Thirteen children, aged between 2 1/2 and 14 years, with full-thickness burns are presented. These children were treated with compression suits according to the method developed by the Jobst Institute in Toledo, Ohio. The material manufactured in Switzerland is described and the advantages and disadvantages of this material are discussed. Group I comprised 8 children who were fitted out with the suit directly after the burns had healed. These were all scalds covering 11 to 30% of the body surface and necessitating Thiersch grafts. Group 2 comprised 5 children who were only fitted with this suit 3 months to 2 years after the original accident. By that time they had all developed massive, hypertrophied scars, limiting flexion and extension of the joints. In the first group the skin colour rapidly returned to normal, the development of hypertrophic scars was not marked and these scars had a definite tendency to regress. Nine of ten affected joints either became normal or showed a considerable improvement in function. In the second group, 19 of 25 affected joints had become normal one year after the suits had been fitted and four showed definite improvement. Here the scars regressed, although admittedly slower than in the first group. The children appeared to wear the suits without discomfort or trouble.
The authors report on their experiences with 21 patients with skull defects which were closed by polymethylmethacrylated plates (PMMA) from 1974 to 1990 at the University Children's Hospital in Zurich and the "Gemeinschaftspraxis fuer Kinderchirurgie". The results were compared with 15 cases treated by autologous grafts. Because of false indication, one case of PMMA-plasty led to an infected fistula. Otherwise no adverse reactions were noted. Three of the 15 cases with autologous grafts showed resorption. Polymethylmethacrylate is an excellent agent for skull reconstruction. The simple procedure, shorter OP time, and lack of pain or disfigurement due to a donor site signify a great advantage to this method.
Every year about a hundred children with burns and scalds are hospitalised in the Burns Unit of the University Children's Hospital in Zürich. 15% of these patients are children between 1/2 to 4 years old with isolated burns and scalds of their hands. The experience gained in the treatment of 53 such children during 4 years is described. The burn healed spontaneously in 31 patients; in 22 cases Thiersch grafts had to be used. In the follow-up treatment compression suits and special splints to prevent secondary contractures were employed. The results of this treatment using splints and compression suits are discussed.
A prospective randomised study was performed on 25 children aged 1.4 to 15.8 years with severe head injury (Glasgow Coma Scale less than or equal to 7) to determine the clinical effectiveness and the impact on endogenous cortisol production of high-dose steroid therapy. Thirteen patients (group 1) received dexamethasone 1 mg/kg/day during the first 3 days and 12 (group 2) not. All patients were treated with a standardized regimen. Urinary free cortisol was measured by radioimmunoassay, and the clinical data were recorded at hourly intervals. Outcome was assessed 6 months later using the Glasgow Outcome Scale. We found a higher frequency of bacterial pneumonias in the dexamethasone-treated patients (7/13 versus 2/12). Group 1 showed a suppression of endogenous cortisol production from day 1 to day 6. In group 2, mean free cortisol was up to 5-fold higher than under basal conditions. The results in group 2 showed that the endogenous steroid production reacts adequately to the stress of severe head injury. It probably is sufficient to elicit maximum glucocorticoid effects. There was no other statistically significant difference in the clinical and laboratory data between the two groups. We conclude that dexamethasone in high doses suppresses endogenous cortisol production up to 6 days and may increase the risk of bacterial infection without affecting the outcome or the clinical and laboratory data.
Glucocorticoids are used in an attempt to reduce brain edema secondary to head injury. Nevertheless, their usefulness remains uncertain and contradictory. In a randomized study of 24 children with severe head injury, urinary free cortisol was measured by radioimmunoassay. Twelve patients (group 1) received dexamethasone and 12 (group 2) did not. All patients were treated with a standardized regimen. In group 1 there was complete suppression of endogenous cortisol production. In group 2 free cortisol was up to 20-fold higher than under basal conditions and reached maximum values on days 1-3. Since the excretion of cortisol in urine reflects the production rate closely and is not influenced by liver function and barbiturates, the results in group 2 show that the endogenous production of steroids is an adequate reaction to severe head injury. Exogenous glucocorticoids are thus unlikely to have any more beneficial effects than endogenous cortisol.
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