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Stevenson AW, Cadby G, Wallace HJ, Melton PE, Martin LJ, Wood FM, Fear MW. Genetic influence on scar vascularity after burn injury in individuals of European ancestry: A prospective cohort study. Burns 2024:S0305-4179(24)00146-3. [PMID: 38902133 DOI: 10.1016/j.burns.2024.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 03/01/2024] [Accepted: 05/02/2024] [Indexed: 06/22/2024]
Abstract
After burn injury there is considerable variation in scar outcome, partially due to genetic factors. Scar vascularity is one characteristic that varies between individuals, and this study aimed to identify genetic variants contributing to different scar vascularity outcomes. An exome-wide array association study and gene pathway analysis was performed on a prospective cohort of 665 patients of European ancestry treated for burn injury, using their scar vascularity (SV) sub-score, part of the modified Vancouver Scar Scale (mVSS), as an outcome measure. DNA was genotyped using the Infinium HumanCoreExome-24 BeadChip, imputed to the Haplotype Reference Consortium panel. Associations between genetic variants (single nucleotide polymorphisms) and SV were estimated using an additive genetic model adjusting for sex, age, % total body surface area and number of surgical procedures, utilising linear and multinomial logistic regression. No individual genetic variants achieved the cut-off threshold for significance. Gene sets were also analysed using the Functional Mapping and Annotation (FUMA) platform, in which biological processes indirectly related to angiogenesis were significantly represented. This study suggests that SNPs in genes associated with angiogenesis may influence SV, but further studies with larger datasets are essential to validate these findings.
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Affiliation(s)
- Andrew W Stevenson
- Burn Injury Research Unit, School of Biomedical Sciences, Faculty of Health and Medical Sciences, The University of Western Australia, Crawley, Australia.
| | - Gemma Cadby
- School of Population and Global Health, The University of Western Australia, Perth, Australia
| | - Hilary J Wallace
- School of Population and Global Health, The University of Western Australia, Perth, Australia
| | - Phillip E Melton
- School of Population and Global Health, The University of Western Australia, Perth, Australia; Menzies Research Institute, University of Tasmania, Hobart, Tasmania, Australia
| | - Lisa J Martin
- Burn Injury Research Unit, School of Biomedical Sciences, Faculty of Health and Medical Sciences, The University of Western Australia, Crawley, Australia; Burns Service of Western Australia, Princess Margaret Hospital for Children and Fiona Stanley Hospital, Perth, Australia
| | - Fiona M Wood
- Burn Injury Research Unit, School of Biomedical Sciences, Faculty of Health and Medical Sciences, The University of Western Australia, Crawley, Australia; Burns Service of Western Australia, Princess Margaret Hospital for Children and Fiona Stanley Hospital, Perth, Australia
| | - Mark W Fear
- Burn Injury Research Unit, School of Biomedical Sciences, Faculty of Health and Medical Sciences, The University of Western Australia, Crawley, Australia
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2
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Langley D, Zimmermann K, Krenske E, Stefanutti G, Kimble RM, Holland AJA, Fear MW, Wood FM, Kenna T, Cuttle L. Unremitting pro-inflammatory T-cell phenotypes, and macrophage activity, following paediatric burn injury. Clin Transl Immunology 2024; 13:e1496. [PMID: 38463658 PMCID: PMC10921233 DOI: 10.1002/cti2.1496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 02/20/2024] [Accepted: 02/23/2024] [Indexed: 03/12/2024] Open
Abstract
Objectives The aim of this study was to characterise the dynamic immune profile of paediatric burn patients for up to 18 months post-burn. Methods Flow cytometry was used to measure 25 cell markers, chemokines and cytokines which reflected both pro-inflammatory and anti-inflammatory immune profiles. Peripheral blood mononuclear cells from 6 paediatric burn patients who had returned for repeated burn and scar treatments for > 4 timepoints within 12 months post-burn were compared to four age-matched healthy controls. Results While overall proportions of T cells, NK cells and macrophages remained relatively constant, over time percentages of these immune cells differentiated into effector and proinflammatory cell phenotypes including Th17 and activated γδ T cells. Circulating proportions of γδ T cells increased their expression of pro-inflammatory mediators throughout the burn recovery, with a 3-6 fold increase of IL-17 at 1-3 weeks, and NFκβ 9-18 months post-burn. T-regulatory cell plasticity was also observed, and Treg phenotype proportions changed from systemically reduced skin-homing T-regs (CCR4+) and increased inflammatory (CCR6+) at 1-month post-burn, to double-positive cell types (CCR4+CCR6+) elevated in circulation for 18 months post-burn. Furthermore, Tregs were observed to proportionally express less IL-10 but increased TNF-α over 18 months. Conclusion Overall, these results indicate the circulating percentages of immune cells do not increase or decrease over time post-burn, instead they become highly specialised, inflammatory and skin-homing. In this patient population, these changes persisted for at least 18 months post-burn, this 'immune distraction' may limit the ability of immune cells to prioritise other threats post-burn, such as respiratory infections.
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Affiliation(s)
- Donna Langley
- School of Biomedical Sciences, Faculty of HealthQueensland University of Technology (QUT)South BrisbaneQLDAustralia
- Centre for Immunology and Infection Control (CIIC)QIMR Berghofer Medical Research Institute, Queensland University of Technology (QUT)BrisbaneQLDAustralia
- Centre for Biomedical Technology (CBT)Queensland University of Technology (QUT)Kelvin GroveQLDAustralia
| | - Kate Zimmermann
- School of Biomedical Sciences, Faculty of HealthQueensland University of Technology (QUT)South BrisbaneQLDAustralia
- Centre for Immunology and Infection Control (CIIC)QIMR Berghofer Medical Research Institute, Queensland University of Technology (QUT)BrisbaneQLDAustralia
| | - Emma Krenske
- School of Biomedical Sciences, Faculty of HealthQueensland University of Technology (QUT)South BrisbaneQLDAustralia
- Centre for Immunology and Infection Control (CIIC)QIMR Berghofer Medical Research Institute, Queensland University of Technology (QUT)BrisbaneQLDAustralia
| | - Giorgio Stefanutti
- Department of Paediatric Surgery, Urology, Burns and TraumaChildren's Health Queensland, Queensland Children's HospitalSouth BrisbaneQLDAustralia
| | - Roy M Kimble
- Department of Paediatric Surgery, Urology, Burns and TraumaChildren's Health Queensland, Queensland Children's HospitalSouth BrisbaneQLDAustralia
| | - Andrew JA Holland
- The Children's Hospital at Westmead Burns Unit, Department of Paediatrics and Child Health, Kids Research InstituteSydney Medical School, The University of SydneySydneyNSWAustralia
| | - Mark W Fear
- Burn Injury Research Unit, School of Biomedical SciencesThe University of Western AustraliaPerthWAAustralia
| | - Fiona M Wood
- Burn Injury Research Unit, School of Biomedical SciencesThe University of Western AustraliaPerthWAAustralia
- Burns Service of Western AustraliaPerth Children's Hospital and Fiona Stanley HospitalPerthWAAustralia
| | - Tony Kenna
- School of Biomedical Sciences, Faculty of HealthQueensland University of Technology (QUT)South BrisbaneQLDAustralia
- Centre for Immunology and Infection Control (CIIC)QIMR Berghofer Medical Research Institute, Queensland University of Technology (QUT)BrisbaneQLDAustralia
| | - Leila Cuttle
- School of Biomedical Sciences, Faculty of HealthQueensland University of Technology (QUT)South BrisbaneQLDAustralia
- Centre for Biomedical Technology (CBT)Queensland University of Technology (QUT)Kelvin GroveQLDAustralia
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3
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Fanstone R, Price P, Bodger O, Potokar T, Khan MRK. Risk factors for burn contractures: A cross-sectional study in a lower income country. Burns 2024; 50:454-465. [PMID: 37980272 DOI: 10.1016/j.burns.2023.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 07/31/2023] [Accepted: 09/09/2023] [Indexed: 11/20/2023]
Abstract
Risk factors for burn contractures require further study, especially in low and middle-income countries (LMICs); existing research has been predominantly conducted in high income countries (HICs). This study aimed to identify risk factors for burn contractures of major joints in a low-income setting. Potential risk factors (n = 104) for burn contracture were identified from the literature and a survey of clinicians with extensive experience in low and middle-income countries (LMIC). An observational cross-sectional study of adult burn survivors was undertaken in Bangladesh to evaluate as many of these risk factors as were feasible against contracture presence and severity. Forty-eight potential risk factors were examined in 48 adult patients with 126 major joints at risk (median 3 per participant) at a median of 2.5 years after burn injury. Contractures were present in 77% of participants and 52% of joints overall. Contracture severity was determined by measurement of loss of movement at all joints at risk. Person level risk factors were defined as those that were common to all joints at risk for the participant and only documented once, whilst joint level risk factors were documented for each of the participant's included joints at risk. Person level risk factors which were significantly correlated with loss of range of movement (ROM) included employment status, full thickness burns, refusal of skin graft, discharged against medical advice, low frequency of follow up and lack of awareness of contracture development. Significant joint level risk factors for loss of ROM included anatomical location, non-grafted burns, and lack of pressure therapy. This study has examined the largest number of potential contracture risk factors in an LMIC setting to date. A key finding was that risk factors for contracture in low-income settings may differ substantially from those seen in high income countries, which has implications for effective prevention strategies in these countries. Better whole person and joint outcome measures are required for accurate determination of risk factors for burn contracture. Recommendations for planning and reporting on future contracture risk factor studies are made.
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Affiliation(s)
- RuthAnn Fanstone
- Centre for Global Burn Injury Policy and Research, Swansea University, UK.
| | - Patricia Price
- Centre for Global Burn Injury Policy and Research, Swansea University, UK
| | - Owen Bodger
- Faculty of Medicine, Health and Life Sciences, Swansea University, UK
| | - Tom Potokar
- Centre for Global Burn Injury Policy and Research, Swansea University, UK
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Kaur D, Sharma N, Samuel AJ. Web-based E-survey in identifying current physiotherapy practices in paediatric burns. Burns 2023; 49:1474-1481. [PMID: 36792471 DOI: 10.1016/j.burns.2023.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 12/20/2022] [Accepted: 01/23/2023] [Indexed: 01/26/2023]
Abstract
INTRODUCTION Physiotherapy practices in pediatric burns involves relaxation techniques and exercise training for attaining physical fitness, improving quality of life and, thereby to prevent primary and secondary complications. Physical activity and exercise act as a meaningful and purposeful tool for attaining physical fitness after burn injury. AIM The aim of this e-survey is to identify the current practices of physiotherapy interventions in pediatric burn rehabilitation among physiotherapy students and professionals. METHODS The e-survey was created with validated questionnaire using a Google Forms to gather the information related to current physiotherapy practices in pediatric burns. After the sample size estimation, survey link were sent to identified 144 physiotherapy students and professionals using social networking sites which includes, WhatsApp, Facebook and Instagram for this cross-sectional e-survey. The frequency and percentage of survey responses were analyzed. RESULTS Among 144 identified participants, 62 participants completed the survey, resulting in the response rate of (43.0%). The findings of this study revealed that> 50% of physiotherapy students, and professionals, are performing pain and scar assessment, along with their regular physiotherapy management in children with burns. In addition to these, they also practice physiotherapy for burn conditions in pediatric intensive care units (PICU), pediatric wards, and clinical outpatient department (OPD) settings. CONCLUSION Physiotherapy students and professionals have sufficient knowledge regarding pediatric burns complications, and also, they are well aware regarding recent physiotherapy practices in pediatric burn care management.
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Affiliation(s)
- Daljit Kaur
- Department of Paediatric and Neonatal Physiotherapy, Maharishi Markandeshwar Institute of Physiotherapy and Rehabilitation, Maharishi Markandeshwar (Deemed to be University), Mullana 133207, Ambala, Haryana, India; Department of Physiotherapy, Narain Hospital & CT Scan Center, Ambala, Haryana
| | - Neha Sharma
- Department of Paediatric and Neonatal Physiotherapy, Maharishi Markandeshwar Institute of Physiotherapy and Rehabilitation, Maharishi Markandeshwar (Deemed to be University), Mullana 133207, Ambala, Haryana, India
| | - Asir John Samuel
- Department of Paediatric and Neonatal Physiotherapy, Maharishi Markandeshwar Institute of Physiotherapy and Rehabilitation, Maharishi Markandeshwar (Deemed to be University), Mullana 133207, Ambala, Haryana, India; Yenepoya Physiotherapy College, Yenepoya (Deemed to be University), Naringana, Deralakatte, Mangalore 575018, Karnataka, India.
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Thomas R, Wicks S, Toose C, Dale M, Pacey V. Reliability, Validity, and Predictive Validity of Cutaneous Functional Units Predicted to Scar Following Palmar Burn Injury in Young Children. J Burn Care Res 2023; 44:918-924. [PMID: 36478206 DOI: 10.1093/jbcr/irac179] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
Identification of children at risk of palmar burn scar is important for early initiation of scar management. This study determined the interrater reliability of face-to-face and photographic assessments of 29 palmar cutaneous functional units (CFUs) predicted to scar following palmar burn. The validity of photographic compared to face-to-face assessment, and the predictive validity of both assessment types to identify scarring at 3 to 6 months following burn, was also established. Thirty-nine children (40 hands) post burn injury were assessed face-to-face in the clinical setting, following healing of their palmar burn, by three burn therapists. Photographs of the children's hands at initial assessment were assessed by the same therapists a minimum of 6 months later. To determine which CFUs scarred, children were reassessed face-to-face in the clinical setting 3 to 6 months following their burn. For analysis, 29 CFUs were merged into eight separate groups to determine the number of CFUs predicted to scar per CFU group for face-to-face and photographic assessments. The range of agreement for individual CFUs within CFU groups was also calculated for both assessment types. Excellent interrater reliability was established for face-to-face assessment in all eight CFU groups (ICC2,1 0.83-0.96). Photographic assessment demonstrated good to excellent interrater reliability in six CFU groups (ICC2,1 0.69-0.90) and validity in seven CFU groups (ICC2,1 0.66-0.87). Good to excellent predictive validity was established for both assessment types in seven CFU groups (face-to-face ICC2,1 0.60-0.95, photographic ICC2,1 0.69-0.89). Experienced therapists can reliably assess CFUs face-to-face or via photographs and predict future scar development.
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Affiliation(s)
- Rhianydd Thomas
- Department of Health Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
- Burns Unit, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Stephanie Wicks
- Burns Unit, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Claire Toose
- Burns Unit, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Marita Dale
- Discipline of Physiotherapy, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Verity Pacey
- Department of Health Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
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Enkhtuvshin S, Odkhuu E, Batchuluun K, Chimeddorj B, Yadamsuren E, Lkhagvasuren N. Children's post-burn scars in Mongolia. Int Wound J 2023. [PMID: 36756785 DOI: 10.1111/iwj.14077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 12/22/2022] [Indexed: 02/10/2023] Open
Abstract
This study aimed to identify some risk factors for post-burn scarring in children aged 0-18 years. One hundred and eighty two participants were involved in this cohort study. Under the age of 18 who were admitted to the Department of Burn Reconstructive Surgery with a diagnosis of upper and lower extremity burns were followed for 6 months. A total of 182 participants (62.1% male, and 37.9% female participants) enrolled in this study. Age ranged from 1 to 17 and the average age was 3.95 ± 3.35. The degree of burn and the anatomical location of the burn had a statistically significant effect on the development of hypertrophic scars. The length of the patient's hospitalisation days and the area of the burn were statistically correlated with wound healing (P = 000, P = .074). For example, the average length of hospitalisation days was 8 ± 5 days in the hypertrophic scars group of patients, and in the group with normal scars, average bed days were 6 ± 3 days (P = .000). Grade IIIb burns increased the risk of hypertrophic scar development by 4.9 times and grade IV burns increased it by 2.5 times. In addition, when the area of burns was 11% or more, the risk of hypertrophic scar development was increased by 58.8%. In the case of wound swab infection, the risk of hypertrophic scar development was 12.4% higher (B = 1.124, 95 EI = 0.55; 2.28, P = .748). Participants' age, burn area and degree of burn are statistically significant risk factors for post-burn scarring in children aged 0-18 years.
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Affiliation(s)
- Saranchimeg Enkhtuvshin
- Department of Traumatology and Orthopedic, School of Medicine, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | - Erdenezaya Odkhuu
- Department of Anatomy, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | - Khongorzul Batchuluun
- Department of Anatomy, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | - Battogtokh Chimeddorj
- Department of Microbiology, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | - Enkhtur Yadamsuren
- Department of Dermatology, School of Medicine, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | - Naranbat Lkhagvasuren
- Department of Traumatology and Orthopedic, School of Medicine, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
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Wong She RB, Gibran NS. Burn Wound Bed Management. J Burn Care Res 2023; 44:S13-S18. [PMID: 36048573 DOI: 10.1093/jbcr/irac128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Indexed: 12/27/2022]
Abstract
Critical to the success of modern burn care is the management of the burn wound. Timely and complete removal of nonviable tissue is complicated by the irreplaceable nature of the tissue lost either through the burn injury or as "collateral damage" as part of the treatment. Challenges in distinguishing between viable and nonviable tissue and "replacing the irreplaceable" are discussed alongside potential disruptive technologies which could fundamentally change how burn care is delivered. Advances in burn wound bed management forms the foundation on which the goal of zero preventable death and disability after burn injury can be achieved.
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Affiliation(s)
- Richard B Wong She
- National Burn Centre of New Zealand, Middlemore Hospital, Auckland, New Zealand
| | - Nicole S Gibran
- UW Department of Surgery, Harborview Medical Center, Seattle, Washington, USA
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McPhail SM, Wiseman J, Simons M, Kimble R, Tyack Z. Cost-effectiveness of scar management post-burn: a trial-based economic evaluation of three intervention models. Sci Rep 2022; 12:18601. [PMID: 36329128 PMCID: PMC9633777 DOI: 10.1038/s41598-022-22488-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 10/14/2022] [Indexed: 11/06/2022] Open
Abstract
Optimal burn scar management has the potential to markedly improve the lives of children, but can require substantial healthcare resources. The study aimed to examine the cost-effectiveness of three scar management interventions: pressure garment; topical silicone gel; combined pressure garment and topical silicone gel therapy, alongside a randomised controlled trial of these interventions. Participants were children (n = 153) referred for burn scar management following grafting, spontaneous healing after acute burn injury, or reconstructive surgery. Healthcare resource use was costed from a health service perspective (6-months post-burn time-horizon). The mean total scar management cost was lowest in the topical silicone gel group ($382.87 (95% CI $337.72, $443.29)) compared to the pressure garment ($1327.02 (95% CI $1081.46, $1659.95)) and combined intervention $1605.97 ($1077.65, $2694.23)) groups. There were no significant between-group differences in Quality Adjusted Life Year estimates. There was a 70% probability that topical silicone gel dominated pressure garment therapy (was cheaper and more effective), a 29% probability that pressure garment therapy dominated combined therapy, and a 63% probability that topical silicone gel dominated combined therapy. In conclusion, topical silicone gel was the cheaper intervention, and may be favoured in the absence of clear clinical effect favouring pressure garment therapy or a combination of these management approaches.Trial registration: ACTRN12616001100482 (prospectively registered).
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Affiliation(s)
- Steven M. McPhail
- grid.1024.70000000089150953Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Social Work and Public Health, Queensland University of Technology, 149 Victoria Park Rd, Kelvin Grove, QLD 4059 Australia ,grid.474142.0Digital Health and Informatics Directorate, Metro South Health, 199 Ipswich Road, Brisbane, Australia
| | - Jodie Wiseman
- grid.1003.20000 0000 9320 7537Centre for Children’s Burns and Trauma Research, Child Health Research Centre, The University of Queensland, 62 Graham St, South Brisbane, QLD Australia
| | - Megan Simons
- grid.1003.20000 0000 9320 7537Centre for Children’s Burns and Trauma Research, Child Health Research Centre, The University of Queensland, 62 Graham St, South Brisbane, QLD Australia ,grid.240562.7Department of Occupational Therapy, Queensland Children’s Hospital, 501 Stanley St, South Brisbane, QLD Australia ,grid.240562.7Pegg Leditschke Children’s Burns Centre, Queensland Children’s Hospital, 501 Stanley St, South Brisbane, QLD Australia
| | - Roy Kimble
- grid.1003.20000 0000 9320 7537Centre for Children’s Burns and Trauma Research, Child Health Research Centre, The University of Queensland, 62 Graham St, South Brisbane, QLD Australia ,grid.240562.7Pegg Leditschke Children’s Burns Centre, Queensland Children’s Hospital, 501 Stanley St, South Brisbane, QLD Australia
| | - Zephanie Tyack
- grid.1024.70000000089150953Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Social Work and Public Health, Queensland University of Technology, 149 Victoria Park Rd, Kelvin Grove, QLD 4059 Australia ,grid.1003.20000 0000 9320 7537Centre for Children’s Burns and Trauma Research, Child Health Research Centre, The University of Queensland, 62 Graham St, South Brisbane, QLD Australia ,grid.240562.7Pegg Leditschke Children’s Burns Centre, Queensland Children’s Hospital, 501 Stanley St, South Brisbane, QLD Australia
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Karlsson M, Elmasry M, Steinvall I, Huss F, Olofsson P, Elawa S, Larsson A, Sjöberg F. Biosynthetic cellulose compared to porcine xenograft in the treatment of partial-thickness burns: A randomised clinical trial. Burns 2022; 48:1236-1245. [PMID: 34629186 DOI: 10.1016/j.burns.2021.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 09/13/2021] [Accepted: 09/15/2021] [Indexed: 12/15/2022]
Abstract
AIM The aim was to compare two dressing treatments for partial-thickness burns: biosynthetic cellulose dressing (BsC) (Epiprotect® S2Medical AB, Linköping, Sweden) and porcine xenograft (EZ Derm®, Mölnlycke Health Care, Gothenburg, Sweden). METHODS Twenty-four adults with partial-thickness burns were included in this randomized clinical trial conducted at The Burn Centers in Linköping and Uppsala, Sweden between June 2016 and November 2018. Time to healing was the primary outcome. Secondary outcomes were wound infection, pain, impact on everyday life, length of hospital stay, cost, and burn scar outcome (evaluated with POSAS). RESULTS We found no significant differences between the two dressing groups regarding time to healing, wound infection, pain, impact on everyday life, duration of hospital stay, cost, or burn scar outcome at the first follow up. Burn scar outcome at the 12-month follow up showed that the porcine xenograft group patients scored their scars higher on the POSAS items thickness (p = 0.048) and relief (p = 0.050). This difference was, however, not confirmed by the observer. CONCLUSIONS The results showed the dressings performed similarly when used in adults with burns evaluated as partial thickness.
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Affiliation(s)
- Matilda Karlsson
- Department of Hand Surgery, Plastic Surgery and Burns, Linköping University, Linköping, Sweden; Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.
| | - Moustafa Elmasry
- Department of Hand Surgery, Plastic Surgery and Burns, Linköping University, Linköping, Sweden; Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Ingrid Steinvall
- Department of Hand Surgery, Plastic Surgery and Burns, Linköping University, Linköping, Sweden; Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Fredrik Huss
- Department of Surgical Sciences, Plastic Surgery, Uppsala University, Uppsala, Sweden; Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden
| | - Pia Olofsson
- Department of Hand Surgery, Plastic Surgery and Burns, Linköping University, Linköping, Sweden; Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Sherif Elawa
- Department of Hand Surgery, Plastic Surgery and Burns, Linköping University, Linköping, Sweden; Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Alexander Larsson
- Department of Hand Surgery, Plastic Surgery and Burns, Linköping University, Linköping, Sweden; Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Folke Sjöberg
- Department of Hand Surgery, Plastic Surgery and Burns, Linköping University, Linköping, Sweden; Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden; Department of Anesthesiology and Intensive Care, Linköping University, Linköping, Sweden
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10
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Luze H, Nischwitz SP, Smolle C, Zrim R, Kamolz LP. The Use of Acellular Fish Skin Grafts in Burn Wound Management-A Systematic Review. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:912. [PMID: 35888631 PMCID: PMC9323726 DOI: 10.3390/medicina58070912] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 06/08/2022] [Accepted: 07/04/2022] [Indexed: 11/16/2022]
Abstract
Background and Objectives: Burn wound healing and management continues to be a major challenge for patients and health care providers resulting in a considerable socio-economic burden. Recent advances in the development of applicable xenografts as an alternative to split-thickness skin grafts have allowed for the development of acellular fish skin. Acellular fish skin acts as a skin substitute, reducing inflammatory responses and advancing proinflammatory cytokines that promote wound healing. Due to these beneficial wound healing properties, acellular fish skin might represent an effective treatment approach in burn wound management. Materials and Methods: A systematic review of the literature, up to March 2022, was conducted using the electronic databases PubMed and Web of Science. Titles and abstracts were screened for the following key terms (variably combined): "fish skin", "fish skin grafts", "acellular fish skin", "Omega3 Wound matrix", "xenograft", "burn injury", "burns". Results: In total, 14 trials investigating the effects of acellular fish skin in burn wounds or split-thickness donor sites were determined eligible and included in the present review. Existing evidence on the use of acellular fish skin indicates an acceleration of wound healing, reduction in pain and necessary dressing changes as well as treatment-related costs and improved aesthetic and functional outcomes compared to conventional treatment options. Conclusions: Acellular fish skin xenografts may represent an effective, low-cost alternative in treatment of superficial- and partial-thickness burns. However, results mainly originate from preclinical and small cohort studies. Future larger cohort studies are warranted to elucidate the full potential of this promising approach.
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Affiliation(s)
- Hanna Luze
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, 8036 Graz, Austria; (S.P.N.); (C.S.); (R.Z.); (L.-P.K.)
- Research Unit for Tissue Regeneration, Repair and Reconstruction c/o Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, 8036 Graz, Austria
| | - Sebastian Philipp Nischwitz
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, 8036 Graz, Austria; (S.P.N.); (C.S.); (R.Z.); (L.-P.K.)
- Research Unit for Tissue Regeneration, Repair and Reconstruction c/o Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, 8036 Graz, Austria
| | - Christian Smolle
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, 8036 Graz, Austria; (S.P.N.); (C.S.); (R.Z.); (L.-P.K.)
| | - Robert Zrim
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, 8036 Graz, Austria; (S.P.N.); (C.S.); (R.Z.); (L.-P.K.)
- International University of Monaco, 98000 Monaco-Ville, Monaco
| | - Lars-Peter Kamolz
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, 8036 Graz, Austria; (S.P.N.); (C.S.); (R.Z.); (L.-P.K.)
- COREMED—Cooperative Centre for Regenerative Medicine, Joanneum Research Forschungsgesellschaft mbH, 8010 Graz, Austria
- Research Unit for Safety in Health c/o Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, 8036 Graz, Austria
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11
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Cuttle L, Fear M, Wood FM, Kimble RM, Holland AJA. Management of non-severe burn wounds in children and adolescents: optimising outcomes through all stages of the patient journey. THE LANCET. CHILD & ADOLESCENT HEALTH 2022; 6:269-278. [PMID: 35051408 DOI: 10.1016/s2352-4642(21)00350-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 10/28/2021] [Accepted: 11/01/2021] [Indexed: 12/11/2022]
Abstract
Paediatric burn injuries are common, especially in children younger than 5 years, and can lead to poor physical and psychosocial outcomes in the long term. In this Review, we aim to summarise the key factors and interventions before hospital admission and following discharge that can improve the long-term outcomes of paediatric burns. Care can be optimised through first aid treatment, correct initial assessment of burn severity, and appropriate patient referral to a burns centre. Scar prevention or treatment and patient follow-up after discharge are also essential. As most burn injuries in children are comparatively small and readily survivable, this Review does not cover the perioperative management associated with severe burns that require fluid resuscitation, or inhalational injury. Burns disproportionately affect children from low socioeconomic backgrounds and those living in low-income and middle-income countries, with ample evidence to suggest that there remains scope for low-cost interventions to improve care for those patients with the greatest burden of burn injury. Current knowledge gaps and future research directions are discussed.
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Affiliation(s)
- Leila Cuttle
- Centre for Children's Health Research, Faculty of Health, School of Biomedical Sciences, Queensland University of Technology, Brisbane, QLD, Australia.
| | - Mark Fear
- Burn Injury Research Unit, School of Biomedical Sciences, The University of Western Australia, Perth, WA, Australia
| | - Fiona M Wood
- Burn Injury Research Unit, School of Biomedical Sciences, The University of Western Australia, Perth, WA, Australia; Burns Service of Western Australia, Perth Children's Hospital and Fiona Stanley Hospital, Perth, WA, Australia
| | - Roy M Kimble
- Centre for Children's Burns and Trauma Research, The University of Queensland, South Brisbane, QLD, Australia; Queensland Children's Hospital, South Brisbane, QLD, Australia
| | - Andrew J A Holland
- The Children's Hospital Burns Research Institute, The Children's Hospital at Westmead, The University of Sydney, NSW, Westmead, Australia
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12
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Brewin M, Docherty S, Heaslip V, Breheny K, Pleat J, Rhodes S. Early Laser for Burn Scars (ELABS): protocol for a multi-centre randomised, controlled trial of both the effectiveness and cost-effectiveness of the treatment of hypertrophic burn scars with Pulsed Dye Laser and standard care compared to standard care alone [version 1; peer review: 2 approved]. NIHR OPEN RESEARCH 2022; 2:1. [PMID: 35392303 PMCID: PMC7612584 DOI: 10.3310/nihropenres.13234.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 11/09/2021] [Indexed: 11/22/2022]
Abstract
This paper outlines the protocol for a study that is being carried out at multiple centres across the UK in the next three years. It is a Research for Patient Benefit (RfPB) study funded by the National Institute for Healthcare Research (NIHR). The aim is to assess the effectiveness of treating hypertrophic burns scars with pulsed dye laser (PDL) at an early stage of scar formation. The objective is to improve Quality of Life for the patient by improving both the appearance and quality of burn scarring, as well as reducing its psychological impact. This is a parallel-arm randomised, controlled trial to compare PDL and standard care against standard care alone. The difference is measured between baseline and six-month follow-up. Recruits are within three months of healing from a burn injury; with wounds showing a defined potential for hypertrophic scarring. A total of 120 patients are recruited in a multi-centre study; with randomisation in a 1:1 allocation to each arm. The treatment arm receives 3 PDL treatments at six-week intervals in addition to standard care, whereas the control arm receives standard care alone. The primary outcome is the patient-rated part of the Patient and Observer Scar Scale (POSAS). Psychological and psycho-social impact is evaluated using the CARe burn scale (UWE, Bristol) and Quality Adjusted Life Years (QALY) is determined using the Short-Form Health Survey (SF-12). The study evaluates both the cost-effectiveness through an economic analysis and the patient-reported experience of the treatment by phone interviews.
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Affiliation(s)
- Mark Brewin
- Burns & Plastics, Salisbury NHS Foundation Trust, Salisbury, Wiltshire, SP2 8BJ, UK
| | | | | | | | - Jonathon Pleat
- Burns & Plastics, North Bristol NHS Trust, Bristol, BS10 5NB, UK
| | - Shelley Rhodes
- Exeter Clinical Trials Unit, University of Exeter, Exeter, EX4 4SB, UK
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13
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Outcomes of grafted skin on the dorsum of the foot after car-tire friction injuries. Arch Plast Surg 2021; 48:678-684. [PMID: 34818716 PMCID: PMC8627940 DOI: 10.5999/aps.2021.00962] [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: 05/21/2021] [Accepted: 08/10/2021] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND A car-tire friction injury on the dorsum of a child's foot often results in hypertrophic scarring of the wound margins. This study describes the clinical appearance of the injured areas and surgical complications that occurred during the follow-up period in a series of children with car-tire friction injuries who were treated with split-thickness skin grafts (STSGs). We describe the clinical features that we believe need to be highlighted when initially treating car-tire injuries in children. METHODS From May 2003 to June 2016, our retrospective study included 15 patients with car-tire injuries on the dorsum of the foot who were treated with surgical excision and STSG to cover the wound. RESULTS A total of 15 patients with car-tire injuries were treated. The average age was 6.26 years old. The average injury grade was 3.26. Two patients were treated using delayed repair, and 13 patients received STSG for initial management. Four patients experienced no complications, while 11 patients had hypertrophic scars and/or scar contracture after surgery. CONCLUSIONS A car-tire friction injury on the dorsum of a child's foot often results in hypertrophic scar formation or scar contracture even if proper management is undertaken. Since the occurrence of these complications in childhood can lead to a secondary deformity, it is important to properly treat car-tire friction wounds, inform patients and caregivers about potential complications, and ensure regular follow-up evaluations over a 12-month period following the initial surgery.
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14
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Müller B, Mazza E, Schiestl C, Elrod J. Longitudinal monitoring and prediction of long-term outcome of scar stiffness on pediatric patients. BURNS & TRAUMA 2021; 9:tkab028. [PMID: 34604394 PMCID: PMC8484205 DOI: 10.1093/burnst/tkab028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 02/25/2021] [Indexed: 11/13/2022]
Abstract
Background Hypertrophic scarring after burn injury is one of the greatest unmet challenges in patients with burn injuries. A better understanding of the characteristics of scar maturation and early prediction of the long-term outcome of scarring are prerequisites for improving targeted therapies and pivotal for patient counselling. Methods Repeated measurements of scar stiffness in 11 pediatric patients were performed over the course of 1 year using 2 suction devices, the Cutometer and the Nimble. In addition, the observer pliability score of the Patient and Observer Scar Assessment Scale was applied. This longitudinal study allowed quantification of the ability of each of the measured parameters to reflect scar maturation, as indicated by change in skin pliability/stiffness, over time (using linear regression); the ability to distinguish individual patients (intraclass correlation coefficient (ICC)); the correlation of the devices (Spearman correlation coefficient); and the ability to predict long-term scar maturation based on early scar assessment (using receiver operating characteristic). Results All the tools used showed significant longitudinal decrease of scar stiffness from 3 months until 12 months after the injury. The Nimble (ICCpatient Nimble = 0.99) and the Cutometer (ICCpatient Cuto = 0.97) demonstrated an excellent ability to distinguish between individual patients. The Nimble seemed to be able to predict the 12-month pliability of scars based on early (3-month) measurements (area under the curve (AUC)12m POSAS = 0.67; AUC12m C = 0.46; AUC12m N = 0.79). Conclusions The results of this preliminary study suggest that all 3 tools provide suitable means to quantify alterations in scar stiffness over time. Initial evidence suggests the Nimble is most favorable for predicting changes in stiffness associated with long-term scar maturation. Further studies with a larger sample size are required to validate tissue suction as a clinical tool for analysis of changes of scar stiffness over time.
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Affiliation(s)
- Bettina Müller
- Institute for Mechanical Systems, Department of Mechanical and Process Engineering, ETH Zurich, Leonhardstrasse 21, 8092 Zurich, Switzerland
| | - Edoardo Mazza
- Institute for Mechanical Systems, Department of Mechanical and Process Engineering, ETH Zurich, Leonhardstrasse 21, 8092 Zurich, Switzerland
| | - Clemens Schiestl
- Burn Center, Division of Plastic and Reconstructive Surgery, University Children's Hospital Zurich, Steinwiesstrasse 75, 8032 Zürich, Switzerland
| | - Julia Elrod
- Burn Center, Division of Plastic and Reconstructive Surgery, University Children's Hospital Zurich, Steinwiesstrasse 75, 8032 Zürich, Switzerland
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15
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Cost-effectiveness of adjunctive negative pressure wound therapy in paediatric burn care: evidence from the SONATA in C randomised controlled trial. Sci Rep 2021; 11:16650. [PMID: 34404842 PMCID: PMC8371025 DOI: 10.1038/s41598-021-95893-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 07/30/2021] [Indexed: 11/24/2022] Open
Abstract
Negative pressure wound therapy (NPWT) has been shown to improve clinical outcomes for children with burns by accelerating wound re-epithelialisation. Its effects on healthcare costs, however, remain poorly understood. The aim of this study was to evaluate the cost-effectiveness of NPWT from a healthcare provider perspective using evidence from the SONATA in C randomised controlled trial, in which 101 children with small-area burns were allocated to either standard care (silver-impregnated dressings) or standard care in combination with adjunctive NPWT. The primary outcome, time to re-epithelialisation, was assessed through a blinded photographic review. Resource usage and costs were prospectively recorded for each participant for up to 6 months. Incremental cost-effectiveness ratios and dominance probabilities were estimated and uncertainty quantified using bootstrap resampling. Mean costs per participant—including dressings, labour, medication, scar management, and theatre operations—were lower in the NPWT group (AUD $903.69) relative to the control group (AUD $1669.01). There was an 89% probability that NPWT was dominant, yielding both faster re-epithelialisation and lower overall costs. Findings remained robust to sensitivity analyses employing alternative theatre costs and time-to-re-epithelialisation estimates for grafted patients. In conclusion, adjunctive NPWT is likely to be a cost-effective and dominant treatment for small-area paediatric burns (ANZCTR.org.au:ACTRN12618000256279).
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16
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Williams H, Suda S, Dervish S, Yap YT, Holland AJA, Medbury HJ. Monocyte M1/M2 profile is altered in paediatric burn patients with hypertrophic scarring. Wound Repair Regen 2021; 29:996-1005. [PMID: 34272902 DOI: 10.1111/wrr.12960] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 05/26/2021] [Accepted: 07/07/2021] [Indexed: 01/06/2023]
Abstract
Hypertrophic scars (HTS) remain a common outcome of burn injury, particularly in children. They can arise from variations in the wound healing stages, such as an excessive inflammatory response or inefficient remodelling. Of the cells contributing to these healing stages, macrophages and fibrocytes are crucial. Specifically, the inflammatory phase is dominated by M1 macrophages, the proliferation/remodelling stages by M2 macrophages, and scar tissue contains numerous fibrocytes. As the progenitors to these cells, monocytes, can also exhibit M1- and M2-skewing, we proposed that their profile, or circulating fibrocyte counts, could be used to predict poor healing outcomes. To investigate this, we obtained blood samples from paediatric controls and burns patients, which were then divided into HTS and NoHTS groups upon scar assessment at 12 months. The samples were assessed by whole blood flow cytometry to quantify fibrocytes and monocyte subset proportions and to determine monocyte levels of M1 (CD86, CD120b, CD319) and M2 (CD93, CD163, CD200R) markers. Both burns groups had higher proportions of classical monocytes compared to controls, indicating increased cell turnover and/or entry of other subsets into the wound. In burns patients who took more than 21 days to heal, the HTS group had lower M2 (CD200R) expression with the ratio of M1/M2 (CD86/CD200R) being significantly higher. These results suggest an elevated early inflammatory monocyte response contributes to development of HTS. Correlations of marker expression with remaining healing time revealed a significant positive correlation with M1 (CD120b) and M1/M2 (CD120b/CD200R), suggesting a potential role for CD120b as an indicator of healing delay. Fibrocytes did not significantly differ between the groups. In conclusion, increased monocyte inflammation likely contributes to slower healing and development of scarring, but further studies are needed to determine the predictive power of monocyte inflammatory profile.
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Affiliation(s)
- Helen Williams
- Department of Surgery, Westmead Hospital, Vascular Biology Research Centre, Westmead, Australia.,Westmead Clinical School, The Faculty of Medicine and Health, Westmead Hospital, The University of Sydney, Westmead, Australia
| | - Sasithorn Suda
- Westmead Clinical School, The Faculty of Medicine and Health, Westmead Hospital, The University of Sydney, Westmead, Australia
| | - Suat Dervish
- Westmead Research Hub, Westmead Institute for Medical Research, Westmead, Australia
| | - Yen Tien Yap
- Westmead Clinical School, The Faculty of Medicine and Health, Westmead Hospital, The University of Sydney, Westmead, Australia
| | - Andrew J A Holland
- The Children's Hospital Burns Research Institute, The Children's Hospital at Westmead, The University of Sydney, Westmead, Australia
| | - Heather J Medbury
- Department of Surgery, Westmead Hospital, Vascular Biology Research Centre, Westmead, Australia.,Westmead Clinical School, The Faculty of Medicine and Health, Westmead Hospital, The University of Sydney, Westmead, Australia
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17
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Nabai L, Pourghadiri A, Ghahary A. Hypertrophic Scarring: Current Knowledge of Predisposing Factors, Cellular and Molecular Mechanisms. J Burn Care Res 2021; 41:48-56. [PMID: 31999336 DOI: 10.1093/jbcr/irz158] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Hypertrophic scarring (HSc) is an age-old problem that still affects millions of people physically, psychologically, and economically. Despite advances in surgical techniques and wound care, prevention and treatment of HSc remains a challenge. Elucidation of factors involved in the development of this common fibroproliferative disorder is crucial for further progress in preventive and/or therapeutic measures. Our knowledge about pathophysiology of HSc at the cellular and molecular level has grown considerably in recent decades. In this article, current knowledge of predisposing factors and the cellular and molecular mechanisms of HSc has been reviewed.
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Affiliation(s)
- Layla Nabai
- BC Professional Firefighters' Burn & Wound Healing Research Laboratory, Department of Surgery, Division of Plastic Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Amir Pourghadiri
- BC Professional Firefighters' Burn & Wound Healing Research Laboratory, Department of Surgery, Division of Plastic Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Aziz Ghahary
- BC Professional Firefighters' Burn & Wound Healing Research Laboratory, Department of Surgery, Division of Plastic Surgery, University of British Columbia, Vancouver, British Columbia, Canada
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18
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Tiruneh CM, Belachew A, Mulatu S, Desie T, Abate MW, Nigat AB, Tibebu NS, Walle BG, Tigabu A, Belete A. Pathological Scar and Its Associated Factors Among Survivor of Burn Victim Pediatrics Admitted to South Gondar Zone Public Hospitals, Amhara Regional State, Ethiopia, 2020 – A Multi-Center Cross-Sectional Study. CHRONIC WOUND CARE MANAGEMENT AND RESEARCH 2021. [DOI: 10.2147/cwcmr.s322794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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19
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Thomas R, Wicks S, Dale M, Pacey V. Outcomes of Early and Intensive Use of a Palm and Digit Extension Orthosis in Young Children After Burn Injury. J Burn Care Res 2021; 42:245-257. [PMID: 32820803 DOI: 10.1093/jbcr/iraa137] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Burns to the palmar aspect of the hand are prevalent in young children. The development of scar tissue across the flexor surface of the hand combined with the years of growth ahead may result in considerable complications. This study was undertaken to describe outcomes of early and intensive use of a palm and digit extension orthosis with the elbow immobilized at 90° flexion following a palmar hand burn. A retrospective review of 107 children (mean age 18 months [SD 10]) treated at a statewide Pediatric Burns Unit from 2012 to 2016 was performed. Three children (3%) developed contracture during the 24-month study follow-up period. The other 104 children (97%) had full ROM at 24 months or at either the point of discharge or loss to follow-up. Early signs of contracture, defined as loss of full movement or significant banding, developed in 26 children (24%) in the first 9 months after burn. With intensive physiotherapy, 23 children regained full movement by 12 months after burn. Children who did not achieve complete wound healing at 1 month after burn and children with hypertrophic scarring at 2 months after burn were significantly more represented among cases of early signs of contracture (P = .013). When undertaken with regular clinical review, early and intensive use of a palm and digit extension orthosis can maintain full extension of the palm and digits in children after palmar burn.
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Affiliation(s)
- Rhianydd Thomas
- Department of Health Professions, Macquarie University, North Ryde, New South Wales, Australia.,Burns Unit, The Children's Hospital at Westmead, New South Wales, Australia
| | - Stephanie Wicks
- Burns Unit, The Children's Hospital at Westmead, New South Wales, Australia
| | - Marita Dale
- Discipline of Physiotherapy, The University of Sydney, Lidcombe, New South Wales, Australia
| | - Verity Pacey
- Department of Health Professions, Macquarie University, North Ryde, New South Wales, Australia
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20
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Frear CC, Cuttle L, McPhail SM, Chatfield MD, Kimble RM, Griffin BR. Randomized clinical trial of negative pressure wound therapy as an adjunctive treatment for small-area thermal burns in children. Br J Surg 2020; 107:1741-1750. [PMID: 32926410 PMCID: PMC7692881 DOI: 10.1002/bjs.11993] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Revised: 04/17/2020] [Accepted: 07/21/2020] [Indexed: 12/03/2022]
Abstract
Background The efficacy of negative pressure wound therapy (NPWT) in the acute management of burns remains unclear. The purpose of this trial was to compare standard Acticoat™ and Mepitel™ dressings with combined Acticoat™, Mepitel™ and continuous NPWT to determine the effect of adjunctive NPWT on re‐epithelialization in paediatric burns. Methods This two‐arm, single‐centre RCT recruited children with acute thermal burns covering less than 5 per cent of their total body surface area. The primary outcome was time to re‐epithelialization. Blinded assessments were performed using photographs captured every 3–5 days until discharge. Secondary measures included pain, itch, grafting, perfusion and scar management referrals. Results Some 114 patients were randomized. Median time to re‐epithelialization was 8 (i.q.r. 7–11) days in the NPWT group and 10 (8–14) days in the control group. In a multivariable model, NPWT decreased the expected time to wound closure by 22 (95 per cent c.i. 7 to 34) per cent (P = 0·005). The risk of referral to scar management was reduced by 60 (18 to 81) per cent (P = 0·013). Four participants in the control group and one in the NPWT group underwent grafting. There were no statistically significant differences between groups in pain, itch or laser Doppler measures of perfusion. Adverse events were rare and minor, although NPWT carried a moderate treatment burden, with ten patients discontinuing early. Conclusion Adjunctive NPWT hastened re‐epithelialization in small‐area burn injuries in children, but had a greater treatment burden than standard dressings alone. Registration number: ACTRN12618000256279 (
http://ANZCTR.org.au).
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Affiliation(s)
- C C Frear
- Centre for Children's Burns and Trauma Research, South Brisbane, Australia.,Faculty of Medicine, University of Queensland, Herston, Australia
| | - L Cuttle
- Centre for Children's Burns and Trauma Research, South Brisbane, Australia.,School of Biomedical Sciences, Brisbane, Queensland, Australia
| | - S M McPhail
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Brisbane, Queensland, Australia.,Clinical Informatics Directorate, Metro South Health, Brisbane, Queensland, Australia
| | - M D Chatfield
- Faculty of Medicine, University of Queensland, Herston, Australia
| | - R M Kimble
- Centre for Children's Burns and Trauma Research, South Brisbane, Australia.,Queensland Children's Hospital, South Brisbane, Australia.,Faculty of Medicine, University of Queensland, Herston, Australia
| | - B R Griffin
- Centre for Children's Burns and Trauma Research, South Brisbane, Australia.,School of Nursing, Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
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21
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Nedelec B, LaSalle L, de Oliveira A, Correa JA. Within-Patient, Single-Blinded, Randomized Controlled Clinical Trial to Evaluate the Efficacy of Triamcinolone Acetonide Injections for the Treatment of Hypertrophic Scar in Adult Burn Survivors. J Burn Care Res 2020; 41:761-769. [DOI: 10.1093/jbcr/iraa057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Abstract
Intralesional corticosteroid (triamcinolone acetonide [TAC]) injections have become one of the cornerstone treatments of hypertrophic scar (HSc). However, the evidence is of limited-quality, and published investigations have almost exclusively been performed in linear scars rather than hypertrophic burn scars. Thus, the aim of this study was to perform an appropriately powered, single-blinded, randomized controlled trial to evaluate the impact of TAC injections on burn HSc compared with patient-matched usual care control scars. Fifty burn survivors with two scars (separated by nonscarred skin preferably on the contralateral side or an anatomically similar site) were selected based on high-frequency ultrasound thickness (>2.034 mm to ensure that the site was outside of the range of normal scar). Pretreatment thickness measurements of the two sites were within 0.5 mm of each other, to ensure homogeneity and an erythema index >300 to establish they were immature HSc. The sites were randomly assigned to treatment or control. The treatment HSc received a 10 mg/ml TAC. When necessary, the injection was repeated after 6 weeks and a third final injection 6 weeks later. Objective evaluation of thickness, elasticity, erythema, and melanin was obtained at the treatment and control sites at pretreatment, posttreatment, and follow-up 6 weeks after the last injection. Thirty participants completed the study, reaching the required number for an adequately powered sample based on pilot study data analyses. Ten participants received only one injection, 27 received only two injections, and 13 received three injections of TAC. Analysis of covariance comparing the treatment vs control HSc posttreatment, controlling for pretreatment values and Fitzpatrick skin type, revealed a significant decrease in thickness and increase in elasticity of the treated compared with control HSc (P = .0003), but no significant difference in erythema or melanin. Pretreatment to posttreatment comparisons using paired t-tests revealed a significant decrease in thickness of both the treated and control HSc, an increase in elasticity of the treated HSc during the treatment period, but no significant change in the control HSc elasticity or erythema of either site, and a significant increase in melanin of both the treated (P < .001) and control (P = .02) HSc. A regression model for repeated measures, controlling for pretreatment values and skin type, revealed no significant change in thickness, elasticity, erythema, or melanin during the 6-week follow-up. Although thickness decreased at both the treated and control HSc across time, there was a significantly greater reduction at the TAC injected HSc and a significantly greater increase in elasticity. Melanin significantly increased at both the treatment and control site. There was no significant change during the follow-up period of any of the HSc characteristics.
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Affiliation(s)
- Bernadette Nedelec
- School of Physical and Occupational Therapy, McGill University, Montreal, Canada
- Hôpital de réadaptation Villa Medica, Montreal, Canada
- Centre de recherche du Centre Hospitalier de l’Université de Montréal (CHUM), Canada
| | - Leo LaSalle
- Hôpital de réadaptation Villa Medica, Montreal, Canada
| | - Ana de Oliveira
- Hôpital de réadaptation Villa Medica, Montreal, Canada
- Centre de recherche du Centre Hospitalier de l’Université de Montréal (CHUM), Canada
| | - José A Correa
- Department of Mathematics and Statistics, McGill University, Montreal, Canada
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22
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Karlsson M, Steinvall I, Sjöberg F, Olofsson P, Elmasry M. Burn scar outcome at six and 12 months after injury in children with partial thickness scalds: Effects of dressing treatment. Burns 2020; 46:546-551. [PMID: 32165027 DOI: 10.1016/j.burns.2020.02.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 01/29/2020] [Accepted: 02/15/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION In line with other researchers in the field of burns' care, we think that research investigating the long-term outcome of scars is largely lacking. As scarring is of the utmost importance to the patient, clinicians who treat burns must aim to find treatments that lead to a good end result. The aim of this study was to study scar outcomes at six and 12 months after injury. It is an extension of a previous randomised controlled trial (RCT) in which two dressings (porcine xenograft and silver foam dressing) were examined with respect to their ability to help heal partial thickness scalds. METHOD Children aged six months - six years with acute partial thickness scalds, on the trunk, or extremities, or both, were included. In the previous study, the silver foam was found to have significantly shorter healing times than the xenograft. Children were assessed at six and 12 months after injury for this study, and photographs were taken of the burn site, and both the patient and observer scar assessment scale (POSAS) and the Vancouver scar scale (VSS) were completed and evaluated by blinded observers. RESULTS Of the 58 children from the original RCT, 39 returned to the clinic for evaluation of their scars at six months, and 34 at 12 months after injury. There were no differences in POSAS, VSS total scores, or incidence of hypertrophic scarring between the different dressings. Fifteen children were assessed as having hypertrophic scarring, all of whom had healing times that had extended beyond 14 days. CONCLUSIONS This study compared burn scarring after two different treatments for burns in children with partial-thickness scalds and the data suggested that neither dressing had a more favourable impact on scar outcome. The conclusion is, however, tempered by the non-return of all the patients to the follow up. However, as anticipated, regardless of the dressing used, longer healing times were associated with higher scar scores (more scarring) and hypertrophic scarring.
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Affiliation(s)
- Matilda Karlsson
- Department of Hand Surgery, Plastic Surgery and Burns, Linköping University, Linköping, Sweden; Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden.
| | - Ingrid Steinvall
- Department of Hand Surgery, Plastic Surgery and Burns, Linköping University, Linköping, Sweden; Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Folke Sjöberg
- Department of Hand Surgery, Plastic Surgery and Burns, Linköping University, Linköping, Sweden; Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden; Department of Anesthesiology and Intensive Care, Linköping University, Linköping, Sweden
| | - Pia Olofsson
- Department of Hand Surgery, Plastic Surgery and Burns, Linköping University, Linköping, Sweden; Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Moustafa Elmasry
- Department of Hand Surgery, Plastic Surgery and Burns, Linköping University, Linköping, Sweden; Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
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Thomas R, Wicks S, Toose C, Pacey V. Outcomes of Early Use of an End of Range Axilla Orthotic in Children Following Burn Injury. J Burn Care Res 2019; 40:678-688. [PMID: 30950500 DOI: 10.1093/jbcr/irz058] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Scar contracture is a significant complication of burn injury. This study aimed to describe outcomes of early axilla orthotic use at end of range abduction in children, following a burn to the axilla region. A retrospective review of 76 children (mean age 3.9 years [SD 3.6]) treated at a tertiary children's hospital from 2006 to 2016 was conducted. No child developed axilla contracture for the duration of the 2-year study follow-up with no adverse events recorded. If orthotic use was ceased <60 days post-burn, it was considered not an essential intervention to maintain range of movement, leaving 49 children using the orthotic ≥60 days. Compared with the children who ceased orthotic use in <60 days, children who required the orthotic ≥60 days had a significantly higher frequency of deep-dermal burn (59 vs 25%, p = .01), flame mechanism (25 vs 5%, p = .03), and burn injury distribution involving the anterior trunk, flank, and arm (18 vs 3%, p = .03). Early signs of contracture, considered loss of full axilla range or significant banding, developed in nine children within 3 months post-burn. With intensive therapy, all returned to full axilla range by 9 months post-burn. Children with skin tension at end of range shoulder movement at the 1-month clinical assessment were 11 times more likely to develop early signs of contracture (95% confidence interval [CI]: 1.9-62.1, p = .007). Intensive orthotic use at end of range shoulder abduction in children with axilla burns is well tolerated. When undertaken with ongoing therapist review, full axilla range can be maintained.
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Affiliation(s)
- Rhianydd Thomas
- Department of Health Professions, Faculty of Medicine and Health Sciences, Macquarie University, New South Wales, Australia.,Physiotherapy Department, The Children's Hospital at Westmead, New South Wales, Australia
| | - Stephanie Wicks
- Physiotherapy Department, The Children's Hospital at Westmead, New South Wales, Australia
| | - Claire Toose
- Physiotherapy Department, The Children's Hospital at Westmead, New South Wales, Australia
| | - Verity Pacey
- Department of Health Professions, Faculty of Medicine and Health Sciences, Macquarie University, New South Wales, Australia
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Kusu-Orkar TE, Islam U, Hall B, Araia E, Allorto N. The use of a non-medicated dressing for superficial-partial thickness burns in children: a case series and review. Scars Burn Heal 2019; 5:2059513119896954. [PMID: 32341804 PMCID: PMC7169358 DOI: 10.1177/2059513119896954] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Cutimed® Sorbact® is a dressing marketed as having antimicrobial properties and easy application without the threat of antibiotic resistance and difficult accessibility. There is little evidence on the clinical outcomes of the use of Cutimed® Sorbact® in adults and currently no evidence of use of Cutimed® Sorbact® on superficial-partial thickness burn injuries in children. OBJECTIVE To summarise the clinical outcome of burn wounds in children with superficial-partial thickness burns in which Cutimed® Sorbact® was used. METHOD An observational case series was conducted in Edendale Hospital, Pietermaritzburg, South Africa over the course of four weeks. Patients where included if they were aged < 10 years and had a ⩽ 15% superficial-partial burn. The primary outcome measure was time to 95% re-epithelialisation. Secondary outcome measures included wound complications, adverse healing and number of dressing changes. RESULTS Ten patients (five girls, five boys; age range = 11 months-8 years) were included in this case series. All participants had a type VI Fitzpatrick skin type and 80% of burns were hot water burns. Of all patients treated with Cutimed® Sorbact®, 50% healed within seven days, 70% within 14 days and 100% within 21 days. There was only one wound complication noted in this study and there was no adverse healing in any burn wounds. The mean number of dressing changes was 1.4 (range = 1-2) and length of hospital stay was in the range of 0-11 days (mean = 5.1 days). CONCLUSION Cutimed® Sorbact® is a safe, useful and cost-effective dressing that should be used as an alternative for superficial-partial burns in children.
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Affiliation(s)
| | - Umar Islam
- School of Medicine, University of Liverpool, Liverpool, UK
| | - Benjamin Hall
- School of Medicine, University of Liverpool, Liverpool, UK
| | - Evan Araia
- St Helens and Knowsley Teaching Hospital, Liverpool, UK
| | - Nikki Allorto
- Burns Department of Surgery, Edendale Hospital, Pietermaritzburg, Kwazulu-Natal, South Africa
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McBride CA, Kimble RM, Stockton KA. Prospective randomised controlled trial of Algisite™ M, Cuticerin™, and Sorbact® as donor site dressings in paediatric split-thickness skin grafts. BURNS & TRAUMA 2018; 6:33. [PMID: 30519595 PMCID: PMC6267093 DOI: 10.1186/s41038-018-0135-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 11/07/2018] [Indexed: 11/10/2022]
Abstract
BACKGROUND This is a parallel three-arm prospective randomised controlled trial (RCT) comparing Algisite™ M, Cuticerin™, and Sorbact® as donor site dressings in paediatric split-thickness skin grafts (STSG). All three were in current use within the Pegg Leditschke Children's Burn centre (PLCBC), the largest paediatric burns centre in Queensland, Australia. Our objective was to find the best performing dressing, following on from previous trials designed to rationalise dressings for the burn wound itself. METHODS All children for STSG, with thigh donor sites, were considered for enrolment in the trial. Primary outcome measures were days to re-epithelialisation, and pain. Secondary measures were cost, itch, and scarring at 3 and 6 months. Patients and parents were blinded to group assignment. Blinding of assessors was possible with the dressing in situ, with partial blinding following first dressing change. Blinded photographic assessments of re-epithelialisation were used. Scar assessment was blinded. Covariates for analysis were sex, age, and graft thickness (as measured from a central biopsy). RESULTS There were 101 patients randomised to the Algisite™ M (33), Cuticerin™ (32), and Sorbact® (36) arms between April 2015 and July 2016. All were analysed for time to re-epithelialisation. Pain scores were not available for all time points in all patients. There were no significant differences between the three arms regarding pain, or time to re-epithelialisation. There were no significant differences for the secondary outcomes of itch, scarring, or cost. Regression analyses demonstrated faster re-epithelialisation in younger patients and decreased donor site scarring at 3 and 6 months with thinner STSG. There were no adverse effects noted. CONCLUSIONS There are no data supporting a preference for one trial dressing over the others, in donor site wounds (DSW) in children. Thinner skin grafts lead to less donor site scarring in children. Younger patients have faster donor site wound healing. TRIAL REGISTRATION Australia and New Zealand Clinical Trials Register (ACTRN12614000380695).Royal Children's Hospital Human Research Ethics Committee (HREC/14/QRCH/36).University of Queensland Medical Research Ethics Committee (#2014000447).
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Affiliation(s)
- Craig A McBride
- Pegg Leditschke Children's Burns Centre, Queensland Children's Hospital, Children's Health Queensland Hospital and Health Service, South Brisbane, Queensland Australia
- 2Centre for Children's Burns and Trauma Research, Centre for Children's Health Research, University of Queensland, South Brisbane, Australia
- 3Discipline of Paediatrics and Child Health, School of Medicine, University of Queensland, St Lucia, Queensland Australia
| | - Roy M Kimble
- Pegg Leditschke Children's Burns Centre, Queensland Children's Hospital, Children's Health Queensland Hospital and Health Service, South Brisbane, Queensland Australia
- 2Centre for Children's Burns and Trauma Research, Centre for Children's Health Research, University of Queensland, South Brisbane, Australia
- 3Discipline of Paediatrics and Child Health, School of Medicine, University of Queensland, St Lucia, Queensland Australia
| | - Kellie A Stockton
- Pegg Leditschke Children's Burns Centre, Queensland Children's Hospital, Children's Health Queensland Hospital and Health Service, South Brisbane, Queensland Australia
- 2Centre for Children's Burns and Trauma Research, Centre for Children's Health Research, University of Queensland, South Brisbane, Australia
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26
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Kim JD, Oh SJ, Kim SG, Ahn SV, Jang YJ, Yang BS, Jeong JY, Kim KJ. Ultrasonographic findings of re-epithelialized skin after partial-thickness burns. BURNS & TRAUMA 2018; 6:21. [PMID: 30123801 PMCID: PMC6091158 DOI: 10.1186/s41038-018-0122-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Accepted: 06/13/2018] [Indexed: 11/10/2022]
Abstract
Background This study aimed to investigate the difference between ultrasonographic findings of normal skin and those of re-epithelialized skin after partial-thickness burns and to evaluate the relationship between these findings and clinical outcomes. Methods This study retrospectively analysed the ultrasound images of re-epithelialized skin after partial-thickness burns and contralateral normal skin from January 2016 to December 2016. A total of 155 lesions from 148 patients were analysed with ultrasound images, and healing time was documented. The scar status of each lesion was evaluated through medical records and photographs. We analysed the difference in ultrasonographic findings between normal skin and re-epithelialized skin after partial-thickness burns and statistically analysed the relationship between healing time, scar status and ultrasonographic findings. Results The re-epithelialized skin after partial-thickness burns was significantly thicker than the contralateral normal skin, and the echogenicity was significantly lower. The ultrasound images of the re-epithelialized skin after partial-thickness burns showed the characteristic findings of low-echogenic bands (LEB), and the proportion of LEB thickness is strongly correlated with healing time. In the multivariate analysis of scar status, only the proportion of LEB thickness was statistically significant. Conclusion In this study, we found that there were ultrasonographic differences between re-epithelialized skin after partial-thickness burns and normal skin and that an LEB of varying thickness was formed after re-epithelialization. The thickness of the LEB in re-epithelialized skin after partial-thickness burns increased with healing time and was related to scar status.
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Affiliation(s)
- Jong Dae Kim
- 1Department of Burn Reconstructive Surgery, Bestian Seoul Hospital, Dogok-ro 429, Gangnam-gu, Seoul, Republic of Korea
| | - Suk Joon Oh
- 1Department of Burn Reconstructive Surgery, Bestian Seoul Hospital, Dogok-ro 429, Gangnam-gu, Seoul, Republic of Korea
| | - Sun Gyu Kim
- 1Department of Burn Reconstructive Surgery, Bestian Seoul Hospital, Dogok-ro 429, Gangnam-gu, Seoul, Republic of Korea
| | - Song Vogue Ahn
- 2Department of Health Convergence, Ewha Womans University, Ewhayeodae-gil 52, Seodaemun-gu, Seoul, Republic of Korea
| | - Yu Jin Jang
- 3Department of Radiology, Bestian Seoul Hospital, Dogok-ro 429, Gangnam-gu, Seoul, Republic of Korea
| | - Ban Seok Yang
- 1Department of Burn Reconstructive Surgery, Bestian Seoul Hospital, Dogok-ro 429, Gangnam-gu, Seoul, Republic of Korea
| | - Ji Yun Jeong
- 1Department of Burn Reconstructive Surgery, Bestian Seoul Hospital, Dogok-ro 429, Gangnam-gu, Seoul, Republic of Korea
| | - Kwang Jo Kim
- 4Department of General Surgery, Bestian Seoul Hospital, Seoul, Republic of Korea
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