The evolution of acute burn care - retiring the split skin graft.

The skin graft was born in 1869 and since then, surgeons have been using split skin grafts for wound repair. Nevertheless, this asset fails the big burn patient, who deserves an elastic, mobile and robust outcome but who receives the poorest possible outcome based on donor site paucity. Negating the need for the skin graft requires an autologous composite cultured skin and a material capable of temporising the burn wound for four weeks until the composite is produced. A novel, biodegradable polyurethane chemistry has been used to create two such products. This paper describes the design, production, optimisation and evaluation of several iterations of these products. The evaluation has occurred in a variety of models, both in vitro and in vivo, employing Hunterian scientific principles, and embracing Hunter's love and appreciation of comparative anatomy. The process has culminated in significant human experience in complex wounds and extensive burn injury. Used serially, the products offer robust and elastic healing in deep burns of any size within 6 weeks of injury.

Prevention of gastrointestinal bleeding due to stress ulceration: a review of current literature.

Our objective was to audit our current stress ulcer prophylaxis protocol (routine prescription of ranitidine and early enteral feeding) by identifying whether routine prescription of histamine-2 receptor antagonists or proton pump inhibitors as prophylaxis against stress-related mucosal disease and subsequent upper gastrointestinal bleeding is supported in the literature. We also aimed to ascertain what literature evidence supports the role of early enteral feeding as an adjunctive prophylactic therapy, as well as to search for burn-patient specific evidence, since burn patients are at high risk for developing this condition, with the aim of changing our practice. PubMed and Cochrane databases were searched for relevant articles, yielding seven randomised controlled trials comparing histamine-2 receptor antagonists and proton pump inhibitors in the prevention of upper gastrointestinal bleeding associated with stress-related mucosal disease and three separate meta-analyses. Despite level 1 clinical evidence, no significant difference in efficacy between histamine-2 receptor antagonists and proton pump inhibitor treatment groups was demonstrated. No significant difference was demonstrated in the incidence of nosocomial pneumonia between the two drugs given in this indication. However, enteral feeding was found to be safe and effective in preventing clinically significant upper gastrointestinal bleeding. Patients able to tolerate feeds demonstrated no additional benefit with concomitant pharmacological prophylactic therapy. Since all burn patients at the Royal Adelaide Hospital are fed from very early in their admission, the literature suggests that we, like our intensive care unit colleagues, should abolish our reliance on pharmacological prophylaxis, the routine prescription of which is not supported by the evidence.

A randomised prospective study of split skin graft donor site dressings: AWBAT-D™ vs. Duoderm®.

OBJECTIVE: To assess patient comfort and wound-healing efficacy of a new, purpose-designed biosynthetic material (AWBAT-D™) in the healing of split-skin graft donor sites in comparison with our standard dressing, Duoderm(®). MATERIALS AND METHODS: We conducted a prospective randomised controlled trial of donor site dressings, comparing AWBAT-D™ with our standard dressing, Duoderm(®). Patients were randomly allocated to have their donor site dressed with one of these materials. Outcome measures included pain scores at rest and during dressing changes, time to re-epithelialisation, time to discharge, scarring and infection. Results were assessed for significance using the Mann-Whitney U-test (non-parametric data) and the Chi-Square test (parametric data). RESULTS: Fourteen patients were recruited with 8 donor sites in each group. The mean pain scores at rest and during dressing changes were not found to be significantly different between the two groups (P=0.99 and P=0.90 respectively). The median time to re-epithelialisation was shorter in the Duoderm(®) group at 11 days compared to 17 days in the AWBAT-D™ group (P=0.007). The median time to discharge was not significantly different (P=0.38). No infection or scarring has been observed. CONCLUSIONS: Based on these early results, AWBAT-D™ appears to have slower donor site healing and does not provide significant improvements in postoperative pain or discharge time compared to Duoderm(®). There is no evidence at this stage that our standard donor site dressing should be changed.

Attenuation of Flightless I, an actin-remodelling protein, improves burn injury repair via modulation of transforming growth factor (TGF)-beta1 and TGF-beta3.

BACKGROUND: The pathophysiological mechanisms involved in burn injury repair are still not fully understood but include processes involving cellular proliferation, migration and adhesion. The actin cytoskeleton is intricately involved in these key wound repair processes. Flightless I (Flii), an actin-remodelling protein and transcriptional regulator, is an important regulator of wound healing. OBJECTIVES: To investigate the function of Flii gene expression in burn injury repair. METHODS: Partial-thickness scald wounds were created on Flii heterozygous (Flii(+/-)), wild-type (WT) and Flii transgenic (Flii(Tg/+)) mice. Burns were assessed using histology and immunohistochemistry, real-time quantitative polymerase chain reaction and biochemical analysis. RESULTS: Flii expression, while upregulated in burn injuries, was significantly lower in the wounds of Flii(+/-) vs. WT vs. Flii(Tg/+) mice and healing was improved in Flii(+/-) mice with their burns healing faster than WT and Flii(Tg/+). Pro-scarring transforming growth factor (TGF)-beta1 protein and gene expression were reduced in Flii(+/-) burns while antiscarring TGF-beta3 was significantly elevated. Anti-alpha-smooth muscle actin (alpha-SMA) was decreased in Flii(+/-) burns suggesting a decrease in contractile myofibroblasts in the developing scars. Although Flii is primarily a nuclear and cytoplasmic protein it is also released by wounded cells. Intradermal injection of Flii-neutralizing antibodies (FliAbs) to WT burn wounds significantly improved their healing, indicating a potential novel approach for treating burns. Decreased TGF-beta1 and elevated TGF-beta3 expression were observed in FliAb-treated burns, which may contribute to their observed improvement in healing. CONCLUSIONS: Strategies aimed at reducing Flii expression, for example using neutralizing antibodies, may lead to improved burn outcomes.

Experience with severe extensive blistering skin disease in a paediatric burns unit.

Vesiculobullous disorders are thankfully uncommon. A brief overview of the literature is presented together with our experience of managing these cases on a paediatric burns unit in the six years 1992 1998. The advantages of management on such a unit are outlined and include a facility for major dressings and frequent changes and a familiarity with fluid resuscitation in the child with major skin loss. The financial cost of treatment and rehabilitation of these children is high.

Monitoring wound healing by odour.

A pilot study using electronic aroma detection was performed over a six-month period to assess the aroma of chronic non-healing venous leg ulcers and the effect of appropriate antibiotic therapy on modification of the aroma. Deep infection with pathogenic organisms was found on biopsy culture in 13 out of 15 patients. Odour analysis was performed at weekly intervals on the ulcer dressings using an AromaScan instrument. Data points on the aroma maps moved from their pre-treatment presentation. Alterations in aroma data correlated well with the progress of the ulcers. Aroma analysis is shown to be a potential tool in monitoring the progress towards healing of chronic venous ulcers.