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Biomedical subjects

J P Barret

Publications and source records attributed to J P Barret.

At least 19 recordsLinked to original sources
PubMed2004

Recurrent branchial sinus tract with aberrant extension.

Second branchial cysts are the commonest lesions among congenital lateral neck anomalies. Good knowledge of anatomy and embryology are necessary for proper treatment. Surgical treatment involves resection of all branchial remnants, which extend laterally in the neck, medial to the sternocleidomastoid muscle with cranial extension to the pharynx and ipsilateral tonsillar fosa. However, infections and previous surgery can distort anatomy, making the approach to branchial anomalies more difficult. We present a case of a 17-year-old patient who presented with a second branchial tract anomaly with an aberrant extension to the midline and part of the contralateral neck. Previous surgical interventions and chronic infections may have been the primary cause for this aberrant tract. All head and neck surgeons should bear in mind that aberrant presentations may exist when reoperating on chronic branchial cysts fistulas.

Adolescent↗
PubMed2003

Acute acalculous cholecystitis after breast reconstruction.

Postoperative acute acalculous cholecystitis (AAC) is a potentially lethal complication that presents with a high morbidity and mortality. Some elective plastic surgery patients are at risk to developing this complication, although it has not been previously reported in the plastic surgery population. Patients at risk are those affected of ischaemic diseases, artheroschlerotic factors, smoking, diabetes, and patients requiring postoperative intensive care monitoring. The clinical presentation is non-specific and it is usually masked by postoperative pain and by the signs and symptoms of the primary disease. Significant delays in diagnosis result in a high incidence of gangrene, perforation, abscess, and death. Although difficult to prevent, a good preoperative planning, with correction of all physiologic abnormalities prior to surgery may help in minimising the incidence of AAC. Cessation of smoking is essential, and careful monitoring of patients during anaesthesia is crucial to avoid low cardiac output and ischaemic insults to the enteric circulation.

Acute Disease↗
PubMed2002

Use of previously burned skin as random cutaneous local flaps in pediatric burn reconstruction.

Reconstruction after post-burn scarring remains a challenge. It is especially true in the severely burned patient, who normally presents with a paucity of donor sites. Healed skin from areas that had been burned and skin from grafted areas (termed as previously burned skin) have been occasionally used as flaps, but their safety is still in debate. We studied all patients undergoing burn reconstruction with normal skin flaps and previously burned skin flaps in the same operative procedure between April 1998 and October 1998 to determine the safety of flaps including burned and healed tissues. Patients served as their own controls. Three hundred and fifty-three local flaps were studied in 74 patients. These included 238 previously burned skin flaps and 115 normal skin flaps. There were no differences in complication rates between groups and only one previously burned skin flap suffered from complete necrosis. The use of local previously burned skin as flaps in burn reconstruction is safe. Reconstruction with flaps should be considered as first choice in burn reconstruction regardless of the quality of the local tissue.

Age Factors↗
PubMed2001

Selective decontamination of the digestive tract in severely burned pediatric patients.

Infection is still one of the leading causes of morbidity and mortality in severely burned patients. Evidence suggests that many of the responsible organisms are endogenous. Systemic antibiotic prophylaxis is not effective, and produces resistant strains of microorganisms. SDD has been postulated to be beneficial for controlling and decreasing infections in critically ill patients. Its efficacy in severely burned patients, however, remains controversial. In order to analyze the efficacy of selective decontamination of the digestive (SDD) tract, to decrease the bacterial colonization of the aerodigestive tract and burn wounds, and the incidence of septic complications in severely burned children, 23 pediatric patients affected of severe burns were prospectively randomized in a double-blinded study. Eleven patients received SDD (Polymyxin E, Tobramycin, and Amphotericin B), and 12 placebo. Demographics, hospital course, microbiology results, complications, infectious episodes, and serum levels of IL-1beta, IL-6, IL-10, and TNF-alpha were compared to determine the efficacy of SDD. Colonization rates to the wound, sputum, nasogastric aspirates, and feces were similar. Pneumonia, sepsis and other complications had similar incidence in both groups. Serum levels of all cytokines studied were also comparable, suggesting a similar inflammatory status in all patients, regardless of the treatment received. Patients in the SDD group, however, had a significantly higher incidence of diarrhea (P=0.003). We can conclude that selective decontamination of the digestive tract with Polymixin E, Tobramycin and Amphotericin B is not effective to decrease bacterial colonization and infectious episodes in severely burned pediatric patients.

Amphotericin B↗
PubMed2001

Fatty infiltration of the liver in severely burned pediatric patients: autopsy findings and clinical implications.

BACKGROUND: Trauma induces hypermetabolic responses that are characterized by the mobilization of all available substrates. The marked increase of peripheral lipolysis after a burn can lead to the development of fatty liver, which has been associated with immunodepression and increased mortality. METHODS: All autopsies of pediatric burn patients between January 1988 and January 1998 were reviewed. Patient demographics, hospital course, cause of death, and hepatic and septic macroscopic and microscopic findings were recorded. RESULTS: Thirty-seven pediatric patients (4 +/- 1 years old) were included in the study. The mean burn size was 69% +/- 5% total body surface area burned. Eighty percent of the patients presented with fatty infiltration of the liver. Liver weight/body weight ratio was 77 +/- 5 gm/kg, representing 2.1 times the liver weight of age- and sex-matched controls (p < 0.001). Patients with severe fatty infiltration of the liver had a higher incidence of sepsis (p < 0.001). CONCLUSION: Fatty infiltration of the liver is a common condition in fatal burns. Severe fatty infiltration of the liver is associated with an increased incidence of sepsis, although a causative effect could not be found. It is notable that fatty infiltration of the liver occurred in the complete absence of parenteral nutrition.

Burns↗
PubMed2000

Effects of tracheostomies on infection and airway complications in pediatric burn patients.

Considerable controversy exists as to whether tracheostomy is ever indicated in burn patients. New advents in the treatment of inhalation injury have improved survival, making the use of tracheostomy more usual. The purpose of this study was to analyze the outcome of tracheostomies, and the effect of time on complications. Patients requiring ventilatory support and tracheostomies were studied. Demographic data, hospital course, ventilatory parameters and complications were analyzed. Two hundred ninety patients required ventilation and 36 tracheostomy. Mean percentage of TBSA burned was 59%+/-4. Ninety percent of these patients presented with inhalation injury. Mortality in tracheostomy patients was 25 and 16% in all ventilated patients. Thirty-five percent of the patients developed late complications. Patients who had their airway converted to tracheostomy before day 10 postinjury had a significantly lower incidence of subglottic stenosis. and patients who required airway pressures over 50 cm H2O for more than 10 days had a significantly higher incidence of tracheomalacia. Pneumonia occurred at similar incidence in ventilated and tracheostomy patients. The mortality and late complications of pediatric burn patients with tracheostomy has decreased over the last decade. They do not present with higher incidence of pneumonia. Maintenance of airway pressures below 50 cm H2O and conversion of the artificial airway to tracheostomy before day 10 postinjury may be advisable in patients requiring long term ventilation to prevent late complications.

Burns, Inhalation↗
PubMed2000

Osteomyelitis in burn patients requiring skeletal fixation.

Deep and severe burns often present with the exposure of musculoskeletal structures and severe deformities. Skeletal fixation, suspension and/or traction are part of their comprehensive treatment. Several factors put burn patients at risk for osteomyelitis, osteosynthesis material being one of them. In order to determine the safety of skeletal fixation, we reviewed all pediatric patients treated with pin insertion during the past 10 years. Forty-one severely burned children (61+/-3% TBSA full thickness burns), had a total of 357 skeletal fixation procedures. Pins were maintained an average of 25.3+/-1.7 days. Thirteen pins (3. 6%) were loose before the expected time of removal, two patients (4. 8%) presented with cellulitis of the pin site and two patients (4. 8%) presented with osteomyelitis. Loose pins, pin site cellulitis, burn wound infection and sepsis were not associated with osteomyelitis. Skeletal fixation in severely burned patients presents with a low incidence of infectious complications. Its use should be considered in patients affected by severe burns that present with exposed deep structures and for positioning purposes. The exact timing for pin removal in burned patients is still to be defined.

Body Surface Area↗
PubMed2000

Cost-efficacy of cultured epidermal autografts in massive pediatric burns.

OBJECTIVE: To assess the efficacy of cultured epidermal autografts (CEA) for closure of burn wounds in pediatric burn patients with full-thickness burns of more than 90% total body surface area. SUMMARY BACKGROUND DATA: Paucity of donor sites in massive burns makes the use of expanded skin of paramount importance. CEA techniques have been used in burned patients with differing and controversial results. The true impact and the efficacy of such techniques in massive burns remain uncertain. METHODS: Patients with full-thickness burns of more than 90% body surface area treated between May 1988 and May 1998 were studied. Patients grafted with CEA were compared with patients grafted with conventional meshed autografts. Rates of death and complications, length of hospital stay (LOS), hospital cost, acute readmissions for reconstruction, and quality of scars were studied as outcome measures. RESULTS: Patients treated with CEA had a better quality of burn scars but incurred a longer LOS and higher hospital costs. Both groups had comparable readmissions for open wounds, but patients treated with CEA required more reconstructive procedures during the first 2 years after the injury. The incidence of sepsis and pneumonia in both groups was comparable. CONCLUSIONS: Conventional meshed autografts are superior to CEA for containing hospital cost, diminishing LOS, and decreasing the number of readmissions for reconstruction of contractures. However, the use of CEA provides better scar quality such that perhaps future research should focus on bioengineered dermal templates to promote take and diminish long-term fragility.

Burns↗
PubMed2000

Biobrane versus 1% silver sulfadiazine in second-degree pediatric burns.

Partial-thickness burns in children have been treated for many years by daily, painful tubbing, washing, and cleansing of the burn wound, followed by topical application of antimicrobial creams. Pain and impaired wound healing are the main problems. We hypothesized that the treatment of second-degree burns with Biobrane is superior to topical treatment. Twenty pediatric patients were prospectively randomized in two groups to compare the efficacy of Biobrane versus 1% silver sulfadiazine. The rest of the routine clinical protocols were followed in both groups. Demographic data, wound healing time, length of hospital stay, pain assessments and pain medication requirements, and infection were analyzed and compared. Main outcome measures included pain, pain medication requirements, wound healing time, length of hospital stay, and infection. The application of Biobrane to partial-thickness burns proved to be superior to the topical treatment. Patients included in the biosynthetic temporary cover group presented with less pain and required less pain medication. Length of hospital stay and wound healing time were also significantly shorter in the Biobrane group. None of the patients in either group presented with wound infection or needed skin autografting. In conclusion, the treatment of partial-thickness burns with Biobrane is superior to topical therapy with 1% silver sulfadiazine. Pain, pain medication requirements, wound healing time, and length of hospital stay are significantly reduced.

Adolescent↗
PubMed2000

The isolated burned palm in children: epidemiology and long-term sequelae.

The isolated burn of the palm is a typical injury in young children. Positioning and splinting in small hands is difficult, and long-term sequelae of these injuries are not uncommon. The objective of the present study was to assess the outcome of palm burns and to identify the risk factors for long-term sequelae. All patients admitted to our hospital affected with isolated palm injuries between January of 1988 and January of 1998 were reviewed. In total, 120 pediatric patients were admitted with isolated palm burns; 110 patients (91.7 percent) had partial-thickness burns, and 10 patients (8.3 percent) had full-thickness burns. Only four patients (3.3 percent) required excision and skin autografting, but all patients whose palms were operated on in the acute phase developed burn contractures. Sixteen patients (13.3 percent) developed palmar contractures, and more than half of them (56 percent) required reconstructive procedures. All palm burns that healed in more than 3 weeks developed scarring and sequelae (p<0.05 compared with no sequelae). Pediatric palmar burns are benign injuries with a low incidence of late sequelae. However, flame and contact burns are more prone to develop scarring. Excision and autografting should be performed on wounds that take over 3 weeks to heal, but it does not prevent late sequelae.

Burns↗
PubMed1999

Sensitivity and specificity of bronchoalveolar lavage and protected bronchial brush in the diagnosis of pneumonia in pediatric burn patients.

BACKGROUND: Infection is still one of the leading causes of death in burn patients. The diagnosis of respiratory tract infection in critically ill burn patients is still difficult. The diagnostic technique of choice remains uncertain, especially because of the lack of a criterion standard by which other diagnostic methods can be compared. HYPOTHESIS: Bronchoalveolar lavage (BAL) and protected bronchial brush (PBB) cultures are not efficacious for the diagnosis of pneumonia in critically ill burn patients. DESIGN: All pediatric patients with burns who died at Shriners Burns Hospital, Galveston, Tex, in the past 10 years were studied. We compared the clinical diagnosis of pneumonia, BAL quantitative culture results, and PBB culture results with autopsy findings. The diagnosis of pneumonia at autopsy was considered the criterion standard, and it was used to calculate the sensitivity and specificity of BAL and PBB cultures. RESULTS: Forty-three patients were studied. Pneumonia was present in 19 (44%) of the 43 autopsies. Pneumonia was diagnosed clinically in 12 (28%) of the 43 patients, and 6 (50%) of them had negative autopsy findings. The sensitivity and specificity of BAL were 56% and 28%, respectively; PBB, 55% and 61%, respectively. The same microorganisms were found at autopsy, in BAL cultures, and in PBB cultures in fewer than 10% of the patients. CONCLUSIONS: Bronchoalveolar lavage and protected bronchial brush have a low sensitivity and specificity and cannot be relied on by themselves for the diagnosis of pneumonia in critically ill burn patients. The results of these sampling techniques must be interpreted in the context of the overall clinical picture of each individual patient.

Bronchoalveolar Lavage Fluid↗
PubMed1999

Epidemiology and mortality of adult burns in Catalonia.

Burn injuries still produce significant morbidity and mortality in developed countries. The incidence of burns in Catalonia is similar to other countries, with 31.2 per 100000 person/year referred to a specialized unit for definitive treatment. The Burn Center of the Vall d'Hebron hospital system is located at the General Hospital. It is the only facility for burns in the state of Catalonia. The catchment population is 6 million people, with 1814 +/- 89 burned patients treated in the emergency room per year and 396 +/- 15 of them admitted per year. Overall mortality is 3.49%. Inhalation injury and ARDS have a low incidence in our series with a high mortality. Factors associated with an increase in mortality are contact burns, inhalation injury, age and burn size. Pre-existing conditions did not affect survival in our series and 75% of all deaths occurred in the first week. Patients were treated with early serial debridement and cerium nitrate sulfadiazine, with results comparable to others in the literature. Mortality rates were compared to the Abbreviated Burn Severity Index, with a disparity in results, advocating the necessity to find a better and more applicable prognostic test for the outcome of burn injuries.

Abbreviated Injury Scale↗
PubMed1999

Dural reconstruction of a class IV calvarial burn with decellularized human dermis.

Calvarial burns involving the brain (Class IV) are reported to be rare. They represent a treatment challenge. Wound coverage can be accomplished with serial debridement of bone and grafting over granulating tissue, local flaps and free tissue transfer. The former techniques are often not feasible in the young infant. We present a successful case of a six-week-old female patient affected of full thickness burns involving the skull and brain. The bone, dura mater and superficial brain were debrided and the defect covered with AlloDerm and split thickness grafts. The area engrafted completely and no complications or CSF leak occurred. An acellular human allogeneic dermis (AlloDerm) can be successfully used to replace dura mater in burn patients.

Brain Injuries↗
PubMed1999

Topical nystatin powder in severe burns: a new treatment for angioinvasive fungal infections refractory to other topical and systemic agents.

Angioinvasive fungal infections have a significant morbidity and mortality in the immunocompromised host. Massive burns produce a profound derangement in cellular immunity along with a loss of cutaneous barrier function. Treatment of fungal burn wound infections poses a difficult therapeutic challenge. We present a new method of treatment for angioinvasive fungal infections with nystatin powder at a concentration of 6,000,000 units/g. It proved to be efficacious in four consecutive severely burned patients affected by massive angioinvasive fungal infection. Both superficial and deep tissue infections were eradicated without any other therapeutic interventions or adverse effects on wound healing.

Administration, Topical↗
PubMed1999

Effect of topical and subcutaneous epinephrine in combination with topical thrombin in blood loss during immediate near-total burn wound excision in pediatric burned patients.

Bleeding is a major concern during burn wound excision. To evaluate the efficacy of epinephrine to control blood loss, a prospective cohort of 42 pediatric patients were examined. Half of the patients received topical epinephrine to excised wounds and donor sites and subcutaneous epinephrine to scalp donor sites during total burn excision, while the other half did not. Both groups of patients received bovine topical thrombin sprayed at a concentration of 1000 U/ml. Mean blood loss in the epinephrine group was 1090 ml (range 20-4000), with a blood loss of 0.48+/-0.12 ml/cm2 excised, while the control group was 1271 ml (range 40-3750) and 0.51+/-0.15 ml/cm2. Differences in preoperative and postoperative hematocrits were respectively -3.4+/-7.8 and -4.6+/-7.5. The groups were not statistically different in this analysis. Subgroup analysis by age, burn size and time of burn to excision showed no differences. No complications or side effects of the use of the vasopressor solution occurred. In conclusion, no differences in blood loss were found between the groups. The routine use of local epinephrine during total wound excision in combination with topical thrombin in pediatric patients operated within 24 h after the admission may not be necessary. The effect of topical thrombin on blood loss should be analyzed separately.

Administration, Topical↗
PubMed1999

Thermal injury.

Intensive care management of severely burned patients demands expertise in several areas. These include airway management, fluid resuscitation, support of the hypermetabolic response, infection control, and treatment of smoke inhalation injury. Surgical management of the burn wound, plastic reconstruction, and long-term rehabilitation are also essential aspects of modern burn care.

Burns↗
PubMed1999

Muscle protein catabolism after severe burn: effects of IGF-1/IGFBP-3 treatment.

OBJECTIVE: To determine the effects of recombinant human insulin-like growth factor-1 (IGF-1) complexed with its principal binding protein, IGFBP-3, on skeletal muscle metabolism in severely burned children. SUMMARY BACKGROUND DATA: Severe burns are associated with a persistent hypermetabolic response characterized by hyperdynamic circulation and severe muscle catabolism and wasting. Previous studies showed that nutritional support and pharmacologic intervention with anabolic agents such as growth hormone and insulin abrogated muscle wasting and improved net protein synthesis in the severely burned. The use of these agents, however, has several adverse side effects. A new combination of IGF-1 and IGFBP-3 is now available for clinical study. METHODS: Twenty-nine severely burned children were prospectively studied before and after treatment with 0.5, 1, 2, or 4 mg/kg/day IGF-1/IGFBP-3 to determine net balance of protein across the leg, muscle protein fractional synthetic rates, and glucose metabolism. Another group was studied in a similar fashion without IGF-1/IGFBP-3 treatment as time controls. RESULTS: Seventeen of 29 children were catabolic before starting treatment. The infusion of 1.0 mg/kg/day IGF-1/IGFBP-3 increased serum IGF-1, which did not further increase with 2.0 and 4.0 mg/kg/day. IGF-1/IGFBP-3 treatment at 1 to 4 mg/ kg/day improved net protein balance and increased muscle protein fractional synthetic rates. This effect was more pronounced in catabolic children. IGF-1/IGFBP-3 did not affect glucose uptake across the leg or change substrate utilization. CONCLUSIONS: IGF-1/IGFBP-3 at doses of 1 to 4 mg/kg/day attenuates catabolism in catabolic burned children with negligible clinical side effects.

Burns↗