Prognostic significance of allelic losses in primary melanoma.

Loss of genetic material, including loss of loci on chromosome arms 6q, 9p, and 10q, occurs frequently in cutaneous melanoma but infrequently in benign melanocytic nevi or other melanocytic lesions, suggesting that these genetic alterations are important in the development and progression of melanoma. To examine whether allelic loss is of prognostic importance in melanoma, disease-free survival was related to loss of heterozygosity on 6q, 9p and 10q in 83 individuals with sporadic primary cutaneous melanoma. Loss of chromosome arms 6q and 10q were each significantly associated with a poorer clinical outcome (P=0.013 and P=0.001 respectively). In a subgroup of 41 subjects whose primary tumours were allelotyped, the fractional allelic loss (FAL) at 39 autosomal arms also significantly correlated with disease-free survival (P=0.013), with an increase in FAL associated with a poorer outcome; this association remained significant when controlled for tumour thickness (P=0.035). In addition, a greater proportion of cells were immunopositive for Ki67 antigen, p53 and p21WAF1 protein in the primary melanomas than in the benign melanocytic nevi, however, only p53 over-expression was significantly associated with improved survival (P=0.041).

Purification and characterization of iduronic acid-rich and glucuronic acid-rich proteoglycans implicated in human post-burn keloid scar.

Small proteoglycans (PGs), extracted from human keloid scar tissue with 4M guanidinium chloride and fractionated by DEAE-cellulose chromatography, were separated by ethanol precipitation into one L-iduronic acid-rich and one D-glucuronic acid-rich fraction. The size of the L-iduronic acid-rich PG was 102 kDa with a 27 kDa glycosaminoglycan chain, that of the D-glucuronic acid-rich PG was 90 kDa with a 26 kDa glycosaminoglycan chain, and the protein core of both PGs was 14.5 kDa. The two PGs carried sulfate groups mostly attached at C-4 of the 2-amino-2-deoxy-D-galactose units. The N-terminal amino acid sequence of both was similar to human bone PGII (decorin), normal and hypertrophic scar, and human dermal tissue PG.

An algorithmic approach to the treatment of hydrofluoric acid burns.

Hydrofluoric acid (HF) injuries have a potential for both systemic toxicity as well as severe tissue destruction. We present an algorithm for the management of HF burns. This algorithm addresses these issues emphasizing the differences between major and minor cutaneous burns, and includes the approach to inhalation, ingestion and eye injuries. Although algorithms can never be complete, we hope this algorithm will be used as an aid in the clinical management of these patients.

Conservative management of acute pseudo-obstruction in a major burn.

We present a case of recurrent acute colonic pseudo-obstruction (ACPO) in a burn patient that responded to a postural change which has not been previously reported.

Burns of the female genitalia and perineum.

Burns of the female genitalia and perineum mostly occur in connection with more extensive thermal injuries to the trunk and lower extremities. Isolated burns to the vulva are very unusual because this area is anatomically well-protected. A few reports in the literature describe injuries due to bizarre accidents and now obsolete techniques. The management of these injuries, possible complications, prognosis and long-term results are discussed following a case report of a 28-year-old woman who sustained extensive deep dermal burns to her external and internal genitalia in a suicide attempt involving a firework.

Hydrofluoric acid burns: a review.

Hydrofluoric acid (HF) is a highly dangerous substance with a wide range of industrial as well as domestic applications. It is unique in both the severity of the cutaneous burns it may produce, and its potential for systemic and occasionally lethal toxicity. The literature on the treatment of HF injuries is extensive, though occasionally confusing and often contradictory, with no coherent management policy emerging. In this paper we present a comprehensive account of the evolution of therapy, drawing on clinical reports and experimental studies.

Severe burns resulting from an exploding teat on a bottle of infant formula milk heated in a microwave oven.

Accidental injury to infants can result from the use of home microwave ovens. The spectrum of injury includes scald burns of the trachea, palate oropharynx and oesophagus due to aspiration and ingestion of foods that have been overheated. There is one previous case report of a child with second-degree burns of 6 per cent of his body area due to explosion of the plastic liner and nipple on a feeding bottle top. We present a case report of an infant who suffered 7 per cent full-thickness burns following explosion of the bottle teat and subsequent splattering with hot milk. He required mid-palmar amputation of his left hand including thumb, index and middle fingers. The full-thickness burns of left cheek and left shoulder were grafted but will result in significant scarring. It is common practice in many homes to heat infant feeds in the microwaves. We suggest that health professionals dealing with children need to be aware of the potential hazards so that appropriate education of parents can take place.

Early cardiorespiratory patterns in patients with major burns and pulmonary insufficiency.

We examined the case records of 50 consecutive patients with major cutaneous burns who required early mechanical ventilation. In 22 patients full haemodynamic and respiratory data were available within 24 h of their injury. Unexpectedly the haemodynamic and oxygen transport patterns of survivors and non-survivors were essentially similar although pulmonary artery occlusion pressure measurements and estimations of net fluid input suggest that non-survivors were relatively underresuscitated compared with survivors. Both groups showed inadequate oxygen utilization in the early stages of their injury despite normal (or above normal) levels of oxygen delivery. Invasive monitoring could possibly help this subgroup of burns patients.

Corneal burns with eyelid sparing and their treatment.

In a flash injury the eyes are protected by the blink reflex. With our patients the eyes were open looking for a means of escape, exposing the globe to injury by hot smoke and protecting the eyelids. It is essential to examine the eyes in any facial burn, especially if there is any history of being injured in an enclosed space. If there are any signs of corneal injuries then the assistance of an ophthalmologist should be sought.

An algorithmic approach to the management of cutaneous burns.

An algorithm of fluid resuscitation for cutaneous burns is presented. The management of these cases entails an initial process of evaluation followed, when appropriate, by the administration of intravenous fluids. The fluid requirements are prospectively calculated and subsequently modified by using closed loop feedback with monitoring of urine output, plasma deficit, osmolality and vital signs. Three 'problem boxes' have been incorporated into the algorithm to outline the management of: 1. fluid deficit and excess; 2. acute renal failure; 3. the critically ill patient. An algorithm such as this can never be complete, but in its present form it provides both a teaching tool for junior staff as well as a valuable clinical aid for those involved in the acute management of burns patients.

Complete fusion of the vocal cords; an unusual case.

A case is presented of a woman who sustained a 35% body surface area mixed depth cutaneous burn, together with a significant inhalational injury. The patient required emergency resuscitation with endotracheal intubation and subsequently tracheostomy. This resulted in an unfortunate complication of a total adhesion between the vocal cords which extended into the subglottic area, causing complete occlusion of the airway.

Fetal wound healing: an in vitro explant model.

The ability of fetal skin wounds to heal without scar formation is remarkable. The mechanisms that endow the fetus with this unique healing ability remain unknown. We have developed an in vitro explant model using fetal sheep skin to investigate fetal wound healing. This model eliminates the complex systemic mechanisms that modulate in vivo wound healing. We demonstrated that using an enriched medium, midgestation fetal sheep skin explants following wounding reepithelialized within 4 days. By 7 days after wounding the confluent epidermis was thicker, but the dermal wound remained open. This model demonstrates that it is possible to achieve conditions in culture that maintain tissue viability and support reepithelialization. This model may allow us to resolve some of the individual components that participate in the process of scarless fetal skin healing.

Midgestational excisional fetal lamb wounds contract in utero.

Clinical observations and experimental data suggest that fetal wound healing is very different from adult wound healing. An understanding of the biology of scarless fetal wound healing has tremendous clinical potential for modulating postnatal wound problems. In this study, the fetal lamb model was used to assess excisional fetal skin wound contraction in utero. Full-thickness 9-mm punch biopsy wounds were created on fetal lambs at 100 days' gestation (term, 145 days). Half of the wounds remained exposed to amniotic fluid, whereas the other half were covered by a silastic patch to exclude amniotic fluid. Wounds were harvested 3, 7, or 14 days later and wound areas were calculated. Exposure to amniotic fluid retarded wound contraction significantly at 3 days, but by 14 days all wounds had completely contracted and reepithelialized. Myofibroblasts are an important cellular element of wound contraction. The presence of wound myofibroblasts was documented by both transmission electronmicroscopy and immunocytochemistry with antimuscle actin antibody. It is concluded that fetal lamb wounds contract in utero and exposure to amniotic fluid appears to retard fetal skin wound contraction only during the early healing process.

Removal of skin staples in an emergency.

We have highlighted this problem as there are situations where skin staples have to be removed rapidly, for example where bleeding and subsequent respiratory distress develop following neck surgery. A survey of junior hospital staff showed that many doctors had never removed skin staples nor were aware how best to remove them in the event of an emergency. Using skin simulation we compared the time to remove sutures and staples, and found it takes 55% longer to remove skin staples. Where the standard staple remover is not immediately available, an artery forceps, correctly applied, is just as quick.

Basal cell carcinoma in a BCG scar in a young woman. Case report.

A 31 year old woman presented with a crusting lesion on the scar of her BCG vaccination. Histological examination showed it to be a basal cell carcinoma, which only rarely arises in vaccination scars, and is particularly unusual in BCG vaccination scars.

The pressure button: a refinement of the traditional "tie-over" dressing.

The "tie-over" dressing is commonly used in plastic surgical practice. A simple, cheap and effective refinement of this established technique is described. This consists of a flanged disc over which can be slipped a "neoprene" sealing ring. The advantages of the device include the ease and speed of application: the facility to tighten and adjust the tie-over sutures once they are in place and the possibility of removing and replacing the device if early inspection of the graft is desired.

Mixed appendageal tumour: case report.

A case of a mixed dermal appendage tumour is described. The relevant literature is reviewed and problems with the histological diagnosis discussed.