The effect of the acute inflammatory response of burns and its treatment on clot characteristics and quality: A prospective case controlled study.

INTRODUCTION: Burns are known to have an effect on coagulation in the early period after burn. Current coagulation tests have been criticised in acute burns due to their inherent limitations. This study aims to investigate the potential for a new quantitative functional biomarker of clot quality, fractal dimension, to identify changes in clot microstructure as a result of the burn inflammatory response and its treatment. METHODS: A total of fifty-eight burn patients were included in this prospective case-controlled study. The control group (29 patients mean TBSA 1%), and case group (29 patients mean TBSA 30%) were compared at baseline and the case group investigated further over four time points (baseline, 12h, 24h and 5-7 days). Fractal analysis was performed, as well as current markers of coagulation, inflammatory markers and point-of-care tests, Thromboelastography and Multiplate analysis. RESULTS: Fractal dimension did not differ between groups at admission (1.73±0.06 and 1.72±0.1), and fell within the healthy index normal range (1.74±0.7), suggesting a normal clot microstructure in the early period after burn. Fractal dimension significantly reduced from baseline over the first 24h following injury (1.59±0.03 p<0.005), indicating a significant reduction in mechanical clot strength and functionality consistent with a hypocoagulable state, not identified with other markers. CONCLUSIONS: This is the first study to quantify the changes in clot microstructure following burn injury. This study confirms clot microstructure is significantly altered during the first 24h after burn, with the production of a weaker, more porous fibrin clot, consistent with a hypocoagulable state.

The impact of socio-economic deprivation on burn injury: A nine-year retrospective study of 6441 patients.

INTRODUCTION: Low socio-economic status is thought to be associated with increased burn risk, however the significance and generalisability across different populations and cultures has been questioned. METHODS: A nine-year retrospective study of burn presentations to a large teaching hospital (2005-2014) was performed to investigate the association between socio-economic status and burns. Demographic and injury data was collected via the trust 'Information portal'. The Welsh Index of Multiple: Deprivation 2011 was used to score for socio-economic status. Chi-squared test and Odds Ratios were calculated and statistical significance defined as p<0.05 throughout. RESULTS: 6441 burns were identified, with 755 (11.7%) admitted. Overall incidence rates were the highest published in the UK (0.35/1000/year) with sub group analysis showing the highest rates in under fives and males. Significant relationships between both age and burn mechanism and gender and burn mechanism (p=0.0005) were identified. Scald (67.1%) was the most common mechanism with the upper limb (48%) most commonly burned. Chi square analysis demonstrated a significant relationship between socio-economic deprivation, age and burn incidence (p≤0.0005), with a disproportionately high number of burns in patients under the age of 16 in the most deprived quintile (OR 1.23; 95% CI 1.06-1.44). CONCLUSION: This study specifically highlights patients under the age of 16 living in poorer socio-economic areas as the most at risk of suffering burns receiving hospital attention. This study demonstrates burns as a significant public health issue, and the results should aid in designing specific burn prevention strategies to target high-risk groups.

Pilot project in rural western Madhya Pradesh, India, to assess the feasibility of using LED and solar-powered lanterns to remove kerosene lamps and related hazards from homes.

BACKGROUND: Globally, 300,000 deaths are estimated to occur annually and the incidence is far greater as a large majority of burns are small and go unreported. Ninety-five percent of the global burden of burns is found in low- and middle-income countries; however, there is relatively little in the literature regarding effective primary prevention in these areas. Flame is the most common cause of burn in Madhya Pradesh, the central state of India. The most common demographic among the burn unit inpatient of Choithram hospital Indore, is young women from 21 to 40 years of age, whose burns are primarily caused by kerosene lamps. A non electrical source of illumination is essential for every household in rural areas due to the infrequent and poor power supply. At the baseline, 23 kerosene lamp burns were reported by villagers in the past 5 years among the study population of this pilot project. METHOD: A pilot project to investigate the strategies for reducing the incidence of domestic burns in rural villages around the city of Indore was performed, by replacing kerosene lamps with safer and more sustainable alternatives, including solar-powered and light-emitting diode (LED) lamps. A total of 1042 households were randomly chosen from 18 villages within the Malwa region of Madhya Pradesh (population of 28,825) to receive the alternative light source (670 LED and 372 solar lamps). We investigated the efficacy of this strategy of reducing the incidence of burns, measured the social acceptance by villagers, and quantified the cost implications and availability of LED lamps in rural communities with a high incidence of burns. RESULTS: Replacing kerosene lamps with LED and solar alternatives was deemed socially acceptable by 99.34% of the participants and reduced the cost of lighting for impoverished rural villagers by 85% over 1 year. We successfully demonstrated a significant decrease in the use of kerosene lamps (p<0.01). More evidence is required to investigate the efficacy of this strategy in reducing burns. CONCLUSION: This pilot study highlights the viability of the approach of replacing kerosene lamps as an effective primary prevention strategy for reducing burns in rural areas. However, barriers remain to the wider adoption of these lamps, including accessibility and availability for the populations of rural India.

Management of open lower limb injuries in South West England and Wales.

INTRODUCTION: The joint British Association of Plastic, Reconstructive and Aesthetic Surgeons/British Orthopaedic Association standards define best practice management in open diaphyseal fractures of the lower limb. The aim of our study was to review the regional approach and experience in South West England and Wales. A further objective was to evaluate service provision with regard to the standards' key recommendations. METHODS: A prospective audit was undertaken of open diaphyseal fracture patients. Compliance with published standards within all orthoplastic services in South West England and Wales was assessed, and facilities were evaluated. RESULTS: A total of 86 patients were managed between October 2012 and March 2013. This was a 56% increase from 2008. Over half (56%) presented directly to the orthoplastic services with all patients undergoing debridement within 24 hours. Two-thirds (66%) of procedures were in daylight hours excluding those requiring immediate surgical intervention. Adherence to correct antibiotic therapy was 88% at admission, 50% at primary surgery and 62% at definitive surgery. Almost two-thirds (60%) of primary procedures were performed with combined senior orthoplastic teams, with 81% achieving definitive soft tissue coverage and fixation within seven days. Compliance improved in units with larger patient caseloads and where there was an early combined approach during daylight hours. CONCLUSIONS: Increased open lower limb fracture workload was demonstrated across South West England and Wales, probably owing to centralisation of trauma services. An improvement in early transfer of this patient group to orthoplastic facilities has allowed all patients to be assessed and debrided within the recommended timeframe. Standards were most likely to be met in those centres seeing higher numbers of injuries and when there was a daylight hours procedure by combined orthoplastic teams.

Scar endometriosis: a rare skin lesion presenting to the plastic surgeon.

Endometriosis is the presence or growth of endometrial tissue outside the uterus, most commonly affecting the ovaries, uterine ligaments and the peritoneum. Cutaneous endometriosis is much rarer, and is mostly found at the sites of surgical scars, such as laparoscopies, hysterectomies and caesarean sections. We present a rare case of scar endometriosis in a 33 year-old women presenting to the plastic surgeon as a possible skin malignancy and review the literature.

The oldest reported mirror hand? The curse of the coal-house frog!

Despite being one of the rarest congenital upper limb abnormalities, a wide spectrum of the typical mirror hand has been described in the literature. We report a very interesting case of a new variant of mirror hand presenting in a 78-year-old man. The unique features of the case include the age at diagnosis, the anatomical features present and the acquired function despite no form of reconstructive surgery.

Outcome after restorative proctocolectomy in children and adolescents.

AIM: The results including function and quality of life (QOL) of restorative proctocolectomy (RPC) performed in children and adolescents with ulcerative colitis (UC), familial adenomatous polyposis (FAP) and idiopathic megarectum were determined. METHOD: Twenty-one patients of a median age of 15 (10-17) years underwent RPC between 1995 and 2006. The indication, use of covering ileostomy, morbidity and mortality were recorded. A structured questionnaire was completed by telephone interview to assess long-term function. The Cleveland Clinic Scoring (CCS) System was used for the assessment of faecal incontinence and the modified McMaster proforma for QoL. RESULTS: There was no mortality. At a median follow-up of 65.5 (26-168) months, all patients had an intact pouch. One had a long-standing ileostomy. Median daytime and nocturnal stool frequencies were 4 (2-16) and 0 (0-3). The mean CCS was 1.47, with only one patient scoring more than 10. Eighteen of 20 patients were satisfied with the result; two patients had a worse QoL (McMaster score >8). One patient had a permanent stoma following pouch sepsis and one had symptoms of pouchitis. CONCLUSION: RPC can be performed in children and adolescents with good functional outcome and acceptable QoL.

[Acceptance of the electronic health card in a field study]. / Akzeptanz der elektronischen Gesundheitskarte im Feldtest.

TARGET: Previous studies have shown that the acceptance of the electronic health card in Germany is higher with the health-insured than with the health-care providers. However, until now there have been no studies looking into the acceptance of real users - only the anticipation of use has been examined . METHODS: In this study 484 health-insured persons and health-care providers with different backgrounds regarding their experience regarding the use of the electronic health card were questioned. Different aspects of acceptance (cognitive, emotional, and conative) were measured. RESULTS: Overall, the health-insured regard the electronic health card more positively than the health-care providers. The conative acceptance in terms of willingness to save health-related information is high in all groups studied: More than 70% of the health-insured want to save information about their blood type, medications, emergency data, allergies/intolerances, vaccination record, as well as diagnoses and illnesses; more than 60% of the health-care providers would advise their patients/customers to have medications, allergies/intolerances, emergency data and vaccination records saved on the electronic health card. CONCLUSION: Although the health-care providers' emotional and cognitive acceptance of the electronic health card is low, they do perceive the saving of specific patient information on it as advantageous and would actively advise their patients/customers to save this information on the electronic health card.

Congenital vascular malformation associated with multiple cranial, vertebral and upper limb skeletal abnormalities.

The association between congenital vascular malformations and altered bone growth, the so-called vascular bone syndrome, is well documented. Various eponymous syndromes each with their individual traits, such as Klippel-Trenaunay, Parkes-Weber and Servelle-Martorell syndrome have been described, along with variations. We report on a previously undescribed case of congenital vascular malformation associated with multiple skeletal abnormalities affecting the skull, vertebrae and right upper limb, and discuss the literature.

Laparoscopic right hemicolectomy for ileocolic intussusception secondary to caecal neoplasm.

Intussusception in adults is a rare cause of abdominal pain. Unlike its paediatric counterpart, intussusception in adults is associated with obvious pathology. We describe a case of ileocolic intussusception extending to the splenic flexure. We were able to reduce the intussusception partially and pedicle was stapled carefully. The specimen was delivered through a small incision and right hemicolectomy was performed adhering to oncological principles. We recommend laparoscopic-assisted surgery is considered for adult intussusceptions.

Red blood cells, phase contrast, interference contrast microscopy and microspectrophotometry.

Following Teorell's (1) observation that the ghosts of hypotonically hemolysed erythrocytes reseal, it was shown that during the time they are permeable to hemoglobin, foreign macromolecules (dextran) can enter and that the hemolysed cell can achieve a final colloid-osmotic equilibrial state containing dextran and some residual Hb. In this way dextran reduces the hemoglobin loss in hypotonic hemolysis. Some hemoglobin loss is, however, inevitable, as it begins with a non-diffusive bulk outflow, sometimes observable as a jet, during which time a diffusive influx of the colloid-osmotic "balancer", dextran, is not possible. Finally, as expected from a process which is for the most part diffusive, transmembrane macromolecular transport is bidirectional; during hemolysis smaller molecules escape to a greater extent than larger ones.

Evaluation by integrated thermography of the beneficial effect of cyclofenil in severe subcutaneous arterial insufficiency.

Integrated thermographic measurements were made in a patient suffering from a complex syndrome which included scleroderma, Osler-Weber-Rendu disease and a marked atherosclerotic circulatory insufficiency. A new anti-estrogenic drug, cyclofenil, elicited a rapid and prolonged curative effect against the entire syndrome. The circulatory amelioration was registered periodically by integrated thermography of the face and both hands. This method enables temperature distribution functions to be calculated and seems to hold considerable promise for the evaluation of circulatory changes and in particular those changes evoked by therapeutic agents.

Jet expulsion of cellular contents from rad cells during photodynamic hemolysis.

When red cells are incubated in the dark in the presence of the dye Rose Bengal and subsequently irradiated with visible light, they hemolyze. Under certain conditions some of the hemoglobin is expelled in the form of a convective jet and appears as a transient cloud beside the cell. Elastic contraction of the membrane is not a sufficient driving force for the jet. A plausible mechanism (an osmotic "pump") is presented.

On how macromolecules reduce hemoglobin loss in hypotonic hemolysis.

When human red cells are hemolysed in hypotonic solutions containing macromolecules, the hemoglobin loss from the individual cells is reduced although the number of cells hemolysed is not affected. The evidence strongly suggests this is a colloid osmotic effect but an additional condition is also necessary if hemoglobin is to be retained. The cell must reseal, at least to hemoglobin and macromolecules. There is some evidence which points to the role of the macromolecule in this process. Further, at least in the case of dextrans, a minimal size of about 2000 daltons is required for suppression of hemoglobin liberation and it is suggested that this limit may be set by the diffusion coefficient.

Passive cutaneous anaphylaxis in guinea pigs elicited by gastric absorption of dextran induced by acetylsalicylic acid.

Passive cutaneous anaphylaxis (PCA) was elicited in guinea pigs sensitized with rabbit antidextran by the absorption of dextran macromolecules from the stomach induced by intragastric acetylsalicylic acid. The gastric contents had a pH sufficiently low to maintain the acid mainly in the unionized form since it is the latter which alters gastric permeability. The acid concentration required to induce PCA was below that which caused mucosal cell loss or bleeding. The maximal molecular weight of the absorbed dextran was approximately 25,000. Dextran was chosen as antigen because of its well-characterized physical and immunological properties. It is suggested that ingestion of acetylsalicylic acid may contribute to sensitization and allergic reactions to antigenic food materials by facilitating their absorption from the stomach.