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2021 Vol. 37, No. 8

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2021, 37(8): F01-F01. doi: 10.3760/cma.j.issn.1009-2587.2021.37.101
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2021, 37(8): 757-757. doi: 10.3760/cma.j.issn.1009-2587.2021.37.102
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2021, 37(8): 769-769. doi: 10.3760/cma.j.issn.1009-2587.2021.37.103
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Expert Forum
Clinical application and mechanism of botulinum toxin type A in scar treatment
Zhang Yixin, Zhang Shunuo
2021, 37(8): 705-710. doi: 10.3760/cma.j.cn501120-20210701-00232
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Pathological scars cause both local physical discomforts and mental disorders for patients. With the development of research, botulinum toxin type A (BTX-A) has been gradually used in the clinical treatment of scars. This article summarizes three potential mechanisms of BTX-A, including early tension reduction, inhibition of connective tissue hyperplasia, and alleviation of skin inflammation, as well as the clinical application of BTX-A in treating different types of scars. However, at present there is no uniform standard for the time, method, and proportioning of BTX-A injection for scar treatment, and there is also a lack of long-term follow-up results. Further researches are needed in future to clarify the mechanism of BTX-A in inhibiting scars, establish a uniform protocol of BTX-A injection, and provide a more effective treatment plan for scars.
Original Articles·Scar Treatment
Clinical effect of fractional carbon dioxide laser in the treatment of contracture scars
Xi Wenjing, Zhang Zheng, Li Jie, Su Weijie, Li Hua, Pu Zheming, Zhang Yan, Feng Shaoqing, Zhang Yixin
2021, 37(8): 711-717. doi: 10.3760/cma.j.cn501120-20210624-00225
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  Objective  To explore the clinical effect of the fractional carbon dioxide laser in the treatment of contracture scars.  Methods  A retrospective before-after self-control study was conducted. From December 2016 to April 2021, 16 patients (7 males and 9 females, aged 3-49 years) with contracture scars causing impaired function of the adjacent joint were admitted to Shanghai Ninth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine. Eighteen joint scars of 16 patients were treated with fractional carbon dioxide laser every 2-3 months until the joint retained its normal range of motion or the effect plateaued. The treatment times of each patient were recorded. Before the first treatment and 6 months after the last treatment, the ranges of motion of the affected joint were measured in each patient, and the difference was calculated, meanwhile, the Vancouver Scar Scale (VSS) was used to evaluate the scar of each patient. In the treatment of 1 joint scar in each of 6 patients (totally 6 times of treatments), the ranges of motion of the affected joint before the current treatment, immediately after the treatment, and at the first follow-up after the treatment were documented, and the differences between the ranges before and immediately after the treatment as well as between the ranges before and at the first follow-up after the treatment were calculated. Adverse effects after the treatment in the treatment area were documented. At the last follow-up, a self-made questionnaire was used to collect the implementation status of the physical therapy and other scar management modalities during the treatment interval and follow-up period. Data were statistically analyzed with Wilcoxon rank sum test.  Results  Eighteen joint scars in 16 patients received 2 (1, 3) times of fractional carbon dioxide laser treatment. The range of motion of the affected joint of 16 patients 6 months after the last treatment was 56.5 (39.0, 128.8)°, notably higher than 38.4 (22.9, 116.3)° before the first treatment (Z=-3.724, P<0.01), showing a remarkable improvement by 17.4 (8.0, 24.1)°. The vascular distribution, softness, and thickness scores, and total score in VSS scoring of scars of 16 patients 6 months after the last treatment were significantly lower than those before the first treatment (Z=-2.989, -3.762, -2.814, -3.739, P<0.01), with the most obvious improvement in softness. In 6 times of treatments, the range of motion of the affected joint immediately after treatment and at the first follow-up of (2.5±0.6) months after treatment were 156.2 (148.0, 164.2)° and 160.2 (156.7, 166.4)°, both notably higher than 151.4 (145.7, 155.3)° before treatment (Z=-2.201, -2.201, P<0.05), showing a remarkable improvement by 9.1 (4.4, 13.0)° and 13.1 (8.0, 15.7)°, respectively. No adverse effects such as blisters, infection, or hypertrophic scar formation were observed in the treatment area of 16 patients after treatment. Most patients adopted physical therapy, compression, silicone gel or sheets, and braces during the treatment interval and follow-up period.  Conclusions  The fractional carbon dioxide laser can soften the scar and increase the range of motion of the affected joint, which is suitable for the clinical treatment of mild contracture scars.
Clinical effects of follicle unit extraction transplantation combined with recombinant bovine basic fibroblast growth factor and minoxidil in the treatment of secondary cicatricial alopecia
Yang Qing, Xue Ping, Dou Wenjie, Fan Xing, Song Baoqiang
2021, 37(8): 718-724. doi: 10.3760/cma.j.cn501120-20210416-00132
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  Objective  To explore the clinical effects of follicle unit extraction (FUE) transplantation combined with recombinant bovine basic fibroblast growth factor (rb-bFGF) gel and minoxidil tincture in treating secondary cicatricial alopecia (hereinafter referred to as cicatricial alopecia).  Methods  A retrospective observational study was conducted. According to the different treatment methods, 50 cicatricial alopecia patients who met the inclusion criteria and only underwent FUE transplantation in the First Affiliated Hospital of Air Force Medical University from March 2013 to April 2017 were recruited into FUE alone group (26 males and 24 females, aged (28±13) years), and 50 cicatricial alopecia patients who met the inclusion criteria and underwent FUE transplantation+rb-bFGF gel during 1 to 14 days after surgery+minoxidil tincture during 15 to 180 days after surgery in this hospital from May 2017 to April 2020 were recruited into FUE+rb-bFGF+minoxidil group (32 males and 18 females, aged (27±9) years). Hair loss rates in post surgery month (PSM) 3 and 6, hair survival rates and satisfaction rates of patients in PSM 12, and the adverse effect rates of patients in the 2 groups within PSM 12 were observed and calculated. Data were statistically analyzed with chi-square test, Fisher's exact probability test, and independent sample t test.  Results  In PSM 3 and 6, the hair loss rates of patients in FUE alone group were significantly higher than those in FUE+rb-bFGF+minoxidil group, respectively (t=70.850, 42.610, P<0.01). In PSM 12, the hair survival rate of patients in FUE+rb-bFGF+minoxidil group was (91.0±2.8)%, which was significantly higher than (80.9±6.9)% in FUE alone group (t=9.665, P<0.01). In PSM 12, 25 patients were very satisfied, 12 patients were fairly satisfied, 10 patients were slightly satisfied, 2 patients were not satisfied, and 1 patient was very unsatisfied in FUE alone group; 42 patients were very satisfied, 5 patients were fairly satisfied, and 3 patients were slightly satisfied in FUE+rb-bFGF+minoxidil group. The satisfaction rate of patients in FUE alone group was 74% (37/50), which was significantly lower than 94% (47/50) in FUE+rb-bFGF+minoxidil group (P<0.01). Within PSM 12, compared with those in FUE+rb-bFGF+minoxidil group, the incidence rates of folliculitis, abnormal growth direction, and skin necrosis in transplant site were not obviously changed in FUE alone group (P>0.05), while the incidence of scar in donor site was significantly higher (P<0.05).  Conclusions  Compared with FUE transplantation alone, FUE transplantation combined with rb-bFGF and minoxidil can reduce the hair loss rate, improve the hair survival rate and the satisfaction rate of patients with cicatricial alopecia after FUE transplantation, with less adverse effects, thus are good for cicatricial alopecia treatment.
Expression of microRNA-296 in rabbit hypertrophic scars and its role to human fibroblasts
Guo Bingyu, Lin Feng, Bai Zeming, Tao Kai, Wang Hongyi
2021, 37(8): 725-730. doi: 10.3760/cma.j.cn501120-20210420-00142
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  Objective  To investigate the expression of microRNA-296 (miR-296) in rabbit hypertrophic scars and its role in human fibroblasts (HFbs).  Methods  The experimental method was used. Twelve healthy adult New Zealand long-eared rabbits regardless gender were randomly divided into normal control group and scar group, with 6 rabbits in each group. The rabbit ear hypertrophic scar model was created in scar group according to the literature, and the rabbits in normal control group did not receive any treatment. On 60 days after setting up the models in scar group, hematoxylin-eosin staining was performed to observe the growth and arrangement of fibroblasts (Fbs) in the ear scars and skin tissue of rabbits in the two groups. The mRNA expressions of miR-296 and transforming growth factor-β1 (TGF-β1) in ear scars and skin tissue of rabbits in the two groups were detected by real-time fluorescent quantitative reverse transcription polymerase chain reaction, and the correlation of mRNA between miR-296 and TGF-β1 was performed with Pearson regression analysis. Two batches of HFbs were used and transfected respectively with corresponding sequences, with the 1st batch being divided into TGF-β1 wild type+miR-296 negative control group and TGF-β1 wild type+miR-296 mimic group and the 2nd batch being divided into TGF-β1 mutant type+miR-296 negative control group and TGF-β1 mutant type+miR-296 mimic group. At 48 h after transfection, luciferase reporter gene detection kit was used to detect the luciferase and renal luciferase expression of TGF-β1 in the cells of each group, with their ratio being used to reflect the gene expression level. Two batches of HFbs were used, and each batch of cells were divided into miR-296 negative control group and miR-296 mimic group, being transfected with the corresponding sequences. At 0 (immediately), 12, 24, 36, and 48 h after transfecting the first batch of cells, the cell proliferation was detected by thiazolyl blue method. At 24 h after transfecting the second batch of cells, the expression of TGF-β1 and collagen type Ⅰ was detected by Western blotting. The number of samples in cell experiments was 3. Data were statistically analyzed with analysis of variance for factorial design, independent sample t test.  Results  On 60 days after setting up the models in scar group, the Fbs of rabbit ear scar tissue in scar group proliferated and arranged disorderly, while the growth and arrangement of Fbs in rabbit ear skin tissue in normal control group were normal. The mRNA expression of miR-296 of rabbit scar tissue in scar group (0.65±0.11) was significantly lower than 1.19±0.12 of rabbit ear skin tissue in normal control group (t=5.175, P<0.01). The mRNA expression of TGF-β1 of rabbit ear scar tissue in scar group (1.47±0.06) was significantly higher than 1.10±0.03 of rabbit ear skin tissue in normal control group (t=12.410, P<0.01). Pearson regression analysis showed that there was a negative correlation between the mRNA expression of miR-296 and TGF-β1 in the ear scars and skin tissue of 12 rabbits (F=7.278, P<0.05). At 48 h after transfection, the gene expression of TGF-β1 of cells in TGF-β1 wild type+miR-296 mimic group was significantly lower than that in TGF-β1 wild type+miR-296 negative control group (t=35.190, P<0.01), while the gene expression of TGF-β1 of cells in the two TGF-β1 mutant type groups were close (P>0.05). The HFbs proliferation ability in miR-296 mimic group was significantly lower than that in miR-296 negative control group at 12, 24, 36, and 48 h after transfection(t=3.275, 11.980, 10.460, 17.260, P<0.05 or P<0.01). At 24 h after transfection, the protein expressions of TGF-β1 and type Ⅰ collagen of cells in miR-296 negative control group were significantly higher than those in miR-296 mimic group (t=3.758, 29.390, P<0.05 or P<0.01).  Conclusions  The miR-296 expression in rabbit hypertrophic scars is down-regulated; miR-296 can inhibit the proliferation of HFbs and the expression of type Ⅰ collagen by down regulating the expression of TGF-β1.
Original Articles
A prospective study of the effect and mechanism of autologous platelet-rich plasma combined with Meek microskin grafts in repairing the wounds of limbs in severely burned patients
Zheng Jiansheng, Liu Shengli, Peng Xiaojing, Liu Xiaofei, Yu Le, Liang Shengqiang
2021, 37(8): 731-737. doi: 10.3760/cma.j.cn501120-20200427-00241
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  Objective  To observe the effect of autologous platelet-rich plasma (PRP) combined with Meek microskin grafts in repairing the wounds of limbs in severely burned patients, and to explore the mechanism.  Methods  The prospective controlled research method was used. From September 2016 to January 2020, 16 patients aged 18-69 years, with extensive deep burns, including 9 males and 7 females, who met the selection criteria were admitted to the Department of Burns and Plastic Surgery of the 909th Hospital of the Joint Logistic Support Force of PLA. The bilateral limbs with similar injury in 8 patients were divided into Meek skin grafting+PRP group and Meek skin grafting alone group according to the random number table; in the other 8 patients, the limbs with severer injury were included in Meek skin grafting+PRP group, and the limbs on the other side were included in Meek skin grafting alone group. The wounds of affected limbs in the two groups were treated correspondingly. On post surgery day (PSD) 10, the survival and fusion of Meek microskin grafts were observed and the survival rate and fusion rate were calculated; the histological morphology and the angiogenesis of the basal tissue of Meek microskin graft were observed by hematoxylin-eosin staining and immunohistochemical staining, respectively, with the microvessels being counted. Data were statistically analyzed with paired sample t test.  Results  On PSD 10, the wounds of affected limbs in Meek skin grafting+PRP group were dry, and most of the transplanted skin grafts were closely adhered to the basal tissue; while a small amount of exudate could be found in the wounds of affected limbs in Meek skin grafting alone group, and a small part of the transplanted microskin grafts fell off or poorly attached to the basal tissue. On PSD 10, the survival rate and the fusion rate of Meek microskin grafts in the wounds of affected limbs in Meek skin grafting+PRP group were (94±3)% and (86±4)%, which were significantly higher than (89±4)% and (79±4)% of Meek skin grafting alone group, respectively (t=3.633, 4.229, P<0.01). On PSD 10, the basal epidermis was closely connected with dermis of Meek microskin grafts in the wounds of affected limbs in Meek skin grafting+PRP group, with more inflammatory cell infiltration and active microvascular hyperplasia, while the basal epidermis was less closely connected with dermis of Meek microskin grafts in the wounds of affected limbs in Meek skin grafting alone group, with obvious degeneration of collagen fibers under the dermis, less inflammatory cell infiltration, and slightly poor microvascular hyperplasia. On PSD 10, the distribution of microvessels in basal tissue of Meek microskin grafts in the wounds of affected limbs in Meek skin grafting+PRP group were densely clustered, while the distribution of microvessels in Meek skin grafting alone group were scattered, sparse, and dotted. On PSD 10, the number of microvessels in basal tissue of Meek microskin grafts in the wounds of affected limbs in Meek skin grafting+PRP group was 36±6 in each 400-fold visual field, which was significantly more than 29±7 of Meek skin grafting alone group (t=2.671, P<0.05).  Conclusions  Autologous PRP can effectively promote the survival rate and fusion rate of Meek microskin grafts in the wounds of limbs after escharectomy in severely burned patients by promoting angiogenesis at the base of Meek microskin grafts.
Analysis of the clinical features and prognostic influencing factors of toxic epidermal necrolysis
Hu Zhengxiang, Bian Huining, Ma Dan, Luo Hongmin, Sun Chuanwei, Lai Wen
2021, 37(8): 738-746. doi: 10.3760/cma.j.cn501120-20200416-00230
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  Objective  To investigate the clinical features and prognostic influencing factors of toxic epidermal necrolysis (TEN).  Methods  A retrospective observational study was conducted. From January 2008 to March 2019, a total of 46 TEN patients who met the inclusion criteria were admitted to Guangdong Provincial People's Hospital. The gender, age, and hospital admission diagnosis of the 46 patients, the category of department admitted of patients complicated with sepsis, death ratio of the sepsis patients with or without treatment history in intensive care unit (ICU)/department of burns and wound repair, and the cause of death of the deceased patients were recorded. Depending on whether complicated with sepsis, the patients were divided into sepsis group (32 cases) and non-sepsis group (14 cases). According to whether died or not, the patients were divided into death group (9 cases) and survival group (37 cases). The specific conditions of suspected pathogenic agents and combined underlying diseases, the abnormality of transaminase/bilirubin, creatinine, and platelet count in blood on admission, and the detection of pathogenic microorganisms and drug resistance during the course of disease of patients were recorded in both sepsis group and non-sepsis group. The gender, age, lesion area, severity of illness score for TEN (SCORTEN) system score, combined underlying diseases on admission, and blood microbial culture positivity, hormone use, and gamma globulin use during the course of disease of patients between sepsis group and non-sepsis group, death group and survival group were compared respectively. Data were statistically analyzed with chi-square test, Fisher's exact probability test, and Mann-Whitney U test. The factors with statistically significant differences between sepsis group and non-sepsis group, death group and survival group were selected for binary multivariate logistic regression analysis, so as to screen the independent risk factors affecting sepsis and death in TEN patients.  Results  Of the 46 TEN patients, 30 were male and 16 were female, aged from 8 months to 92.0 years, with 11 cases (23.91%) of epidermolysis bullosa, 9 cases (19.57%) of exfoliative dermatitis, 9 cases (19.57%) of TEN, 7 cases (15.22%) of epidermolysis bullosa, 6 cases (13.04%) of Stevens-Johnson syndrome, and 4 cases (8.70%) of severe drug rash for hospital admission diagnosis. The patients complicated with sepsis were admitted to 11 departments, and the death ratio of patients with treatment history in ICU/department of burns and wound repair was similar to that of patients without such department treatment history (P>0.05). All the deceased patients were complicated with sepsis, which was also the main cause of death. On admission, the suspected pathogenic agents of patients in sepsis group were mainly allopurinol (8 cases) and non-steroidal anti-inflammatory drugs (4 cases), while those in non-sepsis group were allopurinol (3 cases) and psychotropic drugs (3 cases). Patients in sepsis group combined as many as 10 underlying diseases, while those in non-sepsis group combined only 4 underlying diseases. The proportions of patients with increased creatinine (χ2=13.349, P<0.01) and decreased platelet count (P<0.01) in sepsis group were significantly higher than those in non-sepsis group, while the transaminase/bilirubin abnormality was similar to that in non-sepsis group (P>0.05). A wide variety of pathogens were detected in the blood, respiratory tract secretions, and skin secretions of 21 patients in sepsis group, and 14 patients were infected with drug-resistant bacteria; among the 9 strains cultured from the blood samples, 8 were drug-resistant bacteria and 6 were Gram-positive bacteria. In non-sepsis group, pathogens were detected in blood, respiratory tract secretions, and skin secretions of 8 patients, with fewer species, and 6 patients were infected with drug-resistant bacteria. The gender, age, lesion area, blood microbial culture positivity, hormone use, and gamma globulin use of patients in sepsis group were similar to those in non-sepsis group (P>0.05). The proportion of patients combined with underlying diseases (χ2=4.493, P<0.05) and the proportion of patients with SCORTEN system score of 4-6 points (P<0.01) of patients in sepsis group were significantly higher than those in non-sepsis group. The gender, combined underlying diseases, lesion area, blood microbial culture positivity, hormone use, and gamma globulin use of patients were similar between survival group and death group (P>0.05). The proportion of patients with age≥60 years and the proportion of patients with SCORTEN system score of 4-6 points of patients in death group were significantly higher than those in survival group (χ2=4.412, 11.627, P<0.05 or P<0.01). The SCORTEN system score was an independent risk factor affecting sepsis and death in TEN patients (odds ratio=3.025, 2.757, 95% confidence interval=1.352-6.769, 1.244-6.110, P<0.05 or P<0.01).  Conclusions  The diagnosis of TEN is difficult on admission. Male population is susceptible to TEN, and allopurinol is the common pathogenic agent. The proportion of patients combined with underlying diseases is high in TEN patients complicated with sepsis, with mainly drug-resistant bacteria and mostly Gram-positive bacteria in blood-borne infections. The deceased patients are older than the survived, and the main cause of death is sepsis. The SCORTEN system score is an independent risk factor affecting sepsis and death in TEN patients.
Application value of flexible endoscopy and rigid endoscopy in the clinical examination of chronic sinus tract wounds with different shapes
Tao Guilu, Liu Yingkai, Tang Jiajun, Ma Xian, Huang Lifang, Zhou Jingqi, Wu Fangyi, Yakupu Aobuliaximu, Wang Hanqi, Guan Haonan, Dong Jiaoyun, Lu Shuliang
2021, 37(8): 747-751. doi: 10.3760/cma.j.cn501120-20200318-00179
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  Objective  To explore the application value of flexible endoscopy and rigid endoscopy in the clinical examination of chronic sinus tract wounds with different shapes.  Methods  A retrospective observational study was conducted. From January 1 to December 23, 2019, a total of 46 patients with chronic sinus tract wounds, who met the inclusion criteria were admitted to the Wound Healing Center of Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, including 23 males and 23 females, aged 18-81 (48±21) years. On admission, computer tomography (CT) imaging and three-dimensional reconstruction were performed to examine the shapes of wound sinus tract and classify the wounds, with the lengths of wound sinus tract by CT imaging examination (hereinafter referred to as reference lengths) recorded. The lengths of wound sinus tract were examined and measured by rigid endoscopy and flexible endoscopy. The wounds with and without obviously curved sinus tract were classified into curve group and linear group respectively, and the deviation rates between the lengths of wound sinus tract measured by flexible endoscopy or rigid endoscopy and the reference lengths (hereinafter referred to as deviation rates of lengths) in each group were calculated. The difference between the deviation rates of lengths examined by flexible endoscopy and rigid endoscopy and the differences between the above two and the deviation rate of reference lengths (0) in each group were compared. Data were statistically analyzed with paired sample t test and Wilcoxon signed rank sum test.  Results  CT imaging and three-dimensional reconstruction showed that there were 4 types of wound sinus tract, including tubular (36/46), lamellar (4/46), club-mallet (4/46), and irregular (2/46) shape. Tubular wounds were further divided into type I (23/36), type L (4/36), and type Y (9/36). Wounds with type I tubular, lamellar, and club-mallet sinus tract were classified into linear group (31/46), while those with type Y tubular, type L tubular, and irregular sinus tract were classified into curve group (15/46). In linear group, the deviation rates of lengths examined and measured by rigid endoscopy and flexible endoscopy were 0. In curve group, the deviation rate of lengths examined and measured by flexible endoscopy was 0 (0, 0.58%), which was significantly lower than 41.18% (31.68%, 48.41%) examined and measured by rigid endoscopy, Z=-3.408, P<0.01; the deviation rate of lengths examined and measured by rigid endoscopy (40±19)% was significantly higher than the deviation rate of reference lengths (t=8.343, P<0.01), while the deviation rate of the lengths examined and measured by flexible endoscopy was similar to the deviation rate of reference lengths (Z=-1.342, P>0.05).  Conclusions  Compared with rigid endoscopy, flexible endoscopy can observe the internal characteristics of chronic sinus tract wounds in a wider range in the clinical examination of this kind of wound, especially for the exploration of curved chronic sinus tract wounds. The promotion of this method will be conducive to the diagnosis and treatment of chronic sinus tract wounds.
Clinical effects of expanded flap in repairing the wounds with exposed titanium mesh after cranioplasty with titanium mesh
Ji Peng, Hu Dahai, Han Fu, Yang Chen, Zhang Zhi, Tong Lin, Zhang Yue, Han Juntao, Tao Ke
2021, 37(8): 752-757. doi: 10.3760/cma.j.cn501120-20200613-00306
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  Objective  To explore the clinical effects of expanded flap made by skin and soft tissue expander (hereinafter referred to as expander) in repairing the wounds with exposed titanium mesh after cranioplasty with titanium mesh.  Methods  A retrospective observational study was conducted. From April 2015 to October 2019, 13 patients with wounds with exposed titanium mesh after cranioplasty with titanium mesh were admitted to the First Affiliated Hospital of Air Force Medical University, including 10 males and 3 females, aged 18 to 70 years. Exposure of titanium mesh occurred 3 months to 4 years after cranioplasty with titanium mesh. The wound area of exposed titanium mesh ranged from 1.5 cm×0.6 cm to 6.3 cm×6.0 cm. In the first stage, one or two square expanders with rated capacity of 50-200 mL were placed under the normal scalp 1 cm away from the edge of the wound surface of exposed titanium mesh. The water injection time was 2 to 3 months with the total water injection volume being 1.6 to 2.0 times of the rated capacity of expander. In the second stage, the expander was removed and the expanded flap (size ranging from 4.1 cm×1.8 cm to 9.1 cm×7.9 cm) was transferred to repair the wound of exposed titanium mesh. The placement site of the expander, the transfer form of the expanded flap, the postoperative wound healing of the titanium mesh exposed site, and the survival of expanded flap were recorded. The scar of the head incision and the appearance of head were followed up.  Results  Among the patients in this group, the expanders of 7 were placed in the temporal region, while the other 6 were placed at the top. The 11 patients were treated with advanced expanded flap, while the other 2 patients were treated with pedicled expanded flap. The head wounds of patients in this group successfully healed with retaining of the titanium mesh. The wound was healed after dressing change in 1 patient with necrosis at the tip of the expanded flap. The expanded flaps of 12 patients survived after transfer. Patients in this group were followed up for 12 months after surgery, the exposed titanium meshes were retained, the incisions healed well with the scars concealed, the hair on the scalp grew well, and the appearance of head was comparatively good.  Conclusions  Using expanded flap in the repair of the wounds with exposed titanium mesh after cranioplasty with titanium mesh can effectively cover the wound and retain the titanium mesh, achieving good function and appearance.
Clinical effects of neurocutaneous vascular flap innervated by terminal branch of lateral antebrachial cutaneous nerve in repairing finger tip or finger pulp wounds of the thumb
Wang Hui, Yang Xiaoxi, Huo Yongxin, Hao Ruizheng, Chang Hong, Liu Wei, Wang Bin
2021, 37(8): 758-763. doi: 10.3760/cma.j.cn501120-20200607-00298
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  Objective  To investigate the clinical effects of neurocutaneous vascular flap innervated by terminal branch of lateral antebrachial cutaneous nerve in repairing finger tip or finger pulp wounds of the thumb.  Methods  A retrospective observational study was conducted. From February 2016 to April 2019, a total of 21 patients (21 fingers) with finger tip or finger pulp wounds of the thumbs met the inclusion criteria and were admitted to the Second Hospital of Tangshan, including 13 males and 8 females, aged 21 to 65 years, with the defects located at the finger tips of 14 patients and the finger pulps of 7 patients, and all having exposed bones and/or tendons. The wound sizes of patients in this group after debridement ranged from 2.0 cm×1.5 cm to 4.0 cm×2.7 cm. All the wounds were repaired with the neurocutaneous vascular flap innervated by terminal branch of lateral antebrachial cutaneous nerve, with the flap sizes ranging from 2.3 cm×1.8 cm to 4.3 cm×3.0 cm. In surgery, the terminal branch of lateral antebrachial cutaneous nerve carried by the flaps was anastomosed with the end of the proper digital nerve of the wounds. The donor sites of flaps were sutured directly. The survival of flaps and healing of wounds in donor sites after operation were observed. The appearance of flaps and donor sites were observed during follow-up. At the final follow-up, the static two-point discrimination distances of the flaps were measured, and the degree of satisfaction of patients for the appearances of injured hands were evaluated based on Michigan Hand Function Questionnaire. The total action motion (TAM) of the injured and contralateral thumbs and the angle of thumb web of the injured and contralateral hands were measured. Data were statistically analyzed with paired sample t test.  Results  All the flaps of the 21 patients survived with good blood supply and no infection. The wounds at the donor sites were all healed. All the patients were followed up, with the time ranging from 8 to 22 months. The appearances of flaps were good with their color and texture similar to the surrounding tissue. There was no pain in the finger tip or finger pulp, nor any ectopic sensation in flaps. There was only some linear scar left at the radial side of thumb. At the final follow-up, the static two-point discrimination distances of the flaps of the patients were 6 to 11 mm; 18 patients were very satisfied and 3 patients were satisfied with the overall appearance of the injured hand. The TAM of injured thumbs and the angle of thumb web of the injured hands of the patients were respectively (140±5)º and (94±9)°, which were similar to (141±5)º of the thumbs and (95±9)° of hands in the contralateral side, respectively (t=-2.024, -1.142, P>0.05).  Conclusions  The neurocutaneous vascular flap innervated by terminal branch of lateral antebrachial cutaneous nerve has constant anatomy and is easy to perform. It can repair the finger tip or finger pulp wounds of the thumb achieving good appearance and function recovery. It provides a good option for repair of finger tip or finger pulp wounds of the thumb and is especially suitable for emergency application.
Application of metagenomic next-generation sequencing technology in pathogen detection in patients with burns and patients with acute or chronic wounds
Li Feng, Yin Huinan, Hu Quan, Zhang Qinxue, Chen Qi, Yang Longlong, Chen Xin, Sun Yingjie
2021, 37(8): 764-769. doi: 10.3760/cma.j.cn501120-20200623-00322
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Abstract:
  Objective  To explore the value of using metagenomic next-generation sequencing (mNGS) technology to detect pathogens in patients with burns and patients with acute or chronic wounds.  Methods  A retrospective observational study was conducted. From March 2019 to June 2020, 11 patients with burns and patients with acute or chronic wounds (including 10 males and 1 female, aged 23 to 85 years) in the Fourth Medical Center of PLA General Hospital met the inclusion criteria and were recruited. A total of 23 specimens were collected, including 6 whole blood specimens, 1 skin tissue specimen, 1 drained pus specimen, and 15 wound secretion swab specimens. Each specimen was divided into two parts, which were subjected for pathogen detection using microbial culture method and mNGS method, respectively. The number and types of pathogens detected by the 2 methods and the relative abundance detected by the mNGS method were recorded, and the consistency of the two methods were compared. Data were statistically analyzed with paired Wilcoxon rank sum test.  Results  With the microbial culture method, no pathogen was detected in 5 of the 23 specimens, while 35 pathogens were detected in the remaining 18 specimens, belonging to 9 species of bacteria and 2 species of fungi. Five specimens had one pathogen while 9 specimens had 2 pathogens and 4 specimens had 3 pathogens detected in each specimen. With the mNGS method, no pathogen was detected in one of the 23 specimens, while 75 pathogens were detected in the remaining 22 specimens, belonging to 28 species of bacteria, 3 species of fungi, and 3 species of viruses. Eight specimens had one pathogen, 5 specimens had 2 pathogens, 2 specimens had 3 pathogens, 3 specimens had 4 pathogens, 2 specimens had 6 pathogens, and 1 specimen had 7 pathogens, and 1 specimen had 20 pathogens detected in each specimen. The number of pathogens detected in each specimen by microbial culture method was 2 (1, 2) types, which was significantly less than 2 (1, 4) types by mNGS method (Z=3.359, P<0.01). In 5 specimens, no bacteria were detected by microbial culture method but mNGS method detected bacteria in 2 specimens and virus in 2 different specimens. The mNGS method detected two or more types of bacteria in 13 specimens, the relative abundance of bacteria with the 1st relative abundance ranking ranged from 28.8% to 95.9% in each specimen. Of the 23 specimens detected by two detection methods, 7 specimens (30.4%) showed identical detection results, 5 specimens (21.7%) showed totally different detection results, and 11 specimens (47.8%) had partially consistent detection results.  Conclusions  Compared with the traditional microbial culture method, the mNGS method has higher detection sensitivity and stronger capacity to detect pathogens, and can determine the relative abundance of pathogens in mixed infections. As a supplement to the culture method, the mNGS method is expected to play an important role in the diagnosis of infectious pathogens in burns and acute or chronic wounds.
Biological activity of biomimetic dermal papilla spheres prepared by culture of dermal papilla cells of mice based on hanging drops of gelatin methacrylate and its hair-inducing function in nude mice
Huang Gang, Chen Liang
2021, 37(8): 770-780. doi: 10.3760/cma.j.cn501120-20210330-00109
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Abstract:
  Objective  To investigate the biological activity of biomimetic dermal papilla spheres (DPSs) prepared by three-dimensionally cultured dermal papilla cells (DPCs) of mice based on the biomimetic microenvironment of gelatin methacrylate (GelMA) and hanging drop method and its hair-inducing function in nude mice.  Methods  Experimental research methods were adopted. DPCs from the vibrissa of male C57BL/6J mice aged 5 to 6 weeks and keratinocytes (KCs) from the skin of 1 d old C57BL/6J mice were obtained by enzymatic digestion method. A stable expression of DPCs markers such as nerve cell adhesion molecules, alkaline phosphatase (ALP), β-catenin, and α-smooth muscle actin were identified by immunofluorescence method in the third passage of the former cells, while the latter primary cells stably expressed keratin 15, a marker of KCs. The 8th passage of DPCs were re-suspended with GelMA and inoculated on the bottom surface of the Transwell plate insert, and then the GelMA drops were photocrosslinked and cultured upside down later. The DPCs aggregation in GelMA drops after in cultures of 0 (immediately) and 3 day (s) was observed under an optical microscope (the DPCs aggregates were the biomimetic DPSs). The cell viability of 3 day biomimetic DPSs culture was detected by live/dead staining kit. The primary DPCs and the 8th passage of DPCs derived from traditionally two-dimensional cultures, and the biomimetic DPSs prepared by the above-mentioned method were set as primary DPCs group, the 8th passage of DPCs group, and biomimetic DPSs group, respectively. Transcriptome sequencing was performed using the high-throughput sequencing technology platform, with 3 samples in each group analyzed after three days in culture. The principal component analysis, Pearson similarity analysis, and screening of differentially expressed genes were performed using OmicShare Tools based on the transcriptome data. Cluster analysis of expression patterns of differentially expressed genes was performed using time series trend analysis software. The Kyoto Encyclopedia of Genes and Genomes (KEGG) and Gene Ontology (GO) enrichment analyses of differentially expressed genes with specific expression patterns were performed using the OmicShare Tools. The cells were grouped as before, and the sex determining region Y-Box 8 (SOX8), matrix metallopeptidase 9 (MMP-9), collagen type ΧΧⅥ alpha 1 chain (COL26A1), and wingless-type MMTV integration site family member 6 (Wnt6) were screened out from the differentially expressed genes according to the random number table, which were determined by real-time fluorescent quantitative reverse transcription polymerase chain reaction (RT-PCR) to verify the consistency between mRNA expression of differentially expressed genes and sequencing results (n=9); the mRNA expressions of DPCs biological function markers fibroblast growth factor 7 (FGF7), Wnt10a, lymphoid enhancement factor 1 (LEF1), ALP, β-catenin, versican, and SOX2 were determined by real-time fluorescent quantitative RT-PCR (n=9). Three male BALB/c nude mice aged 5-6 weeks were divided into primary DPCs group, the 8th passage of DPCs group, and biomimetic DPSs group. The primary DPCs, the 8th passage of DPCs, and the biomimetic DPSs were mixed with primary KCs at a ratio of 2∶1 in cell number and then injected subcutaneously into mice of corresponding groups, with 6 injection regions for each mouse. Two weeks after the injection, the full-thickness skin of the injection region was taken, the regenerated hair was counted, and the regenerated hair follicle was observed after hematoxylin-eosin staining. Data were statistically analyzed with one-way analysis of variance, Tukey test, and Bonferroni correction.  Results  After 3 days of culture, DPCs aggregated into biomimetic DPSs in GelMA hanging drops from the dispersed state on culture day 0, and the cells in the biomimetic DPSs had good cell activity. After 3 days of culture, principal component analysis showed that compared with that of the 8th passage of DPCs group, the degree of variation among samples within primary DPCs group and biomimetic DPSs group was relatively low, and the degree of variation was the lowest between samples of biomimetic DPSs group and primary DPCs group; the variation of gene profile data of more than 90% of DPCs samples in 3 groups could be explained by the first and second principal components. Pearson similarity analysis showed that samples within each group had good repeatability. The similarity was 0.84-0.95 between samples of primary DPCs group and biomimetic DPSs group, and was 0.72-0.87 between samples of primary DPCs group and the 8th passage of DPCs group. The differentially expressed genes among the three groups were analyzed and 642 differentially expressed genes with group intersection were screened out. Clusters of expression patterns showed that two gene expression patterns had a significant trend (P<0.05), the first pattern showed that gene expression of the 8th passage of DPCs group was significantly lower than that of primary DPCs group or biomimetic DPSs group, and the second pattern showed that gene expression of the 8th passage of DPCs group was significantly higher than that of primary DPCs group or biomimetic DPSs group, including a total of 411 differentially expressed genes. KEGG enrichment analysis showed that the 411 differentially expressed genes were significantly enriched in Wnt signaling pathway and phosphatidylinositol 3 kinase/protein kinase B pathway (P<0.05), while GO enrichment analysis showed that GO terms such as extracellular matrix, classical Wnt signaling pathway, and cell differentiation were significantly enriched (P<0.05). The mRNA expressions of genes SOX8, MMP-9, COL26A1 and Wnt6 of cells in the 8th passage of DPCs group were significantly decreased compared with those in primary DPCs group and biomimetic DPSs group (q=15.950, 8.854, 11.890, 11.050, 9.851, 5.884, 7.418, 4.870, P<0.01), consistent with the sequencing data. Compared with those in primary DPCs group and biomimetic DPSs group, the mRNA expressions of biological function markers FGF7, Wnt10a, LEF1, ALP, β-catenin, versican, and SOX2 of cells in the 8th passage of DPCs group were significantly decreased (q=11.470, 9.795, 4.165, 9.242, 10.970, 10.570, 8.005, 7.472, 4.976, 3.651, 4.784, 5.236, 6.825, 5.214, P<0.05 or P<0.01). Two weeks after injection, nude mice in the 8th passage of DPCs group failed to regenerate hair, while the numbers of hair regenerated in nude mice in biomimetic DPSs group and primary DPCs group were close (q=1.852, P>0.05) and both were significantly higher than the number in the 8th passage of DPCs group (q=18.980, 17.130, P<0.01). In the 8th passage of DPCs group, only necrotic foci were found in the injection region of the skin of nude mice, while regenerated hair follicles were observed in the injection region of the skin of nude mice in both biomimetic DPSs group and primary DPCs group, and melanosis was observed in the cross section of hair follicles.  Conclusions  Based on GelMA biomimetic microenvironment and hanging drop method, the biomimetic DPSs culturing model prepared by three dimensional culture of DPCs of mice can restore the hair-inducing ability of high passage of DPCs in nude mice to a certain extent, and its biological characteristics are more similar to those of the primary DPCs, which can restore the characteristics of DPCs after amplification.
Original Article·Nursing Column
A prospective before-after self-control study of the scenario simulation teaching of junior nurses in a burns department on the fluid resuscitation care of massive burn patients during shock stage
Xie Lin, Zhang Yin, Wang Jiayu, Yang Dingting, Teng Peimin, Wang Wenliang, Huang Yi
2021, 37(8): 781-787. doi: 10.3760/cma.j.cn501120-20201105-00456
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Abstract:
  Objective  To explore the effects of scenario simulation teaching of junior nurses in a burns department on the fluid resuscitation care of massive burn patients during shock stage.  Methods  From March 2018 to July 2019, 25 junior nurses fixed in the Department of Burn of Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine met the inclusion criteria and were recruited in this prospective before-after self-control study, including 21 females and 4 males, aged 23 to 26 years. They had a work experience of 1.0 (1.0, 2.0) years in the Department of Burn. Three teaching scenarios were made according to the three major problems in the fluid resuscitation nursing of extensive burn patients during shock stage. The teaching plans were written based on the theoretical framework of Jeffrie's nursing simulation teaching. The high feasibility and practicability of the teaching plans was verified through expert consultation and evaluation by junior nurses. According to the three scenarios in the teaching plan, the junior nurses were performed with scenario simulation teaching, with 2 hours for each scenario, 6 hours in total. In one month before and after the teaching (hereinafter referred to as before and after teaching), the comprehensive ability of junior nurses was evaluated by the teachers using the self-designed junior nurse comprehensive ability evaluation scale, and their behaviors were evaluated by themselves with Performance Self-rating Scale for Nursing Students on High Simulation Training. Data were statistically analyzed with paired sample t test.  Results  After teaching, the scores on communication skills, patient admissions, condition assessments, fluid resuscitation, emergency treatment, drug management, nursing skills, instrument use, teamwork, and humanitarian care and total score in the comprehensive ability evaluation of junior nurses as evaluated by teachers were significantly higher than those before teaching (t=-8.060, -11.421, -17.232, -24.800, -4.670, -11.916, -12.131, -11.606, -14.632, -13.325, -25.068, P<0.01), with 4 items including fluid resuscitation, condition assessment, nursing skills, and equipment operation having higher scores. After teaching, the nurses' self-rating scores on communication, division of labor and cooperation, clinical decision-making, professional knowledge and skills, and professional development and critical thinking and total score were (4.6±0.4), (4.8±0.3), (4.6±0.3), (4.6±0.4), (4.6±0.4), and (23.2±1.5) points respectively, which were significantly higher than the corresponding scores of (4.1±0.7), (4.2±0.7), (3.9±0.5), (3.7±0.6), (3.9±0.5), and (18.8±2.6) points before teaching (t=-3.361, -5.721, -6.987, -7.923, -7.922, -7.367, P<0.01).  Conclusions  With solving the practical problems in nursing works of fluid resuscitation care of massive burn patients during shock stage as entry point, scenario simulation teaching aims to train the clinical practice ability and adaptability of junior nurses, thereby improving junior nurses' comprehensive ability of clinical practice in the fluid resuscitation care of massive burn patients during shock stage, enhancing their self-confidence and critical thinking ability.
Wound Repair
Observation on the clinical effect of self-designed modified rhomboid skin flap in facial wound repair
Yi Lei, Dou Yi, Zhou Zengding, Li Xuechuan, Zheng Jiexin, Zhang Qin, Huan Jingning, Liu Yan
2021, 37(8): 788-792. doi: 10.3760/cma.j.cn501120-20200504-00250
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Abstract:
  Objective  To investigate the clinical effect of self-designed modified rhomboid flap in repairing rhomboid, round, and teardrop-shaped wounds on the face.  Methods  A retrospective observational study was conducted. From August 2018 to April 2020, 30 patients with facial lesions admitted into Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine and the People's Hospital of Jianchuan County in Yunnan province met the inclusion criteria, including 16 males and 14 females, aged 23 to 88 years. The wound area ranged from 1.0 cm×1.0 cm to 7.0 cm×5.0 cm, with 10 cases of rhomboid wounds, 12 cases of round wounds, and 8 cases of teardrop-shaped wounds. The self-designed modified rhomboid flaps were applied to repair the wounds and after that, the patients were followed up for 1 to 18 months to record the survival of flaps, wound tension, scar formation and complications after surgery.  Results  No necrosis or blackening was observed at the tip of the flaps after surgery. All the flaps survived and the wounds healed well with little tension, minimal scars, and no complications.  Conclusions  The self-designed modified rhomboid flap is especially suitable for facial wounds with multiple important organs, multiple anatomical subunits, and areas with large changes in soft tissue tension, which can reduce not only the rotation of the flap, but also unnecessary excision of normal skin and soft tissue.
Technique and Method
Reliability study on establishing a rat tuberculosis wound model using Bacillus Calmette-Guérin
Zhou Keqiang, Su Yingjun, Jia Chiyu
2021, 37(8): 793-796. doi: 10.3760/cma.j.cn501120-20200531-00290
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  Objective  To evaluate the reliability of a rat tuberculous wound model established by injecting Bacillus Calmette-Guérin (BCG).  Methods  The experimental research was conducted. According to the random number table, fifteen 6-week-old male Sprague-Dawley rats were divided into normal control group and infection group, with 3 rats in normal control group and 12 rats in infection group. Rats in infection group were injected with Freund's complete adjuvant, 3 weeks later, they were injected subcutaneously with BCG bacterial solution to establish a model of tuberculous wounds in rats; rats in normal control group did not receive any treatment. On the 8th, 15th, 32nd, and 43rd day of infection, the skin condition at the injection sites of the rats in infection group was observed roughly. Skin tissue at the injection sites of 3 rats in infection group at each corresponding time point stated above and skin tissue at the corresponding sites of the rats in normal control group were stained with hematoxylin-eosin to observe the cell arrangement, necrosis and inflammation. On 43rd day of infection, acid-fast staining was performed on the skin tissue at the injection sites of the rats in infection group to observe the distribution of bacteria.  Results  On the 8th, 15th, 32nd, and 43rd day of infection, tuberculous wound lesions were gradually developed at the skin tissues at the injection sites of the rats in infection group. The cells of the diseased tissue of the rats in infection group arranged disorderly or concentrically, and the number of granulomas and necrotic cells gradually increased, while the skin tissue cells in the corresponding parts of the rats in normal control group arranged regularly with no inflammatory cell infiltration. On the 43rd day of infection, a large number of rod-shaped bacteria were observed in the skin tissue at the injection sites of the rats in infection group.  Conclusions  The rat tuberculous wound model established using BCG is stable and reliable, which can meet the experimental requirements.
Lecture
Management of pediatric deep partial-thickness burn wounds
Liu Yan, Zhang Jie
2021, 37(8): 797-800. doi: 10.3760/cma.j.cn501120-20200512-00261
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Abstract:
Deep partial-thickness burns are the most common type of pediatric burns, in which hypertrophic scars usually develop, causing functional and cosmetic impairment. The choice of wound management method and surgical procedures for deep partial-thickness burn are often the issues that concern burn surgeon and the family members of patients. The development of modern functional wound dressings, the establishment of the concept of full rehabilitation of pediatric burns, and the implementation of comprehensive rehabilitation therapy for hypertrophic scars will inevitably change the traditional therapeutic strategies for pediatric deep partial-thickness burn wounds to a certain extent.
Reviews
Research advances on the mechanisms and prevention and treatment of patient self-inflicted lung injury
Ren Zhiguo, Zhu Feng
2021, 37(8): 801-804. doi: 10.3760/cma.j.cn501120-20200610-00302
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Researches have shown that lung injury due to excessive spontaneous breathing effort, that is, patient self-inflicted lung injury (P-SILI), may be the important manifestation and possible mechanism of ventilation-associated lung injury and ventilation-induced diaphragmatic dysfunction in acute respiratory distress syndrome (ARDS) patients who were mechanically ventilated with intense spontaneous breathing. This paper reviews the concept of P-SILI, possible occurrence mechanism, clinical significance, and prevention and treatment, in order to provide more ideas for clinical ARDS management.

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