Plastic physicians: The surgical salamanders of the COVID-19 pandemic

At the time of writing, coronavirus disease-2019 (COVID-19) has affected 6.42 million people globally and over 380,000 deaths, with the United Kingdom now having the highest death rate in Europe. The plastic surgery department at Leeds Teaching Hospitals put necessary steps in place to maintain an excellent urgent elective and acute service whilst also managing COVID-positive medical patients in the ward. We describe the structures and pathways implemented together with complex decision-making, which has allowed us to respond early and effectively. We hope these lessons will prove a useful tool as we look to open conversations around the recovery of normal activity.

Congenital brachial palsy: incidence, causes, and outcome in the United Kingdom and Republic of Ireland

OBJECTIVES

To determine the incidence and study the causes and outcome of congenital brachial palsy (CBP).

DESIGN

Active surveillance of newborn infants using the British Paediatric Surveillance Unit notification system and follow up study of outcome at 6 months of age.

SETTING

The United Kingdom and Republic of Ireland.

PARTICIPANTS

Newborn infants presenting with a flaccid paresis of the arm (usually one, rarely both) born between April 1998 and March 1999.

MAIN OUTCOME MEASURES

Extent of the lesion at birth and degree of recovery at 6 months of age.

FINDINGS

There were 323 confirmed cases giving an incidence of 0.42 per 1000 live births (1 in 2300). Significant associated risk factors in comparison with the normal population were shoulder dystocia (60% v 0.3%), high birth weight with 53% infants weighing more than the 90th centile, and assisted delivery (relative risk (RR) 3.4, 95% confidence interval (CI) 2.9 to 3.9, p = 0.0001). There was a considerably lower risk of CBP in infants delivered by caesarean section (RR 7, 95% CI 2 to 56, p = 0.002). At about 6 months of age, about half of the infants had recovered fully, but the remainder showed incomplete recovery including 2% with no recovery. The relative risk of partial or no recovery in infants with extensive lesions soon after birth compared with those with less extensive lesions was 11.28 (95% CI 2.38 to 63.66, p = 0.000005).

CONCLUSIONS

The incidence of CBP in the United Kingdom and Republic of Ireland is strikingly similar to that previously reported nearly 40 years ago. Most cases are due to trauma at delivery, which is not necessarily excessive or inappropriate. Given the uncertainty about the appropriate management of these infants, serious consideration should be given to a formal clinical trial of microsurgical nerve repair.

Incidence of vomiting in burns and implications for mass burn casualty management

When faced with large numbers of burn patients and limited resources such as in war or disaster, oral fluids may be used as an alternative to intravenous resuscitation. Vomiting during the first 48 h can limit the usefulness of this method; yet its incidence has not been documented. This study aimed to identify those patients at risk of vomiting following burn injury and who therefore might be suitable for oral resuscitation. A retrospective review of case notes from burn patients between 1990 and 2001 was undertaken. Burns requiring intravenous resuscitation (>10% total body surface area (TBSA) in children, >15% TBSA in adults) were included (n=110). Documentation of vomiting during the first 48 h following burn injury to an extent that prevented commencement of feeding was regarded as significant. Patients that vomited were significantly older (28.3 years compared with 18.5 years, P=0.03), and had sustained significantly larger burns (29.8% compared with 22.9%, P=0.047). Administration of opiates and anti-emetics was similar in both groups and not significant. Although the number of patients in this study excludes a logistic regression analysis, it would seem reasonable to attempt oral resuscitation in patients under 25 years of age and with burns up to 25% TBSA given limited resources.