Volume XIII

Number 3

September 2000

TRAITEMENT ET PRONOSTIC DE LA BRULURE GRAVE AU CENTRE DES GRANDS BRULES DE DOUALA, CAMEROUN
(Beyiha G., Binam F., Batamack J.F., Sosso M.A. - Cameroun)
La brûlure constitue une pathologie traumatique fréquente et lincidence de la mortalité reste très préoccupante. Cette étude prospective du Centre des Grands Brûlés de Douala, Cameroun, détermine les indices de gravité de la brûlure thermique par flammes et propose un schéma de prise en charge du grand brûlé. Les accidents domestiques et la brûlure thermique sont les circonstances et le type de brûlure les plus incriminés. La surface corporelle atteinte est le principal élément de gravité. Les perturbations hémodynamiques très précoces surviennent pour une atteinte de 10% chez lenfant et 15%o chez ladulte. Elles sont entretenues par un défaut de remplissage et constituent la première cause de décès dans un tableau de défaillance polyviscérale. Les apports hydroélectrolytiques précoces suffisants et les catécholamines améliorent les résultats des 48 premières heures, considérées comme la première phase. Certaines localisations, comme la face, et latteinte des voies respiratoires par inhalation des fumées chaudes et le blast et la résorption des oedèmes aggravent le pronostic et sont responsables dinsuffisance respiratoire. Lutilisation des diurétiques, proscrite pendant la phase de remplissage, et la ventilation artificielle peuvent savérer nécessaires lors ce cette deuxième phase. La troisième phase, au-delà du 14ème jour, celle du risque infectieux, est une menace permanente pour le brûlé. Il est entretenu par un état de dénutrition et dimmunodéficience. Ce risque ne saurait justifier une utilisation abusive des antibiotiques, source de résistance des souches bactériennes et de survenue des infections systémiques à levures. Lapport calorico-protidique devra par contre être important et justifier un supplément dalimentation par gavage à travers une sonde nasogastrique.

MANAGEMENT OF PAEDIATRIC BURNS
(Atiyeh B.S., Rubeiz M., Ghanimeh G., Nasser A.N., Al-Amm C.A. - Lebanon)
Almost one-third of all burn centre admissions involve children under the age of ten years. Caring for the burned child continues to demand the close attention of a multidisciplinary team to the patient's many needs. Paediatric burns impose enormous economic burdens on families and on society as a whole. Scald burns secondary to household accidents predominate in most series, constituting 70% of all thermal injuries in infants, toddlers, and pre-school children. Most of these injuries are potentially preventable. Children with 5% TBSA third-degree burns or more than 10% TBSA second-and third-degree burns need to be hospitalized for proper resuscitation and burn wound management. Children with burn injuries involving the face, hands, or genital areas also require hospitalization. The goal of the resuscitation of hospitalized burn victims is to restore circulating blood volume and to minimize the early stress response. This is accomplished with adequate fluid replacement, correction of hypoxia and ventilatory disturbances, prevention of hypothermia, and adequate control of pain and anxiety. Minor burns can be treated at home with topical ointments. The recently introduced MEBO (Moist Exposed Burn Ointment) seems to be highly promising in this regard. Burn wounds should be encouraged to heal in the shortest possible period by a judicious combination of topical therapy, eschar excision, and skin grafting.

PREVENTION OF HOSPITAL-ACQUIRED INFECTIONS IN THE PALERMO BURNS CENTRE
(Torregrossa M.V, Valentino L., Cucchiara P., Masellis M., Sucameli M. - Italy)
This paper reports on an extensive epidemiological survey of the microbiological monitoring of the environment, staff, and patients in the Intensive Care Unit of the Palermo Bums Centre (Italy). The aim of the survey was to evaluate the presence and distribution of environmental sources of pathogens and opportunistic bacterial agents of nosocomial infection in immunocompromised hosts. Strains collected from air, tap water, and medical and nursing staff were compared with strains isolated from burn patients in order to study the potential transmission route of bacteria. The results showed environmental strains presenting a profile identical to that of the clinical strains, suggesting a link between the environment, staff, and the patients. A programme of routine microbiological monitoring proved to be effective as a surveillance programme for the reduction of nosocomial infection.

ANALYSIS OF PROLIFERATION /DIFFERENTIATION AND IMMUNOGENICITY OF CULTURED HUMAN KERATINOCYTES AND NORMAL HUMAN EPIDERMIS
(Garcia Fernandez E., Maruri N., Arrieta A., Rinon M., Arranz M.C., Bejar J.M., Garcia Masdevall M.D., Gabilondo F.J. - Spain)
Normal human keratinocytes can be serially cultured in vitro and under appropriate culture conditions to give epidermal sheets which may be used to cover deep and large skin defects or burns. The analysis by flow cytometry of epidermal cells in normal human epidermis and cultured human keratinocytes is proposed to predict the optimal time for the grafting of in vitro prepared allogeneic keratinocytes. This analysis regarded their proliferative and immunogenic stage, and the evaluation of antigens whose level of expression is related to these. In 19 skin biopsies and 22 cultured epidermal sheets we analysed: markers of epidermal proliferation/differentiation (31 integrins (CD29) and Kl/K10 intracytoplasmatic keratins; antibodies of immunogenicity anti-HLA-DR and anti-HLA A,B,C, and antibodies which identify other epidermal cells (anti-vimentin and anti-CD45. We made the following observations. First, the phenotype of epidermal cells that were obtained from cultured epidermal sheets was similar to the phenotype of isolated cells from normal human skin in samples treated with lysolecithin. Second, the CD29+ cells increased compared with the CD29-K1/K10+ in normal human skin and cultured sheets, especially the CD29+K1/K10+ group, which was suprabasal but occasionally basal and highly proliferative. This could be due to the high proliferative ability of keratinocytes in culture. Third, the cultured keratinocytes lost nearly all expression of the HLA class II and class I antigens. The cultured epithelial sheets in the laboratory can therefore be grafted successfully and we may suppose that immunological rejection does not occur.

THE METHOD OF MICROGRAFTING IN THE TREATMENT OF LARGE AREA FULL-THICKNESS BURNS
(Hadjiiski O. - Bulgaria)
A method is proposed for the treatment of large area full-thickness burns (over 40% total body surface area). The preparation of small grafts, called microstamps, is described together with the method of their application to the wound surfaces. The various advantages of the method are defined: use of a small area autograft (some sq. cm), possibility of a large coefficient of distribution up to 1:9, possibility of combination with other methods, use of small donor sites from which it is not possible to take full skin grafts, and good final results.

L'EXCISION TANGENTIELLE PRECOCE AU SECOURS DES BRULURES PROFONDES DE LA MAIN
(Chafiki N., Bahechar N., Boukind E.H. - Maroc)
L'excision greffe précoce (EGP) à visée fonctionnelle des brûlures profondes des mains doit être préférée à la méthode conventionnelle chaque fois que possible. Les Auteurs rapportent une série récente de 19 mains excisées chez dix patients. L'excision est associée à celle d'autres localisations chez un patient sur deux. Les résultats fonctionnels sont globalement jugés bons. Les résultats esthétiques sont variablement appréciés. Les difficultés logistiques qui s'opposent à ce que l'EGP des mains devienne une technique de routine dans notre contexte sont discutées.

HYPERTROPHIC SCARS AND KELOIDS: IMMUNOPHENOTYPIC FEATURES AND SILICONE SHEETS TO PREVENT RECURRENCES
(Borgognoni L., Martini L., Chiarugi C., Gelli R., Giannotti V., Reali U.M. - Italy)
Hypertrophic scars (HS) and keloids (K) very often result from bums and sometimes from minor injuries. It has been hypothesized that immunological mechanisms play a role in the pathogenesis of HS and K. However, the knowledge of the pathogenesis of these disorders is still incomplete and the therapeutic strategies limited and often unsatisfactory. In particular, the surgical excision of the lesion is followed by a high incidence of recurrences, especially in K. In this study, we performed a preliminary clinical and pathological investigation in 20 selected cases of K occurring after a previous surgical excision. Our aims were to evaluate the possible advantage of adhesive silicone sheet application after K excision in order to prevent recurrences and to investigate immunophenotypic modifications in scar tissue after treatment. Ten K underwent surgical excision and ten K underwent surgical excision and silicone sheet application for 3 months. For the immunohistochemical analysis we used the alkaline phosphatase anti-alkaline phosphatase (APAAP) technique and a large panel of monoclonal antibodies. In the K group with surgical excision and silicone sheet application we observed a 60% rate of complete remission, whereas only 10% of complete remission was observed in K treated with surgical excision alone. In the latter group we observed a high number of total recurrences. No side effects were observed after silicone sheet application. The immunohistochetriical investigation showed a high amount of activated immune-cell infiltrate in the excised K, consisting of CD3+, CD4+, CD45R0+, HLA-DR+, LFA-1+ lymphocytes associated with HLA-DR+ and ICAM-1+ dendritic cells. In K treated with surgical excision and silicone sheet application we found a clearly lower amount of the above immune-cell infiltrate and a higher amount of CD36+ dermal dendrocytes and CD68+ macrophages than in the excised lesion. The results of this study support the hypothesis that in situ immune mechanisms are involved in the development of pathological scars. The silicone sheet applications effectively reduced recurrences after K excision and seem to induce a recovery of the balance of the remodelling processes in scar tissue.

THE IMPORTANCE OF EARLY PHYSICAL THERAPY TO PREVENT CONTRACTURE IN THE BURNED HAND
(Petronic I., Nikolic G., Markovic M., Marsavelski A., Golubovic Z., Janjic G., Cirovic D. Yugoslavia)
Keloid scars are most commonly observed after full-thickness and second-degree burns. Keloid scars are commonly localized on the limbs, face, and neck because of the exposed nature of these parts. A prospective investigation was conducted at the University Children's Hospital in Belgrade over a three-year period, during which 35 children with hand burns were treated. Early physical therapy consisted of electrokinetic therapy, corrective orthosis, and the application of elastic bandages. In the late phase, working hydrokinesia and occupation therapy were performed. After physical therapy the outcome was followed up. A significant number (67.7%) of immature scars healed, unlike mature scars, which had to be managed surgically. Treatment aimed at the aesthetic and functional improvement of the hands. It should be noted that favourable aesthetic results and a full range of movement were achieved only in cases where physical therapy was applied simultaneously with wound epithelializafion and initiated as early as possible in collaboration with the surgeon.

BILATERAL SHOULDER FRACTURES FOLLOWING LOW-VOLTAGE ELECTRICAL INJURY
(Duman H., Kopal C., Selmanpakoglu N. - Turkey)
Bilateral shoulder fractures resulting from high energy such as traffic accidents or falls from height are usually associated with thoracic, craniofacial, and spinal injuries. The mechanism of shoulder fractures caused by low-voltage electric shock is quite different from those caused by high energy. Such fractures may be due to tetanic muscle contraction involving the upper extremities and shoulder girdles. This study presents a case of bilateral shoulder fracture after a low-voltage electrical injury.

THE NEW BURNS CENTRE AT THE A. PERRINO HOSPITAL, BRINDISI, ITALY
(Verrienti P. - Italy)
A new burns centre was opened at the A. Perrino Hospital, Brindisi, Italy in November 1999. The new centre continues in the traditions of the previous burns centre, but is more functional. A full description of the new centre is provided. An outline is given of the activity of the burns centre in the period 1986-99 in order to give an idea of the amount of work done and the effectiveness of the treatment administered. Some epidemiological considerations are also expressed.