Growth factor therapy in patients with partial‐thickness burns: a systematic review and meta‐analysis

Growth factor (GF) therapy has shown promise in treating a variety of refractory wounds. However, evidence supporting its routine use in burn injury remains uncertain. We performed this systematic review and meta‐analysis assessing randomised controlled trials (RCTs) to investigate efficacy and safety of GFs in the management of partial‐thickness burns. Electronic searches were conducted in PubMed and the Cochrane databases. Endpoint results analysed included wound healing and scar formation. Thirteen studies comprising a total of 1924 participants with 2130 wounds (1131 GF receiving patients versus 999 controls) were identified and included, evaluating the effect of fibroblast growth factor (FGF), epidermal growth factor (EGF) and granulocyte macrophage‐colony stimulating factor (GM‐CSF) on partial‐thickness burns. Topical application of these agents significantly reduced healing time by 5·02 (95% confidence interval, 2·62 to 7·42), 3·12 (95% CI, 1·11 to 5·13) and 5·1 (95% CI, 4·02 to 6·18) days, respectively, compared with standard wound care alone. In addition, scar improvement following therapy with FGF and EGF was evident in terms of pigmentation, pliability, height and vascularity. No significant increase in adverse events was observed in patients receiving GFs. These results suggested that GF therapy could be an effective and safe add‐on to standard wound care for partial‐thickness burns. High‐quality, adequately powered trials are needed to further confirm the conclusion.     

Metalloproteinases in chronic and acute wounds: A systematic review and meta‐analysis

A systematic review and meta‐analysis were undertaken in order to explore the influence of matrix metalloproteinases and their diagnostic methods in chronic and acute wounds. Searches were conducted in the PubMed (Medline) and Embase (Elsevier) databases from inception to late November 2017. We included clinical trials enrolling patients with cutaneous chronic and acute wounds where a validated diagnostic method was employed for metalloproteinases. We excluded in vitro, animal or preclinical studies, nonoriginal articles, and studies without available data for analysis. In addition, references of narrative and systematic reviews were scrutinized for additional articles. Eight studies met the inclusion criteria. Results revealed that the most frequently determined matrix metalloproteinases were MMP‐2 and MMP‐9, and were found in 54.5% of wounds. MMP‐9 was present in more than 50% of the chronic wounds with a range from 37 to 78%. However, metalloproteinases were found in only 20% of acute wounds, and other types of metalloproteinases were also observed (MMP‐2 and MMP‐3). On the basis of the available evidence, high levels of metalloproteinases have been correlated with significantly delayed wound healing in wounds of a variety of etiologies.     

A systematic review and meta‐analysis of the i‐gel® vs laryngeal mask airway in children

We systematically reviewed randomised controlled trials of the i‐gel^® vs different types of laryngeal mask airway in children. We included nine studies. There was no evidence for differences in: rate of insertion at first attempt; insertion time; ease of insertion; or gastric tube insertion. The mean (95% CI) oropharyngeal leak pressure was 3.29 (2.25–4.34) cmH₂O higher with the i‐gel, p < 0.00001. The relative rate (95% CI) of a good fibreoptic view through the i‐gel was 1.10 (1.01–1.19), p = 0.02. There were no significant differences in the rates of complications, except for blood on the airway, relative rate with the i‐gel 0.46 (0.23–0.91), p = 0.02. We concluded that the clinical performance of the i‐gel and LMA was similar, except for three outcomes that favoured the i‐gel.     

Negative pressure wound therapy for burn patients: A meta‐analysis and systematic review

Negative pressure wound therapy (NPWT), which has been applied in various medical specialties to accelerate wound healing, has been the object of a few investigations. We explored the effectiveness of NPWT and the possibility of its inclusion in burn management guidelines. Randomised controlled trials comparing NPWT with non‐NPWT treatments for burn wounds were extracted from PubMed. For the risk of bias analysis, all included studies were evaluated according to the Cochrane risk of bias tool and the approaches outlined in the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) Handbook. Outcomes such as graft take rate in the first week, infection rate, and overall complication rate were analysed. Six studies that included a total of 701 patients met our inclusion criteria. Qualitative analysis revealed that the NPWT group had a significantly better overall graft rate in the first week (P = 0.001) and a significantly lower infection rate (P = 0.04). No significant difference in the overall complication rate was found. Our results indicate that NPWT is a safe method for stimulating healing and lowering the infection rate of burn wounds. NPWT can be part of general burn management, and its incorporation into burn treatment guidelines is recommended.     

Effect of stem cell treatment on burn wounds: A systemic review and a meta‐analysis

A meta‐analysis was performed to evaluate the effect of stem cells treatment in managing burn wounds. A systematic literature search up to March 2022 incorporated 24 studies reported between 2013 and 2021 including 400 animals with burn wounds at the beginning of the study; 211 were using stem cells treatment, and 189 controlled. Statistical tools like the contentious method were used within a random or fixed‐influence model to establish the mean difference (MD) with 95% confidence intervals (CIs) to evaluate the influence of stem cells treatment in managing burn wounds. Stem cells treatment had a significantly higher burn wound healing rate (MD, 15.18; 95% CI, 11.29‐19.07, P < .001), higher blood vessel number (MD, 12.28; 95% CI, 10.06‐14.51, P < .001), higher vascular endothelial growth factor (MD, 10.24; 95% CI, 7.19‐13.29, P < .001), lower interleukin‐1 level (MD, −98.48; 95% CI, −155.33 to −41.63, P < .001), and lower tumour necrosis factor α level (MD, −28.71; 95% CI, −46.65 to −10.76, P < .002) compared with control in animals'' models with burn wounds. Stem cells treatment had a significantly higher burn wound healing rate, higher blood vessel number, higher vascular endothelial growth factor, lower interleukin‐1 level, and lower tumour necrosis factor α level compared with control in animals'' models with burn wounds. Further studies are required to validate these findings.     

Enzymatic debridement with collagenase in wounds and ulcers: a systematic review and meta‐analysis

Enzymatic debridement with collagenase is a technique that is commonly used in clinical practice. This systematic review examines the effect of collagenase on all kinds of wounds, compared to an alternative therapy, on wound healing, wound bed characteristics, cost‐effectiveness and the occurrence of adverse events. We conducted a systematic literature search on available literature in Cochrane databases, MEDLINE, EMBASE and CINAHL. Two investigators independently assessed the titles and abstracts of all randomised controlled trials obtained involving collagenase of all kinds of wounds based on inclusion criteria. Of the 1411 citations retrieved, 22 studies reported outcomes with the use of collagenase either for wound healing or wound debridement. Results support the use of collagenase for enzymatic debridement in pressure ulcers, diabetic foot ulcers and in conjunction with topical antibiotics for burns. However, studies presented a high risk of bias. Risk ratio of developing an adverse event related to collagenase versus the alternative treatment was statistically significant (for 10 studies, RR: 1·79, 95% CI 1·24–2·59, I²=0%, P = 0·002). There is very limited data on the effect of collagenase as an enzymatic debridement technique on wounds. More independant research and adequate reporting of adverse events are warranted.     

Keratin dressings speed epithelialization of deep partial‐thickness wounds

Keratin gene expression is regarded as a hallmark of epidermal biology. It demarcates the three keratinocyte phenotypes: basal (expressing KRT5 and KRT14), differentiating (expressing KRT1 and KRT10), and activated (wound healing), which is characterized by expression of KRT6, KRT16, and KRT17. Activated keratinocytes are among the first signals of epidermal wound healing. In addition, they are found deregulated in nonhealing chronic wounds. To examine keratins as a potential modality for wound‐healing disorders, we evaluated two different keratin dressings, liquid or solid, and assessed their effects of epithelialization and closure using porcine partial‐thickness wound‐healing model in vivo. We found that both forms of keratin dressings accelerated closure and epithelialization, achieving statistically significant differences on day 5. Evidence suggesting early onset of epithelialization was corroborated further by gene expression analyses revealing induction of KRT6A, KRT16, and KRT17 by day 2 postwounding. The data suggest that keratin dressings may stimulate epithelialization by enhancing the activation of keratinocytes. We conclude that keratin‐containing dressings can accelerate wound healing and closure. Further studies are needed to determine the molecular mechanisms of this activation.     

Incidence of methemoglobinemia in patients receiving cerium nitrate and silver sulfadiazine for the treatment of burn wounds: A burn center's experience

In 1976, the combination of cerium nitrate and silver sulfadiazine was introduced as a topical therapy for burn wounds. Experience with a locally prepared combination agent has shown physical change of the eschar and delayed subeschar bacterial colonization. A potential systemic complication of this treatment is the development of methemoglobinemia (Met‐Hba) due to the oxidizing nature of Ce(NO₃)₃. Met‐Hba has a spectrum of clinical consequences, ranging from headache and cyanosis to cardiac ischemia, hypotension, and even death. Given the frequent use of this combination agent at our burn center, a retrospective review was conducted to evaluate the incidence of Met‐Hba. A query of pharmacy records revealed 170 patients from January 2005 to October 2009 that had received this treatment. Eighteen patients (～10%) developed Met‐Hba as noted on arterial blood gas (methemoglobin>3%) and only three patients (～2%) had methemoglobin levels >10%. In the majority of cases, there were no clinical symptoms of Met‐Hba. Most patients' relative hypoxia resolved with cessation of treatment; however, five patients required treatment with methylene blue. The presence of Met‐Hba associated with this topical therapy can be diagnosed early by vigilant monitoring, thereby reducing morbidity and mortality. In our experience, cerium combined with silver sulfadiazine is a valuable and safe treatment for deep partial and full‐thickness burn wounds.     

A systematic review and meta‐analysis of the i‐gel® vs laryngeal mask airway in adults

We systematically reviewed 31 adult randomised clinical trials of the i‐gel^® vs laryngeal mask airway. The mean (95% CI) leak pressure difference and relative risk (95% CI) of insertion on the first attempt were similar: 0.40 (?1.23 to 2.02) cmH₂O and 0.98 (0.95–1.01), respectively. The mean (95% CI) insertion time and the relative risk (95% CI) of sore throat were less with the i‐gel: by 1.46 (0.33–2.60) s, p = 0.01, and 0.59 (0.38–0.90), p = 0.02, respectively. The relative risk of poor fibreoptic view through the i‐gel was 0.29 (0.16–0.54), p < 0.0001. All outcomes displayed substantial heterogeneity, I² ≥ 75%. Subgroup analyses did not decrease heterogeneity, but suggested that insertion of the i‐gel was faster than for first‐generation laryngeal mask airways and that the i‐gel leak pressure was higher than first generation, but lower than second‐generation, laryngeal mask airways. A less frequent sore throat was the main clinical advantage of the i‐gel.     

Honey compared with silver sulphadiazine in the treatment of superficial partial‐thickness burns

Burn injury is associated with a high incidence of death and disability; yet, its management remains problematic and costly. We conducted this clinical study to evaluate the efficacy of honey in the treatment of superficial and partial‐thickness burns covering less than 40% of body surface area and compared its results with those of silver sulphadiazine (SSD). In this randomised comparative clinical trial, carried out Burn Center of POF Hospital, Wah Cantt, Pakistan, from May 2007 to February 2008, 150 patients of all ages having similar types of superficial and partial‐thickness burns at two sites on different parts of body were included. Each patient had one burn site treated with honey and one treated with topical SSD, randomly. The rate of re‐epithelialization and healing of superficial and partial‐thickness burns was significantly faster in the sites treated with honey than in the sites treated with SSD (13·47 ± 4·06 versus 15·62 ± 4·40 days, respectively: P < 0·0001). The site treated with honey healed completely in less than 21 days versus 24 days for the site treated with SSD. Six patients had positive culture for Pseudomonas aeroginsa in honey‐treated site, whereas 27 patients had positive culture in SSD‐treated site. The results clearly showed greater efficacy of honey over SSD cream for treating superficial and partial‐thickness burns.     

Videolaryngoscopy vs. fibreoptic bronchoscopy for awake tracheal intubation: a systematic review and meta‐analysis

Awake fibreoptic intubation is often considered the technique of choice when a difficult airway is anticipated. However, videolaryngoscopes are being used more commonly. We searched the current literature and performed a meta‐analysis to compare the use of videolaryngoscopy and fibreoptic bronchoscopy for awake tracheal intubation. Our primary outcome was the time needed to intubate the patient's trachea. Secondary outcomes included: failed intubation; the rate of successful intubation at the first attempt; patient‐reported satisfaction with the technique; and any complications resulting from intubation. Eight studies examining 429 patients were included in this review. The intubation time was shorter when videolaryngoscopy was used instead of fibreoptic bronchoscopy (seven trials, 408 participants, mean difference (95%CI) ?45.7 (?66.0 to ?25.4) s, p < 0.0001, low‐quality evidence). There was no significant difference between the two techniques in the failure rate (six studies, 355 participants, risk ratio (95%CI) 1.01 (0.24–4.35), p = 0.99, low‐quality evidence) or the first‐attempt success rate (six studies, 391 participants, risk ratio (95%CI) 1.01 (0.95–1.06), p = 0.8, moderate quality evidence). The level of patient satisfaction was similar between both groups. No difference was found in two reported adverse events: hoarseness/sore throat (three studies, 167 participants, risk ratio (95%CI) 1.07 (0.62–1.85), p = 0.81, low‐quality evidence), and low oxygen saturation (five studies, 337 participants, risk ratio (95%CI) 0.49 (0.22–1.12), p = 0.09, low‐quality evidence). In summary, videolaryngoscopy for awake tracheal intubation is associated with a shorter intubation time. It also seems to have a success rate and safety profile comparable to fibreoptic bronchoscopy.     

Robotic vs. laparoscopic Nissen fundoplication for gastro‐oesophageal reflux disease: systematic review and meta‐analysis

The aim of this meta‐analysis was to compare clinical outcome following laparoscopic and robotic Nissen fundoplication. A systematic literature search of Medline, Embase and Cochrane Library databases was performed. Primary outcome measures were the requirement for re‐operation, postoperative mortality and postoperative dysphagia. Secondary outcome measures were operative time, length of hospital stay, operative complications and cost. Six randomized trials, of 226 patients, were included in this meta‐analysis. There was no significant difference in requirement for re‐operation or in postoperative dysphagia. There was a significantly reduced total operative time in the laparoscopic group (weighted mean difference = 4.154; 95% CI = 1.932–6.375; p = 0.0002). There was no significant difference between robotic and laparoscopic groups for hospital stay or operative complications. Clinical results from robotic Nissen fundoplication were comparable to the standard laparoscopic approach, but there was associated increased operative time and procedure cost. Copyright © 2010 John Wiley & Sons, Ltd.     

Extracorporeal shock wave therapy for chronic wounds: A systematic review and meta‐analysis of randomized controlled trials

A growing number of clinical studies demonstrate that extracorporeal shock wave therapy (ESWT) is a feasible noninvasive method for improving chronic wound healing. This systematic review and meta‐analysis aimed to assess the effectiveness of ESWT compared with that of the standard care treatment for the healing of chronic wounds, irrespective of etiology, in clinical practice. Randomized controlled trials that investigated the effect of ESWT on chronic wounds with different etiologies from 2000 to 2017 were included in this review. The methodological quality of each selected article was rated using the Jadad scale. A fixed or random effects model was used to calculate the pooled effect sizes according to the heterogeneity of the studies. The cumulative effect of ESWT on each outcome was illustrated using forest plots. Seven randomized controlled trials involving 301 subjects were included in this review. Meta‐analyses revealed that the use of ESWT as an adjunct to wound treatment could significantly accelerate the impaired healing process of chronic wounds. Compared with the control treatment, ESWT markedly increased the wound healing rate by 1.86‐fold (OR = 2.86, 95% CI: 1.63–5.03, p = 0.0003) and the percentage of the wound healing area by 30.46% (SMD = 30.46; 95% CI: 23.80–37.12; p < 0.00001). In addition, the wound healing time was reduced by 19 days (SMD = ?19.11, 95% CI: ?23.74–(–14.47), p < 0.00001) in chronic wound patients. No serious complications or adverse effects were observed secondary to the application of ESWT. The above data suggested that ESWT as an adjunct to wound treatment, could more significantly improve the healing process of chronic wounds than the standard care treatment alone. More high‐quality, well‐controlled randomized trials are needed to evaluate the efficacy of ESWT in clinical practice.     

Extracorporeal membrane oxygenation as a bridge vs. non‐bridging for lung transplantation: A systematic review and meta‐analysis

Whether extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplantation (BTT) can achieve a similar survival to non‐BTT remains controversial. We conducted this meta‐analysis to compare the outcomes between ECMO BTT and non‐BTT to facilitate better clinical decision‐making. Seven databases were searched for eligible studies comparing ECMO BTT and non‐BTT. The primary endpoints included survival, intraoperative indicators, postoperative hospitalization indicators, and postoperative complications. Nineteen studies (involving 7061 participants) were included in the final analysis. The outcomes of overall survival, overall survival rate, graft survival rate, in‐hospital mortality, postoperative hospital days, postoperative intensive care unit days, postoperative ventilation time, blood transfusion volume, and postoperative complications were all better in the non‐BTT group. The total mortality in ECMO bridging was 23.03%, in which the top five causes of death were right heart failure (8.03%), multiple organ failure (7.03%), bleeding (not cranial) (4.67%), cranial bleeding (3.15%), and sepsis (2.90%). In summary, Non‐BTT is associated with better survival and fewer complications compared to BTT. When ECMO may be the only option, the patient and medical team need to realize the increased risk of ECMO by complications and survival.     

Topical silver sulfadiazine vs collagenase ointment for the treatment of partial thickness burns in children: a prospective randomized trial

BackgroundThe 2 most commonly used topical agents for partial thickness burns are silver sulfadiazine (SSD) and collagenase ointment (CO). Silver sulfadiazine holds antibacterial properties, and eschar separation occurs naturally. Collagenase ointment is an enzyme that cleaves denatured collagen facilitating separation but has no antibacterial properties. Currently, there are no prospective comparative data in children for these 2 agents. Therefore, we conducted a prospective randomized trial.MethodsAfter institutional review board approval, patients were randomized to daily debridement with SSD or CO. Primary outcome was the need for skin grafting. Patients were treated for 2 days with SSD with subsequent randomization. Polymyxin was mixed with CO for antibacterial coverage. Debridements were performed daily for 10 days or until the burn healed. Grafting was performed after 10 days if not healed.ResultsFrom January 2008 to January 2011, 100 patients were enrolled, with no differences in patient characteristics. There were no differences in clinical course, outcome, or need for skin grafting. Wound infections occurred in 7 patients treated with CO and 1 patient treated with SSD (P = .06). Collagenase ointment was more expensive than SSD (P < .001). However, total hospital charges did not differ.ConclusionThere are no differences in outcomes between topical SSD or CO in the management of childhood burns results.     

Topical silver treatment after escharectomy of infected full thickness burn wounds in rats

White male Sprague Dawley rats (200 g.) with 20% full thickness scald burns seeded with 10 Pseudomonas aeruginosa, strain 59-1244, were used as experimental animals. Studies including the following: (1). Control groups. (2). DC pretreatment groups. (3). Treatment groups. P. aeruginosa infected burn wounds were excised, and then treated with either autograft or silver-nylon dressings, with (SNDC) or without (SN) application direct current. Excision and treatment were initiated 1, 2, 3, 4 or 5 days after burning and inoculation. (4). Groups for antimicrobial barrier function study. Mortality of each group was recorded at 21 days PB.With burns alone, there was no mortality. Without treatment 19 of 20 burn inoculated controls died. In the pretreatment study, the mortality of the group pretreated with SN was 95% while that of the group pretreated with SNDC was only 30%. With excision and autografting, PB mortality rose from 5/20 at day 2 PB to 19/20 at day 3 PB. In the excision and SN groups, mortality rose from 5/20 at day 3 PB to 18/20 at day 4 PB. In the excision and SNDC groups, mortality rose from 5/20 at day 3 PB to 18/20 at day 4 PB. In the antimicrobial barrier function study, the 10% mortality in the SN dressing group was significantly less than that of 95% in the plain nylon dressed group.Histologic examination revealed progressively deepening colonization of non-viable wound tissue, progressing to invasion of underlying viable tissue by PB day 4. With wound excision, SN, SNDC, and autografting were equally protective for the first two days, but only SN and SNDC extended this effect to the third PB day.In conclusion, SN and SNDC have a strong local anti-microbial effect on the burn wound when applied within 72 hours of the time of bacterial inoculation, but little effect if applied after the bacteria have invaded unburned vessels and viable tissue adjacent to the burn.