Surgical release of the chest wall skin and fascia for sclerodermatous graft versus host disease causing restrictive lung disease: A case report

INTRODUCTION

Graft versus host disease (GVHD) remains a significant source of morbidity and mortality in the setting of allogeneic stem cell transplantation. Skin involvement is reported to be as high as 70-95 % in this group with GVHD and the severity of the involvement varies widely. Surgical management of complications of severe cutaneous GVHD is uncommon and is rarely mentioned as a treatment option.

CASE PRESENTATION

We present a case of severe sclerodermatous skin changes restricting chest expansion and exercise tolerance to the point of limiting basic activities of daily life. A 54-year-old male presents with severe restrictive lung disease from sclerodermatous graft versus host disease (GVHD) after stem cell transplant for Chronic Myeloid Leukaemia (CML). He experienced limited symptomatic relief from maximal medical therapy and photochemotherapy, and subsequently underwent a skin release and split skin grafting of his chest and abdomen in an effort to improve exercise tolerance and quality of life.

CLINICAL DISCUSSION

Despite an initial improvement in functioning, the patient's spirometry and lung function continued to decline with time, possibly suggesting that he did not gain a sustained benefit from surgical release of his cutaneous GVHD.

CONCLUSION

While delineating between disease progression and surgical outcome is difficult in this case, the patient would argue that by delaying or reducing further decline in function, the surgical release procedures led to improved quality of life in subsequent years. However further research is required to establish a clear role for surgery in the treatment of refractory cutaneous GVHD.

The seven-fold rise in incidence of Stevens-Johnson syndrome & toxic epidermal necrolysis: Associations with COVID-19 and the vaccine

Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN) is a rare, potentially life threatening mucocutaneous hypersensitivity reaction resulting in desquamation of the skin and mucosa. These patients are managed on burns units due to the widespread desquamation. We report the largest case series of participants developing SJS/TEN in the setting of recent COVID infection or vaccination. We found a seven-fold increase in SJS/TEN since the COVID pandemic. This increase correlates with an increase in COVID infections and vaccination rates. We explore the immunopathological relationships between COVID and SJS/TEN and propose theories for possible associations.

Thermoresponsive and Injectable Hydrogel for Tissue Agnostic Regeneration

Injectable hydrogels can support the body's innate healing capability by providing a temporary matrix for host cell ingrowth and neovascularization. The clinical adoption of current injectable systems remains low due to their cumbersome preparation requirements, device malfunction, product dislodgment during administration, and uncontrolled biological responses at the treatment site. To address these challenges, a fully synthetic and ready-to-use injectable biomaterial is engineered that forms an adhesive hydrogel that remains at the administration site regardless of defect anatomy. The product elicits a negligible local inflammatory response and fully resorbs into nontoxic components with minimal impact on internal organs. Preclinical animal studies confirm that the engineered hydrogel upregulates the regeneration of both soft and hard tissues by providing a temporary matrix to support host cell ingrowth and neovascularization. In a pilot clinical trial, the engineered hydrogel is successfully administered to a socket site post tooth extraction and forms adhesive hydrogel that stabilizes blood clot and supports soft and hard tissue regeneration. Accordingly, this injectable hydrogel exhibits high therapeutic potential and can be adopted to address multiple unmet needs in different clinical settings.

Exploding power: a statewide review of lithium battery related burns

Introduction: With the increase of lithium battery devices, including electronic cigarettes and battery power banks, there has been a steady rise in burn injuries secondary to device malfunction. These devices may cause chemical or flame burns. Our aim was to identify and classify epidemiological trends of explosions from lithium battery devices across the state of New South Wales (NSW), Australia. Methods: A review of the NSW Burn Injury Service (SBIS) database from January 2005–December2019, together with medical records from the burns units at the Children’s Hospital at Westmead (CHW), the Concord Repatriation General Hospital (CRGH) and the Royal North Shore Hospital (RNSH) was conducted. All patients who suffered a burn secondary from a lithium battery device were included and data was extracted on mechanism of injury, severity of injury and management. This study was approved by the ethics committees of CHW, RNSH and CRGH [2020/PID00179]. Results: Of the 24 patients identified, six were paediatric and 18 were adults. The majority were male (7:1) with a mean age of 29.0 (+/- 16.6 years). The mean total body surface area burnt was 2.5% (+/- 0.9) [range 0.1–21.0%]. The majority occurred after 2014 and involved spontaneous explosions. Their injuries ranged from partial to full thickness burns with flame being the most common type (n=15). Three quarters of the cases (n=18) occurred in a home setting. Conclusions: Lithium battery device explosions can result in a mix of burn depth injuries from flame, contact and electrical, or chemical burns. Consumers need to be made more aware of the potential risks associated with use of lithium battery powered devices.

The effects of cross-linking a collagen-elastin dermal template on scaffold bio-stability and degradation

MatriDerm is a collagen-elastin dermal template that promotes regeneration in full-thickness wound repair. Due to its noncross-linked status, MatriDerm biodegrades quickly in a wound. Facilitating vascularization and dermal repair, it is desirable for MatriDerm to remain present until the wound healing process is complete, optimizing tissue regeneration and reducing wound contraction. The aim of this study was to investigate the effect of cross-linking MatriDerm on its mechanical and biological properties and to enhance its regenerative functionality. MatriDerm was chemically cross-linked and characterized in comparison with noncross-linked MatriDerm. Scaffold properties including surface morphology, protein release and mechanical strength were assessed. Cell-scaffold interaction, cell proliferation and migration were examined using human dermal fibroblasts. Scaffold biodegradation and its impact on wound healing and contraction were studied in a mouse model. Results showed that cross-linked MatriDerm displayed a small reduction in pore size, significantly less protein loss and a threefold increase in tensile strength. A significant increase in fibroblast proliferation and migration was observed in cross-linked MatriDerm with reduced scaffold contraction in vitro. In the mouse model, noncross-linked MatriDerm was almost completely biodegraded after 14 days whereas cross-linked MatriDerm remained intact. No significant difference in wound contraction was found between scaffolds. In conclusion, cross-linked MatriDerm showed a significant increase in stability and strength, enhancing its durability and cell-scaffold interaction. in vivo analysis showed cross-linked MatriDerm had a reduced biodegradation rate with a similar host response. The extended structural integrity of cross-linked MatriDerm could potentially facilitate improved skin tissue regeneration, promoting the formation of a more pliable scar.

Ventilatory support in Stevens-Johnson syndrome and toxic epidermal necrolysis: a systematic review and meta-analysis

Introduction: Stevens-Johnson syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) are blistering cutaneous disorders that often manifest with epidermal and mucosal necrosis. In extreme cases, the upper or bronchial airways are threatened, necessitating intubation and mechanical ventilation. This systematic review and meta-analysis examines the prevalence of mechanical ventilation (MV) in patients with SJS or TENS, despite maximal medical therapy, and additionally aims to identify the risk factors associated with this requirement.Materials and methods: A systematic review of the literature was performed using the PRISMA guidelines and meta-analysis of proportions.Results: Six articles were included, with pooled total of 18648 cases. The weighted prevalence of MV was 27.5% (95%CI 17.8-39.9%). The need for MV was more closely associated with TEN, compared to SJS (OR 4.40, 95%CI 2.73-7.10, I²=48%, p<.00001.) Risk factors associated with the need for MV included bacteremia (OR 5.02, 95%CI 2.87-8.79, I²=0%, p<.00001), shock/organ failure on admission (OR 261.99, 95%CI 21.88-3137, I²=71, p<.0001), total body surface area (TBSA) >30% (OR 4.47, 95%CI 1.41-14.20, I²=71, p=.01.)Conclusion: Limited published evidence with significant heterogeneity exists within the literature regarding the need for MV in SJS and TEN. Greater cutaneous involvement, and more critically unwell patients appear more likely to require MV.

SUN-217 Skin Glucocorticoid Metabolism in Burn Injury: Towards Novel Treatments That Reduce Scarring

The most common and severe complication of burn injury is the development of excessive scarring/tissue fibrosis. No current treatments reduce scarring after burns. Prolonged exposure to high levels of glucocorticoids (Cushing’s syndrome) detrimentally impacts skin, leading to reduced collagen production and impaired wound healing. Skin can generate active glucocorticoids locally through expression and activity of the 11β-hydroxysteroid dehydrogenase type 1 enzyme (11β-HSD1). We hypothesised that local glucocorticoid activation by 11β-HSD1 is an important regulator of wound healing, fibrosis and scarring after burn injury. We additionally proposed that pharmacological manipulation of this system would improve outcomes of burn wound healing.

We examined glucocorticoid metabolism (by RT-PCR, immunohistochemistry and specific enzyme activity assays) in burn and non-burn skin from burn injury patients (n=14) and mouse models of burn injury (1cm2 full thickness burn in C57Bl/6 mice). We utilised mice with genetic or pharmacological deletion of 11β-HSD1 in skin to evaluate the effects of 11β-HSD1 on burn injury healing, wound fibrosis and skin properties (by atomic force microscopy and tensile property testing) after wound healing. We also developed slow release scaffolds containing therapeutic agents including inactive glucocorticoids (prednisone) that are selectively reactivated in skin cells expressing 11β-HSD1.

The expression of 11β-HSD1 in human and mouse skin increased substantially after burn injury (7.1+/-1.8 fold increase on day 4–9 post burn compared to non-burn skin, p&lt;0.05). Early after injury, expression was primarily in immune cells but at later stages in fibroblasts. Mice with 11β-HSD1 deletion experienced faster wound healing post burn (17% reduced wound area at day 7 compared to wildtype, p&lt;0.0001) but when healed these wounds had excessive collagen density and skin thickening, and abnormal collagen fibre organisation (assessed by Masson’s Trichrome staining). The post burn scars formed in 11β-HSD1 knockout mice demonstrated different skin elastic properties compared to those formed in wildtype mice. In wildtype mice application of scaffolds loaded with inactive glucocorticoid (prednisone) significantly impacted wound healing demonstrating the feasibility of using enzyme substrates to improve wound outcomes.

The findings demonstrate the importance of skin 11β-HSD1 in wound healing and scarring after burn injury and indicate ways in which excessive scarring might be prevented.

SAT-006 Dihydrotestosterone (DHT) Enhances Major Burn Injury Wound Healing by Regulating the Inflammatory Response in Mice

Androgen analogy (Oxandrolone) have been reported to better maintain lean body mass, with improved hypermetabolic responses and shortened healing time for major burn injured patients. This is contradictory to that androgens inhibit local wound repair in men and male mice. The aim of this study therefore is to identify the role of pure androgen dihydrotesterone (DHT) in complex major burn injury, in particularly whether androgen targets local healing process or systemic burn induced hypermetabolism. A DHT silastic tube was subcutaneously implanted to male Balb/c mice prior to surgery as the treatment group. A 2 X 2 cm² full thickness contact burn wound was created on the dorsal skin of wild type littermates (control) or DHT treated mice. Wound healing rate and body weight changes were measured and compared between treatment and non-treatment group. The serum level of inflammatory cytokine/chemokine was measured using a Multiplex Immunoassay System. Spleen immune cells enumeration was analysis by flow cytometry. Inflammation, re-epithelialization, cell proliferation and collagen deposition was analysed using histology, immunohistochemistry and RT-PCR. In the present study, we found DHT treatment better maintained the body weight in mice and significantly promoted wound healing over 14 days, whereas DHT treatment had no effect on burn-induced hypermetabolism. In control group, major burn injury triggered an acute systematic inflammation response, resulting in significant increased weight of spleen, excess infiltration of nucleated erythroid cells in red pulps of spleen and a significant increase in number of splenic monocytes over 21 days. DHT treatment shortened the systemic inflammation response, evidenced via reduced splenic weight and the number of monocytes in spleen and circulation at day 14 and 21. This finding is further confirmed by less infiltration of macrophages in wound area at day 14 and 21 compared to control group. Taken together, our results suggesting the DHT treatment significantly improve wound healing by accelerated turnover of inflammation response but not through the metabolism. Further studies are necessary to define the exact mechanisms and DHT treatment could be a new therapeutic approach to improve the survivability of major burn injured patient.

Donor white blood cell survival and cytokine profiles following red blood cell transfusion in Australian major trauma patients

BACKGROUND

The potential for the co-existence of genetically disparate cells (microchimerism) and associated cytokine profiles following red blood cell (RBC) transfusion in trauma patients has not been well characterized to date. This study investigated the incidence of surviving donor white blood cells (known as transfused-associated microchimerism (TAM)) and cytokine changes following blood transfusion in trauma patients.

STUDY DESIGN AND METHODS

Trauma patients with an injury severity score (ISS) >12 who had been transfused between 2012-2016 with at least 5 units of RBC units over a 4 h period were recruited. Trauma patients with ISS > 12 who did not require blood transfusion were recruited as controls. The incidence of TAM was determined using a panel of insertion/deletion (InDel) bi-allelic polymorphisms. Selected pro- and anti-inflammatory cytokine profiles were analyzed using cytometric bead array.

RESULTS

The transfused cohort (n = 40) had median ISS of 28 [12-66], received a median of 11 RBC units [4-114] and had median hospital length of stay of 35 days [1-152]. Only 11 (27.5%) patients returned for follow-up blood sampling after discharge. Of these, one patient showed an InDel pattern indicating the presence of TAM. No patients in the control cohort (n = 49) showed TAM. Cytokines IL-10 and IL-6 were found to be elevated in the transfused trauma patients.

CONCLUSION

In this cohort, TAM was found to occur in one patient of the 11 who received a blood transfusion. Elevated IL-6 and IL-10 cytokines were detected in those patients who were transfused. However, the incidence of TAM could not be correlated with the elevated cytokine profiles for this cohort.

Cell therapy for severe burn wound healing

Cell therapy has emerged as an important component of life-saving procedures in treating burns. Over past decades, advances in stem cells and regenerative medicine have offered exciting opportunities of developing cell-based alternatives and demonstrated the potential and feasibility of various stem cells for burn wound healing. However, there are still scientific and technical issues that should be resolved to facilitate the full potential of the cellular devices. More evidence from large, randomly controlled trials is also needed to understand the clinical impact of cell therapy in burns. This article aims to provide an up-to-date review of the research development and clinical applications of cell therapies in burn wound healing and skin regeneration.

An evaluation of Emergency Management of Severe Burn (EMSB) course in Bangladesh: a strategic direction

BACKGROUND

Burn is one of the major public health problems in Bangladesh. Specialized personnel and technologies are required, however, in many cases they are not readily available. Taking the situation into account, Interplast Australia and New Zealand, Australia & New Zealand Burn Association (ANZBA), and Centre for Injury Prevention and Research, Bangladesh (CIPRB) initiated Emergency Management of Severe Burn (EMSB) training programme for Bangladeshi physicians in 2008 to help improving their burn management skill. The study was designed to evaluate the effect of EMSB programme in Bangladesh.

METHODS

Both qualitative and quantitative methods were adopted. A cross-sectional survey was conducted to obtain quantitative information from 38 randomly selected EMSB-trained doctors among 380 trained physicians based on a five year database of EMSB (2008-2012). In-depth interviews (IDIs) and focus group discussion (FGD) were used as data collection techniques to get information.

RESULTS

A total of 32 participants completed the interview. It was found that 87.5% (n=28) doctors were using their skill in burn management that they learnt from the EMSB course. About 43.8% (n=14) doctors felt that the course largely helped improve their confidence. Majority (56.2%, n=18) of doctors stated EMSB is essential for the Bangladeshi doctors to learn better management of burns. Qualitative findings show that the courses were organized successfully with an excellent coordination, maintaining same quality and standard as running anywhere in the world. For its effectiveness, the course has been recommended to train graduate nurses and junior doctors from the periphery of the country.

CONCLUSIONS

EMSB has already created a large doctor community who are able to effectively manage burn patients. It also has proven its indispensability for learning burn management skill. The EMSB established a platform to serve the burn victims and reduce the burden of injuries in Bangladesh.

The Burns Registry of Australia and New Zealand: progressing the evidence base for burn care

OBJECTIVE

Analysis of data from the Burns Registry of Australia and New Zealand (BRANZ) to determine the extent of variation between participating units in treatment and in specific outcomes during the first 4 years of its operation.

DESIGN

BRANZ, an initiative of the Australian and New Zealand Burn Association, is a clinical quality registry developed in accordance with the Australian Commission on Safety and Quality in Healthcare national operating principles.

SETTING

Patients with burn injury who fulfil pre-defined criteria are transferred to and managed in designated burn units. There are 17 adult and paediatric units in Australia and New Zealand that manage almost all patients with significant burn injury. Twelve of these units treat adult patients.

PARTICIPANTS

Data on 7184 adult cases were contributed by ten acute adult burn units to the registry between July 2010 and June 2014.Major outcomes: In-hospital mortality, hospital length of stay, skin grafting rates, and rates of admission to intensive care units.

RESULTS

Considerable variations in unit profiles (including numbers of patients treated), in treatment and in outcomes were identified.

CONCLUSIONS

Despite the highly centralised delivery of care to patients with severe or complex burn injury, and the relatively small number of specialist burn units, we found significant variation between units in clinical management and in outcomes. BRANZ data from its first 4 years of operation support its feasibility and the value of further development of the registry. Based on these results, the focus of ongoing research is to improve understanding of the reasons for variations in practice and of their effect on outcomes for patients, and to develop evidence-informed clinical guidelines for burn management in Australia and New Zealand.

Androgen actions in mouse wound healing: Minimal in vivo effects of local antiandrogen delivery

The aims of this work were to define the role of androgens in female wound healing and to develop and characterize a novel wound dressing with antiandrogens. Androgens retard wound healing in males, but their role in female wound healing has not been established. To understand androgen receptor (AR)-mediated androgen actions in male and female wound healing, we utilized the global AR knockout (ARKO) mouse model, with a mutated AR deleting the second zinc finger to disrupt DNA binding and transcriptional activation. AR inactivation enhanced wound healing rate in males by increasing re-epithelialization and collagen deposition even when wound contraction was eliminated. Cell proliferation and migration in ARKO male fibroblasts was significantly increased compared with wild-type (WT) fibroblasts. However, ARKO females showed a similar healing rate compared to WT females. To exploit local antiandrogen effects in wound healing, while minimizing off-target systemic effects, we developed a novel electrospun polycaprolactone (PCL) scaffold wound dressing material for sustained local antiandrogen delivery. Using the antiandrogen hydroxyl flutamide (HF) at 1, 5, and 10 mg/mL in PCL scaffolds, controlled HF delivery over 21 days significantly enhanced in vitro cell proliferation of human dermal fibroblasts and human keratinocytes. HF-PCL scaffolds also promoted in vivo wound healing in mice compared with open wounds but not to PCL scaffolds.

The effect of endotracheal tube size on voice and swallowing function in patients with thermal burn injury: an evaluation using the Australian Therapy Outcome Measures (AusTOMS)

The objective of this study was to determine if intubation using larger endotracheal tube sizes in mechanically ventilated patients with thermal burn injury adversely affects voice and swallowing function. This prospective, observational study was conducted in patients with thermal burn injuries, who were mechanically ventilated via an endotracheal tube. The primary outcome measures were changes in voice and swallowing function, assessed using the Australian Therapy Outcome Measures (AusTOMS), immediately before the burn injury, and 12 months after the removal of the endotracheal tube. Of 101 patients screened, 20 male patients were followed for 12 months. Patients intubated with size 8.0 or larger endotracheal tubes were compared to patients with size 7.5 endotracheal tubes or smaller. Patients with the larger endotracheal tubes had a significant 1.8-point (9%) decline in their AusTOMS voice score (p =.01) using the paired t-test, but there was no significant difference between the two groups using the independent samples t-test. There was no significant difference in swallowing outcome between the two groups. Male patients with thermal burn injuries, mechanically ventilated using size 8.0 endotracheal tubes or larger, had a statistically significant decline in voice outcome; however, interpretation of this result is limited by methodological considerations.

Electrical flash burns due to switchboard explosions in New South Wales--a 9-year experience

PURPOSE

To document the incidence and outcome of flash burns due to electrical switchboard explosions presenting to Concord Hospital Burns Unit, from January 2000 to December 2008.

METHODS

The Concord Hospital Burns Unit Database was reviewed for admissions due to electrical burns from January 2000 to December 2008.

RESULTS

There were 119 electrical burns admitted during the study period, 20 of which were due to high voltage current. Ninety-nine others were low voltage injuries and included 37 cases of electrical burns due to low voltage electrical switchboard explosions. All of the electrical switchboard burns occurred in male electricians. Twenty-one of the 37 low voltage injuries required admission and 7 of them required skin grafting. The mean LOS was 9.95 days. Twenty cases suffered serious complications including major psychological problems and ocular injuries.

CONCLUSIONS

Flash burns resulting from switchboard explosions account for a significant proportion of all electrical burns presenting to our institution. These burns may highlight deficits in taking safety precautions and the use of personal protection equipment. Despite the small area of injury the long term psychological sequelae were significant resulting in a delayed return to employment, and there was a high incidence of eye injuries. Additional efforts are therefore required towards the prevention of such injuries.

The severe burns patient with tracheostomy: implications for management of dysphagia, dysphonia and laryngotracheal pathology

INTRODUCTION

Insertion of a tracheostomy for a severe burn patient is not uncommon. The method of decannulation, effects of the tracheostomy on voice and swallowing and subsequent complications have not been described in the literature specifically for this population. The aim of this study was to investigate the risk of dysphagia, dysphonia and laryngotracheal pathology in severe burn patients with tracheostomy and following decannulation.

METHOD

A retrospective chart review was conducted for severe burn patients admitted from January 2000 to December 2007 that received tracheostomy as part of their treatment.

RESULTS

Two hundred and thirty patients were admitted during the study period, 26 of whom underwent tracheostomy. Significant positive correlations were identified between tracheostomy duration and %TBSA burn, days to commence oral intake and days to commence pre-morbid oral diet. Several dysphagic features were identified within the oral and pharyngeal phases of swallowing and dysphonia was frequently demonstrated on perceptual voice assessment with the tracheostomy in situ and following decannulation. Laryngotracheal pathology was diagnosed in 12 of the 26 patients (46.2%) whilst the tracheostomy was in place; 2 with laryngeal granulation tissue, 2 with tracheal granulation tissue, 2 with supraglottic oedema and erythema and 6 with reduced vocal mobility.

CONCLUSION

Severe burn patients that have prolonged tracheostomy are likely to have a larger size burn, take longer to commence oral intake and achieve pre-morbid oral diet. These patients are also at risk for dysphagia, dysphonia and laryngotracheal pathology.

Laser-assisted end-to-end BioWeld anastomosis in an ovine model

The BioWeld tube, an albumin-based exovascular stent, has been used for microsurgical anastomoses and compared to conventional sutures. The study presented investigated the potential of the BioWeld tube for vascular anastomosis in larger vessels. Laser-assisted BioWeld anastomoses were compared to conventional-sutured anatomoses of the carotid artery of Merino-x ewes. The BioWeld procedure resulted in 100% survival and 100% patency at 1 and 6 week post-operative periods, with no noticeable foreign body response. Sutured animals showed 100% survival and patency. The ischemic time for BioWeld anastomosis averaged 15 minutes compared with 10 minutes for sutures. This study indicates that the BioWeld tube is an easy to use anastomotic technique with equivalent success rates and comparable anastomotic times.

TOXIC EPIDERMAL NECROLYSIS/STEVENS?JOHNSON SYNDROME: CURRENT TRENDS IN MANAGEMENT

BACKGROUND

Toxic epidermal necrolysis (TEN) is an uncommon but potentially life-threatening condition that involves sloughing of the skin at the dermoepidermal junction. TEN is a well-recognized syndrome and is part of a range of severe mucocutaneous intolerance reactions, mostly elicited by drugs and/or their metabolites. Reported mortality rates vary widely from 20 to 75%. Several systemic treatment protocols for TEN have been published; however, none has been formally standardized in a randomized controlled trial. The present study documents the current management principles and trends seen in 16 patients admitted with TEN or Stevens-Johnson syndrome over a 5-year period at the Concord Repatriation General Hospital Burns Unit.

METHOD

Data were collected by retrospective chart review, and parameters included in the study were patient demographics, causative agents, percentage total body surface area and/or mucosal involvement, complications, treatment and outcome. In particular, dressing choice and documented healing of skin lesions were noted.

RESULTS

Sixteen patients were identified, with the beta-lactam antibiotics most commonly implicated as the cause. Complications tended to relate to degree of sepsis and/or mucous membrane involvement. Nanocrsytalline silver dressings, such as Acticoat (Smith & Nephew, Mount Waverley, Victoria, Australia), were used predominantly in more recent cases.

CONCLUSION

The shift in dressing choice from traditional Vaseline-impregnated gauze coincided with a general trend towards the use of nanocrystalline silver dressings for superficial burns after 2003. The nanocrystalline silver dressings have shown considerable advantage over previously used dressings, with no adverse reactions noted and good healing of the skin lesions for all patients.

Early in-hospital management of burn injuries in Australia

BACKGROUND

The accurate initial assessment and management of burn injuries influences subsequent clinical outcome. The purpose of the present study was to evaluate, over a 12-year period (1989-2001), changes in the practices of referring hospitals in terms of early management of patients with burn injuries prior to transfer to a burns unit.

METHODS

The details of all consecutive patients over two separate 12-month periods between June 1989 to May 1990 and between April 2000 and March 2001 who were transferred to the Burns Unit, Concord Repatriation General Hospital, Sydney, were prospectively recorded and retrospectively reviewed. In particular, the referral procedure, the accuracy of the referring hospital's assessment of burn size and initial fluid resuscitation were compared between the two time frames.

RESULTS

There were 51 patients in the initial 12-month period and 57 patients in the latter 12-month period. Regarding the transfer of the latter group of patients, the referring hospital liaised directly by telephone with the Burns Unit registrar or consultant significantly more often (77%vs 45%, respectively, P < 0.05). Similar proportions of patients in the two time periods received correct initial assessment of burn size (39% in the 1989-1990 group vs 42% in the 2000-2001 group, P = 0.76). The latter group of patients was significantly more likely to receive the correct choice of fluid for initial resuscitation at the referring hospital (98%vs 61%, respectively, P < 0.05).

CONCLUSIONS

Over this 12-year period, there has been marked improvement in referral practices and appropriate initial fluid resuscitation for patients with burn injuries. Referring hospitals' assessment of burn size has not improved. Possible reasons for the observed changes include: increased postgraduate education programmes by the Royal Australasian College of Surgeons and the Australian and New Zealand Burns association; the formalization of emergency medicine training programmes by the Australasian College of Emergency Medicine and increasing awareness within the medical community of the presence of dedicated burns units.

Laser welding of vas deferens in rodents: initial experience with fluid solders

This study evaluates the use of sutureless laser welding for vasovasostomy. In 14 rodents, the left vas deferens underwent vasovasostomy using an albumin-based solder applied to the adventitia of the vas deferens. The solder contained the dye, indocyanine green, to allow selective absorption and denaturation by a fiber-coupled 800-nm diode laser. The right vas deferens served as a control, receiving conventional layered microsurgical repair. We used a removable 4/0 nylon stent and microclamps to appose the vas deferens during repair, with no need for stay sutures. The mean time to perform laser solder repair (23.5 min) and conventional repair (23.3 min) were not significantly different (P=0.91). However, examination after 8 weeks showed that granuloma formation (G) and patency (P) rates for the conventional suture technique (G, 14%; P, 93%) were significantly better than observed for the laser solder technique (G, 57%; P, 50%).

Laser welding of vas deferens in rodents: initial experience with fluid solders

This study evaluates the use of sutureless laser welding for vasovasostomy. In 14 rodents, the left vas deferens underwent vasovasostomy using an albumin-based solder applied to the adventitia of the vas deferens. The solder contained the dye, indocyanine green, to allow selective absorption and denaturation by a fiber-coupled 800-nm diode laser. The right vas deferens served as a control, receiving conventional layered microsurgical repair. We used a removable 4/0 nylon stent and microclamps to appose the vas deferens during repair, with no need for stay sutures. The mean time to perform laser solder repair (23.5 min) and conventional repair (23.3 min) were not significantly different (P=0.91). However, examination after 8 weeks showed that granuloma formation (G) and patency (P) rates for the conventional suture technique (G, 14%; P, 93%) were significantly better than observed for the laser solder technique (G, 57%; P, 50%).