Efficacy of transfer form implementation for adult burn patients between institutions to the Israeli National Burn Center.

Burns are serious injuries associated with significant morbidity and mortality. In Israel, burn patients are often transferred between facilities. However, unstructured and non-standardized transfer processes can compromise the quality of patient care and outcomes. In this retrospective study, we assessed the impact of implementing a transfer form for burn management, comparing two populations: those transferred before and after the transfer form implementation. This study included 47 adult patients; 21 were transferred before and 26 after implementing the transfer form. We observed a statistically significant improvement in reporting rates of crucial information obtained by Emergency Room clinicians and inpatient management indicators. Introducing a standardized transfer form for burn patients resulted in improved communication and enhanced primary management, transfer processes, and emergency room preparation. The burns transfer form facilitated accurate and comprehensive information exchange between clinicians, potentially improving patient outcomes. These findings highlight the importance of structured transfer processes in burn patient care and emphasize the benefits of implementing a transfer form to streamline communication and optimize burn management during transfers to specialized burn centers.

Spincare® System Demonstrates Safety and Efficacy in Treating Partial Thickness Burns.

Partial-thickness burns are the most common form of burns, affecting the dermis and possibly resulting in scarring and infection. The Spincare® System is a new device that uses electrospinning technology to create a temporary skin-like matrix that can be applied to wounds. This study evaluated the performance, safety, and efficacy of Spincare in treating superficial to partial-thickness burns not considered for surgery. A prospective single-arm, open-label, multicenter study was conducted in three adult burn units across Israel. Forty-four patients with superficial to intermediate burns of up to 10% of total body surface area (TBSA) were enrolled. Spincare was applied to the wounds, and follow-up visits were performed on days 7, 14, and 21 and months 3 and 6 post-treatment. Thirty-one patients with 36 wounds completed the day 21 visit. The mean wound healing area on day 21 was 97.26± 9.41%, and the mean healing time was 12.8±4.3 days. Only one moderate adverse event was observed concerning the treatment, and it is important to acknowledge the potential progression of this hypertrophic scar into a keloid. This study demonstrated that Spincare is a safe and effective device for treating superficial to intermediate partial-thickness burns. Spincare achieved rapid and complete wound healing with a low incidence of adverse events.

["PLASTICS" DURING THE WAR OF "IRON SWORDS" - THE ROLE OF A SPECIALIST IN PLASTIC AESTHETIC AND RECONSTRUCTIVE SURGERY].

INTRODUCTION: A war usually requires a new or adjusted set up and needs of all caregivers according to the "new" status. The current war in Israel began on the 7.10.2023. The Israeli Ministries of Defense and Health were in a new status in which they had to complete new requirements according to the use of new weapons, and in numbers and types of injuries that overwhelmed the system from the day the war began. In the past, we published evidence that in times of terror, as in times of war, epidemiology of injuries changes and requires adjustments in human resources, surgical tools and consumables in the Israeli health and defense systems. This article aims to describe the role of specialists in plastic, aesthetic and reconstructive surgery and the first response according to the existing system divided into prevention, preparedness, response and rehabilitation. In the long term rapid response, recruitment of human resources, abilities and flexibility of the system enables overcoming a sudden "new" status as in war, terror and mass casualty events.

The Implications of a Dermatopathologist's Report on Melanoma Diagnosis and Treatment.

An accurate and comprehensive histopathology report is essential for cutaneous melanoma management, providing critical information for accurate staging and risk estimation and determining the optimal surgical approach. In many institutions, a review of melanoma biopsy specimens by expert dermatopathologists is considered a necessary step. This study examined these reviews to determine the critical primary histopathology Breslow score in which a histopathology review would be most beneficial. Histopathology reports of patients referred to our institute between January 2011 and September 2019 were compared with our in-house review conducted by an expert dermatopathologist. The review focused on assessing fundamental histologic and clinical prognostic features. A total of 177 specimens underwent histopathology review. Significant changes in the Breslow index were identified in 103 cases (58.2%). Notably, in many of these cases (73.2%), the revised Breslow was higher than the initially reported score. Consequently, the T-stage was modified in 51 lesions (28.8%). Substantial discordance rates were observed in Tis (57%), T1b (59%), T3a (67%) and T4a (50%) classifications. The revised histopathology reports resulted in alterations to the surgical plan in 15.3% of the cases. These findings emphasize the importance of having all routine pathologies of pigmented lesions referred to a dedicated cancer center and reviewed by an experienced dermatopathologist. This recommendation is particularly crucial in instances where the histopathology review can potentially alter the diagnosis and treatment plan, such as in melanoma in situ and thinner melanomas measuring 0.6-2.2 mm in thickness. Our study highlights the significant impact of histopathology reviews in cutaneous melanoma cases. The observed changes in Breslow scores and subsequent modifications in T-stage classification underline the need for thorough evaluation by an expert dermatopathologist, especially in cases of melanoma in situ and thin melanomas. Incorporating such reviews into routine practice within dedicated cancer centers can improve diagnostic accuracy and guide appropriate treatment decisions, ultimately leading to better patient outcomes.

Personalised burn treatment: bedside electrospun nanofibre scaffold with cultured autologous keratinocytes: a case study.

Nearly four decades after cultured epidermal autografts (CEA) were first used for the treatment of extensive burn wounds, the current gold standard treatment remains grafting healthy autologous skin from a donor site to the damaged areas, with current skin substitutes limited in their clinical use. We propose a novel treatment approach, using an electrospun polymer nanofibrous matrix (EPNM) applied on-site directly on the CEA-grafted areas. In addition, we propose a personalised treatment on hard-to-heal areas, in which we spray suspended autologous keratinocytes integrated with 3D EPNM applied on-site, directly onto the wound bed. This method enables the coverage of larger wound areas than possible with CEA. We present the case of a 26-year-old male patient with full-thickness burns covering 98% of his total body surface area (TBSA). We were able to show that this treatment approach resulted in good re-epithelialisation, seen as early as seven days post CEA grafting, with complete wound closure within three weeks, and to a lesser extent in areas treated with cell spraying. Moreover, in vitro experiments confirmed the feasibility of using keratinocytes embedded within the EPNM: cell and culture viability, identity, purity and potency were determined. These experiments show that the skin cells are viable and can proliferate within the EPNM. The results presented are of a promising novel strategy for the development of personalised wound treatment, integrating on-the-spot 'printed' EPNM with autologous skin cells, which will be applied at the bedside, over deep dermal wounds, to accelerate healing time and wound closure.

The COVID-19 Pandemic Changed the Prevalence of Plastic Surgery in Israel.

BACKGROUND: In late 2019, a new strain of coronavirus (coronavirus disease 2019 [COVID-19]) spread rapidly throughout the world. The American Society of Plastic Surgeons reported a pandemic-related surge in the demand for aesthetic surgery compared to the same popularity of procedures prior to the pandemic. OBJECTIVES: To determine whether this phenomenon also occurred in Israel. METHODS: We collected data from three leading private medical centers in Tel Aviv. Data were compared for the years 2019 and 2020 by surgical procedure. Number of orthopedic, gynecologic, and hand procedures served as control data. RESULTS: We present a detailed pandemic-related timeline relevant to aesthetic surgery in Israel. Overall, the demand for aesthetic surgery increased, with a marked trend toward body contouring procedures. CONCLUSIONS: The Israeli aesthetic surgery market was affected by the COVID-19 pandemic, with a post-closure surge. The popularity and number of procedures are unique to the Israeli market.

Comparison of stationary and dynamic fractional CO2 laser modalities of large burns treatment: Experimental laboratory model.

OBJECTIVES: To experimentally compare two fractional ablative CO2 laser handpieces intended for the treatment of large area burn scars. Each handpiece coverage rate, depth of penetration and application time were measured and compared in a simulation model of large area burns scars using a dynamic/roller handpiece (small footprint) and a stationary/stamping handpiece (large footprint). METHODS: A 30 W fractional ablative CO2 laser was applied using 2 different handpieces and footprints on a A4 size paper stack. The handpieces were a stationary (stamping) handpiece with 7 × 7 (49 pixels/square shape) and dynamic (roller) handpiece with 7 × 1 (7 pixels/single row shape). For both handpieces the laser settings were fixed at "High" power (30 W), providing an energy level of 100 mJ/pixel. Both handpieces were applied perpendicular to the surface, with the process repeated for the dynamic handpiece with an angled operation. The depth of laser penetration was assessed by the number of pages of paper having visible holes and burn area coverage time measured under each handpiece/condition. RESULTS: The application time was faster and the penetration deeper for the dynamic handpiece compared to the stationary handpiece in both the perpendicular and angled conditions. This study has practical implications for lasers operators to improve time efficacy in large area scars with improved clinical endpoints. CONCLUSION: The fractional ablative dynamic handpiece demonstrated superior application efficiency compared to the stationary handpiece in the simulated treatment of large surface area burn scars, reducing treatment time with improved depth of penetration.

Burns in Israel: Etiologic, Demographic, and Clinical trends-A 9-Year Updated Comprehensive Study, 2004-2010 versus 2011-2019.

Based on the Israeli National Trauma Registry (INTR) data, this study reports etiological, demographic, and clinical trends and includes all admissions to burn and trauma centers across Israel from 2011 to 2019 and compares these with 2004 to 2010 rates. From 2011 to 2019, 5,710 patients were admitted to burn centers across Israel. Children aged 0 to 1 years (25.9%), non-Jews (40.7%), and males (67.2%) remain the main groups of the burn casualties. Most of the casualties sustained 1 to 9% total body surface area (TBSA) burns with various depths. Scalds were less fatal than fire/flame-related casualties (<1 vs. 11.5%). Fewer surgical procedures were conducted for burns under 9% TBSA compared with greater TBSA. The percentage of TBSA and burn depth were found to be the most significant predictor of mortality among all age groups (>200 times increased risk with full-thickness burns >30% TBSA burn) and correlated with prolonged length of stay (>7 days).

Novel Technologies in Chronic Wound Care.

In Israel, 20% of wounds do not progress to full healing under treatment with conservative technologies of which 1 to 2% are eventually defined as chronic wounds. Chronic wounds are a complex health burden for patients and pose considerable therapeutic and budgetary burden on health systems. The causes of chronic wounds include systemic and local factors. Initial treatment involves the usual therapeutic means, but as healing does not progress, more advanced therapeutic technologies are used. Undoubtedly, advanced means, such as negative pressure systems, and advanced technologies, such as oxygen systems and micrografts, have vastly improved the treatment of chronic wounds. Our service specializes in treating ulcers and difficult-to-heal wounds while providing a multiprofessional medical response. Herein, we present our experience and protocols in treating chronic wounds using a variety of advanced dressings and technologies.

Humanitarian Medical Aid Mission in the Middle of a Pandemic - Israeli Experience in Equatorial Guinea.

INTRODUCTION: In March 2021, a series of explosions shook a military base in Bata, Equatorial Guinea. As a response to government officials' request, the Israel Defense Forces Medical Corps (IDF-MC) deployed an emergency aid team that faced two major challenges: (1) understanding the scenario, the injury patterns, and the needs of the local medical system; and (2) minimizing the coronavirus disease 2019 (COVID-19) outbreak threats. This report describes the team design, the activities performed before and during the deployment, analyzes the pathology encountered, and shares lessons learned from the mission. SOURCES: Data were collected from the delegation protocols and IDF medical records. All activities of the Israeli delegation were coordinated with the local government. OBSERVATIONS: The local authorities reported that a total of 107 people were killed and more than 700 people were wounded. The team was the first international team to arrive at the scene and assisted the local medical teams to treat 231 patients in the three local hospitals and 213 patients in field clinics in the villages surrounding Bata. The COVID-19 pandemic influenced the operation of this mission, and caution measures were activated. ANALYSIS: Unplanned explosions at munitions sites (UEMS) are a growing problem causing the medical teams to face unique challenges. By understanding the expected challenges, the team was reinforced with a plastic surgeon, portable ultrasound devices, a large amount and a variety of antibiotics, whole blood units, and freeze-dried plasma. Rehabilitation experts were needed in some cases in the week following the injury. An important key for the success of this kind of medical aid delegation is the collaboration with the local medical teams, which enhances patient care.

Soft tissue-related injuries sustained following volcanic eruptions: An integrative review.

BACKGROUND: The contribution of various volcanic phenomena to immediate soft tissue injury types has received limited attention challenging emergency management planning. This integrative review sought to investigate the immediate types of soft tissue-related injury sustained following volcanic eruptions. METHODS: A systematic search was conducted in January 2020 across EMBASE, PubMed, and Scopus databases. 718 articles were retrieved, and 15 studies met the final inclusion criteria. RESULTS: Injuries acquired, and health impacts were categorized by onset-direct/indirect or immediate/delayed. Health concerns following an eruption were categorised: (1) respiratory; (2) ocular; and (3) skin, including deep tissues. Respiratory concerns were attributed to ashfall, volcanic gases and pyroclastic density currents; most ocular injuries to ashfall; and skin/deep tissues to pyroclastic density currents and mudflows. CONCLUSIONS: Volcanic eruptions simultaneously present multiple hazards with immediate/short term health consequences across three major levels (i.e., respiratory, ocular, and skin, including deep tissues). Hazard(s) differ by time of onset and associated mostly with the eruptive phenomena. Understanding local volcanic phenomenon is essential to assisting health personnel provide informed and timely care.

Pain management during a bromelain-based selective enzymatic debridement in paediatric and adult burn patients.

BACKGROUND: Pain associated with surgical or enzymatic burn wound debridement prevents many burn centres from working outside an operating theatre, creating a burden. Alternatives for general anaesthesia to manage pain in burn patients treated with enzymatic debridements, such as regional anaesthesia, have not been studied in detail. This study explores the different possibilities for pain management during a bedside NexoBrid™ procedure. MATERIAL AND METHODS: We performed a single-centre retrospective study that included 82 paediatric, adolescent, and adult patients with deep dermal and full-thickness burns treated bedside with NexoBrid™ under regional or general anaesthesia. Outcome measures were pain during the NexoBrid™ procedure, the safety of the anaesthesia and the NexoBrid™ procedure, logistics of the bedside NexoBrid™ procedure, and time to wound closure. RESULTS: Forty-three patients in the adult group (43/67, 64%) only presented with burn wounds on one upper or the one or two lower extremities. In 29 of them (29/43, 67%), a NexoBrid™ procedure was performed under regional anaesthesia, which resulted in low pain levels without any adverse events. All seven patients in the paediatric group, where only one upper or one or two lower limbs were involved (7/15, 47%), underwent a NexoBrid™ procedure performed under regional anaesthesia where no adverse events were reported. In these children, the use of regional anaesthesia was associated with a significant decrease in time to wound closure (average treatment effect on the treated = -22.5 days, p = 0.021). CONCLUSION: This study highlights that regional anaesthesia administered at the bedside should be the method of choice for pain management during NexoBrid™ procedures because often, it can be adequately and safely performed in all age groups. This approach will reduce the burden on operating theatres. A flow chart has been developed to guide pain management during a NexoBrid™ procedure.

Advances in the Use of Electrospun Nanofibrous Polymeric Matrix for Dermal Healing at the Donor Site After the Split-Thickness Skin Graft Excision: A Prospective, Randomized, Controlled, Open-Label, Multicenter Study.

Dressings used to manage donor site wounds (DSWs) have up to 40% of patients experiencing complications that may cause suboptimal scarring. We evaluated the efficacy and safety of a portable electrospun nanofibrous matrix that provides contactless management of DSWs compared with standard dressing techniques. This study included adult patients who underwent an excised split-thickness skin graft (STSG) with a DSW area of 10 to 200 cm2. Patients were allocated into two groups; ie, the nanofiber group managed with a nanofibrous polymer-based matrix, and the control group managed using the standard of care such as Jelonet® or Biatain® Ibu dressing. Primary outcomes were postoperative dermal healing efficacy assessed by Draize scores. The time to complete re-epithelialization was also recorded. Secondary outcomes included postoperative adverse events, pain, and infections during the first 21 days and extended 12-month follow-up. The itching and scarring were recorded during the extended follow-up (months 1, 3, 6, 9, and 12) using Numerical-Analogue-Score and Vancouver scores, respectively. The nanofiber and control groups included 21 and 20 patients, respectively. The Draize dermal irritation scores were significantly lower in the nanofiber vs control group (Z = -2.509; P = .028) on the first postoperative day but became similar afterward (Z ≥ -1.62; P ≥ .198). In addition, the average time to re-epithelialization was similar in the nanofiber (17.9 ± 4.4 days) and control group (18.3 ± 4.5 days; Z = -0.299; P = .764), so were postoperative adverse events, pain, and infection incidence, itching and scarring. The safety and efficacy of electrospun nanofibrous matrix are similar to standard wound care allowing its use as an alternative donor site dressing following the STSG excision.

The Hidden Danger of Lithium Battery-Powered Electric Bicycles and Scooters: A Case Series of the Israeli National Burn Center Experience.

Electric-powered bicycles and scooters that use rechargeable lithium batteries are an urban transportation alternative and have become increasingly popular. However, in recent years, there has been an increase in patient admissions to the Israeli National Burn Center with burns associated with their use. In this case series of all patients (n = 9) referred to the Emergency Department (February 2016-October 2020) with lithium-related battery burns from electric-powered bicycles and scooters, we present burn depth, size, treatment, inhalation injuries, and hospitalization. All patients were admitted to the Israeli National Burn Center for treatment. The average TBSA was 27.5% (range 3%-57%). All but one patient had a combination of partial to full-thickness burns affecting the upper and lower limbs. Three patients sustained inhalation injuries and a total of four patients required intubation. Seven patients required surgery that included debridement and, in most cases, skin grafting. The availability and increase in the use of battery-powered bicycles and scooters may lead to an increase in injuries and death if consumers are not aware of the potential dangers related to the safe use of lithium batteries.

Bromelain-based enzymatic debridement of chronic wounds: Results of a multicentre randomized controlled trial.

Chronic wounds are estimated to affect over 6 million people annually in the United States with an estimated annual cost of $25 billion. Debridement represents a key step in their management and is considered a basic necessity to induce the functional process of tissue repair. However, there is an unmet need for an efficient rapid acting non-surgical debridement agent. Bromelain-based enzymatic debridement has been proven to provide an effective, selective and safe non-surgical debridement in deep burns. EscharEx (MediWound Ltd, Yavne, Israel), is a bromelain-based enzymatic debridement agent currently in development for chronic wounds. The aim of this study was to assess its safety and efficacy in chronic wounds. Seventy-three patients suffering from a lower extremity ulcer of diabetic/venous insufficiency/post-surgical/traumatic aetiology were enrolled in a multicentre, assessor blinded, randomized controlled trial. Patients were randomized to topical treatment by either EscharEx or its gel vehicle for up to 10 daily 4 hour applications, and then continued follow-up for up to 6 months. The EscharEx arm achieved a significantly higher incidence of complete debridement compared to the gel vehicle arm; 55 versus 29% (p = .047), thus meeting the primary endpoint of this study. The EscharEx and gel vehicle arms achieved similar reductions in wound area, non-viable tissue area and wound healing scores during the debridement period. There were no significant differences between the arms in the incidence of complete wound closure (41% in the EsxcharEx arm vs. 53% in the gel vehicle arm) and in the mean time to complete wound closure (70.0 ± 32.8 days in the EsxcharEx arm vs. 65.7 ± 38.4 days in gel vehicle arm). There were no significant safety issues and EscharEx demonstrated a favourable benefit to risk profile.

Standardization of Burn Patients Transfer: Implementation of a Transfer Request Form to Israel's National Burn Center.

BACKGROUND: Burn injuries are an extreme form of traumatic injury and are a global health issue. The Israeli National Burn Unit at the Sheba Medical Center, a tertiary level 1 trauma center and hence the national referral center, treats burn patients admitted both directly and referred from other medical centers. The transfer and handover of patients is a critical step in patient care. In Israel, to date, there is no standardized and accepted transfer request form for burn patients from one medical facility to another. OBJECTIVES: To construct a transfer request form to be used in all future burn patient referrals. METHODS: After reviewing publicly available international transfer forms and comparing them to the admission checklist used at our unit, a structured transfer request form was constructed. RESULTS: After a pilot study period, testing the form in various scenarios and adapting it, the first standardized transfer form for burn patients in Israel in both English and Hebrew was implemented beginning May 2020. CONCLUSIONS: Implementation of a standardized transfer process will improve communication between healthcare professionals to help maintain a continuum of care. We believe that implementation of a burn transfer form in all future referrals can standardize and assure better care for burn patients, thus improving overall patient care.

[MOHS MICROGRAPHIC SURGERY FOR CUTANEOUS MALIGNANT LESIONS EXCISION: EXPERIENCE OF A SINGLE TERTIARY MEDICAL CENTER IN ISRAEL].

AIMS: To review the literature, to present the experience with MMS of a single medical center in Israel and to compare findings to worldwide MMS trends. BACKGROUND: Mohs Micrographic Surgery (MMS) is a surgical technique that examines all of the cutaneous malignancy margins during surgery through precise mapping. This technique achieves the highest cure rates for cutaneous malignancies, while sparing normal tissue. The incidence of cutaneous malignancy is rising worldwide. The volume of Mohs surgeries increases as well. Therefore, physicians should gain knowledge about MMS utility in the treatment of cutaneous malignancy. This study is the first to be conducted is Israel and it aimed to present trends in the utilization of MMS. METHODS: A retrospective review of all MMS performed from 2012 to 2018 at the Sheba Medical Center. RESULTS: Overall, MMS technique was used in 3,795 cases. There was an upward trend in the utility volume of MMS during study period, from 372 cases in the year 2012 to 702 cases in 2017. We found an upward trend in the volume of MMS procedures within patients groups in the ages 65 to 74 and 75 years old and older. Male patients presented a double fold upward trend, in comparison to the female group. CONCLUSIONS: The upward trends found in this study correlate with the worldwide MMS trends and the rising incidence of cutaneous malignancy in Israel. More specialists are needed due to the increase in demand of MMS procedures.

[DIRECT TO IMPLANT IMMEDIATE BREAST RECONSTRUCTION USING THE FASCIAL SYSTEM IN THE INFRAMAMMARY FOLD, WITHOUT THE USE OF ACELLULAR DERMAL MATRIX].

AIMS: We present our experience of direct to implant breast reconstruction with total musculofascial coverage, without the use of ADM. BACKGROUND: The prevalence of one-stage breast reconstruction with silicone implants has increased markedly in recent years. This is attributed to advances in the surgical technique of mastectomy and to the increased rate of preventive mastectomy. The use of Acellular Dermal Matrix (ADM) became a common practice. Notwithstanding, ADM utilization may lead to higher postoperative complication rates. METHODS: Between 2015 to 2018, a prospective study was conducted at the Sheba Medical Center including all patients undergoing mastectomy and immediate breast reconstruction. In this study, we included patients who underwent direct to implant reconstruction with total musculofascial coverage, without the use of ADM. We gathered demographic, oncologic and surgical features, including post-operative complications, along with aesthetic outcome. RESULTS: A total of 20 patients (25 breasts) underwent direct to implant breast reconstruction with total musculofascial coverage. The overall complication rate was 24% (6 breasts). Minor complications (5 breasts, 20%) were manifested as delayed wound healing, minimal capsular contracture, skin necrosis and minor infection. A major complication of capsular contracture occurred in one patient. Corrective surgery due to aesthetic outcome was offered to 36% of the patients. nevertheless, only 16% chose to undergo an aesthetic reoperation. CONCLUSIONS: Immediate direct to implant breast reconstruction with total musculofascial coverage is an attractive option for single stage breast reconstruction with excellent aesthetic outcomes and low complication rates. Presumably, with a careful patient selection, the complication rates can be reduced even further.

A Retrospective Review of an Off-label Bromelain-based Selective Enzymatic Debridement (Nexobrid®) in the Treatment of Deep, Partial, and Full Thickness Burns and Hard to Heal Wounds.

BACKGROUND: Rapid and selective bromelain-based enzymatic debridement provides a non-surgical alternative for the eschar removal in deep burns, which allows for early debridement of large surface areas, accurate evaluation of burn and wound depth, and the need for skin grafting. OBJECTIVES: To evaluate the efficacy of application of a bromelain-based selective enzymatic debridement (Nexobrid®) beyond the manufacturer's guidelines for use in burns > 48 hours as well as chemical, electrical, and pediatric burns, and chronic wounds. METHODS: This retrospective review included records collected between January 2017 and April 2019, from male and female patients aged 8 months to 99 years with deep burns or wounds treated with bromelain-based selective enzymatic debridement. RESULTS: Of the 33 patients who received the bromelain-based selective enzymatic debridement agent beyond the manufacturer's guidelines, 25 (76%) were observed to have successful debridement of the eschar, 8 (24%) were observed to have little effect on the burn eschar. Sixteen required further surgery after debridement. Clinical data on the use of bromelain-based selective enzymatic debridement agents are limited, but these results suggest the capacity to effectively debride burns > 48 hours (late presentation burns), use for pediatrics and for chemical and electrical burns, and apply to hard to heal full thickness chronic wounds. CONCLUSIONS: Bromelain-based selective enzymatic debridement was found to be an effective treatment modality beyond the recommended guidelines including late presentation burns and chronic wounds. This debridement method warrants further consideration when making clinical decisions concerning burn and wound care.

Treatment Algorithm for Hyaluronic Acid-Related Complication Based on a Systematic Review of Case Reports, Case Series, and Clinical Experience.

STUDY DESIGN: Systematic review of hyaluronic acid (HA)-related complications. OBJECTIVE: To systematically review all available literature including case reports and case series to identify a pattern for the management of vascular compromise resulting in facial skin ischemia and ocular manifestations following HA injection. METHODS: This review was based on a systematic search of 3 electronic databases PubMed, CINAHL, and Scopus for all available literature including case series and case reports from database inception to July 2019. Only a total of 52 case reports/series were eligible for review and included 107 patients. RESULTS: The reviewed literature available was comprised from case reports/series and indicated that management of both impending skin necrosis and visual disturbances is variable with no repetitive pattern of action. Yet, successful management is time dependent as early interventions stopped progression and, in some cases, even reversed adverse effects. CONCLUSION: Results found no universal protocol for achieving optimal results for adverse effects and as such, we present a step-by-step algorithm for the emergency management of complications following HA injection.