Surgical treatment and management of the severely burn patient: Review and update

Use of an electrospun bioveil is safe and does not decrease skin graft take on burn wounds: A randomised, controlled clinical trial

INTRODUCTION

Split-thickness skin autografts are the gold standard for surgical treatment of burns. In preclinical studies, the use of SKINHEALTEX PLGA, an electrospun poly(lactic-co-glycolide) acid (PLGA) bioveil, placed between autografts and their bed has shown potential to stimulate dermal regeneration, increase graft take and improve scar quality. These properties have not yet been evaluated in human clinical trials.

OBJECTIVE

The primary goal of this study was to evaluate tolerability and safety of SKINHEALTEX PLGA on human tissues, specifically, split-thickness skin autografts and wound beds of debrided burns.

MATERIALS AND METHODS

A double-blind randomised controlled clinical trial was conducted with adult patients with deep burns requiring surgical treatment, for 4 years (November 2018 to September 2022). Each patient acted as their own control, and they were followed for 12 months. In the control area a skin autograft was applied, while in the treatment area SKINHEALTEX PLGA was interposed between the autograft and the bed. The outcome variables were incidence of adverse events, the percentage of graft take (evaluated clinically), and Vancouver Scar Scale and Patient and Observer Scar Assesment Scale scores.

RESULTS

The bioveil was well tolerated in the 26 patients that were recruited. No adverse events related to SKINHEALTEX PLGA were observed. No statistically significant differences were observed in split-thickness skin autograft take and subsequent scar quality between the control group (split-thickness skin autografts alone) and the autograft and SKINHEALTEX PLGA group.

CONCLUSION

This is the first clinical trial investigating the application of an electrospun biomaterial in the treatment of burns using skin autografts. SKINHEALTEX PLGA is a biocompatible and safe product that can be applied as an interface between autografts and the debrided bed of a burn without reducing graft take. Further research is needed to assess the value of SKINHEALTEX PLGA for burn wounds and its potential as an administration route of molecules than enhance dermal regeneration in burn patients.

Have the recent advancements in wound repair and scar management technology improved the quality of life in burn patients?

BACKGROUND

The negative physical and psychosocial impact of scars, in particular burn scars, has been well documented. Altered personal appearance together with impaired function related to pain, heat intolerance, and contracture formation may last a lifetime and eventually can lead to low self-esteem and poor social and psychological adjustments. Though most patients recover within the first years and many report generally good life satisfaction and moderate quality of life (QoL), some severely burned patients continue to report impaired QoL almost 10 years after injury. It is repeatedly mentioned in the literature that patients' QoL and health-related quality of life (HRQoL) can be improved by improving wound healing and burn scar quality. Determining whether advances in burn wound healing and scar management modalities are positively impacting the lives of surviving patients is the aim of this review.

METHODS

A systematic literature review was used to identify studies measuring QoL of patients surviving severe burn injuries following various interventions to improve burn wound healing and scar quality.

RESULTS

A limited number of studies was identified. Given the limited available data, a narrative review approach including qualitative studies and reviews in addition to identifying common themes, trends, and gaps in the existing literature was deemed more appropriate for a comprehensive analysis.

CONCLUSION

The assumption that progress made in recent decades to improve burn wound healing and scar quality would improve QoL remains largely hypothetical. Except for functional release of burn scar contractures, improved scar aesthetic quality does not necessarily translate into improved QoL of surviving patients. Well-designed comparative studies are largely lacking.

Experience of multidisciplinary cooperation in treating 15 extensively burned casualties：The Zhejiang LNG tanker explosion on 13 June 2020

BACKGROUND

On June 13, 2020, an explosion involving a liquefied natural gas (LNG) tanker truck occurred in eastern China. Fifteen patients with extremely severe burns (referred to as "June 13" patients) were treated in the burn-intensive care unit (ICU) joint ward within the general ICU.

METHODS

A multidisciplinary treatment team comprising 129 doctors, 126 nurses, and 165 auxiliary staff members was assembled. Additionally, 15 burn and ICU experts from various regions of China joined us. After concluding the treatment, patient data were collected and analyzed. The differences in clinical data between the deceased and surviving patients were retrospectively compared. Subsequently, the clinical data of 177 non-"June 13" patients with total burned body surface area (TBSA) > 50 % treated in the burn department from 2016 to 2023 were collected to compare the efficacy of our multidisciplinary collaborative treatment model.

RESULTS

The average TBSA of 15 "June 13" patients was 85.07 ± 15.85 % (range 50-98 %). Among them, 11 patients had a TBSA greater than 90 %, with 6 exceeding 95 %. Seven patients succumbed to their injuries, while 8 patients survived. The incidence of severe complications, such as multiple organ failure (MOF) and fungal infections, was higher in the deceased group than in the survival group. The surviving patients exhibited larger burn wound areas repaired by skin grafting on the 30th and 60th days, with significantly less residual wound area than the deceased group. In comparison with the non-"June 13" patients, the "June 13" patients were notably older and had larger TBSA, as well as larger areas of third-degree TBSA and higher mean revised Baux scores. After 1:2 matching for revised Baux score, the "June 13" group underwent a significantly higher number of operations (p-value =0.007). The "June 13" group showed a lower mortality rate, although not statistically significant (20 % vs 55 %, p = 0.119; log-rank p = 0.059 for Kaplan-Meier curves).

CONCLUSION

Multidisciplinary collaboration, guided by a comprehensive treatment plan, may improve the management of patients with extensive burns. Timely and effective surgical management is crucial for reducing mortality and improving patient prognosis.

Association between Intestinal Flora Metabolites and Coronary Artery Vulnerable Plaque Characteristics in Coronary Heart Disease

Aims/Background The incidence of coronary heart disease (CHD) has been increasing annually. Patients with severe conditions may die from myocardial infarction, heart failure or malignant arrhythmia. Intestinal flora plays an important role in various metabolic processes, such as atherosclerosis, tumour formation, and inflammation. However, its direct role in promoting plaque vulnerability must be further explored and validated. Therefore, this study aims to explore the relationship between changes in intestinal flora, its metabolites in CHD patients and the vulnerability characteristics of coronary plaques. Methods This study recruited 180 subjects, among these, 90 CHD patients diagnosed between January 2023 and January 2024 were selected as the CHD group and 90 healthy volunteers were selected as the control group following a principle of 1:1 ratio. The differences in intestinal flora composition, metabolite levels, and blood biochemical indexes were compared between the two study groups. Based on the coronary angiography (CAG) and intravascular ultrasound (IVUS) results, the CHD group was divided into two sub-groups for stratified comparative analysis: the stable plaque group (n = 49) and the vulnerable plaque group (n = 41). Results The CHD group had reduced intestinal Bifidobacteria and lactic acid bacteria counts and higher intestinal Escherichia coli and Enterococcus levels than the control group (p < 0.05). Moreover, trimethylamine-N-oxide (TMAO) and phenylacetylglutamine (PAGln) levels were significantly higher in the CHD group compared to the control group (p < 0.05). Similarly, the CHD group exhibited substantially elevated serum triglyceride (TG), total cholesterol (TC), and low-density lipoprotein cholesterol (LDL-C) levels compared to the control group. However, compared to the control group, the high-density lipoprotein cholesterol (HDL-C) levels were significantly lower in the CHD group (p < 0.05). Furthermore, the serum levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), serum urea nitrogen (BUN), and serum creatinine (Scr) were comparable in the two experimental groups (p > 0.05). Similarly, intestinal Bifidobacteria, lactic acid bacteria, Escherichia coli, and Enterococcus compositions were comparable in CHD patients with vulnerable plaque and those with stable plaque (p > 0.05). Moreover, CHD patients with vulnerable plaque had elevated TMAO and PAGln levels than those with stable plaque (p < 0.05). However, TG, TC, HDL-C, LDL-C, ALT, AST, BUN, and Scr levels were comparable between CHD patients with a vulnerable plaque and those with stable plaque (p > 0.05). Multivariate regression analysis showed that diabetes, elevated TMAO levels, and elevated PAGln levels were potential risk factors for coronary plaque vulnerability (p < 0.05). Conclusion In summary, CHD patients exhibit significant intestinal flora imbalance, with elevated TMAO and PAGln metabolite levels, which are related to the characteristics of plaque instability.

Comparison of Efficacy and Safety between Two Silver-Containing Dressings in the Treatment of Deep Partial-Thickness Thermal Burns: A Multicenter, Double-Blind, Non-Inferiority, Randomized Clinical Trial

Aims/Background Silver-containing dressings are commonly utilized in burns treatment by virtue of their excellent antibacterial properties. Further research is needed to determine the type of silver-containing dressing that is more effective and safer for burns treatment. Pyperbranched polyamide-Ag dressing (HBPs-Ag dressing) is a modified polyamide dressing with a uniform coating of the Amino-terminated hyperbranched polymer (HBP-NH2)/Ag+ compound on its surface. This study aimed to evaluate the efficacy and safety of a silver ion-containing dressing (HBPs-Ag) for wound contact layer in the treatment of deep partial-thickness burns versus a silver-impregnated tulle dressing (Atrauman Ag). Methods This study was conducted between October 2019 to January 2021 at six sites in China. A total of 132 patients with deep partial-thickness burns (aged 18-65 years, injury occurring within 72 hours, burns <30% total burn surface area) were randomized 1:1 to HBPs-Ag group (study group) or Atrauman Ag group (control group). Data were obtained and analyzed, including total efficacy, wound healing rate, wound healing time, rate of negative bacterial culture from wound secretions, systemic response, skin or tissue irritation, local skin color changes, wound swelling, wound pain and adverse events. Results For partial thickness burns, the HBPs-Ag dressing was not inferior to Atrauman Ag dressing because the total efficiency of HBPs-Ag group (98.3%) was comparable to that of Atrauman Ag group (94.7%) (p > 0.05). There were no significant differences in efficacy, wound healing rate, wound healing time, and rate of negative bacterial culture from wound secretions between the two groups (p > 0.05). There were no statistical differences in all safety indicators tested between the two groups (p > 0.05). Silver was detected in the blood or urine of only 5 patients (3.79%). Conclusion The HBPs-Ag dressing was not inferior to Atrauman Ag dressing in deep partial-thickness burns treatment, with both of them showcasing comparable efficacy and safety. Clinical Trial Registration Chinese Clinical Trial Registry (ChiCTR2100049814).

Strategies for Optimizing Acute Burn Wound Therapy: A Comprehensive Review

Recent advancements in acute burn wound therapy are transforming the management of burn injuries, with a focus on improving healing times, graft integration, and minimizing complications. However, current clinical treatments face significant challenges, including the difficulty of accurately assessing wound depth and tissue viability, which can lead to suboptimal treatment planning. Traditional closure methods often struggle with issues such as delayed wound closure, limited graft survival, inadequate tissue regeneration, and insufficient vascularization. Furthermore, managing infection and minimizing scarring remain persistent obstacles, impacting functional recovery and aesthetic outcomes. Key areas of innovation include advanced imaging techniques that enable more precise assessment of wound depth, size, and tissue viability, allowing for more accurate treatment planning. In addition, new closure strategies are being developed to accelerate wound closure, enhance graft survival, and address challenges such as tissue regeneration, vascularization, and infection prevention. These strategies aim to optimize both functional recovery and aesthetic outcomes, reducing scarring and improving the quality of life for burn patients. While promising, these emerging techniques require further research and clinical validation to refine their effectiveness and expand their accessibility. Together, these innovations represent a significant shift in acute burn care, offering the potential for more personalized, efficient, and effective treatments.

Bromelain in Burn Care: Advancements in Enzymatic Debridement and Patient Outcomes

The management of severe burns is a complex process that requires a multidimensional approach to ensure optimal healing of burn wounds, minimize complications, and improve the prognosis of patients. Surgical debridement is considered the gold standard for removing necrotic tissue; however, this approach involves risks such as bleeding, the potential removal of viable tissue during excision, and technical challenges in complex anatomical areas. Recent advancements highlight the role of enzymatic debridement using NexoBrid®, which offers a less invasive alternative to surgical excision while having the ability to selectively debride necrotic tissue and preserve viable tissue. NexoBrid® has shown efficacy in reducing debridement time, minimizing the need for additional surgeries, and improving overall wound healing outcomes. This review discusses the clinical indications, advantages, and considerations for choosing between surgical and enzymatic debridement. Emerging studies suggest the potential for enzymatic debridement to be safe and effective even for larger burn areas, making it a promising option in modern burn care. However, ongoing evaluation and integration into clinical protocols will be essential to fully realize its benefits in specialized burn treatment and to establish protocols.

Debridement efficacy of serine protease and formulated cream by In Vitro assessment against artificial wound eschar

Chronic wounds typically comprise of necrotic tissue and dried secretions, often culminating in the formation of a thick and tough layer of dead skin known as eschar. Removal of eschar is imperative to facilitate wound healing. Conventional approach for eschar removal involves surgical excision and grafting, which can be traumatic and frequently leads to viable tissue damage. There has been growing interest in the use of enzymatic agents for a gentler approach to debridement, utilizing proteolytic enzymes. In this study, a purified intracellular recombinant serine protease from Bacillus sp. (SPB) and its cream formulation were employed to evaluate their ability to degrade artificial wound eschar; composed of collagen, fibrin, and elastin. Degradation was assessed based on percentage weight reduction of eschar biomass, analysis via sodium dodecyl sulphate-polyacrylamide gel electrophoresis (SDS-PAGE), and scanning electron microscopy (SEM). Both SPB and its cream formulation were able to degrade up to 50 % artificial wound eschar, with the SPB cream maintaining its degradation efficiency for up to 24 hours. Additionally, the SPB-based cream demonstrated the ability to hydrolyze proteinaceous components of eschars individually (fibrin and collagen) as determined through qualitative assessment. These findings suggest that SPB holds promise for the debridement of wound eschar.

Wound Healing and Scar Patterning After Addition of Autologous Skin Cell Suspension to Meshed Grafts

INTRODUCTION

A common treatment for large deep-to-full-thickness burns is excision and grafting with a widely meshed split-thickness skin graft (mSTSG). Due to the differential healing of the interstices and adhered split-thickness skin graft, wound patterning and delayed wound healing are common outcomes of this treatment. Delayed healing may increase infection rates and wound care requirements, while wound patterning may be psychologically and aesthetically consequential for patients. Autologous skin cell suspension (ASCS) can be used to "over spray" a meshed autograft. It was hypothesized that the use of ASCS combined with mSTSG would increase the rate of wound healing and decrease patterning in healed burn wounds.

METHODS

Full-thickness burns or excisional wounds (n = 8 each) were created in red Duroc pigs and received 4:1 mSTSGs after wound bed preparation. Half of the wounds received ASCS and half did not at the time of grafting. Percent re-epithelialization, patterning, rete ridge ratio, cellularity, dermal and epidermal thickness, immunofluorescent S100β staining, and melanin index were assessed for each scar.

RESULTS

Wounds that received ASCS exhibited increased rates of re-epithelialization (burn +ACSC versus burn-ASCS; day 3 (53.9 ± 3.1 versus 34.3 ± 3.3, P = 0.009): day 5 (68.1 ± 1.6 versus 40.8 ± 3.2, P < 0.001)). Excision +ASCS versus excision-ASCS; day 7 (98.1 ± 1.2 versus 86.4 ± 2.0, day 7 P = 0.022) compared to wounds not treated with ASCS. There was no difference in rete ridge ratio, cellularity, dermal thickness, epidermal thickness, S100β staining, melanin index, or patterning was measured between wounds that received ASCS and those that did not.

CONCLUSIONS

The addition of ASCS to 4:1 mSTSGs leads to increased rate of wound healing but does not impact the degree of patterning in this model, suggesting that ASCS application likely robustly transfers keratinocytes but not functioning melanocytes at acute timepoints.

Free Flap Failure and Contracture Recurrence in Delayed Burn Reconstruction: A Systematic Review and Meta-analysis

Background

Free tissue transfer is often considered a last resort in burn reconstruction due to its complexity and associated risks. A comprehensive review on free flap outcomes in delayed burn reconstruction is currently lacking. The study aimed to evaluate the available evidence on the failure and contracture recurrence rates in free flap delayed burn reconstruction.

Methods

A systematic review and meta-analysis was conducted and reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The protocol was registered on PROSPERO (CRD42023404478). The following databases were accessed: Embase, PubMed, Web of Science, and Cochrane Library. The measured outcomes were free flap loss and contracture recurrence rate.

Results

Of the 1262 retrieved articles, 40 qualified for inclusion, reporting on 1026 free flaps performed in 928 patients. The mean age was 29.25 years [95% confidence interval (CI), 24.63-33.88]. Delayed burn reconstruction was performed at an average of 94.68 months [95% CI, - 9.34 to 198.70] after initial injury, with a follow-up period of 23.02 months [95% CI, 4.46-41.58]. Total flap loss rate was 3.80% [95% CI, 2.79-5.16] and partial flap loss rate was 5.95% [95% CI, 4.65-7.57]. Interestingly, burn contracture recurrence rate was 0.62% [95% CI, 0.20-1.90].

Conclusions

This systematic review provides a comprehensive evaluation of the free flap outcomes in delayed burn reconstruction. The flap loss rate was relatively low, given the complexity of the procedure and potential risks. Furthermore, burn contracture rate was found to be extremely low. This study demonstrates that free flaps are a safe and effective option for delayed burn reconstruction.

A critical overview of challenging roles of medicinal plants in improvement of wound healing technology

PURPOSE

Chronic diseases often hinder the natural healing process, making wound infections a prevalent clinical concern. In severe cases, complications can arise, potentially leading to fatal outcomes. While allopathic treatments offer numerous options for wound repair and management, the enduring popularity of herbal medications may be attributed to their perceived minimal side effects. Hence, this review aims to investigate the potential of herbal remedies in efficiently treating wounds, presenting a promising alternative for consideration.

METHODS

A literature search was done including research, reviews, systematic literature review, meta-analysis, and clinical trials considered. Search engines such as Pubmed, Google Scholar, and Scopus were used while retrieving data. Keywords like Wound healing 'Wound healing and herbal combinations', 'Herbal wound dressing', Nanotechnology and Wound dressing were used.

RESULT

This review provides valuable insights into the role of natural products and technology-based formulations in the treatment of wound infections. It evaluates the use of herbal remedies as an effective approach. Various active principles from herbs, categorized as flavonoids, glycosides, saponins, and phenolic compounds, have shown effectiveness in promoting wound closure. A multitude of herbal remedies have demonstrated significant efficacy in wound management, offering an additional avenue for care. The review encompasses a total of 72 studies, involving 127 distinct herbs (excluding any common herbs shared between studies), primarily belonging to the families Asteraceae, Fabaceae, and Apiaceae. In research, rat models were predominantly utilized to assess wound healing activities. Furthermore, advancements in herbal-based formulations using nanotechnology-based wound dressing materials, such as nanofibers, nanoemulsions, nanofiber mats, polymeric fibers, and hydrogel-based microneedles, are underway. These innovations aim to enhance targeted drug delivery and expedite recovery. Several clinical-based experimental studies have already been documented, evaluating the efficacy of various natural products for wound care and management. This signifies a promising direction in the field of wound treatment.

CONCLUSION

In recent years, scientists have increasingly utilized evidence-based medicine and advanced scientific techniques to validate the efficacy of herbal medicines and delve into the underlying mechanisms of their actions. However, there remains a critical need for further research to thoroughly understand how isolated chemicals extracted from herbs contribute to the healing process of intricate wounds, which may have life-threatening consequences. This ongoing research endeavor holds great promise in not only advancing our understanding but also in the development of innovative formulations that expedite the recovery process.

Carboxymethyl chitosan-based hydrogel-Janus nanofiber scaffolds with unidirectional storage-drainage of biofluid for accelerating full-thickness wound healing

Self-pumping wound scaffolds designed for directional biofluid transport are extensively investigated. They efficiently extract excessive biofluids from wounds, while maintaining an optimally humid wound environment, thus facilitating rapid wound healing. However, the existing designed scaffolds are insufficiently focused on stimulating the hydrophobic layer at the wound site, thereby exacerbating inflammation and impeding the wound healing process. Herein, we engineered and fabricated a hydrophilic-hydrophobic-hydrophilic sandwich-structured hydrogel-Janus nanofiber scaffold (NFS) employing a Layer-by-Layer (LbL) method. This scaffold comprises a hydrophilic carboxymethyl chitosan/silver (CMCS-Ag) hydrogel component in conjunction with a poly(caprolactone)/poly(caprolactone)-poly(citric acid)-co-ε-polylysine (PCL/PCL-PCE) Janus NFS. It is noteworthy that the hydrogel-Janus nanofiber scaffold not only demonstrates outstanding water absorption (202.2 %) and unidirectional biofluid transport capability but also possesses high breathability (308.663 m3/m2 h kPa), appropriate pore size (6.7-7.5 μm), excellent tensile performance (270 ± 10 %), and superior mechanical strength (26.36 ± 1.77 MPa). Moreover, in vitro experimentation has convincingly demonstrated the impeccable biocompatibility of hydrogel-Janus NFS. The inherent dual-antibacterial properties in CMCS-Ag and PCE significantly augment fibroblast proliferation and migration. In vivo studies further underscore its capability to expedite wound healing by absorption and expulsion of wound exudates, thereby fostering collagen deposition and vascularization. As such, this work potentially provides fresh insights into the design and fabrication of multifunctional biomimetic scaffolds, holding immense potential in the medical field for efficient wound healing.

Update on Hypermetabolism in Pediatric Burn Patients

Despite advancements in pediatric burn care, the profound hypermetabolic response associated with severe burns remains a multifaceted challenge throughout the continuum of care. Understanding the various physiologic disturbances that constitute hypermetabolism is crucial for a thorough evaluation and for implementing appropriate surgical and nonsurgical interventions. In this article, we describe the pathophysiology and treatment of hypermetabolism in pediatric burn patients with a focus on reducing resting energy requirements, minimizing infection, and optimizing nutrition for patients undergoing frequent surgical intervention.

Structural characterization of a glycoprotein from white jade snails (Achatina Fulica) and its wound healing activity

Snail mucus is rich in proteins and polysaccharides, which has been proved to promote wound healing in mice in our previous research. The aim of this study was to investigate the effective component in snail mucus that can exert the wound healing potential and its structural characterization. Here, the glycoprotein from the snail mucus (SM1S) was obtained by DEAE-Sepharose Fast Flow and Sephacryl S-300 columns. The structural characteristics of SM1S were investigated via chromatographic techniques, periodic acid oxidation, FT-IR spectroscopy and NMR spectroscopy. Results showed that SM1S was a glycoprotein with a molecular weight of 3.8 kDa (83.23 %), consists of mannose, glucuronic acid, glucose, galactose, xylose, arabinose, fucose at a ratio of 13.180:4.875:1043.173:7.552:1:3.501:2.058. In addition, the periodic acid oxidation and NMR analysis showed that SM1S contained 1,6-glycosidic bonds, and might also contain 1 → 4 and 1 → 2 glycosidic or 1 → 3 glycosidic bonds. Furthermore, the migration experiment of human skin fibroblasts in vitro suggested that SM1S had a good effect to accelerate the scratch healing of cells. This study suggested that SM1S may be a prospective candidate as a natural wound dressing for the development of snail mucus products.

The impact of cognitive behavioural therapy-based psychological intervention on emotional improvement in elderly patients with extensive burns

To evaluate the efficacy of cognitive behavioural therapy (CBT) as a psychological intervention for elderly patients with extensive burns, focusing on its impact on emotional well-being, self-efficacy and quality of life. A prospective, randomized study involving 200 elderly burn patients was conducted from November 2021 to January 2023. The patients were randomly assigned to receive either standard care (control group) or burn care based on cognitive behavioural therapy (CBT-B) (study group), with 100 patients in each group. Outcome measures included the Visual Analog Scale (VAS) for pain assessment, 36-item Short Form Survey (SF-36) for quality of life, General Self-Efficacy Scale (GSES) and Rosenberg Self-Esteem Scale (RSES). The study revealed that CBT-based intervention significantly reduced anxiety and depression scores compared with standard care (p < 0.05). Additionally, patients in the CBT group exhibited improved self-efficacy, self-esteem and quality of life (p < 0.05). CBT proves to be a valuable intervention for elderly burn patients, effectively addressing emotional distress and enhancing their psychological well-being. By modifying negative cognitive patterns, providing coping mechanisms and fostering problem-solving skills, CBT-based care contributes to a more positive recovery experience and improved quality of life.

A novel skin grafting modality: prefabricated large sheet of postage-stamp autografts and allografts to repair extensive burn wounds; a prospective matched-control study

BACKGROUND

The excessively long operative time has been the greatest barrier to the success of transplanting postage-stamp auto- and allografts directly and piece-by-piece onto extensive burn wounds. To solve this challenge, the authors present a novel grafting modality, that is, the prefabricated-large-sheet grafting that moves the labor-intensive and time-consuming process of grafts-positioning before grafting and thereby markedly shortens the operative time.

METHODS

Twenty-one operations using the novel modality were performed on 11 patients with extensive deep burns. The grafting time using the novel modality was recorded and compared with that of the conventional piece-by-piece grafting. Eventually, the take rates of the two modalities were compared.

RESULTS

All patients were healed and discharged. The average grafting time per unit area (100 cm2) of prefabricated-large-sheet grafting and piece-by-piece grafting were (0.41±0.09) min and (7.46±1.07) min, respectively, and the difference is statistically significant(P<0.001). The average take rate of the prefabricated sheets was (85.43±6.14)% and that of the piece-by-piece transplanted grafts was (87.29±5.23)% and there is no significant difference(P>0.05).

CONCLUSIONS

The prefabricated-large-sheet grafting significantly reduces the intraoperative grafting time while ensures uniformity of the skin grafts and secures good outcomes, thereby making the intermingled transplantation of postage-stamp auto- and allografts, which has been an excellent modality per se but limited to repair small residual wounds, now feasible to repair extensive deep burn wounds. It is worth wider understanding and application in the treatment of extensive deep burns.

Effects of photobiomodulation with blue Light Emitting Diode (LED) on the healing of skin burns

The management of skin burns is still challenging. Among the therapeutic methods used, there are topical treatments with pharmacological and herbal agents, low-intensity therapeutic ultrasound, use of biomaterials, reconstructive techniques and photobiomodulation therapy. The aim of this study was to evaluate the effects of photobiomodulation with blue Light Emitting Diode (LED) on burn healing. Fifty Wistar rats were divided into control (CTRL) (n = 25) and blue LED (LED) (n = 25), with subgroups (n = 5) for each time of euthanasia (7, 14, 21, 28 and 32 days). Treated animals were daily irradiated (470 nm, 1W, 0.44 W/cm2, 50 J/cm2). Clinical evaluations were performed and the Wound Retraction Index (WRI) was determined. Histological sections were submitted to hematoxylin-eosin, toluidine blue and the immunohistochemical technique, with anti-α-SMA and anti-TGF-β1 antibodies. All data were directly collected by previously calibrated evaluators in a blind manner. The values were included in a statistical program. For all statistical tests used, 5% significance level (p < 0.05) was considered. No statistically significant differences in WRI between groups were observed (p > 0.05). Re-epithelialization was higher using LED at 7 and 14 days (p < 0.05) and greater amount of inflammatory cells was observed at 7 days (p = 0.01). With LED at 21 and 32 days, greater number of mast cells were observed (p < 0.05), as well as smaller number of myofibroblasts at 14, 21, 28 and 32 days (p < 0.05) and lower percentage of TGF-β1 positive cells in the conjunctiva at 7, 14 and 21 days (p < 0.05). Negative correlations were observed in LED between the percentage of TGF-β1 in the epithelium and the mean number of inflammatory cells and number of myofibroblasts (p < 0.05). The results suggest that, depending on the period, blue LED can modulate the healing processes of third-degree skin burns, such as re-epithelialization, inflammatory response, mast cell concentration, myofibroblast differentiation and TGF-β1 immunoexpression. Despite these effects, this therapy does not seem to have significant influence on the retraction of these wounds. Future studies, using different protocols, should be carried out to expand the knowledge about the photobiomodulatory mechanisms of this type of light in the healing process.

An Overview of Recent Developments in the Management of Burn Injuries

According to the World Health Organization (WHO), around 11 million people suffer from burns every year, and 180,000 die from them. A burn is a condition in which heat, chemical substances, an electrical current or other factors cause tissue damage. Burns mainly affect the skin, but can also affect deeper tissues such as bones or muscles. When burned, the skin loses its main functions, such as protection from the external environment, pathogens, evaporation and heat loss. Depending on the stage of the burn, the patient's condition and the cause of the burn, we need to choose the most appropriate treatment. Personalization and multidisciplinary collaboration are key to the successful management of burn patients. In this comprehensive review, we have collected and discussed the available treatment options, focusing on recent advances in topical treatments, wound cleansing, dressings, skin grafting, nutrition, pain and scar tissue management.

Acellular fish skin for wound healing

Fish skin grafting as a new skin substitute is currently being used in clinical applications. Acceleration of the wound healing, lack of disease transmission, and low cost of the production process can introduce fish skin as a potential alternative to other grafts. An appropriate decellularization process allows the design of 3D acellular scaffolds for skin regeneration without damaging the morphology and extracellular matrix content. Therefore, the role of decellularization processes is very important to maintain the properties of fish skin. In this review article, recent studies on various decellularization processes as well as biological, physical, and mechanical properties of fish skin and its applications with therapeutic effects in wound healing were investigated.

Meek Micro-Skin Grafting and Acellular Dermal Matrix in Pediatric Patients: A Novel Approach to Massive Extravasation Injury

(1) Background: Extravasation injuries in pediatric patients can lead to significant harm if they are not promptly diagnosed and treated. However, evidence-based standardization on extravasation management remains limited, particularly for extensive wound necrosis. This case report presents the management of an 8-week-old premature patient with an extensive extravasation injury involving the right forearm and dorsum of the hand. (2) Methods: The patient was evaluated by a multidisciplinary team in our Neonatal Intensive Care Unit. Surgical intervention involved the debridement of necrotic tissues, followed by temporary coverage with an acellular dermal matrix. Definitive coverage was achieved through Meek micrografting after three weeks. Physical therapy was provided with pre- and post-rehabilitation range of motion assessed using goniometric measurements. Scar quality was evaluated using the Vancouver Scar Scale. (3) Results: The engraftment rate of the Meek micrografts was 93%, with 16 out of 226 micrografts lost. The patient achieved a Vancouver Scar Scale score of 6, indicating a moderate degree of scarring. Significant improvements in elbow, wrist, and finger joint range of motion were observed at a 1-year follow-up. (4) Conclusions: Close observation and heightened awareness of extravasation risks by trained personnel are crucial. Meek micrografting combined with dermal substitute coverage represents an innovative approach to managing extravasation wounds in pediatric patients.

Can Cold Atmospheric Plasma Be Used for Infection Control in Burns? A Preclinical Evaluation

Wound infection with Pseudomonas aeruginosa (PA) is a serious complication and is responsible for higher rates of mortality in burn patients. Because of the resistance of PA to many antibiotics and antiseptics, an effective treatment is difficult. As a possible alternative, cold atmospheric plasma (CAP) can be considered for treatment, as antibacterial effects are known from some types of CAP. Hence, we preclinically tested the CAP device PlasmaOne and found that CAP was effective against PA in various test systems. CAP induced an accumulation of nitrite, nitrate, and hydrogen peroxide, combined with a decrease in pH in agar and solutions, which could be responsible for the antibacterial effects. In an ex vivo contamination wound model using human skin, a reduction in microbial load of about 1 log₁₀ level was observed after 5 min of CAP treatment as well as an inhibition of biofilm formation. However, the efficacy of CAP was significantly lower when compared with commonly used antibacterial wound irrigation solutions. Nevertheless, a clinical use of CAP in the treatment of burn wounds is conceivable on account of the potential resistance of PA to common wound irrigation solutions and the possible wound healing-promoting effects of CAP.

The Effect of Fetal Bovine Acellular Dermal Matrix Seeded with Wharton's Jelly Mesenchymal Stem Cells for Healing Full-Thickness Skin Wounds

The treatment of full-thickness skin wounds is a problem in the clinical setting, as they do not heal spontaneously. Extensive pain at the donor site and a lack of skin grafts limit autogenic and allogeneic skin graft availability. We evaluated fetal bovine acellular dermal matrix (FADM) in combination with human Wharton's jelly mesenchymal stem cells (hWJ-MSCs) to heal full-thickness skin wounds. FADM was prepared from a 6-month-old trauma-aborted fetus. WJ-MSCs were derived from a human umbilical cord and seeded on the FADM. Rat models of full-thickness wounds were created and divided into three groups: control (no treatment), FADM, and FADM-WJMSCs groups. Wound treatment was evaluated microscopically and histologically on days 7, 14, and 21 post-surgery. The prepared FADM was porous and decellularized with a normal range of residual DNA. WJ-MSCs were seeded and proliferated on FADM effectively. The highest wound closure rate was observed in the FADM-WJMSC group on days 7 and 14 post-surgery. Furthermore, this group had fewer inflammatory cells than other groups. Finally, in this study, we observed that, without using the differential cell culture media of fibroblasts, the xenogeneic hWJSCs in combination with FADM could promote an increased rate of full-thickness skin wound closure with less inflammation.

Association of age with perioperative morbidity among patients undergoing surgical management of minor burns

Introduction

Burn injuries are associated with significant morbidity, often necessitating surgical management. Older patients are more prone to burns and more vulnerable to complications following major burns. While the relationship between senescence and major burns has already been thoroughly investigated, the role of age in minor burns remains unclear. To better understand differences between elderly and younger patients with predominantly minor burns, we analyzed a multi-institutional database.

Methods

We reviewed the 2008-2020 ACS-NSQIP database to identify patients who had suffered burns according to ICD coding and underwent initial burn surgery.

Results

We found 460 patients, of which 283 (62%) were male and 177 (38%) were female. The mean age of the study cohort was 46 ± 17 years, with nearly one-fourth (n = 108; 23%) of all patients being aged ≥60 years. While the majority (n = 293; 64%) suffered from third-degree burns, 22% (n = 99) and 15% (n = 68) were diagnosed with second-degree burns and unspecified burns, respectively. An average operation time of 46 min, a low mortality rate of 0.2% (n = 1), a short mean length of hospital stay (1 day), and an equal distribution of in- and outpatient care (51%, n = 234 and 49%, n = 226, respectively) indicated that the vast majority of patients suffered from minor burns. Patients aged ≥60 years showed a significantly prolonged length of hospital stay (p<0.0001) and were significantly more prone to non-home discharge (p<0.0001). In univariate analysis, advanced age was found to be a predictor of surgical complications (p = 0.001) and medical complications (p = 0.0007). Elevated levels of blood urea nitrogen (p>0.0001), creatinine (p>0.0001), white blood cell count (p=0.02), partial thromboplastin time (p = 0.004), and lower levels of albumin (p = 0.0009) and hematocrit (p>0.0001) were identified as risk factors for the occurrence of any complication. Further, complications were more frequent among patients with lower body burns.

Discussion

In conclusion, patients ≥60 years undergoing surgery for predominantly minor burns experienced significantly more complications. Minor lower body burns correlated with worse outcomes and a higher incidence of adverse events. Decreased levels of serum albumin and hematocrit and elevated values of blood urea nitrogen, creatinine, white blood count, and partial thromboplastin time were identified as predictive risk factors for complications.

The results of bacterial contamination of dangerous and borderline cases of burns

The aim is to study the microbiological picture of purulent inflammation of superficial local burns in the center of thermal lesions of Samara.

Material and methods. The etiological structure of local burn infection was analyzed in 29 patients with limited, borderline burns of I-II degree in all phases of the wound process. The collection of wound material was carried out in accordance with the requirements of the Methodological Guidelines of MU 4.2.2039-05 "Technique of collecting and transporting biomaterials to microbiological laboratories". The material was delivered to the laboratory in test tubes with a transport medium under isothermal conditions at a temperature of 20–22 °C within a day after collection.

Results. The analysis of the etiological structure of burn infection showed that staphylococcus (St. aureus, St. warneri, St. gallinarium, St. spp, St. epidermidis) plays a leading role in microbiological examination – in 26 patients (89.6 %) and E. coli (E. coli) in 11 (37.9 %). There were no significant differences in the studied signs in the comparison groups (p > 0.05, p = 0.55, χ2 = 3.841).

Conclusion. The obtained results of the etiological structure of purulent inflammation of limited burns are statistically reliable and can be used in the development of antibacterial agents for the treatment of burn infection. 

Evaluation of healing outcomes combining a novel polymer formulation with autologous skin cell suspension to treat deep partial and full thickness wounds in a porcine model: a pilot study

Autologous skin cell suspensions (ASCS) can treat burns of varying depths with the advantage of reduced donor site wound burden. The current standard primary dressing for ASCS is a nonabsorbant, non-adherent, perforated film (control) which has limited conformability over heterogeneous wound beds and allows for run-off of the ASCS. To address these concerns, a novel spray-on polymer formulation was tested as a potential primary dressing in porcine deep partial thickness (DPT) and full thickness (FT) wounds. It was hypothesized that the polymer would perform as well as control dressing when evaluating wound healing and scarring. DPT or FT wounds were treated with either a spray-on poly(lactic-co-glycolic acid) (PLGA) and poly(lactide-co-caprolactone) (PLCL) formulation or control ASCS dressings. Throughout the experimental time course (to day 50), we found no significant differences between polymer and control wounds in % re-epithelialization, graft-loss, epidermal or dermal thickness, or % dermal cellularity in either model. Pigmentation, erythema, elasticity, and trans-epidermal water loss (TEWL), were not significantly altered between the treatment groups, but differences between healing wounds/scars and un-injured skin were observed. No cytotoxic effect was observed in ASCS incubated with the PLGA and PLCL polymers. These data suggest that the novel spray-on polymer is a viable option as a primary dressing, with improved ease of application and conformation to irregular wounds. Polymer formulation and application technique should be a subject of future research.

Synergistic Use of Novel Technological Advances in Burn Care Significantly Reduces Hospital Length of Stay Below Predicted: A Case Series

Length of stay is an important metric in healthcare systems, primarily because it reflects the cost of care provided. In the US, as in many countries, inpatient hospital stays are significantly more expensive than outpatient care across all healthcare conditions [1], so earlier discharge and transition to outpatient care is crucial to help control the ever-increasing cost of healthcare. In burn patients, length of stay has traditionally been estimated at 1 day per 1% total body surface area of burn. This estimation was first described in a round table discussion in 1986.[2] However, since that time there has been significant evolution in the quality of care available to burn patients, in both the operating room and ICU. The use of new harvesting techniques, synthetic dermal substitution, and autologous epidermal skin cell suspension are allowing large, deep burns to be excised and covered in much quicker time frames than historically were possible. Examples include the skin harvesting and wound debridement device for grafting and excision, biodegradable temporizing matrix as a fully synthetic dermal template, and regenerative epidermal suspension concerning cell harvesting. Although these modalities can all be used separately, we believe that using them in conjunction has allowed us to shorten the length of stay in patients with severe partial and full-thickness burns. We present an initial case series of 3 patients with anticipated hospital lengths of stay of 54.5, 55, and 51 days, who were ready for discharge in 37, 35, and 43 days, respectively.

Secretory Fluid-Aggregated Janus Electrospun Short Fiber Scaffold for Wound Healing

Exudate management is critical to improve chronic wound healing. Herein, inspired by a Janus-structured lotus leaf with asymmetric wettability, a Janus electrospun short fiber scaffold is fabricated via electrospinning technologies and short fiber modeling. This scaffold is composed of hydrophilic 2D curcumin-loaded electrospun fiber and hydrophobic 3D short fiber via layer-by-layer assembly and electrostatic interactions which can aggregate the wound exudate by pumping from the hydrophobic layer to the hydrophilic via multiple contact points between hydrophilic and hydrophobic fibers, and simultaneously trigger the cascade release of curcumin in the upper 2D electrospun fiber. The 3D short fiber with high porosity and hydrophobicity can quickly aggregate exudate within 30 s after compounding with hydrophilic 2D electrospun fiber via a spontaneous pump. In vitro experiments show that Janus electrospun short fiber has good biocompatibility, and the cascade release of curcumin can significantly promote the proliferation and migration of fibroblasts. In vivo experiments show that it can trigger cascade release of curcumin by aggregating wound exudate, so as to accelerate wound healing process and promote collagen deposition and vascularization. Hence, this unique biometric Janus scaffold provides an alternative for chronic wound healing.

The Trend of Burn Injury Patients in Ningbo between 2012 and 2021: A Clinical Study

Objective

This study was designed to understand the local changes of burn injuries in recent 10 years, so as to provide reliable reference data and viewpoints for prevention and vigilance of local burn injuries.

Methods

In this study, 184 patients with a burn injury admitted to our hospital from 2012 to 2021 were enrolled and analyzed retrospectively. According to their information in the electronic database, the number of patients with burn injuries and the location of each disaster each year were analyzed, and the age, sex, hospital stay and hospitalization expense of each patient were collected. With 5 years as the boundary, the patients were divided into a 2012-2016 group and a 2017-2021 group and the differences of the two groups in the abovementioned aspects were compared.

Results

During 2012-2021, the incidence rate of burn injuries in men was higher than that in women and workplaces had a higher burn injury rate than residents' homes. Compared with the period of 2012-2016, the number of fires or explosions and the number of patients with a burn injury during 2017-2028 both increased, but there was no significant change in disaster location, male-female ratio, age, average hospital stay, and average hospitalization expense.

Conclusion

In the face of the increasing prevalence of burn injuries, we should strengthen fire-fighting knowledge-related education and fire prevention management and actively explore post-burn injury treatment strategies and potential treatment targets to promote the development of burn injury management and treatment strategies.

Evaluation of Bromelain-Based Enzymatic Debridement Combined with Laser Doppler Imaging and Healing of Burn Wounds

Background

Accurate estimation of burn depth is crucial for correct treatment decision making. Bromelain-based enzymatic debridement (ED) may improve clinical assessment of burn depth. Laser Doppler imaging (LDI) provides a valuable indicator of burn depth by analyzing microcirculation within tissue beds. This study aimed to evaluate bromelain-based enzymatic debridement combined with laser Doppler imaging and healing of 42 wounds in 19 patients with mixed second- and third-degree thermal burns.

Material/Methods

We included 42 wounds in 19 patients with mixed deep dermal and full-thickness thermal burns. All patients were treated with eschar-specific removal agent for ED. The perfusion of each wound after ED was assessed using LDI. Healing time was estimated by 2 experienced burn surgeons and marked by the observation of epithelization. The usefulness of the LDI performed after ED in predicting healing time was estimated. The findings were analyzed to determine a cut-off value for LDI that indicates if a burn will heal spontaneously.

Results

We observed that burn wounds with higher mean perfusion healed faster. The analysis showed a strong relationship between perfusion after ED and healing time (Spearman rank correlation coefficient=−0.803). A mean perfusion greater than 296.89 indicated that the wound could heal spontaneously and does not require skin grafting.

Conclusions

LDI examination of an already debrided wound allows for a reliable assessment of perfusion at an early stage of treatment. The use of a safe and effective debridement method in conjunction with a non-invasive diagnostic tool could improve burn management.

Abdominoplasty Panniculus as a Source for Human Acellular Dermis: A Preliminary Report

BACKGROUND

In extensive deep dermal burn injuries, split-thickness skin graft (STSG) has been the most preferred treatment option for resurfacing burn wounds. A thick split-thickness skin graft is ideal for preventing graft contracture but is associated with delayed donor healing and the lack of adequate donor skin. When applied with STSG, the dermal substitutes offer better-reconstructed skin than STSG alone. Human-derived acellular dermal matrix (HADM) obtained from cadaver skin is a dermal equivalent with good clinical outcomes. However, high cost and limited cadaver donor skin availability limit its clinical utility. Developing a low-cost preparation method and finding an alternate source of human donated skin can help reduce the cost. The objective of this study was to explore the feasibility of making HADM from abdominoplasty panniculus skin.

METHODS

Skin samples were collected from the abdominoplasty panniculus of ten eligible donors with their informed consent. A combination of low-cost reagents-sodium chloride and hypotonic solution (water for injection) was used for decellularizing the skin. Characterization of the prepared Acellular Dermis Matrix prototype was done.

RESULTS

The skin was deepidermized with one molar NaCl treatment at 37 °C for 24 h. The deepidermized dermis became acellular with hypotonic solution treatment at 4 °C for two weeks. The hematoxylin and eosin staining and cytotoxicity test confirmed the acellularity and non-cytotoxicity of the prepared HADM prototype. The HADM prototype also facilitated the formation of neo-epithelium in the 3D cell co-culture model.

CONCLUSION

This study confirms that abdominoplasty panniculus can be a viable alternative for HADM preparation. Further characterization studies are required to prove the concept.

Biological Effects of Maslinic Acid on Human Epithelial Cells Used in Tissue Engineering

In the present work, we evaluated the potential of maslinic acid (MA) to improve currently available keratinocyte culture methods for use in skin tissue engineering. Results showed that MA can increase cell proliferation and WST-1 activity of human keratinocytes after 24, 48, and 72 h, especially at the concentration of 5 μg/ml, without affecting cell viability. This effect was associated to a significant increase of KI-67 protein expression and upregulation of several genes associated to cell proliferation (PCNA) and differentiation (cytokeratins, intercellular junctions and basement membrane related genes). When human keratinocytes were isolated from skin biopsies, we found that MA at the concentration of 5 μg/ml significantly increased the efficiency of the explant and the cell dissociation methods. These results revealed the positive effects of MA to optimize human keratinocyte culture protocols for use in skin tissue engineering.

Photodynamic therapy for treatment of infected burns

Burns are among the most debilitating and devastating forms of trauma. Such injuries are influenced by infections, causing increased morbidity, mortality, and healthcare costs. Due to the emergence of multidrug-resistant infectious agents, efficient treatment of infections in burns is a challenging issue. Antimicrobial photodynamic therapy (aPDT) is a promising approach to inactivate infectious agents, including multidrug-resistant. In this review, studies on PubMed were gathered, aiming to summarize the achievements regarding the applications of antimicrobial photodynamic therapy for the treatment of infected burns. A literature search was carried out for aPDT published reports assessment on bacterial, fungal, and viral infections in burns. The collected data suggest that aPDT could be a promising new approach against multidrug-resistant infectious agents. However, despite important results being obtained against bacteria, experimental and clinical studies are necessary yet on the effectiveness of aPDT against fungal and viral infections in burns, which could reduce morbidity and mortality of burned patients, mainly those infected by multidrug-resistant strains.

Estimation of the repair efficiency of collagen matrices on the model of thermal burn

Background. In the world, dozens of new local wound healing agents are developed and improved every year, which undergo preliminary tests on laboratory animals due to the presence of common phases of the course of the wound process with humans.

The aim of the study was to evaluate the wound healing effect of matrices obtained on the basis of the recycling of collagen-containing waste.

Materials and methods. Collagen matrices are obtained from substandard leather raw materials subjected to treatment with fermented milk composition (KM1) and lactic acid (KM2). The wound healing effect was studied on the model of thermal burns on Wistar rats in 5 groups: 1st – control (natural wound healing); 2nd – experimental 1 (processing KM1); 3rd – experimental 2 (processing KM2); 4th – experimental 3, comparison group (“Levomekol”) and 5th – intact animals (normal, without burns). Wound healing was assessed by the results of planimetry on days 1, 3, 5, 7, 9, and 13 and by histological analysis of the skin tissue on days 6, 13, and 20. On days 6 and 13, the summary antioxidant activity, the total content of leukocytes, erythrocytes, the activity of the catalase enzyme, and the content of malondialdehyde were determined in the blood of rats.

Results. With thermal damage to the skin, an IIIA degree burn was formed, accompanied by the development of dry coagulation necrosis. The use of collagen matrices restored the total content of leukocytes, reduced the area of the burn wound, normalized the content of malondialdehyde, the total antioxidant activity and the activity of catalase in the blood. Histomorphometric studies have confirmed the dynamics of skin tissue recovery after a burn. The effectiveness of the use of matrices was comparable to the pharmacopoeial drug “Levomekol”. A higher wound healing effect was noted when using the KM1 matrix.

Conclusion. On the model of thermal burn, the wound-healing effect of collagen matrices was established, as evidenced by the results of restoring the number of leukocytes, reducing the area of the burn wound and restoring the histostructure of the skin. One of the molecular and cellular mechanisms of wound healing is the inhibition of lipid peroxidation reactions and the restoration of the antioxidant potential of the body. 

The impact of initial surgical management on outcome in patients with severe burns: a 9-year retrospective analysis

PURPOSE

To investigate the prognostic value of the factors related to the initial surgical management of burn wounds in severely burned patients.

METHODS

A total of 189 severely burned adult patients who were admitted to our institute between January 2012 and December 2020 and met the inclusion criteria were recruited. Patients were divided into survival and nonsurvival groups. The patient data included sex, age, total burn surface area (TBSA), burn index (BI), inhalation injury, mechanical ventilation, initial surgical management of the burn wound (including post-injury time before surgery, surgical duration, surgical area, intraoperative fluid replenishment, intraoperative blood loss, and intraoperative urine output), and duration in the burn intensive care unit (BICU). Independent samples t tests, Mann-Whitney U tests, and χ 2 tests were performed on these data. those of which with statistically significant differences were subjected to univariate and multivariate Cox regression analyses to identify independent risk factors affecting the prognosis of severely burned patients. Receiver operating characteristic (ROC) curves were plotted, and the area under the curve (AUC), optimal cut-off value were calculated. Patients were divided into two groups, according to the optimal cut-off value of the independent risk factors. The TBSA, surgical area and survival rates of the two groups during hospitalization were analysed.

RESULTS

The survival group (146 patients) and the nonsurvival group (43 patients) differed significantly in TBSA, burn index, inhalation injury, mechanical ventilation, initial surgical area, intraoperative fluid replenishment, intraoperative blood loss, and duration in the BICU (P<0.05). Univariate Cox regression analysis showed that TBSA, burn index, mechanical ventilation, initial surgical area, intraoperative fluid replenishment, and intraoperative blood loss were risk factors for death in severely burned patients (P<0.05). Multivariate Cox regression analysis showed that the burn index and intraoperative blood loss were independent risk factors for death in severely burned patients (P<0.05). When the intraoperative blood loss during the initial surgical management of burn wounds was used to predict death in 189 severely burned patients, the AUC was 0.637 (95% confidence interval (CI): 0.545-0.730, P=0.006), and the optimal cut-off for intraoperative blood loss was 750 ml. Kaplan-Meier survival analysis showed that the prognosis of the group with intraoperative blood loss ≤750 ml was better than that of the group with intraoperative blood loss >750 ml (P=0.008). Meanwhile, the TBSA and surgical area in the group with intraoperative blood loss ≤750 ml were significantly lower than that of the group with intraoperative blood loss >750 ml (P<0.05).

CONCLUSION

The burn index and intraoperative blood loss during the initial surgical management of burn wounds are independent risk factors affecting the outcome of severely burned patients with good predictive values. During surgery, haemostatic and anaesthetic strategies should be adopted to reduce bleeding, and the bleeding volume should be controlled within 750 ml to improve the outcome.

Epidemiology of bloodstream infections and surface swab cultures in burn patients

Aim

For infection control in burn patients, it is essential to understand the epidemiology of bloodstream infection (BSI) and the local microbiological situation. There are few studies on blood and swab culture results among burn patients in Japan. The purpose of this study was to investigate the epidemiology of BSI and swab cultures in burn patients.

Methods

Data from 355 burn patients over 13 years from 2008 were analyzed retrospectively. Bloodstream infection was defined as the isolation of bacteria or fungi from two or more blood cultures. The characteristics of burn patients and microorganisms detected from various cultures were analyzed.

Results

The mortality rate among burn patients with BSI was 37.8%, which was more than twice that among burn patients without BSI. The univariate analysis showed that inhalation injury, total burn surface area (TBSA), and mortality were associated with BSI. The multivariate logistic analysis indicated that TBSA was an independent risk factor for BSI. The most frequently isolated organism from blood and swab cultures were Candida species and Pseudomonas aeruginosa, respectively. Seventy‐five percent of the microorganisms isolated from blood were detected previously in swab cultures performed within 1 week from blood cultures.

Conclusions

The prognosis of burn patients with BSI was poor, and TBSA was an independent risk factor for BSI. The predominant organisms isolated from blood and swab cultures were Candida species and P. aeruginosa, respectively. Surveillance wound swab cultures could be utilized for monitoring the local microbiological situation in burn patients.

Burn-Induced Coagulopathies: a Comprehensive Review

Burn-induced coagulopathy is not well understood, and consensus on diagnosis, prevention, and treatments are lacking. In this review, literature on burn-induced (and associated) coagulopathy is presented along with the current understanding of the effects of burn injury on the interactions among coagulation, fibrinolysis, and inflammation in the acute resuscitative phase and reconstructive phase of care. The role of conventional tests of coagulopathy and functional assays like thromboelastography or thromboelastometry will also be discussed. Finally, reported methods for the prevention and treatment of complications related to burn-induced coagulopathy will be reviewed.

Concomitant Pediatric Burns and Craniomaxillofacial Trauma

ABSTRACT

This study is the first to investigate pediatric craniomaxillofacial (CMF) trauma patients that present with concomitant burns. The authors aim to identify differing etiologies, presentations, facial fracture patterns, interventions, and outcomes between pediatric CMF trauma patients with versus without concomitant burns. In this retrospective cohort study of a tertiary care center between the years 1990 and 2010, concomitant burns were identified among pediatric patients presenting with CMF fractures. Patient charts were reviewed for demographics, presentation, burn characteristics (total body surface area %, location, and degree), imaging, interventions, involvement of child protective services, and long-term outcomes. Data were analyzed using two-tailed Student t tests and chi-square analysis. Of the identified 2966 pediatric CMF trauma patients (64.0% boys; age 7 ± 4.7 years), 10 (0.34%) patients presented with concomitant burns. Concomitant burn and CMF traumas were more likely to be due to penetrating injuries (P < 0.0001) and had longer hospital lengths of stay (13 ± 18.6 versus 4 ± 6.2 days, P < 0.0001). 40% were due to child abuse, 40% due to motor vehicle collisions, and 20% due to house fires. All four child abuse patients presented in a delayed fashion; operative burn care was prioritized and 70% of the CMF fractures were managed nonoperatively. Concomitant burn and CMF trauma is a rare injury pattern in pediatrics and warrants skeletal surveys with suspicious injury patterns. Future research is necessary to develop practice guidelines.

Extracorporeal membrane oxygenation combined with continuous renal replacement therapy for the treatment of severe burns: current status and challenges

Severe burns often cause various systemic complications and multiple organ dysfunction syndrome, which is the main cause of death. The lungs and kidneys are vulnerable organs in patients with multiple organ dysfunction syndrome after burns. Extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT) have been gradually applied in clinical practice and are beneficial for severe burn patients with refractory respiratory failure or renal dysfunction. However, the literature on ECMO combined with CRRT for the treatment of severe burns is limited. Here, we focus on the current status of ECMO combined with CRRT for the treatment of severe burns and the associated challenges, including the timing of treatment, nutrition support, heparinization and wound management, catheter-related infection and drug dosing in CRRT. With the advancement of medical technology, ECMO combined with CRRT will be further optimized to improve the outcomes of patients with severe burns.

A Pilot Study of Negative Pressure Therapy with Autologous Skin Cell Suspensions in a Porcine Model

BACKGROUND

Negative pressure wound therapy (NPWT) is an option for securing meshed split thickness skin grafts (mSTSGs) after burn excision to optimize skin graft adherence. Recently, the use of autologous skin cell suspension (ASCS) has been approved for use in the treatment of burn injuries in conjunction with mSTSGs.To date, limited data exists regarding the impact of NPWT on healing outcomes when the cellular suspension is utilized. It was hypothesized that NPWT would not negatively impact wound healing of ASCS+mSTSG.

MATERIALS AND METHODS

A burn, excision, mSTSG, ASCS ± NPWT model was used. Two Duroc pigs were utilized in this experiment, each with 2 sets of paired burns. Four wounds received mSTSG+ASCS+NPWT through post-operative day 3, and 4 wounds received mSTSG+ACSC+ traditional ASCS dressings. Cellular viability was characterized prior to spraying. Percent re-epithelialization, graft-adherence, pigmentation, elasticity, and blood perfusion and blood vessel density were assessed at multiple time points through 2 weeks.

RESULTS

All wounds healed within 14 days with minimal scar pathology and no significant differences in percent re-epithelialization between NPWT, and non-NPWT wounds were observed. Additionally, no differences were detected for pigmentation, perfusion, or blood vessel density. NPWT treated wounds had less graft loss and improved elasticity, with elasticity being statistically different.

CONCLUSIONS

These data suggest the positive attributes of the cellular suspension delivered are retained following the application of negative pressure. Re-epithelialization, revascularization, and repigmentation are not adversely impacted. The use of NPWT may be considered as an option when using ASCS with mSTSGs for the treatment of full-thickness burns.

Trichoderma longibrachiatum and Aspergillus fischeri Infection as a Cause of Skin Graft Failure in a Patient with Critical Burns after Liver Transplantation

Infectious complications are responsible for the majority of mortalities and morbidities of patients with critical burns. Although bacteria are the predominant etiological agents in such patients, yeasts and fungi have become relatively common causes of infections over the last decade. Here, we report a case of a young man with critical burns on 88% TBSA (total body surface area) arising as a part of polytrauma. The patient's history of orthotopic liver transplantation associated with the patient's need to use combined immunosuppressant therapy was an additional complication. Due to deep burns in the forearm region, we have (after a suitable wound bed preparation) applied a new bi-layered dermal substitute. The patient, however, developed a combined fungal infection in the region of this dermal substitute caused by Trichoderma longibrachiatum and Aspergillus fischeri (the first case ever reported). The infection caused the loss of the split-thickness skin grafts (STSGs); we had to perform repeated hydrosurgical and mechanical debridement and a systemic antifungal treatment prior to re-application of the STSGs. The subsequent skin transplant was successful.

Investigation on Potential of Novel Carrier System Containing Silver and Gold Nanoparticles for Burn Surgery: Evaluation in Rat Model

The main aim of the study was to optimization and evaluation of a suitable dosage form i.e., tropical gel containing silver and gold nanoparticles which are synthesized by green synthesis as this is the rapid and better alternative to chemical synthesis. For burn injury systemic route of administration is not suitable due to damaged skin hence tropical route selected to provide controlled effects, low systemic toxicity and easy application. Silver nanoparticles were synthesized by green synthesis by use of neem leaves and gold nanoparticles by Aloe vera. Characterization was done by UV spectroscopy, particle size distribution, TEM and zeta potential. Gel was formulated by simple mixing and stirring method and evaluated for color, homogeneity, Spreadability, viscosity, in vitro release, antimicrobial study and in vivo study. In this study, the combination of Carbopol 934 P and HPMC (ratio 1:3) was found to be ideal formulation (Formulation F5) with optimum viscosity and Spread-ability i.e., 4459 cP and 5.7 gmcm/sec resp. in vitro release was found to be 98.66% in 12 hours. in vitro antimicrobial study and in vivo study on rat showed maximum effects than standard formulations. From this study it can be concluded that, tropical gel is the superior dosage form containing silver and gold nanoparticles which acts as the antimicrobial agents and is effective in treatment of burn surgery.

The Complexity of Managing a Burned Irreducible Umbilical Hernia in an Adult

We present a case of a 65-year-old male with a longstanding non-symptomatic irreducible umbilical hernia who presented with a three-day-old full-thickness thermal burn to the hernia. The burn was sustained while operating a metal drop forger, where the patient was repeatedly exposed to 30-second bursts of heat from the furnace, with temperature exceeding 1350°C. He estimated he had this exposure approximately 48 times during an 8-hour shift, giving him a total of 24 minutes cumulative exposure to the heat. The patient reported that he normally wore an abdominal binder under his heat-resistant apron to temporarily flatten and protect his hernia. On the day of the injury, he had not been wearing this binder. The patient was initially unaware that he had sustained a burn; upon delayed presentation to the hospital, he had cellulitis surrounding a 0.25% total body surface area (TBSA) full-thickness burn. Contrast-enhanced CT abdomen demonstrated an umbilical hernia with a neck diameter of 2.3cm, with breach of the hernia fascia but no communication between the bowel and burnt tissue. After discussion between Plastic Surgery and General Surgery teams the decision was made to manage the burn non-operatively with daily flamazine dressings and empirical antibiotics for the cellulitis. Once this area had healed, elective mesh repair of the umbilical hernia was carried out. This is the first adult case of a full-thickness burn overlying an umbilical hernia to be reported in the literature. The case highlights both an unusual aetiology and a rare injury, as well as the multi-disciplinary teamwork required to manage it successfully.

Plasma Neutrophil-to-Lymphocyte Ratio on the Third Day Postburn is Associated with 90-Day Mortality Among Patients with Burns Over 30% of Total Body Surface Area in Two Chinese Burns Centers

INTRODUCTION

Neutrophil-to-lymphocyte ratio (NLR) is a marker of inflammation. This study aimed to evaluate the potential role of NLR to predict 90-day mortality.

METHODS

Data of 577 patients with burns over 30% of total body surface area were collected and retrospectively analyzed. The risk factors for 90-day mortality were evaluated using logistic regression analyses. Receiver operating characteristic (ROC) curve analysis of the 3rd day NLR was performed and the optimal cut-off value was calculated. The 90-day mortality rates were compared between high and low NLR groups using Kaplan-Meier analysis.

RESULTS

Age, mechanical ventilation, burn index, 3rd day NLR, and 7th day red blood cell and platelet (PLT) counts were found to be independent predictive values for 90-day mortality. In contrast, percentage of total body surface area burned, inhalation injury, 1st day white blood cell and neutrophil counts, the 3rd day lymphocytes and PLT counts, and 7th day hemoglobin level were not independently associated with 90-day mortality. The area under the ROC curve of the 3rd day NLR for severe burn-delayed death prediction was 0.665 (95% confidence interval, 0.591-0.739), and the optimal cut-off value of the 3rd day NLR was 10.50. The 90-day mortality rates differed significantly between the NLR >10.5 group and the NLR ≤ 10.5 group (17.03% vs 5.92%, respectively; P < 0.01).

CONCLUSION

These results suggested that the 3rd day NLR was associated with an increased risk of death in severely burned patients; thus, it can provide useful information to predict 90-day mortality.

A comparison on the scar development when done through overlapping versus approximating seams techniques - A clinical trial

INTRODUCTION

Skin autografting is performed widely for deep burn wounds as an ideal coverage. Scaring at the site of grafting has been always a challenge for surgeons. Many methods have been proposed to lessen the probability of scaring, but conflicting results have been obtained. It is said that the suture type is important in the development of scaring. Seams technique has also been introduced to decrease scar after autografting.

OBJECTIVE

We sought to compare two approximating (AP) and overlapping (OV) Seams technique to compare the development of scars.

METHODS AND MATERIALS

Patients with deep burns of 10% to 50% TBSA who were candidates for grafting entered this double-blind randomized trial. One side of the graft was fixed with a stapler using the "approximating" technique and the other side was fixed by the "overlapping" technique with a 1-2 mm margin overlap. The Vancouver Scar Scale (VSS) standard was used to evaluate scar formation at the graft edges at six months. Data entered SPSS 16 and analyzed. A P-value below 0.05 was considered as statistically significant.

RESULTS

Thirty-six patients entered. Two (5.6%) were females and 34 (94.4%) males. The mean age of patients was 39.14 ± 8.53 years. The mean burn surface area percentage was 15.2 ± 2.84. Vascularity Scar index had no statistically significant difference between the overlapping and approximating techniques (P = 0.564). However, pigmentation (P = 0.014), pliability (P = 0.008) and the height indices (P < 0.001) were statistically significantly better in the approximating technique. The mean of total score of Vancouver was better in the approximating technique as well (P < 0.001).

CONCLUSION

We compared two techniques of Seams between the normal skin and the graft edge for the first time. We showed that the AP method had a better Vancouver score compared to the OV regarding pigmentation, height, and pliability indices.

The prognostic nutritional index on postoperative day one is associated with one-year mortality after burn surgery in elderly patients

BACKGROUND

Burn injury in elderly patients can result in poor outcomes. Prognostic nutritional index (PNI) can predict the perioperative nutritional status and postoperative outcomes. We aim to evaluate the risk factors, including PNI, for one-year mortality after burn surgery in elderly patients.

METHODS

Burn patients aged ≥65 years were retrospectively included. PNI was calculated using the following equation: 10 × serum albumin level (g/dL) + 0.005 × total lymphocyte count (per mm³). Cox regression, receiver operating characteristic curve and Kaplan-Meier survival analyses were performed to evaluate the risk factors for postoperative one-year mortality.

RESULTS

Postoperative one-year mortality occurred in 71 (37.6%) of the 189 elderly burn patients. Risk factors for one-year mortality were PNI on postoperative day one (hazard ratio (HR) = 0.872; 95% CI = 0.812-0.936; p < 0.001), Sequential Organ Failure Assessment score (HR = 1.112; 95% CI = 1.005-1.230; p = 0.040), American Society of Anesthesiologists physical status (HR = 2.064; 95% CI = 1.211-3.517; p = 0.008), total body surface area burned (HR = 1.017; 95% CI = 1.003-1.032; p = 0.015) and preoperative serum creatinine level (HR = 1.386; 95% CI = 1.058-1.816; p = 0.018). The area under the curve of PNI for predicting one-year mortality after burn surgery was 0.774 (optimal cut-off value = 25.5). Patients with PNI ≤25.5 had a significantly lower one-year survival rate than those with PNI >25.5 (32.1% vs 75.9%, p < 0.001).

CONCLUSIONS

PNI on postoperative day one was associated with postoperative one-year mortality in elderly burn patients. The postoperative one-year survival rate was lower in patients with PNI ≤25.5 than in those with PNI >25.5. These findings indicate the importance of identifying elderly burn patients with low PNI, thereby reducing the mortality after burn surgery.

Generation of a novel human dermal substitute functionalized with antibiotic-loaded nanostructured lipid carriers (NLCs) with antimicrobial properties for tissue engineering

BACKGROUND

Treatment of patients affected by severe burns is challenging, especially due to the high risk of Pseudomonas infection. In the present work, we have generated a novel model of bioartificial human dermis substitute by tissue engineering to treat infected wounds using fibrin-agarose biomaterials functionalized with nanostructured lipid carriers (NLCs) loaded with two anti-Pseudomonas antibiotics: sodium colistimethate (SCM) and amikacin (AMK).

RESULTS

Results show that the novel tissue-like substitutes have strong antibacterial effect on Pseudomonas cultures, directly proportional to the NLC concentration. Free DNA quantification, WST-1 and Caspase 7 immunohistochemical assays in the functionalized dermis substitute demonstrated that neither cell viability nor cell proliferation were affected by functionalization in most study groups. Furthermore, immunohistochemistry for PCNA and KI67 and histochemistry for collagen and proteoglycans revealed that cells proliferated and were metabolically active in the functionalized tissue with no differences with controls. When functionalized tissues were biomechanically characterized, we found that NLCs were able to improve some of the major biomechanical properties of these artificial tissues, although this strongly depended on the type and concentration of NLCs.

CONCLUSIONS

These results suggest that functionalization of fibrin-agarose human dermal substitutes with antibiotic-loaded NLCs is able to improve the antibacterial and biomechanical properties of these substitutes with no detectable side effects. This opens the door to future clinical use of functionalized tissues.

Factors impacting time to surgery and the effect on in-hospital mortality

OBJECTIVES

Early surgery improves outcomes after burn injuries but is often not available in limited resource settings (LRS), where a more conservative approach is widespread. This study aimed to analyze factors associated with delay in surgical treatment, and the impact on in-hospital mortality.

METHODS

All patients with burns treated with surgery between 2016 and 2019 at the Pietermaritzburg Burn Service, in South Africa, were included in this retrospective study. Early surgery was defined as patients who underwent surgery within 7 days from injury. The population was analyzed descriptively and differences between groups were tested using t-test, and χ2 test or Fisher's exact test, as appropriate. Multivariable logistic regression was used to analyze the effect of delay in surgical treatment on in-hospital mortality, after adjustment for confounders.

RESULTS

During the study period, 620 patients with burns underwent surgery. Of them, 16% had early surgery. The early surgery group had a median age and TBSA of 11 years (3-35) and 12.0% (5-22) compared to 7 years (2-32) and 6.0% (3-13) in the late surgery group (p=0.45, p<0.001). In logistic regression, female sex [aOR: 3.30 (95% CI: 1.47-7.41)], TBSA% [aOR: 1.09 (95% CI: 1.05-1.12)], and FTB [aOR: 3.21 (95% CI: 1.43-7.18)] were associated with in-hospital mortality, whereas having early surgery was not [aOR: 1.74 (95% CI: 0.76-3.98)].

CONCLUSION

This study found that early surgery was not associated with in-hospital mortality. Independent predictors of in-hospital mortality were female sex, presence of full thickness burn, and larger burn size. Future studies should investigate if burn care capacity in LRS may influence the association between early excision and outcome.

Trends in burn injury mortality in Spain (1979-2018): Sex-specific age-cohort-period effects

BACKGROUND

Previous studies about burns mortality are often exclusively based on hospital and burn centre data. National population-based reports on this topic are rather limited. The aim of this study was to analyse sex- and age-specific mortality rates of burns in Spain during the period 1979-2018.

METHODS

Age-standardised burns mortality rates were calculated from death records and mid-year population data were provided by the Spanish National Statistics Institute. Joinpoint regression analyses were used to identify significant points of change in trends over time and to compute average annual per cent change (AAPC). Age, period and cohort effects were also analysed.

RESULTS

Mortality due to burn injury decreased in both sexes between 1979 and 2018: from the first quinquennium of this period up to the last one age-adjusted mortality rates decreased from 1.37 to 0.49 per 100,000 in men and from 0.96 to 0.26 per 100,000 in women.

CONCLUSIONS

Burns mortality rates in Spain have been decreasing during the last decades. Promotion of primary prevention measures should continue.