The untold truth about "bath salt" highs: A case series demonstrating local tissue injury

The epidemic of injecting cathinone derivatives, marketed as "bath salts", by intravenous drug users among inner city Dubliners led to an associated rise in soft tissue complications. The spectrum of the cases encountered, ranging from self-limiting cellulitis to extensive abscess formation, at a single institution is described.

Free tissue transfer versus pedicled flap reconstruction of head and neck malignancy defects

BACKGROUND

With the advent of microsurgery the pedicled flap is considered by many to be an outdated surgical option.

AIMS

To explore the relationship between flap survival and pre-morbid risk factors, conduct a comparative analysis of flap and systemic morbidities and complete a cosmesis and functionality assessment for oral and oropharyngeal reconstruction patients.

METHODS

114 patients, over a 13-year period, who had a one-stage reconstructive procedure employing the pectoralis major myocutaneous flap (PMMF) or radial forearm-free flap (RFFF).

RESULTS

Variables, including age, smoking and radiation exposure were not statistically significant predictors of flap survival probability. Atelectasis was a significant post-op finding of RFFF patients. Flap dehiscence of >50% was a significant morbidity of PMMF. No statistical difference in cosmetic deformity, diet and socialisation was noted.

CONCLUSIONS

Pectoralis major myocutaneous flap remains an enduring and safe flap; however, the RFFF has markedly improved speech performance over the PMMF.

Burning more than calories: treadmill friction injuries in children

Treadmill injuries in young children are a serious but little documented problem. Friction burns occur when the hands come into contact with the moving belt resulting in deep burns that often require hospital admission and surgery. The aim of this study was to assess the nature and prevalence of injuries sustained and to highlight treadmill friction burns as a public health issue previously undocumented in Ireland. A retrospective chart review from January 2006 until March 2008 was performed and functional outcome was assessed by the modified Michigan Hand Outcomes Questionnaire. Eight girls and four boys from one year and seven months to seven years and five months were treated. Eight children required admission to hospital and to date three have required surgery for their injuries. This is a new and increasing problem in Ireland which must be highlighted.

Analysis of functional results and quality of life following free jejunal flaps for reconstruction after upper aerodigestive neoplastic resection: the St James's experience

Surgical treatment of hypopharyngeal cancers with extension to the postcricoid region generally requires a circumferential pharyngolaryngoesphagectomy followed by reconstruction of the upper aerodigestive tract. Many techniques have been described in order to achieve a safe and functional reconstruction. Interposition of the jejunal free flap (JFF) is a well-established technique and is the flap of choice in our unit. This is a retrospective review of all patients who required a JFF following pharyngolaryngoesphagectomy over an 9-year period. We studied medical charts, histological reports, and speech and language therapy assessments. Eight of the nine surviving patients completed a quality of life questionnaire. Analysis was carried out on patient demographics, flap survival, patient survival and quality of life including swallow function and speech restoration. A total of 23 patients had 24 jejunal free flaps. There were four perioperative deaths. Two flaps failed, and were salvaged with a second JFF in one case and a gastric pull-up in the second. Functioning swallow was established in 74% of patients with four patients complaining of dysphagia. Speech was restored using an electrolarynx or Blom Singer valve in 70% of patients. Most patients required radiotherapy as part of their adjuvant treatment. In our hands the JFF for reconstruction following pharyngolaryngoesophageal resection allows restoration of function following major ablative surgery.

Backyard burning

This study was undertaken to determine whether changes had occurred in the numbers of burns that could be related to backyard burning subsequent to the introduction of the council tax throughout Eire for the collection of household refuse. Numbers of patients admitted to our unit who had sustained burns by burning rubbish were recorded prospectively over a period of 12 months. A random control group was taken as three years prior to this and results found by retrospective chart review. Between January and November 2005, 168 patients were admitted to the National Burns Unit, St James's Hospital Dublin, Ireland. Nineteen of these patients sustained flame burns from backyard burning. One hundred and seventy patients were admitted in the comparative period of 2002; Seven of these from backyard burning. The total number of inpatient days for these patients in 2005 (255) was significantly more than in 2002 (68) (p=0.024). The numbers in our study show a marked increase in the number of patients sustaining burns in this manner, and appear to correlate with the introduction of bin charges by a number of county councils around the country last year. This study demonstrates that the introduction of legislation can have an unforeseen adverse affect on the population if not introduced in correlation with appropriate public education. While the introduction of waste charges represents a very necessary move forward in waste disposal in Ireland, public awareness campaigns should be implemented to prevent further such injuries from occurring.

Firework injuries presenting to a national burn's unit

The sale to the general public of fireworks is illegal in Ireland. However, many fireworks are readily available on the black market from illegal traders. The number of firework injuries presenting to our unit during the three week run-up to Hallowe'en October 2001 was recorded. In addition, each patient was contacted to determine how the fireworks were obtained, the average amount of money spent, and the level of adult supervision present at the time of injury. A total of 19 patients presented, 18 from the local catchment area, with a mean age of 16 yrs (range 5-46 yrs). Thirteen patients required admission. Sixteen patients sustained hand injuries including burns, and three sustained burns to other body areas. The amount of money spent varied between adults and children, the average amount among the paediatric group was Euro 2-4, but Euro 45 in the adult group. None were willing to identify the local source of their fireworks, but most fireworks originated in Northern Ireland. This small review highlights an ongoing problem in Ireland; fireworks are illegal, yet they are easily and cheaply available without quality or safety controls. Our public awareness campaign has failed to reach its target audience, and the illegal traders who sell these often inferior products are seldom charged. Children and adults will continue to sustain serious injuries as a result.

Profiles of grammatical morphology and sentence imitation in children with specific language impairment and Down syndrome

The purpose of the present study was to examine the grammatical morphology and sentence imitation performance of two different groups of children with language impairment and to compare their performance with that of children learning language typically. Expressive use of tense-bearing and non-tense-related grammatical morphemes was explored. Children with specific language impairment (SLI), with Down syndrome (DS), and with typical language development (TL) were matched on mean length of utterance (MW). Performance was compared primarily on composite measures of tense, tense inflections, and non-tense morphemes, as well as on the Sentences subtest of the Wechsler Preschool and Primary Scale of Intelligence-Revised (WPPSI-R; D. Wechsler, 1989). Exploratory analyses were completed on a set of 11 individual grammatical morphemes as a follow-up to the principal analyses. As predicted, the children with SLI performed significantly more poorly than the children with TL on all three composite measures. In addition, the DS group exhibited significantly weaker performance than did the TL group on the tense inflections and non-tense morpheme composites. Although there were no statistically reliable differences between the SLI and DS groups on any morpheme measure, the groups were not comparably weak in their use of the regular post, -ed; the irregular third person singular morphemes (e.g., has, does); the present progressive, -ing; or the use of modals. The SLI and DS groups both performed more poorly than did the TL group on the sentence imitation task.

Static splinting of extensor tendon repairs

In a prospective review we assessed the results of extensor tendon injuries managed postoperatively with a static splint. Thirty-three patients with 44 injured digits were assessed 4 months after primary tendon repair, using the Strickland-Glogovac criteria. Patients were managed in a static splint, the duration of which was guided by the zone of injury. Four months after repair, excellent or good results were obtained in 95%. Overall it was found that static splinting was an effective and safe method of management after extensor tendon repair.

The role of Mepitel silicone net dressings in the management of fingertip injuries in children

Forty-five children with isolated fingertip injuries were randomized for treatment with either Mepitel silicone net dressings or paraffin gauze dressings. Over a 4 week period, the objective adherence of the dressing, and the perceived level of stress caused to the child by the dressing change were scored by linear analogue scales. The wounds were also assessed for the progress of healing and presence of infection. Twenty children received Mepitel dressings and 25 had paraffin gauze dressings. There was no difference in duration of healing or complication rates between the two groups. Statistically lower scores were seen for the Mepitel group for the first 3 weeks in both adherence and stress scores. These results suggest that silicone net dressings may be a less adherent and less painful method of dressing fingertip injuries in children.

Absorbable skin graft staples: a clinical trial using Graftac-X

Skin stapling devices are a quick, effective method for securing skin grafts in burns patients. Removal of staples can be painful, often requiring a general anaesthetic. This problem has led to the recent development of absorbable staples which extrude with time. A prospective controlled clinical trial was performed on 20 burns patients comparing absorbable skin tacks with stainless steel staples. An area of at least 50 cm2 was grafted in each patient, half of which was secured with absorbable tacks and half with stainless steel staples. Each patient therefore acted as his/her own control. The presence of infection, haematoma and graft take using a grided cellophane sheet were assessed at one week. Infection and excess scarring at tack sites were assessed at one month. A statistically significant difference was not found between either group. In our hands absorbable skin staples have proven to be a reliable method of securing skin grafts.

A 3-year epidemiological review of burn unit admissions in Dublin, Ireland: 1988-91

A retrospective multifactorial epidemiological study of all patients admitted to the Burns Unit, St James's Hospital, Dublin during a 3-year period from January 1988 to December 1990 was undertaken. One hundred and twenty patients were admitted. All patients were aged over 14 years. The mean patient age was 48.2 years. Males accounted for 56 per cent of admissions. The mean percentage body surface area (%BSA) burned was 24.9 per cent. Flame was the cause of burns in 60 per cent of cases and produced the most extensive lesions. The home was the most common site of injury. Almost half the patients admitted from residential institutions sustained their burns in hot baths. Those aged over 60 years sustain smaller burns but are at increased risk from thermal injury. Twenty-one per cent of burns were caused by open fires used for heating the home. The mean time in hospital was 49.9 days. Twenty-three per cent of patients died as a result of their injuries. We have identified those living in residential institutions to be at increased risk from scald burns and suggest methods by which they may be protected.

Thirty-five years of paediatric scalds: are lessons being learned?

All paediatric scalds admitted in 1991 to the Welsh Centre for Burns and Plastic Surgery have been analysed retrospectively and the results compared with similar studies from this centre reported in 1956 and 1984. This data was compared with similar reports from 6 other world-wide centres. Despite a modest population increase in Wales, the number of admissions has increased almost 50% in 35 years. Boys are more commonly affected and up to 67% of scalds occur in children under 2 years of age. The number of scalds from teapots has fallen from 20.8% to 2.7%, in contrast to scalds from cups of hot liquid which have increased from 8.9% to 42.5% over the 35-year period. Scalds from hot baths are rare in Holland and Denmark, in contrast to a 15.8% incidence in our centre. Hot kettles are a common cause of scalds, accounting for up to 28% of scalds in all the series reviewed. The incidence of this injury has not decreased over the last 35 years. Recommendations are made about improved health and safety education for parents, the use of coiled kettle flexes, the temperature of stored water which should not exceed 60 degrees C, and the fitting of thermostatic mixer taps to new houses and institutions, in an effort to decrease the incidence of paediatric scalds.

Bupivacaine and Kaltostat reduces post-operative donor site pain

A prospective double blind controlled trial was carried out to examine the differences in post-operative split skin graft donor site pain between sites dressed with three differently treated types of dressing; a dry calcium alginate dressing (Kaltostat Britcair), a saline moistened Kaltostat dressing and a bupivacaine hydrochloride (0.5%) moistened Kaltostat dressing. There was a significant reduction in post-operative pain in the Kaltostat and bupivacaine group (group 3) at 24 and 48 h when compared to the other two groups (p < 0.04). There was no difference in ease of removal of dressings or the quality of wound healing on day 10 between the three groups. This study demonstrates a significant reduction in post-operative pain in bupivacaine soaked Kaltostat without reducing the beneficial effects of Kaltostat on donor site healing and we recommend its use in clinical practice.

Clinical experience with the second metatarsal artery neurovascular flap

Three cases of innervated web space flaps from the foot based on the second metatarsal artery and the second common digital nerve are described. This flap provides glabrous skin for digital reconstruction with good sensory recovery and minimal donor site morbidity.

Enhancement of ischaemic rabbit skin flap survival with the antioxidant and free-radical scavenger N-acetylcysteine

1. The burst of damaging oxygen free-radicals at the time of reperfusion is one of the crucial factors affecting skin flap survival after an ischaemic interval. In these experiments the efficacy of the antioxidant and free-radical scavenger N-acetylcysteine in improving the survival of ischaemic rabbit epigastric skin flaps was tested. 2. At the time of reperfusion flaps were given: (1) balanced salt solution by intravenous whole-body administration, (2) N-acetylcysteine (200 mg/kg) by intravenous whole-body administration, (3) balanced salt solution by intra-arterial infusion into the flap, (4) N-acetylcysteine (20 mg/kg) by intra-arterial infusion into the flap, or (5) N-acetylcysteine (200 mg/kg) by intra-arterial infusion into the flap. Flap survival at 1 week, and tissue levels of parameters related to free-radical production, blood levels of thromboxane B2 and peripheral resistance during reperfusion were determined. 3. Compared with controls (groups 1 and 3) which had flap survival rates (expressed as percentage surface area surviving) of 27.1% and 31.6%, respectively. N-acetylcysteine treatment in group 2 (55.2%) and group 4 (51.9%) resulted in significant (P less than 0.05) improvements in flap survival. The survival rate in group 5 (37.7%) was not significantly better than that of the controls. 4. N-Acetylcysteine significantly reduced parameters related to free-radical production in the skin flap after 30 min of reperfusion, determined as tissue levels of malonyldialdehyde and protein oxidation products. There was also a significant decrease in peripheral resistance when low-dose N-acetylcysteine (group 4) was infused intra-arterially into the flap.(ABSTRACT TRUNCATED AT 250 WORDS)

Double lumen free jejunal transfer for reconstruction of the entire floor of mouth, pharynx and cervical oesophagus

In those patients requiring proximal extension of a laryngopharyngectomy to include resection of the base of the tongue, there is a considerable mismatch between the circumference of the superior pharyngeal defect and a conventional jejunal conduit. An inverted J-shaped jejunal funnel can be prefabricated to enlarge the proximal stoma of a free jejunal transfer to overcome this size discrepancy and so prevent the high incidence of postoperative fistulae at the proximal anastomosis. In the most extreme case it will allow reconstruction of the entire floor of the mouth, pharynx and cervical oesophagus.

Seal finger in a wildlife ranger

We describe a case of septic arthritis of the interphalangeal joint of the thumb in a man following a seal bite. Early and continued treatment with antibiotics of the penicillin family failed to control the infection. Empirical treatment with tetracycline resolved the infection, but the patient has permanent joint damage. In apparently ordinary infective conditions, which fail to respond to therapy, the history may suggest that an unusual organism is responsible.

Rotatory atlantoaxial subluxation following pharyngoplasty

Atlantoaxial rotatory subluxation often presents in childhood as a stiff, painful neck with associated torticollis. It can occur spontaneously following minor trauma or an inflammatory process in the cervical tissues. Failure to recognise the condition may result in a fixed rotatory subluxation which can be difficult to treat. The authors report on two cases of atlantoaxial rotatory subluxation which occurred following pharyngoplasty and discuss the clinical presentation and management of these cases. The literature on this subject is briefly reviewed.