Fiona Wood

International clinical recommendations on scar management

Many techniques for management of hypertrophic scars and keloids have been proven through extensive use, but few have been supported by prospective studies with adequate control groups. Several new therapies showed good results in small-scale trials, but these have not been repeated in larger trials with long-term follow-up. This article reports a qualitative overview of the available clinical literature by an international panel of experts using standard methods of appraisal. The article provides evidence- based recommendations on prevention and treatment of abnormal scarring and, where studies are insufficient, consensus on best practice. The recommendations focus on the management of hypertrophic scars and keloids, and are internationally applicable in a range of clinical situations. These recommendations support a move to a more evidence-based approach in scar management. This approach highlights a primary role for silicon gel sheeting and intralesional corticosteroids in the management of a wide variety of abnormal scars. The authors concluded that these are the only treatments for which sufficient evidence exists to make evidence-based recommendations. A number of other therapies that are in common use have achieved acceptance by the authors as standard practice. However, it is highly desirable that many standard practice and new emerging therapies undergo large-scale studies with long-term follow-up before being recommended conclusively as alternative therapies for scar management.

Designer self-assembling hydrogel scaffolds can impact skin cell proliferation and migration

There is a need to develop economical, efficient and widely available therapeutic approaches to enhance the rate of skin wound healing. The optimal outcome of wound healing is restoration to the pre-wound quality of health. In this study we investigate the cellular response to biological stimuli using functionalized nanofibers from the self-assembling peptide, RADA16. We demonstrate that adding different functional motifs to the RADA16 base peptide can influence the rate of proliferation and migration of keratinocytes and dermal fibroblasts. Relative to unmodified RADA16; the Collagen I motif significantly promotes cell migration, and reduces proliferation.

Cultured autologous keratinocytes in suspension accelerate epithelial maturation in an in vivo wound model as measured by surface electrical capacitance.

Background: Human epidermis serves as a protective covering against loss of endogenous fluids and exogenous microbial invasion. Cultured epithelial autograft suspensions have been used to enhance epithelialization to improve mortality, morbidity, and the overall quality of the scar. The measurement of surface electrical capacitance as an indicator of transepidermal water loss has been used in neonatology and dermatology to determine epidermal maturation. This tool has been used in a double-blind, randomized, controlled trial to compare the effects of cultured epithelial autograft in suspension on epidermal healing and maturation compared with a control in an in vivo partial thickness wound model. Methods: In this double-blind, randomized, controlled trial (n = 8), the authors assessed the effect of cultured epithelial autograft on epidermal healing and maturation in standardized partial thickness wounds. Surface electrical capacitance was compared on 16 split-thickness skin graft donor sites treated with cultured epithelial autograft (n = 8) against controls treated with Dulbecco’s Modified Eagle’s Medium (n = 8) using a NOVA Dermaphase Meter at 4, 5, 6, and 7 days postoperatively. Results: A statistically significant difference on continuous readings at days 5 (p = 0.012) and 7 (p = 0.036) and instantaneously on days 5 (p = 0.025) and 6 (p = 0.036) in surface electrical capacitance was observed in the cultured epithelial autograft over the Dulbecco’s Modified Eagle’s Medium–treated wounds. Conclusions: Measuring surface electrical capacitance provides an objective and repeatable method of assessing epidermal maturation. This study indicates that the rate of epithelialization and epidermal maturation is more rapid in partial thickness epidermal skin wounds treated with cultured epithelial autograft.

Anatomical variations in pressures generated by pressure garments.

&NA; Pressure therapy is the predominant means for prophylaxis and treatment of hypertrophic scar. Despite this, there is little scientific evidence to support its use. This study examines the pressures generated by pressure garments in four subjects at 36 different anatomical sites chosen to represent the varying body geometry. Direct subdermal pressures were measured by an established method, though novel for this application. Pressure garments create a mean increase in subdermal pressures of 22.2 mmHg (range ‐10 to 102 mmHg). A significant objective difference exists in pressures generated at different anatomical sites. These differences correlate to local tissue compliance and to known areas of good clinical response and inversely correlate to the radius of anatomic curvature. The data suggest that pressures around 15 mmHg are required to effect a positive scar response and that close experienced monitoring of garments be performed. (Plast. Reconstr. Surg. 101: 399, 1998.)

Burns education for non-burn specialist clinicians in Western Australia

BACKGROUNDnBurn patients often receive their initial care by non-burn specialist clinicians, with increasingly collaborative burn models of care. The provision of relevant and accessible education for these clinicians is therefore vital for optimal patient care.nnnDESIGN/METHODSnA two phase design was used. A state-wide survey of multidisciplinary non-burn specialist clinicians throughout Western Australia identified learning needs related to paediatric burn care. A targeted education programme was developed and delivered live via videoconference. Pre-post-test analysis evaluated changes in knowledge as a result of attendance at each education session.nnnRESULTSnNon-burn specialist clinicians identified numerous areas of burn care relevant to their practice. Statistically significant differences between perceived relevance of care and confidence in care provision were reported for aspects of acute burn care. Following attendance at the education sessions, statistically significant increases in knowledge were noted for most areas of acute burn care.nnnCONCLUSIONSnIdentification of learning needs facilitated the development of a targeted education programme for non-burn specialist clinicians. Increased non-burn specialist clinician knowledge following attendance at most education sessions supports the use of videoconferencing as an acceptable and effective method of delivering burns education in Western Australia.

An alternative technique for the harvesting of cultured epithelial cell sheets

We describe an efficient and economical method for the harvesting of confluent cell sheets from tissue culture flasks. Our method eliminates the use of clips by utilizing a ‘glass hockey stick’ and the adherent property of the vaseline gauze carrier to enable the cultured epithelial autograft (CEA) to be rapidly removed from the tissue culture flask.

Telehealth for paediatric burn patients in rural areas: a retrospective audit of activity and cost savings

INTRODUCTIONnSince 2005, the Western Australian paediatric burn unit has provided a state-wide clinical consultancy and support service for the assessment and management of acute and rehabilitative burn patients via its telehealth service. Since then, the use of this telehealth service has steadily increased as it has become imbedded in the model of care for paediatric burn patients. Primarily, the service involves acute and long term patient reviews conducted by the metropolitan-located burn unit in contact with health practitioners, advising patients and their families who reside outside the metropolitan area thereby avoiding unnecessary transfers and inpatient bed days. A further benefit of the paediatric burn service using telehealth is more efficient use of tertiary level burn unit beds, with only those patients meeting clinical criteria for admission being transferred.nnnAIMnTo conduct a retrospective audit of avoided transfers and bed days in 2005/06-2012/13 as a result of the use of the paediatric Burns Telehealth Service and estimate their cost savings in 2012/13.nnnMETHODnA retrospective chart audit identified activity, avoided unnecessary acute and scar review patient transfers, inpatient bed days and their associated avoided costs to the tertiary burn unit and patient travel funding.nnnRESULTSnOver the period 2005/06-2012/13 the audit identified 4,905 avoided inpatient bed days, 364 avoided acute patient transfers and 1,763 avoided follow up review transfers for a total of 1,312 paediatric burn patients as a result of this telehealth service. This paper presents the derivation of these outcomes and an estimation of their cost savings in 2012/13 of AUD 1.89million.nnnCONCLUSIONnThis study demonstrates avoided patient transfers, inpatient bed days and associated costs as the result of an integrated burns telehealth service.

Development of a national burn network: providing a co-ordinated response to a burn mass casualty disaster within the Australian health system

With the threat of terrorist activity ever present since the incidents in Bali and Jakarta, the Australian health system must be prepared to manage another mass burn casualty disaster. The Australian and New Zealand Burns Association (ANZBA) highlighted the lack of a national burn disaster response before the 2000 Olympics. With the limited number of burn beds available and the protracted length of stay after such injuries, any state or territory could be overwhelmed with relatively few patient admissions. In 2002, the Australian Health Ministers Conference called for a solution. The objective of this paper is to provide an overview of the process and development of the Australian National Burn Network, which underpins the National Burn Disaster Response (AUSBURNPLAN).