Burns

Regeneration and Repair of Skin Wounds: Various Strategies for Treatment

Skin as a mechanical barrier between the inner and outer environment of our body protects us against infection and electrolyte loss. This organ consists of 3 layers: the epidermis, dermis, and hypodermis. Any disruption in the integrity of skin leads to the formation of wounds, which are divided into 2 main categories: acute wounds and chronic wounds. Generally, acute wounds heal relatively faster. In contrast to acute wounds, closure of chronic wounds is delayed by 3 months after the initial insult. Treatment of chronic wounds has been one of the most challenging issues in the field of regenerative medicine, promoting scientists to develop various therapeutic strategies for a fast, qualified, and most cost-effective treatment modality. Here, we reviewed more recent approaches, including the development of stem cell therapy, tissue-engineered skin substitutes, and skin equivalents, for the healing of complex wounds.

Sodium ascorbate (SA) and l-ascorbic acid (AA) as modifiers of burn affected skin - A comparative analysis

Proper functioning of living organisms requires controlling the factors which govern the level of oxidative stress in the system, that is presence of free radicals at a given, rather low, level and preventing their excess. In this work it is shown that SA and AA active antioxidants, governing the oxidative stress in the wound, modify standard serum solution as well as burn affected necrotic eschar at the molecular structure level. In the case of incubation of skin fragments in SA and AA, the following findings were reported: modification of serum, that is appearance of low molecular weight oligomer bands in AA and recreation of native serum bands in SA. In frozen serum solutions modified by AA FTIR 1759 and 1420-1053 cm^-1 bands are observed, whereas in SA FTIR 1603, 1411-1054 and 536 cm^-1 bands appear. In the case of modification of the burn affected necrotic eschar in SA and AA - frequency shifts in the fingerprint region 1780-1000 cm^-1 can be biomarkers indicating tissue regeneration process under the influence of antioxidants. 1780-1580 cm^-1 and 1418-1250 cm^-1 regions on the Raman spectra are particularly rich in spectral information. Modification of samples of skin burnt with AA activates the regions of the β-sheet aggregates whereas treatment of the samples with SA ascorbate demonstrates changes which testify to reconstruction of α-helix structure (SAXS studies).

Haptoglobin Reduces Inflammatory Cytokine INF-γ and Facilitates Clot Formation in Acute Severe Burn Rat Model

Haptoglobin exerts renal protective function by scavenging free hemoglobin from the urine and blood stream in patients with hemolytic disorders. Recent studies elucidate the relationships between haptoglobin and inflammation. In addition, coagulopathy is often induced by systemic inflammation characterized by the presence of vascular endothelial damage. We hypothesize that haptoglobin might have an anti-inflammatory effect and affect hypercoagulability using rat burn model. Thirty anesthetized rats of six-weeks of age received over 30% full-thickness scald burn on the dorsal skin surface. All rats were injected with either haptoglobin (Hpt) or normal saline (NS) intraperitoneally. The rats were divided into three groups: 1) control group (NS 20 mL/kg); 2) low concentration of Hpt group, L-Hpt, (Hpt 4 mL (80 U) /kg+NS 16 mL/kg); and 3) high concentration of Hpt group, H-Hpt, (Hpt 20 mL (400 U) /kg). While under anesthesia, all rats were euthanized by exsanguination at 6 hours (N=5) and 24 hours (N=5). Inflammatory and anti-inflammatory cytokines were measured and whole-blood viscoelastic tests were performed by thromboelastometry (ROTEM). Haptoglobin significantly reduced free hemoglobin 24 hours after the injury. Improvement of hematuria was confirmed in the H-Hpt group. There were no differences in thrombin-antithrombin complex and plasmin-α2 plasmin inhibitor complex. The haptoglobin tended to decrease interferon-gamma (IFN-γ) in H-Hpt group. ROTEM findings of the L-Hpt group showed significantly higher clot firmness and shorter time to maximum clot formation velocity than the control group. Haptoglobin reduced INF-γ, and accelerated speed of clot formation in acute phase of severe burn.

Correlation Between Legionella Contamination in Water and Surrounding Air

We evaluated Legionella pneumophila contamination of water and surrounding air in a burn care department equipped with bathtubs. In water, the bacterium always aerosolized, but in surrounding air, it diluted itself to such a point that it became undetectable at 1 m or more from the source of emission, which indicated that patients were at low risk of inhaling a dangerous quantity of the microbe.

Pharmacological evaluation and chemical standardization of an ayurvedic formulation for wound healing activity

Wound healing is a topic of substantial prominence in Ayurveda, the Indian traditional system of medicine. Test drug Kshatantak Malam (KM), otherwise named as Baharer Nani, is described in Ayurveda since a long time for wound healing activity but necessitates scientific base. The test drug was prepared in the form of natural ointment with the plants like Achyranthes aspera, Allium cepa, and Canabis sativa under the base of butter in a specialized form of preparation. Chemical standardization was made on the basis of the physical character, rancidity test, extractive value, thin-layer chromatography, and gas chromatography. An 8-mm-diameter full-thickness punch was produced in Wistar rats. The test drug was applied topically and compared with standard comparators like framycetin ointment and povidone iodine ointment. Effects were observed on the basis of physical parameters like wound contraction size (mm(2)), wound index, healing period (days), tensile strength (g) and biochemical parameters like tissue DNA (mg/g), RNA (mg/g), total protein (mg/g), hydroxyproline (mg/g), PAGE study, and histopathological observations. Significant results (P < .05) were observed with KM in the punch wound model on the basis of various physical, biochemical, and histopathological parameters. The drug was found to be safe in acute and chronic toxicity models in animals. Chemically it is enriched with fatty substances.

Isolated inhalational injury: Clinical course and outcomes in a multidisciplinary intensive care unit

Background and Aims:

Although smoke inhalation is well known to cause acute lung injury, there are few reports in literature that study the evolution, clinical course and outcomes of isolated inhalational lung injury in a modern intensive care setting. A major fire disaster provided us the opportunity to study victims of isolated inhalational injury admitted to our Multidisciplinary Intensive Care Unit (MICU).

Materials and Methods:

We studied the clinical course, ICU and hospital outcomes of 13 victims of a fire disaster who required mechanical ventilation for isolated inhalational lung injury. All patients were followed up at regular intervals, and their functional status was assessed at 8 months after hospital discharge.

Results:

The Lung Injury Scores (LIS) worsened to reach a nadir on Day 3 of injury. There was a significant correlation between the LIS on Day 3 and duration of mechanical ventilation (r = 0.8; P = 0.003), ICU (r = 0.8; P = 0.002) and hospital (r = 0.6; P = 0.02) days. Late-onset airway complications were encountered in four patients. Three of them required long-term artificial airways – two with a tracheostomy while the third patient required surgical insertion of a “T” tube. Persistent problems with phonation occurred in two patients. At 8 months postdischarge, all patients were independent with activities of daily living; all were back to work, except for two who continued to need artificial airways.

Conclusions:

Inhalational lung injury progresses over the first few days and is worst after 72 h. Late-onset airway complications may manifest after several weeks and require repeated intervention.

Infection control in severely burned patients

In the last two decades, much progress has been made in the control of burn wound infection and nasocomial infections (NI) in severely burned patients. The continiually changing epidemiology is partially related to greater understanding of and improved techniques for burn patient management as well as effective hospital infection control measures. With the advent of antimicrobial chemotherapeutic agents, infection of the wound site is now not as common as, for example, urinary and blood stream infections. Universal application of early excision of burned tissues has made a substantial improvement in the control of wound-related infections in burns. Additionally, the development of new technologies in wound care have helped to decrease morbidity and mortality in severe burn victims. Many examples can be given of the successful control of wound infection, such as the application of an appropriate antibiotic solution to invasive wound infection sites with simultaneous vacuum-assisted closure, optimal preservation of viable tissues with waterjet debridement systems, edema and exudate controlling dressings impregnated with Ag (Silvercel, Aquacell-Ag). The burned patient is at high risk for NI. Invasive interventions including intravenous and urinary chateterization, and entubation pose a further risk of NIs. The use of newly designed antimicrobial impregnated chateters or silicone devices may help the control of infection in these immunocomprimised patients. Strict infection control practices (physical isolation in a private room, use of gloves and gowns during patient contact) and appropriate empirical antimicrobial therapy guided by laboratory surveillance culture as well as routine microbial burn wound culture are essential to help reduce the incidance of infections due to antibiotic resistant microorganisms.

Biologic and synthetic skin substitutes: An overview

The current trend of burn wound care has shifted to more holistic approach of improvement in the long-term form and function of the healed burn wounds and quality of life. This has demanded the emergence of various skin substitutes in the management of acute burn injury as well as post burn reconstructions. Skin substitutes have important roles in the treatment of deep dermal and full thickness wounds of various aetiologies. At present, there is no ideal substitute in the market. Skin substitutes can be divided into two main classes, namely, biological and synthetic substitutes. The biological skin substitutes have a more intact extracellular matrix structure, while the synthetic skin substitutes can be synthesised on demand and can be modulated for specific purposes. Each class has its advantages and disadvantages. The biological skin substitutes may allow the construction of a more natural new dermis and allow excellent re-epithelialisation characteristics due to the presence of a basement membrane. Synthetic skin substitutes demonstrate the advantages of increase control over scaffold composition. The ultimate goal is to achieve an ideal skin substitute that provides an effective and scar-free wound healing.

Enhancement of neutrophil function by interleukin-18 therapy protects burn-injured mice from methicillin-resistant Staphylococcus aureus

Methicillin-resistant Staphylococcus aureus (MRSA) infection is a grave concern in burn-injured patients. We investigated the efficacy of interleukin-18 (IL-18) treatment in postburn MRSA infection. Alternate-day injections of IL-18 into burn-injured C57BL/6 mice significantly increased their survival after MRSA infection and after methicillin-sensitive S. aureus infection. Although IL-18 treatment of burn-injured mice augmented natural IgM production before MRSA infection and gamma interferon (IFN-γ) production after MRSA infection, neither IgM nor IFN-γ significantly contributed to the improvement in mouse survival. IL-18 treatment increased/restored the serum tumor necrosis factor (TNF), IL-17, IL-23, granulocyte colony-stimulating factor (G-CSF), and macrophage inflammatory protein (MIP-2) levels, as well as the neutrophil count, after MRSA infection of burn-injured mice; it also improved impaired neutrophil functions, phagocytic activity, production of reactive oxygen species, and MRSA-killing activity. However, IL-18 treatment was ineffective against MRSA infection in both burn- and sham-injured neutropenic mice. Enhancement of neutrophil functions by IL-18 was also observed in vitro. Furthermore, when neutrophils from IL-18-treated burn-injured mice were adoptively transferred into nontreated burn-injured mice 2 days after MRSA challenge, survival of the recipient mice increased. NOD-SCID mice that have functionally intact neutrophils and macrophages (but not T, B, or NK cells) were substantially resistant to MRSA infection. IL-18 treatment increased the survival of NOD-SCID mice after burn injury and MRSA infection. An adoptive transfer of neutrophils using NOD-SCID mice also showed a beneficial effect of IL-18-activated neutrophils, similar to that seen in C57BL/6 mice. Thus, although neutrophil functions were impaired in burn-injured mice, IL-18 therapy markedly activated neutrophil functions, thereby increasing survival from postburn MRSA infection.

Predictors of mortality: A comparison between two burn wound treatment policies

Retrospective review of outcomes and experiences of a single burn centre between two time periods during which a new wound care technique was employed after the first period. The time period was divided into two: 1977-1984 and 1984-1990. Due to the use of cerium nitrate-silver sulphadiazine, the introduction of serial excision and grafting became possible in the second time period. Multivariate risk-analysis was done by logistic regression analysis. The mortality rate decreased from 13.7% (1997-1983) to 4.7% (1984-1990). Results of multiple logistic regression analysis indicate that the change in periods was advantageous for patients with >50% TBSA, within the age group, 0 to 30 years. Obviously, the care which a patient receives has improved significantly. Many developments occurred simultaneously and it appears impossible to conclude that only the use of cerium nitrate-silver sulphadiazine was the reason for improved survival. Nevertheless, the use of cerium nitrate-silver sulphadiazine enables sequential excision and grafting and in consequence allows for many of these developments to occur.

Blockade of the renin-angiotensin system improves insulin sensitivity in thermal injury

Insulin resistance after burn is associated with alterations in postreceptor insulin signaling and abnormal glucose homeostasis. The renin-angiotensin system (RAS) exerts a largely inhibitory role on insulin action and is activated after burn injury. We hypothesized that upregulation of RAS is involved in the development of insulin resistance in burned rats. We examined the possibility that an angiotensin II type 1 (AT1) receptor blocker, losartan, enhances insulin sensitivity and thereby increases glucose tolerance in thermally injured rats. A 30% body surface area burn was induced by immersion of the dorsum into water with a temperature level of 95 degrees C for 15 s. Sham-burned rats were immersed in water with a temperature level of 23 degrees C. Losartan (30 mg/kg per day) or placebo (water) was given by gavage immediately after the burn injury and daily for 3 days postburn injury, resulting in sham-burned, burn placebo, and burn losartan groups. Plasma angiotensin II levels between burn placebo and sham-burned groups were not different 3 days after burn injury. However, losartan significantly increased plasma angiotensin II levels (P < 0.05), suggesting blockade of the AT1 receptor. An oral glucose tolerance test was performed 3 days postburn injury. There was an increase in the area under the curve for insulin and the glucose insulin index in burn placebo group as compared with sham-burned group, indicating insulin resistance. Losartan treatment abolished the insulin resistance in burn as evidenced by an area under the curve for insulin and glucose insulin index lower than that in the burn placebo group and similar to that in the sham-burned group. This suggests that insulin resistance and glucose intolerance associated with burn injury is, in part, caused by RAS.

Whey feeding suppresses the measurement of oxidative stress in experimental burn injury

PURPOSE

Burns cause thermal injury to local tissue and trigger systemic acute inflammatory processes, which may lead to multiple distant organ dysfunction. We investigated the protective effect of dietary whey supplementation on distant organs in a rat model.

METHODS

Forty-eight rats were divided into six groups of eight: groups 1 and 2 were the controls, fed a standard diet and a whey-supplemented diet, respectively; groups 3 and 4 were fed a standard diet and subjected to burn injury; and groups 5 and 6 were fed a whey-supplemented diet and subjected to burn injury. We measured the oxidative stress variables, as well as glutathione in the liver and kidney, and histologically examined skin samples obtained 4 h (groups 3 and 5) and 72 h (groups 4 and 6) after burn injury.

RESULTS

Glutathione (GSH) levels remained the same in the liver but were slightly elevated in the kidneys after burn injury in the rats fed a standard diet. Whey supplementation caused a significant increase in hepatic GSH levels 4 h after burn injury. Moreover, there was a significant rebound effect in the liver and kidney GSH levels after 72 h and whey supplementation potentiated this effect. Hepatic and renal lipid peroxide levels were also increased 4 h after burn injury in the rats fed a standard diet. Whey supplementation significantly suppressed the burn-induced increase in hepatic and renal lipid peroxide levels. Histological examination revealed that although whey supplementation resulted in decreased subepidermal inflammation, the indicators of wound healing and collagen deposition were not improved.

CONCLUSION

Whey pretreatment suppressed hepatic and renal oxidative stress measurements after experimental burn injury.

Levofloxacin pharmacokinetics and pharmacodynamics in patients with severe burn injury

Levofloxacin pharmacokinetics were studied in 11 patients with severe burn injuries. Patients (values are means +/- standard deviations; age, 41 +/- 17 years; weight, 81 +/- 12 kg; creatinine clearance, 114 +/- 40 ml/min) received intravenous levofloxacin at 750 mg (n = 10 patients) or 500 mg (n = one patient) once daily. Blood samples were collected on day 1 of levofloxacin therapy; eight patients were studied again on days 4 to 6. The pharmacodynamic probability of target attainment (PTA) was evaluated by Monte Carlo simulation. Mean systemic clearance, half-life, and area under the concentration-time curve over 24 h after levofloxacin at 750 mg were 9.0 +/- 3.2 liters/h, 7.8 +/- 1.6 h, and 93 +/- 31 mg . h/liter, respectively. There were no differences in pharmacokinetic parameters between day 1 and day 4; however, large intrapatient and interpatient variability was observed. Levofloxacin pharmacokinetics in burned patients were similar to those reported in other critically ill populations. Levofloxacin at 750 mg achieved >90% PTA for gram-negative and gram-positive pathogens with MICs of < or =0.5 microg/ml and MICs of < or =1 microg/ml, respectively. However, satisfactory PTA was not obtained with less-susceptible gram-negative organisms with MICs of 1 microg/ml or any organism with a MIC of > or =2 microg/ml. The results of this study indicate that levofloxacin should be administered at 750 mg/day for treatment of systemic infections in severely burned patients. However, even 750 mg/day may be inadequate for gram-negative organisms with MICs of 1 to 2 microg/ml even though they are defined as susceptible. Alternative antibiotics or treatment strategies should be considered for infections due to these pathogens.

Cerium nitrate in the management of burns

BACKGROUND

The introduction of early excision of the burn eschar has contributed to a reduction in burn-related mortality but is not appropriate in all circumstances. Cerium nitrate has been used since 1976, usually in combination with silver sulphadiazine, to improve outcome where early excision is not performed. However, has still not gained universal acceptance. The evidence for its use is reviewed.

METHODS

A MEDLINE search was performed for the years 1966-2003 using keywords 'cerium', 'sulphadiazine', 'Flammacerium', 'lanthanides' and 'topical therapy for burns'. The reference lists of key articles were then sifted for other relevant articles.

RESULTS

Cerium has been shown to reduce mortality and morbidity in the treatment of severe burns. This benefit is derived from its action on the burn eschar. It binds and denatures the lipid protein complex liberated from burnt skin that is responsible for the profound immunosuppression associated with major cutaneous burns. It has only limited antimicrobial properties.

CONCLUSIONS

Cerium nitrate is an excellent topical treatment for most cutaneous burns not undergoing immediate excision and closure.

A general overview of burn care

The majority of burn victims do not need to be treated in a burn centre. Adequate care can be given by non specialised medical personnel, provided that proper guidelines are followed. The article outlines and reviews these guidelines.

Stevens-Johnson syndrome and toxic epidermal necrolysis: a review of the literature

OBJECTIVE

To perform a comprehensive review of Stevens-Johnson syndrome and toxic epidermal necrolysis.

DATA SOURCES

A MEDLINE search was performed for the years 1975 to 2003 using the keywords Stevens-Johnson syndrome and toxic epidermal necrolysis to identify relevant articles published in English in peer-reviewed journals.

STUDY SELECTION

All clinical studies that reported on 4 or more patients, review articles, and experimental studies that concerned disease mechanisms were selected and further analyzed. Clinical reports that included fewer than 4 patients were selected only if they were believed to carry a significant message about disease mechanism or therapy.

RESULTS

Stevens-Johnson syndrome and toxic epidermal necrolysis seem to be variants of the same disease with differing severities. A widely accepted consensus regarding diagnostic criteria and therapy does not exist at present. Despite the recent experimental studies, the pathogenic mechanisms of these diseases remain unknown. Although progress in survival through early hospitalization in specialized burn units has been made, the prevalence of life-long disability from the ocular morbidity of Stevens-Johnson syndrome and toxic epidermal necrolysis has remained unchanged for the past 35 years. Further progress depends on modification of the acute phase of the disease rather than continuation of supportive care. The available published evidence indicates that a principal problem in the pathogenesis is immunologic and that immunomodulatory intervention with short-term, high-dose intravenous steroids or intravenous immunoglobulin holds the most promise for effective change in survival and long-term morbidity.

CONCLUSIONS

The results of this review call for a widely accepted consensus on diagnostic criteria for Stevens-Johnson and toxic epidermal necrolysis and multicenter collaboration in experimental studies and clinical trials that investigate disease mechanisms and novel therapeutic interventions, respectively.

Wound healing potential of Pterocarpus santalinus linn: a pharmacological evaluation

The need for new therapeutics for wound healing has encouraged the drive to examine the nature and value of plant products. Ayurveda, the Indian traditional system of medicine, mentions the values of medicinal plants for wound healing. One of these is Pterocarpus santalinus. This article describes a pharmacological study to evaluate its toxicity as well as wound-healing potential in animal studies. Powder made from the wood of the P. santalinus tree was used to make up an ointment in a petroleum jelly base. No toxic effects were observed in 72 hours. Studies were done on punch and burn wound models on normal and diabetic rats using the test ointment, untreated and vehicle controls, and standard therapy. Physical and biochemical measurements were made. The test ointment-treated wounds healed significantly faster. On healing, collagenesis and biochemical measurements yielded supportive data. These studies permit the conclusion that the P. santalinus ointment is safe and effective in treating acute wounds in animal models.

The use of Flammacerium in British Burns Units

INTRODUCTION

Flammacerium (cerium nitrate-silver sulphadiazine) is marketed throughout Europe, but is only available in UK on a named patient basis. Anecdotally it is widely used in civilian burns units across the country despite the regulatory constraint, although little literature exists regarding its use in UK. We designed a postal survey to assess the use of Flammacerium countrywide and whether its 'named patient only' designation causes problems in treating burns patients.

METHODS

Postal questionnaires were sent to the directors of the 18 adult burns units listed by the British Burns Association, requesting information on the use of Flammacerium. The indications and limitations of its use were recorded, as were any problems obtaining supplies. Finally, burns units were asked if they would like to see Flammacerium fully licensed in this country.

RESULTS

Replies were received from 14 units (response rate=78%). Six units use Flammacerium frequently, six occasionally and two units never use it. It is used in those patients not undergoing early wound excision and closure because of co-morbidity, general age or frailty, paucity of donor sites or mixed depth pattern burns. It was generally used in the belief that it reduces the inflammatory response to burn injury (8/12), decreases bacterial colonization (10/12) and provides a firm eschar for easier wound management (11/12). Although 8 units had no problems with supplies of the agent, 10 respondents indicated they would like to see Flammacerium fully licensed in UK.

Intravenous Immunoglobulin for Treatment of Toxic Epidermal Necrolysis

We report three female patients suffering from toxic epidermal necrolysis, with 30% to 70% epidermal detachment. Alleged causative agents were dipyrone, dibenzazepine, and allopurinol. All patients were treated by intravenous immunoglobulins (IVIG) and survived without further complications, although poor prognostic factors such as concomitant diabetes, large areas of epidermal detachment, and pancytopenia were present. We report these cases with emphasis on the concept that prompt diagnosis, withdrawal of causative drugs, and immediate treatment are imperative for the favorable outcome of the disease. Our patients can be added to the list of those patients who were successfully treated by IVIG, as indicated in this review of the literature.

State of the Art in Burn Treatment

Optimal treatment of burn victims requires deep understanding of the profound pathophysiological changes occurring locally and systemically after injury. Accurate estimation of burn size and depth, as well as early resuscitation, is essential. Good burn care includes also cleansing, debridement, and prevention of sepsis. Wound healing, is of major importance to the survival and clinical outcome of burn patients. An ideal therapy would not only promote rapid healing but would also act as an antiscarring therapy. The present article is a literature review of the most up-to-date modalities applied to burn treatment without overlooking the numerous controversies that still persist.

Immune response in burn patients in relation to HIV infection and sepsis

The post-burn immune dysfunction predisposes patients to sepsis and multiple organ failure leading to increased mortality. HIV infection also results in a depressed immune response. The combination of burn injury and HIV might therefore lead to an increased morbidity and mortality as compared to non-HIV infected burn patients. Twenty burn patients and 10 healthy volunteers were included in a prospective study. To evaluate their immune status, CD4+ and CD8+ T-lymphocyte counts were determined in peripheral blood. HIV serology samples were obtained on admission. Bacteriological cultures were obtained from wound surface samples and wound tissue biopsies. Six burn patients were HIV infected. Clinical signs of sepsis were observed in 10 patients. The number of CD4+ T-lymphocytes were lower in burn patients compared to healthy volunteers (P < 0.05). HIV infected burn patients had lower CD4+ lymphocyte counts than non-HIV infected patients (P < 0.05). Patients with clinical signs of sepsis had lower CD4+ counts compared to patients without sepsis (P < 0.05). There was no difference in the mortality rate or the length of hospitalisation between patient groups. Burn injury, HIV infection and sepsis independently result in immunosuppression.

Albumin as a marker of plasma transudation in experimental skin lesions

Liquid chromatography measurements of albumin levels were obtained for experimental incision wounds, excoriations, and heat and freezing injuries of different ages. Hemoglobin levels in tissue specimens were measured and an equivalent amount of blood-related albumin was subtracted from the analysis results. In specimens taken immediately after death, the mean albumin level as compared to control skin was increased by about 2-fold in freezing injuries aged 60 min. In all other lesions, the same increase was observed even after 30 min. The mean albumin level was about 3-fold as compared with the control skin in excoriations aged 30 min, heat and freezing injuries aged 4 h, and incision wounds aged 12 h. An approximately 5-fold increase was seen in heat and freezing injuries aged 1 and 2 weeks. A marked decrease occurred in mean albumin levels in all lesions aged 4 weeks. An increase in albumin in wounds and excoriations was demonstrable also in specimens taken 3 days postmortem. Postmortem hypostasis resulted in a 1.1 to 1.4-fold increase in mean albumin levels in wounds and excoriations inflicted 1 min postmortem.

Alcohol, injury, and cellular immunity

It is widely accepted that alcohol exposure is a causative factor in the occurrence of burn or other traumatic injury. It is less well known that individuals who have consumed alcohol before sustaining an injury suffer from increased morbidity and mortality compared with the morbidity and mortality of non-alcohol-consuming subjects with similar injuries. Complications due to bacterial infection are the most common burn sequelae in injured patients and are frequently associated with depressed immunity. Independently, alcohol exposure and injury have been shown to influence cellular immunity negatively. These changes in immunity are closely linked to injury- or alcohol-induced alterations in the cytokine milieu in both clinical studies and animal models. Not surprisingly, the combination of insult of alcohol exposure and burn injury results in immune suppression that is greater in magnitude and duration compared with either insult alone. The combined effects of alcohol and injury on immunity have been examined in a limited number of studies. However, results of these studies support the suggestion that altered cytokine production is an integral part of the immune dysregulation and increased mortality that is observed. In particular, the increased presence of macrophage-derived mediators observed after burn or alcohol exposure alone seems to be synergistically increased in a combined injury model. Although more research is needed, it is likely that therapeutic modalities that include manipulation of cytokine networks to boost cellular immunity may improve outcome for patients who sustain injuries subsequent to consuming alcohol.

Epidemiological data of patients hospitalized with burns and other traumas in some cities in the southeast of Brazil from 1991 to 1997

This retrospective analysis of burn patients and victims of other forms of trauma from Ribeirão Preto and nearby cities admitted to hospitals in the city of Ribeirão Preto, São Paulo, Brazil, was carried out to determine the frequency of injuries of all types in order to identify the extent of the problem of burns relative to other forms of trauma. Data concerning 921 patients with burns and 60,344 patients with other traumatic injuries hospitalized during the period from 1991 to 1997 are described. Burns corresponded to 1.5% of the total number of traumatic injuries. When data are reported as absolute numbers or as incidence rate of hospitalized burn patients, burns were two times more frequent among men in most age groups. The case fatality ratio due to burns was 8.4% (77 deaths among 921 patients), with a rate of 6.4% for men and 12.2% for women. The case fatality ratio was higher among women than men regardless of the city of residence. The case fatality ratio was 3.2 and 4.4 times greater for men and women burn victims from other towns than for burn victims from Ribeirão Preto, indicating the need for additional equipment and training of medical and paramedical personnel in the initial measures to be taken with burn patients.

Management of cutaneous drug reactions

Drugs are potent chemicals that often have effects in the body beyond the desired action. These effects may range from mild and expected side effects to dramatic and life-threatening anaphylaxis. Adverse drug reactions account for between 2% and 6% of hospital admissions and may prevent administration of otherwise effective therapeutic agents. Cutaneous and mucocutaneous eruptions are the most common adverse reactions to oral or parenteral drug therapy, and the spectrum ranges from transitory exanthematous rash to the potentially fatal toxic epidermal necrolysis. Different mechanisms, including both immunologic and nonimmunologic, are responsible for cutaneous adverse drug reaction. The treatment of cutaneous drug eruptions essentially rests on accurate history, a thorough physical examination, discontinuation of the offending drug, and supportive care. The management of a cutaneous drug eruption is very much individualized, based on the clinical setting. This review aims to provide a general approach to the patient with a presumed cutaneous drug reaction.

Elevation of plasma free PAI-1 levels as an integrated endothelial response to severe burns

To clarify the role of plasminogen activator inhibitor type 1 (PAI-1) in postburn hypercoagulation, we assayed the plasma levels of tissue-type plasminogen activator (t-PA) antigen, total PAI-1 antigen, and total t-PA-PAI-1 complex in 15 burned patients. The total body surface area of the burn injury ranged from 30 to 80%. Serial blood samples were collected from 12 to 168 h following the thermal injury. The plasma t-PA level and the free PAI-1 level increased significantly in the immediate postburn period, and the percent increase in the latter over the values in the healthy controls was much greater than that of the former. The ratio of the concentrations of t-PA-PAI-1 complex to free PAI-1 decreased throughout the 7 postburn days. The fact that the decreases in this ratio clearly showed no dissociation of the euglobulin fraction suggests that the postburn hypofibrinolysis occurred as a result of increased synthesis of PAI-1. On the other hand, changes in several parameters of the coagulation or fibrinolysis system and in plasma thrombomodulin showed that postburn hypercoagulability is associated with secondary hyperfibrinolysis with no evidence of vascular endothelial injury. The paradoxical coexistence of postburn hyper- and hypofibrinolysis is a good reflection of the character of PAI-1, which is a biphasic protein that is both a functional protein and an acute phase reactant. Thus, increased synthesis of PAI-1 may not enhance postburn hypercoagulability to create a coagulation-dominant type of disseminated intravascular coagulation severe enough to trigger multiple organ dysfunction syndrome. In conclusion, increased synthesis of PAI-1 in the initial postburn period reflects an integrated endothelial response to burn stress, and because it is a functional protein, the concentration of free PAI-1 antigen may be an important index for predicting secondary consumption coagulopathy.

Decreasing incidence of burn injury in a rural state

OBJECTIVES

To determine changes in the incidence of burn injury since the regionalization of burn care and intensification of fire prevention initiatives that occurred in Maine during the 1970s.

METHODS

Death certificate data from Maine and the United States for deaths due to fire or burns were obtained for 1960-98. Hospitalization and burn registry data were obtained for Maine from 1973-98. Frequencies and incidence rates were compared over time and, where possible, between Maine and the United States.

RESULTS

During 1960-79, annual burn mortality in Maine averaged 5.1/100,000, with random variation. After this, the rate declined steadily to an average annual level of 1.4/100,000 during 1993-96. For the entire United States, average annual mortality declined from 4.2/100,000 during 1961-64 to 1.5/100,000 during 1993-96. Reduction in mortality has been principally due to prevention of dwelling fires. Hospitalization for burns in Maine was 34.8/100,000 during 1973-76 and declined to 10.6/100,000 during 1995-98.

CONCLUSIONS

Burn prevention measures have dramatically reduced the incidence of death and hospitalization resulting from burns in Maine.

Decreased serum insulin-like growth factor-I in burn patients: relationship with serum insulin-like growth factor binding protein-3 proteolysis and the influence of lipid composition in nutritional support

OBJECTIVES

To test the effects of the amount and type of fat in the nutritional support on serum insulin-like growth factor (IGF)-I concentrations in burn patients and to test the hypothesis that the serum proteolytic activity for insulin-like growth factor binding protein (IGFBP)-3 is a major mechanism for the decreased serum IGF-I observed in these patients.

DESIGN

Randomized, double-blind trial of three different nutritional supports and analysis of serum IGF-I, IGFBP-3, and serum IGFBP-3 proteolysis.

SETTING

Burn center in a university hospital.

PATIENTS

A total of 23 severely burned (>25% total body surface area burned) adult patients.

INTERVENTIONS

Patients were randomly assigned to three types of nutritional support differing in the amount of energy derived from fat and the presence or absence of fish oil: Group I (control), 35% fat; Group II, 15% fat; Group III, 15% fat with 50% as fish oil. Nutritional support was both parenteral and enteral and was started within 24 hrs of admission.

MEASUREMENTS AND MAIN RESULTS

Serum IGF-I and IGFBP-3 were measured by radioimmunoassay every 3 days for 28 days in 23 severely burned adults. In six patients, IGFBP-3 was measured by ligand binding assay and the serum proteolytic activity for rhIGFBP-3 was measured as well. Serum IGF-I concentration was low in all subjects throughout the study period, but did increase with time (p < .01); significantly higher values were found in Group III (p < .05). Multivariate analysis showed that fish oil and low fat solutions were significantly correlated to serum IGF-I concentrations. Serum IGFBP-3 (radioimmunoassay) was higher than normal throughout the study with no difference between the groups. Between days 4 and 16, IGFBP-3 was cleaved into two fragments in all patients studied, and the molecular weights of the fragments were equal to those observed in the serum of a woman late in pregnancy. During this period of time, serum proteolytic activity for rhIGFBP-3 was >30% in 24 of the 30 samples measured, whereas 20 of the 28 samples measured thereafter were normal (<25%). Serum IGFBP-3 concentration from ligand binding assay was correlated with serum proteolytic capacity in all subjects (mean r2 = 0.77; p < .01) and with serum IGF-I concentrations in five of six subjects (mean r2 = 0.81; p < .01).

CONCLUSIONS

In burn injury, serum IGF-I concentrations are sensitive to the amount and type of fat in their nutritional support. The presence of fish oil allowed for a more rapid recovery of serum IGF-I levels. The proteolysis of IGFBP-3 may be an important cause of the decreased serum IGF-I values and the protease(s) responsible for this seem to be similar to those observed in late pregnancy.

Fire- and flame-related occupational fatalities in the United States, 1980-1994

The National Traumatic Occupational Fatalities surveillance system recorded 1518 fire- and flame-related occupational fatalities among the civilian workforce in the United States between 1980 and 1994. The fatalities resulted from 1221 separate incidents, of which 122 involved more than one victim and accounted for 419 of 1518 deaths. Nearly 4 of 10 fatalities resulting from a multiple-victim fire were workers in the manufacturing industry. Similarly, the highest frequency of fatalities in single-victim events, over one fourth, were in manufacturing. For one fourth of the fatalities within each event category, the usual occupation of the deceased was a precision production, craft, and repair worker. Although this study sheds light on selected characteristics of these fatalities, additional research on the causal factors associated with single- and multiple-victim events is needed to present specific recommendations for prevention efforts.

Cutaneous laser resurfacing

Cutaneous resurfacing with the new generation of carbon dioxide and erbium lasers has recently come into favor for the treatment of facial rhytides, photodamage, and scarring. The precise control of these resurfacing lasers over the extent of tissue vaporization minimizes thermal damage to the skin while maximizing therapeutic efficacy. Proper use of resurfacing lasers is contingent upon a complete understanding of their clinical, histologic, and ultrastructural effects, as well as an appreciation of the principles of laser safety. An organized approach to the preoperative, intraoperative, and postoperative management of the patient undergoing laser resurfacing will be provided, including a discussion of prevention and treatment of postoperative side effects and complications. (J Am Acad Dermatol 1999;41:365-89.)

LEARNING OBJECTIVE

At the conclusion of this learning activity, participants should be familiar with the clinical, histologic, and ultrastructural effects of resurfacing lasers and be able to discuss the preoperative, intraoperative, and postoperative management of patients undergoing laser resurfacing.

Mediators of microvascular injury in dermal burn wounds

In previous studies we have demonstrated that second-degree thermal injury of skin in rats leads to secondary effects, such as systemic complement activation, C5a-mediated activation of blood neutrophils, their adhesion-molecule-guided accumulation in lung capillaries and the development of acute pulmonary injury, largely caused by neutrophil-derived toxic oxygen metabolites. In the dermal burn wound, however, pathophysiologic events are less well understood. The injury is fully developed at four hours post-burn. To further elucidate the pathogenesis of the "late phase" dermal vascular damage, rats were depleted of neutrophils or complement by pretreatment with rabbit antibody against rat neutrophils or with cobra venom factor, respectively. In other experiments, rats were treated with blocking antibodies to IL-6, IL-1, and TNF alpha immediately following thermal burning or were pretreated with hydroxyl radical scavengers (dimethyl sulfoxide, dimethyl thiourea). Extravasation of 125I-labeled bovine serum albumin into the burned skin was studied, as well as, skin myeloperoxidase levels. The studies revealed that, like in secondary lung injury, neutrophils and toxic oxygen metabolites, are required for full development of microvascular injury. In contrast, however, development of dermal vascular damage in thermally injured rats was not affected by complement depletion. Our data suggest that the development of microvascular injury in the dermal burn wound is complement-independent, involves the pro-inflammatory cytokines IL-1, TNF alpha and IL-6, and may result from reactive oxygen metabolites generated by neutrophils accumulating in the burn wound.

Mechanisms of neutropenia involving myeloid maturation arrest in burn sepsis

OBJECTIVE

To determine the mechanisms that lead to the decrease in bone marrow production of neutrophils during burn sepsis.

SUMMARY BACKGROUND DATA

Impaired bone marrow granulopoiesis during burn sepsis often results in neutropenia despite elevated circulating levels of granulocyte colony-stimulating factor (G-CSF). To date, neither the specific stages of neutrophil maturation involved in the bone marrow suppression nor the mechanisms for the impairment have been determined.

METHODS

Peripheral blood absolute neutrophil count and G-CSF levels were determined in mice 3 days after randomization to control, burn alone, or burn plus a topical inoculation of Pseudomonas aeruginosa (1000 colony-forming units). Bone marrow aspirates were analyzed for their neutrophil differentiation patterns by Gr-1 antigen expression and their G-CSF receptor status. Histologic analysis of liver, lung, spleen, and wound site was performed.

RESULTS

In burn sepsis, absolute neutrophil count was reduced whereas plasma G-CSF levels were elevated, and myeloid differentiation was significantly shifted toward the immature mitotic myeloid cells. Bone marrow G-CSF receptor mRNA levels and G-CSF-stimulated proliferation were substantially decreased in burn sepsis. Histologic analysis revealed no significant neutrophil infiltration into the tissues.

CONCLUSIONS

In thermal injury with superimposed sepsis, neutropenia and myeloid maturation arrest, despite the elevated levels of G-CSF, correlate with the reduction in bone marrow G-CSF receptor expression. These observations may provide a potential mechanism for neutropenia in sepsis.

Increased burn patient survival with once-a-day high dose teicoplanin and netilmicin. An Italian multicenter study

This is the final report of a large, controlled, multicenter Italian study on immuno- and chemotherapy in adult patients with burns affecting 20 to 95% of total body surface area (mean 35%). The antibiotic treatment of burn patients consisted of topical silver sulfadiazine, short-term antimicrobial chemoprophylaxis with pefloxacin (800 mg i.v. qd) for the first 4 days and polychemotherapy with teicoplanin (800 mg i.v. qd) together with netilmicin (300 mg i.m. qd) in one or more cycles of 5-12 days. At random, half of the patients received thymostimulin, 70 mg i.m. qd for the first month and every other day thereafter. The analysis at completion of 634 valid cases showed that when the results are stratified by means of the Roi risk index, 396 of the 530 patients who contracted wound infection (84%) after chemoprophylaxis were in the first three categories and a mean of 95% survived. Of the remaining 134 patients (Roi index 4-5) only 50% survived. There was no difference in survival of the immunotherapy group in comparison with the parallel group without thymostimulin. The short-term antimicrobial prophylaxis prevented wound infection in only 104 of 634 patients (16%) and they were at low risk (84% Roi index 1). Of the bacterial pathogens involved in septic complications Staphylococcus aureus and Pseudomonas aeruginosa were prevalent (86%): eradication was achieved in 43% of patients and clinical cure or improvement were seen with combination chemotherapy in 64% of all patients, mainly with only one treatment cycle. This value increased to 79% for the 395 protocol-complying patients and went down to 20% in the 135 non-compliers. The total survival of complier and non-complier patients was 447 of the 530 valid patients (84%). The overall mortality of the 634 evaluable patients was 13.1%, ranging from less than 2% to 68%. Burn mortality was directly proportional to the percentage of burned body surface area, to increasing age and other variables of the Roi index, a 50% mortality being associated with a 72.5% total body surface area burned. Normoergic burn patients had a mortality rate of 9.1% versus 35.7% in anergic patients.

Signaling mechanisms of elevated neutrophil O2- generation after burn injury

A full skin thickness burn injury was produced in anesthetized rats by exposing 25% of total body surface area to 98 degrees C water for 10 s. Sham (exposed to 37 degrees C water) and burn rats were killed 1, 3, 7, or 10 days later. The role of Ca2+ signaling and Ca(2+)-related protein kinase C (PKC) activation in neutrophil O2- generation was ascertained by evaluating the effect of treatment of the rats with the Ca2+ entry blocker, diltiazem. There was an overt enhancement of O2- generation by polymorphonuclear leukocytes from burn rats on days 1, 3, and 7 postburn, with the peak release occurring on day 3 postburn. O2- generation comparable to the sham was noted on day 10 after the burn. O2- releases on days 1, 3, and 7 postburn were accompanied by marked elevation of Cai2+ and PKC responses. Like the O2- release, intracellular Ca2+ concentration ([Ca2+]i) response on day 10 after burn was suppressed to levels found in the sham group. The treatment of burn rats with diltiazem prevented the upregulation of both [Ca2+]i and PKC responses as well as O2- generation in neutrophils in rats on days 1, 3, and 7 after the burn. Because previous studies have shown that increases in [Ca2+]i precede O2- generation and degranulation, our results suggest that neutrophil O2- release enhancement in the early stages after burn injury (e.g., days 1-7 postburn) results from an overactivation of the Cai2+ and PKC signaling pathways. The heightened O2- generation during the early burn injury phase might play a role in tissue damage in one or more of host organs.

Care before and after laser skin resurfacing. A survey and review of the literature

BACKGROUND

The extent of the wound healing period and the final outcome of cutaneous laser resurfacing are influenced not only by the treatment protocol and type of laser used but also on care of the skin before and after the procedure.

OBJECTIVE

This project was conducted to determine the pre- and postresurfacing care protocols currently in practice and to research the literature in an effort to clarify which interventions can accelerate wound healing and improve efficacy of the treatment.

METHODS

Three hundred thirty-nine questionnaires were mailed to all dermatology and plastic surgery members of the American Society for Laser Medicine and Surgery (ASLMS). Questionnaires were completed anonymously to decrease respondent bias. Statistical analysis included calculation of percentages and means of the data.

RESULTS

Survey results are discussed and compared with data from the literature for the following interventions: tretinoin cream, glycolic acid cream, hydroquinone, oral prophylactic antibiotics, oral prophylactic antivirals, hydrogel dressings, semiocclusive ointments, topical antibiotics, topical corticosteroids, oral corticosteroids, and dilute acetic acid soaks.

CONCLUSIONS

Many options are appropriate, based on data from past studies, for pre- and postresurfacing skin care. Approximately 73% of the results of the survey correlate with information from the literature. Past studies do provide information to help us select interventions that can improve wound healing and the final cosmetic outcome. Further studies involving resurfacing patients may clarify some of the more complex wound care issues, such as oral prophylactic antibiotics, hydroquinone, and topical vitamins C and E.