526
burns 40 (2014) 525–537
The underlying pathophysiology of cryogenic burns differs from that of thermal injuries. Tissue damage due to low temperatures is the result of the formation of ice crystals within and around cells and the subsequent break down of cell membranes. High temperatures cause coagulative necrosis with protein destruction. This difference means that a longer trial of conservative management may be permitted in managing cold injury, before surgery is deemed necessary. There are several case series in the literature detailing cutaneous burns due to aerosol sprays which until recently were a rare occurrence [2–4]. Doctors, parents and schools need to be aware of the internet-based media through which this craze is being fuelled. Typing ‘the Lynx challenge’ into an Internet search engine shows multiple videos of people taking part, however, the significant side effects are not obvious. Another similar craze, ‘The Salt and Ice Challenge’, is now well documented to cause significant harm to subjects with understandable outrage amongst parent groups [5]. Peer pressure leading to risk taking behaviour is not a new occurrence but the stage has changed. The coaxing and suggesting now comes from an unknown peer through a computer screen or mobile device and new challenges are set which exceed previous experience. Improved knowledge through education of children, parents, schools and healthcare professionals is the key to lead to prevention of such injuries.
Conflict of interest None declared.
references
[1] Ward M. Frostbite. BMJ 1974;1:67–70. [2] May U, Stirner K, Lauener R, Ring J, Mohrenschlager M. Deodorant spray: a newly identified cause of cold burn. Paediatrics 2010;126(3):716–8. [3] Camp D, Ateaque A, Dickson W. Cryogenic burns from aerosol sprays: a report of two cases and review of the literature. Br J Plast Surg 2003;56:815–7. [4] Stefanutti G, Yee J, Sparnon A. Cryogenic burns from intentional use of aerosol spray in children: an emerging phenomenon. Burns 2010;36:e65–7. [5] Williams J, Cubitt J, Dickson W. The challenge of salt and ice. Burns 2013, http://dx.doi.org/10.1016/j.burns.2013.01.002.
Jonathan J. Cubitt* Tom Combellack Peter J. Drew Welsh Centre for Burns and Plastic Surgery, Heol Maes Eglwys, Morriston Hospital, Swansea SA6 6NL, United Kingdom *Corresponding author. Tel.: +44 07714265457 E-mail address: [email protected] (J.J. Cubitt) 4 September 2013 0305-4179/$36.00 # 2013 Elsevier Ltd and ISBI. All rights reserved. http://dx.doi.org/10.1016/j.burns.2013.09.006
Letter to the Editor Cryopreserved human skin allografts: Efficacy and viability
Dear Editor, We read with attention the article ‘‘Clinical application and viability of cryopreserved cadaveric skin allografts in severe burn: A retrospective analysis’’ by Cleland et al. [Burns (2013), September 6, PII: S0305-4179(13)00153-8. http://dx.doi.org/ 10.1016/j.burns.2013.05.006 (Epub ahead of print)] [1]. In this article, the authors explain their specific modalities in use of cryopreserved allografts for burn surgery due to the ‘‘extremely limited’’ availability of the product in Australia. Thus ‘‘current management algorithm reserves allograft for use in patients with large burns in whom synthetic or composite skin substitutes have failed’’ (retrospective study, 98 procedures of allografting, 32 patients during a 9 year period). Viability was assessed on skin biopsy disks (from 5 donors of cryopreserved skin and 7 other donors of fresh skin) by MTT assay which ‘‘showed between 18% and 26% viability on the whole [cryopreserved] tissue compared to freshly isolated skin’’. Moreover, they argued that ‘‘allografts from younger donors would have higher viability rates’’ relying on a paper by Neely et al. [2] which is not about viability but on transmission of bacterial infection from a donor to a recipient through allografts. In our experience, we never found a correlation between the age of the donor and the viability assessed by MTT assay (data not published). If we focus on this study, on the one hand, ‘‘processed samples have lower viability compared to other skin banks (50–60%)’’ [3–5]. This rate was not discussed. Was it related to the MTT assay protocol, or to the delay between harvesting and cryopreservation, or to the cryopreservation process? On the other hand, we have no detail about the delay of allograft engraftment and its success or failure (whereas allografting is at least the second procedure after failure of initial coverage by synthetic or composite skin substitutes). Finally, they stated that ‘‘a high degree of cellular viability of the graft is not an essential factor in successful engraftment of the wound bed’’. Currently, no literature has established correlation between viability and efficacy of coverage, nor does this study. It is well known that non-viable allografts have a clinical interest, but when viability is required, it is for qualitative advantages; higher viability is usually associated to better wound bed preparation and graft take [6]. We agree with the authors that ‘‘effect of preservation method on clinical outcome rate requires further investigation’’.
Conflict of interest None.
burns 40 (2014) 525–537
references
[1] Cleland H, Wasiak J, Dobson H, Paul M, Pratt G, Paul E, et al. Clinical application and viability of cryopreserved cadaveric skin allografts in severe burn: a retrospective analysis. Burns 2013;September 6. http://dx.doi.org/10.1016/j.burns.2013. 05.006. PII: S0305-4179(13)00153-8 [Epub ahead of print]. [2] Neely AN, Plassinger RT, Stamper B, Kagan RJ. Can contamination of a patient’s allograft be traced back to the allograft donor? J Burn Care Res 2008;29(1):73–6. [3] Bravo D, Rigley TH, Gibran N, Strong DM, Newman-Gage H. Effect of storage and preservation methods on viability in transplantable human skin allografts. Burns 2000;26(4): 367–78. [4] Castagnoli C, Alotto D, Cambieri I, Casimiri R, Aluffi M, Stella M, et al. Evaluation of donor skin viability: fresh and cryopreserved skin using tetrazolium salt assay. Burns 2003;29(December (8)):759–67. [5] Gaucher S, Elie C, Ve´rola O, Jarraya M. Viability of cryopreserved human skin allografts: effects of transport media and cryoprotectant. Cell Tissue Bank 2012;13(1):147–55. [6] Hickerson WL, Compton C, Fletchall S, Smith LR. Cultured epidermal autografts and allodermis combination for permanent burn wound coverage. Burns 1994;20(Suppl. 1):S52–5 [discussion S55–6].
Sonia Gauchera,b,* a Universite´ Paris Descartes, Paris Sorbonne Cite´, 75006 Paris, France b Service de Chirurgie Ge´ne´rale, Plastique et Ambulatoire, Hoˆpitaux Universitaires Paris Centre, Site Port Royal, 75014 Paris, France Mohamed Jarraya Banque des Tissus Humains, AP-HP Hoˆpital Saint Louis, 75010 Paris, France
527
burns patients per annum presenting to emergency departments where physicians require basic emergency burns care competencies [3]. To overcome the current educational deficit, gain plastic surgery exposure, and learn about the speciality, medical students may volunteer to assist in post-graduate courses. We report the educational merit for medical student volunteers as manikins at an Emergency Management of Severe Burns (EMSB) course in the UK, broadly equivalent to the Advanced Burn Life Support (ABLS) Course in the USA. A group of medical students, including one author (AB), volunteered to become a simulated burns victim for staged clinical scenarios. This course provided educational stimuli for medical student volunteers in the following aspects of acute burns management from the EMSB course: Understanding why different colours and shades were used to paint burns to represent different burn depths. Observing course participants assess and resuscitate mock burns patients based on clinical findings. Witnessing participant–examiner interaction as clinical scenarios were explored and participants’ knowledge and reasoning was probed. The EMSB course is a valuable, insightful and fundamental course for all members of the multidisciplinary burns team [4]. The opportunity to act as a mock patient, with make-up to mirror the clinical signs of a burn (Figs. 1 and 2), provided clinically representative scenarios to learn vicariously about emergency burns care. Medical students may gain their first – and potentially only experience in burns as a burns manikin.
*Corresponding author at: Service de Chirurgie Ge´ne´rale, Plastique et Ambulatoire, Hoˆpitaux Universitaires Paris Centre, Site Port Royal, 53 Avenue de l’Observatoire, 75014 Paris, France. Tel.: +33 1 58 41 38 58; fax: +33 1 58 41 38 59 E-mail address: [email protected] (S. Gaucher) 0305-4179/$36.00 # 2013 Elsevier Ltd and ISBI. All rights reserved. http://dx.doi.org/10.1016/j.burns.2013.09.031
Letter to the Editor Medical student manikins – free plastic surgery training for super models Sir, Exposure to plastic surgery training at medical school is minimal, despite this being the most influential period for career decision making [1]. In particular, burns training is absent from the core curricula of all medical schools in the United Kingdom [2]. This deficiency is alarming, with 13,000
Fig. 1 – Course volunteers experience burns moulage.
burns 40 (2014) 525–537
The underlying pathophysiology of cryogenic burns differs from that of thermal injuries. Tissue damage due to low temperatures is the result of the formation of ice crystals within and around cells and the subsequent break down of cell membranes. High temperatures cause coagulative necrosis with protein destruction. This difference means that a longer trial of conservative management may be permitted in managing cold injury, before surgery is deemed necessary. There are several case series in the literature detailing cutaneous burns due to aerosol sprays which until recently were a rare occurrence [2–4]. Doctors, parents and schools need to be aware of the internet-based media through which this craze is being fuelled. Typing ‘the Lynx challenge’ into an Internet search engine shows multiple videos of people taking part, however, the significant side effects are not obvious. Another similar craze, ‘The Salt and Ice Challenge’, is now well documented to cause significant harm to subjects with understandable outrage amongst parent groups [5]. Peer pressure leading to risk taking behaviour is not a new occurrence but the stage has changed. The coaxing and suggesting now comes from an unknown peer through a computer screen or mobile device and new challenges are set which exceed previous experience. Improved knowledge through education of children, parents, schools and healthcare professionals is the key to lead to prevention of such injuries.
Conflict of interest None declared.
references
[1] Ward M. Frostbite. BMJ 1974;1:67–70. [2] May U, Stirner K, Lauener R, Ring J, Mohrenschlager M. Deodorant spray: a newly identified cause of cold burn. Paediatrics 2010;126(3):716–8. [3] Camp D, Ateaque A, Dickson W. Cryogenic burns from aerosol sprays: a report of two cases and review of the literature. Br J Plast Surg 2003;56:815–7. [4] Stefanutti G, Yee J, Sparnon A. Cryogenic burns from intentional use of aerosol spray in children: an emerging phenomenon. Burns 2010;36:e65–7. [5] Williams J, Cubitt J, Dickson W. The challenge of salt and ice. Burns 2013, http://dx.doi.org/10.1016/j.burns.2013.01.002.
Jonathan J. Cubitt* Tom Combellack Peter J. Drew Welsh Centre for Burns and Plastic Surgery, Heol Maes Eglwys, Morriston Hospital, Swansea SA6 6NL, United Kingdom *Corresponding author. Tel.: +44 07714265457 E-mail address: [email protected] (J.J. Cubitt) 4 September 2013 0305-4179/$36.00 # 2013 Elsevier Ltd and ISBI. All rights reserved. http://dx.doi.org/10.1016/j.burns.2013.09.006
Letter to the Editor Cryopreserved human skin allografts: Efficacy and viability
Dear Editor, We read with attention the article ‘‘Clinical application and viability of cryopreserved cadaveric skin allografts in severe burn: A retrospective analysis’’ by Cleland et al. [Burns (2013), September 6, PII: S0305-4179(13)00153-8. http://dx.doi.org/ 10.1016/j.burns.2013.05.006 (Epub ahead of print)] [1]. In this article, the authors explain their specific modalities in use of cryopreserved allografts for burn surgery due to the ‘‘extremely limited’’ availability of the product in Australia. Thus ‘‘current management algorithm reserves allograft for use in patients with large burns in whom synthetic or composite skin substitutes have failed’’ (retrospective study, 98 procedures of allografting, 32 patients during a 9 year period). Viability was assessed on skin biopsy disks (from 5 donors of cryopreserved skin and 7 other donors of fresh skin) by MTT assay which ‘‘showed between 18% and 26% viability on the whole [cryopreserved] tissue compared to freshly isolated skin’’. Moreover, they argued that ‘‘allografts from younger donors would have higher viability rates’’ relying on a paper by Neely et al. [2] which is not about viability but on transmission of bacterial infection from a donor to a recipient through allografts. In our experience, we never found a correlation between the age of the donor and the viability assessed by MTT assay (data not published). If we focus on this study, on the one hand, ‘‘processed samples have lower viability compared to other skin banks (50–60%)’’ [3–5]. This rate was not discussed. Was it related to the MTT assay protocol, or to the delay between harvesting and cryopreservation, or to the cryopreservation process? On the other hand, we have no detail about the delay of allograft engraftment and its success or failure (whereas allografting is at least the second procedure after failure of initial coverage by synthetic or composite skin substitutes). Finally, they stated that ‘‘a high degree of cellular viability of the graft is not an essential factor in successful engraftment of the wound bed’’. Currently, no literature has established correlation between viability and efficacy of coverage, nor does this study. It is well known that non-viable allografts have a clinical interest, but when viability is required, it is for qualitative advantages; higher viability is usually associated to better wound bed preparation and graft take [6]. We agree with the authors that ‘‘effect of preservation method on clinical outcome rate requires further investigation’’.
Conflict of interest None.
burns 40 (2014) 525–537
references
[1] Cleland H, Wasiak J, Dobson H, Paul M, Pratt G, Paul E, et al. Clinical application and viability of cryopreserved cadaveric skin allografts in severe burn: a retrospective analysis. Burns 2013;September 6. http://dx.doi.org/10.1016/j.burns.2013. 05.006. PII: S0305-4179(13)00153-8 [Epub ahead of print]. [2] Neely AN, Plassinger RT, Stamper B, Kagan RJ. Can contamination of a patient’s allograft be traced back to the allograft donor? J Burn Care Res 2008;29(1):73–6. [3] Bravo D, Rigley TH, Gibran N, Strong DM, Newman-Gage H. Effect of storage and preservation methods on viability in transplantable human skin allografts. Burns 2000;26(4): 367–78. [4] Castagnoli C, Alotto D, Cambieri I, Casimiri R, Aluffi M, Stella M, et al. Evaluation of donor skin viability: fresh and cryopreserved skin using tetrazolium salt assay. Burns 2003;29(December (8)):759–67. [5] Gaucher S, Elie C, Ve´rola O, Jarraya M. Viability of cryopreserved human skin allografts: effects of transport media and cryoprotectant. Cell Tissue Bank 2012;13(1):147–55. [6] Hickerson WL, Compton C, Fletchall S, Smith LR. Cultured epidermal autografts and allodermis combination for permanent burn wound coverage. Burns 1994;20(Suppl. 1):S52–5 [discussion S55–6].
Sonia Gauchera,b,* a Universite´ Paris Descartes, Paris Sorbonne Cite´, 75006 Paris, France b Service de Chirurgie Ge´ne´rale, Plastique et Ambulatoire, Hoˆpitaux Universitaires Paris Centre, Site Port Royal, 75014 Paris, France Mohamed Jarraya Banque des Tissus Humains, AP-HP Hoˆpital Saint Louis, 75010 Paris, France
527
burns patients per annum presenting to emergency departments where physicians require basic emergency burns care competencies [3]. To overcome the current educational deficit, gain plastic surgery exposure, and learn about the speciality, medical students may volunteer to assist in post-graduate courses. We report the educational merit for medical student volunteers as manikins at an Emergency Management of Severe Burns (EMSB) course in the UK, broadly equivalent to the Advanced Burn Life Support (ABLS) Course in the USA. A group of medical students, including one author (AB), volunteered to become a simulated burns victim for staged clinical scenarios. This course provided educational stimuli for medical student volunteers in the following aspects of acute burns management from the EMSB course: Understanding why different colours and shades were used to paint burns to represent different burn depths. Observing course participants assess and resuscitate mock burns patients based on clinical findings. Witnessing participant–examiner interaction as clinical scenarios were explored and participants’ knowledge and reasoning was probed. The EMSB course is a valuable, insightful and fundamental course for all members of the multidisciplinary burns team [4]. The opportunity to act as a mock patient, with make-up to mirror the clinical signs of a burn (Figs. 1 and 2), provided clinically representative scenarios to learn vicariously about emergency burns care. Medical students may gain their first – and potentially only experience in burns as a burns manikin.
*Corresponding author at: Service de Chirurgie Ge´ne´rale, Plastique et Ambulatoire, Hoˆpitaux Universitaires Paris Centre, Site Port Royal, 53 Avenue de l’Observatoire, 75014 Paris, France. Tel.: +33 1 58 41 38 58; fax: +33 1 58 41 38 59 E-mail address: [email protected] (S. Gaucher) 0305-4179/$36.00 # 2013 Elsevier Ltd and ISBI. All rights reserved. http://dx.doi.org/10.1016/j.burns.2013.09.031
Letter to the Editor Medical student manikins – free plastic surgery training for super models Sir, Exposure to plastic surgery training at medical school is minimal, despite this being the most influential period for career decision making [1]. In particular, burns training is absent from the core curricula of all medical schools in the United Kingdom [2]. This deficiency is alarming, with 13,000
Fig. 1 – Course volunteers experience burns moulage.
