The use of non-invasive instruments in characterizing human facial and abdominal skin.

BACKGROUND AND OBJECTIVE: The skin is highly variable. This variation, although helpful for function, causes inconsistencies when assessed using subjective scales. The purpose of this study is to measure differences in skin on the face and abdomen using non-invasive, objective devices as a method to eliminate subjective error and help reduce intra- and inter-observer variability in clinical analysis. STUDY DESIGN/MATERIALS AND METHODS: Eighty-eight subjects between the ages of 18 and 61 were enrolled in this study. These subjects varied in age, ethnicity, and Fitzpatrick score. Facial analysis was performed by clinical evaluation and utilizing non-invasive objective devices which included the DermaScan C 20 MHz HFUS (Cyberderm, Broomall, PA), Tru Vu (Johnson and Johnson), BTC 2000 (SRLI Technologies, Nashville, TN), Derma Unit SSC3 (CK Electronic, Köln, Germany), and the Chromometer. RESULTS: Non-invasive devices were shown to be consistent and accurate through repeated measurement at each of the anatomical points with error rates of less than 5%. Chromometer measurements were able to categorize patients into Fitzpatrick level. DermaScan measurements demonstrated decreasing skin thicknesses associated with increasing age, smoking, and female gender. Derma Unit SSC 3 showed gender and sun exposure related differences in sebum concentration, pH, and moisture content. The Derma Unit SSC 3 sebum concentration also showed correlation with Tru Vu readings for clogged pores and bacterial activity. CONCLUSION: The skin assessment scales that are in use today are often prone to variability and inaccuracy due to their subjectivity. Use of the described objective non-invasive facial analysis method provides an accurate, objective analysis of human skin which can be used to measure changes pre- and post-operatively, or even screen patients prior to procedure to identify non-responders or those prone to adverse events. Utilization of these devices introduces a foundation on which a strong evidence-based approach to aesthetic medicine can be built.

Use of Air Transport for Minor Burns: Is There Room for Improvement?

Since 1981, the number of US burn centers has decreased by 29%, resulting in more long distance referrals to remaining facilities. Air transport is often the only feasible method for remote patients to reach few remaining burn centers. A significant proportion of flown-in patients have minor burns and are discharged within 24 hours, representing potential over-utilization of resources with increased cost to the healthcare system for no perceptible benefit. We explored factors associated with air transport of burns and opportunities for system improvement. Retrospective review of burn patients transferred by air to regional burn center between January 2003 and June 2013. Demographic, injury and clinical outcome data were acquired from the institutional Burn Registry. Minor burns constituted 17.7% of all flown admits (236/1331). Children were more likely to be included in this cohort at 32% vs 21.6% of adults (P = .0004). The overtriaged cohort had significantly lower % total BSA than accurately triaged cohort (3.3% vs 15%; P = .0001). Subjects with electrical burn injury were twice as likely to be overtriaged than accurately triaged (10.6% vs 5%; P = .002). The average % total BSA in the overtriaged group was 3.3%; the face was most common area burned (47.7%). The average estimate of charges for transfer was between $25,000 and 30,000/patient. The incidence of overtriage among flown-in burn patients, approximately 20%, represents substantial unnecessary healthcare expenditure. Improved burn care education, incentives to increase use of telemedicine, and modification of American Burn Association guidelines to include consultation with a burn center rather than automatic transfer are needed to reduce this cost to the healthcare system.

Does a Nebulized Heparin/N-acetylcysteine Protocol Improve Outcomes in Adult Smoke Inhalation?

BACKGROUND: Smoke inhalation is a major source of morbidity and mortality. Heparin and N-acetylcysteine treatment has potential efficacy in inhalation injury. We investigated the impact of a heparin/N-acetylcysteine/albuterol nebulization protocol in adult patients with inhalation injury. METHODS: A retrospective review was performed of adult inhalation injury patients, admitted to a regional burn center between January 2011 and July 2012, who underwent a protocol of alternating treatments of heparin and N-acetylcysteine/albuterol nebulization every 4 hours. The study cohort was matched 1:1 by age, sex, and burn size to a control cohort admitted within 5 years before protocol implementation. RESULTS: The study (n = 20) and control cohorts (n = 20) were well matched, with nearly identical age (50 vs 49 years), sex distribution (70% male), burn size (total body surface area, 22% vs 21%), and inhalation injury, except grade I injuries (79% vs 47%, P = 0.01). The protocol did not change mortality (30% vs 25%, P = 0.72) or duration of mechanical ventilation (8.5 vs 8.8 days, P = 0.9). There was no difference in development of sepsis (40% vs 33%, P = 0.7) or acute respiratory distress syndrome (15% vs 10%, P = 1); however, those who received the protocol were more likely to develop pneumonia (45% vs 11%, P = 0.03). CONCLUSIONS: The implementation of a heparin/N-acetylcysteine/albuterol protocol did not reduce mortality or duration of mechanical ventilation in this cohort of adults with inhalation injury and resulted in a significant increase in pneumonia rates. Larger prospective studies are necessary, with close attention paid to minimizing the infection risk incurred from frequent administration of nebulized medications.

An athymic rat model of cutaneous radiation injury designed to study human tissue-based wound therapy.

PURPOSE: To describe a pilot study for a novel preclinical model used to test human tissue-based therapies in the setting of cutaneous radiation injury. METHODS: A protocol was designed to irradiate the skin of athymic rats while sparing the body and internal organs by utilizing a non-occlusive skin clamp along with an x-ray image guided stereotactic irradiator. Each rat was irradiated both on the right and the left flank with a circular field at a 20 cm source-to-surface distance (SSD). Single fractions of 30.4 Gy, 41.5 Gy, 52.6 Gy, 65.5 Gy, and 76.5 Gy were applied in a dose-finding trial. Eight additional wounds were created using the 41.5 Gy dose level. Each wound was photographed and the percentage of the irradiated area ulcerated at given time points was analyzed using ImageJ software. RESULTS: No systemic or lethal sequelae occurred in any animals, and all irradiated skin areas in the multi-dose trial underwent ulceration. Greater than 60% of skin within each irradiated zone underwent ulceration within ten days, with peak ulceration ranging from 62.1% to 79.8%. Peak ulceration showed a weak correlation with radiation dose (r = 0.664). Mean ulceration rate over the study period is more closely correlated to dose (r = 0.753). With the highest dose excluded due to contraction-related distortions, correlation between dose and average ulceration showed a stronger relationship (r = 0.895). Eight additional wounds created using 41.5 Gy all reached peak ulceration above 50%, with all healing significantly but incompletely by the 65-day endpoint. CONCLUSIONS: We developed a functional preclinical model which is currently used to evaluate human tissue-based therapies in the setting of cutaneous radiation injury. Similar models may be widely applicable and useful the development of novel therapies which may improve radiotherapy management over a broad clinical spectrum.