Effectiveness of topical zinc oxide application on hypertrophic scar development in rabbits

Background

The etiology, biology, prevention and effective treatment of hypertrophic scars have not exactly been defined. Topical zinc oxide application was shown to be effective in the treatment of proliferative scars. We studied the effectiveness of topical zinc oxide ointment in the prevention of hypertrophic scar development by using the rabbit ear hypertrophic scar model.

Methods

Circular full-thickness skin excisions were performed on both ears of 10 rabbits. The rabbits were divided into two groups and topical 40% zinc oxide ointment was applied daily to one ear and the ointment base was applied as placebo to the other ear. Scar samples were taken in the 3rd week in group 1 and in the 6th week in group 2. All of the specimens were divided into two halves: one half for histopathologic/histomorphometric examinations and the other half for biochemical studies.

Results

Application of topical zinc oxide ointment decreased clinical scar hypertrophy scores significantly (p = 0.017) at 6th week in comparison with placebo. Topical zinc oxide also reduced nodule formation histopathologically at 6th week in comparison with placebo but this was not significant statistically (p > 0.05).

Conclusion

The findings of this study may have clinical implications on the management of human hypertrophic scars.     

The recovery of post-burn hypertrophic scar in a monitored pressure therapy intervention programme and the timing of intervention

Introduction

Pressure therapy used to be considered as the mainstay non-invasive treatment of hypertrophic scar. However, the maturation process of hypertrophic scar during pressure therapy process has seldom be reported. Moreover, although early application of pressure therapy after burn injuries is reco6mmended, minimal evidence exists to support it. This study aimed to examine the maturation trajectory of post-burn hypertrophic scars in a 6-month monitored pressure therapy intervention programme and investigate the difference in the trajectory between patients receiving early intervention and patients receiving late intervention.

Differential expression of growth differentiation factor-9 in keloids

Objective

The mechanisms of keloid invasion are largely unknown. This study aims to analyze the differentially expressed genes between keloid peripheral and central areas and thus to define the molecule that might be responsible for keloid invasion.

Methods

The gene chip of transforming growth factor-β (TGF-β) superfamily signaling pathway was used to analyze differentially expressed genes of the fibroblasts derived from peripheral area and central area of 3 keloids. The differential expression of growth differentiation factor-9 (GDF-9) was also confirmed by quantitative PCR and Western-blot. Moreover, GDF-9 expression levels were compared among the fibroblasts derived from 3 keloids, hypertrophic scars and normal skin with quantitative PCR and immunofluorescent staining.

Results

GDF-9 expression level was significantly higher in the peripheral area than in the central area (p < 0.05) and was significantly higher in keloid than in hypertrophic scar and normal skin (p < 0.05).

Conclusion

Up-regulated GDF-9 expression in keloid peripheral area may play a role in keloid invasive behavior.     

Effects of silicone gel on burn scars

Aim

To study the efficacy of silicone gel applied to hypertrophic burn scars, in reducing scar interference with normal function and improving cosmesis.

Methods

A randomised, double-blind, placebo-controlled trial involving 38 people with hypertrophic burn scars. Each scar was divided into two segments; silicone gel sheet was applied randomly to one of the two and placebo to the other. Participants were seen again after 1 and 4 months. Their data and wound characteristics were collected using the Vancouver scar scale.

Results

The median age of participants was 22 years (1.5–60 years) and 16 were male; 4 did not attend follow-up and were excluded from the study. There were no significant differences in baseline characteristics. Although after 1 month all scar scale measures were lower in treated areas, only the vascularity scale was significantly different between the two areas. After 4 months, all scale measures were significantly lower in the silicone gel group than in the control group, except for the pain score.

Conclusion

Silicone gel is an effective treatment for hypertrophic burn scars.     

The use of neoprene as a scar management modality

Purpose

Scar formation is one of the most functionally and cosmetically debilitating results of thermal injuries. Burn team members continuously search for new, cost effective, ways to prevent and treat hypertrophic scar formation. This study is a retrospective review of one facility's use of neoprene based products as an adjunct to, or in place of, traditional scar management techniques.

Methods

Records of all patients treated with neoprene patches or neoprene splints from March 2008 through April 2011 were retrospectively reviewed. Vancouver Scar Scores (VSS) were collected, photographs were reviewed and any documented problems reported by the patients were noted.

Results

Mean VSS scores were significantly lower at follow-up (5.3, SD 2.8) than at initial appointment (11.7, SD 1.4) with an estimated mean difference of 6.3 (P = 0.0001). A 95% confidence interval for this mean difference is 3.9–8.7.

Conclusions

In the reviewed cases, the use of neoprene inserts or splints resulted in a statistically significant reduction in hypertrophic scars with no secondary complications.     

Lifestyle Changes for Improving Disease-specific Quality of Life in Sedentary Men on Long-term Androgen-Deprivation Therapy for Advanced Prostate Cancer: A Randomised Controlled Trial

Background

Prostate cancer is a key driver of cancer-related global disability-adjusted life-years. Androgen-deprivation therapy (ADT) for advanced disease is linked to fatigue, reduced physical function, and quality of life (QoL).

Objective

To evaluate the effect of a lifestyle intervention on disease-specific QoL, diastolic blood pressure, and cancer-related fatigue in sedentary men receiving long-term ADT for advanced prostate cancer.

Design, setting, and participants

A total of 100 hundred sedentary men with locally advanced or metastatic prostate cancer on long-term ADT were randomised to an intervention or usual care group.

Intervention

A 12-wk lifestyle intervention consisting of aerobic and resistance exercise with parallel dietary advice.

Outcome measurements and statistical analysis

Disease-specific QoL was measured using the Functional Assessment of Cancer Therapy-Prostate (FACT-P) and Functional Assessment of Cancer Therapy-Fatigue (FACT-F) questionnaires at 12 wk postintervention and at 6 mo following withdrawal of support. Analysis of covariance and mixed regression were conducted.

Results and limitations

Clinically relevant improvements in FACT-P were seen at 12 wk in the intervention group compared with controls (mean difference: 8.9 points; 95% confidence interval [CI], 3.7–14.2; adjusted p = 0.001). No difference was apparent at 6 mo (mean difference: 3.3 points; 95% CI, −2.6 to 9.3; adjusted p = 0.27). No difference in diastolic blood pressure was seen at either follow-up (all p > 0.05). Clinically relevant improvements in FACT-F were seen at 12 wk (mean difference: 5.3 points; 95% CI, 2.7–7.9; adjusted p < 0.001) and maintained following withdrawal of supervision (mean difference: 3.9 points; 95% CI, 1.1–6.8; adjusted p = 0.007). Improvements in exercise tolerance and behaviour were maintained at 6 mo (adjusted p < 0.001 and 0.038).

Conclusions

A lifestyle intervention resulted in a clinically meaningful improvement in disease-specific QoL that was not maintained postintervention. No effect on blood pressure occurred. Durability of response was seen in fatigue and exercise behaviour. Further evaluation of support structures is essential.

Trial registration

ISRCTN88605738.     

Objective evaluation of the effect of autologous platelet concentrate on post-operative scarring in deep burns

Introduction

The healing of grafted areas after surgical treatment of deep burns frequently generates mutilating scars, and rises the risk of subsequent scar hypertrophy. Scar assessment based on clinical evaluation is inherently subjective, which stimulates search for objective means of evaluation.

Objective

The aim of this study was to objectively evaluate the effect of using autologous platelet concentrate (APC) in combination with split thickness skin grafting (STSG) on scarring processes following surgery of deep burns as compared with application of STSG alone.

Method

Selected viscoelastic properties of 38 scars on 23 patients in total were examined using the Cutometer MPA 580 under controlled conditions for long-term outcomes 1, 3, 6 and 12 months after surgery following deep burns.

Results

The findings of this study suggest that the STSG + APC combination reduces the time of scar viscoelastic properties recovery as compared with application of STSG alone. This was statistically significant for viscoelastic parameters R₂ and Q₁.

Conclusion

APC has been advocated to enhance scarring after surgery of deep dermal and full thickness burns. We objectively demonstrated that the viscoelastic properties of scars treated with STSG + APC combination return more rapidly to the plateau state than areas treated with STSG only.     

Reconstruction of large hypertrophic scar on trunk and thigh by means of liposuction technique

Objective

Hypertrophic scars on trunk and thigh are less important in function and appearance than those on face, neck, hand, foot and joint. However, patients suffer itching, pain and disfiguration. Thus far, neither non-surgical nor surgical methods treat these scars perfectly. This study reports on the application of liposuction technique to reconstruct these scars and reviews the outcomes.

Method

Between March 2000 and March 2008, we treated 26 hypertrophic scars on trunk and thigh (20 patients) using liposuction. Tumescent liquids were infiltrated and liposuction was performed in the areas of trunk and thigh where the scars located. Following scar excision, defects were covered by sliding flap created by liposuction. Incisions were closed without tension.

Results

Twenty-six hypertrophic scars were reconstructed in one stage by flaps of similar texture and colour in areas around the scars without wound dehiscence, infection, skin necrosis, sensory deficit, haematoma and seroma. The contours of liposuction areas were natural and even.

Conclusion

Large hypertrophic scar at sites rich in subcutaneous fat such as trunk and thigh can be reconstructed in one stage by liposuction technique, which is easy, safe, effective and economic. Although indications of liposuction scar reconstruction are strict, it is indeed a better option for appropriate cases.     

Validation of the Pliance X System in measuring interface pressure generated by pressure garment

Introduction

Pressure monitoring is crucial for effective pressure therapy. Precise and reliable interface pressure measurement system, however, remains unavailable in current practice.

Methodology

This is a validation study on the application of a recently developed device, the Pliance X System, for static interface pressure measurement. Sensor properties were evaluated through series of laboratory tests in the first phase of the study. Phase II was a clinical study using the Pliance X system to differentiate the loading generated on the patients’ scars through additional inserts and pressure garment.

Results

Results showed high test–retest and inter-rater reliability (ICC ≥ 0.995) with good linearity (adjusted R-square = 0.997) by measuring standard weights. The maximum deviation between the measurement generated by the sensor and the sphygmomanometer cuff was ±1.451 mmHg. Results in the clinical trial revealed its discriminant ability in distinguishing different levels of pressure loading on patients with scars (p < 0.01).

Conclusion

The commercially available pressure measurement system was found to be a reliable tool for measurement of low interface pressure under static condition.     

Dried irradiated human amniotic membrane as a biological dressing for facial burns—A 7-year case series

Background

Facial burns are common and have a significant impact on patient function and psychosocial well being. Human amnion has been used for many years as a temporary biological wound dressing in the management of partial thickness burns. The observed advantages of human amnion treatment include pain relief, ease of use, prevention of infection and acceleration of wound healing.

Objective

This study evaluated our 7 years of working with dried irradiated human amnion in the treatment of facial burns.

Method

A review of patients, treated with dried human amnion for facial burns between 2001 and 2008. Demographic details collected included age, gender, total facial surface area burned, type of burn and cause of injury. The effectiveness of the treatment was determined by wound infection rate, frequency of dressing reapplication, healing time and resulting scarring.

Results

Thirty-three patients with superficial partial thickness burn were identified (25 males, 8 females). The average age of the patients was 16.5 years (range: 8 months to 64 years). The causes included scalding (n = 15), contact burning (n = 13) and flash burning (n = 5). The mean percent total facial surface area burned was 2.7% (range: 0.5–8.5%). None of the patients developed facial wound infections. Eighty-five percent (n = 28) of the patients needed a single application of the dried amnion. The average healing time was 5.4 days (range: 2–14 days). Thirteen patients (39%) had burns confined to the facial area, of which three were discharged and treated as outpatients. Long-term follow up showed two hypopigmented scars, one hyperpigmented scar and one hypertrophic scar.

Conclusion

Superficial partial thickness facial burns can be effectively treated with dried irradiated human amnion membrane.     

The application of 3D-printed transparent facemask for facial scar management and its biomechanical rationale

Introduction

Deep facial burns leave conspicuous scar to the patients and affect their quality of life. Transparent facemask has been adopted for the prevention and treatment of facial hypertrophic scars for decades. Recently, with the advancement of 3D printing, the transparent facemask could facilitate the fitting of the facial contour. However, the effectiveness of the device and its biomechanical characteristics on pressure management of hypertrophic scar would need more objective evaluation.

Videocapillaroscopy in postburn scars: In vivo analysis of the microcirculation

Objective

The aim of the study was the evaluation in vivo of the differences between the microcirculatory characteristics of the postburn scar and the healthy skin.

Methods

Twelve patients with postburn scars were included in the study, evaluating fifteen scar areas and twelve healthy skin areas by means of contact optical probe videocapillaroscopy. The examined areas for each patient were the right and the left upper limb. Capillary density, length and diameter, together with capillary distribution pattern (punctiform, reticular, directional) and the presence of microhaemorrhages and neoangiogenesis were studied.

Results

The results were obtained by two different researchers using the capillaroscope's software. Capillary loop diameter and length, capillary distribution pattern and presence of neoangiogenesis were found to be significantly increased in postburn scars compared with controls. There were also significant differences between hypertrophic tissue in the active phase and the one in the remission phase for capillary diameter and presence of neoangiogenesis.

Conclusion

Videocapillaroscopy showed “in vivo” a change in local microcirculation architecture using a microscope. Patients with hypertrophic burn scars showed a variety of microcirculatory changes, often clustered in a characteristic pattern of abnormally oriented, dilated capillaries and neoangiogenetic phenomena. This methodology is highly likely to be of value in the assessment and prognostication of burn outcome.     

Target blood pressure for hypotensive resuscitation

Background

Good outcomes have resulted from hypotensive resuscitation of hemorrhagic shock patients. We hypothesized that mean arterial pressure (MAP) 60 mmHg is the target blood pressure for hypotensive resuscitation during uncontrolled hemorrhagic shock in trauma.

Methods

To determine the effective target MAP for hypotensive resuscitation during uncontrolled hemorrhagic shock, we randomly assigned 80 rats to one of 8 treatment groups (n = 10 for each group). We then observed the effects of different target MAPs (control, 40, 50, 60, 70, 80, 90 mmHg, and sham) on fluid resuscitation of uncontrolled hemorrhagic shock. Blood pressure, serum lactate, hematocrit, fluid therapy, blood loss, and plasma cytokine levels were measured at 0, 30, 90, 120, 180, 240, 300 min after the start of the surgical procedure.

Results

A target MAP of 90, 80 and 70 mmHg had increased blood loss and decreased hematocrit and IL-6 and TNF-α production. A target MAP of 60, 50 and 40 mmHg had lower blood loss, good hematocrit, higher IL-6 and TNF-α production, and decreased animal survival. Only target MAPs of 40 and 50 had and decreased animal survival. The differences in blood loss, hematocrit, lactate, post-resuscitation MAP, survival, IL-6, IL-10, and TNF-α production between rats with a target MAP of 60 mmHg and those with a target MAP of 70 mmHg were not significant. The amount of fluid therapy in the BP 60 groups was less than in the BP 70 groups (P < 0.001).

Conclusion

A MAP of 60 mmHg should be considered for evaluation in human studies as a target for hypotensive resuscitation.     

Effect of intense pulsed light on immature burn scars: A clinical study

Introduction:

As intense pulsed light (IPL) is widely used to treat cutaneous vascular malformations and also used as non-ablative skin rejunuvation to remodel the skin collagen. A study has been undertaken to gauze the effect of IPL on immature burn scars with regard to vascularity, pliability and height.

Materials and Methods:

This study was conducted between June 2013 and May 2014, among patients with immature burn scars that healed conservatively within 2 months. Photographic evidence of appearance of scars and grading and rating was done with Vancouver Scar Scale parameters. Ratings were done for both case and control scar after the completion of four IPL treatment sessions and were compared.

Results:

Out of the 19 cases, vascularity, pliability and height improved significantly (P < 0.05) in 13, 14 and 11 scars respectively following IPL treatment.

Conclusions:

Intense pulsed light was well-tolerated by patients, caused good improvement in terms of vascularity, pliability, and height of immature burn scar.KEY WORDS: Burn scar, intense pulse light, vancouver scar scale     

Laparoendoscopic Single-site Partial Nephrectomy Without Ischemia for Very Small,Exophytic Renal Masses: Surgical Details and Functional Outcomes

Background

Laparoendoscopic single-site surgery (LESS) has emerged as a natural progression from standard laparoscopy aiming to further minimize the morbidity of urologic procedures.

Objective

To describe our technique and report the surgical and functional outcomes of unclamped LESS partial nephrectomy (PN) in the treatment of small renal masses (SRMs).

Design, setting, and participants

Prospective evaluation of pre- and postoperative variables of patients undergoing the LESS-PN without ischemia between 2009 and 2012. The indications were single exophytic SRMs.

Surgical procedure

Unclamped LESS-PN was performed through a transperitoneal approach. A pararectal Hasson access technique was preferred. Single-port access was achieved via different single-port devices. A combination of straight and articulating laparoscopic instruments was used. The tumor was excised using bipolar scissors during normal renal perfusion. Hemostasis was achieved by bipolar electrocautery, parenchymal stitches, and hemostatic agents.

Outcome measurements and statistical analysis

Demographic, operative, postoperative, and pathologic outcomes data were recorded and analyzed.

Results and limitations

A total of 21 LESS-PN were performed (operative time: 111 ± 41 min; blood loss: 196 ± 195 ml: tumor size: 2.0 ± 0.3 cm). Neither conversion to open surgery nor transfusions occurred. Three patients required conversion to standard laparoscopy. Postoperatively, three complications (Clavien grades 2, 3a, and 4) were recorded. Pathologic examination revealed 14 clear cell carcinomas, four renal cysts, two oncocytomas, and one angiomyolipoma. Hospital stay was 4.4 ± 1.9 d. At the last follow-up (mean: 17 ± 11.5 mo), no port-site, local, or distant recurrences were detected. No significant variation in serum creatinine and estimated glomerular filtration rate was observed. Subjective scar evaluation indicated 66% of patients were very satisfied/enthusiastic. Study limitations include the small sample size, the lack of a control group, the short follow-up period, and the arbitrary measure of patient's scar perception.

Conclusions

Unclamped LESS-PN for selected SRMs is a safe and feasible procedure providing favorable postoperative outcomes and ensuring high levels of subjective, cosmetic satisfaction.     

Burn scar assessment: A systematic review of objective scar assessment tools

Purpose

All deep second and third degree burns are at risk to develop hypertrophic scars which can severely undermine the quality of survival. To assess the severity of scarring, several technical devices or tools have been introduced to evaluate one or more aspects of the scar, enabling comparison of different treatment protocols and allowing an objective follow-up. The objective of this study was to review which tools can be used in objective burn scar assessment.

Basic procedures

The Systematic literature search involving PubMed, the Web of Science (incl. Science Citation Index).

Main findings

51 articles with burn scar assessment as main topic were found. Several characteristics of the scar can be assessed, such as color, metric features and elasticity, but none of the available tools covers the whole aspect of the scar. Especially subjective factors such as pain and itching cannot be assessed with those tools, in spite of their great impact on the patient's quality of life.

Conclusions

Scar tools enable objective and reproducible evaluation of scars, which is essential for scientific studies and medico-legal purposes, and in selected cases for the clinical follow-up of an individual patient. Further studies to evaluate these tools on scars are nevertheless required.     

Values of patients and caregivers for donor site scars: an inter-observer analysis between patients and caregivers and prediction of cosmetic satisfaction

Background

The Patient and Observer Scar Assessment Scale (POSAS) is used to judge scars and involves patients and caregivers. Although the opinions of both are integrated, agreement between them is poorly investigated, especially in donor site scars (DSSs). Furthermore, it is unknown which POSAS-items are mostly associated with overall cosmetic satisfaction with the scar.

Methods

We included 106 DSS-patients. Twelve weeks after wound healing, patients and caregivers rated the DSS in vivo using the POSAS, comprising seven items. They were unaware of each other's judgment. Inter-observer reliability (IOR) was expressed as intra-class correlation coefficients (ICC). Items of the POSAS that best predicted patients’ overall satisfaction were identified using multivariable regression analysis.

Results

Eleven caregivers from different medical centers judged the DSSs. IOR for the POSAS items was ‘moderate’ at best regarding the item ‘overall opinion’ (ICC 0.44; 95% confidence interval 0.27–0.58). IORs regarding other POSAS-items were ‘poor’. Itching and relief best predicted patients’ overall satisfaction (total variance explained, R² = 0.174). For caregivers, pigmentation and pliability were most predictive (R² = 0.318).

Conclusion

Patients and caregivers appreciate different aspects of scar characteristics using the POSAS. This calls for shared decision-making, in which patient opinions are incorporated in the treatment choice.     

Multi-incisional transumbilical laparoscopic surgery for nonpalpable undescended testes: A report of 126 cases

Purpose

The aim of this study was to evaluate the feasibility of multi-incisional transumbilical laparoscopic surgery for the management of nonpalpable undescended testes.

Material and methods

A series of 126 patients with 162 nonpalpable undescended testes underwent transumbilical laparoscopic surgery. Their mean age was 1.8 years (range, 1.1–6.5 years). Of the 126 cases, 73 were left-sided, 17 were right-sided, and 36 had bilateral cryptorchidism. Primary orchidopexy and the Fowler–Stephens procedure were used to mobilize the testes.

Results

All the operations were successfully performed without intraoperative complications. No additional ports or any conversions to an open procedure were required. Of the 162 nonpalpable undescended testes, 21 were absent or atrophied. One-hundred thirteen testes underwent primary orchidopexy, and 28 cases underwent a Fowler–Stephens orchidopexy. Patients were followed-up for 6–15 months. Only one case of testicular retraction was observed, and all others maintained a good size and the correct position. The scars were hidden within the umbilicus.

Conclusion

Transumbilical laparoscopic surgery is safe and feasible for nonpalpable undescended testes, and leaves no obvious abdominal or inguinal scar.     

Involving burn survivors in agenda setting on burn research: An added value?

Background and aim

The role of burn survivors in burn research is usually restricted to being objects of study and beneficiaries of research results, while decision-making on research is traditionally the domain of a small group of experts, mainly scientists. In this article we compare the research priorities of burn survivors and professionals and investigate to what extent it is possible to come to a joint research agenda.

Methodology

The project followed the Dialogue Model for research agenda setting. Initially burn survivors and professionals were consulted separately and group-specific lists of research priorities were established, using a literature survey, exploratory interviews (n = 10), focus groups (n = 58), a questionnaire (n = 224) and Delphi rounds (n = 12). Subsequently, in a dialogue meeting burn survivors and professionals presented and discussed their priorities, developed one integrated list, and prioritized the 15 most important topics on this list.

Results

Considerable overlap was observed between the research priorities of burn survivors and professionals, particularly with respect to biomedical and clinical research on wound healing and scar management. However, differences were also observed, e.g. treatment of itching and oedema on scars and donor places.

Conclusion

The model proved useful in eliciting research priorities from both professionals and burn survivors, and in stimulating a meaningful dialogue between these groups. The involvement of burn survivors identified burn research areas that are currently not the focus of research in The Netherlands.     

Infiltration peropératoire de lévobupivacaïne après césariennes : étude randomisée en double insu contre placebo

Objectives

The efficacy of single-dose intraincisional infiltration with levobupivacaine in postoperative analgesia and chronic pain after caesarean sections is unknown.

Study

A placebo-controlled double-blind randomized trial.

Patients and methods

After ethical approval, and written inform consent, 140 women scheduled for a caesarean section were randomly assigned and received 30 mL of levobupivacaine 0.5% (L group) or saline (placebo-P group) into their wound. The primary endpoint was morphine consumption (using intravenous morphine patient-controlled analgesia) for the first 24 h after surgery. At 1 h to 48 h, side effects, pain at rest and pain 2 months later were recorded.

Results

All included patients had similar demographic and surgical characteristics. The morphine consumption was significantly lower in the L group at h6, h8 and h12 (considering both total intake and each request). At h4, the mean total morphine consumption was 25 (12) mg in the L group versus 31 (14) mg in the P group (P = 0.05). Time until discharge and side effects including nausea-vomiting (14 vs 20%), wound scar complications (6 vs 8%) and chronic pain after 2 months (25% in both groups complained of small pain, and 75% no pain) were similar between the two groups (P > 0.05).

Conclusion

Single-dose local infiltration of levobupivacaine 0.5% reduced opioid requirement at 12 h, with no difference after 24 h. www.clinicaltrials.com, number: NCT00621907.