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Ebrimycin gel has been used for the local treatment of burns of 50 partly hospitalized patients, partly outpatients. According to the observations the product may be successfully used by the exposure method for the treatment of superficial facial burns and by the occlusive dressing method for the treatment of small burns which are infected by Gram-positive bacteria.
Nasal fracture is frequent in children as well as secondary hematoma and nasal septum abscess. Their prompt and appropriate treatment is stressed. Nasal septum deviation may be caused by unequal development of the nose or by trauma, this late being frequently inadverted in small children. Surgical repair of nasal septum deviation should be undertaken only if it causes significant obstruction to air flow and after complete nasal development has occurred. Epistaxis is one of the most prominent problems in nasal pathology, its managements with anterior and posterior nasal occlusive dressings is described. Congenital bilateral choanal atresia is a medical emergency: even thought tracheostomy may be a life saving procedure, surgical intra nasal resection of the atresic segment is encouraged.
Twenty-six women had semipermanent vascular access catheters (VACs) inserted to allow weekly outpatient infusion chemotherapy for advanced breast cancer. VACs were maintained without occlusive dressings, antibiotics, repeated flushings or heparin for a total of 2294 patient days (range 6 to 217 days, median 55 days). Three exit site and one subcutaneous tunnel infection occurred but no patient suffered septicaemia. VACs allowed both blood sampling and drug administration on 267 occasions and drug administration only on 19 occasions. No catheter became completely occluded.
Primary cutaneous infection with Aspergillus species and Rhizopus species was observed in five patients between October 1986 and January 1988. All patients had an underlying hematological malignancy and were neutropenic. Four patients developed skin lesions with eschars at and around the site of intravenous catheter insertion. One patient had two lesions along the course of the intravenous line. The fifth patient developed the lesion on the left side of the lower part of the back subsequent to the appearance of a rash due to excessive perspiration. A diagnosis was made in each case by histopathological studies and cultures of skin biopsy specimens. The fungal organisms cultured were Aspergillus species in three patients and Rhizopus species in two patients. All patients were treated with amphotericin B. Three patients responded to antifungal therapy and local care without surgical débridgement. Two patients died of disseminated fungal infection. The development of cutaneous lesions due to opportunistic fungal pathogens seemed to have been related to the moist and humid conditions created by occlusive dressings or excessive perspiration.
In a randomized double blind study, we investigated the systemic effects of 3 different ointments containing corticoids. Every 7 patients out of a total of 21 patients suffering from various skin diseases were daily treated with 40 g of one of the 3 corticoid preparations over 8 days (group A: 0.05% clobetasol-17-propionate; group B: 0.25% fluocortolone trimethyl acetate; group C: 0.25% fluocortolone trimethyl acetate + 0.25% fluocortolone capronate). The plasma cortisol levels were determined by radioimmune assay. In group B and C, we did not observe any effect on the pituitary-adrenal axis, whereas in group A the plasma cortisol levels were extremely low already after 1 day of corticoid application. This adrenal suppression did not return to normal within 4 days after discontinuation of the corticoid. Our results suggest that highly potent topical corticoids are capable of adrenal suppression even without occlusive dressing and even in healthy persons.
Coarsely ground Lytta vesicatoria FABRICIUS (meloideae/coleoptera), with a cantharidine content of 0.5-1% was dissolved in ethanol and worked into a powdery solution. 1-2 cm2 large swabs were dissolved in the tincture, and with the help of a Karaya plate and an occlusive dressing was administered to the skin in the antebrachii anterior region. This led to a severe inflammation, which after a further 10 h was accompanied by pemphigus and vesiculation. The vesicular liquid was aspirated, centrifuged, the cells resuspended and coated on a small cover-glass in a petri-dish and incubated. The human macrophages were kept in a moisture-saturated atmosphere with 5% CO2 at a temperature of 37 degrees C. The blisters healed quickly and without scaring after a correct dressing of the wounds was administered. The safety of this method was thus tested on human subjects, at first on the author, and proven successful.
Involvement of neutrophils and delayed hypersensitivity in the clearance of Candida albicans infections was investigated with the use of a model of the disease in inbred mice. Experimental infections were produced by rubbing C albicans onto the shaved skin of the flank without the use of occlusive dressings. After a single infection, delayed hypersensitivity to Candida developed in C57BL/6 mice, and the infection cleared more rapidly than in C3H/He mice, in which delayed hypersensitivity did not develop. In both strains, the organisms were associated with neutrophilic microabscesses in the upper epidermis within 1 day of inoculation; by 3 days, the organisms and microabscesses had become relocated to a site just above the skin surface. At this time, the epidermis was intact under the microabscesses and significantly thickened, which indicated that epidermal proliferation had occurred. Delayed hypersensitivity reactions accelerated clearance of the infection, apparently by increasing the rate of removal of the microabscesses and associated organisms from the skin surface. However, delayed hypersensitivity was not an absolute requirement for clearance, because in animals of the C3H/He strain, in which delayed hypersensitivity did not develop during the first infection, the infection was eventually cleared. It is postulated that in these infections an important defense mechanism may be the enhancement, perhaps by the neutrophilic infiltrate, of epidermal proliferation early in the infection such that the infecting organisms are moved to a location above the skin surface from which they can be more easily removed by other processes, including delayed hypersensitivity reactions.
An open, randomized, human-model study was conducted to compare the effects of topical antibiotics, a wound protectant, and antiseptics on the rate of wound healing and bacterial growth using a modification of a method employing ammonium hydroxide-induced intradermal blisters inoculated with Staphylococcus aureus. Each volunteer in the study had six blister wounds (three per forearm) to which a triple antibiotic (neomycin, polymyxin B, bacitracin) ointment or one of four other test agents was applied twice a day. A control wound remained untreated. All wounds were covered with an occlusive dressing after treatment. The time to healing (100 percent epithelialization) was evaluated for each wound. Wounds were cultured for bacterial growth after two treatments. Contaminated blister wounds treated with the triple antibiotic ointment healed significantly faster (mean nine days) than wounds treated with any antiseptic and those receiving no treatment. Only the neomycin-polymyxin B-bacitracin combination effectively eliminated bacterial contamination of the wounds after two applications (within 16 to 24 hours after contamination with Staphylococcus aureus). The overall clinical appearance and healing rates of wounds treated with the triple antibiotic were ranked superior to all treatments (and no treatment) except the other antibiotic ointment in the study.
A 23-year-old woman presented with Trichosporon cutaneum, which invaded deep into the dermis and subcutaneous tissue of the face and developed chronic granulomatous reactions. We postulated that the local use of an occlusive dressing with topical corticosteroid ointment in the early stage of the infection played a role in promoting the process of this opportunistic fungal infection. Antifungal chemotherapies, selected according to sensitivity testing to the isolated organism, were unsuccessful, mainly because of the acquired resistance of the organism to the chemical agent. Surgery was finally performed and a good result was obtained.
Wound infections are a major problem in burned patients. To determine the rate of wound infection associated with initial wound size and the amount of open full-thickness wound, we prospectively studied all patients admitted within 1 week of burn injury during a 2-year period using weekly wound cultures. Wounds were treated with topical silver sulfadiazine and occlusive dressings. Burn wound excision and immediate grafting were initiated during the first postburn week. One thousand five hundred twenty-three patient weeks (483 patients) were evaluated. Serious burn wound infections developed during 55/185 patient weeks (42.3%) when the initial total burn (ITB) was greater than 40% body surface area (BSA). This decreased to 27/304 (8.9%) when the ITB was 21% to 40% and 60/1034 (5.8%) when the ITB was less than 20% BSA. Burn wound infections developed during 57/211 patient weeks (27.0%) when the initial full-thickness burn (IFB) was greater than 20% BSA. The rate of wound infection decreased to 73/776 (9.4%) when the IFB was 1% to 20% and to 12/536 (2.2%) when no IFB was present. We further analyzed the prevalence of serious wound infections in relation to the open wound size during the hospital course. Wound infections occurred during 47 of 96 patient weeks (49.0%) when the current full-thickness wound was greater than 10% BSA. The infection rate decreased to 76 of 594 (12.8%) and 17 of 833 patient weeks (2.0%) when the remaining full-thickness wound was reduced to 1% to 10% and less than 1% BSA, respectively (p less than 0.05). Early wound closure would appear to reduce the risk of serious wound infections, especially in patients with full-thickness burns.
By means of experiments involving pin-pricking, compositions containing 10% ketocaine base in a mixture of 2-propanol, glycerol and water were found to produce a high frequency of block to cutaneous pain following application to volunteers under an occlusive dressing. The local analgesic efficacy was found to be directly related to the degree of saturation of ketocaine in the vehicle and time of application. The degree of hyperaemia observed in the treated skin areas was found to be related to the degree of local analgesia produced.
The phototoxic properties of topical trioxsalen preparations were studied in 73 test subjects. A W/O emulsion base was superior to petrolatum, O/W emulsion, double emulsion and carbowax. The optimal interval between application of the drug and UVA irradiation varied between 40 and 60 min for both cream and ointment bases. An occlusive dressing greatly enhanced the phototoxic effect of the drug. The skin lost photosensitivity in 4 hours when the preparations were removed from the skin 45 min after the application. For clinical use a proper concentration of trioxsalen in emulsion bases was 0.01-0.1%. Both W/O and O/W emulsion bases with 0.01% trioxsalen locally applied gave moderate or good clinical results in 16 psoriatics and in 4 patients with lichen planus, W/O emulsion being better in this respect.
Air embolism--the most dangerous complication of central venous catheterization--may occur in several ways. The most frequent is from disconnection of the catheter from the related intravenous tubing. An embolism may present with a sucking sound, tachypnea, air hunger, wheezing, hypotension and a "mill wheel" murmur. A later manifestation is severe pulmonary edema. In a review of 24 patients, the mortality was 50 per cent. Among the survivors, five (42 per cent) had neurologic damage. Immediate treatment includes placing the patient in the left lateral and Trendelenberg positions, administration of oxygen and aspiration of air from the heart. Cardiac massage and emergency cardiopulmonary bypass may be necessary. Most instances can be prevented by inserting the cannula with the patient in the Trendelenberg position, occluding the cannula hub except briefly while the catheter is inserted, fixation of the catheter hub to its connections and occlusive dressing over the track after removal of the catheter.
Percutaneous absorption, excretion kinetics, and metabolism of dithranol triacetate (2) have been investigated in Wistar rats. By the use of two differently labelled molecules--3H in the anthracene nucleus and 14C in the acetoxy groups of 2, resp.--the fate of the different parts of the dithranol triacetate molecule could be followed. After injection, large amounts of 2 are cleaved under the influence of enzymes into acetate and dithranol. These deacetylated metabolites lose half their 3H label with formation of 3H2O. In urine, 1,8-diacetoxy-9-anthrone, 1-acetoxy-8-hydroxy-9-anthrone, 1,8-dihydroxy-9,10-anthraquinone and its diacetate were found as metabolites. After dermal application, unchanged 2 is practically not absorbed at all. Arylesterases which, according to in vitro studies, are present in or on the skin, hydrolyse dithranol triacetate to give free dithranol. Up to 33% of the latter are absorbed from under an occlusive dressing. Dithranol triacetate, therefore, shows pro-drug characteristics for the treatment of psoriasis.
Plasma cortisol levels were determined by a radioimmunological assay in three groups of ten psoriasis patients treated with 0.05% halometasone ointment, 0.05% halometasone cream and 0.025% fluocinolone acetonide ointment, without occlusive dressings, for 7 days. Fourteen grams of the corticoid topical was applied daily (7 g/b.i.d.) to the psoriasis plaques covering an average of 25% of the body surface. No significant differences with respect to plasma cortisol values at 8 a.m. before, during and after treatment were evident in any of the three treatment groups, nor did the treatment groups significantly differ from one another with regard to their effect on the plasma cortisol levels. No side-effects were observed.
The differential diagnosis of the condition of a patient with acral thickening and normal bone roentgenograms but without obvious signs of Graves' disease may be perplexing. A patient was seen with this disorder, in which the early diagnosis of thyroid acropachy could not be made roentgenographically but was accomplished by bone-scanning techniques. To our knowledge, this is the first demonstration of the evolution of thyroid acropachy, as temporally proved by serial roentgenograms and bone radiographs. The patient complained of severe swelling and decreased finger mobility. His hands were treated in a novel manner, using fluorinated topical steroids under an occlusive dressing, because of the failure of previously described localized medical therapeutic regimens. Treatment, using one hand as a control, resulted in a substantial decrease in hand circumference and volume, as well as increased finger mobility.
Analysis of 300 consecutive hospitalized children with burns. To prevent infection, patients are given a bath with chlorhexidine (0.03%) every day and their burns covered by silver sulfadiazine (1%) and occlusive dressings. In 5.3% of the children positive swabs were obtained during hospitalization and in only 2.3% on several occasions. No case of septicemia could be documented.
A procedure which can serve as a possible basis for the laboratory study of the topical effect of NSAID was investigated in rats or guinea pigs. The effect of NSAID was greatly influenced by physical characteristics of the preparation such as drug particle size, solubility, ointment base and concentration of drug. Moreover, it was also found to be affected by many technical factors such as animal fixation, drug application times and methods (rubbing times or occlusive dressing technique) and amounts applied which play an important role in topical preparation. The topical application of NSAID ointment (1% of indomethacin, ketoprofen or diclofenac sodium) markedly inhibited the paw edema by carrageenin in rats. The inhibitory activity was the same as that of steroidal ointment (0.12% betamethasone 17-valerate or 0.05% fluocinonide), but was less than that by oral administration of these NSAID. Also, the NSAID ointment obviously inhibited the ultraviolet erythema in guinea pigs and the swelling in the hind feet of adjuvant arthritic rats. The inhibitory activities of NSAID ointments on these inflammatory responses were almost the same as those obtained by oral administration of such NSAID and more potent than those of steroidal ointments. Furthermore, NSAID ointments increased the pain threshold in the inflamed foot as determined by the method of Randall and Selitto. The analgesic activity of NSAID ointment was more potent than that of steroidal ointment, but less than that of NSAID administered orally. On the other hand, neither the systemic effects such as decrease in weight of the adrenals and thymus which were noted when steroidal ointment was used, nor the gastrointestinal lesions which were found by oral administration of NSAID, were recognized in rats in which NSAID ointment was applied topically. The anti-inflammatory effects of NSAID ointment correlated well with the drug concentration at the site of inflammation. These findings suggest that NSAID ointment has a clinical use in the treatment of inflammatory diseases.