Mamta Shah

Voriconazole plasma monitoring

Aims: Very little information is available regarding the use of voriconazole drug monitoring in children with invasive fungal infections. The purpose of this study was to report the cases of five paediatric patients treated with voriconazole, in which plasma levels were used to monitor therapy. Methods: Five children treated with voriconazole were included in this case series. Voriconazole plasma levels were determined using either a bioassay or liquid chromatography–tandem mass spectrometry. Results: The patients’ ages ranged from 2 to 10 years old (mean 6.2 years). Three patients had acute leukaemia and two had suffered severe burn injuries. Doses administered varied from 3.4 mg/kg every 12 h to 8.1 mg/kg every 8 h. Plasma voriconazole concentrations were unpredictable for these paediatric patients. Subtherapeutic levels were frequently observed, despite progressive increments in dosage. For others, voriconazole levels markedly increased after a small increment in dosage. Phenobarbitone caused important drug interactions with voriconazole for two of the patients. Conclusions: The dose administered did not correlate with exposure as measured by plasma levels of voriconazole. While the optimal dosage for voriconazole in children is still unknown, drug monitoring seems warranted to ensure adequate exposure, and after dose increments to prevent excessive exposure. Drug interactions significantly altered exposure.

Emergency and early management of burns and scalds

#### Summary points Burn injuries are an important global health problem. Most simple burns can be managed by general practitioners in primary care, but complex burns and all major burns warrant a specialist and skilled multidisciplinary approach for a successful clinical outcome. This article discusses the principles behind managing major burns and scalds using an evidence based approach and provides a framework for managing simple burns in the community. #### Sources and selection criteria We searched Medline, Ovid, Burns, and the Cochrane Library until June 2008 for randomised controlled trials, systematic reviews, evidence reports, and recent evidence based guidelines from international burn associations. Annually in the United Kingdom, around 175 000 people attend accident and emergency departments with burns from various causes (box 1).1 This represents 1% of all emergency department attendances, and about 10% of these patients need inpatient management in a specialist unit.2 A further 250 000 patients are managed in the community by general practitioners and allied professionals. Of patients referred to hospital, some 16 000 are admitted, and about 1000 patients need active fluid resuscitation. The number of burns related deaths average 300 a year.1 #### Box 1 Some important causes of burns and scalds Globally, the World Health Organization estimates that 322 000 people die each year from …

Genetic susceptibility in Dupuytren's disease

Dupuytrens disease is a benign fibroproliferative disease of unknown aetiology. It is often familial and commonly affects Northern European Caucasian men, but genetic studies have yet to identify the relevant genes. Transforming growth factor beta one (TGF-beta1) is a multifunctional cytokine which plays a central role in wound healing and fibrosis. It stimulates the proliferation of fibroblasts and the deposition of extracellular matrix. Previous studies have implicated TGF-beta1 in Dupuytrens disease, suggesting that it may represent a candidate susceptibility gene for this condition. We have investigated the association of four common single nucleotide polymorphisms in TGF-beta1 with the risk of developing Dupuytrens disease. A polymerase chain reaction-restriction fragment length polymorphism method was used for genotyping TGF-beta1 polymorphisms. DNA samples from 135 patients with Dupuytrens disease and 200 control subjects were examined. There was no statistically significant difference in TGF-beta1 genotype or allele frequency distributions between the patients and controls for the codons 10, 25, -509 and -800 polymorphisms. Our observations suggest that common TGF-beta1 polymorphisms are not associated with a risk of developing Dupuytrens disease. These data should be interpreted with caution since the lack of association was shown in only one series of patients with only known, common polymorphisms of TGF-beta1. To our knowledge, this is the first report of a case-control association study in Dupuytrens disease using single nucleotide polymorphisms in TGF-beta1.

Genetic susceptibility in Dupuytren's disease: TGF-β1 Polymorphisms and Dupuytren's disease

Dupuytrens disease is a benign fibroproliferative disease of unknown aetiology. It is often familial and commonly affects Northern European Caucasian men, but genetic studies have yet to identify the relevant genes. Transforming growth factor beta one (TGF-beta1) is a multifunctional cytokine which plays a central role in wound healing and fibrosis. It stimulates the proliferation of fibroblasts and the deposition of extracellular matrix. Previous studies have implicated TGF-beta1 in Dupuytrens disease, suggesting that it may represent a candidate susceptibility gene for this condition. We have investigated the association of four common single nucleotide polymorphisms in TGF-beta1 with the risk of developing Dupuytrens disease. A polymerase chain reaction-restriction fragment length polymorphism method was used for genotyping TGF-beta1 polymorphisms. DNA samples from 135 patients with Dupuytrens disease and 200 control subjects were examined. There was no statistically significant difference in TGF-beta1 genotype or allele frequency distributions between the patients and controls for the codons 10, 25, -509 and -800 polymorphisms. Our observations suggest that common TGF-beta1 polymorphisms are not associated with a risk of developing Dupuytrens disease. These data should be interpreted with caution since the lack of association was shown in only one series of patients with only known, common polymorphisms of TGF-beta1. To our knowledge, this is the first report of a case-control association study in Dupuytrens disease using single nucleotide polymorphisms in TGF-beta1.

Porcin xenograft dressing for facial burns: beware of the mesh imprint

It creates an environment which facilitates migration and proliferation of epithelial cells whilst also protecting against bacterial invasion and evaporative water loss. It is a temporary biological dressing that does not become vascularised [4]. It is rejected by surface-activated rejection mechanism and/or mechanically dislodged by the growth of the epithelium underneath. We have used E-Z Derm dressing for partial thickness facial burns in the Paediatric burns unit for many years. Our main reasons for its use have been the ease of application, avoidance of frequent dressing changes and for patient comfort. We have used perforated sheets of E-Z Derm to allow exudate drainage. E-Z Derm once adherent, has been left in situ until it dries and lifts off, when it is trimmed as per the product information. The manufacturer’s literature states “after the E-Z Derm adheres to the wound, leave it in place until it sloughs.” “In most cases, partial thickness wounds will heal beneath the E-Z Derm dressing in 7–10 days.” Here, we report

Tattoos: ancient body art may assist in medical emergencies.

Tattooing, like medicine, is an ancient art form. However, in the UK, tattooing of minors is illegal except when performed for medical reasons. We present a 15-year-old type I diabetic, who being prone to hypoglycaemic attacks, had a permanent medical alert tattoo on his forearm, with his parents’ consent, whilst on holiday abroad. Tattooing to convey a medical message is employed by many adults for reasons as diverse as anaphylaxis to do not resuscitate orders. We present the patient and propose that clinicians may wish to consider supporting tattooing to convey a medical alert in young people, particularly those at risk of life-threatening complications, such as hypoglycaemia.

Measuring the impact of a burns school reintegration programme on the time taken to return to school: A multi-disciplinary team intervention for children returning to school after a significant burn injury

INTRODUCTION Returning to school can be a major step for burn-injured children, their family, and staff and pupils at the receiving school. Previous literature has recognised the difficulties children may face after a significant injury and factors that may influence a successful reintegration. AIM A regional paediatric burns service recognised that some patients were experiencing difficulties in returning to school. A baseline audit confirmed this and suggested factors that hindered or facilitated this process, initiating the development of a school reintegration programme (SRP). Since the programmes development in 2009, it has been audited annually. The aim of this paper was to evaluate the impact of the SRP by presenting data from the 2009 to 2011 audits. METHOD For the baseline audit, the burn care team gathered information from clinical records (age, gender, total body surface area burned (TBSA), skin grafting and length of stay) and telephone interviews with parents and teachers of the school returners. For the re-audits, the same information was gathered from clinical records and feedback questionnaires. RESULTS Since its introduction, the mean length of time from discharge to return to school has dropped annually for those that opted into the programme, when compared to the baseline by 62.3% (53 days to 20 days). Thematic analysis highlights positive responses to the programme from all involved. Increased awareness and feeling supported were amongst the main themes to emerge. CONCLUSIONS Returning to school after a significant burn injury can be challenging for all involved, but we hypothesise that outreach interventions in schools by burns services can have a positive impact on the time it takes children to successfully reintegrate.

Use of procalcitonin as a biomarker for sepsis in moderate to major paediatric burns

Introduction Accurate and early detection of sepsis poses a significant challenge in burn populations. Our objective was to assess whether procalcitonin is a marker of blood culture positive sepsis in moderate to severe paediatric burns. Methods We analysed procalcitonin levels in 27 children admitted with burns of 15–65% total body surface area. Procalcitonin was measured at admission (baseline), 24 and 48 h post-admission and during periods of suspected sepsis (diagnosed against pre-defined criteria). Patients were categorised into controls with no episodes of suspected sepsis (n = 10) and those with episodes of suspected sepsis (n = 17). The latter were split into two groups based on blood culture results: culture positive (bacteraemia) and culture negative patients. Results Baseline procalcitonin levels increased with burn size (odds ratio (95% confidence interval): 1.15 (1.02–1.29)). Suspected sepsis patients had larger burns than controls (median 31 vs. 20%; p = 0.003). Only 5/23 suspected sepsis episodes were blood culture positive. Procalcitonin levels were similar in culture positive and culture negative patients (p = 0.43). Sensitivity for predicting positive blood culture was 100% (95% confidence interval: 47.8–100.0%) but specificity was only 22.2% (95% confidence interval: 6.4–47.6%). Area under the curve was poor at 0.62 (95% confidence interval: 0.33–0.90). There was no significant change in procalcitonin levels from baseline to septic episode in either group (positive: p = 0.35; negative: p = 0.95). Conclusion We conclude that evidence for the use of procalcitonin to diagnose bacteraemia in this population is poor, with burn size playing a significant role implying a correlation with systemic inflammation rather than sepsis.

Circumoral complications in hereditary sensory and autonomic neuropathy — a case of simple lip reconstruction?

We report a case of a 7-year-old Bangladeshi boy who caused himself oral incontinence by self-mutilation. The patient was known to suffer from hereditary sensory and autonomic neuropathy type V. As definitive management, a full dental clearance was performed along with reconstruction of the lower lip with a good functional and aesthetic outcome. He did not experience any adverse effects from the full dental clearance with regard to feeding, nutrition or development. We discuss the dilemma and challenges raised in the management of this patient and highlight the need for a multi-disciplinary specialist input for what appeared to be a simple case of lip reconstruction for a plastic surgeon.

Reply to the correspondence letter by N Kluger et al. ‘Medical alert tattoos in minors should not be advocated’

We read with interest the correspondence from Dr. Kluger and colleague to our image article [1]. The authors express similar views with regards the need for better understanding of medical alert tattoos within the medical community and also the need for a recognised symbol and site for these tattoos, so they can be readily seen and acted upon in an emergency. However, the authors do not agree that tattooing should be advocated in minors. Their reasons are this is a decision which many adults take a long time to consider and something that should be approached with caution, particularly in diabetic patients. We agree that this does not apply to all young people with a chronic condition or severe allergy, but instead that clinicians should be able to support young people on a case-by-case basis who have taken the time to decide to obtain a medical alert tattoo and are fully aware of the risks, benefits and permanency of the procedure. This is particularly pertinent for UK paediatricians and general practitioners as tattooing is illegal for minors under the age of 18 years in the UK. This article and correspondence highlight an important issue for clinicians, as young people (as well as adults) are increasingly choosing medical alert tattoos over more traditional alert jewellery. We would be interested in Dr. Kluger and colleague expanding on their reasons for not advocating this in minors as we feel the support of clinicians should be available for a competent young person, and their parents, who have made the informed decision to obtain a medical alert tattoo.