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This study describes a recent cluster of 30 patients (median age 52 years) with serious group A streptococcal (GAS) infections in Uppsala County, Sweden, from December 2006 to May 2007. Patients hospitalized with a severe GAS infection, i.e. cases with either invasive GAS (iGAS) disease or patients with a positive non-sterile site culture/rapid antigen test for GAS and clinically considered as having a critical disease, were included in the study. Common clinical presentations were skin and soft tissue infections (53%) and pneumonia (17%). Eight patients (27%) were diagnosed with streptococcal toxic shock syndrome. In 40% of the cases no relevant underlying disease was reported. Among the 16 patients with soft tissue infections, the upper chest, neck or upper arm area was frequently affected and the infection was associated with severe pain. Among the 20 collected isolates, the T1/emm1 type dominated (80%). The majority (86%) of 7 analysed acute sera lacked neutralizing activity against superantigens produced by the patients' own infecting isolate. The study underscores the association between T1/emm1 and outbreaks of serious GAS infections. This highlights the importance of surveillance for prompt identification of more aggressive isolates in the community, thereby increasing awareness among healthcare professionals of these life-threatening infections.

The sentinel node biopsy (SNB) procedure is a multidisciplinary technique, invented to gain prognostic information in different malignant tumors. The aim of the present study was to study the cohort of patients with malignant melanoma, operated with SNB, from the introduction of the technique in Sweden, concerning the prognostic information retrieved and the outcome of the procedures. In Sweden all patients with malignant melanoma are registered at regional Oncological Centers. From these databases ten centers were identified, treating malignant melanoma and performing sentinel node biopsy. Consecutive data concerning tumor characteristics, outcome of the procedure and disease related events during the follow-up time were collected from these ten centers. All cases from the very first in each centre were included. The SNB procedure was performed in 422 patients with a sentinel node (SN) detection rate of 97%, the mean Breslow thickness of the primary tumors was 3.2 mm (median 2.4 mm) and the proportion of ulcerated melanomas 38%. Metastasis in the SN was found in 19% of the patients but there was a wide range in the proportion of SN metastases between the different centers (5-52%). After a follow-up of median 12 months of 361 patients, SN negative patients had better disease-free survival than SN positive (p0.0001). A false negative rate of 14% was found during the follow-up time. In this study the surgical technique seemed acceptable, but the non-centralized pathology work-up sub-optimal. However, SNB was still found to be a significant prognostic indicator, concerning disease free survival.

We describe a technique by which the intravelar veloplasty was reinforced by including the superior part of posterior pillars and their palatopharyngeal muscle sheet in patients with cleft lip and palate. Our aim was to increase the functional length and strength of the velum and to reduce nasal emission and the need for pharyngeal flaps. Since 1990 more than 200 patients have been operated on in this way at Uppsala University Hospital. This is a retrospective follow-up of 162 consecutive patients operated on by two senior surgeons between 1990 and 2000. We describe the technique, timing, and operative observations as well as the outcome and the need for revision of the palatoplasty in some cases because of complications. To facilitate speech, 21 patients born between 1990 and 1997 (16%) were provided with a pharyngeal flap.

Pruritus is a major problem after burn injury; however, prevalence and predictors of prolonged pruritus are not known. The aims were to assess frequency of pruritus and the role of personality traits and coping in prolonged pruritus. The participants were burn patients injured 1-18 years earlier (n=248). Pruritus was assessed with an item from the Abbreviated Burn Specific Health Scale, personality was assessed with the Swedish universities Scales of Personality, and coping with the Coping with Burns Questionnaire. In all, 60% of the participants had pruritus at follow-up, however as the time after injury increased, the number of patients with persistent itch decreased. In logistic regression, 39% of the likelihood of having persistent pruritus was explained by greater extent of burn, less time after injury, and psychological features (being less assertive, and using more instrumental but less emotional support). In summary, chronic burn-related pruritus is rather common and psychological factors such as anxiety-related traits and coping are significantly associated with its presence.

Objective. Toxic epidermal necrolysis (TEN) is a rare but life-threatening disease of the skin and mucous membranes. We report our experience in the treatment of pediatric TEN patients with early debridement of necrotic skin and coverage with human allograft skin. Methods. From 1984 to 2000, 15 children (6 girls, 9 boys, 7.2 ± 1.5 years) with a histologic diagnosis of TEN and involvement of >30% total body surface area were treated at the Shriners Hospitals for Children in Galveston. All were treated in a specialized pediatric burn intensive care unit after our standard treatment protocol, including operative debridement of sloughing skin and allografting within 24 hours of admission. Outcome parameters were mortality, length of hospital stay, wound healing, clinical complications, causative drugs, corticosteroid use, and delay in referral to a burn center. Results. Taking a new medication (antibiotics, anticonvulsive drugs) was associated with all cases of TEN. Patients who were treated with early debridement and coverage with allograft skin showed no wound infection, and overall mortality was 7%. Total length of hospital stay was 26 ± 3 days. Long-term sequelae were changes in skin pigmentation (100%), ophthalmologic problems (40%), and diffuse itching early after wound healing (53%). Conclusion. Although a rare disease in children, TEN was managed successfully in a burn center environment, using early debridement and wound coverage with allograft skin as a biological dressing. The use of corticosteroids and referral patterns seems unchanged during the past 2 decades, indicating an additional need for information and education about the disease.

Mit zunehmender Etablierung der laparoskopischen Cholecystektomie treten seit einigen Jahren juristische Aspekte in den Vordergrund. Zur Klarung der Frage, welche Folgen eine kompliziert oder auch fehlerhaft verlaufene laparoskopische Cholecystektomie in juristischer Hinsicht nach sich zieht, wurden die erreichbaren Entscheidungen der Schlichtungsstellen der Arztekammern sowie der Gerichte aufgearbeitet. Von 40 ausgewerteten Fallen von Behandlungsfehlervorwurfen wurden 16 als Behandlungsfehler anerkannt, 24 mal wurden die Vorwurfe zuruckgewiesen. Der haufigste Vorwurf betraf mit 26 Fallen die Gallenwegverletzung. Von diesen 26 Verletzungen wurden 7 als Behandlungsfehler anerkannt, davon 2 als schwere Behandlungsfehler. Als Grunde fur anerkannte Behandlungsfehler wurden in den Urteilen im wesentlichen ein verzogertes Umsteigen auf die konventionelle Operation, eine verzogerte Revision, die laparoskopische Durchfuhrung einer Revisionsoperation und das fehlende Umsteigen bei unubersichtlichem Situs genannt.

Psychiatric problems frequently occur during burn treatment and can complicate recovery. In addition, preexisting psychiatric disorders are often present and sometimes will have contributed to the burn injury. Pain, itching, and stress during burn recovery can complicate treatment and recovery. It is therefore essential that members of the burn treatment team recognize, assess, and treat psychiatric problems in patients with burn injury. More severe psychiatric disorders in patients may result from the injury and treatment, such as posttraumatic stress disorder and depression. It is useful to have mental health professionals as part of the treatment team. Quick detection and treatment of psychiatric problems contribute to overall recovery and reduce complications.

The Impact of Event Scale (IES) and the Impact of Event Scale-Revised (IES-R) are often used as self-report instruments for symptoms of post-traumatic stress disorder (PTSD). However, there are few validations of the IES and the IES-R against structured clinical interviews. In this study the two scales, together with the three subscales of the IES-R, were assessed for their agreement with a diagnosis of PTSD in patients with burns 1 year after injury. Sixty patients with burns were evaluated 1 year after injury using the Structured Clinical Interview for the DSM-IV Axis I (SCID-I) psychiatric disorders and a Swedish version of the IES-R. The total score of the IES-R had the best discriminant ability (0.89) with a sensitivity of 1.0 and a specificity of 0.78. In conclusion, the total IES-R had good properties as a screening tool for PTSD and subsyndromal PTSD 1 year after burn injury.

Although patients frequently experience sleep disturbances and nightmares in the first weeks after a severe burn, information is scarce on the course and prevention of this problem. Prolonged experience of nightmares in adults is one of the symptoms of posttraumatic stress disorder. The aim of this work was to determine risk factors for developing chronic nightmares after severe burns. Personality traits and coping strategies were assessed. As part of a follow-up study of patients treated at the Burn Center at Uppsala University Hospital, Uppsala, Sweden, between 1980 and 1995, the questionnaires of 166 patients (34 females, 132 males, average age 50 years, average burn size 25% TBSA, full-thickness burn size 10% TBSA, average time since burn 11.4 years) were analyzed. The effects of individual personality traits and coping strategies on the frequency of nightmares were evaluated by regression analysis. Nightmares were reported by 43% of the patients, by females more frequently than males. The frequency of nightmares was shown to be associated with the size of the full-thickness burn. The use of Avoidance or Revaluation/Adjustment scales as coping strategies and the presence of Somatic Trait Anxiety as a personality trait were associated with a higher frequency of nightmares after correction for gender. In contrast, persons seeking Emotional Support as a coping strategy reported significantly fewer nightmares. Certain personality traits and coping strategies apparently increase the risk of having nightmares after a severe burn. Helping persons at risk develop different coping strategies may be a possible means of prevention or treatment.

To test the hypothesis that muscle protein synthesis (MPS) is regulated by the concentration of extracellular amino acids, we investigated the dose-response relationship between the rate of human MPS and the concentrations of blood and intramuscular amino acids. We increased blood mixed amino acid concentrations by up to 240 % above basal levels by infusion of mixed amino acids (Aminosyn 15, 44-261 mg kg−1 h−1) in 21 healthy subjects, (11 men 10 women, aged 29 ± 2 years) and measured the rate of incorporation of D5-phenylalanine or D3-leucine into muscle protein and blood and intramuscular amino acid concentrations. The relationship between the fold increase in MPS and blood essential amino acid concentration ([EAA], mM) was hyperbolic and fitted the equation MPS = (2.68 × [EAA])/(1.51 + [EAA]) (P < 0.01). The pattern of stimulation of myofibrillar, sarcoplasmic and mitochondrial protein was similar. There was no clear relationship between the rate of MPS and the concentration of intramuscular EAAs; indeed, when MPS was increasing most rapidly, the concentration of intramuscular EAAs was below basal levels. We conclude that the rates of synthesis of all classes of muscle proteins are acutely regulated by the blood [EAA] over their normal diurnal range, but become saturated at high concentrations. We propose that the stimulation of protein synthesis depends on the sensing of the concentration of extracellular, rather than intramuscular EAAs.

Delays in growth are commonly observed in children who have sustained a severe cutaneous burn. The reasons for this growth delay are not completely known, but in adults, plasma growth hormone (GH) levels have been shown to decrease after thermal injury. If this is also the case in severely burned children, the low GH levels may contribute to their chronic growth delay. We propose that treatment with rhGH may prevent this burn-induced growth delay. Height velocities were measured for up to 2 years after injury in 38 burned children (age 7+/-1 years) with a 64+/-2% total burn surface area (TBSA) burn and a 59+/-3% third-degree burn who received 0.2 mg/kg/day rhGH during hospitalization. These height velocities were compared to 41 burned children (age 8+/-1 years) with a 64+/-3% TBSA burn and a 60+/-3% TBSA third-degree burn who were treated similarly but did not receive rhGH. Height velocities and height percentiles were compared to standard height velocity and percentile nomograms of unburned children. To determine the effect of rhGH on energy requirements, resting energy expenditures (REE) were measured by indirect calorimetry and compared to values calculated from the Harris-Benedict equation. All data are presented as mean+/-S.E.M. No differences in average height percentile could be shown between those receiving GH and controls at admission and 6 months after burn. There was, however, a significant difference (P

The correction of soft-tissue defects presents a challenge in plastic and reconstructive surgery. The implantation of isolated and culture-expanded adipose precursor cells is a solution to this problem because these cells differentiate into adipocytes when implanted in vivo. Appropriate scaffolds are needed in soft-tissue engineering to allow the differentiation of precursor cells. The optimal carrier needs to be defined. In this study, human preadipocytes were isolated and cultured. Three different carrier materials were seeded with 106 preadipocytes each and implanted in 42 nude mice. Sponges and nonwoven carriers based on hyaluronic acid modified by esterification (HYAFF 11) were compared with collagen sponges. Scaffolds without cells served as negative controls in the same animal. After 3 and 8 weeks, the grafts were explanted. Macroscopic appearance, weight, thickness, microscopy, immunohistochemistry, and TEM (scaffold structure, cellularity, penetration depth of the seeded cells, vascularization) were assessed and evaluated for differences in scaffold-cell interactions.Preadipocytes differentiated earlier in vitro when attached to HYAFF 11 scaffolds than to other carrier materials. Macroscopically, all preadipocyte constructs were yellowish and well vascularized, and the controls were white and avascular. Vessel formation was more pronounced around mature adipocytes. Microscopically, HYAFF 11 constructs showed a higher cell density than collagen constructs. The pores of the sponges contained more differentiated adipocytes than the nonwoven carriers, whereas the undifferentiated preadipocytes were more numerous in the nonwoven material. Penetration of adipose precursor cells was deeper and more homogeneous in HYAFF 11 scaffolds. Electron microscopy demonstrated well-differentiated adipocytes and large amounts of extracellular matrix in HYAFF 11 sponges.HYAFF 11 sponges supported the expansion and differentiation of the adipose precursor cells. This carrier is superior to the nonwoven carrier with regard to adipocyte differentiation and superior to the collagen sponge with regard to cellularity. This is a promising method for the reconstruction of soft-tissue defects. Modifications of the scaffold (larger pore size and coating with adipogenic factors) will be examined in further experiments.

Children with severe burns benefit from acute therapy with recombinant human growth hormone by maintaining their original stature after injury. This effect is particularly apparent in children injured outside growth-spurt years.