Comparative cohort analysis of pressure ulcer/injury in intensive care unit patients before and during the COVID-19 pandemic.

COVID-19 has emerged as a global pandemic leading to an increase in hospitalization and intensive care unit (ICU) admissions worldwide. Due to severe acute respiratory distress syndrome (ARDS), many patients require prone positioning, which is associated with increased pressure ulcer/injury (PU/PI) incidence. COVID-19 pathophysiology may favor the occurrence of PU/PI due to hypoxemia, inflammatory status, and vasculopathy. This study aimed to compare the incidence of PU/PI in ICU patients before and during the COVID-19 pandemic. A retrospective cohort study was conducted at a university hospital in Brazil. Data from the medical charts of every adult patient admitted to ICU from March to July 2019 and the same period in 2020 were collected. The group from 2019 included 408 patients admitted due to multiple causes, and the group from 2020 included 229 patients admitted due to COVID-19 infection. The incidence of PU/PI was significantly higher in patients admitted in 2020 compared to 2019 (62,5 vs. 33,8%, respectively). Also, PU/PI location and severity have been different between groups, with the patients with COVID-19 (2020 group) more exposed to stage 3, 4, and non-stageable lesions, as well as more PU/PI on face skin and other less common locations. In conclusion, the COVID-19 pandemic has highlighted a higher PU/PI incidence. ICU patients were older during the pandemic, had higher body mass index and comorbidities, and needed more invasive medical devices and pronation. The occurrence of PU/PI was also associated with prolonged hospitalization and mortality.

The role of the unilateral pectoralis major muscle flap in the treatment of deep sternal wound infection and dehiscence.

Deep sternal wound infection and dehiscence has been classified as complex wound, and its treatment is a challenge for the surgeon. There are many flap choices for its treatment, each one having advantages and drawbacks. The article by Wang et al. evidenced that the unilateral pectoralis major muscle flap is a simple and effective option for wound closure resulting from sternotomy dehiscence in infants and children. The report discussed herein highlights that the unilateral pectoralis major muscle flap has been a good and feasible option for the reconstruction of the sternal wound in adults, as previously described by our group and other authors. This technique presents low morbidity and acceptable esthetic and functional results, providing stability to the sternal region.

Evaluation of contraction of the split-thickness skin graft using three dermal matrices in the treatment of burn contractures: A randomised clinical trial.

Burn injuries commonly result in serious sequelae (such as skin contractures) in surviving patients, for which no single optimal solution is known. The goal of this study was to compare the late contraction of autologous skin grafts with or without dermal matrices used in the treatment of patients with burn contractures. This parallel design prospective, randomised and controlled clinical trial included patients with burn contracture treated using autologous skin grafts and dermal matrix. Patients were randomly assigned to one of the four groups: Integra® matrix (n = 10), Pelnac® matrix (n = 10), Matriderm® matrix (n = 9) or a Control Group (n = 10, without dermal matrix, only skin graft). The boundaries of skin defect were marked and transferred to a flat sterile surface for area measurement. The current area of the skin grafts was measured during surgery and compared with those obtained at 1, 3, 6 and 12 months postoperatively. Twelve months after surgery, the Control Group presented lower rates of skin graft contraction than Integra® (p < 0.01), Matriderm® (p = 0.01) and Pelnac® (p < 0.01) groups. Pelnac® resulted in larger skin graft contraction than Matriderm® (p < 0.01) and Integra® (p = 0.02), while differences between Integra® and Matriderm® were not significant (p = 0.16). The comparison between intraoperative and 12 months after surgery showed that the worst mean rates of skin graft contraction were from the Pelnac® (51.79%) and Matriderm® (59.17%). In patients with burn contractures, the use of these three dermal matrices did not reduce or avoid the occurrence of late contraction of the skin graft, so their use for this purpose should be carefully evaluated.

The role of negative pressure wound therapy (NPWT) on the treatment of pyoderma gangrenosum: A systematic review and personal experience.

Pyoderma gangrenosum (PG) is a rare painful ulcerative neutrophilic inflammatory skin disease, necessitating a high level of diagnostic suspicion associated with appropriate treatment to avoid progression. Negative pressure wound therapy (NPWT) has been efficiently used in the treatment of different types of wounds. However, the role of NPWT in the management of PG is still controversial, due to the risk of the pathergy phenomenon. In this article, we conducted a systematic review (according to the PRISMA guidelines) on the use of NPWT in the treatment of PG, and we report our personal experience with two patients treated with this device. The result of the review showed that articles on the topic are, in their entirety, of low levels of evidence, such as case series, case reports, and reviews. Improvement in wound healing with the use of NPWT was observed in 85.1% of the patients studied. Besides, a significant association between improvement in wound healing with NPWT and immunosuppressive therapy was observed. Regarding the cases reported here, both showed good outcomes with the use of NPWT and skin graft during the treatment of PG injuries. Due to the rarity of PG, there is a scarcity of studies with robust evidence for standardization and comparison between treatments, which consequently makes it difficult to select therapeutic options. However, based on this systematic review and reported cases, we consider NPWT a safe option for adjuvant treatment of wounds caused by PG if combined with systemic immunosuppression, which plays a key role in greater chances of successful treatment. This approach should be recommended, whenever possible, associated with skin grafting to accelerate wound closure. The role of negative pressure wound therapy (NPWT) on the treatment of pyoderma gangrenosum: a systematic review and personal experience.

Analysis of Adipose-Derived Stem Cells from Different Donor Areas and Their Influence on Fibroblasts In Vitro.

BACKGROUND: New regenerative treatments have emerged with the use of multipotent mesenchymal cells, with special interest in adipose-derived stem cells (ADSCs). In recent years, studies that have sought to identify possible quantitative or qualitative differences in ADSCs derived from different donor subcutaneous adipose tissue have shown divergent results making the determination of a preferential donor area still considered inconclusive. MATERIALS AND METHODS: The number of ADSCs present in the adipose tissue collected by liposuction was quantified between five different body areas from 17 women, by means of the CFU-F assay and to investigate possible qualitative differences in the ADSCs from these different areas by analyzing: cell surface markers, cell kinetics, action of the supernatant produced by ADSCs from different body areas on fibroblast migration and, finally, differences in the secretome present in the supernatant produced by these cells. RESULTS: The highest mean concentration of CFU-Fs was the dorsum (23.20 ± 26.13), and the lowest was the thighs (6.87 ± 5.04). No qualitative differences were observed in the expression of the cell surface markers or in cell kinetics. Supernatants produced by the ADSCs derived from the abdomen and the thighs demonstrated an increased rate of migration of fibroblasts in vitro similarly. No differences were observed in the secretome between the ADSCs groups. CONCLUSIONS: It was observed that the region of the dorsal upper back presented a greater number of ADSCs than the thighs. No qualitative differences were observed between the ADSCs of the five areas analyzed. NO LEVEL ASSIGNED: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Acute otitis externa because of negative pressure wound therapy applied over the head and ear canal for scalping treatment.

Scalping is considered a complex wound with difficult treatment, requiring early surgical intervention, reconstructive plastic surgery, and a multidisciplinary team. The reconstruction of the scalp frequently requires a combination of therapies, including temporary coverage, such as negative pressure wound therapy (NPWT). Complications of NPWT, such as bleeding, infection, and pain, have been described. However, there is no report of acute otitis externa (AOE) because of NPWT. In this article, we present an unprecedented clinical case - a female patient who developed AOE after scalping treatment with NPWT applied over the head and ear canal. We consider that it may be a result of the direct physical action of subatmospheric pressure, the presence of dressing covering the external meatus, and alteration of the bacterial population.

Early Application of Microsurgical Flaps in the Electric Burns of Extremities: A Two Institutional Case Series.

Some groups have avoided early microsurgical flaps in electrical burns under the pretext of injury to the microvasculature, which could increase vascular thrombosis. However, this option frequently results in amputation of the extremity. This study aims to evaluate the early application of microsurgical flaps for the treatment of electrical burns of extremities. A case series was retrospectively evaluated including patients with electrical trauma in extremities undergoing early microsurgical reconstruction. Data were obtained from medical charts, including age, trauma location, flap type and microvascular anastomosis, the need for other procedures, postoperative complications, the length of hospital stay after the flap surgery, and patient outcomes. Five microsurgical flaps were performed in less than 30 days to trauma, one anterolateral thigh flap to cover skin failure in upper limb, and four radial forearm flaps to cover failure in feet. The patient ages had a mean of 25.8 years (from 12 to 42 years). The microsurgical procedure occurred from 21 to 27 days after the burn, with a mean of 24.2 days. Hospital discharge had a mean of 26.6 days (from 19 to 35 days after the surgery). Only one patient required reintervention for re-anastomosis. All patients had a good flap viability, avoiding amputation of the affected extremity and with a proper preservation of function. The early application of microsurgical flaps for patients with electrical burns of extremities may provide adequate, sturdy, and stable skin coverage, contributing to the treatment of noble structures exposed and avoiding amputation of the extremities.

High-voltage electric stimulation of the donor site of skin grafts accelerates the healing process. A randomized blinded clinical trial.

INTRODUCTION: Severe burns benefit from skin grafting, and grafting surgery is of great importance in the treatment of these injuries. As a result, there is formation of an additional wound at the donor site, which is painful and susceptible to infection. However, the therapeutic approach to these problems at donor sites for skin grafting is insufficiently explored in the literature. AIM: To evaluate electrical stimulation of the donor sites of burn patients treated by grafting surgery. METHODS: This work evaluated 30 donor sites of cutaneous graft burn patients treated with high-voltage electrical stimulation. Subjects were randomized into two groups: electrical stimulation (GES), treated with electrostimulation (50min, 100Hz, twin pulses 15 us, monophasic), and the sham group (GS), treated by the same procedures but without current. Pain was assessed by visual analog scale daily before and after the electrical stimulation. The time elapsed until complete epithelization was evaluated (time of primary dressing detached spontaneously). Skin temperature was measured by thermography. The characteristics of donor sites were qualitatively evaluated using images and the plug-in CaPAS® (Carotid Plaque Analysis Software). RESULTS: The results showed a significant decrease in pain, which was absent on the third day in the GES and the sixth day in the GS. The time the primary dressing detached spontaneously in days decreased (p<0.05) (4.7±0.2) compared to the GS group (7.0±1.3). Donor site healing characteristics such as vascularization, pigmentation, height, the quantity of crust formed, irregularities, and the quality of healing was better in the GES; moreover, homogeneity and inertia of the images confirmed higher healing quality. CONCLUSION: As a result of the study, the technology shows promise and merits a larger study with objective assessments and different physical variables.

Unilateral pectoralis major muscle flap for the treatment of sternal wounds due to Ludwig's angina.

Necrotising descending mediastinitis may rarely originate from Ludwig's angina, which is an infection of the submandibular space. The use of the bilateral pectoralis major muscle flap for the treatment of sternal wound dehiscence is common, but reports of the unilateral application of this flap are scarce. This study aims to report the use of the unilateral pectoralis major muscle flap for the treatment of sternotomy dehiscence in a patient with mediastinitis due to Ludwig's angina. A 21-year-old male patient underwent an exploratory cervicotomy and median sternotomy for drainage of a submandibular infection that extended to the anterior, retropharyngeal and mediastinal cervical spaces. The patient had dehiscence of the sternal wound, and the unilateral pectoralis major muscle flap was used for reconstruction of the defect. This flap was able to completely cover the area of dehiscence of the sternotomy, and the patient presented a good postoperative evolution, without complications. The reconstruction technique using the unilateral pectoralis major muscle flap was considered a good option for the treatment of sternotomy dehiscence. It is an adjuvant method in the treatment of infections such as mediastinitis and osteomyelitis of the sternum secondary to Ludwig's angina, allowing a stable coverage of the sternum.

Curbing Inflammation in Skin Wound Healing: A Review.

Wound healing is a complex regulated process that results in skin scar formation in postnatal mammals. Chronic wounds are major medical problems that can confer devastating consequences. Currently, there are no treatments to prevent scarring. In the early fetus wounds heal without scarring and the healing process is characterized by relatively less inflammation compared to adults; therefore, research aimed at reducing the inflammatory process related to wound healing might speed healing and improve the final scar appearance.

Guanylate cyclase inhibition by methylene blue as an option in the treatment of vasoplegia after a severe burn. A medical hypothesis.

Today it is known that severe burns can be accompanied by the phenomenon of vasoplegic syndrome (VS), which is manifested by persistent and diffuse vasodilation, hypotension and low vascular resistance, resulting in circulatory and respiratory failure. The decrease in systemic vascular resistance observed in VS is associated with excessive production of nitric oxide (NO). In the last 2 decades, studies have reported promising results from the administration of an NO competitor, methylene blue (MB), which is an inhibitor of the soluble guanylate cyclase (sGC), in the treatment of refractory cases of vasoplegia. This medical hypothesis rationale is focused on the tripod of burns/vasoplegia catecholamine resistant/methylene blue. This article has 3 main objectives: 1) to study the guanylate cyclase inhibition by MB in burns; 2) to suggest MB as a viable, safe and useful co-adjuvant therapeutic tool of fluid resuscitation, and; 3) to suggest MB as burns hypotensive vasoplegia amine-resistant treatment.