Statistical methods to predict morbidity and mortality: self assessment techniques for burn units

The medical records of 806 adult and paediatric burn patients were retrospectively reviewed. Patient data was summarized, coded and entered in a computer for subsequent analysis.This report describes the use of multiple regression analysis to produce equations useful for the prediction of the morbidity parameters: length of hospital stay, number of transfusions required and number of operative procedures. The multiple regression equations developed are useful as prediction tools, in patient medical audit and in assessing improvements in burn care.The classical technique of probit analysis for predicting the probability of mortality was used to develop the LA₅₀'s of burn injury. These LA₅₀'s were used as the basis for comparison of survival statistics between burned patients in this series and those registered in the National Burn Information Exchange (Feller, 1979). There is an apparent significantly improved survival in the children, young adults through 34 yrs and the older adults (60–74 yrs) in the current series of patients. This observation would support the adoption of the protocol of burn care used in treating these patients.The newer technique of discriminant analysis is also described. Discriminant analysis is a multifactorial method for discriminating between dichotomous outcomes (survivors and non-survivors). The technique of discriminant scoring proved to be 95.8 per cent accurate in predicting burn survival. Use of a burn severity scoring technique will also assist in recognition of the high risk patient.     

The deleterious effects of high dose cimetidine in acute thermal injury

Pharmacological doses of cimetidine have been reported to reduce oedema formation in murine burn models. Sprague-Dawley rats subjected to a 30 per cent full-thickness burn were treated with cimetidine (200 mg/kg) pre and post burn. Untreated, burned animals and sham-burned animals were also studied. No beneficial effects of cimetidine were demonstrated. Cimitidine increased the water content in lung, stomach and eschar of burned animals. No differences were seen in serum or urine electrolytes, or extrarenal water loss. Cimetidine did reduce serum hyperosmolality seen in unresuscitated burned animals. Multiple doses of cimetidine following thermal injury were associated with a significant increment in mortality rate.     

Advanced hidradenitis suppurativa: Review of surgical treatment in 23 patients

Hidradenitis suppurativa remains a poorly understood disease involving the apocrine sweat glands. Management of 23 patients with the advanced form of the disease has been reviewed. Local therapy and incision and drainage all have an unacceptable rate of recurrence. From our experience, we recommend wide and deep excision of the area involved combined with individualized closure.     

Primary malignant retroperitoneal tumors: Current management

Our experience with 16 retroperitoneal tumors seen over a 13 year period has been reported. Patients presented with either an abdominal mass or abdominal pain associated with a large retroperitoneal tumor. Delineation of the tumor is best accomplished with computerized tomography and venacavography. Exploration and resection is possible in most patients. Postoperative radiotherapy and chemotherapy are recommended in most patients. Local recurrence frequently occurs and should be diagnosed early and resected aggressively if found.     

Unilateral inline replacement of infected aortofemoral graft limb with femoral vein

Objective

Aortic graft infection remains a formidable challenge for the vascular surgeon. Traditionally, reconstruction with a neoaortoiliac system (NAIS) involves removal of the entire synthetic graft with in situ reconstruction using femoral vein. Whereas the NAIS procedure is durable with excellent graft patency and a low reinfection rate, it can take up to 10 hours and result in a high perioperative complication rate with significant mortality. Not infrequently, the infection is limited to a single limb. In addition, the patient may be too frail to tolerate aortic clamping for a complete graft excision. Under such circumstances, complete excision of the aortofemoral bypass graft (AFBG) may not be indicated. It is hypothesized that local control of infection and limited reconstruction using femoral vein may be acceptable. The objective of this study was to examine the outcomes of all patients who underwent partial AFBG resection and in situ reconstruction with femoral vein.

Energy metabolism in anesthetized children with burns

Energy dynamics in 10 burned children were studied to determine cause and effect relationships between rates of heat production, heat loss and plasma catecholamine concentrations when thermoregulatory responses were depressed by methoxyflurane anesthesia. Rapid cooling of the burned children was due to increased heat loss during the period of anesthesia. Heat production increased significantly, although not enough to counterbalance the increased heat loss reflecting a block in central thermoregulation by general anesthesia. Mean plasma catecholamine concentrations decreased during general anesthesia as compared with baseline values. Heat production attempted to track heat loss during a period in which plasma catecholamine levels declined. An increased rate of heat loss is concluded to be primary stimulus for increased metabolic acitvity after thermal injury.     

Melanoma today does not require radical surgery

From this study we conclude that melanoma has a more favorable outcome today than 20 years ago, 2 cm margins around the tumor achieve acceptable survival and local recurrence rates, primary closure is preferred when possible, elective regional node dissection is of questionable value, and further trials are warranted to determine optimal therapy for intermediate thickness melanoma.     

Postoperative necrotizing fasciitis of the abdominal wall

Postoperative necrotizing fasciitis of the abdominal wall is usually caused by peritonitis in patients who have undergone multiple procedures for complications of emergency laparotomy. Better patient survival may be achieved by the following method: thorough peritoneal exploration to drain abscesses, excision of necrotic fascia, temporary Marlex placement, and delayed closure of the wound with skin flaps.     

Breast masses in young women

Based on our review we conclude the following concerning breast masses in young women under 30 years of age: (1) Breast masses are nearly always benign. (2) Mammograms are not helpful in most patients. (3) Needle aspiration or needle biopsy is rarely indicated. (4) Excisional biopsy should be performed through a circumareolar or other cosmetic incision. (5) Preparation for frozen section and mastectomy is not indicated. (6) The breast should be reconstructed in layers without drains. (7) Further manifestations of benign disease can be expected in 15 percent of the cases.     

Cisplatin sensitization to radiotherapy of squamous cell carcinomas of the head and neck

A combined modality of treatment utilizing cisplatin as a radiosensitizing agent concomitantly with full-course radical irradiation has been studied in 14 patients. Cisplatin at a dose of 15 mg/M² body surface area was given intravenously on days 1 through 5 and 21 through 25 of the radiation therapy course.Among the 14 patients so treated, 11 patients had evidence of complete clinical regression of their tumors. Most remained in remission without evidence of recurrent disease for as long as 18 months. Recurrence in the field of treatment was even more rare. Symptomatic improvement was very encouraging in these patients. Most of them have had a significant improvement in their tolerance of pain and in the ability to swallow foods and maintain weight without a nasogastric feeding tube. Decannulation of the tracheostomy is usual. Problems included four patients with renal toxicity, one of whom died with renal failure. No patient required interruption of therapy due to mocositis or dysphagia. Nausea was rare.This encouraging data in our pilot study of a new therapeutic regimen justifies a full-scale clinical trial.     

Evaluation of the effectiveness of postoperative radiation therapy for the control of local disease

Although we agree that postoperative irradiation does improve the local and regional control, our findings indicate that the rate of control, especially local control, is somewhat less than 90 percent. Our data reveal a recurrence rate of 32.7 percent in advanced, stage III and IV, squamous cell carcinomas in the head and neck treated by surgery and post-operative irradiation; this rate may be even greater with longer follow-up. We recommend that surgeons avoid “close” surgical margins (less than 5 mm) when resecting primary cancers and not rely too heavily on radiation therapy to control residual subclinical disease. It appears that continued study is needed to establish the true efficacy of irradiation in the control of subclinical disease, and that local recurrence must be differentiated from regional recurrence when reporting these results.     

Acute perforations of the sigmoid colon secondary to diverticulitis.

Diverticulitis is a complex disease and demands careful cooperation between physician and surgeons, because although it is a benign disease, the presence of complications makes it potentially lethal. For successful management, knowledge of the treatment in past decades should be integrated with current surgical technics. A retrospective review of forty-one patients with perforated diverticulitis revealed a significant decrease in morbidity and hospital stay for the group of patients undergoing the Hartmann procedure versus the group undergoing the classic three stage approach. In addition, the Hartmann group required fewer additional surgical procedures for drainage of abscesses. In view of these results as well as those of others, we believe that resection is the primary goal of therapy. The two stage approach therefore offers significant decrease in morbidity with acceptable mortality.     

Lip cancer: Surgical management

On the basis of this review, we believe that most patients with lip cancer should be treated surgically. Wide excision with frozen section examination of margins is imperative. Possible extension along bones, nerves, fascia, or muscle should be considered. In most cases, primary repair can be achieved using local tissue. A plan of specific technic based on the size and location of tumor defects is presented.Application of these principles and technics will result in good cancer control and acceptable cosmetic and functional results.