Julie Mill

Vitronectin: Growth Factor Complexes Hold Potential as a Wound Therapy Approach

Topical administration of growth factors has displayed some potential in wound healing, but variable efficacy, high doses, and costs have hampered their implementation. Moreover, this approach ignores the fact that wound repair is driven by interactions between multiple growth factors and extracellular matrix (ECM) proteins. We report herein that complexes comprising IGF and IGF-binding proteins bound to the ECM protein vitronectin (VN) significantly enhance cellular functions relevant to wound repair in human skin keratinocytes in two- and three-dimensional in vitro cell models and are active, even in the presence of wound fluid. Moreover, these responses require activation of both the IGF receptor and the VN-binding alpha(v) integrins. Further, we assessed the complexes as a topical agent in the treatment of deep dermal partial thickness burns in a porcine model. This pilot study revealed that the complexes may hold promise as a wound healing therapy. Critically, the significant responses observed in vitro and the encouraging preliminary data in vivo were obtained with nanogram doses of growth factors. This suggests that coupling delivery of growth factors to ECM proteins such as VN may ultimately prove to be a more effective strategy for developing a wound healing therapy.

The efficacy of an augmented virtual reality system to alleviate pain in children undergoing burns dressing changes : A randomised controlled trial

In children, the pain and anxiety associated with acute burn dressing changes can be severe, with drug treatment alone frequently proving to be inadequate. Virtual reality (VR) systems have been successfully trialled in limited numbers of adult and paediatric burn patients. Augmented reality (AR) differs from VR in that it overlays virtual images onto the physical world, instead of creating a complete virtual world. This prospective randomised controlled trial investigated the use of AR as an adjunct to analgesia and sedation in children with acute burns. Forty-two children (30 male and 12 female), with an age range of 3-14 years (median age 9 years) and a total burn surface area ranging from 1 to 16% were randomised into a treatment (AR) arm and a control (basic cognitive therapy) arm after administration of analgesia and/or sedation. Pain scores, pulse rates (PR), respiratory rates (RR) and oxygen saturations (SaO2) were recorded pre-procedurally, at 10 min intervals and post-procedurally. Parents were also asked to grade their childs overall pain score for the dressing change. Mean pain scores were significantly lower (p=0.0060) in the AR group compared to the control group, as were parental pain assessment scores (p=0.015). Respiratory and pulse rates showed significant changes over time within groups, however, these were not significantly different between the two study groups. Oxygen saturation did not differ significantly over time or between the two study groups. This trial shows that augmented reality is a useful adjunct to pharmacological analgesia.

Diagnostic accuracy of and patient satisfaction with telemedicine for the follow-up of paediatric burns patients

Videoconferencing has become a routine technique for the post-acute burns care of children in Queensland. We compared the agreement between clinical assessments conducted via videoconference and assessments conducted in the conventional, face-to-face manner (FTF). A total of 35 children with a previous burn injury were studied. Twenty-five children received three consecutive assessments: first FTF by a consultant in the outpatient department, then by a second consultant who reviewed the patient via videoconference, and then by the second consultant in person. The second consultant also reviewed another 10 children twice. At each review, the following variables were measured: scar colour, scar thickening, contractures, range of motion, the patients level of general activity, any breakdown of the graft site, and adequacy of the consultation. Agreement between the two consultants when seeing patients FTF was moderately high, with an overall concordance of 85%. When videoconferencing was used, the level of agreement was almost the same, at 84%. If one consultant reviewed patients FTF first and then via videoconference, the overall concordance was 98%; if the process was reversed, the overall concordance was 97%. This study confirms that the quality of information collected during a videoconference appointment is comparable to that collected during a traditional, FTF appointment for a follow-up burns consultation.

Silver absorption on burns after the application of Acticoat: data from pediatric patients and a porcine burn model.

Silver dressings have been widely used to successfully prevent burn wound infection and sepsis. However, a few case studies have reported the functional abnormality and failure of vital organs, possibly caused by silver deposits. The aim of this study was to investigate the serum silver level in the pediatric burn population and also in several internal organs in a porcine burn model after the application of Acticoat™. A total of 125 blood samples were collected from 46 pediatric burn patients. Thirty-six patients with a mean of 13.4% TBSA burns had a mean peak serum silver level of 114 &mgr;g/L, whereas 10 patients with a mean of 1.85% TBSA burns had an undetectable level of silver (<5.4 &mgr;g/L). Overall, serum silver levels were closely related to burn sizes. However, the highest serum silver was 735 &mgr;g/L in a 15-month-old toddler with 10% TBSA burns and the second highest was 367 &mgr;g/L in a 3-year old with 28% TBSA burns. In a porcine model with 2% TBSA burns, the mean peak silver level was 38 &mgr;g/L at 2 to 3 weeks after application of Acticoat™ and was then significantly reduced to an almost undetectable level at 6 weeks. Of a total of four pigs, silver was detected in all four livers (1.413 &mgr;g/g) and all four hearts (0.342 &mgr;g/g), three of four kidneys (1.113 &mgr;g/g), and two of four brains (0.402 &mgr;g/g). This result demonstrated that although variable, the level of serum silver was positively associated with the size of burns, and significant amounts of silver were deposited in internal organs in pigs with only 2% TBSA burns, after application of Acticoat™.

The efficacy of Aloe vera, tea tree oil and saliva as first aid treatment for partial thickness burn injuries.

Many alternative therapies are used as first aid treatment for burns, despite limited evidence supporting their use. In this study, Aloe vera, saliva and a tea tree oil impregnated dressing (Burnaid) were applied as first aid to a porcine deep dermal contact burn, compared to a control of nothing. After burn creation, the treatments were applied for 20 min and the wounds observed at weekly dressing changes for 6 weeks. Results showed that the alternative treatments did significantly decrease subdermal temperature within the skin during the treatment period. However, they did not decrease the microflora or improve re-epithelialisation, scar strength, scar depth or cosmetic appearance of the scar and cannot be recommended for the first aid treatment of partial thickness burns.

Ultrasound assessed thickness of burn scars in association with laser Doppler imaging determined depth of burns in paediatric patients

This study describes the ultrasound assessment of burn scars in paediatric patients and the association of these scar thickness with laser Doppler imaging (LDI) determined burn depth. A total of 60 ultrasound scar assessments were conducted on 33 scars from 21 paediatric burn patients at 3, 6 and 9 months after-burn. The mean of peak scar thickness was 0.39±0.032 cm, with the thickest at 6 months (0.40±0.036 cm). There were 17 scald burn scars (0.34±0.045 cm), 4 contact burn scars (0.61±0.092 cm), and 10 flame burn scars (0.42±0.058 cm). Each group of scars followed normal distributions. Twenty-three scars had original burns successfully scanned by LDI and various depths of burns were presented by different colours according to blood perfusion units (PU), with dark blue <125, light blue 125-250, and green 250-440 PU. The thickness of these scars was significantly different between the predominant colours of burns, with the thinnest scars for green coloured burns and the thickest for dark blue coloured burns. Within light blue burns, grafted burns healed with significantly thinner scars than non-grafted burns. This study indicates that LDI can be used for predicting the risk of hypertrophic scarring and for guiding burn care. To our knowledge, this is the first study to correlate the thickness of burns scars by ultrasound scan with burn depth determined by LDI.

Burn healing is dependent on burn site : A quantitative analysis from a porcine burn model

This retrospective review examines healing in different sites on a porcine burn model; 24 pairs of burns on 18 pigs from other animal trials were selected for analysis. Each pair of burns was located on the either the cranial or the caudal part of the thoracic ribs region, on the same side of the animal. The burns were 40-50 cm(2) in size and of uniform deep-dermal partial thickness. Caudal burns healed significantly better than cranial burns, demonstrated by earlier closure of wounds, less scar formation and better cosmesis. To our knowledge, this is the first detailed study reporting that burn healing is affected by location on a porcine burn model. We recommend that similar symmetrical burns should be used for future comparative assessments of burn healing.

Laser Doppler imaging in a paediatric burns population

OBJECTIVE Laser Doppler imaging (LDI) was compared to wound outcomes in childrens burns, to determine if the technology could be used to predict these outcomes. METHODS Forty-eight patients with a total of 85 burns were included in the study. Patient median age was 4 years 10 months and scans were taken 0-186 h post-burn using the fast, low-resolution setting on the Moor LDI2 laser Doppler imager. Wounds were managed by standard practice, without taking into account the scan results. Time until complete re-epithelialisation and whether or not grafting and scar management were required were recorded for each wound. If wounds were treated with Silvazine or Acticoat prior to the scan, this was also recorded. RESULTS The predominant colour of the scan was found to be significantly related to the re-epithelialisation, grafting and scar management outcomes and could be used to predict those outcomes. The prior use of Acticoat did not affect the scan relationship to outcomes, however, the use of Silvazine did complicate the relationship for light blue and green scanned partial thickness wounds. Scans taken within the 24-h window after-burn also appeared to be accurate predictors of wound outcome. CONCLUSION Laser Doppler imaging is accurate and effective in a paediatric population with a low-resolution fast-scan.

Conservative surgical debridement as a burn treatment: Supporting evidence from a porcine burn model

In thermal deep‐dermal burns, surgical debridement is normally used in conjunction with skin grafting or skin substitutes and debridement alone as a burn treatment is not usually practiced. The current study addresses whether or not debridement alone would enhance burn wound healing on small deep‐dermal‐partial thickness burns. This was a prospective and blinded experimental trial using a porcine deep‐dermal‐partial thickness burn model. Four burns, approximately 50 cm2 in size, were created on each of eight pigs. Two burns from each pig were immediately surgically debrided and the other two were not debrided as the internal control. Hydrate gel together with paraffin gauze were used to cover the burns for four pigs and silver dressings for the other four. Clinical assessment of wound healing was conducted over a 6‐week period. Skin samples were collected at the end of the experiment and histopathological evaluation was performed. The results show thinner scar formation and lower scar height in the debrided compared with nondebrided wounds in the hydrate gel/paraffin gauze groups. There were no statistically significant differences in wound healing assessment between the debrided and nondebrided wounds dressed with silver dressings. This study provides supporting evidence that immediate debridement with an appropriate dressing and without skin grafting may promote wound healing, suggesting its potential benefit for clinical patients.

Phytophotodermatitis: Case reports of children presenting with blistering after preparing lime juice

Letter to the Editor We read with interest the case report entitled ‘‘Contact with fig tree sap: An unusual cause of burn injury’’ by Mandalia et al. [1] and would like to report our similar experience with phytophotodermatitis caused by lime juice. Phototoxic dermatitis is understandably easily confused with a burn, particularly when a patient presents with large blisters of unknown mechanism. At the Royal Children’s Hospital Burns Centre, this injury was treated in the same manner as a burn and is described here...