2023 Vol. 39, No. 5

Expert Forums
Paying more attention to burn induced coagulopathy
Luo Gaoxing, Zhang Qingrong, Qian Wei, Li Haisheng
2023, 39(5): 401-406. doi: 10.3760/cma.j.cn501225-20221223-00545
Abstract:
Burn induced coagulopathy (BIC) is one of the common complications after burn injury. The types and clinical manifestations of BIC vary dramatically, which frequently leads serious consequences. However, at present BIC does not attract enough attention in clinic. In order to prevent and treat BIC more effectively, the authors suggest that it is necessary to strengthen coagulation surveillance, operation management, infection control, rational application of drugs, prevention and treatment of deep vein thrombosis, relative clinical and basic research, and others.
Pay attention to persistent inflammation-immunosuppression-catabolism syndrome in the late stage of severe burns
Li Xiaojian, Tang Wenbin
2023, 39(5): 407-410. doi: 10.3760/cma.j.cn501225-20230131-00030
Abstract:
With the deepening of researches on organ complications after severe burns and the continuous improvement of monitoring and support technology for organ function, severe burn patients have avoided death in the early and middle to late stages due to shock, infection, etc., and entered the late stage of burns. Due to the failure of timely and effective burn wound healing and long-term exposure and infection of extensive burn wounds, some of these patients were in chronic and critical conditions such as fever, emaciation, and delayed wound healing that are accompanied by decreased immune function, anemia, and hypoproteinemia, etc. It manifested as persistent inflammation-immunosuppression-catabolism syndrome (PICS), leading to prolonged hospitalization and increased long-term mortality. Based on clinical practice of the author's team in burn treatment, this paper briefly expounds the main causes, clinical characteristics, and prevention methods of PICS in the late stage of severe burns of patients, hoping to attract the attention of peers to PICS in the late stage of severe burns.
Elite Comments
Role and prospect of regenerative medicine in early treatment of combat trauma
Tian Guanglei, Cheng Biao, Fu Xiaobing
2023, 39(5): 411-416. doi: 10.3760/cma.j.cn501225-20220419-00147
Abstract:
The regenerative medicine has made great breakthrough in the repair of combat trauma, showing broad prospects, while the method of regenerative medicine applied in the early treatment of combat trauma is not yet clear. The early treatment of combat trauma includes strict control of bleeding, a large amount of blood transfusion, alleviation of acidosis, and correction of hypothermia and improvement of coagulation dysfunction, etc. This paper focuses on the bio-engineered blood, research and development of homeostatic materials, control of inflammation/infection, regulation of immunity, protection of important organs, establishment of military medical model, research and development of biosensors and drugs, and preventive application of stem cell bank in regenerative and tissue engineering in defense medicine to summarize the role of regenerative medicine in the early treatment of combat trauma, hoping to improve the overall treatment level of combat trauma.
Risk factors of early myocardial injury and the impact of early myocardial injury on prognosis of patients with extensive burns
Chen Nuo, Xi Maomao, Ruan Qiongfang, Chu Zhigang, Zhang Wei, Zhang Jinli, Xie Weiguo
2023, 39(5): 417-423. doi: 10.3760/cma.j.cn501225-20230308-00074
Abstract:
  Objective   To analyze the risk factors of early myocardial injury and the impact of early myocardial injury on prognosis of patients with extensive burns.   Methods   A retrospective case series study was conducted. From January 2018 to August 2022, 361 patients with extensive burns who met the inclusion criteria were admitted to Tongren Hospital of Wuhan University & Wuhan Third Hospital, including 231 males and 130 females, aged 50 (36, 58) years, with total burn area of 45% (35%, 60%) total body surface area. According to the highest level of creatine kinase isoenzyme-MB (CK-MB) within 72 h post injury, the patients were divided into early myocardial injury group (CK-MB≥75 U/L, 182 patients) and non-early myocardial injury group (CK-MB<75 U/L, 179 patients). The following data of patients in the 2 groups were collected and analyzed, including gender, age, total burn area, admission time post injury, combination with shock on admission, combination with inhalation injury on admission; the main blood test indexes such as myocardial enzyme spectrum, blood routine, liver and kidney function, and electrolytes within 72 h post injury; and treatment outcomes and fatality rate. Data were statistically analyzed with chi-square test, independent sample t test, or Mann-Whitney U test. The multivariate logistic regression analysis was conducted to screen the independent risk factors for early myocardial injury and for death in patients with extensive burns.   Results   There were statistically significant differences in gender, combination with shock on admission, total burn area, and admission time post injury of patients between the two groups (with χ 2 values of 6.40 and 6.10, Z values of 5.41 and 3.03, respectively, P<0.05). There were no statistically significant differences in age, combination with inhalation injury on admission of patients between the two groups ( P>0.05). The CK-MB, creatine kinase, lactate dehydrogenase, α-hydroxybutyrate dehydrogenase, white blood cell count, neutrophil-to-lymphocyte ratio (NLR), alanine aminotransferase (ALT), aspartate aminotransferase, potassium, and hemoglobin within 72 h post injury were significantly higher than those in non-early myocardial injury group (with Z values of 15.40, 6.26, 7.59, 7.02, 2.64, 4.53, 4.07, 6.32, and 4.12, t=2.34, respectively, P<0.05), while the level of calcium was significantly lower than that in non-early myocardial injury group ( Z=2.72, P<0.05). There were no statistically significant differences in other blood test indexes of patients between the two groups ( P>0.05). The total burn area, admission time post injury, NLR and ALT within 72 h post injury were the independent risk factors for early myocardial injury in patients with extensive burns (with odds ratios of 1.03, 1.07, 1.04, and 1.02, 95% confidence intervals of 1.02-1.05, 1.00-1.11, 1.02-1.07, and 1.00-1.03, respectively, P<0.05). The fatality rate of patients in early myocardial injury group was 8.8% (16/182), which was significantly higher than 2.8% (5/179) in non-early myocardial injury group ( χ 2=5.93, P<0.05). Early myocardial injury, age, combination with shock on admission, and combination with inhalation injury on admission were the independent risk factors for death in patients with extensive burns (with odds ratios of 3.60, 1.04, 6.53, and 3.14, 95% confidence intervals of 1.17-11.05, 1.01-1.07, 1.39-30.68, and 1.15-8.56, respectively, P<0.05).   Conclusions   The total burn area, admission time post injury, NLR and ALT within 72 h post injury were the independent risk factors for early myocardial injury in patients with extensive burns. Patients with extensive burns with early myocardial injury have a higher fatality rate, and early myocardial injury is an independent risk factor for the patients' death.
Study on the mechanism of early pancreatic exocrine function changes in severely scalded rats
Luo Peng, Zhang Bohan, Sun Jiachen, Li Zhisheng, Liu Xinzhu, Yang Jianqiu, Shen Chuan'an
2023, 39(5): 424-433. doi: 10.3760/cma.j.cn501225-20230216-00051
Abstract:
  Objective   To explore the mechanism of early pancreatic exocrine function changes in severely scalded rats.   Methods   The experimental research methods was used. Eighty male Sprague-Dawley rats aged 7-8 weeks were divided into simple sham injury group ( n=8), sham injury+cholecystokinin octapeptide (CCK8) group ( n=8), severe scald+CCK8 group ( n=32), and extremely severe scald+CCK8 group ( n=32) by the random number table, which were treated accordingly. Immediately after injury of rats in the 2 sham injury groups and 1, 2, 3, and 7 days after injury of rats in the 2 scald groups, the improved methods including pancreatic duct puncture and catheterization were used to dynamically collect the pancreatic-bile juice (PBJ) of rats. The PBJ secretory volume within 1 h was recorded, and the content of pancreatic lipase, α-amylase, and trypsin in PBJ was detected by enzyme-linked immunosorbent assay (ELISA), and the number of samples was 8. The femoral venous blood was collected, and the concentrations of pancreatic lipase and α-amylase in serum were detected by standard colorimetry to reflect their activity ( n=8). The pancreatic tissue was extracted, and the levels of interleukin-1β (IL-1β) and IL-6 in pancreatic tissue were detected by ELISA ( n=8), the expression of hypoxia-inducible factor 1α (HIF-1α) in pancreatic tissue was detected by immunofluorescence method, and the histopathological changes in pancreatic tissue were observed by hematoxylin-eosin staining, the severity of pancreatic tissue injury in the 2 scald groups was evaluated by modified Schmidt method ( n=6), and the ultrastructure of acinar cells in pancreatic tissue was observed by transmission electron microscopy. Data were statistically analyzed with analysis of variance for factorial design, Tukey test, independent sample t test, and least significant difference test.   Results   Compared with the PBJ secretory volume (0.740±0.030) mL in the pancreatic tissue of rats in simple sham injury group within 1 h immediately after injury, the (0.823±0.033) mL in sham injury+CCK8 group was significantly increased ( t=4.92, P<0.05). Compared with that of rats in sham injury+CCK8 group immediately after injury, the PBJ secretory volume of rats within 1 h in severe scald+CCK8 group ((0.681±0.024), (0.608±0.056), (0.525±0.025), and (0.720±0.044) mL) and extremely severe scald+CCK8 group ((0.540±0.025), (0.406±0.021), (0.475±0.036), and (0.690±0.018) mL) was significantly decreased on 1, 2, 3, and 7 days after injury ( P<0.05). Compared with that in severe scald+CCK8 group, the PBJ secretory volume of rats within 1 h in extremely severe scald+CCK8 group was significantly decreased on 1 and 2 days after injury ( P<0.05). Compared with that of rats in simple sham injury group immediately after injury, the content of pancreatic lipase, α-amylase, and trypsin in PBJ of rats in sham injury+CCK8 group immediately after injury was significantly increased (with t values of 4.56, 3.30, and 4.99, respectively, P<0.05). Compared with that of rats in sham injury+CCK8 group immediately after injury, the content of pancreatic lipase and α-amylase in PBJ of rats in severe scald+CCK8 group and extremely severe scald+CCK8 group was significantly decreased on 1, 2, 3, and 7 days after injury ( P<0.05), the trypsin content in PBJ of rats in extremely severe scald+CCK8 group was significantly decreased on 2 days after injury ( P<0.05). Compared with that in severe scald+CCK8 group, the content of pancreatic lipase in PBJ of rats in extremely severe scald+CCK8 group was significantly decreased on 1, 2, and 3 days after injury ( P<0.05), and the content of α-amylase and trypsin in PBJ was significantly decreased on 1 and 2 days after injury ( P<0.05). There were no statistically significant differences in the activities of pancreatic lipase and α-amylase in serum of rats among the 4 groups at various time points after injury ( P>0.05). Compared with that of rats in sham injury+CCK8 group immediately after injury, the levels of IL-1β in pancreatic tissue of rats in severe scald+CCK8 group on 1, 2, and 3 days after injury and in extremely severe scald+CCK8 group on 1, 2, 3, and 7 days after injury were significantly increased ( P<0.05), and the levels of IL-6 in pancreatic tissue of rats in severe scald+CCK8 group and extremely severe scald+CCK8 group were significantly increased on 1, 2, 3, and 7 days after injury ( P<0.05). Compared with that in severe scald+CCK8 group, the IL-1β level in pancreatic tissue of rats in extremely severe scald+CCK8 group was significantly increased on 2 and 3 days after injury ( P<0.05), and IL-6 level in pancreatic tissue was significantly increased on 2 days after injury ( P<0.05). The expression levels of HIF-1α in pancreatic tissue of rats in simple sham injury group and sham injury+CCK8 group immediately after injury were lower; and compared with that in sham injury+CCK8 group immediately after injury, the expression levels of HIF-1α in pancreatic tissue of rats in the 2 scald groups increased to a certain extent at different time points after injury, and the expression position was transited from the edge of the pancreatic tissue to the whole pancreas, the expression levels of HIF-1α in pancreatic tissue of rats in the 2 scald groups tended to be normal on 7 days after injury. Compared with that in simple sham injury group immediately after injury, the proportion of acinar cell cytoplasm in pancreatic tissue of rats in sham injury+CCK8 group was increased; and with the increase of time after injury, edema, hemorrhage, necrosis, and inflammatory infiltration appeared in pancreatic tissue of rats in the 2 scald groups. Compared with that in severe scald+CCK8 group, the scores of edema, inflammatory cell infiltration, bleeding, and necrosis in pancreatic tissue of rats in extremely severe scald+CCK8 group were increased to varying degrees at various time points after injury, and the scores of pancreatic tissue of rats in the 2 scald groups basically recovered to normal on 7 days after injury. Compared with that in simple sham injury group immediately after injury, the number of enzyme granules in acinar cells of pancreatic tissue of rats in sham injury+CCK8 group was increased, and with the increase of time after injury, the enzyme granules in acinar cells of rats in the 2 scald groups were gradually reduced basically.   Conclusions   The exocrine functions of pancreas, such as synthesis and secretion of pancreatic enzymes, are decreased in the early stage in severely scalded rats. And the greater the scalded area, the more significant the decline of pancreatic exocrine function. This change may be related to hypoxic injury and inflammation in pancreatic tissue after severe scald.
Effects and mechanism of glycine on rat cardiomyocytes pretreated with serum from burned rats
Lyu Shangjun, Yan Zundong, Fan Ronghui, Peng Xi
2023, 39(5): 434-442. doi: 10.3760/cma.j.cn501225-20230206-00035
Abstract:
  Objective   To investigate the effect and mechanism of glycine on rat cardiomyocytes pretreated with serum from burned rats (hereinafter referred to as burn serum).   Methods   Experimental research methods were adopted. Thirty gender equally balanced Wistar rats aged 7 to 8 weeks were collected, 10 of which were used to prepare normal rat serum (hereinafter referred to as normal serum), and the other 20 were inflicted with full-thickness burn of 30% total body surface area to prepare burn serum. Primary cardiomyocytes were isolated and cultured from the apical tissue of 180 Wistar rats aged 1 to 3 days by either gender for follow-up experiments. Cells were divided into normal serum group and burn serum group treated with corresponding serum according to the random number table (the same grouping method below). Trypanosoma blue staining was performed at post treatment hour (PTH) 1, 3, 6, 9, and 12 to detect the cell survival rate. Cells were divided into burn serum alone group treated with burn serum for 6 h followed by routine culture of 30 min and 0.4 mmol/L glycine group, 0.8 mmol/L glycine group, 1.2 mmol/L glycine group, 1.6 mmol/L glycine group, and 2.0 mmol/L glycine group treated with burn serum for 6 h followed by culture of 30 min with corresponding final molarity of glycine, i.e., at post intervention hour (PIH) 6.5, the cell survival rate was detected as before. Cells were divided into normal serum group, burn serum alone group, 0.8 mmol/L glycine group, 1.2 mmol/L glycine group, and 1.6 mmol/L glycine group, with the same intervention of 6.5 h as before, respectively. The content of adenosine monophosphate (AMP) and adenosine triphosphate (ATP) was detected by high performance liquid chromatography, and the AMP/ATP ratio was calculated. The protein expressions of phosphorylated mammalian target of rapamycin complex 1 (p-mTORC1), phosphorylated p70 ribosomal protein S6 kinase (p-p70 S6K), phosphorylated eukaryotic translation initiation factor 4E-binding protein 1 (p-4E-BP1), and phosphorylated AMP-activated protein kinase (p-AMPK) were detected by Western blotting. Cells were divided into normal serum group, burn serum alone group, 0.8 mmol/L glycine group intervened as before and 0.8 mmol/L glycine+25 ng/mL rapamycin group treated with burn serum followed by culture with two reagents. The expressions of heat shock protein 70 (HSP70), metallothionein (MT), and tubulin were detected by immunofluorescence method after 30 min of corresponding culture at PTH 1, 3, and 6, i.e., at PIH 1.5, 3.5, and 6.5, and the microtubule morphology was observed at PIH 6.5. The sample number at each time point was 10. Data were statistically analyzed with analysis of variance for factorial design, one-way analysis of variance, least significant difference (LSD)- t test, LSD test, and Bonferroni correction.   Results   At PTH 1, 3, 6, 9, and 12, the cell survival rates in burn serum group were significantly lower than those in normal serum group (with t values of 4.96, 16.83, 35.51, 34.33, and 27.88, P<0.05). In burn serum group, the cell survival rate at PTH 3, 6, 9, or 12 was significantly lower than that at PTH 1 ( P<0.05), the cell survival rate at PTH 6, 9, or 12 was significantly lower than that at PTH 3 ( P<0.05), and the cell survival rate at PTH 6 was similar to that at PTH 9 ( P>0.05) but significantly higher than that at PTH 12 ( P<0.05). Treatment of 6 h was selected as the follow-up intervention time of burn serum. At PIH 6.5, compared with that in burn serum alone group, the cell survival rate in each glycine group was significantly increased ( P<0.05). The cell survival rate in 0.8 mmol/L glycine group was the highest, and 0.8, 1.2, and 1.6 mmol/L were selected as subsequent glycine intervention concentrations. At PIH 6.5, the AMP/ATP ratio of cells in burn serum alone group was significantly higher than that in normal serum group, 1.2 mmol/L glycine group, or 1.6 mmol/L glycine group ( P values all <0.05), and the AMP/ATP ratio of cells in 1.6 mmol/L glycine group was significantly lower than that in 0.8 mmol/L glycine group ( P<0.05). At PIH 6.5, the protein expressions of p-mTORC1, p-p70 S6K, and p-4E-BP1 of cells in normal serum group, burn serum alone group, 0.8 mmol/L glycine group, 1.2 mmol/L glycine group, and 1.6 mmol/L glycine group were 1.001±0.037, 0.368±0.020, 1.153±0.019, 1.128±0.062, 1.028±0.037, 0.96±0.07, 0.63±0.12, 1.17±0.13, 1.13±0.16, 1.11±0.11, and 0.98±0.06, 0.45±0.08, 1.13±0.05, 0.77±0.12, 0.51±0.13. Compared with those in burn serum alone group, the protein expressions of p-mTORC1, p-p70 S6K, and p-4E-BP1 of cells in normal serum group and each glycine group were significantly increased ( P<0.05), while the protein expressions of p-AMPK were significantly decreased ( P<0.05). Compared with those in 0.8 mmol/L glycine group, the protein expression of p-4E-BP1 of cells in 1.2 mmol/L glycine group and the protein expressions of p-mTORC1 and p-4E-BP1 of cells in 1.6 mmol/L glycine group were significantly decreased ( P<0.05). Compared with those in 1.2 mmol/L glycine group, the protein expressions of p-mTORC1 and p-4E-BP1 of cells in 1.6 mmol/L glycine group were significantly decreased ( P<0.05), while the protein expression of p-AMPK was significantly increased ( P<0.05). Compared with those in normal serum group, the expression of tubulin of cells in burn serum alone group was significantly decreased at PIH 1.5, 3.5, and 6.5 ( P<0.05), while the expression of HSP70 of cells at PIH 1.5 and 3.5 and the expression of MT at PIH 3.5 and 6.5 were significantly increased ( P<0.05). The expressions of HSP70 and MT of cells at PIH 1.5, 3.5, and 6.5 and the expression of tubulin at PIH 1.5 and 3.5 in burn serum alone group and 0.8 mmol/L glycine+25 ng/mL rapamycin group were significantly lower than those in 0.8 mmol/L glycine group ( P<0.05). At PIH 6.5, compared with that in normal serum group, the cell microtubule structure in burn serum alone group was disordered; the cell boundary in 0.8 mmol/L glycine group was clearer than that in burn serum alone group, and the microtubule structure arranged neatly near the nucleus. Compared with that in 0.8 mmol/L glycine group, 0.8 mmol/L glycine+25 ng/mL rapamycin group had unclear cell boundaries and disordered microtubule structure.   Conclusions   Burn serum can cause cardiomyocytes damage in rats. Glycine can significantly up-regulate mammalian target of rapamycin/p70 ribosomal protein S6 kinase/eukaryotic translation initiation factor 4E-binding protein 1 signaling pathway through AMP-activated protein kinase, promote the synthesis of protective proteins HSP70, MT, and tubulin, stabilize the microtubule structure, and exert cardiomyocytes protection function.
Original Articles
Influence of muscle energy technology combined with Maitland joint mobilization surgery on the elbow joint flexion function in patients with deep burn of elbow joint
Wu Kunping, Yuan Lin, Chen Pei, Ru Tianfeng, Luo Hao, Xie Weiguo
2023, 39(5): 443-449. doi: 10.3760/cma.j.cn501225-20220608-00228
Abstract:
  Objective   To investigate the influence of muscle energy technology (MET) combined with Maitland joint mobilization surgery on the elbow joint flexion function in patients with deep burn of elbow joint.   Methods   A retrospective controlled clinical trial was conducted. From January 2020 to January 2022, 53 patients with elbow joint flexion dysfunction after deep burns who met the inclusion criteria were treated in Tongren Hospital of Wuhan University & Wuhan Third Hospital, including 32 males and 21 females, aged (37±12) years. According to the treatment method used, the patients were divided into conventional treatment alone group (15 cases), conventional treatment+joint mobilization surgery group (18 cases), and conventional treatment+joint mobilization surgery+MET group (20 cases). Before treatment and 2 months after treatment, the patient's elbow joint range of motion was measured using a protractor, the Mayo elbow joint function score was used to evaluate elbow joint function, a portable muscle strength tester was used to measure elbow extensor muscle strength, and visual analogue scale was used to evaluate pain degree. Data were statistically analyzed with one-way analysis of variance, least significant difference test, paired sample t test, Kruskal-Wallis H test, Wilcoxon signed rank-sum test, chi-square test, Fisher's exact probability test, and Bonferroni correction.   Results   After two months of treatment, the elbow joint range of motion and elbow joint function scores of patients in conventional treatment+joint mobilization surgery group and conventional treatment+joint mobilization surgery+MET group ((103±12)° and 60 (50, 66), (131±14)° and 73 (65, 80)) were significantly larger and higher than those in conventional treatment alone group ((77±15)° and 45 (35, 50), Pvalues all <0.05), respectively. The elbow joint range of motion and elbow joint function scores of patients in conventional treatment+joint mobilization surgery+MET group were significantly larger and higher than those in conventional treatment+joint mobilization surgery group ( Pvalues all <0.05), respectively. After two months of treatment, the elbow extensor muscle strength and pain score of patients in conventional treatment+joint mobilization surgery+MET group were respectively significantly larger and lower than those in conventional treatment alone group and conventional treatment+joint mobilization surgery group ( Pvalues all <0.05). The elbow extensor muscle strength and pain score of patients in conventional treatment+joint mobilization surgery group were similar to those in conventional treatment alone group ( P>0.05). The elbow joint range of motion and elbow extensor muscle strength (with t values of 9.37, 25.54, 28.71, 6.70, 7.20, and 7.01, respectively, P<0.05), elbow joint function scores and pain scores (with Z values of 3.15, 3.63, 3.93, 3.30, 3.52, and 3.84, respectively, P<0.05) of patients in conventional treatment alone group, conventional treatment+joint mobilization surgery group, and conventional treatment+joint mobilization surgery+MET group after two months of treatment were significantly improved compared with those before treatment.   Conclusions   The combination of MET and Maitland joint mobilization surgery can effectively improve elbow joint range of motion, elbow joint function, elbow extensor muscle strength, and pain of patients with deep elbow joint burns, therefore it is worthy of promotion.
Clinical effects of free anterolateral thigh perforator flap pedicled with descending genicular artery in repairing wounds after lower leg limb-sparing surgery
Li Lei, Zhou Zhenghu, Ju Wen, Deng Wei, Chen Lucheng, Li Changsong, Xia Yuhang, Ju Jihui
2023, 39(5): 450-455. doi: 10.3760/cma.j.cn501225-20220725-00308
Abstract:
  Objective   To explore the clinical effects of free anterolateral thigh perforator flap pedicled with descending genicular artery in repairing wounds after lower leg limb-sparing surgery.   Methods   A retrospective observational study was conducted. From January 2019 to June 2021, 12 patients with wounds after lower leg limb-sparing surgery who met the inclusion criteria were admitted to Suzhou Ruihua Orthopedic Hospital, including 6 males and 6 females, aged 17 to 74 years, with original wound area ranging from 17 cm×9 cm to 40 cm×15 cm. Five patients had infection in wounds. The wounds were all repaired by free anterolateral thigh perforator flap from contralateral thigh, with area of 18 cm×10 cm to 37 cm×9 cm. The artery of flap was anastomosed with the descending genicular artery, and the wounds in donor areas were sutured directly. Seven patients were transplanted with split-thickness skin grafts from the contralateral thigh to cover the remaining wounds that can not be covered by flap and the wounds in donor areas were covered with gauze. During the operation, the types of perforating branch carried by flap and the types of arteries and veins in recipient areas were recorded. The survival and occurrence of vascular crisis of flap, the survival of skin graft, the wound healing in donor and recipient areas, and the length of hospital stay after flap transplant surgery were recorded. During follow-up, the color and texture of flap, reinfection in lower leg, and fracture healing were recorded. At the last follow-up, the limb salvage function of patients was evaluated according to the functional evaluation criteria of Chen Zhongwei's amputated limb replantation.   Results   The types of perforating branches carried by flaps were as follows: 6 cases of only carrying the descending branch of the lateral circumflex femoral artery, 3 cases of only carrying the oblique branch of the lateral circumflex femoral artery, and 3 cases of carrying the descending branch of the lateral circumflex femoral artery and oblique branch of the lateral circumflex femoral artery after internal pressurization anastomosis. The types of arteries in the recipient area of flap were as follows: one case of main trunk of the descending genicular artery, 8 cases of the saphenous branch of the descending genicular artery, and 3 cases of the articular branch of the descending genicular artery. The types of veins in the recipient area of flap were as follows: 8 cases of one accompanying vein of the descending genicular artery and one branch of the great saphenous vein, and 4 cases of two branches of the great saphenous vein. All the flaps survived without vascular crisis, and all the skin grafts also survived. The wounds in the donor and recipient areas were all healed. The length of hospital stay of patient after flap transplant surgery ranged from 13 to 79 days. During the follow-up of 6 to 23 months, the color and texture of flap were both good, with no infection in lower leg wound. Internal or external fixation were removed after fracture healing in 5 patients, and bone graft internal fixation was performed in 7 patients whose fractures were not healed after surgery and all the incisions healed without infection. At the last follow-up, the limb salvage effect of patients was evaluated as followings: excellent in 7 patients, good in 4 patients, and fair in one patient.   Conclusions   Free anterolateral thigh flap pedicled with descending genicular artery can effectively repair the wounds after lower leg limb-sparing surgery and control infection with short length of hospital stay, while not increasing the risk of secondary injury of distal limb vessels. Thus, it can obtain satisfactory limb salvage effect which is worthy of clinical promotion.
Effects and mechanism of annexin A1-overexpressing human adipose-derived mesenchymal stem cells in the treatment of mice with acute respiratory distress syndrome
Zhu Banghui, Lai Honghao, Wei Chenru, Shen Zong, Sun Yu, Zhu Feng, Wu Guosheng
2023, 39(5): 456-464. doi: 10.3760/cma.j.cn501225-20220408-00130
Abstract:
  Objective   To explore the effects and mechanism of annexin A1 ( ANXA1)-overexpressing human adipose-derived mesenchymal stem cells (AMSCs) in the treatment of mice with acute respiratory distress syndrome (ARDS).   Methods   The experimental study method was adopted. After the adult AMSCs were identified by flow cytometry, the 3 rd passage cells were selected for the follow-up experiments. According to the random number table (the same grouping method below), the cells were divided into ANXA1-overexpressing group transfected with plasmid containing RNA sequences of ANXA1 gene and no-load control group transfected with the corresponding no-load plasmid. The other cells were divided into ANXA1-knockdown group transfected with plasmid containing small interfering RNA sequences of ANXA1gene and no-load control group transfected with the corresponding no-load plasmid. At post transfection hour (PTH) 72, the fluorescence expression was observed under a fluorescence microscope imaging system, and the protein and mRNA expressions of ANXA1 were detected by Western blotting and real-time fluorescence quantitative reverse transcription polymerase chain reaction respectively (with the sample numbers being 3). Fifty male C57BL/6J mice aged 6-8 weeks were divided into sham injury group, ARDS alone group, normal cell group, ANXA1-overexpressing group, and ANXA1-knockdown group, with 10 mice in each group. Mice in the last 4 groups were treated with endotoxin/lipopolysaccharide to make ARDS lung injury model, and mice in sham injury group were simulated to cause false injury. Immediately after injury, mice in sham injury group and ARDS alone group were injected with normal saline through the tail vein, while mice in normal cell group, ANXA1-overexpressing group, and ANXA1-knockdown group were injected with normal AMSCs, ANXA1-overexpressing AMSCs, and ANXA1-knockdown AMSCs, correspondingly. At post injection hour (PIH) 24, 5 mice in each group were selected, the Evans blue staining was performed to observe the gross staining of the right lung tissue, and the absorbance value of bronchoalveolar lavage fluid (BALF) supernatant of left lung was detected by microplate reader to evaluate the pulmonary vascular permeability. Three days after injection, the remaining 5 mice in each group were taken, the right lung tissue was collected for hematoxylin-eosin staining to observe the pathological changes and immunohistochemical staining to observe the CD11b and F4/80 positive macrophages, and the levels of tumor necrosis factor α (TNF-α), interleukin-6 (IL-6), and IL-1β in BALF supernatant of left lung were determined by enzyme-linked immunosorbent assay. Data were statistically analyzed with paired sample t test, one-way analysis of variance, and least significant difference test.   Results   At PTH 72, AMSCs in both ANXA1-overexpressing group and ANXA1-knockdown group expressed higher fluorescence intensity than AMSCs in corresponding no-load control group, respectively. At PTH 72, compared with those in corresponding no-load control group, the protein and mRNA expressions of ANXA1 in ANXA1-overexpressing group were significantly increased (wth t values of 249.80 and 6.56, respectively, P<0.05), while the protein and mRNA expressions of ANXA1 in ANXA1-knockdown group were significantly decreased (wth t values of 176.50 and 18.18, respectively, P<0.05). At PIH 24, compared with those in sham injury group (with the absorbance value of BALF supernatant being 0.041±0.009), the lung tissue of mice in ARDS alone group was obviously blue-stained and the absorbance value of BALF supernatant (0.126±0.022) was significantly increased ( P<0.05). Compared with those in ARDS alone group, the degree of blue-staining in lung tissue of mice was significantly reduced in normal cell group or ANXA1-overexpressing group, and the absorbance values of BALF supernatant (0.095±0.020 and 0.069±0.015) were significantly decreased ( P<0.05), but the degree of blue-staining in lung tissue and the absorbance value of BALF supernatant (0.109±0.016, P>0.05) of mice in ANXA1-knockdown group had no significant change. Compared with that in normal cell group, the absorbance value of BALF supernatant of mice in ANXA1-overexpressing group was significantly decreased ( P<0.05). Three days after injection, the lung tissue structure of mice in ARDS alone group was significantly damaged compared with that in sham injury group. Compared with those in ARDS alone group, hemorrhage, infiltration of inflammatory cells, alveolar collapse, and interstitial widening in the lung tissue of mice were significantly alleviated in normal cell group and ANXA1-overexpressing group, while no significant improvement of above-mentioned lung tissue manifestation was observed in ANXA1-knockdown group. Three days after injection, the numbers of CD11b and F4/80 positive macrophages in the lung tissue of mice in ARDS alone group were significantly increased compared with those in sham injury group. Compared with those in ARDS alone group, the numbers of CD11b and F4/80 positive macrophages in lung tissue of mice in normal cell group, ANXA1-overexpressing group, and ANXA1-knockdown group reduced, with the most significant reduction in ANXA1-overexpressing group. Three days after injection, compared with those in sham injury group, the levels of TNF-α, IL-6, and IL-1β in BALF supernatant of mice in ARDS alone group were significantly increased ( P<0.05). Compared with those in ARDS alone group, the levels of TNF-α, IL-6, and IL-1β in BALF supernatant of mice in normal cell group and ANXA1-overexpressing group, as well as the level of IL-1β in BALF supernatant of mice in ANXA1-knockdown group were significantly decreased ( P<0.05). Compared with that in normal cell group, the level of TNF-α in BALF supernatant of mice was significantly decreased in ANXA1-overexpressing group ( P<0.05) but significantly increased in ANXA1-knockdown group ( P<0.05).   Conclusions   Overexpression of ANXA1 can optimize the efficacy of AMSCs in treating ARDS and enhance the effects of these cells in inhibiting inflammatory response and improving pulmonary vascular permeability, thereby alleviating lung injury of mice with ARDS.
Original Article·Nursing Column
Prospective study on application of mind mapping combined with scenario simulation training on the ability training of junior nurses in hospital transfer of patients with critical burns and trauma
Li Ning, Chen Hualing, Li Maojun, Huang Yuqun, Li Haisheng, Wang Lihua
2023, 39(5): 465-471. doi: 10.3760/cma.j.cn501225-20220524-00200
Abstract:
  Objective   To explore the application effects of mind mapping combined with scenario simulation training on the ability training of junior nurses in hospital transfer of patients with critical burns and trauma.   Methods   A prospective randomized controlled study was conducted. From December 2019 to December 2020, 55 female junior nurses from the Institute of Burn Research of the First Affiliated Hospital of Army Medical University (the Third Military Medical University) who met the inclusion criteria were enrolled in this study and divided into routine group (27 nurses, aged (24.0±0.9) years) and combined group (28 nurses, aged (24.2±0.8) years), according to the random number table. The nurses in routine group were trained with hospital transfer of patients with critical burns and trauma by theory combined with operational skill, and the nurses in combined group were trained with hospital transfer of patients with critical burns and trauma by mind mapping combined with scenario simulation training. Before and after the training, the self-made theoretical examination papers and skill assessment items were used for the examination and assessment to nurses, and their scores were calculated and compared. The self-made emergency ability scoring system was used to evaluate the emergency disposal ability of nurses from five dimensions, including team cooperation ability, emergency response ability, operative technique ability, specialized business ability, and nurse-patient communication ability, and their scores were calculated and compared. The non-standard implementation rates of transfer nursing measures, such as incomplete preparation of goods, poor communication effect of patients, inadequate pipeline nursing, unclear handover, and inadequate final treatment, were calculated and compared in the process of transporting highly simulated human (hereinafter referred to as simulated human) by nurses before and after training; and the rate of disease change and successful rate of transport of simulated human were calculated and compared after training. After assessment, self-made satisfaction questionnaire was used to compare nurses' satisfaction with the training mode, content, and effects. Data were statistically analyzed with independent sample t test, Pearson chi-square test, or Yates corrected chi-square test.   Results   Fifty-five enrolled nurses were fully involved in the training, examination, assessment, and questionnaire filling. Before training, there were no statistically significant differences in theoretical examination and skill assessment scores between the 2 groups ( P>0.05); After training, the theoretical examination and skill assessment scores of nurses in combined group were significantly higher than those in routine group (with t values of -3.89 and -4.24, respectively, P<0.05). Before training, there were no statistically significant differences in the scores of each item of emergency disposal ability between the 2 groups ( P>0.05); after training, the scores in terms of team cooperation ability, emergency response ability, operative technique ability, specialized business ability, and nurse-patient communication ability of nurses in combined group were significantly higher than those in routine group (with t values of -6.49, -6.44, -2.21, -2.85, and -2.34, respectively, P<0.05). Before training, there were no statistically significant differences in the non-standard implementation rates of transfer nursing measures of nurses between the 2 groups ( P>0.05); after training, the non-standard rates of incomplete preparation of goods, unclear handover, and inadequate final treatment of nurses in combined group were significantly lower than those in routine group (with t values of 3.87, 5.89, and 5.28, respectively, P<0.05). After training, the rate of disease change of simulated human of nurses in combined group was 7.14% (2/28), which was significantly lower than 33.33% (9/27) in routine group ( χ 2=5.89, P<0.05); the successful rate of transport was 96.43% (27/28), which was significantly higher than 74.07% (20/27) in routine group ( χ 2=3.87, P<0.05). After assessment, the total score of training satisfaction and scores of satisfaction with training mode and training effect of nurses in combined group were significantly higher than those in routine group (with t values of 5.22, 4.67, and 10.71, respectively, P<0.05). There was no statistically significant difference in the satisfaction score on training content between the two groups ( P>0.05).   Conclusions   Evidence-based mind mapping combined with scenario simulation training significantly improves the nursing skills and emergency handling capabilities of junior nurses in transferring patients with critical burns and trauma.
Case Report
A case of multiple difficult illnesses in a patient with extremely severe burn complicated with type 2 diabetes
Wang Zhen, Zhang Tao, Liu Sirong, Rong Xinzhou
2023, 39(5): 472-474. doi: 10.3760/cma.j.cn501225-20220506-00174
Abstract:
On December 20, 2018, a 40-year-old male patient with extremely severe flame burn was admitted to Guangzhou First People's Hospital. A variety of difficult illnesses occurred simultaneously (refractory hyperglycemia, refractory hypernatremia, and progressive wound deepening) and successively (repeatedly postoperative hypotension, nervous system diseases, and secondary diabetes insipidus). The patient underwent treatments such as anti-shock, reducing blood sugar and blood sodium, scab removing, and gradual skin grafting after admission. Although the hyperglycemia and hypernatremia were basically corrected and the wounds were basically repaired, the patient ultimately died of nervous system diseases and secondary diabetes insipidus 5 months later. Although the cause of the above illnesses can not be fully determined, the targeted treatments to improve clinical symptoms, maintain stable internal environment and physiological function, and accelerate the process of wound repair conducted by the team may provide some experience for the treatment of such severe patients.
Reviews
Advances on the application of physical airway clearance techniques in the treatment of inhalation injury
Zhang Yuxiang, Lan Meijuan, Liang Shiyu, Han Chunmao
2023, 39(5): 475-480. doi: 10.3760/cma.j.cn501225-20220608-00226
Abstract:
Although the treatment of patients with burns combined with inhalation injury has achieved great success, from the perspective of epidemiology, inhalation injury is still the most common cause of death in mass burns. Such patients often suffered burns of large total body surface area, which is difficult to treat, with airway management as one of the core links. Physical airway clearance technique (ACT) acts on a patient's respiratory system by physical means, to discharge secretions and foreign bodies in the airway, achieve airway clearance, and improve gas exchange. In addition, the technique can prevent or alleviate many complications, thereby improving the clinical outcome of patients with inhalation injury. This article reviews the application of physical ACT in the field of inhalation injury, and to provide decision-making basis for clinical medical staff to choose physical ACT corresponding to the patient's condition.
Research advances of natural biomaterials in promoting wound repair
Gao Yixuan, Wang Lingfeng, Ba Te, Zou Xiaofang, Cao Shengjun, Li Junliang, Li Fang, Zhou Biao
2023, 39(5): 481-486. doi: 10.3760/cma.j.cn501225-20220630-00276
Abstract:
Acute and chronic wounds seriously threaten patients' life health and quality of life, therefore, wound repair has become a hot topic of research for scholars at home and abroad in recent years. With the development of material science and tissue engineering, more and more biomaterials prepared from natural ingredients were used in basic research and clinical treatment of wound repair. Such biomaterials can be used as templates for wound tissue regeneration to induce autologous cell adhesion and migration, and promote the deposition of extracellular matrix, which have broad clinical application prospects. This paper reviews the characteristics and application advance of natural biomaterials which are popular in the field of wound repair, aiming to provide ideas for the research and development of new wound dressing and tissue engineering skin.
Research advances on the mechanism of circular RNA in diabetic wound healing
Nong Yule, Lyu Yehui
2023, 39(5): 487-490. doi: 10.3760/cma.j.cn501225-20220727-00317
Abstract:
In recent years, a large number of studies have shown that non-coding RNAs play an important role in wound healing process. Among them, studies on the mechanism of circular RNA (circRNA) have shown that circRNA is closely related to the proliferation of cells related to wound healing, such as endothelial progenitor cells and keratinocytes, and circRNA is also involved in the chronic wound healing process. Based on the introduction of the related concept of circRNA, this paper focuses on the possible regulatory mechanism of circRNA in different stages of diabetic wound healing and summarizes the potential role of circRNA in the process of diabetic peripheral vascular atherosclerosis, aiming to explore the in-depth molecular mechanism and clinical significance of circRNA in diabetic wound healing process, and provide reference for further research.
Research advances on the mechanism of nerve regeneration-related protein in skin fibrosis
Chen Wei, Xu Guangchao, Huang Zhonglu, Chen Li, Nie Kaiyu
2023, 39(5): 491-495. doi: 10.3760/cma.j.cn501225-20220701-00278
Abstract:
The healing process after skin injury is a dynamic process of interaction between various cells, cytokines, and extracellular matrix. Fibrosis is one of the main ways of skin injury repair. The process of fibrosis involves the regulation of many factors. Studies have shown that nerve regeneration-related protein (NREP) plays a key role in the fibrosis of skin tissue and organs. Based on the mechanism of skin fibrosis, this paper discusses the construction of tertiary structure of NREP, summarizes the effects of NREP and different cells in the skin on skin fibrosis and the research progress of mechanism of NREP in skin fibrosis, thus providing new ideas for the treatment of skin fibrosis diseases.
Research advances on the mechanism of oral mucosal stem cells in promoting wound healing
Wei Zhiru, Dong Yan, Li Guangshuai, Liu Linbo
2023, 39(5): 496-500. doi: 10.3760/cma.j.cn501225-20220730-00321
Abstract:
Wound healing is a complex process that requires the participation of multiple cells and cytokines. During the process of wound healing, abnormality in any stage of the process may lead to the development of a chronic refractory wound. Research has confirmed that various stem cells can promote wound healing, but some stem cells are limited in clinical application due to difficulties in isolation, susceptibility to apoptosis, ethical and legal issues. Oral mucosal stem cells (OMSCs) can avoid the above problems. This type of stem cells has the characteristics of embryonic stem cells, immune regulatory ability, and strong homogeneity. It plays an important role in the process of scarless oral wound healing, and has become a research hotspot in promoting wound healing and reducing scar formation. This article reviews the research on the mechanism, clinical application prospects, and current problems of OMSCs in promoting wound healing.