Candida tropicalis burn wound sepsis: A series of histopathology-confirmed cases.

Fungal infection in severely burned patients is a serious problem due to various factors, such as the extensive application of antibiotics. In this study, we report on the course of severely burned patients with Candida tropicalis burn wound sepsis. Five such cases were reviewed. The patients were treated with itraconazole intravenously and simultaneous antibiotics to prevent bacterial infections. In addition, dermabrasion was used to excise the eschar and the wound surface was covered immediately with dermatoplasty. Meanwhile, the skin necrosis related to the fungal infection was removed. The wound surfaces of all five patients were healed well and the parameters of laboratory examination went back to normal. We assume that prompt diagnosis and timely treatment including extensive debridement of necrosis, antifungal drugs, and antibiotics were the key points leading to favourable outcome.

Experience and efficacy of surgery for retaining viable subcutaneous tissue in extensive full-thickness burns.

BACKGROUND AND AIM: For adult patients with extensive full-thickness burns (EFTB), a fascial excision is mostly used but it causes a very significant deformity. This study aims to summarize experience and efficacy of surgery for retaining viable subcutaneous tissue in EFTB. METHOD: Clinical data were reviewed for 31 consecutive adult patients with full-thickness burn (FTB) over 70% total body surface area (TBSA) and undergoing first tangential excision and skin grafting on subcutaneous tissue wound (TESGSTW) within 7 days post burn at our burn center between 2002 and 2013. RESULTS: Average age, total burn area, and FTB area of 31 patients were 32.4 ± 12.8 years, 89.0 ± 6.2% and 80.4 ± 7.6% TBSA, respectively. Of these, 80.6% combined with inhalation injury and 71.0% supervened early shock. Eighteen patients who survived (58.1%) totally underwent 121 times of surgery, of which TESGSTW and autologous skin grafting were 41 and 88 times, respectively. Their average time and area of first tangential excision was 4.1 ± 0.6 days post burn and 33.8 ± 7.6% TBSA, respectively, and accumulated tangential excision area was 58.4 ± 10.8% TBSA. In 39 times of TESGSTW within 14 days post burn, cryopreserved alloskin or fresh young pigskin was applied on 84.6%, and average time and take rate of autologous skin grafting instead of grafted alloskin or xenoskin was 14.6 ± 0.7 days and 89.5 ± 1.4%, respectively. Scalp was the main donor site for autologous skin, especially microskin grafting. Systemic wound healing time roughly was 67.3 ± 1.9 days post burn, meanwhile, viable subcutaneous tissue was retained. Healed wounds were plump, and their extensibility and sensitivity were better by follow-up. CONCLUSION: The surgical treatment in EFTB is practicable and effective.

[Histological observation and vascularization evaluation of porcine acellular dermal matrix processed with matrix metalloproteinase 7 after implanted into rats].

OBJECTIVE: To investigate the histological changes and vascularization of the porcine acellular dermal matrix (P-ADM) processed with matrix metalloproteinase 7 (MMP-7) (P-ADM-pm) after implanted into rats. METHODS: Sixty-two pieces of porcine reticular layer dermis which were from the pig abdominal skin and obtained by using a mechanical method, were randomly divided into group A (n = 31) and group B (n = 31). The porcine reticular layer dermis in 2 groups were treated with decellularization (P-ADM), then the P-ADM in group B were treated with processing by MMP-7 (P-ADM-pm). Thirty adult male Wistar rats were selected. P-ADM (group A) and P-ADM-pm (group B) were subcutaneously transplanted into the left and right fascia lacuna, respectively. The implants were harvested from 6 rats at 3, 7, 14, 21, and 28 days after implantation, respectively. Gross, histochemical, and immunohistochemical observations, and scanning electron microscopy (SEM) examination were performed to observe host cells, microvessels infiltration and histological changes in the implants. RESULTS: No rat died in the experiment, incision healed well and no obvious inflammatory reaction was seen in all rats. Gross observation suggested that the implants of 2 groups were encapsulated by a thin layer of connective tissue at 7 days after implantation. With the time of implantation, the microvessels increased and coarsened, and the changes of group B were more obvious than those of group A. At 21 days, the microvessels of 2 groups decreased, and the implants of group B showed complete vascularization. The histochemical and immunohistochemical observations showed that group A had more severe inflammatory response than group B. Fibroblasts and microvessels in group B appeared in the superficial zone of implant at 3 and 7 days after implantation and they could be observed in the center zone of implant at 14 and21 days. However, fibroblasts and microvessels in group A appeared in the superficial zone of implant at 3 and 14 days and they could not be observed in the center zone of implant at 28 days. Fibroblasts and microvessels of group B were significantly more than those of group A (P < 0.05). SEM examination showed that more fibroblasts and new collagen fibrils were observed in group B at 14 days. CONCLUSION: The host response to P-ADM-pm is similar to normal wound healing, and P-ADM-pm as implantable scaffold material plays a good template conduction role.

Combined application of alginate dressing and human granulocyte-macrophage colony stimulating factor promotes healing in refractory chronic skin ulcers.

The aim of the present study was to evaluate the clinical therapeutic effect of the combined application of alginate and recombinant human granulocyte-macrophage colony-stimulating factor (rhGM-CSF) on the healing of refractory chronic skin ulcers. A single center, three arm, randomized study was performed at Jinan Central Hospital (Jinan, Shandong, China). A total of 60 patients with refractory chronic skin ulcers, which persisted for >1 month, were enrolled and randomly assigned into one of the following three groups: alginate dressing/rhGM-CSF group (group A), rhGM-CSF only group (group B) and conventional (vaseline dressing) group (group C). The wound area rate was measured, granulation and color were observed and pain was evaluated. The data were summarized and statistical analysis was performed. The results demonstrated that group A exhibited a significantly faster wound healing rate and lower pain score compared with the other groups (P<0.01). In conclusion, the combined application of alginate dressing and rhGM-CSF for the treatment of refractory chronic skin ulcers demonstrated significant advantages. It promoted the growth of granulation tissue, accelerated re-epithelialization and also effectively reduced wound pain, and thus improved the quality of life for the patient. This suggests that the combined application of alginate and rhGM-CSF may be an effective therapeutic strategy for the clinical treatment of refractory chronic skin ulcers.

[Efficacies of treating large area third-degree burns by tangential excision and skin grafting for subcutaneous tissue wounds].

OBJECTIVE: To explore the efficacies of treating patients with large area third-degree burns by tangential excision and skin grafting for subcutaneous tissue wounds. METHODS: From January 2002 to December 2013, the medical records were retrospectively reviewed for 31 consecutive adult patients with a third-degree burn area exceeding 70% and undergoing tangential excision and skin grafting on subcutaneous tissue wound (TESGSTW) for the first time within 7 days postburn at Burn Center, Affiliated Jinan Central Hospital, Shandong University. For 31 patients, wounds with relative integrity eschar underwent TESGSTW by stages. Tourniquet was not used in some extremities. The relevant clinical data including patient condition on admission, causes of death, blood loss of tangential excision wound, surgical procedures and efficacies in cured group were analyzed. RESULTS: Average age, burn total area and third-degree burn area of 31 patients were (32.4 ± 12.8) years, (89.0 ± 6.2)% and (80.4 ± 7.6)% respectively. There were inhalation injury (n = 25, 80.6%) and early-stage shock before hospitalization (n = 22, 71.0%). Among 18 cured ones (58.1%), 2 patients had a third-degree burn area ≥ 90%. And 13 patients (41.9%) died and 10 of them died at 4 to 19 days postburn. Burn area was a risk factor of burn mortality. Sepsis and multiple organ dysfunction syndrome (MODS) were major mortality causes. Four patients died from early-stage sepsis. Within 14 days postburn, average blood loss volume per 1% tangential excision area in non-tourniquet group was slightly higher than that in the tourniquet group, but the difference was insignificant. For 18 cured patients, TESGSTW were performed 41 times. For 14 patients (77.8%), TESGSTW was performed twice. The average time of the first tangential excision was (4.1 ± 0.6) days postburn, the time interval between the first two tangential excisions was (6.4 ± 2.0) days, the first tangential excision area (33.8 ± 7.6)% and accumulated tangential excision area (58.4 ± 10.8)%. Among 39 operations within 14 days postburn, refrigerated allogeneic or fresh porcine skin grafts were involved 33 times (84.6%). The wounds were fresh and bleeding after peeling 5 to 7 days postoperation. The time of allogeneic (xenogeneic) skin removal or rejection, recipient bed debridement and auto-skin grafting was (18.0 ± 4.8) days postoperation. And the auto-skin survival rate was (89.5 ± 9.5)%. Wound infection occurred 5 times in 4 patients. During a follow-up period of 6-108 months after TESGSTW, healed wound surface was plump and contraction relatively mild and non-prone to ulceration. And both extensibility and sensitivity were good. CONCLUSIONS: TESGSTW is safe for treating patients with large area third-degree burns. And its short and long-term outcomes are favorable.

Transcranial low-level laser therapy improves neurological performance in traumatic brain injury in mice: effect of treatment repetition regimen.

Low-level laser (light) therapy (LLLT) has been clinically applied around the world for a spectrum of disorders requiring healing, regeneration and prevention of tissue death. One area that is attracting growing interest in this scope is the use of transcranial LLLT to treat stroke and traumatic brain injury (TBI). We developed a mouse model of severe TBI induced by controlled cortical impact and explored the effect of different treatment schedules. Adult male BALB/c mice were divided into 3 broad groups (a) sham-TBI sham-treatment, (b) real-TBI sham-treatment, and (c) real-TBI active-treatment. Mice received active-treatment (transcranial LLLT by continuous wave 810 nm laser, 25 mW/cm(2), 18 J/cm(2), spot diameter 1 cm) while sham-treatment was immobilization only, delivered either as a single treatment at 4 hours post TBI, as 3 daily treatments commencing at 4 hours post TBI or as 14 daily treatments. Mice were sacrificed at 0, 4, 7, 14 and 28 days post-TBI for histology or histomorphometry, and injected with bromodeoxyuridine (BrdU) at days 21-27 to allow identification of proliferating cells. Mice with severe TBI treated with 1-laser Tx (and to a greater extent 3-laser Tx) had significant improvements in neurological severity score (NSS), and wire-grip and motion test (WGMT). However 14-laser Tx provided no benefit over TBI-sham control. Mice receiving 1- and 3-laser Tx had smaller lesion size at 28-days (although the size increased over 4 weeks in all TBI-groups) and less Fluoro-Jade staining for degenerating neurons (at 14 days) than in TBI control and 14-laser Tx groups. There were more BrdU-positive cells in the lesion in 1- and 3-laser groups suggesting LLLT may increase neurogenesis. Transcranial NIR laser may provide benefit in cases of acute TBI provided the optimum treatment regimen is employed.

Low-level laser therapy for closed-head traumatic brain injury in mice: effect of different wavelengths.

BACKGROUND AND OBJECTIVES: Traumatic brain injury (TBI) affects millions worldwide and is without effective treatment. One area that is attracting growing interest is the use of transcranial low-level laser therapy (LLLT) to treat TBI. The fact that near-infrared light can penetrate into the brain would allow non-invasive treatment to be carried out with a low likelihood of treatment-related adverse events. LLLT may treat TBI by increasing respiration in the mitochondria, causing activation of transcription factors, reducing inflammatory mediators and oxidative stress, and inhibiting apoptosis. STUDY DESIGN/MATERIALS AND METHODS: We tested LLLT in a mouse model of closed-head TBI produced by a controlled weight drop onto the skull. Mice received a single treatment with continuous-wave 665, 730, 810, or 980 nm lasers (36 J/cm(2) delivered at 150 mW/cm(2)) 4-hour post-TBI and were followed up by neurological performance testing for 4 weeks. RESULTS: Mice with moderate-to-severe TBI treated with 665 and 810 nm laser (but not with 730 or 980 nm) had a significant improvement in Neurological Severity Score that increased over the course of the follow-up compared to sham-treated controls. Morphometry of brain sections showed a reduction in small deficits in 665 and 810 nm laser treated mouse brains at 28 days. CONCLUSIONS: The effectiveness of 810 nm agrees with previous publications, and together with the effectiveness of 660 nm and non-effectiveness of 730 and 980 nm can be explained by the absorption spectrum of cytochrome oxidase, the candidate mitochondrial chromophore in transcranial LLLT.

Comparison of therapeutic effects between pulsed and continuous wave 810-nm wavelength laser irradiation for traumatic brain injury in mice.

BACKGROUND AND OBJECTIVE: Transcranial low-level laser therapy (LLLT) using near-infrared light can efficiently penetrate through the scalp and skull and could allow non-invasive treatment for traumatic brain injury (TBI). In the present study, we compared the therapeutic effect using 810-nm wavelength laser light in continuous and pulsed wave modes in a mouse model of TBI. STUDY DESIGN/MATERIALS AND METHODS: TBI was induced by a controlled cortical-impact device and 4-hours post-TBI 1-group received a sham treatment and 3-groups received a single exposure to transcranial LLLT, either continuous wave or pulsed at 10-Hz or 100-Hz with a 50% duty cycle. An 810-nm Ga-Al-As diode laser delivered a spot with diameter of 1-cm onto the injured head with a power density of 50-mW/cm(2) for 12-minutes giving a fluence of 36-J/cm(2). Neurological severity score (NSS) and body weight were measured up to 4 weeks. Mice were sacrificed at 2, 15 and 28 days post-TBI and the lesion size was histologically analyzed. The quantity of ATP production in the brain tissue was determined immediately after laser irradiation. We examined the role of LLLT on the psychological state of the mice at 1 day and 4 weeks after TBI using tail suspension test and forced swim test. RESULTS: The 810-nm laser pulsed at 10-Hz was the most effective judged by improvement in NSS and body weight although the other laser regimens were also effective. The brain lesion volume of mice treated with 10-Hz pulsed-laser irradiation was significantly lower than control group at 15-days and 4-weeks post-TBI. Moreover, we found an antidepressant effect of LLLT at 4-weeks as shown by forced swim and tail suspension tests. CONCLUSION: The therapeutic effect of LLLT for TBI with an 810-nm laser was more effective at 10-Hz pulse frequency than at CW and 100-Hz. This finding may provide a new insight into biological mechanisms of LLLT.

Ultraviolet-C light for treatment of Candida albicans burn infection in mice.

Burn patients are at high risk of invasive fungal infections, which are a leading cause of morbidity, mortality, and related expense exacerbated by the emergence of drug resistant fungal strains. In this study, we investigated the use of UVC light (254 nm) for the treatment of yeast Candida albicans infection in mouse third degree burns. In vitro studies demonstrated that UVC could selectively kill the pathogenic C. albicans compared with a normal mouse keratinocyte cell line in a light exposure dependent manner. A mouse model of chronic C. albicans infection in non-lethal third degree burns was developed. The C. albicans strain was stably transformed with a version of the Gaussia princeps luciferase gene that allowed real-time bioluminescence imaging of the progression of C. albicans infection. UVC treatment with a single exposure carried out on day 0 (30 min postinfection) gave an average 2.16-log(10)-unit (99.2%) loss of fungal luminescence when 2.92 J cm(-2) UVC had been delivered, while UVC 24 h postinfection gave 1.94-log(10)-unit (95.8%) reduction of fungal luminescence after 6.48 J cm(-2). Statistical analysis demonstrated that UVC treatment carried out on both day 0 and day 1 significantly reduced the fungal bioburden of infected burns. UVC was found to be superior to a topical antifungal drug, nystatin cream. UVC was tested on normal mouse skin and no gross damage was observed 24 h after 6.48 J cm(-2). DNA lesions (cyclobutane pyrimidine dimers) were observed by immunofluorescence in normal mouse skin immediately after a 6.48 J cm(-2) UVC exposure, but the lesions were extensively repaired at 24 h after UVC exposure.

The influence of temperature on 5-aminolevulinic acid-based photodynamic reaction in keratinocytes in vitro.

BACKGROUND/PURPOSE: Based on the observation that increasing skin temperature could improve 5-aminolevulinic acid (ALA) penetration and accumulation of protoporphyrin IX (PpIX) in the ALA-based photodynamic therapy (PDT), this study was designed to investigate how temperature change varied the therapeutic effect of ALA-based PDT in vitro. METHODS: HaCat cells were cultured with or without ALA at various temperatures. ALA uptake and PpIX accumulation were analyzed before laser irradiation as the baseline. After irradiation, cell death and cytokine secretions in the media, including interleukin (IL)-1alpha, tumor necrosis factor (TNF)-alpha and basic fibroblast growth factor (bFGF) were assayed, and the morphological changes were recorded. RESULTS: With increasing temperature, the amount of ALA uptake, intracellular PpIX concentration and cell death increased in both the PDT and the non-PDT groups. Secretions of IL-1alpha, TNF-alpha and bFGF also increased and reached a peak around 44-47 degrees C and then declined at a higher temperature. This biphasic response might be due to protein thermolysis that occurs when cells reach beyond thermal tolerance. CONCLUSIONS: Elevating temperature could augment photodynamic reactions to a certain extent, but adverse effects occurred when cells were overheated.

[Clinical application of xenogenic (porcine) acellular dermal atrix (ADM) in scar treatment].

OBJECTIVE: To investigate the role of xenogenic (porcine) ADM as dermal substitute in scar treatment. METHODS: After scar excision, the wounds were covered with composite grafts of DR procine ADM and autologous thin split-thickness grafts in one stage or in two stages. RESULTS: 22 out of 47 cases were treated in two-staged procedure. After the ADMs were applied to the wound, the autologous thin split-thickness grafts were implanted 7 days later. 25 cases were treated in one-staged procedure. The survival rates of composite grafts were (88.3 +/- 3.7)% for subcutaneous recipient bed and (89.7 +/- 3.4)% for deep fascia recipient bed in group with two-staged procedure, compared with (92.5 +/- 4.1)% and (93.2 +/- 5.2)%, respectively, in group with one-staged procedure. Early after grafts taken, the grafts had a pink colour and smooth surface. The patients were followed up for 90 days at most. The survived composite grafts were durable, elastic, smooth and soft with good function and appearance like normal skin. They could even be pinched up. The scar along the edge of the grafts was slightly hypertrophic. CONCLUSIONS: The survival rate of composite graft is higher in patients with one-staged procedure. The elasticity and textural of the taken grafts are better on subcutaneous recipient bed than on deep fascia recipient bed, though the function has no difference. Xenogenic (porcine) ADM can be an optimal dermal substitute for wound coverage after scar excision.

The study of inhibiting systematic inflammatory response syndrome by applying xenogenic (porcine) acellular dermal matrix on second-degree burns.

OBJECTIVE: To investigate the influence of xenogenic (porcine) acellular dermal matrix on the systematic inflammatory reaction syndrome (SIRS), and the reaction of burn patients to tissue damage upon application to second-degree burn wounds. METHOD: Seventy-two cases of patients with acute second-degree burns were enrolled in the study. According to the total burn surface area (TBSA) and the treatment methods, we randomly divided the patients into four groups. Group A (treatment group): patients with less than 30% TBSA covered with xenogenic acellular dermal matrix. Group B (control group): patients with less than 30% TBSA covered with betadine ointment gauzes. Group C (treatment group): patients with more than 30% TBSA covered with porcine acellular dermal matrix. Group D (control group): patients with more than 30% TBSA covered with betadine ointment gauzes. Serum level of C-reactive protein (CRP) was measured by single radial immunodiffusion method on 1, 4, 7 and 14 days postburn. RESULTS: The serum level of CRP in group A was significantly less than that of in group B (P<0.05) on days 4, 7 and 14. The serum level of CRP in group C increased slowly, descended quickly and was significantly less than that of in group D on days 4, 7 and 14. CONCLUSION: The application of xenogenic (porcine) acellular dermal matrix on second-degree burn wound can decrease serum level of CRP of the patients, which may play an important role in reducing SIRS and sepsis incidence.

[Treatment of deep partial thickness burns by a single dressing of porcine acellular dermal matrix].

OBJECTIVE: To explore the effect of one dressing of porcine acellular dermal matrix on deep partial thickness burns. METHODS: From January 1997 to January 2004, sixty-seven cases of deep partial thickness total burned surface area (TBSA) from 50% to 90% burn wound were treated by a single dressing of porcine acellular dermal matrix (the porcine acellular dermal matrix group). Ten cases of deep partial thickness burned patients with the same TBSA treated by exposure method served as the exposure method group. The healing time of the wound was observed. The patients were followed up for 3 months to 2 years, and the scar proliferation was observed. RESULTS: The deep partial-thickness wound would be healed without dressing change in the porcine acellular dermal matrix group, and the average healing time was (12.2 +/- 2.6) days. The average healing time of the exposure method group was (27.4 +/- 3.5) days. Follow up of the patients within 3 months to 2 years showed that scar proliferation in the porcine acellular dermal matrix group was much less than that in the exposure method group, even no scar proliferation was observed in some patients. CONCLUSION: Without tangential excision, autografting and dressing change, a single dressing of porcine acellular dermal matrix on deep partial thickness burn wound could shorten the healing time and inhibit scar proliferation.

Control of hypertrophic scar from inception by using xenogenic (porcine) acellular dermal matrix (ADM) to cover deep second degree burn.

OBJECTIVE: We have spent 7 years to investigate the method of applying porcine acellular dermal matrix (ADM) on deep partial thickness burn wound until the wound heals without dressing change. Known as "Feng's pig skin method" by our hospital, the method appears to encourage rapid re-epithilization with minimum scarring. METHOD: The deep partial thickness burn wound was rinsed cleanly under anesthesia when the patient admitted. ADM was applied on the wound after the detached epidermis was thoroughly removed, wrapped and fixed by sterile gauze and bandages. The dressing was removed within two weeks and the wound completely healed. The outcome of the treatment was analyzed by using the modified Vancouver Burn Scar Assessment Scale. RESULT: All the wounds healed with one dressing within 2 weeks, and the time of wound re-epithelialization shortened to 7-12 days. Scar hyperplasia did not occur, or it was greatly ameliorated compared with traditional treatment after a followed-up period of 3 months to 2 years. The Scar Index was significant lower than that of the traditional exposure method. CONCLUSION: Using ADM to cover deep second degree burn can preserve maximally residual dermal tissue and epithelium, help accelerate the regeneration of epithelial and stem cells, thus shorten the healing time, remodel the skin structure, and consequently has the effect of controlling hypertrophic scar at inception.

[Experimental study on the inflammatory and immune responses of xenogenic acellular dermal matrix transplantation combined with thin split-thickness skin autograft].

OBJECTIVE: To investigate the dynamic process of the inflammatory response and the profile of Th1/Th2 cytokines after xenogenic acellular dermal matrix (ADM) transplantation with thin split-thickness skin autograft overlay. METHODS: SD rats were used in the study. In the control group, thin split-thickness skin autograft (STSG) was transplanted in the full-thickness skin defect of the SD rats; in the experimental group, the xenogenic acellular dermal matrix combined with thin split-thickness skin autograft was transplanted. The inflammatory response was examined histologically and Th1/Th2 cytokine mRNA expression in skin grafts was determined by reverse transcription-polymerase chain reaction. RESULTS: Inflammatory reaction was induced by ADM at the early stage of transplantation and decreased gradually. Th2 cytokine mRNA expression was higher in the ADM group than that of the control group whereas the Th1 cytokine mRNA expression was undetected in both groups. CONCLUSION: Xenogenic acellular dermal matrix is immunogenic. The increased expression of Th2 cytokines may be related to the humoral immune responses and the absence of ADM graft rejection.

[An observation of the basement membrane remodeling after the combined grafting of xenogenic acellular dermal matrix with autoskin in rats].

OBJECTIVE: To observe the dynamic process of basement membrane remodeling after the combined grafting of xenogenic acellular dermal matrix with autoskin. METHODS: The rat skin wounds were covered with xenogenic porcine acellular dermal matrix overlaid with razor thin autoskin. The skin samples were collected at 1, 2, 3, 4, 8, 12 and 16 post-grafting weeks. The changes in laminin expression in the basement membrane and the ultrastructure of the basement membrane at 12 post-grafting weeks were observed by immunohistochemistry and transmission electron microscopy. The results were compared with those in simple thin autoskin grafting as the control. RESULTS: The laminin expression in the combined grafting was higher than that in control. At 12 post-grafting weeks, the basement membrane in combined grafting rats was clear and continuous and the hemidesmosome was relatively more in amount and distributed evenly. While in the autoskin group, the lamina densa in the basement membrane was blurred and discontinuous with a decrease in and uneven distribution of hemidesmosome. CONCLUSION: The increased expression of laminin in the basement membrane in the combined grafting rats might be beneficial to the remodeling of the basement membrane and to strengthening the connection of epithelium to the dermis, thus wound healing quality would be improved.