Deep burn of the hands: Early surgical treatment avoids the need for late revisions?

An eight years experience in the management of deep hand burns is presented. We reviewed 116 cases of patients surgically treated with escarectomy and skin autograft. Seventy eight of them underwent early surgery within the first 4-6 days from injury, while 38 were conservatively treated in the fist stage and only lately surgery was performed (usually after the 14th day). In all patients, we applied the same post operative topic treatment and rehabilitation protocol. Several months after first admission, only 6(7.7%) of early treated patients needed secondary correction for unaesthetic and functionally debilitating scars versus 14(36.8%) of the late treated group. Our review confirm the importance of performing early surgery of deep burns of the hands, whenever possible, in order to achieve best results and shows it's utility in reducing re-admissions for secondary revisions.

Pharmacokinetics and tissue penetration of vancomycin in patients undergoing prosthetic mammary surgery.

Vancomycin concentrations in periprosthetic breast tissues were evaluated in 24 women undergoing reconstructive surgery after mastectomy for breast cancer. Patients were given a single prophylactic dose of vancomycin (1 g iv) 1-8 h before surgery, and mean capsular and pericapsular tissue concentrations were measured by HPLC. Vancomycin was not detectable in the majority of patients belonging to the 1-3 h post-dose groups, whereas in the 4-8 h post-dose groups, mean capsular and pericapsular concentrations were as follows: at 4 h, 4.0 mg/kg and 5.9 mg/kg; at 6 h, 4.1 mg/kg and 4. 8 mg/kg; at 8 h, 5.9 mg/kg and 11.1 mg/kg, respectively. Vancomycin tissue concentrations thus were equal to or exceeded the breakpoint of 4 mg/L in most samples collected 4-8 h after dosing. In conclusion, our data suggest that appropriate timing of vancomycin prophylaxis should be considered to allow the maintenance of adequate tissue concentrations throughout the surgical procedure.

Successful reconstruction of refractory posttraumatic skull base defects with free radial forearm flap.

After our experience with two patients who had persistent posttraumatic defects of the anterior skull base, we recommend using a deepithelialized free radial forearm flap for one-stage reconstruction. The flap provides a thin, water-tight barrier between the cranial cavity and the subcranial spaces for effective prevention of cerebrospinal fluid leakage and ascending infection. It is particularly useful when local flap options are not available.

Distally based dorsalis pedis island flap for a distal lateral electric burn of the big toe.

Reconstruction of the small defects in the distal portion of the foot has always represented a difficult problem. A case of a young man with a deep electric burn of the distal lateral side of the big toe successfully treated with a distally based dorsalis pedis island flap based on the first dorsal metatarsal artery (FDMA) is presented. The donor site area of the dorsum of the foot was grafted, and deambulation was reassumed 3 weeks later. Advantages; limits and anatomical consideration regarding the viability of the flap are also discussed.

Prolongation of survival of alloskin grafts with no concurrent general suppression of the burned patient's immune system: a preliminary clinical investigation.

The adequate management of burns is the requisite to save the patient's life, to prevent the onset of secondary infections and to obtain healing with acceptable cosmetic results. Previous data have shown that the use of alloskin grafts in the acute phase of burns yields the best clinical results. Unfortunately, this approach is curbed by the patient's immune response which induces the rejection of the allografts. In this report we endeavoured to solve this problem by ways that would not imply the general suppression of the patient's immune system. Thus, we can now report that a longer survival of alloskin grafts can be induced in situ by pretreating the alloskin samples to be grafted with both an anti-beta 2-microglobulin monoclonal antibody (beta 2mAb) and irradiation with ultraviolet-C light (UVC). The advantage of our novel approach is that it does not need any concomitant administration of immunosuppressive agent(s) to the burned patients. In this study, we followed five severely burned patients grafted with alloskin samples pretreated with either beta 2mAb or beta 2mAb plus UVC irradiation. In comparison with untreated alloskin samples from the same source grafted in parallel, the mean survival time (MST) of the beta 2mAb-pretreated alloskin specimens increased by 35 per cent (i.e. from 18.3 +/- 3.2 days to 24.7 +/- 5.5 days) in three patients. Moreover, the MST of the alloskin grafts pretreated with both beta 2mAb and UVC irradiation was lengthened by 100 per cent (i.e. from 18.5 +/- 4.5 days to 37.0 +/- 8.0 days) in the remaining two patients. These preliminary results lend credence to the view that local immune suppression could be achieved in situ by our approach via: (1) the impairment of the proper functions of the HLA-class I antigen by the bound beta 2mAb; and (2) the inhibition of immune reactions taking place inside the alloskin grafts by some immunosuppressive signal(s) generated by the UVC-pretreated alloepidermal cells. Hence, our approach stands as an exciting and useful alternative to the otherwise well-known, deleterious general suppression of the burned patient's immune system.

C-terminal fragment of parathyroid hormone-related protein, PTHrP-(107-111), stimulates membrane-associated protein kinase C activity and modulates the proliferation of human and murine skin keratinocytes.

Low concentrations of the C-terminal parathyroid hormone-related protein (PTHrP) fragments, PTHrP-(107-111) and PTHrP-(107-139), stimulated membrane-associated protein kinase Cs (PKCs), but not adenylyl cyclase or an internal Ca2+ surge, in early passage human skin keratinocytes and BALB/MK-2 murine skin keratinocytes. The fragment maximally stimulated membrane-associated PKCs in BALB/MK-2 cells at 5 x 10(-9) to 10(-8) M. The maximally PKC-stimulating concentrations of PTHrP-(107-111) also stopped or stimulated BALB/MK-2 keratinocyte proliferation depending on whether the cells were, respectively, cycling or quiescent at the time of exposure. Thus, just one brief (30-minute) pulse of 10(-8) M PTHrP-(107-111) stopped the proliferation of BALB/MK-2 keratinocytes for at least 5 days. On the other hand, daily 30-minute pulses of 10(-8) M PTHrP-(107-111) started and then maintained the proliferation of initially quiescent BALB/MK-2 cells. Similarly PTHrP-(107-111) inhibited DNA synthesis by cycling primary adult human keratinocytes, but it stimulated DNA synthesis by quiescent human keratinocytes.

Fluid replacement in burned patients.

Burn injury involves a large amount of water, electrolytes and proteins loss trough the burn wound. For this reason, to avoid shock, a wide infusion of fluid is necessary in the first hours after trauma. Many reanimation formulas were proposed in the past years, with different composition: saline, colloids, plasma. The authors have studied 40 burned patients admitted in Verona Burn Center within 4 hours after burn, with burns over 30% of the body surface area. Twenty of them were treated with Baxter reanimation formula (ringer lactated saline, RLS) while the others with Monafo hypertonic lactated saline (HLS), modified by Milan Burn Center. The two randomized groups were assessed and compared. In RLS group total fluid volume infused was higher while sodium requirements was lower than in HLS patients, with statistically significative difference (p < 0.01). On the contrary, in HLS group, potassium administered was perhaps twice if compared with the other. Haematocrit, urine output and urine osmolarity were adequate in both the groups, and did not showed statistical differences, such as serum proteins concentration, that was low in all patients, while a significative difference was noted in urine osmolarity (p < 0.01). A metabolic alkalosis was present in HLS patients, while, on the other hand, serum nitrogen was significantly higher (p < 0.05), in the first 48 hours after burn, in RLS group. Patients were assessed for pre-existing diseases too, and data showed that complications were lower in HLS than in RLS group. HLS resuscitation formula guarantees a good electrolytes balance with lower fluid load, reducing tissue oedema and complication rate. Mortality rate was higher in HLS, may be for an higher Roy index in this group.

Skin expansion in burn sequelae: results and complications.

Before Radovan introduced skin expansion, burn sequelae were treated with skin grafts, local or distant flap, with an high morbidity on the donor site. Actually this technique is well known and standardized procedure that allows to obtain local flaps with the same characteristics in colour, texture, hair and sensitivity of the normal skin. The authors analyze their experience in the treatment of burn sequelae from 1985 to 1995. During this period, 157 patients underwent surgery to correct burn scars and contracture, utilizing 262 skin expanders. The implants were positioned on the fascial layer; antibiotic and drainage were routinely used. The inflation of the expander began 2 weeks after surgery, and hyperexpansion was the rule, when possible. Only in 6.4% (10 patients) expansion failed, while in the remaining cases good partial (in patients with too large scars) or total results were achieved. Complication rate in skin expansion is high. In this series complication occurred in 73 of 262 expansion, but 43 were easily solved. So only in 30 expansions the final outcome was influenced by complication, with higher incidence in neck and in lower extremities. Results were generally satisfactory, with an improvement of scars and minimal donor site morbidity. With a careful selection of the patients, skin expansion offers a good solution for burn sequelae, complications can be reduced and successfull results achieved.

Suicide attempted by burning: a 10-year study of self-immolation deaths.

In a 10-year retrospective survey of 699 admissions to the Burns Centre of Verona, 31 patients (4.4 per cent) had self-inflicted burns. No sex difference was found, the mean age was 38 years, with 58 per cent of the patients in the 20-39-year age group. The mean burned surface area (BSA) was 41 per cent, and 12 patients (38.7 per cent) died: seven within the first 24 h. The other five patients died within 40 days (mean survival: 18 days). A large number of patients had a history of previous psychiatric treatment, six patients had previously attempted suicide. Four patients were drug addicts, three of whom were affected by AIDS and one had been HIV-positive for a long time. The patients had continuous psychiatric treatment during the long hospital stay. After discharge the patients were assigned to territorial staff for psychiatric treatment. Our experience shows that these patients have a higher mortality rate and they need constant psychiatric support, which can be useful in preventing further suicide attempts.

An investigation into the mechanisms by which human dermis does not significantly contribute to the rejection of allo-skin grafts.

The dermis is an important element in skin substitutes and in allo- or xeno-skin grafts. However, the reason(s) why dermis does not significantly induce the immune rejection reaction in vivo remain(s) hitherto unknown. To clarify the mechanisms underlying this phenomenon, we undertook the evaluation of: (i) the response of the peripheral blood mononuclear cells (PBM) to isolated allo-dermal cells or to pieces of or to whole allo-dermis, (ii) the migration and homing of the PBM inside allo-dermis or split thickness allo-skin, (iii) the distribution of the ICAM-1 protein within skin, and (iv) the features expressed by the PBM that migrate into allo-skin. The results herein presented show that (1) the isolated allo-dermal cells had the highest and the whole allo-dermis the lowest capacity to initiate the reactive proliferation of the PBM in vitro; (2) in an allo-skin/PBM co-culture model, most of the PBM slowly, yet preferentially, migrated to and homed inside the allo-epidermal compartment, instead of staying in the allo-dermis; (3) under the conditions employed, rather little ICAM-1 could be immunohistochemically detected within the epidermis, conversely, both the dermal cells and the dermal matrix were ICAM-1 positive; and (4) most of the PBM migrating into the allo-skin pieces expressed either the CD18 or the CD19 or the CD8 molecule, yet very few of them exhibited the LFA-1-antigen, and none of them were found to be CD4 positive.2+Therefore, we conclude that because

Benign "metastatic" cellular blue nevus.

This report illustrates the case of a patient with a pigmented lesion on the dorsal skin of his left foot associated with a bulky homolateral inguinal mass. A metastatic melanoma was clinically suspected; therefore, the pigmented foot lesion was excised and grafted, and the groin mass was dissected. The histological examination of the foot lesion revealed a well-preserved epidermal layer, beneath which spindle cells endowed with regular nuclei yet without any atypia or mitotic figures, were present. Melanin-rich histiocytes surrounded the nerve fibers and the vessels that intermingled with such spindle cells. Under light microscopy, the sections of the inguinal lymph nodes revealed clusters of pigmented cells that looked very much like those found in the foot skin lesion. These spindle-shaped cells infiltrated the nodes' capsule and peripheral sinuses and left the inner parenchyma unaltered. The inguinal mass revealed a thick, fibrous capsule surrounding a heavily pigmented tissue rich with blue nevus cells with islands of melanophages. In the case presented here, the differential diagnosis between cellular blue nevus and nodular melanoma was mandatory. In this case report, we provide the differential diagnosis and review the criteria used for it. Further support for the diagnosis was obtained from immunohistochemical findings that were positive for S-100 protein and not for HMB-45. Wide but conservative surgery appears to be the treatment of choice for cellular blue nevus. In fact, the patient described here is still alive 5 years postoperatively. Hence, the clinical evolution of the patient's lesions can be considered benign.

[Intra-oral cancer: immediate reconstruction using a free radial forearm flap]. / Le neoplasie del cavo orale: ricostruzione immediata con lembo libero antibrachiale.

The radial forearm flaps is ideal for intra-oral reconstruction. In that it offers thin, pliable, hairless skin to replace oral mucosa removed during wide resection in surgical treatment of cancer. The vascularity of the area allows considerable variation in design and size of the flap and offers the possibility of covering structures on different levels and, when bone is included, of carrying out immediate reconstruction of the mandible. The Authors used this flap in 24 patients for intra-oral reconstruction. The ages of the subjects ranged from 30 to 70 years. The arteries and the veins of the flap used for microsurgical anastomosis were radial arteries and superficial veins of the elbow. Neck vessels were superior arteries of the thyroid and jugularis externa vein. Operating time was slightly prolonged when compared to repair employing a myocutaneous island flap. This reconstruction method was completely successful in all 24 patients; in one patient a DIC partially compromised the vascularity of the flap on day 8. Morbidity was observed, resouled, however, with minor surgical procedures. Our results support the choice of this method for intraoral reconstruction.

Donor's and recipient's antigen presenting cells co-operatively enhance the allo-reactive proliferation of peripheral blood lymphocytes.

Antigen-presenting cells (APC) play important roles in the allo-reactive proliferation of T cells in vitro and in the allo-graft rejection in vivo. This work was aimed at establishing whether a co-operation of any kind occurs between donor's and recipient's APC during allo-reactions, and whether certain cell surface molecules, such as beta 2-microglobulin (beta 2m) and human leucocyte antigens (HLA), are involved in such an interaction. The data herein reported show that the allo-reactive proliferation of peripheral blood lymphocytes (PBL) is markedly intensified by a positive co-operation between donor's and recipient's APC. Such a synergistic co-stimulatory action can be significantly hindered by a monoclonal antibody aimed against beta 2m while being not changed by monoclonal antibodies binding to either HLA-A-B-C or HLA-DR molecules. Hence, our preliminary results indicate that a positive interaction between donor's and recipient's APC may be of importance for allo-graft rejection.

A novel approach to extend the survival of skin xenografts without entailing general immunosuppression or systemic toxicity.

The feasibility of using antigenically disguised skin xenotransplants to cover extensive burns for a suitable time lag without administering immunosuppressive drugs was tested experimentally. Pieces of human skin that had been preincubated for 3 h at 37 degrees C with either mouse anti-human beta 2-microglobulin monoclonal antibody (beta 2m-McAb) or PBS (controls) were grafted onto the backs of immunologically competent Swiss mice, and the time required for their rejection or substitution by normal autogenous skin was determined. Thus, it was found that the beta 2m-McAb-pretreated xenografts had a significantly longer mean survival time than the control grafts. An even longer skin xenograft MST was obtained when beta 2m-McAb was repeatedly injected, at weekly intervals, just beneath the transplants. Parallel immunohistochemical studies showed that the beta 2m-McAb entered the grafts and was bound to its targets both in epidermis and dermis. Moreover, a small amount of beta 2m-McAb administered at the outset significantly hindered the reactive proliferation of primed mouse spleen cells cultured in the presence of human epidermal cells. Finally, neither toxic effects nor a weakening of immune competence were elicited by repeated intraperitoneal injections of beta 2m-McAb. Therefore, it seems expedient to propose the use of beta 2m-McAb to delay the rejection of skin xenografts as this antibody harmlessly prevents, wholly or in part, the activation of the recipients' lymphocytes. This would positively aid any patient urgently needing xenograft cover of extensive burns.

Merkel-cell carcinoma of the skin.

Three cases of Merkel-cell carcinoma of the skin have been presented. The need for a correct clinical and histologic diagnosis has been highlighted. Rapid widespread growth of the tumor occurs when surgical treatment is delayed. Immunohistochemistry is essential for accurate differential diagnosis.

Monitoring of elastase in plasma of burned patients in relation to other inflammation parameters.

Twenty burned patients divided in three groups according to the severity of the lesions were investigated at 1- or 2-day intervals for up to 5 weeks after injury. Plasma elastase levels were elevated during the first day after injury and were correlated with the area of the burns. However, plasma elastase was rapidly bound and inactivated by protease inhibitors. Leucocyte counts, fever and the concentration of alpha-1-proteinase inhibitor were not correlated with the extent of the burn. The rise of plasma elastase was not accompanied by consumption of the elastase inhibitory capacity (EIC) of plasma, which increased to a plateau around day 5. The EIC values were in accord with the rise of alpha-1-proteinase inhibitor, the major anti-elastase agent in plasma. Studies of blister fluid in eight patients showed that the elastase content was higher than that of corresponding plasma, while the concentration of alpha 1-proteinase inhibitor and the EIC were comparable with those of plasma. Measurements of the levels of tumour necrosis factor released by stimulated macrophages in five patients with major burns showed no significant increase compared with controls.