Early Changes during Skin Repair Using Tissue-Engineered Dermal Template in a Full-Thickness Burn.

Rapid wound closure in extensively burned patients has remained one of the major unresolved issues of medicine. Integra® is the most widely established artificial skin, which is composed of a porous matrix of cross-linked bovine collagen and chondroitin 6-sulphate covered by a semi-permeable silicone layer. We present here a (immuno)histological study of a severely burned patient with a full-thickness burn treated with a tissue-engineered dermal template (Integra®) and split-thickness skin graft-based protocol. Immunohistochemical investigation of the artificial dermis revealed that immune cell infiltration reached its peak on day 10. Tissue immunophenotyping found an increase in CD3+ cells over the course of the study as well as CD4 and CD8 positivity on day 40, indicating remaining T-cell subpopulations. We observed weak/no infiltration of NK cells (CD56+). In conclusion, the use of bi-layer Integra® represents a feasible and safe procedure resulting in formation of non-irritating dermal substitutes.

DERMAL REPLACEMENT WITH MATRIDERM - FIRST EXPERIENCE AT THE PRAGUE BURN CENTRE.

INTRODUCTION: The quality of resulting scar tissue plays an important role in patients return to normal life and full functioning in society. The use of artificial skin substitutes in clinical practice improves functional and cosmetic outcomes. This is true for any patient, and not only those suffering from burns. MATERIAL AND METHODS: The collagen elastin dermal substitute Matriderm® allows for immediate application of a dermal substitute together with a skin graft. The authors present a group of 10 patients representing their first experience in utilizing Matriderm® as a dermal substitute in the treatment of skin losses due to various etiologies. RESULTS: The average healing time in the group was 19.6 days. Healing took place without serious infectious complications and with good functional results. CONCLUSION: Matriderm® can be utilized as an alternative to the most commonly used dermal substitute so far, Integra®, in the treatment of acute skin loss due to various etiologies and in reconstructive surgery.

Toxic epidermal necrolysis data from the CELESTE multinational registry. Part I: Epidemiology and general microbiological characteristics.

INTRODUCTION: Toxic epidermal necrolysis (TEN) is a rare, life-threatening autoimmune disease predominantly manifested in the skin and mucous membranes. Today, infectious complications have the dominant share in mortality of TEN patients. Due to the nature of the therapy and administration of immunosuppressive medications, a wide range of potentially pathogenic microorganisms, which cause infectious complications in different compartments in these patients, is not surprising. MATERIAL AND METHODOLOGY: This is a multicentric study, which included all patients with TEN hospitalized between 2000-2015 in specialized centres in the Czech Republic and Slovakia. The total catchment area was over 12.5 million inhabitants. The actual implementation of the project was carried out using data obtained from the registry CELESTE (Central European LyEll Syndrome: Therapeutic Evaluation), when specific parameters relating to epidemiological indicators and infectious complications in patients with TEN were evaluated in the form of a retrospective analysis. RESULTS: In total, 39 patients with TEN were included in the study (12 patients died, mortality was 31%), who were hospitalized in the monitored period. The median age of patients in the group was 63 years (the range was 4-83 years, the mean was 51 years), the median of the exfoliated area was 70% TBSA (total body surface area) (range 30-100%, mean 67%). SCORTEN was calculated for 38 patients on the day of admission. Its median in all patients was 3 (range 1-6; mean 3). Any kind of infectious complication in the study group was recorded in 33 patients in total (85%). In total, 30 patients (77%) were infected with gram-positive cocci, 27 patients (69%) with gram-negative rods, and yeast cells or fibrous sponge were cultivated in 12 patients (31%). A total of 32 patients (82%) were found to have infectious complications in the exfoliated area, 15 patients (39%) had lower respiratory tract infections, 18 patients (46%) urinary tract infections and 15 patients (39%) an infection in the bloodstream. The most common potentially pathogenic microorganism isolated in our study group was coagulase neg. Staphylococcus, which caused infectious complications in 24 patients. Enterococcus faecalis/faecium (19 patients), Pseudomonas aeruginosa (17 patients), Staphylococcus aureus (11 patients) and Escherichia coli (11 patients) were other most frequently isolated micro-organisms. CONCLUSION: The published data were obtained from the unique registry of TEN patients in Central Europe. In the first part, we have succeeded in defining the basic epidemiological indicators in the group of patients anonymously included in this registry. The study clearly confirms that infectious complications currently play an essential role in TEN patients, often limiting the chances of survival. The study also shows a high prevalence of these complications in the period after 15days from the start of hospitalization, when most patients already have completely regenerated skin cover.

Toxic epidermal necrolysis data from the CELESTE multinational registry. Part II: Specific systemic and local risk factors for the development of infectious complications.

The aim of the study was to identify the most important systemic and local risk factors for the development of infectious complications in patients with toxic epidermal necrolysis (TEN). MATERIAL AND METHODOLOGY: This is a multicentric study that included all patients with TEN who were hospitalized between 2000-2015 in specialized centres in the Czech Republic and Slovakia. The total catchment area included a population of over 12.5 million inhabitants. The actual implementation of the project was carried out using data obtained from the CELESTE (Central European LyEll Syndrome: Therapeutic Evaluation) registry, wherein specific parameters related to epidemiological indicators and infectious complications in patients with TEN were evaluated as a retrospective analysis. RESULTS: A total of 38 patients (97%) of the group were treated with corticosteroids. The comparison of patients with different doses of corticosteroids did not exhibit a statistically significant effect of corticosteroid administration on the development of infectious complications (p=0.421). There was no effect of the extent of the exfoliated area on the development of infectious complications in this area. The average extent of the exfoliated area was 66% TBSA (total body surface area) in patients with reported infectious complications and 71% TBSA (p=0.675) in patients without infectious complications. In the case of the development of an infectious complication in the bloodstream (BSI), the increasing effect of the SCORTEN (SCORe of Toxic Epidermal Necrosis) value was monitored during hospitalization. Within 5days from the beginning of the hospitalization, the average SCORTEN value was 2.7 in 6 patients with BSI and 3.0 in 32 patients without BSI (p=0.588). In the period after the 15th day of hospitalization, 7 patients with BSI had an average SCORTEN value of 3.4, and 16 patients without BSI had an average SCORTEN value of 2.5 (p=0.079). In the case of low respiratory tract infection (LRTI), the effects of the necessity for artificial pulmonary ventilation and the presence of tracheostomy were monitored. The statistically significant effect of mechanical ventilation on the development of LRTI occurred only during the period of 11-15days from the beginning of the hospitalization (p=0.016). The effect of the tracheostomy on the development of LRTI was proven to be more significant. CONCLUSION: We did not find any statistically significant correlation between the nature of immunosuppressive therapy and the risk of developing infectious complications. We failed to identify statistically significant risk factors for the development of BSI. Mechanical ventilation and tracheostomy increase the likelihood of developing LRTIs in patients with TEN.

EXPERIENCE WITH INTEGRA® AT THE PRAGUE BURNS CENTRE 2002-2016.

INTRODUCTION: Integra® dermal replacement has a wide spectrum of use both in burn medicine as well as in reconstructive plastic surgery and traumatology. Since 2002, it has been a part of surgical treatment of patients at Prague Burns Centre of the Královské Vinohrady Teaching Hospital. STUDY GROUP: Integra® was used in 47 patients in total between years 2002 and 2016. In this group there were 28 paediatric patients and 19 adult patients. Eleven children were operated during the reconstructive period, 8 children had an acute injury. There were 11 adult patients with Integra® applied within the trauma treatment, another 9 during reconstructive surgery. In 2016, we examined 11 patients treated by Integra®, at least 2 years ago. The average time since the application was 9 years. All examined patients had Integra® primarily applied to treat an acute injury. METHOD: Scars after the application of Integra® were compared with scars after dermoepidermal grafts (DE) in respective patients. Evaluation was performed on the basis of subjective and objective assessment by means of the modified Vancouver Scale (VSS). Samples were submitted for a histological and immunohistochemical analysis. RESULTS: Areas with Integra® coverage scored 1.4 points on average on the VSS. The scars after dermoepidermal graft scored 4 points on the same scale. Subjective assessment of functional and cosmetic quality of scars by patients was better in all cases in comparison to DE grafting. Notable differences were found between scars following Integra® application and those after DE grafting on histological assessment, namely in the organization and quality of collagen and elastin fibres as well as in tissue revascularization. CONCLUSION: The Integra® artificial skin replacement is a part of surgical strategy in management of extensive burn trauma and plays an important role in reconstructive surgery. The resulting scar quality when using Integra® seems to be better than in DE grafting both from an objective and subjective points of view..

The treatment of palmar contact burns in children: a five-year review.

Pediatric palmar contact burns are becoming a common trauma, especially in young children. Treatment of this kind of burn is challenging as well as controversial, regarding the choice between split-thickness or full-thickness skin graft to close the defect. The aim of this review was to evaluate the treatment algorithm at our clinic. We conducted a retrospective study including all patients 0 - 5 years of age admitted to our department from 2008 to 2012 with isolated superficial or deep partial-thickness palmar burns. The mean age was 16.1 months. In 27 cases (52.9%) we were able to close the wound conservatively. Average healing time in this group was 13.3 days. Two of these 27 patients developed flexion contractures, but none of them required additional operation. Twenty-four patients were treated using split-thickness skin graft. The average time period from the day of injury to the day of surgery was 14.2 days. Contractures occurred in 5 (20.8%) of the patients who underwent grafting, Secondary reconstruction using full-thickness skin graft was performed in all 5 of them, which represents 9.8% of all patients. We consider split-thickness grafting quick, easy and effective, with minimal to no donor site morbidity and insignificant inflammation complications. Due to reduced healing time after the actual grafting, rehabilitation can commence earlier.

Les brûlures palmaires par contact sont devenues un traumatisme commun surtout chez les jeunes enfants. Le traitement de ce type de brûlures est non seulement un challenge, mais il est aussi controversé quant au choix de la greffe de peau mince ou de peau totale pour couvrir la perte de substance. Le but de cette revue est d'évaluer l'algorithme thérapeutique dans notre service. Nous avons conduit une étude rétrospective incluant tous les patients entre 0 et 5 ans admis dans notre département de 2008 à 2012 avec des brûlures palmaires du 2e degré superficiel ou du 2e degré profond. L'âge moyen était de 16,1 mois. Dans 27 cas (52,9%), nous avons pu fermer la plaie sans greffe. Le temps de cicatrisation moyen dans ce groupe était de 13,3 jours. Deux de ces 27 patients ont développé des rétractions en flexion, mais aucune n'a nécessité d'opération secondaire. 24 patients ont été traités par greffe de peau mince. La période moyenne entre le jour de la brûlure et le temps chirurgical était de 14,2 jours. Les rétractions ont été observées chez 5 patients (20,8%) qui avaient subi une greffe. La reconstruction secondaire par greffe de peau totale fur réalisée chez tous les 5, ce qui représente 9,8% de tous les patients. Nous considérons que la greffe de peau mince est rapide, aisée et efficace avec une morbidité minimale ou nulle du site donneur et des suites inflammatoires insignifiantes. La réduction du temps de cicatrisation après la greffe, autorise une rééducation précoce.

[Time-related expression of adhesive proteins and other markers of age of injuries]. / K casovým relacím exprese adhezivních bílkovin a dalsích markeru stárí poranení.

UNLABELLED: In addition to evidence of the vital reaction it is important from the forensic aspect to assess the age of wounds, in particular in wounds with a short time of survival. To both can contribute detection of adhesive molecules, identified in recent years, possibly in combination with other markers of early stages of reparative inflammation. The submitted paper comprises the results of investigation of 465 skin wounds. The investigated samples were obtained from necroptic material, excision from wounds of treated patients and from experimental injuries in mice. Assessment of the age of injuries by means of endothelial adhesive molecules was made in paraffin sections after transfer into Varioclave and using the ABC techniqueref.. In human material a strong positive reaction of ICAM-1 was observed first after 1 and a half hours and latest after 3 and a half days, in P-selectin first after 3 mins., latest after 7 hours, in E-selectin first after 1 hour and latest after 17 days, in VCAM-1 first after 3 hours and latest 3 and a half days after the development of the injury. Expression of L-selectin was not typical for the injury. In skin injuries of mice positive immunohistochemical reactions were found as a rule sooner than in skin injuries of humans. Fibronectin was detected in paraffin sections from 70 skin wounds of dissected subjects immunohistochemically by the indirect immunoperoxidase reaction and by the use of the ABC technique labelled with alkaline phosphatase. Positive evidence was observed first after 5 minutes and latest after 8 hours. CONCLUSION: Detection of a rise of expression of ICAM-1, VCAM-1 and P- and E. selectin and the formation of basic netlike fibronectin structures improves the assessment of the age of wounds with a short survival period.