Extensive Wounds Research Articles

Anti-inflammatory effect of interleukin-6 highly enriched in secretome of two clinically relevant sources of mesenchymal stromal cells.

Despite several advances in the field of regenerative medicine, clinical management of extensive skin wounds or burns remains a major therapeutic issue. During the past few years, Mesenchymal Stromal Cells (MSCs) have emerged as a novel therapeutic tool to promote tissue repair through their anti-inflammatory, pro-trophic and pro-remodeling effects. They exert their biological activity mainly via the secretion of soluble bioactive molecules such as cytokines, growth factors, proteins and microRNAs which can be encapsulated within extracellular vesicles (EV). The recent discovery of their high plasticity to external stimuli has fostered the development of new targeted therapies known as priming strategies, to enhance their potential. Our team recently showed that Interleukin-1β (IL-1β)-primed gingival MSCs promote wound healing and epidermal engraftment in vitro, and in vivo through their secreted products that contain extracellular vesicles. In the present work, we investigated whether two common sources of MSCs, gingiva and bone marrow, could respond similarly to IL-1β to favor pro-healing capabilities of their secretome. We showed that both primed-MSC sources, or their related secreted products, are able to reduce inflammation in LPS-challenged human monocytic THP-1 cell line. IL-1β priming enhanced MSC secretion of wound healing-related growth factors, cytokines and miRNAs in both sources. Among them, interleukin 6 was shown to be involved in the anti-inflammatory effect of MSC secreted products. Overall, these results underline the pro-healing properties of both MSC sources and their secretome upon IL-1β priming and their potential to improve the current medical treatment of severe wounds.

Negyvenéves a Debreceni Bőrklinikán működő Égési Osztály

For decades the burn patients have been treated at dermatological institutions worldwide, due to the similarities of the burns to certain blistering dermatological conditions. Another explanation was the routine of these clinics in the conservative treatment of wounds and general care of patients with extensive skin defects. Later on, together with more knowledge about the pathomechanism of burns and as the operative treatment became dominant, complex burn care was provided by specialized burn departments. Thanks to these developments, most burn care institutions nowadays are either autonomous centers or departments closely associated with traumatology, intensive care, surgical, pediatric surgical, or plastic surgery clinics. In Debrecen, the second profile is dermatologic surgery, which is now a unique combination, so the burn service is provided by the Department of Dermatology. Since its inauguration in 1983, the department introduced an active, operational burns treatment strategy. In the past forty years it pioneered several ground breaking therapeutic approaches, such as fluidization therapy, negative pressure wound therapy (NPWT), biotechnological wound coverage with keratinocyte suspension and sheets, dermal substitution with Alloderm®, Integra®, etc. Thanks to the continuous improvement of the instrumentation of the burn ward and the specific intensive care unit, it became possible to successfully treat patients with extensive deep burn wounds as well as dermatological crisis situations requiring intensive support. The department has remarkable international connections and scientific publication activities. Despite unfavorable tendencies of the most recent years, reducing the work force of both doctors and related professionals, the burn unit in Debrecen is keen on providing continuous, up to date, high quality professional service to burn patients of our region.

Meek Micrografting Technique for Reconstruction of Extensive Necrotizing Fasciitis of the Anterior Abdomen and Bilateral Femoral Region: A Case Report.

Necrotizing fasciitis is an uncommon yet fatal soft tissue infection. Current recommended treatment includes antibiotics with repeat surgical exploration and wound debridement followed by reconstruction. In burn patients, the Meek micrograft has demonstrated a higher true expansion ratio, faster reepithelialization rate, more resilient toward infection, and reduced risk of graft failure as compared with meshed graft. To our best knowledge, the use of Meek micrografting technique in reconstruction of postdebridement wounds of necrotizing fasciitis has not been reported. Hereby, we present a case of a 57-year-old gentleman who was referred to us for wound reconstruction after surgical debridement of Fournier's gangrene and extensive necrotizing fasciitis involving the anterior abdomen and bilateral femoral region. Meek micrografting technique was used to reconstruct the anterior abdomen as the wound bed was large. Although the graft was complicated with a small area of localized infection, it did not spread across the entire graft and was successfully treated with topical antibiotics and regular wound dressing. In our case, wound reconstruction using Meek micrografting technique in a patient with extensive necrotizing fasciitis was successful and showed positive outcome. Therefore, we suggest further studies to be conducted to investigate the applications and outcomes of the Meek micrografting technique, especially in patients with extensive wound bed and limited donor site availability.

Method of Extended Primary Microsurgical Treatment of Extensive Penetrating Scleral Wounds

Purpose: to expand and modernize the technology of primary microsurgical treatment of extensive scleral wounds due to simultaneous subtotal vitrectomy, primary treatment of retinal and choroid wounds, filling of tissue defects with autologous conditioned plasma (ACP), tamponade with silicone oil or C3F8 gas.Methods. 15 patients (15 eyes) with extensive penetrating scleral and corneoscleral wounds ranging from 8 to 15 mm in length, with concomitant complex injuries of various structures of the eye: traumatic cataract, wound of the ciliary body, injury or loss of the iris, subtotal/total hemophthalmos, retinal detachment were monitored. All patients underwent primary surgery according to the original extended technique.Results. The functional results of surgical treatment in patients, taking into account the severity of the injury, were high: in the early postoperative period, 1 month after primary surgery, visual acuity with correction ranged from 0.02 to 0.5. Signs of proliferative vitreoretinopathy were not observed in any case.Conclusion. The proposed method of extended primary microsurgical treatment for extensive penetrating scleral and corneoscleral wounds with severe concomitant damage to intraocular structures is effective and has a number of advantages: early prevention of severe complications in the form of proliferative vitreoretinopathy, shortening the rehabilitation period. The method allows to achieve high functional results in the most severe cases of penetrating eye injury.

Speeding up the production of clinical-grade skin substitutes using off-the-shelf decellularized self-assembled dermal matrices

Patients with deep and extensive wounds need urgent skin coverage to re-establish the cutaneous barrier that prevents life-threatening infections and dehydration. However, the current clinically-available skin substitutes intended for permanent coverage are limited in number, and a trade-off between production time and quality must be made. Here, we report the use of decellularized self-assembled dermal matrices to reduce by half the manufacturing process time of clinical-grade skin substitutes. These decellularized matrices can be stored for over 18 months and recellularized with patients' cells in order to generate skin substitutes that show outstanding histological and mechanical properties in vitro. Once grafted in mice, these substitutes persist over weeks with high graft take, few contraction events, and high stem cell content. These next-generation skin substitutes constitute a substantial advancement in the treatment of major burn patients, combining, for the first time, high functionality, rapid manufacturability and easy handling for surgeons and healthcare practitioners. Future clinical trials will be conducted to assess the advantages of these substitutes over existing treatments. Statement of significanceThe number of patients in need for organ transplantation is ever-growing and there is a shortage in tissue and organ donors. In this study, we show for the first time that we can preserve decellularized self-assembled tissues and keep them in storage. Then, in only three weeks we can use them to produce bilayered skin substitutes that have properties very close to those of the native human skin. These findings therefore represent a major step forward in the field of tissue engineering and organ transplantation, paving the way toward a universal off-the-shelf biomaterial for tissue reconstruction and surgery that will be beneficial for many clinicians and patients.

A Retrospective Study on the Clinical, Laboratory, and Nutritional Status of Pediatric Epidermolysis Bullosa in a Tertiary Referral Hospital in West Java, Indonesia.

Epidermolysis bullosa (EB) is a genodermatosis disease with bullae and erosions of the skin and mucous membrane that can last for a lifetime and decrease quality of life. Oral and gastrointestinal disorders inhibit the patients' ability to achieve optimal nutrition, making the patients prone to infection, leading to prolonged wound healing, and delayed growth and developmental process. However, there has been no research on the clinical, laboratory, and nutritional status of pediatric EB patients in Indonesia. This study aims to describe the clinical, laboratory, and nutritional characteristics of pediatric EB patients treated in Dr. Hasan Sadikin General Hospital Bandung, Indonesia. This was a retrospective descriptive study of pediatric EB patient records in Dermatology and Venereology Outpatient of Dr. Hasan Sadikin General Hospital Bandung, Indonesia, from April 2018-March 2020. Study results showed 12 pediatric EB patients consisting of 7 dystrophic EB (DEB) (4 recessive dystrophic EB [RDEB] patients and 3 dominant dystrophic EB [DDEB]), 3 junctional EB (JEB), and 2 EB simplex (EBS). The most extensive EB wounds was found affecting 10-20% of the body surface area with a <10% infected wound area. Pain was found in all patients. The most frequent abnormalities in laboratory examination were anemia and low zinc levels. Severe malnutrition was found in almost half of the patients. RDEB is the most commonly found type of pediatric EB. Wounds on the skin, tooth decay, hand deformity, pain when changing dressings, low zinc levels, and low hemoglobin levels are the clinical features and laboratory findings that contribute to the development of moderate and severe malnutrition in RDEB patients.

Recent advances in the biological activities of microbial exopolysaccharides.

Microbial exopolysaccharides (EPSs) are valuable extracellular macromolecules secreted as capsules or slime layers. Various microorganisms, including bacteria, yeasts, fungi, and algae have been studied for their ability to produce EPSs. Microbial EPSs exist as homopolysaccharides or heteropolysaccharides with various properties such as different monosaccharide compositions, structural conformation, molecular weight, and functional groups. They are cost-effective alternatives to plant and animal-derived polysaccharides because the microbial cells produced them in large quantities by biotechnological processes using low-cost substrates such as industrial wastes in a short time. Microbial EPSs are safe, biodegradable, and compatible polymers. They have extensive bioactivities, including antibacterial, antifungal, antiviral, antioxidant, antitumor, antidiabetic, antiulcer, anticoagulant, antiaging, immunomodulatory, wound healing, and cholesterol-lowering activities. Microbial EPSs owing to biological activities, special biochemical structures, and attractive physicochemical properties find plenty of potential applications in various industries. The enhancement of the production of EPSs and improving their properties can be provided by genetic engineering methods. The current review aims to provide a comprehensive examination of the therapeutic activities of microbial EPSs in infectious diseases and metabolic disorders, with a focus on the mechanisms involved. Also, the effect of the physicochemical characteristics of EPSs on these bioactivities was discussed to reveal the structure-activity relationship.

The Role of Burn Centres in the Treatment of Necrotizing Soft-Tissue Infections: a Nationwide Dutch Study.

Patients with extensive and complex wounds due to Necrotizing Soft-Tissue Infections (NSTI) may be referred to hospitals with a burn centre. This study describes the characteristics, outcomes, as well as diagnostic challenges of these patients. Patients admitted to three burn centres for the treatment of NSTI in a 5-year period were included. Eighty patients (median age 54 years, 60% male) were identified, of whom 30 (38%) were referred by other centres, usually after survival of the initial septic phase. Those referred from other centres, compared to those primarily admitted to the study hospital, were more likely to have group A streptococcal involvement (62% versus 35%, p=0.02), larger wounds (median 7% versus 2% total body surface area, p<0.001), and a longer length of stay (median 49 versus 22 days, p<0.001). Despite a high incidence of septic shock (50%), the mortality rate was low (12%) for those primarily admitted. Approximately half (53%) of the patients were initially misdiagnosed upon presentation, which was associated with delay to first surgery (16 hours vs 4 hours, p<0.001). Those initially misdiagnosed had more (severe) comorbidities, and less frequently reported pain or blue livid discoloration of the skin. This study underlines the burn centres' function as referral centres for extensively affected patients with NSTI. Besides the unique wound and reconstructive expertise, the low mortality rate indicates these centres provide adequate acute care as well. A major remaining challenge remains recognition of the disease upon presentation. Future studies in which factors associated with misdiagnosis are explored are needed.

The role of laser technologies in coloproctology

Laser (Light Amplification by the Stimulated Emission of Radiation) is a technical device that emits electromagnetic radiation focused in the form of a beam in the range from infrared to ultraviolet, with high energy and biological effect. In the first quarter of the 20th century, A. Einstein laid the foundation for its creation, believing that when atoms are excited from an external radiation source, a multiple increase in the released photons occurs, and the result of this process is recorded as light energy. Back in the late twentieth century, lasers in coloproctology were used as a scalpel, in fact, they performed traditional surgical interventions, but using energy tools, however, this did not deprive patients of extensive wounds and, as a result, pronounced pain sensations. The modern use of laser in proctology is really minimally invasive. An optical fiber is carried through small punctures on the skin or fistula, through which the laser energy flows directly to the target and acts aiming. In coloproctology, lasers are used to treat hemorrhoidal disease, rectal fistulas and pilonidal sinus this isrecorded in clinical guidelines. The use of laser treatment with these nosologies can reduce the severity of pain after surgery, significantly reduce the healing time of wounds, shorten the period of disability, without reducing the quality of life of patients. At the same time, these interventions are almost as effective as classical operations, in some cases even superior. But despite these encouraging data, it is necessary to conduct further research in order to develop clear technical regulations for the use of laser techniques and tracking long-term results.

Pay attention to persistent inflammation-immunosuppression-catabolism syndrome in the late stage of severe burns

With the deepening of researches on organ complications after severe burns and the continuous improvement of monitoring and support technology for organ function, severe burn patients have avoided death in the early and middle to late stages due to shock, infection, etc., and entered the late stage of burns. Due to the failure of timely and effective burn wound healing and long-term exposure and infection of extensive burn wounds, some of these patients were in chronic and critical conditions such as fever, emaciation, and delayed wound healing that are accompanied by decreased immune function, anemia, and hypoproteinemia, etc. It manifested as persistent inflammation-immunosuppression-catabolism syndrome (PICS), leading to prolonged hospitalization and increased long-term mortality. Based on clinical practice of the author's team in burn treatment, this paper briefly expounds the main causes, clinical characteristics, and prevention methods of PICS in the late stage of severe burns of patients, hoping to attract the attention of peers to PICS in the late stage of severe burns.

Post-Panaris Necrosating Fasciitis of the Right Upper Limb in a Case Observed at the Markala Reference Health Center

Necrotizing fasciitis is an infection of the skin and deep subcutaneous tissues, spreading along the fasciae and adipose tissue, mainly caused by Group A streptococcus (Streptococcus pyogenes) but also by other bacteria such as Vibrio vulnificus, Clostridium perfringens or Bacteroides fragilis. Objective: To report a case of Necrotizing Fasciitis received at the Markala Reference Health Center. Clinical observation: It was a 45-year-old rice farmer with no known medical-surgical history received for an extensive wound on the right upper limb evolving for three months with impaired general condition and consciousness. The onset of the symptomatology dates back to about 3 months marked by a paronychia of the pulp of the right thumb extended secondarily to the right forearm. The physical examination finds an extensive necrotic wound of the right upper limb presenting voluminous blisters of brown color with a black background filled with purulent and smelly serosities. The diagnosis of Necrotizing Fasciitis was strongly suspected due to the presence of Pyogenic Streptococcus (Sensitive to gentamycin and Amoxicillin) in the pus sample. The patient was therefore put on antibiotic therapy combining Clavulanic acid at a rate of 2g x 3 per day and gentamicin at a rate of 160 mg per day with wide excision of necrotic tissues under general anesthesia in the operating room followed by a daily dressing with 30V hydrogen peroxide and Polyvidone iodine. The evolution was very favorable with a directed healing on D16. Conclusion: Necrotizing fasciitis is distinguished by its increasingly increasing and worrying frequency, its clinical severity and its detrimental character from a functional and vital point of view, which is why its management must be early.

551 Reduction of Fungus-Related Complications in a Burn Center

Abstract Introduction Fungal wound infections (FWI) cause morbidity and increase mortality in burn patients. Our burn center experienced 44 patients with fungal wound colonization (FWC) and/or FWI between JAN 2015 and JAN 2019. In response, we undertook a performance improvement project to prevent and treat FWC and FWI. Methods Members of the multidisciplinary team met to develop a clinical practice guideline (CPG) for the prevention and management of FWC and FWI based on current evidence. We focused on patients with elevated risk, that is, with burns ≥20% total body surface area (TBSA) and in the Burn ICU (BICU). Interventions included: utilizing alternating silver sulfadiazine and mafenide acetate creams upon admission; reducing the use of mafenide acetate solution; utilizing silver nitrate solution post-operatively; and applying topical nystatin cream or powder for suspected FWC or FWI. We educated all staff members and updated order sets and training materials. We collected data on all burn patients who had a wound biopsy out of concern for possible infection. Biopsy results were categorized as FWC or FWI. Retrospective data were collected for MAR 2020 - MAR 2021 (PRE). Post-implementation, prospective data collection began MAR 2022 (POST) and will continue for one year. Adherence to the CPG was assessed by chart review. Mann-Whitney and Fischer Exact tests were performed. Results The PRE (n=15) and POST (n=9) groups were similar in age (43±13 vs. 48±18 years) but differed in TBSA (49±19 vs 28±25%, p&amp;lt; .05). PRE group biopsies showed FWC in 0 patients and FWI in 11 of 15 patients (73%); 8 of these (53%), all with FWI, died. In the POST group, FWC was found in 1 patient (11%) and FWI was found in 2 of 9 patients (22%); one death occurred in the patient with FWC. Adherence to the CPG for admission topical wound care was 7% in the PRE group vs 89% in the POST group (p=0.0001); adherence to the CPG for day-of-biopsy topical wound care was 27% in the PRE group vs 89% in the POST group (p&amp;lt; 0.01). Conclusions Adherence to a CPG for the prevention and treatment of FWC and FWI was associated with a lower (but not statistically significant) prevalence of these complications. Limitations include a difference in the TBSA between the 2 groups and potential concurrent changes in practice. Ongoing data collection includes the evaluation of other potential contributing factors. Applicability of Research to Practice Fungi are common in the environment, and when combined with immunosuppression and extensive open wounds, may cause wound infection in burn patients. More research is needed to further evaluate effective treatments for the prevention and treatment of FWC and FWI in these patients.

303 Burn Rehabilitation Training for the Pediatric Burn Critical Care RN

Abstract Introduction New registered nurses (RNs) in the burn pediatric intensive care unit (PICU) need extensive pediatric, critical care, and wound care training. Each of these specialties present a challenging learning curve to the new RN and can overshadow the RN’s focus on burn rehabilitation. Our goal was to improve the RN’s understanding of the importance of early rehabilitative care and their role in the provision of burn rehabilitation in the burn PICU setting. Methods We developed an interdisciplinary program which allowed the RN to work alongside burn physical and occupational therapists. The aim of the program was to teach the participants the importance of early and consistent splinting, positioning, mobilization, and other therapeutic interventions and to learn how to incorporate these techniques into their nursing plan of care. Over two years, nine RNs participated in a four-hour shadow program with a senior physical and occupational therapist. The therapists provided direct hands-on training with patients across the care continuum focusing on competencies aligned with the American Burn Association’s Burn Nurse Competencies. The RNs completed a self-assessment tool to score their self-perceived knowledge related to burn rehabilitation. The self-assessment included a 10-question Likert-scale survey, based on Benner’s Novice to Expert Model. Scoring aligned with the Benner Stages of Clinical Competence: 10 = Novice, 20 = Advanced Beginner, 30 = Competent, 40 = Proficient, and 50 = Expert. The survey was completed pre-intervention, immediately post-intervention, and 3-6 months post-intervention. Results Nine RNs completed the serial surveys. The median years of nursing experience was 2.5 (2-3.5) years. The training was provided at a median time of 4 (3.1-4.6) months after orientation completion. The median score for the pre-intervention assessment was 19 (16-25). The immediate post-intervention score significantly increased to a median of 30 (25-31) (p=0.006) and was maintained at 3-6 months post-intervention (32 (29-37) p=0.0002). There was no significant difference in assessment scores between the immediate post intervention and the 3-6 month post intervention assessment (p=0.25). All median values are median (interquartile range) and significance level was set at a p&amp;lt; 0.05. Conclusions New RNs in the burn pediatric critical care unit have a tremendous learning curve. Our training model demonstrates that there may be improved competency when learning is introduced in staged approaches. Additionally, burn rehabilitation in the PICU requires a transdisciplinary understanding of the patient’s needs. Our training program demonstrates that collaboration across professional disciplines to provide nursing education can improve the clinical competency of new RNs. Applicability of Research to Practice Identifying more efficient and effective methods of new RN training can improve the delivery of nursing care and improve patient outcomes.

705 Evaluation of Invasive Fungal Infections in the Burn ICU

Abstract Introduction Fungal infections are increasingly associated with critical illness, especially in major burn injury. The risk factors of invasive fungal infections include central venous catheter (CVC) placement, mechanical ventilation, broad-spectrum antibiotics, renal replacement therapy (RRT), and total parental nutrition. Critically ill burn patients have additional risk factors including extensive wounds, impaired immune system, and repeated surgical intervention. Despite significant morbidity and mortality caused by invasive fungal infections, efforts to prevent them with antifungal prophylaxis have not improved outcomes. In patients who develop invasive fungal infection, appropriate empiric antifungal therapy is imperative to reduce morbidity and mortality especially in the setting of delayed culture and sensitivity data. The purpose of this study was to characterize risk factors associated with the development of invasive fungal infection, invasive fungal infection organisms and surgical and pharmacological management. Methods A retrospective chart review was completed of adult patients admitted to the burn ICU found to have an invasive fungal infection (defined as at least one positive blood or tissue fungal infection and receipt of systemic antifungal therapy). The primary outcome was to identify common fungal organisms. Secondary outcomes included susceptibility pattern of the organism, location of infection, surgical management including debridement and amputation, pharmacological management, median ICU and hospital length of stay, and in hospital mortality. Results A total of 10 patients of a goal of 100 patients with a median 54% TBSA burns were evaluated at this time. The most common yeast species included candida albicans; mold species included a variety of organisms such as fusarium, zygomycete and paecilomyces. Common risk factors among these patients included CVC access (57%), mechanical ventilation (43%), and RRT (43%). Yeast infections were primarily treated with anidulafungin and fluconazole, while mold infections were managed with systemic amphotericin as backbone in addition to voriconazole or isavuconazole. Patients underwent aggressive surgical debridement for source control. Median ICU stay was 53 days with a median hospital stay of 63 days, and 42% mortality. Conclusions Fungal infections among critically ill burn patients are associated with the high morbidity and mortality rates. Therefore, mitigation of modifiable risk factors is of utmost importance. This retrospective review of common fungal growth in our unit will inform future empiric antifungal management for patients with concern of invasive fungal infections. Applicability of Research to Practice Fungal infections present a clinical challenge for burn practitioners, especially in geographically moist areas. Prevention and informed surgical and pharmacological management are key to overcoming this infectious disease threat.

Experience in surgical treatment of enteroatmospheric fistulas in the late period of postoperative peritonitis

Background. Enteroatmospheric fistulas (EAF) that occur during the use of the “open abdomen” surgical tactics are a complex surgical pathology with a high mortality rate.The aim. To assess the effectiveness of treatment of various forms of enteroatmospheric fistulas in patients with postoperative peritonitis using vacuum aspiration technology.Methods. We assessed the results of the surgical treatment of 46 patients with EAF in the late course of postoperative peritonitis (PP). Three clinical and morphological groups were distinguished: group 1 (n = 24) – EAF in small wounds of the anterior abdominal wall; group 2 (n = 15) – EAF opening into limited cavities; group 3 (n = 7) – EAF opening into laparostoma wounds. In group 1, a fistula was formed using continuous aspiration devices or VAC systems. In group 2, we used continuous aspiration of intestinal contents from the cavity. In group 3, laparostoma was treated using vacuum devices with isolation of the intestinal fistula and simulation of a floating enterostoma.Results. Group 3 of patients with EAF was characterized by a high flow rate (1224.2 ± 210.3 ml), duration of treatment (87.3 ± 12.5 day), extensive laparostoma (335.4 ± 14.3 сm2), high mortality rate (57.1 %). The best results of treatment were obtained in groups 1 and 2. The flow rate was 675.8 ± 154.3 and 541.3 ± 114.1 ml, the duration of treatment was 2 or 3 times less (37.7 ± 6.1 and 26.4 ± 5.2 days), the mortality rate was 8.3 % and 6.7 % respectively.Conclusion. EAF that occur when using the “open abdomen” surgical tactics due to the impossibility of their isolation in extensive wounds of the anterior abdominal wall are complicated clinical and morphological forms. For their treatment, it is advisable to use VAC systems, aimed at the treatment of both the anterior abdominal wall wound itself and the intestinal fistula opening into it for its gradual extraterritorialization by modeling a floating enterostoma in a vacuum device.

Vacuum Therapy in Complex Treatment of Purulent-Necrotic Diseases of Soft Tissues: Clinical Cases

Background. Radical surgeries for phlegmons, abscesses, necrotizing infection are often followed by extensive wounds which require an individual approach to their rapid closure by means of plastic surgery methods. In such a case, the optimal wound therapy is primary healing with the use of vacuum therapy.Cases description. The study involved three clinical trials of patients with acute purulent-necrotic diseases of soft tissues of various localizations, volumes and grades, for which vacuum therapy was used as a part of complex therapy. Surgical interventions are proved to be urgently performed in acute purulent-necrotic diseases. Early reconstructive skin and bone plastic surgery aimed at closing post-operative wound defects is also very important.Conclusion. In the demonstrated clinical cases, the purulent process was stopped and wound therapy was performed by means of primary healing, which undoubtedly ensures medical and social rehabilitation of such patients. Notably, vacuum drainage is not an independent method, but an important component in the complex active surgical treatment of purulent wounds.

Keystone perforator island flaps in the reconstruction of lower limb defects resulting from shrapnel and mine-explosive combat injuries. Case series

In the conditions of warfare in Ukraine, the question of providing medical services to injured civilian and military is especially relevant and severe. In plastic surgeons` professional activities, the task is to restore extensive and deep wound defects in a short term and with a high degree of damaged organ`s restoration, especially supporting function. In this article the authors describe their experience with local keystone perforator island flaps, which are used to reconstruct skin and soft tissue defects of the lower limbs caused by combat injuries.&#x0D; Patients and methods. The authors conducted a retrospective review of 49 keystone perforator flaps for 28 patients (26 men and 2 women) who received treatment in the clinic for bullet, shrapnel, and mine‑explosive injuries between 2014 and 2022.&#x0D; Results. In all cases, extensive wound defects were completely closed during a single‑stage surgical procedure, and the patients were discharged after recovery. Non‑critical complications required secondary sutures in two cases (4%), extending the duration of treatment by 6 days. The time spent in the operating room on the transposition of one flap ranged from 40 to 95 min (mean: 67 min).&#x0D; Conclusions. The findings of the study show that local keystone perforator island flaps are highly effective in the successful reconstruction of lower limb defects caused by combat wounds. The keystone perforator island flap technique requires basic preoperative preparation of the patient, is easy‑to‑use, and exhibits a fairly high level of reliability at the same time. In most cases, keystone perforator island flaps provide primary and single‑stage closure of a large defect in the thigh, in the area of the knee joint, and in the lower leg in the absence of secondary defects that are common at donor sites when alternative techniques are chosen.

Effects of local infiltration of peripheral blood mononuclear cells with phonophoresis on wound healing in dogs

A total of six dogs with extensive wounds of 5×5 cm2 size and above were taken with the objective of evaluating the efficacy of autologous peripheral blood mononuclear cells (PBMC) with phonophoresis on wound healing in dogs. Autologous PBMCs were isolated freshly on 0, 7, 14, 21 and 28th day from blood by using density gradient centrifugation. Obtained PBMC was infiltrated around the wounds. Phonophoresis was done using therapeutic ultrasound massage at 0.5 watts/cm2 for 10 min for all the six animals. Clinical evaluation and wound planimetry was performed during post treatment period. Most affected breed was mongrel and main aetiology was automobile accident. The wounds were mostly located on limbs, neck and abdominal region. PBMC was noticed to be compatible to the tissues. No signs of infection were noticed in the wounds after administration of PBMC, rather healthy granulation tissue-formation, increasing values of wound contraction, epithelization and healing were noticed. PBMC-phonophoresis in wound healing of canines in present study was found to be effective in extensive wounds.

STUDI KASUS: PERAWATAN PALIATIF KARSINOMA PAYUDARA STADIUM LANJUT MELALUI PENDEKATAN MODEL ADAPTASI ROY

Breast cancer patients with advanced stages who have undergone previous cancer treatment require palliative care support in an effort to fulfill their health needs. Mrs. N, a 60 year old woman, with metastatic breast carcinoma of the lung and (suspected) skin, was initially admitted to the ward with further chemotherapy plans. The patient and family decided to move treatment at the Jakarta Hospital from the previous hospital with high hopes of recovery. The patient has extensive breast wounds on the chest to the right abdomen and back. The patient complains of fatigue and pain all over the body with a pain scale of NRS=5. With the current state of the advanced stage, the Doctor in Charge of the Patient (DPJP) decides that the patient will switch treatment goals to palliative care. Researchers use this adaptation model with the aim of helping patients and families recognize health problems faced by looking at humans as a whole (bio-psycho-social) and helping to use positive coping to be able to adapt. The nursing assessment was carried out using Roy's Adaptation Model theory so that the main problems were obtained, namely nutritional deficits and knowledge deficits about palliative management. Nutritional management interventions by maintaining nutritional intake by administering a liquid diet 6x250 cc/day and extra egg whites 2-3 eggs/day through a Naso Gastric Tube (NGT) tube and health education about palliative care provided in collaboration with DPJP, a specialist in internal medicine with a subspecialty of hematology -medical oncology. Implementation is carried out by nurses for 6 days of treatment with evaluation assessments every day. The results showed that the patient's nutritional status improved by maintaining nutritional intake through the provision of food and drink per NGT and patient and family knowledge regarding palliative care increased. Result from this case study, nursing care using Roy's Adaptation Model theory can be applied to the condition of advanced cancer patients with palliative care so that the patient's nursing problems can be resolved properly. .

The model pH-controlled delivery system based on gelatin-tannin hydrogels containing ferrous ascorbate: iron release in vitro

Hydrogels have become an essential class among all biomaterials. The specialized biomaterials are highly valued in the field of biomedical applications. One of the problems in wound management is local microelement deficiency associated with extensive wound lesions. The significant lack of elemental iron in the human body leads to serious consequences and prolongs treatment. The synthesis of gelatin-tannin hydrogels with ion delivery function is proposed in this study. The ability to release ions in low acid solution is a sphere of great interest. The pH drop in the wound cavity is usually associated with the contamination of some bacterial cultures. pH-controlled delivery of iron in buffer solutions (рН = 5.5/6.4/7.4) was considered for these hydrogels. The kinetics of iron release was determined by visible spectroscopy. Theoretical models were applied to describe the process of ion delivery. The structure of materials was examined by IR-spectroscopy and demonstrated the incorporation of ferrous ascorbate into hydrogel matrix. Thermal analysis was used to point out the key differences in thermal behavior by isoconversional methods (Flynn-Wall-Ozawa/Kissinger-Akahira-Sunose). The mechanical properties of the materials have been studied. The effect of iron ascorbate on polymer network parameters was discussed. The current study demonstrated the possibility of obtaining gelatin-tannin hydrogels for pH-dependent iron delivery. That provides future perspectives to expand the set of releasing microelements for biomedical applications.