Imiquimod to prevent keloid recurrence postexcision: A systematic review and meta-analysis.

Imiquimod 5% cream, an immune response modifier capable of inducing IFN-α, TNF-α, and interleukins 1, 6, and 8. It was approved for use in the management of genital and perianal warts and soon embraced as a method to diminish the recurrence of keloids postexcision. A previous meta-analysis included four studies. This meta-analysis is part of a larger systematic review project on the effect of moisturizers on scars. It was conducted following an a priori protocol and the guidance of the Joanna Briggs Institute. Databases searched included PubMed, CINAHL, Embase, and Web of Science. After screening and critical appraisal, subgroup meta-analysis on excision method and location of the keloid was conducted using the Miller approach for proportional meta-analysis and a random effects model. Seven studies, including 77 participants and 82 keloids were included. Meta-analysis revealed a recurrence rate of 39% (95% CI = 8.474.4%; I2 = 87.5%) following application of Imiquimod postexcision. The use of primary excision or tangential excision did not alter the outcome. For analysis based on the location of the keloid scar, earlobe keloids had a recurrence rate of 5.4% (95% CI = 0-21.7%; I2 = 52.9%). For keloids excised from other areas (predominantly on the trunk) recurrence rate was higher, at 76.8% (95% CI = 36.1-100%). For keloids, Imiquimod application postexcision results in highly variable recurrence rates. There is very low certainty in the effect of Imiquimod and it therefore is not recommended as a treatment option.

Reconstruction of Extensive Calvarial Exposure After Major Burn Injury in 2 Stages Using a Biodegradable Polyurethane Matrix.

OBJECTIVES: To share our experience of an extensive calvarial reconstruction in a severely burn-injured, elderly patient in a 2-stage procedure utilizing a novel biodegradable temporizing matrix (NovoSorb BTM), followed by autograft. MATERIALS AND METHODS: A 66-year-old patient with 75% full-thickness burns, including 7% total body surface area head and neck, with calvarial exposure of approximately 350 cm(2), complicated by acute renal failure and smoke inhalation injury. Exposed calvarium was burred down to diploe and biodegradable temporizing matrix was applied. Over the next 29 days, the biodegradable temporizing matrix integrated by vascular and tissue ingrowth from the diploe. Delamination and grafting occurred, however, at 43 days postimplantation of biodegradable temporizing matrix due to skin graft donor-site constraints. RESULTS: Graft take was complete, yielding a robust and aesthetically pleasing early result (26 days post-graft application). CONCLUSIONS: Biodegradable temporizing matrix offers an additional resource for reconstructive surgeons faced with fragile patients and complex wounds.

Variation of surface temperatures of different ground materials on hot days: Burn risk for the neuropathic foot.

The purpose of this study is to assess the relationship between ambient temperature and surface temperatures of commonly used building/ground materials, in order to estimate the risk of contact thermal injury. It is an observational study where the air ambient temperature and the surface temperatures of slate, metal, cement, sand, brick and bitumen, were measured, in shaded and unshaded conditions, on cloudy and cloudless days in summer in Adelaide, South Australia. All unshaded surfaces reached temperatures capable of causing significant sole of foot burns given requisite exposure time in both clear and overcast conditions, even with a relatively low ambient temperature. Shade imparted total protection from irreversible thermal injury for all of the ambient temperatures assessed. Although surface temperatures were reduced in overcast conditions, the temperatures recorded were still capable of causing thermal injury. Peripheral neuropathy prolongs heat exposure times, often resulting in significant and complex injury, requiring lengthy treatment and generating potentially poor functional outcomes. This study provides a reference point for the enactment of preventative measures for at risk population groups such a diabetics.

Face care amongst patients admitted to the Adult Burn Service: a best practice implementation project.

BACKGROUND: Burn injuries to the face and neck are very common. Once vital structures such as the mouth, ears, nose and eyes are damaged by burn injury, there will be pain, swelling, deformity and the potential for contractures to develop. This can lead to a lifetime of physical and psychological issues. It is very important to deliver evidence-based recommended practice in order to achieve the best outcome as these structures heal. OBJECTIVES: The aim of this project was to ensure the compliance of face care procedures with JBI evidence-based recommended practice. METHODS: This evidence implementation project employed the Joanna Briggs Institute Practical Application of Clinical Evidence System, and Getting Research into Practice audit and feedback tools. Design and implementation of strategies to improve practice involved identification of barriers and outlining strategies to overcome barriers, resources utilized and outcomes of this process. This project retrospectively surveyed the case notes of ten patients who sustained facial burns, based on both baseline and follow-up audits. RESULTS: Compliance with best practice audit criteria in the baseline audit was moderate to high (70-100%) in four out of 10 criteria. These criteria reflect appropriate administration of analgesia prior to wound care, attendance at education sessions on facial burns, ophthalmic testing being performed, assessment for inhalation injuries and mouth care. Poor compliance rates (10-40%) were seen in the criteria representing nasal care, explanation of the procedure to the client and eye and ear care. Documentation for these criteria was almost non-existent resulting in the outcome of poor compliance. Education sessions were held across both the Adult Burn Service and Intensive Care Unit settings with particular emphasis on the importance of complete documentation. The results of the follow-up audit showed significant improvement (67-100% compliance) in documentation for the performed procedures. CONCLUSIONS: The aims of the project were partially achieved. Future plans to undertake another project and look into the compliance rate of face care procedures with the face care protocol across both Adult Burn Service and Intensive Care Units have been discussed with current stakeholders. This will involve auditing a further ten cases of actual face care procedures performed by nursing staff in both settings.

A 365-day view of the difficult patients treated in an Australian adult burn center.

Although the effect of burns on mental health has been well examined, the aims of this study were to determine the prevalence of pre-existing mental health, drug and alcohol, and forensic problems in an Australian burn patient population; examine differences between these groups in terms of burns characteristics and healing; and also establish any patterns of presentation amongst these groups. Retrospective case notes of all the acute burn admissions, 273 patients, into a busy tertiary adults burn center in a full year were reviewed. Almost half of the patients admitted had underlying complex issues. Those with psychotic, forensic, and/or drug and alcohol problems tended to stay longer in hospital and required more procedures, despite burn sizes comparable with those in the general population. These patients also tended to sustain their burn injuries, and present to hospital, on a Saturday, Sunday, or Monday, rarely coming later in the week. Those with depression/anxiety had similar lengths of stay, number of procedures and random temporal presentations to the general burns population. Burn centers should be well staffed and educated in how to deal with patients with complex needs; this staffing should be actively structured to deal with a clear pattern of presentation over the weekend and Monday.

A randomized, controlled trial of negative pressure wound therapy of pressure ulcers via a novel polyurethane foam.

The objectives of the study were (1) to look for any local, clinically apparent response, within and around a debrided wound, to a novel biocompatible polyurethane foam during repeated, short-term implantation, and (2) to assess the material's efficacy as a negative pressure wound therapy (NPWT) interface compared with a widely used, commercially available foam. Twenty pressure ulcers in 18 patients underwent surgical debridement, then randomization to receive novel treatment or control foam as the wound interface for NPWT. Dressing changes every 2-3 days allowed qualitative wound assessment and quantitative measurement to compare outcomes. No adverse reaction was observed in any patient receiving the new foam. The new "novel foam" performed as a NPWT interface as effectively as the control "standard foam." In deep wounds, the new foam was easier to remove, fragmented less, and showed less retention than the control foam. No marginal in-growth occurred, making removal less traumatic and reducing bleeding from cavity wall granulations. The results support previous large animal studies, and independent ISO10993 testing, that the new foam is safe and biocompatible. Its efficacy as an NPWT interface, nontraumatic removal with low fragmentation and retention rate, favors the new material, especially in deep cavity wounds.

Vitamin D deficiency in burn patients.

Vitamin D deficiency has been reported in pediatric burn patients; however, no formal studies have been conducted in adult burn populations. The available literature on vitamin D status in burn patients has been reviewed. A literature search was conducted using Medline™, the Cochrane central register of controlled trials, and EMBASE to identify any trials of vitamin D deficiency in burn patients. Six published studies regarding vitamin D status in burn patients were found; however, five of these were in pediatric populations and several did not assess vitamin D levels as a major endpoint. Vitamin D deficiency has been demonstrated to result in itching, muscle weakness, and neuropathy, all of which are common postburn sequelae. The major source of vitamin D is synthesis in the skin with a small amount being absorbed through dietary intake. Population groups are at higher risk of vitamin D deficiency if they have inadequate exposure to UV light or reduced biosynthetic capability due to skin damage. Burn patients fall into both risk groups and also suffer common complaints that overlap with those reported by patients with vitamin D deficiency. Further research in adult burn patients is needed to determine the prevalence of deficiency in this population and whether vitamin D deficiency might influence postburn injury symptoms reported by patients.

Burns sustained whilst priming the carburetor: an Australian perspective.

Priming the carburetor is a method that is still commonly practiced amongst trained, amateur, and backyard mechanics. This article aims to look at the data available between 1996 and 2004 in two burns units in South Australia and Queensland. The authors were interested in the number of patients admitted with burns related to the activity of priming the carburetor, the TBSA percentage of burns, and areas affected. It also gives numbers of intensive care unit admissions and the number who underwent surgery for the management of the burns. The results showed that between the two centers, 48 patients were admitted following burns as a result of priming the carburetor. The activity carried no mortality during the time period of study but caused significant morbidity. Through the media, the authors are embarking on an educational program to reduce the risk of such burn injuries from this dangerous practice.

Comparison of a sealed, polymer foam biodegradable temporizing matrix against Integra® dermal regeneration template in a porcine wound model.

The aim of this study is to develop and optimize the first stage of a proposed two-stage skin graft replacement strategy. This entails creation of a material that can be applied immediately after burn excision to "temporize" the wound bed, become integrated as a "neodermis," resist contraction and infection, and provide the grounding for the second stage (an autologous, cultured composite skin). Four 8 × 8 cm wounds were generated in six pigs to assess and compare wound contraction using Integra® dermal regeneration template, a biodegradable temporizing polymer matrix (sealed and unsealed), and a secondary intention wound. All dressings were contiguous. Infection resulted in early spontaneous delamination of the Integra® marring the long-term comparison. The wounds treated with the sealed polymer thus contracted significantly less than the wounds treated with Integra® over the 28 days. Histologically, a thick layer of scar developed superficial to the Integra®, unsealed polymer, and in the secondary intention wounds when compared with the sealed polymer, where such a scar layer was characteristically minimal. No clinical signs of infection were observed for any polymer-treated wound. Once the Integra® silicone layer delaminated, wound contraction was aggressive. Optimization of the biodegradable sealing membrane is imminent, and the second stage of composite skin development is under way.

Split skin graft application over an integrating, biodegradable temporizing polymer matrix: immediate and delayed.

The objective of this study is to further investigate the NovoSorb™ biodegradable polyurethane in generating dermal scaffolds; to perform a pilot study comparing the previously used spun mat against a recently developed NovoSorb™ foam, ascertaining the optimum structure of the matrix; and to evaluate the successful matrix as an immediate adjunct to split skin grafting and as a temporizing matrix in a prospective six-pig study. A pilot study comparing a previously investigated form of the polymer (spun mat) against a new structural form, a foam, was performed. This was followed by a six-pig study of the foam matrix with three treatment arms-autologous split skin graft alone, polymer foam with immediate engraftment, and polymer foam with delayed engraftment. The foams allowed less wound contraction than the spun mats. The foam structure is less dense (cheaper to produce and having less degradation products). The material remained in situ despite clinical wound infection. Proof of concept was achieved in both treatment modalities in the main study. Split skin graft applied immediately over the polymer foam was able to engraft successfully. The result was "thicker" to pinch and "flush" with the skin surrounding the wound. There was no significant difference in the degree of wound contraction between the graft alone and the polymer plus immediate graft groups. Split skin graft also "took" when applied to the surface of a polymer that had been applied to a wound 11 days earlier, again with a thicker result, flush with the surrounding skin. Split skin grafts alone left a persisting depression. However, a significant degree of wound contraction (compared with the other two groups) was observed in the polymer plus delayed graft group. This has prompted further investigation into "sealing" the polymer foam with a membrane, to prevent evaporative water loss, when the foam is to be used as a biodegradable temporizing matrix. The studies indicate that the NovoSorb™ platform will allow the creation of two inexpensive dermal matrix products; an immediate scaffold to allow a thicker grafting result and a biodegradable temporizing matrix (BTM) for wound integration after burn debridement while donor sites become reharvestable. However, further modification on the BTM structure is necessary to further reduce wound contraction pregrafting.

Burns from hot wheat bags: a public safety issue.

INTRODUCTION: Wheat bags are therapeutic devices that are heated in microwaves and commonly used to provide relief from muscle and joint pain. The Royal Adelaide Hospital Burns Unit has observed a number of patients with significant burn injuries resulting from their use. Despite their dangers, the products come with limited safety information. METHODS: Data were collected from the Burns Unit database for all patients admitted with burns due to hot wheat bags from 2004 to 2009. This was analyzed to determine the severity of the burn injury and identify any predisposing factors. An experimental study was performed to measure the temperature of wheat bags when heated to determine their potential for causing thermal injury. RESULTS: 11 patients were admitted with burns due to hot wheat bags. The median age was 52 years and the mean total body surface area was 1.1%. All burns were either deep dermal (45.5%) or full thickness (54.5%). Ten patients required operative management. Predisposing factors (eg, neuropathy) to thermal injury were identified in 7 patients. The experimental study showed that hot wheat bags reached temperatures of 57.3°C (135.1°F) when heated according to instructions, 63.3°C (145.9°F) in a 1000 W microwave and 69.6°C (157.3°F) on reheating. CONCLUSIONS: Hot wheat bags cause serious burn injury. When heated improperly, they can reach temperatures high enough to cause epidermal necrosis in a short period of time. Patients with impaired temperature sensation are particularly at risk. There should be greater public awareness of the dangers of wheat bag use and more specific safety warnings on the products.

A comparison of wound area measurement techniques: visitrak versus photography.

OBJECTIVE: To investigate whether a cheap, fast, easy, and widely available photographic method is an accurate alternative to Visitrak when measuring wound area in cases where a non-wound-contact method is desirable. METHODS: The areas of 40 surgically created wounds on porcine models were measured using 2 techniques-Visitrak and photography combined with ImageJ. The wounds were photographed with a ruler included in the photographic frame to allow ImageJ calibration. The images were uploaded to a computer and opened with ImageJ. The wound outline was defined from the photographic image using a digital pad, and the ImageJ software calculated the wound area. The Visitrak method involved a 2-layered transparent Visitrak film placed on the wound and the outline traced onto the film. The top layer containing the tracing was retraced onto the Visitrak digital pad using the Visitrak pen and the software calculated the wound area. RESULTS: The average wound area using the photographic method was 52.264 cm(2) and using Visitrak was 51.703 cm(2). The mean difference in wound area was 0.560 cm(2). Using a 2-tailed paired T test, the T statistic was 1.285 and the value .206, indicating no statistical difference between the two methods. The interclass correlation coefficient was 0.971. CONCLUSIONS: The photographic method is an accurate alternative to Visitrak for measuring wound area, with no statistical difference in wound area measurement demonstrated during this study. The photographic method is a more appropriate technique for clean and uncontaminated wounds, as contact with the wound bed is avoided.

Capnocytophaga canimorsus: infection, septicaemia, recovery and reconstruction.

A case is presented of a life-threatening septicaemia and associated peripheral necrosing microembolic phenomenon, resulting from a dog lick to an insignificant burn wound. The isolated bacterium was Capnocytophaga canimorsus, a slow-growing Gram-negative bacillus commonly found in dog saliva. Any clinician seeing patients with a history of dog bite/saliva contact and progressive illness should consider this bacterium as a possible offender and take special care to elicit an accurate history, specifically including questions regarding animal contact.