A Critical Update of the Assessment and Acute Management of Patients with Severe Burns

Challenges in the Management of Large Burns

Large burns provoke profound pathophysiological changes. Survival rates of patients with large burns have improved significantly with the advancement of critical care and adaptation of early excision protocols. Nevertheless, care of large burn wounds remains challenging secondary to limited donor sites, prolonged time to wound closure, and immunosuppression. The development of skin substitutes and new grafting techniques decreased time to wound closure. Individually, these methods have limited success, but a combination of them may yield more successful outcomes. Early identification of patients with likely poor prognosis should prompt goals of care discussion and involvement of a palliative care team when possible.

Advancements in Regenerative Hydrogels in Skin Wound Treatment: A Comprehensive Review

This state-of-the-art review explores the emerging field of regenerative hydrogels and their profound impact on the treatment of skin wounds. Regenerative hydrogels, composed mainly of water-absorbing polymers, have garnered attention in wound healing, particularly for skin wounds. Their unique properties make them well suited for tissue regeneration. Notable benefits include excellent water retention, creating a crucially moist wound environment for optimal healing, and facilitating cell migration, and proliferation. Biocompatibility is a key feature, minimizing adverse reactions and promoting the natural healing process. Acting as a supportive scaffold for cell growth, hydrogels mimic the extracellular matrix, aiding the attachment and proliferation of cells like fibroblasts and keratinocytes. Engineered for controlled drug release, hydrogels enhance wound healing by promoting angiogenesis, reducing inflammation, and preventing infection. The demonstrated acceleration of the wound healing process, particularly beneficial for chronic or impaired healing wounds, adds to their appeal. Easy application and conformity to various wound shapes make hydrogels practical, including in irregular or challenging areas. Scar minimization through tissue regeneration is crucial, especially in cosmetic and functional regions. Hydrogels contribute to pain management by creating a protective barrier, reducing friction, and fostering a soothing environment. Some hydrogels, with inherent antimicrobial properties, aid in infection prevention, which is a crucial aspect of successful wound healing. Their flexibility and ability to conform to wound contours ensure optimal tissue contact, enhancing overall treatment effectiveness. In summary, regenerative hydrogels present a promising approach for improving skin wound healing outcomes across diverse clinical scenarios. This review provides a comprehensive analysis of the benefits, mechanisms, and challenges associated with the use of regenerative hydrogels in the treatment of skin wounds. In this review, the authors likely delve into the application of rational design principles to enhance the efficacy and performance of hydrogels in promoting wound healing. Through an exploration of various methodologies and approaches, this paper is poised to highlight how these principles have been instrumental in refining the design of hydrogels, potentially revolutionizing their therapeutic potential in addressing skin wounds. By synthesizing current knowledge and highlighting potential avenues for future research, this review aims to contribute to the advancement of regenerative medicine and ultimately improve clinical outcomes for patients with skin wounds.

The Role of Ketamine as a Component of Multimodal Analgesia in Burns: A Retrospective Observational Study

Background: Burn wound dressing and debridement are excruciatingly painful procedures that call for appropriate analgesia-typically multimodal. Better post-procedural pain management, less opioid use, and consequently fewer side effects, which could prolong recovery and increase morbidity, are all benefits of this type of analgesia. Intravenously administered ketamine can be effective as monotherapy or in combination with opioids, especially with procedural sedation such as in burn wound dressing. Methods: This observational study investigated the effect of ketamine administered in subanesthetic doses combined with opioids during burn wound dressing. The study was conducted from October 2018 to October 2021. A total of 165 patients met the inclusion criteria. A total of 82 patients were in the ketamine group, while 83 patients were dressed without ketamine. The main outcome was the effect of ketamine on intraprocedural opioid consumption. The secondary outcome included the effect of ketamine on postprocedural pain control. Results: Patients dressed with ketamine were significantly older (p = 0.001), while the mean doses of intraoperatively administered propofol and fentanyl were significantly lower than in patients dressed without ketamine (150 vs. 220 mg, p < 0.001; and 0.075 vs. 0.150 mg, p < 0.001; respectively). Conclusions: Ketamine was an independent predictor of lower intraoperative fentanyl consumption, according to the multivariate regression analysis (p = 0.015). Contrarily, both groups of patients required postoperative tramadol treatment, while intraoperative ketamine administration had no beneficial effects on postoperative pain management.

The risks of sedation and pain control during burn resuscitation: Increased opioids lead to over-resuscitation and hypotension

INTRODUCTION

Pain management and sedation are necessary in severely burned persons. Balancing pain control, obtundation, and hemodynamic suppression can be challenging. We hypothesized that increased sedation during burn resuscitation is associated with increased intravenous fluid administration and hemodynamic instability.

METHODS

A retrospective review of a single burn center was performed from 2014 to 2019 for all admissions to the burn unit with > 20% total body surface area (TBSA) burns. Within 48 h of admission, we compared total amounts of sedation/pain medications (morphine milligram equivalents (MME), propofol, dexmedetomidine, benzodiazepines) with total resuscitation volumes and frequency of hypotensive episodes. Resuscitation volumes and frequency of hypotension were modeled with multivariable linear regression adjusting for burn severity and weight.

RESULTS

208 patients were included with median age of 43 years (IQR 29-55) and median %TBSA of 31 (IQR 25-44). Median 48-hour resuscitation milliliters per weight per %TBSA were 3.3 (IQR 2.28-4.92). Pain/sedative medications included a combination of opioids in 99%, benzodiazepines in 73%, propofol in 31%, and dexmedetomidine in 11% of patients. MMEs were associated with greater resuscitation volumes (95% CI: 0.15-0.54, p = 0.01) as well as number of hypotensive events (95% CI: 1.57-2.7, p < 0.001). No associations were noted with other sedative medications when comparing the number of hypotensive events and resuscitation volumes.

CONCLUSIONS

Increased opioid administration has physiological consequences and should be carefully monitored during resuscitation as higher volume administrations lead to worse outcomes. Opioids and sedating medications should be titrated to the least amount needed to achieve reasonable comfort and sedation.

Predictive value of perioperative peripheral blood cells counts for bacteremia and 90-day mortality in severe burn patients

OBJECTIVE

Burn bacteremia is related to immune barrier damage, but whether the level of circulating immune cells predicts outcomes in severe burns is still not clear. This study aimed to explore the predictive value of perioperative blood cells of the first surgery after burn for bacteremia and 90-day death.

METHODS

Data from severe burn patients treated at the First Affiliated Hospital of Sun Yat-sen University from 2011 to 2020 were retrospectively analyzed. Data on monocytes (M), lymphocytes (L), white blood cell-to-platelet ratio (WPR), neutrophil-to-lymphocyte ratio (NLR) in peripheral blood and changes in temperature (T-37) were collected at one day before(X0), the first day after (X1) and the third day after (X3) the primary surgery.Univariate and multivariate logistic regression were used to identify the independent risk factors of bacteremia and death within 90 days, which were used to establish the risk prediction models (xbac and x90d-m) in severely burned patients. Severe burn cases from two other burn centers were selected to verify the prediction models.

RESULTS

We analyzed 169 severe burn cases in the training dataset, with a 90-day mortality of 21.3% (36/169); 56 (33.1%) patients experienced burn bacteremia. Higher M0, WPR0, NLR0, NLR3, T3-37, ∆M (M0-M3) and lower M3, L3 were associated with higher risk of bacteremia (P < 0.05). Multivariate regression analysis showed that SOFA0, WPR0, M3, and T3-37 were independently associated with bacteremia. The prediction model for bacteremia Xbac = 0.1809 × SOFA0 + 6.532 × WPR0-1.171 × M3 + 0.6987 × T3-37- 2.297. TBSAB, SOFA0, and ∆M (M0-M3) were independently correlated with 90-day mortality. The risk prediction model X90d-m= 0.055 × TBSAB + 0.301 ×SOFA0 + 1.508 × ∆M - 7.196. External validation suggested that the specificity, sensitivity and AUC of the prediction model Xbac was 90.7%, 62.5% and 0.797, respectively; of the prediction model X90d-m was 69.2%, 90.0% and 0.873, respectively.

CONCLUSION

Peripheral M3, WPR0 and ∆M (M0-M3) during the primary surgery has reasonable predictive ability for bacteremia and 90-day mortality in severe burn patients, which could inform clinical antimicrobial judgment and prognostication.

Prehospital and Emergency Management

Burn care in the prehospital and emergency settings requires rapid assessment of airway, breathing, and circulation. Intubation (if indicated) and fluid resuscitation are most important in emergency burn care. Total body surface area burned and depth of burn are important early assessments that help guide resuscitation and disposition. Burn care in the emergency department further includes carbon monoxide and cyanide toxicity evaluation and management.

Stability of a two-dimensional biomorphoelastic model for post-burn contraction

We consider the stability analysis of a two-dimensional model for post-burn contraction. The model is based on morphoelasticity for permanent deformations and combined with a chemical-biological model that incorporates cellular densities, collagen density, and the concentration of chemoattractants. We formulate stability conditions depending on the decay rate of signaling molecules for both the continuous partial differential equations-based problem and the (semi-)discrete representation. We analyze the difference and convergence between the resulting spatial eigenvalues from the continuous and semi-discrete problems.

Oxandrolone Efficacy in Wound Healing in Burned and Decubitus Ulcer Patients: A Systematic Review

Wounds with delayed or impaired healing represent a considerable challenge in medical practice. These patients develop a sustained hypermetabolic and catabolic state, directly impacting the wound healing process. The use of oxandrolone has been studied to control this metabolic imbalance and protect lean body mass as a beneficial resource in wound healing. This systematic review aims to analyze previously conducted randomized controlled trials to evaluate the evidence of the applicability of oxandrolone therapy. We compared its use in adult patients with burns and adult patients with pressure ulcers in terms of wound healing and healing time of the skin graft donor site in days. The digital searches were done from March 23-28, 2022, within the databases: Google Scholar, PubMed/MEDLINE, and EBSCO (Elton B. Stephens Company). Data from six studies were analyzed and included in this review. Analysis of the available data demonstrated a significant advantage in skin healing using oxandrolone in adult burn patients as an adjunct. For adult patients with pressure ulcers, the drug showed no benefit on wound healing and skin graft site healing. Importantly, we found only one study evaluating the use of oxandrolone in patients with decubitus ulcers that met our eligibility criteria, and the certainty of the evidence was low. Thus, further prospective randomized studies with larger samples and standard wound care protocols are needed to produce more solid results, allowing more definitive conclusions to be made on this theme.

Topical and oral applications of Aloe vera improve healing of deep second-degree burns in rats via modulation of growth factors

Introduction: Burn injuries are underappreciated injuries that cause significant morbidity and mortality. Burn injuries, especially severe burns, trigger immunological and inflammatory responses, metabolic abnormalities, and distributive shock, all of which can be extended to multiple organ failures. Aloe vera (A. vera) has been exploited for its medicinal properties for centuries. The goal of the present study is to examine the therapeutic effect of topical and oral administration of A. vera against deep second-degree burn in rats. Materials and methods: skin burn was created on the back of rats, and wound healing was assessed within the three examined groups; control, topical A. vera and oral A. vera throughout 30 days. Wound tissues were examined histologically, immunohistochemically for the expression of transforming growth factor beta-1 (TGF-β1), peroxiredoxin (Prdx6), and mRNA abundance of vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (bFGF) was assessed. Results: Our finding showed acceleration of wound contraction with both topical and oral A. vera administration. Maturation of granulation tissues was seen in both A. vera-supplemented groups. The topical application of A. vera revealed marked remodelling of the granulation tissues and higher expression levels of TGF-β1, VEGF, bFGF, and Prdx6 in comparison with control and oral A. vera groups (P < 0.001). Conclusion: Both oral and topical applications of A. vera have beneficial effects in deep second-degree burn wound healing by boosting the growth factors and antioxidant status of skin tissue. The topical treatment was more efficient in accelerating wound healing and hence could be used efficiently to treat second-degree burns.

The Notch pathway attenuates burn-induced acute lung injury in rats by repressing reactive oxygen species

Background

Acute lung injury (ALI) is a common complication following severe burns. The underlying mechanisms of ALI are incompletely understood; thus, available treatments are not sufficient to repair the lung tissue after ALI.

Methods

To investigate the relationship between the Notch pathway and burn-induced lung injury, we established a rat burn injury model by scalding and verified lung injury via lung injury evaluations, including hematoxylin and eosin (H&E) staining, lung injury scoring, bronchoalveolar lavage fluid and wet/dry ratio analyses, myeloperoxidase immunohistochemical staining and reactive oxygen species (ROS) accumulation analysis. To explore whether burn injury affects Notch1 expression, we detected the expression of Notch1 and Hes1 after burn injury. Then, we extracted pulmonary microvascular endothelial cells (PMVECs) and conducted Notch pathway inhibition and activation experiments, via a γ-secretase inhibitor (GSI) and OP9-DLL1 coculture, respectively, to verify the regulatory effect of the Notch pathway on ROS accumulation and apoptosis in burn-serum-stimulated PMVECs. To investigate the regulatory effect of the Notch pathway on ROS accumulation, we detected the expression of oxidative-stress-related molecules such as superoxide dismutase, nicotinamide adenine dinucleotide phosphate (NADPH) oxidase (NOX) 2, NOX4 and cleaved caspase-3. NOX4-specific small interfering RNA (siRNA) and the inhibitor GKT137831 were used to verify the regulatory effect of the Notch pathway on ROS via NOX4.

Results

We successfully established a burn model and revealed that lung injury, excessive ROS accumulation and an inflammatory response occurred. Notch1 detection showed that the expression of Notch1 was significantly increased after burn injury. In PMVECs challenged with burn serum, ROS and cell death were elevated. Moreover, when the Notch pathway was suppressed by GSI, ROS and cell apoptosis levels were significantly increased. Conversely, these parameters were reduced when the Notch pathway was activated by OP9-DLL1. Mechanistically, the inhibition of NOX4 by siRNA and GKT137831 showed that the Notch pathway reduced ROS production and cell apoptosis by downregulating the expression of NOX4 in PMVECs.

Conclusions

The Notch pathway reduced ROS production and apoptosis by downregulating the expression of NOX4 in burn-stimulated PMVECs. The Notch-NOX4 pathway may be a novel therapeutic target to treat burn-induced ALI.

The Role of the Immune System in Pediatric Burns: A Systematic Review

Burns are one of the most common causes of home injuries, characterized by serious damage to the skin and causing the death of affected tissues. In this review, we intended to collect information on the pathophysiological effects of burns in pediatric patients, with particular emphasis on local and systemic responses. A total of 92 articles were included in the review, and the time range of the searched articles was from 2000 to 2021. The occurrence of thermal injuries is a problem that requires special attention in pediatric patients who are still developing. Their exposure to various burns may cause disturbances in the immune response, not only in the area of tissue damage itself but also by disrupting the systemic immune response. The aspect of immunological mechanisms in burns requires further research, and in particular, it is important to focus on younger patients as the existence of subtle differences in wound healing between adults and children may significantly influence the treatment of pediatric patients.

Role of intra-abdominal pressure measurement in patients with acute abdomen requiring exploratory laparotomy

<b>Introduction:</b> Acute abdomen is one of the most common surgical emergencies faced by a surgeon. Monitoring Intra-Abdominal Pressure (IAP) in patients with acute abdomen referred for exploratory laparotomy may help guide the need for early intervention. </br></br> <b>Aim:</b> This study was performed to determine whether preoperative IAP had any significant association with organ failure as assessed using SOFA score. Furthermore, effect of IAP on patient outcome in terms of hospital stay, mortality was also evaluated. </br></br> <b>Materials and methods:</b> 60 patients above 18 years of age presenting with acute abdomen requiring exploratory laparotomy were included in this prospective observational study from November 2013 until March 2015. IAP and SOFA scores were calculated at the time of admission. The outcome of patients was assessed in terms of hospital stay, morbidity and mortality. The correlation between IAP and SOFA scores was also assessed to determine the risk of organ failure. The inferences were drawn with the use of SPSS v22.0 statistical software. ANOVA, Chi-square and Student’s t-test were used in the analysis. </br></br> <b> Results:</b> There was a positive correlation between SOFA score and IAP; and this correlation was found to be statistically significant with Pearson’s correlation coefficient being 0.6247 and significance levels being <0.0001. Both hospital stay and mortality positively correlated with the degree of IAP. </br></br> <b> Conclusions:</b> IAP should be routinely measured in patients with acute abdomen requiring exploratory laparotomy. Patients with preoperatively raised IAP should be referred for emergency surgery as soon as possible for better outcome.

Management of severe burn injuries with novel treatment techniques including maggot debridement and applications of acellular fish skin grafts and autologous skin cell suspension in a dog

CASE DESCRIPTION

A 3-year-old 27-kg female spayed American Bulldog with severe burn injuries caused by a gasoline can explosion was evaluated.

CLINICAL FINDINGS

The dog had extensive partial- and full-thickness burns with 50% of total body surface area affected. The burns involved the dorsum extending from the tail to approximately the 10th thoracic vertebra, left pelvic limb (involving 360° burns from the hip region to the tarsus), inguinal area bilaterally, right medial aspect of the thigh, and entire perineal region. Additional burns affected the margins of the pinnae and periocular regions, with severe corneal involvement bilaterally.

TREATMENT AND OUTCOME

The dog was hospitalized in the hospital's intensive care unit for 78 days. Case management involved provision of aggressive multimodal analgesia, systemic support, and a combination of novel debridement and reconstructive techniques. Debridement was facilitated by traditional surgical techniques in combination with maggot treatment. Reconstructive surgeries involved 6 staged procedures along with the use of novel treatments including applications of widespread acellular fish (cod) skin graft and autologous skin cell suspension.

CLINICAL RELEVANCE

The outcome for the dog of the present report highlighted the successful use of maggot treatment and applications of acellular cod skin and autologous skin cell suspension along with aggressive systemic management and long-term multimodal analgesia with debridement and wound reconstruction for management of severe burn injuries encompassing 50% of an animal's total body surface area.

Clinical significance of serum matrix metalloproteinase 9 and tissue inhibitor of metalloproteinase 1 in the first phase of burn trauma evolution

No prospective study has specifically examined the serum levels of matrix metalloproteinase-9 (MMP-9) and tissue inhibitor of metalloproteinase-1 (TIMP-1) in the early shock phase of burn-injured patients. Thus, we aimed to detect early changes, activity dynamics, and the predictive value of MMP-9, TIMP-1, and the MMP-9/TIMP-1 ratio to better understand the early repair mechanisms for the development of future therapies for patients with thermal burns. Twenty-five patients with a total body surface area (TBSA) affected by burn <25%, and 30 healthy subjects were enrolled in the study. Serum levels of MMP-9 and TIMP-1 were determined by the ELISA method. Our results showed that MMP-9 concentrations increased immediately after injury and remained on a plateau. In contrast, TIMP-1 showed an upward trend throughout the 7-day study period, and the time course of the MMP-9/TIMP-1 ratio followed the inverse dynamics of TIMP-1. Analysis of the areas under the receiver operating characteristic (ROC) curves (AUC) showed that patients with burn wounds tended to have a MMP-9 value higher than 421.5 ng/ml (AUC=0.979), TIMP-1 value higher than 231.6 ng/ml (AUC=0.908), and MMP-9/TIMP-1 ratio higher than 2.31 (AUC=0.959) (P<0.001). Our findings suggest that although the variations in the two biomarkers were different regarding the time of the initial insult, their ratio is a specific and sensitive indicator of burn evolutivity in patients with a TBSA affected by a burn <25%.

Role and dynamics of matrix metalloproteinase 9 and tissue inhibitor of metalloproteinase 1 in burn patients

Burn injuries can trigger tissue changes that can explain the variation in the level of different biochemical markers that can be recorded both locally or systemically. Some events observed in burn wounds such as vascular hyperpermeability have been associated with the release of matrix metalloproteinases (MMPs) and their tissue inhibitors (TIMPs) after trauma. Because it is unknown whether the serum levels of MMP-9 and TIMP-1 are a consequence of these destructions or a local response to thermal damage, we decided to follow their dynamics. Twenty-five patients (mean age 49.40±17.55 years) with a total body surface area (TBSA) affected by a thermal burn of <25% and 30 healthy subjects (mean age 49.70±8.04 years) were enrolled in the present study. Enzyme immunoassays were used to measure the serum levels of MMP-9 and TIMP-1. Our results showed that MMP-9 was increased 6.25-fold immediately after injury compared to the controls and remained on a plateau throughout the 7-day monitoring period. TIMP-1 showed an upward trend with an increase of 49.52% on the seventh day after triggering insult. The time-course of the MMP-9/TIMP-1 ratio followed the inverse dynamics of TIMP-1 starting from a ratio value measured at admission 3.82-fold higher than the one observed in the healthy volunteers and a highly statistically significant correlation between the values measured at different time-points during the monitoring period (P<0.001). The results of this retrospective study indicate that the MMP-9/TIMP-1 ratio may provide information on local changes over time, starting from the triggering insult, and may be considered as a predictive biomarker of burn evolutivity.

Role of mast cells in skin regeneration after thermal burn treated with melatonin-enriched dermal film

The development of novel local therapies for thermal burns (TB) and their pathogenetic rationale are a pressing challenge. Melatonin (MT) is an endogenous factor of hemostasis regulation with pleiotropic potential. The aim of this study was to assess some parameters of tissue regeneration, the functional state of mast cells and the levels of matrix metalloproteinase-9 (MMP-9) and vascular endothelial growth factor (VEGF) in the experimentally induced TB treated with the original MT-enriched dermal film (DF). A second-degree burn (3.5% of the total body surface area) was modelled by exposing a patch of skin to hot water. Applications of 12 cm2 DF enriched with 5 mg/g MT were performed every day for 5 days. The following parameters were calculated: the wound area, the rate of wound epithelization, the number of MC in the wound, the intensity of degranulation, and the levels of MMP-9 and VEGF expression. Over the course of treatment, the absolute wound area shrank by 35%, its epithelization rate increased, the number of MC rose, their functional state changed, and the expression of ММР-9 and VEGF increased. A negative correlation was established between the wound area and the expression of ММР-9 and VEGF, as well as between the wound area and the degranulation coefficient. Applications of MT-enriched DF resulted in the reduction of the wound area, higher epithelization rate, an increase in the total MC count and degranulation intensity on days 5 and 10; it also led to a reduction in the total MC count and a loss in degranulation intensity on day 20 (166.87 (154.95; 178.78) un/mm2 vs. 464.84 (452.92; 476.76) un/mm2) in the group of intact animals), an increase in MMP-9 expression on day 5 (14.20 (11.30; 18.10) vs. 3.30 (2.20; 4.40) in the intact group), an increase in VEGF expression on days 5 and 10 (33.00 (30.20; 34.90) vs 25.40 (22.20; 29.30) in the intact group), and a reduction in MMP-9 expression on days 10 and 20 after thermal injury.

Sensitivity and feasibility of a one-dimensional morphoelastic model for post-burn contraction

We consider a one-dimensional morphoelastic model describing post-burn scar contraction. Contraction can lead to a limited range of motion (contracture). Reported prevalence of burn scar contractures are 58.6% at 3-6 weeks and 20.9% at 12 months post-reconstructive surgery after burns. This model describes the displacement of the dermal layer of the skin and the development of the effective Eulerian strain in the tissue. Besides these components, the model also contains components that play a major role in the skin repair after trauma. These components are signaling molecules, fibroblasts, myofibroblasts, and collagen. We perform a sensitivity analysis for many parameters of the model and use the results for a feasibility study. In this study, we test whether the model is suitable for predicting the extent of contraction in different age groups. To this end, we conduct an extensive literature review to find parameter values. From the sensitivity analysis, we conclude that the most sensitive parameters are the equilibrium collagen concentration in the dermal layer, the apoptosis rate of fibroblasts and myofibroblasts, and the secretion rate of signaling molecules. Further, although we can use the model to simulate significant distinct contraction densities in different age groups, our results differ from what is seen in the clinic. This particularly concerns children and elderly patients. In children we see more intense contractures if the burn injury occurs near a joint, because the growth induces extra forces on the tissue. Elderly patients seem to suffer less from contractures, possibly because of excess skin.

Combination of an engineered Lactococcus lactis expressing CXCL12 with light-emitting diode yellow light as a treatment for scalded skin in mice

Impaired wound closure is an increasingly crucial clinical challenge. Recently, wound healing has shifted towards innovative treatments that exploit nanotechnology, biomaterials, biologics and phototherapy. Here, we constructed an engineered MG1363-pMG36e-mCXCL12 strain with pMG36e plasmid encoding stromal cell-derived factor 1α (named CXCL12) and evaluated the synergistic effects of light-emitting diode (LED) yellow light and MG1363-pMG36e-mCXCL12 on scald wounds in mice. The results indicated that the combined treatment with LED yellow light with mCXCL12 delivering strain accelerated wound closure, tissue remodelling, re-epithelialization and hair follicle regeneration and inhibited over-inflammation oppositely in the central and surrounding wounds by macroscopic, histopathologic and immunohistochemistry parameters. Furthermore, combination therapy increased the epidermal growth factor and Ki67-positive cells and upregulated beta-catenin (β-catenin), cellular-myelocytomatosis (c-Myc), wingless-type MMTV integration site family member 1 (Wnt1), Jagged 1, neurogenic locus notch homolog protein 1 (Notch 1) and hairy and enhancer of split 1 (Hes 1) protein levels of the Wnt and Notch signalling pathways. It also facilitated collagen fibrogenesis and deposition and improved the activities of hydroxyproline, superoxide dismutase and glutathione peroxidase in scalded granulation tissue, in addition to reducing the inflammatory factors interleukin 1 beta (IL-1β) and tumour necrosis factor alpha (TNF-α). The combined treatment effectively reduced skin pathogens Ralstonia and Acinetobacter to further reduce the risk of infection. Overall, combination of LED yellow light and MG1363-pMG36e-mCXCL12 represents a potential strategy for the treatment of cutaneous wounds.

Incidence and Time Point of Sepsis Detection as Related to Different Sepsis Definitions in Severely Burned Patients and Their Accompanying Time Course of Pro-Inflammatory Biomarkers

Background: Diagnosis of sepsis in burn patients remains difficult for various reasons. One major problem is the definition of sepsis itself. Therefore, previous and current sepsis definitions are a matter of ongoing validation, but a well-defined consensus on which clinical and laboratory parameters to incorporate in such a definition is lacking. The aim of the present study was to compare the incidence and time-related occurrence of septic events according to different definitions as well as their accompanying time course of pro-inflammatory biomarkers. Methods: Across the first 14 days after admission, the incidence and time point of sepsis according to three different definitions (Sepsis-3, Sepsis American Burns Association [ABA] 2007, Sepsis Zurich Burn Center) were assessed on a daily basis in adult burn patients with total body surface area (TBSA) ≥15% admitted to the Zurich Burn Center between May 2015 and October 2018. In order to investigate how well daily drawn proinflammatory biomarkers (white blood cells (WBCs), C-reactive protein (CRP), procalcitonin (PCT), and novel pancreatic stone protein (PSP)) reflect the progression of sepsis depending on its type of definition, a longitudinal mixed model analysis was performed across the first 14 days for septic and non-septic patients. Additionally, the relative increase of biomarker levels 24, 48, and 72 h prior to a septic event was analyzed for each definition used. Results: In our cohort of 90 severely burned patients, Sepsis-3 identified 46 patients (51.1%) as septic, while ABA 2007 and the Zurich Burn Center definition counted 33 patients (36.7%) and 24 patients (26.6%), respectively. Sepsis-3 detected sepsis about 1 day earlier than Sepsis ABA 2007 (p < 0.001) and about 0.5 days earlier than Sepsis Zurich Burn Center (p = 0.04). The course of pro-inflammatory biomarkers was largely unaffected by the type of sepsis definition. Irrespective of the sepsis definition, PSP was the only marker to demonstrate a highly significant interaction between time and group (sepsis versus no sepsis) (p < 0.001) with a 3.3–5.5-fold increase within 72 h before the event of sepsis, whereas CRP, PCT, and WBC showed only mild undulations. Conclusions: Despite the ongoing dilemma of how to define sepsis in burn patients, a continually calculated SOFA score as used in Sepsis-3 is advantageous to early identify a patient’s detrimental progression to sepsis. Inclusion of biomarkers, such as PSP, may help support the burn specialist’s diagnosis of sepsis and could improve the diagnostic performance of current and future definitions in burn patients.

Physicians based emergency medical services for the management of burn injuries in trauma centers of the center region of Saudi Arabia: evaluation of physicians' knowledge and experience

BACKGROUND

Medical services at trauma centers regularly encounter severe burn patients but prehospital care of these patients in Saudi Arabia is comparatively unexplored. This study evaluates the knowledge and experience of physicians working in trauma centers of Qassim province of Saudi Arabia for the management of patients with burn injuries.

METHODS

This is a cross sectional study performed on 204 physicians working in the trauma centers of Qassim province. Physicians' knowledge and experience were assessed via administration of validated questionnaires and the data were analyzed using SPSS software.

RESULTS

Among total studied physicians, only 35.3% and 24.0% gave the right answer to the question on the diagnosis of burn skin in depth/extent for adults and pediatric patients, respectively. Importantly, 93.6% physicians responded correctly for first aid treatment. For the parkland concept, 62.2% responded correctly, however, only 22.5% understand the colloid fluid concept. The 74% physicians knew the methods of fluid revival for mass burn injuries and about half of studied physicians showed right knowledge for intubation for breathing for mass burn injuries. Only 47.5% physicians understand the concept of electrolyte disorder.

CONCLUSIONS

This is the first study from the central region of Saudi Arabia that analyzed the knowledge and experience of physicians working in trauma centers for the management of patients with burn injuries. Overall data showed that ~60% physicians working in trauma centers have knowledge for handling the patients with burn injuries but the rest needed counseling, therefore proper training sessions for them are needed for management of burn patients.

Altered Genes and Biological Functions in Response to Severe Burns

Severe burns are acute wounds caused by local heat exposure, resulting in life-threatening systemic effects and poor survival. However, the specific molecular mechanisms remain unclear. First, we downloaded gene expression data related to severe burns from the GEO database (GSE19743, GSE37069, and GSE77791). Then, a gene expression analysis was performed to identify differentially expressed genes (DEGs) and construct protein-protein interaction (PPI) network. The molecular mechanism was identified by enrichment analysis and Gene Set Enrichment Analysis. In addition, STEM software was used to screen for genes persistently expressed during response to severe burns, and receiver operating characteristic (ROC) curve was used to identify key DEGs. A total of 2631 upregulated and 3451 downregulated DEGs were identified. PPI network analysis clustered these DEGs into 13 modules. Importantly, module genes mostly related with immune responses and metabolism. In addition, we identified genes persistently altered during the response to severe burns corresponding to survival and death status. Among the genes with high area under the ROC curve in the PPI network gene, CCL5 and LCK were identified as key DEGs, which may affect the prognosis of burn patients. Gene set variation analysis showed that the immune response was inhibited and several types of immune cells were decreased, while the metabolic response was enhanced. The results showed that persistent gene expression changes occur in response to severe burns, which may underlie chronic alterations in physiological pathways. Identifying the key altered genes may reveal potential therapeutic targets for mitigating the effects of severe burns.

A retrospective surveillance of the prophylactic antibiotics for debridement surgery in burn patients

Burn injury is trauma with a high risk of infection. A method that can be used to prevent and decrease the incidence of infection and accelerate wound healing is debridement. The use of prophylactic antibiotics was considered in debridement to minimize surgical site infection. This study's objective was to characterize the usage of prophylactic antibiotics for debridement in burn patients, including the selection, dose, and route of administration. The second objective was to quantitatively calculate the use of prophylactic antibiotics using ATC/DDD. This was a retrospective study in burn patients admitted to the Dr. Soetomo Hospital's burn unit between 2017 and 2020. Ninety burn patients meet the inclusion criteria enrolled in this study. There were eight prophylactic antibiotics for debridement in this study. Only four from eight antibiotics met the guidelines for prophylactic antibiotics before surgery. All prophylactic antibiotics were given intravenously. The most common prophylactic antibiotics were cefazolin (39%) and followed by ceftazidime (31%) and ceftriaxone (11%). Ceftazidime, cefoperazone, amikacin, and meropenem were used as therapeutic antibiotics to treat burn infection and continued as prophylactic before debridement surgery. Cefazolin and ceftriaxone were the most antibiotics that comply their dose with the guideline. The total of DDD/100 operations was 6.23 and cefazolin was the highest consumed, 3.10 DDD/100 operations. The mortality rate in our study was 33%. For those who survived, there was a significant correlation between % TBSA and length of stay also debridement frequency. Our study concluded there was a difference between daily practice in the hospital and in the guidelines. Improvements were needed to use prophylactic antibiotics more precisely regarding quantity and choice of the type of antibiotics.

Diverse Treatments for Deep Burn Wounds: A Case Report

ABSTRACT

Patients with extensive deep burns usually experience infections and organ dysfunction. Proactive and effective wound repair is key to treatment. If large wounds remain open, systemic infection and multiple organ dysfunction syndrome can occur, threatening the lives of patients. Current wound repair methods include skin grafts, flap repair, negative-pressure wound therapy, and cellular and/or tissue-based products. For deep, complex burn wounds, a single form of treatment is usually ineffective. This article reports a rare case of burn wound repair. The patient was burned by a charcoal flame on multiple parts of his body after carbon monoxide poisoning. Pneumothorax and acute renal failure occurred after the injury, accompanied by multiple osteonecroses of the trunk and lower limbs. A multidisciplinary team formulated an individualized treatment plan; the diverse treatments included closed chest drainage, continuous renal replacement therapy, infection control, analgesia, wound debridement, negative-pressure wound therapy, cellular and/or tissue-based products, autologous dermal scaffold graft, skin grafts, flap transposition, platelet-rich plasma, and rehabilitation, which ultimately saved the patient's life and led to healing of all the wounds.

The History and Development of Hyperbaric Oxygenation (HBO) in Thermal Burn Injury

Background and Objectives: Hyperbaric oxygenation (HBO) denotes breathing of 100% oxygen under elevated ambient pressure. Since the initiation of HBO for burns in 1965, abundant experimental and clinical work has been done. Despite many undisputedly positive and only a few controversial results on the efficacy of adjunctive HBO for burn injury, the method has not yet been established in clinical routine. Materials and Methods: We did a retrospective analysis of the literature according to PRISMA-guidelines, from the very beginning of HBO for burns up to present, trying to elucidate the question why HBO is still sidelined in the treatment of burn injury. Results: Forty-seven publications (32 animal experiments, four trials in human volunteers and 11 clinical studies) fulfilled the inclusion criteria. Except four investigators who found little or no beneficial action, all were able to demonstrate positive effects of HBO, most of them describing less edema, improved healing, less infection or bacterial growth and most recently, reduction of post-burn pain. Secondary enlargement of burn was prevented, as microvascular perfusion could be preserved, and cells were kept viable. The application of HBO, however, concerning pressure, duration, frequency and number of treatment sessions, varied considerably. Authors of large clinical studies underscored the intricate measures required when administering HBO in severe burns. Conclusions: HBO unquestionably has a positive impact on the pathophysiological mechanisms, and hence on the healing and course of burns. The few negative results are most likely due to peculiarities in the administration of HBO and possibly also to interactions when delivering the treatment to severely ill patients. Well-designed studies are needed to definitively assess its clinical value as an adjunctive treatment focusing on relevant outcome criteria such as wound healing time, complications, length of hospital stay, mortality and scar quality, while also defining optimal HBO dosage and timing.

A Cross-Sectional Study of Quality of life, Psychiatric Illness, Perceived Social Support, Suicidal Risk and Selfesteem among patients with burns

INTRODUCTION

Burns is one of the foremost causes of worldwide morbidity. Changes in appearance and functional impairment causes stigmatisation, impacting socio-occupational engagement and causing discomfort.

AIMS AND OBJECTIVES

The study examined prevalence of psychiatric morbidity in post-burn patients, their perceived social support and self-esteem. It further assessed quality of life amongst post-burn patients.

MATERIALS AND METHODS

A cross-sectional study was performed in a tertiary care centre where 100 patients were interviewed using purposive sampling technique over six months. Patients were administered a semi-structured questionnaire along with Mini International Neuropsychiatric Interview (MINI), Rosenberg's Self-Esteem Scale (RSES), Multidimensional Scale of Perceived Social Support (MSPSS) and WHO Quality Of Life - BREF (WHOQOL- BREF) scales. Contingency tables and Spearman's correlation helped to examine associations and correlations. Fischer's exact test, Mann Whitney test and ANOVA test were also used for statistical analysis.

RESULTS AND DISCUSSION

There is high prevalence of psychiatric morbidity among patients with burns. The most common disorder was major depressive episode. Low self-esteem was found in one-third of patients with burns. Patients having low self-esteem had eleven times higher prevalence of suicidality. Patients with burns had high perceived social support. Quality of life in patients with burns depends on self-esteem, perceived social support and presence of psychiatric illnesses.

CONCLUSION

This study illustrates the need for thorough evaluation and screening in patients with burns for psychopathology and self-esteem issues by primary physicians. Behaviour therapy, supportive psychotherapy, counselling and adequate socio-occupational rehabilitation of the patient should be done. Spreading awareness and organising support groups for patients with burns at the primary health centre level can be effective.

Systematic Review of Stem-Cell-Based Therapy of Burn Wounds: Lessons Learned from Animal and Clinical Studies

Treatment of severe burn wounds presents a daunting medical challenge, and novel approaches promoting healing and reducing scarring are highly desirable. The application of mesenchymal stem/stromal cells (MSCs) has been suggested as a novel treatment. In this paper, we present systematic reviews of pre-clinical and clinical studies of MSC therapy for second- or third^-degree thermal burn wounds. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, the PubMed and Embase databases were searched, and interventional studies of MSC therapy using rodent models (21 studies) or human burn patients (three studies) were included in the pre-clinical and clinical reviews, respectively, where both overall outcome and wound-healing-phase-specific methodologies and effects were assessed. The pre-clinical studies demonstrated a promising effect of the application of MSCs on several wound healing phases. The clinical studies also suggested that the MSC treatment was beneficial, particularly in the remodeling phase. However, the limited number of studies, their lack of homogeneity in study design, relatively high risk of bias, lack of reporting on mode of action (MOA), and discontinuity of evidence restrict the strength of these findings. This comprehensive review presents an overview of available methodologies to assess the MOA of MSC treatment for distinct wound healing phases. Furthermore, it includes a set of recommendations for the design of high-quality clinical studies that can determine the efficacy of MSCs as a therapy for burn wounds.

Comparison of Modified Meek Technique with Standard Mesh Method in Patients with Third Degree Burns

BACKGROUND

Covering burn wounds, especially high surface area burns has been always a challenge for surgeons. The Meek technique has been introduced to increase the covering area. There is paucity of clinical trials comparing the Meek technique and mesh in the same individuals to assess it efficacy.

METHODS

In a case-control study, 20 patients with grade III burns who underwent the Meek technique and mesh in different areas/limbs were enrolled. Expansion rate, re-epithelization, operation time, wound infection, graft failure, etc. were compared between the two groups.

RESULTS

Among patients, 18 were males and 2 were females. The mean of total body surface area (TBSA) was 36.9±16.6%. Mean time of re-epithelialization in the Meek group was 2.8±2.5 months and in the mesh group was 5.0±2.1 months (p=0.01). Operation time was shorter in modified Meek technique (p=0.04). Expansion ratio was higher in modified Meek technique (p=0.04). Local wound infection rates were slightly different without a statistically significant difference.

CONCLUSION

Meek technique provided higher surface area coverage in comparison to mesh; in addition to faster re-epithelization. Therefore, it is recommended to consider the Meek technique as a routine procedure, especially those with high surface area burns.