Mortality estimates in the elderly burn patients: the Northern Ireland experience.

There is a relative paucity of mortality data in the medical literature from UK burn units. The objective of this study was to audit our mortality in the elderly during a 10-year period and compare it with the most robust data available in the UK from Birmingham. Data were collected on all patients 65 years of age and older between 1st January 1996 and 31st December 2005. Data included age, burn size, cause of thermal injury, outcome (survival/death) and the expected mortality derived from the revised Bull mortality grid. Notes on 143 patients were available for review. The mean age was 76.7 years and the maximum burn size treated was 65%. Ten patients were diagnosed with smoke inhalation. All but 22 patients had a pre-morbid condition, predominantly cardiovascular disease. Surgical procedures were performed on 113 patients. We performed excision and grafting of burned tissue, in 50% of patients, within 72 h of sustaining thermal injury. There were 18 deaths in the group while the expected number of deaths was estimated to be 33. This difference was found to be statistically significant (x(2)=8.92, d.f.=1, p<0.005). In conclusion, our experience has shown better survival in the elderly than was expected. This we mainly attribute to an aggressive therapy approach including admission to the intensive care unit and early surgery.

Island flap reconstruction of the web space in congenital incomplete syndactyly.

A number of techniques have been described for the correction of incomplete syndactyly, some of which may produce obvious dorsal scarring of the fingers or hand while others rely on the use of skin grafts. Many of the methods require complex planning. We present our experience of a new technique which simplifies the operative planning, allows a natural looking web space to be reconstructed with minimal dorsal scarring and should minimize the need for skin grafts. Seven patients (nine webs) who underwent correction of incomplete syndactyly were reviewed (follow-up range, 6-32 months). Only one patient early on in the series required a small skin graft to cover a residual defect, following which modifications to the flap design were made. All the web spaces healed without complication and at review there were good functional and aesthetic results.

Potential of microemulsion electrokinetic chromatography for the separation of priority endocrine disrupting compounds.

This work examines the potential of microemulsion electrokinetic chromatography for the separation of several priority endocrine disrupting compounds (EDCs). The optimised microemulsion system comprised 25 mM phosphate buffer pH 2, 80 mM octane, 900 mM butanol, 200 mM sodium dodecyl sulphate and was further modified with 20% propanol. The use of a low pH buffer resulted in the suppression of electroosmotic flow within the capillary. Reversal of the conventional electrode polarity resulted in faster migration of hydrophobic compounds. Test analytes included the octylphenol, nonylphenol and nonylphenol diethoxylate, which are breakdown products of the alkylphenolic detergents. The synthetic oestrogens diethylstilbestrol and ethynyloestradiol were also included in the separation along with the plastic monomer bisphenol-A. Test analytes were selected due to their reported presence in environmental samples namely industrial and domestic wastewater treatment effluents and sludges. Using the optimised method a separation of six EDCs was achieved within 15 min. The optimised method was then applied to the analysis of a spiked wastewater influent sample with UV detection of all six compounds at 214 nm.

Development of comparative methods using gas chromatography-mass spectrometry and capillary electrophoresis for determination of endocrine disrupting chemicals in bio-solids.

Two analytical separation techniques are being investigated for their potential in determining a wide range of endocrine disrupting chemicals (EDCs) in the environment. Capillary electrophoresis (CE) in the micellar mode in conjunction with a cyclodextrin (CD) modifier is shown to have potential for determination of alkylphenol breakdown products. Gas chromatography with mass spectrometric (GC-MS) detection is being utilised for validation of the CE method development and in addition as a separation technique to optimise preconcentration using solid-phase extraction. GC has demonstrated potential for the separation of 26 priority chemicals suspected as being endocrine disrupting compounds. The challenge of the method development process lies in the fact that these compounds are of differing polarities, size and charge and therefore are difficult to separate in a single run. Capillary electrophoresis in the CD-MEKC (micellar electrokinetic chromatography) mode is showing potential in this regard. Limits of determination are in the low mg/l range for CE and GC, however, using preconcentration it is possible to improve detection sensitivity with >80% recovery for some analytes and up to 100% recovery for most target species.

Upper root brachial plexus trauma; patient selection and reconstruction.

Injury to the brachial plexus is increasingly common and the initial management of these patients is usually focused on associated life threatening injuries. Appreciation of the management of the brachial plexus injury can greatly assist with subsequent reconstruction and thus we review our experience in this field. A total of nine patients who underwent upper root brachial plexus reconstruction over the period 1980-1998 were reviewed. Causes of injury included road traffic accidents (n=6), open injuries (n=2) and the remaining case was iatrogenic. All patients had cabled grafting of the plexus while one patient had neurotization of the plexus in addition to grafting. Sixty six percent (n=6/9) of patients had a good outcome with return of elbow flexion. Patients with an open injury to the plexus had a better prognosis than those who had a closed injury. Polytrauma patients and those with penetrating neck injuries should be assessed to exclude brachial plexus injury. Baseline assessment and early involvement of surgeons with an interest in this area will help select those patients who will benefit from brachial plexus reconstruction.

Carbon paste-based electrochemical detectors for microchip capillary electrophoresis/electrochemistry.

The first reported use of a carbon paste electrochemical detector for microchip capillary electrophoresis (CE) is described. Poly(dimethylsiloxane) (PDMS)-based microchip CE devices were constructed by reversibly sealing a PDMS layer containing separation and injection channels to a separate PDMS layer that contained carbon paste working electrodes. End-channel amperometric detection with a single electrode was used to detect amino acids derivatized with naphthalene dicarboxaldehyde. Two electrodes were placed in series for dual electrode detection. This approach was demonstrated for the detection of copper(II) peptide complexes. A major advantage of carbon paste is that catalysts can be easily incorporated into the electrode. Carbon paste that was chemically modified with cobalt phthalocyanine was used for the detection of thiols following a CE separation. These devices illustrate the potential for an easily constructed microchip CE system with a carbon-based detector that exhibits adjustable selectivity.

Separation of two groups of oestrogen mimicking compounds using micellar electrokinetic chromatography.

Two groups of compounds are being investigated due to their reported oestrogen mimicking characteristics in the environment. Separation of phenolic compounds and synthetic oestrogens using micellar electrokinetic chromatography is reported. Photodiode array detection is used for both separations. A standard separation buffer can be used for both groups of compounds including zwitterionic buffer cyclohexylamino-1-propanesulfonic acid, 20 mM at pH 11.5. It was found necessary to include 15% acetonitrile and 25 mM sodium dodecyl sulfate to aid separation and maintain analytes in solution. Optimum separations are achieved using 20 kV with hydrodynamic injection for 5 s. The relative standard deviation (RSD) for reproducibility was investigated for a mixture of phenols and synthetic oestrogens. For these compounds RSD was found to be <0.6% in all cases. Peak efficiencies ranged from 76,000 to 150,000 theoretical plates for different analytes. Application to environmental samples is discussed.

Stroke patients' views on stroke outcomes: death versus disability.

AIMS: To determine how elderly stroke patients perceive different stroke outcomes, including death, relative to each other and how these views compare with those of age/sex-matched controls. PARTICIPANTS AND SETTING: Twenty-eight elderly patients discharged from hospital with an acute stroke causing hemiplegia. Twenty-eight age/sex-matched control patients from the same hospital who had never had a stroke or transient ischaemic attack. METHODS: Patients and controls were asked to rank 11 clinical scenarios of potential stroke outcomes, from the most to the least desirable outcome. RESULTS: There was a striking bimodal distribution for sudden painless death in both groups. Painless death was preferred to even a minor stroke disability in over one-third of elderly individuals, whilst 20% would prefer severe disability rather than painless death. Sixty-nine per cent of stroke patients and 82% of controls ranked death as preferable to severe disability. Stroke patients may be more tolerant of disability (compared to death) than their controls (39% patients and 61% controls preferred death to any disability, p = 0.11). CONCLUSIONS: Our results suggest that many elderly individuals would rather die than be alive and severely disabled. This may have important implications for acute stroke treatments such as thrombolysis.

Complications of long operations: a prospective study of morbidity associated with prolonged operative time (> 6 h).

Reconstructive surgical procedures often take a long time to perform and duration of surgery is frequently cited as a major risk factor for postoperative complications. Whether operative time is an independent risk factor is unknown, as patients undergoing long operations may have numerous other risk factors. From September 1996 to September 1997, we prospectively assessed those patients undergoing reconstructive surgery lasting 6 h or more. A total of 62 patients were studied and they were grouped into three categories: head and neck surgery (n = 23), breast reconstruction (n = 18) and upper and lower limb surgery (n = 21). Postoperative complications were recorded and the results of each group compared. Each of the three patient categories had a similar mean duration of surgery but there were large differences in postoperative morbidity between the three groups, e.g. within the head and neck group postoperative respiratory and wound complications occurred in 43% and 26% of patients, respectively. In the limb surgery group, however, only 5% of patients had respiratory complications and 5% had wound complications. Despite having similar duration of surgery the differences in postoperative complications between the three groups suggest that duration of surgery alone is not a major determinant of postoperative morbidity and that the type of surgery performed and the patient's general health are more important predictors of outcome.

Firework related injury and legislation: the epidemiology of firework injuries and the effect of legislation in Northern Ireland.

The efficacy of legislation in reducing firework associated injuries is uncertain as is the nature of the problem within the United Kingdom (UK). In September 1996 the legislation governing firework sale in Northern Ireland was relaxed thus equalling that of the rest of the UK. For the 2 years following the change in legislation we prospectively assessed those patients who were admitted with a firework injury over the Halloween period. We then compared these results with retrospective data for the 3 years prior to the change in firework law. In the pre-legislation series the mean number of patients admitted annually was 0.38 per 100,000 while in the post-legislation series the mean was 0.43 per 100,000. Blast injury to the hand was the commonest injury accounting for 53% of cases in both series. Burn injuries were the second commonest form of injury comprising 30% of all admissions. Of those admitted with a hand injury 47% had at least one finger terminalised and nearly half of those patients admitted with burns (44%) required skin grafting. We conclude that early evidence suggests that liberalisation of the law on firework sale has not resulted in a significant increase in firework related injuries requiring hospital admission.

Drug induced blistering and the plastic surgeon: a case of amitriptyline induced skin necrosis.

We report a case of patchy full thickness skin necrosis following drug overdose with amitriptyline, that required excision and split skin grafting. To our knowledge this is the first report of amitriptyline induced skin necrosis that can be definitively attributed to this drug. The implications of drug related skin necrosis for the surgeon are discussed.

Renal dysfunction in obstructive jaundice.

The association between renal dysfunction and obstructive jaundice is well established. Despite a substantial number of clinical reviews and prospective studies, the exact incidence and extent of the problem has not been determined accurately. Various pathogenic mechanisms and therapeutic strategies have been proposed but renal dysfunction remains a persistent problem in hepatobiliary practice. The intention of this review is to determine the current extent of the problem, outline the proposed pathophysiological mechanisms and assess the current therapeutic options.

A study of the prevalence of male intrameatal warts using meatoscopy in a genitourinary medicine department.

A cross-sectional study is undertaken to determine the prevalence of male intrameatal and distal urethral warts, using meatoscopy. A group of 169 patients presenting for anogenital warts and a group of 74 unselected patients attending the Department for a variety of reasons during the study period, were examined. Twenty-one patients (13.5%) out of 155 patients with anogenital or related warts had external warts at the meatus. Of these 21 cases, 12 (57.1%) had further extension of their warts into the distal urethra. Fifteen other cases of intrameatal and distal urethral warts were detected in the absence of external warts at the meatus. Twenty-three cases out of 107 males with genital warts (21.5%) were found to have intrameatal or distal urethral warts, thus reflecting the common occurrence of these lesions. A highly significant association between the presence of intrameatal/distal urethral warts and the presence of male genital warts was found (P = 0.003). One hundred and fifty-three repeat meatoscopic examinations were carried out, 6 weeks after their first examination. Three new cases of intrameatal/distal urethral warts were found. Intrameatal and distal urethral warts occurred from a depth of 5 mm to 25 mm. One hundred and eighty-three female partners of the study patients were examined. An association between the presence of intrameatal/distal urethral warts and female anogenital warts was found (P = 0.028). No corroborating association between the presence of male and female anogenital warts was found (P = 0.47). This observation may have a bearing on disease transmission and control. The detection of intrameatal/distal urethral warts will be important in achieving successful treatment of male anogenital warts.

The value of primary colposcopy in genitourinary medicine--a six year review.

OBJECTIVE: To evaluate the effectiveness of primary colposcopy in the genitourinary medicine setting by comparing the cervical cytology and punch biopsy results for women identified as having an abnormal cervical transformation zone. METHOD: A retrospective audit of six years' findings in primary colposcopy was carried out. The punch biopsy findings of 1338 women were compared with their last cervical cytology results. A small sample of biopsies were subjected to in situ hybridisation for human papilloma virus types 6, 11, 16, 18 and cytomegalovirus. RESULTS: The tabulated results demonstrated the variability between histology and cytology. This was explored with reference to other studies. The viral typing showed the dominance of low oncogenic risk human papilloma virus types. CONCLUSION: The findings are discussed against the overall concept of sexual health. Primary colposcopy facilitates empowerment of the patient and her partner through the opportunity for demonstration and explanation of disease processes and options for management. Experience and expertise gathered in six years of primary colposcopy confirm the value of primary colposcopy not only in improved diagnosis and management but also in teaching, audit and research.

Isolation and ex vivo expansion of CD34+ cells from cord blood using dextran sedimentation and avidin column selection.

Human umbilical cord bloods were fractionated by unit gravity sedimentation in 1% (v/v) dextran, followed by immunoaffinity selection for CD34+ stem and progenitor cells. Dextran sedimentation alone enabled recovery of more than 80% of the nucleated cells present and 90% of the CD34+ cells, as determined by flow cytometry. The addition of an immunoaffinity selection step for CD34+ cells resulted in a 134-fold enrichment for CD34+ cells, with a mean yield of 64 +/- 15%. The resultant CD34+ population contained almost half the CFU-GM activity initially present in the cord bloods and could be expanded ex vivo in liquid culture.