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Background: Burn-blast combined injury is a kind of injury caused by heat and blast at the same time. The lung injury after burn-blast combined injuries is of primary importance, and investigation of lung injury is needed in the clinical care of patients. Computed tomography (CT) is one of the standard tools used to observe the anatomical basis and pathophysiology of acute lung injury., Methods: We applied a method of fast 3D (three-dimensional) reconstruction to calculate the density value of the lung injury by CT analysis. Blast-injury group (BL group), burn-injury group (B group), burn-blast combined injury group (BBL group), and sham control group (C group) were established. Each group had 16 rats. The three-dimensional images of the lung tissue were obtained at 6h, 24h, and 48h according to the CT value. The average density of the whole lung, left lung, and right lung were measured. The lung tissues were paraffin-embedded and HE stained. Smith scoring was performed according to the pathological findings., Results: In the BBL group, the density of the lung tissue was higher than those of the BL group and B group (P<0.01). The lung tissue density values at 24h after injury were higher than those at 6h and 48h after injury (P<0.01). Pathological results confirmed the changes of density analysis of the lung tissue., Conclusion: The results have indicated that density analysis through a CT scan can be used as a way to evaluate lung injury in a burn-blast injury., (Copyright © 2018 Elsevier Ltd and ISBI. All rights reserved.)

Acute kidney injury (AKI) is a common complication after severe burns. Melatonin has been reported to protect against multiple organ injuries by increasing the expression of SIRT1, a silent information regulator that regulates stress responses, inflammation, cellular senescence and apoptosis. This study aimed to investigate the protective effects of melatonin on renal tissues of burned rats and the role of SIRT1 involving the effects. Rat severely burned model was established, with or without the administration of melatonin and SIRT1 inhibitor. The renal function and histological manifestations were determined to evaluate the severity of kidney injury. The levels of acetylated-p53 (Ac-p53), acetylated-p65 (Ac-p65), NF-κB, acetylated-forkhead box O1 (Ac-FoxO1), Bcl-2 and Bax were analyzed to study the underlying mechanisms. Our results suggested that severe burns could induce acute kidney injury, which could be partially reversed by melatonin. Melatonin attenuated oxidative stress, inflammation and apoptosis accompanied by the increased expression of SIRT1. The protective effects of melatonin were abrogated by the inhibition of SIRT1. In conclusion, we demonstrate that melatonin improves severe burn-induced AKI via the activation of SIRT1 signaling.

Intensive insulin therapy during critical illness protects the endothelium and thereby prevents organ failure. This study tested the hypothesis that insulin directly affects the attenuation of burn injury-induced damage to pulmonary endothelial tight junction and investigated the underlying mechanisms. Sprague Dawley rats with severe burn injury were randomized to treatment with insulin dissolved in normal saline (maintenance of blood glucose at a level between 5.0 and 7.0 mmol/L) or normal saline alone (in vivo treatment). Pulmonary damage was evaluated. Rat pulmonary microvascular endothelial cells were treated with 20% burn serum or 20% burn serum + insulin (in vitro treatment). Selected cultures were pretreated with phosphatidylinositol 3-kinase/protein kinase B (AKT) inhibitor (LY294002). Permeability was assessed by migration of bovine serum albumin across cell monolayers. Cells were stained with rhodamine phalloidin and were examined. Cell extracts were obtained to assess zonula occludens-1, occludin, and phosphorylated AKT levels by immunoblotting. Treatment with insulin attenuated the pulmonary edema, hemorrhage, and inflammatory cell infiltration of rats with severe burn injury. Burn serum significantly enhanced monolayer permeability to albumin, whereas treatment with insulin (10(-7 ) mol/L) limited this effect. Meanwhile, insulin (10(-7 ) mol/L) reduced burn serum-induced F-actin stress fiber formation and decreased zonula occludens-1 expression. LY294002 decreased cytoplasmic AKT phosphorylation and inhibited the protection effects of insulin. Through the phosphatidylinositol 3-kinase/AKT pathway, insulin independent of glucose toxicity can attenuate increased pulmonary endothelial permeability induced by burn injury. The effect is attributed to the attenuation of the architectural disruption of protein components of the endothelial tight junction. This result is useful in inhibiting multiple organ failure after burn injury., (© 2014 by the Wound Healing Society.)

Joints involved in deep burn often result in joint contracture, limb dysfunction, psychological disorder, or even loss of living and working abilities. The management of post-burn joint contracture will directly orientate the functional recovery of the patients. Comprehensive intervention may prevent the contracture process of the affected joints. Orthoses application is an important measure and should be maintained throughout the whole process of burn care, from positioning the joints at the early stage to maintaining the range of joint motion at the late stage. Orthoses should be used on the premise of protecting the joint functions. In order to maintain the tissue tension while enhancing the joint mobility and muscle strength, the static orthoses and the dynamic orthoses are often alternately used. It is showed in clinical practice that orthoses are designed and applied on the basis that biomechanics will lead to a better outcome.

Objective: To reproduce a stable mouse model of deep partial-thickness scald and to determine the hypoxia status in the wound., Methods: (1) A homemade scald-producing apparatus with constant steam (92 °C) emission was used to reproduce scald injury on the back (2 cm in diameter) in 80 male BALB/c mice for different duration (2, 4, 6, and 8 s), with 20 mice for each scald duration. The nozzle was aligned perpendicularly to the back of mice, 2 cm above the skin surface. The gross condition of wound was observed with naked eyes immediately after injury. Skin samples of 5 mice with different burn duration were harvested 0, 12, 24, and 48 h after scald for histopathological observation with hematoxylin and eosin staining, to screen the scalding time and time for biopsy of scalded skin to determine proper scalding time for the experiment. (2) Model of deep partial-thickness scald was reproduced with the desired scalding time as shown in the preliminary experiment in another 5 BALB/c mice. The hypoxia status in subcutaneous tissue was observed with immunohistochemical staining 72 h after scald. Another 20 BALB/c mice were divided into normal control group (n = 5, without scald) and deep partial-thickness scald group (n = 15, scalded for a suitable duration as determined in the preliminary experiment) according to the random number table. The subcutaneous oxygen content in wound center, the margin of the wound, and the normal skin adjacent to the wound was detected with laser Doppler transcutaneous oxygen tension 72 h after scald, with 5 mice in each region. Data were processed with one-way analysis of variance., Results: (1) The wound of mice with different scald durations was pale, clean, and no exudate was observed right after injury. (2) The burn depth developed gradually along with the scalding time and sample harvesting time, and it became stable 24 h after scalding. A deep partial-thickness injury was observed in the dermis of mice scalded for 4 s and harvested 24 h after scald, and it was shown that the external hair sheath was still present, and it was determined to be a deep partial-thickness scald. (3) Dense staining of pimonidazole (hypoxia) was found in deep partial-thickness scald wound 72 h after scald, especially in the marginal zones of the wounds. The partial oxygen pressure in the wound center, wound margin, and normal skin around the wound was respectively (36.2 ± 3.2), (37.0 ± 1.4), (37.4 ± 2.7) mm Hg (1 mm Hg = 0.133 kPa), showing no statistically significant difference among them (F = 74.705, P > 0.05), but they were significantly lower than that of the control group [(53.1 ± 2.4) mm Hg, with F values respectively 82.377, 91.375, 100.531, P values all below 0.05]., Conclusions: Deep partial-thickness scald model can be reproduced in (20.0 ± 1.0) g male BALB/c mice by scalding with 92 °C hot steam for 4 s, and the depth of wound becomes stable 24 h after scalding. Hypoxia can be found in the scalded wounds, especially in the marginal zones of the wounds.

Objective: To investigate the effect and the relevant potential mechanism of nonpeptide neurokinin 1 (NK1) receptor antagonist L-703,606 in the edema formation after burn injury., Method: L-703,606 treatment was performed in Sprague-Dawley (SD) rats at early stage after deep partial-thickness skin scalding. One hundred and fifty two adult male SD rats were used in the study and randomly divided into sham scald (SS, n=8), scald control (SC, n=48), and L-703,606 treatment (LT, n=48) groups. The rats in SC and LT groups were subjected to 20% total body surface area (TBSA) deep partial-thickness skin scalding. Modified Evans blue extravasation, tracing electron microscopy by lanthanum nitrate and mean water content assay were employed to observe and detect the changes of vascular permeability, ultrastructure and edema formation in adjacent tissue to the wounds and in the jejuna of rats at early stage (72 h) after scald., Results: The pathological increase of vascular permeability in the periwound tissue and jejunum of rats in LT group were significantly lower than that in SC group (P<0.01), and recuperated earlier. Meanwhile, the changes of water contents of corresponding tissues in LT group were lighter than those in SC group (P<0.01). The ultrastructural changes of the microvessels in the peri-wound tissue of LT group showed that the junctions between microvascular endothelium cells were more narrow than those of SC group, moreover, and the number of opening and the engorgement and cavitation of the vascular endothelium cells decreased, the areosis and edema in perivascular tissue lightened, and the precipitation of the high eletron density lanthanum tracing agent in the interspace of the tissue decreased significantly in LT group., Conclusions: It is concluded that nonpeptide NK1-receptor antagonist L-703,606 could lighten the vascular permeability and edema formation in the periwound tissue and jejunum, and accelerate the normalization process of pathological changes in the tissues of rats after scald., (Copyright © 2013 Hainan Medical College. Published by Elsevier B.V. All rights reserved.)

Objective: To explore the methods of systemic treatment of defects of skin and soft tissue on the knees after severe trauma or burn., Methods: Twenty patients with defects of skin and soft tissue on the knees after severe trauma or burn hospitalized in our center from January 2009 to December 2011. The injury areas on the knees ranged from 5 cm×4 cm to 30 cm×20 cm. The wounds were treated with radical debridement, vacuum sealing drainage, and douche through dripping to control infection in early stage. Then they were covered with transplantation of skin grafts plus flap or only with flap. Totally 8 local flaps (including 6 local rotation or transposition flaps and 2 saphenous artery flaps) and 12 free flaps (including 8 anterolateral thigh flaps and 4 latissimus dorsi musculocutaneous flaps) were used. The flap size ranged from 6 cm×5 cm to 32 cm×22 cm. The rehabilitation training of the knee joints was carried out in the early stage after wound healing., Results: All free skin grafts and flaps used in 15 patients survived. Thirteen of them were primarily healed, while some small parts of skin grafts of the other two patients were in poor condition because of infection, and they healed after another session of skin transplantation. Infection occurred under the free flap in one of the 5 patients transplanted with flaps only, which was healed after continuous douche through dripping and another surgical debridement following wet dressing. The knee joints were in good function during the follow-up period of 1 - 3 years., Conclusions: The systemic therapy of radical debridement, vacuum sealing drainage technique, douche through dripping, transplantation of large autologous grafts and flaps, and the early rehabilitation training are effective and reliable in repairing defects of skin and soft tissue at the knee region after severe injuries.

Translational medicine is an emerging arena in the 21st century, and it bridges research results of basic sciences to clinical applications. The importance of translational research attracted considerable concern of scientists worldwide, including clinicians and researchers in the field of burn surgery in China. This review highlights some key points on translational medicine practised in the basic and clinical research of burn surgery, and they are summarized here as: the motive of the research project should be focused on how to solve problems of patients; much attention should be drawn to the difference between the cell biology and biochemical reaction in vitro and that in vivo; an animal model which simulates human pathology as much as possible should be reproduced; collaboration and sharing of resources among different disciplines should be strengthened; national and standardized criteria should be established for evaluation of the experimental result and guiding for clinical application. The aforementioned suggestions would be helpful for the application of new medicine and therapeutic approach in treating severe burn.

Skin is the largest organ in human body. It guards the underlying muscles, bones, ligaments, and internal organs. The skin faces the environment, and it is the first line to defend against the assaults of external physical, chemical, and micro-organic factors. The other functions of skin include systemic metabolism, temperature regulation, sensation, and production of vitamin D and folate. Skin injury usually leads to barrier function damage. Extensive skin injury would induce a series of problems such as water-electrolyte disorder, hypoproteinemia, and severe infection. Thus it is important to choose a suitable wound dressing when the skin is severely injured. The characteristics of wound dressings have undergone repeated and noticeable changes over the last several years. Compared with that of the traditional dressing, the ability of new dressings is improved obviously in the properties of wound protection, infection prevention, and wound healing promotion. This article deals with an overview on the characteristics of different wound dressings.

Objective: To explore the means for the reconstruction of extensive deep burn wounds with exposure of bone and joint in late stage., Methods: Among all the patients with extensive deep burn hospitalized between January 2009 and May 2011, 5 patients presented wounds with exposure of bone and joint in the late stage of treatment that could not be covered by free skin grafts or flaps. Two of the five patients had more than 2 and the other 3 patients had only one such wound(s). The wound size ranged from 8 cm×5 cm to 21 cm×8 cm. Wounds were repaired by transplantation of 7 free muscle flaps (including 4 free rectus abdominis flaps and 3 latissimus dorsi flaps) combined with split-thickness skin grafts harvested from scalp., Results: All the muscle flaps and skin grafts survived. Wounds with bone and joint exposure healed well. At one-year follow-up of some patients, good appearance of repaired areas and normal function of joints were observed with no signs of ulceration, arthritis, or osteomyelitis., Conclusions: Transplantation of free muscle flaps combined with split-thickness skin grafts harvested from the scalp provides satisfactory reconstruction for wounds with deep tissue exposure in patients with a shortage of skin donor site.

This study aimed to investigate the feasibility of using an immortal keratinocyte cell line, HaCaT cells, to effectively deliver epidermal growth factor (EGF) in a skin substitute to treat burn wounds. The skin equivalent was constructed with human EGF (hEGF) gene modified HaCaT cells obtained through stable gene transfection; these were applied to full thickness burn wounds in a rat model. The results showed that the hEGF gene modified HaCaT cells produced more than 390ng/l of bioactive hEGF in the culture supernatant. K19 and integrin-β1 as keratinocyte differentiation markers were elevated in the hEGF gene modified HaCaT cells which were shown to be non-tumorigenic. The skin equivalent constructed with hEGF gene modified HaCaT cells demonstrated improved epidermal morphogenesis with a thick and compact epidermis. Wound healing was accelerated noticeably when applied with this skin substitute seeded with hEGF gene modified HaCaT cells in vivo. The results suggest that HaCaT cells modified with hEGF gene might be promising seed cells for construction of genetically modified skin substitute which can effectively secrete hEGF to accelerate wound repair and regeneration., (Copyright © 2012 Elsevier Ltd and ISBI. All rights reserved.)

Thermal injury inhibits Akt activation and upregulates p38 mitogen-activated protein kinase, which in turn induces inflammation and increases apoptosis. This study aimed to elucidate the mechanism underlying the cytoprotective role of insulin in severe burns by examining the effects of insulin on inflammation and apoptosis mediated by p38 mitogen-activated protein kinase in burn serum-challenged cardiomyocytes. Neonatal rat cardiomyocytes were exposed to burn serum for 6 hours in the presence or absence of insulin and pretreated with inhibitors to p38 mitogen-activated protein kinase (SB203580) and Akt (LY294002). The authors examined expression of myocardial tumor necrosis factor-alpha, cardiac myofilament proteins caspase-3 and Bcl2, and apoptosis. Burn serum-induced upregulation of tumor necrosis factor was inhibited by both SB203580 and insulin. LY294002 reversed insulin-mediated downregulation of tumor necrosis factor. Both SB203580 and insulin inhibited apoptosis, resulting in fewer pyknotic nuclei and inhibition of caspase-3 activation and Bcl2 downregulation. LY294002 reversed insulin-mediated inhibition of apoptosis. Insulin decreases inflammatory cytokine expression and apoptosis via PI3K/Akt-mediated inhibition of p38 mitogen-activated protein kinase. The cytoprotective role of insulin suggests that it may have a potential role in strategies for treating thermal injuries.

Nonmetabolic effects of intensive insulin therapy in critically ill patients have been reported, but the underlying mechanisms are unclear. This study was designed to test the hypothesis that intensive insulin treatment would attenuate burn-induced acute lung injury by protecting the pulmonary microvascular endothelium. The rat model of burn injury was achieved by exposure to 92°C water for 18 seconds. The rats were randomly allocated into the sham, burn/normal saline (NS), and burn/intensive insulin treatment groups. Blood glucose level was maintained between 5 and 7 mmol/L in rats in the burn/intensive insulin treatment group. Pulmonary injury was assessed by hematoxylin and eosin staining, scanning electron microscopy, bronchoalveolar lavage fluid protein concentrations, the lung wet:dry weight ratio, and lung myeloperoxidase activity. Pulmonary microvascular endothelial cells were examined by transmission electron microscopy. Western blotting was used to determine the protein expression of caspase-3. Intensive insulin treatment markedly attenuated the acute lung injury, revealed by improvements in histological features and significant decreases in bronchoalveolar lavage fluid protein concentrations, pulmonary wet:dry weight ratio, and myeloperoxidase activity at 12 hours after injury (P < .05 or P < .01 vs burn/NS). Moreover, the injured pulmonary microvascular endothelial cells showed significant improvements, whereas caspase-3 was markedly downregulated in the burn/intensive insulin treatment group when compared with the burn/NS group. Overall, intensive insulin treatment efficiently attenuated pulmonary microvascular endothelial cell dysfunction, decreased cell apoptosis, and inhibited acute lung injury after a burn. These findings may be useful in preventing organ failure after burn injury.

Objective: To study the safety and effects of free composite tissue flaps in repairing devastating wounds in early stage., Methods: One hundred and twenty-three patients with 128 devastating wounds hospitalized in our burns center from 2005 to 2009 were repaired with free flaps or composite tissue flaps. Flap types used included 58 latissimus dorsi muscular flaps, 32 anterolateral thigh flaps, 21 circumflex scapular flaps, 6 dorsalis pedis composite flaps, 3 big toe nail skin flaps, 3 forearm flaps, and 1 lateral thoracic flap. One wound was repaired with lateral lower leg flap with fibula, and 3 wounds with free latissimus dorsi muscular flap plus skin graft., Results: Vascular crisis was observed in 10 transplanted flaps 1 to 5 days after operation; 6 flaps with this complication were saved after emergency surgical exploration. Total survival rate of transplanted flaps and composite tissue flaps was 95.3% (122/128). All patients were followed up for 3 months to 4 years; satisfactory appearance and restoration of partial function were found in all of them., Conclusions: Free composite tissue transplantation reduces amputation rate, achieves primary reconstruction of function with good appearance, shortens length of hospital stay, and reduces surgical operation time, complications, and treatment cost. It is a good approach in the repair of massive devastating soft tissue injury.

Objective: To study the inhibitory effects of insulin on nuclear factor-kappa B (NF-kappaB) nuclear translocation of vascular endothelial cells induced by burn serum and its correlative mechanism., Methods: Human umbilical vein endothelial cells (HUVECs) were cultured in vitro and divided into 5 groups: blank control group (BC, ordinary culture without any stimulation), normal serum control group (NS, cultured with nutrient solution containing 20% healthy human serum), burn serum stimulation group (BS, cultured with nutrient solution containing 20% burn human serum), burn serum+insulin treatment group (BI, cultured with nutrient solution containing 20% burn human serum and 1x10(-7) mol/L insulin), inhibitor pretreatment group [IP, pretreated with 50 micromol/L protein kinase B (Akt) specific inhibitor LY-294002, then cultured with the same medium as used in BI group 30 minutes later] according to the random number table. Six hours later, the injury and apoptosis of HUVECs was respectively observed by the scanning electron microscope and determined by the flow cytometry. Meanwhile, the phosphorylation of inhibitor kappa B-alpha (p-IkappaB-alpha) and Akt (p-Akt) in cytoplasm, and the content of NF-kappaB-p65 in nucleus were determined with Western blot., Results: (1) Compared with those in BC group, HUVECs in BS group shrank obviously with irregular nuclear structure, and intercellular links jagged or vanished. Slight change was observed in HUVECs structure in NS and BI groups, with the cell ductility and nuclear structure much better than those in BS group. (2) The apoptosis rates of HUVECs in BS group [(28.5+/-2.3)%], BI group [(22.3+/-1.8)%], and IP group [(29.7+/-2.4)%] were all obviously higher than that in BC group [(15.7+/-2.2)%, F=14.288, P<0.05 or P<0.01]. There was no significant statistical difference between NS group [(17.0+/-2.5)%] and BC group in apoptosis rate (F=14.288, P>0.05). The apoptosis rate of HUVECs in BI group was obviously lower than that in BS group (F=14.288, P<0.05). (3) Compared with those in BC group, the protein expressions of p-IkappaB-alpha in cytoplasm and NF-kappaB-p65 in nucleus were up-regulated, and the protein expression of p-Akt in cytoplasm was down-regulated in BS and IP groups. The expression levels of the three proteins in NS and BI groups were close to those in BC group., Conclusions: Insulin could inhibit the IkappaB phosphorylation, and then restrict NF-kappaB nuclear translocation and improve the vascular endothelial cells function accordingly through regulating phosphatidylinositol 3 kinase/Akt pathway.

Destructive burns and traumas which create composite tissue damages, as well as intractable wounds, usually cause the difficulties or inefficacy in the repair and management through ordinary skin grafting or tissue transplantation owing to the complex defects, unhealthy healing condition, or high requirements for the function and appearance reconstruction of the injured local tissues. The advantages of free tissue transplantation with microsurgical techniques in the tissue repair and reconstruction have been demonstrated as meeting the composite tissues restoration, improving blood supply, avoiding further damage to the wound surrounding tissues, and simplifying the distant tissue transplantation procedure, and therefore significantly decreasing the deformities with good functional and morphological outcomes, and dramatically reducing the hospitalization duration with less complications and faster restitution. In the present discussion, basing on the general literature review and the summary of our long-time clinical application of microsurgical techniques in dealing with serious injuries, we put forward the view that the microsurgical techniques should be considered as the first option for the treatment of destructive burns and traumas, and intractable wounds. And in some cases, only microsurgical techniques can be used, otherwise amputation would be unavoidable, or the optimal treatment would be abandoned or delayed. Meanwhile, it should be emphasized that the risk and the failure rate of performing microsurgical operation can be overcome through strictly hard training.

With the advances in resuscitation, infection control, and metabolic management, the treatment strategies for burn patients have improved remarkably in the last half century. As a result, more patients with deep burn wound survived, and how to optimize the burn wound care aiming at recovery of the normal appearance and physiologic function of patients has been investigated and discussed widely through both the whole treatment strategy making and the new techniques performing. In the present discussion, early tissue reconstruction as well as early wound covering and repair are emphasized by summarizing the improved aesthetic and functional effects obtained by applying the principles of plastic surgery in early burn wound repair, the use of composite skin grafting, the grafting with split-thickness autografts on the preserved denatured dermis or on the preserved healthy fat tissue, etc. Besides these, more attention should be given to the repair and reconstruction in specialized functional parts of the body, such as head and face, neck, hand, female breast, perineum, and joint areas, after a deep burn. The role of rehabilitation during and after the burn wound treatment process is elucidated by demonstrating its potential biophysical mechanism and preventing scar deformity. Adequate treatment of deep burn wound demands a number of important measures including the timing of surgery, adoption of essential techniques, suitable types of wound covering materials, motivated rehabilitation, and necessary psychological therapy. The optimal recovery of damaged part of body after burn should depend on the similarity of rebuild tissue structure to simulate the nature of the original tissue in the cellular, histological, anatomic characteristics, which is the aim of all burn wound care and the basis of the appearance and function repair or reconstruction.

Objective: To observe the effect of comprehensive rehabilitation treatment on hand burn, and to make a cost-effectiveness analysis., Methods: Sixty-two patients with ninety-eight affected hands were divided into rehabilitation group (32 cases, 48 hands) and control group (30 cases, 50 hands). Patients in rehabilitation group received comprehensive rehabilitation treatment at early stage after burn; patients in control group were given instructions for function training at the same time. The functions of the hands to be restored including grasp, hold, pinch, nip, forearm pronation and supination, fetching, laying, and writing abilities of patients in both groups were quantitatively evaluated with Carroll's upper extremity function test before treatment and 5 months after. Direct medical costs of patients in both groups within 5 months were respectively added up to make a cost-effectiveness analysis., Results: In rehabilitation group, function of digital opposition, palmar opposition, holding, and pinching of 37 hands recovered well, with which patients could pick food, put on clothes, go to toilet, and self-care etc. independently. Function of digital opposition, palmar opposition, holding, pinching half recovered in 7 hands, accompanied with well recovered of metacarpophalangeal function, but recovery of function of interphalangeal joint was less satisfactory. Although patients could grasp and hold, they were still poor in fine and harmonized activities. Joint ranges of motion of 4 hands were poor with limited function, and this was resulted from not strictly following treatment for remaining granulation wound. In control group, 23 hands received reconstructive surgery, 14 of them recovered with good function, but were poor in most of fine and harmonized activities. Severe claw hands were found in 13 hands. The ratio between total mean cost value and total function increment value in rehabilitation group (181 +/- 11) was obviously lower than that in control group (298 +/- 30, P < 0.01)., Conclusions: Comprehensive rehabilitation treatment at early stage after hand burn has a good effect on prevention and treatment of hand deformity, promoting recovery of hand function and improving hand appearance. It is also less costly.

Objective: To investigate the protective effect of melatonin on residual hair follicle cells of scald rats at early stage., Methods: Eighteen male Sprague-Dawley rats were randomly divided into scald group, treatment group, sham group , with 6 rats in each group. The rats in scald group and treatment group were subjected to 30% TBSA partial thickness scald on the back, and were resuscitated with balanced solution after 1 hour, while those in sham group were immersed in water at 37 degrees C for 25 s to simulate scald, and did not receive fluid replacement. Rats in treatment group were intraperitoneally injected with 10 mg/kg melatonin solution at 1 minute, 8 hours and 12 hours after scald, while those in sham group and scald group were given equal volume of 1% alcohol sodium-isotonic saline instead. Tissue samples were harvested at 6, 12 and 24 post scald hours (PSH) for determination of MDA and GSH levels. Apoptosis of residul hair follicle was detected by TUNEL method and immunohistochemistry of caspase-3., Results: The level of MDA in scald group at each time point was much higher than that in sham group (P < 0.01) and treatment group (P < 0.05), and it peaked at 12 PSH. The changes in GSH were just opposite to that of MDA. Under fluorescence microscope, the residual hair follicle cells were blue, and the apoptotic cells appeared green. The apoptosis rate in scald group at 6, 12, 24 PSH was obviously higher than that in sham (P < 0.01) and treatment groups (P < 0.05), which was (20.2 +/- 3.4)% vs (4.3 +/- 2.3)% vs (10.9 +/- 3.2)%, (31.2 +/- 3.6)% vs (5.1 +/- 2.5)% vs (19.1 +/- 3.7)%, (22.4 +/- 2.7)% vs (4.1 +/- 2.4)% vs (13.1 +/- 3.4)%, respectively. The score of caspase-3 positive cell in scald group was higher than those in sham group (P < 0.01) and treatment group (P < 0.05)., Conclusions: There is obvious correlation between oxidative stress and apoptosis rate of hair follicle cells in rats with partial thickness scald. Early administration of melatonin may have anti-apoptosis ability for residual hair follicle cells by attenuation of oxidative stress.

Objective: To explore the methods of repair of massive deep skin and soft tissue injuries., Methods: Fifty-six patients with deep skin and soft tissue injuries were hospitalized from July 2006 to January 2008. Among them, 23 cases were caused by burn, 17 cases by electric injury, 7 cases by hot crush injury, 6 cases by avulsion injury, and 3 cases due to other reasons (including traffic accident, crush injury, soft tissue infection respectively). Sixty-five skin flaps were raised to repair and reconstruct the injured tissues, including 21 local flaps, 18 distant pedicled skin flaps, and 26 free skin flaps. The area of skin flaps ranged from 1.5 cm x 1.0 cm to 39.0 cm x 23.0 cm., Results: Sixty skin flaps survived completely, partial necrosis occurred in 3 flaps, and complete necrosis in 2 flaps. There was no obvious difference in average survival rate among local skin flaps (95.2%), distant pedicled skin flaps (88.8%), and free skin flaps (92.3%, P > 0.05)., Conclusions: Skin flap transposition can be still considered as the major effective method in repair of massive deep skin and soft tissue injury. On the premises of high survival rate, free skin flap transposition can be considered as the first choice.

Objective: To study the protective effect of intensive insulin treatment on cardiac myocytes of severely scalded rats., Methods: Eighteen model Sprague-Dawley (SD) rats were subjected to 30% total body surface area (TBSA) full thickness injury, and they were divided into three groups with 6 rats in each group. The right jugular vein was cannulated for fluid resuscitation and administration of drugs. The rats in burn group were injected with normal saline, the intensive insulin group with injection of insulin to maintain plasma glucose content in normal range, and the sham burn group received physiologic dose of saline without burn injury. Plasma glucose was monitored after burn injury. Rats were sacrificed at 6 hours postburn to examine plasma myocardial enzymes spectrum as well as histological and ultrastructure changes in cardiac tissue. The expression of p-Akt was detected by western blotting., Results: Plasma glucose level was significantly elevated in burn group within postburn 6 hours as compared with the sham burn group, and lowered in intensive insulin group (4.5 approximately 5.2 mmol/L vs. 7.6 approximately 8.4 mmol/L, P<0.05 or P<0.01). And the intensive insulin therapy could effectively inhibit the release of cardiac enzymes [lactate dehydrogenase (LDH): (2 369.3+/- 178.9) U/L vs. (2 684.1+/-335.0) U/L, P<0.05; alpha-hydroxybutyrate dehydrogenase (alpha-HBD): (576.7+/-219.2) U/L vs. (1 002.0+/-347.1) U/L, P<0.01; creatine kinase (CK): (1 041.9+/-623.2) U/L vs. (2 447.1+/-1 183.7) U/L, P<0.01]. The expression of p-Akt was significantly strengthened in the intensive insulin group (1.18+/-0.43 vs. 0.24+/-0.11, P<0.01). Light microscopic and electron microscopic examinations showed that intensive insulin therapy could alleviate the injury to myocardial cells and structural changes., Conclusion: Intensive insulin treatment possesses protective effect on cardiomyocytes after a severe burn, and it is related to its up-regulation of phosphorylation level of Akt in cardiomyocyte, thus inhibiting the damage to myocytes.

To explore new measures for functional reconstruction of multiple severe deformities as a result of extensive deep burn (total burn surface area > or = 90% TBSA, including deep burn > or = 70%TBSA) in late stage. Twelve severe burn patients with above-mentioned deformities were hospitalized in our ward during 1960--2005, the scars resulted from burns were distributed from head to foot with 173 deformities, including 27 scar ulcers. All patients lacked of self-care ability, among them some could not stand. Due to inadequate skin source, deformities were corrected by skin from matured scars expanded with subcutaneous balloon at late postburn stage. Following our former clinical experience, anatomic investigation and experimental research, we chose the following methods to correct deformities and restore functions: application of split-thickness scar skin after expansion (88 wounds); use of scar skin flap/scar-Achilles tendon flaps (59 wounds); combination of thin split-thickness skin grafts from scar and allogeneic acellular dermal matrix (composite skin, 40 wounds). All grafts survived, the appearance and function were improved obviously without complications. Follow-up 1-40 years, all patients could take care themselves with satisfactory function and appearance, and among them 8 patients returned to work (one had worked for 40 years), 2 patients married and had children. The above-mentioned measures are safe, reliable and effective for functional reconstruction of deformities.

Objective: To investigate the possibility of crosstalk between phosphatidylinositol 3-kinase (PI3-K)/Akt pathway and p38 mitogen-activated protein kinase (p38MAPK) pathway in cardiomyocyte with challenge of burn serum, and to explore their influence on cardiomyocyte injury after burn., Methods: The model of murine cardiomyocyte with stimulation of burn serum was established. (1) The level of Akt and p38 phosphorylation in cardiomyocyte were examined with stimulation of 10% burn serum before stimulation and 1, 3, 6, 12, 24 hour after stimulation. (2) The levels of Akt and p38 phosphorylation in cardiomyocyte were determined with stimulation of burn serum (at concentration of 5%, 10%, 20%) or 10% burn serum plus insulin (at concentration of 1 x 10(-8), 1 x 10(-7), 1 x 10(-6)mol/L). The content of creatine kinase (CK) in supernate was also detected. (3) Addition to the inhibitor of p38 MAPK pathway (SB203580) and PI3K/Akt pathway (LY294002), the level of p38MAPK, PI3K/Akt and the content of CK in supernate were determined., Results: (1) The level of p-p38 in cardiomyocyte was 4.0 +/- 0.8, 3.6 +/- 0.8, 5.1 +/- 1.6, 2.4 +/- 0.5, 3.0 +/- 0.6 at 1, 3, 6, 12, 24 hour (s) after stimulation of burn serum, which was obviously higher than that immediate after stimulation (1.0, P < 0.01). The level of p-Akt was 0.15 +/- 0.07, 0.64 +/- 0.10, 0.26 +/- 0.08, 0.38 +/- 0.11, 0.59 +/- 0.13, which was obviously lower than that before stimulation (1.00, P < 0.01). (2) With stimulation of different concentration of burn serum or burn serum plus insulin, the level of p-Akt and p-p38 changed in the opposite directions comparatively. The content of CK increased along with increase of burn serum concentration, but decreased obviously with treatment of insulin (P < 0.05 or 0.01). (3) Low level of p38 induced by burn serum was increased after treatment of LY294002, which neutralized the protection of insulin (P < 0.01). Low level of p-Akt induced by burn serum increased after treatment of SB203580 (P < 0.01), which inhibited the release of CK induced by burn serum., Conclusion: There is being crosstalk between PI3K/Akt pathway and p38 MAPK pathway in cardiomyocytes with challenge of burn serum, which may regulate cardiomyocytes.

Objective: To investigate the anti-apoptosis effect of intensive insulin treatment on cardiac myocytes and its underlying mechanism in severe scald rats., Methods: Twelve SD rats were suffered from 30% TBSA full thickness scald, and they were divided into: IT group [with intravenous injection of isotonic saline including insulin (15 mU x kg(-1) x min(-1)) and 100 g/L glucose], B group [with treatment of isotonic saline (2 mL x kg(-1) x %TBSA(-1) x 8 h(-1)]. Six SD rats received sham burn as controls[sham(S)group, with treatment of fluid at physiologic dose]. + dp/ dtmax (the rate of the rise of left ventricular pressure) and -dp/ dtmax (the rate of the fall of left ventricular pressure)at 6 post burn hour (PBH)were recorded. Apoptosis were determined by TUNEL staining and DNA ladder. The phosphorylation f Akt and protein expression of Bcl-2 in cardiomyocyte were assayed by Western blotting., Results: The + dp/ dtmax in the S group, IT group and B group at6 PBH were respectively (5.5 +/- 0.5) x 10(3) mm Hg/s, (3.4 +/- 0.4) x 10(3 mm Hg/s and (2.5 +/- 0.5) x 10(3) mm Hg/s (1 mm Hg = 0.133 kPa), the - dp/ dtmax were respectively (4.55 +/- 0.34) x 10(3) mmHg/s, (2.94 +/- 0.22) x 10(3) mm Hg/s and (2.05 +/- 0.19) x 10(3) mmHg/s.The +/- dp/dtmax in IT group was significantly higher than those in B group( P < 0.01). The apoptosis index in B group was (13.1 +/- 3.4)%, which was obviously higher than that in IT group (6.7 +/- 1.8)% and S group (0.6 +/- 0.4)% (P < 0.01). DNA ladder showed that no DNA fragmentation in S group, but obvious DNA fragmentation forming ladder pattern in B group, and no obvious ladder pattern in IT group. The phosphorylation of Akt and level of Bcl-2 protein in B group were markedly higher than those in IT group ( P < 0.05 or P < 0.01)., Conclusion: Intensive insulin treatment can upregulate the activity of Akt and enhance the expression of Bcl-2, and they might constitute the mechanisms for anti-apoptosis in cardiomyocyte and protection of cardiac function.

Objective: To observe the effect of static and dynamic splints on recovery of hand functions in burn patients., Methods: Thirty-two burn patients with 52 injured hands were treated with orthotic splints (single or combined application) during different therapeutic stages. Carroll's upper limb functional test was used to evaluate the function of upper limbs and hands from rough to fine movements, including grasp, pinch, nip, forearm pronation and supination, fetching, etc. The hand functions were compared before and after treatment., Results: There were 7 hands with grade IV function, 15 hands with grade III, 23 hands with grade II, and 7 hands with grade I before treatment, while 9 hands achieved grade IV function, 28 hands grade V, 9 hands grade VI, and 6 hands grade III after treatment for three months. Twenty-eight patients with 46 hands recovered well enough to handle daily chores, including digital opposition, palmar opposition, grasp, pinch, etc., Conclusion: The manual splints offer good effects on preventing and treatment scar contracture of hand after burn, and they can promote the recovery of hand functions.

Objective: To investigate the protective effect of insulin on oxygen-radical induced hepatic injury in severely scalded rats in early stage of severe scald., Methods: Eighty-four male Sprague-Dawley rats were randomly divided into three groups: i. e, normal group, saline group, and insulin group, with 28 rat in each group. The rats in the latter two groups were subjected to 30% TBSA full-thickness scald on the back, and received intra-peritoneal injection of 40ml/kg isotonic saline, and subcutaneous injection of 3 IU/kg insulin, respectively. The total anti-oxygen capability (T-AOC), the expression of superoxide dismutase (SOD), reactive oxygen species (ROS) and intercellular adhesion molecule (ICAM-1) in hepatic tissue, and serum alanine transaminase (ALT) were determined in each group at 6, 12, 24, 48 post-scald hours (PSH) with corresponding methods., Results: The hepatic T-AOC and SOD content were obviously decreased, while the ROS content were markedly increased at 6 PSH in saline group compared with that in normal group (P < 0.05 or P < 0.01). The expression of ICAM-1 and serum content of ALT were significantly higher than that in normal group at 12 PSH and 48 PSH (P < 0.01). At 24 PSH, the hepatic T-AOC (386 +/- 75) U/g and SOD content (210 +/- 39 ) U/g were obviously higher in insulin group than those in saline group [(124 +/- 18), (111 +/- 9) U/g, respectively, P < 0.01), but the ROS content (154 +/- 29 ) U/g was much lower than that in saline group [(351 +/- 41) U/g, respectively, P < 0.01]. At 48 PSH, the serum content of ALT and hepatic expression of ICAM-1 in insulin group exhibited obvious difference when compared with those in saline group (P < 0.01). Meanwhile, Pathological examination showed that hepatic injury was alleviated by insulin administration after scald., Conclusion: Insulin administration early after severe scald exhibits protective effect on liver function by improving anti-oxygen radical ability of rat liver.

Objective: To investigate the protective effect of insulin on vascular endothelial cells of rats at early post-burn stage,and its mechanism., Methods: Adult male Sprague-Dawley rats were randomly divided into 3 groups: i. e, sham scald group (n = 7), scald group (n = 7) and treatment group (n = 7). The rats in the latter 2 groups were subjected to 30% TBSA full-thickness burns with 94 degrees C water, and the sham scald rats were treated with 37 degrees C water. Intra-peritoneal injection of 40 ml/kg isotonic saline solution and subcutaneous injection of 3 units/kg insulin were given to the rats in treatment group after being subjected to 30% TBSA full-thickness burns. Subcutaneous injection of equal amount of isotonic saline was given to the sham and burn groups. The changes in vascular endothelial cell structure were observed with electron microscopy at 24 post-scald hours(PSH). Meanwhile, the blood glucose contents, the serum levels of nitric oxide (NO) and nitric oxide synthetase (NOS) were determined with oxidase method and colorimetric method, respectively., Results: The injury of arterial endothelial cells in the treatment group was obviously alleviated compared with that in burn group. The blood glucose content in the treatment group (7.1 +/- 0.7 mmol/L) was significantly lower than that in scald group (8.2 +/- 1.0 mmol/L, P < 0.05), though it was much higher in both groups than that in sham scald group (4.9 +/- 0.8 mmol/L, P < 0.01) at 24 PBH. The serum content of NO, total NOS and cNOS in treatment group were obviously higher than those in scald group (P < 0.01), but there was no obvious difference in iNOS content between the two groups(P > 0.05)., Conclusion: Insulin exhibits protective effect on vascular endothelial cells in severely scalded rats at the early post-burn stage, and it is attributed to its promotion of cNOS level leading to NO production.

Objective: To study the protective effect of intensive insulin treatment on the myocardium of severely scalded rats, and to primarily explore its mechanism., Methods: Eighteen SD rats were divided into three groups, with 6 rats in each group. The rats in burn and intensive insulin group were inflicted with 30% TBSA full-thickness injury on the back. Isotonic saline containing 0.12 U/ml insulin solution, and 100 g/L glucose solution were infused into the rats in the intensive insulin group to keep plasma glucose at the level of 4.0 - 6.6 mmol/L (the total fluid amount was 2 ml x kg(-1) x 8h(-1)). In sham burn group,fluid was given according to physiological demand. The same amount of isotonic saline was infused into the rats in burn group. The venous blood was obtained for the detection of plasma glucose contents, and the left ventricular systolic pressure (LVSP) and left ventricular end-diastolic pressure (LVEDP) were recorded via aortic ventricle cannula before scald and at 1, 2, 3, 4, 5, 6 post-scald hours (PSH). The tissue of the left ventricle was harvested at 6 PSH for the detection of troponin T expression in myocardiocytes., Results: Plasma glucose level was increased to (7.6 +/- 1.7) mmol/L - (8.4 +/- 4.7) mmol/L in burn group during 1-6 PSH, which was significantly higher than that in intensive insulin group (4.5 +/- 0.9) mmol/L - (5.2 +/- 1.3) mmol/L, P < 0.01). Compared with the intensive insulin group, LVSP was markedly decreased in the burn group (60 +/- 11 mm Hg vs 72 +/- 8 mm Hg, P < 0.05) at 1 PSH,whereas LVEDP was increased significantly (21.3 +/- 11.3 mmHg vs 11.7 +/- 5.2 mmHg, P < 0.05). Intensive insulin treatment could significantly inhibit the loss of troponin T protein in myofilaments of myocardium., Conclusion: Intensive insulin treatment possesses a protective effect on myocardia function after severe burns, and it may be related to its preventive effect on the loss of contractile protein in cardiocytes.

Objective: To seek ideal strategies in saving a patient with very extensive deep burns, and measures for functional reconstruction after convalescence., Methods: A patient with 99. 5% TBSA flame burn injury (III degrees 80%, deep second degree 14.5% and superficial II degrees 5%), complicated with hypernatremia and hyperchloraemia was admitted 76 hours after the injury. Early escharectomy and alloskin grafting were performed. Because of the lack of autoskin donor site, the skin grafting of autologous skin was only undertaken whenever there was an available source, and the remaining wounds were temporarily covered with allografts. Finally the patient survived. After healing of all the wounds, contractures were corrected with skin from scars, flaps of scarred skin or composite skin, and more than 30 cicatricial contracture deformities were corrected after convalescence., Results: After initial treatments and extensive early escharectomy, the patient's condition became stable gradually, without adverse complications. After 7 operations, the wounds finally healed completely after 106 days. The function of all joints were restored well and external appearance improved after 15 plastic and reconstructive operations during convalescence period. The patient was fully rehabilitated and resumed his original work 26 months after the injury., Conclusion: For those patients with massive burns and short of donor site, alloskin grafting after early escharectomy, and persistent repeated microskin grafting whenever any small amounts of own skin is available, is essential to stabilize the patients' condition, and reduce complications. Covering the wounds as the result of shedding off of eschar with alloskin can protect the undamaged cells in skin appendages to promote re-epithelization and wound healing. It is feasible to harvest skin grafts from scars, and use scar skin flaps and composite skin to repair contractures after convalescence with good outcome in function and external appearance.

Objective: To explore the better clinical methods for the management of deep facial burn with optimal quality. Methods Fifty-four patients with deep facial burns were enrolled in the study and were divided into delayed skin grafting group (n=48) and early escharectomy group (n=6). In delayed grafting group, after the erosion of new born granulation tissue to the basal layer with blade holder or with peel or eschar shaving method at 3 postburn weeks (PBW) according to the eschar separation and granulation growth status, the whole face of the patients were divided into 10 regions and were then covered by split thickness auto skin. The same treatment was performed on the patients in early escharectomy group at 1 PBW. Physical therapy and plastic surgery were applied after skin grafting, and the patients were followed up from 3 month to 11 years. The first operation time, postburn facial operation time, operation times to repair the whole face, blood content of Hb, the amount of blood transfusion and hemorrhage and the prognosis were compared between the two groups., Results: There was no difference between the two groups in regards to the first operation time, the total operation times,blood concentration of Hb before and after operation,and the amount of blood transfusion during the operation (P > 0.05). The operation time in delayed grafting group (21.9 +/- 3.2) d was obviously later than that in early escharectomy group (12.6 +/- 1.3) d, (P < 0.05). And there was evidently less amount of hemorrhage during operation(98 +/- 52) ml/100 cm2 than that in early escharectomy group (331 +/- 121) ml/100 cm2 (P < 0.01). The facial appearance of the patients in delayed grafting group was plump with more elasticity and richer expression compared with those in early grafting group. There exhibited different degrees of microstomia and both eyebrow defect in both groups during and after 1 postoperative year. In addition, mild to moderate ectropion and hypertrophic scar on the conjunction of grafted skin could appear in 80% of these patients. These deformities might be corrected by several times of plastic surgery., Conclusion: Based on the principle of arranging skin grafts according to the cosmetic and functional area units, split thickness skin grafting can provide satisfactory results for the repair of deep burn injury involving whole face when the wounds were treated with eschar peeling, tangential excision, escharectomy, granulation tissue scaling, or early escharectomy. In comparison with early escharectomy, eschar peeling, tangential excision, escharectomy, or granulation tissue scaling can get better results with less bleeding, full and round facial appearance, more elasticity of grafted skin and richer facial expression appearance after the operation. Meanwhile, effective physical therapy and scheduled plastic surgery after skin grafting can also be very important in achieving cosmetic results in the repair and reconstruction of whole facial deep burn.

Objective: To investigate the influence of non-peptide neuro-kinase 1 (NK1) receptor antagonist L-703, 606 on the early tissue edema formation in rats with deep partial-thickness scald., Methods: One hundred and fifty-two SD rats were enrolled in the study and were randomly divided into normal control (NC, n = 8), scald control (SC, n = 48, with 20% TBSA deep partial thickness scald), L-703, 606 treatment (LT, n = 48, with 20% TBSA deep partial-thickness scald 20 minutes after caudal vein injection of 250 nmol/kg L-703, 606) and beta-aescin treatment (AT, n = 48, with 20% TBSA deep-partial-thickness scald 30 minutes after caudal vein injection of 1.8 mg/kg beta-aescin) groups. The rats were sacrificed at 1, 4, 8, 24, 48 and 72 post scald hours (PSHs), with 8 rats at each time point. The peri-wound tissue and jejunum samples were harvested for the detection of vascular permeability and tissue water content with modified Evans blue extravasation method and average water content assay., Results: The vascular permeability was significantly higher in the peri-wound tissue and jejunum in SC, LT an AT groups than that in NC group (P < 0.01) at 1 PSH, and it decreased gradually at 4 PSH. The vascular permeability in the peri-wound tissue in LT and AT group was significantly lower than that in SC group (P < 0.01), and that in LT group was markedly higher than that in AT group (P < 0.01) at 48 and 72 PSHs. The vascular permeability of jejunum tissue in LT group was lower than that in SC group within 24 PSH (P < 0.01), while that in AT group was lower than that in LT group at the early postscald stage (P < 0.01), but no obvious difference was found between the two groups after 72 PSH (P > 0.05). The change in the tissue water content was as follows: Dehydration was observed in peri-wound tissue in SC, LT and AT groups at 1 PSH. The tissue water content increased gradually thereafter and reached the peak at 8 and 24 PSH. Certain degree of dehydration was observed in jejunum tissue in SC, LT and AT groups at early postscald stage. The water content in jejunum tissue in LT group was evidently higher than that in SC and AT groups (P < 0.05 or 0.01), edema was evident at 8 PSH, and it became more obvious at 48 PSH, then it subsided gradually. Edema was less evident in LT group., Conclusion: Nonpeptide NK1-receptor antagonist L-703, 606 was able to mitigate the vascular permeability and reduce tissue water content in peri-wound and jejunal tissues.

Objective: To investigate the change in neuropeptide substance P (SP) in the burn wound skin in scalded rats., Methods: The SP distribution density in the rat skin samples from the burn wound, peri-wound area and remote area of scalded rats were determined by immunohistochemistry technique. The mRNA expression of SP was observed by in situ hybridization., Results: The distribution density of SP in the skin samples from the above three areas decreased obviously since 15 mins postburn, dropped to the lowest level during 6 - 12 postburn hou (PBH), and then recovered thereafter. Comparatively, the recovery in peri-wound area occurred earlier. In addition, there was emigration of macrophage-like large cells with positive SP immunoreactivity from local blood vessels in the dermal layer of the burn wound and peri-wound areas. The large cells were closely related to the local SP-containing nerve fibres at 12 PBHs. Intensified staining of the cells was identified at 24 PBHs with the disintegration of the cells into pieces with release of large amounts of positive SP immunoreactive granules, followed by disappearance of the cells at 48 PBHs. It was indicated by in situ hybridization that the preprotachykinin A (PPTA) mRNA encoding and synthesizing SP was expressed in various cells at 6 PBHs., Conclusion: SP might be synthesized and released from cutaneous nerve ending or from local inflammatory cells after skin burn injury.