Jaggery: an avoidable cause of severe, deadly pediatric burns.

BACKGROUND: Jaggery is the non-industrial refinement of sugar cane into a sugar product. Sugar cane cultivation, harvest and refinement are central aspects of rural Indian life. METHODS: We present a retrospective review of pediatric burns at a single institution in Southern India, drawing special attention to scald burns incurred when young children fall into the cauldron of boiling jaggery. Descriptive statistics comparing children burned by jaggery and children burned by other mechanisms were performed. Multivariable logistic regression including burn size and mechanism of burn (jaggery and non-jaggery) was performed to determine the increased risk of death when burned by jaggery. RESULTS: Children burned by jaggery immersions are older, more likely male, and have larger burns. They have longer hospital stays, more operations, and are more likely to die. When controlling for age, gender, size of burn, and mechanism, jaggery exposure was associated with a higher mortality. DISCUSSION: Jaggery burns are deadly, devastating burns which could be prevented. While jaggery and sugar cane production can lead to economic independence for rural Indian villages, the cost it exacts from burns and death to the youngest and most vulnerable children must be addressed and prevented.

The 2003 Carl A Moyer Award: real-time metabolic monitors, ischemia-reperfusion, titration endpoints, and ultraprecise burn resuscitation.

Real-time metabolic monitoring of varied vascular beds provides the raw data necessary to conduct ultraprecise burn shock resuscitation based on second-by-second assessment of regional tissue perfusion. It also illustrates shortcomings of current clinical practices. Arterial base deficit was continuously monitored during 11 clinical resuscitations of patients suffering burn shock using a Paratrend monitor. Separately, in a 30% TBSA rat burn model (N = 70), three Paratrend monitors simultaneously recorded arterial blood gas and tissue pCO2 of the burn wound and colonic mucosa during resuscitation at 0, 2, 4, 6, and 8 ml/kg/%TBSA. Paratrend data were analyzed in conjunction with previously reported laser Doppler images of actual burn wound capillary perfusion. With current clinical therapy, continuous monitoring of arterial base deficit revealed repetitive cycles of resolution/worsening/resolution during burn shock resuscitation. In the rat model, tissue pCO2 in both burn wounds and splanchnic circulation differed depending on the rate of fluid resuscitation (P <.01 between sham and 0 ml/kg/%TBSA and between 2 ml/kg/%TBSA and 4 ml/kg/%TBSA). Burn wound pCO2 values correlated well with laser Doppler determination of actual capillary perfusion (rho = -.48, P <.01). The following conclusions were reached: 1). Gratuitous and repetitive ischemia-reperfusion-ischemia cycles plague current clinical therapy as demonstrated by numerous "false starts" in the resolution of arterial base deficit; 2). in a rat model, real-time monitoring of burn wound and splanchnic pCO2 demonstrate a dose-response relationship with rate of fluid administration; and 3). burn wound and splanchnic pCO2 are highly correlated with direct measurement of burn wound capillary perfusion by laser Doppler imager. Either technique can serve as a resuscitation endpoint for real-time feedback-controlled ultraprecise resuscitation.

Carpal injuries in children.

Pediatric carpal injury is unusual. Because of its rarity and imaging difficulties, the diagnosis is often delayed. Open reduction is advocated for displaced injuries. Pin fixation provides temporary stabilization of displaced injuries without permanently compromising joint motion. In older children, intercarpal fusion may be elected for treatment of intercarpal instability.

Behavioral risk factors among women presenting for genetic testing.

Considerable research attention has been given to the impact of genetic testing on psychological outcomes. Participation in genetic testing also may impact on health behaviors that increase the risk of cancer and other chronic diseases. The purpose of this study is to describe behavioral cancer risk factors of women who requested genetic testing for breast and ovarian cancer susceptibility (BRCA1, BRCA2). Before participation in a genetic testing program, 119 women completed a series of questionnaires designed to assess their health behaviors, perception of risk, and depressive symptomatology. Eight percent of participants were current smokers, 27% did not engage in at least moderate exercise, 46% did not regularly protect themselves from the sun, 39% did not consume at least five servings of fruits and vegetables per day, and 9% drank at least one alcoholic beverage per day. Poisson regression analysis revealed that age was the only predictor of behavioral risk profiles, with older women having fewer cancer risk behaviors. These patients who presented for genetic testing generally had better health behaviors than the general population. However, given their possible high-risk status, these patients should consider further improving their preventable cancer risk factors and, in particular, their diet, sun protection, and physical activity levels. Inclusion of behavioral risk factor counseling in the context of the genetic testing process may be an important opportunity to reach this at-risk population.

Influence of a mindfulness meditation-based stress reduction intervention on rates of skin clearing in patients with moderate to severe psoriasis undergoing phototherapy (UVB) and photochemotherapy (PUVA).

OBJECTIVE: This study tests the hypothesis that stress reduction methods based on mindfulness meditation can positively influence the rate at which psoriasis clears in patients undergoing phototherapy or photochemotherapy treatment. METHODS: Thirty-seven patients with psoriasis about to undergo ultraviolet phototherapy (UVB) or photochemotherapy (PUVA) were randomly assigned to one of two conditions: a mindfulness meditation-based stress reduction intervention guided by audiotaped instructions during light treatments, or a control condition consisting of the light treatments alone with no taped instructions. Psoriasis status was assessed in three ways: direct inspection by unblinded clinic nurses; direct inspection by physicians blinded to the patient's study condition (tape or no-tape); and blinded physician evaluation of photographs of psoriasis lesions. Four sequential indicators of skin status were monitored during the study: a First Response Point, a Turning Point, a Halfway Point, and a Clearing Point. RESULTS: Cox-proportional hazards regression analysis showed that subjects in the tape groups reached the Halfway Point (p = .013) and the Clearing Point (p = .033) significantly more rapidly than those in the no-tape condition, for both UVB and PUVA treatments. CONCLUSIONS: A brief mindfulness meditation-based stress reduction intervention delivered by audiotape during ultraviolet light therapy can increase the rate of resolution of psoriatic lesions in patients with psoriasis.

Coronal fracture of the hamate body.

A case of a displaced coronal fracture of the hamate body with a 1-month delay in diagnosis is presented with a review of the literature regarding hamate-body fractures. Mechanism, diagnosis, and treatment options are discussed. This diagnosis should be suspected on initial review of plain radiographs, which must include an oblique view in any patient presenting with pain after blunt trauma to the hand. Open reduction with internal fixation is reserved for unstable, displaced fractures. Care should be taken to preserve the vascular supply to the displaced fragment, and a two-incision technique is recommended to minimize risk to the motor branch of the ulnar nerve.

Testicular torsion.

A retrospective review of 80 patients who underwent scrotal exploration for presumed testicular torsion is presented. Of these, 67 patients were found to have torsion, and the testicular loss rate was 51%. Patients who experienced delays in scrotal exploration of more than 24 h from onset of symptoms had a testicular loss rate of 71%. These delays arose from both hesitation in seeking medical treatment and misdiagnoses. It is emphasized that an acute scrotum in a child or in an adolescent should be explored early to exclude torsion.

Comparison of the effects of five adjuvants on the antibody response to influenza virus antigen in guinea pigs.

Five adjuvants were tested for their effect on the immune response in guinea pigs to the hemagglutinin antigen of influenza virus strain B/Panama. Vaccines containing 924 micrograms of hemagglutinin antigen/ml were prepared at high and low doses of Freund's complete and incomplete adjuvants, Syntex adjuvant, RIBI's adjuvant, TiterMax adjuvant, and aluminum phosphate adjuvant. Responses to these vaccines were compared with those to a control vaccine containing influenza virus B/Panama hemagglutinin antigen and saline. On day 28, vaccines containing the following adjuvant doses had significantly higher titers than the titer for the control: Freund adjuvants at high and low doses, RIBI at high dose, TiterMax at high and low doses, and aluminum phosphate at high dose. On day 42, vaccines containing the following adjuvant doses had significantly higher titers than that for the control: Freund adjuvants at high and low doses, RIBI at high dose, TiterMax at high dose, and aluminum phosphate at high dose. Freund adjuvants at high and low doses, RIBI adjuvant at high dose, and aluminum phosphate at high dose caused significantly greater swelling at the inoculation site than did the control vaccine. TiterMax adjuvant at high and low doses, and aluminum phosphate at low dose caused minor swelling at the inoculation site, but it was not significantly different from the swelling caused by the control vaccine. Syntex adjuvant at high and low doses, RIBI at low dose, and control (saline/antigen) at high and low doses caused no swelling after inoculation. Overall, the high dose of adjuvants caused greater tissue swelling than did the low dose of adjuvants.(ABSTRACT TRUNCATED AT 250 WORDS)

Osteoid osteoma of the upper extremity.

Osteoid osteomas, relatively rare lesions in the upper extremity, can be a persistent source of hand or wrist pain. Patients under age 40 who have otherwise unexplained pain should be evaluated. Relief of pain with oral nonsteroidal anti-inflammatory drugs should suggest the possibility of osteoid osteoma. Examination may demonstrate localized swelling or joint effusion. Radiographs should be examined for sclerosis in the region of pain. If radiographs are nondiagnostic, a bone scan should be obtained. If the nidus cannot be clearly visualized by radiography and bone scan, a CT scan should be obtained. If the location of the nidus makes excision difficult without removal of a large block of bone, localization with a CT-guided needle or by radioisotope labeling will help to assure removal of the nidus.

Functional outcome following traumatic upper limb amputation and prosthetic limb fitting.

Nineteen consecutive patients underwent traumatic upper limb amputation for nonreconstructible or replantible upper limb injury at a Level I trauma center over a 9-year-period. Eleven amputations were at the transradial level, five were transhumeral, and three were shoulder disarticulation. Eighteen patients underwent prosthetic limb fitting. Fifteen of the 18 initially underwent preparatory prosthetic limb fitting within 30 days following amputation with a body-powered, cable-driven prosthesis. Seventeen of the 18 achieved sufficient proficiency with their prostheses to allow them to return to work. Of these, 15 maintained daily functional prosthetic use of at least 8 hours daily at a followup examination of 12 to 110 months. Use of prosthetic limb following traumatic upper limb amputation carries a high probability for functional rehabilitation if limb fitting and prosthetic training are instituted as soon as the residual limb can tolerate the prosthetic socket as opposed to waiting for the residual limb to "mature".

The role of the interosseous membrane and triangular fibrocartilage complex in forearm stability.

This study investigated the relative roles of the interosseous membrane (IOM) and triangular fibrocartilage complex (TFCC) in the transmission of force from the hand to the humerus. Our findings suggest a spectrum of forearm destabilizing injuries. The intact radius abutting the capitellum provides the primary restraint to proximal migration of the radius. After radial head excision, up to 7 mm of proximal radial migration can occur under axial compression. If the TFCC or the IOM alone is disrupted, little alteration in load or displacement is evident. When both the midportion of the IOM and TFCC are incompetent, however, further proximal radial migration occurs, the radial stump abuts the humerus, and load is shifted back to the radial column. These data suggest that the central portion of the IOM is the crucial structural subdivision within the IOM acting as a restraint to proximal radial migration. The TFCC also resists proximal radial migration and participates in load transfer. We propose that clinical migration of the radius under an axial load greater than 7 mm implies disruption of both the midportion of the IOM and TFCC.

Management of intra-articular fractures of the metacarpophalangeal joint.

Displaced intra-articular fractures of the metacarpal head and of the proximal articular surface of the proximal phalanx often require open reduction and internal fixation, particularly if an articular step off is present. If secure internal fixation can be achieved, early motion may be instituted. Diagnosis may be facilitated by special views and tomography. Secondary reconstructive procedures may include tenolysis, osteotomy, arthroplasty, or tissue transfer from the foot.

Complications of the treatment of cubital tunnel syndrome.

Cubital tunnel syndrome is the most common entrapment of the ulnar nerve. Complications in the treatment of cubital tunnel syndrome may be caused by errors in diagnosis, errors in conservative management, and errors of surgical treatment. This article discusses each cause of complications separately, with a division in errors of surgical treatment into complications from decompression of the ulnar nerve, medial epicondylectomy, anterior transposition of the ulnar nerve, intramuscular transposition of the ulnar nerve, subcutaneous transposition of the ulnar nerve, submuscular transposition of the ulnar nerve, and failed surgical treatment.

Nonepiphyseal ossification and pseudoepiphysis formation.

Direct ossification extending from the metaphysis into the epiphysis preceded and continued to be more mature than formation and expansion of the typical epiphyseal ossification center at the opposite end of each longitudinal bone of the hand and foot. Direct metaphyseal to epiphyseal ossification usually started centrally and expanded hemispherically, replacing both physeal and epiphyseal cartilage simultaneously. When remnants of the "physis" were retained, however, while juxtaposed epiphyseal cartilage was replaced, a pseudoepiphysis formed. Three basic patterns of pseudoepiphysis formation were evident: (a) a central osseous bridge, (b) a peripheral osseous bridge, and (c) multiple bridging. In each condition, the remnant of the "physis" lacked typical cell columns capable of contributing to the postnatal longitudinal growth of the involved bone. Pseudoepiphyses were well formed by 4-5 years and coalesced with the rest of the bone months to years before skeletal maturation was attained at the opposite epiphyseal end.

Ossification and pseudoepiphysis formation in the "nonepiphyseal" end of bones of the hands and feet.

Metacarpals, metatarsals, and phalanges were studied to assess the developmental morphology of "secondary" ossification in the "nonepiphyseal" ends of these bones as well as the formation of the pseudoepiphysis as an epiphyseal ossification variant. Both direct ossification extension from the metaphysis into the epiphysis and pseudoepiphysis formation preceded, and continued to be more mature than, formation and expansion of the "classic" epiphyseal (secondary) ossification center at the opposite end of each specific bone. Direct metaphyseal to epiphyseal ossification usually started centrally and expanded hemispherically, replacing both physeal and epiphyseal cartilage simultaneously. In contrast, when remnants of "physis" were retained, while juxtaposed epiphyseal cartilage was replaced, a pseudoepiphysis formed. There were three basic patterns of pseudoepiphysis formation. First, a central osseous bridge extended from the metaphysis across the "physis" into the epiphysis and subsequently expanded to create a mushroom-like osseous structure. In the second pattern a peripheral osseous bridge formed, creating either an osseous ring or an eccentric bridge between the metaphysis and the epiphysis. In the third pattern, multiple bridging occurred. In each situation the associated remnant "physis" lacked typical cell columns and was incapable of significantly contributing to the postnatal longitudinal growth of the involved bone. Pseudoepiphyses were well formed by 4-5 years and coalesced with the rest of the bone months of years before skeletal maturation was attained at the opposite epiphyseal end, which ossified in the typical pattern (i.e., formation of a secondary center de novo completely within the cartilaginous epiphysis). This process may also affect the development and appearance of ossification within the longitudinal epiphyseal bracket ("delta phalanx").

Cross-sectional geometrical properties and bone mineral contents of the human radius and ulna.

The mechanical strength of the human radius and ulna depends on their geometrical and material properties. This study quantifies the cortical bone cross-sectional properties of the adult radius and ulna (cross-sectional area, thickness, centroids, area moments of inertia and section moduli) using computerized tomographic (CT) scanning coupled with image processing along the lengths of eight human cadaveric forearms. Bone mineral mass and apparent ash density were also quantified at serial locations. Sites of significant variation of selected geometric and mineral properties along the length of each forearm bone were determined. Our results show that interpolation of CT measurements made at 10 and 30% of the radial length in the radius and 30 and 90% of the radial length in the ulna can provide approximate geometric values over the 10-90% region. This information can be used to develop a protocol using the fewest sites to clinically assess changes in forearm bone geometry. Regression analyses did not show significant linear relationships between geometric properties and apparent cortical ash density. Thus, CT derived geometric properties are not helpful in estimating the extent of changes in bone density. Area moment of inertia results suggest that the junction of the middle and distal third of the radius, and the ulnar shaft region may have increased vulnerability to fractures. The former is likely due to the change in moment of inertia values, whereas the latter is due to the relatively small magnitude of cross-sectional moments along the ulnar shaft as compared to the proximal or distal ends. This is consistent with fracture patterns observed clinically when a single forearm bone is fractured: Galeazzi fracture of the radius and nightstick fracture of the ulna.

Congenital constriction band syndrome. Pathophysiology and treatment.

The clinical manifestations of 88 children with congenital constriction band syndrome involvement of the hand were reviewed. Seventy-five of these children had evidence of digital or limb amputations, with 235 upper limb amputations and 138 lower limb amputations. In the hand, digital amputations were most common in the index, middle, and ring fingers, whereas in the foot, amputations of the hallux were most often noted. Band indentation was often present at multiple levels. Proximal bands may be associated with neural compression. Syndactyly was invariably associated with a proximal interdigital sinus or cleft and was frequently associated with distal amputation. Examination of a 27-week gestation stillborn specimen having manifestations of congenital constriction band syndrome demonstrated the intrauterine biologic response to band constriction. The variable clinical manifestations of congenital constriction band syndrome can best be explained as the response of the growing, embryologically defined limb to intrauterine deformation or band-induced compression and ischemia.

The pathology of acute chondro-osseous injury in the child.

Skeletal tissues from children sustaining acute skeletal trauma were analyzed with detailed radiologic and histologic techniques to assess the failure patterns of the developing skeleton. In the physis- and epiphysis-specific fracture propagation varied, usually going through the portion of the hypertrophic zone adjacent to the metaphysis. However, the physeal fracture in types 1 and 2 sometimes involved the germinal zone. There may also be microscopic propagation at oblique angles from the primary fracture plane, splitting cell columns apart longitudinally. The cartilage canals supplying the germinal zone appear to be "weak" areas into which the fracture may propagate, especially in infancy. Incomplete type 1 physeal fractures, which cannot be detected by routine radiography, may occur. Types 1, 2, and 4 physeal injuries may be comminuted. In type 3 injuries, discrete segments of physis that include the germinal zone may "adhere" to the metaphysis, separating the cells from their normal vascularity. In types 2 and 3, comminution may occur at the site of fracture redirection from the physis. Direct type 5 crushing of the physeal germinal zone does not occur, even in the presence of significant pressure-related changes within other areas of the epiphysis. Type 7 separation between cartilage and bone at any chondro-osseous epiphyseal interface may occur, but is similarly impossible to diagnose radiographically. In the metaphysis torus, fractures result from plastic deformation of the cortex, coupled with a partial microfracturing that may be difficult to visualize with clinical radiography. Some of the energy absorption may also be transmitted to the physis, causing metaphyseal hemorrhage adjacent to the growth plate and variable microscopic damage within the physis. In the diaphysis, the greenstick fracture is associated with longitudinal tensile failure through the developing osteons of the "intact" cortex. The inability of these failure patterns to "narrow" after the fracture force dissipates is the probable cause of retained bowing (plastic deformation). In both torus and greenstick fractures, the fractured bone ends show micro-splitting through the osteoid seams. In the diaphysis, metaphysis, and epiphyseal ossification center there may be areas of focal hemorrhage and microfracture that correlate with the reported MRI phenomenon of "bone bruising." Again, such injury cannot be diagnosed during routine radiography.