Excision of carbuncle with primary split-thickness skin grafting as a new treatment modality.

Carbuncles are debilitating skin infections commonly seen in diabetic patients. Excision of these infective lesions leads to large defects that require prolonged hospital stay and repeated dressings with ensuing pain and bleeding. This study is an attempt to cover the wounds resulting from excision of carbuncle with primary skin grafting so as to decrease the hospital stay and frequency of dressings.

Prevalence and risk factors of Metallo ß-lactamase producing Pseudomonas aeruginosa and Acinetobacter species in burns and surgical wards in a tertiary care hospital.

INTRODUCTION: The production of Metallo-ß-lactamases (MBLs) is one of the resistance mechanisms of Pseudomonas aeruginosa and Acinetobacter species. There is not much Indian data on the prevalence of MBLs in burns and surgical wards. MATERIALS AND METHODS: A total of 145 non-duplicate isolates of carbapenem-resistant Pseudomonas aeruginosa and Acinetobacter species, isolated from pus/wound swabs and endotracheal secretions from burns and surgical wards, were tested for MBL production by modified ethylene diamine tetra acetic acid (EDTA) disc synergy and double disc synergy tests. RESULTS: Prevalence of MBLs was 26.9% by both the above tests. All MBL-positive isolates were multidrug resistant. Only 6.06% (2/33) P.aeruginosa and 16.67% (1/06) Acinetobacter species were susceptible to piperacillin-tazobactam and netilmycin, respectively. These patients had multiple risk factors like >8 days hospital stay, catheterization, IV lines, previous antibiotic use, mechanical ventilation, etc. Graft application and surgical intervention were significant risk factors in MBL-positive patients. Overall mortality in MBL-positive patients was 34.21%. CONCLUSION: Emergence of MBL-producing Pseudomonas aeruginosa and Acinetobacter species in this hospital is alarming, which reflect excessive use of carbapenems and at the same time, pose a therapeutic challenge to clinicians as well as to microbiologists. Therefore, a strict antibiotic policy and implementation of proper infection control practices will go a long way to prevent further spread of MBLs. Detection of MBLs should also become mandatory in all hospitals.

Deceased donor skin allograft banking: Response and utilization.

BACKGROUND: In the absence of xenograft and biosynthetic skin substitutes, deceased donor skin allografts is a feasible option for saving life of patient with extensive burn injury in our country. AIMS: The first deceased donor skin allograft bank in India became functional at Lokmanya Tilak Municipal (LTM) medical college and hospital on 24(th) April 2000. The response of Indian society to this new concept of skin donation after death and the pattern of utilization of banked allografts from 2000 to 2010 has been presented in this study. SETTINGS AND DESIGN: This allograft skin bank was established by the department of surgery. The departments of surgery and microbiology share the responsibility of smooth functioning of the bank. MATERIALS AND METHODS: The response in terms of number of donations and the profile of donors was analyzed from records. Pattern and outcome of allograft utilization was studied from specially designed forms. RESULTS: During these ten years, 262 deceased donor skin allograft donations were received. The response showed significant improvement after counselling was extended to the community. Majority of the donors were above 70 years of age and procurement was done at home for most. Skin allografts from 249 donors were used for 165 patients in ten years. The outcome was encouraging with seven deaths in 151 recipients with burn injuries. CONCLUSIONS: Our experience shows that the Indian society is ready to accept the concept of skin donation after death. Use of skin allografts is life saving for large burns. We need to prepare guidelines for the establishment of more skin banks in the country.

Fungal colonisation in burn wounds: An Indian scenerio.

UNLABELLED: Burn patients are susceptible hosts for fungal colonisation. AIM: To study incidence and profile of fungal colonisation of burn wounds. MATERIALS AND METHODS: This prospective study was conducted in 201 consecutive adult patients (39 male and 162 female) with burn wounds, admitted from October 2005 to September 2006. Wounds with clinical suspicion of fungal colonisation were biopsied and examined by wet smear, Potassium hydroxide (KOH) mount, nigrosin stain, 1% Acid fast bacilli (AFB) stain, Gomori methenamine silver (GMS) stain, histopathological examination and fungal culture. All wounds with suspicion of fungal colonisation were treated with topical application of miconazole ointment mixed with povidone-iodine/silver sulphadiazine topically and itraconazole (oral) systemically. RESULTS: Fungal infection of burn wound was suspected in 77 patients (38.31%) with 20-70% total body surface area (TBSA) burns. Ninety-two biopsy samples were collected from 77 patients. On investigations, fungal colonisation was confirmed in 35 patients. Culture was positive in 23 patients with Candida in 12 and Aspergillus in 4. GMS stain and KOH stain showed sensitivity and specificity of 70.8% and 86.5%, respectively for detecting fungi in burn wound. Nigrosin stain was negative in all patients. Duration of hospitalisation was more in patients having fungal colonisation without any significant effect on the mortality DISCUSSION: In 38.31% of patients fungal colonisation was clinically suspected and it was confirmed in 17.41% of 201 patients. GMS stain and KOH stain were observed to have acceptable sensitivity and specificity. With increasing prevalence of Aspergillus, flucanazole cannot be relied upon in controlling fungal colonisation and drugs like itraconazole may have to be used as empirical therapy. CONCLUSION: Fungal colonisation of burn wound is not uncommon and should be suspected. Fungi detected most commonly were Candida and Aspergillus. KOH and GMS stain were identified as reliable, simple and inexpensive methods for confirming fungal colonisation.

Galactorrhea and amenorrhea in burn patients.

INTRODUCTION: Galactorrhea and/or amenorrhea, although uncommonly reported in post-burn patients, is a complex problem to treat. Patient is reluctant to volunteer history of these symptoms, unless asked specifically. AIM: To study profile of adult female patients with galactorrhea and/or amenorrhea in post burn period. MATERIALS AND METHOD: A prospective study of all adult female patients presenting with or detected to have galactorrhea and/or amenorrhea in post burn period was conducted over 6 month's period. Detailed clinical examination, estimation of LH, FSH, Prolactin levels and X-ray of skull was done in all patients. The data collected was analyzed. Patients with hyperprolactinemia and galactorrhea were treated with Bromocriptine for 3 weeks to 3 months. In all patients with amenorrhea, pregnancy was ruled out by gynecological examination and urine pregnancy test. RESULTS: During this period, 30 patients (15.15%) were detected to have galactorrhea and/or amenorrhoea. The extent of burn in these patients was 20-65%of body surface area. Out of 30 patients, 5 had galactorrhea and amenorrhea, 1 galactorrhea alone and 24 had amenorrhea alone. Analysis of voluntary disclosures and detection on interrogation was done. Till the end of study, 4 patients with galactorrhea had complete relief, 2 patients reported reduction in discharge. DISCUSSION: Galactorrhea was distressing for all and was always associated with high prolactine levels .The reverse was not true. All the patients had chest burns besides other body areas. Association was noted between menstrual aberration and ovulatory phase at the time of burn. CONCLUSION: Galactorrhea and menstrual disturbances do exist in female patients in reproductive age group in post burn period and patients should be especially interrogated for these symptoms by the burn care providers.

Utility of optic nerve ultrasonography in head injury.

BACKGROUND: CT has evolved as the gold standard for evaluation of head injury, but early CT is not always possible. Bedside ultrasonography is available in most trauma units and optic nerve ultrasound (ONUS) examination should be feasible. OBJECTIVE: To evaluate the role of ONUS for people with head injury. SETTING: Tertiary care trauma service in a teaching hospital in a large metropolitan city in India. DESIGN: Prospective, blinded, observational study. METHODS: From April 2006 to January 2007, all adult patients with head injury but without obvious ocular trauma, for whom it was possible to perform CT, were enrolled. Using a 7.5-MHz ultrasonographic probe on the closed eyelids, optic nerve sheath diameter (ONSD) was measured on either side. A mean binocular ONSD less than 5.00 mm was considered normal. Cranial CT findings were used as a reference standard to evaluate ONUS. RESULTS: The study included 100 participants (72 men, 28 women, median age 28 years, median Glasgow Coma Scale score 11). Clinical features did not correlate with CT for signs of raised intracranial pressure (ICP). The mean binocular ONSD (5.8+/-0.57 mm) was significantly increased among individuals with signs of raised ICP on CT compared with the mean ONSD (3.5+/-0.75 mm) among those without such signs. ONUS revealed evidence of raised ICP in 74 cases (confirmed by CT in 72 cases), 59 of whom had significant intracranial haematoma needing surgical evacuation. Of the 26 cases with negative ONUS, confirmed by CT in 25 cases, only 1 needed surgical intervention for drainage of intracranial haematoma. ONUS was false positive for two and false negative for one person. The sensitivity of ONUS in detecting elevated ICP was 98.6%, specificity 92.8%, positive predictive value 97.26% and negative predictive value 96.3%. CONCLUSION: ONUS has potential as a sensitive bedside screening test for detecting raised ICP and the presence of intracranial haematoma needing surgical intervention in adult head injury. This can be of immense help for unstable patients, in mass casualty situations and in remote locations.

Early prediction of outcome in very severe closed head injury.

BACKGROUND: People with severe head injury and admission Glasgow Coma Scale (GCS) score < or =5 have a poor outcome and greatly strain limited resources. AIM: To identify patients with the best chances of survival, using routine clinical measures. METHODS: People attending the trauma intensive care unit, who had isolated blunt head injury and GCS< or =5 and who had survived > or =4h, were included in the study, resuscitated and clinically assessed. The GCS score was followed serially after admission. Bivariate analysis of various parameters with outcome was performed using the chi-square test. Serial GCS scores were compared with admission GCS by paired t-testing. RESULTS: Of the 102 patients who were studied prospectively, 78 (76.5%) died and 24 (23.5%) survived. Age, gender, pre-hospital delay and admission GCS scores were comparable between the two groups. Adequate spontaneous respiration, brisk pupillary light reactivity on admission and increase in GCS by at least 2 at 24h after admission significantly affected the outcome (p<0.05). In the presence of all these factors, the survival rate increased from 6.1% to 57.1% (p<0.001). CONCLUSIONS: People with GCS score < or =5 still have a reasonable chance of survival, so all patients should be aggressively managed initially. Better survival was observed among those with adequate spontaneous respiration, good pupillary reaction and improvement in GCS of at least 2 at 24h. These clinical parameters can help to predict survival and thus make best use of limited resources.

Virtual bronchoscopy for diagnosis of inhalation injury in burnt patients.

Virtual bronchoscopy using a multislice CT scanner, is a new non-invasive imaging technique and its utility in the diagnosis of inhalation injury in burnt patients has not been reported in literature yet. Initial experience of technique is encouraging and it merits more interest. It overcomes many of the limitations of the presently established procedure of fibreoptic bronchoscopy. Ten burned patients with clinical suspicion of inhalation injury underwent this investigation and in eight of these the diagnosis was confirmed.

Banana leaf dressing for skin graft donor areas.

Skin grafting is an integral part of burn wound management. The pain experienced at skin graft donor sites is significant. Banana leaf dressing (BLD) developed by our unit in 1996 is an excellent, non-adhesive, pain-free, cheap and easily available dressing material. We conducted a trial to compare efficacy of BLD with vaseline gauze (VG) dressing used by majority of burns centers for dressing skin graft donor areas. Thirty patients undergoing skin grafting were included in the study. BLD was applied on one half and VG on the other half of the donor area. Dressing change was done on the eighth day. Using the visual analogue scale we assessed the pain score, the dressing removal pain score and ease of dressing removal score. The advantage of early epithelisation of donor areas cannot be over stressed in burnt patients. The epithelisation status of the donor area on eight post-operative day was noted. The day of complete epithelisation was also noted. The average pain score with BLD was 1.1+0.71 while that with VG was 6.9+0.84. The average dressing removal pain score was 0.97 with BLD while that with VG it was 9.47. Ease of dressing removal score average was 1.1 with BLD while it was 9.53 with VG. In all the above scores the difference observed was statistically significant with P<0.001. The mean complete epithelisation day was 8.67 in the BLD covered areas as compared to 11.73 in the VG covered areas. This observation was highly significant with P<0.001. Our study clearly indicates that BLD is a completely non-adherent and painless dressing. We strongly recommend the use of BLD for all skin graft donor areas.

Evaluation of banana leaf dressing for partial thickness burn wounds.

An important factor in the healing of superficial and moderate partial thickness burn is early and effective coverage with a dressing that protects the wound from trauma and dessication and is non-adherent. In our country cost is also a very important factor. Disturbed by the pain and anxiety experienced by the patients during and after dressing changes, search for a new dressing material was begun for partial thickness burn wounds and the banana leaf dressing (BLD) was subsequently developed and optimised by June 1996. An open controlled study was carried out to compare banana leaf dressing and boiled potato peel bandage (BPPB), the dressing being used in our Burn Unit since 1994. Thirty patients all less than 40 years of age, with burn size less than 50% TBSA, involving comparable body areas with partial thickness burn, were included in the study. BLD along with a topical agent was applied over the right sided extremity while BPPB was applied with the same topical agent on the left sided extremity. Dressing was changed every day. The pain during dressing change, feeling of comfort and ease of handling dressing was assessed by awarding scores by the patients and care givers for each type of dressing. Analysis of the scores revealed that both BLD and BPPB caused easily tolerable, minimal pain during dressing change in majority of the patients. The days taken for epithelialisation, eschar formation and the need for skin grafting over deep partial thickness burns, did not reveal any significant difference between the areas treated by BLD and those by BPPB. So both the dressings were observed to have equal efficacy in protecting the wounds and aiding healing. Thus, the efficacy of BLD and BPPB was parallel in all respects. But BLD is 11 times cheaper than BPPB. Banana plants can be easily grown, the leaves are easily available throughout the year. The leaves of banana are large thus offering larger surface area and the surface is non-adherent, waxy and cool. The dressing can be prepared very easily with little training. It is also the cheapest dressing available today. We strongly recommend the use of banana leaf dressing for all partial thickness burn wounds in our environment.

Recurrent inflammatory pseudotumor of small bowel mesentery presenting as perforative peritonitis.

A 62-year-old man with recurrent inflammatory pseudotumor of the small bowel mesentery presented with perforative peritonitis; such a presentation has not been reported. The mass was excised successfully.