Annals of the MBC - vol. 4 - n' 2 - June 1991

INTERNATIONAL ABSTRACTS

Much research is currently devoted to the possibility of using cyclosporine to prevent rejection of composite tissue allografts, i.e. transplantation of modules of allointegumentary/musculoskeletaI tissues or components thereof for the repair of peripheral tissue defects. This kind of graft gives good functional and cosmetic restoration in surgical reconstruction after full-thickness bum injury. The initial results are very promising.

Hewitt C.W., Black K.S., Achauer B.M., Patel M.P.

J. Bum Care'Rehabil., 11: 74-85, 1990

Tonometry is a technique which makes it possible to quantify the course of cicatrization. A report is given on the evaluation by means of a modified Schiotz tonometer of the effects of burn therapy. Tonometry, though still in the rudimentary stage, evaluates burns scar diagnosis and prognosis very accurately.

Esposito G., Ziecardi R, Scioli M., Pappone N., Scuderi N.

J. Burn Care Rehabil., 11: 86-90, 1990

Post-traumatic stress disorder (PTSD), defined as the development of characteristic symptoms following a psychologically traumatic experience that is generally outside the range of human experience, is a frequent psychiatric disorder in patients who have sustained major burns. In view of the lack of detailed documented information on the subject, a survey was made of 54 consecutive hospitalized burn patients. 63% showed intrusive recollections of the initial trauma (partial diagnostic criteria) and 29,6% met full criteria, for PTSD at some point during hospitalization. PTSD was related to patients' TBSA burn, length of hospital stay, sex (females), and lack of responsibility for the injury. Although PTSD would appear to resolve spontaneously, appropriate psychological treatment soon after the injury might pre~ent it from developing.

Patterson D.R., Carrigan L., Questad K.A., Robinson R.

J. Bum Care Rehabil., 11: 181-184, 1990

In order to gain maximum advantage from educational seminars, which are expensive in terms of time, effort and resources for all concerned (both participants and planners), it is important that they should be assessed accurately as regards participant interests, level of existing participant knowledge, and participant reaction to the materials presented. This allows for modifications in order to improve subsequent seminars. The techniques for seminar evaluation are described in relation to a seminar on organ and tissue procurement with special reference to skin banking.

Ehleben C.M., Phillip Roberts D., Randolph May S., Still J.M.

J. Bum Care Rehabil., 11: 185-189, 1990

An this study, reconstituted skin composed of cultured allogeneic epithelial sheets (CAES) and cultured allogenelc dermis (CAD) was evaluated in a rat model to determine whether it could survive for an extended time without immunosuppression and whether CAD is suitable as a substitute for the original dermis in preventing wound contracture. Four types of wounds coverage were compared: CAES grafts, CAES over CAD grafts, split-thickness isografts (STtG), and STIG over CAD grafts. Results were better (good vascularization, less wound contracture) in the third and fourth of these techniques. It seems that CAD grafts are inadequate dermal substitutes for the prevention of wound contracture. Alternatively, contracture may have occurred because of the poor take of the subsequent CAES grafts. CAES survived however and grew on the cultured allogeneic dermis for up to 180 days without evidence of rejection.

~Sasarnoto Y., Alexander J.W., Babcock G.F.

J. Bum Care Rehabil., 11: 190-200, 1990

A description is given of a knowledge-based information system designed to be used with burn patients as an electronic advisor to guide physicians in fluid resuscitation in the first 48 hours after the burn lesion. The system, which was developed using the SMR (Simulating Medical Reasoning) shell, is also helpful for training purposes. Administrative data, clinical background and monitored data (including tables for recording fluid therapy and laboratory results) are displayed on 10 data screens. The knowledge base consists of a series of heuristic decision rules formulated by a burn case expert and expressing the Uppsala fluid resuscitation programme to prevent shock. The data recorded for a particular patient are compared with data in the knowledge base, and the appropriate conclusions are generated. These conclusions, with the fluid and ventilation prescription and other necessary measures, are then displayed as a report. The system's validity has been tested successfully with 125 hypothetical cases representing typical situations of severely burned patients.

Wiener F., Hedlund A., Groth T.

J. Bum Care Rehabil., 11: 201-213, 1990

Four patients with major burns (two flame, one scald, one electrical) refused blood and albumin transfusions on religious grounds (they were Jehovah's Witnesses), The results of their treatment are compared to those of control patients matched in age and T13SA who were treated by standard methods. Haemoglobin values were lower, but within one standard deviation, although serum protein and albumin treatments fell more than one standard deviation below mean values observed in control patients at comparable times after the lesion. Recovery was assisted by a high-calorie, high-protCin diet, iron supplementation, use of paediatric blood sampling techniques, and infection monitoring and prophylaxis, and allowing eschar to separate spontaneousIv. rather then performing early debridement. It is recommended in such cases 'that amputation of mummified electrically burned limbs should be at more proximal levels, including marginally viable muscle, in order to minimize infection and to reduce the blood loss associated with customary serial debridements.

Schlagintweit S., Snelling C.F.T., Germann E., Warren R.J.,

Fitzpatrick D.G., Kester D.A., Foley B. J. Burn Care Rehabil., 11: 214-220, 1990

COMPARISON OF SCAR CONTRACTURE WITH THE USE OF MICROSKIN AND CHINESE-TYPE INTERMINGLED SKIN GRAFTS ON RATS

The purpose of this study was to compare scar contracture associated with the microskin and the Chinese type of intermingled auto/allografts in rats. Wounds measuring 4x5 em in size were created on the dorsal surfaces of rats. After treatment with the two graft techniques, the size of the grafted wound was recorded on the 5th day after grafting and then weekly for 11 weeks. It was found that the scar contracture associated with the Chinese intermingled techniques was less than that associated with the microskin techniques. Both forms of grafting had uneventful healing processes.

Yeh F.L., Yu G.S., Fang G.H., Carey M., Alexander J.W., Robb E.C.

J. Burn Care Rehabil., 11: 221-223, 1990

The burn injury, although seemingly confined to the skin, has an impact that extends to the muscoloskeletal system, and isokinctic exercise therapy, in conjunction with standard physical therapy, improves strength and power in addition to maintaining range of motion. These considerations are important in relation to work cacacity. Isokinetic training and testing improve both outcome and assessment.

Cronan T., Hammond J., Ward C.G.

J. Burn Care Rehabil., 11: 224-7, 1990

Cultured keratinocytes (CKs) have been used as permanent skin replacement in patients with extensive burns who lack enough donor sites for the traditional mesh graft. However the success of these cultured grafts has been limited. There has been no apparent difference in patients or between 1Is to explain graft failure in some cases. Possib,j variability in keratinocyte graft maturation or three-dimensional structure might contribute to the failure of some grafts, but the structure of keratinocyte has not been extensively described. Scanning Electron Microscopy (SEM) images provide a comprehensive and panoramic view of the basal and apical surfaces of cultured cells. Detailed conditions of membranes, microappendages, and topographic relationships are revealed. In addition, cross sections show certain cytoplasmic differentiation markers, such as lack of nuclei and a number of cell layers which are unobtainable by SEM. The sequence of characteristic morphologic changes may establish criteria for the standardization of orderly events in differentiation and aging of keratinocyte grafts. These observations may be useful in determining when cultured keratinocyte grafts should be used in order to optimize graft take. This study examines the morphologic changes in cultured skin to identify characteristics that might indicate readiness for grafting. Both primary cultures and secondary-passage cultures were studied. A comparison between primary culture and secondary passage noted that primary-cultured keratinocytes were less suitable for grafting purposes because of the variation rates between dishes that were plated at the same time.

The study determined that grafting occurs during secondary passage of cultured keratinocytes, approximately 3 to 5 days after confluence is reached.

Merrick P., Meyer A.A., Herzog S., Woodley D.

J. Burn Care Rehabil., 11: 228-35, 1990

A COMPARISON OF EFFECTS OF THERMAL INJURY AND SMOKE INHALATION ON BACTERIAL TRANSLOCATION

Bacterial translocation to the mesenteric lymph node (MLN), liver, spleen, kidney and lung was studied in a chronic ovine model following sham injury, cutaneous thermal injury, cotton smoke inhalation injury, and combined thermal injury and smoke inhalation injury. Cardiac output, mean arterial pressure and plasma protein concentration remained within 10% of pre-injury levels. Urine output was maintained above 1 ml/kg/hr with fluid and plasma resuscitation. A wide-beam ultrasonic flow probe was chronically implanted to allow serial measurement of cephalic mesenteric arterial blood flow during the 48 hrs of the experiment. The sheep were sacrified at the end of this period for quantitative culture of N1LN, liver, spleen, kidney and lung.

Mesenteric blood flow showed a decrease to 48 +/8%, 80 +/- 5% and 64 +/- 9% of pre-injury values in animals receiving thermal injury, smoke inhalation injury and combination injury, respectively. The sham animals (no injury) maintained mesenteric blood flow at 102 +/- 7% of control levels. Thermal injtiry, as also combination thermal and smoke inhalation injury, induced higher levels of translocation than smoke inhalation injury alone.

Morris S.E., Navaratnam N., Herndon D.N.

J. Trauma, 30: 639-645, 1990

The purpose of this research was to investigate the reason why severe bum injury is often followed by immune suppression. In a series of laboratory experiments, burned mouse skin was implanted into unburned mice. Other materials (gauze, collagen) were also implanted. Ten days after the implantation, splenic lymphocyte proliferation and lymphocyte surface expression of activation antigens (IL-2R and 1a) were analysed after 3 days of culture. The peritoneal neutrophils were analysed for oxidative burst activity using flow cytometry and a dye which reacts with intercellular hydrogen peroxide. The implantation of burned/unburned skin and of cotton gauze or collagen sheet resulted in subsequent suppression of both lymphocyte activation proliteration and neutrophil oxidative burst activity. It would appear that intense local inflammatory response to the burn may be partly responsible for the profound systemic immune suppression subsequent to severe burn injury.

Hansbrough J.., Zapata-Sirvent R., Hoyt D.

J. Trauma, 30: 671-675, 1990

A RSNDOMIZED TRIAL OF INDIRECT CALORIMETRY-BASED FEEDINGS IN THERMAL INJURY

This study was conducted to make a comparison between the effectiveness of indirect calorimetryguided nutrition and support guided by the Curreri formula, in 49 adult patients with major burns. For further assessment of the effects of such support on nitrogen equilibrium, formulae differing in calorie-nitrogen ratio were also examined. The calorie intake of patients receiving the Curreri formula was a mean 3,490 Kcal/day, while those receiving indirect calorimetry-guided nutrition received 3,530 Kcal/day.

Both groups maintained body weight and lymphocyte counts, and survival was equal. There were complications (diarrhoea, nausea, hyperglycaernia) in both groups and their incidence was similar. Patients receiving the lower calorie:nitrogen ratio had greater cumulative nitrogen balance, with no increase in nitrogen excretion. Both forms of nutrition appear to be satisfactory, but if indirect calorimetry is unavailable or impractical, the Curreri formula provides a satisfactory approximation of the energy required for maintenance of body mass and function, during the period of maximal energy expenditure post-burn.

Saffle J.R., Larson C.M., Sullivan J.

J. Trauma, 30: 776-781

The aim of this prospective randomized study was to compare the use of an occlusive hydrocolloid dressing (Duoderm HydroactiVe, Squibb) and silver sulphadiazine (Silvadene, Marion) cream in the out-patient management of second-degree burns. 42 patients completed the study, 20 receiving Silvadene and 22 Duoderm. Duoderm-treated burns had better wound healing and repigmentation, less pain, fewer dressing changes, less time for dressing changes, and less cost. Duoderm-treated patients had less limitation of activity, better compliance, greater comfort and better overall acceptance, and they were more satisfied with the aesthetic results. The conclusion is that Duoderm Hydroactive dressings are superior to Silvadene cream in out-patient management of second-degree bums.

Wyatt D., McGowan D.N., Najarian M.P. J. Trauma, 30: 857-865

The objective of this research was to determine the eflect of the burn injury on endogenous catalase activity in lung and liver at the 3-day postburn period, before an endotoxin insult, to determine if there were changes in endogenous catalase activity caused by the burn which corresponded with the degree of lipid peroxidation after endotoxin. Adult sheep were used. A 15% total body surface third-degree burn was administered, and the post-burn endotoxin response was compared to endotoxin alone. Tissue malondialdehyde was used as an indication of the degree of tissue lipid peroxidation. The results show that an uninfected 15% of total body surface area body burn will result in a persistent decrease in lung and liver catalase activity. Since H202 appears to play a major role in endotoxin injury, the burn-induced catalase depletion may be responsible for the accentuated liver lipid peroxidation seeh after the combined insult. A post-burn decrease in lung catalase also occurred, but did not correspond with an accentuated lung lipid peroxidation as expected. The mechanism for the catalase inactivation and the variable tissue response will need to be pursued further.

Daryani R., Lalonde C., Zhu D., Weidner M., Knox., Demling R.H. J. Trauma, 30: 1330-1334, 1990.