Molecular epidemiology of methicillin-resistant Staphylococcus aureus in a burn unit from Brazil

Methicillin-resistant Staphylococcus aureus (MRSA) poses a threat for patients in burn units. Studies that mix epidemiological designs with molecular typing may contribute to the development of strategies for MRSA control. We conducted a study including: molecular characterization of Staphylococcal Chromosome Cassette mecA (SCCmec), strain typing with pulsed field gel electrophoresis (PFGE) and detection of virulence genes, altogether with a case-case-control study that assessed risk factors for MRSA and for methicillin-susceptible S. aureus (MSSA), using S. aureus negative patients as controls. Strains were collected from clinical and surveillance cultures from October 2006 through March 2009. MRSA was isolated from 96 patients. Most isolates (94.8%) harbored SCCmec type III. SCCmec type IV was identified in isolates from four patients. In only one case it could be epidemiologically characterized as community-associated. PFGE typing identified 36 coexisting MRSA clones. When compared to MSSA (38 isolates), MRSA isolates were more likely to harbor two virulence genes: tst and lukPV. Previous stay in other hospital and admission to Intensive Care Unit were independent risk factors for both MRSA and MSSA, while the number of burn wound excisions was significantly related with the former (OR = 6.80, 95%CI = 3.54-13.07). In conclusion, our study found polyclonal endemicity of MRSA in a burn unit, possibly related to importing of strains from other hospitals. Also, it pointed out to a role of surgical procedures in the dissemination of MRSA strains. © 2013 Elsevier Ltd and ISBI. All rights reserved.

Risk factors for the acquisition of imipenem-resistant Acinetobacter baumannii in a burn unit: An appraisal of the effect of colonization pressure

Imipenem-resistant Acinetobacter baumannii (IRAB) is a major threat for critically ill patients, including those admitted to burn units. Recent studies have suggested that colonization pressure (the proportion of patients or patient-days harbouring the pathogen of interest) is an important driver of the risk for acquisition of multidrug-resistant organisms. With that in mind, we conducted a cohort study, enrolling 208 patients admitted to a burn unit from November 2008 through December 2009. The outcome of interest was the acquisition of IRAB. In addition to the usual risk factors, we assessed the impact of colonization pressure. The number of wound excisions (odds ratio (OR) 12.06, 95% confidence interval (CI) 2.82-51.64) and the number of antimicrobials used (OR 22.82, 95% CI 5.15-101.19) were significant risk factors for the outcome of interest. On the other hand, colonization pressure (measured for whole time of exposure or up to the last 14, 7, or 3 days) was not associated with the risk for IRAB acquisition.

Guanylate cyclase inhibition by methylene blue as an option in the treatment of vasoplegia after a severe burn. A medical hypothesis

Today it is known that severe burns can be accompanied by the phenomenon of vasoplegic syndrome (VS), which is manifested by persistent and diffuse vasodilation, hypotension and low vascular resistance, resulting in circulatory and respiratory failure. The decrease in systemic vascular resistance observed in VS is associated with excessive production of nitric oxide (NO). In the last 2 decades, studies have reported promising results from the administration of an NO competitor, methylene blue (MB), which is an inhibitor of the soluble guanylate cyclase (sGC), in the treatment of refractory cases of vasoplegia. This medical hypothesis rationale is focused on the tripod of burns/vasoplegia catecholamine resistant/methylene blue. This article has 3 main objectives: 1) to study the guanylate cyclase inhibition by MB in burns; 2) to suggest MB as a viable, safe and useful co-adjuvant therapeutic tool of fluid resuscitation, and; 3) to suggest MB as burns hypotensive vasoplegia amine-resistant treatment.

Upregulation of defensins in burn sheep small intestine.

OBJECTIVE: The aim of this study was to visualize and localize the sheep antimicrobials, beta-defensins 1, 2, and 3, (SBD-1, SBD-2, SBD-3), sheep neutrophil defensin alpha (SNP-1), and the cathelicidin LL-37 in sheep small intestine after burn injury, our hypothesis being that these compounds would be upregulated in an effort to overcome a compromised endothelial lining. Response to burn injury includes the release of proinflammatory cytokines and systemic immune suppression that, if untreated, can progress to multiple organ failure and death, so protective mechanisms have to be initiated and implemented. METHODS: Tissue sections were probed with antibodies to the antimicrobials and then visualized with fluorescently labeled secondary antibodies and subjected to fluorescence deconvolution microscopy and image reconstruction. RESULTS: In both the sham and burn samples, all the aforementioned antimicrobials were seen in each of the layers of small intestine, the highest concentration being localized to the epithelium. SBD-2, SBD-3, and SNP-1 were upregulated in both enterocytes and Paneth cells, while SNP-1 and LL-37 showed increases in both the inner circular and outer longitudinal muscle layers of the muscularis externa following burn injury. Each of the defensins, except SBD-1, was also seen in between the muscle layers of the externa and while burn caused slight increases of SBD-2, SBD-3, and SNP-1 in this location, LL-37 content was significantly decreased. CONCLUSION: That while each of these human antimicrobials is present in multiple layers of sheep small intestine, SBD-2, SBD-3, SNP-1, and LL-37 are upregulated in the specific layers of the small intestine.

Mr. Mattocks in the Character of Achilles : How I pant! How I burn for the fight.

Signatur des Originals: S 36/G00096

Sibling relationships in the family of a child with a burn injury

Purpose. Understanding siblings' experiences after a major childhood burn injury was the purpose of this mixed method, qualitative dominant study. The following research questions guided this project: How do siblings describe the impact of a major childhood burn injury experience? How do sibling relationship factors of warmth/closeness, relative status/power, conflict, and rivalry further clarify their relationship and their experience after a major burn injury? ^ Methods. A mixed method, qualitative dominant, design was implemented to understand the sibling experiences in a family with a child suffering from a major burn injury. Informants were selected from patients with childhood burn injuries attending the reconstructive clinic at a Gulf coast children's specialty hospital. The qualitative portion used the life story method, a narrative process, to portray the long-term impact on sibling relationships. A "case" represents a family unit and could be composed of one or multiple family members. Participants from 22 cases (N = 40 participants) were interviewed. Interviews were conducted in person and via telephone. The quantitative portion, or the embedded part of this mixed method design, used the Sibling Relationship Questionnaire Revised (SRQ-R) to conduct an additional structured interview and acquire scoring data. It was postulated that the SRQ-R would provide another perspective on the sibling experience and expand the qualitative data analysis. Thematic analysis was implemented on the qualitative interview data including the qualitative data from the interviews structured on the SRQ-R. Additionally, scores on the SRQ-R were tabulated to further describe the cases. ^ Results. The overall thematic pattern for the sibling relationship in families having a child with a major burn injury was that of normalization. Areas of normalization as well as the process of adjustment were the major themes. Areas of normalization were found in play and other activities, in school and work, and in family relations with their siblings and their parents. The process of adjustment in the sibling relationship was described as varied, involved school and work re-entry, and might even change their life perspective. Further analysis included an examination of the cases in which more than one person were interviewed and completed the SRQ-R. Participants from five ( n = 11) of six cases (n = 14), scored above 3.0 on the five-point scale on the Warmth/Closeness construct, indicating they perceived the sibling relationship as close. Five participants scored high on the Conflict construct and four participants scored high on the Rivalry construct. Finally, Relative Status/Power was low or negative in the six cases (n = 13). ^ Conclusions/implications. These findings suggest the importance of returning to normalcy for many of the families and the significance of sibling relationships on the process. Some of these families were able to use this major life event in a positive way to promote normalization. ^

An outbreak of Multi-Drug Resistant Acinetobacter in the burn intensive care unit of a large tertiary care center

Risk factors for Multi-Drug Resistant Acinetobacter (MDRA) acquisition were studied in patients in a burn intensive care unit (ICU) where there was an outbreak of MDRA. Forty cases were matched with eighty controls based on length of stay in the Burn ICU and statistical analysis was performed on data for several different variables. Matched analysis showed that mechanical ventilation, transport ventilation, number of intubations, number of bronchoscopy procedures, total body surface area burn, and prior Methicillin Resistant Staphylococcus aureus colonization were all significant risk factors for MDRA acquisition. ^ MDRA remains a significant threat to the burn population. Treatment for burn patients with MDRA is challenging as resistance to antibiotics continues to increase. This study underlined the need to closely monitor the most critically ill ventilated patients during an outbreak of MDRA as they are the most at risk for MDRA acquisition.^

Prediction of sepsis in the burn intensive care unit patient

Sepsis is a significant cause for multiple organ failure and death in the burn patient, yet identification in this population is confounded by chronic hypermetabolism and impaired immune function. The purpose of this study was twofold: 1) determine the ability of the systemic inflammatory response syndrome (SIRS) and American Burn Association (ABA) criteria to predict sepsis in the burn patient; and 2) develop a model representing the best combination of clinical predictors associated with sepsis in the same population. A retrospective, case-controlled, within-patient comparison of burn patients admitted to a single intensive care unit (ICU) was conducted for the period January 2005 to September 2010. Blood culture results were paired with clinical condition: "positive-sick"; "negative-sick", and "screening-not sick". Data were collected for the 72 hours prior to each blood culture. The most significant predictors were evaluated using logistic regression, Generalized Estimating Equations (GEE) and ROC area under the curve (AUC) analyses to assess model predictive ability. Bootstrapping methods were employed to evaluate potential model over-fitting. Fifty-nine subjects were included, representing 177 culture periods. SIRS criteria were not found to be associated with culture type, with an average of 98% of subjects meeting criteria in the 3 days prior. ABA sepsis criteria were significantly different among culture type only on the day prior (p = 0.004). The variables identified for the model included: heart rate>130 beats/min, mean blood pressure<60 mmHg, base deficit<-6 mEq/L, temperature>36°C, use of vasoactive medications, and glucose>150 mg/d1. The model was significant in predicting "positive culture-sick" and sepsis state, with AUC of 0.775 (p < 0.001) and 0.714 (p < .001), respectively; comparatively, the ABA criteria AUC was 0.619 (p = 0.028) and 0.597 (p = .035), respectively. SIRS criteria are not appropriate for identifying sepsis in the burn population. The ABA criteria perform better, but only for the day prior to positive blood culture results. The time period useful to diagnose sepsis using clinical criteria may be limited to 24 hours. A combination of predictors is superior to individual variable trends, yet algorithms or computer support will be necessary for the clinician to find such models useful. ^

Monte Carlo uncertainty propagation approaches in ADS burn-up calculations

In activation calculations, there are several approaches to quantify uncertainties: deterministic by means of sensitivity analysis, and stochastic by means of Monte Carlo. Here, two different Monte Carlo approaches for nuclear data uncertainty are presented: the first one is the Total Monte Carlo (TMC). The second one is by means of a Monte Carlo sampling of the covariance information included in the nuclear data libraries to propagate these uncertainties throughout the activation calculations. This last approach is what we named Covariance Uncertainty Propagation, CUP. This work presents both approaches and their differences. Also, they are compared by means of an activation calculation, where the cross-section uncertainties of 239Pu and 241Pu are propagated in an ADS activation calculation.

Everyone Has Their Scars: Meaning Making In a Burn Survivor Support Group.

In the Burn Care literature, there is little on the lived experiences of burn support group members, the perceived benefits of burn support groups for the members, and even less on the meaning the survivors make of the support they receive. In order to provide effective services and to meet the psychosocial needs of burn survivors, it is important to understand the influence a support group has on its members as well as the personal experiences of those individuals who attend these groups. The purpose of this study was to explore the meaning that burn survivors make in a burn survivor support group. A non-random, purposeful convenience sample of six self-identified burn survivors was interviewed using a guided in-depth interview technique to explore their experiences in the support group. Key informant interviews and group observations served to triangulate the data collected in the individual interviews. The experiences of the group's members coalesced around five main themes: acceptance of self, perspective change, value of community, reciprocity, and structural meaning making components. The findings demonstrated the overall positive impact the support group had on psychosocial recovery. Additionally, analysis suggested that the meaning making process experience included Post Traumatic Growth and highlighted the importance of community in psychosocial recovery. Burn survivors reported unique growth opportunities that allowed them to integrate their injury into their identity within an encouraging and safe environment. Certain factors, such as improving group attendance, were addressed and both survivors and support staff generated suggestions for reaching others in need of support.

Prevalence of chronic wasting disease in post burn areas

Chronic wasting disease is a fatal neurological disease found in deer and elk in 14 western and mid-western states and two Canadian provinces. It is believed to have been first observed in Colorado and Wyoming in 1967. It is a disease caused by prions by an unknown transmission vector and impossible to cure at this time. Most of the management options currently available are labor-intensive and costly. The potential use of controlled burns to reduce or eliminate the prions that cause the disease was shown to have no effect on the prevalence of the disease in either study area. The temperatures needed to destroy prions were not reached by either surface or crown fires.