Enzymatic debridement of large burn wounds with papain-urea: Is it safe?

INTRODUCTION: Enzymatic debridement is a method by which burn wounds can be prepared for coverage by skin grafts in patients presenting late. Many agents have been used in the past but none of them have been thoroughly evaluated. The present study was undertaken to assess the efficacy of Debridace, a commonly available debriding agent with papain and urea as its constituents. MATERIAL AND METHODS: A prospective descriptive study design was used to evaluate our experience. Almost symmetrical areas of the burnt surface were assessed and used for comparison. On one half of the wound, Debridace was applied while on the other silver sulphadiazine was used. The primary end point of this study was the extent of the achieved debridement at the end of the study period. Secondary outcomes were the presence of adverse effects such as pain and fever. All patients with sepsis were excluded from the study. RESULTS: The age of the subjects ranged from 9 to 80 years with an SD of 16. Large areas ranging from 5% to 20% body surface area with an SD of 4.27 were debrided by Debridace. Only two patients (3.33%) could complete the study. The rest of the recruited patients either had high fever (63.33%), excruciating pain (13.33%) or both (16.66%), which brought an end to enzymatic debridement. CONCLUSION: Debridace, a papain-urea product, cannot be considered safe as an enzymatic debriding agent in its present form for use in major burn patients who present late with deep burn wounds that are large in size.

Perforator flap: A novel method for providing skin cover to lower limb defects.

BACKGROUND: Soft tissue defects in the lower limb pose a formidable challenge due to lack of reliable local flap options. Due to thin non-expendable soft tissues and predisposition to massive edema formation, even small defects become problematic. Perforator flaps represent the latest trends in soft tissue coverage. The aim of this study was to evaluate the effectiveness of perforator flaps as coverage of soft tissue defects in lower limbs. MATERIAL AND METHODS: A series of patients with soft tissue defects of various etiologies in the lower limb were treated using perforator flap at a tertiary care service hospital. Six were free flaps and fourteen pedicled flaps. Doppler ultrasound was used to identify recipient and donor vessels pre-operatively. RESULTS: Only one flap was lost due to venous congestion. In another case of carcinoma penis there was delayed healing due to persistent lymphorrhoea as a result of post-operative status following lymph node dissection and radiotherapy. Fifteen donor sites required split skin grafting, as they could not be closed directly. CONCLUSION: Perforator flaps are a reliable option for closure of soft tissue defects of lower limb irrespective of size, location and depth. There is minimal donor site morbidity. It has the advantage of rapid dissection, flap elevation and reliable skin territory. As no special equipment is required it can be replicated in smaller centers also.

Surgical outcomes following nerve transfers in upper brachial plexus injuries.

BACKGROUND: Brachial plexus injuries represent devastating injuries with a poor prognosis. Neurolysis, nerve repair, nerve grafts, nerve transfer, functioning free-muscle transfer and pedicle muscle transfer are the main surgical procedures for treating these injuries. Among these, nerve transfer or neurotization is mainly indicated in root avulsion injury. MATERIALS AND METHODS: We analysed the results of various neurotization techniques in 20 patients (age group 20-41 years, mean 25.7 years) in terms of denervation time, recovery time and functional results. The inclusion criteria for the study included irreparable injuries to the upper roots of brachial plexus (C5, C6 and C7 roots in various combinations), surgery within 10 months of injury and a minimum follow-up period of 18 months. The average denervation period was 4.2 months. Shoulder functions were restored by transfer of spinal accessory nerve to suprascapular nerve (19 patients), and phrenic nerve to suprascapular nerve (1 patient). In 11 patients, axillary nerve was also neurotized using different donors - radial nerve branch to the long head triceps (7 patients), intercostal nerves (2 patients), and phrenic nerve with nerve graft (2 patients). Elbow flexion was restored by transfer of ulnar nerve motor fascicle to the motor branch of biceps (4 patients), both ulnar and median nerve motor fascicles to the biceps and brachialis motor nerves (10 patients), spinal accessory nerve to musculocutaneous nerve with an intervening sural nerve graft (1 patient), intercostal nerves (3rd, 4th and 5th) to musculocutaneous nerve (4 patients) and phrenic nerve to musculocutaneous nerve with an intervening graft (1 patient). RESULTS: Motor and sensory recovery was assessed according to Medical Research Council (MRC) Scoring system. In shoulder abduction, five patients scored M4 and three patients M3+. Fair results were obtained in remaining 12 patients. The achieved abduction averaged 95 degrees (range, 50 - 170 degrees). Eight patients scored M4 power in elbow flexion and assessed as excellent results. Good results (M3+) were obtained in seven patients. Five patients had fair results (M2+ to M3).

Management strategy for facial arteriovenous malformations.

Arteriovenous malformations (AVMs) are uncommon errors of vascular morphogenesis; haemodynamically, they are high-flow lesions. Approximately 50% of AVMs are located in the craniofacial region. Subtotal excision or proximal ligation of the feeding vessel frequently results in rapid progression of the AVMs. Hence, the correct treatment consists of highly selective embolisation (super-selective) followed by complete resection 24-48 hours later. We treated 20 patients with facial arteriovenous malformation by using this method. Most of the lesions (80%) were located within the cheek and lip. There were no procedure related complications and cosmetic results were excellent.

Management of Soft Tissue Defects of the Ankle and Foot.

BACKGROUND: Treatment of soft tissue defect of ankle and foot has always been a challenging problem. METHODS: Thirty patients with soft tissue defects of the ankle and foot who underwent various reconstructive procedures in two tertiary care teaching hospitals were studied. RESULTS: Most of the defects (33%) were located in and around the ankle. Trauma was the major cause (56.6%). Defects were reconstructed with a variety of local, regional, distant and microvascular free flaps. Distally based superficial sural artery flap was used in majority of the cases (40%). Free tissue transfer using radial artery forearm flap was done in three (10%) complex wounds where other flaps were not found to be suitable. Superficial soft tissue defects on the dorsum of foot were resurfaced with split thickness skin grafts in 3 (10%) cases. Out of 27 flaps used, 26 survived completely. One inferiorly based fasciocutaneous flap developed partial necrosis. There was graft loss in one patient which required regrafting with the stored autograft. CONCLUSION: Distally based superficial sural artery flap remains the choice for reconstruction of soft tissue defects of ankle and foot because of its reliable blood supply and easy elevation.

Dengue haemorrhagic fever (DHF) outbreak in Calcutta--1990.

An outbreak of Dengue Haemorrhagic Fever (DHF) occurred in Calcutta between September and December, 1990. Children and young adults were the major victims. Haemorrhagic manifestations and shocks were the main features in most of the hospitalised cases. Five mouse pathogenic agents were isolated from 105 acute cases and all were identified as DEN-3. HI and CF test with 55 paired sera revealed evidence of dengue infection in 33 (60 per cent) and flavivirus group reaction including dengue in 17 (30.9 per cent). It was for the first time, that DEN-3 was considered to be the etiologic agent for DHF in Calcutta.

Recurrent outbreaks of Japanese encephalitis in Nagaland (1985-1989)--a seroepidemiological study.

Recurrent epidemics of encephalitis in Nagaland, a North-Eastern State of India, following its first appearance in 1985, were investigated both epidemiologically and virologically. Although, no viral agent could be isolated from any of the clinical samples and mosquitoes, detection of JE specific IgM antibodies in many of the CSF and acute blood samples, together with presence of HI and CF antibodies to JE antigen in a number of acute and convalescent sera established the etiologic role of JE virus in this region. A total number of 83 clinically diagnosed cases could only be investigated virologically between 1985-89, where evidence of JE could be established in 34 (40.9 per cent) and flavivirus (including JE in majority) in 17 (21.5 per cent) cases. A limited serological survey among the close contacts of the victims in 1985 revealed JE antibody in 26.6 per cent of them. Analysis of the epidemiological and serological findings of different years revealed that while the outbreaks of 1985, 1987 and 1988 were due to JE infection, the episodes of 1986 and 1989, on the other hand, had chiefly features of high and prolonged fever with limited number of CNS involvement of undetermined origin, where the possibility of malarial infection has been a suspect apart from JE etiology.

Investigation of an outbreak of Japanese encephalitis in Rourkela City (Orissa) during 1989.

An outbreak of Japanese encephalitis (JE) was reported from Rourkela city for the first time in September-November 1989. 41 cases and 15 deaths occurred with a case fatality rate of 36.6 per cent. Most of the cases (66 per cent) were in the age group of 5-19 years. There was no case under 5 years. Female-male ratio of cases was 1:1.7. Serological examination of convalescent cases showed JE specific IgM indicating strong evidence of recent JE infection. Large number of pigs were seen in the affected areas.

Intracellular tubercle bacilli-alveolar macrophage lysosomal enzymes interaction in experimental tuberculosis.

This study is an attempt to understand the mechanism of macrophage activation and its effect on the microbicidal properties of the macrophage. Alveolar macrophages (AM) from normal and BCG-vaccinated guinea pigs were harvested at intervals of 1, 7, 14, 21, and 28 days. Half of the guinea pigs from each group were challenged intratracheally with Mycobacterium tuberculosis H37Rv. In AM, the levels of three lysosomal enzymes, beta-galactosidase (beta-gal), N-acetylglucosaminidase (N-ac), and lysozyme (lyso), were measured histochemically. The percentage of AM staining positively for these enzymes and the intensity of this staining were estimated as parameters of AM activation, along with the number of intracellular bacilli in these cells. Histochemical methods are preferred to biochemical methods as only the former indicate activation in individual cells. The enzymatic responses of AM depend on the type of vaccination and infection. Thus, beta-gal activity was significantly enhanced in immune animals whereas no such enhancement of activity was observed in the case of N-ac and lyso. The N-ac content was higher in infected animals and in the immune group, whereas lyso fluctuated at different time intervals after infection.

Concurrent smallpox and chickenpox.

Three patients showing smallpox- and chickenpox-like lesions simultaneously were investigated virologically. Both infections were confirmed in the laboratory and, in one case, by electron microscopy.