Laser-Assisted Drug Delivery in the Treatment of Hypertrophic Scars and Keloids: A Systematic Review.

Hypertrophic scars and keloids are the results of an exaggerated healing process and are often associated with significant patient morbidity. Fractional ablative lasers create microchannels in the skin and penetrate into the substance of the scar, inducing a normal healing response in zones of created damage. Focal delivery of scar-modulating agents into the scar through these microchannels-a process termed laser-assisted drug delivery (LADD)-is a promising and developing treatment modality. In this systematic review, we aim to critically examine the evidence of LADD in the treatment of hypertrophic scars and keloids. The evidence suggests that LADD improves outcomes in hypertrophic scars and keloids. LADD is a more effective treatment modality than the topical application of agents in hypertrophic scars and equally effective as the intralesional injection of agents in keloids. There were few reports of adverse events. Evidence supports the use of LADD as an adjunct to non-surgical measures or a treatment modality to be used before more invasive measures such as surgical excision. However, the quality of evidence supporting this conclusion is inconsistent and lacks power. Additional studies are required to optimize dosages, laser settings, and agent choices for the treatment of these lesions.

Mucormycosis following burn injuries: A systematic review.

INTRODUCTION: Mucormycosis is an opportunistic fungal infection with a high mortality rate. Though typically associated with diabetes and other conditions that affect innate immune function, infections can also be precipitated by conditions such as trauma and burns. Burn patients are particularly susceptible to fungal infections due to the immune dysfunction that often accompany their wounds. Indeed case series have described mucormycosis to occur in patients with burn injuries, however the factors contributing to mortality have not been well described. Thus, the purpose of our review was to identify factors contributing to morbidity and mortality in burn patients with Mucormycosis. METHODS: A systematic review of the literature of mucormycosis infection in burn injury patients was performed on Pubmed and Google Scholar using the keywords: Mucor, Mucorales, Mucormycosis, Mucormycotina, Zygomycosis and burn or thermal injury. Clinical trials, observational studies, case reports, and case reviews were included if they provided information regarding mortality in adult and pediatric burn patients diagnosed with mucormycosis, review articles, non-English articles, and articles without patient information were excluded. No time limit was placed on our review. Individual patient data was stratified based on mortality. Statistical analysis was performed to investigate the relationship between patient risk factors and mortality, and the Oxford Level of Evidence was used to evaluate study quality. RESULTS: 46 articles were included in our final review, encompassing 114 patients. On average, survivors had a total body surface area (TBSA)% of 46 (SD 19.8) while non-survivors had a TBSA of 65% (SD 16.4), and this difference was significant (p < .001). Patients with disseminated mucormycosis experienced an 80% mortality rate compared to 36% mortality rate in patients with localized disease (p < .001). We found no statistically significant difference in mean age (p > .05), diabetes (p > .05), mean delay in diagnosis (p > .05), time to antifungal therapy (p > .05), or type of therapy used (p > .05) between survivors and non-survivors. Our review was limited by the lack of prospective, controlled trials; thus, our review primarily consists of case reports. CONCLUSION: Disseminated infections and higher TBSA both increased the risk of mortality in burn patients with mucormycosis, while diabetes did not increase mortality risk. The severity of the initial injury and infection locations must be taken into consideration to inform patient prognosis.

Nonpharmacologic Management of Procedural Pain in Pediatric Burn Patients: A Systematic Review of Randomized Controlled Trials.

Pain following burn injury is associated with long-term health consequences in the pediatric population. Literature suggests nonpharmacologic treatment may provide improved pain control as an effective adjunct for these patients. This study aims to summarize randomized controlled trials on nonpharmacologic procedural pain management in pediatric burn patients. A systematic review was conducted on nonpharmacologic procedural pain management techniques used in the pediatric burn population. Fifteen studies were included and involved virtual reality, distraction devices, child life therapy, directed play, digital tablet games, cartoons, hypnosis, and music therapy. Treatment was effective in 8 out of 15 studies. Compared to controls, nonpharmacologic treatments reduced mid procedure pain by 19.7% and post-procedure pain by 20.1%. This study demonstrates that nonpharmacologic therapy can be an effective adjunct in pediatric procedural burn pain management, however further studies are needed to develop standardized algorithms to integrate nonpharmacologic treatments with pharmacologic therapies.

A systematic review of machine learning and automation in burn wound evaluation: A promising but developing frontier.

BACKGROUND: Visual evaluation is the most common method of evaluating burn wounds. Its subjective nature can lead to inaccurate diagnoses and inappropriate burn center referrals. Machine learning may provide an objective solution. The objective of this study is to summarize the literature on ML in burn wound evaluation. METHODS: A systematic review of articles published between January 2000 and January 2021 was performed using PubMed and MEDLINE (OVID). Articles reporting on ML or automation to evaluate burn wounds were included. Keywords included burns, machine/deep learning, artificial intelligence, burn classification technology, and mobile applications. Data were extracted on study design, method of data acquisition, machine learning techniques, and machine learning accuracy. RESULTS: Thirty articles were included. Nine studies used machine learning and automation to estimate percent total body surface area (%TBSA) burned, 4 calculated fluid estimations, 19 estimated burn depth, 5 estimated need for surgery, and 2 evaluated scarring. Models calculating %TBSA burned demonstrated accuracies comparable to or better than paper methods. Burn depth classification models achieved accuracies of >83%. CONCLUSION: Machine learning provides an objective adjunct that may improve diagnostic accuracy in evaluating burn wound severity. Existing models remain in the early stages with future studies needed to assess their clinical feasibility.

Use of Infrared Thermography for Assessment of Burn Depth and Healing Potential: A Systematic Review.

INTRODUCTION: Burn wound depth assessments are an important component of determining patient prognosis and making appropriate management decisions. Clinical appraisal of the burn wound by an experienced burn surgeon is standard of care but has limitations. IR thermography is a technology in burn care that can provide a non-invasive, quantitative method of evaluating burn wound depth. IR thermography utilizes a specialized camera that can capture the infrared emissivity of the skin, and the resulting images can be analyzed to determine burn depth and healing potential of a burn wound. Though IR thermography has great potential for burn wound assessment, its use for this has not been well documented. Thus, we have conducted a systematic review of the current use of IR thermography to assess burn depth and healing potential. METHODS: A systematic review and meta-analysis of the literature was performed on PubMed and Google Scholar between June 2020-December 2020 using the following keywords: FLIR, FLIR ONE, thermography, forward looking infrared, thermal imaging + burn*, burn wound assessment, burn depth, burn wound depth, burn depth assessment, healing potential, burn healing potential. A meta-analysis was performed on the mean sensitivity and specificity of the ability of IR thermography for predicting healing potential. Inclusion criteria were articles investigating the use of IR thermography for burn wound assessments in adults and pediatric patients. Reviews and non-English articles were excluded. RESULTS: A total of 19 articles were included in the final review. Statistically significant correlations were found between IR thermography and laser doppler imaging (LDI) in 4/4 clinical studies. A case report of a single patient found that IR thermography was more accurate than LDI for assessing burn depth. Five articles investigated the ability of IR thermography to predict healing time, with four reporting statistically significant results. Temperature differences between burnt and unburnt skin were found in 2/2 articles. IR thermography was compared to clinical assessment in five articles, with varying results regarding accuracy of clinical assessment compared to thermography. Mean sensitivity and specificity of the ability of IR thermography to determine healing potential <15 days was 44.5 and 98.8 respectively. Mean sensitivity and specificity of the ability of FLIR to determine healing potential <21 days was 51.2 and 77.9 respectively. CONCLUSION: IR thermography is an accurate, simple, and cost-effective method of burn wound assessment. FLIR has been demonstrated to have significant correlations with other methods of assessing burns such as LDI and can be utilized to accurately assess burn depth and healing potential.

Homeless Tent Fires: A Descriptive Analysis of Tent Fires in the Homeless Population.

Tent fires are a growing issue in regions with large homeless populations given the rise in homelessness within the United States and existing data that suggest worse outcomes in this population. The aim of this study was to describe the characteristics and outcomes of tent fire burn injuries in the homeless population. A retrospective review was conducted involving two verified regional burn centers with patients admitted for tent fire burns between January 2015 and December 2020. Variables recorded include demographics, injury characteristics, hospital course, and patient outcomes. Sixty-nine patients met the study inclusion criteria. The most common mechanisms of injury were by portable stove accident, assault, and tobacco or methamphetamine related. Median percent total body surface area (%TBSA) burned was 6% (interquartile range [IQR] 9%). Maximum depth of injury was partial thickness in 65% (n = 45) and full thickness in 35% (n = 24) of patients. Burns to the upper and lower extremities were present in 87% and 54% of patients, respectively. Median hospital length of stay (LOS) was 10 days (IQR = 10.5) and median ICU LOS was 1 day (IQR = 5). Inhalation injury was present in 14% (n = 10) of patients. Surgical intervention was required in 43% (n = 30) of patients, which included excision, debridement, skin grafting, and escharotomy. In-hospital mortality occurred in 4% (n = 3) of patients. Tent fire burns are severe enough to require inpatient and ICU level of care. A high proportion of injuries involved the extremities and pose significant barriers to functional recovery in this vulnerable population. Strategies to prevent these injuries are paramount.

Fractional CO2 laser treatment for burn scar improvement: A systematic review and meta-analysis.

Burn injury can cause abnormal healing and pathologic scar formation that significantly impairs patients' ability to return to baseline levels of functioning. Quality of life can be significantly diminished due to pain, stiffness, contracture, and the psychological burden of disfigurement. Traditional scar therapies such as silicone sheeting and compression garments are highly reliant on patient compliance, and have not demonstrated satisfactory efficacy. Even more invasive therapies such as intralesional medication delivery or surgical contracture release have high recurrence rates. Recently, fractional CO2 laser therapy has emerged as a promising treatment modality for burn scars, but there is a lack of recent studies that aggregates extant data to demonstrate outcomes after laser therapy. To address this, we conducted a systematic review and meta-analysis to determine the efficacy of fractional CO2 lasers in treating burn scars, and found that laser therapy alone yielded statistically significant improvements in scar profiles. There were very few reports of adverse effects, most treatments were provided as outpatient, and both patient and burn practitioners reported high satisfaction. By sharing our findings, we hope that more burn practitioners will consider adopting laser therapy as a safe and cost-effective first-line therapy for burn scar management.

Non-invasive early detection of cancer four years before conventional diagnosis using a blood test.

Early detection has the potential to reduce cancer mortality, but an effective screening test must demonstrate asymptomatic cancer detection years before conventional diagnosis in a longitudinal study. In the Taizhou Longitudinal Study (TZL), 123,115 healthy subjects provided plasma samples for long-term storage and were then monitored for cancer occurrence. Here we report the preliminary results of PanSeer, a noninvasive blood test based on circulating tumor DNA methylation, on TZL plasma samples from 605 asymptomatic individuals, 191 of whom were later diagnosed with stomach, esophageal, colorectal, lung or liver cancer within four years of blood draw. We also assay plasma samples from an additional 223 cancer patients, plus 200 primary tumor and normal tissues. We show that PanSeer detects five common types of cancer in 88% (95% CI: 80-93%) of post-diagnosis patients with a specificity of 96% (95% CI: 93-98%), We also demonstrate that PanSeer detects cancer in 95% (95% CI: 89-98%) of asymptomatic individuals who were later diagnosed, though future longitudinal studies are required to confirm this result. These results demonstrate that cancer can be non-invasively detected up to four years before current standard of care.

Should patients with chronic liver disease receive venous thromboembolism prophylaxis?

Chronic liver disease has long been considered the prime example of acquired bleeding disorders due to its associated coagulopathies, namely elevated international normalized ratio (INR) and thrombocytopenia. Recent evidence has shown that patients with chronic liver disease also are at risk for hospital-acquired venous thromboembolism (VTE). The safety and efficacy of low-dose anticoagulants for VTE prophylaxis have not been firmly established in this patient population. However, recent studies also indicate pharmacologic VTE prophylaxis can be used with caution in hospitalized patients with chronic liver disease.