Břetislav Lipový

Staphylococcal scalded skin syndrome in the Czech Republic: an epidemiological study

OBJECTIVE To identify the basic epidemiological characteristics of children hospitalized with diagnosis of Staphylococcal scalded skin syndrome in the Czech Republic in the years 1994-2009. INTRODUCTION Staphylococcal scalded skin syndrome (SSSS) is a relatively rare disease in childhood. This syndrome was first defined in 1878 by Baron Gottfried Ritter von Rittershainem and belongs to the group of diseases called Burn-like syndromes. It is a bullous skin disease caused by exfoliative toxins which are produced by certain types of Staphyloccocus aureus. Typical structures affected by these toxins are desmosome proteins called Desmoglein-1 located in the stratum granulosum of epidermis. Unlike in Lyells syndrome or Stevens-Johnsons syndrome, the exfoliation is caused by loss of adhesivity particularly in the stratum granulosum and not by induction of apoptosis in the dermo-epidermal junction. MATERIAL AND METHODS This retrospective study was conducted on patients hospitalized in the Czech Republic in the period from 1.1.1994 to 31.12.2009. The basic condition for the inclusion in the retrospective study was age under 1 year and hospitalization due to SSSS. A total of 399 children (177 girls) fulfilled the criteria for inclusion into the study. Information was obtained from a central data depository, the Department of Health Information and Statistics, Czech Republic. RESULTS A total of 399 children under 1 year were hospitalized for the diagnosis of SSSS in the study period. The group included 177 girls and 222 boys. M:F ratio was 1.25:1. The average incidence of SSSS in the Czech Republic was 25.11 cases per 100,000 children under 1 year of age. The highest recorded incidence in the followed period was in 1994, when a total of 57 cases of SSSS was reported, namely 53.47 per 100,000 children. By contrast, in 2003, there were reported only 12 cases and the incidence of 12.81 per 100,000 children. The average length of hospitalization was 6.39 days. In 1995, the highest average length of hospitalization was reported, which was 8.1 days, and then in 2007, the lowest average length of hospitalization, 4.4 days. There was no significant difference in the length of hospitalization in boys and girls. None of the 399 children in the population died. CONCLUSION In our retrospective study, we established basic epidemiological characteristics of a group of children aged under 1 year with diagnosis of SSSS. As epidemiological data show, the occurrence of this syndrome is not sporadic, but steady.

The epidemiology of pediatric burns undergoing intensive care in Burn Centre Brno, Czech Republic, 1997-2009.

UNLABELLED The aim of this study was to determine the basic epidemiological characteristics of severely burned children who were admitted to the intensive care unit (ICU), Department of Burns and Reconstructive Surgery Faculty Hospital Brno, Czech Republic in the years 1997-2009. METHODS We collected and evaluated epidemiological data such as age, sex, burn etiology, length of hospitalization, duration of the ICU stay, surgical or conservative therapeutic strategies, the use of mechanical ventilation and its duration, day and month of injury and the extent of burned area. RESULTS In total 383 children (253 boys, 130 girls) aged 0-14 years, underwent intensive care for at least 48h. Male to female ratio was 1.95:1. The average range of burn area in the group was 16.43±12.86% TBSA (total body surface area). During the reporting period, 16 children were admitted with burns over 50% TBSA. 328 children suffered burns indoors, with 55 children being burned outdoors. Indoor/outdoor ratio was set at 5.96:1. The most frequent etiological agent was scalding (hot water, soup, coffee, oil, tea). The total number of scalded children in this group was 312 (81.46%). Mechanical ventilation was used in 96 cases (25.07% of all the admitted patients). The duration of mechanical ventilation in these patients was 8.03±5.67 days in average. The average length of stay in ICU was 10.71±10.92 days and total length of hospital stay was an average of 21.55±14.55 days. A total of 184 patients (48.04%) were treated surgically and therefore required necrectomy and skin grafting. The other 199 (51.96%) patients were treated conservatively. During the reporting period 3 children died (0.78%). CONCLUSION In our report we identify basic epidemiological data defined in the aim of this study for burned children requiring intensive care.

Accelerated re-epithelialization of partial-thickness skin wounds by a topical betulin gel: Results of a randomized phase III clinical trials program

The clinical significance of timely re-epithelialization is obvious in burn care, since delayed wound closure is enhancing the risk of wound site infection and extensive scarring. Topical treatments that accelerate wound healing are urgently needed to reduce these sequelae. Evidence from preliminary studies suggests that betulin can accelerate the healing of different types of wounds, including second degree burns and split-thickness skin graft wounds. The goal of this combined study program consisting of two randomized phase III clinical trials in parallel is to evaluate whether a topical betulin gel (TBG) is accelerating re-epithelialization of split-thickness skin graft (STSG) donor site wounds compared to standard of care. Two parallel blindly evaluated, randomised, controlled, multicentre phase III clinical trials were performed in adults undergoing STSG surgery (EudraCT nos. 2012-003390-26 and 2012-000777-23). Donor site wounds were split into two equal halves and randomized 1:1 to standard of care (a non-adhesive moist wound dressing) or standard of care plus TBG consisting of 10% birch bark extract and 90% sunflower oil (Episalvan, Birken AG, Niefern-Oeschelbronn, Germany). The primary efficacy assessment was the intra-individual difference in time to wound closure assessed from digital photographs by three blinded experts. A total of 219 patients were included and treated in the two trials. Wounds closed faster with TBG than without it (15.3 vs. 16.5 days; mean intra-individual difference=-1.1 days [95% CI, -1.5 to -0.7]; p<0.0001). This agreed with unblinded direct clinical assessment (difference=-2.1 days [95% CI, -2.7 to -1.5]; p<0.0001). Adverse events possibly related to treatment were mild or moderate and mostly at the application site. TBG accelerates re-epithelialization of partial thickness wounds compared to the current standard of care, providing a well-tolerated contribution to burn care in practice.

Wrap-around flap in urgent thumb reconstruction after high-voltage electrical injury

In this case we describe a young man, who suffered highvoltage electrical injury (22 000 V) caused by moving rails with a crane standing on a high ramp at the train station and hitting high-voltage wires, followed by fall to the floor and short-term unconsciousness (2 min) with posttraumatic amnesia.

Toxic epidermal necrolysis data from the CELESTE multinational registry. Part I: Epidemiology and general microbiological characteristics

INTRODUCTION Toxic epidermal necrolysis (TEN) is a rare, life-threatening autoimmune disease predominantly manifested in the skin and mucous membranes. Today, infectious complications have the dominant share in mortality of TEN patients. Due to the nature of the therapy and administration of immunosuppressive medications, a wide range of potentially pathogenic microorganisms, which cause infectious complications in different compartments in these patients, is not surprising. MATERIAL AND METHODOLOGY This is a multicentric study, which included all patients with TEN hospitalized between 2000-2015 in specialized centres in the Czech Republic and Slovakia. The total catchment area was over 12.5 million inhabitants. The actual implementation of the project was carried out using data obtained from the registry CELESTE (Central European LyEll Syndrome: Therapeutic Evaluation), when specific parameters relating to epidemiological indicators and infectious complications in patients with TEN were evaluated in the form of a retrospective analysis. RESULTS In total, 39 patients with TEN were included in the study (12 patients died, mortality was 31%), who were hospitalized in the monitored period. The median age of patients in the group was 63 years (the range was 4-83 years, the mean was 51 years), the median of the exfoliated area was 70% TBSA (total body surface area) (range 30-100%, mean 67%). SCORTEN was calculated for 38 patients on the day of admission. Its median in all patients was 3 (range 1-6; mean 3). Any kind of infectious complication in the study group was recorded in 33 patients in total (85%). In total, 30 patients (77%) were infected with gram-positive cocci, 27 patients (69%) with gram-negative rods, and yeast cells or fibrous sponge were cultivated in 12 patients (31%). A total of 32 patients (82%) were found to have infectious complications in the exfoliated area, 15 patients (39%) had lower respiratory tract infections, 18 patients (46%) urinary tract infections and 15 patients (39%) an infection in the bloodstream. The most common potentially pathogenic microorganism isolated in our study group was coagulase neg. Staphylococcus, which caused infectious complications in 24 patients. Enterococcus faecalis/faecium (19 patients), Pseudomonas aeruginosa (17 patients), Staphylococcus aureus (11 patients) and Escherichia coli (11 patients) were other most frequently isolated micro-organisms. CONCLUSION The published data were obtained from the unique registry of TEN patients in Central Europe. In the first part, we have succeeded in defining the basic epidemiological indicators in the group of patients anonymously included in this registry. The study clearly confirms that infectious complications currently play an essential role in TEN patients, often limiting the chances of survival. The study also shows a high prevalence of these complications in the period after 15days from the start of hospitalization, when most patients already have completely regenerated skin cover.

Effect of timing of tracheostomy on changes in bacterial colonisation of the lower respiratory tract in burned children

OBJECTIVE The study aims to evaluate the impact of early and late tracheostomy on microbiological changes in the airways in severely burned children. MATERIALS AND METHODS Early tracheostomy is sometimes performed within 3 days after the start of mechanical ventilation regular microbiological surveillance of the respiratory tract was done in all patients. From each sputum, tracheobronchial aspirate and bronchoalveolar lavage (BAL), a microscopic slide was made and the material was seeded in a culture medium. The standard culture media used for the growth of respiratory pathogens are blood agar, McConkey agar, VL agar and chocolate agar. The obtained values were statistically analysed. RESULTS In the observed period, a total of 68 children underwent mechanical ventilation in our department. A total of 31 (45.59%) children had undergone surgical tracheostomy (18 patients with early tracheostomy and 13 patients with late tracheostomy). The most common bacterium isolated from the lower respiratory tract in patients with early and late tracheostomy was Acinetobacter baumannii (31.53% resp. 44.30% of all bacterial strains). In patients with early tracheostomy, the ratio of G+/G- during the 6-7th day of mechanical ventilation was 1.29:1 and during the 8-10th day, 1:1.43. In patients with late tracheostomy the G+/G- ratio was 1:2.25 and during the 8-10th day, 1:2.25. There was not any statistically significant deviation in the G+/G- ratio in patients with early and late tracheostomy in any of the monitored periods. CONCLUSION The main reasons for performing early tracheostomy are: extent, localisation and depth of the burn. Difficult weaning in an uncooperative patient, failure of extubation with subsequent reintubation and other complications may be an indication for late tracheostomy. The study confirms that the use of appropriately indicated early tracheostomy provides a microbiological benefit for burned children.

Toxic epidermal necrolysis data from the CELESTE multinational registry. Part II: Specific systemic and local risk factors for the development of infectious complications

The aim of the study was to identify the most important systemic and local risk factors for the development of infectious complications in patients with toxic epidermal necrolysis (TEN). MATERIAL AND METHODOLOGY This is a multicentric study that included all patients with TEN who were hospitalized between 2000-2015 in specialized centres in the Czech Republic and Slovakia. The total catchment area included a population of over 12.5 million inhabitants. The actual implementation of the project was carried out using data obtained from the CELESTE (Central European LyEll Syndrome: Therapeutic Evaluation) registry, wherein specific parameters related to epidemiological indicators and infectious complications in patients with TEN were evaluated as a retrospective analysis. RESULTS A total of 38 patients (97%) of the group were treated with corticosteroids. The comparison of patients with different doses of corticosteroids did not exhibit a statistically significant effect of corticosteroid administration on the development of infectious complications (p=0.421). There was no effect of the extent of the exfoliated area on the development of infectious complications in this area. The average extent of the exfoliated area was 66% TBSA (total body surface area) in patients with reported infectious complications and 71% TBSA (p=0.675) in patients without infectious complications. In the case of the development of an infectious complication in the bloodstream (BSI), the increasing effect of the SCORTEN (SCORe of Toxic Epidermal Necrosis) value was monitored during hospitalization. Within 5days from the beginning of the hospitalization, the average SCORTEN value was 2.7 in 6 patients with BSI and 3.0 in 32 patients without BSI (p=0.588). In the period after the 15th day of hospitalization, 7 patients with BSI had an average SCORTEN value of 3.4, and 16 patients without BSI had an average SCORTEN value of 2.5 (p=0.079). In the case of low respiratory tract infection (LRTI), the effects of the necessity for artificial pulmonary ventilation and the presence of tracheostomy were monitored. The statistically significant effect of mechanical ventilation on the development of LRTI occurred only during the period of 11-15days from the beginning of the hospitalization (p=0.016). The effect of the tracheostomy on the development of LRTI was proven to be more significant. CONCLUSION We did not find any statistically significant correlation between the nature of immunosuppressive therapy and the risk of developing infectious complications. We failed to identify statistically significant risk factors for the development of BSI. Mechanical ventilation and tracheostomy increase the likelihood of developing LRTIs in patients with TEN.

The extended medial plantar artery (EMPA) free flap for plantar foot defects

The medial plantar artery (MPA) flap was first introduced by Mir y Mir in 1954 and used to reconstruct a heel defect. The sole of the foot is designed to bear body weight and absorb the shocks of a bipedal gait. The properties of the plantar skin and deeper tissues are therefore highly specialised, and if normal function is to be restored, it is essential to replace “like with like” which is a fundamental principle of reconstructive surgery.The aim of this article is to introduce the concept of an extended medial plantar artery (EMPA) free flap for plantar foot defects. The advantage of the extended version of the MPA flap in the presented cases is the harvest of a larger bulk of tissue and thus the possibility of covering larger defects in the weight-bearing area of the foot.Level of Evidence: Level V, therapeutic study.

A draft of bronchoscopic grading system in patients with toxic epidermal necrolysis

Toxic epidermal necrolysis (TEN) is a rare, life-threatening condition, which is caused by the development of massive apoptosis in the dermoepidermal junction [1]. This apoptosis is mainly caused by caspase mechanisms, which are affected by the activity of T-lymphocytes (CD4+ and CD8+), NK cells, or the bond of CD95L to CD95R [2]. Noncaspase mechanisms are also applied in the TEN pathophysiology, e.g., production of granzyme B CD8+ T lymphocytes or NK cells.

The role of antithrombin in patients with toxic epidermal necrolysis

Toxic epidermal necrolysis (TEN) is a rare systemic disease, which is predominantly manifested in the skin and mucous membranes. Its indicated incidence in the population is 0.5–1.5 cases per million inhabitants a year. It is the most severe syndrome from the SCARs group (Severe Cutaneous Adverse Reactions) with mortality around 30–50%.