Análise semiquantitativa do parênquima distal de pulmões obtidos em autópsia de vítimas de morte por ação do fogo e por sufocação, foi feita para avaliar as alterações em bronquíolos e tecido alveolar (ductos e alvéolos). A análise discriminante dos parâmetros obtidos permitiu classificação de 74% / A semiquantitative analysis of the distal parenchyma in lung autopsies of victims of death by fire and death by suffocation, was done to evaluate the changes in membranous bronchiolar and alveolar tissue (alveolar ducts and alveoli). The discriminant parameters obtained permitted classification of 74% of cases

Magister Scientiae (Physiotherapy) - MSc(Physio) / Millions of patients with burns require medical attention each year. Impairments, disabilities and handicap due to burn injuries among children are increasing. One possible reason could be that burn injury prevention were not given as much attention as infectious diseases such as leprosy, and tuberculosis (TB). The purpose of the study was to compile a profile of burn injuries among children aged 0-12 years, who were treated at the Black Lion Hospital (BLH) between 1996 and 2001 in Ethiopia. A retrospective, quantitative study design was chosen. Data was collected from the hospital records of 250 children seen with burn injuries. Clinical data, such as the cause and severity of the burn, and socio-demographic data such as the age of the child and his or her caregivers, their socio-economic status and educational levels, were captured. Descriptive and inferential statistical analyses of the data were carried out between socio-demographic variables and the burn injuries. The Chi-squared statistical test was used to identify associations and differences between selected variables. The major causes of thermal burns were hot liquids (63.4%) and flames (36.6%). The highest prevalence of burn injuries occurred in those children in the care of illiterate caregivers (p<0.01). The highest risk environment for burn accidents was identified as the kitchen (p<0.05). Most of the burns (64%) occurred in the children below the age of five years old. This finding was not statistically significant but it is of great clinical importance. Health and safety promotion programmes aimed at carers to minimize the risk of childhood disabilities due to burn injuries are recommended. Caregivers and school children have to be taught to use simple fire prevention procedures to avoid thermal burn injuries. Although the results of this study cannot be generalized, it provides a glimpse of the burn status and causes of thermal burn at BLH. However, in order to get more comprehensive information it is important to obtain information from more hospitals in the country through prospective studies.

Introdução: A ressuscitação fluídica agressiva, com volume superior ao preconizado por Baxter, com objetivo de evitar a hipoperfusão de órgãos e restabelecer a volemia rapidamente, se tornou uma tendência nos últimos anos. Esta prática vem sendo discutida mais recentemente após a caracterização do fenômeno fluid creep e pode ser causa de aumento da morbidade e mortalidade em crianças queimadas. A hiperhidratação impacta negativamente a evolução desses pacientes e já se estabeleceram associações do fenômeno fluid creep com diversas complicações, como, por exemplo, a síndrome compartimental abdominal. Pacientes queimados estão sob alto risco para infecção e sepse devido à perda da integridade da pele e à exposição prolongada ao ambiente nosocomial. A principal causa de óbito, se o paciente sobreviver à fase inicial do choque do queimado é a disfunção de múltiplos órgãos e sistemas secundária a sepse. Objetivos: Avaliar a associação entre o fluid creep e episódios infecciosos em crianças queimadas submetidas a duas estratégias diferentes de reanimação hídrica envolvendo albumina. Realizar análises de curvas de probabilidade livre de infecção, além de comparar o tempo de internação e número de procedimentos cirúrgicos realizados nestes grupos de pacientes. Metodologia: Estudo de coorte histórica envolvendo 46 crianças queimadas admitidas no Centro de Tratamento de Queimados do Hospital Universitário de Londrina entre junho de 2012 e janeiro de 2014 e que incluiu casos oriundos de um ensaio clínico randomizado controlado realizado no mesmo período. Foram incluídas crianças entre 1 e 12 anos, com queimaduras entre 15% e 45% de Superfície Corporal Queimada (SCQ) e profundidade de 2º e 3º graus, admitidas até a 12ª hora após o acidente. Todos os pacientes receberam reanimação fluídica com Ringer Lactato (RL), nas primeiras 24 horas, segundo a Fórmula de Parkland modificada (3ml/kg/%SCQ) ajustada de acordo com o débito urinário (DU). Os pacientes do grupo A = Exposto (n=23) receberam albumina 5% entre 8 e 12 horas do momento do acidente, e os do Grupo B= Não Exposto (n=23) receberam albumina 5% partir da 24a hora do acidente. Os grupos foram comparados quanto ao surgimento do fenômeno fluid creep, tempo de internação, número de procedimentos cirúrgicos realizados e infecção até a alta hospitalar. Resultados: Os pacientes do grupo A tiveram menos dias de internação comparadamente ao grupo B (p=0,007). O surgimento do fenômeno fluid creep foi maior em crianças no grupo B (p < 0,001). O tempo de internação maior de 14 dias assim como a presença de fluid creep foi associado com a presença de infecção, respectivamente p=0,002 e p=0,020. O tempo de internação bem como a presença de fluid creep apresentaram diferenças nas curvas de probabilidade livre de infecção (p < 0,05). Todas as crianças do grupo B receberam debridamento comparado com 73,9% daquelas incluídas no grupo A (p=0,022), assim como os enxertos foram mais frequentes no grupo B (p=0,032). Conclusões: Crianças queimadas que receberam albumina entre 8 e 12 horas após o acidente apresentaram significativamente menos fluid creep, menor tempo de internação e menor número de procedimentos cirúrgicos (debridamentos e enxertos) comparativamente ao grupo que recebeu albumina após 24 horas. A presença do fluid creep e o tempo de internação superior a 14 dias apresentaram diferenças nas curvas de probabilidade livre de infecção, demonstrando pior prognóstico infeccioso / Introduction: Aggressive fluid resuscitation, defined as the administration of a superior volume to the parameters recommended by Baxter, intend to rapidly set the euvolemia and avoid organ hypoperfusion in burn individuals. The practice became a trend during the last years and has been extensively discussed after the establishment of the fluid creep phenomenon and has been considered as a possible mortality and morbidity factor in burn children. A strong association of fluid creep development has already been established with many conditions, as abdominal compartment syndrome. Burn patients are at high risk of infection and subsequent progression to sepsis due to the loss of skin integrity and long-term exposure to hospital environment. If those patients survive to the burn shock, their main cause of death is the multiple organ failure secondary to sepsis, what highlights the importance of comprehensive knowledge of infectious complications in burn children. Objectives: Assess the association between fluid creep and infection episodes in burn children that were exposed to two different fluid resuscitation strategies with the use of albumin. Analyze the patients infection-free probability curves, length of stay and number of surgery procedures needed. Methods: We developed a historic cohort of 46 burn children admitted at the Burn Treatment Center, State University of Londrina. The same patients were simultaneously enrolled in a parallel clinical trial. In this study, were included patients from 1 to 12 years old, with 15% to 45% of the body surface area (BSA) compromised, second or third-degree burns, admitted up to 12 hours after the accident. Both groups were compared according to the exposure. All the patients received fluid resuscitation with Ringer Lactate (RL) in the first 24 hours, respecting the modified Parkland formula (3 ml/kg/% TBSA) adjusted according to the urine output (UO). Patients from group A were exposed to 5% albumin between 8 and 12 hours from the accident moment and the patients from group B received 5% albumin after 24 hours from the accident. The outcomes observed were development of fluid creep phenomenon, length of stay, number of surgery procedures needed and infection until the hospital discharge. Results: Compared to the group B, the group A had a shorter median length of stay (p=0,007). Fluid creep development had higher rates on group B compared to group A (p < 0,001). The length of stay for more than 14 days, as the fluid creep arising, was associated with infection (respectively, p=0,002 and p=0,02). Both the length of stay and the fluid creep presence showed difference at the infection-free probability curves (p < 0,05). All the patients from group B were submitted to debridement compared to 73,9 from group A (p=0,022). The need of skin graft procedure was also more frequent in patients from group A (p=0,032). Conclusion: Burn children that received albumin between 8 and 12 hours from the accident moment presented significant less fluid creep, shorter length of stay, and smaller number of surgery procedures (as debridement and skin graft) compared to the group that received albumin after 24 hours from the accident. Fluid creep development and length of stay superior to 14 days presented differences at the infection-free probability curves, providing a negative infectious prognosis

<p>The understanding and practice of leadership in Sub-Saharan Africa, in all spheres, is at the heart beat of this work. Questions and concerns over the quality of leadership in most countries in this particular region are reasons which have led to revisit and investigate the formative training of the current cohort of African leadership with a special focus on the ethical aspect of leadership. It is an assumption, in this thesis, that the contemporary cohort of African leadership received their formative training especially in the 1960s and 1970s and that they were deeply influenced by the black consciousness movement and, in association with that, by the emergence of black theology. In this respect, this research project explores the notions of ethics and leadership with a view to determine ways in which an appropriate leadership ethos was portrayed and articulated in the writings of selected exponents of the black theology movement, namely ML King (Jr), Desmond Tutu and Allan Boesak. The purpose of this work is therefore mainly descriptive: to map discourse on a leadership ethos in the context especially of black theology.</p>

Survival after severe burns has improved in recent decades, but there is limited information on the course of recovery after surviving a burn and on factors that can affect recovery. The aims of this thesis were to investigate the occurrence of physical and psychological problems after burns, and to examine the consequences of psychological problems for the clinical management of burn patients. Three groups of consecutive patients who were treated at the Burn Unit at Uppsala University Hospital between 1980 and 2005 were included in the studies. The Burn Specific Health Scale (BSHS) was used for self-report of burn-specific aspects of health. Personality traits and coping strategies as psychological factors during recovery were examined with the Swedish universities Scales of Personality (SSP) and the Coping with Burns Questionnaire (CBQ). Presence of symptoms of posttraumatic stress were assessed with the Impact of Event Scale-Revised (IES-R), and the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) was used to determine the concurrent validity of the IES-R as a measure of Posttraumatic Stress Disorder (PTSD). Furthermore, the effect of pre-injury psychiatric morbidity on perceived health one year after injury was assessed. Both pruritus and nightmares were common problems after burns; 59% of the individuals in the study reported pruritus and 43% reported nightmares. Neuroticism-related personality traits and avoidant coping strategies were associated with an increased risk of having pruritus or nightmares. The presence of nightmares could be used as a screening tool for high scores in the IES-R. The IES-R was in turn shown to be a good, although overly inclusive, test for the diagnosis of PTSD. Pre-injury psychiatric morbidity predicted perceived outcome in six out of nine burn-specific health domains. These studies show that psychological factors and psychiatric morbidity affect outcome after burns.

Hintergrund: Die regionale Citrat-Antikoagulation im Rahmen der Nierenersatztherapie hat bei interdisziplinären Intensivpatienten in den letzten Jahren zunehmend an Bedeutung gewonnen. Für Schwerbrandverletzte existieren bislang kaum Untersuchungen zu diesem Verfahren. Ziel dieser Arbeit war es, die kontinuierliche Nierenersatztherapie mit Citrat-Antikoagulation bei Intensivpatienten mit akutem Nierenversagen nach schwerem Verbrennungstrauma im Hinblick auf Praktikabilität, Effektivität und Komplikationshäufigkeit sowie die Stabilität von Elektrolyt- und Säure-Basen-Haushalt und Gerinnung zu untersuchen. Daneben sollten Aussagen zur Prävalenz des akuten Nierenversagens in dieser Patientengruppe und zu dessen Einfluss auf die Letalität getroffen werden. Methode: Im Rahmen einer retrospektiven Untersuchung wurden unter Verwendung von Patientenakten und Patientendatenmanagementsystem (PDMS) Daten von 27 Schwerbrandverletzten (VKOF ≥ 20% oder ABSI ≥ 8) mit akutem Nierenversagen ausgewertet, die zwischen Januar 2004 und Dezember 2009 im Verbrennungszentrum des Klinikums Sankt Georg Leipzig mit einer kontinuierlichen Nierenersatztherapie behandelt wurden. Bei allen Patienten kam ein Dialysegerät Prisma CFM (Gambro Hospal GmbH, Deutschland) mit einer Polyacrylnitril-Filtermembran (AN 69, Filterset M 100) der gleichen Firma zum Einsatz. Standardverfahren war eine kontinuierliche veno-venöse Hämodiafiltration (CVVHDF) im Prädilutionsmodus. Bei 18 Patienten wurde eine regionale Citrat-Antikoagulation als Antikoagulationsverfahren eingesetzt, bei 7 Patienten eine systemische Heparin-Antikoagulation, bei 2 Patienten kamen alternierend beide Verfahren zum Einsatz. Für die 18 Patienten unter regionaler Citrat-Antikoagulation erfolgte eine detaillierte Analyse des akuten Nierenversagens unter Einbeziehung des klinischen Verlaufes, der Laborparameter und der Behandlungsdaten des Nierenersatzverfahrens. Ergebnisse: Die Prävalenz eines akuten Nierenversagens mit Notwendigkeit zur Nierenersatztherapie bei Schwerbrandverletzten betrug 15,5%. Die Sterblichkeitsrate war in der Patientengruppe mit Nierenversagen etwa fünffach erhöht (25,9 vs. 4,8%). Die Letalitätsrate bei den Patienten unter systemischer Heparin-Antikoagulation war bei vergleichbarem Verbrennungsausmaß etwa fünfmal höher als unter regionaler Citrat-Antikoagulation (57,1 vs. 11.1%). Die Nierenersatztherapie wurde im Median nach 6 Tagen begonnen, die mediane Behandlungsdauer pro Patient betrug 7 Tage. Bei Start der CVVHDF wiesen 94,4% der Patienten einen Schockzustand mit Notwendigkeit einer Vasopressortherapie auf, 83,3% zeigten schwere Dysfunktionen in mindestens 3 Organsystemen, der SOFA-score lag im Median bei 14. Bei einer mittleren Citratkonzentration von 3,6 mmol/l Blut im Extrakorporalkreiskauf konnte eine mediane effektive Filterlaufzeit von 67 Stunden erreicht werden. Hypocalcämien (<0,9 mmol/l) fanden sich in 1,1%, Hypercalcämien (>1,3 mmol/l) in 0,4%. Hypernatriämien (<150 mmol) waren mit 0,4% ebenso selten wie metabolische Alkalosen (pH >7,50 und BE >4) mit 0,2%. Im Gesamtdialysezeitraum von 3790 Stunden gab es nur ein Blutungsereignis, die Gerinnungsparameter zeigten bis auf einen passageren Abfall der Thrombozytenzahl keine signifikanten Veränderungen. Die erzielte mittlere Dialysedosis war mit 35,1 ml/kg Körpergewicht/h ausreichend hoch. Neben einer Reduktion der Nierenretentionsparameter Serum-Creatinin und Serum-Harnstoff fanden sich unter dem Nierenersatzverfahren verbesserte Oxygenierungsindices und sinkende SOFA-scores. Keiner der überlebenden Patienten war zum Zeitpunkt der Entlassung dialysepflichtig. Zusammenfassung: Die CVVHDF unter regionaler Citrat-Antikoagulation ist bei Schwerbrandverletzten ein effektives und in Bezug auf Säure-Basen-Haushalt, Elektrolyte und Gerinnung sicheres Verfahren. Neben einer effektiven Elimination harnpflichtiger Substanzen konnten eine exzellente Stabilität von Elektrolyten und metabolischen Parametern sowie eine suffiziente Antikoagulation im Extrakorporalkreislauf mit niedrigem Blutungsrisiko und konstant langen Filterlaufzeiten nachgewiesen werden. Die Prävalenz des akuten Nierenversagens bei Schwerbrandverletzten ist hoch, die Letalität bei Vorliegen des Organversagens vier-bis fünffach erhöht.

Fires in buildings ranging in size from small residential houses to large office buildings and sports stadiums pose significant threats to human safety. Many advances have been made in the area of fire behaviour modeling and have lead to much safer, and more efficient fire protection engineering designs, saving countless lives. Fire, however, is still a difficult phenomenon to accurately model and the most important quantity used to describe a fire is the heat (energy) release rate (HRR). Predictions of the fire hazard posed by mattresses, using relatively simple modeling techniques, were investigated in this research work and compared to full-scale experimental results. Specifically, several common methods of predicting the HRR from a mattress fire were examined. Current spatial separation guidelines, which exist in order to mitigate fire spread between buildings, were used to predict radiation heat flux levels emitted by a burning building and compared to experimental results measured in the field. Enclosure ceiling temperatures, predicted using the Alpert temperature correlation, and average hot gas layer temperature predictions were also compared to experimental results. Results from this work indicate that the t-squared fire heat release rate modeling technique combined with the common Alpert ceiling temperature correlation, provide a reasonable prediction of real-life fire temperatures as results within 30% were obtained. The cone calorimeter was also found to be a useful tool in the prediction of full-scale fire behaviour and the guidelines used for spatial separation calculations were found to predict the radiant heat flux emitted by a burning building reasonably well.

Fires in buildings ranging in size from small residential houses to large office buildings and sports stadiums pose significant threats to human safety. Many advances have been made in the area of fire behaviour modeling and have lead to much safer, and more efficient fire protection engineering designs, saving countless lives. Fire, however, is still a difficult phenomenon to accurately model and the most important quantity used to describe a fire is the heat (energy) release rate (HRR). Predictions of the fire hazard posed by mattresses, using relatively simple modeling techniques, were investigated in this research work and compared to full-scale experimental results. Specifically, several common methods of predicting the HRR from a mattress fire were examined. Current spatial separation guidelines, which exist in order to mitigate fire spread between buildings, were used to predict radiation heat flux levels emitted by a burning building and compared to experimental results measured in the field. Enclosure ceiling temperatures, predicted using the Alpert temperature correlation, and average hot gas layer temperature predictions were also compared to experimental results. Results from this work indicate that the t-squared fire heat release rate modeling technique combined with the common Alpert ceiling temperature correlation, provide a reasonable prediction of real-life fire temperatures as results within 30% were obtained. The cone calorimeter was also found to be a useful tool in the prediction of full-scale fire behaviour and the guidelines used for spatial separation calculations were found to predict the radiant heat flux emitted by a burning building reasonably well.

<p>The understanding and practice of leadership in Sub-Saharan Africa, in all spheres, is at the heart beat of this work. Questions and concerns over the quality of leadership in most countries in this particular region are reasons which have led to revisit and investigate the formative training of the current cohort of African leadership with a special focus on the ethical aspect of leadership. It is an assumption, in this thesis, that the contemporary cohort of African leadership received their formative training especially in the 1960s and 1970s and that they were deeply influenced by the black consciousness movement and, in association with that, by the emergence of black theology. In this respect, this research project explores the notions of ethics and leadership with a view to determine ways in which an appropriate leadership ethos was portrayed and articulated in the writings of selected exponents of the black theology movement, namely ML King (Jr), Desmond Tutu and Allan Boesak. The purpose of this work is therefore mainly descriptive: to map discourse on a leadership ethos in the context especially of black theology.</p>

INTRODUCTION. La guérison rapide des sites donneurs des greffes cutanées favorise la survie des victimes de brûlures graves (>50 % de superficie brûlée). La mortalité élevée de ces patients est attribuable au fait que la superficie des brûlures excède celle de la peau saine. Des cultures épithéliales autologues (CEA) sont des feuillets de kératinocytes produits en culture à partir de la peau du patient. Cette étude a évalué l’effet des CEA sur l'épithélialisation des sites donneurs chez les grands brûlés. MÉTHODES. Tous les patients recevant des CEA ont été prospectivement inclus. Les plaies des sites donneurs ont été recouvertes de CEA, sauf pour une région contrôle randomisée de 7 x 7 cm. Des biopsies faites sur la greffe de peau ont permis de contrôler la profondeur des plaies sur les sites donneurs. Il y avait deux types de contrôles, avec gaze non adhérente trempée dans le milieu de culture ou dans le salin. L’épithélialisation était quantifiée globalement (% d’épithélialisation par photographie) et histologiquement (par biopsie au poinçon) à simple insu. La guérison des zones de contrôle et CEA était comparée par analyse de variance et par le test de Student. RÉSULTATS. Entre 2008 et 2009, 6 patients furent recrutés avec un total de 11 sites donneurs. Ces patients avaient en moyenne 43.5 ans, 56 % de superficie brûlée, 45% de brûlure pleine épaisseur, 66% avaient une brûlure d’inhalation, 75 jours de séjour. Il n’y a aucune corrélation entre le pourcentage d’épithélialisation et l’épaisseur du prélèvement des greffes (Pearson 0.19). Le score photographique est significativement influencé par le traitement (CEA vs Contrôle; p = 0,039) et par le jour postopératoire (p < 0,001). Le temps moyen pour atteindre un score photographique de guérison pour les zones contrôles fut de 10.2 jours contre 8.6 jours pour le CEA (p = 0,021). A l’évaluation histologique, les sites donneurs traités par le milieu de culture ont évolué aussi favorablement que ceux traités par des feuillets de CEA. CONCLUSION. L’utilisation de CEA sur les sites donneurs semble accélérer leur épithélialisation chez les victimes de brûlures graves. Cet effet est probablement le résultat d’une stimulation de la réépithélialisation innée de la plaie, plutôt que par une adhérence des feuillets de kératinocytes cultivés à la surface de la plaie. / RATIONALE: Prompt healing of split thickness skin graft donor sites is primordial to the survival of severely burned patients. Increased mortality of patients with >50 % TBSA is attributable to the limited availability of donor sites. This study evaluated the effect of Cultured Epithelial Autograft (CEA) application on skin graft donor site healing. METHODS: All burn patients receiving CEA were prospectively included. Donor site wounds were covered with CEA except a randomly designated 7x7 cm control region. Autograft biopsies were taken to document graft harvest thickness. One half of the controls were covered with non-adherent gauze soaked in the culture media and the other controls only received a non-adherent gauze dressing. Epithelialization was objectively evaluated by scoring blinded photographs with an analogue scale. Punch biopsies of the donor sites were evaluated histologically. Repeated measures ANOVA and T-test were used. RESULTS: Between 2008 and 2009, 6 patients were enrolled for a total of 11 donor sites. The patients averaged 43.5 years, 56 % TBSA, 45 % FT-TBSA, 66 % had inhalation injury and mean length of stay was 75 days. As expected, dermatome settings and autograft thickness measured by microscope did not correlate (Pearson 0.19). There was no correlation between the percentage of epithelialization of the punch biopsies of the donor sites and the thickness of the harvest. Photographic score was significantly influenced by its treatment CEA vs Control (p=0.039) and by postoperative day (p<0.001). Mean time to healing was 8.6 days for CEA compared to 10.2 days for controls (p=0.021). Infection was noted on only one donor site. On histologic analysis, the control sites dressed with gauze soaked in the culture media healed as nicely and promptly as the CEA sheet treated region. CONCLUSION: Use of CEA on donor sites appears to stimulate epithelialization. This effect is probably mediated by stimulation of local wound healing processes rather than by engraftment of keratinocytes from the CEA sheets.