Volume XXII

Number 4

December 2009

BURNET PROJECT
(Masellis A., Atiyeh B.)
The BurNet project, a pilot project of the Eumedis initiative, has become true. The Eumedis (EUro MEDiterranean Information Society) initiative is part of the MEDA programme of the EU to develop the Information Society in the Mediterranean area. In the health care sector, the objective of Eumedis is: the deployment of network-based solutions to interconnect - using userfriendly and affordable solutions - the actors at all levels of the “health care system” of the Euro-Mediterranean region. The Bur- Net project interconnects 17 Burn Centres (BC) in the Mediterranean Area through an information network both to standardize courses of action in the field of prevention, treatment, and functional and psychological rehabilitation of burn patients and to coordinate interactions between BC and emergency rooms in peripheral hospitals using training/information activities and telemedicine to optimize first aid provided to burn patients before referral to a BC. Shared procedure protocols for prevention and the care and rehabilitation of patients, both at individual and mass level, will help to create an international specialized database and a Webbased teleconsultation system.

SKIN DENDRITIC CELLS IN BURN PATIENTS
(D’Arpa N., D’Amelio L., Accardo-Palumbo A., Pileri D., Mogavero R., Amato G., Napoli B., Alessandro G., Lombardo C., Conte F. - Italy)
The body’s immunological response to burn injury has been a subject of great inquiry in recent years. Burn injury disturbs the immune system, resulting in a progressive suppression of the immune response that is thought to contribute to the development of sepsis. Dendritic cells (DCs) are potent antigen-presenting cells that possess the ability to stimulate naïve T cells. DCs are derived from bone marrow progenitors and circulate in the blood as immature precursors prior to migration into peripheral tissues. Within different tissues, DCs differentiate and become active in the taking up and processing of antigens, and their subsequent presentation on the cell surface is linked to major histocompatibility molecules. Upon appropriate stimulation, DCs undergo further maturation and migrate to secondary lymphoid tissues, where they present antigen to T cells and induce an immune response. The purpose of this study was to determine the effects of burn injury on skin DCs in terms of percentage, HLA-DR, and Toll-like receptor-4 (TLR-4) expression. The skin DCs were isolated from burned skin and non-burned skin in the same patient at 7 days post-injury, and skin DCs were isolated from unburned healthy individuals as control. DCs from burned skin notably express low levels of HLA-DR and TLR-4 soon after cell isolation. In the post-burn period the ability of skin DCs to respond to bacterial stimuli is impaired. These changes in DC behaviour might contribute to the impaired host defences against bacteria during burn sepsis.

TRIEN CONJUGATES, SCHIFF BASES, AND CERULOPLASMIN CONCENTRATIONS AS MARKERS OF THE ONSET OF THE RISK OF AUTODERMOPLASTY COMPLICATIONS
(Yarets Y.I.,1 Novikova I.A.,1 Rubanov L.N. - Republic of Belarus)
Background. Surgical interference which includes debridement and further renewal of skin cover by autodermoplasty (ADP) is the most effective method of burn wound treatment. Skin graft failure is a serious complication of ADP procedures leading to the opening of previously closed wounds, graft loss, and an increased wound surface owing to the donor zone. Numerous factors are involved that may affect the results of the ADP procedure. When planning the terms of surgical interference, specialists have to take into consideration criteria regarding the visual readiness of the wound and the patient’s objective state. Aim. We studied the possibility of using concentrations of trien conjugates, Schiff bases, and ceruloplasmin in the plasma of patients with deep local wounds as markers of the risk of autoskin graft failure. Methods. Ninety patients with local wounds of different origin and age were studied. Results and conclusions. It was found out that the amounts of trien conjugates, Schiff bases, and ceruloplasmin in plasma before the operation helped to predict the risk of autoskin graft failure with a high degree of probability (up to 92%). We established optimum cut-off points for trien conjugates, Schiff bases, and ceruloplasmin as indicators of the results of autodermoplasty operations, i.e. 350 mg/l, 0.35 units of oxidation indices (UOI), and 0.05 UOI, respectively.

BRULURES PAR DILUANT
(Benbrahim A., Jerrah H., Diouri M., Bahechar N., Boukind E.H. - Maroc)
La flamme de diluant est une cause non rare de brûlure dans le contexte marocain. Nous avons jugé intéressant de faire une étude épidémiologique sur la brûlure par flamme de diluant (BFD) au centre national des brûlés (CNB) du CHU Ibn-Rochd de Casablanca. Ce travail a été réalisé sur une période de 10 mois (septembre 2007/juin 2008). Le but du travail est de montrer les caractéristiques de ce type de brûlures pour les prévenir et ce par l’information sur le diluant, produit causant ces brûlures, et ses différents dangers, la brûlure notamment. Durant cette période, nous avons colligé 17 cas de BFD sur un total de 356 patients admis au CNB pour brûlures aiguës toute étiologie confondue. La moyenne d’age des patients concernés est de 32 ans. Ils sont presque tous de sexe masculin (16 hommes/1 femme) et ont des antécédents de toxicomanie et/ou de délinquance. Tous nos patients sont de bas niveau socio-économique et habitent dans des bidonvilles pour la plupart. La brûlure est souvent secondaire à une agression dans la rue (92% des cas). Concernant les caractéristiques de la brûlure, la surface cutanée brûlée moyenne est de 23%; elle est souvent profonde et siège surtout au niveau des membres supérieurs et du tronc.

OPTIMIZING BURN TREATMENT IN DEVELOPING LOW- AND MIDDLE-INCOME COUNTRIES WITH LIMITED HEALTH CARE RESOURCES (part 2)
(Atiyeh B.,1 Masellis A.,2 Conte C. - Lebanon, Italy)
The present review of the literature aims at analysing the challenges facing burn management in low- and middleincome countries (LMICs) and exploring probable modalities to optimize burn management in these countries. In Part 1, the epidemiology of burn injuries and the formidable challenges for proper management due to limited resources and inaccessibility to sophisticated skills and technologies in LMICs were presented. Part II will discuss the actual state of burn injuries management in LMICs.

INITIAL RELEASE OF SEVERE POST-BURN CONTRACTURE SCAR OF THE NECK FOR INTUBATION UNDER KETAMINE
(Al-Zacko S.M., Al-Kazzaz D.A. - Iraq)
Background. Severe anterior post-burn contracture (PBC) of the neck poses the anaesthesiologist some difficult problems and results in difficult intubation when extension of the atlanto-occipital joint is impaired. Such patients must therefore have the PBC scar released before other procedures are performed, in order to ensure airway control. Objectives. To show our experience with quick surgical neck release of patients with severe anterior PBC of the neck to facilitate direct laryngoscopy and orotracheal intubation (OTI). Material and methods. A prospective study of patients with severe anterior PBC of the neck was carried out from January 2003 to December 2007 in the Burns Unit of Mosul Teaching Hospital in Mosul, Iraq. The patients were given ketamine, after which a release incision was made over the anterior PBC of the neck scar. OTI was then performed successfully. Results. Twelve patients with severe neck PBC (3 males, 9 females; age range, 7-37 yr; mean age, 20 yr) all had successful OTI after PBC release under intravenous ketamine. None showed any complications attributed to the anaesthesia

BURN FUNCTIONAL OUTCOMES - VENTILATOR USAGE AND DISCHARGE AMBULATION STATUS OF PATIENTS IN A BURN WOUND IN-PATIENT CENTRE
(Harmon R.L., Mian M.A.H., Alam B., Hassan Z., Mullins R.F. - USA)
Anticipating functional outcomes of patients managed in an in-patient burn wound centre can help in advising patients and their families of prognosis as well as assist case managers in discharge planning. The records of 37 burn patients were reviewed; one patient expired and was removed from further analysis. Data were obtained regarding patient characteristics, types and locations of burns and other wounds, ventilator use, level of mobility at hospital discharge, and disposition; three patients lacked discharge ambulation status and were removed from the outcome comparison analysis. Of the 36 patients, 17 had thermal burns and nine (25%) had associated inhalation injuries. Thermal burn patients (p = 0.02), patients requiring ventilator support during their hospital stay (p = 0.04), and those with inhalation injuries (p = 0.04) were less likely to be ambulating independently or with assistance at discharge from the burn wound centre than other patients. This preliminary study suggests that patients with thermal burns and inhalation injuries and those requiring ventilator support were less likely to be ambulatory at hospital discharge. Further studies appear indicated.

A FEAR AVOIDANCE MODEL IN FACIAL BURN BODY IMAGE DISTURBANCE
(Tagkalakis P., Demiri E. - Greece)
The quality of life of burn-injured patients can be impaired physically and psychologically. Burn patients who experience facial disfigurement have psychological, social, and economic difficulties living with their appearance in addition to difficulties associated with their medical treatment. The aim of this review was to investigate, within a cognitive behavioural framework, the effect of facial disfigurement on body image and social integration in burn patients. Body image is a complex concept used to express the mental image of a person’s physical self. Newell offered a cognitive-behavioural model which drew on clinical studies of phobic disorders, assuming that many of the psychological difficulties in patients who have suffered a threat to their body image are mediated primarily by fear and avoidance. The model proposes two ends of a continuum for disturbed body image: confrontation leading to social integration, and avoidance leading to social isolation. The literature suggests that many of the confrontational and adaptive processes described in the model are likely to be important in addressing facial disfigurement issues in burn patients. However, the conclusions drawn may be entirely speculative until they are confirmed by sufficient robust research evidence.

MAMMOPLASTY IN CORRECTING SCAR-INDUCED BREAST DEFORMITIES
(Abulezz T. - Egypt)
Post-burn or post-inflammatory scarring of the breast may have significant effects on the shape and volume of the breast as well as on the nipple-areola complex (NAC). Significant asymmetry of the breasts and distortion of the NAC may result, with marked consequent psychological and physiological sequelae for the patients. This report presents three cases of scar-induced breast deformities and the use of modified reduction mammoplasty for their management. The breast scarring was induced either by burn injuries or by chronic granulomatous mastitis. Reduction mammoplasty was used to reshape the deformed scarred breast and to balance the volume asymmetry between the scarred and the non-scarred breasts. The NAC was mobilized safely on a dermal- parenchymal pedicle in any direction regardless of the orientation of the pedicle. In conclusion, cosmetic surgery in the scarred breast was found to be a safe and rewarding procedure with good aesthetic results. However, it has to be carefully planned.

EPITHELIOMA SPINOCELLULAIRE SUR CICATRICE DE BRULURE (A PROPOS DE CINQ CAS)
(Tourabi K., Mejjati H., Ribqg Y., Achbouk A., Arrob A., Moussaoui A., Ihrai H. - Maroc)
Pour étudier l’ulcère de Marjolin, tous les dossiers des patients qui se sont présentés pendant une période quinquennale à un Service de Chirurgie Plastique et des Brûlés au Maroc ayant un cancer sur cicatrice de brûlure, objectivé par un examen histopathologique, ont été inclus dans une fiche de recueil de données comprenant des paramètres liés à l’identité du malade, à l’inventaire préthérapeutique, au traitement et à l’évolution du cas. Les Auteurs, après avoir présenté les données des cinq patients inclus dans l’étude, considèrent les problèmes posés par les épithéliomas spinocellulaires sur cicatrice de brûlure, qui sont des affections graves et rares. La dégénérescence des cicatrices de brûlures est une évolution dramatique, causée par la négligence. Le traitement préventif par exérèse systématique de toute lésion suspecte doit être fortement souligné puisqu’il garantit la guérison quasi certaine.

CASE REPORT: ISOLATED PERINEAL BURN CONTRACTURES PRESENTING WITH CHRONIC INTESTINAL OBSTRUCTION
(Oladele A.O.,1 Olabanji J.K.,1 Awe O.O. - Nigeria)
Isolated perineal burns are rare and so are perineal contractures. Perineal contractures may however lead to intestinal obstruction, which is a more life-threatening complication. A six-yr-old boy presented with chronic intestinal obstruction following isolated perineal contracture due to a deliberate perineal burn injury to treat a febrile convulsion. The obstruction was successfully relieved using local flaps to release the perineal contracture. There is a need for meticulous care in perineal burns to avoid perineal contractures, which may result in chronic intestinal obstruction.

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