Scrub Sponge as A Wound Debridement Device.

INTRODUCTION: Wound debridement is necessary before skin grafting or wound closure. Inappropriate wound bed preparation will led to graft rejection and sometimes catastrophic results, especially in large wounds,. Usage of popular debridement and excision devices such as dermatomes has some difficulties and disadvantages. In this study we will introduce metallic scrub sponge as a safe and effective debridement device. METHODS: The surgeon usually uses a sterile metallic scrub sponge over the wound with transverse or rotational repeated movement. Wound preparing with metallic sponge should be stopped when pinpoint bleeding occurs. We used sterile metallic sponge for more than 2500 burn patients. RESULTS: The results are excellent for deep second degree burn (and deeper burns at least 5-10 days after burn when some eschar loosening occurs). Work with scrub sponge was effective, fast and safe. DISCUSSION: Metallic scrub sponge is a useful device for wound preparation due to its some special characteristics. Debridement of the burn wound with metallic sponge can preserve the spontaneous epithelialization potential of skin in second degree burns and reduce additional injury to the viable tissue that is inevitable by surgical debridement. Cost effectiveness, easy accessibility, safety, softness, inertness and some others are among the other advantages of metallic sponge usage for wound preparation. CONCLUSION: Due to metallic sponge's simplicity and capability to remove necrotic loose tissues and easy accessibility everywhere and minimal adverse effects, it is a good first line tool for wound preparation and debridement.

Cutaneous Vesicular of COVID-19 in Two Burn Patients.

Despite the whole world's effort for controlling an ongoing global outbreak caused by new corona virus; it is still a major public health issue. Any hospitalized patient or outpatient in burn departments should be considered as a potential infectious source of COVID-19, which may cause an overwhelming of disease. However, there are no previous experiences about COVID-19 in burn patients all over the world, and here we reported two burn cases at Amir-al-Momenin Burn Hospital Affiliated to Shiraz University of Medical Sciences, Shiraz, Iran with skin manifestations, which were detected as a rarely COVID-19 symptom. A 13-year-old girl [total body surface area (TBSA): 18%] and a 37-year-old woman (TBSA: 30%) who had burn injuries by gas explosion and car accident, respectively were enrolled. After admission, some vesicular injuries were visible in burn area. To confirm, skin biopsy specimens were either sent for histopathology examination or for real time polymerase chain reaction (PCR) as follow: Herpes Simplex Virus (HSV), chicken pox, and potassium hydroxide (KOH) for fungal infections. All test results were negative. Although they had no symptoms of COVID-19, two swabs from nasopharyngeal and oropharyngeal samplings were taken, the result was negative either. Specimens were obtained from vesicular lesions for qRT-PCR assay of COVID-19. According to the molecular results for vesicular samples, all the results were positive for COVID-19. Unlike all other COVID-19 patients who have respiratory symptoms, SARS-COV-2 appeared by cutaneous vesicular and blisters in two burn cases.

Effects of Early Versus Delayed Excision and Grafting on Restoring the Functionality of Deep Burn-Injured Hands: A Double-Blind, Randomized Parallel Clinical Trial.

Hand burns have major impacts on daily activities. An interdisciplinary and multifaceted approach is necessary to effectively treat these burns. Generally, hands are common sites for burn injuries. It is known that Early Excision and Grafting (EEG) of deep burn wounds can decrease scar and subsequent contracture formation compared with Delayed Excision and Grafting (DEG) method. Accordingly, this study aimed to compare the effects of these procedures on function of hands with deep burns, by using the Michigan Hand Questionnaire (MHQ). In this double-blind randomized clinical trial, we evaluated a total of 50 patients (age range: 15-70 years) with deep second-degree burns of both hands from January 2013 to December 2015. The subjects were randomly divided into two groups, treatment (EEG) and control (DEG) groups (25 patients per group). They followed up postoperatively for 3 months. MHQ was completed for each of them to determine the function of the hands, pain sensation, limitation of daily activities, overall satisfaction, and cosmetic appearance during follow-up. Data were analyzed in the groups using SPSS version 16. Baseline characteristics of the groups were matched. In early postoperation, hand functions and daily activities, gross appearance, and pain sensation were better in EEG group. After 1 and 3 months, no significant difference was detected between the groups except for patient satisfaction which was better in EEG group. Also, EEG group was associated with a significant shorter hospital stay and lower treatment costs compared with DEG group. Graft take rate was similar in both groups. EEG is recognized as the standard treatment for deep skin burns, but we did not find any significant difference between effects of EEG and DEG on hand functions although EEG group had shorter hospital stay and lower treatment costs compared with DEG. The main goal of treatment of hand burns is restoration of the hand functions. Based on our findings, hand function was not related to the type of surgery. Also, as all wounds in both surgical groups healed less than 3 weeks, the authors suggest that the excision time limit could be change in our burn center from 10 days to 2 to 3 weeks when we use sheet graft as for hands.

Comparing isolated soy protein with flaxseed oil vs isolated soy protein with corn oil and wheat flour with corn oil consumption on muscle catabolism, liver function, blood lipid, and sugar in burn patients: a randomized clinical trial.

BACKGROUND: There is controversy regarding whether increasing isolated soy protein (ISP) with or without flaxseed oil (FO), as functional foods, would lead to reduce muscle catabolism and cachexia in burn patients. METHODS: One hundred and eighty-eight patients were assessed for eligibility in this randomized controlled trial. Of these, seventy-three eligible patients (total burn surface area 20-50%) were randomly assigned to three groups, labeled as Control (wheat flour [WF] + corn oil [CO]), ISP + FO, and ISP + CO, to receive these nutrients for three weeks. Weight, body mass index (BMI), serum hepatic enzymes (alanine transaminase [ALT], aspartate transaminase [AST], alkaline phosphatase [ALP]), systemic inflammatory response syndrome (SIRS), 24-h urinary urea nitrogen excretion (UUN), serum creatinine, 24-h urinary creatinine (UUC) excretion, fasting blood sugar (FBS), triglyceride (TG), and cholesterol were measured. RESULTS: Using analysis of covariance models in the intention-to-treat population (n = 73), we found that at three weeks, patients in the ISP groups had lost significantly less in weight and BMI compared to those in the control group (all P < 0.01). Nitrogen retention and serum creatinine (primary outcomes) increased significantly in the ISP groups compared with the control group. Even after controlling for potential covariates in ANCOVA models, changes in these indices were still statistically significant (P = 0.008 and P = 0.005 for nitrogen balance and serum creatinine, respectively). However, no such significant differences were found between the ISP groups. On the other hand, 24-h UUN, and UUC excretion, serum hepatic enzymes, FBS, TG, and cholesterol were not significant between the groups (P > 0.05). CONCLUSION: ISP and FO compared to WF and CO reduced muscle catabolism and increased body weight in burn patients. TRIAL REGISTRATION: Iranian Registry of Clinical Trials, IRCT2014051817740N1 . Registered on 27 June 2014.

The effect of isolated soy protein adjunctive with flaxseed oil on markers of inflammation, oxidative stress, acute phase proteins, and wound healing of burn patients; a randomized clinical trial.

INTRODUCTION: The objective was to determine the effect of isolated soy protein (ISP) and flaxseed oil (FO) on inflammatory and oxidative stress indices, acute phase proteins, and wound healing of burn patients. METHODS: One hundred eighty-eight patients were assessed for eligibility in this randomized controlled trial. Of these, seventy-three eligible patients (total burn surface area 20-50%) were randomly assigned to 3 isocaloric groups, labeled as control (wheat flour+corn oil (CO)), ISP+FO, and ISP+CO, to receive these nutrients for 3 weeks. We used intention to treat analysis to overcome bias. Because of the large perturbation in water compartments, patients received nutrients from 4th to 25th day of admission. Serum high sensitivity C-reactive protein (hs-CRP), malondialdehyde (MDA), superoxide dismutase (SOD), ferritin, albumin, and transferrin were measured. The wound area was evaluated by stereological test. RESULTS: During the 3-week intervention, hs-CRP (-19.4±5.6, -11.7±4.7µg/ml) and ferritin (-83.8±20.5, -80.1±19.6ng/ml) levels changes significantly reduced compared to the control group (P<0.05). MDA level (-0.05±0.21µmol/l) significantly decreased in group A (P<0/05) but was not significant in groups B and control (P>0.05). Albumin level (0.59±0.14, 0.30±0.12g/dl) significantly increased in group A compared to the control group (P<0.05), but no significant relationship was found between other groups (P>0.05). Transferrin level (4.9±3.6, 2.9±5.1g/dl) significantly increased in ISP groups compared to the control (P<0.05). SOD improved in all groups with no significant difference between them (P>0.05). The stereology examination showed significant improvement in wound healing in the ISP groups on days 22 and 25 compared to the control group. CONCLUSION: Nutritional supplements with ISP may attenuate post-burn oxidative stress and inflammation, leading to improved wound healing in burn patients. Flaxseed oil may not exert a beneficial effect over the ISP.

Comparison of the Results of Early Excision and Grafting between Children and Adults; A Prospective Comparative Study.

OBJECTIVES: To compare the outcomes of early excision and grafting between pediatric and adult patients with deep burns of less than 40% total body surface area burns (TBSA). METHODS: This is a prospective comparative study. Overall, 106 patients admitted to Ghotbodin Burn Center in Shiraz, Iran from September 2012 to September 2013, were included in the study. All patients had less than 40% TBSA burn and had excision and grafting under 14 days from their injury. Patients were divided into two age groups of younger than 14 (n=49) and older than 14 (14-65) years old (n=57). During a 6-month follow-up period, the two groups were compared regarding mean percentage of graft take, total scar score, duration of hospital stay and itching score. RESULTS: During follow-up, the two groups did not show a significant difference in graft take, total scar score and itching score (p=0.461, p=0.363 and p=0.637, respectively). Clinically, the pediatric group showed less hospital stay (12.25±9.1 vs. 16±12.9), however this was not statistically significant (p=0.091). CONCLUSION: Adults and elderly patients (14-65 years old) compared to pediatric patients (less than 14 years old) with less than 40% TBSA burns, can expect similar results regarding scar score, graft take, itch score and hospital stay, after excision and grafting performed less than two weeks from their initial injury.

Myocutaneous Mucormycosis in a Diabetic Burnt Patient Led to Upper Extremity Amputation; A Case Report.

Mucormycosis is a rare opportunistic fungal infection that can implicate cranial sinuses, brain, lungs, gastrointestinal tract and skin. Although it can occur in patients with competent and incompetent immunity such as patients with diabetes mellitus, lymphoma, leukemia and burns, but it has an aggressive, malignant and lethal course in patients with incompetent immunity. To enforce the importance of burn in patients with underlaying diseases such as diabetes, we are going to report a rare case of diabetic burnt patient complicated by right upper extremity myocutaneous mucormycosis. We selected this case to emphasis the importance of underlying disease (diabetes mellitus) with cutaneous burn, aggressive treatment of fungal infection in these patients and referring such case to burn center to prevent catastrophic results. A 50-year-old woman was introduced to us after several days of medical and surgical care of right upper extremity and trunk split-thickness burn. Due to gross muscle necrosis of right upper extremity and poor general condition of the patient, she was taken to the operating room that led to right upper extremity amputation and several times of aggressive debridement to save her life. Pathologic report was indicative of mucormycosis. We can conclude from this case that: 1) Burn, even partially thickness and with little body surface area, should be referred to burn center for better care 2) No response to usual medical treatment should make us more sensitive to consider the unusual causes of infection such as fungi 3) Suspected dead tissues should be excised aggressively especially if suspiciousness to wound sepsis and fungal infection is present especially in an immunocompromised patient.

Ultra-Early versus Early Excision and Grafting for Thermal Burns up to 60% Total Body Surface Area; A Historical Cohort Study.

OBJECTIVE: To compare the outcome of patients with up to 60% total body surface area (TBSA) thermal burns undergoing ultra-early and early excision and grafting. METHODS: This historical cohort study was performed in two referral burn centers of Shiraz during a 1-year period from 2015 to 2016. We included those patients with thermal burns up to 60% TBSA who underwent ultra-early (48-72 hours) and early (7-10 days) excision and grafting. We excluded those who were hemodynamically unstable and those with electrical burns. The outcome of patients was determined by graft success, operation duration, blood loss, hospital length of stay and mortality rate. RESULTS: We included a total number of 107 patients with mean age of 32.1 ± 11.6 years. There were 65 (60.7%) men and 42 (39.3%) women among the patients. Both study groups were comparable regarding the baseline characteristics. Ultra-early excision and grafting was associated with more, higher graft success rate (p=0.048), lower infection rate (p=0.037), shorter hospital length of stay (p=0.044) and lower mortality rate (p=0.027). CONCLUSION: Ultra-early excision and grafting in patients with thermal burns covering less than 60% TBSA was associated with higher graft success rate, shorter hospital length of stay, lower infection rate and lower mortality rate when compared to early surgery.

Effect of Orem Self-Care Program on the Life Quality of Burn Patients Referred to Ghotb-al-Din-e-Shirazi Burn Center, Shiraz, Iran: A Randomized Controlled Trial.

BACKGROUND: Advances in treatment and critical care have largely improved the survival following burns; therefore, the importance of quality of life in burn patients is an issue beyond question. The aim of this study was to determine the effects of Orem self-care program on Quality of Life of burn patients. METHODS: A randomized clinical trial study was conducted on 110 eligible burn patients who were selected using easy sampling method and allocated randomly into two groups of experiment and control. The instrument for data collection was a questionnaire, containing demographic and burn information and burn-specific health scale-brief (BSHS-B) questionnaire. For the experiment group, 5 sessions of theoretical training and 75-90 minutes of practical training were accomplished. The quality of life of the patients with burns was assessed in three phases by the BSHS-B questionnaire. The data were analyzed in SPSS-17 using Chi-square test, Fisher's exact test, Independent t-test and repeated measurement multivariate test. RESULTS: After one month and two months of the use of self-care model, the quality of life of the cases improved from 73.33% to 83.78% and 98.12%, respectively (P<0.001). But the changes in the quality of life of the patients in the control group were not statistically significant (P>0.05). CONCLUSION: Based on the obtained results of this study, designing and implementing a self-care program based on Orem's model and the needs of burn patients will improve their quality of life. Therefore, it is recommended that this program should be considered as a part of treatment program for these patients. Trial Registration Number : 2013042112129N1.

Early Excision and Grafting versus Delayed Skin Grafting in Burns Covering Less than 15% of Total Body Surface Area; A Non- Randomized Clinical Trial.

OBJECTIVE: To compare outcome of patients with burns covering less than 15% of total body surface area(TBSA) undergoing early excision and grafting or delayed skin grafting. METHOD: This was a non-randomized clinical trial including 54 patients with less than 15% TBSA burn referring to Ghotboddin Hospital of Shiraz. They were assigned to two study groups, each group including 27 patients: the early excision and grafting group (EEG group) and the delayed grafting group (DG group). Patients were followed postoperatively for 6 months. Hospital stay, graft success rate, itching score and scar formation during 6 months of follow-up were recorded and compared between two study groups. RESULTS: During the study 1 patient was lost to follow-up in early excision and grafting group. Baseline characteristics were comparable between two study groups. The graft success rate was significantly higher in those patients who underwent early excision and grafting when compared to delayed grafting group (96.88% vs. 92.88%; p=0.033). However the length of hospital stay, itching and scar scores were comparable between two study groups after 6 months of follow-up. CONCLUSION: In patients with burns covering less than 15% TBSA, early excision and grafting is associated with higher graft success rates compared to the delayed excision and grafting. How ever length of hospital stay, itching and scar formation is comparable between the two techniques.

Effect of fresh human amniotic membrane dressing on graft take in patients with chronic burn wounds compared with conventional methods.

BACKGROUND: Burns are among the most devastating forms of injury. Nowadays the standard treatment for deep partial thickness and full-thickness burn is early excision and grafting, but this technique is not always feasible; and this leads to chronicity and microbial colonization of burn wounds. Interesting properties of human amniotic membrane made us use it in management of chronic infected burn wounds. METHODS: From January 2008 to September 2010, in a prospective clinical trail, 38 patients (76 limbs) with symmetric chronic burn wounds in both upper or lower limbs included in this study. Tissue cultures were taken from all the wounds. For the right, after debridement of granulation tissue and meshed split thickness skin grafting, the graft surfaces were covered with amniotic membrane dressing and in left limb wounds, after debridement, skin grafting was done in conventional method. 21 days later, the success rate of graft take was compared between two groups. RESULTS: The study group was composed of 76 limbs in 38 patients with mean age of 27.18±6.38 and burn in 29.18±7.23 TBSA%. The most common causes of the burn wounds chronicity in the selected patients was delayed admission due to poor compliance of the patients (44.8%). Staphylococcus was the most frequent isolate in wounds in our patients (62.85%). Mean graft take was observed in 90.13% of right upper limbs, and 67.36% of left upper limbs; which was significantly different (P<0.001). CONCLUSIONS: Our study showed that human amniotic membrane dressing significantly increases the success rate of graft take in chronic wounds, and it can be recommended as an important dressing in chronic burn wounds management, due to interesting anti-microbial, and better graft take effects.

Sympathetic skin response in electrical burn injury.

BACKGROUND: Electrical burn has been reported to be highly associated with peripheral neuropathy. This study was designed to evaluate the sympathetic skin response (SSR) of electrical burn patients to determine whether the sympathetic nervous system is involved in these patients. MATERIALS AND METHODS: The sympathetic skin response of 28 patients, suffering from electrical burn injury (divided into two groups of high voltage and low voltage exposure) was compared with that of 28 matched subjects, who had never experienced electrical burn. Bilateral palmar and plantar latency and amplitude of SSR were recorded in response to Median and Tibial nerve electrical stimulation. RESULTS: SSR in all recording sites of the electrical burn patients compared showed significantly more prolonged latencies and reduced amplitudes, with their counterparts in the control group with no significant difference between the high voltage and low voltage electrical burns. There was no significant difference in SSR latency, between the entry and exit sites of the electrical current. The SSR amplitude however, showed more reduction in right hand than the left one, in whom the electrical current had entered the body from the right hand. The time lapse between the electrical burn and the SSR study was shown to play no role in the results. DISCUSSION: Increased SSR latency in electrical burn injury may be a sign of autonomic nervous system involvement, through systemic responses to electrical burn.