Enzymatic debridement of burn wound with collagenase in children with partial-thickness burns

Seventy-eight pediatric burn patients treated by enzymatic debridement with collagenase clostridiopeptidase A (CCA), were compared to 41 patients those burn wounds were excised surgically. Patients whose burn wounds were initially assessed as partial-thickness at admission were enrolled in the study. Total removal of eschar was achieved in 49 of 78 (62.8%) patients by CCA only (group D). In 29 patients (37.2%), therapy with CCA was ceased because of the development of burn wound infection or a manifest need for grafting of the wound, therefore, these patients underwent tangential wound excision (group DS). The records of 41 patients, treated by early tangential excision, having similar burn wounds by extent and depth with groups D and DS were used as controls (group S).

There was no significant difference between the time to achieve a clean wound bed in groups D, DS and S (mean 7.8, 8, and 7 days, respectively, P>0.05). In group D, none of the patients required blood transfusion, except one. Patients in group DS were found to have fewer excisions (mean 1.1) when compared to those in group S (mean 1.5, P<0.05). The shortest hospital stay was found in group D (12.5 days, P<0.01). In conclusion, the use of CCA, provided a short hospital stay, reduced the overall need for surgery and blood transfusions in patients with partial-thickness burns. Thus, CCA should be considered as an initial treatment of choice for removal of eschar in children, having a partial-thickness burn wound without infection.     

The management of major burns – a surgical perspective

In the UK, 1000 patients per year will need resuscitation and inpatient treatment for burns. The mortality has improved significantly over the last 50 years but over three hundred people die each year. A greater understanding of the pathophysiology together with improvements in resuscitation, critical care and surgical techniques have all contributed to survival. For larger burns (greater than 25% total body surface area) there is a profound release of cytokines and chemokines. This results in a marked systemic inflammatory response syndrome, leading to edema, effects on multiple organ systems, a hypermetabolic response and suppression of the immune system. Early surgical care is based around the ABCD philosophy (as guided by Advanced Trauma Life Support and also Emergency Management of Severe Burns). An assessment system based on depth is vital for clinical decision making and prognosis. Many centers now aim for early excision and grafting of burns. Early excision modifies the host responses by removing devitalized tissue that might otherwise invoke deleterious effects, but its removal in itself may also provide a major insult. Several variations in approach are possible to modify the impact of excision and an approach tailored to the individual is appropriate. Covering the excised burn area can be achieved with wide range of materials from allograft to synthetic skin substitutes. Key to successful burn care is a directed multi-disciplinary model for providing appropriate expertise on individual sites, together with the development of burn care networks to facilitate effective delivery of burns services across an entire region.     

The effectiveness of caloric value of enteral nutrition in patients with major burns

Enteral nutrition as an important component of modern treatment is mandatory for patients suffering from major burns. Regardless of the initial estimation of caloric requirements, actual daily volume of energy consumption may vary depending on the general condition of the patient and the side effects of enteral nutrition. The aim of our study was to investigate the relation between caloric value of enteral nutrition and treatment course. METHODS: The prospective study involved 103 adult patients treated in the Hospital of Kaunas University of Medicine for 2 degrees -3 degrees burns of 10-80% body surface area from 1 January 2001 till 31 December 2003. All patients received enteral nutrition during the acute phase. After the completion of the treatment, caloric value of enteral nutrition was estimated, and patients were divided into two groups: group A received more than 30 kcal/(kg 24 h); and group B, received less than 30 kcal/(kg 24 h). We compared patients' mortality, complication rate, and hospital stay time. RESULTS: The mortality of patients, who enterally received less than 30 kcal/(kg 24 h), was 32.6%, comparing to 5.3% mortality in patients who received 30 or more kcal/(kg 24 h) (p < 0.01). The caloric value of less than 30 kcal/(kg 24 h) increased the frequency of pneumonia by 2.0 times, and the frequency of sepsis by 1.8 times (p < 0.05). The duration of the treatment of survivors in this group was by 12.6 days longer (p = 0.01). CONCLUSIONS: The caloric value of enteral nutrition seems to be associated with patient mortality, complication rate, and treatment duration. The results of the treatment of patients who received more or 30 kcal/(kg 24 h) were much better. Because determined relationship may not be directly causal, further study is needed to determine whether active intervention to improve nutrition could improve outcomes.     

Pharmacological modulation of wound healing in experimental burns

Factors involved in wound healing and their interdependence are not yet fully understood; nevertheless, new prospects for therapy to favor speedy and optimal healing are emerging. Reports about wound healing modulation by local application of simple and natural agents abound even in the recent literature, however, most are anecdotal and lack solid scientific evidence. We describe the effect of silver sulfadiazine and moist exposed burn ointment (MEBO), a recently described burn ointment of herbal origin, on mast cells and several wound healing cytokines (bFGF, IL-1, TGF-beta, and NGF) in the rabbit experimental burn model. The results demonstrate that various inflammatory cells, growth factors and cytokines present in the wound bed may be modulated by application of local agents with drastic effects on their expression dynamics with characteristic temporal and spatial regulation and changes in the expression pattern. Such data are likely to be important for the development of novel strategies for wound healing since they shed some light on the potential formulations of temporally and combinatory optimized therapeutic regimens.     

Microbiology and clinical characteristics of industrial oil burns

IntroductionInfections complicating burns generally transition from Gram-positive to Gram-negatives over the first couple weeks, but this depends on multiple factors. The microbiology of infections complicating crude oil (CO) and hydraulic fracturing (FRAC) burns is unknown.MethodsWe performed a retrospective study of patients with industrial thermal burns hospitalized >2 days with ≥1 day in the ICU between 4/2011–11/2016. Burns were oil-related (ORB; CO or FRAC) or non-oil related (NORB). Epidemiology and microbiology during the first 15 hospital days was compared.Results149 patients were included, with 11 FRAC and 24 CO. CO burns were more severely burned than those with FRAC and NORB (p < 0.05). Mortality was 17% and 18% for CO and FRAC burns compared to 3% in NORB (p < 0.01). More cultures were obtained from ORB than NORB (p < 0.05). ORB were associated with Stenotrophomonas maltophilia and FRAC associated with Serratia marcescens and Candida glabrata. Patients with FRAC, CO and NORB had a median of 13, 3.5, and 4 days to first positive culture respectively (p = 0.03).ConclusionORB were associated with more severe burns and unique microbiology. FRAC burns had longer to initial positive culture, potentially suggesting our current methodology is inadequate to diagnose infections associated with FRAC.     

Clinical significance of urinary fluoride levels in patients with hydrofluoric acid burns

Objective

We investigated the urinary fluoride level in patients with hydrofluoric acid (HF) burns of different severities and explored the clinical significance of these levels in the diagnosis of acute HF burn.

Clinical characteristics and treatment of burn wound sepsis in extensive burn patients: successful experience with eight cases

Eight burn wound sepsis patients, in which 6 cases were diagnosed as MODS and two as septic shock, were treated consecutively in our hospital from September 1997 to October 1998. The plasma concentration of IL-6, IL-8, TNFα and LPS were assayed before and after surgical intervention, as well as when the patients' vital signs became stable. The results showed: ①The patients' conditions abruptly deteriorated when the burn wound sepsis emerged;②The major cause related to burn wound sepsis was extensive burn injuries, with large areas of deep burn remaining open; ③Although wound swabs taken on admission revealed the presence of colonization by many pathogenic bacteria, Pseudomonas aeruginosa was one of the most frequent bacteria isolated from the subeschar tissue; ④The plasma concentrations of IL-6, IL-8, TNF and LPS before surgical intervention were significantly higher than that after surgical intervention (P＜0.05) ;⑤The lowest level of the inflammatory mediators was observed when the patients' conditions became stable, as compared with before surgical intervention (P＜0. 001).These findings suggest that the clinical characteristics of burn wound sepsis are abrupt deterioration of the general condition and prominent septic symptoms, often complicated by MODS. The main cause of burn wound sepsis is the presence of a large area of open deep burn wounds, which should be excised and covered early. LPS and pro-inflammatory mediators play an important role in the pathogenesis of burn wound sepsis. Although success in treating these patients is the result of appropriate application of multiple treatments, early, aggressive and thorough surgical excision of invasive burn infectious tissue and closure of wound play a crucial role in the successful treatment of patients complicated by burn wound sepsis. Other treatments are adjuvant but also important.     

烧伤早期创面细菌菌种分布及临床意义

目的 探讨近年来笔单位烧伤早期创面细菌菌种分布和临床意义。方法 215例严重烧伤患，在烧伤后6d内作首次创面细菌培养和药物敏感试验。结果(1)检出细菌122株，其中革兰阴性菌62株，革兰阳性菌60株；这些细菌包括凝固酶阴性葡萄球菌28株(占23％)，金黄色葡萄球菌27株(22％)，铜绿假单胞菌17株(14％)，大肠埃希菌11株(9％)，肠杆菌属10株(8％)，肠球菌属9株(7％)，霉菌3株(2．5％)，其他17株(14．5％)；(2)对氨苄青霉素、苯唑青霉素钠、羟氨苄青霉素／克拉维酸耐药的金黄色葡萄球菌耐药率分别为81％、38％和31％，对亚胺培南和头孢他啶耐药的铜绿假单胞菌分别占11％和16％；(3)革兰阳性球菌对万古霉素及去甲万古霉素、氯霉素、替考拉宁(Teicoplanin)、甲氧苄啶／磺胺甲基异恶唑、利福平的敏感率分别达到100％、100％、100％、94％和88％；革兰阴性杆菌对美罗培南、亚胺培南、丁胺卡那霉素、头孢吡肟、头孢哌酮／舒巴坦、头孢他啶的敏感率分别为91％、90％、81％、78％、71％和70％；铜绿假单胞菌对头孢哌酮／舒巴坦、头孢他啶、妥布霉素、美罗培南、环丙沙星、丁胺卡那霉素、头孢吡肟的敏感率在82％—91％之间；MRSA对万古雷素及去甲万古霉素全部敏感。结论 本单位近年来烧伤早期创面细菌以凝固酶阴性葡萄球菌和金黄色葡萄球菌为主，铜绿假单胞菌为次，这些细菌的耐药菌株明显增加；过去在烧伤早期创面较少见到的肠球菌属和霉菌亦有所增加。提示在烧伤早期必须正确使用抗生素，不宜滥用广谱抗生素。     

MicroRNAs involved in human skin burns,wound healing and scarring

MicroRNAs are small, non-coding RNAs that regulate gene expression, and consequently protein synthesis. Downregulation and upregulation of miRNAs and their corresponding genes can alter cell apoptosis, proliferation, migration and fibroproliferative responses following a thermal injury. This review summarises the evidence for altered human miRNA expression post-burn, and during wound healing and scarring. In addition, the most relevant miRNA targets and their roles in potential pathways are described. Previous studies using molecular techniques have identified 197 miRNAs associated with human wound healing, burn wound healing and scarring. Five miRNAs alter the expression of fibroproliferative markers, proliferation and migration of fibroblasts and keratinocytes post-burn: hsa-miR-21 and hsa-miR-31 are increased after wounding, and hsa-miR-23b, hsa-miR-200b and hsa-let-7c are decreased. Four of these five miRNAs are associated with the TGF-β pathway. In the future, large scale, in vivo, longitudinal human studies utilising a range of cell types, ethnicity and clinical healing outcomes are fundamental to identify burn wound healing and scarring specific markers. A comprehensive understanding of the underlying pathways will facilitate the development of clinical diagnostic or prognostic tools for better scar management and the identification of novel treatment targets for improved healing outcomes in burn patients.     

血浆冷沉淀物在深度烧伤创面应用的实验及临床研究

目的　观察血浆冷沉淀物应用烧伤创面的治疗效果。方法　通过对 4 0只豚鼠烧伤模型及 4 6例临床烧伤患者创面应用血浆冷沉淀物与创面应用磺胺嘧啶银对照观察伤后创面愈合率、愈合时间。结果　应用血浆冷沉淀实验组创面愈合率、愈合时间优于应用磺胺嘧啶银对照组 ,表明血浆冷沉淀具有促进烧伤创面愈合作用。结论　血浆冷沉淀中所含的主要成分纤维连接蛋白 ,具有很强的生物活性 ,它能促进上皮细胞生长     

烧伤后24小时内削痂对深Ⅱ度创面局部炎症反应的影响

目的探讨烧伤后24h内行削痂手术对深Ⅱ度创面局部炎症反应以及组织损害的影响。方法选择12例烧伤患者,伤后24h内对深Ⅱ度创面行削痂手术,将患者同一创面分为3个标本采集区,即手术前、手术后和未手术区。手术前标本取自削痂术前创面,手术后和未手术区创面标本于伤后5—7d获取。采用组织培养和比色法测定创面组织释放白细胞介素(IL)8、髓过氧化物酶(MPO)和丙二醛(MDA)的水平,通过HE和Masson染色对创面组织坏死程度进行形态学观察。结果削痂手术后,患者创面组织局部释放IL8、MPO、MDA的水平分别为(6.83±1.85)μg/L、(4.07±0.87)U/g、(8.94±5.66)μmol/g,与未手术创面比较明显降低(P<0.01)。形态学观察显示,手术前创面有凝固性坏死灶;未手术创面炎症反应明显,坏死组织范围扩大;削痂手术后创面局部的炎症反应得到改善,未见坏死组织范围扩大。结论伤后24h内行削痂手术,可以改善深Ⅱ度烧伤创面局部的炎症反应,防止创面进行性加深,有利于创面及早愈合。     

The characteristics of elderly burns in Shanghai

Objective

This study aims to analyse the epidemiologic characteristics of severe burn in the elderly in Shanghai and to discusses a possible prevention programme for this population.

Methods

A retrospective review of all medical records of elderly patients (aged 60 and older) admitted with acute burns to the Burn Center of the RuiJin Hospital between January 1996 and December 2004 was carried out. Patient demographics, etiology of burn, mechanism of injury, burn extent, anatomical areas burned, number of operations, and outcomes were reviewed.

Results

A total of 201 (5.8% of hospitalised patients) elderly patients (mean age (±SD) of 69.3 ± 7.1 years (range 60–90 years)) were admitted. Majority of the patients were men (62.2%) and the most common etiologies were flames (52.7%) and scalds (39.8%). The majority of burns occurred at home (73.6%), followed by burns at workplace (15.9%) and public areas (10.5%). The median total body area burned was 11.7% (range 0–84%), and the majority of burns were classified as mild (60.2%) and moderate (32.8%). Predominant anatomical areas involved were the legs (76.1%), arms (67.2%), head and neck (49.8%) and hands (49.3%). The most common pre-injury conditions were cardiovascular diseases (25.9%), diabetes (8.5%) and neurological diseases (6%). Eighty-seven patients (43.3%) required surgical treatment. The most common complications were multiple organ failure (2%), pneumonia (1%) and wound infection (1%). Sixteen patients (8%) died: half of them in hospital, and the rest at home. There was a significant correlation between post-injury complications and death (r = 0.69, p < 0.001). The mean total hospitalisation cost was ¥22993.09 (US$ 3381.34).

Conclusions

Domestic and workplace burns with devastating consequences are very common in the elderly population in Shanghai. Burn prevention education and implementation of safety measures at home and at workplace would help reduce such incidences.     

The use of cultured epithelial autograft in the treatment of major burn wounds: eleven years of clinical experience

INTRODUCTION: In patients with burns involving over 50% total body surface area (TBSA), donor skin is limited. Tissue engineering, particularly cultured epithelial autograft (CEA), offers a potential solution to assist in expedient wound closure. MATERIALS AND METHODS: Prior to 1994, the application of CEA was restricted to confluent cell sheets. The introduction of an autologous cell suspension (CellSpray) in 1994 enabled cells to be delivered to the wound via aerosol onto debrided burn and donor skin graft wound areas. This retrospective clinical audit of major burn injured patients (n=84) describes the use of CEA in those with over 50%TBSA in Western Australia (WA) between 1992 and 2002. RESULTS: The initial introduction of CEA was as confluent sheets, as this evolved to the use of CEA in suspension there was a reduction in the required surgical intervention and total length of stay (TLOS) divided by %TBSA. DISCUSSION: With the audit covering an 11-year period, many facets of clinical burn care have evolved. The WA experience has demonstrated CEA has been positively integrated into clinical practice in association with traditional wound care techniques of skin grafting to augment wound healing.     

Epidemiologic investigation of burns in the elderly in Sichuan Province

Objective

This study analysed the epidemiology of burns in the elderly in Sichuan Province, China, with the objective of formulating a prevention programme.

Methods

A retrospective review of elderly patients admitted to the Burn Centre of West China Hospital during 2003–2009 was performed, including patient demographics, education and burn aetiology.

Results

A total of 103 patients, mean age 69.5 years (range 60–95 years; 58 male, 45 female) were admitted. The most common causes of burn were flames (51.5%), scalding (37.9%), electrical (4.9%) and chemical (2.9%), respectively. The majority occurred at home (68.9%), principally in the kitchen (35.9%), while 19.4% occurred in the workplace. Burns with total body surface area (TBSA) of 0–10% accounted for 52.5% of those admitted for treatment; 10–30% TBSA burns accounted for 20.3%; 30–50% TBSA burns accounted for 15.5%; and burns with a TBSA >50% accounted for 11.7%. Only 6% of patients received appropriate first aid, and 32% did not receive treatment until more than 24 h after injury. The education level was lower in the rural group. Both urban and rural groups had little knowledge of first aid for burns.

Conclusions

Burn-prevention programmes should promote improved living conditions and medical insurance, with prevention education for the elderly, especially in rural areas.     

Apoptotic death in deep partial thickness burns vs. normal skin of burned patients

BACKGROUND: Deep partial thickness burns have an ambiguous behavior evolving either into spontaneous healing or full thickness burns. The aim of this study was to investigate these lesions for the presence of apoptosis thereby giving a possible cellular explanation to their peculiar clinical progression. METHODS: We used colocalization of DNA fragments (terminal deoxynucleotidyl transferase mediated dUTP nick end labeling) and Fas ligand CD95 antibodies to calculate the apoptotic rate of deep partial thickness burns and normal skin in 21 patients after acute thermal injuries (significant difference considered: P < 0.05). RESULTS: Deep partial thickness burns were associated with a higher apoptotic rate than normal skin (48.15% +/- 17.22% versus 18.6% +/- 7.2%; P = 0.0002). There were no apparent significant correlations of apoptotic rate with age, days from injury, total burn surface area or deep burn area except for a slight correlation with sex (r = 0.484; P = 0.02). CONCLUSIONS: A higher apoptotic rate was present in dermal cells of deep partial thickness burns if compared to that of the unburned skin. These data would suggest that deep partial thickness progression derive from apoptosis. Specific studies are required to confirm this hypothesis and to investigate its clinical and therapeutic significance.     

Epidemiological analysis of pediatric burns in the Dominican Republic reveals a demographic profile at significant risk for electrical burns

Objective

Pediatric burns are preventable with legislative and infrastructural changes. Although retrospective audits of many low- and middle-income countries have aided preventative efforts, the epidemiological status of burns in the Caribbean is not known. This study characterizes pediatric burns in the Dominican Republic (DR) and compares these to age-matched North American records captured by the National Burn Repository.

含药辐照猪角膜在眼烧伤中的应用

目的　探索一种理想的眼烧伤治疗方法。　方法　将 55例 ( 88只 )眼烧伤随机分为治疗组和对照组。治疗组 30例 ( 49只 )眼 ,应用含药辐照猪角膜治疗 ;对照组 2 5例 ( 39只 )眼按常规治疗。　结果　治疗组治愈 32只眼 ,治愈率 65.31% ;对照组治愈 17只眼 ,治愈率 4 3 .59%。两组比较差异有显著性意义 (P <0 .0 5)。　结论　含药辐照猪角膜对眼烧伤具有良好的治疗效果     

Effectiveness of Biobrane for treatment of partial-thickness burns in children

Purpose

Wound care for partial-thickness burns should alleviate pain, decrease hospital length of stay, and be readily applied to a variety of wounds. The effectiveness of Biobrane (UDL Laboratories, Rockford, IL) is compared with that of Beta Glucan Collagen (BGC; Brennan Medical, St. Paul, MN) in a retrospective cohort study.

Methods

A retrospective chart review of all children treated at a tertiary care pediatric hospital between 2003 and 2009 identified patients with partial-thickness burns treated with Biobrane. These patients were compared with historical controls treated with BGC.

Results

A total of 235 children between the ages of 4 weeks and 18 years with an average of 6.0% body surface area partial-thickness burns were treated with Biobrane. In a multivariate statistical analysis, patients treated with Biobrane healed significantly faster than those treated with BGC (Biobrane vs BGC: median, 9 vs 13 days; P = .019; hazard ratio, 1.68). In addition, patients who required inpatient treatment trended toward having shorter length of hospital stay in the Biobrane group (2.6 vs 4.1 days, P = .079).

Conclusion

Partial-thickness burn care consists of early debridement and application of a burn wound dressing. Biobrane dressings result in faster healing compared with BGC and may decrease hospital length of stay for patients requiring inpatient admission.     

Breast burns are not benign: long-term outcomes of burns to the breast in pre-pubertal girls

Chest burns in pre-pubescent girl are commonly seen in paediatric burn units. These patients are at risk of significant long-term problems with scarring and breast development requiring reconstructive surgery many years after the initial burn. Admissions to our unit over a 20-year period were reviewed to determine the frequency of these burns. Patients whose burns required surgical debridement and split skin grafting, and who would now be post-pubertal were included in the study. We attempted to trace and contact these patients and were able to find 13 out of 22 patients, of whom 11 agreed to participate. The mechanism of injury in six was scalds and the other five had flame burns. Mean age of patients with scald was 18 months and for flame burns 4 years 8 months. These women required a variety of reconstructive procedures to improve breast appearance including contracture releases, dermabrasion, breast augmentation and contralateral breast reduction. Girls burned as young children require follow-up and appropriate referral long after the burn to ensure good cosmetic results are achieved during and after puberty.     

A retrospective analysis of ambulatory burn patients: focus on wound dressings and healing times

INTRODUCTION

In this study, we retrospectively analysed healing times of ambulatory burn patients after silver-based dressings were introduced in late December 2005, and compared the results with those obtained before.

PATIENTS AND METHODS

Data were collected in November–December 2005 and in January–February 2006. We excluded from the study: (i) admitted patients; (ii) patients with mixed superficial partial thickness and deep partial thickness burns; (iii) patients with full-thickness burns; and (iv) operated patients that came for follow-up. We recorded the age, sex, cause (flame vs scald), burn depth, dressings used and healing times.

RESULTS

We selected 347 patients corresponding to 455 burned areas (64.4% superficial and 35.6% deep; 47.7% treated in 2005 and 52.3% in 2006). During the years 2005 and 2006, there was an increase in the use of silver-based dressings (2005, 9.7%; 2006, 38.7%; chi-squared test, P < 0.001) and a decrease in the use of paraffin gauzes (2005, 66.4%; 2006, 40.3%; chi-squared test, P < 0.001). The healing time of overall burns and of superficial burns showed no significant differences between 2005 and 2006. However, in deep partial thickness burns, a significant reduction was present (2006, 19; 2005, 29 days; Student''s t-test, P < 0.01). Among all dressings, paraffin gauzes had the shortest healing times in superficial burns (5 days); with silver-based dressings in deep burns, the healing times were nanocrystalline silver (16 days) and silver carboxymethylcellulose (21 days).

CONCLUSIONS

Results of our retrospective study would suggest that paraffin gauzes are a valuable option in superficial burns, while silver-based dressings are preferable in deep burns.