Hugh C. O. Martin

Laser Doppler imaging prediction of burn wound outcome in children

The ability of laser Doppler imaging (LDI) to evaluate burn depth in children was investigated. Fifty-seven patients were prospectively studied over a 10-month period. Each patient was clinically assessed, photographed and independently scanned between 36 and 72 h of the burn. Patients were reviewed until wound healing had occurred within 12 days or skin grafting had been performed. The median age was 1 year and 10 months (range 5 months to 15 years and 8 months). The median body surface area burnt was 7.0% (range 0.5-30%). In 30 patients, the burn did not heal within 12 days, 17 of which were grafted. Clinical examination correctly determined 66% of deep partial or full thickness burns between 36 and 72 h of injury compared to 90% using LDI. The LDI was also more specific; correctly diagnosing 96% of superficial partial thickness burns as opposed to 71% on clinical examination. Moderate degrees of movement did not appear to limit the accuracy of the scan.

Recurrent parotitis of childhood

Background: Recurrent parotitis (RP) of childhood is a rare condition of unknown aetiology, probably immunologically mediated.

Assessment of Cooling on an Acute Scald Burn Injury in a Porcine Model

The current Australian and New Zealand Burn Association (ANZBA) recommended Burns First Aid Treatment is place the burn under cool running water for 20 minutes. Wet towels and water spray also have been used frequently. No scientific data exist to compare the effectiveness of these methods of cooling. This study sought to determine experimental evidence for current Burns First Aid Treatment recommendations and the optimal mode of cooling. Four partial-thickness scald burn injuries were induced in 10 piglets each. First aid was then applied for 20 minutes via cool running water, wet towels, or water spray, with no treatment as a control. At day 1 and day 9, biopsies and clinical photographs were assessed in a blinded manner. The control group showed worsening or no change of depth over the course of 9 days. The outcomes with wet towels and water spray were variable. Cool running water consistently demonstrated improvement in wound recovery over the course of 9 days (P < .05). This study demonstrated that cool running water appeared the most effective first aid for an acute scald burn wound in a porcine model compared with wet towels and water spray.

Portosystemic shunting for paediatric portal hypertension

The records of 22 patients who received portosystemic shunting for portal hypertension from 1985 to 1995 inclusive at the Royal Alexandra Hospital for Children (RAHC) were retrospectively reviewed. There were 11 girls and 11 boys. The average age at operation was 8 years, 3 months (range, 2 years, 3 months to 16 years, 7 months). The aetiology was idiopathic portal cavernomatous transformation (n = 9), billiary atresia (n = 4), cystic fibrosis (n = 3), documented neonatal portal vein thrombosis (n = 3), congenital hepatic fibrosis (n = 2), and portal vein obstruction after liver transplant (n = 1). The major presenting problem was upper gastrointestinal haemorrhage. Two patients had recurrent melaena from Roux-en-Y jejunal loop and caecal varices, respectively. Before receiving shunts, 12 patients had endoscopic sclerotherapy, 1 had gastric transection, and 2 had gastric varices oversewn. Portal pressure at preoperative splenoportogram averaged 28 mm Hg (range, 20 to 41). Urgent shunts were performed on 13 patients. Two disadvantaged patients had prophylactic shunts for severe hypersplenism. The types of shunts used were reversed splenorenal (n = 13), splenoadrenal (n = 6), inferior mesenteric renal (n = 1), portocaval (n = 1), inferior mesenteric caval (n = 1), and superior and inferior mesenteric caval (n = 1). In all, 22 patients had 23 shunts. The patency rate was 96% on 6 months to 10 years follow-up (average, 5.8 years). No spleen was lost. There were 2 late deaths. Two cystic fibrosis patients and one child with extrahepatic portal hypertension experienced post-shunt encephalopathy. Three patients rebled in the early postoperative period despite a patent shunt. Two patients subsequently received liver transplantation without any additional difficulties. Thus, portosystemic shunting using a method appropriate for the patient is a reliable option for treating children with portal hypertension in whom variceal sclerotherapy is inappropriate or has failed.

Optimal duration of cooling for an acute scald contact burn injury in a porcine model.

The Australian and New Zealand Burn Association recommend 20 minutes of cold running tap water as burn first aid. Scientific evidence for the optimal duration of treatment is limited. Our aim was to establish the optimal duration of cooling using cold running tap water to treat the acute burn. Partial thickness contact scald burns were induced at five sites in each of 17 pigs. Treatments with cold running tap water for 5, 10, 20, and 30 minutes were randomly allocated to different sites together with an untreated control site. In the running water 5 and 10 minute treatments intradermal temperatures rose by 1°C per minute when cooling was stopped, compared with 0.5°C per minute for 20 and 30 minutes duration. No differences in the surface area of each burn were noted between the five treatments on day 9. Histological analysis of burn depth on days 1 and 9 revealed that a higher proportion of burns treated for 20 and 30 minutes showed improvement compared with those treated for 5 and 10 minutes only. This difference reached statistical significance (P < .05) only in the cold running water for 20 minutes treatment arm. There was a statistically significant (P < .05) improvement in burn depth in a porcine acute scald burn injury model when the burn was treated with cold running tap water for 20 minutes as opposed to the other treatment durations. This study supports the current burn first aid treatment recommendations for the optimal duration of cooling an acute scald burn.

Balanitis Xerotica Obliterans in Children

Balanitis xerotica obliterans was studied in 48 fully developed and 6 early cases in children aged 2-15 years. It occurred in 9% of 100 consecutive circumcisions for all, including religious, reasons and in 19% of 232 other circumcisions for disease of the prepuce and penis. Seven cases developed after surgery for hypospadias. The boys nearly always presented with inability to retract the prepuce; half also had discomfort after micturition, and a quarter had obstructive signs, usually minor. At surgery, half had involvement of glans or meatus, previously considered rare in childhood, 3 requiring meatotomy. The condition, once seen, was easily recognized clinically as well as microscopically. The early cases, characterized by focal narrow hyaline edematous zones in severe diffuse chronic balanitis, suggest that the condition may be an inflammation in which the usual increased permeability of small vessels in inflammatory reaction is accentuated in a loose vascular region.

Medical management of paediatric burn injuries: Best practice

Burns commonly occur in children and their first aid remains inadequate despite burn prevention programmes. While scald injuries predominate, contact and flame burns remain common. Although typically less severe injuries overall than those in adults, hypertrophic scarring complicating both the burn wound and even donor sites occur more frequently in children. The heterogeneous nature of burn wounds, coupled with the difficulties associated with the early clinical assessment of burn depth, has stimulated the application of novel technologies to predict burn wound outcome. This review explores current best practice in the management of paediatric burns, with a focus on prevention, optimal first aid, resuscitation, burn wound prediction and wound management strategies.

Delayed Cooling of an Acute Scald Contact Burn Injury in a Porcine Model: Is it Worthwhile?

The current Australia and New Zealand Burn Association recommended burns first aid treatment is to place the burn under cool running water for 20 minutes. Immediate cooling of a burn wound has been shown to reduce the depth of the injury. Cooling has also been recommended as beneficial for up to 3 hours after the burn. No scientific data currently exist to support this recommendation. The aim of this study was to identify the effect of delayed cooling of an acute scald contact burn wound in a porcine model. Four partial-thickness contact scald burn injuries were induced in 12 piglets each. First aid treatment consisting of cool running water for 20 minutes was instituted randomly to each wound at different time points: immediately and at time delays of 5, 20, and 60 minutes. The group receiving immediate first aid with cool running water for 20 minutes served as the control group. At day 1 and day 9, biopsies were obtained and assessed in a blinded manner. Histologic analysis of burn depth on days 1 and 9 demonstrated no significant difference in the depth of the burn in the various treatment groups in comparison to the control group receiving immediate first aid. No significant differences in the surface areas of each burn were noted between the various treatment groups on day 9. Core body temperature did not fall below 35°C throughout the cooling process. This study provides scientific evidence that in an animal model delayed cooling for up to 60 minutes postacute contact scald burn is still effective compared with immediate cooling at reducing burn depth.

Atypical mycobacterial disease in children: a personal series.

Abstract.Atypical mycobacterial disease is common in children in Australia. Over 22 years, records were kept prospectively by the senior author. The diagnosis was confirmed in 118 patients, either by culture or by the combination of a positive skin test plus typical histology. There were 46 boys and 72 girls with a median age at diagnosis of 28 months. Most children (n = 56) presented with chronic lymphadenitis or abscess formation (n = 55). The duration of illness varied from 4 days to 18 months. The most common sites affected were the head and neck (n = 112), with the pre-auricular region and anterior end of the submandibular triangle being characteristic. Nine patients had multifocal disease. The aim of treatment is to excise as much of the infected tissue as possible: 47 children had node excision through a planned incision that was closed primarily, with only 4 needing a second operation; 42 had excision of a node through the base of the superficial part of a collar-stud abscess with 6 recurrences. However, of the 33 children who had only drainage/curettage of the cavity or node 10 had recurrences requiring re-operation. Only 1 patient required a third operation. Morbidity was extremely low, with 1 staphylococcal wound infection. No child suffered permanent paresis of the mandibular division of the facial nerve. It is our belief that surgical excision of both the macroscopically affected and adjacent macroscopically unaffected nodes is necessary to achieve cure in the majority of cases.

Biliary dyskinesia: is the problem with Oddi?

We report our experience of cholecystectomy for treating symptoms suggestive of biliary disease in association with a decreased gallbladder ejection fraction (GBEF) but without evidence of cholelithiasis. Five children with normal biliary ultrasounds were evaluated between January 1990 and December 2000 for recurrent upper abdominal pain. Based on a cholecystokinin (CCK)-provoked GBEF of less than 50% and the absence of any other gastrointestinal pathology, patients underwent cholecystectomy with operative cholangiography for presumed biliary dyskinesia. Pathological examination demonstrated chronic inflammation in all cases. Two patients had complete resolution of their symptoms, but three had persistent pain following surgery. Biliary dyskinesia seems an uncommon cause of persistent abdominal pain in childhood. Cholecystectomy was not always effective in relieving symptoms. Biliary scintigraphy with CCK provocation should not be used as the sole criterion for cholecystectomy. Sphincteric manometry may be valuable in the assessment of this small group of patients to avoid inappropriate intervention. The future perhaps lies in better understanding of the physiological action and pharmacological control of the sphincter of Oddi.