Better among the two for Burn Mortality Prediction in Developing Nations: Revised Baux or Modified Abbreviated Burn Severity Index?

Background: Burns is one of the leading causes of mortality in developing countries like India. Most of the major burns requiring hospital care are not triaged adequately for the use of medical resources. An efficient mortality predicting scale would not only help in better care to those who will benefit the most but also make it easy to explain to patient's attendants. Among the various tools, revised Baux (rBaux) and modified Abbreviated Burn Severity Index (ABSI) are two most commonly used scales in developed nations. We proposed this study to analyze the reliability of these two scoring scales in our burn population. Aim: This study aimed to retrospectively study the two scoring systems and analyze them for their reliability in predicting mortality compared to actual observed mortality in each case. Materials and Methods: This study was conducted on all burn patients admitted to the intensive care unit of our hospital. Data on their demographic profile, total burn surface area, thickness of burns, inhalational injury, and other comorbidities were collected from files. rBaux and modified ABSI (mABSI) were calculated. The end result in the form of survival or nonsurvival was also recorded. Appropriate statistical analysis using Mann-Whitney U-test, Chi-square test, and receiver operator characteristic curve was done to look for a better scoring system out of the two. Results: A total of 504 patients were included in the study, out of which 337 were survivors. Female gender was not a risk factor for mortality in our study. The median rBaux score in the survivor group was 100 (80-110) and in nonsurvivor group was 111 (103-123). The median mABSI score in the survivor group was 8 (7-9) and in nonsurvivor group was 10 (9-11). The area under the receiver operating characteristic curve shows mABSI having better specificity for predicting mortality. rBAUX, though more sensitive, overestimates mortality than actual observed mortality. Conclusion: mABSI predicts mortality better than rBaux. A multicentric prospective study is recommended for mABSI to be used as a standard mortality predictor in burns in India.

Role of Lactate Measurement in Flap Monitoring: An Useful Adjunct.

Background Detection of vascular compromise in flap is often a challenging task for reconstructive surgeons. A timely salvage procedure depends on objectivity and reliability of postoperative flap monitoring. This study determined if flap capillary lactate helps in prediction of flap viability in first 48 postoperative hours of surgery. Methods We conducted this study on all flaps with accessible skin paddle where capillary lactate values were assessed along with clinical observation to check viability of flap at 0, 1, 6, 12, 24 and 48 hours of surgery. The data was statistically analyzed for significance and area under the receiver operating characteristic curve was used for calculating cutoff value for lactate. Results Out of a total of 30 patients included in this study, 25 were males and the mean age was 45.03 years. Fifteen patients underwent free flap and rest pedicled. Highly significant association of role of clinical observation in the outcome of flap was found. The average of lactate values for survived and distally ischemic flap was 5.32 ± 1.91 and 8.38 ± 1.81, respectively, which was highly significant. The cutoff value of lactate below which all flaps survived was found to be 6.09 mmol/L. Conclusion Flap capillary lactate measurement is an easy, quick, cost-effective, and objective tool for checking viability of flaps.

Comparative Efficacy of Intralesional Triamcinolone Acetonide and 5-Fluorouracil for Keloid Scars.

Intralesional triamcinolone acetonide (TAC; a synthetic corticosteroid) and 5-fluorouracil (5-FU; a cytotoxic chemotherapy drug) are the medications most commonly used to treat keloid scars. We investigated the clinical efficacy of TAC compared with 5-FU. We included 40 patients in the study and divided them into two equal groups ( n = 20 Group A; n = 20 Group B). Group A patients received 4 mg/cm 2 or 0.1 ml/cm 2 of intralesional TAC (40 mg/ml) at 3-week intervals. Group B patients received 10 mg/cm 2 or 0.2 ml/cm 2 of intralesional 5-FU (50 mg/ml) at 3-week intervals. We assessed the scar using the Vancouver Scar Scale (VSS), visual analog scale (VAS), and patient satisfaction score (PSS). We found that Group A patients had a lower VAS than Group B patients (2.09 vs. 3.18). We saw a reduction in the VSS in both treatment arms; however, we found that Group B patients had a more marked reduction in the VSS compared with Group A patients (2.57 vs. 2.68). The PSS was higher in Group A than in Group B (1.97 vs. 1.78). We concluded that intralesional 5-FU elicits a better response than intralesional TAC. Although 5-FU is less well tolerated and has more side effects than TAC, we found that 5-FU was more effective in resolving keloid scars. Notably, the PSS was higher in the TAC group, but the VSS and VAS were better in Group B.

Grinder Injury of the Hand: A Rare but Devastating Occupational Hazard.

Food handlers and workers are exposed to several occupational hazards not frequented by the general population. Grinder injuries of the hand present a devastating consequence of industrial food processing that is infrequently described. Herein, we describe two cases that presented to our department with meat grinder injuries of the hand.

A statistical analysis of incidence, etiology, and management of palatal fistula.

OBJECTIVE: The purpose of this study was to retrospectively review the incidence, profile, and the management of palatal fistula occurring in patients operated for cleft palate in our institute. MATERIALS AND METHODS: A retrospective analysis was performed on all cleft palatal fistula patients who presented during the period from August 2007 to October 2017, to classify their site, age of presentation, surgery performed, and outcome. A record of the type of cleft palate and previous palatoplasty was also obtained. The outcome in terms of incidence and fistula formation depending on Veau's classification was analyzed. RESULTS: Twenty-two patients reported with palatal fistula during this period. The incidence of fistula formation of our institute was 9.6%. Incisive foramen (13/22) was the most common site of fistula formation. Among various techniques used, local and buccal flaps were found to be useful in a maximum number of cases (14/22). The rate of fistula recurrence was 18.2% (4/22). On retrospective analysis of our institutional data, it was found that the incidence of cleft palate fistula was significantly higher in clefts with Veau Types III and IV (13/18) as compared to Veau Types I and II (5/18). CONCLUSION: This study shows that the fistula rate of our institution was 9.6%. Complete clefts (unilateral or bilateral) involving both primary and secondary palates predispose more to fistula formation.

Diagnostic tools in maxillofacial fractures: Is there really a need of three-dimensional computed tomography?

INTRODUCTION: Because of its functional and cosmetic importance, facial injuries, especially bony fractures are clinically very significant. Missed and maltreated fractures might result in malocclusion and disfigurement of the face, thus making accurate diagnosis of the fracture very essential. In earlier times, conventional radiography along with clinical examination played a major role in diagnosis of maxillofacial fractures. However, it was noted that the overlapping nature of bones and the inability to visualise soft tissue swelling and fracture displacement, especially in face, makes radiography less reliable and useful. Computed tomography (CT), also called as X-ray computed radiography, has helped in solving this problem. This clinical study is to compare three-dimensional (3D) CT reconstruction with conventional radiography in evaluating the maxillofacial fractures preoperatively and effecting the surgical management, accordingly. MATERIALS AND METHODS: Fifty patients, with suspected maxillofacial fractures on clinical examination, were subjected to conventional radiography and CT face with 3D reconstruction. The number and site of fractures in zygoma, maxilla, mandible and nose, detected by both the methods, were enumerated and compared. The final bearing of these additional fractures, on the management protocol, was analysed. RESULTS: CT proved superior to conventional radiography in diagnosing additional number of fractures in zygoma, maxilla, mandible (subcondylar) and nasal bone. Coronal and axial images were found to be significantly more diagnostic in fracture sites such as zygomaticomaxillary complex, orbital floor, arch, lateral maxillary wall and anterior maxillary wall. CONCLUSION: 3D images gave an inside out picture of the actual sites of fractures. It acted as mind's eye for pre-operative planning and intra-operative execution of surgery. Better surgical treatment could be given to 33% of the cases because of better diagnostic ability of CT.

Sub mucous cleft palate with fenestration.

Congenital fenestration in sub mucous cleft palate is not a common identity. This patient is a 16-year-old female who presented with nasal speech. On examination, she had associated microform cleft lip with nasal deformity. Successful palatoplasty with intra velar veloplasty was done.

The role of fibrin glue in the treatment of high and low fistulas in ano.

AIM: The aim of this study was to assess the outcome of fibrin glue in high and low anal fistulas. METHODS: A prospective, non-randomized trial was carried out on 30 patients who were diagnosed to have fistulas in ano. They were evaluated by categorizing them into high (with the internal opening above the anorectal ring)(14/30) and low anal fistulas (with the internal opening below the anorectal ring)(16/30). The fibrin glue was instilled in their anal tracts. The character of the anal tract, whether it was single or multiple and primary or recurrent, was analyzed. The outcome in terms of a postoperative discharge (failure), the incidence of a postoperative perianal pain/abscess and the glue reaction, was noted at 1 week, 1 month, 3 months and 6 months. A success was defined as the absence of any discharge at 6 months. RESULTS: Fourteen patients with high anal fistulas and 16 with low anal fistulas (with a mean age of 48.5yrs) were treated with fibrin glue. 19 patients had primary tracts (7- high group and 12- low group) and 11 had recurrent tracts (7- high group and 4- low group). 20 fistulas were single tracted (8- high and 12- low) and ten were multiple tracted (6- high and 4-low). The success rate at 6 months was 57.14% in the high group and it was 81.25% in the low group. The failure rate was 85.71% in the recurrent high fistula group as compared to 25% in the recurrent low fistula group (p=0.049). 25% of the single tracted high fistulas failed to heal as compared to a 100% healing rate in the single low fistulas group (p=0.90). CONCLUSION: This procedure is thus, superior to the conventional surgical treatment, in terms of the patient comfort, an undisturbed sphincter function, a reduced overall hospital stay, wound pain and the complications and adverse reactions. It showed the best results in the primary, single tracted and the low anal fistulas.

Palatoplasty in a patient with Seckel syndrome.

We report a rare case of a patient of Seckel syndrome having cleft palate born to nonconsanguineous married parents. This 8-year-old male child underwent successful palatoplasty under general anesthesia. Till date there are approximately 60 cases of Seckel syndrome reported in the literature. The syndrome which has autosomal recessive inheritance is characterized by Intra Uterine Growth Retardation, microcephaly, dwarfism, and bird-like face. The associated features of the syndrome and technical details of surgery and anesthesia are discussed.