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2024 Vol. 40, No. 8

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Guideline and Consensus
Expert consensus on diagnosis and treatment of radiation-induced skin injury (2024 version)
2024, 40(8): 701-712. doi: 10.3760/cma.j.cn501225-20240126-00033
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Abstract:
Radiation-induced skin injury refers to damage caused to skin tissue after exposure to large doses of ionizing radiation. It is the most common complication in localized radiation therapy for tumors and can also occur under conditions such as nuclear accident, radiation accident, and long-term occupational exposure. Currently, there is no uniform standard for the diagnosis of radiation-induced skin injury both domestically and internationally, and there is a lack of effective methods for the prevention and treatment, necessitating more evidence-based medical researches to explore. Combining domestic and international literature, national occupational health standards, and existing clinical experience, the consensus writing group organized experts in related fields at home and abroad to repeatedly discuss and formulate an expert consensus for the diagnosis and treatment of radiation-induced skin injury, serving as a reference for clinical use.
Expert Forum
Research on microcirculatory disorders and their diagnosis and treatment after high-voltage electric burns
Zhang Qingfu
2024, 40(8): 713-718. doi: 10.3760/cma.j.cn501225-20240523-00194
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Microcirculatory disorders are important pathological and physiological changes in high-voltage electric burns, playing an important role in the occurrence and development of progressive injury and complications of high-voltage electric burns. High-voltage electric burns can cause microcirculatory disorders not only in the wounds, but also in distant tissue and organs; it can not only cause damage to the structure and function of microvasculature, but also cause abnormalities in microcirculation hemodynamics and cell rheology. Understanding the characteristics and changing patterns of microcirculatory disorders in high-voltage electric burns, and using appropriate treatment methods to improve microcirculation, are of great significance for promoting wound healing and effectively preventing relevant complications in high-voltage electric burns. This article systematically elaborates on the characteristics of microcirculatory disorders after high-voltage electric burns, summarizes the clinical diagnosis and treatment methods of microcirculatory disorders after high-voltage electric burns, and provides new ideas for the comprehensive treatment of high-voltage electric burns.
Strategies for the treatment and prevention of radiation-induced skin ulcers
Xia Chengde, Yang Yang
2024, 40(8): 719-724. doi: 10.3760/cma.j.cn501225-20240415-00134
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Radiation-induced skin ulcer is the most common adverse effect of tumor radiotherapy, and it is also a serious type of ulcer among skin injuries. Due to the varying degrees of radiation damage, the surrounding tissue of ulcers has poor self-renewal ability, which leads to delayed healing of ulcers, then followed by continuous body fluid loss, infection, and other symptoms, which can be life-threatening in severe cases. Due to the damaged blood supply or necrosis, skin ulcers are prone to relapse even after healing, which is a major challenge in clinical treatment. At present, there is still a lack of specific drugs and precise administration guidelines for the treatment of radiation-induced skin ulcers, and symptomatic treatment is the main treatment in clinical practice. Based on the clinical practical experience of authors' team and current relevant literature, this paper proposed corresponding drug therapy, hyperbaric oxygen assisted therapy, surgery therapy, and early prevention strategies for radiation-induced skin ulcers at different stages, in order to provide reference for clinical treatment and prevention of radiation-induced skin ulcer.
Original Article·Electric Burns
Clinical application effect of bypass vein bridging in repairing high-voltage electric burn wounds on the head with free anterolateral thigh flaps
Xing Peipeng, Xue Jidong, Guo Haina, Ma Chao, Zhao Xiaokai, Liang Zhanling, Dong Guoyun, Di Haiping, Xia Chengde
2024, 40(8): 725-731. doi: 10.3760/cma.j.cn501225-20240419-00142
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  Objective  To investigate the clinical application effect of bypass vein bridging in repairing high-voltage electric burn wounds on the head with free anterolateral thigh flaps.  Methods  This study was a retrospective observational study. From May 2017 to December 2022, 8 patients with high-voltage electric burns on the head who met the inclusion criteria were admitted to Zhengzhou First People's Hospital, including 6 males and 2 females, aged 33 to 73 years. All patients had skull exposure, including 3 cases of large skull defect, 1 case of left eye necrosis, and 3 cases of cerebral hemorrhage. After debridement, the head wound area was from 13 cm×7 cm to 21 cm×15 cm, and the free anterolateral thigh flap with the area of 14 cm×8 cm to 22 cm×16 cm was cut for repair. The main descending branch of the lateral circumflex femoral artery carried by the flap was anastomosed end-to-end with the superficial temporal artery in the recipient area. One accompanying vein of the anastomotic artery of the flap was end-to-end anastomosed with the branch of the external jugular vein via great saphenous vein bridging, and the other accompanying vein was end-to-end anastomosed with the superficial temporal vein in the recipient area. The donor site wounds were directly sutured or closed with medium-thickness skin grafts from inner thigh. The blood supply and survival of the flap, and the wound healing on the head were observed after operation. The blood flow and lumen filling of the transplanted vein were observed and recorded by using color ultrasound diagnostic system within 2 weeks after operation. The wound repair method and wound healing of the flap donor site were recorded and observed. Patients were followed up to observe the appearance of the flaps and the flap donor sites, the muscle strength of the lower limbs where the flap donor site was located, and whether the patient could complete standing, walking, and squatting using the lower limbs where the flap donor site was located.  Results  The flaps of 8 patients survived after operation, and no arterial or venous crisis occurred. The wounds of 5 patients on the head healed after operation, and the wounds of 3 patients on the head healed after second debridement 21 to 35 days after operation due to exudates under the flap 2 weeks after operation. Within 2 weeks after operation, the grafted vein continued to be unobstructed. After the ultrasound probe was pressurized, the grafted vein could be deflated, and the blood vessels were rapidly filled after the probe was released. The wounds of flap donor sites of 3 patients were directly sutured and healed 2 weeks after operation. The wounds of flap donor sites of 5 patients were closed with medium-thickness skin grafts from inner thigh, and all the skin grafts survived 12 days after operation. During follow-up of 6 to 12 months, the head flaps of all patients were slightly bloated without hair growth. Mild linear or patchy scar hyperplasia was left in the donor site. The muscle strength of the lower limbs where the flap donor site was located was normal and did not decrease. The patients could stand, walk, and squat with the lower limbs where the flap donor site was located.  Conclusions  When using the free anterolateral thigh flap to repair high-voltage electric burn wounds of various areas and depths on the head, bypass vein bridging can reduce the occurrence of postoperative flap vein crisis and improve the quality of postoperative wound healing without affecting the function of the lower limbs where the flap donor site is located.
Treatment methods and clinical efficacy of penetrating high-voltage electric burns to thoracoabdominal wall
Zhong Ai, Yun Jiao, Li Chenyu, Zhao Tian, Zhang Haoran, Chen Junjie
2024, 40(8): 732-739. doi: 10.3760/cma.j.cn501225-20240429-00157
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  Objective  To explore the treatment methods and clinical efficacy of penetrating high-voltage electric burns to thoracoabdominal wall.  Methods  This study was a retrospective observational study. From March 2020 to March 2023, six male patients with penetrating high-voltage electric burns to thoracoabdominal wall who met the inclusion criteria were hospitalized at West China Hospital of Sichuan University, aged 42 to 57 years. Among them, one patient had thoracoabdominal wall defects with perforation and necrosis of the gastric wall and diaphragm, two patients had thoracoabdominal wall defects with perforation and necrosis of the gastric wall alone, and three patients had abdominal wall defects with perforation and necrosis of the small intestine. In the emergency department, aesthetic plastic and burn surgery, general surgery, and/or thoracic surgery doctors jointly formulated an emergency surgery plan for the patients. Three patients with perforation and necrosis of the gastric wall underwent subtotal gastrectomy and anastomosis. One of them, who also had diaphragmatic perforation and necrosis, underwent resection of the necrotic diaphragm and repair. The other three patients with perforation and necrosis of the small intestine underwent resection and anastomosis of the necrotic intestinal segment. After debriding the thoracoabdominal wall wounds conservatively in stage Ⅰ and repairing the abdominal wall defects with greater omentum coverage, the thoracoabdominal wall wounds were treated with vacuum sealing drainage (VSD). Seven days later, a stage Ⅱ thorough debridement of the thoracoabdominal wall wounds was performed, and bovine acellular dermal matrix was transplanted onto the surface of the greater omentum and the surrounding skin wounds without skin coverage, and the VSD treatment of the thoracoabdominal wall wounds was continued. After 7 days, the VSD treatment was stopped, and after the fresh granulation tissue well developed in the wounds, a stage Ⅲ transplantation of meshed split-thickness skin graft from the lateral femur was performed to close the thoracoabdominal wall wounds, followed by continuing VSD treatment for another 7 days. Data were recorded including the status of patients' enteral nutrition recovery and occurrence of complications such as abdominal infection after stage Ⅰ surgery, the time from starting moist dressing change to the wound being ready for skin grafting after stage Ⅱ surgery, the microbiological culture of wound exudate samples and conditions of wound surrounding areas from starting moist dressing change to wound healing after stage Ⅱ surgery, skin graft survival, and wound healing time. Follow-up was carried out to observe the occurrence of gastrointestinal symptoms, abdominal wall hernia, scars, and functional disorders, etc.  Results  All six patients resumed enteral nutrition on day 2 to 4 after stage Ⅰ surgery, with no occurrence of intestinal obstruction, anastomotic leakage, or abdominal infection. The time from starting moist dressing change to the wound being ready for skin grafting after stage Ⅱ surgery was 8 (6, 12) days. During the period from starting moist dressing change to wound healing after stage Ⅱ surgery, microbiological culture of wound exudate sample showed Enterobacter cloacae in one patient and Pseudomonas aeruginosa in another patient, while the remaining four patients had negative cultures; no patient developed wound edge inflammation. All grafted skin survived, and the wound healing time was 38 (30, 46) days. During follow-up from 12 to 36 months after stage Ⅲ surgery, patients had no intractable constipation or intestinal obstruction symptoms, no obvious local tissue herniation requiring surgical treatment, no scar ulceration, and no functional disorders.  Conclusions  For penetrating high-voltage electric burns to thoracoabdominal wall, a sequential three-stage surgical treatment plan under a multidisciplinary team collaboration model can effectively protect organ function and control wound infection. Long-term follow-up shows good gastrointestinal function and thoracoabdominal wall appearance. This method is highly reproducible and effective, which is suitable for clinical promotion and use.
Diagnostic value of thromboelastography combined with conventional coagulation test for trauma-induced coagulopathy in patients with electric burns in the early stage
Li Quan, Ba Te, Cao Shengjun, Li Fang, Yan Zengqiang, Hou Zhihui, Wang Lingfeng
2024, 40(8): 740-745. doi: 10.3760/cma.j.cn501225-20240416-00135
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  Objective  To explore the diagnostic value of thromboelastography (TEG) combined with conventional coagulation test (CCT) for trauma-induced coagulopathy (TIC) in patients with electric burns in the early stage.  Methods  This study was a retrospective case series research. From February 2018 to February 2024, the clinical data of 128 electric burn patients and 118 thermal burn patients who met the inclusion criteria and admitted to the Department of Burn Surgery of the Third Affiliated Hospital of Inner Mongolia Medical University were collected, including 224 males and 22 females, aged (38±14) years. The patients were divided into electric burn group (128 cases) and thermal burn group (118 cases) according to their injuries. The incidence of TIC, the indicators of CCT, including prothrombin time, activated partial thromboplastin time, thrombin time, fibrinogen level, D-dimer level, platelet count, and the detection indicators of TEG, including coagulation reaction time, K value, coagulation angle, maximum thrombus amplitude, comprehensive coagulation index, and lysis rate at 30 minutes after maximum amplitude within 8 hours of admission were compared between the two groups of patients. The Kappa test was used to analyze the consistency between CCT and TEG in diagnosing TIC in patients with electric burns in the early stage after burns. The receiver operating characteristic curves of CCT, TEG, and TEG combined with CCT in diagnosing TIC in 128 patients with electric burns were drawn, and the area under the curve (AUC), the maximum Jordan index, and sensitivity and specificity at this time were calculated.  Results  The proportion of patients diagnosed with TIC in electric burn group was 19.5% (25/128) within 8 hours of admission, which was significantly higher than 10.2% (12/118) in thermal burn group (χ2=4.21, P<0.05). Compared with those in thermal burn group, prothrombin time was significantly shortened (t=-2.32, P<0.05), D-dimer level, fibrinogen level, and platelet count were significantly increased (with Z values of -2.11 and -4.16, respectively, t=4.69, P<0.05), the coagulation reaction time was significantly shortened (t=-2.51, P<0.05), and the maximum thrombus amplitude and lysis rate at 30 minutes after the maximum amplitude were significantly increased (with t values of 2.50 and 2.10, respectively, P<0.05) in patients in electric burn group within 8 hours of admission. There were no statistically significant differences in the other CCT indicators and TEG detection indicators between the two groups of patients (P>0.05). The CCT and TEG showed high consistency in the diagnosis of TIC in patients with electric burns in the early stage after burns (Kappa=0.63, P<0.05). The AUCs of TEG combined with CCT, TEG, and CCT in diagnosis of TIC in 128 patients with electric burns were 0.92, 0.84, and 0.77 (with 95% confidence intervals of 0.86-0.97, 0.71-0.97, and 0.71-0.97, respectively), with the maximum Jordan indexes of 0.86, 0.57, and 0.65. At this time, the specificity was 93.7%, 83.2%, and 88.2%, respectively, and the sensitivity was 92.3%, 87.5%, and 76.5%, respectively.  Conclusions  Patients with electric burns are in a state of hypercoagulability of coagulation system and hyperfunction of fibrinolysis system in the early stage after burns, and TEG combined with CCT can increase the diagnostic rate of TIC in patients with electric burns.
Characteristics of renal oxidative stress injuries in rats with high-voltage electric burns and the intervention effects of breviscapine
Li Congying, Zhao Xuegang, Hao Jiawen, Ge Chenyang, Lu Mengyuan, Zhang Jing, Zhang Qingfu, Feng Jianke, Tu Lihong
2024, 40(8): 746-755. doi: 10.3760/cma.j.cn501225-20240222-00070
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  Objective  To explore the characteristics of renal oxidative stress injuries in rats with high-voltage electric burns and the intervention effects of breviscapine.  Methods  This study was an experimental study. One hundred and sixty 8-10-week-old male Sprague Dawley rats were divided into sham injury group, electric burn group, saline group, low breviscapine group, middle breviscapine group, and high breviscapine group, with 60 rats in each of the sham injury group and electric burn group, 10 rats in each of the other 4 groups, respectively. The rats in sham injury group and electric burn group were divided into 10 rats at each time point, including post injury hour (PIH) 0 (immediately), 8, 24, 48, and 72, and post injury week (PIW) 1. The rats in sham injury group were not conducted with electrical current to cause sham injury. The rats in the other 5 groups were caused high-voltage electric burns. The rats in sham injury group and electric burn group were not treated after injury. The rats in saline group, low breviscapine group, middle breviscapine group, and high breviscapine group were intraperitoneally injected with 5 mL/kg normal saline or 0.4, 1.6, and 4.0 g/L breviscapine, repeated every 24 h until PIH 72. After the model was successfully made, 14 rats died, including 1, 2, 2, and 1 rat (s) at PIH 24, 48, and 72 and PIW 1 in electric burn group, 4, 1, 2, and 1 rat (s) at PIH 72 in saline group, low breviscapine group, middle breviscapine group, and high breviscapine group, respectively. The kidney tissue collected from rats in the 6 groups was weighed and the kidney/body weight ratio was calculated. The left upper pole tissue of kidney was collected from each 4 rats in sham injury group, and in electric burn group at PIH 8, 24, 48, and 72 and PIW 1, and in saline group, low breviscapine group, middle breviscapine group, and high breviscapine group at PIH 72. The renal tubular and renal interstitial injury was evaluated by a semi-quantitative histological scoring system after hematoxylin-eosin staining. The inferior vena cava blood samples were collected from rats in the 6 groups to measure the serum creatinine levels via sarcosine oxidase method, and serum urea nitrogen levels via urease method. The right renal cortices were collected from rats in the 6 groups to measure the catalase (CAT) activity in the supernatant of renal tissue via molybdic acid method, and the levels of advanced oxidation protein product (AOPP) and Klotho protein in the supernatant of renal tissue via enzyme-linked immunosorbent assay.  Results  At PIH 8, 48, and 72 and PIW 1, the kidney/body weight ratios of rats in electric burn group were significantly higher than those in sham injury group (with t values of -0.52, -3.75, -4.05, and -2.25,respectively, P<0.05). At PIH 72, compared with those in electric burn group, saline group, low breviscapine group, and middle breviscapine group, the kidney/body weight ratio of rats in high breviscapine group was significantly decreased (with P values all <0.05). Compared with those in sham injury group, the renal tubular and renal interstitial injury scores of rats in electric burn group at PIH 48 and 72 and PIW 1 were significantly increased (P<0.05). Compared with those in electric burn group at PIH 8 and 24, the renal tubular and renal interstitial injury score of rats in electric burn group at PIW 1 was significantly increased (with P values all <0.05). At PIH 72, the renal tubular and renal interstitial injury scores of rats in the 5 groups of rats with electric burns were similar (P>0.05). At PIH 8, 24, 48, and 72 and PIW 1, the levels of serum creatinine and serum urea nitrogen of rats in electric burn group were significantly higher than those in sham injury group (with Z values of -2.00, -2.37, -2.62, -2.67, -3.67, -2.34, -3.11, -3.43, -3.11, and -3.51, respectively, P<0.05). Compared with that in electric burn group at PIH 0, the levels of serum creatinine of rats in electric burn group at PIH 72 and PIW 1 were significantly increased (P<0.05). Compared with that in electric burn group at PIH 8, the levels of serum creatinine of rats in electric burn group at PIH 72 and PIW 1 were significantly increased (P<0.05). Compared with that in electric burn group at PIH 24, the level of serum creatinine of rats in electric burn group at PIW 1 was significantly increased (P<0.05). At PIH 72, the levels of serum creatinine of rats in the 5 groups of rats with electric burns were similar (P>0.05). Compared with that in electric burn group, the levels of serum urea nitrogen of rats in low breviscapine group, middle breviscapine group, and high breviscapine group were significantly decreased (P<0.05). Compared with that in saline group, the levels of serum urea nitrogen in middle breviscapine group and high breviscapine group were significantly decreased (P<0.05). At PIH 48 and 72 and PIW 1, the CAT activities in the supernatant of renal tissue of rats in electric burn group were significantly lower than those in sham injury group (with Z values of -2.22, -2.13, and -3.51, respectively, P<0.05). At PIH 8, 24, 48, and 72 and PIW 1, the levels of AOPP in the supernatant of renal tissue of rats in electric burn group were significantly higher than those in sham injury group (with Z values of -2.00, -3.15, -2.71, -2.04, and -2.33, respectively, P<0.05). At PIH 0-PIW 1, the levels of Klotho protein in the supernatant of renal tissue of rats in sham injury group and electric burn group were all similar (P>0.05). Compared with that in electric burn group at PIH 0, the CAT activities in the supernatant of renal tissue of rats in electric burn group at PIH 72 and PIW 1 and the levels of Klotho protein in the supernatant of renal tissue of rats in electric burn group at PIH 48 and 72 and PIW 1 were significantly decreased (P<0.05). Compared with that in electric burn group at PIH 8, the CAT activities in the supernatant of renal tissue of rats in electric burn group at PIH 72 and PIW 1 and the levels of Klotho protein in the supernatant of renal tissue of rats in electric burn group at PIH 48 and 72 and PIW 1 were significantly decreased (P<0.05). Compared with that in electric burn group at PIH 24, the CAT activities in the supernatant of renal tissue of rats in electric burn group at PIH 72 and PIW 1 were significantly decreased (P<0.05). Compared with that in electric burn group at PIH 48, the CAT activity in the supernatant of renal tissue of rats in electric burn group at PIW 1 was significantly decreased (P<0.05). At PIH 72, the levels of Klotho protein in the supernatant of renal tissue of rats in the 5 groups of rats with electric burns were similar (P<0.05). Compared with 14.6 (12.6, 23.6) U/mgprot in electric burn group, the CAT activities in the supernatant of renal tissue of rats in low breviscapine group (20.5 (18.0, 39.8) U/mgprot), middle breviscapine group (24.9 (14.7, 28.9) U/mgprot), and high breviscapine group (28.0 (21.9, 39.1) U/mgprot) were significantly increased (P<0.05). Compared with 15.7 (13.7, 25.6) U/mgprot in saline group, the CAT activities in the supernatant of renal tissue of rats in middle breviscapine group and high breviscapine group were significantly increased (P<0.05). Compared with that in low breviscapine group, the CAT activity in the supernatant of renal tissue of rats in high breviscapine group was significantly increased (P<0.05). Compared with those in electric burn group and saline group, the levels of AOPP in the supernatant of renal tissue of rats in middle breviscapine group and high breviscapine group were significantly decreased (P<0.05).  Conclusions  After high-voltage electric burns, oxidative stress injury occur in the kidneys of rats, which is aggravated with time extension. Breviscapine can alleviate oxidative stress injuries in the kidneys of rats with high-voltage electric burns.
Original Article
Clinical effects of free anterolateral thigh perforator flaps in repairing diabetic foot ulcers under a multi-disciplinary team cooperation model
Zhao Jianjun, Xie Zhenjun, Zhao Guohong, Zhang Jianhua, Sun Huawei, Bai Huikai, Zhang Huifeng, Zhang Dongbin, Xiao Erhui, Zhu Guosong
2024, 40(8): 756-761. doi: 10.3760/cma.j.cn501225-20231107-00184
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Abstract:
  Objective  To explore the clinical effects of free anterolateral thigh perforator flaps in repairing diabetic foot ulcers (DFUs) under a multi-disciplinary team (MDT) cooperation model.  Methods  The study was a retrospective observational study. From June 2018 to December 2022, 49 DFU patients who met the inclusion criteria were admitted to the Department of Hand and Foot Microscopy and Wound Repair Surgery of Henan Provincial People's Hospital (People's Hospital of Zhengzhou University), including 28 males and 21 females, aged from 47 to 68 years, with type 2 diabetes history period ranging from 6 months to 21 years. Under a MDT cooperation model, the physicians from department of endocrinology comprehensively assessed the patients, stabilized the patients' general condition, and controlled their complications, the surgeons from department of vascular surgery assessed and improved the patients' lower limb blood supply, the physicians from department of infectious diseases provided anti-infection treatment plans, the physicians from department of anesthesiology and perioperative medicine assessed the patients' perioperative risk and ensured their perioperative safety, and according to the patients' condition, the physicians from departments such as cardiology, neurology, nutrition, and rehabilitation actively and timely participated in the treatment. The surgeons from department of hand and foot microscopy and wound repair surgery prepared the wound base and used free anterolateral thigh perforator flaps to repair the wounds. After once or multiple debridement in the first stage, the wound area ranged from 5.0 cm×4.5 cm to 17.0 cm×10.0 cm. After once or twice vacuum sealing drainage treatment, the free anterolateral thigh perforator flaps were used to repair the wounds with incision area of 6 cm×5 cm to 18 cm×11 cm in the second stage. The descending branches of lateral circumflex femoral artery and the accompanying veins of flaps were anastomosed to the arteries and veins in the recipient sites, respectively. The wounds in the flap donor sites were sutured directly. After surgery, whether the patient's perioperative period was stable, the survival of flaps, the healing of wounds in the flap donor and recipient sites were observed. During the follow-up, the texture and appearance of flaps, whether there was a new ulcer, and the patient's walking ability were observed.  Results  All the patients had stable perioperative period. Among them, the flaps in 46 patients survived successfully; the flaps in 2 patients developed complete necrosis, including 1 case whose ulcer was healed after repair of pedicled flap from the lower leg, and 1 case who underwent amputation of the lower leg; the flap in 1 patient developed partial necrosis, which was healed after dressing change and skin grafting. The wounds in the flap donor and recipient sites healed well. During the postoperative follow-up of 6-24 months, the flaps had good texture and appearance with no new ulcers, and the patients had no obvious impairment in daily walk.  Conclusions  The MDT cooperation model can sufficiently ensure the perioperative safety of DFU patients. The free anterolateral thigh perforator flaps can repair the DFU wounds achieving good clinical effects with high flap survival rate and decreased amputation rate.
Interaction between fibroblasts and keratinocytes in the wound edge skin tissue of a diabetic foot patient and the mechanism
Ruan Qiongfang, Zhang Siyu, Xi Maomao, Ruan Jingjing, Liu Shuhua, Li Binghui, Xie Weiguo
2024, 40(8): 762-771. doi: 10.3760/cma.j.cn501225-20240221-00067
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  Objective  To investigate the interaction between fibroblasts (Fb) and keratinocytes (KC) in the wound edge skin tissue of a diabetic foot patient and the mechanism.  Methods  This was an experimental research. The wound edge skin tissue from a diabetic foot patient (male and 33 years old) admitted to the Department of Wound Repair of Liyuan Hospital Affiliated to Tongji Medical College of Huazhong University of Science and Technology in August 2021 and from an acute foot injury patient (male and 50 years old) admitted to the Department of Hand Surgery of the hospital in September 2021 was collected. The single-cell transcriptome sequencing was performed to analyze the interaction between chemokine ligands of Fb subgroup and chemokine receptors of KC subgroup. The supernatant was collected after human foreskin fibroblast (HFF) was cultured routinely and with high concentration of glucose for 7 days as normal conditioned medium (CM) and high glucose CM, respectively. HaCaT cells were collected and divided into normal CM group cultured with normal CM and high glucose CM group cultured with high glucose CM, the scratch test was performed to calculate the cell migration rates at 24 and 48 h after scratch (n=3). The content of cytokines in the two kinds of CM was detected by liquid suspension chip (n=5). HFF was collected and divided into normal group cultured routinely and high glucose group cultured with high concentration of glucose for 7 days, and the mRNA expressions of C-X-C motif chemokine ligand 1 (CXCL1), CXCL2, CXCL8, and CXCL12 were detected by real-time fluorescence quantitative reverse transcription polymerase chain reaction (n=6). HaCaT cells in normal CM group and high glucose CM group were collected to detect the protein expressions of C-X-C motif chemokine receptor 4 (CXCR4) in cells cultured for 48 h by Western blotting (n=3). HaCaT cells were collected and divided into normal CM group, high glucose CM group, normal CM+CXCL12 group, and high glucose CM+CXCL12 group. The first two groups of cells were treated as before, and the latter two groups of cells were cultured with normal CM and high glucose CM containing recombinant human CXCL12, respectively. Scratch test was performed, and cell migration rates were calculated at 24 and 48 h after scratch (n=3); the protein expression of CXCR4 in cells cultured for 48 h was detected by Western blotting (n=3).  Results  Compared with those in the wound edge skin tissue of acute foot injury, the interactions between chemokine ligands (CXCL1, CXCL2, CXCL3, CXCL8, and CXCL12) of Fb subgroup and chemokine receptors (CXCR2 and CXCR4) of KC subgroup were significantly weakened in the wound edge skin tissue of diabetic foot. At 24 and 48 h after scratch, the migration rates of HaCaT cells in high glucose CM group were significantly lower than those in normal CM group (with t values of 23.50 and 15.65, respectively, P<0.05). Compared with that in normal CM, the content of CXCL1 in high glucose CM was significantly increased (P<0.05), and the content of CXCL12 was significantly decreased (P<0.05). After 7 days of culture, compared with those in normal group, the mRNA expressions of CXCL1, CXCL2, and CXCL8 in HFF in high glucose group were significantly increased (with t values of 4.25, 4.98, and 10.04, respectively, P<0.05), while the mRNA expression of CXCL12 was significantly decreased (t=4.10, P<0.05). After 48 h of culture, the CXCR4 protein expression in HaCaT cells in high glucose CM group was significantly lower than that in normal CM group (t= 5.13, P<0.05). At 24 and 48 h after scratch, the migration rates of HaCaT cells in high glucose CM group were significantly lower than those in normal CM group and high glucose CM+CXCL12 group (with P values all <0.05); at 24 h after scratch, the migration rate of HaCaT cells in normal CM+CXCL12 group was significantly lower than that in normal CM group (P<0.05); at 48 h after scratch, the migration rate of HaCaT cells in normal CM+CXCL12 group was significantly higher than that in high glucose CM+CXCL12 group (P<0.05). At 48 h of culture, the CXCR4 protein expression of HaCaT cells in high glucose CM+CXCL12 group was 0.446±0.050, which was significantly higher than 0.247±0.010 in high glucose CM group (P<0.05) and similar to 0.522±0.082 in normal CM+CXCL12 group (P>0.05); the CXCR4 protein expression in HaCaT cells in normal CM group was 0.509±0.055, which was significantly higher than that in high glucose CM group (P<0.05).  Conclusions  The interactions between chemokine ligands of Fb subgroup and chemokine receptors of KC subgroup were significantly weakened in the wound edge skin tissue of diabetic foot. High glucose can inhibit CXCL12 secretion of HFF, and the stimulation of its cell culture supernatant can decrease HaCaT cell migration ability and CXCR4 expression. Exogenous CXCL12 protein can increase the CXCR4 protein expression in HaCaT cells and enhance the cell migration ability.
Influence and its mechanism of allogeneic dermal papilla cells on the wound healing of full-thickness skin defects in mice
Shang Yage, Zhang Lixia, Han Chao, Li Mengyang, Luo Liang, Wang Xujie, Hu Dahai
2024, 40(8): 772-780. doi: 10.3760/cma.j.cn501225-20240215-00059
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Abstract:
  Objective  To explore the influence and its mechanism of allogeneic dermal papilla cells (DPCs) on the wound healing of full-thickness skin defects in mice.  Methods  This study was an experimental study. DPCs were isolated from the whisker follicles of five 6-week-old male C57BL/6J mice by combining microdissection with collagenase digestion and were successfully identified. Eighteen 8-week-old male C57BL/6J mice were divided into phosphate buffer solution (PBS) group and DPC group according to the random number table, with 9 mice in each group, and the full-thickness skin defect wound model was created on the back of all mice. On day 2, 4, and 6 after injury, the mice in DPC group were administered 100 μL of cell suspension containing 1×106 DPCs of the 4th passage by subcutaneous injection around the wound, and the mice in PBS group was administered an equal volume of PBS. On day 3, 7, 10, and 14 after injury, the wound healing and hair growth of mice in two groups were observed, and the residual wound area was measured, and the hair coverage area on the wound of mice in two groups was measured on day 14 after injury. On day 14 after injury, the wound tissue samples of mice in two groups were collected. Hematoxylin-eosin staining was performed to observe the condition of newborn hair follicles and the number was counted, Masson staining was performed to observe the collagen deposition in the dermis and the collagen deposition area was measured, the immunofluorescence method was used to detect the protein expressions of Wnt/β-catenin signaling pathway related molecules β-catenin and lymphoid enhancer binding factor 1 (Lef1), and Western blotting and real-time fluorescence quantitative reverse transcription polymerase chain reaction were used to detect the protein and mRNA expressions of β-catenin and Lef1, respectively. The number of samples in each experiment was 3.  Results  Compared with those in PBS group, the mice in DPC group had accelerated wound re-epithelialization at each time point after injury, and more hair growth on day 10 and 14 after injury. On day 7, 10, and 14 after injury, the residual wound areas of mice in DPC group were (13.92±2.90), (3.69±1.78), and (1.09±0.14) mm2, respectively, which were significantly smaller than (26.19±2.06), (10.84±3.59), and (6.75±2.11) mm2 in PBS group, respectively (with t values of 5.85, 3.09, and 4.63, respectively, P values all <0.05). On day 14 after injury, the hair coverage area on the wound of mice in DPC group was (62±7) mm2, which was significantly larger than (35±6) mm2 in PBS group (t=2.89, P<0.05). On day 14 after injury, compared with those in PBS group, the number of newborn hair follicles in the wound tissue of mice in DPC group was significantly increased (t=5.43, P<0.05), and the dermal collagen deposition area was significantly reduced (t=3.56, P<0.05). On day 14 after injury, both the immunofluorescence method and the Western blotting detection showed that the protein expressions of β-catenin (with t values of 5.49 and 4.25, respectively, P values all <0.05) and Lef1 (with t values of 7.50 and 11.54, respectively, P values all <0.05) in the wound tissue of mice in DPC group were significantly higher than those in PBS group; the mRNA expressions of β-catenin and Lef1 in the wound tissue of mice in DPC group were significantly higher than those in PBS group (with t values of 7.68 and 9.67, respectively, P<0.05).  Conclusions  DPCs can accelerate the re-epithelialization of full-thickness skin defect wounds in mice by activating Wnt/β-catenin signaling pathway and promote hair follicle regeneration during the process of wound healing.
Discipline Construction
Exploration of wound repair discipline construction in county-level hospitals
Ding Wei, Ma Tao, Xie Jiabing, Yang Min
2024, 40(8): 781-784. doi: 10.3760/cma.j.cn501225-20240510-00169
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Abstract:
As one of the important components of the construction of the discipline system of wound repair with Chinese characteristics, the wound repair discipline construction in county-level hospitals currently lacks mature construction experience and models for reference. This article is based on the theory of the construction of the discipline system of wound repair with Chinese characteristics, and combines with the practical experience and insights of the construction of Southern Anhui Wound Repair Specialty Alliance to explore how to carry out wound repair discipline construction in county-level hospitals.
Review
Research advances on the role of pyroptosis in diabetic wound healing
He Jiale, Dong Hongfei, Huang Xi, Zhang Yanbiao, Li Xianhui
2024, 40(8): 785-791. doi: 10.3760/cma.j.cn501225-20230829-00068
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Abstract:
Diabetic wound is a complication of diabetes, which is difficult to heal and easy to turn into chronic wound. Compared with ordinary wound healing, diabetic wounds stay in the inflammatory stage and can not enter the proliferative stage. This is because the proportion of pro-inflammatory cytokines increases, leading to the imbalance of inflammatory cells and the accumulation of a large number of inflammatory factors. The production and release of inflammatory factors is closely related to pyroptosis. Pyroptosis is a kind of programmed death mode of inflammatory cells. Mediated by inflammasome, pyroptosis is transduced through typical and atypical inflammasome signaling pathways, resulting in the formation of pores on the cell membrane and inducing cell death. In this process, a large number of pro-inflammatory cytokines are released to maintain the inflammatory environment of wounds, hindering the development of diabetic wounds to the proliferative stage and remodeling stage, thus inhibiting the healing of diabetic wounds. This article reviews the mechanism of pyroptosis and its effect on diabetic wounds, the potential significance of inhibiting pyroptosis in the treatment of diabetic wounds, and the existing problems.
Research advances on fluid resuscitation in pediatric burns
Zheng Yangyang, Huang Ting, Liu Zhihui, Liu Jun
2024, 40(8): 791-795. doi: 10.3760/cma.j.cn501225-20231030-00157
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Abstract:
Fluid resuscitation after burns is very crucial to the survival and prognosis of children. Although the principles of fluid resuscitation in children are similar to those in adults, the unique physiological needs of children must be fully considered to prevent insufficient or excessive fluid resuscitation. In clinical practice, due to the popularization of various monitoring techniques, insufficient fluid resuscitation can be observed in time, but excessive fluid resuscitation is often overlooked. Excessive fluid resuscitation can lead to fluid extravasation, increasing the probability of pediatric burn complications and poor prognosis. This review focuses on the unique pathophysiological characteristics of children with burns and how to avoid excessive fluid resuscitation in order to provide reference for rational fluid rehydration.
Research progress on the application of imaging technology in burn injury assessment
Shang Liutong, Wang Xiao, Li Ruixin, Li Tianran, Sun Tianjun
2024, 40(8): 796-800. doi: 10.3760/cma.j.cn501225-20231012-00112
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Abstract:
The accurate assessment of burn injuries is complex and difficult. The emergence of some new skin imaging techniques, such as hyperspectral imaging, unilateral magnetic resonance imaging, laser Doppler perfusion imaging, etc., has made great progress in research on burn injury assessment. With the continuous progress of imaging technology and medical imaging, medical imaging technologies such as digital radiography, computed tomography, magnetic resonance imaging, and ultrasonography, and so on, have played an important role in burn injury assessment. However, there are still relatively few research reports on burn injury imaging, which may be due to the fact that the imaging techniques and diagnostic experience used for burn injury assessment are not yet fully popular in some medical institutions, and the imaging manifestations related to burns are complex and lack of specificity. This article mainly reviews the application research progress of various imaging techniques in the assessment of burn injury in recent years, aiming to explore the application value of various imaging techniques in burn injury assessment.

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