Mucocutaneous Injuries Research Articles

Acceptance and Tolerability of Helmet CPAP in Pediatric Bronchiolitis and Pneumonia: A Feasibility Study

AbstractContinuous positive airway pressure (CPAP) is a form of noninvasive ventilation used to support pediatric patients with acute respiratory infections. Traditional CPAP interfaces have been associated with inadequate seal, mucocutaneous injury, and aerosolization of infectious particles. The helmet interface may be advantageous given its ability to create a complete seal, avoid skin breakdown, and decrease aerosolization of viruses. We aim to measure tolerability and safety in a pediatric population in the United States and ascertain feedback from parents and health care providers. We performed a prospective, open-label, single-armed feasibility study to assess tolerability and safety of helmet CPAP. Pediatric patients 1 month to 5 years of age admitted to the pediatric intensive care unit with pulmonary infections who were on CPAP for at least 2 hours were eligible. The primary outcome was percentage of patients tolerating helmet CPAP for 4 hours. Secondary measures included the rate of adverse events and change in vital signs. Qualitative feedback was obtained from families, nurses, and respiratory therapists. Five patients were enrolled and 100% tolerated helmet CPAP the full 4-hour study period. No adverse events or significant vital sign changes were observed. All family members preferred to continue the helmet interface, nursing staff noted it made cares easier, and respiratory therapists felt the set up was easy. Helmet CPAP in pediatric patients is well-tolerated, safe, and accepted by medical staff and families in the United States future randomized controlled trials measuring its effectiveness compared with traditional CPAP interfaces are needed.

Underreporting of work accidents associated with blood-borne risk factors.

Work accidents (WA) due to percutaneous or mucocutaneous injury are extremely frequent among health professionals. The notification of these accidents ensures not only the compliance with legal requirements, but it also enables health institutions to develop, implement and evaluate strategies to prevent them. This study aimed to estimate the proportion of underreporting of work accidents caused by percutaneous and mucocutaneous lesions in a hospital setting, as well as its determinants. A self-administered questionnaire was made available to all hospital employees. Age, gender, professional category and type of service adjusted odds ratios (OR) and 95% confidence intervals (95%CI) were computed by multivariate logistic regression models. Underreporting of WA associated with biological risk factors was high, particularly in accidents by mucocutaneous injury (80.9%). Physicians were the professional category that least reported this type of work accidents (OR=4.64; 95%CI 2.20-9.78). The main determinants of underreporting were the underestimation of the risk of transmission and the excessive bureaucracy. The underreporting of work accidents associated with biological risk factors was considerable and it contributes to a high degree of uncertainty on accidents' characterization.

Occult Injury Screening Among Infants With Subconjunctival Hemorrhage.

To assess the frequency and nature of occult injury screening in infants with subconjunctival hemorrhages (SCH), the incidence of occult injuries in these children, and the factors that may have influenced the decision to screen for additional injury. Infants aged 14 days to 6 months with SCH who presented to two tertiary pediatric centers were identified from a local database (N = 84). A retrospective chart review collected demographics, examination findings, and imaging results. Infants were further stratified into two groups depending on the presence of additional mucocutaneous injuries. The groups were compared with two-sample t testing. Skeletal surveys were completed in 31% of patients overall, but the rate of screening was significantly higher among patients who presented with SCH and additional mucocutaneous injuries as opposed to SCH alone. However, the presence of additional mucocutaneous injuries was not associated with an increased risk for positive skeletal survey. Rates of occult injury screening among infants with SCH were low and were significantly influenced by the presence of additional injuries. When screening was conducted, occult injuries were commonly identified. Future studies should assess the true prevalence of abuse in this population. [J Pediatr Ophthalmol Strabismus. 2021;58(4):213-217.].

Time Trends of Percutaneous Injuries in Hospital Nurses: Evidence of the Interference between Effects of Adoption of Safety Devices and Organizational Factors.

Few studies have focused on the combined effects of devices and work organization on needlestick injuries trends. The aim of the study was to estimate trends of percutaneous injury rates (IR) in nurses (N) and nurse assistants (NA) over a 10 year period, in which passive safety devices were progressively adopted. Percutaneous and mucocutaneous injuries registered in a University Hospital in Northern Italy in Ns and NAs in 2007–2016 were analyzed. Organizational data were also available on shift schedules, turnover, downsizing and age- and skill-mix. We estimated IRs per 100 full-time equivalent workers from Poisson models and their average annual percent changes (APC) from joinpoint regression model. In the entire period, monotonic decreases in percutaneous IRs occurred among day-shift Ns (APC = −20.9%; 95% CI: −29.8%, −12%) and NAs (APC = −15.4%; −32.9%, 2.2%). Joinpoint modeling revealed a turning point in 2012 for night-shift Ns, with a steady decline in 2007–2012 (APC = −19.4%; −27.9%, −10.9%), and an increase thereafter (APC = +13.5%; 1.5%, 25.5%). In comparison to 2008 and 2012, in 2016 night-shift Ns were 5.9 and 2.5 times more likely to be younger and less qualified or experienced than day-shift Ns. The observed declines in percutaneous injury rates occurred in a time period when safety devices were progressively implemented. The causal nature of multiple exposures and organizational procedures in affecting injury time trends should be further addressed by quasi-experimental studies.

IFN-γ–Stimulated Apoptotic Keratinocytes Promote Sclerodermatous Changes in Chronic Graft-Versus-Host Disease

Patients with graft-versus-host disease (GVHD) develop characteristic mucocutaneous phenomena consisting of erosive erythema with histopathological findings including interface dermatitis and keratinocyte (KC) death, resulting in widespread sclerodermatous changes. We found that KCs exhibit marked production of TGFβ1 in skin lesions of chronic GVHD but not in those of acute GVHD. To further investigate the roles of KCs, the main targets of donor T cells, in sclerodermatous changes followed by interface dermatitis, we established a murine model of chronic GVHD-like sclerodermatous changes followed by acute GVHD-like mucocutaneous injury in genetically modified mice transferred with KC-specific CD8 T cells. Although transfer of granzyme B-deficient CD8 T cells did not result in either mucocutaneous injury or sclerodermatous changes in recipients, IFN-γ-deficient CD8 T-cell recipients developed severe acute mucocutaneous injury but milder sclerodermatous changes than wild-type CD8 T-cell recipients. Moreover, IFN-γ-deficient CD8 T-cell recipients had a lower expression of TGFβ1 in the epidermis than the control. Murine primary KCs undergoing FasL-induced apoptosis and incubated with IFN-γ produced TGFβ1, the production of which was inhibited by a pan-caspase inhibitor. Our results indicate that IFN-γ promotes TGFβ1 production by apoptotic KCs, which mediates the development of widespread sclerodermatous changes in KC-targeting GVHD.

Current Recommendations on the Workup and Post-exposure Prophylaxis for HIV, HBV, and HCV in Healthcare Workers

Hepatitis B, hepatitis C, and HIV are the most commonly acquired infections related to occupational exposure in the health care setting. Measures to reduce the risk of transmission in health care workers (HCW) include primary prevention and post-exposure prophylaxis (PEP). Primary prevention essentially includes the adoption of standard precautions to avoid percutaneous or mucocutaneous injuries and hepatitis B vaccination. PEP varies according to both the source patient and HCW serologic status. So far PEP is not approved for hepatitis C. The post-exposure management for hepatitis B will depend on the vaccination and immune status of the HCW. Immune HCW do not need prophylaxis. For non-immune HCW, prophylaxis includes hepatitis B vaccination and immune globulin within 7 days of the exposure. HIV-exposed HCW should initiate prophylaxis as soon as possible, using three drugs regardless of the type of exposure risk. New regimens including integrase inhibitors and protease inhibitors have improved HCW adherence to PEP. Timely reporting any exposure remains a challenge and is a priority for an adequate work up and management. HCW frequently do not recognize high-risk exposures and do not seek post exposure prophylactic management. Multidisciplinary efforts are still needed to improve HCW awareness and adherence to PEP.

Seroconversion rate among health care workers exposed to HIV-contaminated body fluids: The University of Pittsburgh 13-year experience

The studies enumerating the risk of HIV transmission to health care workers (HCWs) as 0.3% after percutaneous exposure to HIV-positive blood, and 0.09% after a mucous membrane exposure, are weakened by dated literature. Our study aims to demonstrate the seroconversion rate after exposure to HIV-contaminated body fluids in a major academic center in the United States. A prospectively maintained database of reported occupational injuries occurring between 2002 and 2015 at an academic medical center was analyzed. Data collected included the type of injury, injured body part, type of fluid, contamination of sharps, involvement of resident physicians, use of postexposure prophylaxis, and patients' HIV, hepatitis B virus, and hepatitis C virus status. A total of 266 cases were included in the study. Most exposures were caused by percutaneous injuries (52.6%), followed by 43.2% mucocutaneous injuries. Of the injuries, 52.6% were to the hand and 33.5% to the face and neck. Blood exposure accounted for 64.3% of all cases. Of the patients, 21.1% received postexposure prophylaxis. None of the HCWs exposed to HIV-contaminated body fluids seroconverted (seroconversion rate, 0%). HIV does not seem to be as easily transmitted by needlestick, laceration, or splash injuries as previously surmised. Further large-scale and multicenter studies are needed for a more accurate estimation of the risk of transmission of HIV in U.S. health care workers.

Seroconversion rates among health care workers exposed to hepatitis C virus–contaminated body fluids: The University of Pittsburgh 13-year experience

Hepatitis C virus (HCV) transmission to health care personnel (HCP) after exposure to a HCV-positive source has been reported to occur at an average rate of 1.8% (range, 0%-10%). We aimed to determine the seroconversion rate after exposure to HCV-contaminated body fluid in a major U.S. academic medical center. A longitudinal analysis of a prospectively maintained database of reported occupational injuries occurring between 2002 and 2015 at the University of Pittsburgh Medical Center was performed. Data collected include type of injury and fluid, injured body part, contamination of sharps, resident physicians' involvement, and patients' hepatitis B virus (HBV), HCV, and HIV status. A total of 1,361 cases were included in the study. Most exposures were caused by percutaneous injuries (65.0%), followed by mucocutaneous injuries (33.7%). Most (63.3%) were injuries to the hand, followed by the face and neck (27.6%). Blood exposure accounted for 72.7%, and blood-containing saliva accounted for 3.4%. A total of 6.9% and 3.7% of source patients were coinfected with HIV and HBV, respectively. The HCV seroconversion rate was 0.1% (n = 2) because of blood exposure secondary to percutaneous injuries. This study provides the largest and most recent cohort from a major U.S. academic medical center. The seroconversion rates among HCP exposed to HCV-contaminated body fluids was found to be lower than most of the data found in the literature.

Blockade of perforin prevents mucocutaneous injury in a murine model of interface dermatitis

Blockade of perforin prevents mucocutaneous injury in a murine model of interface dermatitis

Abstract: Seroconversion Rates Among Healthcare Workers Exposed to Human Immunodeficiency Virus and Hepatitis C-Contaminated Body Fluids: The University of Pittsburgh Experience

BACKGROUND: Human Immunodeficiency Virus (HIV) and hepatitis C virus (HCV) transmission to healthcare personnel (HCP) following percutaneous exposure to the blood of a source patient, has been reported to occur at an average rate of 0.3% (0.2–0.5%) 1 and 1.8% (range 0–10%),1,2 respectively. Most of this data is either outdated or was from predominantly non-US centers. We aimed to determine the seroconversion rate after exposure to HIV or HCV-contaminated body fluid at a major academic medical center in the US. METHODS: A longitudinal analysis of a prospectively maintained database of reported occupational injuries occurring between 2002 and 2015 at the University of Pittsburgh Medical Center was performed. Inclusion criteria included HCP who sustained needlestick, laceration, or splash injuries from known HIV or HCV-positive patients. Exclusion criteria included missing data (on the type of injury and fluids), and a positive HIV or HCV status of the HCP. Data collected included the type of injury, injured body part, type of fluid, contamination of sharps, and patients’ HIV and HCV status. Univariate and bivariate statistical analyses were performed using SPSS statistical software (version 19.0; SPSS Inc., Chicago, IL, USA). RESULTS: 1,627 cases (HIV=266, HCV=1,361) were included in the study. The majority of the cases were due to percutaneous injuries (HIV=52.6%, HCV=65.0%) as opposed to mucocutaneous injuries (HIV=43.2%, HCV=33.7%), and the majority of injuries occurred in the hand (HIV=52.6%, HCV=63.3%). Blood exposure accounted for 64.3% (HIV) and 72.7% (HCV) of cases, saliva for 5.6% (HIV) and 3.4% (HCV), and other fluids for 13.6% (HIV) and 11% (HCV). The seroconversion rate was calculated at 0% after a mucocutaneous exposure to either HIV- or HCV-contaminated body fluid, but was 0% (n=0) for HIV and 0.2% (n=2) for HCV, after a percutaneous exposure. The two seroconverted cases were secondary to blood exposure via percutaneous injuries. CONCLUSION: This study provides the most recent data from a major US academic medical center. The seroconversion rates among HCP exposed to HIV and HCV-contaminated body fluids (0% and 0.2% respectively), were found to be lower than most of the data found in the literature. HIV and HCV do not seem to be easily transmitted by needlestick, laceration, or splash injuries. However, further large-scale studies are needed for a more accurate estimation of the risk of transmission. DISCLOSURE:The authors have no financial interest to declare in relation to the content of this article. REFERENCES: 1. CDC. Updated U.S. Public Health Service guidelines for the management of occupational exposures to HBV, HCV, and HIV and recommendations for postexposure prophylaxis. MMWR 2001;50 (No. RR-11):1–52. 2. Mitsui T, Iwano K, Masuko K, Yamazaki C, Okamoto H, Tsuda F, Tanaka T, et al. Hepatitis C virus infection in medical personnel after needlestick accident. HEPATOLOGY 1992;16:1109–1114.

Cuidados de enfermagem ao paciente adulto: prevenção de lesões cutaneomucosas e segurança do paciente

Aim: to identify nursing care for skin and mucosal lesions prevention in hospitalized adult patients and possible difficulties encountered by professionals to promote these actions. Method: A descriptive, exploratory qualitative study conducted in 2014 with interview of 118 active nurses in clinical and surgical inpatient units, intensive care unit and emergency room of a hospital in Southern Brazil. Results: three categories emerged: the meaning of patient safety; patient safety and the prevention of mucocutaneous injuries; the difficulties to promote patient safety and prevention of skin and mucosal lesions. Conclusions: the care provided for the prevention of skin and mucosal lesions mostly agree with what the literature recommends. However, patient safety meaning is limited to preventing tumbles and pressure ulcers

Ehlers-Danlos syndrome(s) mimicking child abuse: Is there an impact on clinical practice?

Ehlers-Danlos syndrome is a heterogeneous group of heritable connective tissue disorders characterized by increased fragility of various non-ossified tissues. It is usually ascertained due to abnormal skin texture, scarring complications, vascular fragility, or chronic symptoms, such as fatigue and musculoskeletal pain. Sometimes, Ehlers-Danlos syndrome remains undetected until the patient, usually in the pediatric age, shows extensive or severe mucocutaneous injuries after only minor traumas. In this scenario, the misdiagnosis of Ehlers-Danlos syndrome with child abuse is a possibility, as occasionally reported in the literature. Recently, more attention was posed by lay people between the possible association of Ehlers-Danlos syndrome and bone fragility. Literature and personal experience show a strong association between Ehlers-Danlos syndrome, generalized joint hypermobility and reduced bone mass density in older children and adults, especially fertile women. The existence of a true increased risk of fracture in Ehlers-Danlos syndrome is still a matter of debate in children and adults with little and conflicting evidence. In case of suspected child abuse, Ehlers-Danlos syndrome is certainly on the differential for bruising, especially in EDS types with marked cutaneous and capillary involvement. In suspected child abuse cases, careful examination of the index case and her/his extended family is routine, as well as exclusion of other disorders such as osteogenesis imperfecta. The hypothesis of Ehlers-Danlos syndrome as an alternative explanation for infantile fractures remains speculative.

The systems approach to error reduction: factors influencing inoculation injury reporting in the operating theatre

To examine the frequency of, and factors influencing, reporting of mucocutaneous and percutaneous injuries in operating theatres. Surgeons and peri-operative nurses risk acquiring blood-borne viral infections during surgical procedures. Appropriate first-aid and prophylactic treatment after an injury can significantly reduce the risk of infection. However, studies indicate that injuries often go unreported. The 'systems approach' to error reduction relies on reporting incidents and near misses. Failure to report will compromise safety. A postal survey of all surgeons and peri-operative nurses engaged in exposure prone procedures in nine Welsh hospitals, face-to-face interviews with selected participants and telephone interviews with Infection Control Nurses. The response rate was 51.47% (315/612). Most respondents reported one or more percutaneous (183/315, 58.1%) and/or mucocutaneous injuries (68/315, 21.6%) in the 5 years preceding the study. Only 54.9% (112/204) reported every injury. Surgeons were poorer at reporting: 70/133 (52.6%) reported all or >50% of their injuries compared with 65/71 nurses (91.5%). Injuries are frequently under-reported, possibly compromising safety in operating theatres. A significant number of inoculation injuries are not reported. Factors influencing under-reporting were identified. This knowledge can assist managers in improving reporting and encouraging a robust safety culture within operating departments.

Prescribing practices in a population-based HIV postexposure prophylaxis program.

To characterize factors associated with being prescribed triple or double postexposure prophylaxis (PEP) against HIV in a population-based program. Individuals potentially exposed to HIV received a 5 day starter kit of either double or triple antiretroviral PEP between April 1999 and November 2000 and did/did not receive the remaining 23 days PEP. Data were collected through dispensation of kits. Logistic regression identified characteristics independently associated with being prescribed triple therapy starter kits and with any 23 day follow-up. Of 2064 people receiving 5 day PEP [403 (20%) triple and 1661 (80%) double], 590 (29%) received 23 day follow-up. Independently associated with being prescribed triple therapy starter kits were being male [adjusted odds ratio (AOR) 1.38; 95% confidence interval (CI) 1.10-1.74; P = 0.006), occupational mucocutaneous injuries (AOR 1.70; 95% CI, 1.14-2.55; P = 0.010), and community needlesticks (AOR 2.04; 95% CI, 1.54-2.69; P < 0.001). Independently associated with being prescribed the 23 day follow-up were being male (AOR 1.24; 95% CI, 1.00-1.53; P = 0.04), community mucocutaneous incidents (AOR 2.83; 95% CI, 1.41-5.70; P = 0.004), community needlesticks (AOR 1.75; 95% CI, 1.33-2.29; P < 0.001), and having received triple therapy as the starter kit (AOR 2.61; 95% CI, 2.07-3.29; P < 0.001). Being prescribed triple therapy starter PEP was associated with being male and with experiencing an occupational mucocutaneous or community needlestick injury. Receiving the remaining 23 days PEP was associated with being male, experiencing a community mucocutaneous or needlestick injury, and triple therapy as the initial 5 day starter PEP.

A survey of percutaneous/mucocutaneous injury reporting in a public teaching hospital

Our objective was to determine if healthcare workers were reporting all percutaneous and/or mucocutaneous injuries and to use such data to formulate appropriate interventions. The Infection Control Department distributed anonymous surveys of healthcare personnel between 1992 and 1995. The elicited information included the number of percutaneous and mucocutaneous injuries experienced and reported in the last five years and the reasons for not reporting every exposure when applicable. Five hundred and forty nine surveys were received, from physicians, dentists, registered nurses, licensed vocational nurses, nurses aides, and operating room technicians. Overall, of the 549 respondents, 45% (245) had no injuries, 30% (163) had been injured and had reported all injuries, and 26% (141) had not reported all injuries. Reasons for not reporting included sterile/clean needlestick (39%), little or no perception of risk to employee (26%), too busy (9%), and dissatisfaction with follow-up procedures (8%). Reasons stated for not reporting injuries indicate a need for continued education in the risk of acquiring blood-borne pathogens from such injuries. The results also illustrate the importance of targeting prevention efforts to specific groups, such as physicians, that would not be identified by routine reporting mechanisms.