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BACKGROUND: Accurate total body surface area burned (TBSAB) estimation is a crucial aspect of early burn management. It helps guide resuscitation and is essential in the calculation of fluid requirements. Conventional methods of estimation can often lead to large discrepancies in burn percentage estimation. We aim to compare a new method of TBSAB estimation using a three-dimensional smart-phone application named 3D Burn Resuscitation (3D Burn) against conventional methods of estimation-Rule of Palm, Rule of Nines and the Lund and Browder chart. METHODS: Three volunteer subjects were moulaged with simulated burn injuries of 25%, 30% and 35% total body surface area (TBSA), respectively. Various healthcare workers were invited to use both the 3D Burn application as well as the conventional methods stated above to estimate the volunteer subjects' burn percentages. RESULTS: Collective relative estimations across the groups showed that when used, the Rule of Palm, Rule of Nines and the Lund and Browder chart all over-estimated burns area by an average of 10.6%, 19.7%, and 8.3% TBSA, respectively, while the 3D Burn application under-estimated burns by an average of 1.9%. There was a statistically significant difference between the 3D Burn application estimations versus all three other modalities (p < 0.05). Time of using the application was found to be significantly longer than traditional methods of estimation. CONCLUSIONS: The 3D Burn application, although slower, allowed more accurate TBSAB measurements when compared to conventional methods. The validation study has shown that the 3D Burn application is useful in improving the accuracy of TBSAB measurement. Further studies are warranted, and there are plans to repeat the above study in a different centre overseas as part of a multi-centre study, with a view of progressing to a prospective study that compares the accuracy of the 3D Burn application against conventional methods on actual burn patients.

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Fournier's gangrene is a polymicrobial necrotising soft tissue infection (NSTI) affecting the perineum and scrotum. It is rapidly progressive and destructive, and is associated with high morbidity and mortality. Management protocol includes prompt diagnosis, early institution of antibiotic therapy and adequate wound debridement, usually requiring multiple operations. The resultant defect can be left to heal by secondary intention, or surgical coverage can be undertaken. We report Fournier's gangrene in a 60-year-old diabetic man and his successful treatment with skin grafting, which utilised a multidisciplinary approach and adjuncts, including negative-pressure wound therapy and hyperbaric oxygen therapy. We also review the literature related to these adjuncts and discuss their usefulness in the management of NSTIs.

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INTRODUCTION: Infection is a major cause of morbidity and mortality in burns patients. METHODOLOGY: A retrospective review of all 94 patients admitted to a regional burns ICU from 2004 to 2009 was performed. All the patients' data and records of all culture isolates from a computerized hospital wide database were studied. Epidemiology of the patients, bacteriology information including yield and correlation of bacteremia with positive cultures from other sites were examined. In addition, the relationship between burns excision surgeries to bacteremia was analyzed. RESULTS: 402 tissue cultures, 238 wound swab cultures, 269 endotracheal cultures, 125 urine cultures, 236 tip of monitoring line cultures and 474 blood cultures were studied. Acinetobacter baumannii was the most prevalent bacteria for all culture methods. Within 24 h of bacteremia, the tissue, line tips, endotracheal and wound swab cultures had yielded very similar pathogens (>70% of the time) to those from the blood stream. Furthermore 60% of all bacteremic episodes occur within 48 h of the surgery. CONCLUSION: In ICUs where multidrug resistant pathogens are endemic, the choice of appropriate antimicrobial empiric cover should be guided by the intensity of colonization with these organisms as indicated by the cultures from various sites.

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The burgeoning global obesity epidemic extends to the military service, where 6-53% of military personnel are overweight. Obese military personnel who adhere to a strict training and diet regime may potentially achieve and maintain significant weight loss. They may however face physical problems such as excess skin folds causing discomfort, difficulty in uniform fitting, personal hygiene, interference with full physical activities and psychological issues such as body image dissatisfaction, low self esteem and difficulty in social acceptance. We present a case report of a highly motivated military conscript who achieved and maintained significant weight loss but had physical defects following Massive Weight Loss. Body contouring surgery was successfully utilised to correct his physical defects and allowed him to return to full physical duties.

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Decompression sickness (DCS) is manifested in a myriad of symptoms, and can affect any part of the body. It is attributed to the formation of inert gas bubbles in the blood and tissues. Following a diving incident, the pathogenesis of DCS is a result of mechanical obstruction caused by the inert gas bubbles and the body's immunological response to the bubbles. Neurological DCS may present with unusual sensory/motor symptoms that may lead to paralysis. This report describes three divers who suffered severe neurological Type II DCS and underwent recompression therapy at the Naval Hyperbaric Centre in 2007.

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The Burns Centre at the Singapore General Hospital (SGH) serves as a tertiary referral centre for burns management for Singapore's 4 million residents as well as the Southeast Asia region. Our study is a multivariate analysis of all burns patients admitted between 2003 and 2005. A total of 482 patients were admitted during this period with an average annual admission of 161. This represents a low incidence of 0.04 per 1000 admissions for the Singapore population. 13.3% of the study population were children, which is lower than previous studies. The mean age at admission was 35 years old and the male:female ratio was 1.9:1. We found a significant difference in age between the local and foreign patients, with the latter being younger. Our study demonstrated a 7.3% increase in cases of occupational burns. The bulk of our patients (57.3%) were directly admitted from SGH's Accident and Emergency Department. The patient characteristics of the various referral sources were found to be very different. GP referrals had significantly lower TBSA while overseas patients had significantly higher TBSA and longer length of stay. The mean and median time to admission was 3.05 days (+/-6.26) and 0 (0-60) day, respectively and the mean and median time to surgery was 7.33 days (+/-8.18) and 5 (0-22) days, respectively. The most common cause of burns was due to scalding. The mean extent of burn (TBSA) was 13.5% (+/-18.0), with significant correlation with the social background. Length of stay was dependent on the need for surgery. The overall mortality rate in this study population was 4.5%, with inhalation injury the main aetiological factor. In addition, the mean duration of the first surgery that patients undergo was significantly longer than that of the second one. This information will be useful for estimating operation times in the future. Finally, Acinetobacter baumannii was the most common bacteria in wound cultures. There is a need for periodic reviews of wound cultures in burns patients in order to modify the preventive and therapeutic strategies against these bacteria.

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BACKGROUND: Various types of external stress cause the skin and central neuroendocrine system to express corticotropin-releasing hormone (CRH)-proopiomelanocortin (POMC) axis-related hormones. However, the precise role of the CRH-POMC axis-related hormones in various skin tumours is unclear. OBJECTIVES: This study examined expression patterns of the CRH-POMC axis-related hormones in skin tumours. METHODS: The production of CRH, adrenocorticotropic hormone (ACTH) and alpha-melanocyte-stimulating hormone (alpha-MSH) in various tumour cell lines including HaCaT and primary keratinocytes was examined using an enzyme-linked immunosorbent assay. Immunohistochemical analysis of the skin tumours was also performed. RESULTS: CRH, ACTH and alpha-MSH were strongly expressed in malignant skin tumour cell lines such as G-361 and DX-3 (both malignant melanoma, MM). However, normal and haematological malignancy cell lines did not express the CRH-POMC axis-related hormones. Immunohistochemical analysis of the skin tumours showed that MM (80%), squamous cell carcinoma (SCC, 70%) and basal cell carcinoma (BCC, 10%) had strong immunoreactivity (++/+++) for CRH. Strong ACTH and alpha-MSH expression was observed in MM (70% and 50%, respectively), SCC (80% and 60%, respectively) and BCC (70% and 50%, respectively). CONCLUSIONS: We report that an increase in the level of the CRH-POMC axis-related hormones is associated with malignant skin tumours such as MM. These results highlight the importance of the CRH-POMC axis-related hormones in the malignant tendency of skin tumours.

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Emphysematous cystitis is an uncommon infection of the bladder with the formation of carbon dioxide either within the bladder or within its wall. It is commonly seen in women and those with poorly controlled diabetes mellitus, in association with some form of urinary stasis and obstruction. The clinical features are very varied and the outcome is often unpredictable. Radiography may reveal a radiolucent line around the bladder wall or gas within the bladder. Occasionally, computed tomography scans are required to help in the diagnosis due to their atypical presentation with acute abdominal pain. Herein, we report three patients with such a condition who were treated with favourable outcomes. Of the three patients, two had to undergo exploratory laparotomy due to their initial presentations with acute abdomens.

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INTRODUCTION: Report of a rare presentation of mucinous cystadenoma of the vermiform appendix. CLINICAL PICTURE: A lady who presented with intestinal obstruction and peritonitis was found to have gangrenous small bowel caused by strangulation by a tumour of the appendix. TREATMENT: Right hemicolectomy. OUTCOME: The histology of the appendicular tumour was mucinous cystadenoma. The patient recovered well. CONCLUSION: Mucinous cystadenoma of the appendix can present in many ways and it is important to recognise the pathology at operation.

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Methods for the preparation of adult pig pancreatic cells using enzymatic- or auto-digestion are described, and a comparison of these methods was performed. A greater number of cells staining red with dithizone with the highest viability and insulin secretory response to glucose stimulation were obtained with dispersed pancreatic cells prepared by auto-digestion of the pancreas. On the other hand, many damaged cells were observed when the pancreas was exposed to collagenase or EDTA-Dispase and only a few cells stained red with dithizone. Insulin secretion in response to glucose stimulation was observed for up to 6 h in cells prepared using the auto-digestion procedure and an approximately 2- to 3-fold increase in insulin secretion was seen in response to glucose. Cells obtained by the collagenase or EDTA-Dispase exposure did not show a secretory response to either low (5.5 mmol/l) or high (16.7 mmol/l) glucose concentrations. This report shows that it is possible to prepare pancreatic endocrine cells from the adult pig pancreas which represents an inexpensive way to obtain cells for pancreatic cell transplantation or studies of their biochemical or physiological properties.

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