Acellular Dermal Matrix in Plastic and Reconstructive Surgery

Despite significant advances in medical research, plastic surgeons still face a shortage of suitable patient tissues, and soft tissue reconstruction is no exception. In recent years, there has been a rapid boom in the use of acellular dermal matrix (ADM) in reconstructive and aesthetic surgery. ADM is incorporated into the surrounding tissue and gradually replaced by the host's collagen, thus promoting and supporting the healing process and reducing the formation of scar tissue. The main goal of this article is to provide a brief review of the current literature assessing the clinical applications of ADM across a broad spectrum of applications in plastic and reconstructive surgery.

Preparation and processing of human allogenic dermal matrix for utilization in reconstructive surgical procedures

AIM

This article presents the development of a novel preparation and processing method as well as indication for clinical applications of human allogeneic acellular dermal matrix, which was developed originally in the Central Tissue Bank (CTB) for use in burn medicine and reconstructive surgery.

METHODS

Acellular dermal matrix (ADM) is a biological material assigned for utilization in several surgical procedures due to its unique structure and advantageous properties. The article focuses on a novel preparation and processing method developed by CTB, which differs in its impact on the structure, biological and biomechanical properties of the final ADM compared to the wide range of commercially available ADM products and currently available ADM products of other tissue banks.

RESULTS

The ubiquitous acellular allogeneic dermal collagen matrix is the main substance participating in advantageous properties facilitating the use of ADM in numerous indications from dermal replacement and soft tissue augmentation to more extensive surgical reconstructive procedures. Dermal substitutes play an essential role in the reconstruction of full-thickness skin defects, both in acute and chronic wounds, defects of fasciae, peritoneum, etc., and there is a strong evidence that they can improve the final scar quality as well. Differences in preparation methods of ADMs are recently causing concerns among surgeons utilizing the ADMs. We present three different cases with favourable outcomes by using human acellular ADM grafts.

CONCLUSIONS

Although ADMs did not fulfil all of the requirements for an ideal dermal substitute, their applications have been advanced for diverse indications in soft tissue reconstructions and augmentations. Early revascularization of the allografts reduces bacterial contamination. Research and development of new generation of acellular dermal matrices with incorporated autologous in vitro cultured cells will likely yield new products and give new hope for continued improve-ments in functional and cosmetic outcomes (Fig. 9, Ref. 60).

Adipose derived mesenchymal stem cells harvesting

BACKGROUND

The lipografting is increasingly used in the field of plastic surgery. Widely used harvesting technique of fatderived stem-cells is lipoaspiration. There exist two big streams of fat harvesting for lipografting: mechanical liposuction and manual liposuction.

METHODS

Two harvested specimens were compared in this prospective blind study in the means of stem-cells viability and their ability to grow in cell-cultures. Techniques to compare were: manual lipoaspiration with 50 ml syringe and WAL (water-jet assisted liposuction).

RESULTS

Twenty specimens from ten patients were investigated in the tissue bank. There were no differences in the amount of live stem-cells between two groups. Also no differences were found between both harvesting techniques in the mean of cell ability to grow in cell-cultures.

CONCLUSION

It can be concluded that there are no statistically significant differences in the number, vitality and viability of stem cells when comparing two ways of mesenchymal stem cell collection, both manual and machine sampling (WAL). When cultured in vitro, both samples collected from each patient also appeared to be able to multiply with no statistical differences (Tab. 2, Fig. 2, Ref. 18).

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.

Detection of melanoma metastases With Tc-99m-tetrofosmin

Aim: The aim of this study was to evaluate Tc-99mtetrofosmin whole-body imaging in the detection of metastases in patients with malignant melanoma. Methods: In 30 patients with suspected melanoma metastases we performed whole body imaging. After administration of about 600 MBq Tc-99m-tetrofosmin dynamic images up to 10 min were performed in 7 patients (1 image per 10 sec) to evaluate the optimal tracer uptake in the metastases. In all patients whole-body images were performed 5-10 min p. i. using an acquisition time of 5 min per image. The final diagnosis was confirmed by surgical histology in 30 lesions, by computertomogaphy and clinical course in the remaining lesions. Results: Out of 64 melanoma metastases 49 were detected using Tc-99m-tetrofosmin scintigraphy (49 rp., 15 fn.). The overall sensitivity for the detection of malignant lesions was 77%. Referring only to the lymph node metastases, the sensitivity was 87% (26 rp.; 4 fn.). The maximal tracer uptake was reached 1 min after injection, with a slow decrease in the following 10 minutes. The size of the lesions ranged between 0.5 and 7.0 cm and the T/B ratios between 1.3 and 3.0 (mean 1.88). Conclusions: Tc-99m-tetrofosmin whole body imaging is a simple and side-effectless method for the detection of melanoma metastases especially of lymph node metastases. The results are comparable to Tc-99m-sestamibi and TI-201 scintigraphy.

COMPLICATIONS OF LOWER EXTREMITY HEMATOMAS IN PATIENTS WITH PRE-INJURY WARFARINE USE

INTRODUCTION

The aim of this paper is to ascertain the number of patients with pre-injury warfarin use who developed lower extremity hematomas treated in our facility, to analyse the data, used treatment methods and outcomes in these patients.

PATIENTS AND METHODS

We performed a retrospective review, identifying all the patients with pre-injury Warfarin use admitted with hematoma or full-thickness skin loss in the ten years period from January 2006 to December 2015.

RESULTS

Overall 9 women and 2 men with mean age of 72 years were identified. All the injuries were sustained in a domestic setting. Except of one female patient primarily admitted to our department, all patients had been hospitalized primarily in local/regional hospitals for an average period of 32.6 days. All the patients transferred to our department required surgical wound closure. The mean wound surface area was 136.3cm² (range 45-525). The duration of hospital stay was 15 days in average.

DISCUSSION

The data obtained were compared with the results and findings of similar studies and were discussed.

CONCLUSION

The results achieved in the present study showed the beneficial effect of used treatment methods based on the surgical wound closure techniques during hospital stay of the patients. Clinicians, first contact physicians, and also patients alone need to be aware of the vulnerability of this group of patients. The consequences of even minor lower extremity trauma can be serious, with development of a very complex chronic wound that is difficult to manage.

[AMNIOTIC MEMBRANE APPLICATIONS - OUR EXPERIENCE]

INTRODUCTION

Amniotic membrane is the innermost part of the fetal and packaging for its exceptional qualities likes to be used in treating many ocular pathologies. Amniotic membrane has improved the ability to treat ocular surface disease. It has unique features like support conjunctival and corneal epithelialization.

MATERIAL AND METHODS

Retrospective analysis of group patients who underwent amniotic membrane transplantation at the Department of Ophthalmology Faculty of Medicine and UN Bratislava in 2013-2015. We evaluated indications amniotic membrane transplantation, the percentage, the number of transplants and the number of failures and retransplantation of the membrane.

RESULTS

In group of 71 patients (amniotic membrane covering defects of conjunctiva and cornea) male patients formed a slight predominance of males in the number of patients a slightly larger preponderance in 38 women (53.5 %) - 52 surgeries (59.09 %) and 33 male (46.5 %) in 36 interventions (40.91 %). The left eye was affected in 40 interventions (45.45 %), 48 interventions were on the right eye (54.54 %). The most common cause application of 30.68 % in 27 eyes was corneal ulcer, bullous keratopathy followed by the 11.36 % in 10 eyes, and the ulcer herpetic keratitis in 9.10 % in 8 eyes. Injury or vulnus penetrans 6.82 % in 6 eyes, ulcers caused by paresis n. facialis 6.82 % in 6 eyes and sicca syndrome 5.68 % in 5 eyes.In 2015 we applied amniotic membrane covering the defect of eyelids after trauma in one patient.

CONCLUSION

Amniotic membrane is the appropriate treatment in a number of diseases of ocular surface when conservative methods of treatment fail. In corneal application can prevent the execution of more aggressive treatment, such as keratoplasty, or to soothe inflammation and keratoplasty is not performed as emergent, but elective.Key words: amniotic membrane transplantation, eye diseases.

Minimally invasive burn care: a review of seven clinical studies of rapid and selective debridement using a bromelain-based debriding enzyme (Nexobrid®)

Current surgical and non-surgical eschar removal-debridement techniques are invasive or ineffective. A bromelainbased rapid and selective enzymatic debriding agent was developed to overcome these disadvantages and compared with the standard of care (SOC). The safety and efficacy of a novel Debriding Gel Dressing (DGD) was determined in patients with deep partial and full thickness burns covering up to 67% total body surface area (TBSA). This review summarizes data from seven studies, four of which were randomized clinical trials that included a SOC or control vehicle. DGD eschar debridement efficacy was >90% in all studies, comparable to the SOC and significantly greater than the control vehicle. The total area excised was less in patients treated with DGD compared with the control vehicle (22.9% vs. 73.2%, P<0.001) or the surgical/non-surgical SOC (50.5%, P=0.006). The incidence of surgical debridement in patients treated with DGD was lower than the SOC (40/163 [24.5%] vs. 119/170 [70.0%], P0.001). Less autografting was used in all studies. Long-term scar quality and function were similar in DGD- and SOCtreated. DGD is a safe and effective method of burn debridement that offers an alternative to surgical and non-surgical SOC.

Ferromagnetic State of a Model Chain System

Ferromagnetic states of two linear chains are determined. The comparison with the solution of the restricted Hartree-Fock method shows that such states are energetically very unlikely

LCAO Approach to SCF-Xα Method

An LCAO approach to the Slater SCF-Xα method is described. The equilibrium distances and Hellman-Feynman forces are determined.

Some ab Initio Calculations on Indole, Isoindole, Benzofuran, and Isobenzofuran

Ab initio calculations in the framework of the methodology of Pople et al. have been performed on indole, isoindole, benzofuran. and isobenzofuran. Several molecular properties (dipole moments, n. m. r. chemical shifts, stabilities, and reactivities) correlate well with calculated indices (charge densities, HOMO-LUMO separation). The calculations failed to give magnitudes of first ionization potentials, although the correct trends are reproduced, i. e. giving higher values to more stable isomers. Some of the obtained results (charge densities, dipole moments) parallel CNDO/2 values.

Epileptics and burns

BACKGROUND

The aim of this paper is to ascertain the number of patients with a burn injury sustained during an epileptic seizure treated in our facility, to identify the characteristics of these types of injuries and to suggest preventive measures, which could reduce the frequency and morbidity of such injuries.

PATIENTS AND METHODS

We performed a retrospective study, identifying all patients admitted with burns sustained during an epileptic seizure within a period of six years.

RESULTS

Totally 7 women with an average age of 45 years were enrolled in this retrospective study. Mean BSAB was 2.4% (range 0.5-6). All burns occurred in a domestic setting during household activities (cooking, ironing). Thermal injury included contact burn (6 patients with deep burns), followed by scald (one patient with superficial burns). 6 of 7 patients (85%) required excision of deep burns and skin grafting procedure. The average duration of hospital stay was 13 days. Collected data were compared with the results and findings of similar studies and analysed. A list of preventive measures is included.

CONCLUSION

Patients with epilepsy should be informed about all potential threats at the time of neurological diagnosis including also the risk of serious burn injury, which should be emphasised.

Clinical trial of the temporary biosynthetic dermal skin substitute based on a collagen and hyaluronic acid named Coladerm H/HM, first part

BACKGROUND

This paper presents the results of the first part of the clinical study of temporary biosynthetic dermal skin substitute based a on collagen and hyaluronic acid, named Coladerm H/HM. The aim of this study was to evaluate safety and effects of Coladerm H/HM in covering the split-thickness skin graft donor sites in humans. This membrane was applied to a part of the split-thickness skin graft donor site; its effects and properties were compared to standard dressing used for covering the split-thickness skin graft donor sites at the Department of Burns and Reconstructive Surgery, University Hospital Bratislava, Slovakia, Dermazin® (Lek) + Acidum Aceticum 1% (magistraliter), which were applied together to the rest of the donor site.

MATERIAL AND METHODS

Twenty patients were randomly selected with the following criteria: age of 18-65 years, no severe accompanying diseases such as diabetes, renal failure, immune disorders, severe arteriosclerosis, severe allergic conditions. Evaluation was done according to the evaluation protocol.

RESULTS

Primary assessment showed that Coladerm H/HM does not influence the rate of epithelization from a long term point of view, but the initial faster epithelization contributes to the reduction of the risk of complications, which may arise from a long term open wounds. Secondary assessment showed the effect of Coladerm H/HM to the secretion of the wounds in the second inspection interval when the wound was dry in the whole group. Next, Coladerm H/HM contributed to the temporarily statistically significant positive effect to the color of donor area in the third inspection interval. Positive bacteriological finding occurred in one patient secondary. Analgetic effect of Coladerm H/HM assessed by a doctor was expressed as good in 70%. 95% of patients reported only mild pain after application of Coladerm H/HM. There were no significant side effects recorded, only 1 patient stated itching, which disappeared spontaneously. Application of Coladerm H/HM has positive properties for treating the split-thickness skin graft donor sites in humans.

CONCLUSION

Coladerm H/HM showed positive results covering the split-thickness skin graft donor sites in the first part of the clinical trial. Production of the Coladerm H/HM and its introduction into the clinical practice is planned after successful completion of all the parts of clinical trial.

Cultured keratinocytes and their possible applications

Skin is the largest organ, providing an outer layer of the body and thus creating a barrier against the surrounding environment. It possesses many important functions and can be damaged by various mechanisms. The substitution of damaged skin, mainly in the treatment of deep extensive burns, represents a key challenge. Damaged skin can be replaced permanently by skin autografts, cultured autogenous and allogenic keratinocytes or by the combination of skin substitutes with in vitro cultured autologous keratinocytes. In this article the preparation method and the possible applications of cultured autologous and allogeneic keratinocytes are described; we have long experience of this issue at the Department of Burns and Reconstructive Surgery in the University Hospital Bratislava.

Nosocomial Staphylococcal scalded skin syndrome caused by intra-articular injection

BACKGROUND

The pathogenic role of nasal carriage as a source for cutaneous and soft-tissue Staphylococcus aureus (SA) infections, and Staphylococcal scalded skin syndrome (SSSS) in particular, is unclear.

OBSERVATION

We herein describe a nosocomial outbreak of SSSS in three orthopaedic patients who received intra-articular injections by a single orthopaedic surgeon. Bacteriological samples from the index patients and medical personnel involved in their care were assessed by phage typing, polymerase chain reaction for exfoliative toxin genes, SmaI macro-restriction analysis and molecular spa-typing. These studies first revealed SA cultural growth in synovial fluid of all three patients as well as nasal mucosa of one medical assistant. Moreover, all SA isolates had the same phage typing and antibiotic susceptibilities and were positive for exfoliative toxin ETa by polymerase chain reaction. SmaI macro-restriction and spa-typing further confirmed all proband isolates to be identical.

CONCLUSION

These findings provide evidence that SA nasal colonization of otherwise healthy carriers is a risk factor for SA infections, including SSSS, in predisposed individuals.

Estimates and relationships between aboveground and belowground resource exchange surface areas in a Sitka spruce managed forest

Our knowledge of the nature of belowground competition for moisture and nutrients is limited. In this study, we used an earth impedance method to determine the root absorbing area of Sitka spruce (Picea sitchensis (Bong.) Carr.) trees, making measurements in stands of differing density (2-, 4- and 6-m inter-tree spacing). We compared absorbing root area index (RAI(absorbing); based on the impedance measure) with fine root area index (RAI(fine); based on estimates of total surface area of fine roots) and related these results to investment in conductive roots. Root absorbing area was a near-linear function of tree stem diameter at 1.3 m height. At the stand level, RAI(absorbing), which is analogous to and scaled with transpiring leaf area index (maximum stomatal pore area per unit ground area; LAI(transpiring)), increased proportionally with basal area across the three stands. In contrast, RAI(fine) was inversely propotional to basal area. The ratio of RAI(absorbing) to LAI(transpiring) ranged from 7.7 to 17.1, giving an estimate of the relative aboveground versus belowground resource exchange areas. RAI(absorbing) provides a way of characterizing ecosystem functioning as a physiologically meaningful index of belowground absorbing area.

European quality system for tissue banking

AIM

The aims of this project were to analyze the factors that influence quality and safety of tissues for transplantation and to develop the method to ensure standards of quality and safety in relation to tissue banking as demanded by European Directive 2004/23/EC and its technical annexes. It is organized in 4 Working Groups, the objectives of each one being focused in a specific area.

STANDARDS

The Guide of Recommendations for Tissue Banking is structured into 4 parts: (1) quality systems that apply to tissue banking and general quality system requirements, (2) regulatory framework in Europe, (3) standards available, and (4) recommendations of the fundamental quality and safety keypoints.

REGISTRY

This Working Group handled design of a multinational musculoskeletal tissue registry prototype.

TRAINING

This Working Group handled design and validation of a specialized training model structured into online and face-to-face courses. The model was improved with suggestions from students, and 100% certification was obtained.

AUDIT

The Guide for Auditing Tissue Establishments provides guidance for auditors, a self-assessment questionnaire, and an audit report form. The effectiveness and sustainability of the outputs were assessed. Both guides are useful for experienced tissue establishments and auditors and also for professionals that are starting in the field. The registry prototype proves it is possible to exchange tissues between establishments throughout Europe. The training model has been effective in educating staff and means having professionals with excellent expertise. Member states could adapt/adopt it. The guides should be updated periodically and perhaps a European organization should take responsibility for this and even create a body of auditors.

Treatment of partial-thickness scalds by skin xenografts--a retrospective study of 109 cases in a three-year period

BACKGROUND

The purpose of the present study was to confirm the clinical expediency of using a particular type of biological skin substitute--porcine skin xenograft--in the treatment of partial-thickness scald burns.

MATERIAL AND METHODS

Over a period of three years (from the beginning of the 2005 to the end of the 2007) 109 admitted patients with partial-thickness scald burns were treated with skin xenografts. The mean age of the patients was 7.6 years (S.D.: 15.3), while mean TBSA was 13% (S.D.: 8.2).

RESULTS

The number of patients healed by the 14th day postburn or sooner and their mean healing time, the mean healing time for all 109 patients, mean hospital stay and number of patients undergoing surgery were all evaluated. Of the 109 patients, 78 (71%) healed within 14 days with a mean time of 9.6 days (S.D.: 3.2). One sample t-test which compared mean healing times achieved within 14 days with the value of 14 days established a significant difference (p = 0.0001). For all 109 cases the mean healing time was 15.1 days (S.D.: 11.6), with no significant difference between mean healing times and the value of 14 days (p = 0.3). The mean hospital stay was up to 10 days (S.D.: 6.7). Four patients (3.6%) received split thickness skin grafts with an average extent of 4.5% TBSA. The data obtained were compared with similar studies and other treatment options for this indication and were discussed.

CONCLUSION

This retrospective study proves the clinical efficiency of using skin xenografts for the treatment of partial-thickness scald burns. Skin xenografts showed good adherence on the wound surfaces, decreased the amount of exudate and reduced pain. In addition, the risk of hypertrophic scar formation was lower when wound healing was achieved within 14 days.

Quality-of-life (QoL) impairment in melanoma patients receiving high-dose interferon alpha 2b (IFNa2b)

e20011

Background: High-dose interferon (HDI) for patients with malignant melanoma (MM) has consistently demonstrated benefits as an adjuvant treatment. Side effects and impairment of QoL have played a major role in patients motivation to continue treatment. The adjuvant, randomized, controlled phase III DeCOG MM-ADJ-5 trial evaluates QoL and tolerability of pulsed high-dose intravenous (iv) IFNα2b compared to standard HDI regimen. In the pulsed arm, 3 courses of IFNα2b, 20 Mio IU/m2 iv 5 days a wk for 4 wks, repeated every 4 months was administered, whereas the subcutaneous (sc) treatment was 10 Mio IU/m2 3 times a wk for 11 months, after 4 wks of iv therapy. As a secondary endpoint, health related QoL was evaluated during iv and sc treatment and during treatment free intervals. Methods: 631 patients have been recruited for an expected 300 events (distant metastasis) during 4 years of follow-up. A planned interim analysis was performed after a third of the expected events occurred. The EORTC QLQ-C30 questionnaire modified for typical IFN side effects, was administered to pts before therapy, at 4, 16, 24, and 40 wks of treatment. Global QoL questions were completed by pts weekly by a visual analogue scale over the entire year of treatment. Results: Out of 377 patients having completed treatment, 300 were evaluable for QoL analysis. The iv HDI treatment led to a globally decreased QoL score in 84% of patients. During the 4 wk course of iv IFN, impairment of QoL was mainly due to physical symptoms. During the sc treatment phase, global QoL remained reduced by an average of 24%, despite dose adjustments in a majority of patients. Analysis of particular dimensions of decreased QoL revealed that fatigue was the most important determinant, especially during continuous treatment. In contrast, depression only played a minor role, being less important than physical and cognitive impairment. Conclusions: QoL impairment caused by long term sc HDI is mostly mediated by chronic fatigue, and more likely to interfere with treatment adherence than short term iv HDI treatment.

[Table: see text]

Enzymatic necrolysis of acute deep burns--report of preliminary results with 22 patients

Enzymatic debridement by the use of a proteolytic enzyme complex derived, isolated and purified from pineapple stems proves to be an innovative, rapid, effective, selective and safe method of postburn necrotic skin removal. The major advantages of the procedure include minimal invasivity, rapidity, effectiveness, possibility to perform the debridement at the bedside, minimal or no loss of blood and minimal interference with natural wound healing processes. Our preliminary experience with this treatment method showed that in most of the cases treated the debridement was excellent, safe and rapid. The average duration of the debridement was less than 4 hours. The debridement was accompanied by minor to moderate pain which could be treated by analgetic medications. No serious adverse events or reactions have been observed during the study. The time for healing was comparable with the standard of care methods. The second randomized multicenter study is still in progress and has not yet been finished.

Epidemiology and therapeutic aspects of burn injuries in Slovakia (1993-2003)

The authors analyze the epidemiology and trend of thermal injuries in Slovakia since 1990. The article includes statistics from both of the burn injury workplaces in Bratislava and Kosice. The article contains conclusions and proposals for preventive measures which have contributed to the decrease of thermal injuries in Slovakia since 2000.

Skin grafting options at the Burn and Reconstructive Surgery Department of the Faculty Hospital in Bratislava

Replacement of devastated or severely damaged skin presents a key problem in the treatment of extensive deep burns in humans. The skin is an organ serving many functions, which can be replaced with skin transplants or temporary skin replacements only up to a certain extent. At the Burn and Reconstructive Surgery Department of the Faculty Hospital in Bratislava, located in Ruzinov, we have been concerned with the problem of skin replacement since its establishment in 1987. In this article we review skin replacement options and our experience with indications and use of various types of skin substitutes, mainly of biological origin, such as allotransplants, xenotransplants and amnion.

Temozolomide and interferon alpha 2b in metastatic melanoma stage IV

BACKGROUND

A multicentre, centrally randomized, open-labelled study with temozolomide and interferon (IFN)-alpha 2b was carried out to study the therapeutic effect in patients with metastatic melanoma stage IV.

OBJECTIVES

The response rate, efficacy, side-effects, reasons for discontinuation of therapy and survival rate of 47 patients treated with temozolomide in combination with two different dosing regimens of IFN-alpha 2b were documented.

PATIENTS/METHODS

Twenty-nine male and 18 female patients (mean age 57.6 years, range 34-74) were centrally randomized to two different arms: 20 patients received a treatment schedule with temozolomide 150 mg m(-2) on days 1-5 orally every 28 days in combination with IFN-alpha 2b 10 MIU m(-2) every other day and 27 patients received temozolomide 150 mg m(-2) on days 1-5 every 28 days in combination with IFN-alpha 2b in a fixed dose of 10 MIU every other day.

RESULTS

We observed an overall response rate of 27.6% comprising five complete remissions (10.6%: one patient group A, four patients group B), in two of these five patients at the last follow-up in the study (4.3%, both in group B); and eight partial remissions (17%: six patients in group A, two patients in group B), in three of these eight patients at the last follow-up in the study (6.4%, two patients in group A, one patient in group B). Three patients showed stable disease (6.4%: one patient in group A, two patients in group B). Mean survival was 14.5 months [95% confidence interval (CI) 10-19] with no significant differences between treatment groups. However, there was a significant correlation with response after three cycles (log rank test, P < 0.03). Within the 32 patients who completed at least three cycles of therapy, seven patients (three in group A and four in group B) with a partial or complete response showed a significantly better mean survival of 30.6 months (95% CI 19.1-42) compared with 25 patients who did not respond (13.7 months 95% CI 9.2-18.3). In total, patients with at least one complete remission showed the longest survival (37.1 months 95% CI 26.3-47.9), followed by patients with at least one partial response (17.4 95% CI 10.9-23.9). Major side-effects of the treatment were nausea, vomiting, headache, leucopenia, thrombopenia, elevation of liver function parameters and neurological symptoms. In five patients, the side-effects led to a discontinuation of treatment: neurological symptoms (two patients), sepsis (one patient), brain haemorrhage (one patient) and exanthema (one patient). There were no treatment-related deaths.

CONCLUSIONS

The combination of temozolomide and IFN-alpha 2b can easily be administered and shows tolerable toxicity. When an objective response occurs after three cycles, it indicates a significant survival advantage.

Information access at the point of care: what can we learn for designing a mobile CPR system?

OBJECTIVES

Hospitals have started to migrate their paper-based records to computerized patient records (CPR). The majority of today's CPR systems are stationary, which means that physicians use a clinical workstation to access CPR information. But health care professionals need to request and enter information at different locations, for example, on their daily ward round. This suggests the use of mobile computers, enabling an ubiquitous access to needed data. Different studies show that health care professionals are reluctant to use poorly designed mobile CPR systems, as the work at the point of care is very time-pressured and hectic. To design a system with high acceptance, it is essential to obtain empirical insight into the work practices and context in which the mobile CPR system will be used.

METHOD

We investigated the physicians' work with the patient record during their daily round. With the help of a compact notation method, the physicians' interaction with the information system was recorded in real time. Fourteen physicians from three different departments (internal medicine, surgery, and geriatrics) of a middle-sized Swiss hospital participated in our study.

RESULTS

Physicians have clear access preferences when they interact with the patient record during their daily round. There exists a clear profile of access frequencies and patterns, respectively. As an example, approximately 50% of all patient record accesses concern information about medications, vital signs and lab test results.

DISCUSSION/CONCLUSION

A CPR system which is designed to reflect the access frequencies and patterns should improve the efficiency of data entry and retrieval and thus result in a system with high acceptance among physicians in the demanding environment during hospital rounds.

Biocompatibility studies of modified collagen/Hyaluronan membranes after implantation

Two varieties of collagen/sodium hyaluronan membranes were used as dermal substitutes in a biocompatibility implantation study on rats. In order to improve especially the physical and mechanical properties of the material, the membranes were chemically modified using a combination of hexamethylenediisocyanate (HMDC) as a crosslinker and polyoxy-ethylene (POE) as a spacer. According to both macroscopic and microscopic histological observations, the membranes were well accepted by the surrounding host tissue in all the animals. No major differences in relation to the outgrowth of the material by host tissue have been observed between the implant varieties A and B. The most important finding was that no pathological changes or important alterations of the host tissues were detected.

Topical treatment of partial thickness burns by silver sulfadiazine plus hyaluronic acid compared to silver sulfadiazine alone: a double-blind, clinical study

Since its introduction into clinical practice in 1967 by Charles Fox Jr., silver sulfadiazine has been the gold standard for topical burn therapy. The addition to it of hyaluronic acid, which forms a substantial part of the human tissue intercellular matrix, is aimed at overcoming one of its very few disadvantages, i.e. prolongation of the wound re-epithelialization process. Since both hyaluronic acid and silver sulfadiazine have been used in therapy for decades and their efficacy is well documented, a topical treatment combining these two agents was formulated. The aim of the study was to investigate the efficacy and tolerability of a cream containing a hyaluronic acid/silver sulfadiazine fixed combination, compared with silver sulfadiazine cream alone, for the treatment of superficial and deep second-degree burns in a prospective, double-blind, controlled clinical study. The findings of the study confirmed that the association of the two compounds in a new topical treatment significantly reduced the healing time and significantly accelerated the reduction of local edema occurring shortly after injury. Furthermore, this new hyaluronic acid and silver sulfadiazine formulation has proven to have favorable antibacterial, anti-edematous and local analgesic effects, together with a clear stimulatory activity on the re-epithelialization process. This product may, therefore, significantly enrich the assortment of topical medications available for the treatment of burns and skin defects of other origin.

Thoracic epidural catheter placement via the caudal approach in infants by using electrocardiographic guidance

We examined the success of inserting epidural catheters via the caudal route in infants by using electrocardiographic guidance. A case series of 20 patients with thoracic epidural analgesia was studied. After the induction of general anesthesia, an 18-gauge IV catheter was inserted into the caudal space to allow threading of a 20-gauge epidural catheter. The electrocardiogram (ECG) tracings via the epidural catheter, as well as the surface ECG at the target spine level, were recorded simultaneously with a modified two-channel five-lead ECG system. The epidural catheter was advanced from the caudal space until the tip reached the target level as demonstrated by a match in the configuration of the epidural ECG tracing to that of the surface ECG tracing at the target level. The catheter tip location was verified by postoperative radiographs. All catheter tips were located within two vertebrae of the target level, and satisfactory intraoperative epidural anesthesia was achieved in all subjects.

IMPLICATIONS

Epidural electrocardiography may be used to guide the positioning of the thoracic epidural catheter tip via the caudal approach to the appropriate dermatome for optimum analgesia.

Prognostic factors for survival and factors associated with long-term remission in patients with advanced melanoma receiving cytokine-based treatments: second analysis of a randomised EORTC Melanoma Group trial comparing interferon-alpha2a (IFNalpha) and interleukin 2 (IL-2) with or without cisplatin

The aim of this study was to define prognostic factors for survival, and especially for long-term survival in a mature data-set of patients with stage IV melanoma treated within a randomised trial of cytokine-based protocols. Long-term follow-up data on patients enrolled into a European Organization for Research and Treatment of Cancer (EORTC) trial comparing interferon-alpha (IFNalpha) plus interleukin-2 (IL-2) with or without cisplatin were collected. Univariate and multivariate Cox regression analyses were performed to define prognostic factors for survival. The characteristics of patients alive at 2 and 5 years after randomisation were compared with the entire cohort using the chi(2) test. The minimum potential follow-up of the 131 evaluable patients was 5 years. 18 patients (14%) were alive 2 years after randomisation, and 11 (8%) 5 years after randomisation. Pretreatment performance status (PS), serum lactate dehydrogenase (LDH) and tumour mass were significant predictors for survival, whereas site of metastases and number of sites were non-significant. PS and LDH were the only independent prognostic factors. All except 1 patient alive at 2 and 5 years had a pretreatment PS of 100%, and only three long-term survivors had elevated pretreatment LDH. There was no association between the site of metastases and long-term survival. Response to treatment was a major predictor for long-term survival, whereas addition of cisplatin did not impact upon overall survival probability or on long-term survival. The probability of long-term survival in stage IV melanoma patients after IL-2-based treatments is governed by pretreatment PS, serum LDH and response to treatment. Site of metastases, the basis for the M-subcategories of the new AJCC staging system, was not informative in this study.

The seventh prototype of the mini-spindle-pump: does it fulfill the expectations of a short-term pump?

According to recent trends to develop implantable nonpulsatile blood pumps for different function modes and times, our intention was and still is to build a Mini-Spindle-Pump for a pumping duration of about 14 days. Initial conception for this plan was the premise that the device in a mock circuit should move 4 L of water/min at a speed of 12,000 to 15,000 rpm against a pressure difference of 90 mm Hg between pump inlet and outlet. Despite the development of 6 different prototypes, this project was not realized. Under the above-mentioned conditions, the main problem of this type of blood pump, the blood trauma, could not be reduced to an adequate level, i.e., the Mini-Spindle-Pump is not a high speed pump. Therefore, a revision of the conception was necessary. The device in a mock circuit should transport 5 L of water/min at a speed of about 9,000 rpm against a pressure difference of 90 mm Hg between its inlet and outlet. Considering the implantability of the blood pump, the following measurements for its components were arrived at. The U-shaped blockformed plexiglas housing was enlarged to 120 x 40 x 40 mm (length of blood chamber 86 mm, inner diameter 27 mm), and the rotor with 5 windings was redesigned at a length of 64 mm (outer diameter 25 mm, inner diameter 6.7 mm). In a mock circuit, this 7th prototype transported with a speed of 9,000 rpm about 10 L of water/min at an afterload of 80 mm Hg. In acute animal experiments with calves up to 15 h of pumping duration, the device showed the expected efficiency. Experiments with a longer pumping duration are necessary to confirm that this prototype will fulfill the criteria of a short-term pump according to Dr. Y. Nosé's advice.

Thoracic epidural analgesia via the caudal approach in pediatric patients undergoing fundoplication using nerve stimulation guidance

IMPLICATIONS

Epidural catheter placement using electrical stimulation guidance is an alternative approach for positioning the catheter into the thoracic region via the caudal space. This easily performed clinical assessment provides optimization of catheter tip positioning for achieving effective pain control.