Burn Therapy Research Articles

The effectiveness of trace element supplementation following severe burn injury: A systematic review protocol

Review question/objective The objective of this review is to assess the effectiveness of trace element supplementation on clinically meaningful outcomes following severe burn injury in children and adults. More specifically, the objectives are to assess the effectiveness of selenium, copper and zinc supplementation on mortality, length of intensive care unit (ICU) hospital stay, wound healing and infection rates (wound and nosocomial) in patients who have sustained a severe burn injury. Inclusion criteria Types of participation This review will consider studies that include children (2-18 years of age) and adults (≥ 18 years of age) who have sustained a severe burn injury (defined as burn injury ≥ 10% Total Body Surface Area (TBSA) in children and ≥ 15% TBSA in adults) and been admitted to an ICU, Burns ICU (BICU), or burns unit for surgical management of their injury. Studies that include patients with significant multi-trauma in addition to burn injury will be excluded. Types of intervention(s)/phenomena of interest This review will consider studies that evaluate enteral or parenteral supplementation of selenium, copper and zinc, either alone or combined and compared to placebo or regular treatment. Intervention and comparison groups will have received standard nutrition intervention including enteral or parenteral nutrition and multi-vitamin supplements. Studies that include trace element supplementation in combination with other predefined nutrient supplementations will be considered for inclusion. Types of outcomes This review will consider studies that include the following outcome measures: mortality; length of ICU/ hospital stay; rate of wound healing (time to first donor site healing or time to wound closure); complications (e.g. wound infection, hospital acquired pneumonia). Secondary outcome measures: tissue (measured from skin biopsies) and plasma (measured via blood sampling) selenium, copper and zinc levels.

Anti-Allergic Effect of Ulmus davidiana Cortex on Contact Dermatitis Induced by Dinitrofluoro- Benzene in Mice.

Objective:The root bark of Ulmus davidiana var. Japonica (Ulmi Radicis cortex, URC) is a medicinal herb used for promoting diuresis and treating dampness. In Korea, URC has long been used as an efficacious therapy for inflammation, burns, frostbite and skin diseases such as eczema and psoriasis.Methods:In the present study, we used 1-fluoro-2,4- dinitrofluorobenzene (DNFB)-induced contact dermatitis (CD) mouse model to investigate the antiallergic and the anti-inflammatory effects of URC on skin lesion, histopathological changes and specific antibody production.Results:URC treatment, 10 mg/mL, effectively inhibited skin lesions induced by repeated paintings with DNFB. In the histopathological observation, topical application of URC inhibited spongiosis. In addition, URC lowered the production levels of total immunoglobulin and IgG2a in serum.Conclusion:These data indicate that URC has an anti-inflammatory effect that produces an improvement of skin lesions in CD mice.

ESPEN endorsed recommendations: Nutritional therapy in major burns

Nutrition therapy is a cornerstone of burn care from the early resuscitation phase until the end of rehabilitation. While several aspects of nutrition therapy are similar in major burns and other critical care conditions, the patho-physiology of burn injury with its major endocrine, inflammatory, metabolic and immune alterations requires some specific nutritional interventions. The present text developed by the French speaking societies, is updated to provide evidenced-based recommendations for clinical practice. A group of burn specialists used the GRADE methodology (Grade of Recommendation, Assessment, Development and Evaluation) to evaluate human burn clinical trials between 1979 and 2011. The resulting recommendations, strong suggestions or suggestions were then rated by the non-burn specialized experts according to their agreement (strong, moderate or weak). Eight major recommendations were made. Strong recommendations were made regarding, 1) early enteral feeding, 2) the elevated protein requirements (1.5-2 g/kg in adults, 3 g/kg in children), 3) the limitation of glucose delivery to a maximum of 55% of energy and 5 mg/kg/h associated with moderate blood glucose (target ≤ 8 mmol/l) control by means of continuous infusion, 4) to associated trace element and vitamin substitution early on, and 5) to use non-nutritional strategies to attenuate hypermetabolism by pharmacological (propranolol, oxandrolone) and physical tools (early surgery and thermo-neutral room) during the first weeks after injury. Suggestion were made in absence of indirect calorimetry, to use of the Toronto equation (Schoffield in children) for energy requirement determination (risk of overfeeding), and to maintain fat administration ≤ 30% of total energy delivery. The nutritional therapy in major burns has evidence-based specificities that contribute to improve clinical outcome.

Influence of skin grafts on oxidation-reduction processes in elderly and old people with deep burns

Introduction: Severe burns in the elderly have a much higher mortality in comparison to the younger population. The most complicated problem in burn therapy is in the treatment of patients with deep burns especially those who are elderly. Aim and Methodology: To study the different surgical treatments and test the intermediary metabolism in elderly deep burns admitted to our unit over a period of 11 years including patients from 1999 to 2009. Results: In our burn center in Uzbekistan, skin grafts were performed in 356 patients (age range, 60-92 year) with deep burns (107 in the early post-burn period of 7-15 days, plus 249 over granulating wounds). Skin grafts in extensive burns were performed in 32 patients for the purpose of achieving early closure of the burn area. In these 32 cases, a stamp graft procedure was used in 17 patients and Moule-Jackson method of skin grafting in 15 cases. Testing intermediary metabolism indicators in 102 patients before and after free skin grafting provided interesting findings. We identified common scenarios of elderly patients, which helped in treatment.

Silver Sulfadiazine Nanosystems for Burn Therapy

The objective of the present study was to formulate stable silver sulfadiazine (SSD) nanosuspensions and nanogels suitable for topical delivery with a view to increase bactericidal activity in burn therapy. SSD nanosuspensions were formulated using the microprecipitation-high-pressure homogenization technique. An optimized microsuspension of 0.5% SSD formulated with 6% Cremophor EL and 4% Lauroglycol 90 was subjected to 30cycles of 1,000-bar pressure to give a nanosuspension with an average particle size of 367.85nm. Transmission electron microscopy studies revealed that ovoid- to rectangular-shaped SSD particles were present as clusters. It was evident through X-ray diffraction studies that SSD was present in amorphous state both in microprecipitate and in nanosuspension. SSD (0.5%) nanogels were prepared using 1% Carbopol 974 P for topical delivery of nanosized SSD. In vitro release studies demonstrated that SSD release was faster from solutions and nanosuspensions compared to gel formulation owing to the influence of the gel matrix on SSD release. The bacterial inhibitory efficiency of SSD nanosuspension was as good as that of SSD solution against Staphylococcus aureus, Escherichia coli, and Pseudomonas aeruginosa. In vivo studies revealed that a nanogel containing 0.5% SSD was more effective in wound healing compared to 0.5% and 1% marketed cream.

Determination of surface location between two sub-domains using the temperature distribution on the external surface

In the paper two sub-domains which are in thermal contact are considered. The temperature field in these domains is described by the system of two Laplace equations supplemented by the boundary conditions. The position of surface between sub-domains is unknown. Additional information necessary to solve the identification problem results from a knowledge of external surface temperature distribution. The direct problem is solved using the boundary element method. To solve the inverse problem formulated the gradient method is applied. In the final part of the paper the results of computations are shown. The algorithm proposed here can be used, among others, in the medical practice (e.g. in burns therapy).

Cost-effect analysis of 2 therapeutic regimens for deep II burn patients

To compare the cost-effect of 2 therapeutic regimens and to find out a better therapeutic regimen with reasonable price and better effect, hoping to improve the quality of burn patients and reduce the waste of medical resources. We collected 1017 burn patients from Hunan and Sichuan, and divided them into a research group (the moist exposed burn therapy group) and a control group (the escharectomy and grafting group). We analyzed the cost and effect of the 2 groups from general condition, direct medical cost during treatment and curative effect. The average total cost of the research group [93633.71 (82260.79, 107576.34) yuan] was significantly lower than the control group [175077.93 (131433.23, 228918.83) yuan] (P<0.05). The total effective rate of the research group was higher (97.28%) than that in the control group (92.89%) (P<0.05). The cost-effect of the research group (962.52) was better than that of the control group (1884.79). Cost-effect analysis is objective and direct in the evaluation of different treatments. The moist exposed burn therapy is a better and cheaper therapeutic regimen.

Fragmentation of Poly(lactic acid) Nanosheets and Patchwork Treatment for Burn Wounds

Freestanding poly(L-lactic acid) (PLLA) nanosheets are mass-produced by a simple combination of a spin-coating-assisted multi-layering process and a peeling technique. The resulting PLLA nanosheets are fragmented by homogenization and then reconstructed into a "patchwork" sheet on various surfaces without any adhesive reagents. The patchwork is shown to offer excellent protection against burn wound infection with Pseudomonas aeruginosa, and may therefore be an alternative to conventional burn therapy for prevention of infection.

Functional late outgrowth endothelial progenitors isolated from peripheral blood of burned patients

BackgroundBioengineered skin substitutes are increasingly considered as a useful option for the treatment of full thickness burn injury. Their viability following grafting can be enhanced by seeding the skin substitute with late outgrowth endothelial progenitor cells (EPCs). However, it is not known whether autologous EPCs can be obtained from burned patients shortly after injury. MethodsLate outgrowth EPCs were isolated from peripheral blood sampled obtained from 10 burned patients (extent 19.6±10.3% TBSA) within the first 24h of hospital admission, and from 7 healthy subjects. Late outgrowth EPCs were phenotyped in vitro. ResultsIn comparison with similar cells obtained from healthy subjects, growing colonies from burned patients yielded a higher percentage of EPC clones (46 versus 17%, p=0.013). Furthermore, EPCs from burned patients secreted more vascular endothelial growth factor (VEGF) into the culture medium than did their counterparts from healthy subjects (85.8±56.2 versus 17.6±14pg/mg protein, p=0.018). When injected to athymic nude mice 6h after unilateral ligation of the femoral artery, EPCs from both groups of subjects greatly accelerated the reperfusion of the ischaemic hindlimb and increased the number of vascular smooth muscle cells. ConclusionsThe present study supports that, in patients with burns of moderate extension, it is feasible to obtain functional autologous late outgrowth EPCs from peripheral blood. These results constitute a strong incentive to pursue approaches based on using autotransplantation of these cells to improve the therapy of full thickness burns.

Fluid therapy in burns

Outcome after burn injury, as also paralleled by other trauma, has been improving steadily over the years. In this aspect a significant improvement was seen especially in the 1970-ties when the 50% survival chance from a burn injury increased from 45% total body surface area burned (TBSA%) in a 21 year old patient up to almost 80% (TBSA%). Although this improvement may be claimed to have many reasons, a significant one that needs to be stressed is the introduction of more thorough use of protocolized fluid treatment strategies

Improved Burns Therapy: Liposomes‐in‐Hydrogel Delivery System for Mupirocin

Wounds, particularly burns, are prone to colonization of potentially life-threatening bacteria. Local delivery of antimicrobial agents in sufficient quantities and over longer period of time can reduce risk of burn infections. Mupirocin-in-liposomes-in-hydrogels were proposed as advanced delivery system for improved burn therapy. Mupirocin was entrapped in phosphatidylcholine liposomes of various sizes, namely larger (micron size) vesicles entrapping 74% of drug and sonicated vesicles (below 300 nm) entrapping 49% of drug. Liposomes containing mupirocin were incorporated in chitosan hydrogels (10%, w/w). Incorporation of liposomes in hydrogels resulted in prolonged release of liposomally associated mupirocin, as observed in both in vitro and ex vivo studies. The drug release was affected by the vesicle size. Microbiological evaluation of newly developed system confirmed its antimicrobial potential against Staphylococcus aureus and Bacillus subtilis. Bioadhesiveness of the system was compared with the marketed cream containing mupirocin. Our system exhibited superior bioadhesiveness and sustained mupirocin release profiles to marketed product.

Burn survivors’ perceptions of rehabilitation

BackgroundThe perspectives of burn survivors offer a powerful tool in assessing the efficacy of burn therapy interventions and methods. Despite this potential wealth of data, comprehensive analysis of burn survivor feedback remains largely uninvestigated and underdocumented. The aim of this study was to evaluate specific burn therapy interventions based on the opinions of a sample of the burn community. MethodsThe survey was distributed to a convenience sample drawn from burn survivors attending the Phoenix Society's 21st Annual World Burn Congress in New York City, New York. Items of inquiry focused on therapeutic intervention and reintegration. The 164 surveys (a 44% response rate) returned included burn survivors from a variety of demographic segments and with burn injuries of disparate size, location, and severity. Interventions of interest included splinting and positioning, pressure garments, therapeutic exercise, group therapy, and nontraditional therapy. Respondents also rated the contribution of acute burn rehabilitation toward reintegration into familial, societal, and professional roles. ResultsThe vast majority of respondents felt that the rehabilitative interventions they experienced positively affected their long-term physical and psychosocial outcomes. In the areas of improving movement and scarring and expediting reintegration and usefulness, the majority of applicable interventions generated “strongly agree” or “agree” as the most popular responses. ConclusionsThese findings support the efficacy of many practices employed by burn rehabilitation specialists and offer a glimpse into the inherent benefits found in assessment of burn survivors’ perspectives.

Rehabilitation of burn patients: An underestimated socio-economic burden

PurposePatients with burns utilise intensive medical care and rehabilitation. Deep dermal burns lead to scar contractures. Virtually no published data exists on costs for treatment of acute burns in comparison to burn sequelae. Our purpose was to collect financial data on burn therapy to estimate the socio-economic burden of thermal injuries. MethodsGerman-DRG for in-patient treatment of burns was collected from our burn center. DRG-related T95.- coding served as a search tool for burn associated sequelae. To include rehabilitation costs, data from the largest health care insurance and a workmen compensation fund were acquired. FindingsAcute burn treatment comprised 92% of costs for intensive care with approximately 4.600 EUR per percent total burned surface area (TBSA). Expenses for non-intensive care patients were significantly lower than for burn sequelae. Rehabilitation expenses were 4.4-fold higher than costs for acute burns including 59% for manual therapy and 37% for auxiliary material. ConclusionsTBSA multiplied by factor 4600 could serve for cost calculation of severely burned patients. Approximately 0.3 billion EUR in total or 270.000 EUR per patient/year were spent on burn sequelae. Early admission to specialized burn centers is advocated with state-of-the-art treatment to minimize burn sequelae and health care expenses.

Effect of Lithospermi Radix on Contact Dermatitis Induced by Dinitrofluorobenzene in Mice

Objective:The root of Lithospermum erythrorhizon Sieb. et Zucc. (Lithospermi Radix, LR) is a kind of heat clearing and blood cooling medicinal herbs. It can clear away heat and cool the blood, reduce toxins and disperse maculae. LR has long been used as efficacious therapy for inflammation, burns, frostbite and skin diseases such as eczema and psoriasis.Methods:In the present study, we investigate anti-allergic and anti-inflammatory effects of LR by using the 1-fluoro-2, 4- dinitrofluorobenzene (DNFB)-induced contact dermatitis mouse model.Results:Topical application of 10 mg/mL of LR effectively inhibited skin lesions induced by repeated paintings with DNFB. Topical application of LR also inhibited hyperplasia, edema, spongiosis and infiltrations of mononuclear cells. In addition, production levels of total immunoglobulin and IgG1 in serum were decreased by using LR in vivo.Conclusion:These data suggest that LR acts as an antiinflammatory agent, improving skin lesions in CD mice.

An update review of stem cell applications in burns and wound care

The ultimate goal of the treatment of cutaneous burns and wounds is to restore the damaged skin both structurally and functionally to its original state. Recent research advances have shown the great potential of stem cells in improving the rate and quality of wound healing and regenerating the skin and its appendages. Stem cell-based therapeutic strategies offer new prospects in the medical technology for burns and wounds care. This review seeks to give an updated overview of the applications of stem cell therapy in burns and wound management since our previous review of the “stem cell strategies in burns care”.

Analysis of attitudes toward the source of progenitor cells in tissue‐engineered products for use in burns compared with other disease states

The first trials using progenitor cells to improve burn wound healing are beginning. However, there remains a paucity of data on patients' opinions of the source of stem cells. In this study, 279 patients attending plastic surgery/burns outpatient and medical outpatient clinics were questioned to assess willingness to accept a tissue-engineered skin product derived from a variety of sources. Levels of acceptance for the use of progenitor cells derived from these sources for treatment across a range of disease states (burns, Parkinson's disease, diabetes, and for cosmetic use) were also assessed. Overall, 80% of those questioned would accept a tissue-engineered product. Autologous cells were the preferred choice of cells (acute burns 94%, diabetes 95%, Parkinson's 93.9%). Allogeneic cells were still widely accepted (acute burns 67%, diabetes 66.7%, Parkinson's 69.2%). There was no difference observed between plastic surgical patients and medical patients in acceptance of cell therapy for burns, Parkinson's disease, or diabetes. There is good potential acceptance for the use of both autologous and allogeneic cells for the treatment of acute burns and burns' scarring as well as in diabetes and Parkinson's disease. Disease state does not appear to influence overall acceptability and choice of cells.

Commercially available interactive video games in burn rehabilitation: therapeutic potential

Commercially available interactive video games (IVG) like the Nintendo Wii™ (NW) and PlayStation™II Eye Toy (PE) are increasingly used in the rehabilitation of patients with burn. Such games have gained popularity in burn rehabilitation because they encourage range of motion (ROM) while distracting from pain. However, IVGs were not originally designed for rehabilitation purposes but rather for entertainment and may lack specificity for achieving rehabilitative goals. Objectively evaluating the specific demands of IVGs in relation to common burn therapy goals will determine their true therapeutic benefit and guide their use in burn rehabilitation. Upper extremity (UE) motion of 24 normal children was measured using 3D motion analysis during play with the two types of IVGs most commonly described for use after burn: NW and PE. Data was analyzed using t-tests and One-way Analysis of Variance. Active range of motion for shoulder flexion and abduction during play with both PE and NW was within functional range, thus supporting the idea that IVGs offer activities with therapeutic potential to improve ROM. PE resulted in higher demands and longer duration of UE motion than NW, and therefore may be the preferred tool when UE ROM or muscular endurance are the goals of rehabilitation. When choosing a suitable IVG for application in rehabilitation, the user's impairment together with the therapeutic attributes of the IVG should be considered to optimize outcome.

Potentials of chitosan-based delivery systems in wound therapy: bioadhesion study.

Chitosan is currently proposed to be one of the most promising polymers in wound dressing development. Our research focuses on its potential as a vehicle for nano-delivery systems destined for burn therapy. One of the most important features of wound dressing is its bioadhesion to the wounded site. We compared the bioadhesive properties of chitosan with those of Carbopol, a synthetic origin polymer. Chitosan-based hydrogels of different molecular weights were first analyzed by texture analysis for gel cohesiveness, adhesiveness and hardness. In vitro release studies showed no difference in release of model antimicrobial drug from the different hydrogel formulations. Bioadhesion tests were performed on pig ear skin and the detachment force, necessary to remove the die from the skin, and the amount of remaining formulation on the skin were determined. Although no significant difference regarding detachment force could be seen between Carbopol-based and chitosan-based formulations, almost double the amount of chitosan formulation remained on the skin as compared to Carbopol formulations. The findings confirmed the great potential of chitosan-based delivery systems in advanced wound therapy. Moreover, results suggest that formulation retention on the ex vivo skin samples could provide deeper insight on formulation bioadhesiveness than the determination of detachment force.

The Relationship between Fructose, Glucose and Maltose Content with Diastase Number and Anti-Pseudomonal Activity of Natural Honey Combined with Potato Starch

Honey whose medicinal uses date from ancient times has been lately rediscovered as therapy for burns. Objective: To evaluate the additive action of potato starch on the antipseudomonal activity of natural honey. Methods: Physicochemical parameters of 6 samples of Algerian honeys were analysed; four parameters were measured, including Diastase, glucose, fructose and maltose. The antibacterial activity was tested using the well-agar diffusion assay. Results: Six honey samples with initial diastase activity between 22.1 and 7.3 Schade units were tested. Glucose, fructose and maltose values range between 21, 45-30, 95%, 25, 20-37, 81% and 4, 72-78, 45% respectively. The zone inhibition diameter (ZID) for the six honey samples without starch against P. aureogenosa ranged between 26 and 31 mm. When starch was mixed with honey and then added to well, a zone inhibition increase diameter (ZIID) 27 and 32 mm. The percentage increase (PI %) was noticed with each variety and it ranged between 3, 57 and 18, 75%. Positive correlation has been established between the zone increase of inhibition and the Diastase number (r value was 0.072 at p<0.05). Conclusion: The use of potato starch allows honey benefit and would constitute an additive effect to the antibacterial activity of natural honey.

Cell therapy of burns

Cell therapy of burns