Administration and effects of beta blockers and oxandrolone in severely burned adults: a post hoc analysis of the RE-ENERGIZE trial.

Background: Prospective randomized trials in severely burned children have shown the positive effects of oxandrolone (OX), beta blockers (BB) and a combination of the two (BBOX) on hypermetabolism, catabolism and hyperinflammation short- and long-term post-burn. Although data on severely burned adults are lacking in comparison, BB, OX and BBOX appear to be commonly employed in this patient population. In this study, we perform a secondary analysis of an international prospective randomized trial dataset to provide descriptive evidence regarding the current utilization patterns and potential treatment effects of OX, BB and BBOX. Methods: The RE-ENERGIZE (RandomizEd Trial of ENtERal Glutamine to minimIZE Thermal Injury, NCT00985205) trial included 1200 adult patients with severe burns. We stratified patients according to their receipt of OX, BB, BBOX or none of these drugs (None) during acute hospitalization. Descriptive statistics describe the details of drug therapy and unadjusted analyses identify predisposing factors for drug use per group. Association between OX, BB and BBOX and clinical outcomes such as time to discharge alive and 6-month mortality were modeled using adjusted multivariable Cox regressions. Results: More than half of all patients in the trial received either OX (n = 138), BB (n = 293) or BBOX (n = 282), as opposed to None (n = 487, 40.6%). Per study site and geographical region, use of OX, BB and BBOX was highly variable. Predisposing factors for the use of OX, BB and BBOX included larger total body surface area (TBSA) burned, higher acute physiology and chronic health evaluation (APACHE) II scores on admission and younger patient age. After adjustment for multiple covariates, the use of OX was associated with a longer time to discharge alive [hazard ratio (HR) 0.62, confidence interval (CI) (0.47-0.82) per 100% increase, p = 0.001]. A higher proportion of days on BB was associated with lower in-hospital-mortality (HR: 0.5, CI 0.28-0.87, p = 0.015) and 6-month mortality (HR: 0.44, CI 0.24-0.82, p = 0.01). Conclusions: The use of OX, BB and BBOX is common within the adult burn patient population, with its use varying considerably across sites worldwide. Our findings found mixed associations between outcomes and the use of BB and OX in adult burn patients, with lower acute and 6-month-mortality with BB and longer times to discharge with OX. Further research into these pharmacological modulators of the pathophysiological response to severe burn injury is indicated.

The long-term intercorrelation between post-burn pain, anxiety, and depression: a post hoc analysis of the "RE-ENERGIZE" double-blind, randomized, multicenter placebo-controlled trial.

BACKGROUND: Despite the growing prevalence of burn survivors, a gap persists in our understanding of the correlation between acute burn trauma and the long-term impact on psychosocial health. This study set out to investigate the prevalence of long-term pain and symptoms of anxiety and depression in survivors of extensive burns, comparing this to the general population, and identify injury and demographic-related factors predisposing individuals to psychosocial compromise. METHODS: RE-ENERGIZE was an international, double-blinded, randomized-controlled trial that enrolled 1200 patients with partial- or full-thickness burns that required surgical treatment. For the post hoc analysis, we excluded participants who did not complete the Short Form Health Survey (SF-36) questionnaire. Normative data were taken from the 2021 National Health Interview Survey dataset. Propensity score matching was performed using the nearest-neighbor 1-to-1 method, and the two cohorts were compared in terms of chronic pain, and symptoms of anxiety and depression. A multivariable analysis was performed on the burns cohort to identify factors predicting post-discharge pain and symptoms of anxiety and depression. RESULTS: A total of 600 burn patients and 26,666 general population adults were included in this study. Following propensity score matching, both groups comprised 478 participants each, who were predominately male, white, overweight and between 20 and 60 years old. Compared to the general population, burn patients were significantly more likely to report the presence of moderate and a lot of pain (p = 0.002). Symptoms of anxiety were significantly higher in the burn population in two of four levels (most of the time; some of the time; p < 0.0001 for both). Responders in the burn population were significantly less likely to report the absence of depressive symptoms (p < 0.0001). Burn patients were also significantly more likely to report that their mental health affects their social life. TBSA, history of depression, and female sex were identified as independently associated factors for pain, anxiety, and depressive symptoms. The presence of chronic pain and anxiety symptoms independently predicted for symptoms of depression. CONCLUSIONS: Analyzing the largest multicenter cohort of patients with extensive burns, we find that burn injury is associated with chronic pain, and symptoms of anxiety and depression. In addition, TBSA-burned and history of depression directly correlate with the prevalence of chronic pain, and symptoms of anxiety and depression. Finally, pain, and symptoms of anxiety and depression are interrelated and may have interactive effects on the process of recovery following burn injury. Burn patients would, therefore, benefit from a multidisciplinary team approach with early mobilization of pain and mental health experts, in order to promptly prevent the development of psychosocial challenges and their consequences.

The combined risk predictive power of frailty and hypoalbuminemia in free tissue flap reconstruction: A cohort study of 34,571 patients from the NSQIP database.

INTRODUCTION: Significant morbidity and mortality are hallmarks of the functional decline seen in physically frail patients. The modified frailty index 5 (mFI-5) represents a risk predictor score that has been validated as a comorbidity-based scale in surgery. Serum albumin levels of <3.5 g/dL (hypoalbuminemia) have also been implicated with poor postoperative outcomes. However, the association between these two parameters remains to be investigated. We aimed to elucidate the interdependence of preoperative albumin levels and frailty, as evaluated by the mFI-5 score, and its reliability to prognosticate postoperative results in free flap reconstruction (FFR). METHODS: We conducted a multicenter, retrospective cohort study and accessed the ACS National Surgical Quality Improvement Program (ACS-NSQIP) from 2008 to 2021. We identified all adult patients (≥18 years of age) who underwent a FFR. We extracted perioperative data and lab values including albumin. Multivariable linear and logistic regression analyses were performed to identify independent risk predictors. Main outcomes involved mortality, length of hospital stay, reoperation, medical and surgical complications, and discharge destination within the 30-day postoperative period. RESULTS: A total of 34,571 patients were included in the study, with an average age of 53.9 years (standard deviation [SD] 12.2) and an average body mass index (BMI) of 28.8 (SD 6.1). Of these patients, 7484 were male (21.6%), whereas 22,363 (64.7%) had no frailty (mFI = 0). Additionally, 9466 patients had a frailty score of 1 (27.4%), 2505 had a score of 2 (7.2%), 226 had a score of 3 (0.7%), and 11 had a score of 4 or higher (0.0%). Albumin levels were available for 16,250 patients (47.0%), and among them, 1334 (8.2%) had hypoalbuminemia. Regression analyses showed that higher mFI scores were independent predictors of any, surgical, and medical complications, as well as increased rates of reoperations, unplanned readmissions, and prolonged hospital stays. Hypoalbuminemia independently predicted any, surgical, and medical complications, and higher mortality, reoperation, and longer hospital stay. When both frailty and albumin levels (mFI-5 and albumin) were considered together, this combined assessment was found to be a more accurate predictor of all major outcomes (any, medical and surgical complications, mortality, and reoperation). Further, our analysis identified a weak negative correlation between serum albumin levels and mFI scores (Spearman R: -.1; p < .0001). CONCLUSION: In conclusion, this cohort study highlights the association of hypoalbuminemia with adverse postoperative outcomes, including those not directly related to frailty. Simultaneously, higher mFI scores independently predicted outcomes not associated with hypoalbuminemia. Stemming from these findings, we recommend considering both serum albumin levels and frailty in patients receiving FFR. This perioperative algorithm may help provide more individualized planning including multidisciplinary care and pre and posthabilitation.

Outcomes of Chronically Anticoagulated Patients Undergoing Split-Thickness Skin Grafting for Diabetic Foot Ulcers.

OBJECTIVE: Split-thickness skin grafting (STSG) is commonly used for wound closure in diabetic foot ulcers (DFUs). In many cases, patients with diabetes present on long-term anticoagulation therapy. The complications associated with anticoagulants can be discouraging to surgeons considering STSG. The goal of this study was to evaluate STSG outcomes in the setting of chronic anticoagulation across a large, multicenter database. METHODS: The authors queried the TriNetX Network, which provides access to electronic medical records for more than 75 million patients, to search for patients with a history of DFUs treated with STSG. They divided those found into two groups: long-term anticoagulant use prior to grafting and no long-term anticoagulant use. After matching, the researchers evaluated outcomes following STSG after 1 month and 5 years. RESULTS: The authors identified 722 patients on chronic anticoagulation with DFUs who were treated with STSG; 446 of these patients were matched to 446 patients with no prior anticoagulation. One month following STSG, the anticoagulated group showed no significant increase in death, graft failure, or regrafting. At 5 years, there was no significant increase in mortality, graft failure, regrafting, or lower extremity amputation rates. CONCLUSIONS: Chronic anticoagulation therapy does not lead to increased short- or long-term postoperative complications such as graft failure, regrafting, or increased amputation rates following STSG for wound closure. Negative outcomes following STSG for DFUs in chronically anticoagulated individuals are minimal, and grafting should be performed without hesitation.

The impact of COVID-19 on clinical outcomes of burn patients.

Background: Multiple studies have shown the SARS-CoV-2 virus (COVID-19) to be associated with deleterious outcomes in a wide range of patients. The impact of COVID-19 has not been well investigated among burned patients. We suspect that patients will have worsened respiratory and thrombotic complications, ultimately leading to increased mortality. The objective of this study is to determine the impact a concurrent infection of COVID-19 has on clinical outcomes after a burn injury. Methods: This is a retrospective, propensity matched, cohort study. We examined a de-identified database of electronic medical records of over 75 million patients across 75 health care associations in the United States for patients treated for thermal burns from 1 January 2020, to 31 July 2021, and those who also were diagnosed with COVID-19 infection within one day before or after injury based on International Classification of Disease, tenth revision (ICD-10) codes. Study participants included adults who were treated for a burn injury during the study period. Results: We included 736 patients with burn injury and concomitant COVID-19 infection matched to 736 patients with burn injury and no concurrent COVID-19 infection (total 1472 patients, mean age 36.3 ± 24.3). We found no significant increase in mortality observed for patients with concurrent COVID-19 (OR 1.203, 95% CI 0.517-2.803; p = 0.6675). We did observe significant increase in infections (OR 3.537, 95% CI 2.798-4.471; p = 0.0001), thrombotic complications (OR 2.342, 95% CI 1.351-4.058; p = 0.0018), as was the incidence of hypertrophic scarring (OR 3.368, 95% CI 2.326-4.877; p = 0.0001). Conclusions: We observed that concurrent COVID-19 infection was associated with an increase in infections, thrombosis and hypertrophic scarring but no increase in mortality in our cohort of burn patients.

Outcomes in patients with burns to the perineum, buttocks and genitalia: A retrospective cohort study.

BACKGROUND: Burns that involve the perineum, buttocks and genitals (PBG) have been associated with more challenging therapeutic needs and worse clinical outcomes. We aimed to investigate whether PBG burns are an independent predictor for mortality, morbidity and complications in a large, heterogenous patient collective and in comparison to patients without PBG burns. PATIENTS AND METHODS: Patients admitted to a level one burn center between August 2014 and July 2022 were included and stratified based on the presence of PBG burns on admission (PBG & control group = CTR). Demographic baseline data, burn aetiology, inhalation trauma (IHT), full-thickness burns (FT), number of operations (NOR), mortality, length of ICU stay (LOS-ICU), length of in-hospital stay (LOHS) and bacteraemia were assessed to compare key clinical characteristics and outcomes between the groups. Multivariate regression analyses and a 1:1 propensity score matching were conducted for key clinical outcomes. RESULTS: A total of 1024 patients were included in the analysis (PBG: n = 227; CTR: n = 797). PBG burns were older (median (IQR) 54 (34-72) vs. 44, (30-61) years, p < 0.0001), more frequently female (35% vs. 23%, p = 0.002) presented with larger total body surface area (TBSA) burns overall (27 (32-39) vs. 10 (13-15) %, p < 0.0001) and sustained FT burns more frequently (69% vs. 26% p < 0.0001). Scald burns were more frequently the cause of PBG burns (45% vs. 15%, p < 0.0001), PBG patients needed twice as many surgical procedures (Mean (SD) 2 (2.84) vs. 1 (1.6), p < 0.0001) as CTR. In multivariate analyses, a significant correlation was identified between length of ICU stay and presence of PBG burns. Following strict cohort matching to account for sex, age, cause of burn, TBSA %, presence of FT burn, inhalation trauma and bacteraemia, PBG burns were an independent predictor for mortality (p = 0.0003). CONCLUSION: PBG burns are at risk for prolonged intensive care, hospitalization and complications during treatment. Furthermore, the presence of PBG burns appears to be a risk factor for mortality, irrespective of patient age, TBSA affected and other relevant covariates.

The Impact of Facial Burns on Short- and Long-Term Quality of Life and Psychological Distress-A Prospective Matched Cohort Study.

Burn injuries are a major healthcare challenge worldwide, with up to 50% of all minor burns located on the head and neck. With this study, we sought to describe the effect of facial burns (FB) on health-related quality of life through a prospective and matched cohort study design. Patients completed the 36 Item Short Form (SF-36) and the Hospital Anxiety and Depression Scale (HADS). Results were analyzed based on the distribution of datasets. In total, 55 patients with FB and 55 age-and sex-matched candidates were recruited. The most common mechanism of thermal injury was burns from flames. The FB group scored lower in physical and psychological dimensions than the control group, both acutely and one year after injury. An analysis of each domain showed that subjects in the FB group trended toward improvements in their score after one-year post-burn in physical functioning (acute: 71.0 ± 29.2; one-year: 83.7 ± 23.9; p = 0.02) and bodily pain (acute: 58.5 ± 30.3; one-year: 77.9 ± 30.5; p = 0.01) domains. Additionally, the FB group had significanlyt higher scores for anxiety (FB: 4.8 ± 3.2; control: 2.5 ± 2.8; p = <0.002) and depression (FB: 3.9 ± 3.5; control: 2.1 ± 2.7; p = 0.01) compared to the control. In conclusion, facial burns are associated with physical and psychosocial deficits, as well as elevated levels of psychological distress.

Early wound excision within three days decreases risks of wound infection and death in burned patients.

INTRODUCTION: In lieu of limited studies on the timing of burn wound eschar excision for burns, a more comprehensive analysis is indicated to determine the effects of early wound excision following burns. This study aims to address the outcomes of early wound excision in burn patients. METHODS: Data collection were from TriNetX research database. Three groups of burn patients were stratified by the number of days in which they received burn wound excision within 14 days of injury. Five outcomes were observed: death, wound infection, sepsis, myocardial contractile dysfunction, and blood transfusion. Risk and incidence of various health outcomes were compared between the groups after propensity-matching age, sex, ethnicity, race and burn size using a z-test with p < 0.05 considered significant. RESULTS: We identified 6158 burn patients with wound excision within 14 days of injury, the majority of whom (60.1%) received burn wound excision between 0 and 3 days after burn. 72.5% of patients had burns covering less than 20% of total body surface area. After propensity matching, we found a significantly lower risk of mortality in those who received burn wound excision within the first three days (3.84%) as compared to 8-14 days after burn (6.09%) (p < 0.05). Moreover, we found a decreased risk of wound infection in patients with burn wound excision within 0-3 days (37.84%) compared to those 4-7 days (42.48%) (p < 0.05). No statistical difference was detected in propensity-matched groups for myocardial contractile dysfunction, blood transfusion, or sepsis. In addition, the risk of hypertrophic scaring significantly decreased when wound excision was performed within 0-3 days (22% within 0-3 days, 28% within 4-7 days, p < 0.05). CONCLUSION: Burn wound excision within 3 days of injury is beneficial when comparing to later treatment between 4 and 14 days, which results in a significantly lowered risk of mortality and infection in burn patient.

Implications of COVID-19 Infection on Arteriovenous Fistula Thrombosis.

Objective: This study aims to identify and analyze implications of COVID-19 positivity on AVF occlusion, subsequent treatment patterns, and ESRD patient outcomes. Our aim is to provide a quantitative context for vascular access surgeons in order to optimize surgical decision making and minimize patient morbidity. Methods: The de-identified national TriNetX database was queried to extracted all adult patients who had a known AVF between January 1, 2020 and December 31, 2021. From this cohort individuals who also were diagnosed with COVID-19 prior to creation of their AVF were identified. Cohorts were propensity score matched according to age at AVF surgery, gender, ethnicity, diabetes mellitus, nicotine dependence, tobacco use, use of anticoagulant medications, and use of platelet aggregation inhibitors, hypertensive diseases, hyperlipidemia, and prothrombotic states. Results: After propensity score matching there were 5170 patients; 2585 patients in each group. The total patient population had 3023 (58.5%) males and 2147 (41.5%) females. The overall rate of thrombosis of AV fistulas was 300 (11.6%) in the cohort with COVID-19 and 256 (9.9%) in the control group (OR 1.199, CI 1.005-1.43, P =.0453). Open revisions of AVF with thrombectomy were significantly higher in the COVID-19 cohort compared to the non-COVID-19 group (1.5% vs .5% P = .0002, OR 3.199, CI 1.668-6.136). Regarding the time from AVF creation to intervention, the median days for open thrombectomy in COVID-19 patients was 72 vs 105 days in controls. For endovascular thrombectomy, the median was 175 vs 168 days for the COVID-19 and control cohorts respectively. Conclusion: As for this study, there were significant differences in rates of thrombosis and open revisions of recent created AVF, however endovascular interventions remained remarkably low. As noted in this study, the persistent prothrombotic state of patients with a history of COVID-19 may persist beyond the acute infectious period of the disease.

The Burn Wound.

Skin serves as a protective barrier against infection, prevents excessive fluid and electrolyte losses, performs crucial thermoregulation, and provides tactile feedback of surroundings. The skin also plays an essential role in human perception of body image, personal appearance, and self-confidence. With these many diverse functions, understanding normal anatomic composition of skin is pivotal to evaluating the extent of its disruption from burn injury. This article discusses the pathophysiology, initial evaluation, subsequent progression, and healing of burn wounds. By delineating the various microcellular and macrocellular alterations of burn injury, this review also augments providers' capacity to deliver patient-centered, evidence-based burn care.

Effects of Aerobic Exercise in the Intensive Care Unit on Patient-Reported Physical Function and Mental Health Outcomes in Severely Burned Children-A Multicenter Prospective Randomized Trial.

Severe burns are life-altering and can have lasting effects on patients' physical and mental health. Alterations in physical function, changes in appearance, and psychological disturbances resulting from severe burns are especially concerning in children, as they are still in the early stages of identity formation. Exercise in the nonburn population has been shown to improve quality of life and result in better physical and mental status. However, the effect of early exercise on the quality of life in pediatric burn patients requires more research. METHODS: Forty-eight children between the ages of seven and seventeen with ≥30% total body surface area (TBSA) burn were randomized in a 1:2 fashion to receive treatment with standard-of-care (SOC) or standard-of-care plus exercise (SOC+Ex). Surveys administered at admission and discharge collected patient-reported information regarding physical and mental health outcomes. The results are given as means +/- standard deviation. Significance was set at p < 0.05. RESULTS: The average age of the SOC and SOC+Ex groups were 12 ± 3 and 13 ± 4 years, respectively. The average %TBSA burned in the SOC and SOC+Ex groups were 54 ± 17 and 48 ± 14, respectively. The SOC+Ex group averaged 10 ± 9 exercise sessions (range of 1 to 38 sessions) with an attendance rate of 25% (10 sessions out of 40 BICU days). Both groups demonstrated significant improvement in patient-reported physical and mental outcomes during hospital admission (p < 0.05) However, additional exercise did not exhibit any additional benefits for measured levels. CONCLUSIONS: Our recommendation is for all pediatric patients in the BICU to continue with the SOC and consult with their physician over the benefits of additional aerobic exercise. This study suggests that perhaps there is potential for increasing the amount of exercise that can be administered to pediatric burn survivors beyond SOC as we did not find aerobic exercise to be of any harm to any patients if it is performed properly and under supervision.

Risk factors for opioid use disorder after severe burns in adults.

INTRODUCTION: Risk factors for opioid dependence amongst burn patients have not been well-explored compared to other surgical fields. METHODS: The TrinetX database was queried for patients diagnosed with opioid use disorder (OUD) after thermal or chemical burn. Propensity score matching was performed. Opioid and non-opioid analgesia use, ICU care, surgery, and comparative risks among common opiates were examined using descriptive and univariate regression models, including odds ratios. Subgroup analysis evaluated the impact of multimodal analgesia. RESULTS: Odds of receiving IV opioids for acute analgesia (p = <0.0001, OR = 1.80, CI = 1.45-2.25), undergoing surgery (p = <0.0001, OR = 1.58, CI = 1.26-1.98), and ICU care (p = <0.0001, OR = 3.60, CI = 2.00-3.83) after burn injury were higher in patients who developed OUD. Patients receiving multimodal therapy within 24 hours of admission had lower odds of developing OUD (OR = 0.74, CI = 2.76-4.68, p = 0.0001) and chronic pain (OR = 0.89, CI = 0.78-1.00, p = 0.05) regardless of TBSA. CONCLUSION: Patients who developed opioid use disorder following burn injury had higher odds of receiving opioid exclusive pain management, more frequent surgery, ICU care.

The relationship between the lateral cutaneous antebrachial nerve and the superficial branch of the radial nerve and its impact on regional anesthetic and pain blocks of the thumb; What is more important: Nerves or dermatomes?

BACKGROUND: Innervation of the thumb and radial part of the dorsum of the hand is achieved primarily by the radial nerve, which is usually blocked for hand surgery. Inefficient blocks occur because the lateral antebrachial cutaneous nerve also extends into this area. The question then arises, whether skin innervation and peripheral blocking techniques should be directed at from the innervation by these nerves or more by the dermatome and its spinal segments. METHODS: In 68 human upper limbs embalmed with Thiel's method, the topography of the lateral antebrachial cutaneous nerve (LACN), the superficial branch of the radial nerve (sbRN) and communicating branch (CB) were investigated by meticulous dissection from the cubital fossa to the most distal macroscopically dissectible branch, and the areas reached by these nerves were compared to the described dermatome. RESULTS: In 52.9% of all specimens, the LACN was found proximal to the rascetta, in 35.3% it extended to the base of the thumb, and in 8 cases (11.8%) it extended distally to the base of the thumb. In 50%, the LACN was anterolateral to the brachioradialis muscle, and in 38.2%, strictly lateral. Only in 8 cases (11.8%) the LACN presented itself running more dorsally and laterally. A CB was observed in 28 specimens (41.2%). Both investigated nerves were found to innervate the dermatomes of C6 and C7. CONCLUSIONS: The LACN should be considered for individual targeted blocks for surgical procedures and pain therapy within the wrist and thumb region as all nerves that might contribute to innervation of a targeted dermatome should be blocked.

Therapeutic Strategies to Reduce Burn Wound Conversion.

Burn wound conversion refers to the phenomenon whereby superficial burns that appear to retain the ability to spontaneously heal, convert later into deeper wounds in need of excision. While no current treatment can definitively stop burn wound conversion, attempts to slow tissue damage remain unsatisfactory, justifying the need for new therapeutic interventions. To attenuate burn wound conversion, various studies have targeted at least one of the molecular mechanisms underlying burn wound conversion, including ischemia, inflammation, apoptosis, autophagy, generation of reactive oxygen species, hypothermia, and wound rehydration. However, therapeutic strategies that can target various mechanisms involved in burn wound conversion are still lacking. This review highlights the pathophysiology of burn wound conversion and focuses on recent studies that have turned to the novel use of biologics such as mesenchymal stem cells, biomaterials, and immune regulators to mitigate wound conversion. Future research should investigate mechanistic pathways, side effects, safety, and efficacy of these different treatments before translation into clinical studies.

Comparison of Six-Minute Walk Test and Modified Bruce Treadmill Test in Paediatric Patients With Severe Burns: A Cross-Over Study.

OBJECTIVE: To compare the six-minute walk test and the Modified Bruce treadmill test in paediatric patients with severe burns. SUBJECTS: A total of 67 children, aged 7-17 years, with severe burns. METHODS: Participants were assigned to perform the six-minute walk test and the Modified Bruce treadmill test in randomized order on discharge from acute burn care. Primary outcome measure was heart rate. Secondary outcome measures were distance walked, Borg's CR-10 rate of perceived exertion, and maximal oxygen uptake (VO2). RESULTS: A total of 67 participants were enrolled. Thirty-eight patients completed both tests. The mean six-minute walk test maximum heart rate was 135 ± 19 bpm (range 97-180 bpm) and the mean Modified Bruce treadmill test maximum heart rate was 148 ± 24 bpm (range 100-197 bpm; p ≤ 0.05), with a weak positive correlation of R² = 0.14. The mean six-minute walk test maximum distance was 294 ± 124 m (range 55 to 522 m) while the mean Modified Bruce treadmill test maximum distance was 439 ± 181 m (range 53 to 976 m; p ≤ 0.05), with no correlation of R² = 0.006. The mean RPE CR-10 score for the six-minute walk test was 3 ± 2.5 (range 0-10) vs a mean RPE CR-10 score of 10 ± 0 for the Modified Bruce treadmill test. CONCLUSION: The Modified Bruce treadmill test challenges the cardiorespiratory system significantly more than the six-minute walk test, as reflected by maximum heart rate measurements, and the perception of effort (i.e. rate of perceived exertion) by the patient. When possible, the Modified Bruce treadmill test should be used to assess cardiovascular functional capacity. However, the six-minute walk test may be more clinically feasible for use with paediatric patients with burns, and provides information about submaximal functional exercise capacity.

Orchestrating the Dermal/Epidermal Tissue Ratio during Wound Healing by Controlling the Moisture Content.

A balanced and moist wound environment and surface increases the effect of various growth factors, cytokines, and chemokines, stimulating cell growth and wound healing. Considering this fact, we tested in vitro and in vivo water evaporation rates from the cellulose dressing epicitehydro when combined with different secondary dressings as well as the resulting wound healing efficacy in a porcine donor site model. The aim of this study was to evaluate how the different rates of water evaporation affected wound healing efficacy. To this end, epicitehydro primary dressing, in combination with different secondary dressing materials (cotton gauze, JELONET◊, AQUACEL® Extra ™, and OPSITE◊ Flexifix), was placed on 3 × 3 cm-sized dermatome wounds with a depth of 1.2 mm on the flanks of domestic pigs. The healing process was analyzed histologically and quantified by morphometry. High water evaporation rates by using the correct secondary dressing, such as cotton gauze, favored a better re-epithelialization in comparison with the low water evaporation resulting from an occlusive secondary dressing, which favored the formation of a new and intact dermal tissue that nearly fully replaced all the dermis that was removed during wounding. This newly available evidence may be of great benefit to clinical wound management.

The Role of Skin Substitutes in Acute Burn and Reconstructive Burn Surgery: An Updated Comprehensive Review.

Burns disrupt the protective skin barrier with consequent loss of cutaneous temperature regulation, infection prevention, evaporative losses, and other vital functions. Chronically, burns lead to scarring, contractures, pain, and impaired psychosocial well-being. Several skin substitutes are available and replace the skin and partially restore functional outcomes and improve cosmesis. We performed a literature review to update readers on biologic and synthetic skin substitutes to date applied in acute and reconstructive burn surgery. Improvement has been rapid in the development of skin substitutes in the last decade; however, no available skin substitute fulfills criteria as a perfect replacement for damaged skin.

Galunisertib Exerts Antifibrotic Effects on TGF-ß-Induced Fibroproliferative Dermal Fibroblasts.

Dermal fibroblasts in pathological scars secrete constitutively elevated levels of TGF-ß, signaling the transcription of fibrotic genes via activin-like kinase 5 (ALK5). In the present study, we examine the antifibrotic effects of galunisertib, a small-molecule inhibitor of ALK5, on fibroproliferative dermal fibroblasts in an in vitro model of wound healing. We induced fibrosis in human dermal fibroblasts with exogenous TGF-ß and performed cellular proliferation assays after treatment with varying concentrations of galunisertib. Dermal fibroblast proliferation was diminished to homeostatic levels without cytotoxicity at concentrations as high as 10 µM. An in vitro scratch assay revealed that galunisertib significantly enhanced cellular migration and in vitro wound closure beginning 24 h post-injury. A gene expression analysis demonstrated a significant attenuation of fibrotic gene expression, including collagen-1a, alpha-smooth muscle actin, fibronectin, and connective tissue growth factor, with increased expression of the antifibrotic genes MMP1 and decorin. Protein synthesis assays confirmed drug activity and corroborated the transcription findings. In summary, galunisertib simultaneously exerts antifibrotic effects on dermal fibroblasts while enhancing rates of in vitro wound closure. Galunisertib has already completed phase II clinical trials for cancer therapy with minimal adverse effects and is a promising candidate for the treatment and prevention of pathological cutaneous scars.

Conchal Excision Techniques in Otoplasty: A Literature Review.

Prominent ears are a common congenital deformity of the head and neck. Correcting concha hypertrophy is an important step in otoplasty. Despite the risk of postoperative deformity due to the sharp edges created by excision, removing a section of cartilage is sometimes the only method to obtain a satisfying and long-lasting result. Multiple conchal excision techniques have been reported in the literature, with significant differences in approach, outcome evaluation, and complication classification. The objective was to review cartilage excision-based otoplasty procedures to offer plastic surgeons' insights into current data on outcomes and complications of conchal excision techniques. Methods: We conducted a literature search through the MEDLINE, EMBASE, Scopus, and Cochrane databases. Prospective and retrospective studies on otoplasty, including revision surgeries and conchal excision techniques involving concha cartilage resection, were included. Articles with no outcomes data, review articles, case reports, expert opinion or comment, and nonclinical studies were excluded. Results: There were a total of four manuscripts that fulfilled our criteria. Three out of four authors preferred posterior access that separates the skin excision from the cartilage excision. Following resection, cartilage edges can be approximated by placing cartilage sutures, or they can be allowed to collapse spontaneously. Although only two authors employed a systematic classification for complications, all the articles reviewed indicated a low complication rate and excellent postoperative cosmetic outcomes. Conclusion: Although the techniques and principles stated in the literature varied to some extent, the outcomes of all studies reviewed were comparable.