Topically administered rhGM-CSF affects PPARß expression in the stasis zone.

Using a rat comb thermal damage model, we investigated the effects of topically administered recombinant human granulocyte-macrophage colony-stimulating factor (rhGM-CSF) on peroxisome proliferator-activated receptor PPARß expression. We created bilateral comb scald models on the backs of fifty Sprague-Dawley rats. The left sides of the backs served as the experimental group and the right sides served as the control group. The experimental group received topically applied rhGM-CSF hydrogel and the control group did not. The survival situations of the stasis zones were compared between the experimental and control groups on the 1st, 3rd, 7th, 14th and 21st post-burn days. Tissues from the surviving stasis zones of both groups were collected at different time-points. Reverse transcriptase-polymerase chain reaction (RT-PCR) and western blotting were used to detect the PPARß mRNA and protein expression levels. Immunohistochemical methods were applied to detect the localization of PPARß protein expression. The results showed that, first, the tissue viability numbers for the stasis zones of the experimental group were significantly increased compared with those of the control group. Second, RT-PCR revealed that the PPARß mRNA expression first increased and then gradually declined in both groups. At all time-points, the expression level in the experimental group was increased compared with that in the control group and the highest expression levels were observed in both groups on the 3rd post-burn day. Third, western blot analysis revealed that the PPARß protein expression in both groups increased after thermal damage and then gradually decreased. PPARß protein expression in the experimental group was greater than that in the control group, and the highest expression quantities in both groups were observed on the 3rd post-burn day. In conclusion, rhGM-CSF hydrogel effectively promotes the expression of PPARß, and the hydrogel had a specific protective effect for the stasis zone.

Effective symptomatic treatment for severe and intractable pruritus associated with severe burn-induced hypertrophic scars: A prospective, multicenter, controlled trial.

BACKGROUND: Burn-induced hypertrophic scars are disfiguring and can be associated with severe and intractable pruritus. No effective treatment modalities are currently available for symptomatic control of pruritus for most patients. We assessed the effect of the Antipruritic Hydrogel (CQ-01) in the symptomatic treatment of severe and intractable pruritus associated with burn-induced hypertrophic scars in a prospective, multicenter, controlled trial. METHODS: A pilot study was conducted in healthy adult volunteers to identify the most appropriate hydrogel formulation. A selected preparation called Chongqing No. 1 (CQ-01; a guar gum-based hydrogel impregnated with peppermint oil, menthol, and methyl salicylate by a nanoemulsion), showed an excellent symptomatic relief in an exploratory study in 2 patients with intractable pruritus. A statistically powered, prospective, multicenter, controlled study was then conducted in 74 patients to evaluate the efficacy and safety of a 24-h application of CQ-01 compared to a gel control and a negative control on three separate areas in each patient. Symptom assessment was based on our visual analog JW scale (ranging from 0 to 100) at baseline and various time points up to 7 days after application. Follow-up studies were conducted to determine the reproducibility of CQ-01 in repeated applications. RESULTS: Of the 74 enrolled subjects, the only observed adverse event was skin irritation reported in 6 patients (8%) and resolved shortly after gel removal. Compared to the baseline, the gauze negative control had a mean JW score reduction of 7; while the gel control and CQ-01 had a drop of 18 (p<0.001) and 36 (p<0.001), respectively. The CQ-01 clinical effect was significant for up to 3 days and waned slowly from 3 to 7 days. There was no statistical correlation between the treatment response and any of the demographic, patient or burn-related factors. Further studies showed a trend that repeated applications might be more effective, suggesting the absence of tachyphylaxis. CONCLUSIONS: This prospective, multicenter, controlled study showed that this novel hydrogel CQ-01 is safe and provides significant symptomatic relief for severe and intractable pruritus associated with hypertrophic scars, an unmet medical need for these patients. This effect is independent of the etiology of the burn trauma, extent of the scarring, and duration of the scar formation.

[Retrospective study on the myocardial damage of 252 patients with severe burn].

OBJECTIVE: To retrospectively analyze the risk factors and clinical manifestations of myocardial damage of patients with severe burn in order to provide evidence for its prevention and treatment. METHODS: Two hundred and fifty-two patients with severe burn admitted to 5 burn centers from January 2010 to June 2015, conforming to the study criteria, were treated in accordance with the fluid resuscitation formula of the Third Military Medical University. According to the creatine kinase isoenzyme-MB (CK-MB) level before treatment on admission, patients were divided into non-myocardial damage group (n=118, CK-MB level less than 75 U/mL) and myocardial damage group (n=134, CK-MB level higher than or equal to 75 U/mL). Data of patients in two groups were collected and evaluated such as gender, age, body mass, number of patients with chemical burn, admission time after injury, total burn area, full-thickness burn area, number of patients with inhalation injury, levels of haemoglobin, hematocrit, and blood lactate on admission and at post injury hour (PIH) 24 and 48, volumes of urine output and fluid input at PIH 24 and 48, levels of creatinine, urea nitrogen, total bile acid, diamine oxidase on admission and at PIH 24 and 48, and mortality. Furthermore, patients were divided into three groups, i. e. less than 50% total body surface area (TBSA) group (n=110), larger than or equal to 50% TBSA and less than 80% TBSA group (n=83), and larger than or equal to 80% TBSA group (n=59) according to the total burn area, and the incidence rates of myocardial damage in patients of three groups were recorded. Data were processed with chi-square test, t test, Wilcoxon test, analysis of variance for repeated measurement, and the values of P were adjusted by Bonferroni. Basic data of 252 patients were processed with binary logistic regression analysis. Receiver operating characteristic curve of total burn area of 252 patients was drawn to predict myocardial damage. RESULTS: (1) There were no statistically significant differences in age, body mass, number of patients with chemical burn, number of patients with inhalation injury, and full-thickness burn area between two groups (with t values respectively 0.20 and 0.31, χ(2) values respectively 0.49 and 4.10, Z=1.42, P values above 0.05). There were statistically significant differences in gender, admission time after injury, and total burn area of patients between two groups (χ(2)=5.00, with t values respectively 2.44 and 3.13, P<0.05 or P<0.01). (2) Gender, admission time after injury, and total burn area were independent risk factors related to myocardial damage in the patients (with odds ratios respectively 2.608, 3.620, and 1.030; 95% confidence intervals respectively 1.315-5.175, 1.916-6.839, and 1.011-1.049; P values below 0.01). (3) The incidence rates of myocardial damage of patients in less than 50% TBSA group, larger than or equal to 50% TBSA and less than 80% TBSA group, and larger than or equal to 80% TBSA group were 38.2% (42/110), 54.2% (45/83), and 61.0% (36/59) respectively, and there was statistically significant difference among them (χ(2)=9.46, P<0.05). (4) The total area under receiver operating characteristic curve of total burn area to predict myocardial damage of 252 patients was 0.706 (with 95% confidence interval 0.641-0.772, P<0.01), and 51.5% TBSA was chosen as the optimal threshold value, with sensitivity of 62.6% and specificity of 65.3%. (5) Compared with those in non-myocardial damage group, except the levels of haemoglobin and hematocrit at PIH 48 (with t values respectively -0.76 and -0.61, P values above 0.05), the levels of haemoglobin, hematocrit, and blood lactate of patients in myocardial damage group were significantly increased at each time point (with t values from -2.80 to -2.06, P<0.05 or P<0.01). Compared with those in non-myocardial damage group, the volume of urine output of patients was significantly declined (with t values respectively 2.05 and 3.68, P<0.05 or P<0.01), while the volume of fluid input of patients was not obviously changed in myocardial damage group at PIH 24 and 48 (with t values respectively 1.01 and 1.08, P values above 0.05). (6) Compared with those in non-myocardial damage group, the level of creatinine of patients was significantly increased on admission and at PIH 24 and 48 (with Z values from -2.91 to -1.99, P<0.05 or P<0.01), the level of urea nitrogen of patients was only significantly increased at PIH 24 and 48 (with t values respectively -4.75 and -5.24, P values below 0.01), the level of total bile acid of patients was not obviously changed on admission and at PIH 24 and 48 (with t values from -0.81 to -0.20, P values above 0.05), and the level of diamine oxidase of patients was only significantly increased on admission and PIH 24 in myocardial damage group (with t values respectively -3.97 and -2.02, P<0.05 or P<0.01). (7) Compared with that in myocardial damage group, the mortality of patients in non-myocardial damage group was significantly declined (χ(2)=5.81, P<0.05). CONCLUSIONS: Patients with severe burn have high incidence of myocardial damage, which may be predicted by total burn area. Severely burned patients with myocardial damage are more likely to suffer from decline of effective circulating volume, tissue oxygenation disorders, and damage in other organs in shock stage.

[Prevention and treatment strategy for burn wound sepsis in children].

Wound sepsis is one of the main causes of death in patients with severe burn and trauma. The high incidence of burn wound sepsis in children is attributed to their imperfect immune system function, poor resistance against infection, and the weakened skin barrier function after burn. The key to reduce the mortality of pediatric patients with burn wound sepsis is to enhance the understanding of its etiology, epidemiology, pathogenesis, and diagnostic criteria, in order to improve its early diagnosis and treatment.

An open, parallel, randomized, comparative, multicenter investigation evaluating the efficacy and tolerability of Mepilex Ag versus silver sulfadiazine in the treatment of deep partial-thickness burn injuries.

BACKGROUND: Partial-thickness burns are among the most frequently encountered types of burns, and numerous dressing materials are available for their treatment. A multicenter, open, randomized, and parallel study was undertaken to determine the efficacy and tolerability of silver sulfadiazine (SSD) compared with an absorbent foam silver dressing, Mepilex Ag, on patients aged between 5 years and 65 years with deep partial-thickness thermal burn injuries (2.5-25% total body surface area). METHODS: Patients were randomly assigned to either SSD (n = 82) applied daily or a Mepilex Ag dressing (n = 71) applied every 5 days to 7 days. The treatment period was up to 4 weeks. RESULTS: There was no significant difference between the two treatment groups with respect to the primary end point of time to healing, which occurred in 56 (79%) of 71 patients after a median follow-up time of 15 days in the Mepilex Ag group compared with 65 (79%) of 82 patients after a median follow-up time of 16 days in the SSD group (p = 0.74). There was also no significant difference in the percentage of study burn healed. Patients in the Mepilex Ag group had 87.1% of their study burn healed (out of the total burn area) compared with 85.2% of patients in the SSD group. However, the mean total number of dressings used was significantly more in the SSD group (14.0) compared with the Mepilex Ag group (3.06, p < 0.0001). There was no significant difference in the time until skin graft was performed between the two study groups. CONCLUSION: There was no difference in healing rates between Mepilex Ag and SSD, with both products well tolerated. The longer wear time of Mepilex Ag promotes undisturbed healing and makes it easier for patients to continue with their normal lives sooner. LEVEL OF EVIDENCE: Therapeutic study, level III.

Guidelines for burn rehabilitation in China.

Quality of life and functional recovery after burn injury is the final goal of burn care, especially as most of burn patients survive the injury due to advanced medical science. However, dysfunction, disfigurement, contractures, psychological problems and other discomforts due to burns and the consequent scars are common, and physical therapy and occupational therapy provide alternative treatments for these problems of burn patients. This guideline, organized by the Chinese Burn Association and Chinese Association of Burn Surgeons aims to emphasize the importance of team work in burn care and provide a brief introduction of the outlines of physical and occupational therapies during burn treatment, which is suitable for the current medical circumstances of China. It can be used as the start of the tools for burn rehabilitation.

[STUDY ON MODIFICATION OF BIOMATERIALS OF ACELLULAR BOVINE PERICARDIUM WITH DIFFERENT CROSSLINKING REAGENTS].

OBJECTIVE: To investigate the effects of modification of acellular bovine pericardium with 1-ethyl-3-(3- dinethylami-nopropyl) carbodimide (EDC)/N-hydroxysuccininide (NHS) or genipin and find out the best crosslinking reagent. METHODS: The cellular components of the bovine pericardiums were removed. The effects of decellularization were tested by HE staining. The acellular bovine pericardiums were crosslinked with EDC/NHS (EDC/NHS group) or genipin (genipin group). The properties of the crosslinked acellular matrix were evaluated by scanning electron microscope (SEM), matrix thickness, crosslinking index, mechanical property, denaturation temperature, enzymatic degradation, and cytotoxicity test before and after the crosslinking. Acellular bovine pericardium (ABP group) or normal bovine pericardium (control group) were harvested as controls. RESULTS: SEM showed that collagen fibers were reticulated in bovine pericardial tissues after crosslinked by EDC/NHS or genipin, and relative aperture of the collagen fiber was from 10 to 20 µm. The thickness and denaturation temperature of the scaffolds were increased significantly after crosslinking with EDC/NHS or genipin (P < 0.05), while there was no significant difference between EDC/NHS group and genipin group (P > 0.05). The difference had no statistical significance in crosslinking index between EDC/NHS group and genipin group (t = 0.205, P = 0.218). The degradation rate in EDC/NHS group and genipin group was significantly lower than that in ABP group and control group (P < 0.05). Elastic modulus and fracture stress in EDC/NHS group and genipin group were significantly lower than those in ABP group (P < 0.05), but there was no significant difference among EDC/NHS group, genipin group, and control group (P > 0.05). The break elongation in EDC/NHS group and genipin group were significantly increased than those in ABP group and control group (P < 0.05). The difference had no statistical significance in stability and mechanical properties between EDC/NHS group and genipin group (P > 0.05). Cytotoxicity of genipin crosslinked tissue (grade 1) were much lower than that of EDC/NHS (grade 2) at 5 days. CONCLUSION: Acellular bovine pericardium crosslinked with genipin has better biocompatibility than EDC/NHS.

Repair of lower extremity soft tissue defect with free musculo-cutaneous flaps bridging with healthy contralateral posterior tibial vessel / 中华整形外科杂志

<p><b>OBJECTIVE</b>To observe the clinical effects of free musculo-cutaneous flap bridging with contralateral posterior tibial vessel on repair of lower extremity soft tissue defect.</p><p><b>METHODS</b>From February 2006 to June 2013, 10 patients with soft tissue defect on lower shank and foot were included. The posterior tibial vessel on healthy lower extremity was chosen as recipient vessel and anastomosed with free latissimus dorsi musculo-cutaneous flap, or free latissimus dorsi musculo-cutaneous flap combined with thoracic-umbilical skin flap or anterolateral femoral musculo-cutaneous flap. The retrograde bridged flap was transposed to repair defect on contralateral lower shank and foot. The wound area ranged from 40 cm x 21 cm to 22 cm x 15 cm, with flap size from 48 cm x 26 cm to 25 cm x 18 cm. Meanwhile the defects on donor sites were covered with skin graft and both lower extremities were fixed with kirschner wires at middle tibia and calcaneus. The kirschner wires were removed at 4 weeks and pedicles were cut off 5-8 weeks postoperatively. Six patients received posterior tibial vessel reanastomosis at the same time of pedicle cutting.</p><p><b>RESULTS</b>All the 10 flaps survived and 3 patients received thinning of flaps due to excessive thickness. During the follow-up period of 3 months to 2 years follow up, the ambulatory function of injured legs recovered gradually with satisfactory appearance. The reanastomosed posterior tibial vessel on the healthy side was recovered.</p><p><b>CONCLUSIONS</b>Appropriate bridged musculo-cutaneous flaps is suitable for extensive soft tissue defect of lower shank and foot. It is a safe and effective method for limb salvage.</p>

Guideline for diagnosis, prophylaxis and treatment of invasive fungal infection post burn injury in China 2013.

Invasive fungal infection is one of the major complication of severe burns which can induce local or systemic inflammatory response and cause serious substantial damage to the patient. The incidence of fungal infection for burn victims is increasing dramatically during recent years. This guideline, organized by Chinese Society of Burn Surgeons, aims to standardize the diagnosis, prevention and treatment of burn invasive fungal infection. It can be used as one of the tools for treatment of major burn patients.

[Multi-center clinical trial of FLAMIGEL (hydrogel dressing) for the treatment of residual burn wound].

OBJECTIVE: To evaluate the effect of FLAMIGEL (hydrogel dressing) on the repair of residual burn wound. METHODS: Sixty burn patients with residual wounds hospitalized in 6 burn units from November 2011 to May 2012 were enrolled in the multi-center, randomized, and self-control clinical trial. Two residual wounds of each patient were divided into groups T (treated with FLAMIGEL) and C (treated with iodophor gauze) according to the random number table. On post treatment day (PTD) 7 and 14, wound healing rate was calculated, with the number of completely healed wound counted. The degree of pain patient felt during dressing change was evaluated using the visual analogue scale (VAS). The mean numbers of wounds with score equal to zero, more than zero and less than or equal to 3, more than 3 and less than or equal to 6, more than 6 and less than or equal to 10 were recorded respectively. Wound secretion or exudate samples were collected for bacterial culture, and the side effect was observed. Data were processed with repeated measure analysis of variance, t test, chi-square test, and nonparametric rank sum test. RESULTS: Wound healing rate of groups T, C on PTD 7 was respectively (67 ± 24)%, (45 ± 25)%, and it was respectively (92 ± 16)%, (72 ± 23)% on PTD 14. There was statistically significant difference in wound healing rate on PTD 7, 14 between group T and group C (F = 32.388, P < 0.01). Ten wounds in group T and four wounds in group C were healed completely on PTD 7, with no significant difference between them (χ(2) = 0, P > 0.05). Forty-two wounds in group T and seven wounds in group C healed completely on PTD 14, with statistically significant difference between them (χ(2) = 42.254, P < 0.01). Patients in group T felt mild pain during dressing change for 37 wounds, with VAS score higher than zero and lower than or equal to 3. Evident pain was observed in patients of group C during dressing change for 43 wounds, and it scored higher than 3 and less than or equal to 6 by VAS evaluation. There was statistically significant difference in mean number of wounds with different grade of VAS score between group T and group C (Z = -4.638, P < 0.01). Staphylococcus aureus, Pseudomonas aeruginosa, Klebsiella pneumoniae, E. coli, Baumanii, and Staphylococcus epidermidis were all detected in both groups, but there was no statistical difference between group T and group C (χ(2) = 0.051, P > 0.05). No side effect was observed in either of the two groups during the whole trial. CONCLUSIONS: FLAMIGEL can accelerate the healing of residual burn wounds and obviously relieve painful sensation during dressing change.

[Analgesic and sedative effects of inhaling a mixture of nitrous oxide and oxygen on burn patient during and after dressing change].

OBJECTIVE: To investigate the analgesic and sedative effects of inhaling a mixture of nitrous oxide and oxygen on burn patient during and after dressing change. METHODS: A total of 240 burn patients hospitalized in the Institute of Burn Research of Changhai Hospital Affiliated to the Second Military Medical University, Department of Burns of the First People's Hospital in Zhengzhou, and Department of Burns and Plastic Surgery of General Hospital of Ningxia Medical University from October 2011 to September 2012 were enrolled in our study, and they were all in accordance with the inclusion criteria. The 240 patients were divided into control group (n = 60, treated with inhalation of oxygen during dressing change) and treatment group (n = 180, treated with inhalation of a mixture of 65% nitrous oxide and oxygen during dressing change) according to the computer-generated list of random number. The other treatments in control group and treatment group were the same. Before, during, and after dressing change, heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), oxygen saturation (SO2), and adverse effects were observed. The degree of pain and anxiety felt by the patients were respectively evaluated with the visual analogue scale (VAS) and Chinese version of the burn specific pain anxiety scale (C-BSPAS) at the same time points as above. Data were processed with analysis of covariance, chi-square test, analysis of variance, and rank sum test. RESULTS: There were no significant differences between control group and treatment group in the levels of HR, SBP, DBP, and SO2 before dressing change (with F values respectively 0.76, 0.06, 1.11, 0.70, P values all above 0.05). Compared with those of control group, the levels of HR, SBP, DBP, and SO2 in treatment group were significantly ameliorated during dressing change (with F values respectively 81.78, 146.36, 226.44, 205.62, P values all below 0.01). After dressing change, the levels of DBP in the two groups were close (F = 0.31, P > 0.05), but the levels of HR, SBP, and SO2 showed statistical differences (with F values respectively 7.02, 8.69, 12.23, P < 0.05 or P < 0.01). Before dressing change, the VAS scores were approximate between control group and treatment group (Z = 0.21, P > 0.05). Compared with those in control group (9.4 ± 0.7, 1.7 ± 2.5), the VAS scores were significantly lowered in treatment group during and after dressing change (1.6 ± 1.3, 0.7 ± 1.1, with Z values respectively 11.84, 3.35, P values all below 0.01). There was no significant difference in C-BSPAS score between control group and treatment group before dressing change (Z = 0.62, P > 0.05). Compared with those in control group (75 ± 13, 73 ± 12), the C-BSPAS scores in treatment group were decreased during and after dressing change (9 ± 15, 9 ± 14, with Z values respectively 11.91, 12.28, P values all below 0.01). There were no obvious adverse effects in two groups before, during, and after dressing change. CONCLUSIONS: A mixture of nitrous oxide and oxygen seems to have obvious analgesic and sedative effects on burn patients during dressing change, and it can be widely used.

[Repairment of laryngeal fistula following electrical burn].

OBJECTIVE: To explore a method for the repairment of laryngeal fistula following electrical burn. METHOD: Sternocleidomastoid myocutaneous flap was applied to restore laryngeal fistula following electrical injuries. RESULT: The patient was cured with good repairment of cutaneous defect and laryngeal function following operation. CONCLUSION: Application of neighboring myocutaneous flap is beneficial for the reconstruction of damaged tissue.

[Early repair of full layer eyelid defect caused by chemical burn].

OBJECTIVE: To investigate the optimal time and method of the early repair of the full layer eyelid defect caused by chemical burn. METHODS: Free nasal septum mucosal cartilage flap with muscle flap, skin grafting, or skin flap were performed in 18 cases (19 eyelids) with chemical burn within 4 postburn weeks. Eyelid reconstruction and corneal transplantation were performed at the same time in 4 patients. RESULTS: All the reconstructed eyelids and transplanted cornea survived. The incidence of severe complications, such as exposure keratitis, corneal ulcer and eyeball perforation decreased. CONCLUSION: Full layer eyelid defect caused by chemical burn should receive early reconstruction and repair, including timely reconstruction of eyelid for the sake of protecting the eyesight and of alleviating the inflammatory reactions, and the corneal transplantation should be done at the same time to avoid corneal perforation. Nasal septum mucosal cartilage flap could be ideal for the eyelid reconstruction.