Micrografting in the treatment of severely burned patients

The micrografting technique, employed to treat patients with extensive TBSA burns and reduced areas of healthy donor skin, was assessed simultaneously with traditional mesh grafts (STSG) or Tiersch grafts in the treatment five severely burned subjects (average TBSA burned 35.6 per cent; average per cent of full thickness wounds 32.6 per cent). At the first clinical control on day 6 post-surgery, 93 per cent of the micrografted area was in situ and health; epithelialization of the wound sites was complete at day 21. Meshed STSG yielded 90 per cent attachment at day 6 post-surgery, with epithelialization complete at 12 +/- 2 days post-surgery. Functional results were equivalent no matter what technique was used, while aesthetic results were better in the areas where micrografting was carried out. Although the micrograft technique is labour-intensive, if the expansion needed is at least 1:6, the aesthetic and functional results obtained are comparable to, or better than, those with meshed grafts. Also, large segments of micrograft are not compromised if a small area of mesh becomes detached, and epithelialization is faster and more uniform, enabling a reduction in both infection and length of hospital stay.     

GTP-binding proteins in polymorphonuclear granulocytes of severely burned patients

Femoral head remnants, joint capsules and acetabular membranes were retrieved at revision of 40 failed uncemented, Gerard double-cup hip arthroplasties. All femoral heads were covered with a fibrous membrane containing polyethylene and metal particles, macrophages, and giant cells. The same histopathologic features were found in the joint capsules and acetabular membranes. There was a relationship between the amount of polyethylene particles in the fibrous membrane of the femoral head and the presence of osteonecrosis. Resorption of necrotic bone contributed to failure of the arthroplasty, aided by granulomatous reactions to the wear particles that appeared to induce osteolysis. The overall findings indicate that the severity of the foreign body reaction in periprosthetic tissues is related to the amount of wear particles. Future designs of resurfacing hip arthroplasties should be focused on wear-resistant material combinations.     

Plasma norepinephrine, epinephrine, and thyroid hormone interactions in severely burned patients

In this prospective study of thyroid catecholamine interactions, 15 severely burned patients were divided into two groups. Nine patients receiving 200 micrograms/day of triiodothyronine constituted the T3-treated group. Eight additional patients constituted the untreated group. Mean serum concentrations of T3 were significantly lower in the untreated group than in the treated group. Mean serum thyroxine (T4) concentrations were significantly higher in the untreated group than in the treated group. The mean plasma norepinephrine concentration in the untreated group was significantly greater than that of the treated group. In the untreated group, log plasma norepinephrine correlated inversely with serum T3. Similarly, in the untreated group, log plasma epinephrine correlated inversely with serum T3. Metabolic rates were not different between groups. These data suggest that a reciprocal relationship exists between plasma concentration of T3 and both norepinephrine and epinephrine in untreated burn patients and that treatment with the metabolically active hormone, triiodothyronine, does not alter the level of hypermetabolism accompanying thermal injury.     

Trimethoprim-sulfamethoxazole for the prevention of methicillin-resistant Staphylococcus aureus pneumonia in severely burned patients

This study sought to examine the association between cigarette smoking and serum bilirubin antioxidant concentrations in 715 middle-aged men undergoing coronary angiography. The study involved 153 current smokers, 251 who quit smoking and 311 who never smoked. Serum bilirubin concentrations were divided into the following quartiles; 0.20-0.57, 0.58-0.73, 0.74-0.95 and 0.96-3.26 mg/dl. The percentage of individuals within each quartile were as follows; current smokers (42, 22, 24, 12), former smokers (22, 27, 23, 28), nonsmokers (16, 28, 27, 29). A total of 42% of the current smokers had bilirubin concentrations in the lowest quartile compared to 16% of the nonsmokers. Also, 12% of the current smokers had bilirubin concentrations in the highest quartile compared to 29% in the nonsmoking group. The Mantel-Haenszel chi-square test for association between ordered categorical variables was 30.6 (P < 0.0001). Subdividing the subjects according to maximum percent stenosis on angiography (< 10, 10-49, 50-100%) revealed a significant inverse association between smoking and bilirubin (< 0.01) within each subset. The data shows that smoking is associated with decreased serum bilirubin concentrations. In addition, it supports the hypothesis that cigarette smoking may increase the risk of coronary artery disease by lowering antioxidant concentrations and raising oxidized lipid and lipoprotein concentrations.     

Therapeutic monitoring of teicoplanin in a severely burned patient

It is now well documented that E-cadherin expression correlates inversely with tumor grade in various carcinomas including prostate cancer. We also demonstrated a statistically significant correlation between decreased E-cadherin expression and progression-free period in early stage patients treated by radical prostatectomy and decreased survival in patients with advanced stage disease. We now study the relationship between E cadherin and alpha-catenin expression, because in prostate cancer cell lines, mutational inactivation of the alpha-catenin gene can be the cause of the impaired E-cadherin function. Twenty patients treated by radical prostatectomy and 32 advanced stage patients were evaluated immunohistochemically for E-cadherin and alpha-catenin expression. The results were related to tumor grade and disease progression. Four patients in the radical prostatectomy group had aberrant E-cadherin and alpha-catenin expression and showed disease progression. The other 16 patients were free of progression and had normal E-cadherin and alpha-catenin expression. In the advanced stage group, 4 of 13 patients with normal E-cadherin staining showed aberrant alpha-catenin expression and 2 patients (50%) progressed, compared with only 22% progression in patients with both normal E-cadherin and alpha-catenin expression. The other 19 patients with aberrant E-cadherin and alpha-catenin staining had the poorest prognosis. Our results suggest that loss of alpha-catenin expression could be one of the mechanisms responsible for the loss of E-cadherin-mediated cell-cell adhesion in human prostate cancer and might in some cases provide prognostic information.     

Survey of intensive care of severely head injured patients in the United Kingdom

OBJECTIVES: To study practice in intensive care of patients with severe head injury in neurosurgical referral centres in United Kingdom. DESIGN: Structured telephone interview of senior nursing staff in intensive care unit of adult neurosurgical referral centre. SETTING: 39 intensive care units in hospitals that accepted acute head injuries for specialist neurosurgical management, identified from Medical Directory and information from professional bodies. MAIN OUTCOME MEASURES: Details of organisation and administration of intensive care and patterns of monitoring and treatment for patients admitted with severe head injury. RESULTS: Patients were managed in specialist neurosurgical intensive care units in 21 of the centres and in general intensive care units in 18. Their intensive care was coordinated by an anaesthetist in 25 units and by a neurosurgeon in 12. Annual case-load varied between units: 20 received > 100 patients, 12 received 50-100, and seven received 25-49. Monitoring and treatment varied considerably between centres. Invasive arterial pressure monitoring was used routinely in 36 units, but central venous pressure monitoring was routinely used in 24 and intracranial pressure was routinely monitored in only 19. Corticosteroids were used to treat intracranial hypertension in 19 units. Seventeen units routinely aimed for arterial carbon dioxide pressure of 3.3-4.0 kPa, and one unit still used severe hyperventilation to a pressure of < 3.3 kPa. CONCLUSION: The intensive care of patients with acute head injuries varied widely between the centres surveyed. Rationalisation of the intensive care of severe head injury with the production of widely accepted guidelines ought to improve the quality of care.     

Effects of hypertonic sodium lactate dextran resuscitation in severely burned dogs

12 dogs with 35% TBSA third degree burns received HLD resuscitation (HLD group, n = 6) or LR resuscitation (LR group, n = 6). Fluid resuscitation started one hour postburn. The amount of fluid infused with HLD resuscitation was calculated by that after giving HLD 19.6 ml/kg in 3 hours and 6 ml/kg/% TBSA lactate Ringer's solution followed. The amount of fluid infused with LR resuscitation was calculated by 8 ml/kg/% TBSA lactate Ringer's solution. Infusion of lactated Ringer's solution in both groups was adjusted by maintaining urinary output 0.5-1 ml/kg/h. The volume of fluid infused in HLD group (5.05 +/- 1.11 ml/kg/% TBSA) was much less than that of LR group (10.03 +/- 1.30 ml/kg/%TBSA) (P < 0.01). There was no significant difference in urinary output, serum Na+ and albumin, and plasmacrystalloid osmolarity between two groups. Plasma level of MDA decreased after resuscitation with HLD, which (0.81 +/- 0.20 mmol/g Hb) was much lower than that (1.39 +/- 0.44 mmol/g Hb) of LR group 4 hours postburn (P < 0.05). Plasma SOD activity (7.22 +/- 0.68 u/g Hb) of HLD group were much higher than that of LR group (4.86 +/- 0.53 u/g Hb) 4 hours postburn (P < 0.05). HLD resuscitation could significant reduce the amount of fluid infused comparing with lactate Ringer's solution. HLD resuscitation could attenuate postburn damage to tissue induced by lipid peroxide by elevating plasma SOD activity.     

In-house board-certified surgeons improve outcome for severely injured patients: a comparison of two university centers

The benefit derived from in-house board-certified attending surgeons (IHBCS) staffing trauma centers has recently been questioned. We compared the outcomes and provider-related complications of patients with severe injuries who were treated at two university trauma centers, one with IHBCS, and one with PGY-4 or PGY-5 residents in house (RIH). The RIH center had a significantly longer resuscitation time (160 vs. 58.8 minutes; p < 0.01). Except in cases of vascular injury, the odds ratio of dying at the RIH institution was significantly greater in all groups when the variables of transport time, Revised Trauma Score, and ISS were controlled. Errors in judgment were significantly more likely to have been made at the RIH institution in all groups. It is concluded that the management and ultimate outcome are significantly improved when IHBCS are involved with the resuscitation and early care of specific cohorts of severely injured patients.     

Vicryl mesh for repair of severely injured kidneys: an experimental study

We evaluated the efficacy of wrapping the kidney with semi-elastic Vicryl mesh for control of hemorrhage and preservation of renal function following grade III kidney lacerations (shattered kidney) in dogs in which nephrectomy was indicated clinically. Wrapping of fragmented kidneys resulted in prompt, sustained hemostasis and reapposition of the renal parenchyma. At an average of 80 days after injury the renal lacerations were well healed. The Vicryl mesh had been fully reabsorbed and there was considerably less scar tissue at the site of parenchymal rupture and neither perirenal or intrarenal abscess nor hematoma was found, grossly or microscopically. Among 12 dogs with grade III kidney lacerations, the mean ratio of the effective renal plasma flow (ERPF) in the affected kidney to the ERPF in the uninjured contralateral kidney was 0.53 +/- 0.22. The mean ratio of creatinine clearance of the injured kidney to that of the uninjured contralateral kidney was 0.41 +/- 0.23. Changes in the serum renin levels were not statistically significant following injury. Our results seem to confirm that simple and rapid surgical treatment of severely shattered kidneys using semi-elastic Vicryl mesh is possible. The method may also be suitable for uncontrollable bleeding during nonextirpative kidney surgery.     

Changes in the secretion of growth hormone in severely injured persons (author's transl)

The secretion of growth hormone was studied in 25 severely injured persons during the adaptive and convalescent stage. The ages of the patients varied between 9--65 years. During the first few days after the trauma hormone concentrations rose to up to 7--15 times their normal upper limits (about 10 mU/l). In some cases the hormone levels subsequently fell to the lower limits of normal. No attempt was made to calculate average values and the reasons for the omission are stated. The results are discussed with reference to the metabolic condition of the severely injured persons.     

Fusarium fungaemia in severely neutropenic patients

We report two cases of Fusarium infection with evidence of fungaemia in severely neutropenic patients with leukaemia. One patient was a 65-year-old woman with chronic lymphocytic leukaemia infected by Fusarium verticillioides. The other patient was a 45-year-old woman with acute myeloblastic leukaemia infected by Fusarium spp. Fungaemia was the only evident manifestation of these fungal infections.     

The critical care of the severely injured patient--II. Pulmonary and renal support

The management of pulmonary support in trauma patients is a balance of risk versus benefit. Decisions must be based upon the patient's physiologic needs, with constant attention to the potential complications of the therapy. The avoidance of renal failure by volume replacement, careful attention to the use of potentially nephrotoxic agents, and close monitoring of renal function can reduce the incidence and severity of this serious complication of trauma. If renal failure does occur, aggressive renal replacement therapy with either intermittent hemodialysis or CRRT should be tailored to the clinical situation.     

How many severely injured multiple-trauma patients can benefit from the biomechanical advantage of early mobilization following femoral intramedullary nailing?

The benefit of early operative stabilization of femoral fractures is established in patients with multiple injuries. In the last few years the unreamed femoral nail is favoured for internal fixation of femoral fractures despite pathophysiological concerns. The foremost advantage of femoral nails compared with plate fixation is the possibility of early full weight bearing. The aim of this retrospective study was to investigate, under consideration of the severity of injury, the extent of injury, and the clinical course, if multiple injured patients with concomitant femoral fractures benefit from the preferred intramedullary nailing with early weight bearing. Three hundred and two (23.8%) out of 1271 multiple injured patients (ISS > 17) had a concomitant femoral fracture. Fourty-seven out of 302 patients were children under 16 years of age, remaining 255 patients. Eighteen out of 255 patients died within the first 21 days after trauma and 66 patients required mechanical ventilation for more than three weeks (171/255). Thirty patients suffered from severe head injury (AIS-head > 3) and seven from severe pulmonary contusion with concomitant abdominal injury (134/255). Two patients had grade III open femoral fractures with vascular injury. Ipsilateral unstable pelvic fractures were seen in 11 patients, seven patients had ipsilateral intraarticular femoral fractures, and ipsilateral intraarticular fractures of the lower leg or foot were observed in 40 patients (74/255). The results demonstrate, that only 74 (29%) out of 255 multiple injured patients (> 16 years of age) had a theoretical benefit of early weight bearing. Seventy percent of the patients did not benefit from intramedullary nailing considering full weight bearing. With regard to pathophysiological concerns alternative methods of fracture fixation should be discussed for these patients. Primary fracture fixation with external fixators and secondary internal fixation proved to be a save alternative method. The complication rate of plating is comparable to intramedullary nailing but associated with less severe systemic risks. Primary plating of femoral fractures would not delay mobilization of most multiple injured patients.     

Comparison of wound culture and bronchial lavage in the severely burned child: implications for antimicrobial therapy

BACKGROUND: The relationship of the burn wound flora to microbial pathogens in the tracheobronchial tree has important implications for antimicrobial therapy in the severely burned patient. Management of septic complications is bolstered by surveillance quantitative wound cultures (QWC) and bronchial lavage fluid (BLF) cultures. OBJECTIVES: To compare the organisms present in BLF with those found in QWC and to determine if QWC can predict BLF results. DESIGN: Results of BLF cultures from all patients who underwent bronchial lavage from January 1, 1996, to December 31, 1996, at our institution were compared with QWC data from the same date. Criteria for a positive match included an identical antibiotic susceptibility pattern and biotype. Match rates were calculated qualitatively and quantitatively. RESULTS: In 30 (48%) of the 62 BLF cultures, there was a match between the organism identified in the BLF and the QWC. When strict quantitative criteria were applied, the match rate was only 9 (14%) of 62. Burn size and inhalation injury had no significant effect on match rate. CONCLUSIONS: Whereas the microbial pathogens were similar in the QWC and BLF, linear regression showed no value of QWC in predicting BLF culture results. The difference between qualitative and quantitative match rates suggests cross-colonization between the burn wound and tracheobronchial tree, but little to no cross-infection. The QWC and BLF cultures must be performed independently in determining antimicrobial specificity in the burned patient.     

Value of thoracic computed tomography in the first assessment of severely injured patients with blunt chest trauma: results of a prospective study

OBJECTIVE: The aim of this prospective study was to evaluate whether early thoracic computed tomography (TCT) is superior to routine chest x-ray (CXR) in the diagnostic work-up of blunt thoracic trauma and whether the additional information influences subsequent therapeutic decisions on the early management of severely injured patients. PATIENTS AND METHODS: In a prospective study of 103 consecutive patients with clinical or radiologic signs of chest trauma (94 multiple injured patients with chest trauma, nine patients with isolated chest trauma), an average Injury Severity Score of 30 and an average Abbreviated Injury Scale thorax score of 3, initial CXR and TCT were compared after initial assessment in our emergency department of a Level I trauma center. RESULTS: In 67 patients (65%) TCT detected major chest trauma complications that have been missed on CXR (lung contusion (n = 33), pneumothorax (n = 27), residual pneumothorax after chest tube placement (n = 7), hemothorax (n = 21), displaced chest tube (n = 5), diaphragmatic rupture (n = 2), myocardial rupture (n = 1)). In 11 patients only minor additional pathologic findings (dystelectasis, small pleural effusion) were visualized on TCT, and in 14 patients CXR and TCT showed the same pathologic results. Eleven patients underwent both CXR and TCT without pathologic fundings. The TCT scan was significantly more effective than routine CXR in detecting lung contusions (p < 0.001), pneumothorax (p < 0.005), and hemothorax (p < 0.05). In 42 patients (41%) the additional TCT findings resulted in a change of therapy: chest tube placement, chest tube correction of pneumothoraces or large hemothoraces (n = 31), change in mode of ventilation and respiratory care (n = 14), influence on the management of fracture stabilization (n = 12), laparotomy in cases of diaphragmatic lacerations (n = 2), bronchoscopy for atelectasis (n = 2), exclusion of aortic rupture (n = 2), endotracheal intubation (n = 1), and pericardiocentesis (n = 1). To evaluate the efficacy of all those therapeutic changes after TCT the rates of respiratory failure, adult respiratory distress syndrome, and mortality in the subgroup of patients with Abbreviated Injury Scale thorax score of > 2 were compared with a historical control group, consisting of 84 patients with multiple trauma and with blunt chest trauma Abbreviated Injury Scale thorax score of > 2, prospectively studied between 1986 and 1992. Age (38 vs. 39 years), average Injury Severity Score (33 vs. 38), and the rate of respiratory failure (36 vs. 56%) were not statistically different between the two groups, but the rates of adult respiratory distress syndrome (8 vs. 20%; p < 0.05) and mortality (10 vs. 21%; p < 0.05) were significantly reduced in the TCT group. CONCLUSIONS: TCT is highly sensitive in detecting thoracic injuries after blunt chest trauma and is superior to routine CXR in visualzing lung contusions, pneumothorax, and hemothorax. Early TCT influences therapeutic management in a significant number of patients. We therefore recommend TCT in the initial diagnostic work-up of patients with multiple injuries and with suspected chest trauma because early and exact diagnosis of all thoracic injuries along with sufficient therapeutic consequences may reduce complications and improve outcome of severely injured patients with blunt chest trauma.     

Blood alcohol levels in a series of injured patients with special reference to accident and type of injury

Blood alcohol was determined in 1012 injury victims. It was found that the alcohol involvement (AI) rate was 37% in the total number of patients, 19% in industrial, 38% in traffic, 36% in home, 45% in other freetime accidents, and 69% in the victims of fights, assaults, and suicide attempts. The most common external cause of injury was falling (447 cases) with an AI rate of 38%, while the 172 other nontraffic true accident cases had a rate of 24%. The road and stairs were the usual places of falls while intoxicated. Head injuries had a high (47%) and upper extremity injuries a low (25%) AI rate. Tibial and ankle fractures were also very often associated with alcohol intake. Contrarily to traffic and industrial accidents the slightly injured at home and in other freetime environments had been drinking more frequently than the severely injured. The data suggest that alcohol is a powerful contributing factor in leisure-time injuries. Head and low leg are especially vulnerable in drunken persons. Not only driving but even when walking while intoxicated means taking risks.