Peripheral blood T and B lymphocytes in patients with burns. I. Test parameters and clinical evaluation of the rosette assays

Rosetting techniques identifying receptors for sheep red blood cells, for Fc in antigen-antibody complexes (EA) and C₃ in antigen-antibody-complement complexes (EAC) were employed in the sequential evaluation of 10 normal individuals over an 8-week period and in the testing of burn patients' blood samples. Mean values with standard deviations were 59 ± 7 per cent or 959 ± 260 E rosettes, 34 ± 6 per cent or 500 ± 186 EA rosettes and 41 ± 7 or 657 ± 214 EAC rosettes. Variations in percentage results were attributed to the handling of rosetted cells for counting. Variations between samples from the same individual were similar to variations between samples from different individuals. Lymphocyte preparation of peripheral blood samples from burn patients resulted in red cell contamination of the separated lymphocytes. Ox red cell rosette assay and E and EAC percentages were used to evaluate samples from burn patients for non-rosetting cells or possible multiple reactive cells to explain diverse results obtained from these samples relative to normal control samples.     

Burn wound biopsy bacterial quantitation: a statistical analysis.

Sequential paired punch biopsy samples were taken from three separate locations on each of four burn patients and were quantitated for the number of viable bacteria per gram of tissue. The range (log10 0.02 to log10 1.51) and the standard deviation (log10 0.67) were determined for each pair. The 95 per cent confidence interval based on any single observation, x, was determined to be x +/- 1.31. It is concluded that the burn wound biopsy is a reliable procedure for quantitating organisms in a burn wound and that changes in sequential samples give an indication of the dynamics of infection in the burn patients.     

Secure closure of duodenal stump with staples

A modification of the GIA stapler is described that allows closure of a duodenal stump with four rows of staples without any sutures. This method of closing the duodenal stump is simple, quick and secure. It has been used successfully in 12 patients with no postoperative leaks.     

Effects of fracture stabilization by internal fixation: I. A haemodynamic and blood gas evaluation of the systemic and regional changes

The effect of internal stabilization of a fracture of the femur on arterial blood oxygen levels, limb blood flow and oxygen consumption was measured in 24 dogs. Those with stabilized fractures bore weight on their limbs and were much more active. Without fracture stabilization the arterial oxygen tension fell by 10 per cent. With internal fixation this hypoxia did not develop. In fact, there was a 10 per cent increase beginning in the third week. Stabilization of the fracture gave a persistent increase in limb blood flow, but without stabilization this increase was transient and followed by a significant decrease. Over the 7-week observation period, the total oxygen consumption of the uninjured limbs in the stabilized group was twice that in the unstabilized group, an indication of their functional activity. Also with stabilization, the oxygen consumption of the injured limb was not significantly different from the opposite limb, whereas without stabilization the consumption was 32 per cent greater, an indication of the energy cost of countering instability.     

Predicting the survival of burned patients using discriminant function analysis

Data from 291 burn patients treated at the burn centre of the University of Kansas Medical Center were analysed by discriminant function analysis. Age, sex, extent of burn and body weight were examined in an attempt to predict which patients could be expected to survive. Several sets of predictor variables, corresponding to varying states of knowledge about the patient, are presented. Comparisons with results from previous investigations are also included.     

Treatment of the Zollinger-Ellison syndrome. A 25 year assessment

An assessment of treatment methods for the Zollinger-Ellison syndrome over 25 years suggests that the dual surgical approach of excision of resectable tumor and total gastrectomy provides the greatest possibility of attaining tumor and serum gastrin control. Normal serum gastrin levels and reduction of tumor status, not observed with nonoperative management, were attained by surgical treatment, particularly when the tumor (or hyperplasia) was limited to the pancreas, stomach, duodenum and regional lymph nodes. Eleven of 16 such operations resulted in tumor control, and 10 of these patients developed normal serum gastrin concentrations. In elective clinical situations combined medical and surgical therapy is a rational approach allowing confirmation of diagnosis and safe, definitive surgical control of the syndrome before metastases occur.     

Segmental pancreas transplantation in the canine model. A reappraisal

Segmental vascularized grafts of pancreatic tissue have been recommended in the treatment of juvenile onset insulin-dependent diabetes mellitus. The method of intraperitoneal placement and unligated pancreatic duct provided a low incidence of exocrine complications, but clinical results were less than ideal. To further assess this technique, we used segmental pancreatic autografts in the canine model. Five of the 22 dogs survived with good function of the autograft as determined by glucose homeostasis and a slow return to normal of serum amylase levels. In 12 dogs, however, pancreatic dysfunction was evident within 24 hours and death followed within days. At reexploration or necropsy, necrotic pancreatic tissue and clotted vessels were found. We suggest from these findings that although few, if any, complications of exocrine drainage or endocrine function were encountered, a major technical problem with segmental pancreatic transplantation may involve inadequate arterial runoff to maintain patency of vessels and viability of the graft. Terminal arteriovenous fistulas do not seem to improve vascular patency in the canine model in our experience.     

Factors influencing the expectation of pain among patients in a children's burns unit

The study was undertaken to identify factors increasing anxiety, fear and anticipation of pain among patients in a children's Burns Unit and to establish means of modifying such factors in order to reduce the children's experience of pain during nursing and treatment sessions. Sixty patients were observed and, where possible, interviewed at periods throughout their stay in the unit. The results indicated that expectation of pain might be reduced by correcting the child's erroneous beliefs about the nature of the healing process and the role of clinical therapy, and by undertaking certain changes in the manner in which treatment and nursing procedures upon the conscious patient were normally conducted.     

Enhanced recovery of pseudomonas from blood cultures

Pseudomonas and staphylococcal septicaemia are frequent complications of paediatric patients with significant burns. Early diagnosis and appropriate treatment afford the greatest likelihood of clinical response. Blood cultures from these patients may be negative or may become positive only after prolonged incubation. To evaluate more rapid culture methods for precise diagnosis, an in vitro study was done. The effects of venting and/or rotating on low inocula blood cultures was evaluated. Both venting and rotating contributed to more rapid bacterial growth and the effects were additive, affording a much more rapid and, therefore, potentially more useful culture method.     

Psychosocial concerns in the paediatric burn unit

In reviewing the medical charts of 264 patients treated in the Indiana University Riley Pediatric Burn Unit over a 10-year period, we found that 52 per cent came from broken homes or other abnormal situations. This paper describes these findings and the protocol we now follow for the psychosocial evaluation and treatment of the burned child.     

Oxygen affinity of whole blood in vivo and under standard conditions in patients with severe burns

The four different ways of improvement of oxygen supply to tissues in different phases of the burn syndrome are: 1. increase in cardiac output, 2. increase in haemoglobin level, 3. increase in arterial oxygen saturation and 4. decrease in oxygen affinity of haemoglobin.The observed decrease in oxygen affinity of haemoglobin due to increased synthesis of 2,3-DPG in the erythrocytes (‘the oxygen affinity reserve’) is of great importance for the maintenance of a constant and sufficient tissue oxygen tension in patients with severe burns during several weeks after the trauma.     

Calciuretic response to protein loading in burn patients

The effect of dietary protein on calcium excretion has been evaluated in 6 patients with major burns. A marked calciuresis was noted when patients received more than 150g protein per day while urinary calciums approaching normal levels were noted when protein intake was less than 150 g. Excessive calcium mobilization and excretion secondary to protein loading may account for heterotopic calcium deposits and renal stones frequently seen in burn patients. Although the mechanism is not clearly defined, a primary alteration in calcium transport by the kidney seems likely.     

The relationship of bacteremia to levels of transferrin,albumin and total serum protein in burn patients

The mean serum concentration of transferrin in 54 burn patients with injuries ≥ 45 per cent was 205 ± 4 mg/dl, the mean concentration of albumin was 32 ± 0–04g/dl, and the mean level of total protein was 6-0 ± 0–06 g/dl during the first 6 weeks post burn. These patients had a 20 per cent risk of associated bacteremia when transferrin levels were below 205 mg/dl, but only a 9 per cent risk with higher levels (P<0?025). There was a 13 per cent risk of developing bacteremia with albumin levels of 3–5 g/dl, compared to a 7 per cent risk with higher levels (P<0?1). The risk of associated bacteremia to levels of total serum protein less than 5-5 g/dl was 13 per cent compared to 10 per cent for higher concentrations (not significant). The increased incidence of bacteremia in burn patients with low levels of transferrin is probably related to the nutritional status of the patient.     

Renal microembolization syndrome. A cause for renal dysfunction after abdominal aortic reconstruction

Moderate renal dysfunction due to renal microembolization developed in eight patients who underwent abdominal aortic reconstruction for aneurysmal or occlusive disease. In each patient, the aorta around the renal arteries was thrombus-lined or severely ulcerated and was therefore the source of embolization, and aortic clamping near the renal arteries was required and provided the mechanism for embolization. Renal failure was moderate and did not require dialysis. Renal dysfunction appeared to be largely reversible, although some degree of permanent damage did occur. Similar changes in renal function were noted in a dog model of renal microembolization. Prevention of this complication depends on awareness of aortic lesions that increase the risk of renal embolization.     

Peripheral neurological problems in the acute burn patient

Electromyographic and nerve conduction data in evaluation of 66 burn patients revealed a 29 per cent incidence of peripheral polyneuropathy. Patchy myopathic findings, probably related to multiple injections, were noted in the proximal muscles of 22 patients. Entrapment mononeuropathies of the ulnar, median and peroneal nerver were found. These neuromuscular abnormalities produce clinical motor and sensory deficits which limit rehabilitation in the burned patient, and further work is immediately needed to determine the pathophysiology of these abnormalities.     

Hormonal and associated metabolic alterations following burn injury: Part II. A comparative evaluation in surviving and non-surviving patients

In surviving burn patients the elevated circulating levels of catecholamines, cortisol and blood sugar start declining from week 1 onwards along with a gradual rise in insulin levels. On the other hand, in non-surviving burn cases these levels remain markedly elevated up to week 2 with a further reduction in insulin. Quite possibly, such a prolonged and marked increase in catecholamines, cortisol and suppression of insulin in non-surviving burn patients might be responsible for higher mortality, because of their known effects on various metabolic processes.     

Treatment for hydrofluoric acid burns

Various approaches to HF burn have been studied. This presentation offers a somewhat different approach which centres around the use of benzethonium chloride solution and betamethasone. A review of 10 case records confirms the effectiveness of this treatment when compared to that in prior use, especially in the treatment of an emergency.     

Severe abdominal vasculitis with hepatitis B antigenemia

Two cases of necrotizing abdominal vasculitis associated with hepatitis B are reported. The diagnosis of mesenteric vasculitis is often delayed, and intestinal perforation is common. Early recognition of the disease and early treatment with corticosteroid and immunosuppressive drugs may alter the course of the disease. Preoperative diagnosis is best made by mesenteric arteriography and rectal biopsy.