INTERNATIONAL ABSTRACTS

C&ND1DAAUB1CM!S STUDIES: A HYPOTHESIS FOR THE PATHOGENESIS OF CANDIDA INFECTION IN BUMS

It is not clearly understood why burn patients are more susceptible to fatal candidiasis than normal individuals. The purpose of this study was to investigate in what way the micro-organism Candida albicans, rather than the host, may be infected by the proteolytic environment. Renal fungal load was measured in burned mice and a significantly greater Candida census was found in kidneys from mice challenged with a high proteinase-generating parent C. albicans (MY 1044) compared to those challenged with its low proteinase- generating mutant (MY 1049). In vitro the MY 1044 cells grew more rapidly than MY 1049 cells in media containing sera from burned mice as the only nitrogen source. When the media were augmented with proteinase or a mixture of amino acids the growth of MY 1049 cells increased, while augmentation with proteinase inhibitor decreased MY 1044 growth. The in vitro growth of both the mutant and its parent strain was affected by their proteolytic environment, and this would suggest that virulence differences for MY 1044 and MY 1049 could be partially due to growth differences between the two strains in different proteolytic environments. Combining these results with existing observations, a theory is proposed for the pathogenesis of C. albicans in burns.

Neely A.N., Orloff M.M., Holder I.A. J. Burn Care Rehabil., 13: 323-9, 1992.

The purposes of this study were to determine whether certain easily measured variables (height, age, sex, weight, ventilatory status and diagnosis) could be correlated with measured energy expenditures, and whether equations could be derived from these variables in order to make accurate predictions of the energy expenditures of hospitalized patients with burns and other diagnoses. Using data from 200 patients (14 years and over, with various medical and surgical diagnoses including major burns), stepwise multivariate regression analysis derived two equations (respectively for ventilatordependent and spontaneously breathing patients) which, when tested on 100 comparable patients, showed that measured energy expenditures were not significantly different from calculated energy expenditures. Energy expenditure can therefore be accurately estimated in a variety of patients, including those with major burns, with the use of easily obtained data.

Ireton-Jones C.S., Turner W.W., Liepa G.U., Baxter C.R. J. Bum Care Rehabil., 13: 330-3, 1992.

This research, involving 13 patients with partialthickness sheet grafts, determined the efficacy of measuring transcutaneous partial pressure of oxygen (TCP02) and transcutaneous partial pressure of carbon dioxide (TCPC02) as a method of estimating skin graft take. Transcutaneous measurements were obtained from the grafts and areas of normal skin starting on the day of surgery and thereafter for 2 weeks. Graft TCP02 was initially very low (<8 trun Hg) and it never exceeded 40 trun Hg, whereas skin levels ranged between 60 and 80 mm Hg. Graft TCP02 levels did not approach skin levels until the skin graft matured. Graft TCPC02 ranged between 80 and 100 rarn Hg on the first few days after grafting and then dropped to values slightly above skin levels (40 to 50 nun Hg) on day 5 or 6 after grafting. Graft TCPC02 became normal at the time of clinical graft vascularization and remained at levels slightly above those of skin during the remainder of the study. The determination of graft TCPC02 'S thus a non-invasive and objective measure of skin graft vascularization, while graft TCP02 values reflect graft maturity.

GreenhaIgh D.G., Warden G.D. J. Burn Care Rehabil., 13: 334-9, 1992.

The prevalence of present and lifetime depressive disorders in a sample of children and adolescents with burns was determined by interviewing 30 children and adolescents with burns (range, 5% to 95% BSA) and their parents, using a system known as the Diagnostic Instrument for Children and Adolescents. The diagnoses were then determined according to the American Psychiatric Association's Diagnostic and Statistic Manual for Mental Disorders. The mean time interval between the burn injury and the assessment of depression was 9 years. It was found that depression frequently remained unrecognized. At the time of assessment only one child presented symptoms of major depression and only three had symptoms of dysthymic disorder. However, eight children had a history of major depression; four had made suicide attempts and thirteen had suicidal thoughts, of which their parents were often unaware. Other types of affective disorders were present. Depression was not found to be significantly related to burn size or disfigurement. It is concluded that referral for diagnostic services and psychotherapy, and for some children treatment with antidepressant medication, are often a necessary part of medical services for burned children.

Stoddard F.J., Stroud L., Murphy J.M.M. J. Burn Care Rehabil., 13: 340-7, 1992.

Six patients were studied from the beginning of hospitalization for 30 days by measuring sequential serum growth hormone (GH) and insulin-like growth factor (IGF-1) concentrations in order to determine whether bum patients are relatively deficient in GH, which is known to be one of several hormones secreted in response to stress. If GH secretion is in fact reduced by the stress of burn injury, there is an evident rationale for the use in such patients of synthetic human GH, which is now readily available. Plasma cortisol and urine cortisol excretion were measured as indicators of the stress of the illness. The results showed that patients with burn injury have inappropriately low GH secretion and IG17-1 production in spite of the stress of the injury and more than adequate nutritional therapy. This suggests that GH (or possibly IGF- 1) treatment might promote more rapid recovery.

Jeffries M.K., Vance M.L. J. Burn Care Rehabil., 13: 391-5, 1992.

The causes of progressive vascular occlusion and tissue necrosis in the zone of capillary stasis are multifactorial. Wound desiccation impairs tissue viability and encourages progressive tissue necrosis after bum injury. It was however found some years ago that tissue in the zone of capillary stasis has bleeding arterioles during tangential excision and that the tissue accepts skin grafts. It was also shown that second-degree burns, after 72 hours of pallor or capillary stasis, become pink and can revascularize split-thickness skin grafts, indicating that capillary circulation can be re-established. Capillary stasis was therefore shown to be reversible, even if the physiological mechanism was not understood. This article considers research conducted in this specific field and finds that considerable progress has been achieved. It is clear that the reversal of burn injury is possible. The reversal of dermal vascular occlusion in burned tissue seems to preserve this tissue.

Rockwell W.B., Ehrlich H.P. J. Burn Care Rehabil., 13: 403-6, 1992.

This retrospective study shows that prophylactic antibiotic iontophoresis markedly reduces the occurrence of suppurative auricular chondritis in the patient with ear burns. The results are compared of conventional treatment, used in the St Vincent Burn Unit (Ohio) from 1967 to 1983, and of treatment with antibiotic iontophoresis with penicillin or gentamycin, used from 1983 to 1990. The incidence of infection, the need for chondrectomy, and ear infection were practically eliminated by the use of antibiotic iontophoresis, and no complications were noted. This method of treatment proved to be a safe, simple and effective way of managing burned ears, and consequently reduced post-burn ear deformities.

Rigano W., Kanik M., Barone F.A., Baibak G., Cislo C. J. Burn Care Rehabil., 13: 407-9, 1992.

Purpura fulminans is a rare disease characterized by cutaneous ecchymosis, hypotension, fever and disseminated intravascular coagulation (DIC). It usually follows a viral or bacterial infection, often meningococcal, and it may be related to a protein C or protein S deficiency. The acute phase of purpura fulminans is often accompanied by gastrointestinal bleeding. The mortality rate in the acute phase ranges from 18% to 40%. If the patient survives, the management of the skin necrosis and extremity gangrene is of paramount importance. A case is presented of an adult male suffering from purpura fulminans illustrating the management of the severe full-thickness skin loss and the use of surgical excision and allograft.

Chasan RE, Hansbrough LE, Cooper M.L. J. Burn Care Rehabil., 13: 410-3, 1992.

A survey is made of 79 patients admitted to Grady Memorial Hospital Burn Unit (Atlanta) suffering from automobile engine carburettor- and radiator-related burns. Forty of the patients (37 males) had carburettor-priming flame burns and 39 (36 males) had scald burns caused by uncapping an automobile radiator. The mean ages in the two groups were respectively 31.5 yrs and 29.6 yrs. Clearly this type of accident is highly preventable and it is stressed that preventive education should be directed at those persons most liable to this kind of accident -young males and in particular motor mechanics.

Renz B.M., Sherman R. J. Burn Care Rehabil., 13: 414-21, 1992.

The purposes of this retrospective review were to calculate burn incidence (overall and for various burn types), to assess hospitalization time and the frequency of inhalation injury as a function of burn size, to relate the frequency of inhalation injury and burn size to age, and to study the effect of several variables on outcome. The period considered was February 1987 to July 1990, during which time 844 patients were admitted (73% male, mean age 25.5 yrs, mean burn size 16.5% TBSA, mean survivor hospital length stay 15.9 days, overall survival 90.5%). The three variables of age, burn size and inhalation injury each influenced survival significantly but they appeared to be interdependent: all three tended to increase or decrease together. Logistic regression equations were developed to predict survival.

Renz B.M., Sherman R. J. Burn Care Rehabil., 13: 414-21, 1992.

This preliminary report postulates that extrarenal creatinine clearance by the burn wound may account in part for the increase in the glomerular filtration rate that is observed in patients with burns. The closure of burn wounds in such patients may unmask unrecognized renal failure. A case is presented in which these features are involved. In the light of the clinical observations made, it is suggested that the true nature of renal function in burned patients, which was thought to be well understood, should be re-examined and reconsidered.

Sosa J.L., Ward C.G., Hammond J.S. J. Bum Care Rehabil., 13: 414-21, 1992.

This study shows firstly that tolbutamide, an old drug used to treat diabetes mellitus, decreases hypermetabolism in severely burned rabbits (experiments performed on 18 burned animals immediately after burn injury until day 10) and secondly that a satisfactory reduction in hypennetabolism can be obtained in severely burned patients (observations on 31 bum patients with T13SA burned >40%). This may be the result of the correction of relative insulin insufficiency, tissue insulin resistance and improving glucose utilization.

Xie W., Li A. (N.), Wang S. Bums, 18: 443-7, 1992.

This wide-ranging essay considers all aspects of burn wound healing: pathophysiology and basic principles of burn wound healing (inflammation, granulation, epithelialization, maturation, infection); clinical techniques (initial management, dressings and skin substitutes, topical antimicrobial agents, debridement, bum wound closure); and the outcome of the burn wound (mortality and morbidity). It is stressed that all patients with burns are individuals and that there is no standard way to treat a burn: treatment must be tailored to suit the needs and requirements of both the patient and the burn wound. Bum wound healing is not the specific domain of any one specialist: it requires input from all disciplines and can be best achieved by the burn team approach.

DziewuIski P. Burns, 18: 466-78, 1992.

An analysis was made of the results of microbiological tests performed in a Burn Unit in Milan, Italy, between January 1989 and December 1990. In all, 7950 examinations were considered, related to burn wound swabs and biopsies, blood cultures, central venous and urinary catheters, bronchial aspirates, pharyngeal swabs and faecal cultures. The most frequently isolated bacterium was Staphylococcus aureus, followed by Staphylococcus epidermidis, Pseudomonas aeruginosa and E. coli. The antibiograms showed a low efficacy rate of cephalosporins, even of the latest generation, while with Gram-positive isolates the highest rates of activity were recorded with vancomycin and teicoplanin (100% sensitivity). The situation appears to be better with Gram-negative organisms as they are sensitive to a larger number of antimicrobial agents.

Signorini M., Grappolini S., Magliano E, Donati L. Burns, 18: 466-78, 1992.

Scar contraction of the burned chest, if severe, may lead to breast deformity. This article considers 24 such deformities in female patients treated surgically over a period of 3 years. The types of deformity and the reconstructive techniques employed are described. In the milder deformities (10 cases) reconstruction with skin grafts and local skin flaps proved to be satisfactory. In the more serious deformities, affecting mammary development (14 cases), mammary prostheses were used, either directly or under the soft tissue obtained by skin expansion or musculocutaneous flaps. In 3 patients reduction mammoplasty or mastoplexy was needed to achieve symmetry of the breasts.

Ozgur E, Gokalan L, Mavili E, Erk Y., Kecik A. Burns, 18: 504-9, 1992.