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Intrahepatic islet transplantation for type 1 diabetes is limited by the need for multiple infusions and poor islet viability posttransplantation. The development of alternative transplantation sites is necessary to improve islet survival and facilitate monitoring and retrieval. We tested a clinically proven biodegradable temporizing matrix (BTM), a polyurethane-based scaffold, to generate a well-vascularized intracutaneous “neodermis” within the skin for islet transplantation. In murine models, BTM did not impair syngeneic islet renal-subcapsular transplant viability or function, and it facilitated diabetes cure for over 150 days. Furthermore, BTM supported functional neonatal porcine islet transplants into RAG-1−/− mice for 400 days. Hence, BTM is nontoxic for islets. Two-photon intravital imaging used to map vessel growth through time identified dense vascular networks, with significant collagen deposition and increases in vessel mass up to 30 days after BTM implantation. In a preclinical porcine skin model, BTM implants created a highly vascularized intracutaneous site by day 7 postimplantation. When syngeneic neonatal porcine islets were transplanted intracutaneously, the islets remained differentiated as insulin-producing cells, maintained normal islet architecture, secreted c-peptide, and survived for over 100 days. Here, we show that BTM facilitates formation of an islet-supportive intracutaneous neodermis in a porcine preclinical model, as an alternative islet-transplant site. Article Highlights Human and porcine pancreatic islets were transplanted into a fully vascularized biodegradable temporizing matrix (Novosorb) that creates a unique intracutaneous site outside of the liver in a large-animal preclinical model. The intracutaneous prevascularized site supported pancreatic islet survival for 3 months in a syngeneic porcine-transplant model. Pancreatic (human and porcine) islet survival and function were demonstrated in an intracutaneous site outside of the liver for the first time in a large-animal preclinical model.

Intra-hepatic islet transplantation for type-1 diabetes is limited by the need for multiple infusions and poor islet viability post-transplantation. The development of alternative transplantation sites is necessary to improve islet survival, and facilitate monitoring and retrieval. We tested a clinically proven Biodegradable Temporizing Matrix (BTM), a polyurethane-based scaffold, to generate a well vascularized intracutaneous ‘neo-dermis’ within the skin for islet transplantation. In murine models, BTM did not impair syngeneic islet renal-subcapsular transplant viability or function, and facilitated diabetes cure for over 150 days. Further, BTM supported functional neonatal porcine islet transplants into RAG-1-/- mice for 400 days. Hence, BTM is non-toxic for islets. two-photon intravital imaging used to map vessel growth through time identified dense vascular networks, with significant collagen deposition and increases in vessel mass up to 30 days post-BTM implantation. In a pre-clinical porcine skin model, BTM implants created a highly-vascularized intracutaneous site by day 7 post-implantation. When syngeneic neonatal porcine islets were transplanted intracutaneously the islets remained differentiated as insulin producing cells, maintained normal islet architecture, secreted c-peptide, and survived for over 100 days. Here we show that BTM facilitates formation of an islet-supportive intracutaneous ‘neo-dermis’ in a porcine pre-clinical model, as an alternative islet transplant site.

This study compared three acellular scaffolds as templates for the fabrication of skin substitutes. A collagen-glycosaminoglycan (C-GAG), a biodegradable polyurethane foam (PUR) and a hybrid combination (PUR/C-GAG) were investigated. Scaffolds were prepared for cell inoculation. Fibroblasts and keratinocytes were serially inoculated onto the scaffolds and co-cultured for 14 days before transplantation. Three pigs each received four full-thickness 8cm x 8cm surgical wounds, into which a biodegradable temporising matrix (BTM) was implanted. Surface seals were removed after integration (28 days), and three laboratory-generated skin analogues and a control split-thickness skin graft (STSG) were applied for 16 weeks. Punch biopsies confirmed engraftment and re-epithelialisation. Biophysical wound parameters were also measured and analysed. All wounds showed greater than 80% epithelialisation by day 14 post-transplantation. The control STSG displayed 44% contraction over the 16 weeks, and the test scaffolds, C-GAG 64%, Hybrid 66.7% and PUR 67.8%. Immunohistochemistry confirmed positive epidermal keratins and basement membrane components (Integrin alpha-6, collagens IV and VII). Collagen deposition and fibre organisation indicated the degree of fibrosis and scar produced for each graft. All scaffold substitutes re-epithelialised by four weeks. The percentage of original wound area for the Hybrid and PUR was significantly different than the STSG and C-GAG, indicating the importance of scaffold retainment within the first three months post-transplant. The PUR/C-GAG scaffolds reduced the polymer pore size, assisting cell retention and reducing the contraction of in vitro collagen. Further investigation is required to ensure reproducibility and scale-up feasibility. This article is protected by copyright. All rights reserved.

This case report details our experience using a two-stage Biodegradable Temporizing Matrix (NovoSorb® PolyNovo Ltd) and autograft for acute reconstruction of a complex perineal burn wound in an elderly comorbid patient. A 77-year-old man sustained 42% full-thickness burns extending circumferentially from bilateral thighs and buttocks, across the entire perineal and genital regions up to his mid-trunk, following self-immolation using an accelerant. Early total burn wound excision was carried out with acute application of Biodegradable Temporizing Matrix to all affected sites. Excellent integration and vascularization of Biodegradable Temporizing Matrix took place despite the challenge of intermittent fecal contamination affecting the perineal and buttock burn sites and matrix colonization with multidrug-resistant organisms. Delamination and serial split-thickness skin autografting were carried out 42 days after the first matrix application with complete and robust graft take. Perineal burns present a reconstructive challenge due to the proximity of specialized structures such as the genitalia, urethral, and anal orifices. Restoration of complex anatomy and function may be required after debridement with increased risks of infection, contracture formation, and mortality compared with burns affecting other anatomical sites. Two-stage Biodegradable Temporizing Matrix represents a reliable reconstruction option for complex extensive perineal wounds in frail elderly patients, despite an unfavorable local microbial environment.

Skin substitutes have modernised burn wound reconstruction since their use was first pioneered by Burke and Yannas in the 1980s. Skin substitutes offer a solution to the problem of insufficient autologous skin graft availability in major burn wound closure. A growing body of evidence supports the role of skin substitutes in both acute major burns and secondary burn scar resurfacing. Classification of skin substitutes has become increasingly complex given the large variety of synthetic and biologic dermal matrices now available as the result of ongoing advances in regenerative medicine techniques. Classification systems are required to assist clinicians with selection and comparison of outcomes across a wide diversity of skin substitutes. Professor John Greenwood, invented, designed and developed one such dermal substitute, \'Biodegradable Temporising Matrix\', which is approved for use across the globe for reconstruction of major burns and complex wounds. This chapter provides a review of available classification systems for skin substitutes with a summary of the latest evidence in relation to their role and impact on burn wound outcomes. Future developments toward the elusive ‘ideal’ skin substitute may be possible through ongoing research efforts focused on clinical translation of modern skin tissue engineering techniques for burn wound reconstruction.

Background Burns are complex, multifaceted injuries that can pose significant challenges to the treating team. The Royal Adelaide Hospital (RAH) Burns Service has undergone a major evolution over the past two decades, with perceived improvement in outcomes. We present here a longitudinal audit of the RAH Burns Service Mortality Data between 2004 and 2019. Methods An audit was conducted of all index admissions to the RAH Burns Unit from 1 January 2004 to 31 December 2019. Age at admission, total body surface area, burn depth, presence of inhalation injury and outcome were recorded. Baux and revised Baux Scores were calculated. Lethal Area 50% for different time points and age groups, Baux50/100 and Revised Baux50/100 values were then calculated using logistical regression. Results During 2004-2019, there were 5653 index admissions to the RAH Burns Unit. The mean total body surface area of burn injuries admitted was 5.1% and the survival rate was 99.17%. The Lethal Area 50% for the study period was 74%, with an improvement from 70% (2004-2011) to 80% (2012-2019). The Baux50 score for the time period was 120 and the Revised Baux50 was 129. Conclusion The RAH results are comparable with other high-income country Burn Services and demonstrated significant improvement across the study period. The data also highlight areas for ongoing focus such as the elderly burns patient.

Background Gastrointestinal (GI) dysmotility impedes nutrient delivery in critically ill patients with major burns. We aimed to quantify the incidence, timing, and factors associated with GI dysmotility and subsequent nutrition delivery. Methods A 10-year retrospective observational study included mechanically ventilated, adult, critically ill patients with ≥15% total body surface area (TBSA) burns receiving nutrition support. Patients with a single gastric residual volume ≥250 mL were categorized as having GI dysmotility. Daily medical and nutrition data were extracted for ≤14 days in the intensive care unit (ICU). Data are mean (SD) or median (interquartile range). Factors associated with GI dysmotility and the effect on nutrition and clinical outcomes were assessed. Results Fifty-nine patients were eligible; 51% (n = 30) with GI dysmotility and 49% (n = 29) without. Baseline characteristics (dysmotility vs no dysmotility) were age (48 [33-60] vs 34 [26-46] years); Acute Physiology and Chronic Health Evaluation II score (16 [12-17] vs 13 [10-16]); sex ([men] 80% vs 86%); and TBSA (49% [35%-59%] vs 38% [26%-55%]). Older age was associated with increased probability of dysmotility (P = .049). GI dysmotility occurred 32 (19-63) hours after ICU admission but was not associated with reduced nutrient delivery. Postpyloric tube insertions were attempted in 83% (n = 25) of patients, with 72% (n = 18) being successful. Postpyloric feeding achieved higher nutrition adequacy than gastric feeding (energy: 82% [95% CI, 70-94] vs 68% [95% CI, 63-74], P = .036; protein: 75% [95% CI, 65-86] vs 61% [95% CI, 56-65], P = .009). Conclusion GI dysmotility occurs early in critically ill burn patients, and postpyloric feeding improves nutrition delivery.

In 2004, in response to inadequacies in wound management techniques employed in the management of massive burns and the consequent high mortality and morbidity, a two stage strategy was conceived to reduce the traditional reliance on autograft, where donor sites were scarce, or absent. Over the next 14 years, two products were developed based in a novel, biodegradable polyurethane foam – a Biodegradable Temporising Matrix (BTM) and an autologous, bilayer (dermis and epidermis) Composite Cultured Skin (CCS). Following immediate burn escharectomy, the 1st stage of the strategy (either at the same operation or a few days later) would involve BTM implantation into the resultant wounds and harvesting of a small autograft for keratinocyte and fibroblast isolation for culture and CCS production. The 2nd stage, five weeks later, would involve delamination of the BTM and the application of the prepared CCS to the BTM ‘neo-dermis’. The two stages together designed to reduce the requirement for autograft to the small piece harvested to provide the cells for CCS production. At the end of 2018, an adult male with 95% TBSA burns (85% full-thickness) and significant smoke inhalation was received and was the first to undergo the ‘two-stage strategy’. His treatment course and outcome are described herein.

Imiquimod 5% cream, an immune response modifier capable of inducing IFN-α, TNF-α, and interleukins 1, 6, and 8. It was approved for use in the management of genital and perianal warts and soon embraced as a method to diminish the recurrence of keloids postexcision. A previous meta-analysis included four studies. This meta-analysis is part of a larger systematic review project on the effect of moisturizers on scars. It was conducted following an a priori protocol and the guidance of the Joanna Briggs Institute. Databases searched included PubMed, CINAHL, Embase, and Web of Science. After screening and critical appraisal, subgroup meta-analysis on excision method and location of the keloid was conducted using the Miller approach for proportional meta-analysis and a random effects model. Seven studies, including 77 participants and 82 keloids were included. Meta-analysis revealed a recurrence rate of 39% (95% CI = 8.474.4%; I2 = 87.5%) following application of Imiquimod postexcision. The use of primary excision or tangential excision did not alter the outcome. For analysis based on the location of the keloid scar, earlobe keloids had a recurrence rate of 5.4% (95% CI = 0-21.7%; I2 = 52.9%). For keloids excised from other areas (predominantly on the trunk) recurrence rate was higher, at 76.8% (95% CI = 36.1-100%). For keloids, Imiquimod application postexcision results in highly variable recurrence rates. There is very low certainty in the effect of Imiquimod and it therefore is not recommended as a treatment option.

Serial debridement of tissue affected by necrotising fasciitis results in extensive and deep wounds, sometimes complicated by the exposure of major vessels, tendons, bone or other tissue incapable of supporting healing by skin grafts alone. When skin grafts are used, their contraction can result in contracture of joints, or the neck. On the other hand, reconstruction using tissue flaps can be bulky, with poor contour definition and healing of both reconstruction, and donor site, may be compromised by patient comorbidity and instability. In our institution, concerns regarding infection and loss of dermal substitutes of biological origin in these scenarios (e.g. collagen/glycosaminoglycan) have precluded their use. We present a series of seven consecutive cases of such challenging wounds; temporised and reconstructed with a totally synthetic polyurethane dermal substitute and secondary skin grafting, resulting in durable cover with minimal contracture. The cohort includes anterior neck defects exposing major vessels (2/7), multiple exposed ribs on the chest wall (2/7), lower limbs crossing knee or ankle joints (3/7) and a lower limb amputation by hip disarticulation (1/7). This is the first published series of the use of a completely synthetic dermal substitute in necrotising fasciitis wounds, and the joint largest using any dermal substitute.

Expanding experience with NovoSorb Biodegradable Temporising Matrix™ (BTM, PolyNovo Biomaterials Pty Ltd, Port Melbourne, Victoria, Australia) for complex wounds encouraged its use in the following case, which required reconstruction of extensive soft-tissue defects with exposed bone resulting from the sequelae of meningococcal B infection with septic shock and disseminated intravascular coagulation.

Objective The purpose of this study was to investigate and develop range of motion (ROM) and mobilisation guidelines in adult patients where a newly developed synthetic dermal substitute was applied in our adult burn centre. Method A retrospective case note audit was conducted on the first 20 acute burn injured patients who had a synthetic dermal substitute applied. Data collected included days to commencement of ROM, days to clearance for mobilisation, and joint ROM achieved after dermal substitute application (prior to delamination) and after split skin grafting (SSG) for the elbow, knee and shoulder joints. Scar assessments were completed at 12 months after injury using two scar assessment scales. Results Clearance to mobilise occurred at mean 10.4 and 4.9 days after dermal substitute and after skin graft application to lower limbs respectively. ROM commenced at a mean of 9.9 (upper limbs) and 12.7 (lower limbs) days after dermal substitute application. Following skin grafting, ROM commenced at a mean of 6.6 and 6.5 days for upper limbs and lower limbs respectively. Prior to dermal substitute delamination mean flexion at the knee (86.3°), elbow (114.0°) and shoulder (143.4°) was achieved. Mean ROM continued to improve after grafting with knee (133.2°), elbow (126.1°) and shoulder (151.0°) flexion approaching normal ROM in most cases. Mean extension of the elbow (-4.6°) was maintained close to normal levels after skin grafting. There were no recorded instances of knee extension contracture. Patient and Observer Scar Assessment Scale and Matching Assessment of Photographs of Scars scores indicated good cosmetic outcomes with relatively low levels of itch and minimal pain reported at 12 months after injury. Conclusion A steep learning curve was encountered in providing therapy treatment for patients managed with this relatively new synthetic dermal substitute. Trends indicated that as experience with this new dermal substitute grew, patients progressed toward active therapy earlier. A guideline for therapy treatment has been developed but will continue to be evaluated and adjusted when required.

Early excision of deep burn eschar and the expeditious closure of the resultant wounds have become established as gold standard burn care. However, early burn excision has been accepted as up to four days post injury based on a series of misconceptions, not least that the patient is too unwell to undergo surgery and tolerate anaesthesia too soon after injury. There are several reasons why immediate burn excision yields superior survival outcomes, and these are expounded in this article. The systemic pathophysiology following major burn injury, especially when complicated by the respiratory pathophysiology accompanying smoke inhalation, evolves. The hours immediately after burn injury offer several windows of surgical opportunity, windows closed by the pathophysiological events that peak 24 hours later and make surgery and anaesthesia at that time both dangerous and ill-advised.

After major burn injury, once survival is achieved by the immediate excision of all deep burn eschar, we are faced with a patient who is often physiologically well but with very extensive wounds. While very early grafting yields excellent results after the excision of small burns, it is not possible to achieve the same results once the wound size exceeds the available donor site. In patients where 50%–100% of the total body surface area is wound, we rely on serial skin graft harvest, from finite donor site resources, and the massive expansion of those harvested grafts to effect healing. The result is frequently disabling and dysaesthetic. Temporisation of the wounds both passively, with cadaver allograft, and actively, with dermal scaffolds, has been successfully employed to ameliorate some of the problems caused by our inability to definitively close wounds early. Recent advances in technology have demonstrated that superior functional and cosmetic outcomes can be achieved in actively temporised areas even when compared with definitive early closure with skin graft. This has several beneficial implications for both patient and surgeon, affecting the timing of definitive wound closure and creating a paradigm shift in the care of the burned patient.

Objective: The recovery of patients with partial thickness isolated hand burns managed with an epidermal skin substitute appears to be rapid and the necessity for routine hand therapy interventions in this setting is unknown. This study investigated the need for hand therapy for these patients. Methods: A randomized controlled trial was undertaken. The Treatment Group received routine hand therapy provided by a physiotherapist, including assessment, daily range of motion exercises, education and, if required, edema management and outpatient physiotherapy follow-up. Control Group participants received no hand therapy input. Outcomes included the Michigan Hand Questionnaire (baseline, 1, 2, 4 weeks and 3 months post-injury), finger total active motion, wrist range, grip strength (1, 2 and 4 weeks) and participant satisfaction (4 weeks). Results: Twenty-nine participants were recruited over a 2.3 year period. All outcomes significantly improved over time (p ≤ 0.008). No significant between-group differences were observed for any outcome except the pain subscale of the Michigan Hand Questionnaire. Participants with deeper burns had significantly poorer outcomes for some Michigan Hand Questionnaire data. Study limitations included a small sample size, heterogeneity and some loss to follow-up. Conclusions: While the provision of routine hand therapy interventions for patients with partial thickness isolated hand/forearm burns that were managed with an epidermal skin substitute did not appear to be of benefit, study limitations means these results cannot be extrapolated and reinforces the need for further research. Routine hand therapy input may be of benefit for those with deeper burns. Keywords: Burns, Skin, Artificial, Physical therapy modalities, Hand, Injuries

The NovoSorb™ Biodegradable Temporising Matrix (BTM) has been developed and evaluated over the past 12 years, with publications documenting each step. The final step in our evaluation was a pilot human study of the efficacy of BTM in significant (20–50% TBSA full-thickness) burns. Following immediate (or very early) burn excision, BTM implantation was followed by its monitored integration. The timing of delamination and definitive grafting over the integrated polyurethane foam matrix was determined by the subject’s physiological status and the availability of split-skin autograft donor site but was typically around four weeks after the burn debridement. Donor site shortage forced serial grafting in some, which required the BTM to remain laminated for up to 7 weeks without ill effect (spontaneous delamination, granulation tissue formation and wound contraction). The five subjects survived. Of 122% TBSA covered by BTM over the 5 subjects

The skin graft was born in 1869 and since then, surgeons have been using split skin grafts for wound repair. Nevertheless, this asset fails the big burn patient, who deserves an elastic, mobile and robust outcome but who receives the poorest possible outcome based on donor site paucity. Negating the need for the skin graft requires an autologous composite cultured skin and a material capable of temporising the burn wound for four weeks until the composite is produced. A novel, biodegradable polyurethane chemistry has been used to create two such products. This paper describes the design, production, optimisation and evaluation of several iterations of these products. The evaluation has occurred in a variety of models, both in vitro and in vivo, employing Hunterian scientific principles, and embracing Hunter’s love and appreciation of comparative anatomy. The process has culminated in significant human experience in complex wounds and extensive burn injury. Used serially, the products offer robust and elastic healing in deep burns of any size within 6 weeks of injury.

The objectives of the review are to identify the effect of any moisturizers or creams (medicated or unmedicated) on immature scars (linear, keloid or hypertrophic) on any persons of any age. Effects will be assessed by changes in scar activity, changes in the final appearance/cosmesis of the scar, improvements in patient reported features of scars (e.g. itch, tightness, range of movement) and/or by altering measurable features of the scar such as vascularity, color, height, length, pliability and/or transepidermal water loss.Specifically the review question is: are moisturizers or creams effective in modifying immature scars?

Supplemental Digital Content is available in the text., Summary: Presented is the case of an obese, 72 year-old diabetic man with a dorsal foot de-gloving injury. Whilst the tendons of extensor hallucis longus, extensor digitorum longus to all digits, and extensor digitorum brevis to hallux and second toe were intact after surgical debridement, none had any covering paratenon. The joint between the medial cuneiform and first metatarsal was open. Reconstructive options were limited by his age and co-morbidities. A novel, completely synthetic dermal matrix (NovoSorb BTM) was applied, after which the patient was discharged home to attend for dressings and review of integration progress as an outpatient. He was allowed to mobilise without limitation. Because of the poor quality of the wound bed (and patient), the material integrated slowly over 9 weeks. Delamination of the matrix, and definitive closure by application of sheet split skin autograft, produced a robust, soft, mobile and excellent aesthetic result, over which he could wear footwear immediately. Clinically, the paratenon-denuded tendons glided under the neo-dermis without tethering to the overlying integrated matrix, allowing a full range of digital movement. This was confirmed on ultrasound examination, which also demonstrated no inflammation or oedema. Already proven in extensive burns, necrotising fasciitis and complex surgical wounds, BTM represents a useful addition to the reconstructive surgeon’s toolbox.

The purpose of this study is to assess the relationship between ambient temperature and surface temperatures of commonly used building/ground materials, in order to estimate the risk of contact thermal injury. It is an observational study where the air ambient temperature and the surface temperatures of slate, metal, cement, sand, brick and bitumen, were measured, in shaded and unshaded conditions, on cloudy and cloudless days in summer in Adelaide, South Australia. All unshaded surfaces reached temperatures capable of causing significant sole of foot burns given requisite exposure time in both clear and overcast conditions, even with a relatively low ambient temperature. Shade imparted total protection from irreversible thermal injury for all of the ambient temperatures assessed. Although surface temperatures were reduced in overcast conditions, the temperatures recorded were still capable of causing thermal injury. Peripheral neuropathy prolongs heat exposure times, often resulting in significant and complex injury, requiring lengthy treatment and generating potentially poor functional outcomes. This study provides a reference point for the enactment of preventative measures for at risk population groups such a diabetics.

Trace elements have an important physiological role after severe burn injury with patients routinely receiving supplementation. Although commonly prescribed after burn injury, variation exists among supplement composition, frequency, and the dosage administered. This review aims to assess the effectiveness of trace element supplementation on clinically meaningful outcomes in patients who have sustained a severe burn injury. Supplementation of selenium, copper and zinc, either alone or combined, compared with placebo or standard treatment were eligible for inclusion. Predetermined primary outcome measures were mortality, length of stay, rate of wound healing, and complications. A comprehensive search strategy was undertaken. Methodological quality of eligible studies was appraised and relevant data extracted for meta-analysis. Eight studies met eligibility criteria for the review; four randomized controlled trials and four nonrandomized experimental trials, including a total of 398 participants with an age range of 6 to 67 years. Parenteral supplementation of combined trace elements was associated with a significant decrease in infectious episodes (weighted mean difference: -1.25 episodes, 95% confidence intervals: -1.70, -0.80; P < .00001). The results of this review indicate that the use of parentally administered combined trace elements after burn injury confer positive effects in decreasing infectious complications. Combined parenteral trace element supplementation and combined oral and parenteral zinc supplementation have potentially clinically significant findings on reducing length of stay. Oral zinc supplementation shows possible beneficial effects on mortality. Definitive studies are required to accurately define optimal trace element supplementation regimens, dosages, and routes after burn injury.

BACKGROUND Burn injuries to the face and neck are very common. Once vital structures such as the mouth, ears, nose and eyes are damaged by burn injury, there will be pain, swelling, deformity and the potential for contractures to develop. This can lead to a lifetime of physical and psychological issues. It is very important to deliver evidence-based recommended practice in order to achieve the best outcome as these structures heal. OBJECTIVES The aim of this project was to ensure the compliance of face care procedures with Joanna Briggs Institute evidence-based recommended practice. METHODS This evidence implementation project employed the Joanna Briggs Institute Practical Application of Clinical Evidence System, and Getting Research into Practice audit and feedback tools. Design and implementation of strategies to improve practice involved identification of barriers and outlining strategies to overcome barriers, resources utilized and outcomes of this process. This project retrospectively surveyed the case notes of ten patients who sustained facial burns, based on both baseline and follow-up audits. RESULTS Compliance with best practice audit criteria in the baseline audit was moderate to high (70-100%) in four out of 10 criteria. These criteria reflect appropriate administration of analgesia prior to wound care, attendance at education sessions on facial burns, ophthalmic testing being performed, assessment for inhalation injuries and mouth care. Poor compliance rates (10-40%) were seen in the criteria representing nasal care, explanation of the procedure to the client and eye and ear care. Documentation for these criteria was almost non-existent resulting in the outcome of poor compliance. Education sessions were held across both the Adult Burn Service and Intensive Care Unit settings with particular emphasis on the importance of complete documentation. The results of the follow-up audit showed significant improvement (67-100% compliance) in documentation for the performed procedures. CONCLUSIONS The aims of the project were partially achieved. Future plans to undertake another project and look into the compliance rate of face care procedures with the face care protocol across both Adult Burn Service and Intensive Care Units have been discussed with current stakeholders. This will involve auditing a further ten cases of actual face care procedures performed by nursing staff in both settings.

Myeloperoxidase and eosinophil peroxidase are heme-containing enzymes often physically associated with fibrotic tissue and cancer in various organs, without any direct involvement in promoting fibroblast recruitment and extracellular matrix (ECM) biosynthesis at these sites. We report herein novel findings that show peroxidase enzymes possess a well-conserved profibrogenic capacity to stimulate the migration of fibroblastic cells and promote their ability to secrete collagenous proteins to generate a functional ECM both in vitro and in vivo. Mechanistic studies conducted using cultured fibroblasts show that these cells are capable of rapidly binding and internalizing both myeloperoxidase and eosinophil peroxidase. Peroxidase enzymes stimulate collagen biosynthesis at a post-translational level in a prolyl 4-hydroxylase-dependent manner that does not require ascorbic acid. This response was blocked by the irreversible myeloperoxidase inhibitor 4-amino-benzoic acid hydrazide, indicating peroxidase catalytic activity is essential for collagen biosynthesis. These results suggest that peroxidase enzymes, such as myeloperoxidase and eosinophil peroxidase, may play a fundamental role in regulating the recruitment of fibroblast and the biosynthesis of collagen ECM at sites of normal tissue repair and fibrosis, with enormous implications for many disease states where infiltrating inflammatory cells deposit peroxidases. Refereed/Peer-reviewed

Introduction: Although we have previously described the use of a novel polyurethane biodegradable dermal substitute in the reconstruction of 20 free flap donor sites, and extensive cutaneous defects, including a large area of exposed calvarium secondary to burn injury, our experience with this material now extends to 35 free flap donor site reconstructions and 13 major or complex burns. Methods: The polyurethane material (NovoSorb BTM; PolyNovo Biomaterials Pty Ltd, Port Melbourne, Victoria, Australia) was recently employed in another complex wound scenario, implanted into a large anterior cervical cutaneous and soft-tissue defect remaining after serial radical debridement for necrotizing fasciitis. Results: Implantation, integration, delamination, and split-skin graft application proceeded without complication, mirroring our previous experience in other wounds (including major burns). The result was a robust, supple, mobile, and well-contoured reconstruction over the deep tissues of the neck. The functional and cosmetic outcomes exceeded all expectation. Discussion: The wound environment created after necrotizing fasciitis infection and debridement is austere. In this particular case, reconstructive options were limited to large free flap repair, skin graft alone, and skin graft augmented by commercially available collagen/glycosaminoglycan dermal matrix. Each option was discarded for various reasons. Our previous success with NovoSorb BTM, developed at our center, prompted its use following regulatory approval. The patient was physiologically stronger after the temporization afforded by the biodegradable temporizing matrix over 4 weeks of integration. Conclusion: This is the first description of the successful use of an entirely synthetic biodegradable dermal substitute for the reconstruction of both necrotizing fasciitis and an anterior cervical defect.

The objectives of the study were (1) to look for any local, clinically apparent response, within and around a debrided wound, to a novel biocompatible polyurethane foam during repeated, short-term implantation, and (2) to assess the material's efficacy as a negative pressure wound therapy (NPWT) interface compared with a widely used, commercially available foam. Twenty pressure ulcers in 18 patients underwent surgical debridement, then randomization to receive novel treatment or control foam as the wound interface for NPWT. Dressing changes every 2-3 days allowed qualitative wound assessment and quantitative measurement to compare outcomes. No adverse reaction was observed in any patient receiving the new foam. The new "novel foam" performed as a NPWT interface as effectively as the control "standard foam." In deep wounds, the new foam was easier to remove, fragmented less, and showed less retention than the control foam. No marginal in-growth occurred, making removal less traumatic and reducing bleeding from cavity wall granulations. The results support previous large animal studies, and independent ISO10993 testing, that the new foam is safe and biocompatible. Its efficacy as an NPWT interface, nontraumatic removal with low fragmentation and retention rate, favors the new material, especially in deep cavity wounds.

Background: The development of new therapies for hypertrophic scarring has been hampered by the lack of an appropriate animal model. The authors' objective was to establish a reproducible murine model of hypertrophic scarring by infusing bleomycin over a prolonged period to stimulate dermal fibroproliferation. Conclusions: The bleomycin infusion model stimulates dermal fibroproliferation, creating reproducible murine scars that are comparable to human hypertrophic scars in terms of histological features, collagen content and organization, cellularity, the presence of myofibroblasts, and expression of transforming growth factor β1. The bleomycin model represents a promising technique for studying scar formation and testing new antiscarring therapies. Methods: Osmotic pumps filled with 90 μl of 2.8 mg/ml bleomycin or a control solution (phosphate-buffered saline) were inserted subcutaneously under the dorsal skin of BALB/c mice. The pumps delivered their content at a constant rate of 0.11 μl/hour for 28 days before mice were euthanized or kept alive for a further 28 days and euthanized at day 56. The resulting lesions were analyzed using histological and immunohistochemical techniques. Results: The lesions displayed histopathological features of hypertrophic scar similar to those observed in humans and had increased cellularity, abnormal collagen I-collagen III ratios, elevated levels of the proscarring cytokine transforming growth factor β1, and increased numbers of myofibroblasts. The 28-day model displayed features analogous to those of a developing human hypertrophic scar, while the 56-day model was analogous to a mature hypertrophic scar. Refereed/Peer-reviewed

Review question/objective The objective of this review is to assess the effectiveness of trace element supplementation on clinically meaningful outcomes following severe burn injury in children and adults. More specifically, the objectives are to assess the effectiveness of selenium, copper and zinc supplementation on mortality, length of intensive care unit (ICU) hospital stay, wound healing and infection rates (wound and nosocomial) in patients who have sustained a severe burn injury. Inclusion criteria Types of participation This review will consider studies that include children (2-18 years of age) and adults (≥ 18 years of age) who have sustained a severe burn injury (defined as burn injury ≥ 10% Total Body Surface Area (TBSA) in children and ≥ 15% TBSA in adults) and been admitted to an ICU, Burns ICU (BICU), or burns unit for surgical management of their injury. Studies that include patients with significant multi-trauma in addition to burn injury will be excluded. Types of intervention(s)/phenomena of interest This review will consider studies that evaluate enteral or parenteral supplementation of selenium, copper and zinc, either alone or combined and compared to placebo or regular treatment. Intervention and comparison groups will have received standard nutrition intervention including enteral or parenteral nutrition and multi-vitamin supplements. Studies that include trace element supplementation in combination with other predefined nutrient supplementations will be considered for inclusion. Types of outcomes This review will consider studies that include the following outcome measures: mortality; length of ICU/ hospital stay; rate of wound healing (time to first donor site healing or time to wound closure); complications (e.g. wound infection, hospital acquired pneumonia). Secondary outcome measures: tissue (measured from skin biopsies) and plasma (measured via blood sampling) selenium, copper and zinc levels.

This study aimed to investigate the ability of an autologous cultured composite skin (CCS) to close similar biodegradable temporizing matrix (BTM)-integrated wounds, and its effectiveness in healing fresh full-thickness wounds after the failure of cultured epithelial autograft in its two forms (sheets and suspensions) to epithelialize over an integrated polymer BTM. Using a porcine model, autologous split-skin grafts were harvested three of four dorsal 8 × 8 cm treatment sites. These three sites were subsequently converted to full-thickness wounds and BTMs were implanted. The grafts were used to produce autologous CCSs for each pig. These consisted of a 1 mm thick biodegradable polymer foam scaffold into which fibroblasts and keratinocytes harvested from the grafts were cocultured. At Day 28, on each animal, the autologous CCSs were applied to two of the integrated BTMs, an autologous split-skin graft was applied to the third integrated BTM, and one CCS was applied immediately into a fresh, "naked" (no BTM applied) wound. The CCSs were capable of generating a bilayer repair over the naked wound's fat base and BTM-integrated wounds, which consisted of dermal elements and a keratinized stratified squamous epidermis anchored with a basement membrane by day 7. The CCSs behaved in different ways: either as a delivery vehicle allowing similar development of a bilayer repair while the polymer foam was shed from the wound, or generating a bilayer repair with the foam scaffold being retained (composite "take"). These results conclude our porcine program and provide proof of concept that the integrated BTM can be closed with an autologous CCS. Once fully optimized, this may provide robust repair without resorting to the split-skin graft, important in those cases where unburned donor site is unavailable.

Scar management is a recognised key component of rehabilitation following burn. Moisturising often combined with massage is commenced once healing tissue has gained sufficient strength to tolerate surface friction, with the aim being to hydrate the dry scar. The studies on various moisturisers and creams provide some guidance on moisturiser selection, but many are inconclusive. Objective This survey aimed to determine the current expert opinion regarding moisturiser recommendations, including the basis for these recommendations, across the burns community. Methods A brief web-based survey was distributed to burn therapists via mailing lists of the Australian and New Zealand Burn Association (ANZBA), and American Burn Association (ABA) ‘Occupational and Physical Therapist Burn Special Interest Group’. Results The fifty three respondents indicated that there were 29 different moisturisers commonly recommended in practice. Three main themes were indicated as influencing recommendations for moisturiser: the perceived effects on the scar/skin (48%); the general properties of the moisturiser (38%); the ingredients (14%). Therapists reported that the principle stimuli determining their recommendations were patient feedback and the choice of the previous burn therapist in their service. Many were also guided by medical staff, pharmacists and sales representatives. Only three respondents were able to provide citations for published evidence supporting their recommendations. Conclusions There is a paucity of evidence currently to support optimal moisturiser choice. This survey demonstrates that conflicting opinions are held on the ideal moisturiser brand, properties and ingredients. The recommendations made are based on low level evidence. Further research is required to inform clinicians which moisturiser to recommend to their clients. An ideal moisturiser should be one that is conducive to scar maturation, non- or minimally irritant, prevent skin drying, minimise transepidermal water loss and have no negative effect on barrier function.

Skin tissue engineering is a rapidly developing field based on advances made in the last quarter of the twentieth century, both in cellular culture technique and in biocompatible matrix technology. Materials can be devoid of cells and used in vivo to guide fibroblast invasion, collagen deposition, and neodermal production. The materials in this group are invariably bilayers, all consisting of an integrating dermal component, and a temporary epidermal component designed merely to prevent evaporative water loss and signal wound “closure.” The second group of materials are usually monolayer scaffolds into which bilayer composite cultured skins have been created in vitro. This review describes the development and direction of both groups, specifically emphasizing the emerging role of synthetic materials, favored because of their cost and resistance to infection.

Priming the carburetor is a method that is still commonly practiced among trained mechanic, amateur, and backyard mechanics. This article aims to look at the data available between 1996 and 2004 in two burns units in South Australia and Queensland. The authors were interested in the number of patients admitted with burns related to the activity of priming the carburetor, the TBSA percentage of burns, and areas affected. It also gives numbers of intensive care unit admissions and the number who underwent surgery for the management of the burns. The results showed that between the two centers, 48 patients were admitted following burns as a result of priming the carburetor. The activity carried no mortality during the time period of study but caused significant morbidity. Through the media, the authors are embarking on an educational program to reduce the risk of such burn injuries from this dangerous practice. Language: en

Vitamin D deficiency has been reported in pediatric burn patients; however, no formal studies have been conducted in adult burn populations. The available literature on vitamin D status in burn patients has been reviewed. A literature search was conducted using Medline™, the Cochrane central register of controlled trials, and EMBASE to identify any trials of vitamin D deficiency in burn patients. Six published studies regarding vitamin D status in burn patients were found; however, five of these were in pediatric populations and several did not assess vitamin D levels as a major endpoint. Vitamin D deficiency has been demonstrated to result in itching, muscle weakness, and neuropathy, all of which are common postburn sequelae. The major source of vitamin D is synthesis in the skin with a small amount being absorbed through dietary intake. Population groups are at higher risk of vitamin D deficiency if they have inadequate exposure to UV light or reduced biosynthetic capability due to skin damage. Burn patients fall into both risk groups and also suffer common complaints that overlap with those reported by patients with vitamin D deficiency. Further research in adult burn patients is needed to determine the prevalence of deficiency in this population and whether vitamin D deficiency might influence postburn injury symptoms reported by patients.