A single-center, open-labeled, randomized, 6-month, parallel-group study to assess the safety and efficacy of allogeneic cultured keratinocyte sheet transplantation for deep second-degree burn wounds: rationale and design of phase I/II clinical trial.

BACKGROUND: Burn-related injuries are a major global health issue, causing 180,000 deaths per year. Early debridement of necrotic tissue in association with a split-thickness skin graft is usually administered for some of the 2nd- and 3rd-degree injuries. However, this approach can be complicated by factors such as a lack of proper donor sites. Artificial skin substitutes have attracted much attention for burn-related injuries. Keratinocyte sheets are one of the skin substitutes that their safety and efficacy have been reported by previous studies. METHODS: Two consecutive clinical trials were designed, one of them is phase I, a non-randomized, open-label trial with 5 patients, and phase II is a randomized and open-label trial with 35 patients. A total number of 40 patients diagnosed with 2nd-degree burn injury will receive allogenic keratinocyte sheet transplantation. The safety and efficacy of allogeneic skin graft with autograft skin transplantation and conventional treatments, including Vaseline dressing and topical antibiotic, will be compared in different wounds of a single patient in phase II. After the transplantation, patients will be followed up on days 3, 7, 10, 14, 21, and 28. In the 3rd and 6th months after the transplantation scar, a wound closure assessment will be conducted based on the Vancouver Scar Scale and the Patient and Observer Scar Assessment Scale. DISCUSSION: This study will explain the design and rationale of a cellular-based skin substitute for the first time in Iran. In addition, this work proposes this product being registered as an off-the-shelf product for burn wound management in the country. TRIAL REGISTRATION: Iranian Registry of Clinical Trials (IRCT) IRCT20080728001031N31, 2022-04-23 for phase I and IRCT20080728001031N36, 2024-03-15 for phase II.

Accuracy of infrared thermography evaluation in burn wound healing: a systematic review and meta-analysis.

OBJECTIVE: Accurate assessment of burn depth and burn wound healing potential is essential to determine early treatments. Infrared thermography (IRT) is a non-invasive and objective tool to do this. This systematic review evaluated the accuracy of IRT to determine burn wound healing potential. METHOD: This systematic review and meta-analysis used MEDLINE, EMBASE, CINAHL, PEDro, DiTA and CENTRAL databases. IRT data were extracted from primary studies and categorised into four cells (i.e., true positives, false positives, true negatives and false negatives). Subgroup analysis was performed according to methods used to capture thermal images. RESULTS: The search strategy identified 2727 publications; however, 15 articles were selected for review and 11 for meta-analysis. In our meta-analysis, the accuracy of IRT was 84.8% (63% sensitivity and 81.9% specificity). CONCLUSION: IRT is a moderately accurate tool to identify burn depth and healing potential. Thus, IRT should be used carefully for evaluating burn wounds.

Acute Burn Care.

LEARNING OBJECTIVES: After studying this article and viewing the videos, the participant should be able to: 1. Describe the current epidemiology of burn injuries. 2. Understand burn pathophysiology and perform a wound assessment. 3. Summarize the initial emergency management of a burn patient. 4. Calculate the anticipated fluid resuscitation requirements for a burn injury, and diagnose the complications of overresuscitation. 5. Describe the diagnosis and management of inhalation injury. 6. List the goals of wound care for superficial and deep burns, and describe the closed dressing technique. 7. Perform excision of a burn wound. 8. Compare various wound closure techniques using autografts and skin substitutes. SUMMARY: Plastic surgeons are essential members of the multidisciplinary burn team. Burn injuries remain common, and plastic surgeons have an opportunity to develop and innovate the field of acute burn care in light of workforce shortages. Burn pathophysiology is complex and dynamic, which informs the challenges encountered during the perioperative phase. Accurate burn wound assessment remains difficult, with implications for diagnosis and management. A systematic approach is required when stabilizing a major burn and/or inhalation injury with newly updated fluid resuscitation and triage guidelines. Wound care continues to evolve, with an emphasis on a closed dressing technique. For deeper burns, new surgical techniques are emerging for surgical débridement, along with improvements to traditional methods of tangential excision. Following excision, a number of established and novel techniques are available to close the wound with either autografts or skin substitutes.

[Multicenter retrospect analysis of early clinical features and analysis of risk factors on prognosis of elderly patients with severe burns].

Objective: To investigate the early clinical characteristics of elderly patients with severe burns and the risk factors on prognosis. Methods: This study was a retrospective case series study. Clinical data of 124 elderly patients with severe burns who met the inclusion criteria and were admitted to the 12 hospitals from January 2015 to December 2020 were collected, including 4 patients from the Fourth People's Hospital of Dalian, 5 patients from Fujian Medical University Union Hospital, 22 patients from Guangzhou Red Cross Hospital of Jinan University, 5 patients from Heilongjiang Provincial Hospital, 27 patients from the First Affiliated Hospital of Naval Medical University, 9 patients from the First Affiliated Hospital of Nanchang University, 10 patients from Affiliated Hospital of Nantong University, 9 patients from Tongren Hospital of Wuhan University & Wuhan Third Hospital, 12 patients from the 924th Hospital of PLA, 6 patients from Zhangjiagang First People's Hospital, 4 patients from Taizhou Hospital of Zhejiang Province, and 11 patients from Zhengzhou First People's Hospital. The patients' overall clinical characteristics, such as gender, age, body mass index, total burn area, full-thickness burn area, inhalation injury, causative factors, whether combined with underlying medical diseases, and admission time after injury were recorded. According to the survival outcome within 28 days after injury, the patients were divided into survival group (89 cases) and death group (35 cases). The following data of patients were compared between the two groups, including the basic data and injuries (the same as the overall clinical characteristics ahead); the coagulation indexes within the first 24 hours of injury such as prothrombin time (PT), activated partial thromboplastin time (APTT), thrombin time, D-dimer, fibrinogen degradation product (FDP), international normalized ratio (INR), and fibrinogen; the blood routine indexes within the first 24 hours of injury such as white blood cell count, platelet count, neutrophil-to-lymphocyte ratio, monocyte count, red blood cell count, hemoglobin, and hematocrit; the organ function indexes within the first 24 hours of injury such as direct bilirubin, total bilirubin, urea, serum creatinine, aspartate aminotransferase, alanine aminotransferase, total protein, albumin, globulin, blood glucose, triglyceride, total cholesterol, alkaline phosphatase, creatine kinase, electrolyte indexes (potassium, sodium, chlorine, calcium, magnesium, and phosphorus in blood), uric acid, myoglobin, and brain natriuretic peptide; the infection and blood gas indexes within the first 24 hours of injury such as procalcitonin, C-reactive protein, pH value, oxygenation index, base excess, and lactate; treatment such as whether conducted with mechanical ventilation, whether conducted with continuous renal replacement therapy, whether conducted with anticoagulation therapy, whether applied with vasoactive drugs, and fluid resuscitation. The analysis was conducted to screen the independent risk factors for the mortality within 28 days after injury in elderly patients with severe burns. Results: Among 124 patients, there were 82 males and 42 females, aged 60-97 years, with body mass index of 23.44 (21.09, 25.95) kg/m2, total burn area of 54.00% (42.00%, 75.00%) total body surface area (TBSA), and full-thickness burn area of 25.00% (10.00%, 40.00%) TBSA. The patients were mainly combined with moderate to severe inhalation injury and caused by flame burns. There were 43 cases with underlying medical diseases. The majority of patients were admitted to the hospital within 8 hours after injury. There were statistically significant differences between patients in the 2 groups in terms of age, total burn area, full-thickness burn area, and inhalation injury, and PT, APTT, D-dimer, FDP, INR, white blood cell count, platelet count, urea, serum creatinine, blood glucose, blood sodium, uric acid, myoglobin, and urine volume within the first 24 hours of injury (with Z values of 2.37, 5.49, 5.26, 5.97, 2.18, 1.95, 2.68, 2.68, 2.51, 2.82, 2.14, 3.40, 5.31, 3.41, 2.35, 3.81, 2.16, and -3.82, respectively, P<0.05); there were statistically significant differences between two groups of patients in whether conducted with mechanical ventilation and whether applied with vasoactive drugs (with χ2 values of 9.44 and 28.50, respectively, P<0.05). Age, total burn area, full-thickness burn area, serum creatinine within the first 24 hours of injury, and APTT within the first 24 hours of injury were the independent risk factors for the mortality within 28 days after injury in elderly patients with severe burns (with odds ratios of 1.17, 1.10, 1.10, 1.09, and 1.27, 95% confidence intervals of 1.03-1.40, 1.04-1.21, 1.05-1.19, 1.05-1.17, and 1.07-1.69, respectively, P<0.05). Conclusions: The elderly patients with severe burns had the injuries mainly from flame burns, often accompanied by moderate to severe inhalation injury and enhanced inflammatory response, elevated blood glucose levels, activated fibrinolysis, and impaired organ function in the early stage, which are associated with their prognosis. Age, total burn area, full-thickness burn area, and serum creatinine and APTT within the first 24 hours of injury are the independent risk factors for death within 28 days after injury in this population.

Cutaneous functional units prediction in outcomes of early and intensive splinting following palmar burn injury in young children: a prospective study.

BACKGROUND: Palmar burn injuries are common in young children and can result in contracture. METHODS: A prospective longitudinal study describes outcomes of palm and digit extension splint use following burn in 75 children (83 hands) aged < 5 years and determines whether specific cutaneous functional units (CFUs) are associated with early signs of contracture (ESC). Outcomes were assessed up to 9-18 months following burn. Routine clinical data was collected at therapy reviews. RESULTS: Children were splinted > 12 h/day for a mean of 158 days following burn. The mean time to splint cessation was 264 days following burn. Fourteen hands developed ESC (17%): 12 hands had full ROM restored following conservative management, 2 hands (3%) progressed to contracture. Hands that developed ESC had greater healing time (p = 0.002), greater number of CFUs affected (p < 0.001), and greater number of immediate first webspace and extended first webspace CFUs affected (p = 0.002, p < 0.001 respectively). ESC risk increases for each day to heal (odds ratio [OR] 1.1, 95% CI 1.0-1.2) and each CFU in extended first webspace (OR 2.8, 95% CI 1.5-5.0). CONCLUSION: Early and intensive splinting following palmar burn results in excellent ROM. Burns involving more CFUs or the first webspace are associated with ESC.

[Expert consensus on the treatment of second-degree burn wounds (2024 edition)â : pre-hospital first aid and non-surgical treatment].

Second-degree burn is the most common type of burns in clinical practice and hard to manage. At present, there is no unified standard or specification for the first aid, diagnosis, classification, manner of conservative dressing change, and choice of external dressings or medications for second-degree burn wounds, which significantly affects the formulation of clinical treatment plans and the consistency of clinical studies. The consensus writing group developed the Expert consensus on the treatment of second-degree burn wounds (2024 edition)Ⅰ: pre-hospital first aid and non-surgical treatment based on evidence-based medicine evidence and expert opinion. This expert consensus put forward 29 specific recommendations from 2 aspects: pre-hospital first aid and non-surgical treatment for second-degree burn wounds, aiming to form a standardized clinical treatment plan for second-degree burn wounds.

Concise Review on Scientific Approaches to Burns and Scars.

Burns are large open surgical lesions bathed in virulent pus that result in rupturing of the cutaneous membrane, which has serious consequences such as an extensive loss of proteins, and body fluids, increased chances of infections, and sometimes death. These can be classified based on their penetration levels, i.e., first-degree burns penetrating the epidermis, second-degree burns including both epidermis and dermis, third-degree burns to both layers including the hair follicular cells, sweat glands and various core tissues, fourth-degree burns to adipose tissue, fifth stage burns to muscles, and sixth stage burns to bones. Wound healing/wound repair is a very perplexing process in which the tissues of the affected/burnt area repairs themselves to attain their original form and functionality but develop a scar at the wound site. This article mainly focuses on the algorithms to differentiate various degrees of burns, general first aid approaches to burns and scars, the rationale of treatment of burns, basic mechanisms highlighting the healing processes in humans in terms of free from scar formation as well as with scar formation at their elementary levels including cellular as well as biochemical levels, utility, and progression of pre-clinical data to humans and finally approaches for the improvement of scar formation in man.

Examining Disparities in Alcohol Use Testing on Burn Patient Admissions: A Call for Association Guidance.

Burn injuries are associated with as well as complicated by alcohol misuse. To date, there are no stated guidelines for alcohol testing upon burn patient admissions. This study investigated if there were associations between race and testing for alcohol upon burn admissions, controlling for demographics, burn severity (degree), and other circumstances associated with burn injuries. This study was a secondary analysis of 32 258 cases from the National Burn Data Repository. The dependent variable was whether a burn case was screened for alcohol use, and independent variables were age, gender, whether physical abuse was reported, mental health comorbidities, marital status, the severity of burns, whether the injury was work-related, injury circumstances, and etiology of injury. Controlling for independent variables, race was associated with an increased probability of having been screened for alcohol use on admission to a burn center. Data reflecting alcohol screening/testing results reported in the NBR were not included in the analysis. Study results were consistent with the possibility of bias and may have influenced decisions to screen/test for alcohol misuse/abuse in reported burn cases. It is argued these findings support the recommendation that guidelines for alcohol testing of burn patients are warranted and would benefit from specific guidance from the American Burn Association.

Do pre-burn center management algorithms work? Evaluation of pre-admission diagnosis and treatment adequacy of burn patients referred to a burn center.

Interventions for burn management until the patient is transferred to a burn center affect mortality and morbidity. Therefore, adherence to the developed algorithms is an important issue. This study aimed to determine deficiencies in different aspects of the implementation of these algorithms during the pre-admission diagnosis and treatment processes of patients referred to our burn center. This study involved a 4-year review of patients referred to our burn center. One hundred and seventy burn cases admitted by referral were enrolled in the study. Adequacy of resuscitation within the first 24 hours, adherence to guidelines, and mortality were investigated. Resuscitation performed within the first 24 hours was found to be inadequate in 88 patients (51.8%). When the burned surface area percentages were evaluated all percentages were calculated higher before arrival. There were 78 major burn cases (45.9%), and the frequency of inhalation burns, intubation requirements and renal failure were more common in this group compared to the minor burn group (P < .001). The frequency of intubation without accurate indications was found to be 70.58%. Inadequate escharotomy was detected at a rate of 52.9%, and inadequate fasciotomy at a rate of 66.6%. The mortality rate was 22.4% among all patients. Interventions undertaken during the period until the patients' referral to these centers affect mortality and morbidity. In this study, it was found that the pre-hospital applications generated were insufficient, and it was proposed that burn patient care algorithms be developed with in-service training throughout the country.

A New Ex Vivo Human Skin Burn Model.

Currently, most burn models for preclinical testing are on animals. For obvious ethical, anatomical, and physiological reasons, these models could be replaced with optimized ex vivo systems. The creation of a burn model on human skin using a pulsed dye laser could represent a relevant model for preclinical research. Six samples of excess human abdominal skin were obtained within one hour after surgery. Burn injuries were induced on small samples of cleaned skin using a pulsed dye laser on skin samples, at varying fluences, pulse numbers and illumination duration. In total, 70 burn injuries were performed on skin ex vivo before being histologically and dermato-pathologically analyzed. Irradiated burned skin samples were classified with a specified code representing burn degrees. Then, a selection of samples was inspected after 14 and 21 days to assess their capacity to heal spontaneously and re-epithelize. We determined the parameters of a pulsed dye laser inducing first, second, and third degree burns on human skin and with fixed parameters, especially superficial and deep second degree burns. After 21 days with the ex vivo model, neo-epidermis was formed. Our results showed that this simple, rapid, user-independent process creates reproducible and uniform burns of different, predictable degrees that are close to clinical reality. Human skin ex vivo models can be an alternative to and complete animal experimentation, particularly for preclinical large screening. This model could be used to foster the testing of new treatments on standardized degrees of burn injuries and thus improve therapeutic strategies.

[Research progress of mucormycosis in burns].

Mucormycosis is a relatively rare but dangerous infectious diseases. Burn patients, especially severe burn patients, are at high risk of mucormycosis. In recent years, the incidence of mucormycosis in burn patients has increased. At present, there are a few domestic literatures on mucormycosis in burns, with most being case reports without systematic summary. Based on the relevant literature at home and abroad in recent years, this article reviewed the epidemiological characteristics, clinical manifestations, diagnostic methods, and treatment methods of mucormycosis in burns, hoping to provide some basis for the diagnosis and treatment of mucormycosis in burns in China.

Frailty as a predictor of adverse outcomes in burn patients: a systematic review.

BACKGROUND: The identification of new prognostic tools for the prediction of burn patients' morbidity outcomes is necessary. Considering the feasibility of frailty assessment in the clinical setting, we aim to systematically review the literature on the associations between frailty and adverse outcomes in burn patients. METHODS: Studies were retrieved from MEDLINE (through PubMed), Web of Science, Scopus, and Embase from their inception up to 8 September 2022. Included studies were those that used frailty indices to predict adverse outcomes in burn patients. The quality assessment was done using the National, Heart, Lung, and Blood Institute (NHLBI) checklist. The results were synthesized narratively. RESULTS: We included 18 studies. The sample size among the included studies varied between 42-1615 patients. There were 12 research articles and 6 conference abstracts. Most of the studies were recently published in 2021 and 2022. Seven different frailty measures were evaluated. The following frailty measures were used: Canadian Study for Health and Ageing (CSHA) Clinical Frailty score (CFS), Modified frailty index-11 (mFI-11), Hospital frailty index, FRAIL scale, Emergency General Surgery Frailty Index (EGSFI), and Burn frailty index (BFI). There was only one report regarding a specific frailty index designed for the burn population (BFI). Except for one study (which used mFI-11), all included studies have shown a significant effect between assessing frailty and predicting worse outcomes. The CFS was an independent predictor of mortality among the burn population with high certainty of evidence. We found a significant association for other frailty indices as a predictor of mortality, however, the certainty of evidence regarding those was not high. Eight studies found a positive association between assessing frailty and unfavorable discharge location. There was no association between frailty and increased length of stay. CONCLUSION: In conclusion, the postadmission assessment of frailty can be a reliable tool for predicting unfavorable outcomes and mortalities among patients with burn injuries. In addition, future studies with various populations from other countries are required to evaluate the efficacy of frailty indices measurement in order to strengthen the available evidence.

[National expert consensus on clinical diagnosis and treatment of hot crush injury wound (2023 version)].

Hot crush injury is a kind of damage with high disability rate. Although some experience has been accumulated in diagnosis and treatment of hot crush injury over the years, its treatment is often not standardized and difficult to achieve a satisfactory therapeutic effect due to insufficient understanding of the particularity of hot crush injury wounds. In order to standardize the treatment of hot crush injury wounds and improve the treatment effect of hot crush injury wounds and the life quality of patients, the Burns and Trauma Branch of Chinese Geriatrics Society, Branch of Burn and Trauma Wound Repair Materials of Chinese Society of Biomaterials, and Wound Repair Professional Committee of Chinese Medical Doctor Association have reached a consensus on the causes, types, wound treatment, and precautions of hot crush injury based on the current situation and clinical experience in the diagnosis and treatment of hot crush injury at home and abroad. It would provide a reference for clinical diagnosis and treatment of hot crush injury wounds.

Assessment and Management of Acute Burn Injuries.

Burn injuries can affect patients from all walks of life and represent a significant healthcare problem globally. The skin is the largest organ of the body and consequences of injury range of minor pain to severe end-organ dysfunction and even death. The acute assessment and management of burn-injured patients is a critical part of their short-term and long-term outcomes and often benefit from specialty, multidisciplinary care. Local wound care and appropriate excision and grafting are important parts of managing the functional, cosmetic, and physiologic derangements caused by burn injuries. Large burns also require judicious fluid resuscitation. Electrical, chemical, and inhalational injuries are less common than thermal burns but require additional care and are often associated with increased morbidity.

[Rational local wound therapy in children with burn injury]. / Ratsional'naya mestnaya terapiya ran u detei s ozhogovoi travmoi.

The outcomes of the Optimelle® dressing line use were analyzed. The effectiveness and safety of these therapeutic dressings in patients with thermal injury have been proven. A significant therapeutic effect was shown with the combination use of the proposed dressings, depending on the phase of the wound process and the depth of tissue injury due to hot fluid. Possible complications, particularly allergic reactions and contact dermatitis, were identified. Prevention and adequate local non-surgical therapy of complications are described. Three clinical cases are presented.

Meta-analysis of the diagnostic value of serum procalcitonin for burn sepsis in adults.

OBJECTIVE: Serum procalcitonin (PCT) reflects the infection status of the organism and the severity of the infection. The purpose of this study was to systematically evaluate the diagnostic value of serum PCT for burn sepsis in adults and to provide a factual basis for future clinical diagnosis and decision-making. MATERIALS AND METHODS: On August 16, 2022, six databases were searched in this study and a total of 856 studies were found. The retrieved literature was comprehensively evaluated according to the inclusion and exclusion criteria, and the valid data were extracted and included for analysis. The number of true positives, false positives, true negatives and false negatives were used as indicators to evaluate the diagnostic value of serum PCT for burn sepsis in adults. RESULTS: In total, 15 studies met the inclusion criteria. Meta-analysis showed a combined sensitivity of 0.78 (95% CI: 0.69-0.84), a combined specificity of 0.85 (95% CI: 0.77-0.91), a combined positive likelihood ratio of 5.17 (95% CI: 3.25-8.25), a combined negative likelihood ratio of 0.26 (95% CI: 0.19-0.37), and a combined diagnostic ratio of 19.63 (95% CI: 10.17-37.90). The AUC was 0.88 (95% CI: 0.85-0.90). CONCLUSIONS: Serum PCT provides good early diagnostic benefits for burn sepsis in adults. More high-quality studies are required to clarify its specific early diagnostic value.

Burns in Children: Accidental or Inflicted?

This article provides a review of burns in childhood with a focus on the characteristics that help differentiate abusive from accidental burns. Case presentations are used to highlight important differences in the way that abusive versus accidental burns present to medical care.

A prospective study for an alternative probe site for pulse oximetry measurement in male patients with severe burn trauma: penile shaf.

BACKGROUND: Authors widely use pulse oximetry in clinical monitoring of heart rate (HR) and peripheral oxygen saturation (SpO2) by attachment to the fingers; however, there can be a need for an alternative attachment site, especially for burned patients. We investigate the availability of a pulse oximeter probe attached to the penile shaft as an alternative site in pediatric male patients if all extremities became unavailable for pulse oximetry measurement due to severe burn and/or trauma. METHODS: We designed a prospective comparative study in a training and research hospital. After local ethical committee approval, pediatric male cases eligible for penile and extremity pulse measurements were evaluated during general anesthesia for medical dressing and/or grafting due to severe burns. One probe was attached to the fingers of the unburned extremity, and the other was to the penile shaft. Furthermore, we recorded SpO2and HR values at 5-min intervals; 0th (baseline), 5th, 10th and 15th minutes. We compared HR and SpO2values measured by the finger probe with those measured by the penile probe. RESULTS: Data of 51 patients (median age, 2.9 years (interquartile range, 2.0-5.0 years)) in whom the duration of dressing was at least 15min were analyzed. There was no significant difference either in comparisons of hemodynamic measurements (HR and SpO2 ) obtainedby finger probe and by a penile probe for each measurement time. The Bland-Altman plot analysis reveals agreement for penile and finger probes with a mean bias value between 0.20 and 0.37 on HR and between 0.43 and -0.20 on SpO2. DISCUSSION: This clinical trial demonstrated that pulse oximetry measurement under nonhypoxic conditions we could perform confidently using penile probes in pediatric male patients whose extremities are unavailable for measurement.

[Treatment of patients with burns in surgical clinics of Leningrad hospitals in 1920-1930s]. / Lechenie bol'nykh s ozhogami v khirurgicheskikh klinikakh meditsinskikh institutov Leningrada v 1920­1930-kh godakh.

OBJECTIVE: To reconstruct the events of early period of Soviet school of combustiology (1920-1930s) via analysis and systematization of clinical and experimental studies devoted to burns and performed in the Leningrad medical institutes in 1920-1930s. MATERIAL AND METHODS: We analyzed various reports by employees of the Leningrad medical institutes devoted to practice and theory of burn treatment within the above-mentioned historical period. RESULTS: Analysis of Soviet and foreign reports for 1920-1930s made it possible to systematize data on the treatment of burns in the Leningrad medical institutes for the period from the mid-1920s to the beginning of the Great Patriotic War. We presented experimental data on local and general processes following burn injuries. CONCLUSION: We discovered and introduced into scientific circulation some reports of Leningrad scientists on clinical and theoretical aspects of burn injuries which fell out of the field of view of modern researchers for various reasons. These data emphasize diverse work carried out by the staff of surgical and theoretical departments regarding the treatment of burn injuries.