Healing of chronic sickle cell disease-associated foot and ankle wounds using transdermal continuous oxygen therapy.

OBJECTIVE: Sickle cell disease (SCD) is a complex cause of capillary stasis that can lead to lower extremity venous ulcers. Since SCD is characterised by impaired oxygen delivery that can be exacerbated by lower extremity venous stasis, we sought to determine if direct delivery of oxygen to a lower extremity ulcer associated with SCD could augment healing. METHOD: We performed a pilot study of a portable device that delivers oxygen directly to the wound site to assess this possibility. The device was assessed in a single patient with three longstanding wounds of the lower extremities associated with SCD: the lateral right ankle, the medial aspect of the distal left leg, and the dorsal left foot. The left leg and left foot wounds received 15 weeks of treatment each. RESULTS: Both left lower extremity wounds healed, and neither wound has relapsed in the 42 months since the treatment was completed. At 36 months from the completion of treatment, the patient presented to the hospital with renal failure, and with the 27 days of complete bed rest and wound elevation, the right ankle wound shrunk to 55% of the original wound surface area. Transdermal oxygen appears to have assisted in healing and to have provided a sustained benefit that has delayed relapse of the two SCD-associated leg ulcers that received an extended course of treatment. Similarly, complete bed rest appears to aid in the healing of SCD-associated leg ulcers. Further study is needed to determine the mechanism of action and the optimal method of use of the transdermal continuous oxygen delivery device for SCD-associated lower extremity ulcers. DECLARATION OF INTEREST: No competing financial interests exist for any author. The content of this article was expressly written by the authors listed. No ghostwriters were used to write this article.

A quality assessment of randomized control trials of primary treatment of breast cancer.

The methodology of randomized control trials (RCTs) of the primary treatment of early breast cancer has been reviewed using a quantitative method. Sixty-three RCTs comparing various treatment modalities tested on over 34,000 patients and reported in 119 papers were evaluated according to a standardized scoring system. A percentage score was developed to assess the internal validity of a study (referring to the quality of its design and execution) and its external validity (referring to presentation of information required to determine its generalizability). An overall score was also calculated as the combination of the two. The mean overall score for the 63 RCTs was 50% (95% confidence interval [CI] = 46% to 54%) with small and nonstatistically significant differences between types of trial. The most common methodologic deficiencies encountered in these studies were related to the randomization process (only 27 of the 63 RCTs adopted a truly blinded procedure), the handling of withdrawals (only 26 RCTs included all patients in the analyses), the description of the follow-up schedule (only 12 RCTs reported adequately), the report of side effects (adequate information given in 33 RCTs), and the description of the patient population (satisfactory in 29 RCTs). Telephone calls to the principal investigators improved the quality scores by seven points on a scale of 100, indicating that some of the deficiencies lay in reporting rather than performance. There was evidence that quality has improved over time and that the increasing tendency of involving a biostatistician in the research team was positively associated with the improvement of the internal validity but not with the external.

Frostbite of the face after recreational misuse of nitrous oxide.

Exposure of the skin to nitrous oxide, a liquified gas stored under pressure in a cylinder, can occur in anaesthesiologists and in those involved in recreational misuse of the gas. A case is reported of a man who presented to the emergency department after sniffing nitrous oxide and sustaining frostbite injury to his left cheek. Conservative management of this injury allowed spontaneous separation of the necrotic tissue and healing of the granulating wound by contraction.

Bilateral amputations following hydrotherapy tank burns in a paraplegic patient.

Hydrotherapy is an important part of wound care and physical therapy. The benefits of hydrotherapy are derived from water's cleansing ability, buoyancy, drag, inertia and temperature. If the temperature of the water is not adequately controlled, an immersion scald burn can occur. A paraplegic patient who was receiving hydrotherapy for treatment of his malleolar ulcers sustained immersion scald burns that ultimately necessitated below-the-knee amputations.

The use of recombinant human erythropoietin and cultured epithelial autografts in a Jehovah's Witness with a major thermal injury.

Haemostatic debridement, recombinant-human erythropoietin and cultured epithelial autografts have been used successfully in a Jehovah's Witness with a major burn injury. Tourniquet ischaemia complemented by a topical haemostatic agent minimized excisional blood loss, while recombinant-human erythropoietin accelerated erythropoiesis, thereby correcting postburn anaemia. Cultured epithelial autografts provided coverage of the granulating wounds without creating donor sites.

Surgeons', nurses' and bereaved families' attitudes toward dying in the burn centre.

Because death of a patient is one of the most emotionally disruptive events in the health professionals' life as well as the bereaved, it was hypothesized that surgeons' and nurses' attitudes in the burn centre would interfere with their emotional support of the bereaved family. Consequently, we performed a psychometric assessment of the surgeons', nurses' and bereaved families' attitudes about death and dying in the burn centre. A psychometric instrument was developed and validated that assessed 13 surgical directors' of burn centres, 13 burn nurses' and nine bereaved family members' attitudes on death and dying in the burn centre. In the case of the bereaved family member, this instrument was complemented by interviews to ensure that the respondents understood each question. All surgeons and nurses were experienced health professionals working for an average of 12 +/- 8 years and 3 +/- 1 years respectively. The majority of burn surgeons (six) and the burn nurses (seven) found it to be emotionally difficult to support emotionally the bereaved family after the death of the patient. Over half the burn surgeons (seven) and nurses (seven) felt that the process of dealing with the bereaved family was different from that experienced in other hospital settings. The surgeons attributed this difference to the long duration of the patients' illnesses, while the nurses felt that it was due to the traumatic and painful qualities of burn injury. These emotional difficulties experienced by the staff in dealing with the dying patients were associated with a relatively low frequency of contact with the bereaved families after the patients' death.(ABSTRACT TRUNCATED AT 250 WORDS)

Electrical burn injuries of workers using portable aluminium ladders near overhead power lines.

The use of aluminium ladders around high voltage power lines has resulted in a significant number of electrical injuries and electrocutions. Workers often misjudge wire distances or lose control of fully extended ladders, thereby exposing themselves to electrocution hazard. High-voltage electrical burns of two workers using an aluminium ladder that contacted a high voltage power line are reported. The circumstances surrounding the injury, the clinical management of the case, and the methods of prevention are presented and discussed.

Salvage of a patient with burn inhalation injury and pancreatitis.

A multidisciplinary approach by the staffs of the Emergency Department and the Regional Burn Center saved the life of a burn patient with an inhalation injury and pancreatitis. This successful treatment is attributed to ventilatory management using fibreoptic bronchoscopy in the Emergency Department, followed by burn eschar excision with coverage by cultured skin and non-operative management of an enlarging pseudocyst by percutaneous transgastric drainage.

New advances in automatic disposable rotating cartridge skin staplers.

This report describes the design, operation, and mechanical performance of Auto Suture Multifire Premium disposable skin staplers and staples in a biomechanical laboratory investigation and a clinical evaluation. The performance of this reloadable stapler has been compared with that of a new disposable skin stapler with a rotating cartridge, the Proximate RH stapler. The latter exemplifies a disposable skin stapler whose cartridge cannot be reloaded. The Auto Suture Multifire Premium disposable skin stapler has been designed so that its cartridge can be reloaded during a single surgical procedure. The most obvious advantage of this new device is that it substantially reduces the cost of skin stapling during surgery. Another unique benefit of this stapler is that it can accommodate either regular or wide staples, allowing the surgeon to use both size of staples without discarding the stapler. On the basis of this investigation, the Auto Suture Multifire Premium disposable skin stapler is recommended for skin incision and graft closure, since it provides maximal visualization of the wound as well as the staple during its formation. It delivers the staple into the skin or skin graft so that the topspan of the staple is above the skin or wound surface. In addition, the Auto Suture Multifire Premium disposable skin stapler has a prepositioning (precocking mechanism) that is controlled by the surgeon with minimal force, a mechanism which allows the stapler to hold its staple securely, even when its pointed legs extend beyond the delivery end of the stapler. The force required to form its staples is so low that the surgeon can staple repetitively without fatigue.(ABSTRACT TRUNCATED AT 250 WORDS)

Biomechanical performance of a disposable graft stapler with absorbable skin tacs.

A stapler has been specially designed for fixing skin grafts to the underlying wound. The stapler has a loading unit which can be reloaded with cartridges of absorbable tacs. Each tac is made of a polymer which is biocompatible with tissue. The stapler ejects the tac into the graft, reliably securing it to the underlying tissue. The force and work required to eject the tacs were significantly less than that needed to form the metal staples. The most obvious advantage of the tac is that the majority of the tacs spontaneously extrude after the first dressing change. The performance of the disposable graft stapler with absorbable skin tacs has been compared to that of the disposable skin stapler with metal staples.

Non-insulin-dependent diabetes mellitus: diagnostic and therapeutic challenges in the severely burned patient--a case report.

The purpose of this paper is to describe the management of a previously undiagnosed non-insulin-dependent diabetic patient with a severe burn injury. The hyperglycaemia and glucose intolerance following burn injury was complicated by the hyperglycaemia of diabetes mellitus. Intravenous insulin infusion monitored by hourly glucose levels was required to manage this hyperglycaemia. During day 11 postburn injury, this patient required 2104 units of insulin to control his hyperglycaemia. Aggressive detection and management of infections complemented by early debridement and coverage of the burn wound were other important considerations in the management of this patient. The diagnosis of non-insulin-dependent diabetes mellitus (NIDDM) was made after the patient recovered from his burn injury. His rehabilitation programme has included primary prevention strategies for NIDDM that focus on health-improving behaviours such as improved diet, exercise, and weight control.

Effect of the timing of tourniquet release on postoperative hematoma formation: an experimental animal study.

There is a controversy over when to release a pneumatic tourniquet after completing a hand surgical procedure. To study this controversy, we performed a standardized operation with tourniquet inflow occlusion on both lower legs of a series of rabbits. Total tourniquet time and the procedure performed, including intraoperative Bovie electrocautery of actual and potential bleeding points identified with 2.5 X loupe magnification, were identical on the two sides, except for the method of tourniquet release. On one leg, the tourniquet was released and all new bleeding points were controlled prior to wound closure. On the other leg, the tourniquet was released after the wound had been closed and dressed. Animals were injected with technetium-99m-labeled red blood cells and scanned to measure hematoma formation. Qualitatively, we observed more label in the leg whose tourniquet was released after wound closure in 17 of the 20 animals (p less than 0.005). Quantitatively, we also measured more mean label in the leg whose tourniquet was released after the wound was closed (p less than 0.001). Tourniquet release after wound closure was associated with greater hematoma formation.

Pilot study of a unique film dressing for the treatment of donor site wounds.

The clinical benefits of using the VENTEX Wound Dressing System (VWDS) (The Kendall Co.) in the management of donor site wounds were evaluated in this pilot study involving 10 informed and consenting patients. The study was a prospective, randomized, controlled study in which one donor site wound was managed with VWDS, and the other donor site wound on the same patient was managed by our standard of care, which involved the use of Xeroform gauze (The Kendall Co.). Each donor site wound was independently assessed daily for pain, rate of reepithelialization, adverse reactions, and ease of dressing use while patients were hospitalized. Quality of scar was assessed during regularly scheduled follow-up visits. The use of VWDS eliminated donor site pain and accelerated reepithelialization compared with Xeroform gauze. There were no adverse reactions associated with the use of VWDS. In contrast, there were two cases of suspected infection at the donor sites treated with Xeroform gauze. The VWDS was more complicated to apply and use compared with Xeroform gauze. There were no differences observed in scar quality of donor sites treated with these dressings.

Psychometric assessment of psychologic factors influencing adult burn rehabilitation.

This article describes psychometric assessment instruments that are available for the screening of psychosocial problems that can interfere with patient rehabilitation. Structured assessment of patient depression, anxiety, substance abuse, social support, and willingness to take control and responsibility for health care is important throughout all stages of the patient's treatment. There are psychometrically sound, relatively brief, and nonintrusive measures with which to assess these variables. The hope is that the early and accurate identification of those patients who are in need of psychosocial services can lead to the implementation of services that will ameliorate psychosocial problems and facilitate total patient rehabilitation. Although many excellent measures exist, the most important assessment tool for the screening of psychosocial problems in patients with burns, which has emerged from this review, is the Psychological Adjustment to Illness Scale (PAIS). The PAIS integrates many of the relevant characteristics of psychologic screening and provides normative values that are specific to patients with burns. Ideally, this scale should be supplemented by an assessment of post-traumatic stress disorder, substance abuse, and personality and coping styles, because these critical factors are not adequately covered by the PAIS. Finally, the Burn Specific Health Scale shows promise for the assessment of health status and quality of life in patients with burns. Future clinical research will hopefully compare and contrast the efficacy and relevance of these measures. Furthermore, future clinical evaluation and research will need to relate the influence of psychosocial factors on the patient's total health functioning. Structured psychometric evaluation of the psychosocial and health characteristics will ensure that patients who have been burned will attain the most fulfilling quality of life that is available to them.

Health risks to fire fighters.

Fire fighters work in varied and dangerous environments and face unique health hazards that increase their risk for line-of-duty injury and death. While working with sophisticated equipment within such environments, the fire fighter is exposed to high noise levels, changing thermal conditions, and hazardous breathing atmospheres. In addition, his or her protective equipment can impose limitations on efficiency and performance. These conditions have been related to specific physical performance requirements that will reduce line-of-duty injury, disability, and even death. Physical fitness and health maintenance programs that reduce the risk for cardiovascular disease and musculoskeletal injuries have been prescribed for fire fighters. These programs are essential components of any modern fire service.

Aquatic access for the disabled.

Innovations in rehabilitation engineering can now provide aquatic access for the disabled. In the regional burn center, the Bodi-Gard cart shower system (Hospital Therapy Products, Inc., Wood Dale, Ill.) uses three flexible hoses to provide precise hydrotherapy and debridement. Its main mixing valve controls temperature and pressure and is easily disinfected by an in-line chamber. This shower system is complemented by the foldable Bodi-Gard mobile seat shower system (Hospital Therapy Products, Inc.). This system, which is covered by a disposable liner, surrounds the patient with eight water jets that empty into any floor drain. The Bather 2001 (Silcraft Corp., Traverse City, Mich.) is a fiberglass hydrotherapy bathtub with a unique Aqua-Seal door (Silcraft Corp.) that can be raised to provide patient access. Its unique closed-loop disinfection system prevents contamination of its internal components. The Nolan Tublift (Aquatic Access, Louisville, Ky.) is a lightweight, removable lift that uses water power to gently raise and lower its seat. It can be manually swiveled to allow access from a wheelchair. Transfer benches span the tub wall to provide access to the shower and bathtub. Although they are a less expensive alternative to the Tublift, they allow water to spill outside the tub, which may create a slippery bathroom floor. The Nolan Poolift (Guardian Products, Arleta, Calif.) is a water-powered pool lift, which automatically rotates as it descends. It is capable of lifting up to 135 kg with a home water pressure of 55 psi. In contrast, the water-powered Aquatic Access Poolift is a less expensive pool lift, which rotates manually with assistance.(ABSTRACT TRUNCATED AT 250 WORDS)

A multicenter clinical trial of a biosynthetic skin replacement, Dermagraft-TC, compared with cryopreserved human cadaver skin for temporary coverage of excised burn wounds.

This multicenter study compared the use of a biosynthetic human skin substitute with frozen human cadaver allograft for the temporary closure of excised burn wounds. Dermagraft-TC (Advanced Tissue Sciences, Inc.) (DG-TC) consists of a synthetic material onto which human neonatal fibroblasts are cultured. Burn wounds in 66 patients with a mean age of 36 years and a mean burn size of 44% total body surface area (28% total body surface area full-thickness) were surgically excised. Two comparable sites, each approximately 1% total body surface area in size, were randomized to receive either DG-TC or allograft. Both sites were then treated in the same manner. When clinically indicated (> 5 days after application) both skin replacements were removed, and the wound beds were evaluated and prepared for grafting. DG-TC was equivalent or superior to allograft with regard to autograft take at postautograft day 14. DG-TC was also easier to remove, had no epidermal slough, and resulted in less bleeding than did allograft while maintaining an adequate wound bed. Overall satisfaction was better with DG-TC.

Steam vaporizer burn injuries.

Steam vaporizers increase indoor relative humidity by releasing steam into the air. The temperature of the steam is sufficiently high to cause severe burns. We report two cases of children who received partial thickness burns from steam vaporizers. Because of the high risk of burn injury, the manufacturers should be required to label the surface of the boiling chamber of the vaporizer with a warning statement.

Electric heating pad burns.

Patients with sensory deficits are especially prone to heating pad burns. Two cases are reported of patients with anesthetic skin who received partial and full-thickness burns of their feet from an electric heating pad. These burn injuries could have been prevented if the patients understood the potential hazard of heating pads.

Immersion scald burns: strategies for prevention.

Tap water scald burns are common injuries to persons with disabilities, young children, and the elderly. A case is reported of an elderly woman with a physical and neurological handicap who while bathing received partial and full thickness (tap water) scald burns covering 20% of her total body surface area. This life-threatening injury could have been prevented with a Shower Safe, Inc. temperature-controlling water valve.