中华烧伤与创面修复杂志

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Objective To investigate the effects of hypoxia-pretreated rat adipose-derived mesenchymal stem cells (ADSCs) conditioned medium on wound healing of rats with full-thickness defects. Methods (1) A 6-week-old male Sprague-Dawley rat was sacrificed by cervical dislocation, the bilateral inguinal adipose tissue was collected, the third generation ADSCs were isolated by collagenase digestion method, and the cells morphology was observed. The cells were harvested and divided into adipogenic induction group and osteogenic induction group according to the random number table (the same grouping method below), with 6 wells in each group. The cells in adipogenic induction group were cultured for 14 days to observe adipogenesis, and cells in osteogenic induction group were cultured for 28 days to observe osteogenesis. (2) The third generation ADSCs were collected and divided into normoxic group and hypoxic group. Cells in normoxic group was incubated in normal oxygen incubator with oxygen volume fraction of 21%, and cells in hypoxic group was incubated in low oxygen incubator with oxygen volume fraction of 2% respectively, with 3 samples in each group for each time point. Three samples in normoxic group on 3 h of culture and in hypoxic group on 3, 6, 12, 24, and 48 h of culture were collected for detecting the following indexes. The mRNA expressions of hypoxia inducible factor-1α (HIF-1α), vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF), and peroxisome proliferator-activated receptor γ (PPAR-γ) were detected by real time fluorescent quantitative reverse transcription polymerase chain reaction. The cell culture supernatant in the two groups was collected, centrifuged, and filtered to obtain normoxic conditioned medium (normo-CM ) and hypoxic conditioned medium (hypo-CM). Enzyme linked immunosorbent assay was used to detect content of VEGF, transforming growth factor β (TGF-β), epidermal growth factor (EGF), and insulin-like growth factor (IGF) in conditioned medium. (3) Twenty-seven male Sprague-Dawley rats aged 6-8 weeks were collected and divided into phosphate buffer solution (PBS) group, normo-CM group, and hypo-CM group, with 9 rats in each group. A circular full-thickness skin defect wound with diameter of 1 cm was made on the back of each rat, and the wounds of rats in PBS, normo-CM, and hypo-CM groups were respectively dropped with 50 μL PBS, normo-CM, and hypo-CM. On post injury day (PID) 0, 3, 5, 7, 9, and 11, the gross condition of wound was observed, wound area was measured, and the non-healing rate of wound was calculated. The wound tissue was collected for hematoxylin eosin staining to observe inflammatory reaction of wound on PID 3, 9, and 11 and re-epithelialization of wound on PID 9. Masson staining was used to observe the collagen deposition and analyze collagen volume fraction of wound on PID 11. Data were statistically analyzed with analysis of variance for repeated measurement, one-way analysis of variance, t test, and Bonferroni correction. Results (1) The isolated cells showed a fusiform, in adherent growth and close arrangement when in low fusion degree. On 14 d of culture, the red lipid droplets stained with oil red O were observed in cells in adipogenic induction group, and on 28 d of culture, the red nodules stained with alizarin red S were observed in cells in osteogenic induction group. The cells were identified as ADSCs. (2) Compared with that in normoxic group, the mRNA expression of HIF-1α was significantly increased at 12 and 24 h of culture (t=5.43, 5.11, P<0.05), the mRNA expression of VEGF was significantly increased at 6 and 12 h of culture (t=3.29, 2.33, P<0.05 or P<0.01), the mRNA expression of bFGF was significantly increased at 12 h of culture (t=12.59, P<0.01) and significantly reduced at 48 h of culture (t=9.34, P<0.01), and the mRNA expression of PPAR-γ was significantly reduced at 3, 12, and 24 h of culture in hypoxic group (t=5.14, 6.56, 4.97, P<0.05). (3) Compared with that in normoxic group, the VEGF content was significantly increased at 3, 6, 12, 24, and 48 h of culture (t=5.74, 12.37, 14.80, 15.70, 34.63, P<0.05 or P<0.01), and the IGF content was significantly increased at 6, 12, 24, and 48 h of culture (t=5.65, 8.06, 20.12, 22.99, P<0.05 or P<0.01), and the content of TGF-β and EGF showed no obvious change at 3, 6, 12, 24, and 48 h of culture in hypoxic group. (4) From PID 0 to 11, the wound of rats in the three groups shrank to varying degrees, with no obvious infection or exudate. On PID 11, the wound area of rats in PBS group was still large, which was larger than that in normo-CM group, and the wound area of rats in hypo-CM group was basically healed. On PID 0, 3, and 5, the non-healing rates of wound of rats in the three groups were similar. On PID 7, the non-healing rates of wound of rats in normo-CM and hypo-CM groups were significantly lower than that in PBS group (t=10.26, 16.03, P<0.05). On PID 9, the non-healing rate of wound of rats in hypo-CM group was significantly lower than that of PBS group and normo-CM group, respectively (t=17.25, 6.89, P<0.05 or P<0.01), and the non-healing rate of wound of rats in normo-CM group was significantly lower than that in PBS group (t=8.81, P<0.05). On PID 11, the non-healing rate of wound of rats in hypo-CM group was (2.4±1.5)%, which was significantly lower than (20.0±5.0)% in PBS group and (7.7±1.7)% in normo-CM group (t= 30.15, 84.80, P<0.05). (5) On PID 3, the infiltration of inflammatory cells in the wound of rats in hypo-CM group was obviously more than those in the other two groups. On PID 9, the infiltration of inflammatory cells in the wound of rats in hypo-CM and normo-CM groups was obviously less than that in PBS group. On PID 11, the infiltration of inflammatory cells in the wound of rats in hypo-CM group was obviously less than those in PBS and normo-CM groups. On PID 9, the length of " epidermal migration tongue" on the wound of rats in hypo-CM group was longer than those of the other two groups, and the epidermis thickness was close to normal skin. On PID 11, compared with those in PBS and normo-CM groups, a large number of collagen deposits with dense structure, neat arrangement, and higher maturity were seen in the wound of rats in hypo-CM group. The wound collagen volume fraction of rats in PBS group was (22.90±1.25)%, which was significantly lower than (31.96±0.14)% in normo-CM group and (56.10±1.50)% in hypo-CM group (t=12.48, 29.43, P<0.05), and the wound collagen volume fraction of rats in normo-CM group was significantly lower than that in hypo-CM group (t=27.73, P<0.05). Conclusions Hypoxia-pretreated can significantly enhance paracrine effect of rat ADSCs. Hypoxia-pretreated rat ADSC conditioned medium can accelerate the healing of full-thickness skin defect wound in rats by regulating inflammatory cell infiltration, promoting re-epithelialization and collagen deposition in the wound.

Randomized controlled trial on application of negative pressure materials of polyvinyl alcohol and polyurethane in full-thickness burn wounds after escharotomy

Huang Zhen, Wang Peng, Pan Zhenyi, Dong Liang, Su Jian, Xu Nengwu

2020, 36(9): 813-820. doi: 10.3760/cma.j.cn501120-20191225-00472

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Objective To compare the effects and characteristic difference of negative pressure materials of polyvinyl alcohol and polyurethane in the treatment of full-thickness burn wounds after escharotomy. Methods From January 2018 to December 2019, 60 patients with full-thickness burns who met the inclusion criteria and hospitalized in Xuzhou Renci Hospital were recruited in this prospective randomized controlled trial. According to the random number table, 60 cases were divided into polyvinyl alcohol group (n =30, 13 males and 17 females) and polyurethane group (n =30, 14 males and 16 females), aged (34±7) and (35±6) years respectively, with burn area of 4.20% (2.23%, 4.90%) total body surface area (TBSA) and 3.89% (2.18%, 4.76%)TBSA and escharectomy area of 2.70% (1.97%, 3.42%) TBSA and 2.87% (2.12%, 3.34%)TBSA, respectively. After patient′s admission, debridement was immediately performed on the full-thickness burn wound, and the dressing was changed with iodophor once a day. Escharectomy was performed on post injury day 3. After thorough hemostasis and washing the wounds with normal saline, patients of the two groups chose corresponding foam materials and supporting facilities for continuous negative-pressure treatment for 1 week, with the negative pressure value setting at -19.9 kPa. Installation time of negative-pressure material was recorded. After a week of negative-pressure treatment, the maximum pulling force of removing foam material was recorded to evaluate the adhesional degree between foam materials and wounds. The amount of bleeding in the process of removing foam materials was recorded, hyperplasiaof granulation tissue was observed with hematoxylin eosin (HE) staining, and the expression of CD31 was detected by immunohistochemical staining and Western blotting to denote vascularization. The ratio of R1 to R0 of coefficient of restitution of foam material before and one week after negative-pressure treatment and drainage volume of wound exudate within a week of negative-pressure treatment were recorded to denote the drainage ability of foam material to wound exudate. One week after negative-pressure treatment, the bacterial colonization, residual foreign body, and eczema rate of skin edge were recorded. Data were statistically analyzed with chi-square test, independent-sample t test, and Mann-Whitney U test. Results (1) Installation time of negative-pressure material of patients in polyurethane group was (14±3) min, which was significantly shorter than (18±3) min in polyvinyl alcohol group (t=2.788, P<0.01). (2) One week after negative-pressure treatment, the maximum pulling force of removing foam material of patients in polyvinyl alcohol group was (6.4±0.4) N, which was significantly lower than (16.7±0.8) N in polyurethane group (t=12.010, P<0.01). (3) One week after negative-pressure treatment, the volume of wound bleeding of patients in polyvinyl alcohol group was (20±3) mL in the process of removing foam material, which was significantly less than (59±3) mL in polyurethane group (t=50.200, P<0.01). (4) One week after negative-pressure treatment, HE staining showed that hyperplastic thickness of wound granulation tissue of patients in polyurethane group was (2.3±0.6) mm which was significantly higher than (1.6±0.4) mm in polyvinyl alcohol group ( t=6.667, P<0.01); immunohistochemical staining showed that the number of microvascular lumen in wound granulation tissue of patients in polyurethane group was significantly more than that in polyvinyl alcohol group; Western blotting showed that protein expression of CD31 in wound granulation tissue of patients in polyurethane group (1.00±0.05) was significantly higher than 0.42±0.03 of polyvinyl alcohol group (t=10.490, P<0.01). (5)The ratio of R1 to R0 of coefficient of restitution of foam material of patients in polyvinyl alcohol group was 0.39±0.19, which was significantly lower than 0.52±0.16 in polyurethane group (t=2.975, P<0.01). In patients of polyvinyl alcohol group, the drainage volume of wound exudate of foam material during one week after negative-pressure treatment was (1 258±444) mL, significantly less than (1 658±580) mL of polyurethane group (t=3.003, P<0.01). (6) One week after negative-pressure treatment, the number of residual foreign body in wounds of patients of polyurethane group was (14.14±0.37) particles, which was significantly more than (3.36±0.15) particles in polyvinyl alcohol group (t=26.200, P<0.01). The level of bacterial colonization of wounds and eczema rate of skin edge of patients between the two groups were close. Conclusions Polyurethane foam material is easy to install and operate, relatively difficult to dry and shrink, and has strong ability to discharge wound exudation. Polyurethane foam material is better than polyvinyl alcohol foam material in promoting wound angiogenesis and tissue proliferation. Polyurethane foam material can be chosen firstly for the wounds with need of protecting deep tissues and important organs, as well as the wounds with obvious inflammatory edema and serious contamination. Polyvinyl alcohol foam material is less adherent to wounds, which is better than polyurethane foam material in the aspects of reducing wound bleeding and residual foreign body. Polyvinyl alcohol foam material can be firstly selected to fix and promote skin graft survival after skin grafting, wound bed preparation before skin grafting of burn with large area and deep wound cavity or sinus, etc. Both types of foam materials need to be improved in the aspects of bacterial colonization and prevention and treatment of skin eczema.

Retrospective analysis of 2 997 inpatients with skin and soft tissue injuries

Yang Yi, Chu Wanli, Feng Guang, Zhang Haijun, Hao Daifeng

2020, 36(9): 821-829. doi: 10.3760/cma.j.cn501120-20200202-00036

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Objective To analyze the epidemiological characteristics and the related information on the diagnosis and treatment of inpatients with skin and soft tissue injuries. Methods The medical records of inpatients with skin and soft tissue injuries who were admitted to the Fourth Medical Center of PLA General Hospital (hereinafter referred to as the author′s unit) from January 1, 2014 to December 31, 2018, conforming to the study criteria, were retrospectively analyzed. The indexes included inpatients′gender, age, wound course, underlying disease, wound type, wound site, and wound microbiological culture result, methods and outcome of treatment, type of medical payment, hospital day, and hospitalization cost. Data were statistically analyzed with Mann-Whitney U test, Kruskal-Wallis H test, and chi-square test. Results (1) A total of 2 997 inpatients, conforming to the study criteria, were admitted to the author′s unit during the 5 years. There were 1 803 (60.16%) males and 1 194 (39.84%) females. The distribution of gender of patients showed significant differences during the 5 years (χ²=13.203, P<0.05). The age of female patients was significantly older than that of male patients (Z=-6.387, P<0.01). There were 882 (29.43%) patients with acute wounds and 2 115 (70.57%) patients with chronic wounds. The distribution of acute wounds and chronic wounds of patients showed significant differences during the 5 years (χ²=66.806, P<0.01). The age of patients with chronic wounds was significantly older than that of patients with acute wounds (Z=-12.582, P<0.01). A total of 1 910 patients (3 847 cases) were complicated with underlying diseases. The common underlying diseases orderly were diabetes 1 151 (29.92%) cases, hypertension 884 (22.98%) cases, coro-nary atherosclerotic heart disease 414 (10.76%) cases, old cerebral infarction 258 (6.71%) cases, and paraplegia 258 (6.71%) cases. More patients with chronic wounds were complicated with various underlying diseases compared with patients with acute wounds (χ²=130.649, P<0.01). (2) The common types of wounds were postoperative non-healing wounds, burn wounds, diabetic foot ulcers, pressure ulcers, and skin and soft tissue infection. The distribution of types of wounds showed significant differences during the 5 years (χ²=342.265, P<0.01). There were 3 957 wounds. The common wound sites were feet, legs, chests, and so on. A total of 976 patients underwent microbiological examination. The results of 719 (73.67%) patients were positive and 257 (26.33%) patients were negative. The positive rate of wound microbiological culture of patients with chronic wounds was significantly higher than that of patients with acute wounds (χ²=33.981, P<0.01). Among the patients with acute wounds, 111 patients (72.08%) were simply infected, 43 (27.92%) patients were mixed infected. Among the patients with chronic wounds, 364 (64.42%) patients were simply infected, and 201 (35.58%) patients were mixed infected. A total of 1 010 strains of pathogenic bacteria were detected in 719 patients, including 447 (44.26%) Gram-positive bacteria, 548 (54.26%) Gram-negative bacteria, and 15 (1.48%) fungi. There was a significant difference in the distribution of pathogenic microorganisms between patients with acute wounds and chronic wounds (χ²=12.215, P<0.01). In this group of patients, the common strains of wounds were Staphylococcus aureus, Escherichia coli, Pseudomonas aeruginosa, and so on. The common strains of patients with acute wounds were Staphylococcus aureus, Escherichia coli, Staphylococcus epidermidis, and so on. The common strains of patients with chronic wounds were Staphylococcus aureus, Pseudomonas aeruginosa, Escherichia colis, and so on. (3) The patients in this group were mainly treated by surgery. Finally, 1 330 patients were cured, 1 393 patients were improved, 257 patients were not cured, and 17 patients died. There was a significant difference in the distribution of outcome in patients with acute wounds and chronic wounds (Z=-7.622, P<0.01). (4) The main types of payment of medical expenses for patients in this group were local medical insurance, remote medical insurance, and self-paying. The total hospitalization cost of patients in this group was 169 268 523.65 yuan, which was mainly consist of the costs of materials and drugs. The hospital day of patients in this group was 21.00 (11.00, 36.00) d, and the hospitalization cost was 30 016.34 (14 439.41, 63 685.60) yuan. There were significant differences in the hospital day and hospitalization cost among patients with different medical payment types (χ²=285.986, 327.436, P<0.01). There were significant differences in the hospital day and hospitalization cost among patients with different wound types (χ²=125.912, 131.485, P<0.01). Conclusions The patients with skin and soft tissue injuries are mainly middle-aged and elderly patients, with more males than females, more chronic wounds than acute wounds. Skin and soft tissue injuries are prone to occur in sites with prominent bone, thin subcutaneous fat, and poor blood supply. The result of wound microbiological culture is mainly Gram-negative bacteria, and the positive rate of wound microbiological culture of patients with chronic wounds is higher than that of patients with acute wounds. The proportion of Gram-positive bacterial infection ranks the highest in patients with acute wounds. The proportion of Gram-negative bacterial infection ranks the highest in patients with chronic wounds. Patients with chronic wounds are often complicated with various underlying diseases, and the course of disease is long, so the constituent ratio of cured patients is lower than that of patients with acute wounds. Patients with skin and soft tissue injuries have long hospital days and high proportion of material cost, which are directly related to the clinical characteristics and long treatment cycle of chronic wounds. Therefore, it is suggested that the medical insurance administration department should adjust the consumption ratio and other management indicators according to the actual clinical needs of elderly patients with chronic wounds.

Study of thermal injury effects on human HaCaT cells under simulated microgravity environment

Lin Jingjing, Yan Hongfeng, Sun Peiming, Zhang Tao, Hu Gang, Zhao Yan, Sun Hongwei, Zhou Jinlian, Cui Yan

2020, 36(9): 830-837. doi: 10.3760/cma.j.cn501120-20190718-00301

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Objective To investigate the thermal injury effects on human HaCaT cells under simulated microgravity environment. Methods The human HaCaT cells were collected and divided into simulated microgravity thermal injury (SMGTI) group, normal gravity thermal injury (NGTI) group, and normal gravity false injury (NGFI) group according to the random number table. Cells in NGTI and NGFI groups were cultured routinely in culture bottle, and cells in SMGTI group were cultured in the rotary cell culture system to simulate microgravity environment. Cells in SMGTI and NGTI groups were bathed in hot water of 45 ℃ for 10 minutes to make thermal injury model, and cells in NGFI group were bathed in warm water of 37 ℃ for 10 minutes to simulate thermal injury. At post injury hour (PIH) 12, cell morphology of 3 groups was observed under inverted phase contrast electron microscope. At PIH 2, 6, and 12, single cell suspension in the 3 groups was collected to detect the cell cycle by flow cytometer and the mRNA expressions of heat shock protein 70 (HSP70), matrix metalloproteinase 9 (MMP-9), and cysteine-aspartic protease 3 (caspase-3) by real time fluorescence quantitative reverse transcription polymerase chain reaction, and the experiments were repeated for 3 times. At PIH 2, 6, and 12, cell culture supernatant in the 3 groups was collected to detect the concentration of heparin-binding epidermal growth factor (HB-EGF) by enzyme linked immunosorbent assay method, the experiment was repeated for 3 times. The sample in each group and each time point was 3. Data were statistically analyzed with analysis of variance for factorial design, one-way analysis of variance, least significant difference test, Kruskal-Wallis H test, and Mann-Whitney U test. Results (1) At PIH 12, cells in NGFI group showed regular shape and regular arrangement, with no cell debris. The cell shape in NGTI group was generally regular, with fewer cell debris and closer arrangement than that in NGFI group. The cells in SMGTI group showed more irregular shapes, different sizes, and dead cell debris. (2) The percentage of G1 phase cells in NGTI group was significantly higher than that in NGFI group and SMGTI group at PIH 2, respectively (P<0.05), and the percentage of G1 phase cells in NGTI group was significantly lower than that in NGFI group and SMGTI group at PIH 6 and 12, respectively (P<0.05). The percentage of G2/M phase cells in NGTI group was significantly lower than that in SMGTI group at PIH 2 (P<0.05), and the percentage of G2/M phase cells in NGTI group was significantly higher than that in NGFI group and SMGTI group at PIH 6 and 12, respectively (P<0.05). The percentage of S phase cells in NGTI group at PIH 2, 6, and 12 was significantly higher than that in SMGTI group (P<0.05), and the percentage of S phase cells in NGTI group at PIH 2 and 6 was significantly lower than that in NGFI group (P<0.05). (3) The HSP70 mRNA expressions of cells in NGTI group were 2.50±0.30 and 3.99±0.35 at PIH 2 and 6, which were significantly higher than 1.14±0.15 and 0.82±0.27 in NGFI group (P<0.05), and 1.17±0.53 and 1.65±0.59 in SMGTI group (P<0.05). The MMP-9 mRNA expression of cells in SMGTI group was significantly higher than that in NGTI group at PIH 2, 6, and 12, respectively (Z=-2.319, -2.882, -2.908, P<0.05). At each time point after injury, the mRNA expression of caspase-3 of cells in NGTI group was similar to that in NGFI group and SMGTI group, respectively (P>0.05). (4) The concentration of HB-EGF in cell culture supernatant of NGTI group was significantly lower than that in NGFI group at PIH 2, 6 and 12 (P<0.05), and the concentration of HB-EGF in cell culture supernatant of SMGTI group was significantly higher than that in NGTI group at PIH 2 and 6 (P<0.05). Conclusions The proliferation and secretion functions and expression of wound repair related protein of human HaCaT cells inflicted with thermal injury in simulated microgravity environment showed complex and diversified changes, which provide theoretical basis for further research on damage repair under weightlessness.

Clinical effects of single pedicle transfer of expanded axial flap across the midline of the frontal-parietal region in reconstruction of large scar deformities in the face and neck

Xia Chengde, Xue Jidong, Di Haiping, Cao Dayong, Han Dawei, Xie Jiangfan, Guo Haina, Xing Peipeng, Ma Xianjie

2020, 36(9): 838-844. doi: 10.3760/cma.j.cn501120-20200311-00149

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Objective To explore the clinical effects of single pedicle transfer of expanded axial flap across the midline of the frontal-parietal region in reconstruction of large scar deformities in the face and neck. Methods From January 2016 to August 2019, 10 male patients, aged from 20 to 52 years with post-burn facial and cervical scar deformities, were admitted to the First People′s Hospital of Zhengzhou, with the size of scar ranging from 15 cm×7 cm to 23 cm×11 cm. In the first stage, a cylindrical skin and soft tissue expander with rated capacity ranging from 400 to 600 mL was placed in the frontal-parietal region. Another cylindrical expander with rated capacity ranging from 50 to 100 mL was placed in the temporal region of the patient with scars in front of the ear and in cheek. The injection time was 3 to 5 months with the total injection volume being 1.5 to 2.5 times of the rated capacity of expander. In the second stage, the superficial temporal artery frontal branch and its branches were explored, the expander was removed, the scars in the face and neck were conducted resection and contracture relaxation, and the single pedicle transfer of expanded axial flap across the midline of the frontal-parietal region for reconstruction was performed. When the branches of the superficial temporal vessels were difficult to be detected by Doppler ultrasonic blood stream detector, the patient underwent computed tomography (CT) angiography and three-dimensional reconstruction. The donor site in frontal-parietal region was directly sutured, and the wound of the exposed donor site at the pedicle and temporal region was temporarily covered with scar skin. After the suture wound was healed and the hair in expanded flap grew out, hair removal and laser hair removal were performed. Three to four weeks after transplantation of expanded flap, the flap pedicle was cut off, restored, and trimmed in the third stage. The status about the completion of operation, the implantation of expander in the temporal region, CT angiography and three-dimensional reconstruction were recorded. The effective resection area of expanded flap, the length across the midline and the length of the pedicle, and the survival status of the expanded flap and complications after operation were observed. The appearance of donor and recipient sites, the scar recurrence, the appearance and function improvement of patients, and the satisfaction degree of patients were followed up. Results All the 10 patients successfully completed three stages of operation, of which 6 patients had an auxiliary expander placement in the temporal region, and 5 patients underwent CT angiography and three-dimensional reconstruction. The effective resection area of expanded flap ranged from 18 cm×8 cm to 25 cm×13 cm. The distal end of the flap across the midline extended 4-6 cm to the opposite side, and the length of pedicle was 2-6 cm. All the expanded flaps of patients survived well after formation and transfer. The venous reflux disorder and obvious swelling occurred in 6 patients at the distal end of the flap after operation, and the blood supply recovered after acupuncture bloodletting, etc. Follow-up of 6 to 24 months showed that the color, texture, and thickness of the expanded flaps were similar to those of the facial skin, and no recurrence of scar was observed; the incision in the donor site of the frontal-parietal region was concealed, the hair growth of the temples and head was normal, and the reconstructed hairline was natural; compared with those before operation, the appearance, head-up, mouth-opening, and other functions of patients were significantly improved; the patients were satisfied with the effect of reconstruction. Conclusions Clinical application of single pedicle transfer of expanded axial flap across the midline of the frontal-parietal region in reconstruction of large scar deformities in the face and neck can achieve a good appearance and function, and the donor site shows good shape, which enriches the application range of the trans-regional blood supply flap. It is a reliable method for reconstruction of large scar deformities in the face and neck.

Establishment of nomogram predicting model for the death risk of extremely severe burn patients and the predictive value

Zeng Qingling, Wang Qingmei, Tao Liju, Hao Fen, Luo Qizhi

2020, 36(9): 845-852. doi: 10.3760/cma.j.cn501120-20190620-00280

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Objective To explore the death risk factors of extremely severe burn patients, establish a death risk nomogram predicting model, and investigate the predictive value for death risk of extremely severe burn patients. Methods The medical records of 231 extremely severe burn patients (190 males and 41 females, aged 18-60 years) who were admitted to the Institute of Burn Research of the First Affiliated Hospital of Army Medical University from January 2010 to October 2018 and met the inclusion criteria were analyzed retrospectively. According to the final outcome, the patients were divided into survival group of 173 patients and death group of 58 patients. The sex, age, severity of inhalation injury, total burn area, full-thickness burn area, burn index, rehydration coefficient and urine volume coefficient of the first and second 24 h after injury, the first base excess, shock index, and hematocrit (HCT) after admission, whether to have pre-hospital fluid infusion, use of ventilator, and use of continuous renal replacement therapy (CRRT), and abbreviated burn severity index (ABSI ) and Baux score on admission of patients in the two groups were recorded or calculated. According to the use of ventilator, the patients were divided into with ventilator group of 131 patients and without ventilator group of 100 patients, and the death, total burn surface area, burn index, incidence and severity of inhalation injury were recorded. According to the use of CRRT, the patients were divided into with CRRT group of 59 patients and without CRRT group of 172 patients, and the death, total burn surface area, and burn index were recorded. Data were statistically analyzed with t test, chi-square test, and Mann-Whitney U test to screen the death related factors of patients. The indexes with statistically significant differences between survival group and death group were included in the multivariate logistic regression analysis to screen the independent death risk factors of patients, and the death risk nomogram predicting model was constructed based on the results.The Bootstrap method was used to validate the death risk nomogram predicting model internally. The predictive value of the nomogram model for predicting death risk of patients was detected by drawing calibration graph and calculating concordance index, and the death risk scores of 231 patients were acquired according to the death risk nomogram model. The receiver′s operating characteristic (ROC) curve was drawn, and the optimal threshold and the sensitivity and specificity of optimal threshold in the ROC curve and the area under the curve were calculated. Results (1) There were statistically significant differences in burn index, ABSI on admission, severity of inhalation injury, total burn area, full-thickness burn area, rehydration coefficient at the first 24 h after injury, use of ventilator, use of CRRT, and Baux score on admission of patients between the two groups (Z=-7.696, -7.031, χ²=18.304, 63.065, 23.300, 13.073, 34.240, 59.586, t=-7.536, P<0.01). (2) There were statistically significant differences in death, incidence and severity of inhalation injury, total burn area, and burn index of patients between with ventilator group and without ventilator group (χ²=34.240, 17.394, 25.479, Z=-6.557, -7.049, P<0.01). (3) There were statistically significant differences in death, total burn area, and burn index of patients between with CRRT group and without CRRT group (χ²=62.982, Z= -47.421, -6.678, P<0.01). (4) The use of ventilator, use of CRRT, and burn index were independent risk factors for the death of extremely severe burn patients (odds ratio=3.277, 5.587, 1.067, 95% confidence interval=1.073-10.008, 2.384-13.093, 1.038-1.096, P<0.05 or P<0.01). (5) The initial concordance index of nomogram predicting model was 0.90 and the corrected concordance index was 0.89. The concordance indexes before and after correction were higher and similar, which showed that the nomogram had good concordance and predictive effect. The optimum threshold of ROC curve was 0.23, the sensitivity and specificity of optimum threshold were 86.0% and 80.0%, respectively, and the area under ROC curve was 0.90 (95% confidence interval=0.86-0.94, P<0.01). Conclusions Severe burns and damage and/or failure of organ are the main death causes of extremely severe burn patients. The death risk nomogram predicting model established on the basis of use of ventilator, use of CRRT, and burn index have good predictive ability for death of extremely severe burn patients.

Research value of 50 MHz high-frequency ultrasound on sonography of normal facial skin in adult

Wang Xue, Yang Ruqian, Yang Yuting, Liu Hongjun, Yan Hong

2020, 36(9): 853-860. doi: 10.3760/cma.j.cn501120-20190701-00288

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Objective To observe the differences in normal facial skin thickness and echo density by different ages and sites of healthy adults of the same sex using 50 MHz high-frequency ultrasound. Methods From January to June 2019, 200 healthy adult volunteers with normal facial skin who were from Sichuan, Yunnan, Guizhou, and Chongqing and met the inclusion criteria were recruited by the Affiliated Hospital of Southwest Medical University with simple random sampling method, and then were included in this cross-sectional investigation study. Then 50 MHz high-frequency ultrasound was used to obtain skin ultrasonogram of volunteers′ forehead, canthus, eyelid, and cheek. According to the ages, 100 female volunteers were divided into 20-29 years old (30 females), 30-39 years old (25 females), 40-49 years old (20 females), and 50-70 years old (25 females) groups; 100 male volunteers were divided into 20-29 years old (30 males), 30-39 years old (25 males), 40-49 years old (20 males), and 50-70 years old (25 males) groups. The thickness of full-skin, the upper dermal echo density, and the lower dermal echo density of the female and male volunteers′forehead, canthus, eyelid, and cheek were recorded respectively. Data were statistically analyzed with one-way analysis of variance, analysis of variance for repeated measurement, least significant difference test, and Bonferroni correction. Results (1) The thickness of full-thickness skin in forehead, canthus, eyelid, and cheek of female and male volunteers in 20-29 years old group were (1.86±0.26), (1.36±0.11), (1.24±0.25), and (1.90±0.21) mm, (2.45±0.37), (1.64±0.19), (1.44±0.16), and (2.53±0.26) mm, respectively, in 30-39 years old group were (1.98±0.24), (1.43±0.13), (1.15±0.15), and (2.12±0.13) mm, (2.34±0.27), (1.63±0.27), (1.50±0.38), and (2.43±0.40) mm, respectively, in 40-49 years old group were (1.90±0.21), (1.43±0.18), (1.24±0.27), and (1.98±0.12) mm, (2.14±0.24), (1.54±0.25), (1.28±0.14), and (2.39±0.36) mm, respectively, in 50-70 years old group were (1.64±0.25), (1.36±0.19), (1.16±0.12), and (1.89±0.29) mm, (2.28±0.27), (1.73±0.25), (1.58±0.18), and (2.38±0.32) mm, respectively. There were no statistically significant differences between female volunteers in the 4 groups and male volunteers in the 4 groups in thickness of full-thickness skin in canthus, eyelid, and cheek (F=0.677, 0.666, 0.136, 0.697, 0.294, 0.888, P>0.05). The thickness of full-thickness skin in forehead and cheek of the female volunteers in the 4 groups and male volunteers in the 4 groups was similar (P>0.05), and was significantly higher than that of canthus and eyelid (P<0.05). The thickness of full-thickness skin in canthus and eyelid of female volunteers in 20-29 years old, 40-49 years old, and 50-70 years old group was similar (P>0.05), while thickness of full-thickness skin in canthus and eyelid of male volunteers in the 4 groups was similar (P>0.05). (2) The upper dermal echo density of forehead, canthus, eyelid, and cheek of female volunteers in 50-70 years old group was significantly lower than that in 20-29 years old and 30-39 years old groups (P<0.05). The upper dermal echo density of forehead, canthus, eyelid, and cheek of male volunteers in 50-70 years old group was significantly lower than that in 20-29 years old group (P<0.05). The upper dermal echo density of forehead, canthus, eyelid, and cheek of female and male volunteers in 20-29 years old and 30-39 years old groups was similar (P>0.05). The upper dermal echo density of forehead and cheek of female volunteers in 20-29 years old, 40-49 years old, and 50-70 years old groups was significantly lower than that of canthus and eyelid (P<0.05). The echo density of upper dermis of cheek of male volunteers in the 4 groups was significantly lower than that of canthus and eyelid (P<0.05). The upper dermal echo density of canthus and eyelid of female volunteers in the 4 groups and male volunteers in the 4 groups was similar (P>0.05), the upper dermal echo density of forehead and cheek was similar (P>0.05). (3) The lower dermal echo density of forehead, canthus, eyelid, and cheek of female volunteers in 50-70 years old group was significantly higher than that in 20-29 years old and 30-39 years old groups (P<0.05). The lower dermal echo density of forehead, canthus, eyelid, and cheek of male volunteers in 50-70 years old group was significantly higher than that in 20-29 years old group (P<0.05). The echo density of the lower dermis of forehead, eyelid, and cheek of female and male volunteers in 20-29 years old, 30-39 years old, and 40-49 years old groups was similar (P>0.05). The lower dermal echo density of forehead and cheek of female volunteers in the 4 groups was significantly lower than that of canthus and eyelid (P<0.05). The lower dermal echo density of forehead and cheek of male volunteers in 30-39 years old, 40-49 years old, and 50-70 years old groups was significantly lower than that of canthus and eyelid (P<0.05). The lower dermal echo density between canthus and eyelid and between forehead and check of female volunteers in the 4 groups and male volunteers in the 4 groups was similar (P>0.05). Conclusions The 50 MHz high-frequency ultrasonography shows that the thickness of full-thickness skin of canthus, eyelid, and cheek is similar in all age groups of female and male adult volunteers with normal facial skin. In the same age group, the thickness of full-thickness skin of forehead and cheek of male and female volunteers is significantly higher than that of canthus and eyelid. The upper dermal echo density of forehead, canthus, eyelid, and cheek of female and male volunteers shows a decreasing trend with age, while the lower dermal echo density shows an increasing trend with age. In addition, the echo density of upper and lower dermis of canthus and eyelid was significantly higher than that of cheek in all the four age groups.

Application of antigen-free porcine peritoneum as carrier of autologous microskin grafting in patients with extensive burn

Pan Bohan, Sun Yu, Tang Tao, Xiang Yang, Zhu Shihui

2020, 36(9): 861-864. doi: 10.3760/cma.j.cn501120-20190725-00311

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Abstract:
Objective To investigate the effects of microskin transplantation with antigen-free porcine peritoneum (AFPP) as substitutive carrier for allogeneic skin graft in treating patients with extensive deep burns. Methods Medical records of 32 patients with extensive deep burns, hospitalized in Changhai Hospital of Naval Medical University meeting the inclusion criteria were investigated from January 2014 to December 2017. Twenty patients [12 males and 8 females, aged (35.4±2.2) years]with microskin transplantation using allogeneic skin graft as microskin carrier were included in allogeneic skin graft group and 12 patients [6 males and 6 females, aged (32.1±4.8) years] with microskin transplantation using AFPP as microskin carrier were included in AFPP group. On post injury day 3-7, the vital signs of patients were stable and escharectomy and autologous microskin grafting of head were performed. The expansion ratio of microskin, the application time of albumin and antibiotics, the percentage of infectious autologous microskin grafting area, the survival rate of microskin, and dressing change times of patients in 2 groups were recorded. Data were statistically analyzed with t test. Results The expansion ratio of microskin of patient in AFPP group was 14.8±0.6, which was close to 13.5±0.6 of allogeneic skin graft group (t=1.531, P>0.05). The application time of albumin and antibiotics of patients in AFPP group were close to those of allogeneic skin graft group (t=0.027, 1.121, P>0.05). The percentage of infectious autologous microskin grafting area of patients in AFPP group was (8.5±1.2)%, which was significantly lower than (18.1±0.6)% in allogeneic skin graft group in 4 weeks after surgery(t=7.593, P<0.01), the survival rate of microskin of patients in AFPP group was (82.5±1.1)%, which was significantly higher than (72.5±0.6)% in allogeneic skin graft group (t=8.689, P<0.01). The dressing change time of patients in AFPP group was significantly less than that in allogeneic skin graft group (t=4.743, P<0.01). Conclusions Compared with allogeneic skin graft, microskin transplantation with AFPP as carrier can reduce wound infection, improve the survival rate of microskin graft, and reduce dressing change time, so that AFPP is a good carrier of microskin.

Design and clinical application of specialized protective cap for patients with alopecia after autologous hair transplantation

Li Mengfan, Gu Lan, Wang Ling, Dai Jiaojiao, Yang Xuekang, Guan Hao, Han Juntao, Hu Dahai

2020, 36(9): 865-869. doi: 10.3760/cma.j.cn501120-20190815-00352

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Abstract:
Objective To investigate the design of specialized protective cap for patients with alopecia after autologous hair transplantation and its application value in nursing care after autologous hair transplantation. Methods The author designed a kind of specialized protective cap for patients with alopecia after autologous hair transplantation with elastic gauze, fiber, silica gel, and other materials. It was divided into two parts, the front piece was mainly used to protect the hair receiving site, and the back piece was mainly used for pressure hemostasis at the hair donor site. From February 2017 to January 2019, 81 patients with alopecia and had autologous hair transplantation in the First Affiliated Hospital of Air Force Military Medical University, who met the inclusion criteria, were enrolled in this prospective controlled study. According to the tail number of admission number of each patient, 43 patients with odd numbers were recruited in protective cap group (38 males and 5 females, aged 23 to 52 years) and 38 patients with even numbers were recruited in convention group (34 males and 4 females, aged 22 to 55 years). After hair transplantation surgery, patients in the two groups received routine postoperative education. Patients in the conventional group were treated with conventional dressing after surgery. On this basis, patients in protective cap group wore the specialized protective caps for at least 1 week continuously except for necessary dressing change, wound clean, and dressing remove. The follow-ups was performed by responsible doctors and nurses at clinic. The postoperative hemorrhage at the hair donor site on post surgery day (PSD) 3 and swelling of scalp at the surgical site on PSD 7, the folliculitis at the hair receiving site and survival condition of transplanted hair follicle at the receiving site, and satisfaction score within 3 months after surgery were observed and recorded. Data were statistically analyzed with two independent sample t test, chi-square test, and Fisher′s exact probability test. Results (1) On PSD 3, one patient in protective cap group had hemorrhage at the hair donor site, which was significantly less than 8 patients in convention group (P<0.05). (2) On PSD 7, 4 patients in protective cap group had swelling of scalp at the surgical site, which was significantly less than 11 patients in convention group (χ²=5.160, P<0.05). (3) Within 3 months after surgery, 0 patient in protective cap group had folliculitis at the hair receiving site, which was less than 3 patients in convention group. (4) In 3 months after surgery, the survival number of hair follicle in each 100 transplanted hair follicles at the hair receiving site of patients in protective cap group was 94.9±2.8, which was significantly more than 91.1±4.7 in convention group (t=4.354, P<0.01). (5) The patients′ satisfaction score in protective cap group was (14.2±2.6) points, which was significantly higher than (12.1±3.0) points in convention group (t=3.338, P<0.01). Conclusions After autologous hair transplantation, the specialized protective cap can reduce postoperative hemorrhage at the hair donor site, swelling of scalp at the surgical site, as well as improve the survival rate of transplanted hair follicles at the hair receiving site and score of patient satisfaction.

Thirty-nine cases of stage 4 pressure ulcers treated by a two-stage method of debridement and skin flap transfer