Ramin Ipaktchi

Percutaneous collagen induction therapy: an alternative treatment for burn scars

OBJECTIVE This study aims to evaluate percutaneous collagen induction (PCI) in post-burn scarring. BACKGROUND Patients with scarring after burn frequently request help in improving the aesthetic appearance of their residual cicatricial deformity. Their scars are generally treated by tissue transfer, W- and Z-plasties, flaps, cortisone injections or ablative procedures that injure or destroy the epidermis and its basement membrane and subsequently lead to fibrosis of the papillary dermis. The ideal treatment would be to preserve the epidermis and promote normal collagen and elastin formation in the dermis. PATIENTS A total of 16 consecutive patients (average age: 37+/-15.5 years, average body mass index (BMI): 25.7) in Germany with post-burn scarring. INTERVENTION PCI using the Medical Roll-CIT (Vivida, Cape Town, South Africa). This device was designed to multiply-puncture the skin to the level of the dermal scar to institute remodelling. Patients were prepared with topical vitamin A and C cosmetic creams for a minimum of 4 weeks preoperatively to maximise collagen stimulation. OUTCOME MEASURES The outcome was measured rating (visual analogue scale (VAS) and Vancouver Scar Scale (VSS)), histological specimen 12 months after intervention. RESULTS On average, patients rated their improvement as a mean of 80% better (+/-15.5) than before treatment. Histologic examination revealed considerable increase in collagen and elastin deposition 12 months postoperatively. The epidermis demonstrated 45% thickening of stratum spinosum and normal rete ridges as well as the normalisation of the collagen/elastin matrix in the reticular dermis at 1 year postoperatively. CONCLUSIONS This pilot study shows that PCI appears to be a safe method for treating post-burn scarring without destroying the epidermis. The procedure can be repeated safely and is also applicable in regions where laser treatments and deep peels are of limited use. However, it is necessary to initiate an efficacy trial to prove the data of this pilot study.

Validation of the German version of the Burn Specific Health Scale-Brief (BSHS-B)

BACKGROUND The Burn Specific Health Scale-Brief (BSHS-B) is recognized as a valid self-rating scale to evaluate quality of life after burn. AIM To validate the translated German version of the BSHS-B. METHOD One hundred and forty one burn survivors (65.2% men) with a mean age of 49.62 years (SD=15.16) and a mean duration after burn of 45.01 months (SD=26.18) answered the BSHS-B. Factor structure was tested by using confirmatory factor analysis, reliability (internal consistency) of the scales was determined by means of Cronbachs α. Construct validity was explored through correlations between the BSHS-B and the Short-Form 8 Health Survey (SF-8). In addition, the know-groups technique was used to determine to which degree the BSHS-B discriminates between patients with low and high burn severity based on the abbreviated burn severity index (ABSI). The Hospital Anxiety and Depression Scale (HADS) was used to examine criterion validity. RESULTS The nine BSHS-B subscales showed good internal consistency. A second-order confirmatory factor analysis revealed the following main components: (1) Affect and Relationship, (2) Function and (3) Skin Involvement. The second-order factors were positively correlated with the SF-8 and negatively correlated with symptoms of anxiety and depression. Patients with low ABSI scored higher on all three BSHS-B domains than those with high ABSI. CONCLUSIONS The results indicate good psychometric properties of the German BSHS-B. Further studies are needed to investigate the utility of the questionnaire in clinical routine practice, evaluation of burn management programs, and burn-specific research.

Trauma mechanisms, patterns of injury, and outcomes in a retrospective study of 71 burns from civil gas explosions.

BACKGROUND Although explosion injuries caused by terror attacks or in war are evaluated in many studies, limited information about civil explosion injuries can be found in the literature. METHODS In a retrospective study of 71 civil gas explosion injuries treated in a single burn center during a 16-year period, we evaluated trauma mechanisms, patterns of injury, and clinical outcome. RESULTS More than 50% of all gas explosions injuries occurred in private households. The mortality correlated significantly with higher burned total body surface area (TBSA), higher abbreviated burn severity index (ABSI) score, accompanying inhalation injuries, and lung contusions. Although mean ABSI score and burned TBSA were similar in men and women (6 vs. 7 and 22% vs. 21%), the female mortality from gas explosions was noticeably higher, albeit not statistically significant due to small patient numbers (32% vs. 17%). Although mean burned TBSA, ABSI scores, and intensive care unit lengths of stay in patients with burns from gas explosions were comparable and not significantly different compared with all burn patients treated in our burn center (TBSA: 22% vs. 17%; ABSI: 6 vs. 6; and intensive care unit lengths of stay: 12 vs. 11 days), the mortality from gas explosions was significantly higher (21% vs. 12%, p = 0.04). CONCLUSIONS The mortality from gas explosion-related burns correlated significantly with burned TBSA, ABSI score, accompanying inhalation injuries, and lung contusions. Despite comparable ABSI scores, the mortality from gas explosion-related burns was significantly higher than the mortality for all burn victims.

Subclavian artery and jugular vein rupture after a blunt thoracic trauma due to a BMX handlebar

A 14-year-old BMX driver suffered a blunt trauma towards the lateral neck (Fig. 1). A computed tomography (CT) angiography revealed a dye stop in the left subclavian artery with collateral blood flow (Fig. 2). Interventional catheterisation revealed a rupture. However, no peripheral pulse deficit was evident, and, therefore, no immediate vascular surgery was performed. www.elsevier.com/locate/ejcts European Journal of Cardio-thoracic Surgery 37 (2010) 235

Secondary sclerosing cholangitis following major burn injury—An underestimated issue in burn care?

Second, inaddition toVR,music therapyhasbeenproven todecrease procedural pain, anxiety and muscle tension levels associated with daily burn care [2]. The music in the VR system, which therefore may also be a factor for pain relief for burn patients, should be mentioned. Once again, thanks for this valued comment and observation. We understand that the music may have seemed like a confounding factor; however, in effect, the music and visuals encompass the VR system and were therefore treated as a whole system and not separately. VR as a whole was investigated as an intervention. Third, different frommost VR studies applied for the rehabilitation of patients, the VR system in these burn patients was operated by an unaffected region of the body and focussed on pain and anxiety relief. From the rehabilitation point of view, we often implement a VR system, which is operated by the affected or impaired limbs emphasising functional restoration. This article can remind us that VR systems are designed for different purposes of therapy, and may be a reference for integrated VR systems in the future. The VR system used in this study was indeed not used as a rehabilitation intervention, but rather as an aid to assist in reducing pain and anxiety related to burn rehabilitation and ultimately improving compliance to rehabilitation. Since burn rehabilitation is often excruciating for both patient and health professional, the VR may be a solution in making the rehabilitation process bearable for burn injury patients [3,4]. Physiotherapists can therefore focus less on the pain and anxiety the burn injury patients experience during physiotherapy management and more on the rehabilitation process and reintegration of the patient back into society [1].

Validation of the German version of the Perceived Stigmatization Questionnaire/Social Comfort Questionnaire in adult burn survivors

OBJECTIVE To investigate the factor structure, reliability, and validity of the German version of the Perceived Stigmatization Questionnaire/Social Comfort Questionnaire (PSQ/SCQ) in burn victims. METHODS The PSQ/SCQ was answered by 139 adult burn survivors (age M=49.69, SD=15.16 years). Factor structure was examined using a confirmatory factor analysis (CFA). Validity was investigated through correlations between the PSQ/SCQ scales and questionnaires assessing perceived social support, burn-specific health-related quality of life, symptoms of anxiety/depression, and percent of total body surface area (TBSA) burned. Additionally, the link between perceived stigmatization/social comfort and current partnership status was investigated. RESULTS The four-factor model showed the best fit to the data with three PSQ factors (Absence of Friendly Behavior, Confused/Staring Behavior, and Hostile Behavior) and one single SCQ factor. All PSQ/SCQ scales showed good internal consistency. Higher PSQ/lower SCQ means were related to less perceived social support, less burn-specific quality of life, and more symptoms of anxiety/depression. With the exception of a positive correlation with the PSQ subscale Confused Behavior and Staring, no other significant correlations were found between the PSQ/SCQ subscales and TBSA burned. While PSQ/SCQ scores were not linked to age or gender, less perceived social stigmatization/more social comfort was reported by participants who were currently living with a partner. CONCLUSIONS The results indicate a four-factor structure and a good validity of the PSQ/SCQ which is in line with prior research. Further studies should investigate the application of the PSQ/SCQ in individuals with appearance distinctions that are not related to burns.

Hand and facial burns related to liquefied petroleum gas (LPG) refuelling and cigarette smoking—An underestimated risk?

A number of liquid petroleum gas (LPG) burns have been reported in the last 3 years in line with the evolving widespread acceptance of LPG-powered cars in the public. LPG is a mixture of commercial butane and propane gas. Depending on the mixture of both, butane and propane, the boiling point of LPG lies in between 45 and 2 8C [1]. Refinements in the engineering process of LPG tanks using the Finite Element Method (FEM) lowered the wall sheet thickness from 3 to 2.8 mm without different bursting results [2]. To date some 25 cases are reported in the literature. In the largest case series with LPG-related burns among 18 patients (9 adults and 9 children), various injury mechanisms are described [1]. The weakening of the tank wall, crashes resulting in an impact to the tank and leakage from the tank was reported. Thus, technical errors or malfunctions were detected. All burned patients were inside the car when the explosion occurred with eleven cases of inhalation injury with seven of them requiring mechanical ventilation. Another case highlights a hand burn during refuelling a car with LPG [3]. He was struck by splashing LPG while he was disconnecting the LPG hose nozzle. The fact that LPG has such a low boiling point (between 45 and 2 8C) and its rapid vaporisation, frostbite injuries have been reported as the aforementioned case and another series on two patients [4]. Both cases were related to Article history: Accepted 22 July 2010

A multimodal infection control concept in a burn intensive care unit – lessons learnt from a meticillin-resistant Staphylococcus aureus outbreak

BACKGROUND Meticillin-resistant Staphylococcus aureus (MRSA) is a frequently encountered pathogen in burn units. Burn patients are especially susceptible to MRSA acquisition and MRSA spread may cause outbreaks in burn units. AIM To report the characteristics and successful control of an MRSA outbreak and to demonstrate a multimodal infection control concept. METHODS In addition to a pre-existing infection control concept, several control measures were implemented including weekly prevalence screenings for MRSA, reinforcement of disinfection, restriction of admissions, and short-term unit closure. Epidemiologic investigation and environmental examinations were performed. The outbreak isolates were analysed by pulsed-field gel electrophoresis and spa-typing. A PubMed search was conducted, focusing on MRSA outbreaks in burn units. FINDINGS This outbreak of hospital-acquired MRSA affected eight patients during a seven-month period, yielding an attack rate of 8%. Epidemiologic and environmental examinations suggested patient-to-patient transmission, which was confirmed by molecular analysis of bacterial isolates revealing a monoclonal pattern. In accordance with findings from other outbreaks in burn units, the implemented measures including patient screening and temporary unit closure resulted in successful control of the outbreak. CONCLUSION A comprehensive concept is required to control the spread of all multidrug-resistant micro-organisms including MRSA on a burn unit. Where patients colonized or infected with MRSA appear to be the main reservoir, transfer of these patients to other units, or temporary closure of the unit, accompanied by intensive cleaning are very effective measures to stop transmission events.

Free flaps in scar treatment

Abstract Introduction: Scar management needs defined concepts and an algorithm to restore functional and aesthetic units. After an unsuccessful conservative treatment, surgical measures provide a vast spectrum of possibilities for remediation. The spectrum of possibilities consists of excision and Z-plasty, regional flaps, vascularized pedicled flaps, tissue expansion, and finally free tissue transfer. Severe scarring and highly destructed tissues with inferior functional and aesthetic units can be effectively treated with radical excision and free flap reconstruction. The complexity of flap architecture and tissue qualities allows for an individualized approach. Specific attention should be paid to the long-term consequences of severe scarring with progressive loss of functionality. Materials and methods: We worked out the most common surgical approaches and treatment algorithm for a stepwise and effective approach. Part of this algorithm is a seven-step surgical approach. Results: This article provides modern plastic and reconstructive surgery concepts with an algorithm for scar management. Discussion: The treatment of scars follows an algorithm with the level of complexity of techniques adjusted to the individual case and the conditions. Disabilities induced by scarring can lead to further functional loss. In these cases, surgical strategies have to be considered.

Biobrane versus topical agents in the treatment of adult scald burns

BACKGROUND Limited data is available for treatment of scald lesions in adults. The use of the biosynthetic matrix Biobrane® has been suggested as treatment option with more benefits over topical dressings. Application of Biobrane® in scalds in our center led to a perceived increase of infection, secondary deepening, surgery and length of stay. We therefore assessed the effect of different treatment options in adult scalds in our center. METHODS We performed a retrospective cohort study of adult patients that have been admitted with scalds in our center between 2011 and 2014. We assessed two groups, group 1 with Biobrane® as initial treatment and group 2 with topical treatment using polyhexanid hydrogel and fatty gauze. Primary outcome variables were rate of secondary deepening, surgery, infection (defined as positive microbiological swabs and antibiotic treatment) and length of stay. Total body surface area (TBSA) as well as diabetes mellitus (DM), hypertension, smoking and alcohol consumption as potential confounders were included. RESULTS A total of 52 patients were included in this study. 36 patients received treatment with Biobrane® and 16 with ointment and fatty gauze. No significant differences were found for age and TBSA whereas gender ratio was different (25/11 male/female in group 1 vs 4/12 in group 2, p=0.003). Rate of secondary deepening, surgery, infection as well as days of hospital stay (DOHS) were comparable. Logistic and multilinear regression showed TBSA to be a predictive factor for infection (p=0.041), and TBSA and age for length of stay (age p=0.036; TBSA p=0.042) in group 1. CONCLUSION The use of Biobrane® in adult scald lesions is safe and non-inferior to topical treatment options. In elder patients and larger TBSA Biobrane® may increase the risk of infection or a prolonged stay in hospital. LEVEL OF EVIDENCE Level 3 - retrospective cohort study.