Burn Care on Cruise Ships-Epidemiology, international regulations, risk situation, disaster management and qualification of the ship's doctor.

With the increasing numbers of passengers and crew on board vessels that are becoming larger and larger, the demand for ship's doctors who can adequately treat burns on board has also increased. In the cruise ship industry it is usually those doctor's with internal and general medical training who are recruited from an epidemiological point of view. Training content or recommendations for the treatment of thermal lesions with the limited options available in ship's hospitals and where doctors with no surgical training operate do not yet exist. The guidelines recommended by the Cruise Lines International Association (CLIA) regarding medical staff have only included physicians with minor surgical skills until now. With the introduction of the ATLS(®) course developed by the American College of Surgeons, the requirements for the qualification of the ship's doctor on board cruise ships shall change from January 2017. The article discusses the question of whether having completed the ATLS(®) course, the ship's doctor is trained to adequately treat thermal lesions or severe burns persons on-board, and presents the current discussion on the training content for ship's doctors within the International Maritime Health Association (IMHA). It also provides an overview of existing international regulatory frameworks, the risks presented by a fire on board, the problem of treating burns victims out of reach of coastal rescue services, and alternative training concepts for ship's doctors regarding the therapy of thermal lesions on-board.

[Assessment of REC (Reduction in Earning Capacity) after Thermal Trauma as Part of the Appraisal Process for Statutory Accident Insurance in Germany (Part 2): The New REC Form Developed by Ottomann and Hartmann in 2010]. / Die Einstufung der MdE nach thermischem Trauma im Rahmen der Begutachtung der gesetzlichen Unfallversicherung (Teil II): Der neue MdE Bogen nach Ottomann und Hartmann 2010.

The calculation of REC forms the basis of expert opinions for the purposes of making accident insurance assessments after an occupational accident or an accident suffered en route while travelling to or from the workplace. The estimation of REC is based on a procedure quoted in the 1995 "Jahrbuch der Versicherungsmedizin" (Yearbook of Insurance Medicine) using a form developed by Henkel von Donnersmarck and Hoerbrand. The overall estimation of damages resulting from the accident comprises 3 main components, namely the functional impairment, the assessment of local findings and the resulting somatic and vegetative complaints. The criteria for all 3 components are nevertheless imprecise and open to a great deal of interpretation on the part of the evaluator, leading to a highly variable and subjective overall assessment of REC. The new REC form includes a modified factor-based categorisation of the scar quality and the localisation, so that assessment can now be carried out in a differentiated manner. Visible, stigmatising areas such as the neck are provided with their own Q values. The pigmental and textural alterations describing the scar quality are now more precisely defined. Considering the complexity of the somatic and vegetative alterations, more precise (objective) assessments can now be derived. The new REC form increases the validity and transparency of post-thermal trauma REC assessments for the purposes of making statutory accident insurance assessments.

[The Assessment of REC after Thermal Trauma as Part of the Appraisal Process for Statutory Accident Insurance in Germany (Part 1): Low Validity of the REC Form Developed by Donnersmarck and Hörbrand]. / Die Einstufung der MdE nach thermischen Trauma im Rahmen der Begutachtung der gesetzlichen Unfallversicherung (Teil I): Geringe Validität des MdE Bogens nach Donnersmarck und Hörbrand.

The total REC (reduction in earning capacity) after a thermal trauma is usually assessed using an appraisal form for burns victims, initially developed by Hoerbrandt and von Donnersmarck (1995). The criteria for functional impairment, local findings and vegetative-somatic complaints are somewhat imprecise given the broad scope of interpretation which the evaluator can employ in making an appraisal. This means that the overall appraisal of REC is subjective on the part of the evaluator. In addition, one can only calculate an overall REC of at most 40% from local findings and vegetative-somatic symptoms, even in patients with extensive large area burns. Considering these points we investigated the dependency of the results on the evaluator as well as the limited validity of the appraisal form originally developed by Hörbrand and Donnersmark.

A tribute to Cicero Parker Meek.

Cicero Parker Meek (1914-1979) was working as a general practitioner at the Aiken County Hospital in South Carolina, USA, and had a special interest in the treatment of burn patients. The procedure first presented in 1958 by Meek for a device-based expansion of split-skin (micrografting), which was invented before the mesh technique, is a milestone in the history of burns surgery. The method was forgotten until well into the 90s of the last century, and was only readopted and improved by no longer identifiable physicians at the Red Cross Hospital in Beverwijk. The Meek translation procedure was subsequently modified through the innovations of Kreis and Raff. With increased survival of massively burned patients, mesh grafting fell short of requirements. Mesh grafts of 1:9 expansion are difficult to handle and are vulnerable to dislodgement on the wound bed. Kreis and Raff showed in 1994 that 1:9 expanded mesh grafts did not achieve a true 1:9 expansion on the wound surface, in contrast to 1:9 expanded Meek grafts. Thus Meek grafts provided a highly effective autograft expansion in very large burns. Cicero Parker Meek was an exceptional person in the history of burn therapy.

[Medicine aboard cruise ships--law insurance specifics]. / Versicherungsrechtliche Betrachtungen zur Tätigkeit des Arztes an Bord von Kreuzfahrtschiffen.

The booming cruise industry, associated with ships with more passengers and crew on board, results in growing medical needs for the ship doctor. The ship's doctor insurance policy includes different jurisdictions, namely national law, international law, tort law, insurance law and labor law. In addition, international agreements must be taken into account, which complicates the design of an adequate insurance policy. Equally high are the costs and defense costs for the ship's doctor in case of liability. In order to limit the liability for all parties is to ask for appropriately qualified medical staff, hired on board.

Pirogow's Amputation: A Modification of the Operation Method.

Introduction. Pirogow's amputation at the ankle presents a valuable alternative to lower leg amputation for patients with the corresponding indications. Although this method offers the ability to stay mobile without the use of a prosthesis, it is rarely performed. This paper proposes a modification regarding the operation method of the Pirogow amputation. The results of the modified operation method on ten patients were objectified 12 months after the operation using a patient questionnaire (Ankle Score). Material and Methods. We modified the original method by rotating the calcaneus. To fix the calcaneus to the tibia, Kirschner wire and a 3/0 spongiosa tension screw as well as a Fixateur externe were used. Results. 70% of those questioned who were amputated following the modified Pirogow method indicated an excellent or very good result in total points whereas in the control group (original Pirogow's amputation) only 40% reported excellent or very good result. In addition, the level of pain experienced one year after the completed operation showed different results in favour of the group being operated with the modified way. Furthermore, patients in both groups showed differences in radiological results, postoperative leg length difference, and postoperative mobility. Conclusion. The modified Pirogow amputation presents a valuable alternative to the original amputation method for patients with the corresponding indications. The benefits are found in the significantly reduced pain, difference in reduced radiological complications, the increase in mobility without a prosthesis, and the reduction of postoperative leg length difference.

[Pirogow's amputation as an alternative to lower leg amputation?]. / Die Amputation nach Pirogow als Alternative zur Unterschenkelamputation?

Pirogow's amputation at the ankle presents a valuable alternative to lower leg amputation for patients with the corresponding indications. Although this method offers numerous advantages for the patient, such as the ability to stay mobile without the use of a prosthesis, it is rarely performed (0.1% of all lower limb amputations). The results of the operations on 20 patients were objectified 12 months after the operation using a patient questionnaire (Ankle Score), and these results were then compared to those of 20 patients who underwent lower leg amputation. Using a point system the criteria pain, functional and radiological assessment, difference in leg length, and mobility without prosthesis were recorded and evaluated. 65% of those questioned who were amputated following the Pirogow method indicated an excellent or very good result, in the control group 60% of those having undergone a lower leg amputation responded similarly, indicating an excellent or very good result.In 30% in the Pirogow group in contrast to 20% after lower leg amputation postoperative complications lead to a revision-operation. In patients suffering from diabetes or restricted perfusion of the lower extremity an amputation at the level of the ankle has to be considered critically keeping the necessity of a revision-operation in mind. However, if it can be carried out successfully, the benefits of Pirogow-amputation are found in the significantly reduced difference in leg length and the increase in mobility without prosthesis.

[Increased self-confidence and decreased sexual discomfort after subpectoral mammaplasty]. / Gesteigertes Selbstvertrauen und vermindertes körperlich-sexuelles Missempfinden nach subpektoraler Mammaaugmentation.

INTRODUCTION: The study objectively discusses the causal relationship between submuscular breast augmentation mammaplasty and improved aspects of quality of life. The goal was to assess a possible increase in certain aspects after undergoing cosmetic breast enlargement surgery under consideration of 4 different aspects. MATERIALS AND METHODS: Between 2005 and 2006, a total of 65 women were given a standardised patient questionnaire (body image assessment questionnaire) preoperatively as well as 6 months postoperatively after undergoing cosmetic submuscular augmentation mammaplasty: 58 of these questionnaires could be evaluated successfully. All of the patients had undergone augmentation mammaplasty for the first time. The following criteria were assessed and evaluated using a point value system (0-100 points): attractiveness/self-confidence, insecurity/anxiety, emphasis placed on physical appearance, and sexual discomfort. RESULTS: With regard to the questions dealing with attractiveness/self-confidence, a highly significant improvement in the patient's self-assessment of said criteria after undergoing cosmetic submuscular augmentation mammaplasty as compared to their own preoperative assessment was apparent. In addition, a significantly improved level of sexual satisfaction after the medical procedure was also demonstrated. In the same fashion, the answers to the series of questions dealing with emphasis placed on physical appearance also exhibited a positive change. The only topic that exhibited next to no change was the series of questions dealing with insecurity/anxiety. CONCLUSION: Cosmetic augmentation mammaplasty is an available therapy that can increase a patient's own self-assessment of attractiveness and self-confidence in a significant way. In addition, this operation leads to a significant increase in sexual satisfaction, and because of this and the aforementioned change of emphasis placed on physical appearance, an overall improvement in certain aspects of the quality of life can be achieved.

Joseph Beuys: trauma and catharsis.

Joseph Beuys was one of the most significant artists of the 20th century. He was a gunner and radio operator in the German Air Force during World War II, and was severely injured several times. In March 1943 he had a life-changing experience after the dive bomber he was assigned to crashed in the Crimean peninsula. This trauma influenced Beuys' entire artistic career, and is known in art history as the 'Tartar Legend' or 'Tartar Myth'. Profoundly affected by the crash, the severe trauma, the near-death experience and his rescue, which he perceived as a "rebirth", Beuys no longer saw himself, other people or society as a whole in the same way as previously. With his new consciousness, he ignored boundaries and created visions whereby all mankind could experience the healing he had undergone. Beuys did not bring society far enough for the turning point towards "the healing of the world" to be visible, yet today it is important to keep his work alive as a record of his extraordinary strength, which arose from trauma and severe injury, and was carried by a passionate commitment to mankind and to life itself.

[Wound care within an Interplast mission]. / Wundversorgung innerhalb eines Interplasteinsatzes.

As of 2001, the Centre for Severely Burned Patients at the Unfallkrankenhaus (Casualty Hospital) in Berlin has been working together with the sole centre for wound care in Kyrgyzstan. This cooperation consists not only of on-site operative applications; since the first contact with our Kyrgyzstani colleagues we have sought to improve the overall level of wound therapy in Kyrgyzstan. For this purpose, we organised educational trips to Germany for our Kyrgyzstani colleagues in addition to the numerous material donations (donations-in-kind). From the beginning of this project the motto of our cooperation was"helping them help themselves". This is in corresponds to the modern challenges of the OECD (Organisation for Economic Cooperation and Development) of development partnerships and global cooperation.

[Deep dermal alkali burns caused by work with screed]. / Tiefe Laugenverätzung durch Arbeiten mit Estrich.

INTRODUCTION: In the Center for Plastic Surgery of the Trauma Hospital Berlin, between the years 2000 and 2007 we observed a total of 10 deep dermal alkali burns caused by screed. MATERIAL AND METHODS: The 10 patients were retrospectively surveyed to assess the risk of alkali burn injury. They were also questioned about the protective clothing worn when the accidents occurred. The severity of the injuries was compared to the patients' estimates of the perceived risks. RESULTS: Despite the safety advice and warnings, all patients underestimated the risk of injury. Six patients ranked the risk of injury as low, two patients as medium, and two as high. None of the 10 patients who suffered deep alkali burns (second and third degree) was wearing the recommended protective clothing at the time of injury. CONCLUSION: The existing safety advice insufficiently reflects the potential risk of injury. The author demands a change in the safety warnings from "irritant" to "can cause alkali burns"; with such a change, workers may be better aware of the dangers of working with screed.

Development and restructuring of a burn centre in an emerging nation, based on the example of Kyrgyzstan.

AIM: To implement and review a four-tier plan to develop a burn centre in an emerging nation (Kyrgyzstan). METHOD: From 2001, the developing burn centre in Bishkek was supported with numerous material donations and, once a year, teams from Germany operatively treated numerous burn victims on site. Training and further education for our Kyrgyzstani colleagues were based on 'helping them to help themselves', with additional consultations on conceptual hygienic and structural improvements. RESULTS: Material donations were delivered personally by the project teams. Education and training were also limited due to physician emigration. However, in the seven trips made by the team from Germany, numerous operations were performed and there was fundamental progress in the areas of bandaging protocols, hygienic concepts and structural improvements. CONCLUSION: An exact plan patiently tailored to the local situation and culture must be followed, to provide cost-effective support.

[Pharmacological therapy of keloids in an athymic mouse model]. / Pharmakologische keloidtherapie im tiermodell.

PURPOSE: In spite of the high incidence of dermal fibroproliferative disorders, there is no agreement about the treatment of choice. Due to the inability of animals to produce keloid tissue, a standardised model to study the effects of different treatment modalities in vivo is lacking. Therefore, a comparative study on the effect of three pharmacological agents was conducted with human keloid implants in an athymic mouse model. MATERIAL AND METHODS: Cubic keloid tissue blocks from 10 human volunteers were implanted in 54 male, athymic, homozygotic mice. The animals were divided into 4 groups, including an untreated control group. Members of each section received either colchicine, nicardipine or triamcinolone applied transdermally into the keloid tissue or into the peritoneum. The tissue specimens of 5 mice each were explanted according to a predetermined time schedule on days 28, 42 and 56 post-implantation and examined using various histological techniques including standard dye and immune histochemistry. The freeze-dried and moist weights of the keloid tissue were determined and analysed. RESULTS: Statistically significant changes regarding declining weight parameters were seen in the colchicines-treated group. Moreover, the densities of fibroblasts and endothelial cells were significantly reduced through colchicines treatment when compared to the control group and the groups treated with the other agents. The triamcinolone group also showed partially significant changes of weight compared to the control group, whereas no statistically significant effect of nicardipine on any parameter was found. Any influence of the host organism could be excluded as there were no signs of rejection or lymphocytic infiltration. CONCLUSION: Our study represents a successful attempt to create a standardised model for a comparative investigation on keloid tissue in vivo. The effect of colchicine was demonstrated in the light of an inhibitory effect on fibroblastic proliferative activity. The studied model allows a direct comparison of implanted, vascularised keloid tissue and its reactivity to various agents without being biased by numerous unknown variables in humans.

Culture of subconfluent human fibroblasts and keratinocytes using biodegradable transfer membranes.

This study aims to assess the suitability of biodegradable membranes as transfer matrix materials for the culture of subconfluent fibroblasts and keratinocytes. The materials investigated were based on collagen, chitosan and enzyme-digestible cellulose. The proliferation and growth behaviour of human keratinocytes and dermal fibroblasts were analysed and morphology and distribution determined. Cultured fibroblasts exhibited no significant differences in proliferation for the different membrane types, whereas keratinocytes revealed significantly higher proliferation on collagen membranes compared with membranes based on cellulose and chitosan. Co-cultured fibroblasts and keratinocytes from the same donor on collagen membranes showed more homogenous cell distribution, but they segregated in heterologous co-cultures; this effect must be further investigated. Thus, collagen and collagen-coated chitosan membranes are suitable for the subconfluent transfer of human fibroblasts and keratinocytes.

[Liposuction curettage versus Botox for axillary hyperhidrosis. A prospective study of the quality of life]. / Liposuktionskürettage versus Botox bei axillärer Hyperhidrosis. Eine prospektive Studie der Lebensqualität.

BACKGROUND: Axillary hyperhidrosis is a dysfunction of the secretion of sweat glands. Conservative treatment modalities are mostly ineffective. Liposuction combined with subcutaneous curettage (TLC) destroys the sweat glands, while Botox injections inhibit the cholinergic transmission. MATERIAL AND METHOD: Of a total of 88 patients, TLC was carried out in 47 and 41 patients received intradermal Botox injections. The effect of both forms of treatment on the quality of life was assessed using a specific hyperhidrosis questionnaire and was correlated with sweat volumes measured by gravimetry. RESULTS: Follow-up after 6 months showed significantly changed sweat volumes of 52+/-41 mg/min of TLC patients versus 78+/-87 mg/min in the Botox group. In the TLC group 91% and in the Botox group 98% were satisfied with the result. CONCLUSION: The stress of a single surgical intervention is to be weighed against the necessary repetitive application of multiple Botox injections. Both methods are superior to other, more radical surgical methods in terms of efficacy and complication rates. Botox and TLC lead to a significant improvement of the quality of life.

[Management with v.a.C. in phlegmonous tissue defects of the abdominal wall after abdominoplasty]. / Komplikationsmanagement mittels V.A.C.V.A.C.-Therapie bei phlegmonösen Bauchdeckeninfektionen nach Abdominoplastik.

Infected defects with tissue defects of the abdomial wall after abdomioplasty are a severe complication. Management of these progessive infections involves multiple step surgery. V.A.C.-therapy could be an alternative to open wound treatment.