that there is no correlation between the expression of TSST-1 and lack of exotoxin production. We also suggest that apurulence in an S. aureus–infected burn wound in a child should not be used to rule out toxic shock syndrome.

The management of small area burns and unexpected illness after burn in children under five years of age — A costing study in the English healthcare setting

The objective of this economic study was to evaluate the resource use and cost associated with the management of small area burns, including the additional costs associated with unexpected illness after burn in children of less than five years of age. This study was conducted as a secondary analysis of a multi-centre prospective observational cohort study investigating the physiological response to burns in children. 452 children were included in the economic analysis (median age=1.60years, 61.3% boys, median total burn surface area [TBSA]=1.00%) with a mean length of stay of 0.69 days. Of these children, 21.5% re-presented to medical care with an unexpected illness within fourteen days of injury. The cost of managing a burn of less than 10% TBSA in a child less than five years of age was £785. The additional cost associated with the management of illness after burn was £1381. A generalised linear regression model was used to determine the association between an unexpected illness after burn, presenting child characteristics and NHS cost. Our findings may be of value to those planning economic evaluations of novel technologies in burn care.