Biology and function of fetal and pediatric skin

Mid-Term Follow-Up Study of Children Undergoing Autologous Skin Transplantation for Burns

Deep partial and full-thickness burns require surgical treatment with autologous skin grafts after necrectomy, which is the generally accepted way to achieve permanent wound coverage. This study sought to examine the grafted and donor areas of children who underwent autologous skin transplantation, using two assessment scales to determine the severity of the scarring and the cosmetic outcome during long-term follow-up. At the Surgical Unit of the Department of Paediatrics of the University of Pécs, between 1 January 2015 and 31 December 2019, children who had been admitted consecutively and received autologous skin transplantation were analyzed. Twenty patients met the inclusion criteria in this retrospective cohort study. The authors assessed the results using the Patient and Observer Scar Assessment Scale (POSAS) and the Vancouver Scar Scale (VSS). There was a significant difference in how parents and examiners perceived the children’s scars. In the evaluation of the observer scale, the most critical variables for the area of skin grafted were relief and thickness. Besides color, relief was the worst clinical characteristic on the patient scale. However, when medical professionals evaluated the donor site, significantly better results were obtained compared to the transplanted area (average observer scale score: 1.4 and 2.35, p = 0.001; VSS: 0.85 vs. 2.60, p < 0.001), yet it was similar to the graft site in the parents’ opinion (Patient Scale: 2.95 and 4.45, p = 0.181).

The dynamic balance of the skin microbiome across the lifespan

For decades research has centered on identifying the ideal balanced skin microbiome that prevents disease and on developing therapeutics to foster this balance. However, this single idealized balance may not exist. The skin microbiome changes across the lifespan. This is reflected in the dynamic shifts of the skin microbiome's diverse, inter-connected community of microorganisms with age. While there are core skin microbial taxa, the precise community composition for any individual person is determined by local skin physiology, genetics, microbe-host interactions, and microbe-microbe interactions. As a key interface with the environment, the skin surface and its appendages are also constantly exchanging microbes with close personal contacts and the environment. Hormone fluctuations and immune system maturation also drive age-dependent changes in skin physiology that support different microbial community structures over time. Here, we review recent insights into the factors that shape the skin microbiome throughout life. Collectively, the works summarized within this review highlight how, depending on where we are in lifespan, our skin supports robust microbial communities, while still maintaining microbial features unique to us. This review will also highlight how disruptions to this dynamic microbial balance can influence risk for dermatological diseases as well as impact lifelong health.

Biofabrication of Human Skin with Its Appendages

Much effort has been made to generate human skin organ in the laboratory. Yet, the current models are limited due to the lack of many critical biological and structural features of the skin. Importantly, these in vitro models lack appendages and fail to recapitulate the whole human skin construction. Thus, engineering a human skin with the capacity to generate all components, including appendages, is a major challenge. This review intends to provide an update on the recent efforts underway to regenerate appendage-bearing skin organs based on scaffold-free and scaffold-based bioengineering approaches. Although the mouse skin equivalents containing hair follicles, sebaceous glands, and sweat glands have been established in vitro, there has been limited success in humans. A combination of biofabricated matrices and cell aggregates, such as organoids, can pave the way for generating skin substitutes with human-like biological, structural, and physical features. Accordingly, the formation of human skin organoids and reconstruction of vascularized skin equipped with immune cells prompt calls for more scientific research. The generation of appendage-bearing skin substitutes can be applied in practice for wound healing, hair restoration, and scar treatment.

Advances in non-invasive biosensing measures to monitor wound healing progression

Impaired wound healing is a significant financial and medical burden. The synthesis and deposition of extracellular matrix (ECM) in a new wound is a dynamic process that is constantly changing and adapting to the biochemical and biomechanical signaling from the extracellular microenvironments of the wound. This drives either a regenerative or fibrotic and scar-forming healing outcome. Disruptions in ECM deposition, structure, and composition lead to impaired healing in diseased states, such as in diabetes. Valid measures of the principal determinants of successful ECM deposition and wound healing include lack of bacterial contamination, good tissue perfusion, and reduced mechanical injury and strain. These measures are used by wound-care providers to intervene upon the healing wound to steer healing toward a more functional phenotype with improved structural integrity and healing outcomes and to prevent adverse wound developments. In this review, we discuss bioengineering advances in 1) non-invasive detection of biologic and physiologic factors of the healing wound, 2) visualizing and modeling the ECM, and 3) computational tools that efficiently evaluate the complex data acquired from the wounds based on basic science, preclinical, translational and clinical studies, that would allow us to prognosticate healing outcomes and intervene effectively. We focus on bioelectronics and biologic interfaces of the sensors and actuators for real time biosensing and actuation of the tissues. We also discuss high-resolution, advanced imaging techniques, which go beyond traditional confocal and fluorescence microscopy to visualize microscopic details of the composition of the wound matrix, linearity of collagen, and live tracking of components within the wound microenvironment. Computational modeling of the wound matrix, including partial differential equation datasets as well as machine learning models that can serve as powerful tools for physicians to guide their decision-making process are discussed.

Cellular and biological factors involved in healing wounds and burns and treatment options in tissue engineering

Severe traumatic wounds and burns have a high chance of mortality and can leave survivors with many functional disabilities and cosmetic problems, including scars. The healing process requires a harmonious interplay of various cells and growth factors. Different structures of the skin house numerous cells, matrix components and growth factors. Any disturbance in the balance between these components can impair the healing process. The function of cells and growth factors can be manipulated and facilitated to aid tissue repair. In the current review, the authors focus on the importance of the skin microenvironment, the pathophysiology of various types of burns, mechanisms and factors involved in skin repair and wound healing and regeneration of the skin using tissue engineering approaches.

Early life host-microbe interactions in skin

Our skin is the interface through which we mediate lifelong interactions with our surrounding environment. Initial development of the skin's epidermis, adnexal structures, and barrier function is necessary for normal cutaneous microbial colonization, immune development, and prevention of disease. Early life microbial exposures can have unique and long-lasting impacts on skin health. The identity of neonatal skin microbes and the context in which they are first encountered, i.e., through a compromised skin barrier or in conjunction with cutaneous inflammation, can have additional short- and long-term health consequences. Here, we discuss key attributes of infant skin and endogenous and exogenous factors that shape its relationship to the early life cutaneous microbiome, with a focus on their clinical implications.

The Role of the Immune System in Pediatric Burns: A Systematic Review

Burns are one of the most common causes of home injuries, characterized by serious damage to the skin and causing the death of affected tissues. In this review, we intended to collect information on the pathophysiological effects of burns in pediatric patients, with particular emphasis on local and systemic responses. A total of 92 articles were included in the review, and the time range of the searched articles was from 2000 to 2021. The occurrence of thermal injuries is a problem that requires special attention in pediatric patients who are still developing. Their exposure to various burns may cause disturbances in the immune response, not only in the area of tissue damage itself but also by disrupting the systemic immune response. The aspect of immunological mechanisms in burns requires further research, and in particular, it is important to focus on younger patients as the existence of subtle differences in wound healing between adults and children may significantly influence the treatment of pediatric patients.

Cell secretomes for wound healing and tissue regeneration: Next generation acellular based tissue engineered products

Wound represents a significant socioeconomic burden for both affected individuals and as a whole healthcare system. Accordingly, stem cells have garnered attention due to their differentiation capacity and ability to aid tissue regeneration by releasing biologically active molecules, found in the cells’ cultivated medium which known as conditioned medium (CM) or secretomes. This acellular approach provides a huge advantage over conventional treatment options, which are mainly used cellular treatment at wound closure. Interestingly, the secretomes contained the cell-secreted proteins such as growth factors, cytokines, chemokines, extracellular matrix (ECM), and small molecules including metabolites, microvesicles, and exosomes. This review aims to provide a general view on secretomes and how it is proven to have great potential in accelerating wound healing. Utilizing the use of secretomes with its secreted proteins and suitable biomaterials for fabrications of acellular skin substitutes can be promising in treating skin loss and accelerate the healing process.

Association between the chronology of gestation and the morphometrical skin characteristics at childbirth: a development of predictive model

Objective

The structural maturation of the skin is considered a potential marker of pregnancy dating. This study investigated the correlation between the morphometrical skin characteristics with the pregnancy chronology to propose models for predicting gestational age.

Methods

A cross-sectional analysis selected 35 corpses of newborns. The biopsy was performed up to 48 hours after death in the periumbilical abdomen, palm and sole regions. Pregnancy chronology was based on the obstetric ultrasound before 14 weeks. The dimensions of the skin layers, area of glands and connective fibrous tissue were measured with imaging software support. Univariate and multivariate regression models on morphometric values were used to predict gestational age.

Results

Gestational age at birth ranged from 20.3 to 41.2 weeks. Seventy-one skin specimens resulted in the analysis of 1183 digital histological images. The correlation between skin thickness and gestational age was positive and strong in both regions of the body. The highest univariate correlation between gestational age and skin thickness was using the epidermal layer dimensions, in palm (r=0.867, p<0.001). The multivariate modelling with the thickness of the abdominal epidermis, the dermis and the area of the sebaceous glands adjusted had the highest correlation with gestational age (r=0.99, p<0.001).

Conclusion

The thickness of the protective epidermal barrier is, in itself, a potential marker of pregnancy dating. However, sets of values obtained from skin morphometry enhanced the estimation of the gestational age. Such findings may support non-invasive image approaches to estimate pregnancy dating with various clinical applications.

Epidemiology And Risk Factors For Death Of Pediatric Burns In A Developing Country. An Experience From The National Burn Hospital

This retrospective study investigated burn features and predicted factors for death of pediatric burn patients in Vietnam. The results showed that pediatric burn accounted for 48.1% of total admitted burn patients. Preschool children and boys were predominant, burns were mostly caused by scald (76.2%) and the majority of patients lived in a rural area (64.1%). In addition, 94.5% had burn size less than 30% total body surface area and deep burn injury was seen in 45.5% patients. Moreover, a significantly higher incidence of deep burn injury was recorded in preschool age, patients living in a rural area, and non-scald burn. Overall LA50 was 81.5% and a significantly higher mortality rate was seen in non-scald burns, older children, extensive burn and inhalation injury. Multivariate logistic analysis indicated that only burn extent and inhalation injury were independent risk factors for death. An increased 1% of burn extent resulted in a .7 probability unit of death (OR=1.08) and this was 2.16 in the case of inhalation injury (OR=8.67). This health issue should be highlighted in order to develop appropriate policies and intervention measures in developing countries.

A review of the success and challenges in characterizing human dermal exposure to flame retardants

Since organic flame retardants (FRs) have several industrial applications, they have been largely detected in environmental and biological samples, and humans have been highly exposed to them. Although the effects of oral and inhaled FRs have been well studied, dermal exposure to them has only recently been pointed out as a potential route of human exposure. Consequently, the effects of FRs on the skin and secondary target organs have been poorly investigated. This review article summarizes the main findings regarding dermal exposure to FRs, points the limitation of the published studies, and suggests future perspectives for better understanding of how dermal exposure to FRs impacts the human health. This review lists some gaps that must be filled in future studies, including characterization of the bioavailable fraction and assessment of exposure for new FRs, to establish their physiological significance and to improve the development of 3D dermal tissue for more reliable results to be obtained.

Epidemiology, Pathophysiology, and Management Strategies of Neonatal Wound Care

Guidelines for neonatal skin care are scarce, and there is no consensus on the best management practices for neonatal skin breakdown. This review presents the pathology and phases of wound healing, reasons for neonatal skin fragility, and approaches to recognition of commonly encountered neonatal wounds. This review also provides general strategies for neonatal wound prevention, care, dressing, and management to avoid further damage to the fragile neonatal skin. The importance and role of retaining moisture in expediting wound healing is discussed, as well as updated classifications on how to grade and assess pressure ulcers and the role of negative pressure wound therapy and silver dressings. Lastly, this review discusses prevention and treatment options for surgical wounds, intravenous extravasation wounds, congenital wounds, and thermal injuries, in addition to how to differentiate these wounds from the common diaper dermatitis and contact dermatitis.

Split-thickness skin graft donor-site morbidity: A systematic literature review

The purpose of this systematic literature review is to critically evaluate split-thickness skin graft (STSG) donor-site morbidities. The search of peer-reviewed articles in three databases from January 2009 to July 2019 identified 4271 English-language publications reporting STSG donor-site clinical outcomes, complications, or quality of life. Of these studies, 77 met inclusion criteria for analysis. Mean time to donor-site epithelialization ranged from 4.7 to 35.0 days. Mean pain scores (0-10 scale) ranged from 1.24 to 6.38 on postoperative Day 3. Mean scar scores (0-13 scale) ranged from 0 to 10.9 at Year 1. One study reported 28% of patients had donor-site scar hypertrophy at 8 years. Infection rates were generally low but ranged from 0 to 56%. Less frequently reported outcomes included pruritus, wound exudation, and esthetic dissatisfaction. Donor-site wounds underwent days of wound care and were frequently associated with pain and scarring. Widespread variations were noted in STSG donor-site outcomes likely due to inconsistencies in the definition of outcomes and utilization of various assessment tools. Understanding the true burden of donor sites may drive innovative treatments that would reduce the use of STSGs and address the associated morbidities.

Examining Factors That Contribute to Delayed Wound Healing in Children with Tracheostomy Wounds

OBJECTIVE

To identify variables that may contribute to delayed wound healing times in pediatric patients with tracheostomy wounds.

DESIGN

Researchers identified 134 charts spanning January 2013 to June 2017; 95 charts met the inclusion criteria. The study examined Pressure Ulcer Scale for Healing (PUSH) scores, pressure injury staging, and albumin levels.

SETTING

Arkansas Children's Hospital.

PATIENTS

Patients (birth to 18 years) who developed or were admitted with a wound caused by a tracheostomy device.

MAIN OUTCOME MEASURE

Time in days to wound closure.

MAIN RESULTS

There was a moderate positive correlation between albumin and days to healing (r = 0.432, n = 22, P = .045) with higher albumin levels associated with shorter healing times. The PUSH scores and pressure injury stage were significant in explaining 14.1% of variance in days to healing (F77,2 = 7.458; P < .001).

CONCLUSIONS

Wound healing appears to be multifactorial in nature in the pediatric population; albumin levels, pressure injury stage, and PUSH scores are all positively correlated with healing times. Further research is needed to investigate the contribution of race to healing time predication for the pediatric population.

Profile and outcome of burn injuries amongst preschool children in a developing country

The aim of this study was to investigate characteristics, outcomes and risk factors for death from burn in preschool children. A retrospective study was conducted on 3688 preschool burn children admitted to the National Burn Hospital from 1/1/2016 to 31/12/2018. Collected data included patient demographics and burn characteristics. Bivariate and multivariate analysis was conducted to determine independent risk factors for death. Results showed that preschool children accounted for 78.8% of total admitted burn children. The main causal agent was scald. Boys were predominant, and 76.5% patients lived in rural areas. The highest number of burn accidents occurred in winter. In addition, average burn surface area was of 8.8% total body surface area (TBSA) and 43.5% of patients suffered deep burn injury. Overall mortality rate was 0.5% with LA50 of 81.7% and 49.1% for full thickness burn area. A significantly higher mortality rate was seen in patients with inhalation injury. Compared to survivors, patients who died had a significantly larger burn surface area and larger deep burn area. Multivariate logistic analysis for death indicated that presence of inhalation injury and increased burn extent were independent risk factors for death. Inhalation injury resulted in a 3.4 probability unit of death. In conclusion, preschool burn injuries were more common in boys living in the countryside and were mostly caused by scald, with a high proportion of deep injuries. Except for in cases of extensive burn, inhalation injury was not common but was still the main cause of death.

Evidências sobre prevenção de lesões de pele em recém-nascidos: revisão integrativa

Objetivo: identificar estratégias para a prevenção de lesões de pele em recém-nascidos (RN) hospitalizados, publicadas em periódicos científicos no período de 2013 a 2018. Método: revisão integrativa de literatura realizada em dois momentos de busca em bases de dados, sendo selecionados 37 estudos publicados entre os anos de 2013 e 2018. Resultados: termorregulação, uso de antisséptico, uso de emolientes e limpeza do coto umbilical foram as recomendações mais encontradas. Entre as práticas baseadas em evidência, destacam-se as que previnem o risco de hipotermia, como o uso de saco de polietileno e o contato pele a pele, que respaldam a assistência e que garantem segurança no cuidado do paciente neonatal. Conclusão: a prevenção de lesões de pele é um tema relevante, entretanto, existe escassez de evidências robustas para sustentar, com segurança, as práticas de cuidados com o RN. Observa-se ainda que as evidências são insuficientes para englobar o universo do tema, demonstrando que o cuidado com a pele é um tema que demanda investimentos e mais pesquisas.

Evidence on prevention of skin lesions in newborns: integrative review

Objective: To identify strategies for the prevention of skin lesions in hospitalized newborns (NBs), published in scientific journals from 2013 to 2018. Method: Integrative literature review performed in two moments of database search, selecting 37 studies published between 2013 and 2018. Results: Thermoregulation, use of antiseptic, use of emollients and cleaning of the umbilical stump were the most commonly found recommendations. Among the evidence-based practices, we highlight those that prevent the risk of hypothermia, such as the use of a polyethylene bag and skin-to-skin contact, which support the assistance and ensure safety in the care of the neonatal patient. Conclusion: The prevention of skin lesions is a relevant topic. However, there is a scarcity of robust evidence to safely sustain NB care practices. It is also observed that the evidence is insufficient to encompass the universe of the theme, demonstrating that skin care is a theme that requires investment and more research.

External fixation: Role in decreasing postoperative complications of complex syndactyly release - A review of 18 patients

BACKGROUND

Primary and revision surgery for complete complex congenital syndactyly (CCCS) of the hand carries a risk of complications such as web maceration, which can result in flap or graft loss and alter the final appearance. No consensus emerges from the scant published data on postoperative care after CCCS surgery. The objective of this study was to assess the role for temporary external fixation in stabilising the commissure and facilitating surgical wound care.

HYPOTHESIS

Using external fixation after CCCS release facilitates postoperative wound care and decreases the complication rate.

MATERIAL AND METHODS

Eighteen patients requiring primary CCCS surgery or revision CCCS surgery due to adhesions or web creep were included in a single-centre retrospective study. After release, an external fixator made of Kirschner pins was installed to temporarily immobilise the inter-phalangeal joints. The dressing was changed every 3 days for 3 weeks, and the external fixator was then removed. The parents and nurses completed questionnaires that used 0-10 point scales to assess ease and duration of dressing changes and perceptions and apprehensions experienced by parents and nurses, as well as pain by patients, during dressing changes.

RESULTS

No patient experienced maceration or failure of a graft or flap. Pin site discharge was noted in 1 patient and resolved fully after pin removal. Pain intensity was estimated at 4.2/10 during the first dressing change and 1.3/10 during the last dressing change. In the parents, apprehension was 9.6/10 and 5.1/10 during the first and last dressing changes, and stress was 8.1/10 and 4.1/10, respectively. Dressing change difficulty was rated 1.1/10 at the first and 0.9/10 at the last dressing change. Dressing change duration decreased from 13 to 10minutes.

CONCLUSION

These encouraging results support temporary commissure stabilisation by an external fixator to decrease postoperative complication rates and facilitate dressing changes after CCCS release.

LEVEL OF EVIDENCE

IV, retrospective observational study.

Skin thickness dimensions in histological section measurement during late-fetal and neonatal developmental period: A systematic review

BACKGROUND

The development and maturation of the skin is a process that occurs during the gestation and neonatal period. Histological skin biopsy studies are relevant to improve knowledge on the skin protective barrier during the perinatal period. The thin skin of preterm newborns is unable to maintain homeostasis, thermal regulation through the skin, and is susceptible to infections. This study systematically reviewed the evidence regarding histological thickness dimensions of the skin and its layers during the late-fetal and neonatal period.

METHODS

PubMed, Scopus, BVS, and e SciELO library databases, with no limits in the period of analysis or idiom. Eligibility criteria were as follows: studies describing the thickness of the entire skin or its layers during late-fetal life or the neonatal period; human being; skin biopsy analysis; and any scientific report. Two independent reviewers screened the search and extracted the following standard data: fetal or neonatal age of assessment, biopsy site, technique used for preparation and staining of histological slides, measurement techniques, and values of skin thickness.

RESULTS

Fifty-nine studies were screened, and eleven were identified from other sources. We recognized six studies that met the criteria for inclusion for proper extraction. Expressive differences between sites for sampling, methods of slide preparation, and number of layers measured made the thicknesses values summarization difficult. There were no reliable dimensions reported on this tissue.

CONCLUSION

Despite the importance of studying the human skin barrier, these findings confirmed limited evidence on skin thickness dimensions obtained by histology.

First bathing time of newborn infants after birth: A comparative analysis

PURPOSE

The study was designed as an experimental study to describe the effect of the first bathing time on the body temperature and skin moisture of a newborn after birth.

DESIGN AND METHODS

The study population consisted of term newborns between January and June 2016 in the Istanbul University, Cerrahpaşa Medical Faculty Hospital at Istanbul. The sample group was randomly divided into two groups according to different bathing times. The first group (39 infants) was given a bath 24 hr after birth, and the second group (34 infants) was given a bath 48 hr after birth. The infants in both the groups were dried with the first towel and then wrapped in a second dry towel, and a cap put to prevent hypothermia and to minimize any minor fluid loss. The body temperature and skin moisture level were measured before the bath, after the bath, and 10 min after the bath.

RESULTS

It was determined that the 10th-minute body temperatures of the infants with the first bathing time 48 hr after birth were significantly higher compared with the infants with the first bath time 24 hr after birth (Z = -2.654; p = .008).

PRACTICAL IMPLICATIONS

Postponing of the first bathing time of newborns to 48 hr after birth was effective in preserving the body temperature of the infant. Postponing the bath to the 48th hr improved moisture, which may improve skin integrity and aid with skin development.

Point-of-Care Ultrasound Use in Neonatal Peripheral Intravenous Extravasation Injuries: A Case Series

PURPOSE

The primary aim of this study was to examine and describe peripheral intravenous extravasation (PIVE) injuries using point-of-care ultrasound (POC-US). A secondary aim was to define skin tissue changes before and after hyaluronidase application using POC-US.

DESIGN

Case series design.

SUBJECTS AND SETTING

We report on 10 neonates with stage 3 or 4 PIVE who were studied clinically and with POC-US. All infants were studied during the December 2015 to September 2016 period in a large academic neonatal intensive care unit.

METHODS

Initially, neonates with PIVE were staged using 3 criteria: physical findings, nature of the infusate, and the size of the injury. Next, we described different ultrasound appearances of the tissue injury in PIVE based on the type of the infusate (clear fluid, blood, or both). We then located the largest PIVE pocket and measured the skin elevation over it. Skin elevation ratio was measured at 3 time points: before hyaluronidase injection followed by 3 to 6 hours and 24 hours after hyaluronidase therapy. Each ultrasound examination of the skin injury was staged (severe, moderate, mild, or minimal) based on the skin elevation ratio obtained. In addition, we described changes in the skin using ultrasound before and after hyaluronidase treatment.

RESULTS

Three types of ultrasound images based on the type of the extravasated fluid were described in detail. Based on the initial ultrasound measurements of the skin elevation ratio, 6 infants were staged with severe PIVE and 4 were staged as moderate PIVE. Finally, POC-US was used to describe the tissue changes before and after hyaluronidase injection.

CONCLUSIONS

Point-of-care ultrasound may offer more structured and objective staging of PIVE injuries due to direct visualization of the skin tissue. This method needs to be further studied and introduced as a practical tool to complement physical examination of PIVE injuries.

Newborn Skin Care

The skin serves as a unique barrier from the outside world and undergoes critical changes during its development and maturation. This article reviews evidence-based recommendations for the routine care of newborn skin that should be integrated into the pediatrician's practice. [Pediatr Ann. 2019;48(1):e11-e15.].

Tinea faciei starting at day two of life

Dermatophyte infections are exceedingly rare in neonates, possibly due to the thin stratum corneum and high sebum content of neonatal skin. Only a handful of cases of tinea faciei have been reported in neonates, with the majority of reports occuring in India. Here, we report what to our knowledge is the earliest reported presentation of tinea faciei in the United States. We also provide a brief literature review of other reported cases of tinea faciei in neonates less than 30 days of age.

Pediatric Thermal Burns and Treatment: A Review of Progress and Future Prospects

Burn injuries are a devastating critical care problem. In children, burns continue to be a major epidemiologic problem around the globe resulting in significant morbidity and death. Apparently, treating these burn injuries in children and adults remains similar, but there are significant physiological and psychological differences. The dermal layer of the skin is generally thinner in neonates, infants, and children than in adults. Enhanced evaporative loss and need for isotonic fluids increases the risk of hypothermia in the pediatric population. The pain management of the children with major burns challenges the skills of the personnel of every unit. Managing these wounds requires intensive therapeutic treatment for multi-organ dysfunction, and surgical treatment to prevent sepsis and other complications that further delay wound closure. Alternatives to the practice of donor site harvest and autografting for the treatment of severe burns and other complex skin defects are urgently needed for both adult and pediatric populations. This review article focuses on thermal burn pathophysiology and pain management and provides an overview of currently approved products used for the treatment of pediatric burn wounds. A new promising approach has been presented as a first-line therapy in the treatment of burns to reduce surgical autografting in pediatric patients.

Impact of antepartum diagnostic amnioinfusion on targeted ultrasound imaging of pregnancies presenting with severe oligo- and anhydramnios: An analysis of 61 cases

OBJECTIVES

The primary objective our study was to assess the role of diagnostic antepartum amnioinfusion on the yield from targeted ultrasounds performed in pregnancies with severe oligo- and anhydramnios.

STUDY DESIGN

This was a retrospective and descriptive study, conducted in the fetal medicine units of two private tertiary care referral centers in south India. The details of all the cases of diagnostic amnioinfusion performed at these two centers from January 2009 to June 2016 were collected and analyzed. Inclusion criteria were pregnancies between 17 and 26 weeks of gestational age with severe oligo- or anhydramnios. Pregnancies with obvious preterm premature rupture of membranes (PPROM) were excluded. The primary outcome measure was the improvement in diagnostic information pertaining to cause of severe oligo- and anhydramnios, and the nature of such anomalies.

RESULTS

A total of 61 cases of were identified. The median gestational age at performance of the procedure was 22 weeks [IQR, 19.5-23]. The mean volume of normal saline infused was 314±54ml. A significant increase in the single vertical pocket (SVP) was observed following the procedure (pre-procedure SVP=0.6±0.9cm, post procedure SVP=3.4±1.7; paired t test, p<0.001). In 37 cases (37/61, 60.7%), there were no pre-procedure ultrasound findings. There was significant overall detection of abnormalities post procedure (mean pre-procedure findings=0.39±0.49, mean post procedure findings=1.59±1.24; paired t test, p<0.001). The most frequent group of anomalies/abnormalities were renal (36/61, 59%), followed by PPROM (13/61, 21.3%) and finally fetal growth restriction (11/61, 18%).

CONCLUSION(S)

Antepartum amnioinfusion is a valuable ancillary technique in prenatal diagnosis as it increases the diagnostic yield from pregnancies presenting with severe oligo- and anhydramnios.

Estimation of human percutaneous bioavailability for two novel brominated flame retardants, 2-ethylhexyl 2,3,4,5-tetrabromobenzoate (EH-TBB) and bis(2-ethylhexyl) tetrabromophthalate (BEH-TEBP)

2-Ethylhexyl-2,3,4,5-tetrabromobenzoate (EH-TBB) and bis(2-ethylhexyl)tetrabromophthalate (BEH-TEBP) are novel brominated flame retardants used in consumer products. A parallelogram approach was used to predict human dermal absorption and flux for EH-TBB and BEH-TEBP. [¹⁴C]-EH-TBB or [¹⁴C]-BEH-TEBP was applied to human or rat skin at 100nmol/cm² using a flow-through system. Intact rats received analogous dermal doses. Treated skin was washed and tape-stripped to remove "unabsorbed" [¹⁴C]-radioactivity after continuous exposure (24h). "Absorbed" was quantified using dermally retained [¹⁴C]-radioactivity; "penetrated" was calculated based on [¹⁴C]-radioactivity in media (in vitro) or excreta+tissues (in vivo). Human skin absorbed EH-TBB (24±1%) while 0.2±0.1% penetrated skin. Rat skin absorbed more (51±10%) and was more permeable (2±0.5%) to EH-TBB in vitro; maximal EH-TBB flux was 11±7 and 102±24pmol-eq/cm²/h for human and rat skin, respectively. In vivo, 27±5% was absorbed and 13% reached systemic circulation after 24h (maximum flux was 464±65pmol-eq/cm²/h). BEH-TEBP in vitro penetrance was minimal (<0.01%) for rat or human skin. BEH-TEBP absorption was 12±11% for human skin and 41±3% for rat skin. In vivo, total absorption was 27±9%; 1.2% reached systemic circulation. In vitro maximal BEH-TEBP flux was 0.3±0.2 and 1±0.3pmol-eq/cm²/h for human and rat skin; in vivo maximum flux for rat skin was 16±7pmol-eq/cm²/h. EH-TBB was metabolized in rat and human skin to tetrabromobenzoic acid. BEH-TEBP-derived [¹⁴C]-radioactivity in the perfusion media could not be characterized. <1% of the dose of EH-TBB and BEH-TEHP is estimated to reach the systemic circulation following human dermal exposure under the conditions tested.

CHEMICAL COMPOUNDS STUDIED IN THIS ARTICLE

2-Ethylhexyl 2,3,4,5-tetrabromobenzoate (PubChem CID: 71316600; CAS No. 183658-27-7 FW: 549.92g/mol logP_est: 7.73-8.75 (12)) Abdallah et al., 2015a. Other published abbreviations for 2-ethylhexyl-2,3,4,5-tetrabromobenzoate are TBB EHTeBB or EHTBB Abdallah and Harrad, 2011. bis(2-ethylhexyl) tetrabromophthalate (PubChem CID: 117291; CAS No. 26040-51-7 FW: 706.14g/mol logP_est: 9.48-11.95 (12)). Other published abbreviations for bis(2-ethylhexyl)tetrabromophthalate are TeBrDEPH TBPH or BEHTBP.

Comparison of impedance measurements near the skin of newborns and adults

Electrical impedance tomography (EIT) is a non-invasive imaging technology that has been extensively studied for monitoring lung function of neonatal and adult subjects, especially in neonatal intensive care unit (NICU) and intensive care unit (ICU) environments. The sources of the total impedance in these applications include internal organs, near-boundary tissues, electrode-skin impedance, electrodes and conducting wires. This total impedance must be considered for system design and setting voltage gain since it will contribute to the measured voltage. To adapt a single instrument for use on infants and adults, we studied the difference between the impedance near the skin in both classes of patients. We used a simultaneous multi-source EIT (SMS-EIT) system to make impedance measurements. Characteristic resistance was calculated for two different current patterns: one that is more sensitive to boundary region impedance and another that is more sensitive to interior changes. We present ratios of these resistances to assess the relative contribution of near-skin effects to the overall impedance. Twenty adult ICU subjects (10 male, 10 female, age: 49.05  ±  16.32 years (mean  ±  standard deviation)) and 45 neonates (23 male, 22 female, gestational age: 37.67  ±  2.11 weeks, postnatal age, 2.56  ±  2.67 d) were studied at Columbia University Medical Center. Impedance measurements at 10 kHz were collected for approximately one hour from each subject. The characteristic resistance ratio for each subject was computed and analyzed. The result shows the impedance at or near the skin of newborns is significantly higher than in adult subjects.

Female rats are less susceptible during puberty to the lethal effects of percutaneous exposure to VX

Nerve agents with low volatility such as VX are primarily absorbed through the skin when released during combat or a terrorist attack. The barrier function of the stratum corneum may be compromised during certain stages of development, allowing VX to more easily penetrate through the skin. However, age-related differences in the lethal potency of VX have yet to be evaluated using the percutaneous (pc) route of exposure. Thus, we estimated the 24 and 48 h median lethal dose for pc exposure to VX in male and female rats during puberty and early adulthood. Pubescent, female rats were less susceptible than both their male and adult counterparts to the lethal effects associated with pc exposure to VX possibly because of hormonal changes during that stage of development. This study emphasizes the need to control for both age and sex when evaluating the toxicological effects associated with nerve agent exposure in the rat model.

Morphological and inflammatory changes in the skin of autopsied fetuses according to the type of stress

INTRODUCTION

The fetal skin acts on the development and activation of the immune response via immune-neuroendocrine communication coordinated by corticotropin-releasing hormone.

OBJECTIVE

This study aimed to evaluate the morphological and inflammatory changes in the skin due to acute stress and chronic stress, associated with perinatal asphyxia, ascending infection and congenital malformation.

METHODS

We measured dermal and epidermal thickness, the diameter of keratinocytes, and the percentage of collagen and elastic fibers. Immunohistochemistry was used to evaluate both Langerhans cell and mast cell density, and corticotropin-releasing hormone expression in the epidermis, sebaceous gland, sebaceous duct, sudoriparous gland and in the hair follicle.

RESULTS

The epidermis was thinner in the cases with perinatal asphyxia, ascending infection and chronic stress. The diameter of keratinocytes was smaller in ascending infection and chronic stress. Mast cell density showed an indirect correlation with gestational age. Corticotropin-releasing hormone expression was significantly higher in ascending infection and chronic stress.

CONCLUSIONS

Chronic stress is associated with immunological and morphological changes in the skin of fetuses with perinatal asphyxia and ascending infection. Thus, corticotropin-releasing hormone seems to play a vital role in the differentiation and activation of innate and adaptive immune cells of the skin of fetuses.