A Questionnaire-Based Study to Obtain a Consensus from 5 Polish Burns Centers on Eschar Removal by Bromelain-Based Enzymatic Debridement (Nexobrid®) in Burns Following the 2020 Updated European Consensus Guidelines.

BACKGROUND The supplementary treatment of burns with enzymatic debridement with Nexobrid® was approved in Europe in 2013. The 2017 European consensus guidelines on the removal of eschar in burns by bromelain-based enzymatic debridement were updated in 2020. This questionnaire-based study aimed to obtain a consensus from 5 Polish burns centers on eschar removal by Nexobrid® in burns following the 2020 updated European consensus guidelines. MATERIAL AND METHODS A panel of 5 experts representing the leading burn treatment centers in Poland (Cracow, Gryfice, Siemanowice Slaskie, Poznan, and Leczna) was convened. A modified Delphi process was implemented with panel member selection, literature review, 2 rounds of voting in which panelists were asked to evaluate the European consensus and Polish consensus building by data analysis, statements preparation, final voting, and manuscript drafting. RESULTS The knowledge and experience of experts from Poland's leading burn centers resulted in the development of guidelines, formulated as 24 statements representing the following areas: indications and usage, pain management, application principles, post-enzymatic debridement wound dressing, and early and long-term outcomes. An analysis of the 7-point Likert scale polls revealed that 23 of the 24 statements achieved 100% consensus. CONCLUSIONS The findings from this survey from 5 major centers in Poland supported the main recommendations from the 2020 updated European consensus guidelines on the removal of eschar in burns by Nexobrid® and may serve as a practical guide for surgeons who care for patients with burns in this country.

Accuracy of SCORTEN in predicting mortality in toxic epidermal necrolysis.

BACKGROUND: Toxic epidermal necrolysis (TEN) patients require multi-directional and multi-disciplinary treatment. In most cases, they are hospitalised at intensive care units and require multi-directional, burn-complication preventive care. Choosing the most appropriate treatment option might be troublesome even when predicting scores are used. SCORTEN is the most renowned prognostic score for TEN patients, however, there are some data indicating that the accuracy of this test may be limited. The credibility of not just the predicted mortality risk, but also componential laboratory results and clinical features subject to debate. The aim of this study was to evaluate the efficacy and credibility of SCORTEN in clinical practice, on proprietary material. METHODS: A retrospective analysis of 35 patients with diagnosed in histopathology TEN was performed. The inclusion criteria were as follows: day of submission before 5th day from the onset of the symptoms, full protocol of plasmaphereses and IVIGs according to our scheme. Our protocol includes cycle of plasmapheresis with frozen fresh plasma twice daily for the first 2 days following admission, and once daily for the subsequent 5 to 7 days. IVIGs were administered after the first two sessions of plasmapheresis, for 4 to 7 days. The dosage was calculated according to body weight, at 0.4 to 0.5 g/kg per dose. RESULTS: The sensitivity of SCORTEN for the analysed cohort was 100%, with a specificity of 24%. The estimated death was 41,9%, while the actual death rates were 12,5%. Our protocol improved the survival, OR = 26,57, RR = 6,34, p = 0,022. Decrease in mortality was caused by a combined treatment protocol we use- plasmaphereses with IVIGs. No independent risk factor was significant in death evaluation. CONCLUSION: Our data suggest that the scoring system for predicting death among TEN patients are reliable when they are high. New prognostic factors should be found to improve the evaluation of patients with low SCORTEN.

Chlorine Gas Sensor with Surface Temperature Control.

The work describes the design, manufacturing, and user interface of a thin-film gas transducer platform that is able to provide real-time detection of toxic vapor. This proof-of-concept system has applications in the field of real-time detection of hazardous gaseous agents that are harmful to the person exposed to the environment. The small-size gas sensor allows for integration with an unmanned aerial vehicle, thus combining high-level mobility with the ability for the real-time detection of hazardous/toxic chemicals or use as a standalone system in industries that deal with harmful gaseous substances. The sensor was designed based on the ability of thin-film metal oxide sensors to detect chlorine gas in real time. Specifically, a concentration of 10 ppm of Cl2 was tested.

Surgical Repair of Small Bowel Fistulas: Risk Factors of Complications or Fistula Recurrence.

BACKGROUND Definitive surgical repair of persistent fistulas of the small intestine remains a surgical challenge with a high rate of re-fistulation and mortality. The aim of this study was to evaluate the type and incidence of complications after definitive surgical repair, and to identify factors predictive of severe postoperative complications or fistula recurrence. MATERIAL AND METHODS This was a retrospective study of 42 patients who underwent elective surgical repair of a persistent fistula of the small intestine. The analysis included preoperative and intraoperative parameters. RESULTS The healing rate after definitive surgery was 71.4%. Postoperative complications developed in 88.1% of patients. The mortality rate was 7.2%. Fistula recurrence was recognized in 21.4% of cases. Overall, 93 complications occurred in 37 patients. The most common complications were septic (48.0%). Hemorrhagic and digestive tract-related complications accounted for 19.0% and 15.0% of all complications, respectively. Severe complications (Clavien-Dindo grade III-V) made up 28.0% of all complications. In univariate analysis, multiple fistulas (p=0.03), higher C-reactive protein level (p=0.01), and longer time interval from admission to definitive surgery (p=0.01) were associated with an increased risk of severe complications or fistula recurrence. In multivariate analysis, only multiple fistulas were an independent risk factor for severe complications or fistula recurrence (OR=8.2, p=0.04). CONCLUSIONS Fistula complexity determines the risk of severe postoperative complications or fistula recurrence after definitive surgical repair of the persistent small intestine fistulas. Inflammatory parameters should be normalized before definitive surgery.

Immunomodulatory Treatment of Lyell's Syndrome: A Simultaneous Plasmapheresis and Intravenous Immunoglobulins Therapy.

Lyell's syndrome, or toxic epidermal necrolysis (TEN) is a rare but life-threatening condition. It manifests with blistering of skin and mucous due to subepidermal bullae and keratinocyte necrosis. In most cases, it is an immune response to drugs or their metabolites. The mortality in TEN is high despite optimal infection and wound control. There are no unequivocal treatment guidelines in TEN. Immunosuppressive treatment may increase the wound infection risk and mortality. The aim of the study was to evaluate a 10-year experience with immunomodulatory therapy in TEN. We perform a combination of plasmapheresis and intravenous immunoglobulins to control the disease. There were 35 patients in the group and we performed a post hoc evaluation. Twenty-eight patients received the full protocol and there were seven patients who did not complete the treatment (single therapy group). The mortality in the test group was 14.29%, and the difference reached statistical significance in comparison with the single therapy group (P < .05). Our protocol reduced the mortality risk five times. Our study proved that simultaneous plasmaphereses with intravenous immunoglobulins administration were safe and improved patients' outcome in TEN.

Qualitative analysis of surgical smoke produced during burn operations.

Burned tissue is necrotic and it is surrounded by a zone of stasis and hyperaemia with changed cell metabolism. The removal of burned tissue using an electric knife releases large amounts of surgical smoke. The aim of the research was to analyse volatile, nonpolar, organic compounds that are released during the excision of burned tissue using an electric knife (mono- and bipolar). The study includes analysis from 40 solid-phase microextraction (SPME) fibres, exposed during 10 interventions (6 escharotomy and 4 necrectomy). The analysis of volatile compounds was performed using mass spectrometry gas chromatography (GCxGC-ToFMS).The total analysis covered 432 compounds, whereas after the removal of the "background" compounds - 153 volatile organic substances remained. The analysis of surgical smoke showed that, including derivatives, benzene constituted as much as 17.65% of all of the studied compounds. Cyclic compounds constituted on average 22.5% of the analysed substances, out of which cycloheptatrien constituted 20.26%. Alkanes, alcohols and their derivatives constituted nearly 25% of volatile organic compounds, with chloromethane constituting as much as 13.7%. Permutational multivariate analysis of variance (PERMANOVA) revealed statistically significant differences between escharotomy and necrectomy patients (F(1.9) = 5.91, p = 0.007).Our study revealed the presence of complex toxic hydrocarbon derivatives in surgical smoke. We also observed that the content of surgical smoke is different depending on the type of the conducted intervention. So far, no studies focusing on hazards posed by surgical smoke that is released during the resection of burned tissue are in the literature.

25-Hydroxycholecalciferol Concentration Is Associated with Protein Loss and Serum Albumin Level during the Acute Phase of Burn Injury.

BACKGROUND: Burned patients have an increased need for vitamin D supply related to the maintenance of calcium-phosphate homeostasis and the regulation of cell proliferation/differentiation. This study aimed to analyze the concentration of 25-hydroxycholecalciferol and its relationship with severe condition after burn injury. METHODS: 126 patients were enrolled in the study. Patients were qualified due to thermal burns-over 10% of total body surface area. On the day of admission, the following parameters were assessed: 25-hydroxycholecalciferol concentration, total protein concentration, albumin concentration, aspartate transaminase activity, alanine transaminase activity, albumin concentration, creatinine concentration, c-reactive protein concentration, procalcitonin concentration, and interleukin-6 concentration. RESULTS: Almost all patients (92%) in the study group had an improper level of vitamin D (<30 ng/mL), with the average of 11.6 ± 10.7 ng/mL; 17.5% of patients had levels of vitamin D below the limit of determination-under 3 ng/mL. The study showed that there are several factors which correlated with vitamin D concentration during the acute phase of burn injury, including: total protein (r = 0.42, p < 0.01), albumin, (r = 0.62, p < 0.01), percentage of body burns (r = 0.36, p < 0.05), aspartate aminotransferase (r = 0.21, p < 0.05), and c-reactive protein (r = 0.22, p < 0.05). We did not find any significant correlation between vitamin D concentration and body mass index. CONCLUSIONS: The burn injury has an enormous impact on the metabolism and the risk factors of the deficiency for the general population (BMI) have an effect on burned patients. Our study showed that concentration of 25-hydroxycholecalciferol is strongly correlated with serum albumin level, even more than total burn surface area and burn degrees as expected. We suspect that increased supplementation of vitamin D should be based on albumin level and last until albumin levels are balanced.

Bioelements in the treatment of burn injuries - The complex review of metabolism and supplementation (copper, selenium, zinc, iron, manganese, chromium and magnesium).

Appropriate nutrition is a key component of burn treatment and should be regarded as an integral part of the therapeutic process in burn patients. A nutritional intervention plan should not only allow for adequate quantities of energy and protein but also carefully consider the supply of macro- and micronutrients. As a result of the severe inflammatory response, oxidative stress, and hypermetabolic state, accompanied by often extensive exudation in burn patients, there is a considerable loss of macro- and micronutrients, including essential trace elements. This leads to certain complications, involving e.g. more frequent infections and impaired wound healing. Our current body of knowledge is still insufficient, and the studies carried out to date focus for the most part on the imbalances in trace elements, such as copper (Cu), selenium (Se), and zinc (Zn). Nevertheless, there are many other trace elements involved in immune functions, regulating gene expression or antioxidant defense, and many of those have not been properly investigated in a clinical setting. Due to the insufficient amount of unambiguous literature data and relatively few, often dated, studies carried out with small patient groups, further evaluation of macro- and microelements in burn patients seems indispensable, e.g. to bring up to date local nutritional protocols.

Toxic Epidermal Necrolysis Therapy with TPE and IVIG-10 Years of Experience of the Burns Treatment Center.

Toxic epidermal necrolysis (TEN) is a potentially life-threatening, exfoliative disease. It is described as idiosyncratic, severe, skin reaction to drugs. With Stevens-Johnson's Syndrome, it presents as a continuum of a disease being categorized relating to the percentage of affected skin. Without any multicenter trials comparing TEN treatment modalities, there is dearth of strong evidence-based guidelines of care. Total plasma exchange with intravenous immunoglobulin (IVIG) is one among plethora of possible treatment strategies. In our 10-year experience, we have observed 21 patients admitted to our burns center due to TEN. All of them were placed under intensive care with daily plasmapheresis (TPE) and IVIG. We have observed 52% mortality, with observed severe concomitant diseases in every patient in nonsurvivor group (average Acute Physiology and Chronic Health Evaluation II score at admission: 31.5%). We consider that TPE with IVIG might be of use in selected group of patients with TEN without any severe comorbidities. However, further multicenter trials are needed because in some cases it may raise mortality.

Infeasibility of endoscopic transmural drainage due to pancreatic pseudocyst wall calcifications - case report.

Postinflammatory pancreatic pseudocysts are one of the most common complications of acute pancreatitis. In most cases, pseudocysts self-absorb in the course of treatment of pancreatitis. In some patients, pancreatic pseudocysts are symptomatic and cause pain, problems with gastrointestinal transit, and other complications. In such cases, drainage or resection should be performed. Among the invasive methods, mini invasive procedures like endoscopic transmural drainage through the wall of the stomach or duodenum play an important role. For endoscopic transmural drainage, it is necessary that the cyst wall adheres to the stomach or duodenum, making a visible impression. We present a very rare case of infeasibility of endoscopic drainage of a postinflammatory pancreatic pseudocyst, impressing the stomach, due to cyst wall calcifications. A 55-year-old man after acute pancreatitis presented with a 1-year history of epigastric pain and was admitted due to a postinflammatory pseudocyst in the body and tail of pancreas. On admission, blood tests, including CA 19-9 and CEA, were normal. An ultrasound examination revealed a 100-mm pseudocyst in the tail of pancreas, which was confirmed on CT and EUS. Acoustic shadowing caused by cyst wall calcifications made the cyst unavailable to ultrasound assessment and percutaneous drainage. Gastroscopy revealed an impression on the stomach wall from the outside. The patient was scheduled for endoscopic transmural drainage. After insufflation of the stomach, a large mass protruding from the wall was observed. The stomach mucosa was punctured with a cystotome needle knife, and the pancreatic cyst wall was reached. Due to cyst wall calcifications, endoscopic drainage of the cyst was unfeasible. Profuse submucosal bleeding at the puncture site was stopped by placing clips. The patient was scheduled for open surgery, and distal pancreatectomy with splenectomy was performed. The histopathological examination confirmed the initial diagnosis of postinflammatory pancreatic pseudocyst. Endoscopic transmural drainage is a highly effective procedure for treating postinflammatory pancreatic pseudocysts. In some patents, especially with large pseudocysts, pseudocysts with calcified walls, and cysts of primary origin, resection should be performed.

Active dynamic infrared thermal imaging in burn depth evaluation.

The aim of this study was to find the relationship between active dynamic thermography (ADT) with cold excitation and burn depth. This new modality of evaluation of burns seems to be an attractive proposal for quantitative classification, allowing proper choice of burn wound treatment: conservative or surgical, especially compared with static thermography. The work was an in vivo experiment on domestic pigs, and a small number of patients were also diagnosed as part of the study. Statistical analysis showed a high correlation between the ADT synthetic parameter--thermal time constant, τ--and the classification of burn wounds that were predicted to heal within 3 weeks and so were treated conservatively and those that were predicted to not heal within 3 weeks and so were surgically treated. The results of the study show an accuracy of 60.7% for clinical evaluation, 69.6% for static thermography, 83.0% for ADT, and 84.0% for histopathologic assessment. The authors have concluded that the ADT method with cold excitation is suitable for the qualitative and quantitative assessment of burn depth.

Stem cells, including a population of very small embryonic-like stem cells, are mobilized into peripheral blood in patients after skin burn injury.

BACKGROUND: Developmentally early cells, including hematopoietic stem progenitor cells (HSPCs), as well as very small embryonic-like stem cells (VSELs), are mobilized into peripheral blood (PB) in response to tissue and organ injury (e.g., heart infarct or stroke). OBJECTIVE: We seek to determine whether these cells are also mobilized into PB in patients with skin burn injuries. METHODS: Forty-four (44) patients (33-57 years of age) with total body surface burn area of 30-60%, as well as 23 healthy control subjects, were recruited and PB samples were harvested during the first 24 hours, day +2, and day +5 after burn injury and compared to normal controls. The circulating human CD34(+)CD133(+) cells enriched for HSPCs, as well as small CXCR4(+)CD34(+)CD133(+) subsets of Lin(-)CD45(-) cells that correspond to the population of VSELs, were counted by FACS and evaluated by direct immunofluorescence staining for pluripotency markers (Oct-4, Nanog, and SSEA-4). In parallel, we also measured by ELISA the serum concentration of factors that regulate stem cell trafficking, such as SDF-1, VEGF, and HGF. RESULTS: Our data indicate that skin burn injury mobilizes cells expressing stem cell-associated markers, such as CD133, CD34, and CXCR4, into PB. More importantly, we found an increase in the number of circulating primitive, small Oct-4(+)Nanog(+)SSEA-4(+)CXCR4(+)lin(-)CD45(-) VSELs. All these changes were accompanied by increased serum concentrations of SDF-1 and VEGF. LIMITATIONS: Further studies are needed to fully assess the role of mobilized stem cells in the healing process to see if they can contribute to skin regeneration. CONCLUSION: Skin burn injury triggers the mobilization of HSPCs and CXCR4(+) VSELs, while the significance and precise role of mobilized VSELs in skin repair requires further study.