Challenges in Burn Care during the COVID-19 Pandemic—A Scoping Review

Objective: The aim of this review is to map and summarize the experiences of various burn centers worldwide during the COVID-19 pandemic, in order to enable future strategies with regard to the most effective measures in burn care during pandemics and to detect possible gaps in knowledge. Background: The coronavirus disease 2019 (COVID-19) pandemic had a major impact on economies, social interactions, and health systems worldwide. Burn units all over the world face a new challenge in maintaining the care of acute burn wounds and follow-up treatments while dealing with constantly changing regulations. Infrastructural changes, the establishment of efficient triage systems, protective measures, personnel resources, in addition to the maintenance of efficient patient care and the guarantee of supply chains, are challenging tasks to be addressed. This review provides an overview of recent developments regarding different strategies and methods used by burn units worldwide to safely overcome the COVID-19 pandemic outbreak. Methods: A scoping review of the literature was conducted using the electronic databases PubMed and Google Scholar. Publications were screened for the following key terms: burns, burn injuries, thermal injuries, burn center, burn unit, burn ward, in combination with COVID-19, COVID-19 pandemic, SARS-CoV-2, Corona, and Coronavirus. Articles dealing with the management of burn units during the pandemic were further analyzed and included. Results: Of the 136 publications, 10 were considered relevant to the key question and were included in the present review. Results were divided into six major topics, such as infrastructural and personnel management, triaging, severe burns and emergencies, elective surgeries, patient and visitor management, and outpatient management. Conclusion: Only a few studies about managing burn units during the COVID-19 pandemic have been published. Personnel resources and equipment needed to be redistributed to cope with country-specific challenges during the COVID-19 pandemic and to maintain adequate burn care. Since all of these articles refer to the period of the initial outbreak, a lack of clinical studies exists regarding the prevention measures taken by burn units during the COVID-19 pandemic. In addition, we identified gaps in knowledge about the impact of implemented measures on burn patient outcomes in the published literature. Further studies are mandatory in order to provide generally applicable guidelines regarding COVID-19 prevention measures at a burn unit

Historical Evolution of Skin Grafting—A Journey through Time

Autologous skin grafting was developed more than 3500 years ago. Several approaches and techniques have been discovered and established in burn care since then. Great achievements were made during the 19th and 20th century. Many of these techniques are still part of the surgical burn care. Today, autologous skin grafting is still considered to be the gold standard for burn wound coverage. The present paper gives an overview about the evolution of skin grafting and its usage in burn care nowadays

The Use of Acellular Fish Skin Grafts in Burn Wound Management—A Systematic Review

Background and Objectives: Burn wound healing and management continues to be a major challenge for patients and health care providers resulting in a considerable socio-economic burden. Recent advances in the development of applicable xenografts as an alternative to split-thickness skin grafts have allowed for the development of acellular fish skin. Acellular fish skin acts as a skin substitute, reducing inflammatory responses and advancing proinflammatory cytokines that promote wound healing. Due to these beneficial wound healing properties, acellular fish skin might represent an effective treatment approach in burn wound management. Materials and Methods: A systematic review of the literature, up to March 2022, was conducted using the electronic databases PubMed and Web of Science. Titles and abstracts were screened for the following key terms (variably combined): “fish skin”, “fish skin grafts”, “acellular fish skin”, “Omega3 Wound matrix”, “xenograft”, “burn injury”, “burns”. Results: In total, 14 trials investigating the effects of acellular fish skin in burn wounds or split-thickness donor sites were determined eligible and included in the present review. Existing evidence on the use of acellular fish skin indicates an acceleration of wound healing, reduction in pain and necessary dressing changes as well as treatment-related costs and improved aesthetic and functional outcomes compared to conventional treatment options. Conclusions: Acellular fish skin xenografts may represent an effective, low-cost alternative in treatment of superficial- and partial-thickness burns. However, results mainly originate from preclinical and small cohort studies. Future larger cohort studies are warranted to elucidate the full potential of this promising approach

Assessment of Mastectomy Skin Flaps for Immediate Reconstruction with Implants via Thermal Imaging—A Suitable, Personalized Approach?

Background: Impaired perfusion of the remaining skin flap after subcutaneous mastectomy can cause wound-healing disorders and consecutive necrosis. Personalized intraoperative imaging, possibly performed via the FLIR ONE thermal-imaging device, may assist in flap assessment and detect areas at risk for postoperative complications. Methods: Fifteen female patients undergoing elective subcutaneous mastectomy and immediate breast reconstruction with implants were enrolled. Pre-, intra- and postoperative thermal imaging was performed via FLIR ONE. Potential patient-, surgery- and environment-related risk factors were acquired and correlated with the occurrence of postoperative complications. Results: Wound-healing disorders and mastectomy-skin-flap necrosis occurred in 26.7%, whereby areas expressing intraoperative temperatures less than 26 °C were mainly affected. These complications were associated with a statistically significantly higher BMI, longer surgery duration, lower body and room temperature and a trend towards larger implant sizes. Conclusion: Impaired skin-flap perfusion may be multifactorially conditioned. Preoperative screening for risk factors and intraoperative skin-perfusion assessment via FLIR ONE thermal-imaging device is recommendable to reduce postoperative complications. Intraoperative detectable areas with a temperature of lower than 26 °C are highly likely to develop mastectomy-skin-flap necrosis and early detection allows individual treatment concept adaption, ultimately improving the patient’s outcome

The Impact of Antiseptic-Loaded Bacterial Nanocellulose on Different Biofilms—An Effective Treatment for Chronic Wounds?

Introduction: Pathogenic biofilms are an important factor for impaired wound healing, subsequently leading to chronic wounds. Nonsurgical treatment of chronic wound infections is limited to the use of conventional systemic antibiotics and antiseptics. Wound dressings based on bacterial nanocellulose (BNC) are considered a promising approach as an effective carrier for antiseptics. The aim of the present study was to investigate the antimicrobial activity of antiseptic-loaded BNC against in vitro biofilms. Materials and Methods: BNC was loaded with the commercially available antiseptics Prontosan® and Octenisept®. The silver-based dressing Aquacel®Ag Extra was used as a positive control. The biofilm efficacy of the loaded BNC sheets was tested against an in vitro 24-hour biofilm of Staphylococcus aureus and Candida albicans and a 48-hour biofilm of Pseudomonas aeruginosa. In vivo tests using a porcine excisional wound model was used to analyze the effect of a prolonged treatment with the antiseptics on the healing process. Results: We observed complete eradication of S. aureus biofilm in BNC loaded with Octenisept® and C. albicans biofilm for BNC loaded with Octenisept® or Prontosan®. Treatment with unloaded BNC also resulted in a statistically significant reduction in bacterial cell density of S. aureus compared to untreated biofilm. No difference on the wound healing outcome was observed for the wounds treated for seven days using BNC alone in comparison to BNC combined with Prontosan® or with Octenisept®. Conclusions: Based on these results, antiseptic-loaded BNC represents a promising and effective approach for the treatment of biofilms. Additionally, the prolonged exposure to the antiseptics does not affect the healing outcome. Prevention and treatment of chronic wound infections may be feasible with this novel approach and may even be superior to existing modalities

In Vivo Models for Hypertrophic Scars—A Systematic Review

Backgroundand Objectives: Hypertrophic scars following surgeries or burns present a serious concern for many patients because these scars not only lead to an aesthetical but also to a functional and psychological burden. Treatment of hypertrophic scars is challenging because despite various treatment options, a low level of evidence hinders preference of any specific treatment plan. To properly identify new therapeutic approaches, the use of in vivo models remains indispensable. A gold standard for hypertrophic scars has not been established to date. This review aims at giving a comprehensive overview of the available in vivo models. Materials and Methods: PubMed and CINAHL were queried for currently existing models. Results: Models with mice, rats, rabbits, pigs, guinea pigs and dogs are used in hypertrophic scar research. Rodent models provide the advantage of ready availability and low costs, but the number of scars per animal is limited due to their relatively small body surface, leading to a high number of test animals which should be avoided according to the 3Rs. Multiple scars per animal can be created in the guinea pig and rabbit ear model; but like other rodent models, these models exhibit low transferability to human conditions. Pig models show a good transferability, but are cost-intensive and require adequate housing facilities. Further, it is not clear if a currently available pig model can deliver clinical and histological features of human hypertrophic scars concurrently. Conclusions: None of the analyzed animal models can be clearly recommended as a standard model in hypertrophic scar research because the particular research question must be considered to elect a suitable model

Analysis of social media use by European plastic surgery societies: A missing link for #PlasticSurgery

Purpose: The field of Plastic Surgery is prominent on social media around the world. Board certified plastic surgeons and societies of plastic surgery play a role in providing accurate, evidence-based information to the public, patients, and colleagues. The aim of this study was to explore the use of social media by European Plastic Surgery Societies. Methods and materials: A retrospective analysis of the presence and activity of European Plastic Surgery Societies on Facebook, Twitter and Instagram was conducted between December 12th 2018 and December 12th 2019. The results have been compared to the American Society of Plastic Surgeons. Results: Twenty, eleven and nine European societies yielded an active account on Facebook, Twitter and Instagram respectively. Only seven European societies had an account on all three platforms and were therefore considered polypresent. The amount of followers of those seven societies was significantly higher than of the others (p-value = 0.02). Their activity yielded significantly more posts on Facebook (p-value = 0.02). The American Society of Plastic Surgeons had more followers on all three platforms than all European societies combined. Conclusion: Social media are still rather unexploited by European Plastic Surgery Societies. A tendency towards increased visibility can be observed, yet a higher penetration is required to further educate and engage through social media. The quantitative data provided serve as reasonable foundation for further studies and a guide for growth of #PlasticSurgery

The Role of Local Inflammation and Hypoxia in the Formation of Hypertrophic Scars—A New Model in the Duroc Pig

Hypertrophic scars continue to be a major burden, especially after burns. Persistent inflammation during wound healing appears to be the precipitating aspect in pathologic scarring. The lack of a standardized model hinders research from fully elucidating pathophysiology and therapy, as most therapeutic approaches have sparse evidence. The goal of this project was to investigate the mechanisms of scar formation after prolonged wound inflammation and to introduce a method for generating standardized hypertrophic scars by inducing prolonged inflammation. Four wound types were created in Duroc pigs: full-thickness wounds, burn wounds, and both of them with induced hyperinflammation by resiquimod. Clinical assessment (Vancouver Scar Scale), tissue oxygenation by hyperspectral imaging, histologic assessment, and gene expression analysis were performed at various time points during the following five months. Native burn wounds as well as resiquimod-induced full-thickness and burn wounds resulted in more hypertrophic scars than full-thickness wounds. The scar scale showed significantly higher scores in burn- and resiquimod-induced wounds compared with full-thickness wounds as of day 77. These three wound types also showed relative hypoxia compared with uninduced full-thickness wounds in hyperspectral imaging and increased expression of HIF1a levels. The highest number of inflammatory cells was detected in resiquimod-induced full-thickness wounds with histologic features of hypertrophic scars in burn and resiquimod-induced wounds. Gene expression analysis revealed increased inflammation with only moderately altered fibrosis markers. We successfully created hypertrophic scars in the Duroc pig by using different wound etiologies. Inflammation caused by burns or resiquimod induction led to scars similar to human hypertrophic scars. This model may allow for the further investigation of the exact mechanisms of pathological scars, the role of hypoxia and inflammation, and the testing of therapeutic approaches

Introducing the “SIMline”—A Simulation Course in the Management of Severe Burns as a Tool in Undergraduate Medical Education

Background: Management of burn injuries presents a complex and challenging situation for medical staff, especially for inexperienced young doctors. However, training on how to treat burn victims in the clinical setting is rarely taught in undergraduate medical classes. We have created the “SIMline”, a simulation training program explicitly designed for coaching medical students in burn management. Methods: A total of 43 students participated in the “SIMline” course, which took place at the training facility at the Medical University of Graz, between 2018 and 2019. The course provided theoretical classes, practical exercises, and a full-scale care process simulation training. The learning progress of the students was monitored via a formative integrated test. Results: Students showed great progress throughout the course of the “SIMline” program, as their test scores improved by an average of 88%. The passing rate was 0% at the first exam (prior to course) as compared to 87% at the final exam, taken after the training. Conclusions: Comprehensive practical training programs in burn care are underrepresented in medical education. The “SIMline” course presents a novel and effective approach in training medical students in burn management. However, follow-up evaluation is necessary to confirm long-term educational benefits

Suction Drain Volume following Axillary Lymph Node Dissection for Melanoma—When to Remove Drains? A Retrospective Cohort Study

Postoperative complications such as seroma formation and wound-site infection occur following completion axillary lymph node dissection (ALND) for melanoma. We analyzed the impact of time-to-drain removal and drainage volume on seroma formation after ALND. We retrospectively analyzed data from 118 patients after completion ALND for melanoma. Primary endpoints were daily amount of drainage volume, seroma formation and time-to-drain removal. Secondary endpoints included patient-related, disease-specific and perioperative parameters as well as the number of histologically analyzed lymph nodes and surgical complications graded by the Clavien–Dindo classification (CDCL). Statistical analyses were performed using logistic regression models. Drain removal around the 8th postoperative day was statistically associated with a lower risk for the occurrence of seroma formation (p < 0.001). Patients with an increased drainage volume during the early postoperative days were more prone to develop seroma after drain removal. With 49% (CDCL I and II), most complications were managed conservatively, while only 5.9% (CDCL III) required revision surgery (CDCL overall: 55.9%). ALND is a safe procedure with a low rate of severe CDCL III type of complications. To decrease seroma evacuation, our results imply that drains should be removed around the 8th postoperative day to reduce the risk of infection, readmission or prolonged hospitalization