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Cao LL, Yang ZG, Qi WH, Zhang H, Bi Y, Shan Y, Cui XW, Jiang F. A preliminary study on ultrasound techniques applied to evaluate the curative effect of botulinum toxin type a in hypertrophic scars. Heliyon 2024; 10:e34723. [PMID: 39144951 PMCID: PMC11320163 DOI: 10.1016/j.heliyon.2024.e34723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 07/12/2024] [Accepted: 07/15/2024] [Indexed: 08/16/2024] Open
Abstract
Objective To validate the feasibility of ultrasound in assessing the curative effect of botulinum toxin type A (BTXA) in treating hypertrophic scar (HS). Methods Eight healthy New Zealand long-eared rabbits were utilized in the study. Four wounds, each measuring 1.0 cm in diameter, were created on both ears of each rabbit. Immediately after surgery, each of these wounds received an injection containing a distinct concentration of BTXA. On postoperative week 6, scar thickness, vascularity, and hardness were assessed based on high frequency ultrasound (HFUS), superb microvascular imaging (SMI), shear wave elastography (SWE), Masson staining, and immunohistochemical staining for CD31. Results All wounds healed well, and HSs formed after 6 weeks post-surgery. Scar thickness based on HFUS presented a significant decrease with increasing BTXA concentration (p < 0.05), aligning with the gross morphology. Simultaneously, scar stiffness, evaluated using SWE, showed a significant decrease in accordance with the variation of the collagen volume fraction, which refers to the ratio of the collagen positive area to the total area (p < 0.05). Although the vascularity index obtained by SMI did not exhibit a statistically significant change across different BTXA concentrations, this technique effectively illustrated the microvascular perfusion in HS. Immunohistochemical staining for CD31 revealed that BTXA inhibited angiogenesis. Conclusion HFUS and SWE displayed excellent performance in evaluating HS thickness and stiffness. SMI showed a good performance in reflecting microvascular signals in HS. These ultrasound techniques have great potential in assessing the therapeutic effect of BTXA in HS.
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Affiliation(s)
- Liu-liu Cao
- Department of Medical Ultrasound, The Second Hospital of Anhui Medical University, Hefei, 230601, Anhui Province, China
| | - Zhi-guo Yang
- Department of Plastic and Reconstructive Surgery, The Second Hospital of Anhui Medical University, Hefei, 230601, Anhui Province, China
| | - Wei-hong Qi
- Department of Medical Ultrasound, The Second Hospital of Anhui Medical University, Hefei, 230601, Anhui Province, China
| | - Huan Zhang
- Department of Medical Ultrasound, The Second Hospital of Anhui Medical University, Hefei, 230601, Anhui Province, China
| | - Yu Bi
- Department of Medical Ultrasound, The Second Hospital of Anhui Medical University, Hefei, 230601, Anhui Province, China
| | - Yong Shan
- Department of Medical Ultrasound, The Second Hospital of Anhui Medical University, Hefei, 230601, Anhui Province, China
| | - Xin-wu Cui
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan Province, China
| | - Fan Jiang
- Department of Medical Ultrasound, The Second Hospital of Anhui Medical University, Hefei, 230601, Anhui Province, China
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Meikle B, Simons M, Mahoney T, Reddan T, Dai B, Kimble RM, Tyack Z. Ultrasound measurement of traumatic scar and skin thickness: a scoping review of evidence across the translational pipeline of research-to-practice. BMJ Open 2024; 14:e078361. [PMID: 38594186 PMCID: PMC11015304 DOI: 10.1136/bmjopen-2023-078361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 03/18/2024] [Indexed: 04/11/2024] Open
Abstract
OBJECTIVES To identify the ultrasound methods used in the literature to measure traumatic scar thickness, and map gaps in the translation of these methods using evidence across the research-to-practice pipeline. DESIGN Scoping review. DATA SOURCES Electronic database searches of Ovid MEDLINE, Embase, Cumulative Index of Nursing and Allied Health Literature and Web of Science. Grey literature searches were conducted in Google. Searches were conducted from inception (date last searched 27 May 2022). DATA EXTRACTION Records using brightness mode (B-mode) ultrasound to measure scar and skin thickness across the research-to-practice pipeline of evidence were included. Data were extracted from included records pertaining to: methods used; reliability and measurement error; clinical, health service, implementation and feasibility outcomes; factors influencing measurement methods; strengths and limitations; and use of measurement guidelines and/or frameworks. RESULTS Of the 9309 records identified, 118 were analysed (n=82 articles, n=36 abstracts) encompassing 5213 participants. Reporting of methods used was poor. B-mode, including high-frequency (ie, >20 MHz) ultrasound was the most common type of ultrasound used (n=72 records; 61% of records), and measurement of the combined epidermal and dermal thickness (n=28; 24%) was more commonly measured than the epidermis or dermis alone (n=7, 6%). Reliability of ultrasound measurement was poorly reported (n=14; 12%). The scar characteristics most commonly reported to be measured were epidermal oedema, dermal fibrosis and hair follicle density. Most records analysed (n=115; 97%) pertained to the early stages of the research-to-practice pipeline, as part of research initiatives. CONCLUSIONS The lack of evaluation of measurement initiatives in routine clinical practice was identified as an evidence gap. Diverse methods used in the literature identified the need for greater standardisation of ultrasound thickness measurements. Findings have been used to develop nine methodological considerations for practitioners to guide methods and reporting.
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Affiliation(s)
- Brandon Meikle
- Centre for Children's Burns and Trauma Research, Queensland Children's Hospital, South Brisbane, Queensland, Australia
- Children's Health Research Centre, The University of Queensland Faculty of Medicine, South Brisbane, Queensland, Australia
| | - Megan Simons
- Children's Health Research Centre, The University of Queensland Faculty of Medicine, South Brisbane, Queensland, Australia
- Occupational Therapy, Queensland Children's Hospital, South Brisbane, Queensland, Australia
- Pegg Leditschke Children's Burns Centre, Children's Health Queensland Hospital and Health Service, South Brisbane, Queensland, Australia
| | - Tamsin Mahoney
- Surgical, Treatment and Rehabilitation Services (STARS), Metro North Hospital and Health Service, Herston, Queensland, Australia
| | - Tristan Reddan
- Medical Imaging and Nuclear Medicine, Children's Health Queensland Hospital and Health Service, South Brisbane, Queensland, Australia
- School of Clinical Sciences, Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Bryan Dai
- The University of Queensland, Saint Lucia, Queensland, Australia
| | - Roy M Kimble
- Centre for Children's Burns and Trauma Research, Queensland Children's Hospital, South Brisbane, Queensland, Australia
- Children's Health Research Centre, The University of Queensland Faculty of Medicine, South Brisbane, Queensland, Australia
- Pegg Leditschke Children's Burns Centre, Children's Health Queensland Hospital and Health Service, South Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Saint Lucia, Queensland, Australia
| | - Zephanie Tyack
- Children's Health Research Centre, The University of Queensland Faculty of Medicine, South Brisbane, Queensland, Australia
- Australian Centre for Health Service Innovation (AusHI), Centre for Healthcare Transformation, and School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
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Liu Y, Xiong X, Cao N, Zhao Y. Diagnosis and Treatment of Keloid: Method Summary and Effect Evaluation. Clin Cosmet Investig Dermatol 2023; 16:3775-3783. [PMID: 38170138 PMCID: PMC10759814 DOI: 10.2147/ccid.s446018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Accepted: 12/18/2023] [Indexed: 01/05/2024]
Abstract
Keloid is a prevalent skin disorder characterized by the abnormal growth of keloid tissue, which usually occurs following wound healing or surgical incisions. It typically progresses through several stages: the inflammatory stage, the proliferative stage, collagen remodeling, and ultimately the formation of keloid. This review aims to summarize the diagnostic and therapeutic methods for keloid, and evaluate their effectiveness. The diagnosis of keloid is usually based on medical history and clinical manifestations such as pain, itching, erythema, and induration. Other commonly used diagnostic methods include tissue biopsy and ultrasound examination. Various treatment options for keloid exist, including physical therapy, medication, surgical treatment, and radiation therapy. Physical therapy includes pressure therapy, laser therapy, such as silicone sheets, elastic bandages, and laser irradiation. Medication treatment mainly involves the application of topical medications or intralesional injections, such as topical corticosteroids, 5-fluorouracil, and others. Radiation therapy can be administered using applicators and superficial radiation therapy, among other methods. The treatment outcomes of keloid vary from person to person and recurrence is common. Therefore, a comprehensive treatment approach may be the most effective strategy. Individualized treatment plans should consider factors such as the patient's age, gender, medical history, and the severity of the condition. In conclusion, the diagnosis and treatment of keloid require consideration of multiple factors and the implementation of individualized treatment plans. Future research should focus on identifying the molecular mechanisms underlying the occurrence and progression of keloid in order to develop more effective treatment methods.
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Affiliation(s)
- Yu Liu
- Nuclear Medicine Department, Jilin University Second Hospital, Changchun, Jilin Province, People’s Republic of China
| | - Xiaoliang Xiong
- Nuclear Medicine Department, Jilin University Second Hospital, Changchun, Jilin Province, People’s Republic of China
| | - Nan Cao
- Nuclear Medicine Department, Jilin University Second Hospital, Changchun, Jilin Province, People’s Republic of China
| | - Yinlong Zhao
- Nuclear Medicine Department, Jilin University Second Hospital, Changchun, Jilin Province, People’s Republic of China
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Correlation between elastic modulus and clinical severity of pathological scars: a cross-sectional study. Sci Rep 2021; 11:23324. [PMID: 34857833 PMCID: PMC8639709 DOI: 10.1038/s41598-021-02730-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 11/10/2021] [Indexed: 12/19/2022] Open
Abstract
Though widely used to assess pathological scars, the modified Vancouver Scar Scale (mVSS) is neither convenient nor objective. Shear wave elastography (SWE) is used to evaluate the stiffness of pathological scars. We aimed to determine the correlation between mVSS score and elastic modulus (EM) measured by SWE for pathological scars. Clinical information including ultrasound (US) results of the enrolled patients with pathological scars was analyzed. The clinical severity of the pathological scars was evaluated by mVSS. Skin stiffness, as represented by EM, was calculated using SWE. The average EM of the whole scar (EMWHOLE), hardest part of the scar (EMHARDEST), and normal appearance of the skin around the scar (EMNORMAL) were also recorded. Enrolled in this study were 69 pathological scars, including 28 hypertrophic scars and 41 keloids. The univariable regression analyses showed that the EM of pathological scars was closely related to mVSS score, while the linear multivariable regression analyses showed no significantly correlation. Curve fitting and threshold effect analysis revealed that when EMWHOLE was less than 166.6 kPa or EMHARDEST was less than 133.07 kPa, EM was positively correlated with mVSS score. In stratified analysis, there was no significant linear correlation and threshold effect between EMWHOLE and mVSS score in hypertrophic scars or keloids. However, the fully adjusted smooth curves presented a linear association between mVSS score and EMHARDEST in keloids (the adjusted β [95% CI] was 0.010 [0.001, 0.018]), but a threshold and nonlinear association were found in hypertrophic scars. When EMHARDEST was less than 156.13 kPa, the mVSS score increased along with the hardest scar part stiffness; the adjusted β (95% CI) was 0.024 (0.009, 0.038). In conclusion, EM of pathological scars measured by SWE were correlated with mVSS within a threshold range, and showed different association patterns in hypertrophic scars and keloids.
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Rosicka K, Mierzejewska-Krzyżowska B, Mrówczyński W. Skin biomechanical and viscoelastic properties measured with MyotonPRO in different areas of human body. Skin Res Technol 2021; 28:236-245. [PMID: 34751466 PMCID: PMC9907614 DOI: 10.1111/srt.13116] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 10/16/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND There is still a lack of clinically practical device, which allows to perform rapid and accurate examination of the skin condition. For this reason, suitability of the MyotonPRO for the assessment of skin biomechanical and viscoelastic parameters was evaluated in this study. The aim of the study was to establish the reference values of five parameters measured by MyotonPRO various locations of human skin. MATERIALS AND METHODS Oscillation frequency, dynamic stiffness, logarithmic decrement, mechanical stress relaxation and creep were measured at three different skin locations (clavicula, volar forearm and shin), using L-shape short and medium arm probes in 32 young female volunteers. Mean values of obtained parameters recorded by both probes were compared among three skin locations while reliabilities of measurements were assessed. Additionally, relationships between all recorded parameters were examined RESULTS: There were no statistically significant differences between the mean values of five measured parameters obtained with both probes in all investigated areas. However, statistically significant differences of mean values of almost all parameters measured among three places examined were found. Despite considerable differences in mean values of obtained parameters, there were visible strong correlations between some studied parameters in all three investigated areas of skin. CONCLUSION It was demonstrated in all locations studied that the higher value of oscillation frequency corresponds to the higher value of dynamic stiffness, moreover such tissue recovers faster to its initial shape, and it was characterized by lower creep values. Such results indicate the existence of identical relationships between the same studied parameters in different areas of skin.
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Affiliation(s)
- Katarzyna Rosicka
- Department of Biological Sciences, Faculty of Physical Culture, Poznań University of Physical Education, Gorzów Wielkopolski, Poland
| | - Barbara Mierzejewska-Krzyżowska
- Department of Biological Sciences, Faculty of Physical Culture, Poznań University of Physical Education, Gorzów Wielkopolski, Poland
| | - Włodzimierz Mrówczyński
- Department of Neurobiology, Faculty of Health Sciences, Poznań University of Physical Education, Poznań, Poland
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Tang X, Zhu B, Tian M, Guo R, Huang S, Tang Y, Qiu L. Preliminary study on the influencing factors of shear wave elastography for peripheral nerves in healthy population. Sci Rep 2021; 11:5582. [PMID: 33692411 PMCID: PMC7946935 DOI: 10.1038/s41598-021-84900-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 02/23/2021] [Indexed: 02/08/2023] Open
Abstract
This study took shear wave elastography (SWE) technology to measure the shear wave velocity (SWV) of peripheral nerve in healthy population, which represents the stiffness of the peripheral nerves, and research whether these parameters (location, age, sex, body mass index (BMI), the thickness and cross-sectional area(CSA) of the nerve) would affect the stiffness of the peripheral nerves. 105 healthy volunteers were enrolled in this study. We recorded the genders and ages of these volunteers, measured height and weight, calculated BMI, measured nerve thickness and CSA using high-frequency ultrasound (HFUS), and then, we measured and compared the SWV of the right median nerve at the middle of the forearm and at the proximal entrance of the carpal tunnel. The SWV of the median nerve of the left side was measured to explore whether there exist differences of SWV in bilateral median nerve. Additionally, we also measured the SWV of the right tibial nerve at the ankle canal to test whether there is any difference in shear wave velocity between different peripheral nerves. This study found that there existed significant differences of SWV between different sites in one nerve and between different peripheral nerves. No significant difference was found in SWV between bilateral median nerves. Additionally, the SWV of peripheral nerves was associated with gender, while not associated with age or BMI. The mean SWV of the studied male volunteers in median nerve were significantly higher than those of female (p < 0.05). Peripheral nerve SWE measurement in healthy people is affected by different sites, different nerves and genders, and not associated with age, BMI, nerve thickness or CSA.
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Affiliation(s)
- Xinyi Tang
- Department of Medical Ultrasound, West China Hospital of Sichuan University, No.37 Guoxue Alley, Chengdu, 610041, Sichuan Province, People's Republic of China
| | - Bihui Zhu
- Department of Medical Ultrasound, West China Hospital of Sichuan University, No.37 Guoxue Alley, Chengdu, 610041, Sichuan Province, People's Republic of China
| | - Mei Tian
- Department of Medical Ultrasound, West China Hospital of Sichuan University, No.37 Guoxue Alley, Chengdu, 610041, Sichuan Province, People's Republic of China
| | - Ruiqian Guo
- Department of Medical Ultrasound, West China Hospital of Sichuan University, No.37 Guoxue Alley, Chengdu, 610041, Sichuan Province, People's Republic of China
| | - Songya Huang
- Department of Medical Ultrasound, West China Hospital of Sichuan University, No.37 Guoxue Alley, Chengdu, 610041, Sichuan Province, People's Republic of China
| | - Yuanjiao Tang
- Department of Medical Ultrasound, West China Hospital of Sichuan University, No.37 Guoxue Alley, Chengdu, 610041, Sichuan Province, People's Republic of China
| | - Li Qiu
- Department of Medical Ultrasound, West China Hospital of Sichuan University, No.37 Guoxue Alley, Chengdu, 610041, Sichuan Province, People's Republic of China.
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Rosicka K, Mierzejewska-Krzyżowska B, Mrówczyński W. Comparison of different MyotonPRO probes for skin stiffness evaluation in young women. Skin Res Technol 2020; 27:332-339. [PMID: 33078499 DOI: 10.1111/srt.12946] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 09/05/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Stiffness of skin is widely used parameter in many research areas, for example cosmetic industry, dermatology or rheumatology for assessing of skin condition as well as changes occurring in skin. In this pioneering study, we conducted measurements of skin stiffness using MyotonPRO -novel tool, which was mainly used to evaluate biomechanical properties of muscles, ligaments and tendons. We expected that MyotonPRO , which shows great reproducibility in previous studies, will also be able to measure skin stiffness. MATERIALS AND METHODS Four replaceable probes designed by MyotonPRO (L-shape short and medium arm, standard cylindrical flat-end probe and the same standard probe with disc attachment ) were tested for measurement of skin stiffness in young women (30 healthy females) at three different locations (clavicula, volar forearm and shin). RESULTS There was no significant difference between stiffness values obtained with L-shape short and L-shape medium arm probes in all investigated areas. Stiffness values recorded by regular probe and regular probe with disc attachment differ significantly from those collected with L-shape probes. There was also significant difference between values of stiffness obtained by standard with disc attachment and standard probes. CONCLUSION Both L-shape probes show a great reliability for skin stiffness assessment. Therefore, MyotonPRO can be considered a reliable device for assessing skin stiffness.
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Affiliation(s)
- Katarzyna Rosicka
- Department of Biological Sciences, Faculty of Physical Culture in Gorzów Wlkp., Poznań University of Physical Education, Gorzów Wlkp., Poland
| | - Barbara Mierzejewska-Krzyżowska
- Department of Biological Sciences, Faculty of Physical Culture in Gorzów Wlkp., Poznań University of Physical Education, Gorzów Wlkp., Poland
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DeJong H, Abbott S, Zelesco M, Spilsbury K, Ziman M, Kennedy BF, Martin L, Wood FM. Objective quantification of burn scar stiffness using shear-wave elastography: Initial evidence of validity. Burns 2020; 46:1787-1798. [PMID: 32534890 DOI: 10.1016/j.burns.2020.05.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 04/21/2020] [Accepted: 05/12/2020] [Indexed: 12/18/2022]
Abstract
Shear-wave elastography (SWE) is an ultrasound based technology that can provide reliable measurements (velocity) of scar stiffness. The aim of this research was to evaluate the concurrent validity of using both the measured velocity and the calculated difference in velocity between scars and matched controls, in addition to evaluating potential patient factors that may influence the interpretation of the measurements. METHODS A cross-sectional study of 32 participants, with 48 burn scars and 48 matched contralateral control sites were evaluated with SWE, the Vancouver Scar Scale (VSS) and the Patient and Observer Scar Assessment Scale (POSAS) tactile sub-scores. RESULTS Spearman's rho demonstrated high correlations (r > 0.7) between the measured scar velocity and both the POSAS and VSS pliability sub-scores, whereas moderate correlations (r > 0.6) were found with the calculated difference in velocity. Regression analysis indicated that the association of increased velocity in scars, varied by length of time after burn injury and gender. Body location and Fitzpatrick skin type also demonstrated significant associations with velocity, whereas age did not. CONCLUSION SWE shows potential as a novel tool to quantify burn scar stiffness, however patient factors need to be considered when interpreting results. Further research is recommended on a larger variety of scars to support the findings.
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Affiliation(s)
- Helen DeJong
- Perth Scar and Pain Clinic, 2/5 Norfolk Street, Fremantle, Western Australia 6160, Australia; School of Medical and Health Science, Edith Cowan University, 270 Joondalup Drive, Joondalup, Western Australia 6027, Australia; BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre Nedlands and Centre for Medical Research, The University of Western Australia, 35 Stirling Hwy, Crawley, Western Australia 6009, Australia; Fiona Wood Foundation, Fiona Stanley Hospital, 11 Robin Warren Dr, Murdoch, Western Australian 6150, Australia.
| | - Steven Abbott
- Department of Medical Imaging, Fiona Stanley Hospital, 11 Robin Warren Dr, Murdoch, Western Australian, 6150, Australia
| | - Marilyn Zelesco
- Department of Medical Imaging, Fiona Stanley Hospital, 11 Robin Warren Dr, Murdoch, Western Australian, 6150, Australia
| | - Katrina Spilsbury
- Institute for Health Research, University of Notre Dame Australia, Fremantle, Western Australia, Australia
| | - Melanie Ziman
- School of Medical and Health Science, Edith Cowan University, 270 Joondalup Drive, Joondalup, Western Australia 6027, Australia; School of Biomedical Science, The University of Western Australia, 35 Stirling Hwy, Crawley, Western Australia 6009, Australia
| | - Brendan F Kennedy
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre Nedlands and Centre for Medical Research, The University of Western Australia, 35 Stirling Hwy, Crawley, Western Australia 6009, Australia; Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, 35 Stirling Hwy, Crawley, 6009, Western Australia, Australia; Australian Research Council Centre for Personalised Therapeutics Technologies, Australia
| | - Lisa Martin
- Fiona Wood Foundation, Fiona Stanley Hospital, 11 Robin Warren Dr, Murdoch, Western Australian 6150, Australia
| | - Fiona M Wood
- Fiona Wood Foundation, Fiona Stanley Hospital, 11 Robin Warren Dr, Murdoch, Western Australian 6150, Australia; Burn Injury Research Unit, The University of Western Australia, 35 Stirling Hwy, Crawley, Western Australia 6009, Australia; Burn Service of Western Australia, Fiona Stanley Hospital, 11 Robin Warren Dr, Murdoch, Western Australian 6150, Australia
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