Assessing the Effect of Enzymatic Debridement on the Scar Quality in Partial-Thickness Burns to Deep Dermal Burns of the Hand: A Long-Term Evaluation.

Background and Objectives: Burn surgery on the hands is a difficult procedure due to the complex anatomy and fragility of the area. Enzymatic debridement has been shown to effectively remove burn eschar while minimizing damage to the surrounding tissue and has therefore become a standard procedure in many burn centers worldwide over the past decade. However, surprisingly, our recent literature review showed limited valid data on the long-term scarring after the enzymatic debridement of the hands. Therefore, we decided to present our study on this topic to fill this gap. Materials and Methods: This study analyzed partial-thickness to deep dermal burns on the hands that had undergone enzymatic debridement at least 12 months prior. Objective measures, like flexibility, trans-epidermal water loss, erythema, pigmentation, and microcirculation, were recorded and compared intraindividually to the uninjured skin in the same area of the other hand to assess the regenerative potential of the skin after EDNX. The subjective scar quality was evaluated using the patient and observer scar assessment scale (POSAS), the Vancouver Scar Scale (VSS), and the "Disabilities of the Arm, Shoulder, and Hand" (DASH) questionnaire and compared interindividually to a control group of 15 patients who had received traditional surgical debridement for hand burns of the same depth. Results: Between January 2014 and December 2015, 31 hand burns in 28 male and 3 female patients were treated with enzymatic debridement. After 12 months, the treated wounds showed no significant differences compared to the untreated skin in terms of flexibility, trans-epidermal water loss, pigmentation, and skin surface. However, the treated wounds still exhibited significantly increased blood circulation and erythema compared to the untreated areas. In comparison to the control group who received traditional surgical debridement, scarring was rated as significantly superior. Conclusions: In summary, it can be concluded that the objective skin quality following enzymatic debridement is comparable to that of healthy skin after 12 months and subjectively fares better than that after tangential excision. This confirms the superiority of enzymatic debridement in the treatment of deep dermal burns of the hand and solidifies its position as the gold standard.

Early Enzymatic Burn Debridement: Results of the DETECT Multicenter Randomized Controlled Trial.

Since 1970 surgeons have managed deep burns by surgical debridement and autografting. We tested the hypothesis that enzymatic debridement with NexoBrid would remove the eschar reducing surgery and achieve comparable long-term outcomes as standard of care (SOC). In this Phase 3 trial, we randomly assigned adults with deep burns (covering 3-30% of total body surface area [TBSA]) to NexoBrid, surgical or nonsurgical SOC, or placebo Gel Vehicle (GV) in a 3:3:1 ratio. The primary endpoint was complete eschar removal (ER) at the end of the debridement phase. Secondary outcomes were need for surgery, time to complete ER, and blood loss. Safety endpoints included wound closure and 12 and 24-months cosmesis on the Modified Vancouver Scar Scale. Patients were randomized to NexoBrid (n = 75), SOC (n = 75), and GV (n = 25). Complete ER was higher in the NexoBrid versus the GV group (93% vs 4%; P < .001). Surgical excision was lower in the NexoBrid vs the SOC group (4% vs 72%; P < .001). Median time to ER was 1.0 and 3.8 days for the NexoBrid and SOC respectively (P < .001). ER blood loss was lower in the NexoBrid than the SOC group (14 ± 512 mL vs 814 ± 1020 mL, respectively; P < .0001). MVSS scores at 12 and 24 months were noninferior in the NexoBrid versus SOC groups (3.7 ± 2.1 vs 5.0 ± 3.1 for the 12 months and 3.04 ± 2.2 vs 3.30 ± 2.76 for the 24 months). NexoBrid resulted in early complete ER in >90% of burn patients, reduced surgery and blood loss. NexoBrid was safe and well tolerated without deleterious effects on wound closure and scarring.

Implementing Nexobrid for Burn Debridement in a Major Italian Burn Center: A Retrospective Review of Patient Outcomes.

This retrospective study examines the implementation of Nexobrid, an enzymatic debriding agent developed from bromelain, for burn debridement in a major Italian burn center. With previous research showing encouraging results for Nexobrid in terms of reducing the need for surgical intervention and faster eschar removal, the current study aims to add to the growing body of evidence regarding its potential benefits and limitations. The patient database was utilized to identify patients who received Nexobrid treatment between October 2019 and June 2023. A retrospective analysis was conducted to gather demographic information, burn causes, procedural details, and patient outcomes. Of the 30 patients treated with Nexobrid, 10% did not require further surgical intervention, showcasing Nexobrid's potential to improve patient outcomes. However, over 80% of patients still required additional surgical intervention, demonstrating that Nexobrid's effectiveness varies across patients and should be considered a tool rather than a definitive solution in burn wound management. A few patients developed complications, and about 10% of patients succumbed to systemic complications. The study results reveal both the potential benefits and limitations of using Nexobrid in burn debridement. While it successfully eliminated the need for further surgical intervention in a small percentage of patients, the majority still required additional surgical procedures. These findings not only highlight Nexobrid's role as a tool in burn wound management but also point toward the discrepancies with previous studies. The authors suggest future research should include randomized controlled trials, direct comparisons between Nexobrid and traditional debridement methods, and studies incorporating larger and more diverse patient groups.

The use of NexoBrid™ enzymatic debridement and coagulation abnormalities.

OBJECTIVES: Current evidence on how the use of bromelain-based enzymatic debridement techniques (NexoBrid™) affect patient coagulation is limited. A single patient case report [1] suggests that a patient with 15% total body surface area (TBSA) burn developed decreased coagulation activity following debridement with NexoBrid™ enzymatic debridement (ED). Regional Burns Centres in the United Kingdom may be reluctant to use ED, particularly in larger burns, citing concerns regarding coagulation. At our centre we have routinely used ED on deep partial thickness burns since 2017 including on patients with burns over 15% TBSA. This study aims to investigate whether there is a significant disruption in coagulation in patients undergoing ED with burns > 15% TBSA or admitted to intensive care compared to the standard of care (SOC) which is surgical debridement in theatre. METHODS: This single-centre retrospective study includes all patients with a burn treated with ED at Pinderfields General Hospital Regional Burns Centre intensive care unit (ITU) from 2017 to 2020. Patients were matched to those treated with SOC at the same centre by age, % TBSA burn and presence of inhalational injury. These parameters correlate with the Baux score [9]. Percentage of burn debrided was matched as closely as possible, with coagulation profiles and platelet count taken the day before, the day of and three days following surgery. RESULTS: Thirty-one patients were treated with ED in the intensive care unit between 2017 and 2020. Four patients were excluded due to insufficient records and one patient was anti-coagulated. Twenty-six patients were included and matched as described above. Average age of patients receiving ED was 44 years, the same in the matched group. Average TBSA burn is 35.5% (35.8% in matched group). No statistically significant difference in coagulation was seen between patients undergoing ED compared to SOC when considering prothrombin time (PT), activated partial thromboplastin time (aPTT) and platelet count. Both groups slightly breached the upper limit of normal on day 2 post ED and SOC. There was a slight breach of the lower limit of the average platelet count on day 2 post-ED which was neither statistically nor clinically significant. CONCLUSIONS: Large burns are associated with coagulation abnormalities, therefore isolating a single variable in this cohort is challenging. However, this study found no significant change following ED use when compared to SOC and therefore no convincing evidence that ED is associated with coagulation abnormalities. This study represents one of the largest focusing on coagulation abnormalities following the use of ED, as the current literature is limited. Our study suggests that concerns regarding coagulation abnormalities should not prevent patients with large, deep partial thickness burns or full thickness burns being treated with ED.

Clinical study of drug-loaded calcium sulfate in the treatment of hematogenous osteomyelitis in children.

BACKGROUND: At present, good results have been obtained in the treatment of hematogenous osteomyelitis(HO) in children by the use of drug-loaded calcium sulfate, but there are few clinical studies reported. The aim of this study was to investigate the clinical efficacy of radical debridement combined with drug-laden calcium sulphate antibiotics in paediatric haematogenous osteomyelitis. METHODS: In this study, we retrospectively analyzed the clinical data of 15 cases of pediatric hematogenous osteomyelitis admitted to our hospital in recent years. A total of 15 pediatric patients with HO treated in our hospital from January 2018 to February 2022 were included for evaluation. RESULTS: All 15 patients were treated with drug-laden calcium sulfate, and the antibiotic of choice was vancomycin in 14 cases and vancomycin combined with gentamicin in 1 case. The follow-up period ranged from 12 to 36 months, with a mean follow-up time of 24.73 months, and all children were treated with drug-laden calcium sulfate with satisfactory clinical outcomes. The results of serological examination showed that the preoperative white blood cell count level, C-reactive protein and erythrocyte sedimentation rate were higher than the postoperative ones, and the differences were statistically significant (P < 0.05).After the operation, referring to the treatment standard of McKee's osteomyelitis, 15 cases were cured without recurrence; According to the Lower Extremities Functional Scale, 12 cases were excellent, 2 cases were good and 1 case was moderate, with an excellent rate of 93.33%. Children with lower limb involvement could walk with full weight bearing, and gait was basically normal. CONCLUSION: Drug-loaded calcium sulfate is a good therapeutic method for the treatment of hematogenous osteomyelitis in children, with a effect of reducing complications and reducing recurrence.

Anacaulase-bcdb for the treatment of severe thermal burns.

INTRODUCTION: Accurate burn depth assessment and early excision of burn eschar with maximal dermal preservation are key concepts in the optimal care of burn injury. Although excision with knife has long since been standard of care, a newer technique for wound bed preparation utilizing a bromelain-based enzyme has gained popularity worldwide and may offer several advantages. AREAS COVERED: Here we report the pharmacologic properties, evidence for clinical efficacy, safety, and tolerability of anacaulase-bcdb for the treatment of deep partial thickness and full thickness burns. EXPERT OPINION: Anacaulase-bcdb is a safe, non-surgical, selective eschar removal agent. It offers advantages over surgical excision of burn with knife and fulfills two unmet needs: burn depth assessment and dermal preservation during excision. Evidence supports a faster time to complete eschar removal; reduced number of operations; reduction in the amount of autografting, length of stay, and blood loss; prevention of burn induced compartment syndrome; and improved cosmetic outcome.

Bromelain-based enzymatic burn debridement: A systematic review of clinical studies on patient safety, efficacy and long-term outcomes.

In 2012 the European Medicines Agency approved a pineapple stem-derived Bromelain-based debridement concentrate of proteolytic enzymes (NexoBrid®, MediWound Ltd, Yavne, Israel) for adult deep burns. Over 10 000 patients have been successfully treated with NexoBrid® globally, including in the US. The aim of our study is to perform a systematic review of the current literature on Nexobrid® outcomes. We conducted a literature search in PubMed, Google Scholar, Embase, and other search engines (2013-2023). The online screening process was performed by two independent reviewers with the Covidence tool. The protocol was reported using the Preferred Reporting Items for Systematic Review and Meta-Analyses, and it was registered at the International Prospective Register of Systematic Reviews of the National Institute for Health Research. We identified 103 relevant studies of which 34 were found eligible. The included studies report the positive effects of Nexobrid® on burn debridement, functional and cosmetic outcomes, scarring, and quality of life. Also, they validate the high patient satisfaction thanks to enhanced protocols of analgosedation and/or locoregional anaesthesia during Bromelain-based debridement. Two studies investigate potential risks (coagulopathy, burn wound infection) which concluded there is no strong evidence of these adverse events. NexoBrid® is a safe, selective, non-surgical eschar removal treatment modality. The benefits of Bromelain-based debridement are faster debridement and healing times, reduced operations, length of stay, cases of sepsis, blood transfusions, and prevention of compartment syndrome. Existing evidence suggests that the indications and the role of Bromelain-based debridement are expanding to cover "off-label" cases with significant benefits to the global healthcare economy.

Reappraisal and updated review of maggot debridement therapy in chronic lower extremity ulcers.

BACKGROUND: Dating back to the mid-1500s, maggot debridement therapy (MDT) has been a viable treatment modality for chronic wounds. In early 2004, the sterile larvae of Lucilia sericata received FDA approval for medical marketing for neuropathic, venous, and pressure ulcers, traumatic or surgical wounds, and nonhealing wounds that have not responded to standard care. However, it currently remains an under-utilized therapy. The proven efficacy of MDT begs the question if this treatment modality should be considered as a first-line option for all or a subset of chronic lower extremity ulcers. OBJECTIVE: This article aims to address the history, production, and evidence of MDT and discuss future considerations for maggot therapy in the healthcare field. METHODS: A literature search using the PubMed database was conducted using keywords, such as wound debridement, maggot therapy, diabetic ulcers, venous ulcers, among others. RESULTS: MDT reduced short-term morbidity in non-ambulatory patients with neuroischemic diabetic ulcers and comorbidity with peripheral vascular disease. Larval therapy was associated with statistically significant bioburden reductions against both Staphylococcus aureus and Pseudomonas aeruginosa. Faster time to debridement was achieved when chronic venous or mixed venous and arterial ulcers were treated with maggot therapy versus hydrogels. CONCLUSIONS: The literature supports the use of MDT in decreasing the significant costs of treating chronic lower extremity ulcers, with emphasis on those of diabetic origin. Additional studies with global standards for reporting outcomes are necessary to substantiate our results.

Enzymatic debridement for circumferential deep burns: the role of surgical escharotomy.

INTRODUCTION: Circumferential deep burns carry a high risk for a burn induced compartment syndrome. It was recently shown that an enzymatic bromelain-based debridement with Nexobrid® is a safe and efficient procedure to release pressure in deep circumferential extremity burns reducing the need for surgical escharotomy. We therefore herein aimed to analyze the conceptual relation between Nexobrid® and surgical escharotomy. PATIENTS AND METHODS: We conducted a retrospective study on all patients with circumferential deep partial-thickness or full-thickness burns requiring immediate escharotomy that was either performed by surgical incision or Nexobrid®. Medical records of 792 patients that were treated at the burn center of the University Hospital Zurich between 2016 and 2021 were analyzed. RESULTS: Overall, 62 patients with circumferential deep partial-thickness or full-thickness burns who received preventive decompression either by Nexobrid® (N = 29) or surgical escharotomy (N = 33), were included. Whilst distribution of age, sex, BMI and type of injury showed no difference between the groups, the ABSI score, TBSA, percentage of third degree burns and mortality were significantly higher in patients who received a surgical escharotomy. CONCLUSION: While the use of Nexobrid® to prevent burn induced compartment syndrome has steadily increased, surgical escharotomies were predominantly performed in severely burned patients with a high degree of full-thickness burns. Thus, higher mortality in this patient group needs to be considered with caution and is mainly attributed to the higher TBSA. Although evidence is lacking for the use of Nexobrid® for larger body areas exceeding 15%, escharotomy is also the more reliable and faster approach in such critically burned patients.

Low-level laser therapy has an additional effect with open flap debridement on the treatment of stage III periodontitis: a split-mouth randomized clinical trial.

OBJECTIVE: The purpose of this randomized, controlled, split-mouth trial was to clarify the clinical efficacy of using low-level laser therapy (LLLT) as an adjunct to open flap debridement in the treatment of periodontitis. METHOD AND MATERIALS: The study was conducted on 10 patients with stage III periodontitis. Clinical parameters were recorded for 70 sites of periodontal pockets at baseline and after 3 months and included Plaque Index (PI), Gingival Index (GI), bleeding on probing (BOP), probing depth (PD), relative gingival recession (RGR), and relative attachment level (RAL), and evaluated postoperative pain and dental hypersensitivity. After open flap debridement, the sites were randomly divided into test sites receiving the low-level diode laser (wavelength 808 nm) and control sites treated with laser-off. The Wilcoxon test and Mann-Whitney U-test were used for intra- and inter-group comparisons, respectively, and the Friedman test to test between different periods. RESULTS: Both treatments produced a reduction in GI, BOP, and PD, an increased RGR, and a gain in RAL between baseline and 3 months after surgery. There were significant improvements in GI, PD, and RAL after 3 months; postoperative pain after 24 hours and after 3 days; and dental hypersensitivity after 1 week and 1 month of the surgery, which significantly decreased in the test group. CONCLUSION: Both groups were clinically effective in treating stage III periodontitis, with a significant preference in reduction of GI and PD and gain of RAL, and decreased postoperative pain (after 24 hours and 3 days) and dentinal hypersensitivity (after 1 week and 1 month) for open flap debridement+LLLT. CLINICAL RELEVANCE: The use of LLLT as an adjunct to open flap debridement improved the clinical indices, postoperative pain, and dentinal hypersensitivity better than open flap debridement alone in the treatment of stage III periodontitis.

Palliative arthroscopic debridement with continuous irrigation for infected total knee arthroplasty in high mortality risk patients.

PURPOSE: This study aimed to evaluate the infection control rate of palliative arthroscopic debridement, antibiotics, and implant retention (DAIR) for the high mortality risk or terminal cancer stage patients. METHODS: From March 2018 to August 2021, 21 patients met the following inclusion criteria: old age of more than 80, diagnosed as a terminal stage of cancer, high risk of mortality and morbidity representing as Charlson comorbidity index (CCI) ≥ 5, low daily activity with disabled extremity, and re-infection after two-stage revision. Each patient underwent arthroscopic DAIR and additional continuous irrigation for 48 hours. The need for subsequent re-arthroscopic DAIR or two-stage revision was determined by the post-operative trends of C-reactive protein (CRP) levels. Infection control was defined as continuing controlled status of infection based on clinical and laboratory results by one or two times of arthroscopic DAIR within initial two months. Treatment failure was defined as more than three times arthroscopic debridement, two-stage revision surgery, or expired due to uncontrolled infection. RESULTS: Arthroscopic DAIR controlled the infection in 19 (90.5%) of the 21 cases. The other knee underwent a total of three times of re-arthroscopic DAIR and the other one underwent two-stage revision. Although five patients expired during the follow-up period due to worsening medical problems or terminal cancer, there were no deaths from uncontrolled infection, sepsis, or surgery-related complications. CONCLUSIONS: Arthroscopic debridement with continuous irrigation for the infection TKA with high mortality risk or terminal cancer patients showed a 90.5% infection control rate. For high-risk patients, arthroscopic debridement with continuous irrigation can be an alternative treatment to improve the quality of life during survival.

The process to obtain reimbursement for enzymatic debridement in clinically deep burns.

INTRODUCTION: Burn eschar removal by enzymatic debridement with NexoBrid® (EDNX) results in a maximum preservation of all viable tissue, which is the main advantage over traditional tangential excision. The authors participated in a marketing authorization holder process to obtain reimbursement from the national health authorities in Belgium. MATERIAL AND METHODS: The reimbursement process consisted of three phases, as specified by the reimbursement regulations required by the Belgian National Institute for Health and Disability Insurance (NIHDI). RESULTS: Forty-one patients with clinically deep 2nd and 3rd degree burns, treated with EDNX in two Belgian burn centers, were included in the registry for the first phase of the reimbursement process. The total success rate of the EDNX treatment was 95.1% (39/41). Over half of the burn wounds treated with NexoBrid® (55.2%) did not require any additional surgical debridement or skin grafting. To obtain definitive reimbursement, an extra 16 patients were included. In this population, 51.4% did not require any surgical intervention. The total success rate of the EDNX debridement in this group was 100%. Based on an estimated market share of 12% and around 75 patients in the third year after final reimbursement, a market access consultant calculated that NexoBrid® will realize yearly savings for the Belgian Healthcare budget of at least €30.000. CONCLUSION: Based on the results of this Belgian registry study in combination with the yearly healthcare budget savings, the NIHDI granted a final reimbursement for EDNX treatment in adults, endorsed by the Minister of Health on November 5th, 2019.

Helpful hints in deciding what and when to operate after enzymatic debridement.

INTRODUCTION: In recent years, it has become clear that the burn eschar in deep burns can be selectively removed using the enzymatically debriding agent NexoBrid® (EDNX). In deep partial-thickness burns, such selective debridement preserves all non-injured dermis, which is sometimes sufficient for spontaneous re-epithelization. Nevertheless, it can be extremely challenging to determine exactly what and when to operate after an EDNX procedure. In this manuscript, we sought to investigate the clinical aspect of the enzymatically debrided wound bed of laser Doppler imaging (LDI)-confirmed deep dermal and full-thickness burns after NexoBrid® application. This to evaluate the residual wound healing capacity and implement specific indications for surgical therapy after enzymatic debridement. MATERIAL AND METHODS: Mainly LDI-blue areas, determined between 48 h and 5d after burn and afterwards treated with EDNX were selected. Six practical and three expert EDNX users evaluated the high-quality digital images of the wound beds immediately post NexoBrid® removal and after a 2 h wet-to-dry (WTD) dressing period. RESULTS: One hundred and two mainly LDI-blue areas in 32 patients were analyzed. Regarding the early decision-making, there were no significant differences in the wound bed evaluations, wound healing assessment and treatment decision of all 9 EDNX users post EDNX removal versus post WTD. Moreover, there was a good to excellent consensus between the practical and expert EDNX users in the individual wound bed evaluations. Even in the evaluation of a newly developed wound bed color code, with 7 different colors/patterns to choose from, the consensus was 80%. There was also an 84% consensus on the decision whether or not to operate. All mainly LDI-blue areas with incomplete enzymatic debridement, determined during clinical investigation by expert EDNX users, required surgery. Additionally, the expert investigators demonstrated that the following wound bed characteristics were independent predictors of the need for surgical treatment: visible fat lobules (p = 0.028), translucent fat lobules (p < 0.001), dermal step-off in the wound bed (p < 0.001), visible blood vessels (p < 0.001) and coagulated blood vessels (p = 0.023). Also, higher color code ranges on our own developed wound bed classification were significantly related to a surgical intervention (p = 0.006). When including the LDI flux values, the perfusion units were significantly different (p < 0.001) between the exclusively LDI-blue areas treated conservatively (mean 145.7) and the areas ultimately treated with autografts (mean 119.5). CONCLUSION: To the best of our knowledge, this study is the first to address the clinical wound bed evaluation of LDI-confirmed deep burns after NexoBrid® application. Based on our results, it is recommended to evaluate the wound bed twice: immediately after removing NexoBrid® to assess the viability of the wound bed and after the WTD period to reach a more complete decision. During these evaluations, wound bed characteristics such as incomplete debridement, visible and/or translucent fat lobules, visible and/or coagulated blood vessels and a dermal step-off in the wound bed combined with a higher range (4-5) in the newly developed wound bed color code should lead to an early and reliable decision for skin grafting. For burn centers using LDI, mean flux values below 119.5PU - in addition to the above-mentioned wound bed evaluation - are a clear indicator for surgical therapy.

An open-label, proof-of-concept study assessing the effects of bromelain-based enzymatic debridement on biofilm and microbial loads in patients with venous leg ulcers and diabetic foot ulcers.

BACKGROUND: Most chronic wounds contain biofilm, and debridement remains the centerpiece of treatment. Enzymatic debridement is an effective tool in removing nonviable tissue, however, there is little evidence supporting its effect on planktonic and biofilm bacteria. OBJECTIVE: This study evaluated the effects of a novel BBD agent on removal of nonviable tissue, biofilm, and microbial loads in patients with chronic ulcers. MATERIALS AND METHODS: Twelve patients with DFU or VLU were treated with up to 8 once-daily applications of BBD and then followed for an additional 2 weeks. Punch biopsy specimens were collected and analyzed for biofilm, and fluorescence imaging was used to measure bacterial load. RESULTS: Ten patients completed treatment, and 7 achieved complete debridement within a median of 2 applications (range, 2-8). By the end of the 2-week follow-up period, the mean ± SD reduction in wound area was 35% ± 38. In all 6 patients who were positive for biofilm at baseline, the biofilm was reduced to single individual or no detected microorganisms by the end of treatment. Red fluorescence for Staphylococcus aureus decreased from a mean of 1.09 cm² ± 0.58 before treatment to 0.39 cm² ± 0.25 after treatment. BBD was safe and well tolerated. CONCLUSION: Preliminary data suggest that BBD is safe and that it can be used to effectively debride DFU and VLU, reduce biofilm and planktonic bacterial load, and promote reduction in wound size.

Antibiotic-impregnated calcium sulfate for the treatment of pediatric hematogenous osteomyelitis.

BACKGROUND: Antibiotic-impregnated calcium sulfate has excellent curative efficacy in chronic osteomyelitis. However, its curative efficacy in pediatric hematogenous osteomyelitis has not been sufficiently studied. The purpose of this study was to evaluate the curative effects of antibiotic-impregnated calcium sulfate in the treatment of pediatric hematogenous osteomyelitis. METHODS: Overall, twenty-one pediatric patients with hematogenous osteomyelitis treated at our hospital between 2013 and 2018 were included for assessment. The clinical history, clinical manifestation, infection recurrence rate, sinus leakage, incision leakage, pathological fractures, bone growth and surgical procedures were analyzed. RESULTS: The infection recurrence rate was 0% (0/21) at a minimum of 31 months (range 31 to 91 months) of follow-up. Postoperative incision leakage was found in one pediatric patient. Osteolysis was found in one pediatric patient. Acceleration of bone growth occurred in one pediatric patient. Retardation of bone growth occurred in one pediatric patient. Genu valgus deformity occurred in one pediatric patient. CONCLUSIONS: Although noninfectious complications occurred, the curative effect of antibiotic-impregnated calcium sulfate in pediatric hematogenous osteomyelitis was satisfactory.

Maggot debridement therapy and complementary wound care: a case series from Nigeria.

OBJECTIVE: Maggot debridement therapy (MDT) is an emerging procedure involving the application of sterile maggots of the Dipteran species (commonly Lucilia sericata) to effect debridement, disinfection and promote healing in wounds not responding to antimicrobial therapy. Data on MDT in sub-Saharan Africa (including Nigeria) are scarce. This study aimed to use medicinal grade maggots as a complementary method to debride hard-to-heal necrotic ulcers and thereby promote wound healing. METHOD: In this descriptive study, we reported on the first group of patients who had MDT at Aminu Kano Teaching Hospital (AKTH), a tertiary hospital in northern Nigeria. The first instar larvae of Lucilia sericata were applied using the confinement (free-range) maggot therapy dressing method under aseptic conditions. RESULTS: Diabetic foot ulcer (DFU) grade III-IV constituted more than half of the wounds (53.3%), followed by necrotising fasciitis (30%), and post-traumatic wound infection (10%). Others (6.7%, included pyomyositis, surgical site infection and post traumatic wound infection). The median surface area of the wounds was 56cm2. Of the 30 patients, half (50%) had two MDT cycles with a median time of four days. Of the wounds, 22 (73%) were completely debrided using maggots alone while eight (27%) achieved complete debridement together with surgical debridement. Wound culture pre-MDT yielded bacterial growth for all the patients and Staphylococcus aureus was the predominant isolate in 17 wounds (56.7%) while Pseudomonas aeruginosa and Streptococcus pyogenes were predominant in five wounds (16.7%) each. Only four (13.3%) wound cultures yielded bacterial growth after MDT, all Staphylococcus aureus. CONCLUSION: A good prognosis was achieved post-MDT for various wounds. MDT effectively debrides and significantly disinfects wounds involving different anatomical sites, thus enhancing wound healing and recovery. MDT is recommended in such wounds.

Evaluating nursing opinion and perception of maggot therapy for hard-to-heal wound management.

OBJECTIVE: Maggot therapy (MT) or larval debridement therapy is a recognised, effective but underutilised treatment for the management of hard-to-heal wounds and infected ulcers. It is available on NHS prescription in the UK, where wound management is predominantly nurse-led. Anecdotal reports and published literature suggest that nurses may be reluctant to utilise the therapy. The aim of this study was to evaluate the feelings and opinions of nurses regarding the use of MT. METHOD: The first stage of this mixed-methods study was a focus group held to discuss MT and opinions of specialist nurse clinicians. Next, an anonymised web-based online survey was launched through the Nursing Times journal and distributed through social media targeting all nurses. Finally, in-depth interviews were held with specialist and generalist nurses. RESULTS: Awareness of MT among all nurses was extremely high. A breakdown of results showed that MT was much more highly regarded by wound specialist nurses than non-wound specialist nurses. The latter exhibited a greater level of reluctance to administer the therapy, with almost one-third of these nurses surveyed saying they found maggots disgusting and that the idea of MT made their skin crawl. In-depth interviews revealed that a lack of knowledge about MT was a prime concern. CONCLUSION: Wound specialist nurses are more likely to embrace MT than non-wound nurse specialists, who report a varying degree of wariness to MT. Our study highlights a need for better education and training in MT for all nurses, to address issues with acceptance and willingness to treat or help treat patients with hard-to-heal wounds which are suitable for MT.

An exploration of public perceptions and attitudes towards maggot therapy.

OBJECTIVE: The aim of the study was to explore public opinion and perceptions of maggot therapy (larval therapy), a treatment option for hard-to-heal wounds. METHOD: The study used a mixed-method approach to obtain quantitative and qualitative data. A focus group was convened to explore opinions and views of maggot therapy with a small group of members of the public. Analysis of emerging themes from the focus group was used to design an anonymised web-based survey, which was made available online to members of the public through email and social media. RESULTS: The focus group participants identified four key themes concerning the acceptability of maggot therapy. The subsequent online survey was completed by 412 participants, analysis of which revealed some worries and fears. Only 36% of survey participants agreed that they would accept maggot therapy as a first choice for a hypothetical painful wound, although this number increased with wound severity. The most predominant concerns regarding maggot therapy were sensation and a feeling of disgust associated with the therapy. However, participants could see some benefits to maggot therapy. CONCLUSION: Our study showed that public perception of maggot therapy is varied. Survey participants expressed worries and fears associated with its use. However, positive relationships existed between knowledge scores and potential acceptability of maggot therapy, suggesting that information dissemination and education may be an important factor in public perception and acceptability of maggot therapy.

Evaluation of Bromelain-Based Enzymatic Debridement Combined with Laser Doppler Imaging and Healing of Burn Wounds.

BACKGROUND Accurate estimation of burn depth is crucial for correct treatment decision making. Bromelain-based enzymatic debridement (ED) may improve clinical assessment of burn depth. Laser Doppler imaging (LDI) provides a valuable indicator of burn depth by analyzing microcirculation within tissue beds. This study aimed to evaluate bromelain-based enzymatic debridement combined with laser Doppler imaging and healing of 42 wounds in 19 patients with mixed second- and third-degree thermal burns. MATERIAL AND METHODS We included 42 wounds in 19 patients with mixed deep dermal and full-thickness thermal burns. All patients were treated with eschar-specific removal agent for ED. The perfusion of each wound after ED was assessed using LDI. Healing time was estimated by 2 experienced burn surgeons and marked by the observation of epithelization. The usefulness of the LDI performed after ED in predicting healing time was estimated. The findings were analyzed to determine a cut-off value for LDI that indicates if a burn will heal spontaneously. RESULTS We observed that burn wounds with higher mean perfusion healed faster. The analysis showed a strong relationship between perfusion after ED and healing time (Spearman rank correlation coefficient=-0.803). A mean perfusion greater than 296.89 indicated that the wound could heal spontaneously and does not require skin grafting. CONCLUSIONS LDI examination of an already debrided wound allows for a reliable assessment of perfusion at an early stage of treatment. The use of a safe and effective debridement method in conjunction with a non-invasive diagnostic tool could improve burn management.

Clinical outcome of multidisciplinary treatment of vulvar necrotising fasciitis.

OBJECTIVE: Vulvar necrotising fasciitis (VNF) is a severe soft tissue infection associated with substantial morbidity and high mortality. At Stony Brook Medicine, US, patients with known or suspected VNF are treated by a structured multidisciplinary team consisting of members of the Departments of Emergency Medicine and Medicine, the Divisions of Gynecologic Oncology, Burn and Surgical Intensive Care Units, Infectious Disease and Plastic Surgery, and the nursing, nutrition, physical/occupational therapy and social work services. METHOD: This is a retrospective review of patients presenting to Stony Brook University Hospital with VNF over an 18-month period. RESULTS: A total of 10 patients were treated for VNF during the study period. All patients were treated by the structured multidisciplinary team, including extensive initial surgical debridement by the gynaecologic oncologists. All patients survived to discharge. CONCLUSION: The results of this review demonstrated that prompt diagnosis, rapid implementation of appropriate antibiotic coverage, surgical debridement of necrotic tissue, and comprehensive care delivered by a structured multidisciplinary team contributed to positive clinical outcomes and decreased the risk of death from VNF.