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Background. The use of Integra Dermal Reconstruction Template has emerged as an option for wound reconstruction, after resection of congenital nevi, especially giant congenital nevi. There have been many reports on Integra use in the literature for this purpose. This systematic review with pooled analysis examines the current literature regarding Integra use after resection of congenital nevi, including patient characteristics and reported outcomes. Methods. Systematic electronic searches were performed using PubMed, Ovid, Embase, and Cochrane library databases for studies reporting the use of Integra to reconstruct defects after nevi resection. Studies were analyzed if they met the inclusion criteria. Pooled descriptive statistics were performed. Results. Thirteen studies that met the inclusion criteria were included for analysis, yielding 31 procedures in 31 patients. Eleven of the thirteen studies were case reports representing 17 of the 31 patients. One study was retrospective, and the other study was a prospective study. The mean follow-up was 2.67 years (range, 0.2–13 years). The overall wound closure rate was 100%. The overall initial Integra take rate was 90.3% and the skin graft take rate was 100%. The rate of reported complications was 14.8%. The average age of patients was 7.36 years. The average size of the nevus was 6.29% TBSA (range, 0.005%–26%), and the time to definitive skin grafting was 3.28 weeks. Significant heterogeneity was found among the published studies. Conclusion. We conclude that the use of Integra appears to be a safe and viable option for defect reconstruction after the primary or secondary excision of congenital nevi of different sizes and on most parts of the body. Long-term follow-up studies and prospective cohort studies are required in order to fully estimate the incidence of complications. However, the rarity of this condition make these types of studies very difficult.

Objectives: The objectives of this study were to: (1) determine the prevalence of otitis media with effusion in patients with nonsyndromic craniosynostosis; (2) determine the prevalence of hearing loss in patients with nonsyndromic craniosynostosis; and (3) identify potential patterns and outcomes in patients with nonsyndromic craniosynostosis. Methods: A retrospective chart review was conducted at 2 academic institutions, St Christopher’s Hospital for Children and SUNY Upstate Medical University, from January 2015 through August 2018, to identify patients having nonsyndromic craniosynostosis with a concurrent diagnosis of otitis media and/or hearing loss. The demographic data and categorical variables were analyzed using descriptive statistics and chi-square testing, respectively. Results: In the entire cohort of patients (N = 113, age range 0-123 months), 36% had otitis media with effusion on either history, physical examination, tympanometry, and/or imaging. Half (50%) of patients with coronal synostosis had otitis media with effusion compared to sagittal (40.7%), metopic (26.3%), multiple (25%), and lambdoid (0%). However, these differences were not statistically significant ( P = .190). Most patients had normal hearing (91%), while a minority had either conductive (7%) or sensorineural (2%) hearing loss. Conclusion: The presence of otitis media in our cohort of patients with nonsyndromic craniosynostosis appears to be at the upper limit of normal when compared to historical rates in normocephalic children. Synostosis subtype did not appear to predict the presence of otitis media. Only 9% of patients with nonsyndromic craniosynostosis were found to have a hearing loss.

Objective: In the Amish community, natural therapies, such as Burns and Wounds (B&W) ointment and burdock leaves, are preferred over modern medicine when treating burn wounds. The primary aim of this case series is to highlight the use and clinical outcomes of this treatment for paediatric Amish patients. Method: At the a paediatric burn centre, two patients were treated with B&W ointment and burdock leaves. The first patient was 11 months old with 17% total body surface area (TBSA) partial and full-thickness scald burns to her lower extremities. The second patient was 24 months old with 20% TBSA partial-thickness scald burns to the torso, bilateral upper extremities, neck and chin. Results: Soon after presentation to the hospital, both patients developed positive wound cultures and required cessation of ointment and burdock leaf therapy. Both patients ultimately underwent surgical interventions. Conclusion: Managing burn wounds with B&W ointment and burdock leaves should be considered as an additional option for wound care in select cases. However, the efficacy of this therapy is limited and standard-of-care modern medical burn treatments should remain an option for these patients. It is critically important to build a mutually respectful relationship with Amish patients' community leaders, as this allows open communication and collaboration in patient care and increases the likelihood that Amish guardians will bring their children to a hospital when necessary.

Burn injuries can present with catastrophic physical and psychiatric harm with extensive, long-term sequelae. The pediatric population may especially be at-risk given this population's early neurocognitive and behavioral state of development. Innovations in treatment modalities and the development of evidence-based guidelines have helped mitigate burn morbidity and mortality in the pediatric population. Unfortunately, a surprising dearth of literature identifies risk-factors, epidemiological data, injury mechanisms, and prognostic factors within the pediatric population in the setting of craniofacial burns.An analysis of emergency department visits under the National Electronic Injury Surveillance System was conducted for the most recent 5-year period available (2014-2018). Available information includes demographical data, such as age and sex, mechanism of injury, visit circumstances, as well as visit disposition. Additionally, details surrounding the injury, including type of burn and anatomical location of injury, were compared.After a review of results, a total of 2599 patients were included for analysis. Our study shows that infants and young children are at increased risk for grave injury 27.3% and 13% of infants and toddlers transferred or admitted, respectively, p0.05). 59.8% of infant burns in particular were caused by liquid or kitchen products, while 44.5% of burns in toddlers were caused by chemical products (p0.05 for both). Conversely, adolescents are at greater risk of burns in the setting of occupational and hobby-based activities (20.4% of adolescent burns).Craniofacial burns in the pediatric population may present with complex pathology and sometimes necessitate advanced care. Presentations and prognoses are different dependent upon age and injury mechanism. These findings may serve as important framework in the establishment of guidelines for medical and legislative reform.

Autologous cell harvesting and processing devices are designed to facilitate the harvesting of cells using enzymatic and physical disruption techniques to immediately apply non-cultured autologous cell suspension (ACS) to the wound area.This case report evaluates clinical outcomes following application of cellular suspension with split-thickness skin grafts (STSGs) as an adjunct for definitive closure of burn injuries and donor sites in 2 pediatric patients.The cases were performed under a humanitarian use protocol following institutional review board approval at St. Christopher's Hospital for Children (Philadelphia, PA).The first patient was a 4-year-old girl with partial- and full-thickness (32% total body surface area) burn injuries of her head, trunk, flank, arms, thighs, and feet. The patient was discharged 19 days following ACS treatment. The second patient was an 18-month-old girl with partial- and full-thickness (21% total body surface area) burns involving the bilateral lower extremities. She was discharged 22 days after ACS treatment with widely meshed autograft. Neither patient required additional surgical interventions. All treatment and donor areas for both patients remained uninfected and neither patient experienced any unexpected treatment-related adverse events.These cases are the first of their kind reported in the pediatric population and suggest ACS in conjunction with STSGs can help decrease surgical procedures and expedite healing in pediatric patients with large surface burns.

To formally evaluate the functional and aesthetic outcomes between full versus split thickness skin graft coverage of radial forearm free flap donor sites. A retrospective chart review of 47 patients who underwent pedicled or free radial forearm free flap reconstruction from May 1997 to August 2004 was performed. Comparisons were made between patients who had donor site coverage with split thickness skin grafts (STSG) or full thickness skin grafts (FTSG). There was no statistically significant difference between the STSG and FTSG in the number of post-operative dressings, incidence of tendon exposure, time to healing at the skin graft donor site, and time to healing at the skin graft recipient site. The questionnaire data showed there was a trend toward higher scores with the radial forearm scar aesthetics and satisfaction in the FTSG group. Full thickness skin graft coverage of radial forearm free flap donor site is superior to split thickness skin graft coverage in terms of aesthetic outcome, and has no statistically significant difference in terms of tendon exposure, time to healing at the skin graft donor site, time to healing at the skin graft recipient site, or post operative pain.

An often overlooked, yet useful, technique in the treatment of palmar hand burns is the use of glabrous skin grafting, particularly in dark-skinned individuals. Pediatric palmar burns are a particularly unique subset of burns. The typical split-thickness or full-thickness skin grafts leave a notably different skin texture and pigmentation. It is also known that the psychological aspects of a pediatric burn can be quite burdensome for a child as he or she progresses through childhood and adolescence. For a dark-skinned patient the placement a standard full-thickness skin graft in a nonpigmented palm provides for a constant reminder of a traumatic event. We report a case series of pediatric patients who were managed with glabrous skin grafting from the plantar aspect of the foot.A retrospective review of palmar skin burns requiring grafting at a single pediatric burn center experience over a 2 and a half year time period was performed. Seventeen patients were identified. Our treatment algorithm for deep partial thickness burns first relies on a combination of operative and nonoperative measures to expedite the demarcation of the burn injury. If the burn is full thickness in nature or if a lack of progression of healing is identified within the first 14 days of injury, then skin grafting is recommended. Our technique for performing the graft is described.The average age at time of surgery was 2.05 years (6 months to 6.8 years). Fourteen of the 17 patients had darker skin types (Fitzpatrick Type III-VI) and identified themselves as either Hispanic or African American. The average size of the area requiring skin graft after debridement was 0.94% total body surface area (0.5%-2.0%). Of the patients that were not lost to follow-up, 1 patient required additional grafting after developing a finger contracture for splint noncompliance. Aesthetically, the wounds went on to heal with an excellent pigment match and an inconspicuous donor site.In the management of deep-partial or full-thickness palmar skin burns in the pediatric population that require grafting, the use of plantar glabrous skin grafts offers a reliable option for coverage. The aesthetic and functional results are improved over standard techniques.

Objective: Despite extensive research into the treatment of partial-thickness burns, to date there has not been the emergence of a preeminent modality. This pilot study, the first such study to be performed in a burn unit in the US, was designed to evaluate the efficacy and outcomes of the application of copolymer dressing (Suprathel; PolyMedics Innovations Corporation, Stuttgart, Germany) for both superficial and deeper partial-thickness burns. Method: The copolymer dressing was used as a primary wound dressing to treat superficial and deep partial-thickness burns (average 5% total body surface area) in paediatric patients. Burns were debrided within 24 hours, at bedside, in the burn unit or in the operating room. The copolymer dressing was then applied directly to the wound and covered with a non-adherent second layer and an absorptive outer dressing. After discharge, patients were seen every 5–7 days until healed. Parameters evaluated included average hospital length of stay, average number of intravenous doses of narcotics administered, pain score at first follow-up visit, average time to complete re epithelialisation, incidence of burn wound infection, and patient/parent satisfaction on a 4-point scale. We also evaluated our experience with the dressing. Data were evaluated retrospectively under an Investigational Review Board approved protocol. Results: Of the 17 patients assessed the average hospital length of stay was 1.4 days during which the average number of intravenous narcotic doses administered before copolymer dressing application was 1.5 and after was 0.1 doses. At the first follow-up visit, average pain score was 1.2 on a 10-point scale and the average time to re epithelialisation was 9.5 days. There was no incidence of burn wound infection. Patient/parent satisfaction was average of 3.66 on a 4-point scale. The staff had found that the self-adherence and elasticity of the dressing made it easy to apply and stay adherent, especially in areas of difficult contour. There were no readmissions for further debridement or skin grafting. Conclusion: Our experience shows that patients may be discharged shortly after the application of the copolymer dressing, with manageable pain scores and ease of use as determined by the caretakers high satisfaction. This new, fully synthetic copolymer dressing is easy to apply, does not require any additional antimicrobial coverage and may be used to successfully manage deeper partial-thickness burns, donor sites or burns in areas of contour, where many other dressings might not be considered or be appropriate. Declaration of interest: None declared

Respiratory epithelial cysts are rare orbital cysts that can arise secondary to choristomatous rests of respiratory epithelium. Approximately 15 congenital cases have been described in the literature, making it a rare disease entity. We present a case of a 14-month-old Middle Eastern male with a right infraorbital respiratory epithelial cyst. Magnetic resonance imaging of the brain and orbits revealed a right infraorbital cyst hyperintense on T1-weighted images and followed fluid density on T2-weighted images. This cyst was noted to displace the globe superiorly and inferior rectus muscle laterally. This cyst was excised using a transconjunctival approach. Histologically, the cyst wall was lined by ciliated columnar cells with interspersed mucus-containing cells and ciliated transitional epithelium was present, establishing the diagnosis of respiratory epithelial cyst. To our knowledge, this is the youngest patient with a respiratory epithelial cyst of the orbit reported in the literature.

Objective: Traditional burn dressings demonstrate unfavourable tendencies of shrinking when wet and failing to maintain their integrity when manipulated. To overcome these obstacles, gel-forming fibre dressings have emerged as an alternative. Our objective was to observe the clinical properties and healing ability in the setting of burn wounds in a paediatric centre of a chitosan-based dressing containing silver. Methods: A sample of 12 partial-thickness burns in 10 children were identified for treatment with the chitosan-based silver dressing. The dressings were moistened before application, and monitored for any shrinkage on application. Patients were monitored for healing at outpatient follow-up visits and the dressings were allowed to separate as healing occurred. Results: We treated 12 burns in 10 children with an average age of 5.2 years. The burns had an average proportion of total body surface area (TBSA) of 3.6 % and involved the trunk and all extremities. Wounds healed mostly or completely in an average of 8.3 days. Dressings retained their size when wet and integrity when removed. No burns were found to be infected at any point in the study. Conclusions: The chitosan-based dressing offered an optimal environment for moist wound management, and did not demonstrate the shrinkage or disintegration that diminishes the clinical usability of widely used hydrofibre dressings. The burns healed within an expected period of time, and did not undergo any infectious processes. Based on the results of this pilot study, the chitosan-based silver dressing is deserving of further study as an alternative to traditional burn dressings.

Objective Porcine xenograft (PX) has become a valuable part of the armamentarium of treatment options in a US paediatric burn centre. The use in adult patients has been well described in the burn literature, but there is minimal literature describing its use in children. The objective of this article is to describe a three-years' experience with PX use in paediatric burns. Method A retrospective medical record review of patients with superficial partial-thickness burns treated with PX admitted to a paediatric burn centre between February 2009 and November 2012. Results A total of 164 patients met the inclusion criteria. Burn total body surface area (TBSA) ranged from 0.5% to 28%. After the placement of PX, significant decreases were seen in the need for narcotic analgesics and burn dressing changes. Only four of 164 patients (2.4%) developed infections, although only one of these infections was at the site of the xenograft. Conclusion PX appears to reduce pain and eliminate the need for procedural intravenous sedation in many patients. This can make burn wound care more child-friendly and shorten hospital length of stay. The complication rate is low and manageable. The authors believe that PX is an effective and safe treatment for superficial partial-thickness burns in children. Declaration of interest: P. M.Glat, is a paid consultant and speaker for Mölnlycke Health Care, the manufacturer of EZ Derm.

Objective: Mepilex Ag, a silver-impregnated foam dressing, was introduced to our institution in 2007 and our outcomes in the treatment of paediatric burns were observed to improve significantly. In order to confirm these observations, we wanted to evaluate the results of using the silver-impregnated foam dressing in partial-thickness paediatric burns. Method: In this retrospective study, the St. Christopher's Hospital burn registry was used to identify subjects, who were otherwise in excellent health at baseline, over an18-month period. Outcomes included length of stay, intravenous narcotic use, and time to healing. No direct comparative studies were performed. This was followed by a non-comparative prospective study involving 22 paediatric patients, aged 1–4 years, with partial-thickness burns. This was a sub-study of a larger randomised controlled trial involving adults with partial-thickness burns, comparing the silver-impregnated foam dressing with Silvadene. Results: In the retrospective part of the study, the silver-impregnated foam dressing was used successfully for the treatment of partial-thickness paediatric burns, with few complications and infections, allowing a shorter hospital stay, fewer dressings, and less pain medication than for historical controls. In the non-comparative prospective study, of 22 paediatric patients 50% healed completely within 1 week of treatment. The mean length of stay was 3.77 days and the mean number of dressings used was 1.64. Although narcotic usage was not assessed, patient surveys showed stinging or burning to be recorded as ‘never’ in 13 patients, ‘rarely’ in 8 patients, and ‘sometimes’ in 1 patient. Conclusion: The silver-impregnated foam dressing is effective and safe for use in partial-thickness paediatric burns, eliminating the need for daily dressings. Declaration of interest: The study was supported by an educational grant from Mölnlycke Health Care.

A model of chronic heart failure has been induced in dogs by repeated intracoronary infusion of doxorubicin, which is an antineoplastic medication that has dose-limiting cardiotoxic side effects. Although many of the dogs receiving doxorubicin develop typical signs of dilated cardiomypathy over 4–6 weeks, some of them suddenly die before completing the four weekly infusions of the drug. The present study was undertaken to determine whether such sudden death may be caused by the development of fatal arrhythmias during doxorubicin treatment. This was assessed by telemetrically monitoring the EKG of seven dogs, which received intracoronary infusion of 1 mg/kg doxorubicin given in four divided weekly doses. The recordings were obtained for 8–10 h on alternate days up to 4 weeks. Echo-cardiographic recordings were obtained once a week. The acute effects with each infusion of doxorubicin included a significant increase in heart rate, and no significant change in QRS complex. The cumulative prolonged effects of doxorubicin included slight reduction in QRS amplitude and duration, and marked arrhythmic changes. Four out of seven dogs showed a spectrum of arrhythmic events such as single or groups of premature ventricular complexes (PVCs), bigeminy, ventricular tachycardia (VTAC), ventricular fibrillations (VFIB), and asystole. All dogs did not show each of the events listed above and the same dog did not show all the events all the time. One of these four dogs developed VFIB for 25 min and then asystole leading to sudden death. These studies conclusively showed that fatal arrhythmias develop in some of the dogs receiving doxorubicin treatment accounting for the sporadic incidence of sudden death. Prophylactic treatment with antiarrhythmic agents may prevent such adverse events.

Aims: The purpose of this study was to determine that the administration of an angiotensin converting enzyme (ACE) inhibitor enalapril would confer protection against doxorubicin-induced experimental heart failure, and attenuate the development of left ventricular dysfunction. Methods: Seventeen dogs were chronically instrumented with an intracoronary catheter and received doxorubicin weekly for 4 weeks. Animals were assigned to two groups: group 1: untreated heart failure; and group 2: simultaneous enalapril administration (5 mg twice a week). Hemodynamic data were obtained at week 0 and 12. Echocardiography was performed weekly. Results Survival improved with simultaneous enalapril administration (36% in group 1 vs. 100% in group 2, P=0.04). The increase in the left ventricular end-diastolic pressure was significantly reduced at week 12 (17±1 mmHg in group 1 vs. 9±1 mmHg in group 2, P=0.0042). The fall in left ventricular stroke work index was significantly prevented (52% in group 1 vs. 21% in group 2, P=0.006). The increase in right ventricular end-diastolic diameter was significantly reduced by enalapril prophylaxis. Conclusion: Simultaneous treatment with enalapril was beneficial in the prevention of doxorubicin-induced cardiomyopathy.

In this report, the authors investigate and discuss a galactocele that developed in the breast of a 5-month-old male. Based on the histological and immunohistochemical findings, they suggest that the rare and intriguing process that is exclusively observed in males in the absence of any detectable hormonal stimulation at time of investigation could represent a developmental anomaly possibly promoted by an obstructive phenomenon involving a defect of hollowing of some primary epidermal buds, the precursors of the mammary ducts.

This prospective, randomized study assessed the clinical, microbiological, and patient comfort characteristics of two silver-based topical agents in the management of partial-thickness burn wounds. Pediatric patients were randomly assigned to treatment with either SilvaSorb Gel (Medline Industries, Munedelein, IL) or Silvadene silver sulfadiazine cream (King Pharmaceuticals, Bristol, TN) for up to 21 days or to the point of full reepithelialization of the wound. Inclusion criteria were patients ranging in age from 2 months to 18 years with TBSA ranging from 1 up to 40%. A total of 24 patients were enrolled and completed the study. Findings demonstrated that the use of SilvaSorb Gel was associated with less pain and greater patient satisfaction when compared with Silvadene. No statistically significant differences were found when assessing the rate of infection, time to reepithelialization, or the number of dressings changes required during treatment. The reduction of pain and improved overall patient satisfaction with the use of SilvaSorb Gel compared with Silvadene indicates an important role for SilvaSorb Gel in treatment of partial-thickness burns in a pediatric population.

Background There has been an increase in the number of elderly patients considered for cardiac surgery. Several reports have documented acceptable morbidity and mortality in patients 80 years and older. The results from surgical patients 85 years and older were analyzed. Methods The records of 89 consecutive patients 85 years and older having cardiac operations between June 1993 and May 1999 were retrospectively reviewed. For purposes of statistical analysis follow-up was considered as a minimum of one office visit to the surgeon, cardiologist, or internist at least 1 month postoperatively. Results Eighty-seven patients underwent coronary artery grafting and two patients had mitral valve replacement. Follow-up was 100% complete. The operative mortality rate was 12.3%; probability of in-hospital death was 8.2%; risk-adjusted mortality rate was 3.2%. The complication rate was 31.5%. The actuarial 1-, 3-, and 5-year survivals were as follows: 75%, 67%, and 40%. Multivariate predictors of 30-day mortality were preoperative EF, less than 30% (p = 0.029) and postoperative renal failure (p = 0.0039). Conclusions Cardiac surgery can be performed in patients 85 years and older with good results. There is an associated prolonged hospital stay for elderly patients. Consistent successful outcomes can be expected in this patient population with selective criteria identifying risk factors.