Gerald P. Kealey

Effect of gastric bypass on gastric secretion

Gastric bypass as a 90 per cent gastric exclusion operation was used in 393 patients with massive obesity to limit food intake. Stomal ulcer has occurred in 1.8 per cent of such patients or one ulcer per 140 man years of observation. The studies of indwelling fundic pH and of gastric acid secretion from the excluded stomach indicate that acid secretion is reduced after gastric bypass but that the acid, unbuffered by food in the excluded stomach, results in a lowered gastrin secretion after a meal. Thus, gastric bypass in inhibitory to acid secretion in most morbidly obese patients who do not have known acid peptic disease.

Prospective, randomized study of the efficacy of pressure garment therapy in patients with burns

A randomized, prospective study was undertaken to determine the efficacy of pressure garment therapy in patients with burns. Patients were randomly assigned to receive either pressure garment therapy or no pressure garment therapy. Patients were observed by use of the Vancouver Burn Scar Assessment Scale to assess the maturity of all involved areas. One hundred and twenty-two consecutive patients were enrolled in the study; 64 were assigned to pressure garment therapy and 58 to no pressure garment therapy. Eight of the patients receiving pressure garment therapy and nine receiving no pressure garment therapy were not involved in the follow-up. No significant differences were found between the two groups when age, body surface area burn, length of hospital stay, or time to wound maturation were compared.

Treatment-resistant pain and distress during pediatric burn-dressing changes

Recent research has suggested some efficacy for the use of hypnosis in the control of pain and distress in a pediatric population undergoing painful medical procedures. Here, we study a sample (N=23) of pediatric subjects undergoing burn-dressing changes and receiving either an imagery-based or control (social-support) treatment. Subjects levels of distress were assessed with the Observational Scale of Behavioral Distress. Results indicated that distress behaviors in this population can be measured reliably using this scale. However, no support was found for the main hypothesis that imagery treatment would be superior to control treatment in the alleviation of distress, nor were these treatments effective in comparison to baseline conditions. We discuss the formidable problem that burn and dressing-change pain presents, as well as the reasons why this treatment attempt might have failed to have the predicted effects. We also discuss important developmental considerations regarding the adequate assessment of pain and distress.

The prevalence of venous thromboembolism of the lower extremity among thermally injured patients determined by duplex sonography.

BACKGROUNDnMorbidity and mortality from venous thromboembolism (VTE) remains a significant problem for hospitalized patients. Despite the ample prospective literature defining the prevalence of VTE in hospitalized patient populations, the prevalence of VTE in the thermally injured population remains largely unknown.nnnMETHODSnWe prospectively studied 148 thermally injured patients with hospital stays of greater than 3 days with lower extremity duplex ultrasonograms obtained at admission and discharge.nnnRESULTSnNine patients experienced VTE (6.08%). Eight of the nine deep venous thromboses were proximal. One of the two pulmonary embolisms was fatal. Treatment risk factors that were associated with VTE were the presence of a central venous line (p = 0.020) and transfusion of more than 4 units of packed red blood cells (p = 0.023). These treatment factors were significantly related to each other (p < 0.0001), to body surface area burned, and to intervention.nnnCONCLUSIONnThe prevalence of VTE in burn patients is similar to that of moderate- to high-risk general surgical patients for whom VTE prophylaxis is recommended. VTE prophylaxis of burn patients, especially those requiring central venous lines and more than 4 units of packed red blood cells, should be considered.

Prospective Randomized Comparison of Two Types of Pressure Therapy Garments

A prospective randomized study was undertaken to compare compliance efficacy and cost of the elastic nylon pressure garment (Jobst Institute, Inc., Toledo, Ohio) with the cotton elastic pressure garment (Tubigrip, SePro Healthcare Inc., Montgomeryville, Penn.). Of 110 patients enrolled, 54 received Jobst pressure garments and 56 received Tubigrip pressure garments. Time spent in pressure-therapy garments was the same for both groups. Comparable clinical results were achieved with either Tubigrip or Jobst garments. A significantly greater percentage of patients were compliant with Tubigrip pressure-garment therapy than with Jobst pressure-garment therapy. The cost of the Tubigrip garments was significantly lower than that of Jobst garments. These data suggest that the use of elasticized cotton pressure garments results in significantly better patient compliance, a lower cost, and equal therapeutic efficacy when compared with the elasticized nylon pressure garments.

Risk reduction in gastric operations for obesity.

Although nearly devoid of late complications, gastric operations for obesity have resulted in 4.7% early postoperative perforations. For patients over 39 years of age who perforated, the first 11 patients died and the last 9 survived. Perforations are equally common in upper stomach, anastomosis, and lower stomach. They have become more frequent with the 50 ml upper stomach volume and 12 mm stoma that are required to assure optimum weight control. Perforation is as common with gastroplasty as with gastric bypass. If it occurs, it is normally within the first ten postoperative days. Acute dilatation and rupture of the stomach can happen if all the nasogastric tube holes are in the jejunum after gastric bypass. Erosion of the stomach by the hard end of the nasogastric tube has occurred when the tube was positioned in the upper stomach. This paper is dedicated to the prevention of death by early recognition and aggressive management of perforation and by prevention of perforations through careful attention to the details of these operations and early postoperative care.

Our chemical burn experience: exposing the dangers of anhydrous ammonia.

Although chemical injuries account for only a small number of one burn units cases, the diversity, resulting complications, and sequelae of these burns pose special problems. We reviewed a 19-year period of the chemical burn experience of our burn unit. The population of patients with these types of burns consisted of young men (mean age: 29.8 years), the majority of whom were injured on the job. Unique to our series is the largest collection of injuries (30%) resulting from the common fertilizer anhydrous ammonia. Another population of concern, accounting for 14% of the injuries in our unit, is that of patients injured at home with routine household cleaners. Nearly one half of those patients injured at home incurred injuries that required grafting. The cornerstone of chemical burn prevention and treatment involves education regarding the caustic nature of chemicals, proper handling, adequate protection, and copious irrigation of the wound at the scene. From the analysis of our retrospective review, adequate education and treatment at the scene appear to be well implemented in the industrial and farming communities. The focus of our education efforts should be directed toward the public and emphasize the safe use of household chemicals. Finally our review illuminated the potential benefit of immediate excision and grafting for decreasing the length of stay, complications, and loss of productivity.

Long-term outcomes of patients with necrotizing fasciitis.

Context:Necrotizing fasciitis is an aggressive infection affecting the skin and soft tissue. It has a very high acute mortality. The long-term survival and cause of death of patients who survive an index hospitalization for necrotizing fasciitis are not known. Objective:To define the long-term survival of patients who survive an index admission for necrotizing fasciitis. We hypothesize that survivors will have a shorter life span than population controls. Design:Long-term follow-up of a registry of patients from 1989 to 2006 who survived a hospitalization for necrotizing fasciitis. Last date of follow-up was January 1, 2008. Settings:A university-based Burn and Trauma Center. Patients:A prospective registry of patients with necrotizing fasciitis has been collected from 1989 to 2006. This registry was linked to data from the Department of Health, Department of Motor Vehicles, and the University Hospital Medical Records Department in January 2008 to obtain follow-up and vital status data. Intervention:None. Main Outcome Measures:Date and cause of death were abstracted from death certificates. Date of last live follow-up was determined from the medical record and by the last drivers license renewal. The death rate of the cohort was standardized for age and sex against 2005 statewide mortality rates. Cause of death was collated into infectious and noninfectious and compared with the statewide causes of death. Statistical analysis included standardized mortality rates, Kaplan-Meier survival curves, and Aalens additive hazard model. Results:Three hundred forty-five patients of the 377 in the registry survived at least 30 days and were analyzed. Average age at presentation was 49 years (range, 1–86; median, 49). Patients were followed up an average of 3.3 years (range, 0.0–15.7; median, 2.4). Eighty-seven of these patients died (25%). Median survival was 10.0 years (95% confidence interval: 7.25–13.11). There was a trend toward higher mortality in women. Twelve of the 87 deaths were due to infectious causes. Using three different statistical analytic techniques, there was a statistically significant increase in the long-term death rate when compared with population-based controls. Infectious causes of death were statistically higher than controls as well. Conclusions:Patients who survive an episode of necrotizing fasciitis are at continued risk for premature death; many of these deaths were due to infectious causes such as pneumonia, cholecystitis, urinary tract infections, and sepsis. These patients should be counseled, followed, and immunized to minimize chances of death. Modification of other risk factors for death such as obesity, diabetes, smoking, and atherosclerotic disease should also be undertaken. The sex difference in long-term survival is intriguing and needs to be addressed in further studies.

Population-based assessment of burn injury in southern Iowa: identification of children and young-adult at-risk groups and behaviors.

Although nonfatal burn injuries vastly outnumber fatal injuries, their epidemiology is not well defined. We sought to determine the epidemiology of nonfatal burn injuries in a largely rural region of a midwestern state to target intervention efforts at populations and injury mechanisms at risk. Data were retrospectively collected on a population-based sample of medically treated burn injuries in 10 counties in southern Iowa from 1997 to 1999 using International Classification of Diseases, 9th Revision, Clinical Modification codes (ICD-9-CM, Ncode 940-949) to identify burn-related emergency room visits from computerized lists. A total of 1430 emergency room visits were identified, with 1382 records available for review. Injuries were grouped into etiology subcategories to better delineate common mechanisms and determine methods of prevention. Scald and hot-object contact and flame-related injuries were the leading causes of burn injury. Scald and contact injuries were subdivided into three major sets of scenarios, scald and contact injuries related to household food preparation and consumption, work-related scald and contact injuries. and injuries resulting from contact with nonfood and nonbeverage-related household objects. Children ages 0 to 4 had the highest population-based scald and hot-object contact injury rate of all age groups, with an average annual incidence rate of 35.9 per 10,000. Injuries in this age group were most commonly related to household objects (34.7%) followed by food preparation (25.3%). Children and young adults ages 5 to 24 were also the most likely to be injured by flame and fire-related causes secondary to open fires. Nonfatal burn injuries typically afflict children and young adults in definable patterns, suggesting intervention strategies. Future studies need to better delineate the contributing factors associated with these injuries to refine the intervention strategies.

Parent participation during burn debridement in relation to behavioral distress.

The data on the benefits of parent participation during pediatric medical procedures are mixed. Although a wealth of clinical experience and survey data strongly recommend parent participation in a childs medical care, the mere presence of a parent, particularly during medical procedures, may be insufficient to decrease behavioral distress. This study examined a sample of children aged 3 through 12 undergoing three successive burn dressing changes. For some sessions, parents were present, and for others, they were not. A valid and reliable measure of behavioral distress was taken, as was an informal measure of the level of parent participation. Results indicated no differences between mothers and fathers in the level or the nature of participation, little change in the level of participation across time, and higher levels of physical comforting than verbal comforting. Results also indicated higher levels of behavioral distress in subjects when parents were present versus when absent, which extends previous findings. Results are discussed in terms of the literature on parent and child preferences for parent involvement and parent coaching programs.