Scars, burns & healing最新文献

Introduction: The UK government introduced lockdown measures on 23 March 2020 due to the first wave of the COVID-19 pandemic. A restructuring of clinical services was necessary to accommodate mandatory changes while also maintaining the best possible standards for patient care. The present study explored the initial management, follow-up and patient-reported outcomes of burn injuries <15% total body surface area (TBSA) during the height of the COVID-19 lockdown at a tertiary burns centre.

Methods: A retrospective review of all adult patients with burns <15% TBSA during the national lockdown (23 March 2020 to 10 May 2020) was undertaken at The Queen Elizabeth Hospital Birmingham (QEHB), UK. All referrals from non-QEHB telemedicine (external) or QEHB emergency (internal) departments were reviewed for management, length of hospital stay and pattern of follow-up (ward attender, self-care, community or outreach nurses). A telephone survey based on a structured questionnaire was conducted to establish patients' satisfaction.

Results: A total of 84 burn patients were included in the study. The mean age was 39 years (age range = 19-91 years) and the male:female ratio was 4:1. Patients were managed non-operatively (n = 69, 82%) or operatively (n = 15, 18%). Patients attended the ward attender acute burns clinic only once (n = 36, 61%). The telephone survey captured 70% (n = 59) of the study population and 57 patients (97% of respondents) were pleased with the ongoing care and burn healing.

Conclusion: The integration of patient led self-care, reduction in admissions, minimal clinics attendance and a telemedicine follow-up is an effective model for small burns management during the COVID-19 pandemic. A high degree of patient satisfaction was achieved with continuous and approachable communication channels with the burn multidisciplinary team. We continue to implement this effective model of burns management throughout the COVID-19 pandemic and the subsequent period.

Lay summary: The lockdown measures due to the first wave of COVID-19 pandemic affected the way we manage all medical emergencies including burns. The initial management, follow-up and patient satisfaction for small burn injuries during lockdown has not been reported previously. The aim of this study is to examine the outcome in terms of small burn management, hospital stay, number of clinic reviews, healing and patient satisfaction during the lockdown period in a burn centre in the UK. This would look at the need for operations and whether patients stayed longer if they required an intervention. We reviewed adult patients with small burns during the national lockdown (23 March 2020 to 10 May 2020) at The Queen Elizabeth Hospital Birmingham (QEHB). All referrals from telemedicine, referral system (external) or QEHB (internal) were reviewed for management, length of hospital stay and pa

Introduction: Keloids are pathological scars that are notorious for their chronic and relentless invasion into adjacent healthy skin, with commonly seen post-therapeutic recurrence after monotherapies.

Methods: An English literature review on keloid pathophysiology was performed by searching the PubMed, Embase and Web of Science databases, to find out the up-to-date relevant articles. The level of evidence was evaluated based on the included studies with the highest level of evidence first.

Results: Keloid morphology, signs, symptoms and the histopathological changes that occur in the local cells and extracellular matrix components are described. The theories on the pathophysiology of keloidogenesis that have been proposed to date are also covered; these include endocrinological, nutritional, vascular, and autoimmunological factors. In addition, we describe the local mechanical forces (and the mechanosignalling pathways by which these forces shape keloid cell activities) that promote keloid formation and determine the direction of invasion of keloids and the body sites that are prone to them.

Conclusion: A better understanding of this pathological entity, particularly its mechanobiology, will aid the development of new diagnostic and therapeutic strategies for use in the clinic to prevent, reduce or even reverse the growth of this pathological scar.

Lay summary: Keloids are skin scars that are famous for their chronic invasion into healthy skin, with commonly seen recurrence after surgeries. Cells such as lymphocytes, macrophages, mast cells and endothelial cells are involved in keloid growth. Particularly, endocrinological, nutritional, vascular, autoimmunological and mechanical factors actively take part in keloid progression.

Introduction: Many risk factors have been reported to increase mortality among burn patients. Previously, a higher mortality incidence was reported in acute burn patients infected with multidrug-resistant organisms (MDROs) when compared to patients infected with non-MDROs. However, considering this as an independent risk factor for mortality in acute burn patients is not yet confirmed.

Methods: We conducted an observational retrospective study in Qatar. We included adult patients admitted to the surgical intensive care unit (ICU) between January 2015 and December 2017 with burn injuries involving either at least 15% of the total body surface area (TBSA) or less than 15% with facial involvement. All patients developed infection with a positive culture of either MDRO or non-MDRO. The primary outcome was in-hospital mortality. Other outcomes included days of mechanical ventilation, ICU, length of stay in hospital, and requirement of vasoactive agents.

Results: Fifty-eight patients were included in the final analysis: 33 patients in the MDRO group and 25 patients in the non-MDRO group. Six patients (18.2%) died in the MDRO group versus four patients (16%) in the non-MDRO group (P = 1). No significant difference was observed between the two groups with regard to the ICU length of stay. However, there was a trend towards increased median length of stay in hospital in the MDRO group: 62 days versus 45 days in the non-MDRO group (P = 0.057). No significant differences were observed in the other outcomes.

Conclusion: In severely burned patients, infection with MDRO was not associated with increased mortality. There was a trend towards increased hospitalisation in MDRO-infected patients. Further studies with a larger sample size are needed to confirm these results.

Lay summary: Many factors affect mortality in burn patients admitted to the intensive care unit, such as age, total body surface area involved in the injury, and others. In this retrospective study, we evaluated whether wound infection with a bacterial organism resistant to multiple classes of antibiotics (multidrug-resistant) is considered an independent risk factor for mortality in critically ill burn patients. We included 58 patients requiring intensive care admission with burn injuries involving 15% or more of the total body surface area or less than 15% but with facial involvement. A total of 33 patients were infected with multidrug-resistant organisms (MDROs) and 25 patients with non-MDROs. Six patients (18.2%) from the MDRO group died versus four (16%) in the non-MDRO group. The MDRO group required a longer stay in hospital and an average of one more day on a mechanical ventilator. We concluded that wound infection with MDROs might not increase mortality when compared to wound infection with non-MDROs, although other studies with a larger number of patients involve

Introduction: Ophthalmological complications such as orbital compartment syndrome (OCS) and ischemic optic neuropathy are rare complications in patients with burns and have been described in patients where aggressive fluid resuscitation was performed. While OCS requires urgent surgical intervention, no current treatment is established to treat, or prevent, ischemic optic neuropathy in patients with burns.

Methods: The authors report a case of a 38-year-old woman with flame burns including the periorbital regions who developed OCS on the left side and anterior ischemic optic neuropathy (AION) on the right side despite non-aggressive fluid resuscitation. Immediate lateral canthotomy combined with inferior cantholysis was performed on the left side.

Discussion and conclusion: OCS and AION need to be considered as potential complications even in critically ill patients with facial burns who do not receive aggressive fluid resuscitation. Whether an early surgical intervention will lower the risk of AION development is, however, speculative.

Lay summary: Ophthalmological complications such as orbital compartment syndrome and ischemic optic neuropathy are rare complications in patients with burns and have been described in patients where aggressive fluid resuscitation was performed. We present a case of a critically ill patient with severe facial burns who developed orbital compartment syndrome on the left side and anterior ischemic optic neuropathy on the right side even though our patient did not receive aggressive fluid resuscitation.Our case is particular because both of these rare complications are seen in a single patient and neither received aggressive fluid resuscitation. The fact that the patient did not develop ischemic optic neuropathy on the side where the lateral canthotomy was performed (only on the side where the patient had orbital compartment syndrome), this case might raise the discussion of whether an early surgical intervention might lower the risk of ischemic optic neuropathy development in patients with facial burns.

Introduction: Scar treatments aim to address pathologic collagen deposition; however, they can be expensive or difficult to control. Electrochemical therapy (ECT) offers a simple alternative treatment. The purpose of this study is to examine the acid-base and histological changes in ex vivo human abdominal skin following ECT.

Methods: Forty-two ex vivo human panniculus tissue sections collected from six individuals were tumesced with normal saline. ECT was performed by inserting two platinum needle electrodes connected to a DC power supply into each specimen. Voltage was varied (3-6 V) and applied for 5 minutes. Each specimen was sectioned across both electrode insertion sites and immediately stained with pH sensitive dye. The width of dye color change for each dosimetry pair was calculated. Hematoxylin and eosin staining was used to evaluate samples.

Results and discussion: ECT caused a spatially localised and dose-dependent increased area of acidic and basic pH around the anode and cathode, respectively. A significantly greater mean width of pH change was generated at the cathode compared to the anode in all treatment groups. Histological evaluation displayed broad condensation and hyalinisation of dermal collagen.

Conclusion: ECT triggered dermal pH alterations and changed the underlying structural framework of the specimen. This technology may serve as a low-cost, minimally invasive local soft-tissue remodeling technique with potential application in scar management.

Level of evidence: 5.

Lay summary: Electrochemical therapy is a novel treatment that causes spatially selective dermal injury in areas of interest. This study measures the effects of electrochemical therapy when applied to abdominal skin. Electrochemical therapy appears to have beneficial effects by causing a highly localised reduction in collagen content or local softening of tissue, which is consistent with other studies on scar therapies, including chemexfoliation, radiofrequency technologies, and lasers. However, electrochemical therapy can be performed at a fraction of the costs of these aforementioned modalities.

Introduction: Pyogenic granuloma (PG) is a reactive inflammatory vascular lesion of the skin and mucous membranes, characterised by the presence of enlarged venules and seamed and seamless capillaries with plump endothelial cells (EC), and numerous macrophages. EC activation upregulates the synthesis of galectins and induces their translocation to the EC surface promoting angiogenesis and lymphangiogenesis, particularly galectin-1 (Gal-1), Gal-3 and Gal-8. However, the presence and distribution of Gal-1, -3 and -8, as well as their implications in the pathogenesis of PG, has not been considered.

Materials and methods: Eight biopsies from patients diagnosed with PG were selected. The presence of PECAM-1/CD31, IL-1β, VEGF-C, VEGFR-2, VEGFR-3, integrin β1, CD44, fibronectin and Gal-1, -3 and -8 was assessed by immunofluorescence staining using confocal laser scanning microscopy.

Results and discussion: Immunostaining revealed that these molecules were present in the enlarged venules with plump ECs, in some macrophages and other immune cells. We propose that macrophages release VEGF-A and VEGF-C inducing VEGFR-2/VEGFR-3 expression and activation, leading macrophages to transdifferentiate into plump ECs that might integrate into pre-existing venules, contributing to the formation of enlarged venules with transluminal bridges and capillaries. EC activation, induced by certain cytokines, has been shown to stimulate galectin expression and changes in the cellular localisation through association and activation of specific EC surface glycoproteins. Therefore, it is plausible that Gal-1, -3 and -8, acting in a concerted manner, could be mediating the transdifferentiation of macrophages into plump ECs and facilitating their migration and incorporation into the new vessels.

Lay summary: In this study, immunostaining of pyogenic granuloma (PG) tissue sections showed immunoreactivity for PECAM-1/CD31, IL-1β, VEGF-C, VEGFR-2 and VEGFR-3, and galectin-1, -3 and -8 in enlarged venules with plump endothelial cells (EC), as well as in some macrophages and other immune cells. Interestingly, enlarged and thin-walled transient vessels lined by PECAM-1/CD31 and VEGFR-2 immunopositive ECs that form from pre-existing normal venules in response to VEGF-A (called 'mother' vessels [MV]) and that undergo intraluminal bridging evolving into various types of capillaries (called 'daughter' vessels [DV]) have been observed in benign and malignant tumours, in physiological and pathological angiogenesis as well as in vascular malformations, suggesting an important role for VEGF-A and VEGFR-2 in such a process. However, it is not only the mechanisms by which the MVs evolve in different types of DVs that remains to be elucidated, but also whether the cells that form intraluminal bridges proceed from locally activated ECs or whether they are derived from bone marrow precursors or from resident ma

Background: The surgical approach to the volar structures in the digits must be designed to provide adequate exposure of tendons, vessels and nerves but also in a way that prevents flexion contracture of the digit as the scar contracts. This is traditionally done using a zigzag 'Bruner' incision, first described by Dr Julian M Bruner in 1967. In this paper, we describe an alternative approach, the Volar Oblique incision, and present a single institutional cohort of patients who have undergone procedures beginning with this approach.

Methods: A retrospective cohort study was performed on eight cases that involved a Bruner incision and eight similar cases that involved a volar oblique incision. Charts were reviewed for demographic data. Patients were asked to return to clinic postoperatively for scar assessment using the Patient and Observer Scar Assessment Scale (POSAS), where lower scores correspond to more favourable scar characteristics. The average follow-up period was 22 months. While in clinic, standard joint measurements were taken to assess for any proximal interphalangeal joint contracture. Demographics and questionnaire data were analysed using the Mann-Whitney U test for non-parametric data and quantitative joint measurements were analysed using Student's t-test.

Results: There was no difference in flexion contracture between the two groups. The POSAS patient score for scar irregularity was lower in the volar oblique group compared to the Bruner group, but there was no difference in any of the other subcategories, the total patient score, nor the overall patient opinion. The total POSAS observer score was lower in the volar oblique group compared to the Bruner group, with lower scores in the scar thickness, observed relief and observed pliability subcategories as well as the overall observer opinion.

Conclusion: The volar oblique incision appears to be satisfactory alternative to the classic Bruner incision in hand surgery that requires volar exposure of the digits. Future studies are needed to assess the validity of these findings on a larger scale.

Lay summary: There are various types of incisions that surgeons use when they operate on fingers. When choosing an incision, it is important that the incision provides good exposure to the deeper structures but does not form a tight scar that limits movement of the finger (contracture).A commonly used incision for the palmar side of the finger is the zig-zag or 'Bruner' incision. Some people, however, find this zig-zag scar unappealing. We started using a single diagonal incision, which we have called the volar oblique, instead of the zig-zag Bruner for access to the middle joint of the finger. We wanted to describe the volar oblique technique and then compare the quality of these two scars and also assess if one limits movement of the finger more than the other.Our researc

Introduction: Laser Doppler imaging (LDI) is the 'gold standard' tool for the assessment of burn depth. However, it is costly. The FLIR ONE is a novel, mobile-attached, thermal imaging camera used to assess burn wound temperature. This study compares the FLIR ONE and LDI in assessing burn depth and predicting healing times.

Methods: Forty-five adult patients with burn wounds, presenting at 1-5 days, were imaged with the FLIR ONE and LDI. Infected, chemical and electrical burns were excluded. Healing potential was determined by comparing wound and normal skin temperature for the FLIR ONE and blood flow changes with the LDI. Healing potential was categorised into wounds healing in less than and over 21 days. Pearson's test was used to determine the correlation between changes in wound temperature and healing potential.

Results: Percent total body surface area (%TBSA) was in the range of 0.5-45. FLIR demonstrated a sensitivity of 66.67% and specificity of 76.67% in predicting healing within 21 days, while LDI demonstrated a sensitivity of 93.33% and specificity of 40%. The FLIR ONE showed a significant difference in the mean temperature changes between burns that healed in less than (0.1933 ± 0.3554) and over 21 days (-1 ± 0.4329) (P = 0.04904). Pearson's test showed a significant correlation between the difference in wound and normal skin temperature with healing times (P = 0.04517).

Conclusion: The inexpensive FLIR ONE shows a significant correlation between changes in wound temperature and healing times. It is useful in predicting healing within 21 days. However, evaporative cooling at the wound surface can lead to overprediction of healing times and overtreatment.

Lay summary: Background Laser Doppler imaging is currently the main tool for burn depth assessment. It works by analysing the blood flow in a burn wound. Based on these findings, it can predict the depth of the burn injury and predict if it will heal in less than or over 21 days. The main problem is that it is costly. The FLIR ONE is a novel, mobile-attached, thermal imaging camera. It can be used to assess burn depth by comparing the temperature of the burn wound to the surrounding normal skin. This information can then be used to predict healing times into less than and over 21 days. The issue being explored The usefulness of the FLIR ONE in assessing burn depth and predicting healing time when compared to the LDI. How was the work conducted? Forty-five adult patients who sustained a burn injury within the last five days were imaged with both the FLIR ONE and LDI. Those with infected, electrical or chemical burns were excluded. Healing potential was determined by comparing the temperature of the burn wound with normal skin for the FLIR ONE and by changes in wound blood flow with the LDI. Healing potential was categorised into wounds healin

Introduction: A wide variety of non-invasive treatments has been proposed for the management of hypertrophic burn scars. Unfortunately, the reported efficacy has not been consistent, and especially in the first three months after wound closure, fragility of the scarred skin limits the treatment options. Extracorporeal shock wave therapy (ESWT) is a new non-invasive type of mechanotherapy to treat wounds and scars. The aim of the present study was to examine the objective and subjective scar-related effects of ESWT on burn scars in the early remodelling phase.

Material and methods: Evaluations included the Patient and Observer Scar Assessment Scale (POSAS) for scar quality, tri-stimulus colorimetry for redness, tewametry for trans-epidermal water loss (TEWL) and cutometry for elasticity. Patients were randomly assigned to one of two groups, the low-energy intervention group or the placebo control group, and were tested at baseline, after one, three and six months. All patients were treated with pressure garments, silicone and moisturisers. Both groups received the ESWT treatment (real or placebo) once a week for 10 weeks.

Results: Results for 20 patients in each group after six months are presented. The objective assessments showed a statistically significant effect of ESWT compared with placebo on elasticity (P = 0.011, η2P=0.107) but revealed no significant effects on redness and TEWL. Results of the clinical assessments showed no significant interactions between intervention and time for the POSAS Patient and Observer scores.

Conclusion: ESWT can give added value to the non-invasive treatment of hypertrophic scars, more specifically to improve elasticity when the treatment was already started in the first three months after wound closure.

Lay summary: Pathological scarring is a common problem after a burn injury. A wide variety of non-invasive treatments has been proposed for the management of these scars. Unfortunately, the reported efficacy of these interventions has not been consistent, and especially in the first three months after wound closure, fragility of the scarred skin limits the treatment options. Extracorporeal shock wave therapy (ESWT) is a relatively new non-invasive therapy to treat both wounds and scars. The aim of the present study was to examine the scar-related effects of ESWT on burn scars in the early phase of healing.The scars were subjectively assessed for scar quality by the patient and an observer using the Patient and Observer Scar Assessment Scale (POSAS). Objective assessments included measurements to assess redness, water loss and elasticity. Forty patients were randomly assigned to one of two groups, the low-energy intervention group or the placebo control group (the device simulated the sound of an ESWT treatment but no real shocks were applied), and were tested at four timepoints up to si