Peter J. Davenport

Patterns of Staphylococcus aureus colonization, toxin production, immunity and illness in burned children.

Toxic shock syndrome toxin-one (TSST-1) produced from some but not all strains of Staphylococcus aureus is considered to be responsible for the development of the serious illness, toxic shock syndrome (TSS). The aim of this study was to establish the importance of S. aureus in the aetiology of suspected cases of TSS in acutely burned children. The pattern of colonization of S. aureus, and in particular toxic shock syndrome toxin-one (TSST-1) producing isolates, was studied in 53 burned children admitted as consecutive cases. S. aureus was not normally present on admission. Although it was the most common wound pathogen, it was acquired during the first few days after admission. Antibody status to TSST-1 on admission and at discharge was determined. Only half (49 per cent) of the children had antibodies to TSST-1. When it was possible to obtain paired admission and discharge samples in patients who had been given blood products, an assessment of seroconversion could be made. Two of the four patients given blood products during the resuscitation and postoperative period were antibody negative on admission (the other two were TSST-1 antibody positive). By discharge they had antibodies to TSST-1. Whilst the majority of donated blood products had antibodies to TSST-1 (76 per cent), some (24 per cent) did not. Seven of 53 children (13 per cent) developed a toxic shock-like illness which caused clinical concern.(ABSTRACT TRUNCATED AT 250 WORDS)

Scandcleft randomised trials of primary surgery for unilateral cleft lip and palate: 2. Surgical results

Abstract Background: Longstanding uncertainty surrounds the selection of surgical protocols for unilateral cleft lip and palate, and randomised trials have only rarely been performed. The Scandcleft Project consists of three trials commenced in 1997 involving ten centres in Denmark, Finland, Norway, Sweden, and the UK. Three groups of centres tested a newly-defined common technique for palatal repair (Arm A) against their local protocols (Arms B, C, D). Arm A was familiar to most of the surgeons in Trial 1, but not to the surgeons in the other Trials. Aim: To evaluate surgical events and complications of the 448 (293 boys, 155 girls) patients with complete unilateral cleft lip and palate (UCLP) enrolled in the three trials. Method: The three trials were carried out in parallel in adherence with a fully developed, ethically approved protocol. Operative time, bleeding, complications, and major dehiscence during and after both primary surgeries were recorded by the surgeon. Rates of fistula and surgery for velopharyngeal incompetence (VPI) were assessed until the youngest patient of the study had reached the age of 9 years. Pearson Chi-square statistical analysis was used to compare the outcomes. Results: No significant differences in bleeding, infection, anaesthetic complications or length of hospital stay between the different arms were found for Trial 1. However, in Trials 2 and 3 there were more airway problems in Arm A than with the traditional local protocols (Arms C or D). In Trial 3 fistula and VPI surgery rates were also higher in Arm A. Conclusions: The results do not provide statistical evidence that any technique is better than others, but indicate that surgery was more problematic for surgeons who were still gaining experience with an unfamiliar surgical protocol. Trial registration: ISRCTN29932826.

Scandcleft randomised trials of primary surgery for unilateral cleft lip and palate: 1. Planning and management

Abstract Background and aims: Longstanding uncertainty surrounds the selection of surgical protocols for the closure of unilateral cleft lip and palate, and randomised trials have only rarely been performed. This paper is an introduction to three randomised trials of primary surgery for children born with complete unilateral cleft lip and palate (UCLP). It presents the protocol developed for the trials in CONSORT format, and describes the management structure that was developed to achieve the long-term engagement and commitment required to complete the project. Method: Ten established national or regional cleft centres participated. Lip and soft palate closure at 3–4 months, and hard palate closure at 12 months served as a common method in each trial. Trial 1 compared this with hard palate closure at 36 months. Trial 2 compared it with lip closure at 3–4 months and hard and soft palate closure at 12 months. Trial 3 compared it with lip and hard palate closure at 3–4 months and soft palate closure at 12 months. The primary outcomes were speech and dentofacial development, with a series of perioperative and longer-term secondary outcomes. Results: Recruitment of 448 infants took place over a 9-year period, with 99.8% subsequent retention at 5 years. Conclusion: The series of reports that follow this introductory paper include comparisons at age 5 of surgical outcomes, speech outcomes, measures of dentofacial development and appearance, and parental satisfaction. The outcomes recorded and the numbers analysed for each outcome and time point are described in the series. Trial registration: ISRCTN29932826.

Moraxella Catarrhalis: An Unrecognized Pathogen of the Oral Cavity?

Objective We investigated the effect of the bacterial flora of the nose and throat on the outcome of the initial repairs of the cleft palate in the presence of prophylactic antibiotics. Design A retrospective review of 90 procedures in 66 patients who had cleft palate repair between April 2005 and June 2007 was conducted at Booth Hall Childrens Hospital, Manchester, U.K. Both isolated cleft palate and cleft lip and palate patients were included. Exclusion criteria included syndromic cases, other medical disorders, and revisions of previous cleft palate repairs. Nose and throat swabs were taken on admission. Benzyl penicillin and flucloxacillin were given perioperatively. The occurrence of oronasal fistulas was correlated with the bacteria grown on culture. Results The oronasal fistula rate was 15.9%. The highest fistula rate in procedures with positive swabs was seen with Moraxella catarrhalis. Conclusions M. catarrhalis has not been previously recognized as a pathogen in cleft palate repairs. This study demonstrates a higher fistula rate in procedures positive for M. catarrhalis. Other factors that may have contributed to the fistula formation include the severity of the initial cleft and technical factors. Further study is required before a definitive link can be established.

The acute febrile response to burn injury in children may be modified by the type of intravenous fluid used during resuscitation--observations using fresh frozen plasma (FFP) or Hartmann's solution.

Fever is a common clinical problem in burned children. The purpose of this study was to compare rectal temperature (T(r)) in two groups of children with burns, > or =10% of the total body surface area (tbsa) who received fresh frozen plasma (FFP) or a crystalloid solution (Hartmanns) for restoration of blood volume. Twelve to 16 h after the burn T(r) reached a peak. The children who had received FFP for restoration of blood volume had significantly higher fever than those children who received crystalloid solutions only.