Reduction in skin grafting after the introduction of hydrofiber dressings in partial thickness burns: A comparison between a hydrofiber and silver sulphadiazine

Aim/purpose

The aim of this study was to compare clinical outcome of children with scald burns treated with a hydrofiber dressing (Aquacel^®, Convatec Inc.) with the former standard of care with silver sulfadiazine (Flammazine^®; Solvay Pharmaceuticals), considering surgical intervention and length of stay (LOS).

Methods

A retrospective study of all consecutive children from zero to four years with primary scald burns up to 10% admitted to the Burn Centre of the Maasstad Hospital Rotterdam between January 1987 and January 2010 were reviewed. For data collection a prospective computerized database was used. For comparison the study period was divided into two periods representing the period before and after the introduction of the hydrofiber dressing (HFD), respectively 1987–1999 (period 1) and 1999–2010 (period 2).

Results

Over the whole study period 27.3% of 502 patients treated with silver sulfadiazine (Ag-SD) underwent surgery, while before the introduction of HFD 30.5% of 338 Ag-SD treated patients were operated upon. After the introduction of the HFD 20.7% of 164 patients treated with Ag-SD eventually underwent skin grafting, a significant difference with the 11.6% of 302 patients whose wounds were dressed with HFD (p < 0.01).

Conclusions

Compared to silver sulfadiazine treatment a reduced number of surgical interventions was observed in mixed partial thickness scald burns up to 10% TBSA burned in children aged 0–4 years after the introduction of hydrofiber dressings. The mode of treatment with this wound dressing also limited hospital length of stay.     

Prospective randomised controlled trial of nanocrystalline silver dressing versus plain gauze as the initial post-debridement management of military wounds on wound microbiology and healing

Introduction

Recent conflicts have been characterised by the use of improvised explosive devices causing devastating injuries, including heavily contaminated wounds requiring meticulous surgical debridement. After being rendered surgical clean, these wounds are dressed and the patient transferred back to the UK for on-going treatment. A dressing that would prevent wounds from becoming colonised during transit would be desirable. The aim of this study was to establish whether using nanocrystalline silver dressings, as an adjunct to the initial debridement, would positively affect wound microbiology and wound healing compared to standard plain gauze dressings.

Methods

Patients were prospectively randomised to receive either silver dressings, in a nanocrystalline preparation (Acticoat™), or standard of care dressings (plain gauze) following their initial debridement in the field hospital. On repatriation to the UK microbiological swabs were taken from the dressing and the wound, and an odour score recorded. Wounds were followed prospectively and time to wound healing was recorded. Additionally, patient demographic data were recorded, as well as the mechanism of injury and Injury Severity Score.

Results

76 patients were recruited to the trial between February 2010 and February 2012. 39 received current dressings and 37 received the trial dressings. Eleven patients were not swabbed. There was no difference (p = 0.1384, Fishers) in the primary outcome measure of wound colonisation between the treatment arm (14/33) and the control arm (20/32). Similarly time to wound healing was not statistically different (p = 0.5009, Mann–Whitney). Wounds in the control group were scored as being significantly more malodorous (p = 0.002, Mann–Whitney) than those in the treatment arm.

Conclusions

This is the first randomised controlled trial to report results from an active theatre of war. Performing research under these conditions poses additional challenges to military clinicians. Meticulous debridement of wounds remains the critical determinant in wound healing and infection and this study did not demonstrate a benefit of nanocrystaline silver dressing in respect to preventing wound colonisation or promoting healing, these dressings do however seem to significantly reduce the unpleasant odour commonly associated with battlefield wounds.     

Management of split-thickness skin graft donor site: A prospective clinical trial for comparison of five different dressing materials

Introduction

Split-thickness skin grafting (STSG) is a frequently used reconstructive technique but is associated with a large variation regarding the management of the donor site. The aim of this study is to compare five different dressings for management of the STSG donor site in a prospective trial.

Patients and methods

100 consecutive patients, in whom reconstruction with STSG was performed, were included into the study. The grafts are harvested in a standard manner and the donor sites were dressed with one of the following materials: Aquacel^® Ag, Bactigras^® with Melolin^®, Comfeel^® Plus Transparent, Opsite^® Flexigrid and Adaptic^®. The materials are compared regarding to the time required for complete epithelialization, pain sensed by the patients, incidence of infection, scar formation, ease of application and the cost.

Results

The earliest complete epithelialization was observed for Aquacel^® Ag and the latest for Bactigras^® with Melolin^®·Comfeel^® Plus Transparent was the most painless dressing and Bactigras^® with Melolin^® was the most painful. The incidence of infection was highest for Bactigras^® with Melolin^®·Opsite^® Flexigrid was the most economical dressing and Aquacel^® Ag was the most expensive one.

Conclusion

The aim is to provide the earliest complete epithelialization with minimal patient discomfort and lower cost in management of the STSG donor sites. None of the tested materials were ideal regarding these criteria, but Comfeel^® Plus Transparent, as the least painful and one of the most economical materials, may be offered as the dressing of choice among the tested materials.     

Comparison of silver-coated dressing (Acticoat®), chlorhexidine acetate 0.5% (Bactigrass®) and nystatin for topical antifungal effect in Candida albicans-contaminated, full-skin-thickness rat burn wounds

Background

In this experimental animal study, the effects of three different topical antimicrobial dressings on Candida albicans contaminated full-thickness burn in rats were analyzed.

Methods

In total 32 adult Wistar rats (body weight 200-220 g) were used. Silver-coated dressing (Acticoat™^®), chlorhexidine acetate 0.5% (Bactigrass^®) and Mycostatine (Nystatin^®) were compared to assess the antifungal effect of a once-daily application on experimental rat 15% full-skin thickness burn wound seeded 24 h earlier with a 10⁸ CFU/mL standard strain of C. albicans ATCC 90028. All the animals were sacrificed at post burn day 7. The quantitative counts of seeded organism in burn eschar and subjacent muscle were determined, in addition to the cultures of left ventricle blood and lung biopsies.

Results

While there were significant differences between Acticoat™^® group (4 ± 10 × 10⁴) and control group (5 ± 6 × 10⁶), and between Nystatin group (4 ± 4 × 10⁴) and control group (P = 0.01, P = 0.01), there were no significant differences between chlorhexidine acetate 0.5% group (2 ± 3 × 10⁴) and control group (P = 0.7) respectively. Acticoat™^® and Nystatin were sufficient to prevent to C. albicans from invading to the muscle and from causing systemic infection.

Conclusions

The animal data suggest that nystatin is the most effective agents in the treatment of C. albicans-contaminated burn wounds, and Acticoat™^® is a choice of treatment on fungal burn wound infection with antibacterial effect and the particular advantage of limiting the frequency of replacement of the dressing.     

Moist occlusive dressing (Aquacel(®) Ag) versus moist open dressing (MEBO(®)) in the management of partial-thickness facial burns: a comparative study in Ain Shams University

Introduction

The face is the central point of the physical features; it transmits expressions and emotions, communicates feelings and allows for individual identity. Facial burns are very common and are devastating to the affected patient and results into numerous physical, emotional and psychosocial sequels. Partial thickness facial burns are very common especially among children. This study compares the effect of standard moist open technique management and a moist closed technique for partial thickness burns of the face.

Patients and methods

Patients with partial-thickness facial burns admitted in the burn unit, Ain Shams University, Cairo, Egypt in the period from April 2009 to December 2009 were included in this study. They were divided into two groups to receive either open treatment with MEBO^® (n = 20) or coverage with Aquacel^® Ag (n = 20). Demographics (age, gender, ethnicity, TBSA, burn areas), length of hospital stay (LOS), rate of infections, time to total healing, frequency of dressing changes, pain, cost benefit and patient discomfort were compared between the two groups. The long-term outcome (incidence of hypertrophic scarring) was assessed for up to 6 months follow-up period.

Results

There were no significant differences in demographics between the two groups. In the group treated with the Aquacel^® Ag, the mean time for re-epithelialization was 10.5 days, while it was 12.4 days in the MEBO^® group (p < 0.05). Frequency of changes, pain and patient discomfort were less with Aquacel^® Ag. Cost was of no significant difference between the two groups. Scar quality improved in the Aquacel^® Ag treatment group. Three and 6 months follow-up was done and long-term outcomes were recorded in both groups.

Conclusion

Moist occlusive dressing (Aquacel^® Ag) significantly improves the management and healing rate of partial thickness facial burns with better long-term outcome compared to moist open dressing (MEBO^®).     

Antimicrobial efficacy of a novel silver hydrogel dressing compared to two common silver burn wound dressings: Acticoat™ and PolyMem Silver

A novel burn wound hydrogel dressing has been previously developed which is composed of 2-acrylamido-2-methylpropane sulfonic acid sodium salt with silver nanoparticles. This study compared the antimicrobial efficacy of this novel dressing to two commercially available silver dressings; Acticoat™ and PolyMem Silver^®. Three different antimicrobial tests were used: disc diffusion, broth culture, and the Live/Dead^® Baclight™ bacterial viability assay. Burn wound pathogens (P. aeruginosa, MSSA, A. baumannii and C. albicans) and antibiotic resistant strains (MRSA and VRE) were tested. All three antimicrobial tests indicated that Acticoat™ was the most effective antimicrobial agent, with inhibition zone lengths of 13.9–18.4 mm. It reduced the microbial inocula below the limit of detection (10² CFU/ml) and reduced viability by 99% within 4 h. PolyMem Silver^® had no zone of inhibition for most tested micro-organisms, and it also showed poor antimicrobial activity in the broth culture and Live/Dead^® Baclight™ assays. Alarmingly, it appeared to promote the growth of VRE. The silver hydrogel reduced most of the tested microbial inocula below the detection limit and decreased bacterial viability by 94–99% after 24 h exposure. These results support the possibility of using this novel silver hydrogel as a burn wound dressing in the future.     

Hydrofiber dressing with silver for the management of split-thickness donor sites: A randomized evaluation of two protocols of care

Background

This randomized, open-label study evaluated Aquacel Ag^® Hydrofiber^® dressing with silver (HDS; ConvaTec, Skillman, NJ, USA) with an adherent or gelled protocol in the management of split-thickness donor sites.

Methods

HDS was the primary dressing in the adherent group (gauze as secondary covering) and gelled group (transparent film as secondary covering). Dressings were changed on study day 1 or 2 and study days 5 (optional), 10 (optional), and 14. The primary outcome was healing (≥90% re-epithelialization) at study day 14.

Results

Seventy subjects were treated (36 adherent, 34 gelled). By study day 14, 77% of donor sites had healed (67% adherent, 88% gelled). Pain scores decreased over time in both treatment groups. Investigators were “very satisfied” or “satisfied” with (adherent, gelled) time required to manage dressing change (89%, 79% of subjects), minimization of donor-site pain (64%, 82%), ease of application (97%, 94%), management of drainage (92%, 82%), ease of removal (77%, 85%), and ability of dressing to remain in place (69%, 76%). Thirty-nine (56%) subjects had adverse events, most commonly non-donor-site infection (11%) and gastrointestinal events (11%).

Conclusion

In this randomized, open-label study, HDS was well-tolerated, versatile, and effective in the management of split-thickness donor sites.     

A comparative study of 1% silver sulphadiazine (Flammazine) versus an enzyme alginogel (Flaminal) in the treatment of partial thickness burns

Introduction

In the conservative treatment of burns, rapid wound healing is desirable to obtain good a esthetic and functional results. The aim of this study was to compare the efficacy of 1% Silversulfadiazine (SSD/Flammazine^®) and an enzyme alginogel (Flaminal^® or Flaminal^® Forte) on the healing of superficial and intermediate partial thickness burns.

Methods

In this retrospective cohort study comparable burn wounds treated with Flaminal^® or with 1% SSD were included. Outcome parameters included: length of hospital stay, bacterial burden and time to wound closure. Significance was tested using SPSS package.

Results

44 wounds in the Flaminal^® group, and 39 wounds in the 1% SSD group were included. Wounds treated with Flaminal^® showed a significantly higher bacterial load (p = 0.024) and contained significantly more bacterial species (p = 0.010) but showed a significantly shorter healing time of 17 vs. 24 days (p < 0.0001).

Conclusion

A significantly shorter healing time was demonstrated in partial thickness burn wounds treated with Flaminal^® versus 1% SSD, which may lead to a shorter length of hospital stay and better scar quality. The possibility of accurate burn depth assessment and the results in this study corroborate the change in treatment protocol made in the year 2000 when we switched from 1% SSD to Flaminal^®.     

Comparative in vitro study of honey based and silver based wound preparations on cell viability

Background

Since the early 1980s a plethora of dressings has been developed to promote wound healing. The objective of this study was to compare the effects of silver based dressings and honey based dressings on cell viability.

Materials and methods

In this blinded study, keratinocyte cultures were exposed to prepared extracts of each of the following wound dressings for 40 h:

•

Silver based dressings: Acticoat, Actisorb, Askina, Atrauman-Ag and Contreet.

•

Honey based dressings: Melladerm gel, Melladerm mesh, Melladerm plus and Mellarsorb. Controls consisted of cells that were cultured in the same medium, and under the same conditions as those exposed to extracts.

Results

All dressing extracts had an effect on cell viability. Changes in cell morphology from different wound dressing extracts were noted and compared with control groups after 24 h of incubation.

Conclusions

In the silver based extracts group, Atrauman-silver and Acticoat had the most viable cells. For the honey based group, the most viable cells were seen with Melladerm mesh and Mellasorb. There was no significant difference between the best performing silver and honey based wound preparations with regard to cell viability.     

Effectiveness of a topical local anaesthetic spray as analgesia for dressing changes: A double-blinded randomised pilot trial comparing an emulsion with an aqueous lidocaine formulation

Background

Partial thickness skin graft wounds are painful. Topically applied lidocaine has been used for analgesia in several clinical trials. This study compared the effectiveness of two different formulations of topical local anaesthetic for dressing changes of partial thickness skin graft donor sites.

Methods

A double-blind randomised controlled, pilot trial was conducted in 29 patients undergoing split thickness skin graft surgery. Subjects were randomised to either a 3% lidocaine emulsion formulation “Treatment E” (NOPAYNE™) or a 4% aqueous solution “Treatment A” (Xylocaine™). Subjects received one spray per 3 cm² of donor site area followed by up to two further spays as required. Endpoints included pain intensity measured by the numerical rating scale (NRS) up to 1 h after dressing change commencement, sting sensation, overall satisfaction and lidocaine plasma concentration.

Results

The 60 min pain scores for E and A were 1.3 ± 0.3 (mean ± SEM) and 1.8 ± 0.4 (p = 0.98) respectively. Nearly 90% of patients were very satisfied with their treatment. The mean plasma concentrations of lidocaine for A and E were 0.132 mg/l and 0.040 mg/l respectively (p = 0.069).

Conclusion

The topical local anaesthetic formulations achieved low pain scores during dressing changes. The safety profile was potentially improved with the emulsion formulation of lidocaine.     

Hydrocolloid dressing in pediatric burns may decrease operative intervention rates

Introduction

Partial-thickness scalds are the most common pediatric burn injury, and primary management consists of wound dressings to optimize the environment for reepithelialization. Operative intervention is reserved for burns that fail to heal using conservative methods. Worldwide, paraffin-based gauze (Jelonet) is the most common burn dressing; but literature suggests that it adheres to wounds and requires more frequent dressing change that may traumatize newly epithelialized surfaces. Hydrocolloid dressings (DuoDERM) provide an occlusive moist environment to optimize healing and are associated with less frequent dressing changes.

Aim

The aim of the study was to retrospectively analyze pediatric burns in a single tertiary referral center over a 10-year period comparing the impact of Jelonet and DuoDERM dressings relative to operative intervention rates.

Methods

All pediatric burns admitted between 1997 and 2007 were identified using the Hospital Inpatient Enquiry system. Demographics were collected from hospital records and theater logbooks. Acute, partial-thickness burns in patients younger than 15 years were analyzed according to dressing type applied (Jelonet or DuoDERM).

Results

Two hundred forty-eight pediatric burns were analyzed between 1997 and 2007. One hundred thirty-nine patients were treated with Jelonet dressings, and 109 were treated with DuoDERM. Debridement and grafting were required in 60 (43%) of the Jelonet patients compared with 10 (9%) of the DuoDERM patients (P < .05). The DuoDERM-managed patients maintained a significantly lower graft rate on subanalysis of scalds excluding early grafting within 5 days (P < .001).

Conclusion

Observational evidence suggests that DuoDERM leads to less operative intervention and should be preferentially used in pediatric burns.     

Changes in the plasma cytokine and growth factor profile are associated with impaired healing in pediatric patients treated with INTEGRA for reconstructive procedures

Background

Large full thickness skin defects caused by trauma or surgery require skin grafting, often in conjunction with dermal scaffolds such as INTEGRA^®. Due to the size and severity of these procedures, complications such as infection may occur. This can lead to poor healing outcomes.

Objective

To identify early biomarkers of complications during INTEGRA^® healing.

Methods

Levels of EGF, TGF-β1, FGF-2, VEGF, IFN-α, GM-CSF, IL-4 and IL-8 were measured pre-surgery and at days 1, 7 and 25 post-surgery in peripheral blood of 15 pediatric patients treated with INTEGRA^® for reconstructive procedures. The levels of these molecules were analysed with respect to the occurrence of complications.

Results

Complications (local infection) occurred in a group of 4 patients. This resulted in a reduced INTEGRA^® take rate comparing to the group without complications (71.5 ± 5.4% vs. 98.1 ± 0.7%). In cases with complications there were significantly higher plasma concentrations of IL-4 and FGF-2 on day 7 (p = 0.037 and p = 0.008 respectively). Other markers were not significantly different between groups or at very low level at all time-points. WCC and CRP remained within normal ranges at all time-points.

Conclusions

This data suggests that elevated levels of IL-4 and FGF-2 at early time-points after surgery may predict the development of complications in patients with INTEGRA^®. This may enable early interventions to prevent complications in procedures involving the use of INTEGRA^®.     

Antibacterial potency of V.A.C. GranuFoam Silver Dressing

Introduction

V.A.C.^® GranuFoam™ therapy is regularly used in the surgical therapy of infected wounds and soft tissue injuries. Silver nanoparticles can destroy bacterial cell walls and inhibit enzymes for cell replication. Silver dressings are therefore successfully used for many indications in wound therapy. In this study, we investigated the antimicrobial potency of ionic silver released from the silver-coated V.A.C.^® GranuFoam™ during vacuum therapy. Silver dressing was exposed to agar plates populated with bacteria to measure silver release.

Materials and methods

A total of 15 agar plates colonised with either Staphylococcus aureus populations or with Staphylococcus epidermidis, were loaded with V.A.C. GranuFoam Silver^® Dressing polyurethane foam (KCI, San Antonio, Texas). Each of 13 pieces of silver-coated foam was applied to an agar plate. Two plates were loaded with conventional black foam without any coating. After connecting to a vacuum pump, the vacuum therapy of the 15 plates lasted 5 days. The zone of inhibition of bacterial growth around the foam was measured daily. Silver release was also determined as a function of time.

Results

At each time point, there was evidence of silver in the agar independent of bacterial colonisation.The S. aureus agar showed a consecutive increase in silver concentration from baseline upon 48 h after exposure to the negative pressure of V.A.C. therapy.An increasing mean silver level after 48, 72 and 96 h was measured under V.A.C. therapy with a peak value after 120 h.In contrast, the results from the S. epidermidis plates did not follow a linear pattern. At the beginning of vacuum therapy, we documented a rise in silver concentration. After 48–96 h, the silver levels fluctuated.A maximum zone of inhibition in both bacterial colonised plates (S. aureus and S. epidermidis) was found 39 h after the start of the V.A.C. GranuFoam Silver^® therapy.

Conclusion

From our results, we confirmed the antimicrobial effect of the silver ions against S. aureus and S. epidermidis under continuous V.A.C. GranuFoam^® Silver therapy with a negative pressure of 25 mmHg. Furthermore we could quantify the amounts of silver, which were released from the foam under negative pressure as a function of time.     

Intérêt du mélange sérum salé hypertonique–hydroxyéthylamidon lors du choc hémorragique

Objective

Assessment of haemodynamic, respiratory and renal effects of hypertonic saline–hydroxyethyl starch (HyperHES^®) in critically ill-patients with hemorrhagic shock.

Patients and methods

Seventeen mechanically ventilated patients with hemorragic shock benefiting from a cardiovascular monitoring by PiCCO device and requiring rapid volume loading. Two hundred and fifty milliliters of HyperHES^® were given over 5 minutes. The efficacy of volume loading was assessed by the measure of the systolic arterial pressure (SAP), cardiac index (CI), stroke volume variation (SVV) and the indexed systemic vascular resistance (iSVR). Studied parameters were assessed at baseline, 5, 30, 60 and 180 minutes after the end of HyperHES^® infusion.

Results

SAP (105 ± 23 vs 77 ± 10; p < 0.001) and CI (4.8 ± 1.1 vs 3.5 ± 0.9; p < 0.001) were significantly increased whereas iSVR (1175 ± 310 vs 1501 ± 337; p < 0.01) and SVV (13 ± 7 vs 20 ± 5; p < 0.01) were significantly decreased 5 minutes after the HyperHES^® infusion. Sodium (145 ± 6 vs 136 ± 5; p < 0.001) and chloride (118 ± 7 vs 107 ± 6; p < 0.001) were increased 5 minutes after the infusion. The PaO₂/FiO₂ ratio as the extravascular lung water was not influenced by the infusion. The follow-up of renal parameters during the three first days (creatinemia, uremia and diuresis) did not revelead significant variations.

Conclusion

In patients with hemorrhagic shock, the infusion of hypertonic saline (7.5%) hydroxyethyl starch association was followed by an increase in SAP, CI serum sodium and chloride concentrations.

Study design

Prospective observational study.     

Randomized controlled single center study comparing a polyhexanide containing bio-cellulose dressing with silver sulfadiazine cream in partial-thickness dermal burns

Objective

A prospective, randomized, controlled single center study was designed to evaluate clinical efficacy of a polyhexanide containing bio-cellulose dressing (group B) compared to a silver-sulfadiazine cream (group A) in sixty partial-thickness burn patients.

Patients and methods

Local ethics committee approval was obtained and patients consented. Parameters were: pain reduction (VAS), healing time and wound bed condition, comparing day 0 (start) versus day 14 (end), as well as, ease of dressing use and treatment costs.

Results

All completed the study (n = 30/n = 30) and were included in the ITT analysis, with a total of 72 burns (group A: n = 38, group B: n = 34). We noted no differences in healing time. Pain reduction was significantly faster and better in group B (p < 0.01). There were fewer dressing changes in group B, compared to group A. Ease of use for the bio-cellulose dressing was rated better compared to group A. In group B, € 95.20 was saved for a 10 day treatment period, compared to group A.

Conclusion

Group B demonstrated a better and faster pain reduction in the treated partial-thickness burns, compared to group A. The results indicate the polyhexanide containing bio-cellulose dressing to be a safe and cost effective treatment for partial-thickness burns.     

OnabotulinumtoxinA 100 U Significantly Improves All Idiopathic Overactive Bladder Symptoms and Quality of Life in Patients with Overactive Bladder and Urinary Incontinence: A Randomised,Double-Blind,Placebo-Controlled Trial

Background

Overactive bladder (OAB) syndrome with urinary incontinence (UI) is prevalent in the population and impairs health-related quality of life (HRQOL).

Objective

To assess the impact on efficacy, safety, and HRQOL of onabotulinumtoxinA (BOTOX^®, Allergan, Inc.) treatment in patients with OAB with UI.

Design, setting, and participants

This pivotal, multicentre, double-blind, randomised, placebo-controlled, phase 3 study enrolled patients with idiopathic OAB with ≥3 urgency UI episodes over 3 d and ≥8 micturitions per day who were inadequately managed by anticholinergics.

Intervention

OnabotulinumtoxinA at a 100 U dose (n = 277) or placebo (n = 271), administered as 20 intradetrusor injections of 0.5 ml.

Outcome measurements and statistical analysis

Co–primary end points were change from baseline in the number of UI episodes per day and proportion of patients reporting positive treatment response on the treatment benefit scale (TBS) at week 12. Additional end points included other OAB symptoms (episodes of urinary urgency incontinence, micturition, urgency, and nocturia) and HRQOL (Incontinence Quality of Life [I-QOL], King's Health Questionnaire [KHQ]). Safety assessments included adverse events (AEs), postvoid residual (PVR) urine volume, and initiation of clean intermittent catheterisation (CIC).

Results and limitations

OnabotulinumtoxinA significantly decreased UI episodes per day at week 12 (−2.95 for onabotulinumtoxinA versus −1.03 for placebo; p < 0.001). Reductions from baseline in all other OAB symptoms were also significantly greater following onabotulinumtoxinA compared with placebo (p ≤ 0.01). Patients perceived a significant improvement in their condition, as measured by patients with a positive treatment response on the TBS (62.8% for onabotulinumtoxinA versus 26.8% for placebo; p < 0.001). Clinically meaningful improvements from baseline in all I-QOL and KHQ multi-item domains (p < 0.001 versus placebo) indicated positive impact on HRQOL. AEs were mainly localised to the urinary tract. Mean PVR was higher in the onabotulinumtoxinA group (46.9 ml versus 10.1 ml at week 2; p < 0.001); 6.9% of onabotulinumtoxinA patients versus 0.7% of placebo patients initiated CIC.

Conclusions

OnabotulinumtoxinA 100 U was well tolerated and demonstrated significant and clinically relevant improvements in all OAB symptoms, patient-reported benefit, and HRQOL in patients inadequately managed by anticholinergics.

Trial registration

ClinicalTrials.gov: NCT00910520.     

Wound closure of leg fasciotomy: Comparison of vacuum-assisted closure versus shoelace technique. A randomised study

Background

Fasciotomies, though essential for the prevention and management of compartment syndromes, may increase morbidity and prolong hospitalisation. Two widely applied methods of delayed primary closure are compared in leg fasciotomy wounds.

Patients and methods

Two groups, each of 25 patients with leg fasciotomies due to fractures and soft tissue injuries, who were randomly assigned to be treated either by vacuum assisted closure (VAC^®, n = 42 wounds, group V) or by the shoelace technique (n = 40 wounds, group S), were evaluated in this study. Wound length, time to definite closure, complications, need for additional interventions and daily treatment costs were data collected and statistically assessed.

Results

Wound closure time was significantly higher in group V compared to group S (p = 0.001; 95% CI of the difference, 1.8–6.3 days).Five group V patients required split thickness skin grafts. In six group S patients, the vessel loops had to be replaced.The mean daily cost of negative pressure therapy alone was 135 euro (range 117–144 euro), whilst the mean daily cost of treatment for the shoelace technique was 14 euro ranging from 8 to 18 euro (p = <0.001).

Conclusions

Both VAC^® and the shoelace technique are safe, reliable and effective methods for closure of leg fasciotomy wounds. VAC^® requires longer time to definite wound closure and is far more expensive than the shoelace technique, especially when additional skin grafting is required.     

The primary determinants of radiation use during fixation of proximal femur fractures

Objectives

To establish the primary determinants of operative radiation use during fixation of proximal femur fractures.

Design

Retrospective cohort study.

Setting

Level I trauma centre.

Cohort

205 patients treated surgically for subtrochanteric and intertrochanteric femoral fractures.

Main outcome measures

Fluoroscopy time, dose-area-product (DAP).

Results

Longer fluoroscopy time was correlated with higher body mass index (p = 0.04), subtrochanteric fracture (p < 0.001), attending surgeon (p = 0.001), and implant type (p < 0.001). Increased DAP was associated with higher body mass index (p < 0.001), subtrochanteric fracture (p = 0.002), attending surgeon (p = 0.003), lateral body position (p < 0.001), and implant type (p = 0.05).

Conclusion

The strongest determinants of radiation use during surgical fixation of intertrochanteric and subtrochanteric femur fractures were location of fracture, patient body position, patient body mass index, and the use of cephalomedullary devices. Surgeon style, presumably as it relates to teaching efforts, seems to strongly influence radiation use.     

A randomized comparison study of Aquacel Ag and Alginate Silver as skin graft donor site dressings

Objective

This study was conducted to compare pain, healing time, infection rate, and cosmetic outcome between Aquacel Ag (convatec) and Alginate Silver (coloplast) as donor site dressings.

Materials and Methods

We conducted a prospective randomized controlled trial of donor site dressings, comparing Aquacel Ag with Alginate Silver. Patients were randomly allocated to donor site dressing with one of these materials. Outcome measures included pain scores at rest and during dressing changes, time to re-epithelialization, cosmetic outcome and infection rate. Results were assessed for significance using the independent t-test (non-parametric data) and the chi-square test (parametric data).

Results

A total of 20 subjects were enrolled in this study. Subjects included in both groups were comparable with no significant differences in demographic data of age, gender, location of burn and type of burns (P > 0.05 evaluated by paired t-test) between both group. The pain scores were found to be higher in Aquacel Ag group than in Alginate Silver group. Time to re-epithelialization was longer in Aquacel Ag group than in Alginate Silver group. There were no significant differences between the two treatment groups with respect to cosmetic outcome and infection rate.

Conclusions

Based on these results, we find that Alginate Silver is better than Aquacel Ag to cover the skin graft donor site.     

Biological markers of stress in pediatric acute burn injury

Background

Burns and their associated wound care procedures evoke significant stress and anxiety, particularly for children. Little is known about the body's physiological stress reactions throughout the stages of re-epithelialization following an acute burn injury. Previously, serum and urinary cortisol have been used to measure stress in burn patients, however these measures are not suitable for a pediatric burn outpatient setting.

Aim

To assess the sensitivity of salivary cortisol and sAA in detecting stress during acute burn wound care procedures and to investigate the body's physiological stress reactions throughout burn re-epithelialization.

Methods

Seventy-seven participants aged four to thirteen years who presented with an acute burn injury to the burn center at the Royal Children's Hospital, Brisbane, Australia, were recruited between August 2011 and August 2012.

Results

Both biomarkers were responsive to the stress of burn wound care procedures. sAA levels were on average 50.2 U/ml higher (p < 0.001) at 10 min post-dressing removal compared to baseline levels. Salivary cortisol levels showed a blunted effect with average levels at ten minutes post dressing removal decreasing by 0.54 nmol/L (p < 0.001) compared to baseline levels. sAA levels were associated with pain (p = 0.021), no medication (p = 0.047) and Child Trauma Screening Questionnaire scores at three months post re-epithelialization (p = 0.008). Similarly, salivary cortisol was associated with no medication (p < 0.001), pain scores (p = 0.045) and total body surface area of the burn (p = 0.010).

Conclusion

Factors which support the use of sAA over salivary cortisol to assess stress during morning acute burn wound care procedures include; sensitivity, morning clinic times relative to cortisol's diurnal peaks, and relative cost.