Total care requirements of burn patients: implications for a disaster management plan.

The purpose of this study was to determine the operative and ward-based requirements of burn patients as a first step in the development of a National Health Emergency Multiple Complex Burn Action Plan. A retrospective review of 1043 patients admitted to the National Burn Centre at Middlemore Hospital, Auckland, New Zealand, from June 2006 to June 2009 was undertaken. Outcome measures included the number of operative procedures, operative time, length of inpatient stay, nursing hours, and allied health hours. A mean of 0.3 operating theater visits and 22.8 minutes of operating time was needed per percentage total body surface area (TBSA) burn. Length of inpatient stay equated to 1.1 days per percentage TBSA burn. There was an exponential relationship between operative requirements and burn surface area. Total operating theater time could be predicted from a formula based on burn surface area, mean depth, and type of burn. Operative time required was greatest in the first week and roughly halved each week after this, whereas nursing and allied health hours remained relatively constant. On the basis of operative requirements in the first week, patients with acute burn injuries totaling up to 129% TBSA could be treated at one time at the authors' institution. This study provides an objective trigger point for the activation of a disaster plan and enables us to predict operative and staffing requirements on a week by week basis, taking into account the existing workload. This information can be used to plan both the acute and protracted phase of a national response to a burn disaster.

Middle ear disease in children with cleft palate: protocols for management.

OBJECTIVE: There is wide international variation in the protocols used for middle ear disease management in cleft palate patients. Ventilation tube (grommet) insertion may occur routinely at the time of palatoplasty or selectively on a separate occasion if symptomatic middle ear disease develops. The audiological and otologic outcomes of cleft palate patients were studied in a single institution over a timeframe in which both protocols were utilised. METHODS: This was a retrospective study of 234 cleft palate patients who underwent palatoplasty from 1990 to 2005 at Middlemore Hospital, Auckland, New Zealand. Data on hearing loss, middle ear disease, and tympanic membrane abnormalities was collected from clinical notes. Audiological data was obtained from pure tone audiogram reports. RESULTS: Forty-five patients had routine grommets inserted concurrent with palatoplasty and 189 patients were managed conservatively with selective grommet insertion if indicated. Grommets were subsequently required in 79 (41.8%) of these 189 patients. There was no difference in the incidence of persistent conductive hearing loss, but recurrent middle ear disease, tympanic membrane abnormalities, and the total number of grommet insertions were significantly higher in the routine grommet group. Poorer outcomes were noted in patients who had undergone a greater number of grommet insertions. CONCLUSION: No significant deterioration in audiological outcomes and better otologic outcomes were found in cleft palate patients undergoing selective grommet insertion compared to routine grommet insertion. It is recommended that ventilation tube placement occur in patients selected on the basis of symptomatic infection or significant hearing loss.

Incidence of oronasal fistulae and velopharyngeal insufficiency after cleft palate repair: an audit of 211 children born between 1990 and 2004.

OBJECTIVE: We present an audit of primary cleft palate surgery at our unit, including rates of oronasal fistula development, speech outcomes, and rates of velopharyngeal insufficiency requiring secondary surgery. DESIGN: A retrospective study of patients with all cleft palate types, born between January 1990 and December 2004, who underwent primary palatoplasty at Middlemore Hospital, Auckland, New Zealand. PATIENTS: The study included 211 patients, collectively operated on by five different surgeons. RESULTS: The overall rate of true fistula development was 12.8% over a mean follow-up period of 4 years 10 months. The incidence of true fistulae that required surgical repair was 8.1%. Fistula rates were higher for more severe degrees of clefting but were not affected by gender or type of surgical repair. Overall, 31.8% of the study population had some degree of hypernasality following primary palatoplasty. Secondary surgery for velopharyngeal insufficiency was required in 13.3% of patients. Following surgical correction of velopharyngeal insufficiency, no patients were reported to have appreciable hypernasality and 21.7% were reported to have mild hypernasality, a result comparable to previously published audits. The requirement for secondary surgery was higher in patients with more severe clefts. CONCLUSION: Our results are comparable to other recent studies. We believe that highly coordinated cleft care helps ensure such outcomes. These data provide a benchmark against which we can measure future performance in our attempts to improve outcomes of cleft repair.

Clinical and microstructural analysis of patients with hyper-reflective corneal endothelial nuclei imaged by in vivo confocal microscopy.

The purpose of this study was to determine the significance of hyper-reflective corneal endothelial nuclei imaged by in vivo confocal microscopy. A retrospective analysis was performed using a database of 505 patients that had undergone in vivo confocal microscopy of the cornea. All subjects with hyper-reflective endothelial nuclei were identified and these images were analysed to determine corneal endothelial cell density and morphology. The clinical notes of these patients were reviewed and corresponding data regarding corneal thickness was obtained from a related database of Orbscan II pachymetry. Hyper-reflective endothelial nuclei were identified in 41 eyes of 39 (7.7%) patients. Diagnoses included previous cataract surgery or penetrating keratoplasty, posterior polymorphous dystrophy, Fuchs' endothelial dystrophy and irido-corneal endothelial syndrome. No patients with clinically normal corneas exhibited bright endothelial nuclei. The mean endothelial cell density in this group was 1325+/-872 cells mm(-2) and endothelial density was below age-adjusted normal values in 69.2% of patients. Both cellular polymegathism (coefficient of variation of cell area 33.9+/-7.4%) and cellular pleomorphism were noted (51.8+/-9.0% hexagonal cells). The mean central corneal thickness was 582+/-52 microm. There was no significant difference in endothelial density and morphology compared to cases that had low endothelial density but did not exhibit bright nuclei. In conclusion, this study is the first to investigate the significance of bright endothelial nuclei detected by in vivo confocal microscopy. The strong association with corneal disease states suggests that the most likely explanation for this appearance is the alteration in cellular/nuclear morphology, composition or function.

In vivo confocal microstructural analysis of corneal endothelial changes in a patient on long-term chlorpromazine therapy.

BACKGROUND: Deposits in the cornea and lens are a known complication of long-term chlorpromazine therapy. METHOD: A 59-year-old woman had previously taken chlorpromazine for 20 years with doses up to 1,200 mg/day, with a mean dose of 400 mg/day. She presented with gradual onset of blurred vision in her left eye. Slit-lamp biomicroscopy revealed multiple fine creamy-white deposits on her corneal endothelium and anterior crystalline lens capsule bilaterally. RESULTS: In vivo confocal microscopy of the cornea identified irregular hyper-reflective deposits on the posterior surface of the endothelium. The deposits varied from 1 microm to 70 microm in diameter and had well-defined edges. Endothelial morphology was otherwise normal bilaterally. CONCLUSIONS: This is the first report of in vivo confocal imaging of deposits resulting from long-term chlorpromazine use. Microstructural analysis of the corneal endothelium reveals that there were no abnormalities in cellular morphology resulting from these deposits.