27 years of a single burn centre experience with Stevens-Johnson syndrome and toxic epidermal necrolysis: analysis of mortality risk for causative agents.

INTRODUCTION: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life threatening unwanted side effects, mainly from medication. Pathophysiology is still being debated. The disease usually requires treatment in burn units. PATIENTS AND METHODS: In a retrospective study over 27 years we evaluated 72 patients admitted with SJS, SJS/TEN and TEN to our burns unit. Patients were evaluated for age, gender, total body surface area (TBSA) involved, causing agents, blood transfusion, dialysis, steroid administration, intubation, length of intensive care stay and death rate. Participants were grouped according to TBSA from 0 to 10, 11 to 30, and 31 to 100% and also into causing agent. Statistical analysis was done using a step-wise regression analysis. Because of small sample sizes for each drug group the percentage of related death rates for each drug group was calculated. RESULTS: The highest incidence of SJS and TEN was in the age group of 61-70 years. Overall mortality was 38%, mainly due to sepsis. For each subgroup SJS/TEN overlap had the highest mortality. The highest mortality for causing agents was found from antibiotic treatment, the lowest from using non-steroidal anti-inflammatory drugs. Most transfusions were done in the antibiotic group also the group underwent the highest number of dialysis events. Step-wise regression analysis identified dialysis, mechanical ventilation and age over 65 years as mortality high risk factors. CONCLUSION: When SJS/TEN is caused by antibiotics suspicion of developing a fatal sepsis should be high. Patients' medical condition when initiating therapy with a potential causing agent also might influence medical outcome.

Clinical profile of assault burned victims: a 16-year review.

OBJECTIVE: Assaults by burning occur infrequently and are related to the social circumstances and demographics of each population. We aimed to explore the mechanisms, complications, morbidity and mortality associated with assault burn injuries admitted to the Burns Intensive Care Unit of Merheim University Hospital in Cologne. METHODS: A retrospective data analysis of a consecutive series of 1 243 burn patients between 1989 and 2004. The cohort was divided into two groups: AG (assault group) and CG (control group). Analyses were controlled for clinical data, treatment and outcome of all patients involved. RESULTS: Forty-one patients with assault burn injuries were identified during the study period. Compared with the general burn population (CG), the AG had a significantly larger size of third-degree burns (p=0.047), a higher incidence of inhalation injury (p<0.001) and a longer intubation period (p=0.047). Patients in the AG were also more likely to undergo escharotomy (p=0.013) and to receive antibiotics on admission (p=0.016). The mortality rate was higher in the AG than in the CG (26.8% v. 19.9%), but this difference was not significant. CONCLUSIONS: Burned patients who were victims of assault tend to have more severe injuries than the general burn population. These injuries are not only physical, and their management requires a multidisciplinary approach to improve outcome.

Cologne burn centre experience with assault burn injuries.

OBJECTIVE: To evaluate demographic and socioeconomic factors associated with assault burn injuries. BACKGROUND: Assault by burning demonstrates a rare but severe public health issue and accounts for unique injury characteristics in the burn intensive care unit (BICU). METHODS: We conducted a retrospective cohort study involving patients with thermal injuries admitted to the BICU of a university hospital. The patient cohort was divided into two groups (ABI group: patients with assault burns, n=41; CONTROL GROUP: population of all other burned patients admitted to the BICU, n=1202). Bivariate and multivariate analyses including demographic and socioeconomic data were used to identify factors associated with assault burns. RESULTS: Forty-one assault-related burn victims were identified in the study period. This represents 3.3% of all significant burns admitted. Comparing battery victims with the control population, assault patients were more likely to be young (mean age 36.2 years vs. 42.2 years) and immigrants (41.5% vs. 15.1%). Furthermore, marital status (65.9% vs. 40.8% singles), employment status (36.6% vs. 9.7% unemployed) and insurance status (41.5% vs. 12.3% social insurance) were significantly different in the bivariate analysis. Logistic regression evaluation identified three variables that were independently associated with assault burns: younger age (< or =25 years) (odds ratio, 2.54 [95% confidence interval, 1.29-5.02]; p=0.007), ethnic minority (odds ratio, 3.71 [95% confidence interval, 1.91-7.20]; p<0.001) and unemployment (odds ratio, 4.02 [95% confidence interval, 2.03-7.97]; p<0.001). CONCLUSIONS: The high incidence of youngsters, unemployment and the great proportion of immigrants in victims of assault might provide several opportunities for community-based psychosocial and occupational programs. A multidisciplinary approach targeting issues specific to the violent nature of the injury and the socioeconomic background of the victims may be of benefit to improve their perspectives for rehabilitation.

Acalculous cholecystitis in severely burned patients: incidence and predisposing factors.

OBJECTIVE: To investigate the incidence and predisposing factors of acalculous cholecystitis (AAC) in severely burned patients. BACKGROUND DATA: Although some studies report on AAC in critically ill patients, very little is known about AAC after severe burns. METHODS: We conducted a retrospective cohort study involving patients with burns admitted to the burn intensive care unit (BICU) of a university hospital. The patient cohort was divided into two groups (AAC group: burned patients with histological proven acalculous cholecystitis, n=15; CONTROL GROUP: population of all other burned patients admitted to the BICU, n=1225). Univariate and multivariate analyses were used to identify predisposing factors for the development of AAC. RESULTS: Fifteen patients with acalculous cholecystitis were identified in the study period. This represents 1.2% of all significant burns admitted. Comparing the AAC group with the Control population the following patients' characteristics, therapeutic measures and outcome parameters were significantly different in the univariate analysis: mean age (54.0 years vs. 42.0 years), BMI (28.9 kg/m(2) vs. 25.6 kg/m(2)), abbreviated burn severity index (8.3 vs. 6.4), total body surface area burn deep partial thickness (12.0% vs. 6.2%) and full thickness (10.2% vs. 6.8%), concomitant inhalation injury (80.0% vs. 28.9%), sepsis (46.7% vs. 14.9%), catecholamine (100% vs. 30.4%) and antibiotic requirement (100% vs. 58.2%), non-biliary tract operations (4.9 vs. 1.5), BICU length of stay (63.4 days vs. 21.0 days), ventilator days (50.3 vs. 11.9), packed red blood cells (PRBCs) administration (70.0 units vs.13.0 units) and mortality (53.3% vs. 19.7%). In the multivariate analysis however, only age, the number of administered units of PRBCs and the duration of mechanical ventilation turned out to be independent predictors for the occurrence of AAC. CONCLUSION: AAC is a rare complication of severely burned patients and may reflect the severity of the patient's general conditions. Predisposing factors for AAC are advanced age, the need of blood transfusions and prolonged mechanical ventilation. In the presence of these predisposing factors, early monitoring may help to detect AAC earlier and to initiate appropriate intervention.

[The oculocardiac reflex in blepharoplasties]. / Der okulokardiale Reflex bei Blepharoplastiken.

The oculocardiac reflex (OCR) is a well-known phenomenon in ophthalmic surgery, but is rarely described in aesthetic blepharoplasty surgery. It was first mentioned in 1908 by Ascher and Dagnini. Since then, ophthalmologists and anaesthesiologists have regarded the onset of the oculocardiac reflex as a significant intraoperative problem, which is undermined by several case reports that describe dysrhythmias which have haved caused morbidity and death. Per definition the OCR is caused by ocular manipulation and involves intraoperative bradycardia by a change of 20 beats/minute compared to the preoperative heart rate or any dysrhythmia during the manipulation via a trigeminal-vagal-mediated reflex arc. Having operated on a 48-year-old, healthy woman in our clinic, who underwent a cardiac arrest during the blepharoplasty procedure, followed by a successful resuscitation, we investigated the onset of the OCR in our blepharoplasty patients within the last 3 years. The onset of the OCR was noted in 22 of 110 (20 %) blepharoplasty patients, mainly affecting younger, low-weighted patients operated under local anaesthesia. Awareness and treatment of this potentially life-threatening oculocardiac reflex are necessary. In most cases the onset of the reflex may be avoided by a gentle operation technique and by refraining from severe traction to the muscle or fat pad. The best treatment of a profound bradycardia caused by the OCR is to release tension to the muscle or fat pad in order to permit the heart rate to return to normal. Intraoperative monitoring is of utmost importance.

[Reconstruction of the oral commissure in microstomia patients with deep dermal facial burns: a modified technique]. / Rekonstruktion der oralen Kommissur bei Mikrostomie nach tief dermaler Verbrennung - eine modifizierte Technik.

BACKGROUND: Deep thermal dermal wounds of the oral region with subsequent microstomia are a rare and complex indication for surgical reconstruction of the oral commissure. Apart from functional and mimic aspects, aesthetic expectations are high. Based on converse technique, we performed a reconstruction of the oral commissure in 17 patients. 8 of these needed surgical re-operation due to recurrence and insufficient results. This high rate of complications led to a modification of the surgical procedure. PATIENTS: We present a modified technique which gave good results in our clinic. Based on Fairbank's technique, we altered the technique by covering the soft tissue defect of the lateral lip with an additional rotation flap raised from the mucosa of the enoral lower lip. Resulting scars were thereby shifted to the enoral side of the lower lip which caused less contracture in the region of the oral commissure. RESULTS: Using this modified technique, we were able to achieve a lasting displacement of the oral commissure to the lateral side. Long-term follow-up showed good functional results with no need for additional procedures.

[Merkel cell carcinoma -- a case report with regard to the current treatment concepts]. / Das Merkel-Zell-Karzinom -- Eine Falldarstellung unter Berücksichtigung der aktuellen Behandlungskonzepte.

A 54-year-old female patient was admitted due to a slow growing, painless resistance on the dorsum of the left hand. The intraoperative aspect of the tumor showed a yellow to white doughy tissue mass infiltrating the metacarpal musculature and bone. After immunohistopathological staining, the diagnosis of a Merkel cell carcinoma was confirmed. A high frequency of local recurrences (25 to 77 %) and lymph node metastases (50 %) are characteristic features of Merkel cell carcinoma. In 30 % of the cases, the disease has a fatal outcome. In primary Merkel cell tumors, surgical excision is the basic therapy, although this carcinoma is highly radiosensitive. Thus, besides surgical treatment, radiation should be included into the treatment concept. In the presented case, after radical excision of the tumor and sentinel-lymphnode biopsy, the patient has been free of local recurrence and metastases for 13 months.

[Skin cultivation in treatment of severely burned patients]. / Die Hautzüchtung bei der Behandlung Schwerstverbrannter.

In severe burns a total body surface area (TBSA) of more than 60% restricts possible donor areas for autologous STS coverage. Additional wound surfaces may further harm the patient. From a skin biopsy of 5 cm2 the total body surface can be covered using keratinocyte cultures to multiply cells by 1000 up to 10,000. The cultured keratinocytes may be used as "sheets" (CEA) or suspended in fibrin glue (KFGS), which must be covered with meshed allogenic STS graft. Long culture times from 14 (KFGS) up to 28 days (CEA), infection of the culture and the woundbed, mechanical instability in the first period after grafting, restoring the dermal equivalent in full thickness burns and high costs are the problems of this new means of burn wound covering. Technical details of cultivation and coverage procedures using CEA and KFGS are discussed.

[Costs and long-term results of plastic surgery treatment of decubitus ulcers in paraplegic patients]. / Aufwand und Langzeitergebnisse der plastisch-chirurgischen Behandlung von Dekubitalulzera bei Paraplegikern.

Costs and long-term results of plastic surgical procedures were evaluated in 17 paraplegics with a mean age of 39 years and Campbell-Grade 5 pressure sores. Seven sacral, nine ischial and one trochanteric ulcers were treated by myocutaneous or fasciocutaneous flaps. The mean hospitalization period was 82 days: up to 44 days in the plastic surgical department, 29 days in referring hospitals. During the follow-up period, averaging 18 (6 to 33) months, four patients suffered recurrences, all of them ischial sores. Evaluated regarding occupational resumption or duration of wheelchair mobility, eleven patients achieved full and two patients partial rehabilitation. The success rate justifies the operative procedures. Cost reduction by shortened hospitalization could be achieved through earlier transfer of patients to specialized units since preoperative preparation requires rarely more than one week and surgical relief can usually be achieved within a confined period of time. Orthopaedic deformities contributed to the majority of sores and to all recurrences.

Alcohol and drug abuse in burn injuries.

Two studies are described in this paper. In the first study 225 acutely, severely burned patients were retrospectively investigated as to admission blood alcohol level and history of chronic alcohol abuse. The influence of further risk factors, circumstances and therapeutic data was studied, in particular the influence of gender, full-thickness burns, smoke inhalation injury, smoking, length of total and ICU stay, and suicide attempt. The 70 patients with positive blood alcohol levels on admission had a significantly higher fatality rate (31.5 per cent) in comparison with the 18.1 per cent fatality rate of patients with a negative blood alcohol level. Both groups had nearly identical mean TBSA and mean age. Chronic alcohol abuse was noted in 59 patients. These patients were found to have a higher fatality rate (31.4 per cent, 22/70) compared with that of patients without a history of chronic alcohol abuse who had an overall fatality rate of 18.1 per cent (28/155). No significant difference was found between non-intoxicated and acutely intoxicated alcoholics (31.4 vs 29.3 per cent). Our conclusion is that intake of alcohol before burn injury represents an independent risk factor. The second study was a prospective study of 16 consecutively admitted burn patients, who were evaluated for both drug and alcohol intake. Five patients had positive drug levels and five had positive alcohol levels. Five patients had a history of chronic drug and/or alcohol abuse. This incidence of alcohol and drug abuse supports the findings of our retrospective study.

[Preoperative prevention of infection with cefuroxime in hand surgery emergencies. Efficacy, control of concentration, follow-up]. / Pröperative Infektionsprophylaxe mit Cefuroxim beim handchirurgischen Notfall. Effizienz, Konzentrationskontrolle, Verlaufskontrolle.

Clinical efficacy and drug safety of Cefuroxime for preoperative prophylaxis of wound infection was investigated in 20 cases of acute open hand injuries. Ten minutes before filling of the tourniquet, Cefuroxime was given. Tissue and serum levels of ten patients were determined 10 and 70 minutes later. Levels far above the minimum inhibitory concentrations of possible pathogenic bacteria were obtained. No serious infection occurred. Wound complications not related to infection occurred in 15%.

[Single dose prevention with cefuroxime in plastic surgery. Control of serum level, efficacy and tolerance]. / Einmal-Prophylaxe mit Cefuroxim in der Plastischen Chirurgie. Spiegelkontrolle, Effizienz und Verträglichkeit.

Clinical efficacy and drug safety of single-shot prophylaxis with Cefuroxime was investigated in a series of 50 elective plastic surgical operations. Serum and tissue concentrations at one hour after application were determined in ten patients undergoing breast reduction. Levels far above the minimum inhibitory concentrations for possible pathogenic bacteria were obtained. No infection occurred. Wound complications not related to wound infection occurred in 12%.

Cultured autologous keratinocytes in fibrin glue suspension, exclusively and combined with STS-allograft (preliminary clinical and histological report of a new technique).

The use of cultured epidermal cell sheets has become a recognized method for the coverage of extensive burns. The disadvantages are a long time-lag until the cells are available, the fragility and difficult handling of the grafts, an unpredictable 'take' and extremely high costs. In three patients with deep partial and full skin thickness burns we have applied cultured autologous keratinocytes suspended in fibrin glue. In two of these patients the keratinocyte culture in the fibrin matrix (KFGS) was overgrafted with allogeneic, glycerine-preserved split thickness cadaver skin. The area thus covered ranged from 3 to 15 per cent TBSA. Cultured grafts were available between 2.5 and 3 weeks. The non-confluent cells developed a continuous epithelial layer within the 4 days until the first dressing change. Histological examination showed a stratified neoepidermis. Clinically the new skin had satisfactory stability and mechanical quality. The epidermis of the allogeneic overgrafts desquamated within a few days without signs of inflammation, but there are indications that the STS-allograft dermis is at least partly integrated into the new skin and may serve as a scaffold for the grafted cell culture. The fibrin glue matrix seems to give sufficient adherence stability to keratinocytes that are grafted in an actively proliferating state. Further advantages are the easy repetition and application, as well as a reduction in operating time and costs in these severely injured patients.

Phenol burns and intoxications.

Phenol burns and intoxications are life-threatening injuries. Roughly 50 per cent of all reported cases have a fatal outcome. Only a small number of cases have been reported with high serum concentrations after phenol burns who survived. In our own experience a patient with 20.5 per cent total body surface area deep partial skin thickness phenol burns and serum concentrations of 17,400 micrograms/litre survived after immediate and repeated treatment of the scalds with polyethylene glycol (PEG) and silver sulphadiazine. A literature review of experiences with phenol intoxications reveals the advantages of PEG application. Questions on the need for enforced diuresis and haemodialysis as well as the initial treatment procedures are discussed. Advantages of different solutions for local therapy are reported.

Cologne Burn Centre experiences with glycerol-preserved allogeneic skin: Part I: Clinical experiences and histological findings (overgraft and sandwich technique).

In an effort to improve the take of finely meshed autografts a modification of the sandwich technique, as first published by Alexander et al. (1981), was developed. In contrast to the techniques described by other authors, the wound bed is sealed with fibrin glue spray after excision of the burns. Widely meshed autografts are then covered with non-meshed (only scarcely sliced) glycerolized allograft sheets, being fixed with staples. Patients are placed on fluidized beds and are exposed without dressings from the fifth day onwards. Histologically and clinically, it can be assumed that part of the glycerolized allodermis is incorporated. During the weeks after transplantation, a creeping substitution of the allodermis by autologous tissue takes place. This would suggest a co-existence between glycerol-preserved hypo-allergenic allografts and auto-epidermis. Research on the definitive fate of allodermis in cases of sandwich grafting is continuing.

[Treatment of perianal burns with submerged skin particles]. / Behandlung der perianalen Verbrennungen mit versenkten Hautpartikeln.

Perianal burn wounds often cannot be cured by conventional split-thickness skin grafting procedures. This is due to the mechanical stress and the enormous bacterial colonization. Transplantation of small skin pieces, submerged into the granulation tissue, is able to produce small epithelial islands within 2 weeks. These enlarge continuously and produce complete epithelialisation in the further course. Own results with 7 burn patients prove that this technique is suitable to epithelialize gluteal and perianal problem wounds with comparatively little expenditure.

[Serum IgG concentrations and antibody titer of burn patients after preventive intravenous IgG substitution with a Pseudomonas immunoglobulin]. / IgG-Serum-Konzentrationen und Antikörpertiter brandverletzter Patienten nach prophylaktischer intravenöser IgG-Substitution mit einem Pseudomonas-Immunglobulin.

In a randomized clinical trial 30 patients with burn injury received supportive therapy with a Pseudomonas hyperimmunoglobulin (Psomaglobin N). The control group received no additional therapy. The patients of both groups were between 15 and 60 years of age and had a full-thickness burn of 30-70% of the body surface area with inhalational trauma being optional. The whole trauma was classified and scored with the 'Abbreviated Burn Severity Index' (which allows another extra score point for inhalational trauma). Both groups underwent the same intensive care unit treatment with preference to early wound excision and wound grafting following functional aspects of reconstructive surgery. Bacteriological monitoring was performed on suspicion of wound infection and bacteremia by taking wound swabs and blood cultures. The supportive treatment group received a total of 250 mg/kg hyperimmunoglobulin on days 3, 5, 7, 10, and 13. Of 30 patients in the control group 16 had an additional inhalation trauma, and 8 of those (50%) died (only 1 of 14 patients without inhalation trauma died). In the group receiving supportive treatment, 23 out of 30 patients had an inhalation trauma, and 8 of those (35%) died (1 of 7 patients without inhalation trauma). In both groups with inhalation injury, the patients were at risk of developing bacteremia: 13 of 23 of the immunoglobulin-treated patients and 12 of 16 patients of the control group. Bacteremic controls died at a lower score than bacteremic immunoglobulin-treated patients (8.6 vs. 10.3 points).(ABSTRACT TRUNCATED AT 250 WORDS)

Prehospital care of burns: an analysis of 3 years use of the emergency physician system (EPS) Cologne.

Little information is available about the vital parameters of burns victims shortly after the accident. Therefore cases of burns, electrical and caustic injuries presenting to the Cologne Emergency Physician System over 3 years (n = 262) were prospectively studied and analysed. The average incidence in Cologne, Germany (population 1 million), of burns victims attended by the Emergency Medical System and emergency physicians at the scene was 74 adults and 14 children per year. Children are mainly injured by scalds (41.4 per cent); adults by fire accidents (43 per cent). A classification of the victims at the site of the accident according to their vital signs (Trauma Score (TS) after Champion H. R., Sacco W. J. and Carnazzo A. J. et al. (1981) Trauma Score. Crit. Care Med. 9, 672) showed, that in spite of a major burn injury, the vital signs were usually not or only slightly impaired. Subsequent measurements instituted by the emergency physician at the scene increased with decreasing initial TS. With TS = 14, 50 per cent of the patients were intubated; below 14 points nearly 100 per cent. The fluid administered also increased with a decreasing TS.

Tissue suction of the male and female breast.

Liposuction has been used either alone or combined with resection for the correction of male and female breast deformities. The majority of the 32 patients in our study were treated for gynecomastia (69%). Other indications were Madelung's disease, gender dysphoria, asymmetry, hypertrophy, postburn and postreconstruction deformities. In 54% of the gynecomastia cases, suction alone gave a satisfactory result. In all but one male patient suction permitted us to avoid incisions other than periareolar incisions. Thirteen aspirates from gynecomastias and three glands resected secondarily after suction were examined histologically. All aspirates included glandular tissue. We conclude that breast tissue is accessible to the suction cannula, and that this is a valuable tool for correcting gynecomastia and for use in many aesthetic procedures on female patients.

[Open intercarpal palmar dislocation fracture with capitate fracture--stabilization by external fixation]. / Offene interkarpale palmare Luxationsfraktur mit Kapitatumfraktur--Stabilisierung durch Fixateur externe.

A case of open carpal dislocation fracture not previously described is reported on. Reduction and stabilization of the dislocation were successfully performed using external fixation without additional Kirschner wires. Despite extensive trauma, hand function is now excellent, and there are no signs of residual carpal instability.