Cent Of Body Surface Area Research Articles

Safety and efficacy of secukinumab in psoriasis patients infected with hepatitis B virus: a retrospective study

The burden of hepatitis B virus (HBV) infection in China is high. The safety and efficacy of secukinumab in psoriasis patients with HBV infection have not been fully elucidated. To investigate the safety and efficacy of secukinumab in psoriasis patients with HBV infection in China. In this retrospective study, 20 psoriasis patients with HBV infection were identified, all of whom had been treated with secukinumab for ≥24 weeks Four patients had chronic inactive HBV infection, two patients had occult HBV infection, and the other 14 patients had resolved HBV infection. The HBV-DNA load and HBV markers measured at baseline and Week 24 showed no viral reactivation. Nineteen patients showed normal levels of liver enzymes after 24 weeks of therapy. However, one patient with resolved HBV infection and fatty liver with elevated baseline liver enzymes experienced hepatitis, with negative HBV load at baseline and Week 24. All patients showed a significant improvement in the Psoriasis Area and Severity Index (−13.35 ± 7.41: p < 0.0001), per cent of body surface area (−17.11 ± 17: p = 0.0002), Investigator Global Assessment (−2.55 ± 0.94: p < 0.0001), and Dermatology Life Quality Index (−12.3 ± 7.39; p < 0.0001) Secukinumab showed good efficacy in psoriasis patients with HBV infection. Chronic, inactive, occult and resolved HBV infection may not increase the risk of hepatitis during secukinumab treatment. Patients with poor baseline liver function, without any intervention during secukinumab treatment, may experience hepatitis. Periodic monitoring with HBV markers, HBV-DNA load, and serological liver function tests is necessary during secukinumab treatment.

Psoriasis severity: commonly used clinical thresholds may not adequately convey patient impact.

Psoriasis severity is usually evaluated using quantitative and qualitative measures, including per cent body surface area (BSA) involvement, the Psoriasis Area and Severity Index (PASI) and the Dermatology Life Quality Index (DLQI), a patient-reported questionnaire. However, standardized definitions for psoriasis severity categories have not been well established. A PASI of 10 or 12 has remained the minimal severity threshold defining eligibility for psoriasis treatments. In the present study, the validity of this cut-off was re-evaluated in the context of quality of life. To determine whether the thresholds commonly used to define moderate psoriasis (PASI of 10-12 and BSA of 10) are supported by patient-reported DLQI data. A systematic review of randomized controlled trials that enrolled mild or moderate patients published between January 2000 and June 2017 was used to assess correlations between provider and patient-generated severity at baseline. For subject groups with high impact on quality of life (DLQI>10), the mean weighted BSA was 7.6 (Range: 7.1-8.4) and the mean weighted DLQI was 11 (Range: 10.2-12.2). Similarly, the mean weighted PASI for patients with DLQI>10 was 8.7 (Range: 7.1-10.1) and the mean weighted DLQI was 10.9 (Range: 10.1-12.2). Patients with PASI or BSA scores less than 10 can have major quality of life impairment. In general, the objective measures of BSA and PASI alone, when excluding DLQI, may not fully capture the impact of disease severity.

Intrabronchial surfactant application in cases of inhalation injury: First results from patients with severe burns and ARDS

Damage to the respiratory tract caused by inhalation of toxic products of combustion with subsequent development of an acute respiratory distress syndrome (ARDS) is one of the main causes of death in burn patients. Treatment with an exogenous surfactant is a therapeutic option for which there has previously been no empirical data. We report on four severely burned patients with deep partial thickness and full thickness burns of between 40 and 70 per cent body surface area (BSA), and with inhalation injury complicated by ARDS. These patients were treated once or more than once with bovine surfactant replacement (Alveofact ®). In addition to biophysical and biochemical analysis, the influence of this substance on oxygenation and lung function were evaluated. After the limits of mechanical ventilation had been reached, bronchoscopic intrabronchial administration of surfactant was followed by temporarily improved gas exchange with an increase in arterial O 2 partial pressure ( PaO 2), accompanied by a reduction in inspiratory O 2 concentration ( FiO 2), and also improved lung compliance. All the patients survived in spite of an initially unfavourable prognosis. Replacement of exogenous surfactant in the treatment of inhalation traumatized severe burn patients with ARDS appears to show considerable promise as an approach to improving the survival chances of these high-risk patients.

Successful recovery of 14 patients afflicted with full-thickness burns for more than 70 per cent body surface area

Fourteen cases suffering full-thickness burns of more than 70 per cent total body surface area (TBSA) have been successfully treated during the last 8 years (1988–1995). Among these patients, 10 cases suffered from burns of more than 90 per cent TBSA. Five cases had full-thickness burns of 80–90 per cent TBSA. Escharectomy, followed by coverage of wounds with a homograft to the lower surface of which, adjacent to the wound bed, microautoskin grafts had been attached was employed to close wounds in the early stages after burn. The remaining non-surgically treated wound was treated by exposure and topical silver sulfadiazine. The temperature and humidity of the ward was controlled by air conditioning and dehumidification. Aggressive excision of eschar and auto-skingrafting was carried out 3 weeks post-injury. Strictly limiting the uncovered wound to less than 5 per cent appeared to be the major effective measure in preventing burn infection.

A 3 year prospective audit of burns patients treated at the Western Regional Hospital of Nepal

Burns in Nepal cause an estimated 1700 deaths per year and much suffering. We carried out a prospective 3 year audit of 237 burns patients admitted. to the Western Regional Hospital in Pokhara. The aims were to assess the profile of burns injuries and what could be achieved in local conditions to guide colleagues in developing countries with limited medical facilities. The majority of burns occurred at home and were largely preventable. 61 per cent of patients were children under 15 years of age. There were more female patients and females had more severe burns. No patients with greater than 40 per cent body surface area burns of any age group survived. Public education on burns prevention is needed but poverty, ignorance and a fatalistic attitude are difficult underlying causes to change.

The last 10 years in a burn centre in Ankara, Turkey: an analysis of 5264 cases

This is a retrospective study analysing 5264 patients treated in the burn centre at Gülhane Military Medical Academy from 1 January 1986 to 31 December 1995. Our burn centre is not only the firs, but one of the best established and supported in Turkey. Our present study has the largest patient group of other previously published studies from Turkey. Of the total patients studied, 4464 patients had minor burns and were treated on an outpatient basis and 800 patients had moderate to major burns. Although our centre is in a military area in Ankara, only 1047 (20 per cent) patients were military personnel and the military-related burn causes comprised only 6 per cent of the total. The remaining 4217 (80 per cent of the total patients) were civilians. Flame injuries were also more frequent in military patients than civilians. Minor burns were most common in the age group 0–10 years old (40 per cent) and moderate to major burns in the age group 21–30 years (54 per cent). Scalds were the main cause of paediatric burns. Male patients were dominant. The overall mortality among inpatients was 18.2 per cent and mean total body surface area (TBSA) was 57.6 per cent in patients who died. 134 patients demonstrated inhalation injury and 82 per cent of these patients died. The epidemiological pattern of our patients is similar to that in other studies from developed countries, although some ethnic causative factors could be found. Our study indicates that emergency measures should be taken to prevent flame injuries at military barracks and industrial workplaces and scalding accidents to children at home and throughout the country.

Fatal rhabdomyolysis in a flame burn patient

Rhabdomyolysis due to flame burns is not well described. A case of fatal rhabdomyolysis in an epileptic patient who sustained 65 per cent body surface area, very deep, flame burns is described. It appears as if the sustained muscle compression from the restrictive, circumferential eschar was the major factor in the actiology of the rhabdomyolysis. Despite aggressive fluid management, the patient died of acute renal failure and adult respiratory distress syndrome. We have subsequently identified three other cases of pigmenturia occurring following burns. It would seem as if rhabdomyolysis following extensive full thickness burns may be more common than previously suggested. Fluid requirements are in excess of those proposed by traditional protocols. Rhabdomyolysis in flame burn patients indicates a poor prognosis.

Psoralens used for cosmetic sun tanning: an unusual cause of extensive burn injury

Psoralen combined with long-wave ultraviolt radiation (UV-A) has become a standard, method of psoriasis treatment. A well-known and often appreciated ‘side-effect’ is the hyperpigmentation caused by this treatment. Three patients demonstrating a novel cause of severe skin loss, ‘psoralen burn’, are presented. No patient was afflicted by psoriasis and all three had used psoralen and ultraviolet exposure with the intent to enhance sun tanning. In the case histories presented, it is notable that two of the patients share an alarmingly extensive skin injury (90–95 per cent body surface area), while the third had an extensive but rather superficial injury. In addition, a very similar time-table for the development of the injury could be observed, with a maximum distribution of skin loss not reached until 7 or 8 days after exposure. Psorelen-UV-A can cause life-threatening skin losses when used in an erratic manner. Early recognition of the nature and knowledge of the time-course in the development of these lesions is necessary for optimal treatment. Some principles of treatment are discussed. Dermatologists prescribing PUVA treatment should further increase their warnings of uncontrolled use of psoralens in non-psoriatrics.

Use of invasive cardiovascular monitoring in patients with burns greater than 30 per cent body surface area: a survey of 251 centres

A survey of the use of invasive cardiovascular monitoring in patients with burns greater than 30 per cent body surface area was performed. Questinnaires were sent to a total of 251 burns units in the UK, USA, Canada, Australia and New Zealand. The overall response rate was 68 per cent. Most centres reported that they managed less than 20 of these patients each year. Fifty-five per cent of centres used central venous pressure monitoring in more than half of their patients. In contrast, only 8 per cent of burn units used pulmonary artery catheters in over half of their patients. Few centres described the use of predetermined goals to direct therapy associated with PA catheter insertion.

How big is a hand?

Use of patient's hand to estimate percentage body surface area (BSA) of injury is well established in management of burns. Exactly what constitutes the palm of hand' and how large an area this is, depends on whether you follow Advanced Trauma Life Support teaching. United Kingdom teaching, or use a Lund and Browder chart'. A study was designed to measure areas in question to find which was most accurate. The conclusions challenge standard teaching and show a sex difference. The area of palm alone is 0.5 per cent BSA in males and 0.4 per cent BSA in females, whereas area of palm plus palmar surface of five digits is 0.8 per cent BSA in males and 0.7 per cent BSA in females. Therefore if a hand alone is used to assess size of a burn per cent BSA could be overestimated.

How big is a hand?

Use of the patient's hand to estimate percentage body surface area (BSA) of injury is well established in the management of burns. Exactly what constitutes ‘the palm of the hand’ and how large an area this is, depends on whether you follow Advanced Trauma Life Support teaching, United Kingdom teaching, or use a ‘Lund and Browder chart’. A study was designed to measure the areas in question to find which was most accurate. The conclusions challenge standard teaching and show a sex difference. The area of the palm alone is 0.5 per cent BSA in males and 0.4 per cent BSA in females, whereas the area of the palm plus the palmar surface of the five digits is 0.8 per cent BSA in males and 0.7 per cent BSA in females. Therefore if a hand alone is used to assess the size of a burn the per cent BSA could be overestimated.

Early, fatal disseminated intravascular coagulation in a patient with 60 per cent burns

A 23-year-old, previously fit and healthy young man was admitted to the West Midlands Regional Burns Unit at the Birmingham Accident Hospital, with 60 per cent body surface area burns and smoke inhalation. On arrival, he was briskly tachycardiac, hypotensive and disorientated. He was admitted to the intensive care unit, intubated and started on intermittent positive pressure ventilation. Despite prompt commencement of resuscitation and the infusion of enormous volumes of colloids, the patient remained oliguric. He soon developed severe haemorrhage from his gastrointestinal, urinary and respiratory tracts. He required several units of blood, but was persistently hypotensive. His condition deteriorated rapidly despite intensive supportive measures. He developed metabolic acidosis, refractory hypotension and died anuric, 20 h later. The post-mortem examination showed the presence of disseminated intravascular coagulation and adult respiratory distress syndrome.

Serum cytokine levels (IL-4, IL-6, IL-8, G-CSF, GM-CSF) in burned patients

The presence and concentration of selected cytokines (interleukin 4 (IL-4), interleukin 6 (IL-6), interleukin 8 (IL-8), granulocyte colony-stimulating factor (G-CSF) and granulocyte-macrophage colony-stimulating factor (GM-CSF)) were evaluated in the sera of 12 burned patients (6–90 per cent body surface area). The presence of cytokines in the sera of 20 healthy volunteers (control group) was always undetectable (< 2 pg/ml). In sera of the burned patients the concentrations of IL-4 or GM-CSF were also below the test sensitivity levels, while G-CSF and IL-6 were present throughout all the observation period and IL-8 was detectable at the onset of massive infections. The serum concentrations of G-CSF and IL-6 increased during the episodes of clinically and bacteriologically detectable infections. Their increases were, however, observable 12–24 h later than the other infection symptoms. Similar increases in G-CSF and IL-6 levels have been detected during corrective surgery (covering of granulation tissue with skin grafts). It may be concluded that serum G-CSF and IL-6 levels in burned patients may be considered as diagnostic factors, but the delays in the reaction to the massive infection do not allow us to use them for predicting the time of onset of the infection.

The association of circulating endotoxaemia with the development of multiple organ failure in burned patients

In this study, we examined the relationship of plasma endotoxin levels to the development of multiple organ failure (MOF), and the outcome in patients with thermal injury. A prospective cohort study of 17 patients admitted with burns covering more than 70 per cent of body surface area was undertaken. Circulating endotoxin concentrations were measured by modified limulus amoebocyte lysate assay in serial samples of plasma. Seven out of 17 burned patients developed MOF according to multiple criteria. The plasma endotoxin concentrations of patients with MOF were 0.512 – 1.127 EU/ml, which were significantly higher than that of 10 patients without MOF (0.216 – 0.553 EU/ml), on 3, 14, 21 and 28 days postburn (p < 0.05−0.01). A significantly higher incidence of positive endotoxin tests (≥ 0.120 EU/ml) was found in patients who developed MOF as compared to those patients who did not develop MOF during the observation period (p < 0.05). As the mean endotoxin levels increased, the incidence of MOF and death rate also increased, and persistent endotoxemia carried a poor prognosis. The present investigation provides further evidence that endotoxemia in severely burned patients commonly occurs. Circulating endotoxin has also been found to be strongly associated with the development of MOF and mortality following major burn injury.

Prophylactic anti-lipopolysaccharide freeze-dried plasma in major burns: a double blind controlled trial

A double-blind controlled trial to test the efficacy of freeze-dried plasma containing a high titre of anti-lipopolysaccharide (anti-LPS) IgG in preventing or reducing sepsis in burns was carried out on 60 consecutive consenting adult burn victims with burns between 20 and 55 per cent of body surface area. Statistics failed to demonstrate a reduction in the mortality ( P = 0.12) but did demonstrate a reduction in the incidence of burn wound infection ( P = 0.0443), a fall in endotoxin levels in the first week ( P = 0.041) and a rise in the anti-endotoxin levels after 5 units of anti-LPS plasma ( P = 0.027). The logistics of carrying out such a trial are difficult but a larger patient population and modification of the original protocol might demonstrate a significant fall in mortality and morbidity. It was felt that some of the positive benefits of the high titre anti-LPS plasma might be due to factors other than the anti-LPS IgG.

Successful management of a patient with 95 per cent body surface area burns

This report describes the medical treatment of a patient with 95 per cent total body surface area burns, with over 50 per cent full thickness skin loss who survived.

Young, scarred children and their mothers—a short-term investigation into the practical, psychological and social implications of thermal injury to the preschool child. Part I: implications for the mother

A short-term, prospective study, using both quantitative and qualitative methods, was designed to determine the practical, psychological and social implications of thermal injury resulting in scarring, for the mothers of thermally injured children, during the 6 months following the child's discharge from hospital. Mothers of 57 thermally injured children under 5 years of age were interviewed whilst the child was in hospital and at home, at 1 week, 2 months and 6 months following hospital discharge. Thermal injuries ranged from 1 to 41 per cent of body surface area and all required skin grafting. Qualitative analysis of interview transcripts resulted in the development of a model of the mother's response-The Maternal Thermal Injury Response Pattern (MTIRP) - which describes a phasic pattern of general response categories. The mothers' psychiatric morbidity was measured using Goldberg's (1978) 60-item General Health Questionnaire (GHQ). The mean of the mothers' total GHQ scores was 2.42 for the retrospective, pre-injury score, 24.5 at the hospital interview and 5.96 at 6 months following the child's discharge from hospital. In conclusion, the mother is a neglected victim of a young child's thermal injury. Use of the MTIRP as an educational tool for carers would promote increased understanding and, thus, more appropriate support.

Young, scarred children and their mothers — a shortterm investigation into the practical, psychological and social implications of thermal injury to the preschool child. Part II: implications for the child

A short-term, prospective study, using both quantitative and qualitative methods, was designed to determine the practical, psychological and social implications of thermal injury resulting in scarring for children under 5 years of age, during the 6 months following the child's discharge from hospital. Mothers of 57 children (whose thermal injuries ranged from 1 to 41 per cent of body surface area and who all required skin grafting) were interviewed whilst the child was in hospital and at home, at 1 week, 2 months and 6 months following hospital discharge. From the mothers' descriptions, four categories of child behavioural response to thermal injury and hospitalization were identified. In the first week after discharge from the burns unit, 56 per cent (32/57) of children displayed minor or major disturbed behaviour, which had reduced to 19.3 per cent (11/57) by the 6-month interview. There were many reported physical and practical problems associated with the thermal injury and after-care. The MacGregor Deformity Scale was employed to assess the child's appearance. The child behaviour test scores (S. Jenkins et al. J. Child Psychol. Psychiatr. 1980; 21:5; N. Richman et al. Pre-school to School -A Behavioural Study. 1982; Academic) demonstrated a similar progression of behavioural responses as the qualitative data, and, furthermore, indicated that the children under 2 years of age seemed to be affected for a more prolonged period.

Burns in the disabled

A retrospective analysis of 812 patients admitted to the Ross Tilley Burn Centre between 1984 and 1992 resulted in 37 cases of burn injuries which were directly related to premorbid disabilities. The majority of these burns (83.8 per cent) occurred in the patient's home, most commonly as scald injuries in the bath tub, the shower, or following hot water spills. Nineteen patients were male, 17 were female. The median age was 58 years. Six patients had spinal cord disorders: four had traumatic cord damage, two had spina bifida. Six patients had seizure disorders. Five of these patients had been taking anti-seizure medications, but all had subtherapeutic blood levels on admission to hospital. Two patients had diabetes mellitus with peripheral neuropathies. Thirteen patients had four miscellaneous neurological disorders, including: tardive dyskinesia (two), CVA (four), Parkinson's disease (two), Alzheimer's disease (two), cerebral palsy (one), multiple sclerosis (one) and blindness (one). Three patients had a diagnosis of syncope. Two patients had emphysema, and four were morbidly obese. The average length of stay (LOS) for the disabled patients was 27.6 days for a median burn size of 10 per cent body surface area (BSA), compared to an average LOS for the general population of 25.7 days for a larger median burn size of 21 per cent BSA. The mortality rate was also much higher in the disabled population (22.2 per cent vs. 6.0 per cent). Most of these burn injuries were preventable. A series of burn prevention guidelines is presented, in an attempt to reduce the incidence of these burn injuries in disabled patients.

Intravenous Pluronic F-127 in early burn wound treatment in rats.

A dramatic improvement in full skin thickness burn wounds in rats treated intravenously with the non-ionic surfactant Pluronic F-127 (F-127) has been demonstrated. In this study the F-127 was given 30 min postburn to simulate conditions encountered in a clinical setting. Anaesthetized male rats (300-320 g) received full skin thickness burns by immersion of the anterior chest wall (8 per cent body surface area in a 70 degrees C water-bath for 12 s). Burn wound area was measured immediately and after 48 h. Thirty minutes after the burn, half the animals received equal volumes (8 ml/kg body wt) of either saline or F-127 (12 mM/l concentration) via the tail vein. The animals autopsied at 48 h showed a significant (P < 0.05) reduction in the degree of wound contraction and the wound appeared grossly less damaged in the F-127-treated animals. Histologically, skin biopsies showed less of the microscopic damage usually associated with full skin thickness burns in the F-127-treated animals than in the saline controls. We also used thermography to measure skin temperature of the burn area at 90 min and 48 h postinjury demonstrating alterations in the F-127-treated animals (P < 0.05). In animals followed for 30 days postinjury, there was a significant (P < 0.01) improvement in the wound closure rates in the F-127-treated animals. These observations show a positive therapeutic effect of F-127 on the inflammatory process in the area of a burn that may improve wound healing.