Biomedical subjects
Publications and source records attributed to D A Burd.
A case is presented of a woman who sustained a 35% body surface area mixed depth cutaneous burn, together with a significant inhalational injury. The patient required emergency resuscitation with endotracheal intubation and subsequently tracheostomy. This resulted in an unfortunate complication of a total adhesion between the vocal cords which extended into the subglottic area, causing complete occlusion of the airway.
We present a case of recurrent acute colonic pseudo-obstruction (ACPO) in a burn patient that responded to a postural change which has not been previously reported.
Loss of genetic material, including loss of loci on chromosome arms 6q, 9p, and 10q, occurs frequently in cutaneous melanoma but infrequently in benign melanocytic nevi or other melanocytic lesions, suggesting that these genetic alterations are important in the development and progression of melanoma. To examine whether allelic loss is of prognostic importance in melanoma, disease-free survival was related to loss of heterozygosity on 6q, 9p and 10q in 83 individuals with sporadic primary cutaneous melanoma. Loss of chromosome arms 6q and 10q were each significantly associated with a poorer clinical outcome (P=0.013 and P=0.001 respectively). In a subgroup of 41 subjects whose primary tumours were allelotyped, the fractional allelic loss (FAL) at 39 autosomal arms also significantly correlated with disease-free survival (P=0.013), with an increase in FAL associated with a poorer outcome; this association remained significant when controlled for tumour thickness (P=0.035). In addition, a greater proportion of cells were immunopositive for Ki67 antigen, p53 and p21WAF1 protein in the primary melanomas than in the benign melanocytic nevi, however, only p53 over-expression was significantly associated with improved survival (P=0.041).
Between the years 1967 and 1993, 3246 patients were diagnosed with malignant melanoma at Frenchay Hospital, Bristol. This paper reports 47 patients, 21 years of age or under, including 10 preadolescent cases under 14 years of age. It represents a further follow-up of a cohort originally published from this centre in 1986 in addition to 18 new cases. Most (89%) of the lesions occurred on the trunk and extremities, with females showing a predominance of lesions on the lower limbs. 83% of the melanomas were of the superficial spreading type: 72% invaded to Clark level III and IV. Thickness ranged from 0.29 mm to 50.00 mm (median 1.20 mm). Ulceration was present in 17% of cases and 32% of melanomas arose within a pre-existing small congenital melanocytic naevus. Overall 5-year survival was 81%, with a mean follow-up of 8.5 years. Ulceration and tumour thickness of greater than 1.5 mm were associated with a poor prognosis.
Accidental injury to infants can result from the use of home microwave ovens. The spectrum of injury includes scald burns of the trachea, palate oropharynx and oesophagus due to aspiration and ingestion of foods that have been overheated. There is one previous case report of a child with second-degree burns of 6 per cent of his body area due to explosion of the plastic liner and nipple on a feeding bottle top. We present a case report of an infant who suffered 7 per cent full-thickness burns following explosion of the bottle teat and subsequent splattering with hot milk. He required mid-palmar amputation of his left hand including thumb, index and middle fingers. The full-thickness burns of left cheek and left shoulder were grafted but will result in significant scarring. It is common practice in many homes to heat infant feeds in the microwaves. We suggest that health professionals dealing with children need to be aware of the potential hazards so that appropriate education of parents can take place.
According to figures published by the College of Health, 34,837 patients were waiting for in-patient plastic surgery treatment nationwide in 1986. By 1989 this number had increased to 40,085--an increase of 15%. Out of this waiting list, nearly 2000 patients were waiting in Manchester in 1990. Increasing public concern over the length of surgical waiting lists forced the Government to allocate extra resources to reduce both waiting lists and waiting times. We have reviewed the extra work done on a waiting list initiative scheme in Manchester in one year, from 1 August 1990 to 31 July 1991. The waiting list was reduced by 932 patients in one year. The attendance rate of the patients for surgery was excellent and the patients in general were very grateful for having had the treatment. The problems associated with setting us such schemes are enormous and are discussed in detail, with alternative suggestions for preventing waiting lists from building up again in future.
Burns of the female genitalia and perineum mostly occur in connection with more extensive thermal injuries to the trunk and lower extremities. Isolated burns to the vulva are very unusual because this area is anatomically well-protected. A few reports in the literature describe injuries due to bizarre accidents and now obsolete techniques. The management of these injuries, possible complications, prognosis and long-term results are discussed following a case report of a 28-year-old woman who sustained extensive deep dermal burns to her external and internal genitalia in a suicide attempt involving a firework.
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Hydrofluoric acid (HF) injuries have a potential for both systemic toxicity as well as severe tissue destruction. We present an algorithm for the management of HF burns. This algorithm addresses these issues emphasizing the differences between major and minor cutaneous burns, and includes the approach to inhalation, ingestion and eye injuries. Although algorithms can never be complete, we hope this algorithm will be used as an aid in the clinical management of these patients.
Hydrofluoric acid (HF) is a highly dangerous substance with a wide range of industrial as well as domestic applications. It is unique in both the severity of the cutaneous burns it may produce, and its potential for systemic and occasionally lethal toxicity. The literature on the treatment of HF injuries is extensive, though occasionally confusing and often contradictory, with no coherent management policy emerging. In this paper we present a comprehensive account of the evolution of therapy, drawing on clinical reports and experimental studies.
We examined the case records of 50 consecutive patients with major cutaneous burns who required early mechanical ventilation. In 22 patients full haemodynamic and respiratory data were available within 24 h of their injury. Unexpectedly the haemodynamic and oxygen transport patterns of survivors and non-survivors were essentially similar although pulmonary artery occlusion pressure measurements and estimations of net fluid input suggest that non-survivors were relatively underresuscitated compared with survivors. Both groups showed inadequate oxygen utilization in the early stages of their injury despite normal (or above normal) levels of oxygen delivery. Invasive monitoring could possibly help this subgroup of burns patients.
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.
An algorithm of fluid resuscitation for cutaneous burns is presented. The management of these cases entails an initial process of evaluation followed, when appropriate, by the administration of intravenous fluids. The fluid requirements are prospectively calculated and subsequently modified by using closed loop feedback with monitoring of urine output, plasma deficit, osmolality and vital signs. Three 'problem boxes' have been incorporated into the algorithm to outline the management of: 1. fluid deficit and excess; 2. acute renal failure; 3. the critically ill patient. An algorithm such as this can never be complete, but in its present form it provides both a teaching tool for junior staff as well as a valuable clinical aid for those involved in the acute management of burns patients.
Tissue expansion alters the function of skin cells. We studied the effects of expansion on the contractile function of dermal fibroblasts using an in vitro model, the fibroblast-populated collagen lattice (FPCL). Spherical expanders were placed dorsally in 30 Sprague-Dawley rats; one-half were serially inflated. One, 2, and 4 weeks later, 5 rats from each group were killed. Fibroblasts were cultured from dermis overlying the expanders and mixed with collagen, medium, and serum in petri dishes to form FPCL. Fibroblasts from 5 rats that had not undergone surgery were cultured to make control FPCL. Contraction was assessed by measuring the areas of the FPCL. At 48 hours, FPCL containing expanded fibroblasts had contracted significantly less than those containing unexpanded or control fibroblasts. Four weeks of expansion resulted in less contraction than 1 or 2 weeks. Tissue expansion inhibits the in vitro contractile function of dermal fibroblasts in the rat in a time-related fashion.
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