Response of keloid fibroblasts to Vitamin D3 and quercetin treatment - in vitro study

Keloid scars continue to pose a challenge to clinicians as the treatment armamentarium lacks a formidable agent to tackle them. We have undertaken an in vitro study based on the mechanism of action of Vitamin D3 and quercetin on isolated keloid fibroblasts. Dose-dependent action on the reduction of cellular proliferation, collagen synthesis and induction of apoptosis by Vitamin D3 and quercetin are analyzed and probable mechanism of action is elaborated. This study thus opens up newer avenues in tackling keloid scars effectively.

High voltage electrical burn injuries in teenage children: case studies with similarities (an Indian perspective)

From 1992 to 2012, a total of 911 paediatric burns were admitted and treated at Kanchi Kamakoti Childs Trust Hospital Intensive Burn Care Unit, of these 28 children had suffered electrical injuries and burns. 7 teenagers suffered high voltage electrical burn injuries: 2 were involved in train accidents which caused fatal electrical injuries, and 5 had electrical burn injuries caused by similar types of accidents, requiring Paediatric Intensive Care Unit (PICU) care, repeated surgeries and extensive rehabilitation. A common factor among these latter 5 patients was that they were injured by overhead high electrical voltage cables. Their management was labour intensive and highly costly. In this report, the type of accident, the electrical voltage that produced burns and the treatment details are elaborated. Findings included similarities in age and type of accident, and failure to implement safety procedures and apply standard norms of high voltage transmission feeder lines.

Advantages of collagen based biological dressings in the management of superficial and superficial partial thickness burns in children

Collagen based dressings for acute burn wound management have been extensively used in India, particularly in the city of Chennai. Due to the high levels of humidity in our city, closed dressings become infected and treatment with topical antimicrobials, like Silver Sulfadiazine cream, quickly become desiccated. Collagen membrane dressings were manufactured by the biomaterial laboratory of the Central Leather Research Institute (CLRI), Government of India in Chennai, and then the process was patented. Collagen was extracted from bovine skin and Achilles tendons, and then reconstituted. This was used on burn wounds as dressings after clearance from the Institutional Review Board and Ethics Committees of the Hospital and CLRI. Continued research in this field to enable resulted in the design of silver sulphadiazine loaded alginate microspheres which were embedded in the reconstituted collagen. Controlled delivery of silver sulphadiazine. This collagen membrane was used in chronic infected burns. Low molecular weight heparin was given subcutaneously to improve wound healing in burn injuries and collagen membrane dressings were also applied. After several trials the process technology was patented. The advantages and disadvantages of the collagen membrane cover is elaborated in a group of 487 pediatric burn patients. The trial was conducted at the burn unit of Kanchi Kamakoti Childs Trust Hospital (KKCTH) in Chennai, India.

Expression of fibrocyte markers by keloid fibroblasts: an insight into fibrosis during burn wound healing - a preliminary study

In extensive burns it becomes difficult for fibroblasts to migrate from the periphery of the healthy tissue and colonize the injured area. Even under such circumstances healing takes place, and this is attributed to the differentiation of circulating fibrocytes which enter the wound site. This normal cell type is identified in keloid fibroblasts: it expresses fibrocyte markers and secretes extra cellular matrix proteins. In-vitro collagen contraction assay reveals that fibrocytes contract collagen gels with an efficacy similar to normal fibroblasts. The contribution of fibrocytes to the formation of keloid fibroblasts in post-burn healing is discussed.

Profile of burn sepsis challenges and outcome in an exclusive children's hospital in Chennai, India

A group of 273 paediatric patients admitted to Kanchi Kamakoti Childs Trust Hospital Burn Unit, Chennai, India between the years 2004 to 2010 were analysed retrospectively. Of these, 89 were suffering from sepsis and septic shock and 15 died. Strict adherence to antibiotic administration and to the Paediatric Intensive Care Unit (PICU) and management protocol improved the outcome, especially in 2009 and 2010.

Profile of children abused by burning

In an analysis of paediatric burn admissions to a hospital in India during the years 1992-2007, 9.3% of burn injuries were found to be secondary to abuse. These had valid documented evidence and child neglect was excluded. This incidence of child abuse has been on the rise in the last seven years and was more evident due to careful investigation by a team comprising a plastic surgeon, a paediatrician, a legal expert, a psychologist, and a social worker. As with the incidence reported by many other researchers, most of the injuries were caused by scalding.

Facially disfigured children--dedicated approach and rehabilitation

Facial disfigurement following congenital anomalies or acquired defects due to accidents or scars results in mental trauma and other related consequences. A multidisciplinary team approach with special importance to rehabilitation is required in handling such patients.

Low molecular weight heparin-induced pharmacological modulation of burn wound healing

Low molecular weight heparin (LMWH) appears to be a promising solution for reducing inflammatory post-burn episodes and results in improved healing. The clinical examination presented here includes patients with burn wounds ranging from 20 to 35% total body surface area (TBSA) who were categorized into two groups, of which one received subcutaneous LMWH treatment (10,000 units/day) and the other acted as control. The process of healing was assessed through regular examination of clinical features such as regression of erythema and oedema, eschar formation, and rate of re-epithelialization. Various studies have demonstrated an increase in levels of serum IL-6 indicating the severity of the morbid condition. In the present investigation, LMWH-treated patients exhibited a faster decline in levels of serum IL-6 (within 12 days) than control. Infiltration of inflammatory cells at the local wound site was assessed through a histological analysis of tissue samples taken on various days during the healing process. The LMWH-treated groups exhibited an organized healing pattern with better remodelling in a shorter duration (28 days), while control patients took more than 28 days for complete healing. A slight correlation was observed with TBSA to the inflammatory process, which subsided in patients treated with LMWH, favourably modulating the events involved in the inflammatory process of burn wound healing.

Ultrastructural differentiation of abnormal scars

AIM

To evaluate the differences between keloid and hypertrophic scars by biochemical and ultrastructural techniques.

METHOD

Over 1000 patients with different types of scars were studied and followed up for a period of 20 years. The histochemical and biochemical analysis with respect to the composition of the extracellular matrix of the dermis was conducted. At the ultrastructural level, collagen deposition and assembly were studied using electron microscopy. The rate of proliferation and metabolic activity of the dermal fibroblasts isolated from the normal skin and scar biopsies were studied to assess the cause of excess matrix deposition in scar tissues.

RESULTS

Evaluation of different types of scars showed that both keloid and hypertrophic scars have excess matrix deposition in terms of collagen and proteoglycans. Keloid shows a high amount of acid-soluble collagen. The assembly of collagen fibrils is also abnormal in keloids. Studies on the proliferation and metabolic activity showed that keloid fibroblasts have a higher rate of proliferation and metabolic activity than fibroblasts from hypertrophic scars and normal skin. Finally, keloid fibroblasts show high and intense staining for the endoplasmic reticulum, suggesting a possible reason for high activity of these fibroblasts.

CONCLUSION

Keloids and hypertrophic scars show distinct ultrastructural patterns of both collagen deposition and assembly. These parameters could be refined by further research, and they would thus serve as a useful tool for surgeons to distinguish different types of scars and adopt suitable therapeutic strategies.

Profile of pediatric burns

Pediatric burns admitted to the tertiary care burn facility of Kanchi Kamakoti CHILDS Trust Hospital in Chennai (India) were retrospectively analysed between 1992 and 2003. Five hundred and thirty-five burn cases were admitted during these years. These children belonged to the age group of 0-18 years (as WHO has increased the pediatric age group range to 0 to 18 years). The etiology of these burns was looked into and the outcome of these patients in respect to etiology and complications were studied. After analysis, they were classified according to age, sex, TBSA and the occurrence of infection during the course of treatment. The complications that really affected the outcome were looked into and infection ranked first in fatal cases. Inhalation burns were not very common in our group and were associated only with large flame burns, which occur when a child is burnt while the mother commits suicide, or in cases of abuse of female children in a closed room with lots of inflammable upholstery. Scalds were the most common type of burn among children under 4 years of age. Flame burns predominated the older age group. Although there were 13 deaths among the entire group, the majority occurred within the 2-4 years age group. There was no significant gender difference with respect to mortality. Large burn size and infection were the strongest predictors of mortality.

Paediatric rehabilitation in a developing country--India in relation to aetiology, consequences and outcome in a group of 459 burnt children

Age, aetiology of burn, percentage body surface area burnt and post-burn sequelae have a direct relationship to the rehabilitative necessity in burnt children in a developing country--India. In spite of the gross disfigurements and sequelae, only adolescent children required psychosocial rehabilitation. These are the results following a retrospective analysis of 459 paediatric burn patients in Madras, India.

Management of partial-thickness burn wounds by amniotic membrane: a cost-effective treatment in developing countries

Burns incidence in our country has been on the increase over the past two decades. Cost-effective management of burn wounds has become the prerogative as our annual budget for burn care is limited. We have used human amniotic membrane procured from HbSAg, HIV-seronegative mothers undergoing caesarean section as a temporary biological dressing on superficial and deep partial-thickness burns. The advantages of amniotic membrane cover are reduction in pain, early drying of the wound and epithelialization. This type of wound management has been used in 350 cases. It has reduced the number of days stay in hospital and the bulky dressings that are conventional. Considering the patient acceptability, reduced hospital stay and reduction in cost, we find that treatment of superficial and deep partial-thickness burns with amniotic membrane is ideal for a developing country.

Action of trypsin:chymotrypsin (Chymoral forte DS) preparation on acute-phase proteins following burn injury in humans

A study was carried out to investigate the efficacy of trypsin: chymotrypsin (Chymoral forte DS) preparation on burn patients by analysing the changes taking place in serum acute-phase proteins. Serum proteins were analysed qualitatively and quantitatively for both control and enzyme-treated groups by the methods of Western Blot, ELISA and Turbidimetric assays. Furthermore, the trypsin inhibitory capacity (TIC) of the sera was also determined. Significant differences were observed between a control group of patients and a parallel group treated with trypsin: chymotrypsin preparation. During the first phase of burn wounds an initial rise was seen in C-reactive protein, alpha 1-antitrypsin, alpha 2-macroglobulin and TIC in both the groups. In the following days, enzyme preparation inhibited the rise in C-reactive protein titres and enhanced the rise in alpha 1-antitrypsin, alpha 2-macroglobulin and TIC. The above studies clearly indicate that the changes in serum acute-phase proteins between the control and treated groups reflect the anti-inflammatory activity and hence the therapeutic efficacy of Chymoral forte DS.

Burns in Madras, India: an analysis of 1368 patients in 1 year

Analyses were made of 1368 patients who attended Kilpauk Medical College Hospital, Madras with burns between 1 May 1987 and 30 April 1988. Nine hundred and sixty-five patients were admitted, of whom 505 died. The peak age incidence was in young adults (11-30 years; 58.9 per cent of all burns). Three quarters of the patients came from the low family income group, 39.5 per cent were illiterate and 86.2 per cent of burns occurred in the home. Of those admitted 81 per cent of the injuries were flame burns; in 31.3 per cent the burn affected more than half of the body surface. Of the 505 deaths 94.8 per cent were the result of flame burns (at least 323 being caused by kerosene), and 20.4 per cent were suicide. Most of the deaths (91 per cent) occurred in the first 5 days. The urgent need for burn prevention in the Madras area is discussed.

Electrical burns treated in an Indian hospital

A 17-year survey of all electrical burns admitted to the Department of Plastic and Reconstructive Surgery at the Kilpauk Medical College Hospital, Madras between 1973 and 1990 has been made. A total of 8040 cases of burns were treated in this Department and in this group 923 were pure electrical burns. The majority of electrical burns occurred in the age group 20-40 years. Some of the clinical features of our electrical burns resembled closely those of a crush injury. Most of the patients required primary reconstruction and this was delayed when the viability of tissues was in doubt. Human error was responsible for the injury in 68 per cent of patients and all the 64 patients who were below the age of 10 years belonged to this group.

Deepithelialized turnover flaps in burns

Acute and chronic burns leave behind a full-thickness defect that always requires a flap cover. Such defects are common in electrical burn injuries of the limbs. This paper deals with 35 patients with full-thickness defects following burns in whom deepithelialized turnover dermis flaps and deepithelialized turnover flaps with deep fascia have been used. This flap is an extension of Hynes's reversed dermis graft and Smahel's deepithelialized turnover flap where there is a larger area of blood supply on the deeper aspect of the dermis. If a good hinge is provided for safe blood supply, such a flap settles well in the defect, and cumbersome multistaged procedures can be avoided. If there is less fatty tissue in the area of flap used, then reversed dermis flaps are ideal because split-skin graft take is good. When there is a lot of fatty tissue on the undersurface of dermis, the fascia is also included to make it a reversed fasciocutaneous flap to augment the blood supply and for better split-skin graft survival. Advantages of the procedure and complications are elaborated.

Denervated palmaris longus tendon as a skeletal muscle transplant in circumferential pharyngoplasty

The incidence of velopharyngeal incompetence (VPI) following cleft palate surgery is fairly high in our country. We have attempted to analyse the aetiology and then selected 50 cases of VPI from our group of operated cleft palates. These patients were then evaluated using cephalometry, speech rating, pressure studies and nasendoscopy. We identified 13 patients in whom there was incompetence due to failure of movement of the walls responsible for proper closure of the velopharyngeal port. In these patients we performed circumferential sling pharyngoplasty using denervated palmaris longus; since this procedure narrowed the port circumferentially. We re-evaluated these patients and the results have been gratifying. Speech rating improved and E.M.G. tracings after 6 months showed evidence of reinnervation of the Palmaris Longus.

The management of anaerobic infection in extensive burns

A survey of 300 patients with burns covering more than 30 per cent of the body surface area indicated that 33 patients had proven wound infection with anaerobic bacteria and 11 patients showed positive blood cultures. Although metronidazole was the anti-bacterial agent of choice for treating these 33 patients, treatment was not always successful since 7 patients died. The most common sites of infection were the perineum and upper parts of the legs.

Incidence of burn wound sepsis in 600 burned patients treated in a developing country

Infection is the most important problem in the treatment of burns in a developing country. A burn compromises a major body protective mechanism, namely the skin. Hence, the susceptibility to local infection increases at these sites. The incidence of burn wound sepsis is very high in south India as the socio-economic conditions and the standard of personal hygiene are poor and the hot moist climatic conditions encourage bacterial growth. These three factors are rarely present in the temperate zone countries of Europe and North America. This study was undertaken to identify more clearly the factors that are responsible for the higher incidence of burn wound infection and to formulate methods of treatment which are appropriate for our patient population living in a tropical country.

Congenital inversion of the human nipple

Congenital inversion of the nipple can be corrected surgically for both functional and cosmetic satisfaction. We have used the technique of Schwager et al. on 14 of 17 patients, with the aid of mammograms before and after the operation. The results proved to be highly satisfactory.