ABSTRACT
Hand burns are common injuries that can result in long-term impairment of hand function. Enzymatic debridement (ED) prevents damage to the viable dermis due to the procedure's selectivity and has become an option for obtaining an accurate depth assessment and enabling wound re-epithelialization with less skin graft use. We conducted a prospective study from July 2015 to July 2018, which enrolled patients with deep partial-thickness hand burns and treated them with ED using bromelain. After a specified period, we assessed the patients' hand function, using the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and the Michigan Hand Outcomes Questionnaire (MHOQ) to assess their disabilities and activities of daily life, respectively. We assessed the hand joint range of motion using a goniometer and assessed scar quality with the Vancouver Scar Scale (VSS). We analyzed 72 patients with 90 burned hands at 3 months and, at the final assessment, 69 patients with 86 burned hands. Fire was the most common cause of the burns. Bromelain allowed for early debridement (73.6% during the first 24 h). At the 3-month evaluation, the mean DASH and MHOQ scores were 2.35 and 97.9%, respectively, with a high inverse correlation between the 2 types of scores (Spearman's rho, -0.78; p < .001). The mean wrist flexion and extension were 85.7 and 80°, respectively, the mean metacarpophalangeal flexion was 88.3°, the proximal interphalangeal (PIP) flexion was 112.9°, and the thumb opposition was 77°. The mean VSS score was 2.87. At the final evaluation, with a minimum follow-up of 391 days, the mean DASH and MHOQ scores were 0.18 and 99.71%, respectively. ED with bromelain in deep partial-thickness hand burns resulted in normal values at 3 months and at over 1 year of follow-up, with complete restoration of function and quality of life and good scar results.
Subject(s)
Burns , Hand Injuries , Burns/surgery , Debridement/methods , Hand Injuries/surgery , Humans , Prospective Studies , Quality of Life , Skin TransplantationABSTRACT
INTRODUCCIÓN Y OBJETIVO: El desbridamiento enzimático ha demostrado ser eficaz y rápido en su aplicación sobre quemaduras, a la vez que conservador con el tejido sano. Su uso sobre quemaduras inferiores al 15% ha mostrado reducir la cantidad de injertos, el sangrado y las escarotomías quirúrgicas. El objetivo de este estudio es comparar 2 grupos de pacientes grandes quemados, uno tratado mediante desbridamiento enzimático frente a otro tratado mediante tratamiento estándar, y su impacto en la estancia hospitalaria, necesidades de escarotomías, tiempo hasta desbridamiento, uso de hemoderivados y cantidad de cirugías durante el ingreso. MATERIAL Y MÉTODO: Estudio de cohortes retrospectivas con 197 pacientes (SCQ 20-50%), mayores de 18 años, tratados entre 2012 y 2017, con 2 grupos: 32 pacientes tratados con Nexobrid® para el desbridamiento enzimático, y 165 pacientes en el grupo control con desbridamiento tangencial convencional. Ambos homogéneos para SCQ, edad, sexo, mecanismo de lesión y comorbilidades. RESULTADOS: La edad media fue de 48.4 ± 19.4 años, con una SCQ media de 29.5 ± 9.4%. Observamos disminución del tiempo hasta el inicio del desbridamiento de la quemadura (5.1 ± 4.9 días en el grupo control frente a 0.8±0.9 en el grupo de desbridamiento enzimático, p < 0.05). El grupo de Nexobrid® presentó una reducción de la cantidad de tiempos quirúrgicos durante su ingreso, siendo de 1.9±2.0 frente a 2.6±2.1 en el grupo control. El uso de hemoderivados se redujo en un 95% durante el desbridamiento. La necesidad de escarotomías se redujo un 60%. Finalmente, el grupo de Nexobrid® tuvo un 36% menos de estancia en la Unidad de Quemados Críticos, con diferencias estadísticamente significativas. CONCLUSIONES: La aplicación precoz del desbridamiento enzimático en grandes quemados (20-50% SCQ), permite la escarectomía completa del paciente reduciendo la necesidad de hemoderivados, el número de tiempos quirúrgicos, las escarotomías y la estancia en la unidad de cuidados intensivos
BACKGROUND AND OBJECTIVE: Use of enzymatic debridement has demonstrated be fast and efficient after its application over burn wounds, being more delicate over healthy tissue. Its use in burns under 15% TBSA has shown less grafting procedures, bleeding and surgical escharotomies. The aim of this study was compare 2 groups of major burns; one treated by enzymatic debridement and other treated by standard of care. Length of stay, escharotomies, time until debridement, use of blood packs and number of surgeries during hospitalization were evaluated. METHODS: A retrospective cohort study was designed with 197 patients (TBSA 20-50%), older than 18 years old, treated between 2012 and 2017, and divided in 2 groups: 32 patients were debrided using Nexobrid®, and 165 patients were included in the control group. Both groups were homogeneous for TBSA, age, gender, mechanism and comorbidities index. RESULTS: Mean age was 48.4±19.4 years, with a 29.5±9.4% of TBSA. A reduction of the number of days until the burns debridement were found, with 5.1±4.9 in the control group and 0.8±0.9 days in the enzymatic debridement group (p < 0.05). The number of surgeries during the hospitalization were less in the Nexobrid® group, with a reduction of 2.6±2.1 surgeries to 1.9±2.0. The number of blood packs was a 95% lower in the enzymatic debridement, and a 60% less escharotomies were observed. Finally, a shorter length of stay in the intensive care unit were found in the Nexobrid® group, with 36% less days, this difference were statistically significant. CONCLUSIONS: Early application of enzymatic debridement in major burns (20-50% TBSA) allows a complete removal of eschar reducing the blood packs use, number of surgeries, escharotomies and length of stay in the intensive care unit
Subject(s)
Humans , Male , Female , Adult , Middle Aged , Aged , Burns/surgery , Debridement/methods , Skin Ulcer/therapy , Cohort Studies , Bromelains/therapeutic use , Peptide Hydrolases/therapeutic use , Retrospective Studies , Length of Stay , Cicatrix/surgeryABSTRACT
Aim To validate surgical costotransversectomy as a technique for creating a scoliosis model in minipigs and to assess whether differences in approach (posterior medial approach, posterior paramedial approach and anterior approach by video-assisted thoracoscopy) lead to differences in the production of spinal deformity. Creation of disease models in experimental animals, specifically in minipigs, is controversial, as no appropriate technique has been reported. Methods Surgical costotransversectomy was performed in 11 minipigs using 3 different approaches: posterior medial approach (4 animals, group I), posterior paramedial approach (3 animals, group II) and anterior approach by videothoracoscopy (4 animals, group III). A conventional x-ray study was performed in the immediate postoperative period. Follow-up lasted for 4 months. Specimens were humanely killed according to current protocols, and a second x-ray study was performed. A deformation was measured using the Cobb angle and direct observation of the rotational component. Results Data from group I revealed a scoliosis deformation of 27º-41º (mean 34.5º) with a macroscopic rotational component. No deformity (<10º) or rotational component was observed in groups II and III. Only a posterior medial costotransversectomy produced a significant deformity in minipigs and established a valid model for studying scoliosis in these animals. Conclusion Only a posterior medial costotransversectomy produces a significant deformity in minipigs and establish a valid model for studying scoliosis in these animals. A tensegrity model would elucidate such results and harmonize disparate conclusions. Further investigation is needed to demonstrate the reliability of tensegrity principles for spinal biomechanics.
ABSTRACT
Introducción y Objetivo: El desbridamiento enzimático con Nexo-brid(R), concentrado de enzimas proteolíticas enriquecidas en bromelaína, supone un avance terapéutico importante. El objetivo de este trabajo es realizar un análisis económico del tratamiento de quemaduras térmicas con Nexobrid(R), investigando los determinantes del coste. Material y Método: Analizamos retrospectivamente los recursos utilizados en el tratamiento mediante desbridamiento enzimático con Nexobrid(R) de las heridas por quemadura térmica de espesor parcial superficial/profundo y completo, de los pacientes adultos ingresados consecutivamente en nuestro hospital entre 2014 y 2016. Investigamos la participación de cada recurso en el coste total para algunos subgrupos de pacientes. Resultados: Estudiamos a 71 pacientes con edad media de 45.4 años; el 73.2% varones. Las lesiones fueron en un 64.8% por llama el 77.5% fueron quemaduras dérmicas profundas y la superficie corporal total afectada fue ≤10% en el 70.4%. El coste medio estimado por paciente fue de 20.844€ (rango: 2.192€ - 145.198€), correspondiendo el 68,1% a la estancia en la Unidad de Quemados Críticos y en hospitalización convencional y el 13.9% al uso de Nexobrid(R). El coste medio de las quemaduras subdérmicas fue significativamente superior al de las dérmicas profundas (p=0.0004) y dérmicas superficiales (p=0.013). El porcentaje de superficie corporal total quemada marcó una diferencia significativa del coste (p<0.0001), observando una correlación importante (R2 = 0.77) con la estancia hospitalaria total. Conclusiones: La estancia hospitalaria en Unidad de Quemados Críticos y en hospitalización convencional constituye el principal determinante del coste del tratamiento de las quemaduras térmicas de espesor parcial superficial/profundo y completo mediante desbridamiento enzimático (48,7% y 19,4% del total, respectivamente); Nexobrid(R)contribuye sólo con un 13,9% del total. Asimismo, el porcentaje de superficie corporal total quemada muestra una fuerte correlación con la estancia hospitalaria
Background and Objective: Enzymatic debridement with Nexo-brid(R), a concentrate of proteolytic enzymes enriched in bromelain, represents an important therapeutic breakthrough. Our aim is to carry out an economic analysis of the treatment of thermal burns with Nexobrid(R), researching the cost determinants. Methods: We analyzed retrospectively the resources used in the treatment by enzymatic debridement with Nexobrid(R) of wounds by thermal burn of superficial/deep partial and full-thickness, of the adult patients admitted consecutively in our hospital (2014-2016). Participation of each resource in total cost was analyzed for some patient subgroups. Results: Seventy one patients were analyzed: age: 45.4 years; men: 73.2%; flame wound: 64.8%; full-thickness burn: 77.5%; Total Body Surface Area ≤10%: 70.4%. Average cost per patient was estimated in €20.844 (range: €2.192-€145.198); 68.1% was associated to length of Critical Burn Unit and conventional hospital stay. Cost of full-thickness burns was significantly higher than that of the superficial (p=0.013) and deep partial ones (p=0.0004). Total Body Surface Area leaded a significant cost difference (p<0.0001), showing a high correlation (R2=0.77) with the total hospital length of stay. Conclusions: Hospital length of stay (Critical Burn Unit and conventional hospital) is the main cost determinant of the treatment of thermal burns of superficial/deep partial and full-thickness with enzymatic debridement (48.7% and 19.4%, respectively); Nexobrid(R) contributes only with 13.9% of total cost. Likewise, total body surface area shows a strong correlation with length of stay
Subject(s)
Humans , Male , Female , Middle Aged , Burns/economics , Burns/therapy , Length of Stay , Debridement , Retrospective Studies , Burn Units/economicsABSTRACT
Introducción y Objetivo. En los últimos años se han publicado resultados que demuestran un desbridamiento enzimático rápido, eficaz y específico de tejidos quemados con el uso de Nexobrid(R) (Mediwound, Alemania), producto compuesto por un concentrado de enzimas proteolíticas enriquecidas con bromelaína. En este estudio comparamos el uso de Nexobrid(R) como desbridante enzimático frente a un Grupo Control con tratamiento estándar, con el objetivo de evaluar; en función de la superficie corporal quemada (SCQ), la cantidad de intervenciones quirúrgicas realizadas, la colonización del lecho quirúrgico, la necesidad de escarotomías, así como los requerimientos transfusionales de los pacientes tratados. Material y Método. Estudio retrospectivo con 65 pacientes, edad media de 46.87 años, tratados con Nexobrid(R) entre septiembre de 2015 y diciembre de 2016. Comparamos con un grupo control de 177 pacientes, edad media de 48.24 años, intervenidos mediante desbridamiento tangencial desde enero a diciembre de 2014. El Grupo Control presenta unas características homogéneas a las del Grupo Nexobrid(R). Ambos grupos fueron estratificados en función de su SCQ mayor o menor del 15%. Resultados. Encontramos diferencias estadísticamente significativas (p <0.01) con un menor número de días desde la quemadura y el ingreso hasta la cirugía para el Grupo Nexobrid(R) independientemente de la SCQ. Obtuvimos diferencias estadísticamente significativas para la cantidad de cirugías (p <0.01) en el subgrupo de SCQ <15%. Evaluamos la colonización sin obtener diferencias estadísticamente significativas entre los grupos. El número de escarotomías en el Grupo Nexobrid(R) fue significativamente menor que en el Grupo Control para las poblaciones con SCQ ≥15%. Los requerimientos transfusionales fueron menores en el Grupo Nexobrid(R) frente al Grupo Control en los pacientes con SCQ ≥ 15% (p <0.05). Conclusiones. Nexobrid(R) permite reducir el número de cirugías y el tiempo hasta el primer desbridamiento sin aumentar la tasa de colonización respecto al Grupo Control. El desbridamiento enzimático precoz reduce la necesidad de escarotomías en pacientes con SCQ ≥15%. Finalmente, reduce la necesidad de transfusión sanguínea en pacientes con SCQ mayor del 15% (AU)
Background and Objective. During the last years, results have been published demonstrating fast, efficient and specific enzymatic debridement of burned tissues with the use of a concentrate of proteolytic enzymes enriched with bromelain (Nexobrid(R), Mediwound, Germany). In this study we compare the use of Nexobrid(R) against a Control Group with standard treatment, in order to evaluate; the number of surgical procedures performed, the colonization of the surgical bed, the need for scarotomies, as well as the number of transfusions of the treated patients according to the total burned surface area (TBSA). Methods. We conduct a retrospective study evaluating 65 patients (mean age 46.87 years) treated with Nexobrid(R) between September 2015 and December 2016. We compare this population with a control group of 177 patients (mean age 48.24 years) treated with tangential excision from January to December 2014. The Control Group was homogeneous to Nexobrid(R) Group. Both groups were stratified according to their TBSA in 2 groups: more or less than 15%. Results. We found lesser number of days from burn and hospital admission to the first debridement for the Nexobrid(R) Group regardless of the burned body surface. Statistically significant differences were obtained for the number of surgeries (p <0.01) in the subgroup with <15% TBSA. We evaluated the colonization without obtaining statistically significant differences between the groups. The number of scarotomies carried out in the Nexobrid(R) Group was significantly lower than in the Control Group when comparing the populations with ≥15% TSBA. The transfusion requirements were lower in the Nexobrid(R) Group compared to the Control Group in patients with ≥15% TBSA (p <0.05). Conclusions. The use of Nexobrid(R) allows reducing the number of surgeries and the time elapsed to first debridement without increasing the rate of colonization when compared to the Control Group. Early enzymatic debridement reduces the need for scarotomies in ≥15% TBSA patients. The use of Nexobrid (R) reduces the need for blood transfusion in patients with ≥15% TBSA (AU)
Subject(s)
Humans , Male , Female , Middle Aged , Aged , Aged, 80 and over , Burns/enzymology , Burns/therapy , Debridement , Cohort Studies , Cicatrix/surgery , Bromelains/therapeutic use , Retrospective Studies , Data Collection , 28599ABSTRACT
Introducción y Objetivo. El tratamiento clásico de las quemaduras se basa en la eliminación precoz de la escara; sin embargo, el desbridamiento tangencial de las quemaduras mixtas y profundas retira tejidos dérmicos viables, obligando a la cobertura con autoinjertos. El desbridamiento enzimático con enzimas proteolíticos enriquecidos con Bromelaína (Nexobrid®) mantiene restos dérmicos que pueden permitir la reepitelización por sí misma de la quemadura. Evaluamos el uso en nuestra unidad de Nexobrid® (MediWound Ltd., Israel) en quemaduras mixtas y dérmicas profundas, valorando la capacidad de reepitelización tras su uso, la tasa de injerto en los pacientes tratados, y la aparición de cicatrización hipertrófica. Pacientes y Método. Evaluamos retrospectivamente 36 pacientes tratados con Nexobrid® entre enero de 2015 y febrero de 2016, 11 mujeres y 25 varones con una media de edad de 42.89 años. La superficie corporal quemada media fue del 7.47% y la diagnosticada como profunda del 6.42%.Todos los pacientes presentaron quemaduras profundas con necesidad de cirugía para su desbridamiento y cobertura con injertos. Resultados. Tras el desbridamiento enzimático solo el 36.1% de los pacientes (13 de 36) requirió cobertura con injertos (p < 0.001).La superficie injertada fue tan solo del 2.67% frente al 4.98% que fue desbridada enzimáticamente (p < 0.001). A pesar de que el tiempo hasta la epitelización total de las quemaduras se alargó hasta los 25.69 días, tan solo un 11.1% de los pacientes desarrolló cicatriz hipertrófica. Conclusiones. Nexobrid® permite el desbridamiento completo de las quemaduras mixtas y dérmicas profundas disminuyendo el porcentaje de pacientes que requieren autoinjertos y la superficie injertada, con bajas tasas de cicatrización hipertrófica (AU)
Background and Objective. Early burn scar removal is the standard of care for burn patients; excisional debridement, however, often leads to excision of dermal remnants, making autografting unavoidable. Enzymatic debridement with proteolytic enzymes enriched in Bromelain (Nexobrid®) leaves these dermal remnants to allow spontaneous healing of partial thickness burns. This study evaluates if Nexobrid® (MediWound Ltd., Israel) reduces the need for surgery and autografting in intermediate and deepdermal burns, the reduction in the excised and grafted area, and the development of hypertrophic scarring. Patients and Methods. We conduct a prospective study between January 2015 and February 2016 evaluating 36 patients (11 females, 25 males) whose mean age was 42.89, with burns covering a mean of 7.47% of their total body surface area (6.42% deep burns). All patients would need excision and autografting as their previous standard of care. Results. After enzymatic debridement, only 13 patients (36.1%) needed surgery (p < 0.001). The area of burns excised and grafted was reduced (2.67% vs. 4.98% p < 0.001). Since wound closure was delayed until 25.69 days, only 11.1% of the patients developed hypertrophic scars. Conclusions. Nexobrid® allows scar removal in deep-dermal and intermediate burns, reducing the need of surgery and the grafted body surface area, while achieving good scars (AU)
Subject(s)
Humans , Male , Female , Young Adult , Adult , Middle Aged , Aged , Debridement/methods , Enzymes/therapeutic use , Transplantation, Autologous , Burns/surgery , Surgical Flaps , Treatment OutcomeABSTRACT
Secondary surgical procedures can improve the function of revascularised and replanted digits. We describe the case of a patient who underwent multidigit revascularisation and replantation following a saw injury at flexor tendon Zone II. To achieve maximal functional improvement after finger revascularisation, we performed secondary surgical procedures in an order that was determined by following a reconstructive decision procedure that covered late revascularisation, nerve reconstruction, pedicled vascularised joint transfer, staged flexor tendon reconstruction and skin revision. Performing the procedures in this manner ensured overall safety. The patient's disabilities of the arm, hand and shoulder questionnaire score improved by 45 points, and the patient was able to return to work with an almost complete range of motion.
ABSTRACT
Antecedentes y Objetivos. La escoliosis idiopática infantil no tiene un tratamiento satisfactorio que permita reducir la importante morbilidad y mortalidad asociada a los casos más severos y progresivos de la enfermedad. El desarrollo de procedimientos que puedan ralentizar la progresión de la enfermedad durante el desarrollo del niño puede influir favorablemente en el crecimiento y retrasar el tratamiento definitivo de la deformidad al momento de la madurez músculoesquelética. Presentamos un estudio sobre la influencia de la toxina botulínica en el desarrollo de deformidad en un modelo animal de escoliosis progresiva. Material y Método. Utilizamos 52 pollos Broiler hembra, en los que se practicó pinealectomía para producir escoliosis. Comparamos la evolución de la deformidad entre un grupo control y un grupo intervención asignado a recibir toxina botulínica paravertebral en la concavidad de la curva, bajo control electromiográfico. Realizamos estudios radiográficos y anatomopatológicos de los animales para evaluar los resultados. El grado de escoliosis se midió utilizando el método del ángulo de Cobb. Resultados. Cinco animales no sobrevivieron al estudio (1 en el grupo control y 4 en el de intervención). En el grupo control observamos una deformidad media de 32.9º (n= 25) y en el grupo intervención de 18.8º (n=22), encontrando diferencias estadísticamente significativas (p<0.05). Por tanto, la aplicación de toxina botulínica en la concavidad de la deformidad de pollos pinealectomizados frena la progresión de escoliosis. Conclusiones. La consideración de la columna vertebral y sus tejidos blandos asociados como una estructura de tensegridad puede explicar el fenómeno mediante el desequilibrio generado entre los componentes de tensión (músculos y ligamentos) y compresión (vértebras) que conforman el sistema. Estos resultados justifican nuevos estudios en investigación clínica para explorar una nueva alternativa para el tratamiento de la escoliosis idiopática infantil (AU)
Background and Objectives. Severe and progressive adolescent idiopathic scoliosis has no satisfactory treatment since high rates of morbidity and mortality are associated. Development of procedures that might slow down the progression of the deformity in the growing children may postpone definitive surgery to the end of musculoskeletal maturity period. A study about the influence of botulinum toxin in the development of deformity in a progressive scoliosis animal model is reported. Methods. Surgical pinealectomy was performed in 52 Broiler chickens to induce progressive scoliosis. Scoliosis progression among a control group and an intervention group assigned to paravertebral injection of botulinum toxin in curve´s concavity electromyographycally assisted is compared. Conventional x-ray and anatomopathologic studies were conducted to evaluate results. Cobb angle method was used to measure spine deformation. Results. Five animals died (1 in the control group and 4 in the intervention group). Mean scoliosis values observed were 32.9 degrees (n= 25) and 18.8 degrees (n= 22) for control and intervention groups respectively (p<0.05). Therefore, the use of botulinum toxin in the deformity´s concavity restrains scoliosis progression in pinealectomized chickens. Conclusions. The assumption of the spine and its associated soft tissues as a tensegrity structure may explain these results, through the induced imbalance between the tension (muscles and ligaments) and compression (vertebrae) components that shape the system. Further studies are necessary to determine clinical applications of this therapy in adolescent idiopathic scoliosis (AU)