Trash and brush burning: an underappreciated mechanism of thermal injury in a rural community.

Open-fire injuries associated with burning trash or brush result in a significant number of burn admissions annually. Trash- and brush-burning injuries are more prevalent in rural environments where open burning is an acceptable practice of waste disposal. These injuries are not "unavoidable accidents" but follow a predictable injury pattern. Understanding this injury pattern is paramount to effective prevention. The purpose of this work is to describe the epidemiology of burn injuries associated with burning trash or brush. Charts were retrospectively reviewed for all trash and brush burning injuries from July 1989 to December 2000. One hundred ninety-four injuries were identified, accounting for one fifth of all flame admissions for the study period. Persons most at risk for these burn injuries were males between the ages of 25 to 45, followed by males ages 16 to 24. Accelerant use was identified in over 80% of these injuries. The median cost for admission was $9,363.00 US dollars. Cost was significantly related to age, percent body surface area burned, and operative intervention. Brush and trash burning can lead to costly injuries especially when accelerants are used. Additional research is needed to explore the cultural and social influences associated with these injuries to target effective prevention.

Spontaneous extraperitoneal hemorrhage with hemodynamic collapse in patients undergoing anticoagulation: management with selective arterial embolization.

The authors report their experience with management of unstable spontaneous extraperitoneal hemorrhage (SEH) with selective transcatheter embolization. Five consecutive patients underwent angiographic evaluation for SEH complicated by hemodynamic collapse while undergoing anticoagulation therapy. Bleeding occurred via one or two lumbar arteries in psoas hematomas. Two abdominal wall hematomas were supplied by the inferior epigastric artery, with additional supply via the deep circumflex iliac artery in one. Microcoil embolization successfully controlled extravasation in all patients, with stabilization of hemodynamic parameters. Four of the five patients survived the immediate postprocedural interval. Selective transcatheter embolization may be a viable life-saving option in SEH-associated hemodynamic collapse.

Predicting survival in an elderly burn patient population.

The purpose of this study was to analyze the outcome of elderly burn victims and to determine an instrument to predict survival in this population. Charts of three hundred and eight burn patients > or =60 yr of age who were admitted to a university-based hospital between the years of 1977-1996 were retrospectively analyzed. The mean age of the population was 71.5+/-8.6, with a male predominance (1.8 to 1, P < 0.001). The majority of the burns were secondary to flame injuries (210, 68.6%). The median body surface area (BSAB) was 13.0% with an in-hospital mortality rate of 30.2%. We demonstrated improved survival in patients aged 60-74 yr as compared to 1965-1971 national burn survival data. A similar trend could not be shown in the very old (> 75 yr of age). Only age and BSAB were related to death by multiple stepwise forward linear regression. The Baux score, which adds age and BSAB, was predictive of outcome in 87.0% of our population. In conclusion, this study reinforces the high mortality associated with burn injuries in the elderly and the superior ability of the Baux score (age + percent burn) in predicting outcome in this population.

Our chemical burn experience: exposing the dangers of anhydrous ammonia.

Although chemical injuries account for only a small number of one burn unit's cases, the diversity, resulting complications, and sequelae of these burns pose special problems. We reviewed a 19-year period of the chemical burn experience of our burn unit. The population of patients with these types of burns consisted of young men (mean age: 29.8 years), the majority of whom were injured on the job. Unique to our series is the largest collection of injuries (30%) resulting from the common fertilizer anhydrous ammonia. Another population of concern, accounting for 14% of the injuries in our unit, is that of patients injured at home with routine household cleaners. Nearly one half of those patients injured at home incurred injuries that required grafting. The cornerstone of chemical burn prevention and treatment involves education regarding the caustic nature of chemicals, proper handling, adequate protection, and copious irrigation of the wound at the scene. From the analysis of our retrospective review, adequate education and treatment at the scene appear to be well implemented in the industrial and farming communities. The focus of our education efforts should be directed toward the public and emphasize the safe use of household chemicals. Finally our review illuminated the potential benefit of immediate excision and grafting for decreasing the length of stay, complications, and loss of productivity.

Laparoscopic cholecystectomy can disseminate in situ carcinoma of the gallbladder.

BACKGROUND: Early case reports suggest more frequent and rapid recurrences of carcinoma of the gallbladder after laparoscopic cholecystectomy (LC) than after open cholecystectomy. This cancer has a poor prognosis and occurs in 1 percent of patients who undergo cholecystectomies. STUDY DESIGN: A recent community hospital series of gallbladder carcinoma (GBC) was reviewed and the total reported experience of GBC after LC was compiled. Diagnostic findings were compared for patients with GBC and a consecutive series of 24 patients who had LC for benign disease. RESULTS: Nine patients with GBC were found among 928 patients who had undergone cholecystectomy (0.97 percent incidence). Compared to patients without GBC, patients with carcinoma were older, had thicker gallbladder walls, and had more abnormalities detected intraoperatively (all p < or = 0.05). Recurrence of GBC occurred more rapidly after LC, and in diffuse peritoneal and port sites when compared with recurrence patterns after open cholecystectomy. CONCLUSIONS: In patients with GBC, LC may be sufficient when the disease is confined to the gallbladder mucosa and the gallbladder is excised intact without bile spillage. However, patients whose gallbladders are torn during dissection or patients who have invasive tumors should undergo laparotomy and local reexcision. In situ GBC can be implanted if the organ is torn during dissection. When gallbladders with suspicious wall thickening or adhesions are noted at LC, especially in older patients, the procedure should be converted to open cholecystectomy.

Sonographic diagnosis of unsuspected gallbladder cancer: imaging findings in comparison with benign gallbladder conditions.

OBJECTIVE: Several sonographic findings were analyzed to determine their significance in distinguishing gallbladder cancer from benign conditions of the gallbladder. The analyzed findings were gallstone number and size; floating stones; displaced stones; wall thickening, irregularity, and echogenicity; mucosal plaque; intraluminal mass; gallbladder-replacing mass; invasive gallbladder mass; gallbladder mucosal discontinuity; hyperechoic gallbladder mucosa; and submucosal or transmural echolucency. MATERIALS AND METHODS: Sonograms of 20 patients with unsuspected, pathologically proven gallbaldder cancer and 65 patients with benign gallbladder conditions (predominantly acute or chronic cholecystitis) were retrospectively assessed by two observers who were unaware of experimental conditions. Gallstone number and size were assessed, and the presence of floating stone (neither settling nor wall-adherent), displaced stone (lifted from the gallbladder wall by mass or focal wall thickening), wall irregularity, mucosal plaque, intracystic mass, and gallbladder-replacing or invasive mass was evaluated. The echogenicity pattern of the gallbladder wall was characterized, and its thickness was measured and classified as normal/mildly thickened (< 7 mm) or moderately/severely thickened (> or = 7 mm). In addition, the gallbladder wall was evaluated for discontinuous mucosal echo, hyperechoic mucosa, submucosal or mural echolucency, and pericholecystic fluid collection. Sonographic findings were compared by the Mann-Whitney test for nonparametric variables and by Student's t test for continuous variables. RESULTS: Solitary gallstone, displaced stone, intraluminal mass, gallbladder-replacing or invasive mass, and discontinuity of the mucosal echo were all statistically significantly more common in patients with gallbladder cancer (.001 < p < .05). Mucosal plaque and wall irregularity were nonspecific findings. Gallbladder wall thickening by itself was nonspecific, although associated echolayering, transmural or submucosal edema, or a distinctly specular mucosal lining favored benign etiologies. CONCLUSION: Several sonographic findings were significantly more common in patients with gallbladder cancer compared with patients with benign gallbladder conditions. Assessment of these signs may be helpful in distinguishing gallbladder cancer from benign conditions of the gallbladder.

Downregulation of E. coli-induced TNF-alpha expression in perfused liver by hypoxia-reoxygenation.

We tested the hypothesis that reducing the hepatic O2 supply by 30 min of constant-flow hypoxia (PO2, approximately 45 Torr) following gram-negative bacteremia downregulates tumor necrosis factor-alpha (TNF-alpha) in buffer-perfused rat lives (total n = 44). Eight groups were studied after intraportal 10(9) viable E. coli serotype 055:B5 (EC) or 0.9% NaCl (NS) at t = 0:1) normoxic EC; 2) normoxic NS controls; 3) EC+hypoxia (H)-reoxygenation (R) in which H began 30 min after EC followed by 120 min of R; and 4) NS+H/R. To assess the role of cyclooxygenase vs. xanthine oxidase activation, the effects of 10(-5) M indomethacin (Indo) in 5) Indo+EC+H/R and 6) Indo+NS+H/R were compared with allopurinol (Allo) in 7) Allo+EC+H/R and 8) Allo+NS+H/R groups. Bacterial clearance, bioactive and antigenic TNF-alpha, and hepatic O2 uptake and performance were serially assessed, as was prostaglandin (PG) E2 at baseline and peak hypoxia in EC-challenged groups. Intrahepatic bacterial killing and TNF-alpha mRNA were determined at t = 180 min. Bioactive venous TNF-alpha did not increase in normoxic NS controls (6 +/- 3 U/ml at t = 180 min; mean +/- SE), whereas levels rose in NS4H/R by 180 min (111 +/- 34 U/ml; P < 0.01) without increases in TNF-alpha mRNA. In contrast, EC-induced increases in TNF-alpha transcripts during normoxia were attenuated in EC+H/R, as were protein levels (57 +/- 20 U/ml; P < 0.05), despite similar bacterial clearance. Neither Indo-mediated reductions in PGE2 nor allopurinol increased TNF-alpha after EC+H/R.(ABSTRACT TRUNCATED AT 250 WORDS)