Heng-Yu Li

Epidemiology and Outcome Analysis of Severe Extensive Burns: A 12-Year Summary of 103 Cases in a Burn Center in China

The purpose of this article is to improve the treatment of severe extensive burns (SEB) patients by summarizing treatment experience in recent 12 years in China and analyzing the follow-up quality of life (QOL) in these patients. Clinical data and rescue measures of 103 SEB patients (≥70% TBSA) admitted in a burn center in Shanghai between 1997 and 2009 were reviewed, and QOL and hand function of those who survived more than 2 years were assessed by Brief Version of Burn Specific Health scale-B and Michigan Hand Outcome Questionnaire. Of these, 76.7% were caused by flames and 15.5% caused by scald. The median burn area was 87.5% (interquartile range, 77.0–95.0%) TBSA, of which third-degree burns accounted for 56.5% (interquartile range, 25.8–80.0%) TBSA; 71.8% were complicated by inhalation injury. The occurrence of in-hospital complications was 75.7%, with the respiratory system complications predominating (49.5%). The fatality rate was 28.2%, mainly due to sepsis and multiple organ dysfunction syndrome. Work, body image, and heat sensitivity got the lowest Brief Version of Burn Specific Health scale-B scores in all nine domains, and Michigan Hand Outcome Questionnaire scores were also relatively poor. Flame burns remain to be the main cause of SEB in China in recent 12 years. Treatment is still challenged because of the depth and extensive burn area and high occurrence of multiple system complications. How to ameliorate QOL of SEB patients, intensify the functional rehabilitation, and improve their physical appearance in particular remain to be a crux.

Suppressed acute phase response to LPS-induced hepatic injury in Smad3-deficient mice

The generation of animals lacking Smad proteins has made it possible to explore the contribution of the TGF-beta-Smad signaling to immune activity in vivo. And there have been related issues actively pursued by many laboratories. Here we report that, in contrast to the markedly enhanced inflammatory response, Smad3 gene knockout (Smad3(ex8/ex8)) mice paradoxically show suppressed hepatic acute phase response to the injury induced by lipopolysaccharide (LPS) compared with wild-type mice, characterized by significantly weaker reaction of several typical acute phase proteins in mRNA level. The increase of positive acute phase proteins, e.g. alpha1-acid glycoprotein (alpha1-AGP), haptoglobin (HP) and C-reaction protein (CRP), and the decrease of negative acute phase proteins, including albumin (ALB) and transferrin (TRF), were both repressed according to the expression in liver estimated by optimized RT-PCR. Smad3(ex8/ex8) mice also exhibited lower survival rate as stimulated by LPS, which was probably on account of the suppressed acute phase response. These data are, to our knowledge, the first to implicate Smad3 in specific pathways of acute phase response in the liver.

Repair of Complex Abdominal Wall Defects From High-Voltage Electric Injury With Two Layers of Acellular Dermal Matrix : A Case Report

High-voltage electric burn causing full-thickness necrosis of the abdominal wall and exposure of visceral organs is a real clinical challenge. This article reports a case of high-voltage electric burn causing a giant full-thickness abdominal wall defect. Seeing that it was unable to repair the abdominal wall defect with the conventional method, we used two layers of allogenic acellular dermal matrix substitutes to reconstruct and repair the defected abdominal wall. A 1-year follow-up showed that the abdominal wall of the patient recovered strong tenacity and strength without the evidence of significant complications.

Successful treatment of a patient with an extraordinarily large deep burn.

Summary Background Treatment of extraordinarily large deep burns remains a huge clinical challenge. Case Report This article is a summary of our experience with the treatment of a patient with an extraordinarily large deep burn (99.5% TBSA and 23% fourth degree burn) by using the “microskin autografting and alloskin repeated grafting” method to close the deep burn wound because of scarcity of skin sources of the patient. Conclusions The patient has been observed for 2 years, and is able to face the reality of life peacefully with the support of his family.

A New Strategy of Using Keratinocytes for Skin Graft: Animal Experimental Study of Keratinocyte Suspension Combined with the Dermal Substitutes

Objective: To provide a new and simple strategy for keratinocyte transplantation. Methods: Keratinocyte suspension and dermal substitutes including acellular dermal matrix (ADM) and collagen membrane were prepared. Full-thickness skin defect wounds of Balb/c-nu mice were created and the mice were assigned into 5 groups: the control group, where the wound was grafted with keratinocyte suspension only; the one-step ADM and collagen membrane groups, where the wound was grafted with ADM or collagen membrane plus dripping of keratinocyte suspension; the two-step ADM and collagen membrane groups, where keratinocyte suspension was dripped 2 weeks after ADM or collagen membrane grafting. The percentage of epithelium was observed. Results: Two weeks after grafting, no evidence of re-epithelialization was seen in the one-step ADM group, and the re-epithelialization rate in the one-step collagen membrane group, two-step ADM group and two-step collagen membrane group was 54.1, 41.8 and 76.8%, respectively, indicating that the re-epithelialization rate in the two-step collagen membrane group was higher than that in the other two groups (p < 0.01). Conclusions: Keratinocyte suspension combined with dermal substitutes grafting offers a more flexible way of making use of keratinocytes. Compared with ADM, microporous collagen membrane is a more preferable option for combined use with keratinocyte suspension for skin grafting.

Treatment of tracheal stenosis with an extended tracheal cannula in a patient with extensive burn.

Burn-induced tracheal stenosis is rare. This article reports an extensive burn patient who developed severe tracheomalacia and stenosis before wound healing. Given the ineffectiveness of the conventional techniques available for the treatment of tracheal stenosis, we used an extended tracheal cannula to dilate the narrowed part of the trachea successfully. As a result, the extensive burn wound was repaired, and the symptoms of tracheal stenosis were eventually relieved. No serious restenosis was observed during a 2-year follow-up period.

A new strategy of promoting vascularization of skin substitutes by capturing endothelial progenitor cells automatically.

How to promote vascularization of a skin substitute is the key to successful skin transplantation. Current methods are mainly through releasing angiogenesis-related factors (ARF) or seeding angiogenesis-related cells (ARC), but the efficacy of these methods is not satisfactory, because angiogenesis needs participation of multiple factors, extracellular matrix and related cells. The latest research has demonstrated that endothelial progenitor cells (EPCs) originating from bone marrow and existing in peripheral blood are the key element participating in revascularization of adult tissues. They directly participate in both stem cell vasculogenesis of ischemic tissues and local angiogenesis. We therefore hypothesize whether it is possible to construct a new skin substitute and use it to mobilize EPCs in bone marrow to peripheral circulation and capture EPCs automatically as a simple and effective method of promoting vascularization of the skin substitute for the sake of improving its post-transplant survival.

Radiologic signs of barotrauma.

An otherwise healthy 22-year-old woman was admitted to our burn intensive care unit with deep dermal flame burns of upper limbs, thorax, neck, and head because of a civil-bus deflagrating crash. Fibrobronchoscopy revealed carbon particles attached to the injured mucous membrane of main trachea, confirming the presence of inhalation injury. She was intubated and supported by mechanical ventilation with synchronized intermittent mandatory ventilation mode. Fluid replacement therapy based on a burn formula was performed. During the first 24 hours after admission, her blood pressure was maintained within normal range; however, blood oxygen saturation remained at relatively low levels. Subsequent chest radiography disclosed a right-sited pneumatocele 8 cm in diameter (Fig. 1, large white arrow) associated with right pneumothorax (Fig. 1, small white arrowheads point out “pneumothorax line” of compressed right lung) and left-sided emphysema (Fig. 1, black arrow). It was noticed that lung damage was located mainly in the lower lobes of both lung and that the lesions of the right lung were more severe than those of the left, suggesting that the right lung was exposed to greater barotrauma, because, anatomically, the right main bronchus forms a lesser angle with the trachea than does the left main bronchus, which allows airflow to go through more smoothly to the right bronchus segments. Decreased chest wall compliance can contribute to hyperinflation of the lower lobes as a result of abdominal compensation.1 An emergency thoracic escharotomy was performed to allow the thoracic cage to increase in size with inhalation, following which the tidal volume was lowered from 10 mL/kg to 8 mL/kg. A right percutaneous tube thoracostomy was placed and continuous negative pressure aspiration applied. Her blood oxygen saturation then returned to normal levels. The radiographic features mentioned above disappeared in 3 days without recurrence in a 3-month follow-up study. Her inhalation injury also healed by repeated airway flushing and local use of basic fibroblast growth factor2 through a fibrobronchoscope, and by local and systemic use of mucosolvan (ambroxol).3 Pneumatocele and pneumothorax are not common manifestations of smoke inhalation unless there is a secondary complication, whereas patients exposed to relatively high airway pressure may be at greater risk for developing barotrauma or volutrauma. The radiologic signs of barotrauma can be produced by sufficiently high inspiratory pressures, even in the absence of decreased chest wall compliance.

Risk factors and prognosis of lower digestive tract haemorrhage in severe burns: a 12-year retrospective analysis.

OBJECTIVE To explore the risk factors relating to lower digestive tract haemorrhage in severe burns and summarise the experience in clinical diagnosis and treatment. METHOD General data of 103 patients with severe extensive burns (EBs) admitted to our burn centre in Shanghai between 1997 and 2009 were reviewed retrospectively. The risk factors relating to EB-complicated lower digestive tract haemorrhage were analysed systematically with respect to the clinical features and experiences in treatment, and prognosis. RESULTS Of the 103 severe EBs, five developed lower digestive tract haemorrhage with an occurrence of 4.9%. Four of them were proved to have multiple mucosal erosions in caecum, colon and rectum, and the remaining one was proved rectal ulcerative haemorrhage. In comparison with upper digestive tract haemorrhage, lower digestive tract haemorrhage in the present group was characterised by a longer duration (median 4.0 days, interquartile range (IQR) 1.5-14.5 days vs. median 2.0 days (IQR 1.0-3.0 days), P < 0.05). Deep burns, especially fourth-degree burns, with complications of severe systemic infection, formed the main risk factors relating to lower digestive tract haemorrhage in severe EB patients. CONCLUSION Severe EB-complicated lower digestive tract haemorrhage is a critical condition in burns, which usually have deep wounds with severe infection surfaces that are difficult to deal with. Enteroscopic haemostasis in controlling lower digestive tract haemorrhage is usually ineffective. Clinical experiences indicate that early management of the wound with effective preventive and therapeutive measures for infection control may be a good choice in the prevention and treatment of lower digestive tract haemorrhage leading to improvement in its prognosis.

Pulmonary Aspergillosis in a Non-neutropenic Critical Patient

A 52-year-old male worker was transferred to our burn intensive care unit for an exacerbation of pulmonary dysfunction after accidental inhalation of toxic hydrogen sulfide, with 10 days of unsuccessful treatment of broadspectrum antibiotics and methylprednisolone. At admission, respiratory distress, hypoxemia, and high fever were noted. Contrast-enhanced chest computed tomography revealed two large, pleural-based, mass-like, uneven-density, and unshapededge consolidations (Fig. 1A, black arrows) in the inferior lobe of the right lung, along with multiple nodosity opacities with central necrosis (Fig. 1A, white arrow) in the lungs. His white cell count was 14,900/mm with 88.8% neutrophils, and serum HIV test was negative. Bronchofibroscopy revealed ulcerative lesions with white-colored pseudomembrane on them, spreading over the right bronchial tree. Galactomannan antigen (enzyme-linked immunosorbent assay) in two consecutive serum samples and three consecutive bronchoalveolar lavage fluid samples were positive, and repeated cultures of bronchoalveolar aspiration fluid grew Aspergillus fumigatus, supporting a diagnosis of probable pulmonary aspergillosis. Clinical improvement was seen after substituting caspofungin acetate1 (50 mg/d, intravenously) and voriconazole2 (300 mg/time, twice a day, orally) for broad-spectrum antibiotics and methylprednisolone. Follow-up chest computed tomography scans at day 15 (Fig. 1B) and day 45 (Fig. 1C) of the antifungus treatment revealed significant decrease in pulmonary focuses.