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Biomedical subjects

J L Hunt

Publications and source records attributed to J L Hunt.

107 records · Page 6Linked to original sources
PubMedDate not supplied

Acute adrenal insufficiency in the patient with burns.

Acute adrenal insufficiency is an uncommon but devastating complication of severe burn injury. The diagnosis is rarely made antemortem. Acute, fatal, adrenal insufficiency developed in three patients among 807 critically ill patients with burns treated at this institution during the past 6 years. Thermal injuries elevate corticosteroid secretion for weeks after injury, severely stressing the adrenal glands. Overload of the hypothalamic-pituitary-adrenal axis is thought to make this system unusually vulnerable to acute infarction. Although the actual mechanism of adrenal hemorrhage is not clear, the combination of excessive adrenocorticotropic hormone stimulation and hemodynamic instability have been implicated in its evolution. Survival may be too short for characteristic Addisonian metabolic changes to develop. Acute adrenal insufficiency is a rare event that is historically associated with meningococcemia, although any life-threatening illness may precipitate this catastrophe. Therefore, when a sudden deterioration in the patient with thermal injuries is encountered, adrenal insufficiency must be considered.

Acute Disease↗
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Effects of propranolol administration on cardiac responses to burn injury.

Previous studies showing that propranolol upregulates beta-adrenergic receptors and protects against myocardial ischemia led us to hypothesize that preburn propranolol would protect against postburn cardiac dysfunction. Guinea pigs were treated with propranolol 3 mg/kg/day for 14 days, then deeply anesthetized and subjected to a 45% 3 degrees scald burn; eight guinea pigs treated with propranolol served as the control group (group 1). Burned guinea pigs were resuscitated with Ringer's lactate given as either 4 ml (group 2, N = 8), 6 ml (group 3, N = 10), or 8 ml (group 4, N = 6) per kg/% burn. Guinea pigs treated for 14 days with vehicle (water) were subjected to either sham burn (non-propranolol control, group 5, N = 10) or burn and treatment (group 6, N = 10) as described for group 2. Fluid resuscitation in non-propranolol-treated guinea pigs failed to overcome burn-induced cardiac deficits, as indicated by significantly lower left ventricular pressure, 86 +/- 2 versus 62 +/- 3 mm Hg; +dP/dt max, 1365 +/- 43 versus 1110 +/- 44 mm Hg/sec; -dP/dt max, 1184 +/- 31 versus 881 +/- 40 mm Hg/sec, p < 0.001. Burn-mediated cardiac defects occurred in all propranolol-treated guinea pigs regardless of the fluid volume given. Our data show that (1) propranolol did not protect against burn-induced cardiac dysfunction, and (2) chronic beta-adrenergic blockade increases postburn fluid requirements for maintenance of cardiodynamic stability and for survival.

Animals↗
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Acute pseudo-obstruction in critically ill patients with burns.

Acute pseudo-obstruction of the colon (Ogilvie's syndrome) is a rare but potentially morbid complication of burn injury. Two thousand seven hundred three consecutive critically ill patients with burns were reviewed for findings consistent with pseudo-obstruction. Eight (0.29%) patients were identified. Mean age was 63.5 years, and mean burn size was 24.6% total body surface area. All patients were undergoing mechanical ventilation at the time of diagnosis. Six had a previous cardiac condition or complication, and five were on digoxin. Diagnosis was suspected in seven patients before colonoscopy or surgery. Six patients were treated with colonoscopy alone with one treatment failure. Two deaths occurred during hospitalization. Two late deaths were due to underlying cardiac conditions. The preferred treatment of Ogilvie's syndrome is nasogastric suction, colonic decompression, and close observation with surgery reserved for treatment failures or when diagnosis is in doubt. The incidence of Ogilvie's syndrome in patients with burns appears to be related to nonburn medical conditions, especially cardiopulmonary complications and age, rather than to the burn itself.

Acute Disease↗
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Alcohol, drug intoxication, or both at the time of burn injury as a predictor of complications and mortality in hospitalized patients with burns.

The objective of this study was to characterize the association between drug and alcohol intoxication at the time of injury and subsequent complications and mortality in hospitalized patients with burns. A computerized burn database was used to analyze data on 3047 consecutive adult (21 to 75 years) hospitalized patients with burns admitted between January 1982 and August 1994. Data for intoxicated (by history, blood alcohol content, or positive drug screen) and nonintoxicated patients were compared. The same analysis was also conducted on 429 consecutive adolescent patients with burns (ages 14 to 20 years) admitted during the same time period. The incidence of intoxication at the time of burn was 6.9%. No significant differences in age, sex, race, or burn size were noted. Intoxicated patients had a higher incidence of associated injuries. Skin graft loss, cellulitis, donor site conversion, hypotension, and pneumonia were more common in the intoxicated group. They also had more intensive care unit admissions, ventilator days, operations, transfusions, and total hospital days. Intoxicated patients had a lower mortality (7.1%) than patients in the control group (10.9%). Intoxication at the time of burn injury is an important predictor of complications in adult patients with burns.

Adolescent↗
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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.

Adult↗
PubMedDate not supplied

A multicenter review of toxic epidermal necrolysis treated in U.S. burn centers at the end of the twentieth century.

Toxic epidermal necrolysis (TEN) is a potentially fatal disorder that involves large areas of skin desquamation. Patients with TEN are often referred to burn centers for expert wound management and comprehensive care. The purpose of this study was to define the presenting characteristics and treatment of TEN before and after admission to regional burn centers and to evaluate the efficacy of burn center treatment for this disorder. A retrospective multicenter chart review was completed for patients admitted with TEN to 15 burn centers from 1995 to 2000. Charts were reviewed for patient characteristics, non-burn hospital and burn center treatment, and outcome. A total of 199 patients were admitted. Patients had a mean age of 47 years, mean 67.7% total body surface area skin slough, and mean Acute Physiology and Chronic Health Evaluation (APACHE II) score of 10. Sixty-four patients died, for a mortality rate of 32%. Mortality increased to 51% for patients transferred to a burn center more than one week after onset of disease. Burn centers and non-burn hospitals differed in their use of enteral nutrition (70 vs 12%, respectively, P < 0.05), prophylactic antibiotics (22 vs 37.9%, P < 0.05), corticosteroid use (22 vs 51%, P < 0.05), and wound management. Age, body surface area involvement, APACHE II score, complications, and parenteral nutrition before transfer correlated with increased mortality. The treatment of TEN differs markedly between burn centers and non-burn centers. Early transport to a burn unit is warranted to improve patient outcome.

APACHE↗
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Serial measurements increase the accuracy of laser Doppler assessment of burn wounds.

Traditional methods of judging burn depth by clinical evaluation of the wound based on appearance and sensation remain in wide use but are subject to individual variation by examiner. In addition to the clinical difficulties with burn wound management, observer dependency of wound assessment complicates clinical trials of burn wound therapy. A laser Doppler flowmeter with a multichannel probe was used to measure burn wound perfusion as a tool to predict wound outcome. Serial measurement with laser Doppler flowmetry had an 88% specificity and a positive predictive value of 81% for identifying nonhealing wounds. These results suggest that laser Doppler flowmetry is a potentially useful tool for burn wound assessment.

Adolescent↗
PubMedDate not supplied

Sentinel lymph node biopsy identifies occult nodal metastases in patients with Marjolin's ulcer.

Since Marjolin's description, the management of burn scar carcinoma has remained controversial. A multitude of options and recommendations exist for the management of both primary lesions and regional nodal metastasis. This work reviews six cases of Marjolin's ulcer staged using sentinel lymph node biopsy. All primary lesions were confirmed to be squamous cell carcinoma and occurred a median of 29.5 years after burn. No patient had clinically detectable lymphadenopathy. In all cases, preoperative lymphoscintigraphy successfully identified a single draining regional nodal basin. Subsequent intraoperative lymphatic mapping/sentinel lymph node (SLN) biopsy was successful in five of six cases (83%). A successful intraoperative lymphatic mapping/SLN biopsy was defined as the identification of blue (uptake of isosulfan blue dye) or "hot" (uptake of radiolabeled sulfur colloid as measured with a handheld gamma counter) node(s) and subsequent excision. Four of five SLN biopsies identified previously occult nodal metastasis. SLN biopsy represents a minimally invasive and accurate staging procedure for Marjolin's ulcer.

Burns↗
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Ovarian teratomas: tumor types and imaging characteristics.

Ovarian teratomas include mature cystic teratomas (dermoid cysts), immature teratomas, and monodermal teratomas (eg, struma ovarii, carcinoid tumors, neural tumors). Most mature cystic teratomas can be diagnosed at ultrasonography (US) but may have a variety of appearances, characterized by echogenic sebaceous material and calcification. At computed tomography (CT), fat attenuation within a cyst is diagnostic. At magnetic resonance (MR) imaging, the sebaceous component is specifically identified with fat-saturation techniques. The US appearances of immature teratoma are nonspecific, although the tumors are typically heterogeneous, partially solid lesions, usually with scattered calcifications. At CT and MR imaging, immature teratomas characteristically have a large, irregular solid component containing coarse calcifications. Small foci of fat help identify these tumors. The US features of struma ovarii are also nonspecific, but a heterogeneous, predominantly solid mass may be seen. On T1- and T2-weighted images, the cystic spaces demonstrate both high and low signal intensity. Familiarity with the US, CT, and MR imaging features of ovarian teratomas can aid in differentiation and diagnosis.

Diagnosis, Differential↗
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Marjolin's ulcer: a review and reevaluation of a difficult problem.

The formation of an epidermoid carcinoma in nonhealing scar tissue, a Marjolin's ulcer, is a well described neoplasm. These lesions are, however, frequently overlooked and often inadequately treated. This paper reviews six cases of scar-tissue carcinoma. All lesions were secondary to various kinds of burns. Four of the Marjolin's ulcers were well-differentiated squamous cell carcinomas. One was a moderately differentiated squamous cell carcinoma, and one was a malignant melanoma. The average age at presentation was 59 years, and the mean interval from time of burn injury to appearance of neoplasm was 36.8 years. The lesions varied in anatomic location and involved the upper extremities, lower extremities, and scalp. In addition to the case studies, this paper reviews the literature and provides a logical treatment plan for a patient with a Marjolin's ulcer. Because these lesions can be very aggressive, a well thought-out treatment plan is necessary to optimize care and assure patient survival.

Aged↗
PubMedDate not supplied

Serial casting: a method for treating burn contractures.

The purpose of this study was to assess the effectiveness of serial casting of burn contractures that were resistant to traditional methods of treatment such as paraffin therapy, massage, exercise, and splinting. Serial casting was used to increase the range of motion in 35 joints in 15 patients with burns. A mean increase of 54% was achieved. Casting provided immediate results with minimal complications and was accepted well by patients. Casts were easy to apply and effective even with noncompliant patients. They also delayed or eliminated the need for surgical correction.

Adult↗
PubMedDate not supplied

Burn-wound management.

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Anti-Infective Agents↗
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Toxic epidermal necrolysis.

Toxic epidermal necrolysis (TEN) is a poorly understood and devastating condition. It is usually diagnosed in a primary care setting. Treatment of severe cases by burn care personnel is usually by referral. In this review, we report excessive mortality rates associated with prolonged use of systemic steroid therapy and delayed referral (more than 1 week from diagnosis). Forty-four consecutive patients admitted to a regional burn center with the diagnosis of TEN over a 14-year period, (0.7% of all admissions) were included. Precipitating factors were identified in 30 cases. Twenty-one patients had known prehospital allergy conditions directly related to the inciting agent. The mean age of this population was 44.9 years, and the mean total body surface area (TBSA) injury was 52.4%. Eighty-four and one-half percent of all patients with TEN were admitted to the ICU. Twenty-four patients required ventilator support. Overall mortality rate was 36%. Nonsurviving patients had a mean age of 61.6 years, compared to 35.3 years for survivors. Nonsurvivors had a mean TBSA of 64.4%, survivors had a mean TBSA of 44%. TEN, although a nonthermal injury, is best managed by personnel experienced in the care of severe thermal injuries. Despite the availability of this expertise, delayed transfer of severe presentations continues to contribute to exceptionally high morbidity and mortality rates.

Adult↗