Areta Kowal-Vern

Erythema multiforme, Stevens Johnson syndrome, and toxic epidermal necrolysis syndrome in patients undergoing radiation therapy: a literature review.

Objective:Erythema multiforme (EM), Stevens Johnson syndrome (SJS), and toxic epidermal necrolysis syndrome (TENS) are exfoliative disorders that may present as complications in some patients undergoing radiotherapy. The purpose of this literature review was to determine the reported frequency of these exanthemata in irradiated patients. Methods:A comprehensive search from 1903 to 2011, identified 89 articles with 165 cases. Results:Of 151 evaluable cases, 57 (38%) described EM; 46 (30.5%) SJS; 14 (9%) SJS/TENS overlap; and 34 (22.5%) TENS. Ninety-three percent underwent radiotherapy for either a primary or metastatic malignancy. A majority of patients were simultaneously treated with medications known to precipitate these exanthemata. Of the 61 patients receiving antiepileptic medications during radiotherapy, 48 were treated prophylactically and 13 for seizures, most frequently with phenytoin or phenobarbital. Amifostine was the second most common medication associated with radiotherapy and these reactions. Fourteen (23%) patients on anticonvulsant medication, and 11 (38%) on other medications died compared with 3 (8%) patients treated with radiotherapy alone (P=0.002). No deaths occurred among irradiated patients receiving amifostine. Conclusions:EM, SJS, and TENS were rarely reported in patients undergoing radiotherapy alone. The majority of SJS and TENS occurred in irradiated patients with concomitant prescribed medications.

Paediatric burn rehabilitation

Therapy is very important during all phases of burn wound care in preventing scar contractures, limb deformities, skin graft preservation and healing, and reconstruction. The following review details the course of a paediatric burn injury and outlines the vital role played by the physical, occupational and child therapists during resuscitation, hospitalization and recovery.

Antithrombin (human) concentrate infusion in pediatric patients with >50% TBSA burns

BACKGROUNDnAntithrombin (human) [AT(H)] concentrate infusions have been safely utilized in adult burn patients to counteract subclinical disseminated intravascular coagulopathy and pulmonary complications.nnnOBJECTIVEnAT(H) concentrate was given to two thermally injured pediatric patients to evaluate safety and dosage requirements.nnnDESIGNnThe first patient was a 2-year-old with 83% total burn surface area (TBSA) full thickness flame burn and severe inhalation injury. The second patient was a 14-month-old who sustained 56% TBSA deep partial and full thickness scald injury. Each child received 10 infusions of AT(H) concentrate (106 units/kg) in the first 4 days post-injury.nnnRESULTnFor these two patients, the plasma AT level (normal range: 100+/-20%) increased, respectively, from 25 and 66% on admission to 224 and 217% on day 1, 114 and 116% on day 2, and 193 and 171% on day 3. Both patients tolerated the infusions well. In one patient, the eschar on all four extremities easily peeled off the subcutaneous tissues along a natural demarcation between viable and non-viable tissue with only a 40cc estimated blood loss (EBL).nnnCONCLUSIONSnAT(H) concentrate is tolerated in the pediatric population in the acute phase of injury. Lack of bleeding during eschar removal may be of benefit to burn excision and grafting.

Blister fluid composition in a pediatric patient with toxic epidermal necrolysis.

Toxic epidermal necrolysis (TEN) is a rare life-threatening disease mostly related to drug ingestion. Apoptotic keratinocytes lead to separation of the epidermis from dermis and widespread blistering of the skin. This case is a pediatric patient with a seizure disorder who developed TEN after starting carbamezepine. Blister fluid was analyzed for protein, chemical, and mineral content. The TEN blister fluid composition was similar to burn blister, except that the burn blister fluid has a 3-fold increase in albumin and protein. There was a substantial increase in lactate dehydrogenase, calcium, and magnesium in both blister fluid specimens compared with serum levels. To our knowledge, this report is the first in the literature to analyze TEN blister fluid composition and compare it to burn blister fluid.

Treatment of frostbite with subatmospheric pressure therapy.

Frostbite may result in loss of skin and tissue requiring amputation; it occurs most often on the exposed areas such as extremity digits, ears, etc. The usual treatment is observation for demarcation of the injury before amputation or autoamputation of the dry gangrene that may set in between 1 and 3 weeks. In some instances, tissue viability is assessed by a pyrophosphate nuclear scan. This was a 43-year-old African-American man who developed frostbite of his right foot. He presented 72 hours after injury with hyperemia and cellulitis over the dorsum of the foot and a blistered dorsal surface of the great toe with loss of sensation on all toes and early signs of necrosis. The patient received a 7-day course of ampicillin-sulbactam and a 6-day course of vacuum-assisted closure therapy during a 7-day hospitalization. At the time of discharge, he had re-epithialialization of the dorsal surface of the right toe and healthy granulation tissue with islands of epidermis emerging on the ventral surface of the right toe. Re-epithelialization was complete by 26 days after injury. In the future, this treatment therapy may find a larger application in frostbite injuries because it may accelerate healing. A study of frostbite treatment confirming the usefulness of this modality may be indicated.

Demographics of the homeless in an urban burn unit.

There are few articles about the homeless in burn literature. We sought to determine the demographic characteristics of the homeless citizens admitted to an urban burn center. This was a retrospective review from March 1999 to May 2004. Statistical analysis included &khgr;2 and one-way analysis of variance. There were 1615 burn admissions, and 73 (4.5%) of these patients were homeless. Although the %TBSA affected was similar for the homeless and domiciled patients, the mean (±SD) age of the homeless was 44 ± 10 years and their length of stay was 15 ± 15 days, compared with 31 ± 22 years and 9 ± 13 days, respectively, for the domiciled. Twenty-one (29%) of the 73 homeless were admitted for frostbite, vs 21 (1.4%) of the 1542 domiciled patients (P= .000). Because of the frostbite, the majority (53%) arrived in the winter, compared with 15% in each of the other three seasons (P= .000). The homeless had a higher frequency of acute and chronic ethanol and cocaine use than the domiciled population (21% vs 6%). There was no significant difference between the homeless and the domiciled population in %TBSA affected, nutritional values, and assault frequency. More than half of the homeless patient admissions to the burn unit resulted from assault or frostbite. The homeless were mainly African-Americans and Caucasians, with a higher frequency of ethanol and cocaine use than in the domiciled burn population. Lack of discharge options for the homeless prolonged the average length of stay, leading to increased costs, often borne by the burn unit.

Trephination and subatmospheric pressure therapy in the management of extremity exposed bone.

BACKGROUNDnDistal lower and upper extremity wounds with bone and tendon exposure present unique challenges to reconstructive surgeons. The limitations of the local anatomy usually make simpler reconstructive modalities such as primary closure and skin grafting difficult. As a result, wounds in this area, especially ones with bone or tendon exposures, are classically treated with free tissue transfer.nnnMETHODSnLimb preservation using the combination of bone trephination and subatmospheric pressure therapy is described.nnnRESULTSnSix cases with preserved extremities are presented. Three cases illustrate extremity wound with bone and tendon exposure healing through pregrafting wound optimization (bone trephination) with the use of subatmospheric pressure therapy.nnnCONCLUSIONSnThis treatment may offer an alternative method of limb salvage, in cases where flaps or free tissue transfer are not possible or optimal.

Toxic Epidermal Necrolysis in an Irradiated Patient Treated with a Nanocrystalline Silver Dressing

Toxic epidermal necrolysis syndrome is a severe exfoliative condition, which may be triggered by anticonvulsant medication. We report a case of toxic epidermal necrolysis syndrome in a 43-year-old female who was receiving radiotherapy for brain metastases from a recurring breast cancer and phenytoin. She had 80% total body surface area involvement and recovered successfully with the application of a nanocrystalline silver dressing.