Seasonal flu-vaccination in the immunocompromised burns patient.

BACKGROUND AND AIMS: Influenza is a serious disease which can be life threatening. Patients with significant burns have reduced physiological reserve and are at risk both of incurring dangerous respiratory complications. In other susceptible patient groups the flu vaccine is used to reduce the risk of flu and lessen its effects. We aim to investigate whether there were any existing local and national trends in the use of flu vaccination in burns patients. Our second objective was to review any current evidence in the literature. METHODS: A questionnaire was carried out of consultants in our own health board and of 5 of the major burns units in the UK to assess current practice. RESULTS: None of the local respondent were aware of any existing guidelines. None of the external units contacted reported the use of a guideline for flu vaccination in burns patients. On searching the literature there were no existing studies investigating the use of flu vaccination in burns patients. CONCLUSIONS: Through review of the literature on flu vaccination in immunocompromised patients we show how this could be extrapolated to patients with significant burns. We propose a guideline to aid in the decision to prescribe flu vaccine to patients with significant burns taking into account age, % TBSA burn and comorbidity. The decision to recommend the flu vaccine in this group should be considered on an individual basis. However, flu vaccination represents a simple, low-risk measure which could prevent the dangerous complications of influenza in an at risk group.

Universal decontamination of hospital surfaces in an occupied inpatient room with a continuous 405 nm light source.

BACKGROUND: Previous work has shown that a ceiling-mounted, 405 nm high-intensity narrow-spectrum light environmental decontamination system (HINS-light EDS) reduces bacterial contamination of environmental surfaces in a burns unit by between 27% and 75%. Examination of the efficacy of the light over extended exposure times and its probable mode of action was performed. AIM: To ascertain the correlation between bacterial kill achieved on sampled surface sites around the burns unit and both irradiance levels of the 405 nm light, and exposure time. METHODS: Seventy samples were taken using contact agar plates from surfaces within an occupied side-room in the burns unit before, during, and after a seven-day use of the HINS-light EDS. This was repeated in three separate studies. Statistical analysis determined whether there was significant decrease in environmental contamination during prolonged periods of HINS-light treatment, and whether there was an association between irradiance and bacterial kill. FINDINGS: A decrease of between 22% and 86% in the mean number of surface bacteria was shown during the use of the HINS-light EDS. When the light ceased to be used, increases of between 78% and 309% occurred. There was no correlation between bacterial kill and irradiance levels at each sampling site but strong correlation between bacterial kill and exposure time. CONCLUSION: Prolonged exposure to the HINS-light EDS causes a cumulative decontamination of the surfaces within a burns unit. The importance of exposure time and possible airborne effect over irradiance levels is emphasized.

Environmental decontamination of a hospital isolation room using high-intensity narrow-spectrum light.

The performance of a new decontamination technology, referred to as 'high-intensity narrow-spectrum light environmental decontamination system' (HINS-light EDS) was evaluated by a series of three studies carried out in a hospital isolation room used to treat burns patients. The ceiling-mounted HINS-light EDS emits high-intensity 405nm light which, although bactericidal, is harmless to patients and staff thereby permitting continuous environmental disinfection throughout the day. Performance efficacy was assessed by contact agar plate sampling and enumeration of staphylococcal bacteria on environmental surfaces within the room before, during and after HINS-light EDS treatment. When the room was unoccupied, use of HINS-light EDS resulted in ∼90% reduction of surface bacterial levels and when the room was occupied by an MRSA-infected burns patient, reductions between 56% and 86% were achieved, with the highest reduction (86%) measured following an extended period of HINS-light EDS operation. In an on/off intervention study, surface bacterial levels were reduced by 62% by HINS-light EDS treatment and returned to normal contamination levels two days after the system was switched off. These reductions of staphylococci, including Staphylococcus aureus and meticillin-resistant S. aureus, by HINS-light EDS treatment were greater than the reductions achieved by normal infection control and cleaning activities alone. The findings provide strong evidence that HINS-light EDS, used as a supplementary procedure, can make a significant contribution to bacterial decontamination in clinical environments.

Tertiary resurfacing after one of the first free flaps in Europe, a reflection on 30 years of microsurgical progress.

Free flaps have been used for over 30 years. During this period, improved anatomical understanding has increased donor options and available pedicle lengths, permitting safer, single-stage reconstructions with simpler anastomoses. Refinements, such as perforator flaps in particular, have greatly improved donor morbidity, recipient site cosmesis, and the ability to replace 'like with like' while retaining options for innervation. This case highlights the evolution from one of Europe's first free tissue transfers, effectively a perforator flap, through the advent of free muscle flaps to the current generation of contourable perforator flaps. Free flap transfer has become increasingly sophisticated, safer, and more predictable, yet the potential quality of reconstructive outcome has changed little.

Assessment of burn depth: a prospective, blinded comparison of laser Doppler imaging and videomicroscopy.

INTRODUCTION AND AIMS: There is a need, both in clinical and research settings, for an affordable, objective method of assessing burn depth. This study compares burn depth assessment by videomicroscopy with laser Doppler imaging (LDI) in patients with dermal burns. The videomicroscope is inexpensive compared to LDI, and can visualise the dermal capillary structure, therefore potentially allowing objective assessment of dermal burn injuries. METHODS: Patients admitted <72 h post-injury were included in the trial. Blinded LDI and videomicroscopy assessments were carried out. The patients were then followed up to one of three end-points: primary healing without surgery; early surgery; delayed healing and subsequent split skin grafting. The incidence of infection was also noted. RESULTS: Twenty-seven burn wounds were examined. In superficial partial thickness injuries, the videomicroscope reliably demonstrated an intact or nearly intact dermal vascular structure, progressing through to large amounts of capillary destruction and haemoglobin deposition in deep partial thickness injuries and complete destruction in full thickness injuries. The videomicroscope findings correlated strongly with both those of the LDI (p<0.001) and with clinical outcome (p<0.001). DISCUSSION: The videomicroscope is capable of accurately and objectively assessing burn depth. The results correlated well with both the clinical outcome and the laser Doppler findings. In addition, videomicroscopy is significantly cheaper than LDI and avoids several of the disadvantages of LDI.

Are burns photographs useful?

UNLABELLED: Routine photography of all patients admitted to the West of Scotland Regional Burns Unit was introduced in 2003. To date, there are few burns units to evaluate the usefulness of photographs taken. AIM: To assess the usefulness of photographs of patients admitted to the burns unit to various members of the multidisciplinary team. METHOD: A questionnaire was completed by hospital staff involved in the management of burns patients over a 3-month period. A total of 43 questionnaires were completed. RESULTS: The majority of questionnaires were completed by nursing staff (55%) followed by medical staff (23%); physiotherapy (5%); anaesthetists (7%); theatre staff (5%); students (2%); dietician (2%). About 98% of respondents agreed that photographs were useful overall, particularly for teaching purposes. About 9% disagreed that photographs were useful for assessment due to difficulty in assessing depth of burn. About 72% agreed that the photographs were useful for patient management and improve patient care. About 88% agreed that all patients should have photographs available in future. Advantages of photographs include; moving and handling of patients; patient positioning in theatre; reviewing wound healing and complications. They are useful for assessing site, size and type of burn. Disadvantages include difficulty in assessing depth of burn, technical factors, and unavailability out of hours. CONCLUSIONS: Photographs of burns patients are useful overall to all members of the multidisciplinary team.

The influence of crosslinking agents and diamines on the pore size, morphology and the biological stability of collagen sponges and their effect on cell penetration through the sponge matrix.

Artificial skin substitutes based on autologous keratinocytes cultured on collagen substrata are being developed for treating patients with severe burns. The properties of the collagen substrate can be manipulated, for example, by crosslinking, to optimize desirable properties such as cell growth and penetration into the substrate, biological stability and mechanical strength. Collagen sponges crosslinked with 1-ethyl-3-(3-dimethylaminopropyl)carbodiimide (EDAC) and the diamine, diaminohexane, were used to determine the effect of crosslinking on pore size and morphology, on the stability of the crosslinked sponges both in cell culture media and during incubation with collagenase, and on the penetration of keratinocytes and fibroblasts through the sponge matrix. Crosslinking of the sponges reduced the pore size, particularly at the surface, and altered sponge morphology. After crosslinking the collagen fibers were thinner, and appeared lacy and delicate. Crosslinking also influenced sponge stability. In keratinocyte serum-free medium the pore size of plain collagen sponges increased with increasing incubation time, and crosslinking appeared to prevent this, and may have stabilized sponge structure. Incubation in serum-containing Dulbecco's minimum essential medium caused a marked reduction in pore size in both plain collagen and crosslinked collagen sponges. Crosslinking did not appear to influence this cell-free contraction of collagen sponges. Treatment of sponges with EDAC markedly increased the resistance of sponges to collagenase digestion. The penetration of both keratinocytes and fibroblasts was retarded by crosslinking the sponges. Fibroblasts penetrated through the sponges to a greater extent than keratinocytes, and their proliferation rate was faster. The total number of cells populating the crosslinked sponges after 10 days culture was approximately 50% of that on untreated collagen sponges. The mechanism responsible for this effect was different with the two crosslinkers used. Diaminohexane appeared to inhibit cell growth, whereas EDAC may have caused a decrease in cell adhesion to the sponges, without an apparent inhibition of growth rate. In terms of morphology, fibroblasts were elongated to a greater extent on crosslinked sponges, and alligned themselves along the collagen fibers. Keratinocytes grew in colonies on untreated sponges, but on crosslinked sponges they grew in isolation, with minimal cell-cell interactions. It may be necessary to reach a compromise to obtain the best combination of properties for using collagen sponges as substrata for artificial skin substitutes.

Successful free flap transfer following venous thrombectomy in recipient vessel.

We report the case of a 53-year-old male patient who suffered a high velocity multiple trauma with bilateral open tibial fractures. At definitive orthopaedic and plastic surgical reconstruction 5 days post initial trauma, he was found peroperatively to have an existing deep venous thrombosis in his popliteal vein on one side. He underwent venous thrombectomy and had subsequent successful latissimus dorsi flap transfer using the unblocked popliteal vein as a recipient vessel.

Endoscopic transaxillary subglandular breast augmentation using silicone gel textured implants.

We present our experience with endoscopic transaxillary subglandular breast augmentation using textured silicon gel implants. Fourteen implants were placed in seven patients through a 4 cm axillary incision, in a subglandular pocket, with the help of a 10 mm, 30 degrees endoscope with a subcutaneous retractor and endoscopic diathermy. The implant was inserted with the help of a plastic bag. No drains were left in place. The duration of the procedure was 1 h 30 min in the most recent cases. Bleeding during surgery was kept to a minimum, and there were no complications such as capsular contracture, hematoma, or hypertrophic scar. Infection occurred in one implant and it was necessary to extract it. This technique is an excellent tool for patients requiring subglandular implants who prefer a distant incision. It provides good control over dissection and allows the use of silicone gel implants, thus avoiding the risk of deflation. In addition, recovery is faster and there is less bruising and pain.

Use of tissue glue in field situations.

Tissue glues are in widespread use in Accident & Emergency departments, and are simple to use. Results of closure of uncomplicated wounds using glue are comparable to traditional methods such as suture, 'sterile strips'. There are certain times in the field situation where evacuation of a casualty with a simple laceration could be impossible. These circumstances could be suitable for an individual suitably trained to effect wound closure using a tissue glue. This study simply set out to establish whether it was possible to train an infantry soldier how and when to close a wound using a tissue glue. A short period of instruction was followed by a practical session using wound simulators. It was found that the theoretical concepts and practical skills required to successfully glue a simulated wound were readily acquired by infantry soldiers, irrespective of their previous level of first aid training. The authors suggest that this concept should be pursued with the aim of field trials of cyanoacrylate tissue adhesives being carried out.

Magnetic resonance imaging of acute tendon injury in the finger.

Accurate assessment of flexor tendon function in a digit with an acute, non-penetrating injury is difficult. MR imaging can negate the need for surgical exploration and the associated morbidity.

A pigmented lesion clinic: analysis of the first year's 1055 patients.

The Pigmented Lesion Clinic (PLC) at Frenchay Hospital was started in January 1993 to deal rapidly and effectively with a growing number of referrals of suspicious pigmented lesions. Its objectives were to offer expert assessment and either reassurance or excision at the first PLC following referral by the patient's general practitioner. During 1993, 1055 patients were seen in 37 PLCs and 357 excision biopsies were performed. We have compared the Breslow thicknesses of malignant melanomas diagnosed from the PLCs with those of all other (non-PLC) malignant melanomas referred to our unit over the same period. We discuss the development and results of the first year of our PLC and the advantages it confers.

Mammography and breast implants.

Mammography in the presence of breast implants is complicated by the opacity of the implants, the displacement of breast tissue by the implant, and the presence of secondary changes such as calcification within a fibrous capsule. A special technique of mammography, known as the displacement technique, has been developed by Eklund in the USA, where it is widely used. The displacement technique of X-ray mammography has been shown to provide superior results to the standard compression method. We conducted a telephone survey of 23 mammography units in order to assess mammographic practice in the United Kingdom for the patient with breast implants. We found a wide variation in practice. There was a general lack of awareness of the displacement technique and of its advantages. Only 4 mammography units in our sample (17.4%) used the displacement technique.

Corneal burns with eyelid sparing and their treatment.

In a flash injury the eyes are protected by the blink reflex. With our patients the eyes were open looking for a means of escape, exposing the globe to injury by hot smoke and protecting the eyelids. It is essential to examine the eyes in any facial burn, especially if there is any history of being injured in an enclosed space. If there are any signs of corneal injuries then the assistance of an ophthalmologist should be sought.

Penetrating abdominal stab wounds: a plea for a more conservative policy.

This is a retrospective study of 107 penetrating abdominal stab wounds which have been reviewed on the basis of the clinical indications for surgery. Eighty-four patients underwent laparotomy. The unnecessary laparotomy rate was 35 per cent and the mortality 2.4 per cent. Important complications developed in 44 per cent of those undergoing surgery. Evaluation of clinical variables is presented and it is suggested that in the absence of shock, generalized peritonitis or evisceration, careful initial assessment, monitoring and regular re-examination would be a satisfactory method of treatment for many cases. This would result in a decrease in unnecessary laparotomies and associated excess morbidity.

Effect of intravenous naftidrofuryl on transcutaneous oxygen pressure in severe peripheral vascular disease.

Intravenous naftidrofuryl has been shown to improve transcutaneous oxygen pressure values in patients with severe ischemia of the lower limbs who were considered unsuitable for reconstructive surgery. Although it did not alter the outcome in patients with rest pain, the clinical impression is that it afforded symptomatic relief for a period of time. Clinical implications of these findings require further long-term studies.