The role of enzymatic debridement in burn care in the COVID-19 pandemic. Commentary by the Italian Society of Burn Surgery (SIUST)

Abstract Introduction Bromelain based Enzymatic Debridement (ED) has been introduced as an additional concept to the burn surgeon’s armamentarium, and is best indicated for mid-to deep dermal burns with mixed patterns. Increasing evidence has been published on special regions and settings, adressing success and limitations of ED for improved patient care. To better guide ED in view of the increasing experience, there is a need to publish updated consensus guidelines with user-orientated recommendations. Methods A multiprofessional expert panel of plastic surgeons and burn care specialists from 10 European countries was convened, to assist in developing current recommendations for best practices with use of ED. Consensus statements were based on peer-reviewed publications and clinical relevance. For consensus agreement, the methodology employed was an agreement algorithm based on a modification of the Willy and Stellar method. For this study on ED, consensus was considered when there was at least 80 % agreement to each statement. Results The updated consensus guidelines from 2019 refer to a diversity of experience and practice patterns of 1232 summarized patient cases in Europe (2017: 500 cases), reflecting the impact of the published recommendations. Forty-three statements were formulated, addressing the following topics: indications, pain management and anesthesia, large surface indication, timing of application for various indications, preparation and application, post-interventional wound management, skin grafting, outcome, scar and revision management, cost-effectiveness, patient′s perspective, logistic aspects and training strategies. The degree of consensus was remarkably high, with consensus in 42 of 43 statements (97.7%), while no consensus was achieved on the role of outpatient treatment/ED as day cases in minor burns in experienced burn centers. A classifications with regard to timing of application for ED was introduced, with „immediate/ very early“(≤12h), early (12-72h) or delayed (>72h) treatment. All further recommendations are addressed in the presentation. Conclusions The updated guidelines in this paper represent further refinement of the recommended indication, application and post-interventional management for the use of ED. The published statements contain detailed, user-orientated recommendations aiming to align current and future users and prevent unnecessary pitfalls. The significance of this work is reflected by the magnitude of patient experience behind it, larger than the total number of patients treated in all published ED clinical trials. Applicability of Research to Practice These consensus guidelines may serve as refined user-orientated recommendations for implementation and successful application of ED in further countries (e.g. USA) based on the evidence and experience of 1232 summarized patient cases.

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Perspective on Contemporary Burn Surgery and Burn Care in Sweden

Scandinavian Journal of Surgery ◽

10.1177/145749690309200408 ◽

2003 ◽

Vol 92 (4) ◽

pp. 281-286 ◽

Cited By ~ 1

Author(s):

D. Jergovic ◽

P.A. Danielsson

Keyword(s):

Burn Care ◽

Burn Surgery

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Italian recommendations on enzymatic debridement in burn surgery

Burns ◽

10.1016/j.burns.2020.07.006 ◽

2020 ◽

Author(s):

Rosario Ranno ◽

Michelangelo Vestita ◽

Giulio Maggio ◽

Pasquale Verrienti ◽

Davide Melandri ◽

...

Keyword(s):

Burn Surgery ◽

Enzymatic Debridement

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Gender Disparities Among Burn Surgery Leadership

Journal of Burn Care & Research ◽

10.1093/jbcr/iraa013 ◽

2020 ◽

Vol 41 (3) ◽

pp. 674-680 ◽

Cited By ~ 1

Author(s):

Anisha Konanur ◽

Francesco M Egro ◽

Caroline E Kettering ◽

Brandon T Smith ◽

Alain C Corcos ◽

...

Keyword(s):

Gender Diversity ◽

Junior Faculty ◽

Fellowship Training ◽

Cross Sectional Study ◽

Gender Disparities ◽

Cross Sectional ◽

Burn Care ◽

Burn Unit ◽

Burn Surgery

Abstract Gender disparities have been described in the plastic surgery and general surgery literature, but no data have been reported in burn surgery. The aim of this study is to determine gender disparities among burn surgery leadership. A cross-sectional study was performed. Burn surgeons included were directors of American Burn Association (ABA)-verified burn centers, past presidents of the ABA, and International Society for Burn Injuries (ISBI), and editors of the Journal of Burn Care & Research, Burns, Burns & Trauma, Annals of Burns & Fire Disasters, and the International Journal of Burns and Trauma. Training, age, H-index, and academic level and leadership position were compared among surgeons identified. Among the 69 ABA and ISBI past presidents, 203 burn journals’ editorial board members, and 71 burn unit directors, females represented only 2.9%, 10.5%, and 17%, respectively. Among burn unit directors, females completed fellowship training more recently than males (female = 2006, male = 1999, P < .02), have lower H-indexes (female = 8.6, male = 17.3, P = .03), and are less represented as full professors (female = 8.3%, male = 42.4%, P = .026). There were no differences in age, residency, research fellowship, or number of fellowships. Gender disparities exist in burn surgery and are highlighted at the leadership level, even though female surgeons have a similar age, residency training, and other background factors. However, gender diversity in burn surgery may improve as females in junior faculty positions advance in their careers.

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746 Racial and Ethnic Disparities Among Burn Surgery Leadership

Journal of Burn Care & Research ◽

10.1093/jbcr/iraa024.328 ◽

2020 ◽

Vol 41 (Supplement_1) ◽

pp. S206-S206

Author(s):

Francesco M Egro ◽

Caroline E Kettering ◽

Anisha Konanur ◽

Alain C Corcos ◽

Guy M Stofman ◽

...

Keyword(s):

Group Representation ◽

Minority Group ◽

Ethnic Disparities ◽

Full Professor ◽

Academic Rank ◽

H Index ◽

Burn Care ◽

Burn Center ◽

Major Burn ◽

Burn Surgery

Abstract Introduction The underrepresentation of racial and ethnic minority groups has existed and been well documented in general and plastic surgery literature but has not been described in burn surgery. The aim of this study is to evaluate current minority group representation among burn surgery leadership. Methods A cross-sectional study was performed in January 2019 to evaluate minority group representation among burn surgery leadership. Burn surgeons included were directors of American Burn Association (ABA)-verified burn centers in the US, past and current presidents of the ABA and International Society of Burn Injuries (ISBI), and editorial board members of five major burn journals (Journal of Burn Care & Research, Burns, Burns & Trauma, Annals of Burns & Fire Disasters, and the International Journal of Burns and Trauma). Surgeons were compared based on factors including age, gender, training, academic rank, and h-index. Results Among 71 burn center directors, 68 societal presidents, and 197 journal editors, minority ethnic groups represented 18.3, 7.4, and 34.5 percent, respectively. Among US burn center directors, the group classified collectively as non-white was significantly younger (white = 56 years, non-white = 49 years; p< 0.01), graduated more recently (white = 1996, non-white = 2003; p < 0.01), and had a lower h-index (white = 17.4, non-white = 9.5; p < 0.05) than white colleagues. There were no significant differences in gender, type of residency training, advanced degrees obtained, and fellowships completed between white and non-white groups.The were no significant differences in the likelihood of white and non-white directors in academia to be full professor, residency or fellowship director, or chair of the department.When compared to the 2018 US National Census, burn unit directors had a 5.1 percent decrease in non-white representation. Specifically, Asians had an 8.3 percent increase in representation, while there was a decrease in both Black (12.0%) and Hispanic (15.3%) representation. Conclusions Disparities in representation of ethnic and racial minorities exist in burn surgery leadership. The most extreme disparities were seen with Black and Hispanic surgeons. However, because these surgeons are younger and graduated more recently, it is promising that minority representation will continue to rise in the future. Applicability of Research to Practice Programs should be initiated in burn surgery that address the implicit biases of burn surgeons and increase mentorship opportunities for underrepresented minorities.

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The Role of Telemedicine in Follow-up Burn Care

Journal of Burn Care & Rehabilitation ◽

10.1097/00004630-200103002-00260 ◽

2001 ◽

Vol 22 ◽

pp. S177

Author(s):

F. P. Redlick ◽

B. Roston ◽

M. Gomez ◽

R. C. Cartotto ◽

J. S. Fish

Keyword(s):

Burn Care

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The role of inferior petrosal sinus sampling in ACTH-dependent Cushing's syndrome: review and joint opinion statement by members of the Italian Society for Endocrinology, Italian Society for Neurosurgery, and Italian Society for Neuroradiology

Neurosurgical FOCUS ◽

10.3171/2014.11.focus14766 ◽

2015 ◽

Vol 38 (2) ◽

pp. E5 ◽

Cited By ~ 31

Author(s):

Francesca Pecori Giraldi ◽

Luigi Maria Cavallo ◽

Fabio Tortora ◽

Rosario Pivonello ◽

Annamaria Colao ◽

...

Keyword(s):

Cushing’S Syndrome ◽

Adrenocorticotropic Hormone ◽

Dynamic Testing ◽

Cushing's Syndrome ◽

Italian Society ◽

The Other ◽

Inferior Petrosal Sinus ◽

Etiological Diagnosis ◽

Inferior Petrosal Sinus Sampling

In the management of adrenocorticotropic hormone (ACTH)–dependent Cushing's syndrome, inferior petrosal sinus sampling (IPSS) provides information for the endocrinologist, the neurosurgeon, and the neuroradiologist. To the endocrinologist who performs the etiological diagnosis, results of IPSS confirm or exclude the diagnosis of Cushing's disease with 80%–100% sensitivity and over 95% specificity. Baseline central-peripheral gradients have suboptimal accuracy, and stimulation with corticotropin-releasing hormone (CRH), possibly desmopressin, has to be performed. The rationale for the use of IPSS in this context depends on other diagnostic means, taking availability of CRH and reliability of dynamic testing and pituitary imaging into account. As regards the other specialists, the neuroradiologist may collate results of IPSS with findings at imaging, while IPSS may prove useful to the neurosurgeon to chart a surgical course. The present review illustrates the current standpoint of these 3 specialists on the role of IPSS.

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Burn Care in the Era of Rapid Enzymatic Debridement: Challenging the Dogma that Healing Beyond 21 Days Results in Hypertrophic Scarring

The Open Dermatology Journal ◽

10.2174/1874372202115010066 ◽

2021 ◽

Vol 15 (1) ◽

pp. 66-77

Author(s):

Lior Rosenberg ◽

Yaron Shoham ◽

Stan Monstrey ◽

Henk Hoeksema ◽

Jeremy Goverman ◽

...

Keyword(s):

Inflammatory Response ◽

Granulation Tissue ◽

Wound Closure ◽

Major Advance ◽

Tissue Formation ◽

Hypertrophic Scarring ◽

Granulation Tissue Formation ◽

Burn Care ◽

Secondary Intention ◽

Enzymatic Debridement

Deep burns are characterized by the presence of a necrotic eschar that delays healing and results in a local and systemic inflammatory response and following healing by secondary intention: heavy scarring. Early surgical debridement followed by grafting was a major advance in deep burn care and is now the standard of care, reducing mortality and hypertrophic scarring. Eschars have alternatively been managed by non-surgical, autolytic debridement, which often results in infection-inflammation, slow epithelialization, granulation tissue formation and subsequent scarring. Studies based on these traditional approaches have demonstrated an association between delayed wound closure (beyond 21 days) and scarring. Early enzymatic debridement with NexoBrid (NXB) followed by appropriate wound care is a novel minimally invasive modality that challenges the well-accepted dictum of a high risk of hypertrophic scarring associated with wound closure that extends beyond 21 days. This is not surprising since early and selective removal of only the necrotic eschar often leaves enough viable dermis and skin appendages to allow healing by epithelialization over the dermis. In the absence of necrotic tissue, healing is similar to epithelialization of clean dermal wounds (like many donor sites) and not healing by the secondary intention that is based on granulation tissue formation and subsequent scarring. If and when granulation islands start to appear on the epithelializing dermis, they and the inflammatory response generally can be controlled by short courses (1-3 days) of topically applied low strength corticosteroid ointments minimizing the risk of hypertrophic scarring, albeit with wound closure delayed beyond the magic number of 21 days. Results from multiple studies and field experience confirm that while deep burns managed with early enzymatic debridement often require more than 21 days to reepithelialize, long-term cosmetic results are at least as good as with excision and grafting.

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Italian Society of Arterial Hypertension (SIIA) Position Paper on the Role of Renal Denervation in the Management of the Difficult-to-Treat Hypertensive Patient

High Blood Pressure & Cardiovascular Prevention ◽

10.1007/s40292-020-00367-0 ◽

2020 ◽

Vol 27 (2) ◽

pp. 109-117 ◽

Cited By ~ 2

Author(s):

Rosa Maria Bruno ◽

Stefano Taddei ◽

Claudio Borghi ◽

Furio Colivicchi ◽

Giovambattista Desideri ◽

...

Keyword(s):

Arterial Hypertension ◽

Hypertensive Patient ◽

Renal Denervation ◽

Position Paper ◽

Italian Society

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The role of plastic and reconstructive surgeon in trauma care: Perspectives from a Level 1 trauma centre in India

Indian Journal of Plastic Surgery ◽

10.4103/ijps.ijps_212_17 ◽

2018 ◽

Vol 51 (02) ◽

pp. 170-176

Author(s):

Maneesh Singhal ◽

Ravikiran Naalla ◽

Aniket Dave ◽

Moumita De ◽

Deepti Gupta ◽

...

Keyword(s):

Trauma Care ◽

Demographic Data ◽

Maxillofacial Surgery ◽

Trauma Centre ◽

Care Facilities ◽

Integral Role ◽

Burn Surgery ◽

Post Traumatic ◽

Level 1

ABSTRACT Background: As the morbidity and mortality due to trauma are ever increasing, there is proportionally growing need of trauma care facilities across the country. In the context of expanding designated trauma care facilities, the role of plastic and reconstructive surgeon needs to be analysed and defined at least at a Level 1 trauma centre. Materials and Methods: We included the patients who were operated under the department of plastic, reconstructive & burns surgery at a Level 1 urban trauma centre between January 2016 and December 2017. We analysed the demographic data and categorised operative data according to anatomical areas and interacting specialties. Results: A total of 1539 procedures were performed under the division of plastic reconstructive and burn surgery. Amongst them, 81% were male, and 19% were female. Mean age was 27.3 years (range: 3–90 years). The anatomical locations treated were upper limb (49%), lower limb (35%), head and neck (8%) and trunk (8%). Interdepartmental cases were 600 and majority of them were in collaboration with orthopaedics (n = 298), general surgery (n = 163), neurosurgery (79) and maxillofacial surgery (60). Conclusion: There is a significant role of plastic surgeon at a Level 1 trauma centre in India. The plastic surgeon's interventions are limb saving and sometimes lifesaving, many at times morbidity of post-traumatic sequelae are either prevented or treated. Along with other core specialties involved in the management of trauma, plastic surgeons play an integral role in a Level 1 trauma centre. The policymakers should take note to augment the number of plastic surgeons at a Level 1 apex trauma centre on par with other specialties, as the workload is heavy and is steadily on an increasing trend.

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