A prospective randomised clinical pilot study to compare the effectiveness of Biobrane® synthetic wound dressing, with or without autologous cell suspension, to the local standard treatment regimen in paediatric scald injuries

Advancements in cell-based therapies for thermal burn wounds: a comprehensive systematic review of clinical trials outcomes

BACKGROUND

Burn trauma is one of the major causes of morbidity and mortality worldwide. The standard management of burn wounds consists of early debridement, dressing changes, surgical management, and split-thickness skin autografts (STSGs). However, there are limitations for the standard management that inclines us to find alternative treatment approaches, such as innovative cell-based therapies. We aimed to systematically review the different aspects of cell-based treatment approaches for burn wounds in clinical trials.

METHODS

A systematic search through PubMed, Medline, Embase, and Cochrane Library databases was carried out using a combination of keywords, including "Cell transplantation", "Fibroblast", "Keratinocyte", "Melanocyte", or "Stem Cell" with "Burn", "Burn wound", or "Burn injury". Firstly, titles and abstracts of the studies existing in these databases until "February 2024" were screened. Then, the selected studies were read thoroughly, and considering the inclusion and exclusion criteria, final articles were included in this systematic review. Moreover, a manual search was performed through the reference lists of the included studies to minimize the risk of missing reports.

RESULTS

Overall, 30 clinical trials with 970 patients were included in our study. Considering the type of cells, six studies used keratinocytes, nine used fibroblasts, eight used combined keratinocytes and fibroblasts, one study used combined keratinocytes and melanocytes, five used combined keratinocytes and fibroblasts and melanocytes, and one study used mesenchymal stem cells (MSCs). Evaluation of the preparation type in these studies showed that cultured method was used in 25 trials, and non-cultured method in 5 trials. Also, the graft type of 17 trials was allogeneic, and of 13 other trials was autologous.

CONCLUSIONS

Our study showed that employing cell-based therapies for the treatment of burn wounds have significant results in clinical studies and are promising approaches that can be considered as alternative treatments in many cases. However, choosing appropriate cell-based treatment for each burn wound is essential and depends on the situation of each patient.

Benefits of Aerosolized, Point-of-care, Autologous Skin Cell Suspension (ASCS) for the Closure of Full-thickness Wounds From Thermal and Nonthermal Causes: Learning Curves From the First 50 Consecutive Cases at an Urban, Level 1 Trauma Center

OBJECTIVE

To determine the utility of Autologous Skin Cell Suspension (ASCS) in closing full-thickness (FT) defects from injury and infection.

BACKGROUND

Although ASCS has documented success in closing partial-thickness burns, far less is known about the efficacy of ASCS in FT defects.

METHODS

Fifty consecutive patients with FT defects (burn 17, necrotizing infection 13, crush 7, degloving 5, and other 8) underwent closure with the bilayer technique of 3:1 widely meshed, thin, split-thickness skin graft and 80:1 expanded ASCS. End points were limb salvage rate, donor site reduction, operative and hospital throughput, incidence of complications, and re-epithelialization by 4, 8, and 12 weeks.

RESULTS

Definitive wound closure was achieved in 76%, 94%, and 98% of patients, at 4, 8, and 12 weeks, respectively. Limb salvage occurred in 42/43 patients (10 upper and 33 lower extremities). The mean area grafted was 435 cm 2 ; donor site size was 212 cm 2 , representing a potential reduction of 50%. The mean surgical time was 71 minutes; the total operating room time was 124 minutes. The mean length of stay was 26.4 days; the time from grafting to discharge was 11.2 days. Four out of 50 patients (8%) required 6 reoperations for bleeding (1), breakdown (4), and amputation (1). Four out of 50 patients (8%) developed hypertrophic scarring, which responded to silicone sheeting (2) and laser resurfacing (2). The mean follow-up was 92.7 days.

CONCLUSIONS

When used for the closure of FT wounds, point-of-care ASCS is effective and safe. Benefits include rapid re-epithelialization, high rate of limb salvage, reduction of donor site size and morbidity, and low incidence of hypertrophic scarring.

Membrane Applications in Autologous Cell Therapy

Stem cell and cell therapies, particularly autologous cell therapies, are becoming a common practice. However, in order for these technologies to achieve wide-scale clinical application, the prohibitively high cost associated with these therapies must be addressed through creative engineering. Membranes can be a disruptive technology to reshape the bioprocessing and manufacture of cellular products and significantly reduce the cost of autologous cell therapies. Examples of successful membrane applications include expansions of CAR-T cells, various human stem cells, and production of extracellular vesicles (EVs) using hollow fibre membrane bioreactors. Novel membranes with tailored functions and surface properties and novel membrane modules that can accommodate the changing needs for surface area and transport properties are to be developed to fulfil this key role.

Paediatric Partial-Thickness Burn Therapy: A Meta-Analysis and Systematic Review of Randomised Controlled Trials

Background: Paediatric second-degree burn injuries are a significant source of medical challenges to the population that may cause severe, lifelong complications. Currently, there are dozens of therapeutic modalities and we aimed to summarise their reported outcomes and determine their effectiveness, compared to the widely used silver sulphadiazine (SSD). Methods: We conducted the meta-analysis and systematic review of randomised controlled trials (RCTs), which investigated the performance of dressings in acute paediatric partial-thickness burns. The evaluated endpoints were time until wound closure, grafting and infection rate, number of dressing changes and length of hospitalisation. Results: Twenty-nine RCTs were included in the qualitative and 25 in the quantitative synthesis, but only three trials compared SSD directly to the same intervention (Biobrane). Data analysis showed a tendency for faster healing times and a reduced complication rate linked to biosynthetic, silver foam and amnion membrane dressings. A substantial difference was found between the number of dressing changes associated with less pain, narcosis and treatment duration. Conclusions: Considerable between-study heterogeneity was caused by the unequal depth subcategory ratio and surface area of the injuries; therefore, no significant difference was found in the main outcomes. Further research is necessary to establish the most effective treatment for these burns.

The Current Challenges on Spray-Based Cell Delivery to the Skin Wounds

Cell delivery through spray instruments is a promising and effective method in tissue engineering and regenerative medicine. It is used for treating different acute and chronic wounds, including burns with different etiologies, chronic diabetic or venous wounds, postcancer surgery, and hypopigmentation disorders. Cell spray can decrease the needed donor site area compared with conventional autologous skin grafting. Keratinocytes, fibroblasts, melanocytes, and mesenchymal stem cells are promising cell sources for cell spray procedures. Different spray instruments are designed and utilized to deliver the cells to the intended skin area. In an efficient spray instrument, cell viability and wound coverage are two determining parameters influenced by various physical and biological factors such as air pressure, spraying distance, viscosity of suspension, stiffness of the wound surface, and velocity of impact. Besides, to improve cell delivery by spray instruments, some matrices and growth factors can be added to cell suspensions. This review focuses on the different types of cells and spray instruments used in cell delivery procedures. It also discusses physical and biological parameters associated with cell viability and wound coverage in spray instruments. Moreover, the recent advances in codelivery of cells with biological glues and growth factors, as well as clinical translation of cell spraying, have been reviewed. Impact statement Skin wounds are a group of prevalent injuries that can lead to life-threatening complexities. As a focus of interest, stem cell therapy and spray-based cell delivery have effectively decreased associated morbidity and mortality. This review summarizes a broad scope of recent evidence related to spray-based cell therapy, instruments, and approaches adopted to make the process more efficient in treating skin wounds. An overview including utilized cell types, clinical cases, and current challenges is also provided.

A systematic review and meta-analysis of randomized trials evaluating the efficacy of autologous skin cell suspensions for re-epithelialization of acute partial thickness burn injuries and split-thickness skin graft donor sites

BACKGROUND

This systematic review evaluated the efficacy of autologous skin cell suspensions (ASCS) on the re-epithelialization of partial thickness burn injuries and skin graft donor site wounds.

METHODS

Four databases (EMBASE, Google Scholar, MEDLINE, Web of Science), grey literature and select journal hand-searching identified studies from 1975 - 2020. Randomized trials evaluating partial thickness burn management with non-cultured ASCS compared to any other intervention were included. Time to re-epithelialization (TTRE) was the primary outcome. Three independent researchers completed screening, data extraction and certainty of evidence assessment using Cochrane Risk of Bias Tool and Grading of Recommendations Assessment, Development and Evaluation.

RESULTS

Five trials (n = 347) reported on adults (2 trials) and children (1 trial) with burn wounds, and adults with donor site wounds (2 trials). The effect of ASCS compared to control on TTRE in adult burn wounds was not estimable. TTRE was shorter in pediatric burn wounds (SMD -1.75 [95% CI: -3.45 to -0.05]) and adult donor site wounds (SMD-5.71 [95% CI: -10.61 to-0.81]) treated with ASCS. The certainty of evidence was very low.

CONCLUSION

Compared to standard care, ACSC may reduce pediatric partial thickness burn wound and adult split-thickness skin graft donor site TTRE.

REGISTRATION

PROSPERO CRD42019133171.

Applications of nanomaterials in tissue engineering

Recent advancement in nanotechnology has brought prominent benefits in tissue engineering, which has been used to repair or reconstruct damaged tissues or organs and design smart drug delivery systems. With numerous applications of nanomaterials in tissue engineering, it is vital to choose appropriate nanomaterials for different tissue engineering applications because of the tissue heterogeneity. Indeed, the use of nanomaterials in tissue engineering is directly determined by the choice. In this review, we mainly introduced the use of nanomaterials in tissue engineering. First, the basic characteristics, preparation and characterization methods of the types of nanomaterials are introduced briefly, followed by a detailed description of the application and research progress of nanomaterials in tissue engineering and drug delivery. Finally, the existing challenges and prospects for future applications of nanomaterials in tissue engineering are discussed.

Porcine Xenograft and Epidermal Fully Synthetic Skin Substitutes in the Treatment of Partial-Thickness Burns: A Literature Review

Background and Objectives: Porcine xenografts have been used successfully in partial thickness burn treatment for many years. Their disappearance from the market led to the search for effective and efficient alternatives. In this article, we examine the synthetic epidermal skin substitute Suprathel^® as a substitute in the treatment of partial thickness burns. Materials and Methods: A systematic review following the PRISMA guidelines has been performed. Sixteen Suprathel^® and 12 porcine xenograft studies could be included. Advantages and disadvantages between the treatments and the studies’ primary endpoints have been investigated qualitatively and quantitatively. Results: Although Suprathel had a nearly six times larger TBSA in their studies (p < 0.001), it showed a significantly lower necessity for skin grafts (p < 0.001), and we found a significantly lower infection rate (p < 0.001) than in Porcine Xenografts. Nonetheless, no significant differences in the healing time (p = 0.67) and the number of dressing changes until complete wound healing (p = 0.139) could be found. Both products reduced pain to various degrees with the impression of a better performance of Suprathel^® on a qualitative level. Porcine xenograft was not recommended for donor sites or coverage of sheet-transplanted keratinocytes, while Suprathel^® was used successfully in both indications. Conclusion: The investigated parameters indicate that Suprathel^® to be an effective replacement for porcine xenografts with even lower subsequent treatment rates. Suprathel^® appears to be usable in an extended range of indications compared to porcine xenograft. Data heterogeneity limited conclusions from the results.

Made in Germany: A Quality Indicator Not Only in the Automobile Industry But Also When It Comes to Skin Replacement: How an Automobile Textile Research Institute Developed a New Skin Substitute

Successful research and development cooperation between a textile research institute, the German Federal Ministry of Education and Research via the Center for Biomaterials and Organ Substitutes, the University of Tübingen, and the Burn Center of Marienhospital, Stuttgart, Germany, led to the development of a fully synthetic resorbable temporary epidermal skin substitute for the treatment of burns, burn-like syndromes, donor areas, and chronic wounds. This article describes the demands of the product and the steps that were taken to meet these requirements. The material choice was based on the degradation and full resorption of polylactides to lactic acid and its salts. The structure and morphology of the physical, biological, and degradation properties were selected to increase the angiogenetic abilities, fibroblasts, and extracellular matrix generation. Water vapor permeability and plasticity were adapted for clinical use. The available scientific literature was screened for the use of this product. A clinical application demonstrated pain relief paired with a reduced workload, fast wound healing with a low infection rate, and good cosmetic results. A better understanding of the product's degradation process explained the reduction in systemic oxidative stress shown in clinical investigations compared to other dressings, positively affecting wound healing time and reducing the total area requiring skin grafts. Today, the product is in clinical use in 37 countries. This article describes its development, the indications for product growth over time, and the scientific foundation of treatments.

Using Various Skin Graft Techniques in Major Burn Reconstruction: A Lesson Learned From a Taiwanese Cornstarch Explosion

PURPOSE

Four hundred and ninety-nine patients had burn injuries in an explosion in Taiwan on June 27, 2015, 24 were admitted to the intensive care units of Taipei Veterans General Hospital. This study details our experience with surgical management of these patients, focusing primarily on various skin graft techniques.

MATERIALS AND METHODS

This single-center retrospective study included patients who underwent at least one of the previously mentioned skin graft techniques because of extensive skin defects. The demography, burn diagram, treatment modalities, postoperative outcome, and costs were all analyzed, and a comparison with traditional mesh skin grafts was performed. The literature was also reviewed.

RESULTS

Fourteen patients underwent the Meek skin graft technique. Only 3 received ReCell and 1 cultured epithelial autograft (CEA) at separate time point. Overall, the autologous skin grafts, including Meek/ReCell/CEA were completed within 6 months. The average skin graft success rate was approximately 72.9%, 79.2%, and 38% in Meek, ReCell, and CEA, respectively. The infection rate was approximately 35.7%, 25%, and 100% in Meek, ReCell, and CEA, respectively. The average surgical cost and total medical cost were significantly higher in patients who underwent Meek/ReCell/CEA treatments.

CONCLUSIONS

In our experience, Meek and ReCell treatments had acceptable success rates, but CEA treatment not. ReCell and CEA treatments are useful in the event of extremely limited donor sites, and they are fragile, easily infected, and technically challenging. These techniques also require longer hospitalization and tend to be more expensive, all factors that should be considered when assessing treatment options.

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.

Long-term stability of a novel platelet-rich plasma-based topical serum for cutaneous applications

BACKGROUND

Skin alterations are usually related to chronic diseases that demand sustained and long-term dosages; hence, it is pivotal that the stability of treatments is preserved. A novel storable and endogenous topical serum (ES) based on the patient's own blood has been recently developed.

AIMS

To investigate the long-term stability of the formulation and to provide preliminary data of its biologic potential.

METHODS

Samples from six donors were obtained and either used as fresh samples or cold-stored for 6 months. Physicochemical, rheological, and biological stability of the formulation was determined.

RESULTS

Endogenous topical serum maintained unaltered its organoleptic properties, viscosity, pH, spreadability index, and sterility. The growth factor content including TGFβ-I, EGF, PDGF-AB, HGF, and Ang-I showed no decrease. In contrast, ES showed lower levels of IGF-I once stored. Dermal fibroblasts showed no change in their proliferative activity.

CONCLUSION

Endogenous topical serum showed to maintain its physicochemical and biological properties after six months of storage. ES might reduce the frequency of blood extractions and would enable patients with chronic disorders to maintain a daily use of the product in a minimally invasive way.

A pilot multi-centre prospective randomised controlled trial of RECELL for the treatment of venous leg ulcers

Venous leg ulcers (VLUs) have a significant impact on approximately 3% of the adult population worldwide, with a mean NHS wound care cost of £7600 per VLU over 12 months. The standard care for VLUs is compression therapy, with a significant number of ulcers failing to heal with this treatment, especially with wound size being a risk factor for non-healing. This multicentre, prospective, randomised trial evaluated the safety and effectiveness of autologous skin cell suspension (ASCS) combined with compression therapy compared with standard compression alone (Control) for the treatment of VLUs. Incidence of complete wound closure at 14 weeks, donor site closure, pain, Health-Related Quality of Life (HRQoL), satisfaction, and safety were assessed in 52 patients. At Week 14, VLUs treated with ASCS + compression had a statistically greater decrease in ulcer area compared with the Control (8.94 cm2 versus 1.23 cm2 , P = .0143). This finding was largely driven by ulcers >10 to 80 cm2 in size, as these ulcers had a higher mean percentage of reepithelialization at 14 weeks (ASCS + compression: 69.97% and Control: 11.07%, P = .0480). Additionally, subjects treated with ASCS + compression experienced a decrease in pain and an increase in HRQoL compared with the Control. This study indicates that application of ASCS + compression accelerates healing in large venous ulcers.

Initial Experience With Autologous Skin Cell Suspension for Treatment of Deep Partial-Thickness Facial Burns

Facial burns present a challenge in burn care, as hypertrophic scarring and dyspigmentation can interfere with patients’ personal identities, ocular and oral functional outcomes, and have long-term deleterious effects. The purpose of this study is to evaluate our initial experience with non-cultured, autologous skin cell suspension (ASCS) for the treatment of deep partial-thickness (DPT) facial burns. Patients were enrolled at a single burn center during a multicenter, prospective, single-arm, observational study involving the compassionate use of ASCS for the treatment of large total BSA (TBSA) burns. Treatment decisions concerning facial burns were made by the senior author. Facial burns were initially excised and treated with allograft. The timing of ASCS application was influenced by an individual’s clinical status; however, all patients were treated within 30 days of injury. Outcomes included subjective cosmetic parameters and the number of reoperations within 3 months. Five patients (4 males, 1 female) were treated with ASCS for DPT facial burns. Age ranged from 2.1 to 40.7 years (mean 18.2 ± 17.3 years). Average follow-up was 231.2 ± 173.1 days (range 63–424 days). Two patients required reoperation for partial graft loss within 3 months in areas of full-thickness injury. There were no major complications and one superficial hematoma. Healing and cosmetic outcomes were equivalent to, and sometimes substantially better than, outcomes typical of split-thickness autografting. Non-cultured, ASCS was successfully used to treat DPT facial burns containing confluent dermis with remarkable cosmetic outcomes. Treatment of DPT burns with ASCS may be an alternative to current treatments, particularly in patients prone to dyspigmentation, scarring sequelae, and with limited donor sites.

A Retrospective Study on the Use of Dermis Micrografts in Platelet-Rich Fibrin for the Resurfacing of Massive and Chronic Full-Thickness Burns

The coverage of massive burns still represents a big challenge, even if several strategies are to date available to deal with this situation. In this study, we describe the use of a combination of platelet-rich fibrin and micrograft spray-on skin in order to increase the yield of grafted cells in patients. We treated a total of five patients, of which two were affected by massive burns and three with chronic burn wounds. Briefly, autologous micrografts were obtained by Rigenera technology using a class I medical device called Rigeneracons. The micrografts were then combined with PRF and sprayed on the wound bed by a Spraypen. Before applying PRF/micrograft spray-on skin, the wound bed was covered with an Integra® dermal template, and the wounds were dressed with a layer of antimicrobial dressing applied directly over the silicone layer. When the silicone layer of the dermal template started showing signs of separation, the wound was considered ready for grafting. In all cases, we observed a fast and complete skin graft on average after 7-10 days by PRF/micrograft spray-on skin treatment. In particular, two patients with massive burns reported rapid reepithelialization, and three patients with chronic burn wounds, two of whom had failed skin grafts before the procedure, had complete wound healing within a week. In conclusion, the results showed in this study suggest that the use of PRF/micrograft spray-on skin represents a promising approach in the management of burns or chronic burn wounds.

Isolating human dermal fibroblasts using serial explant culture

Background

The purpose of this study was to introduce an applicable culture technique to isolate human dermal fibroblasts (HDFs); which could also contribute to research, clinical practices, as well as tissue engineering.

Methods

Samples from the human skin were dissected and cultured via serial explant technique. Subsequently, the isolated fibroblasts were assessed for their protein markers and genetic variations via immunofluorescence (IF) and karyotyping; respectively. Following the employment of this technique, a small piece of explant completely disappeared; while no dermis remained after 10 days.

Results

The quantity of HDFs harvested through this culture technique was reported at a normal level. The results of immunostaining also indicated that the isolated fibroblasts had expressed vimentin and fibronectin; whereas no cells had shown cytokeratin and epidermal marker. Moreover, karyotyping results for the fibroblasts isolated by the given technique revealed no chromosomal diversity after passage 20.

Conclusions

It was concluded that serial explant culture was an efficient technique for isolating HDFs from a small piece of skin in short-time periods; which could also preserve their normal morphology and molecular characteristics.

A novel protein-based autologous topical serum for skin regeneration

BACKGROUND

As skin ages, a functional decrement occurs. To avoid future vulnerability to dermatologic diseases, an optimal cutaneous regeneration is mandatory. Biological therapies based on blood-derived autologous proteins are gaining attention of scientists and dermatologists.

OBJECTIVES

A novel 100% autologous topical serum has been developed using plasma rich in growth factors technology. The physicochemical characterization and the biologic potential of the novel formulation have been studied.

METHODS

Rheological and mechanical properties and the biological capacity of the formulation were characterized. Human dermal fibroblast culture and 3D organotypic skin explants were used as in vitro and ex vivo cutaneous models, respectively.

RESULTS

The autologous topical serum presented an optimal spreadability index and appropriate shear thinning behavior that allowed an easy handling and rapid integration within the cutaneous tissue. The formulation has a high growth factor load with the ability to progressively penetrate into the dermal/epidermal layers of the skin. It is biocompatible and promotes cell proliferation and chemotactic activity. The autologous topical serum promotes the biosynthetic activity of cells by the stimulation of collagen and hyaluronic acid expression.

CONCLUSIONS

These findings present an in situ and easy to prepare autologous topical serum based on the patient's own blood with physicochemical and bioactive properties that may be used for skin regeneration purposes.

ReCell® Spray-On Skin System for Treating Skin Loss, Scarring and Depigmentation after Burn Injury: A NICE Medical Technology Guidance

The gold standard treatment for deep burns is an autologous skin graft; in larger burns this may be meshed to increase the area covered. However, long-term aesthetic and functional outcomes of graft scars may be poor. ReCell^® is a medical device that processes skin samples in the operating theatre into a cell suspension to be sprayed or dripped onto a wound. It is claimed to improve healing and scar appearance. This device was evaluated by the National Institute for Health and Care Excellence (NICE) Medical Technologies Evaluation Programme. Two groups were defined: ReCell compared to conventional dressings in shallower burns, and meshed grafts plus ReCell compared to meshed grafts alone in larger deeper burns. The manufacturer's clinical evidence submission included three papers and eight conference abstracts. The External Assessment Centre (EAC) excluded two of these and added seven abstracts. In general, the evidence did not fit the defined groups, but suggested that ReCell was clinically comparable to skin grafts for partial thickness burns; however, ReCell is not used in this way in the UK. The manufacturer submitted an economic model in which ReCell treatment of partial thickness burns reduced the requirement for later skin grafts. This indicated that ReCell alone was cost saving in comparison to conventional dressings. The EAC indicated that this model was clinically inappropriate, but data were not available to populate a new model. NICE Medical Technologies Guidance 21 recommended that additional research was needed to address the uncertainties regarding the potential benefits of ReCell.

Systematic review of clinical outcome reporting in randomised controlled trials of burn care

INTRODUCTION

Systematic reviews collate trial data to provide evidence to support clinical decision-making. For effective synthesis, there must be consistency in outcome reporting. There is no agreed set of outcomes for reporting the effect of burn care interventions. Issues with outcome reporting have been identified, although not systematically investigated. This study gathers empirical evidence on any variation in outcome reporting and assesses the need for a core outcome set for burn care research.

METHODS

Electronic searches of four search engines were undertaken from January 2012 to December 2016 for randomised controlled trials (RCTs), using medical subject headings and free text terms including 'burn', 'scald' 'thermal injury' and 'RCT'. Two authors independently screened papers, extracted outcomes verbatim and recorded the timing of outcome measurement. Duplicate outcomes (exact wording ± different spelling), similar outcomes (albumin in blood, serum albumin) and identical outcomes measured at different times were removed. Variation in outcome reporting was determined by assessing the number of unique outcomes reported across all included trials. Outcomes were classified into domains. Bias was reduced using five researchers and a patient working independently and together.

RESULTS

147 trials were included, of which 127 (86.4%) were RCTs, 13 (8.8%) pilot studies and 7 (4.8%) RCT protocols. 1494 verbatim clinical outcomes were reported; 955 were unique. 76.8% of outcomes were measured within 6 months of injury. Commonly reported outcomes were defined differently. Numbers of unique outcomes per trial varied from one to 37 (median 9; IQR 5,13). No single outcome was reported across all studies demonstrating inconsistency of reporting. Outcomes were classified into 54 domains. Numbers of outcomes per domain ranged from 1 to 166 (median 11; IQR 3,24).

CONCLUSIONS

This review has demonstrated heterogeneity in outcome reporting in burn care research which will hinder amalgamation of study data. We recommend the development of a Core Outcome Set.

PROSPERO REGISTRATION NUMBER

CRD42017060908.

Comparative effectiveness of Biobrane®, RECELL® Autologous skin Cell suspension and Silver dressings in partial thickness paediatric burns: BRACS randomised trial protocol

BACKGROUND

Mixed partial thickness burns are the most common depth of burn injury managed at a large Australian paediatric hospital specialty burns unit. Prolonged time until re-epithelialisation is associated with increased burn depth and scar formation. Whilst current wound management approaches have benefits such as anti-microbial cover, these are not without inherent limitations including multiple dressing changes. The Biobrane® RECELL® Autologous skin Cell suspension and Silver dressings (BRACS) trial aims to identify the most effective wound management approach for mixed partial thickness injuries in children.

METHODS

All children presenting with an acute burn injury to the study site will be screened for eligibility. This is a single-centre, three-arm, parallel group, randomised trial. Children younger than 16 years, with burns ≥ 5% total body surface area involving any anatomical location, up to 48 h after the burn injury, and of a superficial partial to mid-dermal depth, will be included. A sample size of 84 participants will be randomised to standard silver dressing or a Regenerative Epithelial Suspension (RES™) with Biobrane® or Biobrane® alone. The first dressing will be applied under general anaesthesia and subsequent dressings will be changed every 3 to 5 days until the wound is ≥ 95% re-epithelialised, with re-epithelialisation time the primary outcome. Secondary outcomes of acute pain, acute itch, scar severity, health-related quality of life, treatment satisfaction, dressing application ease and healthcare resource use will be assessed at each dressing change and 3, 6 and 12 months post-burn injury.

DISCUSSION

The findings of this study can potentially change the wound management approach for superficial partial to mid-dermal burns in children locally and worldwide.

TRIAL REGISTRATION

The Australian New Zealand Clinical Trials Registry (ACTRN12618000245291) approved prospective registration on 15 February 2018. Registration details can be viewed at https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=374272&isReview=true.

Delivery systems of current biologicals for the treatment of chronic cutaneous wounds and severe burns

While wound therapy remains a clinical challenge in current medical practice, much effort has focused on developing biological therapeutic approaches. This paper presents a comprehensive review of delivery systems for current biologicals for the treatment of chronic wounds and severe burns. The biologicals discussed here include proteins such as growth factors and gene modifying molecules, which may be delivered to wounds free, encapsulated, or released from living systems (cells, skin grafts or skin equivalents) or biomaterials. Advances in biomaterial science and technologies have enabled the synthesis of delivery systems such as scaffolds, hydrogels and nanoparticles, designed to not only allow spatially and temporally controlled release of biologicals, but to also emulate the natural extracellular matrix microenvironment. These technologies represent an attractive field for regenerative wound therapy, by offering more personalised and effective treatments.

Biobrane dressing for paediatric burns in Singapore: a retrospective review

INTRODUCTION

The ideal burn dressing for children should aim to alleviate pain, decrease length of hospital stay and minimise complications such as conversion and infection. The current literature is still inconclusive with regard to the gold standard burn dressing for the paediatric population.

METHODS

We retrospectively reviewed children with superficial partial thickness burns admitted to our paediatric burns unit from January 2014 to April 2015. A total of 30 patients were included in our study, of whom 13 had Biobrane^® dressing. The remaining 17 patients were treated with conventional silver foam dressing (i.e. Biatain^® Ag) and served as matched controls. Long-term follow-up scar evaluation was carried out at an average interval of two years after injury.

RESULTS

In the Biobrane group, the length of hospital stay was significantly shorter (Biobrane vs. silver foam: 4.76 ± 2.64 days vs. 8.88 ± 5.09 days; p = 0.01) and the infection rate was significantly lower (Biobrane vs. silver foam: 0% vs. 35.3%; p = 0.02). The Biobrane group had no hypergranulation or wound infection and did not require skin grafting. Long-term follow-up scar evaluation did not reveal any statistical difference between the patient groups at the two-year interval.

CONCLUSION

Paediatric patients with partial thickness burns treated with Biobrane dressing had shorter hospital stay and lower incidence of infection compared to those treated with conventional silver foam dressing. Biobrane and silver foam dressings did not demonstrate any significant difference in terms of long-term scar outcomes over an average follow-up duration of two years.

Stem cells, niches and scaffolds: Applications to burns and wound care

The importance of skin to survival, and the devastating physical and psychological consequences of scarring following reparative healing of extensive or difficult to heal human wounds, cannot be disputed. We discuss the significant challenges faced by patients and healthcare providers alike in treating these wounds. New state of the art technologies have provided remarkable insights into the role of skin stem and progenitor cells and their niches in maintaining skin homeostasis and in reparative wound healing. Based on this knowledge, we examine different approaches to repair extensive burn injury and chronic wounds, including full and split thickness skin grafts, temporising matrices and scaffolds, and composite cultured skin products. Notable developments include next generation skin substitutes to replace split thickness skin autografts and next generation gene editing coupled with cell therapies to treat genodermatoses. Further refinements are predicted with the advent of bioprinting technologies, and newly defined biomaterials and autologous cell sources that can be engineered to more accurately replicate human skin architecture, function and cosmesis. These advances will undoubtedly improve quality of life for patients with extensive burns and difficult to heal wounds.

Comparison of advanced therapy medicinal product gingiva and skin substitutes and their in vitro wound healing potentials

Skin and oral mucosa substitutes are a therapeutic option for closing hard‐to‐heal skin and oral wounds. Our aim was to develop bi‐layered skin and gingiva substitutes, from 3 mm diameter biopsies, cultured under identical conditions, which are compliant with current European regulations for advanced therapy medicinal products. We present in vitro mode of action methods to (i) determine viability: epithelial expansion, proliferation (Ki‐67), metabolic activity (MTT assay); (ii) characterize skin and gingiva substitutes: histology and immunohistochemistry; and (iii) determine potency: soluble wound healing mediator release (enzyme‐linked immunosorbent assay). Both skin and gingiva substitutes consist of metabolically active autologous reconstructed differentiated epithelium expanding from the original biopsy sheet on a fibroblast populated connective tissue matrix (donor dermis). Gingival epithelium expanded 1.7‐fold more than skin epithelium during the 3 week culture period. The percentage of proliferating Ki‐67‐positive cells located in the basal layer of the gingiva substitute was >1.5‐fold higher than in the skin substitute. Keratins 16 and 17, which are upregulated during normal wound healing, were expressed in both the skin and gingiva substitutes. Notably, the gingiva substitute secreted higher amounts of key cytokines involved in mitogenesis, motogenesis and chemotaxis (interleukin‐6 > 23‐fold, CXCL8 > 2.5‐fold) as well as higher amounts of the anti‐fibrotic growth factor, hepatocyte growth factor (>7‐fold), compared with the skin substitute. In conclusion, while addressing the viability, characterization and potency of the tissue substitutes, important intrinsic differences between skin and gingiva were discovered that may explain in part the superior quality of wound healing observed in the oral mucosa compared with skin.

Randomized clinical trial of autologous skin cell suspension for accelerating re-epithelialization of split-thickness donor sites

BACKGROUND

Split-thickness skin graft (STSG) is used frequently, but may result in complications at the donor site. Rapid healing of donor-site wounds is critical to relieving morbidity. This study investigated whether autologous skin cell suspension could improve healing of STSG donor-site wounds.

METHODS

Between September 2014 and February 2016, patients requiring STSGs were randomized to receive autologous skin cell suspension plus hydrocolloid dressings (experimental group) or hydrocolloid dressings alone (control group) for the donor site. The primary outcome was time to complete re-epithelialization. Secondary outcomes included pain and itching scores measured on a visual analogue scale, and adverse events. Patients were followed for 12 weeks to evaluate quality of healing. Analysis was by intention to treat.

RESULTS

Some 106 patients were included, 53 in each group. Median time to complete re-epithelialization was 9·0 (95 per cent c.i. 8·3 to 9·7) days in the experimental group, compared with 13·0 (12·4 to 13·6) days in the control group (P < 0·001). Overall postoperative pain and itching scores were similar in both groups. No between-group differences in treatment-related complications were observed. Both patients and observers were more satisfied with healing quality after autologous skin cell suspension had been used.

CONCLUSION

The use of autologous skin cell suspension with hydrocolloid dressings accelerated epithelialization and improved healing quality of the donor site compared with hydrocolloid dressings alone. Registration number: UMIN000015000 ( http://www.umin.ac.jp/ctr).

Epidemiology of pediatric burns in southwest China from 2011 to 2015

BACKGROUND

Burns are a major form of injury in children worldwide. This study aimed to investigate the epidemiology, outcome, cost and risk factors of pediatric burns in southwest China.

METHODS

This retrospective study was performed at the Institute of Burn Research of the Third Military Medical University from 2011 to 2015. Data, including demographic, injury-related, and clinical data and patient outcome, were collected from medical records.

RESULTS

A total of 2478 children with burns (58.03% boys), accounting for 39.2% of total burn patients, were included. The average age of the burn patients was 2.86±2.86years, and most patients (85.55%) were under five years old. The incidence of burns peaked in January, February and May. Scald burns were the most frequent (79.06%), followed by flame burns (14.0%) and electrical burns (3.35%). Limbs were the most common burn sites (69.73%), and the average total body surface area (TBSA) was 11.57±11.61%. The percentage of children who underwent operations and the number of operations were significantly increased in cases of electrical burns, the older-age group, a larger TBSA and full-thickness burns. Six deaths were recorded, yielding a mortality of 0.24%. The median length of stay and cost were 14days and 9541 CNY, respectively, and the major risk factors for length of stay and cost were the TBSA, number of operations, full-thickness burns and outcome.

CONCLUSIONS

In southwest China, among children under five years old, scald and flame burns should become the key prevention target, and future prevention strategies should be based on related risk factors.

[Surgical treatment of burns : Special aspects of pediatric burns]

BACKGROUND

Treatment of pediatric burn patients is very important because of the sheer frequency of burn wounds and the possible long-term ramifications. Extensive burns need special care and are treated in specialized burn centers.

OBJECTIVES

The goal of this work is to present current standards in burn therapy and important innovations in the treatment of burns in children so that the common and small area burn wounds and scalds in pediatric patients in day-to-day dermatological practice can be adequately treated.

MATERIALS AND METHODS

Analysis of current literature, discussion of reviews, incorporation of current guidelines.

RESULTS

Burns in pediatric patients are common. Improvement of survival can be achieved by treatment in burn centers. The assessment of burn depth and area is an important factor for proper treatment. We give an overview for outpatient treatment of partial thickness burns. New methods may result in better long-term outcome.

CONCLUSIONS

Adequate treatment of burn injuries considering current literature and guidelines improves patient outcome. Rational implementation of new methods is recommended.

Hypertrophic scarring: the greatest unmet challenge after burn injury

Improvements in acute burn care have enabled patients to survive massive burns that would have once been fatal. Now up to 70% of patients develop hypertrophic scars after burns. The functional and psychosocial sequelae remain a major rehabilitative challenge, decreasing quality of life and delaying reintegration into society. Approaches to optimise healing potential of burn wounds use targeted wound care and surgery to minimise the development of hypertrophic scarring. Such approaches often fail, and modulation of the established scar is continued although the optimal indication, timing, and combination of therapies have yet to be established. The need for novel treatments is paramount, and future efforts to improve outcomes and quality of life should include optimisation of wound healing to attenuate or prevent hypertrophic scarring, well-designed trials to confirm treatment efficacy, and further elucidation of molecular mechanisms to allow development of new preventive and therapeutic strategies.

Usability and effectiveness of Suprathel® in partial thickness burns in children

Purpose

Evaluation of usability and effectiveness of Suprathel^® in the treatment of partial thickness burns in children.

Methods

A prospective, observational study to evaluate adherence of Suprathel^® to the wound bed, reepithelialization time, grafting, wound colonization and infection, pain, dressing changes, length of hospital stay (LOS) and scar formation.

Results

Twenty-one children (median age 2.4 years, range 5 months–14 years) with a median total body surface area (TBSA) of 4 % (range 1–18) were included. Median LOS was 10 days (range 3–20). Median outer layer dressing changes was 3 (range 1–14). Suprathel^® was only adherent in wounds debrided with Versajet^®. Median reepithelialization time was 13 days (range 7–29). Three patients needed a split skin graft. There were 7 (33 %) patients with wound colonization before application of Suprathel^®. This increased to 12 (57 %) patients during treatment. One patient developed a wound infection. Median visual analog scale (VAS) scores for background and procedural pain in patients >7 years were 3.2 (range 2–5) and 3.5 (range 2–5), respectively. In younger patients, median background and procedural COMFORT-B scores were 13.8 (range 10–23) and 14.8 (range 13–23, p = 0.03), respectively. Patient and Observer Scar Assessment Scale (POSAS) scores were favorable after 3 and 6 months post burn.

Conclusions

Suprathel^® provides potential advantages regarding pain and scar formation, but extensive wound debridement is needed to achieve adequate adherence.

Outcome of Burns Treated With Autologous Cultured Proliferating Epidermal Cells: A Prospective Randomized Multicenter Intrapatient Comparative Trial

Standard treatment for large burns is transplantation with meshed split skin autografts (SSGs). A disadvantage of this treatment is that healing is accompanied by scar formation. Application of autologous epidermal cells (keratinocytes and melanocytes) may be a suitable therapeutic alternative, since this may enhance wound closure and improve scar quality. A prospective, multicenter randomized clinical trial was performed in 40 adult patients with acute full thickness burns. On two comparable wound areas, conventional treatment with SSGs was compared to an experimental treatment consisting of SSGs in combination with cultured autologous epidermal cells (ECs) seeded in a collagen carrier. The primary outcome measure was wound closure after 5-7 days. Secondary outcomes were safety aspects and scar quality measured by graft take, scar score (POSAS), skin colorimeter (DermaSpectrometer) and elasticity (Cutometer). Wound epithelialization after 5-7 days was significantly better for the experimental treatment (71%) compared to the standard treatment (67%) (p = 0.034, Wilcoxon), whereas the take rates of the grafts were similar. No related adverse events were recorded. Scar quality was evaluated at 3 (n = 33) and 12 (n = 28) months. The POSAS of the observer after 3 and 12 months and of the patient after 12 months were significantly better for the experimental area. Improvements between 12% and 23% (p ≤ 0.010, Wilcoxon) were detected for redness, pigmentation, thickness, relief, and pliability. Melanin index at 3 and 12 months and erythema index at 12 months were closer to normal skin for the experimental treatment than for conventional treatment (p ≤ 0.025 paired samples t-test). Skin elasticity showed significantly higher elasticity (p = 0.030) in the experimental area at 3 months follow-up. We showed a safe application and significant improvements of wound healing and scar quality in burn patients after treatment with ECs versus SSGs only. The relevance of cultured autologous cells in treatment of extensive burns is supported by our current findings.

Randomized clinical trial of autologous skin cell suspension combined with skin grafting for chronic wounds

BACKGROUND

Treatment of chronic wounds using traditional surgical procedures is challenging because of the low graft take rates. This study investigated the combination approach of split-thickness autografts with harvested skin cell suspension for chronic wound treatment.

METHODS

This randomized clinical trial enrolled patients with chronic wounds between March 2012 and December 2013. Patients who were assigned randomly to the active treatment received a split-thickness autograft combined with harvested skin cell suspension. Control patients received the split-thickness autograft alone. The primary outcome was the rate of complete wound closure by postoperative day 28. Analysis was by intention to treat. Patients who achieved wound closure were followed up for a minimum of 6 months to evaluate the quality of healing.

RESULTS

A total of 88 patients were included, 44 in each group. More patients achieved complete wound closure in the skin cell group than in the control group (41 versus 34 patients; P = 0·035). Complete wound closure was observed at a median of 14 (95 per cent c.i. 12·0 to 16·0) days in the skin cell group and 20 (15·7 to 24·3) days in the control group (P = 0·001). The skin cell group had significantly fewer complications (4 versus 11 patients; P = 0·047). The autografted sites displayed better physical attributes and a reduced tendency for wound recurrence in the skin cell group.

CONCLUSION

Complementary split-thickness autologous skin grafting with autologous skin cells harvested using ReCell® (Avita Medical, Cambridge, UK) technology improved the healing rate of chronic wounds.

REGISTRATION NUMBER

UMIN000011966 (http://www.umin.ac.jp/ctr).

Progress towards cell-based burn wound treatments

Cell therapy as part of the concept of regenerative medicine represents an upcoming platform technology. Although cultured epidermal cells have been used in burn treatment for decades, new developments have renewed the interest in this type of treatment. Whereas early results were hampered by long culture times in order to produce confluent sheets of keratinocytes, undifferentiated proliferating cells can nowadays be applied on burns with different application techniques. The application of cells on carriers has improved early as well as long-term results in experimental settings. The results of several commercially available epidermal substitutes for burn wound treatment are reviewed in this article. These data clearly demonstrate a lack of randomized comparative trials and application of measurable outcome parameters. Experimental research in culture systems and animal models has demonstrated new developments and proof of concepts of further improvements in epidermal coverage. These include combinations of epidermal cells and mesenchymal stem cells, and the guidance of both material and cell interactions towards regeneration of skin appendages as well as vascular and nerve structures.

Current wound healing procedures and potential care

In this review, we describe current and future potential wound healing treatments for acute and chronic wounds. The current wound healing approaches are based on autografts, allografts, and cultured epithelial autografts, and wound dressings based on biocompatible and biodegradable polymers. The Food and Drug Administration approved wound healing dressings based on several polymers including collagen, silicon, chitosan, and hyaluronic acid. The new potential therapeutic intervention for wound healing includes sustained delivery of growth factors, and siRNA delivery, targeting microRNA, and stem cell therapy. In addition, environment sensors can also potentially utilize to monitor and manage microenvironment at wound site. Sensors use optical, odor, pH, and hydration sensors to detect such characteristics as uric acid level, pH, protease level, and infection - all in the hopes of early detection of complications.

Combined use of hyperbaric oxygen and sprayed keratinocyte suspension to tackle a difficult wound

This is the first reported case in the literature to combine the use of a well established therapy to achieve wound healing (ie hyperbaric oxygen treatment) and a novel sprayed keratinocyte suspension technique to treat a challenging wound successfully. The merits and potential issues associated with these treatments are outlined and the case is detailed.

Skin regeneration: the complexities of translation into clinical practise

The integration of engineering into biological science has resulted in the capacity to provide tissue engineered solutions for tissue damage. Skin regeneration remains the goal of skin repair to reduce the long term consequences of scarring to the individual. A scar is abnormal in its architecture, chemistry and cell phenotype, tissue engineering of scaffolds and cells opens up the potential of tissue regeneration into the future. Tissue engineering solutions have been applied to skin many decades despite technical success the clinical application has been modest. To realise the potential of the developing technologies needs alignment of not only the science and engineering but also the commercial upscaling of production in a safe and regulated framework for clinical use. In addition the education and training for the introduction of new technology within the health system is essential, bringing together the technology and systems for utilisation to optimise the patient outcome. This article is part of a Directed Issue entitled: Regenerative Medicine: The challenge of translation.

On the horizon: research priorities in burns for the next decade

This review demonstrates that many advances have been made in burn care that have made dramatic differences in mortality, clinical outcomes, and quality of life in burn survivors; however, much work remains. In reality, the current standard of care is insufficient and we cannot be satisfied with the status quo. We must strive for the following goals: no deaths due to burn, no scarring, and no pain. These particular goals have only begun to be confronted.

Burns in children: standard and new treatments

Outcomes of patients with burns have improved substantially over the past two decades. Findings from a 2012 study in The Lancet showed that a burn size of more than 60% total body surface area burned (an increase from 40% a decade ago) is associated with risks and mortality. Similar data have been obtained in adults and elderly people who have been severely burned. We discuss recent and future developments in burn care to improve outcomes of children.