富氢盐水对高原环境下烧伤小鼠肠道损伤的影响

目的 探究富氢盐水对高原环境下烧伤小鼠肠道损伤的保护作用及可能机制。方法 36只♀BALB/c小鼠随机分为假烧伤组、烧伤模型组和富氢盐水组,实验均在低压氧舱室中模拟海拔3000m的高原环境。假烧伤组小鼠背部采用温水浴(37℃,10s)模拟致伤,烧伤模型组和富氢盐水组小鼠背部采用沸水浴法(90℃,10s)致30%TBSA Ⅲ烫伤。烧伤后,富氢盐水组注射富氢盐水10mL·kg^-1(0.6mmol·L^-1),假烧伤组和烧伤模型组注射等量生理盐水。通过分析小肠组织病理情况,血清中脂多糖的表达及肠道中紧密黏连蛋白1(zonula occludens-1,ZO-1)、闭合蛋白(Occludin)、胆碱乙酰转移酶(choline acetyltransferase,ChAT)、酪氨酸羟化酶(tyrosine hydroxylase,TH)和神经元型一氧化氮合酶(neuronal nitric oxide synthase,nNOS)的表达以阐明富氢盐水对高原环境下烧伤小鼠肠道屏障及肠神经系统的影响。另外,通过分析血清中丙二醛(malondialdehyde,MDA)、过氧化氢酶(catalase,CAT)和谷胱甘肽过氧化物酶(glutathione peroxidase,GSH-Px)的表达,肠道中炎症因子TNF-α、IL-1β和IL-17A的表达及CD3 T淋巴细胞浸润情况以探究富氢盐水对高原烧伤小鼠氧化应激及炎症反应的影响。结果 与假烧伤组相比,烧伤模型组小鼠表现出明显的肠道病理损伤、ZO-1、Occludin、ChAT、TH和nNOS的表达显著降低;富氢盐水显著改善了模型组小鼠的肠道病理损伤、肠黏膜屏障损伤,并且对肠神经系统表现出积极作用。另外,富氢盐水可显著调控烧伤模型组小鼠血清中MDA、CAT及GSH-Px的表达,降低炎症细胞因子的表达,减少CD3 T淋巴细胞的浸润。结论 富氢盐水可减轻高原环境下烧伤小鼠的肠道病理损伤,修复肠黏膜屏障,并对肠神经系统发挥保护作用,其作用可能通过调控氧化应激及炎症反应实现。     

氟比洛芬酯对严重烧伤患者急性期应激反应的影响

目的:探讨静脉注射氟比洛芬酯对严重烧伤患者急性期应激反应的影响。方法:收治62例严重烧伤患者,于伤后24 h内入院,随机分为治疗组(氟比洛芬酯镇痛)和对照组(肌内注射镇痛药)。检测镇痛开始前及开始后3 h、18 h、24 h、48 h的血浆胰岛素(INS)、血糖(GLU)、促肾上腺素(ACTH)、去甲肾上腺素(NA)、肾上腺素(AD)和皮质醇(COR)的水平。结果:用药后两组对比,治疗组VAS镇痛效果优于对照组;治疗组镇痛后3~48 h血糖和8~48 h血浆应激激素与镇痛前比较均有所降低,尤其是24~48 h效果明显;组间比较,其血糖和血浆胰岛素水平统计学比较差异有统计学意义(P<0.05或P<0.01)。两组患者均无恶心、呕吐、幻觉以及呼吸抑制、镇静过度等不良反应。结论:氟比洛芬酯能抑制严重烧伤患者急性期应激反应,镇痛效果良好,不良反应少,值得临床推广。     

A Comparative Study of Paediatric Thermal Burns Treated with Topical Heparin and Without Heparin

Following reports of heparin use in burn treatment, an ethics-committee-approved prospective randomized study with controls compared results obtained using traditional usual burn treatment without heparin with results in similar patients similarly treated with heparin added topically. The subjects were 100 consecutive burn patients (age <15 years) with second-degree superficial and deep burns of 5–45 % total body surface area size. Two largely similar cohort groups—a control group (C) and a heparin group (H) with 50 subjects per group—were randomly treated. The 50 control group patients received traditional routine treatment, including topical antimicrobial cream, debridement, and, when needed, skin grafts in the early postburn period. The 50 heparin group patients, without topical cream, were additionally treated, starting on day 1 postburn, with 200 IU/ml sodium aqueous heparin solution USP (heparin) dripped on the burn surfaces and inserted into the blisters two to four times a day for 1–2 days, and then only on burn surfaces for a total of 5–7 days, before skin grafting, when needed. Thereafter, control and heparin group treatment was similar. It was found that the heparin patients complained of less pain and received less pain medicine than the control patients. The heparin group needed fewer dressings and oral antibiotics than the control group. The 50 heparin group patients had 4 skin graftings (8 %), while the 50 control group patients had 10 (20 %). Five control group patients died (mortality 10 %). No heparin group patients died. The number of days in hospital for the heparin group versus control group was significantly less (overall P < 0.0001): 58 % of heparin group patients were discharged within 10 days versus 6 % of control group patients; 82 % of heparin group patients were out in 20 days versus 14 % of control group patients; 98 % of the heparin group versus 44 % of the control group were out in 30 days; and while 100 % of heparin group patients were discharged by day 40, 56 % of the control group required up to another 10 days. Burns in heparin group patients healed on average in 15 days (maximum period 37 days) versus an average of 25 days (maximum >48 days) in control group patients (P < 0.0006). Procedures and costs in the heparin group were much reduced compared with the control group. Differences between the heparin and control groups are presented for the sake of comparison. It was concluded that heparin applied topically for 5–7 days improved burn treatment: it reduced pain, pain medicine, dressings, and use of antibiotics; it significantly reduced IV fluids (P < 0.04), days in hospital (P < 0.0001), and healing time (P < 0.0006); and it reduced skin grafts, mortality, and costs.     

Conservative management of caustic substance ingestion in a pediatric department setting,short‐term and long‐term outcome

Patients with caustic substance ingestion are usually referred to surgery departments where endoscopic evaluation is the first step towards appropriate treatment. The aim of this study was to evaluate the safety and efficacy of conservative management of caustic substance ingestion in a pediatric department setting following a standard protocol including endoscopy in selected cases and conservative treatment based on clinical and endoscopy criteria. In this single center observational study, all children admitted for caustic substance ingestion to a pediatric department over an 8‐year‐period were managed according to a standard protocol that included endoscopy within 24 hours, if the endoscopy criteria were met, and conservative treatment as judged appropriate according to endoscopic classification. Patients were followed up for 8–10 years. Of the 24 patients (age 4/12 to 6 years) admitted, 14 met the endoscopy criteria. Grade II and III esophageal burns were found in 10/14 patients, and they were treated with H2‐blockers, antibiotics, corticosteroids, and nutritional support (parenteral in 8/10). Patients with grade II or III esophageal burns necessitated prolonged hospitalization (x ± standard deviation, 23 ± 3 days; range, 21–30 days). Complications included esophageal strictures (n = 1), treated successfully with dilatations, and bleeding (n = 1) treated conservatively. During the 8‐ to 10‐year follow‐up all patients were recorded being well. Based on the study findings it is concluded that conservative management of children with caustic substance ingestion using a standard protocol, including endoscopy as indicated, is feasible within the pediatric department, and conservative treatment on demand is safe and effective in preventing short‐term and long‐term complications.     

Incidence and risk factors for deep vein thrombosis among pediatric burn patients

BackgroundPatients with major burns covering a large total body surface area (%TBSA) fulfill all the criteria of Virchow’s triad, as a sequela of their injury. This places these patients at increased risk for developing deep vein thrombosis (DVT). However, data regarding the incidence of DVT in burn patients are minimal, especially in the pediatric age group. Therefore, the aim of this study is to determine the incidence of DVT in pediatric burn patients, identify possible risk factors for developing DVT, and explore the need for prophylactic treatment.MethodsA retrospective chart review of 95 patients admitted to our Burn Unit was conducted. We included all pediatric patients with second- and third-degree burns admitted to the unit. Exclusion criteria were adult patients, those with first-degree burns and admitted to the unit for <72 h, patients discharged against medical advice, those admitted for elective reconstructive surgery, secondary admissions for non-healing/infected burns, and patients with trauma-induced skin loss. A data collection sheet was utilized.ResultsThe total incidence of thrombosis in our population was 4.2% (DVT, 3.1%; arterial thrombosis, 1.1%). Factors significantly associated with DVT included length of hospitalization (p = 0.012), central venous catheter placement (p = 0.013), and %TBSA (p = 0.004). Unlike adult patients, weight for age (percentile) and body mass index were not significant risk factors for DVT in our patients.ConclusionBurns are a major risk factor for DVT, especially when covering large surface areas (≥40% TBSA) and combined with other factors (i.e., prolonged hospitalization and central lines). Thus, investigations for DVT and prophylactic anticoagulation should be considered for pediatric burn patients with these risk factors, even if they are asymptomatic.     

WEILBY-BURTON ARTHROPLASTY OF THE TRAPEZIOMETACARPAL JOINT OF THE THUMB

Twenty-three patients (25 thumbs) were treated by tendon interposition arthroplasty for trapeziometacarpal arthrosis as described by Weilby and modified slightly as described by Burton and Pellegrini. There was good (4/25, 16%) or complete (19/25, 76%) pain relief in 23 (92%) of the cases. Activities of daily living were generally easier. Mobility and strength of the thumb were satisfactory. One patient had signs of instability during a stress test. We conclude that our technique produces a stable and pain-free thumb joint. However, careful selection of the patients for this procedure is essential, and the patient must be given comprehensive information about all stages.     

Measuring distress in South African children during burns dressing changes: A pilot study

Objectives: To establish and trial a practical, evidence-based, sensitive, language-fair, and culture-fair test battery to measure South African children’s distress during burns dressing change. Methods: We previously identified a broad test battery for pediatric procedural distress from the literature. This comprised child and parent heart rate; three instruments for observed distress behaviors—(1) Face, Legs, Activity, Cry, Consolability (FLACC); (2) Pain Behavior Check List (PBCL); and (3) Children’s Hospital Eastern Ontario Pain Scale (CHEOPS); and dressing change time, number of nurses required, and nurses’ perspectives of child’s distress. A consecutive cohort of South African inpatient children with burns was recruited. In the first study, three observers independently piloted the broad set of measures on four children. This set was subsequently modified to increase practicality of application and measurement sensitivity. In the second study, the modified battery was tested on 16 children for sensitivity to different children’s distress levels during burns dressing change phases. Results: The modified test battery was comprised of the CHEOPS, dressing change time, number of nurses required, and nurses’ qualitative perspectives of child’s distress. In combination, these tests were practical and sensitive to children’s distress. Discussion: South African children’s distress during burn dressing changes manifests in different ways. Adequate capture of it requires a comprehensive set of objective, observational, and qualitative measures, which are independent of language and culture.