Wound healing after cultured epithelial autografting in patients with massive burn injury: A cohort study

Current Approaches to Wound Repair in Burns: How far Have we Come From Cover to Close? A Narrative Review

Burn injuries are a significant global health concern, with more than 11 million people requiring medical intervention each year and approximately 180,000 deaths annually. Despite progress in health and social care, burn injuries continue to result in socioeconomic burdens for victims and their families. The management of severe burn injuries involves preventing and treating burn shock and promoting skin repair through a two-step procedure of covering and closing the wound. Currently, split-thickness/full-thickness skin autografts are the gold standard for permanent skin substitution. However, deep burns treated with split-thickness skin autografts may contract, leading to functional and appearance issues. Conversely, defects treated with full-thickness skin autografts often result in more satisfactory function and appearance. The development of tissue-engineered dermal templates has further expanded the scope of wound repair, providing scar reductive and regenerative properties that have extended their use to reconstructive surgical interventions. Although their interactions with the wound microenvironment are not fully understood, these templates have shown potential in local infection control. This narrative review discusses the current state of wound repair in burn injuries, focusing on the progress made from wound cover to wound closure and local infection control. Advancements in technology and therapies hold promise for improving the outcomes for burn injury patients. Understanding the underlying mechanisms of wound repair and tissue regeneration may provide new insights for developing more effective treatments in the future.

Minced skin grafts for chronic wounds compared to conventional mesh grafts

Background and Aims

Skin grafting is the single most effective method to close a chronic wound. The current standard of care is to use meshed split thickness skin grafts. This entails the use of surgical instruments that need to be autoclaved and to have a power source, which usually requires an OR facility. The minced skin technique uses single use, presterilized instruments and the procedure can be done under local anesthesia, by a wound care practitioner, in a wound clinic, a physician's office or even at the bedside. The current study was designed to determine if the results from micrografting were non inferior to conventional mesh grafting.

Methods

In a prospective non inferiority study, 26 chronic ulcers were treated with micrografting (MSG) and 24 with conventional mesh grafts 1:3 (control group-CG) in a total of 21 patients, 10 male and 11 female. The donor site areas in the MSG group were predetermined to 2.5 × 5 cm and the mesh grafts expansion was set at 1:3.

Results

In the first weeks postoperatively, micrograft healing initially lagged behind the conventional mesh grafts but at 60 days after grafting, all MSG wounds were healed. The MSG wounds had better pigmentation, less itching, and less scarring. The micrografting procedure was easy to learn and expeditious to perform. The MSG mean expansion was 9.1 compared to three times (CG).

Conclusion

The MSG procedure is not inferior to conventional mesh grafting, requires smaller donor sites, and can be done with single use instruments, under local anesthesia, with early discharge.

Understanding the mechanisms of spontaneous and skin-grafted wound repair: the path to engineered skin grafts

Spontaneous wound repair is a complex process that involves overlapping phases of inflammation, proliferation and remodelling, co-ordinated by growth factors and proteases. In extensive wounds such as burns, the repair process would not be achieved in a timely fashion unless grafted. Although spontaneous wound repair has been extensively described, the processes by which wound repair mechanisms mediate graft take are yet to be fully explored. This review describes engraftment stages and summarises current understanding of molecular mechanisms which regulate autologous skin graft healing, with the goal of directing innovation in permanent wound closure with skin substitutes. Graftability and vascularisation of various skin substitutes that are either in the market or in development phase are discussed. In doing so, we cast a spotlight on the paucity of scientific information available as to how skin grafts (both autologous and engineered) heal a wound bed. Better understanding of these processes may assist in developing novel methods of wound management and treatments.

Examining the perceived stress and body image in burn patients: A cross-sectional study

This study aimed to examine the perceived stress and body image in burn patients and the relationship between these two variables. This is a descriptive and cross-sectional study. The study included total of 144 patients who had burn injuries, received treatment in a research and training hospital and were scheduled to be discharged. The data were collected prospectively by the researchers, using descriptive methods, Kruskal Wallis test, paired samples t test, and Pearson's correlation analysis. Of the patients, 59% were between the ages of 18 and 35 years, 68.1% were male, 65.3% had second-degree burns, 77.1% had burn surfaces ranging between 10% and 20% of their body, and 54.9% had autograft surgery. The burn patients aged 51 years and over had higher perceived stress than younger patients, and the difference between them was statistically significant (P < 0.05). As the percentage of burn surface increased, the perceived stress increased, and the perceived body image weakened (P < 0.05). The burn patients with autograft surgery had lower perceived stress and higher perceived body image than those without autograft surgery, and the difference between them was statistically significant (P < 0.01). This study found an inverse relationship between perceived stress and body image in burn patients, which was affected by the percentage of burn surface and autograft surgery. Relevant interventions are suggested to increase perceived body image in burn patients and reduce their perceived stress.

Alternative Approaches for the Management of Diabetic Foot Ulcers

Diabetic foot ulcers (DFU) represent a growing public health problem. The emergence of multidrug-resistant (MDR) bacteria is a complication due to the difficulties in distinguishing between infection and colonization in DFU. Another problem lies in biofilm formation on the skin surface of DFU. Biofilm is an important pathophysiology step in DFU and may contribute to healing delays. Both MDR bacteria and biofilm producing microorganism create hostile conditions to antibiotic action that lead to chronicity of the wound, followed by infection and, in the worst scenario, lower limb amputation. In this context, alternative approaches to antibiotics for the management of DFU would be very welcome. In this review, we discuss current knowledge on biofilm in DFU and we focus on some new alternative solutions for the management of these wounds, such as antibiofilm approaches that could prevent the establishment of microbial biofilms and wound chronicity. These innovative therapeutic strategies could replace or complement the classical strategy for the management of DFU to improve the healing process.

Massive burns: retrospective analysis of changes in outcomes indicators across 18 years

BACKGROUND

The treatment and management of massive burns, defined as burns affecting≥ 50% of total body surface area (TBSA) has considerably changed since the 90s. This study aimed at analyzing if the length of intensive care unit (ICU) stay, the success of skin grafting operations and the mortality changed in the last 18 years.

METHODS

Between 2000 and 2018, 77 patients were admitted for massive burns to the ICU of a university hospital. Transfers and early care withdrawal precluded inclusion for 38 patients, leaving 39 for analysis. Study variables were year of admission, demographics, burn characteristics, critical care treatment (fluid resuscitation, ventilation and nutrition) and surgical therapy. Association between outcomes and year of admission were assessed through correlation and logistic regression analysis. Potential confounders were assessed through stepwise linear regression.

RESULTS

Patients' characteristics were stable over time with a median age of 36[25.0, 48.0] years, burns 65% [55.0, 83.0] TBSA and deep burns 55% [50.0, 68.0] TBSA . Length of ICU stay remained stable at 0.97 [0.6, 1.5] days/%TBSA. Mortality was stable as well. Energy and carbohydrate delivery decreased in parallel with the number of infectious episodes per patient. Number of operations was stable but the take rate of skin grafts increased significantly. The multivariate analysis retained year of admission, weight, total number of infections, daily lipid intakes and fluid resuscitation as independent predicting variables.

CONCLUSION

Length of ICU stay and mortality did not change over time but skin grafts take rates improved significantly.

Local Treatment of Burns with Cell-Based Therapies Tested in Clinical Studies

Effective wound management is an important determinant of the survival and prognosis of patients with severe burns. Thus, novel techniques for timely and full closure of full-thickness burn wounds are urgently needed. The purpose of this review is to present the current state of knowledge on the local treatment of burn wounds (distinguishing radiation injury from other types of burns) with the application of cellular therapies conducted in clinical studies. PubMed search engine and ClinicalTrials.gov were used to analyze the available data. The analysis covered 49 articles, assessing the use of keratinocytes (30), keratinocytes and fibroblasts (6), fibroblasts (2), bone marrow-derived cells (8), and adipose tissue cells (3). Studies on the cell-based products that are commercially available (Epicel^®, Keraheal™, ReCell^®, JACE, Biobrane^®) were also included, with the majority of reports found on autologous and allogeneic keratinocytes. Promising data demonstrate the effectiveness of various cell-based therapies; however, there are still scientific and technical issues that need to be solved before cell therapies become standard of care. Further evidence is required to demonstrate the clinical efficacy and safety of cell-based therapies in burns. In particular, comparative studies with long-term follow-up are critical.

[Standards in medical treatment of burns]

Thermal injuries occur in every age group and are caused by flames, fluids, steam and direct contact. They are often trivialized but should actually be treated immediately to reduce secondary complications, such as infections and hypertrophic scars. Besides the pain, large wound areas are given priority. Surgical treatment is necessary if at least second degree (IIb) deep dermal burns are present. In this case the reconstructive surgeon has various techniques in the therapeutic armamentarium. Furthermore, in cases of severe burns a perioperative intensive care monitoring and treatment are obligatory as massive systemic inflammatory response syndrome (SIRS), shock, sepsis, organ failure, fluid resuscitation and complications, such as delirium and exacerbation of pain have been proven to negatively influence the outcome.

Multiple Injections of Autologous Adipose-Derived Stem Cells Accelerate the Burn Wound Healing Process and Promote Blood Vessel Regeneration in a Rat Model

Stem cell-based therapies have the potential to heal burn wounds, but thus far have had limited success in clinical practice. This study aimed to test and improve the therapeutic effects of adipose-derived stem cells (ASCs) on burn wound healing in a rat model. We also explored the role of ASCs in burn wound healing We first isolated the autologous ASCs of each Sprague-Dawley rat used in this experiment and expanded them in vitro. Then, a 2-cm² burn wound was made on the dorsal skin of each rat using a specialized heating iron. The treated rats received either one or three injections of 2 × 10⁶ green fluorescent protein-labeled autologous ASCs, and the control rats received injections of the same volume of phosphate-buffered saline. A digital camera was employed to capture images of the wound area. We explored the role of ASCs in burn wound healing by cell tracing, evaluation of blood vessel number, analysis of a rat cytokine array panel, and cell proliferation in vivo. Multiple injections of autologous ASCs accelerated the wound healing process more efficiently compared with that observed in the control treatment. A rat cytokine array test showed that transplanting ASCs led to significantly elevated expression of VEGF. Therefore, angiogenesis was significantly improved in ASC-treated rats, as more microvessels were observed in the wound skin of the experimental rats than in that of the control rats. Transplanted ASCs not only survived in the wound bed but also participated in the blood vessel regeneration process. ASCs also accelerated the wound healing process by increasing the rate of cell proliferation in the wound skin. Our data suggest that autologous ASCs transplantation accelerated the burn wound healing process and promoted blood vessel regeneration. ASCs could potentially be used in burn wound healing treatment.