Is there a risk for bacterial transmission from surgical marker pens?

Markers for preoperative skin marking are used several times and bear a risk of transmitting bacteria. Bacterial contamination was assessed by sonication and culture. Antimicrobial susceptibility testing (AST) was performed for facultative pathogens to assess multi-drug resistance (MDR). An accelerated failure time model was applied to assess the statistical relationship between the bacterial contamination and the filling status of markers. Of 45 markers, 13 had a colony count <10 cfu/mL and 32 had counts from 10 to 12,500 cfu/mL. Three markers were colonized by Staphylococcus aureus. No MDR bacteria were found. We recommend single use of markers to reduce transmission risk.

Does the time interval between sentinel lymph node biopsy and completion lymph node dissection affect outcome in malignant melanoma? A retrospective cohort study.

Nodal clearance was recommended after positive sentinel lymph node biopsy (SLNB) despite further metastases to the regional lymph node basin being found in only 6-21% in the literature. This retrospective study was conducted to determine the role of the time interval between excision of primary melanoma and confirmed metastasis in the sentinel lymph node biopsy as well as the one between positive sentinel lymph node biopsy (SLNB-positive patients) and subsequent completion lymph node dissection (CLND) on the presence of metastases. The monocentric analysis included 121 patients with a history of completion lymph node dissection after positive SLNB from January 2005 to October 2013. Additional metastases in the regional lymph node basin (non-sentinels) were found in 14.05% (n = 17). Significant risk factors for the presence of metastases in CLND were the time between confirmed primary tumour to metastasis in sentinel lymph nodes (SLN) (p = 0.0034), N-category of TNM-classification (p = 0.0066) and independent of thickness of primary tumour (p = 0.11). If SLNB was performed up to forty-three days after confirmed primary melanoma, subsequent lymph node dissection was positive in less than 9.1%. When SLNB was performed with a delay of more than 80 days, all patients had metastases in the CLND specimens. Our data analysis suggests that delays in subsequent procedures of SLNB after diagnosis of primary melanoma may have a greater impact on positivity of non-sentinel lymph nodes than previously assumed. Our retrospective analysis may indicate the reconsideration of time schedule in the management of primary melanoma to potentially avoid local relapse in the draining lymph node region after positive SLNB.

Viability of five different pre- and intraoperative imaging methods for autologous breast reconstruction.

BACKGROUND: Autologous breast reconstruction is an integral part in the treatment of breast cancer. While computed tomography angiography (CTA) is an established preoperative diagnostic tool for microsurgeons, no study has so far evaluated and compared five different imaging methods and their value for the reconstructive team. In order to determine the feasibility of each of the tools for routine or specialized diagnostic application, the methods' efficiency and informative value were analyzed. METHODS: We retrospectively analyzed imaging data of 41 patients used for perforator location and assessment for regional perfusion and vessel patency in patients undergoing autologous breast reconstruction with deep inferior epigastric perforator flap (DIEP), transverse rectus abdominis muscle flap (TRAM), or transverse myocutaneous gracilis flap (TMG). Five different imaging techniques were used: hand held Doppler (HHD), CT angiography (CTA), macroscopic indocyanine green (ICG) video angiography, microscope-integrated ICG video angiography, and laser Doppler imaging (LDI). RESULTS: CTA proved to be the best tool for preoperative determination of the highly variable anatomy of the abdominal region, whereas HHD showed the same information on perforator localization with some false-positive results. Intraoperative HHD was an excellent tool for dissection and vessel patency judgment. Microscope-integrated ICG was an excellent tool to document the patency of microanastomoses. In our series, macroscopic perfusion measurement with ICG or LDI was only justified in special situations, where information on perfusion of abdominal or mastectomy flaps was required. LDI did not add any additional information. CONCLUSION: Preoperative assessment should be performed by CTA with verification of the perforator location by HHD. Intraoperative HHD and microscope-integrated ICG contribute most toward the evaluation of vessel patency. ICG and LDI should only be used for special indications.

[Thermal injuries in the OEAMTC air rescue service. Epidemiological characteristics of burns/scalds in children and adults]. / Thermische Verletzungen in der ÖAMTC-Luftrettung. Einsatzcharakteristika bei Verbrennungen/Verbrühungen von Kindern und Erwachsenen.

BACKGROUND: Few data exist on the epidemiological characteristics of thermal injuries in prehospital emergency care, especially in the context of air rescue. Therefore, this study aimed to analyze the epidemiology of pediatric and adult thermal injuries in the helicopter emergency medical service (HEMS) run by the Austrian Automobile Motorcycle Touring Club (OEAMTC) air rescue service from an almost nationwide sample. METHODS: All OEAMTC-HEMS rescue missions flown for thermal injuries in 2009 were retrospectively reviewed. Primary (n=88) and secondary missions (n=17) were collated and all primary missions were analyzed in detail. RESULTS: In total 71 out of 16,100 (0.4 %) primary HEMS rescue missions were for patients suffering from burns or scalds (children n=27, adults n=44). The proportion of major burns (burns covering >20 % of the total body surface area) was 40.7 % in children and 54.5 % in adults, 44 (62 %) burn/scald injuries were related to the head/neck, 37 (52.1 %) to the upper limbs and 10 (14.1 %) to the anogenital region. More than half of the victims (63.4%) suffered potentially life-threatening injury. CONCLUSIONS: In HEMS thermal injuries are infrequent but mostly life-threatening. Differences in epidemiological characteristics of pediatric and adult burns/scalds may have important operational, training and public health implications.

Smartphones and burn size estimation: "Rapid Burn Assessor".

Estimation of the total body surface area burned (%TBSA) following a burn injury is used in determining whether to transfer the patient to a burn center and the required fluid resuscitation volumes. Unfortunately, the commonly applied methods of estimation have revealed inaccuracies, which are mostly related to human error. To calculate the %TBSA (quotient), it is necessary to divide the burned surface area (Burned BSA) (numerator in cm2) by the total body surface area (Total BSA) (denominator in cm2). By using everyday objects (eg. credit cards, smartphones) with well-defined surface areas as reference for estimations of Burned BSA on the one hand and established formulas for Total BSA calculation on the other (eg. Mosteller), we propose an approximation method to assess %TBSA more accurately than the established methods. To facilitate distribution, and respective user feedback, we have developed a smartphone app integrating all of the above parameters, available on popular mobile device platforms. This method represents a simple and ready-to-use clinical decision support system which addresses common errors associated with estimations of Burned BSA (=numerator). Following validation and respective user feedback, it could be deployed for testing in future clinical trials. This study has a level of evidence of IV and is a brief report based on clinical observation, which points to further study.

L'estimation de la totale de la surface corporelle brûlée (% de la SCT) à la suite d'une brûlure est importante en déterminant le transfert du patient vers un centre de brûlés et les volumes nécessaires des fluides de réanimation. Malheureusement, les méthodes d'estimation couramment appliquées ont révélé des inexactitudes, qui sont principalement liés à l'erreur humaine. Pour calculer le % de la SCT il faut diviser la surface brûlée (numérateur en cm2) de la surface corporelle totale (dénominateur en cm2). En utilisant des objets du quotidien (par exemple cartes de crédit et smartphones) avec des surfaces bien définies comme référence pour les estimations de la SC brûlée d'une part, et des formules établies pour le calcul de la SC totale sur l'autre (par exemple Mosteller), nous proposons une méthode d'approximation d'évaluer le % de la SCT brûlée plus de précision que les méthodes établies. Pour faciliter la distribution, et les commentaires des utilisateurs, nous avons développé une application intégrant tous les paramètres ci-dessus, disponibles sur les plates-formes d'appareils mobiles populaires. Cette méthode représente un système simple et prêt à l'emploi aide à la décision clinique qui traite les erreurs courantes associées aux estimations de BSA brûlé (= numérateur). Après la validation et la rétroaction des utilisateurs, il pourrait être déployé pour les tests dans les futurs essais cliniques. Cette étude a un niveau de preuve IV et elle présente un bref rapport basé sur l'observation clinique, qui pointe vers une étude plus approfondie.

The use of telemedicine in burn care: development of a mobile system for TBSA documentation and remote assessment.

The requirements for accurate documentation within the process of burn assessment have increased dramatically over the years. TBSA (total body surface area) and burn depth are commonly determined by visual inspection, especially in the emergency or acute care setting. However, inexperience often results in incorrect estimation of these factors. In 2001, BurnCase 3D was initiated in order to develop a tool for objective burn assessment and documentation on mobile devices (Apple iPhoneTM). The centerpiece is a 3D model representing the actual patient. At two international burn meetings, a survey containing three pictures of patients was conducted and this data was collected. A patient-specific 3D model adapted to the height and weight of the real patient was created and the digital picture was superimposed in the computer system. The burns were transferred to the model and the TBSA in % was calculated by the software BurnCase 3D. The preferred methods of the 80 respondents for burn extent estimation were: the Rule of Nines (38%), the Rule of Palm (37%) and the Lund-Browder chart (18%). Analysis showed very high deviations of TBSA within the participants, even among the group of experts. In comparison to a computer-aided method we found massive overestimation of up to 230%. The use of BurnCase 3D could have a true impact on the quality of treatment in burns. In the acute care setting for burn injuries, telemedicine has great potential to help guide decisions regarding triage and transfer based on TBSA, burn depth, patient age and injury mechanism.

Les exigences en matière de documentation précise dans le processus de l'évaluation des brûlures ont augmenté de façon spectaculaire au cours des années. La SCT (surface corporelle totale) et la profondeur de la brûlure sont généralement déterminées par inspection visuelle, en particulier dans le contexte d'urgence ou de soins aigus. Cependant, l'inexpérience se traduit souvent par une estimation incorrecte de ces facteurs. En 2001, BurnCase 3D a été lancé afin de développer un outil d'évaluation des brûlures objectif et de la documentation sur les appareils mobiles d'Apple (iPhone™). La pièce maîtresse est un modèle 3D représentant le patient réel. Sur deux réunions de brûlures internationales, une enquête contenant trois photos de patients a été réalisée. Ces données ont été collectées. Un modèle 3D spécifique au patient adapté à la taille et le poids du patient réel a été créé et l'image a été superposée dans le système informatique. Les brûlures ont été transférés dans le modèle et le % de la surface corporelle totale a été calculé par le logiciel BurnCase 3D. Les méthodes préférées des 80 répondants pour l'estimation de la taille de la brûlure étaient : la règle des neuf (38%), la règle des palm (37%) et les tables de Lund et Browder (18%). L'analyse montre des écarts très élevés de SCT dans les participants, même parmi le groupe d'experts. Par rapport à un procédé assisté par ordinateur, nous avons trouvé surestimation massive de jusqu'à 230%. L'utilisation de BurnCase 3D pourrait avoir un véritable impact sur la qualité du traitement des brûlures. Dans le cadre de soins de courte durée pour les brûlures, la télémédecine a un grand potentiel pour aider à guider les décisions concernant le triage et le transfert sur la base de la SCT et la profondeur de la brûlure, l'âge du patient et le mécanisme de blessure.

Skin graft fixation in severe burns: use of topical negative pressure.

Over the last 50 years, the evolution of burn care has led to a significant decrease in mortality. The biggest impact on survival has been the change in the approach to burn surgery. Early excision and grafting has become a standard of care for the majority of patients with deep burns; the survival of a given patient suffering from major burns is invariably linked to the take rate and survival of skin grafts. The application of topical negative pressure (TNP) therapy devices has demonstrated improved graft take in comparison to conventional dressing methods alone. The aim of this study was to analyze the impact of TNP therapy on skin graft fixation in large burns. In all patients, we applied TNP dressings covering a %TBSA of >25. The following parameters were recorded and documented using BurnCase 3D: age, gender, %TBSA, burn depth, hospital length-of-stay, Baux score, survival, as well as duration and incidence of TNP dressings. After a burn depth adapted wound debridement, coverage was simultaneously performed using split-thickness skin grafts, which were fixed with staples and covered with fatty gauzes and TNP foam. The TNP foam was again fixed with staples to prevent displacement and finally covered with the supplied transparent adhesive film. A continuous subatmospheric pressure between 75-120 mm Hg was applied (VAC®, KCI, Vienna, Austria). The first dressing change was performed on day 4. Thirty-six out of 37 patients, suffering from full thickness burns, were discharged with complete wound closure; only one patient succumbed to their injuries. The overall skin graft take rate was over 95%. In conclusion, we consider that split thickness skin graft fixation by TNP is an efficient method in major burns, notably in areas with irregular wound surfaces or subject to movement (e.g. joint proximity), and is worth considering for the treatment of aged patients.

Au cours des 50 dernières années, l'évolution des soins de brûlure a conduit à une diminution significative de la mortalité. Le plus grand impact sur la survie a été le changement dans l'approche de la chirurgie. L'excision précoce et la greffe sont devenues une norme de soins pour la majorité des patients atteints de brûlures profondes; la survie chez les grands brûlés est invariablement liée à la taux de prise et à la survie des greffes de peau. L'application de la pression négative topique (PNT) a démontré une amélioration dans la prise des greffes par rapport aux méthodes conventionnelles. Le but de cette étude était d'analyser l'impact du traitement de PNT sur la prise des greffes de peau dans les grandes brûlures. Chez tous les patients, nous avons appliqué des pansements PNT, couvrant à moins 25% de la SCT. Les paramètres suivants ont été enregistrés et documentés via "BurnCase 3D" : âge, sexe, % de la SCT, profondeur de brûlure, durée de séjour à l'hôpital, le score Baux, survie, ainsi que la durée et la fréquence des pansements PNT. Après le débridement des plaies, la couverture était simultanément réalisée à l'aide de greffes de peau de demi-épaisseur, qui ont été fixées avec des agrafes et couvertes de toiles gras et de mousse de PNT. La mousse PNT a été de nouveau fixée avec des agrafes pour empêcher le déplacement et finalement recouverte avec le film adhésif transparent. Une pression atmosphérique continue entre 75 à 120 mm Hg a été appliquée (VAC®, KCI, Vienne, Autriche). Le premier changement de pansement a été effectué pendant le quatrième jour. Trente-six des 37 patients, souffrant de brûlures au troisième degré, ont obtenu leur congé avec la fermeture complète de la plaie ; un seul patient a succombé à ses blessures. Le taux de la prise des greffes de peau était supérieur à 95%. La greffe de peau mince par PNT est une méthode efficace dans les grandes brûlures, notamment dans les zones avec des surfaces irrégulières et des zones soumises à un mouvement (par exemple, de proximité joint), et est à considérer pour le traitement des patients âgés.

The real expansion rate of meshers and micrografts: things we should keep in mind.

Skin graft expansion techniques (mesh and micrograft) are widely used, but there is ample evidence that skin graft meshers do not provide their claimed expansion rates. Although this finding might not be new for the majority of surgeons, less is known about surgeons' actual knowledge of expansion rates. The aim of this study was to evaluate the true expansion rates of commonly used expansion techniques with regard to claimed, achieved, and polled results. In the first part of the study, 54 surgeons were polled during an annual burns meeting regarding the most commonly used expansion techniques and expansion ratios; in the second step the true (achievable) expansion rates of the most widely used meshers and micrografts were analysed; and in third step, a poll involving 40 surgeons was conducted to estimate the true expansion rates of the most frequently used skin expansion techniques. The skin meshers (1:1.5 / 1:3) did not achieve their claimed values: (1:1.5) 84.7% of the claimed expansion (mean ± SD: 1:1.27 ± 0.15) and (1:3) 53.1% of the 1:3 (1:1.59 ± 0.15) mesher. The use of the micrografting technique resulted in 99.8% of the 1:3 (1:2.99 ± 0.09), 93.6% of the 1:4 (1:3.74 ± 0.12) and 93.8% of the 1:6 (1:5.63 ± 0.12) claimed expansion rates, respectively. In general the surgeons overestimated the achievable expansion rates. In general the achieved expansion rate was lower than the estimated and claimed expansion rates. The micrografting technique provided reliable and valid expansion rates compared to the skin meshers. We recommend using the micrograft technique when large expansion ratios are required, for example in severe extensive burns.

Les techniques pour l'extension des greffes cutanées (en filet ou microgreffes) sont largement utilisées, mais il est amplement prouvé que les greffes cutanées en filet ne correspondent aux taux d'expansion réclamés. Il est bien possible que cette constatation ne constitue pas rien de nouveau pour les chirurgiens, mais nous savons encore moins des connaissances réelles des chirurgiens pour ce qui concerne cette matière. Le but de cette étude était d'évaluer l'exact taux d'expansion des techniques d'expansion couramment utilisées à l'égard des résultats revendiqués, réalisés et soumis à sondage. Dans la première partie de l'étude, 54 chirurgiens ont été interrogés lors d'une réunion annuelle des brûlologues sur les techniques d'expansion les plus utilisées et les rapports d'expansion. Dans la deuxième étape, les taux effectifs d'extension (possibles) des greffes en filet et les microgreffes les plus utilisés ont été analysés. Dans la troisième étape, un sondage auprès de 40 chirurgiens a été réalisé pour évaluer les taux effectifs des techniques d'expansion cutanée les plus utilisées. Les greffes en filet évaluées (1 : 1,5 / 1:3) en effet n'atteignaient pas les valeurs revendiquées: 1:1,5 = 84,7% de l'expansion revendiquée (moyenne ± écart-type = 1:1.27 ± 0,15) et 1:3 = 53,1% du mesher 1:3 (1:1.59 ± 0,15). L'utilisation de la technique de la microgreffe a produit des taux revendiqués d'expansion de 99,8% dans le cas de 1:3 (1:2,99 ± 0,09), de 93,6% dans le cas de 1:4 (1:3,74 ± 0,12) et de 93,8% dans le cas de 1:6 (1:5.63 ± 0,12). En général, les chirurgiens ont surestimé les taux d'expansion réalisables. Ainsi, toutes choses considérées, le taux d'expansion effectivement réalisé était inférieur aux divers taux d'expansion estimés et revendiqués. Les microgreffes montraient des taux d'expansion fiables et valides par rapport aux greffes en filet. Les Auteurs recommandent l'utilisation de la technique de la microgreffe quand il faut obtenir un rapport d'expansion élevé, par exemple dans le cas de brûlures graves de grande extension.

The determination of total burn surface area: How much difference?

Burn depth and burn size are crucial determinants for assessing patients suffering from burns. Therefore, a correct evaluation of these factors is optimal for adapting the appropriate treatment in modern burn care. Burn surface assessment is subject to considerable differences among clinicians. This work investigated the accuracy among experts based on conventional surface estimation methods (e.g. "Rule of Palm", "Rule of Nines" or "Lund-Browder Chart"). The estimation results were compared to a computer-based evaluation method. Survey data was collected during one national and one international burn conference. The poll confirmed deviations of burn depth/size estimates of up to 62% in relation to the mean value of all participants. In comparison to the computer-based method, overestimation of up to 161% was found. We suggest introducing improved methods for burn depth/size assessment in clinical routine in order to efficiently allocate and distribute the available resources for practicing burn care.

The properties of the "ideal" donor site dressing: results of a worldwide online survey.

Split skin grafting is a widely used technique for reconstructing skin defects. Although a vast number of different coverage options for donor sites have become available in daily clinical practice, no optimum dressing material has been found to date. For this reason, we conducted a globally-distributed online survey to poll for the properties of such an "ideal" donor site dressing, possibly leading to an improved clinically-driven direction of future wound dressing developments. A total of 69 respondents from 34 countries took part in the questionnaire, resulting in a response rate of 13.8% (69/500) over a 1-month period. The majority of respondents rated the characteristics of an "ideal" donor site dressing to be either "essential" or "desirable" as follows: lack of adhesion to the wound bed ("essential": 31/69, 44.9%; "desirable": 30/69, 43.5%); pain-free dressing changes ("essential": 38/69, 55.1%; "desirable": 30/69, 43.5%); absorbency ("essential": 27/69, 39.1%; "desirable": 33/69, 47.8%); ease of removal ("essential": 37/69, 53.6%; "desirable": 27/69, 39.13%). With regard to the desired frequency of dressing changes, respondents preferred "no dressing change until the donor site has healed" (51/69, 73.9%) in the majority of cases, followed by "twice weekly" (10/69, 14.5%), "alternate days" (5/69, 7.2%) and "daily" (3/69, 4.3%). With regard to the design of the dressing material, the majority of participants preferred a one-piece (composite) dressing product (44/69, 63.8%). The majority of respondents also denied the current availability of an "ideal" donor site dressing (49/69, 71%). The strength of this study was the remarkable geographic distribution of responses; all parts of the world were included and participated. We believe that this globally conducted online survey has polled for the properties of the "ideal" donor site dressing and possibly will lead to an improved clinically-driven direction of future wound dressing development.

Les greffes de peau mince sont largement utilisées pour reconstruire les défauts de la peau. Même si un grand nombre de différentes options de couverture des sites donneurs sont devenus disponibles dans la pratique clinique quotidienne, à ce jour, aucun matériel de pansement optimum n'a été trouvé. Pour cette raison, nous avons mené un sondage en ligne mondialement distribué à scrutin pour les propriétés d'un tel pansement de site donneur «idéal¼, qui peut conduire à une meilleure direction en ce qui concerne des futurs développements de pansement. Un total de 69 répondants de 34 pays ont été inclus dans le questionnaire, soit un taux de réponse de 13,8% (69/500) sur une période de 1 mois. La majorité des répondants ont évalué les caractéristiques d'un pansement «idéal¼ pour les sites donneurs d'être «essentiel¼ ou «souhaitable¼ comme suit: le manque d'adhérence au lit de la plaie («essentiel¼: 31/69, 44,9%; «souhaitable¼ : 30/69, 43,5%), le changement de pansement sans douleur («essentiel¼: 38/69, 55,1%; «souhaitable¼: 30/69, 43,5%); l'absorption («essentiel¼: 27/69, 39,1% ; «souhaitable¼: 33/69, 47,8%), la facilité de retrait («essentiel¼: 37/69, 53,6%; «souhaitable¼: 27/69, 39.13%), par rapport à la fréquence souhaitée des changements de pansements, les répondants préféraient «aucun changement de pansement jusqu'à ce que le site donneur est guéri¼ (51/69, 73,9%) dans la majorité des cas, suivi par «deux fois par semaine¼ (10/69, 14,5%), «deux jours¼ (5/69 , 7,2%) et «quotidienne¼ (3/69, 4,3%). En ce qui concerne la conception du matériel de pansement, la majorité des participants ont préféré une seule pièce (composite) (44/69, 63,8%). La majorité des répondants a également nié l'existence actuelle d'un pansement au site donneur «idéal¼ (49/69, 71%). La force de cette étude est la répartition géographique remarquable de réponses ; toutes les parties du monde ont été inclus et ont participé. Nous croyons que cette enquête en ligne, menée au niveau mondial, concernant les propriétés du pansement «idéal¼ pour les sites donneurs se traduira, éventuellement, par une amélioration future dans le développement des pansements.

The epidemiology of amputation injuries in the Austrian helicopter emergency medical service: a retrospective, nationwide cohort study.

PURPOSE: Data on the epidemiological characteristics of traumatic amputations in prehospital emergency care, especially in the context of air rescue, are scarce. Therefore, we aimed to describe the epidemiology of total and subtotal amputation injuries encountered by the OEAMTC helicopter emergency medical service (HEMS) in Austria, based on an almost nationwide sample. METHODS: We retrospectively reviewed all HEMS rescue missions flown for amputation injuries in 2009. Only primary missions were analyzed. RESULTS: In total, 149 out of 16,100 (0.9 %) primary HEMS rescue missions were for patients suffering from amputation injuries. Among these, HEMS physicians diagnosed 63.3 % (n = 94) total and 36.9 % (n = 55) subtotal amputations, with both groups showing a predominance of male victims (male:female ratios were 8:1 and 6:1, respectively).The highest rate occurred among adults between 45 and 64 years of age (35.6 %, n = 53). The most common causes were working with a circular saw (28.9 %, n = 43) and processing wood (16.8 %, n = 25). The majority of the cases included digital amputation injuries (77.2 %, n = 115) that were mainly related to the index finger (36.2 %, n = 54). One hundred forty patients (94.0 %) showed a total GCS of more than 12. Amputations were most prevalent in rural areas (84.6 %, n = 126) and between Thursday and Saturday (55.0 %, n = 82). The replantation rate after primary air transport was low (28 %). CONCLUSIONS: In the HEMS, amputation injuries are infrequent and mostly not life-threatening. However, HEMS crews need to maintain their focus on providing sufficient and fast primary care while facilitating rapid transport to a specialized hospital. The knowledge of the epidemiological characteristics of amputation injuries encountered in the HEMS gained in this study may be useful for educational and operational purposes.

Evaluation of the online-presence (homepage) of burn units/burn centers in Germany, Austria and Switzerland.

PURPOSE: A successful online presence is an important key factor in the competition among hospitals today. However, little is known about the internet presence and the quality of websites of burn units on the World Wide Web. The aim was to assess the online presence of hospitals provided by specialized burn units in German speaking countries with a focus on the rate and the performance of actively run websites. METHODS: A multicenter, observational, cross-sectional study was performed over a period of 1.5 month (October-December 2010). Forty-four burn units were assessed by using a previously generated criteria list. The list included 36 criteria with following topics: "research and teaching"; "patient care"; "clinical emphases", "general information"; "information brokerage". RESULTS: Overall, the websites examined offered a good overview about their different online services with many multimedia-based elements included. All websites consisted of hyperlinks, general multimedia-based elements and information on means of communication with the hospital, respectively. In contrast, the quality of specific information for burn patients was relatively poor. With regard to the need of elderly people, the usability and the layout, the different websites offer a lot of options for future improvements. CONCLUSION: Burn centers in Germany, Austria and Switzerland already consider the World Wide Web as an important tool for self-promotion and communication. The potential of burn center websites to function as a knowledge base for first aid as well as preventive measurements should be considered and realized in future web site designs.

The use of Suprathel(®) in deep dermal burns: first results of a prospective study.

INTRODUCTION: While autologous skin grafting has been the standard for coverage of full-thickness areas, several options for deep-partial-thickness defects exist. With regard to economising donor sites, we compared a copolymer based on DL-lactid acid (Suprathel(®)) as temporary wound dressing with autologous skin, and analysed time to healing and scar quality in matched areas of deep-partial-thickness burn. METHODS: We recruited 18 patients with a median age of 45 years (range: 25-83 years), for this prospective, non-blinded controlled non-inferiority study, suffering from deep-partial-thickness burns from November 2009 to July 2010. After early tangential excision, matched deep-partial-thickness areas were covered with 1:1.5 meshed autologous skin grafts and the copolymer for direct intra-individual comparison. Scars were evaluated by means of the Vancouver Scar Scale (VSS), the Patient and Observer Scar Assessment Scale (POSAS) and suction cutometry (MPA 580, Courage and Khazaka Electronic GmbH, Cologne, Germany) on days 30 and 90, postoperatively. RESULTS: Fifteen days after surgery, complete wound closure was present in 44.4% (8/18) of all areas covered with copolymer and 88.9% (16/18) in the split-thickness skin graft (STSG) area (p=0.008). Evaluation of the total VSS, POSAS and cutometry satisfied the criterion of non-inferiority for Suprathel(®) on day 30. Ninety days after surgery, only the Observer Scar Scale showed that Suprathel is non-inferior to STSG, albeit the mean total VSS and Patient Scar Scale were better in Suprathel(®) areas. CONCLUSION: Suprathel(®) represents a solid, reliable epidermal skin substitute with longer healing times in comparison to skin grafts but comparable results concerning early scar formation. Suprathel(®) can serve as a tool in treatment portfolio for adult patients suffering from deep dermal burns. Especially in patients with extensive burns, Suprathel(®) can be used to cover the deep dermal burn wounds to save STSGs and its donor sites for the coverage of full-thickness burned areas.

Emotional associations with skin: differences between burned and non-burned individuals.

INTRODUCTION: The appearance of skin is crucial for our physical and psychological integrity, and is strongly associated with our emotional self-awareness. Burn victims have to cope with negative and even threatening sensations resulting from the changed appearance of their skin after injury and also linked to experiences during the treatment. The aim of this study was to analyse differences regarding the emotional associations with skin in burn victims (burn group) to persons not having subdued any burn (control group). METHODS: In the first instance over 960 volunteers were recruited for the rating of emotional associations with skin in the control group and thereby a representative profile for non-injured individuals. In the second part, 44 burn patients of the Vienna Burn Center answered the same questionnaire. The quantitative rating of emotional associations with skin was performed with a newly designed questionnaire using a semantic differential on eight dimensions with a 5-point scale system. RESULTS: Both groups have positive associations with skin. One significant difference (p=0.0090, Chi-square test for trend) was the overall rating of the item "importance": for burn victims skin is more "important" than for controls. Patients with visible burns tended to put more emphasize on the possible exposure to danger ("threatened") of skin, and patients with >/=20% TBSA rated skin as more "noticeable" and "strong" as compared to small burns (<20% TBSA). Patients with burns to the face, hands and neck ("visible burns") were more likely to judge skin as threatened item. DISCUSSION: Our poll suggests that despite long treatment, rehabilitation and even near-death experiences burn patients continue to have positive associations with skin. This in turn, should encourage all specialists dealing with burns to engage in a continuous follow-up as well as enhance psychological and social support.

The treatment of deep dermal hand burns: How do we achieve better results? Should we use allogeneic keratinocytes or skin grafts?

The treatment of deep dermal burns has a broad spectrum and has been subject to discussion over the past years. The treatment of hand burns is challenging due to the high requirements to aesthetic and functional outcome. 27 patients, 7 women and 20 men with deep dermal hand burns with a mean age of 41.3+/-16.5 and a mean TBSA of 15%+/-19.6% were treated either with allogeneic cryopreserved keratinocytes or with split skin grafts. Long-term follow-up revealed no statistical significant differences between the two groups concerning Vancouver Scar Scale as well as hand function judged by the DASH score; however there was a tendency to higher VSS scores and impaired aesthetic results in the keratinocyte group. Allogeneic keratinocytes are a suitable armentarium for the treatment of deep dermal hand burns; and, if used correctly, they can produce a timely healing comparable to split-thickness skin grafts. Limited availability, high costs as well as the need for special skills are key factors, which render application of this technique outside specialist burn centres virtually impossible. In our opinion, the cultivation and use of keratinocytes should be reserved to these centres in order to facilitate a sensible application for a full range of indications. We recommend usage of allogeneic keratinocytes for deep dermal hand burns only in severely burned patients with a lack of donor sites. Patients with unrestricted availability of donor sites seem to profit from the application of split-thickness skin grafts according to our results.

Burn treatment in the elderly.

The population of elderly patients is expected to rise continuously over the next decades due to global demographic changes. The elderly seem to be most vulnerable to burns and their management remains undoubtedly a challenge. A clear age margin for elderly patients is not yet defined, but most studies adhere to the inclusion of patients 65 years and above, but the general condition and social situation must be taken into account. The understanding of the physiological basis of aging and its related pathophysiological changes has only marginally influenced treatment and decision making in elderly burn patients. When looking at treatment regimens currently applied in elderly burn patients, the discussion of standards in intensive care as well as surgical strategies is ongoing. However, trends towards a moderate, non-aggressive resuscitation approach and careful inclusion of key parameters like physiological age, pre-burn functional status and premorbid conditions, seem to be useful guidelines for interdisciplinary treatment decisions. Once ordered for surgical treatment, the amount of body surface area operated in one session should be adapted to the general status of the patient. Even if older burn victims have a reported higher mortality rate than younger patients, improved therapeutic options have contributed to a reduced mortality rate even in the elderly over the last decades. As a result of improved outcome, more attention has to be given to a comprehensive rehabilitation program. This review will give an overview of the current literature and will draw attention to specific topics related to this important subpopulation of burn patients.

A new diagnostic tool for the classification of patients with self-inflicted burns (SIB): the SIB-Typology and its implications for clinical practice.

Although self-inflicted burns comprise a rather small percentage of patients treated in burn units, they represent a challenging subgroup for the specialist team. According to the literature, these patients, often with a past psychiatric history, remain in the hospital longer due to delayed wound healing, increased number of operative sessions and reduced compliance. The aim of this study was to analyse the incidence of psychiatric disorders and the overall outcome in patients with self-inflicted burns admitted to the Vienna Burn Centre in the past 11 years. We therefore reviewed the following parameters: past psychiatric history, burn extent, burn depth, mechanism of burn, treatment, length of hospital stay, and mortality. Based on our evaluation patients can be grouped into three distinct categories based on a simple two-axis diagram, the Self-Inflicted-Burns-Typology (SIB-T), including the parameters "psychiatric disorder" and "suicide attempt": "typical", "delirious" and "reactive". These three groups seem to differ in treatment outcome and later course of rehabilitation.