Annals of Burns and Fire Disasters - vol. XIII - n. 2 - June 2000

THE LAING ESSAY: ETHICAL ISSUES IN BURN CAME
This article covers a wide range of ethical issues related to burn care: autonomy (the right to control one's own life), paternalism (where the physician's action is intended to benefit the recipient whether the recipient consents or dissents), professional autonomy, informed consent, legal competence, and responsibility. The funding of health care gives rise to other considerations. Medicine has made great progress in recent years and patients with massive injuries can now survive, but the quality of their lives poses some difficult ethical problems. Mass disasters and war situations are also reviewed. The ethical dilemma is thus summed up: "It is as ethically unacceptable for one individual to deny another a chance of life as for society to assume that a severely disfigured person cannot enjoy life."

THE EFFECT OF THE ANTI-ALLERGIC AGENT AVIL ON ABNORMAL SCAR FIBROBLASTS
Abnormal wound healing leads to the formation of hypertrophic scars and keloids. Such scars accumulate excessive extracellular matrix proteins owing to two processes: increased synthesis and decreased degradation. With a view to finding a therapeutic control for the formation of scars, a study was made of the effect of avil (phenimarine maleate) on fibroblasts cultured from abnormal scars, compared with normal skin. There was seen to be a decrease in the proliferation rate in cells from normal skin (39%), hypertrophic scar (55%), and keloid (63%), treated with 8 mM avil (72 h). It was found that the rate of decrease in collagen synthesis in normal skin (44%), hypertrophic, scar (74%), and keloid fibroblast (73%) correlated with changes in DNA synthesis.

Venugopal J., Ramakrishnan M., Habibullah C.M., Babu M.
Burns, 25: 223-8, 1999

CONTROLLED PARTIAL-SKIN THICKNESS BURNS: AN ANIMAL MODEL FOR STUDIES OF BURN WOUND PROGRESSION
This paper presents a practical, reproducible, and reliable model that was used to inflict partial-skin thickness burns in New Zealand white rabbits for use in experimental studies on the influence of drugs on burn wounds. The wounds were inflicted using a round aluminium stamp which was applied in a contact area of 4 cm² at a temperature of 80 °C for 14 sec. The stamp weighed 85 g. The depth of the lesions was measured using HE-stained paraffin sections. In 80% of cases, the border of the necrotic zone was found in the central third of the dermis, and in 100% in the central two quarters. These findings were obtained when the animal hair at the burn infliction site was in the anagen phase of the growdi cycle. Reproducible results can be achieved if the same parameters are followed.

Knabl J.S., Bayer G.S., Bauer W.A., Schwendenwein I., Dado P.F., Kucher K., Horvat R., Turkof E., Schossmann
B.,Meissl G. Burns, 25: 239-45, 1999

BETA-HAEMOLYTIC STREPTOCOCCUS INFECTION IN BURNS
This prospective study was undertaken in order to evaluate the incidence of beta-haernolytic Streptococcus infection in our burn patients. Until December 1992 we used penicillin prophylaxis and we wished to make a comparison of the two periods before and after suspension of penicillin prophylaxis. Between January 1993 and December 1997 (i.e. after suspension of penicillin) 14 out of the 1213 burn patients we admitted to our hospital in Kuwait presented either colonialization or infection with Streptococcus spp. Streptococci were isolated from burn wounds in ten patients, from the throat in three, and in blood culture in one. Group A Streptococcus was found in five, group C in three, and group D in six. The organisms were isolated ³ 72 h post-burn in all patients but one. The infections were kept successfully under control by means of antibiotics and no detrimental effects wore observed. There were no mortalities. This study showed that only 1.1% of our burn patients presented Streptococcus, and only one-third of these were group A. It therefore appears that the use of penicillin prophylaxis in the first 5 days post-burn may serve no useful purpose and should be discontinued in burn units where the incidence of this organism is limited.

Bang R.L., Gang R.K., Sanyal S.C., Mokaddas E.M., Lari A.R.A.
Burns, 25: 242-6, 1999

DEVELOPMENT IN THE TREATMENT OF BURNS IN SOUTH AMERICA DURING THE LAST DECADES
This article reviews some 50 years in the development of burns treatment in South America. The truly scientific approach to the problem began in the 1930s, and affirmed itself more positively in the 1940s thanks to the influence of the Latin American Congresses of Plastic Surgery, which started up in 1941. The first specialized burns facilities date back to the 1950s. The advances then included more adequate fluid replacement, early excision and grafting, enteral feeding, the use of new topical antibacterial agents, better prevention and treatment of infection, a deeper understanding of smoke inhalation injuries, and improved management of physical and psychological rehabilitation. Burn care in South America has thus dramatically improved in the last 25 years. The Latin American Committee for Prevention and Care of Burns, founded in 1964, has become an important factor in the development of burns treatment in Latin America. Many national burn associations have been created, and in 1991 the Latin American Federation of Burn Associations was founded. Specialists in South American countries have remained in the forefront of international scientific developments and represent an important body of workers devoted not only to the day-to-day treatment of the burned but also to the academic and scientific aspects of the burns disease.

Benaim R, Artigas Nambrard R.
Burns, 25: 250-5, 1999.

CLOSTRIDIAL COLLAGENASE RELEASES BIOACTIVE FRAGMENTS FROM EXTRACELLULAR MATRIX MOLECULES
An investigation was made of the biological role of small extracellular matrix fragments in wound healing. Some human burn eschar tissue was digested with bacterial collagenase, and some small aminoacidic fragments were inoculated in human dermal fibroblast cultures and in polyvinyl alcohol sponges that were subcutaneously implanted in rats. We then performed proliferation assays on cell cultures, and biochemical and histological analyses of the animal model. It was found that fibroblasts treated with low concentrations of eschar fragments showed a significantly faster duplication rate than controls. It was also found that the inflammatory response was increased by eschar-derived fragments at post-operative day 2. Protein and hydroxyproline synthesis, in contrast, was decreased at day 14. Our findings indicate that the use of bacterial collagenase to debride necrotic tissue may lead to indirect healing effects. These effects are due to the local release of bioactive matrix-derived fragments.

Radice M., Brun R, Bemardi D., Fontana C., Cortivo R., Abatangelo G.
J. Burn Care Rehabil., 20: 282-91, 1999

BILATERAL FACIAL NERVE PARALYSIS AFTER HIGHVOLTAGE ELECTRICAL INJURY
The case is described of a man who after receiving a 12,000 V burn suffered bilateral facial nerve paralysis. An exhaustive search of the literature has not yielded any similar cases involving electrical burns. The patient began to develop facial weakness on post-burn day 7, with left peripheral seventh cranial nerve paralysis and a corresponding though lesser deficit on the right. A course of empirical antiviral therapy did not improve the patient's paralysis, suggesting that the cause was not viral. Five months after the injury the patient showed remarkable neurological improvement, but he was still not able to achieve tight closure of the eyelids.

Vasquez J.C., Shusterman E.M., Hansbrough J.F.
J. Burn Care Rehabil., 20: 307-8, 1999

THE SEARCH FOR COST-EFFECTIVE PREVENTION OF POST-OPERATIVE NAUSEA AND VOMITING IN THE CHILD UNDERGOING RECONSTRUCTIVE BURN SURGERY- ONDANSETRON VERSUS DIMENHYDRINATE
Many children undergoing reconstructive burn surgery suffer from post-operative nausea and vomiting (PONV). A prospective, randomized double-blind placebo-controlled test was conducted in order to compare the effects of ondansetron and dimenbydrinate in the prevention of PONV in children. The patients were divided into three groups, receiving either 0.1 mg/kg of ondansetron, 0.5 mg/kg of dimenhydrinate, dr a placebo. It was found that there were statistically significant reductions in the incidence of PONV in patients receiving ondansetron or dimenhydrinate, compared with patients receiving a placebo. The differences between ondansetron and dimenhydrinate were significant. The two treatments were thus equally effective, but ondansetron was much more expensive than dimenhydrinate ($19.34 per dose for ondansetron compared with $0.90 for dimenhydrinate).

McCall LE., Stubbs K., Saylors S., Pohlman S., Ivers B., Smith S., Fisher C.G., Kopcha R., Warden G.
J. Burn Care Rehabil., 20: 309-15, 1999

THE USE OF THE MILLARD"CRANE" FLAP FOR DEEP HAND BURNS WITH EXPOSED TENDONS OR JOINTS
The "crane" flap was first described by Millard in 1969. This procedure enables the surgeon to use a skin flap to lift, transport, and deposit subcutaneous tissue to cover bones, joints, tendons, and other vital structures. This type of flap is particularly indicated in deep hand burns with exposed tendons and joints, which cannot be grafted. We compared results in six patients treated with the crane flap and five with the conventional abdominal skin flap. All the crane procedures gave graftable wound beds. The range of movement in all 11 patients six months after surgery did not show any statistical difference. None of the crane-flap treated hands needed procedures to separate the digits or to debulk the flaps, whereas all the conventionally treated patients required such procedures.

EXPERIENCE WITH BANKED SKIN IN THE PRAGUE BURNS CENTRE
In the Prague Burns Centre human allografts and xenografts of porcine origin continue to be among the preferred means of temporary burn wound cover, despite the progress that has been made in material sciences. True closure is effected only with living autografts on isografts (identical twins). Our method of preparing fresh porcine grafts has a 25-year history: dermo-epidermal sheets are obtained in strips, which are then treated with a lavage using chemotherapeurics and antibiotics, spread on sterile wet gauze, and stored in Petri dishes at 4 °C. Cell viability is maintained for 10-14 days after transfer to patients. The Prague Skin Bank started functioning in 1986. Our protocol for skin cryopreservation is as follows: pre-treated skin is kept in aluminium vessels in containers with liquid nitrogen vapour, and cryoprotective medium is used with 15% glycerol. At present we produce some 2 million sq em of skin graft per year.

Broz L., Vogtovą D., Königovą R.
Acta Chirurgicae Plasticae, 41: 54-8, 1999