INTERNATIONAL ABSTRACTS

HISTORICAL NOTES ON THE USE OF PRESSURE IN THE TREATMENT OF HYPERTROPHIC SCARS OR KELOIDS

This interesting and wide-ranging article considers descriptions in the literature of deforming scars and contractures. Apart from some uncertain allusions in occasional ancient sources, the first known specific reference was in The Works of Ambrose Parey (1678). Other landmarks in the literature were Retz's Treatise on Skin Disease and Things of the Mind (1790) and various works (1806-1817) by Alibert, who coined the term "keloid". Rayer, in 1835, was the first to describe a keloid developing from a burn scar. At this time, the use of pressure as a therapeutic method was already prescribed, and many references are to be found to this kind of treatment throughout the nineteenth century. However, the use of pressure in the treatment of hypertrophic scars or keloids only gained universal support after the pioneer work at the Shriners Burns Institute at Galveston in the USA, which led to the use of pressure, positioning, splinting, exercise and pressure garments as standard treatment modalities in burns centres. The development of these techniques and the devices designed are described.

Linares H.A., Larson D.L., Willis-Galstaun B.A. Burns, 19: 17-21, 1993

The diagnosis of toxic shock syndrome in burned children is made on clinical grounds supported by haematological and biochemical tests: there is a prodromal 24-48 h period with diarrhoea, vomiting, general malaise, pyrexia, tachycardia and tachypnoca, together with a drop in the white cell count and haemoglobin concentration prior to the shock phase, which has its onset 3-4 days postburn. If shock occurs the mortality rate is usually in the region of 50%. A retrospective review is made of six burned children with a clinical diagnosis of toxic shock syndrome observed in a 2-year period. With careful treatment such patients can recover and in fact these six children all survived. The modalities of their treatment are described. It is pointed out that early diagnosis of staphylococcal toxaemia and prompt specific treatment prior to the development of shock is likely to reduce mortality. The term "staphylococcal toxaemia" emphasizes the need to treat this condition in burned children before the development of shock, with its high mortality risk.

McAllister R.M.R., Mercer N.S.G., Morgan B.D.G., Sanders R. Burns, 19: 22-5, 1993.

This paper describes a psychiatric liaison service in a burns unit, with a review of the results achieved in the first year. A definition of the objectives of the service is followed by a discussion of the ways in which contact can be maintained between the psychiatrist and the burns team. The referrals observed are divided into three diagnostic categories. Although diagnostic criteria may not be achieved in all patients, the burns team still benefits from any help in the management of cases presenting psychological disturbances. It is now fairly well established that attentive care of the psychological status of medical and surgical patients improved their physical outcome: the provision of effective liaison psychiatry services is a sensible statagern in terms of patient health, staff satisfaction and the rational allocation of resources.

Antebi D. Burns, 19: 43-6, 1993.

BURN EPIDEMIOLOGY: THE PINK CITY SCENE

A retrospective study is presented of 629 burn cases treated between January 1989 and August 1990 in the new Burn Unit opened in Jaipur (the "Pink City"), India, in April 1988. The data analysed refer to age, sex, cause of burn, and related mortality. Further information concerns socioeconomic and marital status, place of burn, family size, type of burn, time of accident and time delay between injury and hospital admission. Adolescents and young adults (11-40 years) constituted 64.8% of the patients. The male/female ratio was 54 to 46. Domestic burns represented 82.65% of the total. The majority of the patients belonged to low or lower middle socio-economic strata, with large families. The vast majority (95.5%) of the accidents were accidental in nature. The overall mortality rate was 48.3% (20.1% in children), flame burns being the most dangerous (mortality rate 62.1%). In patients with over 40% TBSA burns the mortality rate was about 80%; there were no survivors among patients with more than 70% burns.

Gupta M., Gupta O.K., Yaduvanshi R.K., Upadhyaya J. Burns, 19: 47-51, 1993.

After an alarming increase was observed in the infection rate in a Burns Unit in Bombay, India, it was decided to carry out a programme of bacteriological surveillance and analysis of wound sepsis. This was done for a l-year period (January-December 1988). Various sources of infection were thus discovered, including a contaminated disinfectant container and transient pathogenic flora on a staff member involved in changing dressings. The most common pathogen isolated from infected wounds and from the blood of patients developing sepsis was Pseudomonas aeruginosa. A number of changes were implemented in procedure and the infection rate dropped considerably. This underlines the importance of strict vigilance by all personnel involved in the care of burned patients, in order to reduce the incidence of hospital infection and thus to shorten hospital stay.

Pandit D.V., Gore M.A., Saileshwar N., Deodhar L.P. Burns, 19: 52-5, 1993.

The threat of legionnaires' disease, particularly in hospitals and other health-care premises, is so real that building services engineers are recommended - and in some countries required by national legislation - to store and operate hot water systems at a temperature of 60 'C. The causative organism of the disease, Legionella pneumophila, which can be fatal to immunosuppressed persons and those with chronic respiratory conditions, can colonize hot water systems but is killed off by temperatures above 50 'C. The high water temperature is evidently a risk and serious scaldings may result if adequate water. mixing devices are not installed to cool the water before normal use for washing or bathing. Three such hot-and-cold water blending devices are compared (Aquamix Mixing Valve, Horne 15 Thermostatic Mixing Valve and Taco Automatic Tempering Valve). It was found that while all three operated satisfactorily in normal supply conditions, only the most expensive (the Horne model; cost US$ 194) was consistently able to shut off the hot water in the event of failure of the cold water supply. As this is not a negligible risk, especially where young children and handicapped persons are concerned, it is recommended that the cheaper tempering valves, which in certain circumstances may be inefficient, should not be installed.

Stephen F.R., Murray J.P.

Unsuspected acute adrenal insufficiency can underlie a confusing and stormy intensive care unit course in the bum patient because the haemodynamic picture is identical to that seen with sepsis. The possibility of acute adrenal insufficiency should be considered in burn patients who develop unexplained hypotension, delirium and fever - especially when accompanied by hyponatraemia and hyperkalaemia. The case histories are given of two such patients who were diagnosed antemortern but successfully treated with replacement therapy. The aetiology, presentation, diagnosis and treatment of acute adrenal insufficiency in the intensive care unit is reviewed.

Sheridan R.L., Ryan C.M., Tompkins R.G. Burns, 19: 63-6, 1993.

This report discusses ocular chemical bums, the nature of the substances involved, the type of people at risk and the severity of the injury. The clinical and demographic profile of 145 chemical eye injuries in 102 patients treated at a major referral centre in Chandigarh, India, is presented. Acids and alkalis were responsible for 80% of the injuries. Two-thirds of the patients were young people working in laboratories and factories. Fifty-two eyes (35.9%) suffered severe injuries (Grade III/IV). Injuries caused by deliberate assault were more severe and caused proportionately more lost eyes. It is emphasized that first-aid measures at the scene of the accident, particularly copious irrigation with water, can be of paramount importance in limiting the severity of eye injuries, thereby limiting ocular morbidity.

Saini J.S., Sharma A. Burns, 19: 67-9, 1993.