Divulging the Complexities of Deep Partial- and Full-Thickness Burn Wounds Afflicted by Staphylococcus Aureus Biofilms in a Rat Burn Model

Every year, thousands of soldiers and civilians succumb to burn wound trauma with highly unfavorable outcomes. We previously established a modified Walker-Mason rat scald model exhibiting a P. aeruginosa infection. Here we characterize deep partial- (DPT) and full-thickness (FT) burn wounds inoculated with Staphylococcus aureus. Male Sprague-Dawley rats (350–450 g) inflicted with 10% total body surface area burn inoculated with S. aureus (103–5 CFU/wound) were monitored over an 11-day period. S. aureus rapidly dominated the wound bed, with bacterial loads reaching at least 1 × 109 CFU/g tissue in all wounds. Within 3 days, S. aureus biofilm formation occurred based on genetic transcripts and Giemsa staining of the tissue. S. aureus infection resulted in a slightly faster recruitment of neutrophils in FT wounds, which was related to necrotic neutrophils. The extent of the inflammatory response in S. aureus infected burn wounds correlated with elevated G-CSF, GM-CSF, GRO/KC and/or TNF-α levels, but a majority of pro- and anti-inflammatory cytokines (IL-1β, IL-6, IFN-γ, IL-10, and IL-13) were found to be suppressed, compared to burn-only controls. S. aureus infection resulted in dynamic changes in DAMPs, including elevated HMGB-1 and reduced levels of circulating hyaluronan within FT wounds. S. aureus also reduced complement C3 at all time points in DPT and FT wounds. These changes in DAMPs are believed to be correlated with burn severity and S. aureus specific bioburden. Collectively, this model showcases the evasiveness of S. aureus through dampening the immune response to flourish in the burn wound.

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Deep Learning Assisted Burn Wound Diagnosis (Preprint)

10.2196/preprints.22798 ◽

2020 ◽

Author(s):

Che Wei Chang ◽

Feipei Lai ◽

Mesakh Christian ◽

Yu Chun Chen ◽

Ching Hsu ◽

...

Keyword(s):

Deep Learning ◽

Total Body Surface Area ◽

Ground Truth ◽

Burn Patients ◽

Burn Wound ◽

Burn Wounds ◽

Burn Victims ◽

Step Procedure ◽

Resuscitation Fluid ◽

Total Body

BACKGROUND Accurate assessment of the percentage of total body surface area (%TBSA) of burn wounds is crucial in the management of burn patients. The resuscitation fluid and nutritional needs of burn patients, their need for intensive unit care, and probability of mortality are all directly related to %TBSA. It is difficult to estimate a burn area of irregular shape by inspection. Many articles have reported discrepancy in estimating %TBSA by different doctors. OBJECTIVE We propose a method, based on deep learning, for burn wound detection, segmentation and calculation of % TBSA on a pixel-to-pixel basis. METHODS A two-step procedure was used to convert burn wound diagnosis into %TBSA. In the first step, images of burn wounds were collected and labeled by burn surgeons and the dataset was then input into two deep learning architectures, U-Net and Mask R-CNN, each configured with two different backbones, to segment the burn wounds. In the second step, we collected and labeled images of hands to create another dataset, which was also input into U-Net and Mask R-CNN to segment the hands. The percentage of TBSA of the burn wounds was then calculated by comparing the pixels of mask areas on the images of the burn wound and hand of the same patient according to the rule of hand, which says that one’s hand accounts for 0.8% of TBSA. RESULTS A total of 2591 images of burn wounds were collected and labeled to form the burn-wound dataset. The dataset was randomly split into a ratio of 8:1:1 to form the training, validation, and testing sets. Four hundred images of volar hands were collected and labeled to form the hand dataset, which was also split into three sets using the same method. For the images of burn wounds, Mask R-CNN with ResNet101 had the best segmentation result with a Dice coefficient (DC) of 0.9496, while U-Net with ResNet101 had a DC of 0.8545. For the hand images, U-Net and Mask R-CNN had similar performance with a DC of 0.9920 and 0.9910, respectively. Lastly, we conducted a test diagnosis in a burn patient. Mask R-CNN with ResNet-101 had on average less deviation (0.115% TBSA) from the ground truth than burn surgeons. CONCLUSIONS This is one of the first studies to diagnose all depths of burn wounds and convert the segmentation results into %TBSA using different deep learning models. We aimed to assist medical staff in estimating burn size more accurately and thereby helping to provide precise care to burn victims.

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Adipose-Derived Stem Cell Condition Medium Enhances Expression of Ephrin-B2 Related to Neovascularization in Burn Wound Tissue

Advanced Science Letters ◽

10.1166/asl.2018.12668 ◽

2018 ◽

Vol 24 (8) ◽

pp. 6168-6172

Author(s):

Elvin Clara Angmalisang ◽

Dewi Sukmawati ◽

Lia Damayanti ◽

Astheria Eryani ◽

Jeanne A Pawitan

Keyword(s):

Wound Healing ◽

Conditioned Medium ◽

Granulation Tissue ◽

Skin Wound ◽

Full Thickness ◽

Sprague Dawley ◽

Burn Wound ◽

Burn Wounds ◽

Burn Wound Healing ◽

Wound Tissue

The transmembrane ligand ephrin-B2 is molecular marker for arterial endothelial cells and early blood vessel formation. Neovascularization is one of the important event that support wound healing. Adiposederived stem cells conditioned medium (ADSC-CM) is known to contain cytokines and growth factors as regenerative agent. This study aims to investigate the effect of ADSC-CM on ephrin-B2 expression that represent as neovascularization marker in burn wound granulation tissue. Male Sprague dawley rats were randomly divided into control, conditioned medium (CM) and medium complete (MC) groups. Full-thickness burn wounds were created by placing preheated metal plat on dorsal thorax of the prepared rats. The burn wounds were treated once daily according to their group. Skin wound tissues were collected at day 7, 14, and 21 post wounded for histological analysis. The expression of ephrin-B2 was demonstrated by immunohistochemistry staining. Neovascularization evaluation was done by calculating the number of newly formed capillaries that expressed Ephrin-B2 in wound granulation tissues. Expression of Ephrin-B2 in burn wound tissue was prominently increased in CM compared to control and MC groups on day 7, 14 and 21 post wounded. The CM group also showed higher neovascular number in granulation tissue compared to control and MC group on day 7, 14 and 21 (p < 0.05). Our results showed prominent ephrin-B2 expression in burn wound tissue after treated with ADSC-CM. Topical application of ADSC-CM has shown to promote angiogenesis in full-thickness burn wound in part through the increased of ephrin-B2 expression. Therefore ADSC-CM could act as an alternative strategy to promote burn wound healing.

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Formation of Pseudomonas aeruginosa Biofilms in Full-thickness Scald Burn Wounds in Rats

Scientific Reports ◽

10.1038/s41598-019-50003-8 ◽

2019 ◽

Vol 9 (1) ◽

Cited By ~ 5

Author(s):

Kenneth S. Brandenburg ◽

Alan J. Weaver ◽

S. L. Rajasekhar Karna ◽

Tao You ◽

Ping Chen ◽

...

Keyword(s):

Pseudomonas Aeruginosa ◽

Burn Injury ◽

Infection Model ◽

Myeloperoxidase Activity ◽

Full Thickness ◽

Sprague Dawley ◽

Burn Wound ◽

Bacterial Gene ◽

Burn Wounds ◽

Cell Counts

Abstract Using Sprague-Dawley rats (350–450 g; n = 61) and the recently updated Walker-Mason rat scald burn model, we demonstrated that Pseudomonas aeruginosa readily formed biofilms within full-thickness burn wounds. Following the burn, wounds were surface-inoculated with P. aeruginosa in phosphate-buffered saline (PBS), while sterile PBS was used for controls. On post-burn days 1, 3, 7, and 11, animals were euthanized and samples collected for quantitative bacteriology, bacterial gene expression, complete blood cell counts, histology, and myeloperoxidase activity. Robust biofilm infections developed in the full-thickness burn wounds inoculated with 1 × 104 CFU of P. aeruginosa. Both histology and scanning electron microscopy showed the pathogen throughout the histologic cross-sections of burned skin. Quantigene analysis revealed significant upregulation of alginate and pellicle biofilm matrix genes of P. aeruginosa within the burn eschar. Additionally, expression of P. aeruginosa proteases and siderophores increased significantly in the burn wound environment. Interestingly, the host’s neutrophil response to the pathogen was not elevated in either the eschar or circulating blood when compared to the control burn. This new full-thickness burn biofilm infection model will be used to test new anti-biofilm therapies that may be deployed with soldiers in combat for immediate use at the site of burn injury on the battlefield.

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556 The Use of a Concentrated Surfactant Based Gel to Promote Burn Wound Healing

Journal of Burn Care & Research ◽

10.1093/jbcr/irab032.206 ◽

2021 ◽

Vol 42 (Supplement_1) ◽

pp. S126-S127

Author(s):

Rebecca Coffey ◽

Rachel Penny

Keyword(s):

Wound Healing ◽

New Product ◽

Ease Of Use ◽

Burn Injuries ◽

Full Thickness ◽

Burn Wound ◽

Burn Wounds ◽

Burn Care ◽

Product Trial ◽

Burn Wound Healing

Abstract Introduction Strategies to remove necrotic tissue from burn wounds include excisional and non-excisional debridement. Alternative treatments could promote burn wound healing while minimizing patient discomfort and the need for surgery. We evaluated the usage of a concentrated surfactant gel (CSG) to promote burn wound healing in those with indeterminate depth and full thickness burn injuries. Methods An IRB approved retrospective study was conducted during a 10-patient new product trial period with enrollment between September and October 2019. Patients included in this study had indeterminate or full thickness burn wounds and were treated with a concentrated surfactant-based gel. Patients with non-burn diagnoses were excluded. Data collected included demographic information, injury descriptors, and additional burn wound characteristics. Results A total of 10 patients were included in this study as part of a new product trial. The subjects were 80% male with an average TBSA of 7.5%. 40% had indeterminate and 60% had full thickness burn wounds. Prior to initiation of the CSG, the burn wounds had been open for an average of 41 days. There were no infections or complications with usage of the CSG. 90% of patients reported less pain than the standard of care topical agents for burns. Average duration of treatment with the CSG until healing was 28 days. After usage of the CSG, no patients required surgery. Conclusions Our findings support the usage of a concentrated surfactant-based gel in patients with burn wounds. Patients reported decreased pain during dressing changes and ease of use compared to the standard topical agent in burn care. It also prevented surgical debridement in those with indeterminate and full thickness burn injuries.

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549 Lessons Learned from Two Survivors of Greater Than 90% Total Body Surface Area Full Thickness Burn Injuries Using a Dermal Biodegradable Substitute and Autologous Skin Cell Suspension: A Case Series

Journal of Burn Care & Research ◽

10.1093/jbcr/irab032.199 ◽

2021 ◽

Vol 42 (Supplement_1) ◽

pp. S123-S123

Author(s):

Aldin Malkoc ◽

David Wong

Keyword(s):

Cell Suspension ◽

Body Surface ◽

Total Body Surface Area ◽

Fluid Loss ◽

Dermal Substitute ◽

Full Thickness ◽

Skin Cell ◽

Thickness Skin ◽

Total Body ◽

Skin Coverage

Abstract Introduction Advances in burn injury knowledge, critical care, and pharmacological developments have increased survival rates among extensive burn patients. Survival now dependents not just on skin coverage, but effective control of SIRS response, metabolic derangement, fluid loss and sepsis. Novel synthetic dermal substitutes create robustness, thickness, and pliability of the skin in addition to an improved aesthetic appearance while; point-of-care autologous skin cell harvesting enhances treatment by amplifying small split-thickness skin samples to produce an autologous skin cell suspension (ASCS) to cover a larger burn area. This study reports on two survivors with greater than 90% total body surface area full-thickness burns utilizing a combined treatment of a dermal substitute along with ASCS and traditional burn management strategies. Methods Chart review of two patients with >90% burns and inhalation injury after being trapped in a burning vehicle following a traffic collision occurred. Most of the burns in both patients were “leathery” and consistent with full thickness, sparing only the plantar and dorsal aspect of the feet and bilateral small areas of the hip in Patient 1. Patient 2 had fourth-degree burns in some areas of the chest and flank with only the bilateral groin regions and feet spared. The patients were treated with a multi-step process which included using allograft, dermal substitute, and ASCS with split-thickness skin grafts (STSG) in place of cultured epidermal autograft to achieve coverage of >90% burns with high meshed ratio. Results The dermal substitute was limited to deep burns that penetrated down to fat, muscle, and/or joints. Fluid loss was well controlled by the dermal substitute during initial resuscitation. Post reconstruction, areas covered with the dermal substitute and grafted with autogenous STSG with ASCS exhibited less hypertrophy and contracture bands. The elbow and knee joints showed minimal restriction with passive motion and good skin compliance, but contractures persisted in areas where 4th degree tendon and fascia thermal injury occurred. Areas that showed signs of infection were trimmed or unroofed and allowed to drain while maintaining the remainder of the dermal substitute. Conclusions The use of dermal substitutes and ASCS allowed the care team to achieve SIRS control, improved fluid management, enhanced skin coverage, and reduced hospitalization stay. The process experienced in these cases shows promise for future patients with extensive burns. Both patients were able to survive and show improvement during rehabilitation.

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A Framework for Automatic Burn Image Segmentation and Burn Depth Diagnosis Using Deep Learning

Computational and Mathematical Methods in Medicine ◽

10.1155/2021/5514224 ◽

2021 ◽

Vol 2021 ◽

pp. 1-12

Author(s):

Hao Liu ◽

Keqiang Yue ◽

Siyi Cheng ◽

Wenjun Li ◽

Zhihui Fu

Keyword(s):

Deep Learning ◽

Total Body Surface Area ◽

High Morbidity ◽

Learning Technology ◽

Human Errors ◽

Burn Wounds ◽

Output Structure ◽

Network Output ◽

Total Body ◽

Burn Depth

Burn is a common traumatic disease with high morbidity and mortality. The treatment of burns requires accurate and reliable diagnosis of burn wounds and burn depth, which can save lives in some cases. However, due to the complexity of burn wounds, the early diagnosis of burns lacks accuracy and difference. Therefore, we use deep learning technology to automate and standardize burn diagnosis to reduce human errors and improve burn diagnosis. First, the burn dataset with detailed burn area segmentation and burn depth labelling is created. Then, an end-to-end framework based on deep learning method for advanced burn area segmentation and burn depth diagnosis is proposed. The framework is firstly used to segment the burn area in the burn images. On this basis, the calculation of the percentage of the burn area in the total body surface area (TBSA) can be realized by extending the network output structure and the labels of the burn dataset. Then, the framework is used to segment multiple burn depth areas. Finally, the network achieves the best result with IOU of 0.8467 for the segmentation of burn and no burn area. And for multiple burn depth areas segmentation, the best average IOU is 0.5144.

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Acanthus ebracteatusVahl. Ethanol Extract Enhancement of the Efficacy of the Collagen Scaffold in Wound Closure: A Study in a Full-Thickness-Wound Mouse Model

Journal of Biomedicine and Biotechnology ◽

10.1155/2012/754527 ◽

2012 ◽

Vol 2012 ◽

pp. 1-8 ◽

Cited By ~ 9

Author(s):

Jutamas Somchaichana ◽

Tanom Bunaprasert ◽

Suthiluk Patumraj

Keyword(s):

Wound Closure ◽

Total Body Surface Area ◽

Collagen Scaffold ◽

Ethanol Extract ◽

Neutrophil Infiltration ◽

Skin Incision ◽

Full Thickness ◽

Combined Application ◽

Acanthus Ebracteatus ◽

Total Body

Acanthus ebracteatusVahl. is a Thai herb that is effective in wound healing. We sought to quantitatively determine whether or not the combined application ofAcanthus ebracteatusVahl. and a collagen scaffold will increase wound closure and angiogenesis. Balb/c mice (body weight: 22–25 g) were anesthetized with sodium thiopental. The dorsal skin incision measuring 1.5 × 1.5 cm was made and then deepened using scissors to produce a full-thickness incision down to the level of the panniculus carnosus. The size of the wound was approximately 10% of the total body surface area. The collagen sheet was implanted onto the wound. Animals were divided into 4 major groups as follows: wound with normal saline (W-NSS), wound treated with 0.3 g/kg BW ofAcanthus ebracteatusVahl. extract (W-AE (0.3 g/kg.bw)), wound implanted with collagen scaffold (W-Coll), and wound implanted with collagen scaffold and treated with 0.3 g/kg BW ofAcanthus ebracteatusVahl. (W-Coll-AE combination). On day 14, the W-Coll-AE group showed decreased wound areas and increased capillary vascularity (CV) when compared to the other 3 groups, W-NSS, W-AE0.3, and W-Coll. In the present study, the combination of AE0.3 with collagen showed the best effect on skin angiogenesis and promoted wound closure with less neutrophil infiltration.

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Dermal Nanoemulsion Treatment Reduces Burn Wound Conversion and Improves Skin Healing in a Porcine Model of Thermal Burn Injury

Journal of Burn Care & Research ◽

10.1093/jbcr/irab118 ◽

2021 ◽

Author(s):

Vladislav A Dolgachev ◽

Susan Ciotti ◽

Emma Liechty ◽

Benjamin Levi ◽

Stewart C Wang ◽

...

Keyword(s):

Burn Injury ◽

Hair Follicles ◽

Silver Sulfadiazine ◽

Histological Evaluation ◽

Full Thickness ◽

Burn Wound ◽

Thermal Burn ◽

Burn Wounds ◽

Partial Thickness ◽

Mediators Of Inflammation

Abstract Objective Burn wound progression is an inflammation driven process where an initial partial-thickness thermal burn wound can evolve over time to a full-thickness injury. We have developed an oil-in-water nanoemulsion formulation (NB-201) containing benzalkonium chloride for use in burn wounds that is antimicrobial and potentially inhibits burn wound progression. We used a porcine burn injury model to evaluate the effect of topical nanoemulsion treatment on burn wound conversion and healing. Methods Anesthetized swine received thermal burn wounds using a 25cm 2 surface area copper bar heated to 80 oC. Three different concentrations of NB-201 (10%, 20%, or 40% nanoemulsion), silver sulfadiazine cream or saline were applied to burned skin immediately after injury and on days 1, 2, 4, 7, 10, 14, and 18 post-injury. Digital images and skin biopsies were taken at each dressing change. Skin biopsy samples were stained for histological evaluation and graded. Skin tissue samples were also assayed for mediators of inflammation. Results Dermal treatment with NB-201 diminished thermal burn wound conversion to a full-thickness injury as determined by both histological and visual evaluation. Comparison of epithelial restoration on day 21 showed that 77.8% of the nanoemulsion treated wounds had an epidermal injury score of 0 compared to 16.7% of the silver sulfadiazine treated burns (p=0.01). Silver sulfadiazine cream and saline treated wounds (controls) converted to full-thickness burns by day 4. Histological evaluation revealed reduced inflammation and evidence of skin injury in NB-201 treated sites compared to control wounds. The nanoemulsion treated wounds often healed with complete regrowth of epithelium and no loss of hair follicles (NB-201: 4.8±2.1, saline: 0±0, silver sulfadiazine: 0±0 hair follicles per 4mm biopsy section, p<0.05). Production of inflammatory mediators and sequestration of neutrophils were also inhibited by NB-201. Conclusions Topically applied NB-201 prevented the progression of a partial-thickness burn wound to full-thickness injury and was associated with a concurrent decrease in dermal inflammation.

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524 Effectiveness of Burns Wound Cleansing by Comparison of Prewash and Post Wash Swab Reports

British Journal of Surgery ◽

10.1093/bjs/znab259.062 ◽

2021 ◽

Vol 108 (Supplement_6) ◽

Author(s):

M A Sayed ◽

S Jabeen ◽

A Soueid

Keyword(s):

Bacterial Load ◽

Total Body Surface Area ◽

Wound Management ◽

Burn Patients ◽

Burn Wound ◽

Staph Aureus ◽

Sex Type ◽

Total Body ◽

Burns Unit ◽

Type Of Injury

Abstract Aim The main aim and objective were to optimise wound healing through infection prevention. This clinical audit aimed to investigate the effectiveness of burn wound cleansing in decreasing bacterial load by comparing pre-wash and post-wash swab results against local burn wound management and aseptic non touch technique (ANTT) guidelines. Method The audit was conducted retrospectively on children admitted to Burns Unit during August 2019, excluding resuscitation burn patients. Pre- and post-wash swabs taken on admission were included and the results obtained from Chameleon database. Data were collected on excel spread sheets including demographic variables such as age, sex, type of injury, percentage total body surface area (TBSA) and mechanism of injury. Data were analysed and results compiled. Results Fifty patients were admitted over a month period; amongst those 60% were male and 40% female of ages ranging from 5 months to 14 years. Scald (50%) was found to be the most common mode of injury followed by contact burn (36%) involving 0.30 to 9% TBSA. Among 50 patients, 30 (60%) showed no growth in pre-wash and 36 (72%) in post-wash swabs. However, 6% post-wash swabs that were initially negative later showed bacillus cereus, staph aureus, Enterobacter, and Acinetobacter. Similarly, another 4% post-wash swabs developed new microorganisms as compared to pre-wash swabs. Conclusions The most common bacteria colonising both pre- and post-wash swabs was staph aureus. Overall, cleansing had reduced the bacterial load significantly around 82% very effective. It is imperative to stick to local guidelines to reduce morbidity and mortality in burn patients.

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Presentation and Management of Staphylococcal Scalded Skin Syndrome in a Child After a Burn Injury: A Case Report

Journal of Burn Care & Research ◽

10.1093/jbcr/irz035 ◽

2019 ◽

Author(s):

Thomas Edward Pidgeon ◽

Federica D’Asta ◽

Malobi Ogboli ◽

Yvonne Wilson

Keyword(s):

Case Report ◽

Burn Injury ◽

Wound Care ◽

Total Body Surface Area ◽

Granular Cell ◽

Burn Wound ◽

Staphylococcal Scalded Skin Syndrome ◽

The Face ◽

Total Body ◽

Learning Points

Abstract This case report describes the clinical course of a child who developed staphylococcal scalded skin syndrome (SSSS) after a burn injury. The intent is to aid other units in recognizing the presentation of SSSS after a pediatric burn and to optimize subsequent management. The main clinical finding was of rapid, progressive, superficial epidermal loss at sites separate from the original burn, involving 55% of the total body surface area, 13 days after a 6% scald burn to the face, neck, and chest. Diagnosis was confirmed by multidisciplinary team clinical assessment and histopathology of an intraoperative skin biopsy. This confirmed epidermal cleavage at the granular cell layer. These findings were later supported by Staphylococcus aureus cultured from the burn wound, and a positive epidermolytic toxin A assay. Management was with general medical supportive care, clindamycin and flucloxacillin intravenous antibiotic therapy, and cleansing and dressing of the areas of epidermal loss. Key learning points from this case were that SSSS presented after a burn injury and that 13 days elapsed between the burn and SSSS. Factors differentiating it from toxic epidermal necrolysis are described, including the value of histopathology in confirming the diagnosis. The prompt use of antibiotics and attentive wound care are advocated as an effective management strategy.

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