[Anterior uveitis caused by electrical discharge in whole body injuries (fifteen years study)]. / Prední uveitida vyvolaná elektrickým výbojem u celotelového poranení (patnáctiletá studie).

AIM: To inform about clinical analysis of early ophthalmologic complication (uveitis) in patients sustained electric discharge injury. STUDY GROUP: The authors refer about fifteen years follow-up of pediatric patients at the Department of Burns Medicine, 3rd Medical Faculty, Charles University in Prague, Czech Republic, E.U., with electric discharge injury, in which the anterior uveitis was detected. Out of 43 patients after electric discharge injury, the always-unilateral iritis (iridocyclitis) was diagnosed in four (9 %) patients according to thorough going follow-up after first accidental diagnosis in the year 1998. Out of four boys aged 12 - 15 years, the first two were injured during the "play" - due to the contact with electrical trolley wire while running on railroad wagons roofs, and the two others were stuck by lighting under a tree by secondary electrical discharge. More serious skin burns were noticed in high-voltage current injury - 69 % or 55 % of body surface respectively, with the necessity of skin transplantation. The same was necessary in one boy injured by lighting with burns of 25 % of body surface, while the last one had on the skin the lighting signs only. In most of the patients, the resuscitation care due to unconsciousness and posttraumatic shock was necessary. The anterior uveitis was diagnosed subsequently, after initial preliminary diagnoses as conjunctivitis, episcleritis, or ophthalmia electrical. The iritis without visual function decrease was discovered in few days after the injury in three patients. Treatment and results: The inflammation was in these cases treated with short-term application of mydriatic and corticosteroid eye drops. Once only, the uveitis appeared after two months during the patients hospitalization and then the signs of iridocyclitis in the anterior chamber worsened and caused visual acuity decrease to hand movement in front of the eye. The condition was successfully treated by means of parabulbar betamethasone injection and long-term application of mydriatic and corticosteroid drops. CONCLUSION: Uveitis in electrical discharge injury of different origin is a rare early complication, which may be determined solely by regular ophthalmologic follow-up examinations of the patients.

Toxic epidermal necrolysis and Stevens-Johnson syndrome at the Prague Burn Centre 1998-2008.

BACKGROUND: Toxic epidermal necrolysis (TEN) and Stevens-Johnson syndrome (SJS) are skin disorders characterized by extensive necrosis of the mucous membranes and the epidermis caused by an autoimmune response. OBJECTIVES: To present experience of treating TEN and SJS at the Prague Burn Centre (PBC) 1998-2008. METHODS: 22 patients with the diagnosis TEN or SJS were enrolled. We collected data including the extent of the skin involvement, the ratio of men:women, the average age, the mortality rate, presence of comorbidities, the length of hospital stay, the period from the first symptoms to the admission to the PBC, corticosteroids administration prior to admission. RESULTS: 82% patients had injuries larger than 30% of body surface area. The ratio of men:women was 1 : 1.5; the average age was 48.4 years; the mortality was 32%. Significant comorbidities were present in 41% of the cases. The average length of hospital stay was 12.9 days. The period from the first symptoms to the admission to the PBC was 9.6 days; corticosteroids were administered to 68% of the cases. CONCLUSION: Treatment strategies at the PBC are based upon a multidisciplinary approach and focus on the general principles of treating patients with extensive skin loss. Corticosteroids must be avoided, antibiotics are not indicated and intravenous immunoglobulins are not justified in the standard therapy. Early diagnosis, prompt transport to a burn center are essential for patients outcomes. The medical community should be informed about these rare but potentially life threatening diseases.

Nutrition in patients with burn injuries in the intensive care unit.

Authors discuss the choices of nutritional support in patient after severe burn injury during the last three decades. Severe burn injury presents one of the most critical states of starvation under a severe stress to the organism. Timely and appropriate metabolic intervention can positively influence the hypermetabolism, which is a common reaction after an injury. Burn injury causes a long-term reaction with a great risk of multiple organ dysfunction (requirement to perform repeated dressing changes under general anesthesia, repeated surgeries, and infections). Incorporation of a nutritional support is based on the knowledge of pathophysiology and metabolic response to injury, and is influenced by choice of nutrition substrates and by possibility of its administration.

Care for children after burn injury.

Authors are summing up basic approach in the treatment of severe burn injury in children. Thorough evaluation of severity of the injury is essential and determines further therapy. In this phase connection between care prior to hospitalization and in hospital is important. During the course of therapy in hospital, interdisciplinary teamwork is essential for the solution of various complications after burn injury. Important part of the care is cooperation with family of the child.

Inhalation trauma in burns, cytology and biochemical findings.

We have followed in a pilot study a group of patients for cytological and biochemical changes of lavage in the upper and lower respiratory system. Into the study patients with respiratory burns confirmed by bronchoscopy and skiagraphy were included. We divided patients according to the Lung Injury Scores (LIS). We obtained the values in our sample group between intubation and last swab (before extubation). Listed are the risk factors, probability of survival, and lung histology results are listed for patients who died.

The role of skin bank in the treatment of severely burnt patients.

The accessibility of suitable temporary covers plays the key role in the treatment of severe skin losses. Biological covers have got the longest tradition in the wound healing. Skin banks are engaged in their production and distribution. Already in 1973 J. Moserová developed the methodology of harvesting pig xenografts. Later on, the short-term and the long-term method of storage were verified (Böhm, Konícková, Vogtová). In 1986, the Skin Bank in the Prague Burn Centre was established. In Prague Burn Centre the allografts are used very rarely, usually from the living donors, family members of the patients. Therefore, in our bank, we specialized in harvesting porcine xenografts. They are produced in three different forms--fresh, deep frozen in vapours of liquid nitrogen, and glycerolized. Porcine xenografts serve as a biological cover; they make barrier against infection and evaporation and protect the wound against desiccation. They are used namely for the treatment of superficial burn wounds, as a temporary coverage of excised wounds and as a dressing on release incision. Every year more than 10,000 strips have been used in our Burn Centre, it represents the area 200 m2. Since 1991 cultivation laboratory has been a part of our Skin Bank. We are interested in cultivation of human epidermal cells--keratinocytes. Cultured epidermal grafts became the first human in vitro prepared tissue, which was successfully transplanted to the patient. For the treatment of deep dermal skin losses we use either autologous keratinocytes, which can create permanent cover, or allogeneic cells, which stimulate spontaneous healing. Cultured keratinocytes are used in the treatment of burnt patients as well as in the trophic defects.

[Findings in bronchial lavage in patients with burns of the upper respiratory tract]. / Nálezy v bronchiálních lavázích u pacientu s popálením horních dýchacích cest.

The study is focused on cytologic and biochemical changes in bronchoalveolar lavage (BAL) at the group of patients from the Clinic of Burns Medicine at the University Hospital Královské Vinohrady in Prague. Only patients with inhalation trauma were involved in the study. The obtained data are from BAL measurements collected between intubation and extubation. There was the greater number of polymorphonuclears in the first two weeks in all patients. After 2-3 weeks there was a gradual increase in the number of macrophages at four patients and three patients had still the greater number of polymorphonuclears. There was a positive findings of PCNA at one patient and other markers (bcl-2, p53) were negative. The cytoflowmetry proved the increase in number of CD3 cells by 20% in one patient. The amount of proteins in the last BAL just before extubation was lower than 22 g/l. Serin proteinase activity was lower than 50 ncat/l at five patients and the ratio of MMP-8/TIMP-2 was higher than one in all analysed samples. There was no development of lung inflammation into chronic stadium. Two patients died.

Influence of inadequate prehospital and primary hospital treatment on the maturation of scars after thermal injuries.

The objective of the work was to verify or rule out the hypothesis on the negative effect of incorrect prehospital and primary hospital care on the maturation of scars after thermal injuries with a depth of II.b or more. In a medium-term study the authors investigated the maturation of scars in children aged 3 months to 12 years with different quality of treatment during lay first aid, during prehospital and primary hospital care. They focused attention in particular on the formation of hypertrophic scars and possibly other complications during the functional and aesthetic stabilisation of the scar.

Early and late fatal complications of inhalation injury.

Severe inhalation injury causes a substantial deterioration in the prognosis and increases the general mortality of patients with extensive burns. Recently, in particular due to the development of invasive monitoring of patients and effective treatment of acute burn shock, we encounter with increasing frequency patients who survive the acute stage, including complications such as ARDS, and reach the stage of late complications. The latter include tracheooesophageal fistulas that develop on the basis of pressure ulcers and chondromalacia, usually at the site of the balloon of the tracheostomic cannula, and the overproduction of fibrous tissue in the area of the airways which leads to the development of stenosis, pulmonary fibrosis and bronchiectasia. Frequently, different early and late complications combine.

Topigel in the treatment of hypertrophic scars after burn injuries.

The authors present the results of a medium-term study in which they investigated the therapeutic effect of the silicone elastomer TopiGel on developing hypertrophic scars in a group of patients after burn injuries classified as IIb or deeper. The hitherto published results are very encouraging. This medium-term study confirmed the hypothesis that TopiGel has a positive effect on the reduction, stabilization and normalization of hypertrophic scars. In 48 patients (96%) out of a total of 50, stabilization of the scar occurred as well as its functional and cosmetic normalization, although the subjective view of the patients or parents (in case of pediatric patients) differed in some instances. In two children (4%) only a significant reduction of the scar occurred and not normalization, due to incorrect application of the gel by the parents, lack of adherence to basic hygienic principles or the recommended procedure of gel application. In case of repeated complications, treatment was not pursued. In two patients (4%) treatment was discontinued for a short time due to an allergic skin reaction subsequently, treatment was resumed until complete stabilization of the scar was achieved. The study ruled out a positive therapeutic effect of the silicone sheet on the painfulness of a scar and old, mature hypertrophic scars.

New type of anaesthesia with sevofluran improves surgical and post-surgical course of burns treatment (IGA 6116/2).

The objectives of this open-perspective clinical study were to test the effect of a new type of anaesthesia using sevofluran during surgical treatment of patients with burns, and to compare it with that of ketamin, at present the most frequently used anaesthetic. The study, conceived as a pilot study, was performed on 10 paediatric and 8 adult patients with 2nd degree burns covering between 7% and 35% of body surface. Owing to highly significant differences in parameters in favour of sevofluran, it was recommended by our ethical committee not to increase the number of patients. The parameters considered were ease of induction, undesirable effects, span of time before oral administration of liquids. Daily uptake of energy was measured for both types of anaesthetics in another group of 10 patients. In adult patients the two anaesthetics, ketamin versus sevofluran, differed in terms of incidence of unrest during surgery (ketamin 50% vs. sevofluran 0%, p < 0.05), time between end of surgery and return to full consciousness (11.3 min. vs. 2.7 min. p < 0.001), post-surgical inhibition (75% vs. 0%, p < 0.01) psychomimetic reactions after surgery (50% vs. 0%, p < 0.05), time until first intake of liquids (86.7 min. vs. 8.5 min, p < 0.001), and mobilisation (110.8 min. vs. 17 min., p < 0.001). In paedriatic patients, differences in speed of onset of anaesthesia (216 sec. vs. 66 sec., p < 0.001) and time until first uptake of liquids (75 min. vs. 22 min., p < 0.001) were statistically significant. Apart from problems associated with anesthesia, another considerable advantage of the new anaesthetic sevofluran was a significantly increased uptake of calories after use than was the case after ketamin (1645 kJ higher on the average, p < 0.05). Based on these results, sevofluran was introduced to burns surgery as a routine anaesthetic.

Burns of the perineum and anus.

One of the critical sites of the thermal injuries is the region of the perineum. Burns of the perineum are relatively frequent, while affections of the anus and sphincters are rare. At the Prague Burns Centre, University Hospital Královské Vinohrady, two patients were treated with this kind of injury. The site of the burns proved in both instances decisive for treatment and for subsequent prognosis. The surgical procedures (necrectomy and autotransplantation) had to be prepared with regard to the case-histories: in the 11-year-old boy by colostomy and in the adult man suffering from muscular dystrophy by a synthetic low-residue diet.

Y chromosome and vimentin used to trace the fate of allogeneic keratinocytes delivered to the wound by the recombined human/pig skin.

RHPS, composed of confluent allogeneic keratinocytes cultured on cell-free pig dermis, stimulates wound healing when applied with the keratinocyte layer facing the wound. So far it has not been clarified whether the confluent keratinocytes implanted 'upside-down' can 'take' or only stimulate healing by producing growth factors. Confluent male keratinocytes were grafted onto donor sites of three female patients. Biopsies were taken on days 4, 6 and 9 after grafting. The fate of donor cells was followed in paraffin sections by FISH for the Y chromosome and by persisting expression of vimentin taken as a marker of cultured keratinocytes. Histological evaluation was complemented by detection of keratin 10 and involucrin. All three donor sites healed within one week. On day 4 the early neoepidermis was multilayered but disordered after transplantation. A large proportion of cells were apparently of donor origin as indicated by the presence of Y chromosomes, irregular morphology, expression of vimentin in the bottom and upper layers of the neoepidermis, and by irregular expression of involucrin and keratin 10 only in the central layer of the neoepidermis. From day 6 onwards, the new epidermis acquired an ordered stratification. Involucrin and keratin 10 renewed normal distribution in suprabasal layers. Concomitantly, vimentin expression was decreasing. The Y chromosome was still found on day 6 but not on day 9. We concluded that confluent allogeneic keratinocytes temporarily 'take' to the wound and contribute to rapid wound closure, being replaced by the patient's epidermal cells after about one week.

Necrobiotic process causing burn wound conversion may be prevented by allogeneic keratinocytes delivered by the recombined human/pig skin.

The spontaneous necrobiotic process frequently causes conversion of DDB (deep 2nd degree wounds) into full-thickness skin loss (3rd degree wounds). We found that this process may be positively influenced by the activity of living human allogeneic keratinocytes cultured on acellular pig dermis. This RHPS, if applied 'upside-down' with the epidermal layer facing the wound, provides an opportunity for keratinocytes to influence the healing. The aim of the present study was to find conditions, in terms of timing and wound-bed preparation, for optimum healing activity of RHPS. The wound beds were prepared either with tangential excision, surface dermabrasion or deep dermabrasion. Out of 17 wounds grafted with RHPS after tangential excision, 15 (88%) healed in 4-10 days; early excised wounds (up to day 5) healed within less than 10 days after the injury. Out of 8 wounds grafted after surface dermabrasion, only 2 (25%) healed. Out of 6 wounds grafted with RHPS after deep dermabrasion, 4 (67%) healed. The optimum healing effect of RHPS and prevention of conversion was achieved in early tangentially excised wounds.

Biological properties of copolymer of 2-hydroxyethyl methacrylate with sulfopropyl methacrylate.

Interaction of organism with non-toxic implanted polymers depends on the physicochemical properties of the implant surface, which influence the adsorption of bioactive proteins and subsequently adhesion and growth of cells. The synthetic hydrogels are known as poorly adhesive surfaces. In this study we demonstrated the adsorption of albumin, fibrinogen, fibronectin, basic fibroblast growth factor, heparin-binding epidermal growth factor-like growth factor and epidermal growth factor to poly(2-hydroxyethyl methacrylate) (pHEMA) and copolymer of 2-hydroxyethyl methacrylate (HEMA) and potassium salt of 3-sulfopropyl methacrylate (SPMAK). The adhesion and growth of 3T3 cells and human keratinocytes on surface of these polymers was tested without and with pretreatment of polymers with heparin-binding epidermal growth factor-like growth factor. The adhesion of mixture of human granulocytes and monocytes to these surfaces was also tested. The strips of both polymers were subcutaneously and intracerebrally implanted into the rat and the extent of foreign body reaction and brain biocompatibility was evaluated. The results showed the extensive adsorption of basic fibroblast growth factor and heparin-binding epidermal growth factor-like growth factor to copolymer containing SPMAK. However the adhesion (and growth) of cells to this type of copolymers was very low. Preadsorption of human plasma to pHEMA clearly stimulated the leukocyte adhesion in contrary to copolymer containing SPMAK. The extent of foreign-body reaction was significantly higher against the pHEMA compared to tested copolymer p(HEMA-co-SPMAK). In conclusion, the tested copolymer was a poorly adhesive substrate that is only poorly recognized by the non-specific immunity, although the adsorption of basic growth factors to this substrate is highly significant. Both polymers were well tolerated by the brain tissue. The phenotype of surrounding neurons was more close to the control neurons in the brain tissue surrounding the p(HEMA-co-SPMAK) implants.

Burn wound coverage and burn wound closure.

Early excision and grafting changed dramatically topical wound treatment, but are restricted by difficulty in diagnosing burn depth, by limited donor sites and by technical skills to excise special areas (perineum, face). In addition to the extent of burn and the age of the patient the depth is determinant of mortality, morbidity and of patient's quality of life. It results from the time-temperature relation and is further influenced by local and systemic causes of conversion: dehydration, edema, infection and shock hypoxia, metabolic derangements, peripheral vessels diseases may contribute do deepening of burn wound. Superficial burn on day one appears deep dermal by day three, where spontaneous epithelization lasts much longer than 21 days and results in hypertrophic scarring. To prevent this sequelae deep dermal burn may be treated like full-thickness injury with excision and autografting. Another way is removal of dead layers of corium and using biological or synthetic cover. We have found a more effective way to reach wound closure (not only cover) in the method of "upside-down" application of recombined human/pig skin (RHPS), composed of allogeneic human keratinocytes cultured on cell-free pig dermis. The allogeneic epidermal cells temporarily "take", "close" the excised wound and simultaneously encourage epithelization from adnexa remnants in the wound bed. Thus definitive closure is achieved.

Tissue-engineered skin in the treatment of vitiligo lesions.

Vitiligo is characterized by the loss of skin pigmentation due to the destruction of melanocytes. Its treatment is usually difficult. For stable cases, melanocyte transplantation is the method of choice. A newly developed treatment with recombined human/porcine skin methodology, permitting easy handling of the graft, is described in the present work. In five vitiligo patients, autologous epidermal cells were obtained from pigmented thin skin biopsies. The cells were cultured on a dried cell-free porcine dermis by the 3T3 feeder layer technique. After 10 days melanocytes were regularly dispersed in confluent keratinocyte cultures. Upside-down delivery of epidermal cells was used. The epidermal layer was directly applied onto a dermabraded vitiligo lesion, with porcine dermis covering the lesion. Pigmentation started to be visible 4-6 weeks after grafting. After using the above described methodology, the pigmentation appeared in the range of 65-80% of the grafted area. Additional UVA irradiation enhanced the treatment success up to 100%. The surgical vitiligo treatment appears to be a reasonable method of choice in stable vitiligo cases of a disease lasting for at least two years, which means for approximately 5% of all vitiligo patients.

Non-thermic skin affections.

The Centre for Burns can help by its means (material, technical and personal) in the treatment of burns with extensive and deep losses of the skin cover and other tissue structures and in some affections with a different etiology (non-thermic affections). Indicated for admission are, in particular, extensive exfoliative affections--Stevens-Johnson's syndrome (SJS), Lyell's syndrome--toxic epidermal necrolysis (TEN) and staphylococcal scalded skin syndrome (SSSS), deep skin and tissue affections associated with fulminant purpura (PF), possibly other affections (epidermolysis bullosa, posttraumatic avulsions etc.). The similarity with burn injuries with loss of the skin cover grade II is typical, in particular in exfoliative affections with a need for adequate fluid replacement in the acute stage and aseptic surgical treatment of the affected area from the onset of the disease. In conditions leading to full thickness skin loss, in addition to general treatment rapid plastic surgical interventions dominate.