Evaluating invasion risk and population dynamics of the brown marmorated stink bug across the contiguous United States

BACKGROUND

Invasive species threaten the productivity and stability of natural and managed ecosystems. Predicting the spread of invaders, which can aid in early mitigation efforts, is a major challenge, especially in the face of climate change. While ecological niche models are effective tools to assess habitat suitability for invaders, such models have rarely been created for invasive pest species with rapidly expanding ranges. Here, we leveraged a national monitoring effort from 543 sites over 3 years to assess factors mediating the occurrence and abundance of brown marmorated stink bug (BMSB, Halyomorpha halys), an invasive insect pest that has readily established throughout much of the United States.

RESULTS

We used maximum entropy models to estimate the suitable habitat of BMSB under several climate scenarios, and generalized boosted models to assess environmental factors that regulated BMSB abundance. Our models captured BMSB distribution and abundance with high accuracy, and predicted a 70% increase in suitable habitat under future climate scenarios. However, environmental factors that mediated the geographical distribution of BMSB were different from those driving abundance. While BMSB occurrence was most affected by winter precipitation and proximity to populated areas, BMSB abundance was influenced most strongly by evapotranspiration and solar photoperiod.

CONCLUSION

Our results suggest that linking models of establishment (occurrence) and population dynamics (abundance) offers a more effective way to forecast the spread and impact of BMSB and other invasive species than simply occurrence-based models, allowing for targeted mitigation efforts. Implications of distribution shifts under climate change are discussed. © 2022 The Authors. Pest Management Science published by John Wiley & Sons Ltd on behalf of Society of Chemical Industry.

Return to jeopardy: the fate of pediatric burn patients who are victims of abuse and neglect

Child abuse and neglect continue to account for a significant number of pediatric burn injuries. Although the epidemiology of intentional burn injuries has been studied, this report compares victims of abuse with victims of neglect. Furthermore, we investigate the long-term fate of both victim and perpetrator. A retrospective search of the North Carolina Jaycee Burn Center database identified 21 abuse and 21 neglect patients among 238 pediatric admissions (mean age, 5.4 years, mean surface area 14%) from 1992 to 1994. The medical, social, and legal records of each patients were examined by two independent reviewers. History, hospital course, and disposition were compared between groups by chi-square analysis and Student's t test. Compared with victims of neglect, abused children were slightly younger (2.1 vs 2.7 years), had somewhat larger burns (12.3% vs 9.05 total body surface area), had inconsistent mechanisms of injury (90% vs 33%, p < 0.002) that were bathroom related (81% vs 29%, p < 0.001), were likely to have a history of abuse (57% vs 24%, p < 0.05) or stigmata of abuse on exam (43% vs 14%, p < 0.05), had longer lengths of stay (23.8 vs 14.1 days, p < 0.05), had similar complication rates, and were place more often in foster care (65% vs 15%, p < 0.01). Inpatient mortality was 5%. Mean follow-up was 108 days, during which time two children were readmitted for repeat abuse. Regarding the caregivers, 57% were single mothers, 36% had been investigated for abuse or neglect, and 12% had lost custody of other children. Of the perpetrators involved in abuse, 71% were charged with a felony, 43% were convicted, and 19% were incarcerated longer than 30 days. Victims of burn abuse and neglect differ considerably in terms of history and disposition but not hospital course. Children in both groups, however, remain at risk for abuse and neglect after discharge. We recommend that more aggressive efforts be made to secure safe environments for these children and that the perpetrator, if clearly identified, be dealt with in a fashion to prevent recurrence of the offense.

State study of pyrotechnics-related injuries and property damage

In December 1993, the State of North Carolina legalized the sale of certain types of fireworks. To date, no study has examined the impact of legalization of fireworks on health care and public safety. The purpose of this study was to examine the impact of legalized pyrotechnics specific to our state with regard to injury, property damage, and suppression costs. The population groups surveyed were the state fire departments, county fire marshals, hospital emergency departments, and county forest rangers. Each group was asked to complete a questionnaire on all incidents involving pyrotechnics devices, both legal and illegal, used during the study period. A total of 233 responses were received from the 1644 agencies surveyed. Forty-one injuries and 129 fireworks-related fires were reported. Total property loss was $185,570. Property loss, injury costs, and fire suppression costs totaled $799,450. This study provides a very conservative estimate of the problem within our state. Stronger legislation to restrict access to pyrotechnics may reduce the damage and costs they cause.

Smoke inhalation is a multilevel insult to the pulmonary system

Inhalation injury represents an ongoing threat to patients with thermal injury. The magnitude of the disease severity is related to the multilevel insult to the pulmonary system. Asphyxiants present in inhaled smoke can compromise oxygen delivery, resulting in cell death. Also, early changes in the microcirculation of the lung parenchyma, related to polymorphonuclear cell activation and oxygen free radical production, are responsible for early pulmonary edema. Perhaps the most significant pathologic change caused by smoke inhalation is loss of the respiratory epithelium and the formation of tracheobronchial casts. The recent application of high-frequency flow interruption ventilation and intrapulmonary percussive ventilation has made the largest impact on improved survival in patients suffering from smoke inhalation.

Allogeneic fibroblasts used to grow cultured epidermal autografts persist in vivo and sensitize the graft recipient for accelerated second-set rejection

INTRODUCTION

Cultured epidermal autografts (CEAs) have been used for wound coverage in patients with massive burns and other skin defects. However, CEAs often display late breakdown, which may be immunologically mediated and initiated by persistent foreign fibroblasts used as a feeder layer to optimize keratinocyte growth. This study investigates whether these fibroblasts, previously shown to persist in vitro, survive after grafting and induce host sensitization to alloantigen.

METHODS

CEAs from CBA donors (H-2k) were grown on allogeneic NIH 3T3 (H-2q) or syngeneic LTK (H-2k) fibroblasts, which were removed by trypsinization 7 days later. CBA mice (n = 85) were flank-grafted with NIH allografts (positive control), CEA/3T3s, CEA/LTKs, or CBA autografts (negative control). Hosts were challenged with second set NIH tail allografts 3 weeks later. Median graft survival was compared between groups by Wilcoxon rank and chi 2 analysis. Additional CBA mice (n = 15) received CEAs that were biopsied 0, 4, and 8 days after grafting. The presence of allogeneic fibroblasts was determined by Western immunoblotting, using KL295, a monoclonal antibody that recognizes H-2q (but not H-2k) class II histocompatibility antigens.

RESULTS

Allogeneic fibroblasts persisted after grafting but decreased over time, as determined by alloantigen expression on Western immunoblots. Accelerated tail graft rejection occurred in hosts primed by NIH allografts (9 days, p < 0.05), as well as by CEAs growth with an allogeneic (10 days, p < 0.05) but not a syngeneic feeder layer (12 days, NS). Mice receiving flank autografts rejected second set tail allografts at 12 days.

CONCLUSIONS

Immunogenic fibroblasts used to grow CEAs survive in vivo and sensitize the graft recipient for accelerated second-set rejection. These persistent cells may initiate an inflammatory response that may result in late graft breakdown and limit the utility of CEAs grown with a foreign fibroblast feeder layer.

Etiology and outcome of pediatric burns

A 6-year retrospective review of burn victims hospitalized at a major burn center was conducted to determine the etiology and outcome of pediatric burns. Four hundred forty-nine patients under age 16 years were identified and stratified by age, sex, burn size, presence or absence of inhalation injury, cause of burn, and county of residence. The mean patient age was 4.3 +/- 0.2 years, and the male:female ratio was 1.9:1. There were 21 deaths overall (4.7%), the majority of which (18) were among children under 4 years of age. With respect to large burns, defined as > and = 30% total body surface area (TBSA), the mortality rate for children under age 4 was significantly higher than that for older children (46.9% v 12.5%; P < .01), despite the nearly identical mean burn size of the two groups. Except for burn incidence, there were no significant differences between males and females. The mean burn size was 15.1% +/- 0.7%, and was significantly larger for nonsurvivors than survivors (55.3% +/- 5.7 v 13.1% +/- 0.5%; P < .01). Inhalation injuries were strongly associated with large burns and were present in all 15 flame-burn fatalities. Scalds were the most common type of burn among children under 4 years of age; flame burns predominated in older children. There were 6 deaths related to scalds, all of which occurred in children under 4. Burn type, size, and mortality rate did not differ between children from urban and rural counties. Large burn size was the strongest predictor of mortality, followed by (in order) age less than 4 and the presence of inhalation injury. Infants and young children have the highest risk of death from burn injury. Burns smaller than 30% TBSA without an inhalation injury (such as small scald injuries) occasionally are lethal in infants and small children, despite modern therapy.

Comparison of the Furlow double-opposing Z-palatoplasty with the Wardill-Kilner procedure for isolated clefts of the soft palate

This retrospective investigation compared the operative experience speech results of 21 patients who underwent a Furlow double-opposing Z-palatoplasty with those of 10 patients who underwent a modified Wardill-Kilner procedure. The modification consisted of not incising the nasal mucosa. All patients presented with an isolated cleft of the soft palate and were operated on by a single surgeon. The choice of operative technique was based solely on the fact that the surgeon developed an increasing preference for the Furlow procedure over time. The mean age at surgery was 1.3 and 1.5 years for the Furlow group and the Wardill-Kilner group, respectively. The average postoperative follow-up was 2.5 and 3.1 years, respectively. The mean operative times and hospital stay were the same for both groups. Postoperative speech assessments involved equal-appearing interval scale ratings of hypernasality and nasal emission, as well as pressure-flow testing and perceptual judgments of overall velopharyngeal adequacy. Analysis failed to reveal any statistically or clinically significant differences between the two groups.

Regional and institutional variation in burn care

In reviewing the literature on burn therapy and observing clinical burn care, we noted differences among institutions and individual experts in several areas. To study variation in burn care, we surveyed the 140 burn centers listed by the American Burn Association to determine how burn care is currently administered in the United States and Canada. Responses were obtained from 83 hospitals (60%). The survey addressed resuscitation, operative and nonoperative wound care, medications, antimicrobial agents, and pain control. The major influence on care appeared to be the experience of the director (considered "very influential" in 85%) compared with the literature ("very influential" in 12%) and habit/what works for us ("very influential" in 48%). The Parkland formula was used "always" or "often" by 78%, and the Brooke formula "never" by 81% of respondents. Lactated Ringer's solution was the most popular initial fluid, and most (78%) respondents changed fluids after 24 hours. However, the fluids used in the second 24 hours varied equally among several choices. The use of colloids also varied without a set pattern. Furosemide (Lasix) and nonsteroidal antiinflammatory drugs were used "rarely" or "never" by 67% of centers in the acute stage. H2 blockers were used for gastritis prophylaxis "always" or "often" in 60% (vs 53% for antacids and 20% for sucralfate [Carafate]). Tube feedings were started on day 1 after burn injury "always" by less than 30% of centers. Total parenteral nutrition was not commonly used. Most centers use of silver sulfadiazine on the body and hands, but facial topical antimicrobial therapy varied.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of inhalation injury, burn size, and age on mortality: a study of 1447 consecutive burn patients

The relative impact of inhalation injury, burn size, and age on overall outcome following burn injury was examined in 1447 consecutive burn patients over a five and a half year period. The overall mortality for all patients was 9.5% (138 of 1447). The presence of inhalation injury, increasing burn size, and advancing age were all associated with an increased mortality (p < 0.01). The incidence of inhalation injury was 19.6% (284 of 1447) and correlated with increasing percent total body surface area (%TBSA) burn (r = 0.41, p < 0.01) and advancing age (r = 0.15, p < 0.01). The overall mortality for patients with inhalation injury was 31% (88 of 284) compared with 4.3% (50 of 1163) for those without inhalation injury. Using multivariate analysis inhalation injury was found to be an important variable in determining outcome, but the most important factor in predicting mortality was %TBSA burn (accuracy = 92.8%) or a combination of %TBSA burn and patient age (accuracy = 93.0%). Adding inhalation injury only slightly improved the ability to predict mortality (accuracy = 93.3%). The presence of inhalation injury is significantly associated with mortality after thermal injury but adds little to the prediction of mortality using %TBSA and age alone.

Skin replacements. The biotechnological quest for optimal wound closure

Extensive skin loss from a variety of conditions is associated with significant functional morbidity and loss of life. In many patients, a limited number of donor sites available for harvesting autologous split-thickness skin grafts prevents early, effective, and permanent wound closure. In the past 25 years, significant biotechnological advancements have been made in defining the criteria and manufacturing ingredients in materials that could serve as skin replacements for permanent wound closure. The optimal skin replacement should have the functional and cosmetic properties of the dermis and the epidermis. It should provide rapid, functional wound coverage and barrier protection to microorganisms, normalize fluid flux and hypermetabolism, and provide long-term stability without contraction or hypertrophic scarring. In addition, the optimal skin replacement should be nontoxic, easily stored and used, and relatively cost-effective. This report will discuss the two major skin replacement designs available today, cultured keratinocyte grafts and bioartificial bilaminate systems, outline the advantages and disadvantages of each material, report the results of clinical trials for each, and speculate on the potential for each material to serve as a practical skin replacement.

Evaluation of a burn prevention program in a public school system

The "Learn Not to Burn" prevention program is a burn prevention curriculum sponsored by the North Carolina Jaycee Burn Center, the State Department of Public Instruction, and the North Carolina Department of Insurance Fire and Rescue Division. The goal of the program is to reduce burn-related deaths and injuries in North Carolina through burn prevention education by making the "Learn Not to Burn" curriculum available to primary school children across the state at no cost to the schools. The curriculum instrument is a reusable notebook that provides a means for teachers to integrate burn prevention into regular class subject areas. At the time of initiation of this study approximately 70% of the school systems in North Carolina had been provided with the "Learn Not to Burn" curriculum.

Reevaluation of benzene exposure for the Pliofilm (rubberworker) cohort (1936-1976)

The Pliofilm cohort is the most intensely studied group of workers chronically exposed to benzene. Information on this cohort has been the basis for regulations and/or guidelines for occupational and environmental exposure to benzene. Rinsky et al. (1986, 1987) and Crump and Allen (1984) developed different approaches for reconstructing the exposure history of each member of the group. The predicted levels of exposure, combined with the data on the incidence of disease, have been used to estimate benzene's carcinogenic potency. In this paper, recent information from worker interviews and historical records from the National Archives and elsewhere were used to evaluate the accuracy of prior exposure estimates and to develop better ones for the cohort. The following factors were accounted for: (1) uptake of benzene due to short-term, high-level exposure to vapors, (2) uptake due to background concentrations in the manufacturing building, (3) uptake due to contact with the skin, (4) morbidity and mortality data on workers in the Pliofilm process, (5) the installation of industrial hygiene engineering controls, (6) extraordinarily long work weeks during the 1940s, (7) data indicating that airborne concentrations of benzene were underestimated due to inaccurate monitoring devices and the lack of adequate field calibration mated due to inaccurate monitoring devices and the lack of adequate field calibration of these devices, and (8) likely effectiveness of respirators and gloves. Our estimates suggest that Crump and Allen (1984) overestimated the exposure of workers in some job classifications and underestimated others, and that Rinsky et al. (1981, 1986) almost certainly underestimated the exposure of nearly all workers. Airborne concentrations of benzene at the St. Marys facility during the years of its operation were found (on average) to be about half those of the two Akron facilities. Our analysis indicates that short-term, high-level exposure to benzene vapors and dermal exposure significantly increased (by about 25-50%) the total absorbed dose of benzene for some workers. One of the key findings was that, unlike prior analyses, the three facilities probably had significantly different airborne concentrations of benzene, especially during the 1940s and 1950s.

Causes and time course of acute hemolysis after burn injury in the rat

Thermal injury can cause acute red blood cell damage and destruction, but the mechanisms of these effects are not well described. To investigate the red blood cell abnormalities that occur after burn injury we studied the time course of red blood cell changes that are seen early after burn injury. Male Sprague-Dawley rats were divided into control, sham-burn, and burn (30% total body surface area full-thickness) groups. Plasma-free hemoglobin, erythrocyte osmotic fragility, and red blood cell membrane deformability were measured in the first 8 hours after burn injury. Plasma-free hemoglobin was significantly increased 1 hour after injury. It fell promptly but remained significantly higher than the control value at 4 and 8 hours after burn injury. Osmotic fragility was also significantly increased when compared with control values, whereas membrane deformability was less than control values for the duration of the experiment. This study identifies an early hemolytic effect of burn injury and documents red blood cell changes in osmotic fragility and membrane deformability that may contribute to accelerated red blood cell loss later in the course of burn management.

Antigenic cross-reactivity between media supplements for cultured keratinocyte grafts

Patients who were grafted with cultured human keratinocytes have been shown to make antibodies to the xenogeneic proteins, which supplement the culture media. An immune response to these antigens may lead to late graft loss or accelerated rejection of subsequent cultured keratinocyte grafts. Methods to eliminate this potential problem include growing cells in a serum-free medium with bovine pituitary extract as a serum substitute. To determine whether bovine pituitary extract would be subject to an immune response similar to that which is evoked by fetal bovine serum, we investigated their antigenic cross-reactivity. When compared by sodium dodecylsulfate-polyacrylamide gel electrophoresis, considerable similarity was identified between the two supplements. Immunostaining with antibodies to both bovine pituitary extract and fetal bovine serum confirmed antigenic cross-reactivity. Inhibitory enzyme-linked immunosorbent assay studies demonstrated specific cross-reactivity that ranged from 60% to 68%. When tested for antibody cross-reactivity to bovine pituitary extract, serum samples from five patients who were receiving human-keratinocyte grafts that were grown in fetal bovine serum-supplemented media and that exhibited a positive antibody titer to fetal bovine serum showed cross-reactivity that ranged from 30% to 141%. Bovine pituitary extract contains proteins that cross-react with fetal bovine serum. Human keratinocytes that are cultured in media that is supplemented with bovine pituitary extract would therefore be subject to an immune response similar to that which is evoked by human keratinocytes that have been cultured in fetal bovine serum.

Persistence of fetal bovine serum proteins in human keratinocytes

Cultured human keratinocytes are used for skin grafts, but their success is limited by late graft loss. Development of antibody to fetal bovine serum (FBS) protein used in culture media for in vitro keratinocyte growth has been identified. The persistence of FBS antigen in skin grafts is important in the induction of the immune response and the susceptibility of the keratinocytes to immune-mediated injury. The magnitude and longevity of FBS protein persistence on human keratinocytes was studied. Secondary passage human keratinocytes were grown in media supplemented with 5% FBS. The media was changed to one supplemented with pooled human AB serum, and the amount of FBS protein incorporated in the tissue was measured over the following 8 days by an ELISA reaction directed against FBS antigen. Incorporated FBS antigen decreased for the first 3 days to 31% of maximum. There was no further significant decrease for 5 days. Keratinocytes grown in alternative serum supplements (NuSerum [Collaborative Research Inc., Bedford, Mass.] and Serum Plus [Hazelton Research Products Inc., Lenexa, Kan.]), which contain reduced amounts of FBS, offered no significant reduction in FBS protein incorporation. This duration of antigen persistence would make human keratinocytes susceptible to cell destruction by immune response to FBS and may contribute to delayed loss of human keratinocyte grafts.

Bilateral simultaneous fractures of the femoral neck: case report

A case of bilateral fractures of the femoral neck resulting from high-voltage electric injury is reported. Surgeons caring for patients with electrical injuries must be aware of the possibility of this injury as well as other skeletal injuries which may result from muscle contraction or falls related to electric shock. Without vigilance for these injuries, diagnosis may be delayed.

Effects of acute ethanol ingestion and burn injury on serum immunoglobulin

Previous studies have found that acute ethanol ingestion before burn injury caused further impairment of mitogenic response of B lymphocytes compared with burn injury alone. The principal role of B lymphocytes is immunoglobulin production. This study was designed to determine the effect of acute ethanol ingestion on circulating immunoglobulin levels before injury. Serum concentrations of IgG, IgM, and IgA in rats were measured with the use of radial immunodiffusion plates at 4 days after a 30% burn injury in animals that had received a single ingestion of 3.0 ml ethanol per kilogram of body weight. The immunoglobulin levels were compared with appropriate controls. A 30% burn injury produced significant decreases in serum IgG and IgA levels but not in IgM levels, whereas acute ethanol ingestion only decreased IgA levels. Acute ethanol ingestion before injury did not induce any further significant decrease than did burn injury alone.

Characterization of "neo-dermis" formation beneath cultured human epidermal autografts transplanted on muscle fascia

Cultured human keratinocyte autografts were transplanted to burn wounds that had been completely excised down to muscle fascia such that all cutaneous elements were removed from the wounds. Healing autografts were biopsied from days 6-153 in five patients, and the "neo-dermis" beneath the autografts was examined by immunofluorescent staining using antibody probes to connective tissue molecules, by histochemical staining for elastin fibers, and by electron microscopy. We found that the neo-dermis contained most of the major connective tissue elements early in the post-transplantation period. However, regardless of the time examined, there was a paucity of elastin fibers and poor organization of linkin (microthread-like fibers) in the neo-dermis beneath autografts. The perturbations of these connective tissue components in the neo-dermis may play a role in the poor recoil and elastic properties of burn wounds treated with autografts.

Patient tolerance study of topical chlorhexidine diphosphanilate: a new topical agent for burns

Effective topical antimicrobial agents decrease infection and mortality in burn patients. Chlorhexidine phosphanilate (CHP), a new broad-spectrum antimicrobial agent, has been evaluated as a topical burn wound dressing in cream form, but preliminary clinical trials reported that it was painful upon application. This study compared various concentrations of CHP to determine if a tolerable concentration could be identified with retention of antimicrobial efficacy. Twenty-nine burn patients, each with two similar burns which could be separately treated, were given pairs of treatments at successive 12-h intervals over a 3-day period. One burn site was treated with each of four different CHP concentrations, from 0.25 per cent to 2 per cent, their vehicle, and 1 per cent silver sulphadiazine (AgSD) cream, an antimicrobial agent frequently used for topical treatment of burn wounds. The other site was always treated with AgSD cream. There was a direct relationship between CHP concentration and patients' ratings of pain on an analogue scale. The 0.25 per cent CHP cream was closest to AgSD in pain tolerance; however, none of the treatments differed statistically from AgSD or from each other. In addition, ease of application of CHP creams was less satisfactory than that of AgSD. It was concluded that formulations at or below 0.5 per cent CHP may prove acceptable for wound care, but the vehicle system needs pharmaceutical improvement to render it more tolerable and easier to use.

Bilateral femoral neck fractures after electrical injury: a case report and literature review

Simultaneous bilateral fractures of the femoral necks are rare injuries, especially when there is no underlying pathologic condition. A review of the literature revealed only 10 cases of this injury as a result of trauma, only one of which was due to accidental electric shock. A second case in which such an injury was caused by accidental electric shock is presented here. It is important to be aware of this injury and to diagnose it early to avoid the increased risk of complications after a delay in diagnosis or treatment.

Chronic ethanol exposure before injury produces greater immune dysfunction after thermal injury in rats

Chronic alcoholics constitute a small but significant subgroup of burned patients. The effects of chronic alcohol exposure on immune function in burned patients has not to our knowledge been studied. This study was designed to determine the effect of chronic alcohol exposure before burn injury on immune function after injury in rats. Immune function assessed by in vivo chemotaxis and responsiveness of non-adherent splenocytes to both a T-cell mitogen, concanavalin A, and a B-cell mitogen, lipopolysaccharide, was measured at 4 days after a 20% BSA full-thickness burn injury and/or gavage of 2.4 gm/kg/day of ethanol for 14 days. Chronic ethanol ingestion before burn injury produced significant suppression in chemotaxis and response to lipopolysaccharide but not in response to concanavalin A. These results suggest that chronic alcohol exposure before injury can contribute to further impaired immune function after injury, and may lead to increased susceptibility to infection and increased mortality.

Techniques to accelerate the availability of human keratinocyte grafts

Human keratinocytes grown in cultures have been used successfully in the coverage of large burns. The time required to grow sufficient human keratinocytes for grafting is a major limitation of this technique. Three variables--plating density, length of time to confluence in secondary culture, and media supplementation--were studied to find conditions that increase the rate of keratinocyte growth. Normal human keratinocytes were used for all studies. Plating densities varied between 2.5 x 10(3) and 3.7 x 10(4) cells per square centimeter. Time in secondary culture was studied daily from day 2 to day 17. Media supplements included fetal bovine serum, human serum, and three commercially available serum supplements. These studies indicate that human keratinocytes, grown for wound grafting, can grow more rapidly to a higher cell number if they are plated at a density of 2 x 10(4) cells per square centimeter, passaged by 8 to 10 days or before confluence slows cell growth, and grown in 5% fetal bovine serum, 1.25% fetal bovine serum, or 5% human serum. Use of these techniques may decrease the time necessary for wound coverage with human keratinocytes.

Analysis of life expectancy and living status of elderly patients surviving a burn injury

This study evaluates the long-term outcome of elderly patients discharged from hospital after a burn injury. Ninety-three patients over the age of 60 years, admitted to a regional burn center, were included in the study from January 1981 to January 1986. The in-hospital mortality rate was 49.4%. Patients' living status was graded according to dependency: 47% of patients were reduced to a more dependent living status on discharge, and 36% of the survivors were followed up for between 1 and 5 years. During this time seven (19.4%) patients died, three (8.3%) became more independent, four (11.1%) less independent. Life table analysis of discharged patients showed no accelerated death rate in comparison with the normal population. The high mortality associated with burns in the elderly was confirmed. Half the survivors were at least temporarily less independent. Projected life expectancy for the elderly surviving a burn is comparable with his/her uninjured counterpart.

Menkes kinky hair disease with 'ragged red' fibers

A 30-month-old infant with Menkes kinky-hair disease died, with prominent vascular, cerebral and cerebellar degeneration. Increased numbers of mitochondria containing homogeneous dense bodies were seen on electron-microscopic examination of Purkinje cells. Subsarcolemmal aggregates of mitochondria ('ragged red' fibers) were present in skeletal muscle. These mitochondrial alterations support the hypothesis that copper deficiency results in mitochondrial encephalomyopathy.

Antibody response to xenogeneic proteins in burned patients receiving cultured keratinocyte grafts

Cultured keratinocytes (CK) have been used to resurface large burn wounds with some success. These CK are grown in the presence of fetal bovine serum (FBS) and mouse fibroblasts (MF). Serum from ten patients who received CK grafts as part of burn wound coverage was studied by ELISA technique for antibody to these xenogeneic antigens. All patients had some amount of antibody to FBS but no detectable antibody to MF. The amount of antibody to FBS varied between patients and with respect to time after graft application. Generally, the levels of antibody to FBS were moderate by 30 days, declined, and then rose slowly by 5 to 6 months. The majority of antibody to FBS was against bovine serum albumin (BSA), demonstrated by Western blot technique. The presence of such antibody to FBS might produce clinical problems of graft rejection, anaphylaxis, and serum sickness in patients receiving CK grown in FBS supplemental medium. Further investigation will need to determine the likelihood and potential severity of such clinical problems.

Burn wounds resurfaced by cultured epidermal autografts show abnormal reconstitution of anchoring fibrils

We studied epidermal autografts placed on four severely burned patients. All of the patients experienced skin fragility in the autograft sites, and three of the four patients reported spontaneous blisters. Epidermal-dermal adherence was objectively examined in one patient by comparing suction blistering times in the autograft and in a parallel, control, unburned site. Blisters formed in the autograft at 17 minutes, and the cleavage plane of the blister was below the lamina densa of the basement membrane. In contrast, the normal skin blistered at 65 minutes and had a superficial cleavage plane, above the basal lamina. In all four patients, the reconstituted basement membrane zone beneath the autografts was incomplete and lacked type IV (basement membrane) collagen 7-S sites and anchoring fibrils. We conclude that skin fragility, apparent as late as seven months after transplantation, may result from defective anchoring fibrils.

Wound coverage with cultured autologous keratinocytes: use after burn wound excision, including biopsy followup

Cultured autologous keratinocytes (CAK) have been used in eight patients as part of their definitive treatment for burn wound closure. The CAK grafts were placed on surgically excised wounds rather than mature granulation tissue. This technique guaranteed that permanent skin coverage derived from cultured cells, and not residual epidermal cells from surviving dermis. Graft take was variable, ranging from zero in the case of one of the children to 85%. Long-term assessment noted adequate permanent coverage, confirmed by biopsy. Electron micrographs demonstrated no well formed anchoring fibrils, which may account for the graft fragility which has been reported as much as 1 year postgraft. Advantages of using CAK are that an acceptable permanent wound closure can be achieved without depending on donor site availability. An almost unlimited quantity of skin is available because the original biopsy can be expanded manyfold in the laboratory.

Cell populations of tendon: a simplified method for isolation of synovial cells and internal fibroblasts: confirmation of origin and biologic properties

Tendons transmit the force of muscle contraction to bone to effect limb movement. Special structural and biological properties of tendon have developed to facilitate force transmission. The tendon has a complex organization of cells surrounding the collagen bundles inside tendon as well as at the tendon surface. Internal cells may act to maintain the bulk of the collagen in tendon. External cells in the epitenon may provide lubrication for tendon gliding. To develop better understanding of these processes and the roles the cell populations play, we isolated cells from the surface and interior of tendon and studied them in vitro. Flexor tendons from 8-week-old white Leghorn chickens were separated into two distinct cell populations: the outer synovial cells and the fibroblasts more internal in tendon. These cell populations were discernible by their locations in the intact tendon, determined by sequential enzymatic and physical release from their substrata. Initially, some cells eluted in Hanks' salt solution (HSS) (population 1); then synovial cells were released after a 2-min treatment with 0.5% collagenase (population 2). Next, a population of synovial cells was released in high yield by treatment with 0.25% trypsin (step III, population 3). Step III, population 3 cells were used as synovial cells (SCs). Next, a population of SCs and fibroblasts were released by scraping with a rubber policeman (population 4). Subsequently, fibroblasts were released after incubation with 0.5% collagenase (population 5). A more direct procedure (procedure 2) to isolate the synovial and internal tendon cells involved treatment in 0.5% collagenase followed by sedimentation at 900 g. Cells that sedimented were largely fibroblasts, whereas the cells that remained at the top of the tube were largely SCs. Cells designated as SCs, isolated by procedure 2, most likely contained surface cells from epitenon and internal interfascicular cells from endotenon and paratenon. Surface tendon cells separated by sequential enzymatic and physical release from their substrata (by procedure 1) had all the following characteristics: distinct subpopulations of cells based on morphology; presence of cytoplasmic, lipid-containing vesicles; decreased sensitivity to trypsin; and reduced generation time as compared with that of internal fibroblasts. Conversely, the internal fibroblasts (IFs) appeared to represent a more uniform population based on morphological characteristics.

Tendon synovial cells secrete fibronectin in vivo and in vitro

The chemistry and cell biology of the tendon have been largely overlooked due to the emphasis on collagen, the principle structural component of the tendon. The tendon must not only transmit the force of muscle contraction to bone to effect movement, but it must also glide simultaneously over extratendonous tissues. Fibronectin is classified as a cell attachment molecule that induces cell spreading and adhesion to substratum. The external surface of intact avian flexor tendon stained positively with antibody to cellular fibronectin. However, if the surface synovial cells were first removed with collagenase, no positive reaction with antifibronectin antibody was detected. Analysis of immunologically stained frozen sections of tendon also revealed fibronectin at the tendon synovium, but little was associated with cells internal in tendon. The staining pattern with isolated, cultured synovial cells and fibroblasts from the tendon interior substantiated the histological observations. Analysis of polyacrylamide gel profiles of 35S-methionine-labeled proteins synthesized by synovial cells and internal fibroblasts indicated that fibronectin was synthesized principally by synovial cells. Fibronectin at the tendon surface may play a role in cell attachment to prevent cell removal by the friction of gliding. Alternatively, fibronectin, with its binding sites for hyaluronic acid and collagen, may act as a complex for boundary lubrication.

Prevalence of "compressed" and asymmetric lateral ventricles in healthy full-term neonates: sonographic study

The premature infant brain has been thoroughly studied by sonography, and normal standards for ventricular size have been established. Whether these apply to normal full-term infants is uncertain. Fifty-three healthy full-term infants were electively examined by real-time sonography through the anterior fontanelle on the first to sixth days of life. Nine had asymmetric lateral ventricles; two of these had unexpected evidence of intracranial hemorrhage, while a third had a ventricular cyst. Forty-four infants had symmetric ventricles, but in 36 the ventricles had little or no cerebrospinal fluid. Vaginal delivery had a statistically significant association with these "compressed' lateral ventricles. This study indicates that seemingly healthy infants may have unsuspected intracranial hemorrhage, that asymmetric ventricular size may be normal, and that shortly after birth most healthy infants have "compressed" lateral ventricles that should not be interpreted as cerebral edema.

The role of vasoconstrictors in control of blood loss in reduction mammaplasty

Because blood loss has been a concern in reduction mammaplasty, a prospective double-blind study was undertaken to determine whether instillation of an epinephrine solution into the breast parenchyma would reduce blood loss during this procedure. the inferior glandular pedicle technique was used with each patient serving as her own control. A significant reduction in operative blood loss compared with the control solution was observed. We believe that instillation of an epinephrine solution should be a routine part of the reduction mammaplasty procedure.

Mycobacterium avium infection in a silicone-injected breast

A case of atypical mycobacterial infection (M. avium intracellulare) in a silicone-injection augmented breast is described. The silicone injection may have been a contributing factor to the development of this unusual infection. Disseminated M. avium was present in this patient, with breast involvement being suggested by the rapid appearance and disappearance of localized areas of erythema and tenderness. Aggressive treatment of these breast infections while they are still localized may prevent systemic spread. Conventional incision and drainage of the breast abscess combined with multidrug treatment directed against M. avium is the recommended therapy.

Blepharochalasis after a bee sting

Blepharochalasis is a distinct entity of redundant eyelids. It is characterized by a history of recurrent edema that leads to permanent changes in the eyelids. Even in the young, blepharoplasty may be indicated for psychological reasons or to relieve obstruction of vision, eyelid asthenia, and fatigue. Following surgery, recurrent edema may compromise the results or cause further eyelid changes. Effort should be made to define the etiology of the edema and correct the defect if possible.

Toxic epidermal necrolysis-case report and review of the literature

A patient who developed toxic epidermal necrolysis secondary to a sulfonamide derivative is presented. Treatment consisted of fluid resuscitation and silver nitrate soaks to the affected areas. Silver nitrate was selected over silver sulfadiazine (Silvadene) and mafenide in view of the nature of the offending agent. Tissue biopsy helps in the differentiation of toxic epidermal necrolysis from staphylococcal scalded skin syndrome. A biopsy is especially useful if the offending agent is not known so that appropriate treatment can be started promptly. The mortality associated with toxic epidermal necrolysis is in the neighborhood of 30%. The priniciples of burn wound management are the key to treatment of this disease. The wound usually heals by epithelialization without the need of skin grafting.

Disappearance of the polyurethane cover of the Ashley Natural Y prosthesis

Polyurethane foam implanted in our patient was neither inert nor permanent. Clinical observations and animal studies suggest that all polyurethanes implanted to date have slowly disintegrated and have been absorbed in tissue. This process takes several years to complete. The exact time sequence and histology are not known.

Efficacy of tangential excision and immediate autografting of deep second-degree burns of the hand

Fifty patients, with 71 hands affected by deep dermal burns, underwent tangetial excision and immediate autografting at a mean of the fifth postburn day. Assessment of the group at 6 weeks showed an 8% mortality, good hand function in 50%, fair function in 18%, and poor function in 24%. The total group was partitioned into patients with burns of 40% or less and those with burns of greater than 40% of body surface. The former group had significantly better hand function than the latter. Early tangetial excision with immediate autografting of deep dermal hand burns is recommedned for almost all patients with small to moderate thermal cutaneous injury. However, only after careful evaluation should patients with large, life-threatening thermal injuries be selected for this procedure.

Behr syndrome: a clinicopathologic report

Two sisters had Behr syndrome; autopsy was performed on one. The autopsy revealed central atrophy of the optic nerves and total disarray of the normal laminar pattern of the lateral geniculate nucleus, dropout of neurons, and gliosis. There were numerous axonal spheroids in the neuropil. Similar spheroids with cell loss and gliosis were also observed in other thalamic nuclei and, rarely, in the pallida. We raise the possibility that Behr syndrome is a manifestation of a heterogeneous group of disorders, and suggest relationship of this particular disease to infantile neuroaxonal dystrophy.

Scalp as a donor site

Our experience in twenty-six patients suggests that the scalp is an excellent source of split thickness skin grafts. Healing is rapid, infection is rare, and the regrowth of hair conceals the donor site.

Clinical evaluation of the carbon dioxide laser for burn wound excisions: a comparison of the laser, scalpel, and electrocautery

The use of a 100 watt carbon dioxide laser for surgical excisions of burn eschar was evaluated in 13 patients with symmetrical burns. In each patient, laser excision was compared with either scalpel or electrocautery excision of a comparable area. Graft "take," blood loss, and operative speed were measured. Graft "take" following laser excisions was comparable to that obtained when either scalpel or electrocautery was used. Regression analysis indicates that laser excisions involved 29% of the blood loss encountered with scalpel excisions and that laser speed was 1.49 times scalpel speed. Although laser blood loss was 60% of electrocautery blood loss, laser speed was significantly slower: 73% of electrocautery speed. These differences, however, were of small clinical consequence. It is felt that the surgical arm of this laser is at present quite awkward and is in need of technological refinement if the full potential of the laser is to be realized.

Laser, scalpel, electrosurgical, and tangential excisions of third degree burns. A preliminary report

Our clinical experience with laser, electrosurgical, scalpel, and tangential burn wound excisions in 26 patients is presented.

Early treatment of war wounds of the hand and forearm in Vietnam

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