Preliminary analysis of the FAM174A gene suggests it lacks a strong association with equine metabolic syndrome in ponies.

Equine metabolic syndrome (EMS) describes a group of risk factors, including obesity and insulin dysregulation (hyperinsulinemia and/or insulin resistance), that can lead to the development of the debilitating hoof disease laminitis. Although the underlying mechanisms of EMS are not fully understood, a genetic component has been reported, and an 11 guanine polymorphism located at the FAM174A gene has been identified as a risk locus for the syndrome in Arabian horses. To examine associations between the FAM174A risk allele and the clinical signs of EMS, the allele was examined in an Australian cohort of ponies (n = 20) with known metabolic status. The 11 guanine polymorphism was identified in only 3 of 13 ponies with EMS, and no significant association could be made between the risk loci and morphometric measurements associated with obesity (BCS [P = 0.21], cresty neck score [P = 0.58], basal triglyceride concentration [P = 0.85], and adiponectin concentration [P = 0.48]), or insulin dysregulation (insulin dysregulation status [P = 0.35] and serum insulin concentration during an oral glucose test [P = 0.44]). These results suggest that the FAM174A 11 guanine homopolymer allele is unlikely to be a singular key gene polymorphism associated with EMS in ponies. However, due to the small number of ponies identified with the polymorphism, further study of the FAM174A risk allele in a larger cohort of horses and ponies of uniform breed would be useful.

Glucagon-like peptide-2: A potential role in equine insulin dysregulation.

BACKGROUND: Equine insulin dysregulation (ID) is a common and poorly understood disorder that increases the risk of laminitis. Recent data show that the condition may be associated with alteration of the enteroinsular axis and enhanced glucose bioavailability. Upregulation of glucagon-like peptide-2 (GLP-2), an intestinotrophic peptide, leads to enhanced nutrient uptake and metabolic dysfunction in other species. OBJECTIVES: The study aimed to 1) determine whether GLP-2 is differentially expressed in insulin-dysregulated ponies, compared with healthy ponies, and 2) confirm intestinal expression of the GLP-2 receptor in horses (eGLP-2R). STUDY DESIGN: Cohort study. METHODS: Fasting and post-prandial GLP-2 concentrations were measured in archived plasma samples obtained from 25 mixed-breed ponies during two feeding studies. Measurements were undertaken with an ELISA that was validated for equine use as part of the current study. Ponies were designated as healthy or insulin-dysregulated based on an oral glucose test, and the results were compared between groups. The gene expression of the eGLP-2R was determined with polymerase chain reaction. RESULTS: Basal, fasted plasma GLP-2 concentrations were higher in ponies with ID, compared with healthy ponies. Grazing increased GLP-2 in healthy, but not in insulin-dysregulated, ponies. The eGLP-2R gene was expressed in the small intestine and pancreas. MAIN LIMITATIONS: The study was performed with a relatively small sample size. The specificity of the GLP-2 assay could not be determined due to the lack of equine-specific assay standards. CONCLUSIONS: This study has demonstrated that GLP-2 may be important in the pathogenesis of equine ID and suggests that the eGLP-2R may be a novel therapeutic target for the treatment of equine ID.

Burn wound healing time assessed by laser Doppler imaging (LDI). Part 1: Derivation of a dedicated colour code for image interpretation.

INTRODUCTION: Laser Doppler imaging produces a colour-coded image of dermal blood flow, which can be used to quantify the inflammatory response in a burn. The original colour palette had arbitrary boundaries, which inexperienced clinicians found difficult to interpret. The aim of this study was to define clinically useful boundaries that would assist in the prediction of burn healing potential. METHOD: We conducted a prospective, multi-centre study of burns in adults and children. LDI scans were performed between 48 h and 5 days after injury. The burns were assessed clinically and photographed on day of scan, day 14 and day 21 post-injury. Areas healed at day 14, healed between day 14 and 21 and unhealed at day 21 were identified on the LDI scan. The flow values for the pixels in these regions were analysed to calculate boundaries between the three healing categories. RESULTS: We recruited 137 patients (ages 1-88 years, 65% male); 392 LDI scans contained 433 different burn sites; 109 regions of interest were studied. Analysis allowed us to define ranges for the three healing categories: HP14 colour coded red, >600 PU; HP14-21, yellow, 260-440 PU; HP>21, blue, <200 PU; separated by two overlap regions pink, 440-600 PU and green, 200-260 PU. Blue was subdivided to show the very high association between LDI<140 PU and non-healing at day 21. CONCLUSION: We have devised a new colour palette for LDI burn imaging based on healing times of a series of burns. Validation of this palette is described separately, in Part 2.

A multicenter review of toxic epidermal necrolysis treated in U.S. burn centers at the end of the twentieth century.

Toxic epidermal necrolysis (TEN) is a potentially fatal disorder that involves large areas of skin desquamation. Patients with TEN are often referred to burn centers for expert wound management and comprehensive care. The purpose of this study was to define the presenting characteristics and treatment of TEN before and after admission to regional burn centers and to evaluate the efficacy of burn center treatment for this disorder. A retrospective multicenter chart review was completed for patients admitted with TEN to 15 burn centers from 1995 to 2000. Charts were reviewed for patient characteristics, non-burn hospital and burn center treatment, and outcome. A total of 199 patients were admitted. Patients had a mean age of 47 years, mean 67.7% total body surface area skin slough, and mean Acute Physiology and Chronic Health Evaluation (APACHE II) score of 10. Sixty-four patients died, for a mortality rate of 32%. Mortality increased to 51% for patients transferred to a burn center more than one week after onset of disease. Burn centers and non-burn hospitals differed in their use of enteral nutrition (70 vs 12%, respectively, P < 0.05), prophylactic antibiotics (22 vs 37.9%, P < 0.05), corticosteroid use (22 vs 51%, P < 0.05), and wound management. Age, body surface area involvement, APACHE II score, complications, and parenteral nutrition before transfer correlated with increased mortality. The treatment of TEN differs markedly between burn centers and non-burn centers. Early transport to a burn unit is warranted to improve patient outcome.

Methods and results of rhinophyma treatment.

Rhinophyma is a disfiguring soft-tissue hypertrophy of the nose. It is an uncommon disease that primarily affects Caucasian men in the fifth to seventh decades of life. Nine cases from the authors' series and a comparison of results following various treatment modalities are presented. Eight of the patients were Caucasian and one was African American. Excision of the diseased tissue with a scalpel or Goulian dermatome using loupe magnification provided the safest means of preserving the underlying sebaceous gland fundi that permit spontaneous re-epithelialization with the least scarring.

Effect of early body image dissatisfaction on subsequent psychological and physical adjustment after disfiguring injury.

OBJECTIVE: The impact of body image dissatisfaction on quality of life after severe burn injury was investigated after controlling for other determinants of outcome (i.e., injury, distress, and preburn quality of life). METHODS: The postburn quality of life (2-months postdischarge) of groups with and without body image dissatisfaction was studied after controlling for preburn quality of life (measured 2-3 days postadmission). The patient population (N = 86) was 77.9% men, had an average total body surface area burned of 17.02%, and average full-thickness burn of 6.09%. Forty percent had facial injuries, 68.6% required surgery, most were injured by flame (39.5%), and 76.8% were employed. RESULTS: Multivariate analysis of covariance (covarying preburn level of Mental quality of life, facial injury, and size of burn) contrasting body image dissatisfaction groups found significantly lower psychosocial adjustment at 2-month follow-up in those with greater body image dissatisfaction (multivariate F = 3.61; p<.01). A second MANCOVA (covarying the preburn level of Physical quality of life and both facial injury and size of burn) found significantly lower physical functioning at 2-month follow-up in those with greater body image dissatisfaction (multivariate F = 2.78; p < .03). Adding two more covariates (depression and posttrauma distress) eliminated the effect of body image dissatisfaction on postburn Physical but not Mental adjustment. CONCLUSIONS: Body image dissatisfaction affects quality of life after severe burn injury. Distress moderates this impact on aspects of physical but not psychosocial health.

Increased alpha2-adrenergic constriction of isolated arterioles in diffuse scleroderma.

OBJECTIVE: Vasospasm and ischemic organ injury are important in the pathogenesis of systemic sclerosis (SSc; scleroderma). The present study was performed to determine whether SSc arterioles have an intrinsic disturbance in vasoconstrictor activity. METHODS: Skin biopsy samples were obtained from the upper arm of 11 patients with diffuse SSc (clinically uninvolved skin) and 8 age- and sex-matched control subjects. Dermal arterioles were dissected from the biopsy sample and mounted in a myograph for continuous monitoring of arteriolar diameter. The resting internal diameter of control and SSc arterioles was similar (mean +/- SEM 164+/-15 micro and 166+/-18micro, respectively). RESULTS: Dermal arterioles displayed no spontaneous constrictor activity in the absence of stimulation. Vasoconstriction in response to KCI, a receptor-independent activator of smooth muscle, or to phenylephrine, a selective alpha1-adrenergic receptor (alpha1-AR) agonist, was similar in control and SSc arterioles. However, constrictor responses to UK 14,304, a selective alpha2-AR agonist, were increased in SSc compared with control arterioles (maximal constriction responses of 25+/-5% and 67+/-4% [mean +/- SEM] in control and SSc arterioles, respectively; P = 0.000014). Mechanical denudation of the endothelium did not alter reactivity to alpha2-AR activation, indicating that the enhanced constriction in SSc was not mediated by changes in endothelial dilator activity. Indeed, in arterioles constricted with phenylephrine, the endothelial stimuli acetylcholine or bradykinin evoked endothelium-dependent relaxation that was similar in control and SSc arterioles. CONCLUSIONS: Vascular smooth muscle in SSc arterioles displayed a selective increase in alpha2-AR reactivity. The endothelial dilator function appeared normal. Altered activity of smooth muscle alpha2-ARs may contribute to the vasospastic activity that is a prominent feature of the SSc disease process.

Escharotomy and fasciotomy of the burned upper extremity.

Escharotomy and fasciotomy are performed in the burned upper extremity to prevent and treat the sequelae of circumferential full-thickness burns and high-voltage electrical burns. Indications to perform these procedures are determined primarily by clinical examination but can be supplemented by measurements of subfascial pressures. The techniques are designed to avoid further complications. Options for wound closure are discussed. The use of allograft as temporary coverage of fasciotomy incisions may allow delayed primary closure.

Burns of the hand and upper limb--a review.

This review article addresses the principles and controversies associated with thermal injury to the hand and upper limb. Accepted principles are outlined and areas of controversy are discussed in a balanced manner. The importance of hand burns is described functionally and epidemiologically. Burns appropriate to outpatient care are defined and treatment discussed, including debridement, topical therapy, rehabilitation and follow-up. The general principles of inpatient management are given, including the controversial issue to timing of surgery and treatment of the exposed tendon or joint. The extent of surgery, methods of wound closure and difficult problem of palm burns are also discussed. Reconstructive principles are outlined and a problem oriented approach to the most common reconstructive problems given.

Psychologic factors involved in the decision to undergo reconstructive surgery after burn injury.

Burn injuries often result in permanent changes in physical appearance and function. Although reconstructive surgery is often considered to improve function or physical appearance, or a combination, variables that may predict use of surgery are relatively unknown. Burn survivors (N = 46; 48% male) were assessed at an evaluation for potential reconstructive surgery. Measures of adjustment, distress, and personality were administered. Several psychologic and demographic variables differed among those who did versus those who did not subsequently undergo surgery. Social, sexual, and family relationships were poorer among those who later used surgery, and surgery patients had higher scores on somatization. Subjects who had not returned to work, and individuals with private insurance or managed care, were significantly less likely to follow-up with reconstructive surgery. Contrary to hypothesized results, indexes of burn severity and the injury location were not significantly different between the two groups. Results suggest that interventions designed to aid adjustment after injury may result in the best surgical candidates completing reconstruction.

The enhancement of wound healing with human skin allograft.

Although clean incisional wounds can be closed easily, contaminated wounds, wounds with tissue loss that cannot be closed primarily, and chronic wounds are generally not closed and suffer the effects of being open. It follows that wound healing would be enhanced if these wounds could be closed. This article describes how skin allograft biologic dressings are used to close such wounds temporarily to bestow the benefits of wound closure. It also describes the benefits of human skin allografts and the history and basic science related to their use. Reference is made to newer wound covers that have the potential to provide similar benefits to open wounds.

Porcine dermal collagen as a wound dressing for skin donor sites and deep partial skin thickness burns.

Collagen was extracted by pepsin digestion from porcine skin, and collagen membrane was prepared by salt precipitation. The porcine collagen membrane was evaluated as a burn wound dressing in deep partial skin thickness burn wounds in rats. Burn wounds, 4 x 4 cm, were inflicted by exposure of skin to 75 degrees C for 15 s followed by de-epithelialization. Wound healing was assessed by planimetry of epithelialization on day 10 after injury. Open wounds exhibited 24 per cent of wound area re-epithelialized. Collagen membrane dressing significantly improved the healing to 69 per cent of wound area (P < 0.0001). In a completely separate experiment, the porcine collagen membrane was applied as a wound dressing to the donor sites of burn patients, and its effect on wound healing was compared with that of a petroleum jelly gauze dressing. The donor sites covered with petroleum jelly gauze had re-epithelialized by an average of 14.5 days (ranging from 13 to 16 days) after wounding. The wounds dressed with collagen membrane demonstrated a significant increase in the healing rate. Complete re-epithelialization was observed by 10.3 days (ranging from 10 to 12 days) after wounding (P < 0.0001).

Posttraumatic adaptation and distress among adult burn survivors.

OBJECTIVE: The purpose of this study was to examine the prevalence, natural history, and psychosocial impact of posttraumatic symptoms in adult burn survivors. METHOD: Forty-three adult inpatients at a regional burn center were assessed at discharge with standardized instruments to determine the presence of psychiatric disorder, assess personality, and quantify depression. Thirty-one patients were evaluated 4 months after discharge. RESULTS: Posttraumatic stress disorder was diagnosed in 7% of patients at discharge and in over 22% of patients at follow-up. Symptoms of avoidance and emotional numbing (DSM-III-R criterion C symptoms) tended to emerge after discharge from the hospital. While posttraumatic symptoms were associated with symptoms of depression, they were not strongly associated with psychosocial adjustment to illness; psychosocial adjustment was more strongly related to aspects of personality, the injury itself, and its treatment. CONCLUSIONS: Since adult burn survivors often develop new symptoms of posttraumatic distress after leaving the hospital, longitudinal surveillance is required to detect new cases and provide appropriate treatment. Survivors at risk for poor psychosocial adjustment after discharge may be identifiable during hospitalization, and preventive treatment strategies should be developed and tested for this population.

Anticentromere antibody as a predictor of digital ischemic loss in patients with systemic sclerosis.

OBJECTIVE: To determine the clinical and serologic risk factors for digital ischemic events in patients with systemic sclerosis (SSc). METHODS: Retrospective review of clinical and laboratory data and review of current clinical status of 98 patients with SSc, seen between 1985 and 1990. RESULTS: Amputation of 1 or more digits due to ischemia occurred in 20.4% of the patients; 9.2% had multiple digit loss. Sclerodactyly alone and anticentromere antibody (ACA) were associated with loss of 1 or more digits. Age, smoking status, duration of disease, or duration of Raynaud's phenomenon were not predictive for loss of digits. CONCLUSION: Patients with limited SSc who are positive for ACA have an increased risk of major peripheral vascular occlusive disease.

Experience with novel uses of tissue expanders in burn reconstruction of the face and neck.

Total or subtotal resurfacing of the face with suitable, well-matched skin from the upper trunk and neck is usually difficult because of the dearth of unscarred donor site. Tissue expanders have been used primarily to construct local advancement flaps of tissue immediately adjacent to a tissue defect or deformity. These flaps often lack adequate mobility to allow coverage of large areas. In this report, I describe a clinical experience of 11 patients followed for 27 to 75 months in whom tissue expanders were used to develop large, full-thickness skin grafts or transposition flaps for total or subtotal resurfacing of the face and neck. Large, full-thickness skin grafts were developed from relatively small donor sites using tissue expanders. They behaved identically to unexpanded full-thickness skin grafts. They were found not to shrink with storage. The donor sites were closed primarily, obviating the need to graft the donor site. The tissue expander-enhanced transposition flaps appeared to have enhanced vascularity and provided ample, suitable tissue for reconstruction of the face and neck. Tissue expansion resulted in very mobile, thin, hearty flaps that provided excellently matched skin cover for the face and neck. Complications, some of which are unique to these techniques, and indications for the techniques are reviewed.

Bilateral reconstruction of the male nipple.

The opportunity to reconstruct the male nipple rarely presents itself. The loss of the nipple due to trauma or surgery is itself rare. Most patients consider its loss a minor problem and the nipple not worth reconstructing. The only description of a male nipple reconstruction in the literature is that of a unilateral reconstruction using a split-thickness graft from the opposite side with a suboptimal result. In this report, I detail the reconstruction of bilateral male nipples in the survivor of a severe burn. The final result is a culmination of three successive procedures performed to improve each previous result. The result of each procedure is critically analyzed, with an excellent final result. We conclude that the best male nipple reconstruction is that in which the areola and papilla are given independent attention during reconstruction. We recommend a single, safe, procedure that fulfills this requirement and can be performed under local anesthesia.

Disaster mitigation

The purpose of this training module is to introduce the trainee to basic mitigation concepts and to discuss the range of mitigation actions which can be considered as a response to the variety of natural and man-made hazars which may be encountered. The first section discusses the concept of mitigation and briefly surveys the range of hazards which may need to be considered, describing their nature, consequences and some of the mitigation actions specific to each. The second section describes the types of mitigation actions which might be appropriate including engineering and construction, physical planning, economic, institutional and social measures, discussing the usefulness and potential limitations of each type. The third section considers how the various types of measures available may be combined to form a comprehensive disaster mitigation strategy, how alternative possible strategy options may be assessed, and discusses opportunities and obstacles to implementation of disaster mitigation plans. The final section looks at the role of the UN, and in particular UNDRO and UNDP in promoting the incorporation of disaster mitigation into a country's own development planning and institution building processes, and examines the possible contribution of other UN agencies to this activity

Vulnerability and risk assessment

This module examines the scope for measuring the risk of future losses and for using this knowledge to assist in the selection of an appropriate disaster mitigation strategy. It considers the nature of risk, and the difference between actual and perceived risk. It discusses the techniques by which natural hazards and the accompanying risk of future losses can be estimated; and it discusses the ways in which future risk estimates can be used to assist the choice of the optimum disaster mitigation strategy

Expanding the limits of composite grafting: a case report of successful nose replantation assisted by hyperbaric oxygen therapy.

A successful nose replantation assisted by hyperbaric oxygen therapy is presented, with a brief discussion of the possible mechanisms and a brief literature review of the use of hyperbaric oxygen in tissue preservation and replantation. Although it is not certain that the hyperbaric oxygenation ensured the survival of the replanted nose in this 2-year-old girl, there was documented change in graft appearance during the initial hyperbaric oxygen treatment. A 1-month, 1-year, and 2-year follow-up is included.