IPHREHAB : Group Discussion Methods and Procedures

IPHREHAB

Group Discussion Methods and Procedures

Research has shown that participants in Extension educational programs strongly prefer interactive delivery methods, which allow them to learn new information by seeing, experiencing, and discussing. In working with groups, Extension educators often find it easier to provide opportunities for seeing and experiencing than for discussion. This fact sheet briefly describes methods that can be used to promote effective discussions in learner groups. When used as one part of a broader program delivery system, these methods can be very helpful in facilitating the learning process.

Discussion Methods

Panel. 

In a panel discussion, a small group of individuals (from three to five) who are knowledgeable about a particular subject discuss the topic among themselves in front of an audience. Panel participants make no formal presentations; they exchange ideas through conversation.

Dialogue. 

This method is very similar to a panel discussion, but only two individuals take part in discussing the subject in front of an audience.

Symposium. In a symposium, a small number of speakers who are knowledgeable about a particular subject make short presentations in succession. These presentations usually range from five to fifteen minutes each.

Forum.

This form of discussion allows for participation by the audience. There are several types of forums. The most common are:

Open forum: Members of the audience are allowed to participate at any time during the meeting.

Panel-forum: Members of an audience hear a panel discussion and are then allowed to ask questions or to comment on the subject under discussion.

Symposium-forum: Members of the audience hear presentations by invited speakers and are then allowed to question, discuss, or comment.

Dialogue-forum: Members of the audience are allowed to question, discuss, or comment after the dialogue.

Lecture-forum: After a formal presentation by a knowledgeable speaker, audience members are given the opportunity to question, comment, seek clarification, or discuss the information presented.

Colloquy. 

This method combines a panel discussion with a forum. During the course of a panel discussion, audience members may be invited to comment or ask questions if panel members or the chair perceive a need to clarify points, avoid neglecting an issue, or assure that a misperception is not allowed to stand. Any interruptions of the panel discussion must be focused on the point at hand. When the matter has been resolved, the organized discussion among panel members resumes.

Buzz Session.

The audience is divided into groups of six to eight persons for discussion of relevant questions posed by the leader. One individual from each group may be asked to summarize the group's discussion and report to the entire audience.

Audience Reaction Team. 

Three to five members of the audience are preselected to listen to a presentation and respond by offering a brief summary and interpretation of the information presented. This discussion method can be used effectively in large group settings and when time is limited.

Question Period. 

Members of the audience are provided an opportunity to ask questions of program participants after their formal presentations have been completed. Usually, a time limit is set for each question and for the entire question-and-answer period.

Brainstorming. 

Members of the audience are encouraged to participate by sharing their ideas or suggestions for solving a problem. No discussion of each point is allowed until all ideas have been expressed. Since the intent of this discussion method is to generate a wide range of ideas, no contributor is allowed to defend the information presented. The atmosphere should be open and encouraging.

Discussion Group. 

A group of people meet informally to discuss a topic of mutual concern.

Workshop. 

A small group of people (25 or fewer) with a common interest meet to study, research, and discuss a specific subject or to enhance their individual knowledge and proficiency.

Seminar. 

A group of people who are studying a specific subject meet for a discussion led by a recognized authority.

Conference. 

Large or small groups of people having similar interests meet to hear formal presentations to the entire group; they also meet in smaller groups to discuss specific aspects of the conference's general topic. 

IPHREHAB : CHEMICAL BURNS CASE REPORT DISCUSSION

IPHREHAB

CHEMICAL BURNS - OUR EXPERIENCE OVER ELEVEN YEARS
SUMMARY. An eleven-year review is made of chemical burns consisting of 59 cases presenting at the University Hospital, Varanasi. Chemical burns are an uncommon entity which require special considerations in management. In the period studied, they constituted 4.7% of all burn admissions. Most cases were intentionally inflicted with acids, following property disputes. The patients were usually in their second, third or fourth decades. Depth of burn at the initial assessment was often found to be fallacious. Ocular involvement was common (30.5%). Slough separation was delayed compared to thermal bums. Hydrotherapy was the mainstay of first-aid and casualty department care. Early debridement and skin grafting yielded good results especially in chemical burns of the ear and hand.


Introduction
Chemical bums are relatively infrequent and consequently the experience of doctors in any centre is limited. Social development and industrialization influence the type of corrosive involved. Industrial accidents, which constitute a major proportion of cases in the west, are but a small case group in India. We present our experience with chemical burns over the past eleven years at the Burns Unit, Division of Plastic Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi.


Materials and methods
Over the period January 1979 to December 1989 a total of 1248 patients with burns were admitted to the Burns Unit at Varanasi, of whom 59 had chemical burns (4.7%). Fifty of these patients were in the second to fourth decades of life (84.8%) while only one patient was less than ten years of age (Table 1). 67.8% of patients were males. Acid burns by far exceeded all other types of burns and sulphuric acid was the commonest agent (Table 2). Most of the cases were intentionally inflicted (71.2%) while only 18.6% were accidental. In 10.2% of cases the aetiology was unknown. In most cases the burns surface constituted less than 15% of total body surface area (Table 3), with the head being the commonest region affected (74.6%) (Table 4). The neck and trunk were other areas to be commonly affected. Estimation of depth of burn was often incorrect initially and frequent reassessment was required subsequently. Most of the burns were third degree (60%) while about 25% of the burns were second degree, the remaining being first degree. 18 patients (30.5%) had associated ocular burns while fractures were present in 4 patients. 5 patients (8.5%) had systemic toxicity owing to absorption of the chemical.


On presentation, the patients were received in the casualty department. Most patients presented late (after 24 hours). In those presenting early, hydrotherapy by copious water irrigation of the burned area was performed. This was given for an average of about 30 minutes.
 Analgesics and intravenous fluids (3 mI crystalloid solution per kg for each % of BSA burned) were given as required. Two patients needed blood transfusion due to associated fractures. Consciousness, vital signs, urine output and electrolytes were monitored.


The patients were subsequently transferred to the Burns Unit where topical chemotherapy with 1% silver sulphadiazine cream was performed. The wound was dressed on alternate days with bi-weekly baths in a Hubbard tank. Debridement was performed as required either after sedation at bedside or under general anaesthesia in the operating theatre, and split thickness skin grafting was performed. Physiotherapy was commenced in the hospital and patients were discharged following recovery.


Results
Separation of slough required a longer time than in thermal burns and generally occurred between 3 and 5 weeks post-burn. Wounds were sterile in the first two weeks (80% of patients). Most cases showed bacterial growth after 30 days (86%). The common organisms involved wereStaphylococcus aureus, Pseudomonas aeruginosa, Proteus and E. Coli in order of frequency. The hospital stay of these patients was prolonged - generally between 3 and 8 weeks, with one patient staying 66 days before discharge. Only two patients died and in both cases the cause was overwhelming septicaemia following burn wound sepsis.


The commonest operation performed was split thickness skin grafting (29%) which either followed spontaneous eschar separation or was done following debridement (Table 5). Early debridement and split thickness grafting was performed in most cases of burns of the car and this helped minimize the problem of intractable chondritis. Early debridement and split thickness skin grafting yielded good results in selected cases.


Discussion
The outstanding feature of chemical burns is the prolonged period for which the burning effect continues. Most patients in our region present late (after 24 hours). In patients presenting early, dilution and removal of the chemical by hydrotherapy is now well established, both as a first-aid measure and in the casualty department (1, 2, 3). In alkali burns there is a place for hydrotherapy even in those patients who present late, as there may be a prolonged burning effect at the subeschar level (4). It is important to minimize the time interval between contact with the chemical and hydrotherapy (5) and time spent in searching for neutralizing agents leads to more extensive burns (3).


In the period studied, 4.7% of burn admissions were chemical burns. This is in contrast to other reports between 1.4% and 4.8% (6, 7, 8) Most of the cases were intentional and occurred outside industry, compared to a high incidence of industrial chemical burns in the west (3). In this region the bums can be attributed to two major groups. The first is due to property feuds where corrosives are poured on the face of a sleeping adversary involved in disputes regarding property. Often a definite attempt is made to damage the eyes, a fact which accounts for the high percentage of ocular burns in this series (30.5%). Serious ocular burns have also been reported by others (1, 9). Such burns usually occur in males. The other major group is composed of young girls on whom acid is thrown out of sexual frustration. These two factors also account for the burns occurring in the active age group.


Sulphuric acid was the commonest agent involved, with a low incidence of alkali burns in contrast to the high incidence of alkali and hydrofluoric acid burns in the west (3). Lysol burns proved to be a special occupational hazard to hospital staff and doctors, in hospitals where lysol is used to sterilize instruments. It is thus important to educate all hospital staff in the handling of lysol.
Assessment of the depth of burn at the onset was often inaccurate. Areas of apparent partial -thickness burns often turned out to be full-thickness burns.
Slough separation is delayed in chemical burns probably owing to the sterilizing action of the chemical as well as the tough leathery impenetrable eschar that usually results. It usually occurs between 3 and 5 weeks (8). Wound cultures are sterile in the first two weeks but are positive in most cases by the end of the fourth week (8).


In many cases no operation is required and the wound heals spontaneously. The commonest operation performed is split thickness skin grafting. This may be performed following debridement or after spontaneous separation of the eschar (8). Early debridement and skin grafting yield good results especially in chemical burns of the car, where a delay may result in intractable chondritis or crippling deformities.
Chemical burns require intensive therapy and specialized care. The literature on the subject is unfortunately scanty. Better communication among those involved in the treatment of such cases is required in order to improve the outcome.

IPHREHAB : TISSUE EXPANSION IN THE TREATMENT OF BURN SCARS

IPHREHAB

TISSUE EXPANSION IN THE TREATMENT OF BURN SCARS

SUMMARY. Major post-burn scars are a serious morphological and functional problem and old techniques like skin grafts and distant flaps are not very effective to improve the final result. Expansion of the local skin allows us to obtain very large local flaps and the replacement of the scar tissue with a good skin for colour and texture. We have used the tissue expansion technique in the treatment of burn scars in the head and neck, trunk, upper and lower extremities. In the head and neck, tissue expansion is useful to obtain good results but the complication rate is higher than in the treatment of other pathologies with the same technique. Good results are obtained in the back where very large amounts of scarred tissue can be removed. In the thorax the morphological results are less satisfactory because of the hypertrophic scars resulting after the operation. In the thigh a good cosmetic improvement has very often been achieved; in the leg, on the contrary, we have observed the highest rate of complications: the use of tissue expansion in this area must be very careful and limited to selected cases.

In the last few years tissue expansion has improved thanks to technical refinements in plastic surgery.

In the past, the treatment of bum scars was carried out by the use of skin grafts or the transposition of local flaps. With skin grafts recurrence of contracture, chronic breakdowns and unsatisfactory cosmetic outcomes were observed; local flaps may be insufficient to resurface large defects after debridement or excision of a post-bum scar.

Expansion of the local skin makes it possible to obtain very large local flaps and to replace a great amount of scar tissue with a good skin for colour and texture (Argenta, 1985; Chang, 1986; Cohen 1988; Manders, 1984; Nordstrom, 1985; Radovan, 1979).

We have used the tissue expansion technique in the surgical treatment of burn scars in the head and neck, trunk, and the upper and lower extremities. We report a few cases to illustrate our surgical procedures.

Case report 1 (Fig. 1)

A 48-year-old man had sustained a burn of the back 23 years previously. In recent years he observed a recurrent ulceration in the centre of the scar. A biopsy did not show malignant cells but the recurrence of chronic breakdown was an indication for surgical excision of the scar tissue. In the first operation two tissue expanders were placed; one (1200 cc) was inserted in the paravertebral area and the other (1700 cc) in the right gluteal region. Two months later partial removal of the scar including the ulcerated area and reconstruction with the expander flap were performed. A re-expansion was performed one year later and 3 tissue expanders were placed at gluteal and lateral the level of the paravertebral thoracic regions.

Three months later removal of the expander, excision of the scar and reconstruction were performed. The ultimate result is satisfactory; further refinements can he achieved with a final expansion.

Case report 2 (Fig. 2)

A 32-year-old woman had sustained a bum of the face, neck and upper extremities at the age of six months. Scar and contractures of the cheek and oral region were inacceptable for the patient.

A preliminary expansion was performed by inserting an expander in the left side of the neck; a second expansion was carried out one year later on the opposite side of the neck: during expansion a breakdown was observed of the expanding tissue with partial exposure of the prosthesis. This complication did not impair the reconstructive procedure which yielded a satisfactory cosmetic result.

Discussion

In our series tissue expansion has yielded satisfactory results if compared with old techniques such as skin grafts or local flaps. However, the tissue expansion complication rate is higher in the treatment of large post-burn scars than in the treatment of other pathologies such as haemangiomas, giant naevi, post-mastectomy defects, bone exposure, etc.

The extensive scarring probably weakens the surrounding skin and impairs microvascularity.

We have observed that the complication rate is different in the various body areas.

In the head and neck the treatment of post-burn alopecia is satisfactory; the coverage of extensive facial or neck defects is often less satisfactory than in the treatment of other pathologies with the same technique: impairment of the expanding tissue, inflammation and exposure of the implant may be observed. In the thorax the morphological results may be compromised by the high rate of hypertrophic scars after the operation.

Excellent results have been obtained in the back, where very large amounts of scarred tissue can be removed in a single operation; re-expansion is also reliable and very useful to perform removal of scars.

In the thigh, good cosmetic improvement has very often been achieved; in the leg, on the contrary, we have observed the highest rate of complications. The use of tissue expansion in this area must be very careful and limited to selected cases: probably the stiffness of the tissue impairs the venous and lymphatic function and causes complications during tissue expansion: the fibrosis surrounding scar tissue may reduce venous and lymphatic flow from the expanding area and compromise tissue subjected to continuous mechanical stretching.

On the basis of our experience, tissue expansion is undoubtedly a method of choice in the treatment of post-burn scars; expansion must by very careful where stiffness of the tissue or terminal vascularization is present (leg, finger). At the level of the knee, elbow and neck, a very large amount of expanded skin is always necessary to carry out adequate reconstruction.