Pressure sores-a reappraisal.

Pressure sores are a common problem. They are casually accepted, their etiology is well defined, and treatment is standardized. How, therefore, can the subject justify reappraisal? On detailed review, evidence is presented showing that pressure sores can be minimized, that their pathophysiology is far from certain, and that their management is changing dramatically. During the past decade, new preventive measures have been adopted consisting of multidisciplinary tissue trauma clinics for paraplegic patients, based in rehabilitation hospitals, as well as early identification of the "at-risk" subgroup of geriatric patients who will require aggressive nursing care. Although pressure is the most widely accepted etiological factor, no sophisticated experimental studies have corroborated this hypothesis, and in fact, the majority of research conflicts with clinical observations. Recently, new surgical proceudres-myocutaneous and sensory skin flaps-have been devised to solve complex coverage problems which will possibly reduce the recurrence rate. An in-depth review of pressure sores is therefore warranted and will, we hope, stimulate renewed interest in this all-too-frequent clinical affliction.     

Assault by burning in Dhaka,Bangladesh

Assault by burning in Dhaka, Bangladesh, occurs in a variety of forms, resulting from various causes and motives. A total of 311 cases of intentional burns from the Burn Unit of Dhaka Medical College Hospital from April 2004 to May 2011 (6 years) were studied by retrospective and prospective observational review. The majority of victims (68%) were female. Concentrated sulphuric acid was the most commonly used chemical for attack. Disfigurement was the principal complication (mortality, 4%). Dowry-related issues, divorce and other marital quarrels were frequent backgrounds for assault by burning. Kerosene oil was used to ignite 78 girls or young women, most often related to conflicts over dowry (mortality 97%). A total of 102 victims (32%) in all burn groups were attacked because of dowry-related issues. Intentional contact burns were often inflicted on domestic servants. Although physical morbidity and mortality were not reported in contact and other types of burns, psychological disturbances were reported in all victims. A few victims had been assaulted prior to receiving burns, and fractures and deformities were also present on examination at the time of presentation for burn treatment. Ophthalmic injury, with frequent visual impairment, was very common in cases of chemical attack. Legal and social support for victims and their families are frequently inadequate to compensate for losses. Clearly, more attention in our community should be focussed on the prevention of burn assaults, adequate compensation and medical care for victims, as well as speedy retribution for perpetrators.     

Congenital syndactyly: a reappraisal.

Digital syndactyly is a common congenital anomaly and is associated with other anomalies affecting the digits, the hand, the arm or even the entire body. In the past it has been considered a single entity. However, recent information provided by experimental embryology, studies of morphogenesis and other sources, suggests that there are at least two distinct entities: primary syndactyly due to interference with the sequence of events that normally culminate in the division of digits into discrete parts and secondary syndactyly due to readhesion of adjacent digits as a result of close contact between raw surfaces. Primary syndactylyl may arise de novo, or it may occur as a manifestation of a mutation phenomenon or as a genetically controlled syndrome. Secondary syndactyly is the result of mechanical adhesion of adjacent parts involved in a general reparative or healing process. The initial insult leading to amputation of a portion of the digits may or may not be genetically controlled; adhesion is fortuitous. Management of syndactyly is determined by the complexity of the malformation. For simple cutaneous syndactyly the surgeon should make a zigzag incision and provide a rectangular, proximally based flap for the floor of the web, usually before the child is 2 years of age. A full- or split-thickness skin graft should be applied to the defects. For complex deformities involving several digits and associated with postural or osseous malformation, several operative procedures may be required. The surgeon must be vigilant to note and correct the sequelae resulting from recurrent contractures and imbalances associated with growth.     

Assault by burning and its relationship to social circumstances

The phenomenon of burns through assault seen amongst patients admitted to the Burn Unit of Tygerberg Hospital is increasing drastically. This paper reports the results of a study which examined the possible relationship between the above-named phenomenon and socioeconomic factors of 50 coloured and black patients amongst whom this form of assault is mainly found.

The social behaviour of the patients as well as their housing conditions, employment, income, religious practices, use of leisure time, etc. were examined and shortcomings in all these areas were found to be related to the patients' methods of settling conflict.     

A reappraisal of the Pfannenstiel incision.

The postoperative morbidity of incisions used in retropublic prostatectomies was examined. 350 patients with vertical midline incisions were compared with 411 patients with transverse or Pfannenstiel incisions. There was a significantly increased incidence of postoperative inguinal hernias in the group of patients who had had transverse incisions. The possible reasons for this were discussed. It was concluded that the normal architecture of the inguinal canal was deformed and weakened by extra-wide transverse incisions.     

Rubella--a reappraisal

Rubella infection is reviewed and new information about congenital infection, possible sources of infection in pregnant women and the optimum ages and population groups for rubella vaccination is considered. Investigations required to confirm a suspected and possibly 'silent' infection during pregnancy are outlined.     

Tubal conservation with ectopic gestations. A reappraisal

Ectopic pregnancies have shown an increasing trend during the past decade. Factors that appear to be responsible are the intrauterine device (IUD), fallopian tube surgery (ligation reversals, reconstructive tuboplasty), and more effective antibiotics against pelvic inflammatory disease (precluding radical pelvic surgery). Our ability to diagnose an ectopic pregnancy at an earlier gestation (prior to rupture) through the use of highly sensitive pregnancy tests (Beta-HCG), ultrasonography, and diagnostic laparoscopy, has significantly altered our approach in treatment. Because these ectopic gestations are seen in a younger population, older nulliparous patients, and patients who desire future fertility, earlier diagnosis precludes an emergency approach to a now-elective procedure. In this paper, we will explore the pros and cons of conservative management for ectopic pregnancies, emphasizing present day evaluation and microsurgical approaches for repair.     

Injury to segmental bile ducts. A reappraisal

No principles have so far been applied to the management advocated for injuries to segmental bile ducts. On the basis of experimental data and clinical evidence related to the pathophysiological sequelae of segmental bile duct obstruction, and given the potentially harmful complications of reconstructive surgery in combination with its uncertain outcome, it is suggested that simple ligation of injured segmental ducts is the treatment of choice, irrespective of their size.     

Assault Induced Stab Injuries: Epidemiology and Actual Treatment Strategy.

Objectives : To investigate and analyse epidemiology, demographics and patterns of presentation of assault induced stab injuries in a main Belgian trauma centre. To evaluate surgical management, complications and postoperative follow-up of the stab wound victims.

Methods : One hundred and seventy assaulted patients, hospitalised because of stab injuries from January 2000 to June 2007 are studied retrospectively.

Results : Ninety-five percent of the assaults occurred on men and the mean age of the patients was 31.1 ± 9.7 years. Ethnic minorities represent 77% of the patients hospitalised for assaults and 26.5% of all patients proved to be under toxic influence, predominantly from alcohol (21.8%). A decline of admissions of patients with stab injuries during the period 20022004 is recorded. However, the incidence doubled in the next two-year period. A weekend peak and circadian rhythm is apparent with more than 20% of the patients admitted between 4 and 6 am. The trunk is most frequently stabbed (54.5%) resulting in a laparotomy rate of 51%. One third of the patients who underwent thoraco-abdominal surgery revealed diaphragmatic injuries. Seventy-five percent of the patients left the hospital in a good condition while 2.4% had neuromuscular lesions. Two patients had serious vascular complications during follow-up. During the study period, no mortality was recorded.

Conclusions : Stab wounds were recorded mainly in young and middle-aged men from ethnic minorities, whereas almost 27% were under the influence of drugs. A conservative approach was generally used resulting in a low laparotomy and thoracotomy rate without affecting mortality. Neuromuscular lesions are important long-term complications of stab injuries.