国际糖尿病足工作组:指南的制定和方法学(2023)——《国际糖尿病足工作组:糖尿病相关的足病预防与管理指南(2023)》的一部分

糖尿病相关的足病是造成糖尿病患者经济负担和增加社会成本的主要原因之一。本指南以主要目标为导向,以循证医学为依据,且在全球得到合理实施。践行国际糖尿病相关的足病指南对于减轻患者经济负担和社会成本有着重要影响。国际糖尿病足工作组(IWGDF)从1999年起开始发布并随后更新国际指南。2023年更新版指南相关推荐均基于推荐、评估、发展和评价分级(GRADE)系统,包括制定相关临床问题和重要结局,完成系统的文献系统综述和荟萃分析,完成评判表汇总,并且给予具体、明确、操作性强的推荐以及理论依据。本文阐述了《国际糖尿病足工作组:糖尿病相关的足病预防和管理指南(2023版)》(以下简称为指南)的制定过程。指南由7个部分组成,包括预防、糖尿病相关的足溃疡分类、减压、周围动脉病变、感染、创面愈合干预以及活动性夏科神经骨关节病,分别由7个独立的国际专家工作组编写。IWGDF编辑委员会对7个章节进行了整合和简化,形成IWGDF实践指南。指南中的每条推荐均经过IWGDF编辑委员会成员和相关领域的独立的国际专家审阅通过。本文是IWGDF指南的制定和方法学。我们相信,医务人员、公共卫生机构和政策制定者采用和实施2023年IWGDF指南,将会改善糖尿病相关的足病的预防和管理水平,从而减少全球该疾病患者和减轻该疾病引起的全球社会负担。

糖尿病患者足溃疡减压指南(2023年更新版)——《国际糖尿病足工作组:糖尿病相关的足病预防与管理指南(2023)》的一部分

减轻组织的机械性压力在治愈糖尿病相关的足溃疡所需的多种干预措施中最为重要。本文是2023年国际糖尿病足工作组(IWGDF)发布的减压治疗促进糖尿病相关的足溃疡愈合的循证指南,也是对2019年IWGDF指南的更新。我们遵循推荐、评估、发展和评价分级(GRADE)方法学,以患者-干预-比较-结局(patient-intervention-control-outcome,PICO)模式设计临床问题和重要结果,进行系统评价和Meta分析,制定评判表汇总,为每个问题编写推荐和理由。每项推荐都是基于系统综述中发现的证据,在无证据情况下则采用专家意见,以及对判断项目的GRADE等级总结进行仔细权衡,包括可预期和不可预期的影响、证据的确定性、患者价值、所需资源、成本效益、公平性、可行性和可接受性。为了治愈糖尿病患者神经性前足底或中足底溃疡,要使用不可拆卸的齐膝高减压装置作为首选减压干预措施。如果患者存在对不可拆卸减压装置的禁忌证或不能耐受,考虑使用可拆卸齐膝(或踝)高减压装置作为减压干预措施的第二选择。如果无可用的减压装置,考虑使用合适的鞋具结合毡制泡沫作为减压干预措施的第三选择。如果这种非手术减压治疗不能治愈前足底溃疡,可以考虑跟腱延长术、跖骨头切除术、关节置换术或跖骨截骨术。为了治疗继发于屈趾畸形的神经性足底或小趾远端溃疡,可行趾屈肌腱切开术。为了促进后足、非足底或并发感染或缺血的溃疡的愈合,提出了进一步的推荐。所有推荐都已在减压临床路径中进行了总结,以帮助促进本指南在临床实践中的实施。这些减压推荐将帮助医务人员为糖尿病相关的足溃疡患者提供最佳的治疗和预后,降低患者感染、住院和截肢的风险。

糖尿病相关的足病的定义和标准(2023年更新版)

糖尿病相关的足病管理涉及多个学科,通用的专业词汇对于各学科间准确沟通交流至关重要。国际糖尿病足工作组(IWGDF)对相关文献进行了系统综述,构成了制定IWGDF指南的基础,并且明确了糖尿病相关的足病的一系列定义、标准及名词解释。本文介绍2023年IWGDF对这些定义和标准的更新,并建议在临床实践和研究中一致使用,以利于世界各地不同学科人员针对糖尿病相关的足病的专业性交流。

Exploring influences and risk of bias of studies on return to sport and work after lateral ankle sprain:A systematic review and metaanalysis

BACKGROUND Lateral ankle sprains are the most common traumatic musculoskeletal injuries of the lower extremity,with an incidence rate of 15%-20%.The high incidence and prevalence highlights the economic impact of this injury.Ankle sprains lead to a high socioeconomic burden due to the combination of the high injury incidence and high medical expenses.Up to 40%of patients who suffer from an ankle sprain develop chronic ankle instability.Chronic instability can lead to prolonged periods of pain,immobility and injury recurrence.Identification of factors that influence return to work(RTW)and return to sports(RTS)after a lateral ankle sprain(LAS)may help seriously reduce healthcare costs.AIM To explore which factors may potentially affect RTW and RTS after sustaining an LAS.METHODS EMBASE and PubMed were systematically searched for relevant studies published until June 2023.Inclusion criteria were as follows:(1)Injury including LAS or chronic ankle instability;(2)Described any form of treatment;(3)Assessment of RTW or RTS;(4)Studies published in English;and(5)Study designs including randomized controlled clinical trials,clinical trials or cohort studies.Exclusion criteria were:(1)Studies involving children(age<16 year);or(2)Patients with concomitant ankle injury besides lateral ankle ligament damage.A quality assessment was performed for each of the included studies using established risk of bias tools.Additionally quality of evidence was assessed using the GRADEpro tool in cases where outcomes were included in the quantitative analysis.A best evidence synthesis was performed in cases of qualitative outcome analysis.For all studied outcomes suitable for quantitative analysis a forest plot was created to calculate the effect on RTW and RTS.RESULTS A total of 8904 patients were included in 21 studies,10 randomized controlled trials,7 retrospective cohort studies and 4 prospective cohort studies.Fifteen studies were eligible for meta-analysis.The overall RTS rate ranged were 80%and 83%in the all treatments pool and surgical treatments pool,respectively.The pooled mean days to RTS ranged from 23-93 d.The overall RTW rate was 89%.The pooled mean time to RTW ranged from 5.8-8.1 d.For patients with chronic ankle instability,higher preoperative motivation was the sole factor significantly and independently(P=0.001)associated with the rate of and time to RTS following ligament repair or reconstruction.Higher body mass index was identified as a significant factor(P=0.04)linked to not resuming sports or returning at a lower level(median 24,range 20-37),compared to those who resumed at the same or higher level(median 23,range 17-38).Patients with a history of psychological illness or brain injury,experienced a delay in their rehabilitation process for sprains with fractures and unspecified sprains.The extent of the delayed rehabilitation was directly proportional to the increased likelihood of experiencing a recurrence of the ankle sprain and the number of ankle-related medical visits.We also observed that 10%of athletes who did return to sport after lateral ankle sprain without fractures described non-ankle-related reasons for not returning.CONCLUSION All treatments yielded comparable results,with each treatment potentially offering unique advantages or benefits.Preoperative motivation may influence rehabilitation after LAS.Grading which factor had a greater impact was not possible due to the lack of comparability among the included patients.

Minimal active domain of human salivary histatin 1 is efficacious in promoting acute skin wound healing

Dear Editor,The skin barrier can be impaired by acute skin wounds,which may lead to a series of complications.It is essential to accelerate wound healing and rapidly restore the structural integrity and functionality of skin.One of the promising bioactive agents is human salivary histatin 1(Hst1),a 38-amino acid histidine-rich peptide that functions to maintain the homeostasis of oral mucosa with a cellular mechanism of promoting the adhesion,spreading,migration of epithelial cells and thus re-epithelialization[1].In recent years,Hst1 has been shown to be effective against various skin-related cell types,such as fibroblasts,myo-fibroblasts,keratinocytes and endothelial cells.In our latest in-vivo study,Hst1 not only promotes angiogenesis,re-epithelialization and collagen production,but also suppresses inflammation,thereby significantly accelerating acute skin wound healing in mice[2].All these studies show that Hst1 is a potent bioactive agent for accelerating acute skin wound healing.

Can bedside needle arthroscopy of the ankle be an accurate option for intra-articular delivery of injectable agents?

BACKGROUND Bedside needle arthroscopy of the ankle under local anesthesia has been proposed for intra-articular delivery of injectable agents.Accuracy and tolerability of this approach in the clinical setting–including patients with end-stage ankle pathology and/or a history of prior surgery–is not known.AIM To assess clinical accuracy and tolerability of bedside needle arthroscopy as a delivery system for injectable agents into the tibiotalar joint.METHODS This was a prospective study that included adult patients who were scheduled for an injection with hyaluronic acid to the tibiotalar joint.In our center,these injections are used as a last resort prior to extensive surgery.The primary outcome was injection accuracy,which was defined as injecting through the arthroscopic cannula with intra-articular positioning confirmed by a clear arthroscopic view of the joint space.Secondary outcome measures included a patientreported numeric rating scale(NRS,0-10)of pain during the procedure and willingness of patients to return for the same procedure.NRS of ankle pain at rest and during walking was collected at baseline and at 2-wk follow-up.Complications were monitored from inclusion up to a 2-wk control visit.RESULTS We performed 24 inspection-injections.Eleven(46%)participants were male,and mean age was 46.8±14.5 years.Osteoarthritis was the indication for injection in 20(83%)cases,of which 8(33%)patients suffered from osteoarthritis Kellgren-Lawrence grade IV,and 10(42%)patients from Kellgren-Lawrence grade III.An osteochondral defect was the indication for injection in 4(17%)cases.A history of ankle surgery was present in 14(58%)participants and a history of multiple ankle surgeries in 11(46%)participants.It was possible to confirm accuracy in 21(88%)procedures.The 3(12%)participants where needle arthroscopy did not reach a clear view of the joint space all suffered from Kellgren-Lawrence grade IV osteoarthritis.Pain during the procedure was reported with a median of 1[interquartile ranges(IQR):0–2].Willingness to return was 100%.Pain in rest decreased from a median NRS of 4(IQR:2–7)at baseline to a median of 3(IQR:1–5)at follow-up(P<0.01).Pain during walking decreased from a median NRS of 8(IQR:6–9)to a median of 7(IQR:4–8)(P<0.01).Infections or other complications were not encountered.CONCLUSION Clinical accuracy and tolerability of bedside needle arthroscopy of the ankle as a delivery system for injectable agents are excellent.Accuracy was 100%in patients without total ventral joint obliteration.

GPCR/endocytosis/ERK signaling/S2R is involved in the regulation of the internalization,mitochondria-targeting and-activating properties of human salivary histatin 1

Human salivary histatin 1(Hst1)exhibits a series of cell-activating properties,such as promoting cell spreading,migration,and metabolic activity.We recently have shown that fluorescently labeled Hst1(F-Hst1)targets and activates mitochondria,presenting an important molecular mechanism.However,its regulating signaling pathways remain to be elucidated.We investigated the influence of specific inhibitors of G protein-coupled receptors(GPCR),endocytosis pathways,extracellular signal-regulated kinases1/2(ERK1/2)signaling,p38 signaling,mitochondrial respiration and Na+/K+-ATPase activity on the uptake,mitochondria-targeting and-activating properties of F-Hst1.We performed a si RNA knockdown(KD)to assess the effect of Sigma-2 receptor(S2R)/Transmembrane Protein 97(TMEM97)—a recently identified target protein of Hst1.We also adopted live cell imaging to monitor the whole intracellular trafficking process of F-Hst1.Our results showed that the inhibition of cellular respiration hindered the internalization of F-Hst1.The inhibitors of GPCR,ERK1/2,phagocytosis,and clathrin-mediated endocytosis(CME)as well as siRNA KD of S2R/TMEM97 significantly reduced the uptake,which was accompanied by the nullification of the promoting effect of F-Hst1 on cell metabolic activity.Only the inhibitor of CME and KD of S2R/TMEM97 significantly compromised the mitochondria-targeting of Hst1.We further showed the intracellular trafficking and targeting process of F-Hst1,in which early endosome plays an important role.Overall,phagocytosis,CME,GPCR,ERK signaling,and S2R/TMEM97 are involved in the internalization of Hst1,while only CME and S2R/TMEM97 are critical for its subcellular targeting.The inhibition of either internalization or mitochondria-targeting of Hst1 could significantly compromise its mitochondria-activating property.

Toward more reliable stability measurements in stance: recommendations for number of measurements, foot position and feedback——a cross-sectional study among servicemen

Background:In the military,insufficient postural stability is a risk factor for developing lower extremity injuries.Postural stability training programs are effective in preventing these injuries.However,an objective method for the measurement of postural stability in servicemen is lacking.The primary objective of this study was to assess the influence of the number of repetitions,different foot positions and real-time visual feedback on postural stability,as well as their effects on the intrasession reliability of postural stability measurements in servicemen.The secondary objective was to assess the concurrent validity of the measurements.Methods:Twenty healthy servicemen between 20 and 50 years of age and in active duty were eligible for this quantitative,cross-sectional study.The measurements took place on a force plate,measuring the mean velocity of the center of pressure.The participants were asked to stand as still as possible in three different foot positions(wide stance,small stance,and on one leg),five times each for 45 s each time,and the measurements were performed with and without real-time visual feedback.Results:We observed a significant main effect of foot position(P<0.001),but not of visual feedback(P=0.119)or repetition number(P=0.915).Postural stability decreased in the more challenging foot positions.The ICC estimates varied from 0.809(one repetition in wide stance)to 0.985(five repetitions on one leg).The common variance(R2)between different foot positions without feedback varied between 0.008(wide stance)and 0.412.Conclusions:To yield reliable data,wide-stance measurements should be conducted three times,and small-stance measurements and measurements on one leg should be conducted two times.The scores of a measurement in a particular foot position cannot predict the scores of measurements in other foot positions.

Osteocyte morphology and orientation in relation to strain in the jaw bone

Bone mass is important for dental implant success and is regulated by mechanoresponsive osteocytes. We aimed to investigate the relationship between the levels and orientation of tensile strain and morphology and orientation of osteocytes at different dental implant positions in the maxillary bone. Bone biopsies were retrieved from eight patients who underwent maxillary sinus-floor elevation with β-tricalcium phosphate prior to implant placement. Gap versus free-ending locations were compared using 1) a three-dimensional finite-element model of the maxilla to predict the tensile strain magnitude and direction and 2) histology and histomorphometric analyses. The finite-element model predicted larger, differently directed tensile strains in the gap versus freeending locations. The mean percentage of mineralised residual native-tissue volume, osteocyte number(mean ± standard deviations:97 ± 40/region-of-interest), and osteocyte shape(90% elongated,10% round) were similar for both locations. However, the osteocyte surface area was 1.5-times larger in the gap than in the free-ending locations, and the elongated osteocytes in these locations were more cranially caudally oriented. In conclusion, significant differences in the osteocyte surface area and orientation seem to exist locally in the maxillary bone, which may be related to the tensile strain magnitude and orientation. This might reflect local differences in the osteocyte mechanosensitivity and bone quality, suggesting differences in dental implant success based on the location in the maxilla.

Regulation of hypoxic stress and oxidative stress in bone grafting: Current trends and future perspectives

Tissue engineering aims to offer large-scale replacement of damaged organs using implants with the com-bination of cells,growth factors and scaffolds.However,the intra/peri-implant region is exposed to se-vere hypoxic stress and oxidative stress during the early stage of implantation with bone graft materials,which endangers the survival,proliferation and differentiation of seed cells within the implants as well as the host cells surrounding the implants.If the bone graft material could spontaneously and intelligently regulate the hypoxic stress and oxidative stress to a moderate level,it will facilitate the vascularization of the implants and the rapid regeneration of the bone tissue.In this review,we will first introduce the signaling pathways of cellular response under hypoxic stress and oxidative stress,then present the clas-sical material designs and examples in response to hypoxic stress and oxidative stress.And finally,we will address the important role of epigenetic mechanisms in the regulation of hypoxic stress and oxida-tive stress and describe the potential applications and prospective smart bone graft materials based on novel epigenetic factors against hypoxic stress and oxidative stress in bone repair.The main content of this review is summarized in the following graphical abstract.

Exercise-induced increase in brain-derived neurotrophic factor in human Parkinson's disease:a systematic review and metaanalysis

Background:Animal models of exercise and Parkinson’s disease(PD)have found that the physiologic use of exercise may interact with the neurodegenerative disease process,likely mediated by brain derived neurotrophic factor(BDNF).No reviews so far have assessed the methodologic quality of available intervention studies or have bundled the effect sizes of individual studies on exercise-induced effects on BDNF blood levels in human PD.Research design and methods:We searched MEDLINE,EMBASE,Cochrane Library,PsycINFO and PubMed from inception to June 2017.Results:Data aggregated from two randomized controlled trials and four pre-experimental studies with a total of 100 ambulatory patients with idiopathic PD(Hoehn/Yahr≤3)found improvements in BDNF blood concentration levels in all 6 studies(two RCTs and 4 pre-experimental studies).Pooled BDNF level change scores from the 2 RCTs resulted in a significant homogeneous summary effect size(Standardized Mean Difference 2.06,95% CI 1.36 to 2.76),and a significant heterogeneous SES for the motor part of the UPDRS-Ⅲ examination(MD-5.53,95% CI-10.42 to-0.64).Clinical improvements were noted in all studies using a variety of outcome measures.Limitations:The evidence-base consists primarily of small studies with low to moderate methodological quality.Conclusions:This review provides preliminary evidence for the effectiveness of physical exercise treatments for persons with PD on BDNF blood levels.Further research is needed.

Skin bioprinting:the future of burn wound reconstruction?

Burns are a significant cause of trauma,and over the years,the focus of patient care has shifted from just survival to facilitation of improved functional outcomes.Typically,burn treatment,especially in the case of extensive burn injuries,involves surgical excision of injured skin and reconstruction of the burn injury with the aid of skin substitutes.Conventional skin substitutes do not contain all skin cell types and do not facilitate recapitulation of native skin physiology.Three-dimensional(3D)bioprinting for reconstruction of burn injuries involves layer-by-layer deposition of cells along with scaffolding materials over the injured areas.Skin bioprinting can be done either in situ or in vitro.Both these approaches are similar except for the site of printing and tissue maturation.There are technological and regulatory challenges that need to be overcome for clinical translation of bioprinted skin for burn reconstruction.However,the use of bioprinting for skin reconstruction following burns is promising;bioprinting will enable accurate placement of cell types and precise and reproducible fabrication of constructs to replace the injured or damaged sites.Overall,3D bioprinting is a very transformative technology,and its use for wound reconstruction will lead to a paradigm shift in patient outcomes.In this review,we aim to introduce bioprinting,the different stages involved,in vitro and in vivo skin bioprinting,and the various clinical and regulatory challenges in adoption of this technology.

Chondroinductive/chondroconductive peptides and their-functionalized biomaterials for cartilage tissue engineering

The repair of articular cartilage defects is still challenging in the fields of orthopedics and maxillofacial surgery due to the avascular structure of articular cartilage and the limited regenerative capacity of mature chondrocytes.To provide viable treatment options,tremendous efforts have been made to develop various chondrogenically-functionalized biomaterials for cartilage tissue engineering.Peptides that are derived from and mimic the functions of chondroconductive cartilage extracellular matrix and chondroinductive growth factors,represent a unique group of bioactive agents for chondrogenic functionalization.Since they can be chemically synthesized,peptides bear better reproducibility,more stable efficacy,higher modifiability and yielding efficiency in comparison with naturally derived biomaterials and recombinant growth factors.In this review,we summarize the current knowledge in the designs of the chondroinductive/chondroconductive peptides,the underlying molecular mechanisms and their-functionalized biomaterials for cartilage tissue engineering.We also systematically compare their in-vitro and in-vivo efficacies in inducing chondrogenesis.Our vision is to stimulate the development of novel peptides and their-functionalized biomaterials for cartilage tissue engineering.

Co-administration of platelet-rich plasma and small intestinal submucosa is more beneficial than their individual use in promoting acute skin wound healing

Background:Acute skin wounds may compromise the skin barrier,posing a risk of infection.Small intestinal submucosa(SIS)is widely used to treat acute and chronic wounds.However,the efficacy of SIS to accelerate wound healing still needs to be improved to meet clinical demands.To tackle this problem,platelet-rich plasma(PRP)is used due to its potency to promote proliferation,migration and adhesion of target cells.In this study,we applied PRP and SIS to skin wounds to explore their effects on wound healing by evaluating re-epithelialization,collagen production,angiogenesis and the inflammatory response.Methods:A1×1-cm full-thickness skin defectwas established in mice.Sixty mice were divided into four treatment groups:PRP+SIS,PRP,SIS and control.On days 3,5,7,10 and 14 post-surgery,tissue specimens were harvested.Haematoxylin and eosin,Masson’s trichrome,immunohistochemical and immunofluorescence double staining were used to visualize epidermal thickness,collagen and vascular regeneration and inflammation.Results:Wound contraction in the PRP and PRP+SIS groups was significantly greater,compared with the other groups,on days 3 and 5 post-surgery.A histological analysis showed higher collagen expression in the PRP and PRP+SIS groups on day 7,whichwas associated with a thicker epidermal layer on day 14.In addition,immunohistochemical staining showed that CD31-positive blood vessels and vascular endothelial growth factor expression in the PRP+SIS and PRP groups were significantly higher,compared with the control group.Furthermore,immunofluorescence double staining showed that the number of M1 and M2 macrophages in the PRP+SIS and PRP groups was higher,compared with the control and SIS groups alone,on day 3.However,on day 7,the number of M1 macrophages dramatically decreased in the PRP+SIS and PRP groups.The ratio of M2 to M1 macrophages in the PRP+SIS and PRP groups was 3.97 and 2.93 times that of the control group and 4.56 and 3.37 times that of the SIS group,respectively.Conclusion:Co-administration of SIS and PRP has a better effect on promoting angiogenesis,reepithelialization and collagen regeneration in managing acute wound healing than either agent alone.

Neuro-regenerative imidazole-functionalized GelMA hydrogel loaded with hAMSC and SDF-1α promote stem cell differentiation and repair focal brain injury

Brain tissues that are severely damaged by traumatic brain injury(TBI)is hardly regenerated,which leads to a cavity or a repair with glial scarring.Stem-cell therapy is one viable option to treat TBI-caused brain tissue damage,whose use is,whereas,limited by the low survival rate and differentiation efficiency of stem cells.To approach this problem,we developed an injectable hydrogel using imidazole groups-modified gelatin methacrylate(GelMA-imid).In addition,polydopamine(PDA)nanoparticles were used as carrier for stromal-cell derived factor-1(SDF-1α).GelMA-imid hydrogel loaded with PDA@SDF-1αnanoparticles and human amniotic mesenchymal stromal cells(hAMSCs)were injected into the damaged area in an in-vivo cryogenic injury model in rats.The hydrogel had low module and its average pore size was 204.61±41.41 nm,which were suitable for the migration,proliferation and differentiation of stem cells.In-vitro cell scratch and differentiation assays showed that the imidazole groups and SDF-1αcould promote the migration of hAMSCs to injury site and their differentiation into nerve cells.The highest amount of nissl body was detected in the group of GelMA-imid/SDF-1α/hAMSCs hydrogel in the in-vivo model.Additionally,histological analysis showed that GelMA-imid/SDF-1α/hAMSCs hydrogel could facilitate the regeneration of regenerate endogenous nerve cells.In summary,the GelMA-imid/SDF-1α/hAMSCs hydrogel promoted homing and differentiation of hAMSCs into nerve cells,and showed great application potential for the physiological recovery of TBI.

Review of additive manufactured tissue engineering scaffolds:relationship between geometry and performance

Material extrusion additive manufacturing has rapidly grown in use for tissue engineering research since its adoption in the year 2000. It has enabled researchers to produce scaffolds with intricate porous geometries that were not feasible with traditional manufacturing processes. Researchers can control the structural geometry through a wide range of customisable printing parameters and design choices including material, print path, temperature, and many other process parameters. Currently, the impact of these choices is not fully understood. This review focuses on how the position and orientation of extruded filaments, which sometimes referred to as the print path, lay-down pattern, or simply'scaffold design', affect scaffold properties and biological performance. By analysing trends across multiple studies, new understanding was developed on how filament position affects mechanical properties. Biological performance was also found to be affected by filament position, but a lack of consensus between studies indicates a need for further research and understanding. In most research studies, scaffold design was dictated by capabilities of additive manufacturing software rather than free-form design of structural geometry optimised for biological requirements. There is scope for much greater application of engineering innovation to additive manufacture novel geometries. To achieve this, better understanding of biological requirements is needed to enable the effective specification of ideal scaffold geometries.

3D printing of patient-specific neck splints for the treatment of post-burn neck contractures

Dear Editor,Burn scar contracture is a common problem in healing burn wounds of the neck. It can cause both pain and dysfunction if not treated adequately (1)The treatment of such wounds often involves a combination of surgery and splinting therapy (2)A variety of splints, including the thermoplastic static neck splint [3], the Watusi collar [4], manually fabricated splints, and pre-fabricated splints such as the Philadelphia collar have been used for the management of scar contractures. However, each type of splint has its own advantages and disadvantages, and none of these splints seem to reduce the need for skin reconstruction nor delays the time until surgical re-construction [5].

Burns in the elderly:a nationwide study on management and clinical outcomes

Background:In modern-day burn care,advanced age remains an important predictor for mortality among burn victims.In this study,we compared the complete treatment trajectory(including prehospital and surgical treatment)and the outcomes between an elderly burn population and a younger adult burn population.Methods:In this nationwide study,data from the Dutch Burn Repository were used.This is a uniform national registration for Dutch specialized burn care.All adult patients that were admitted to one of the three Dutch burn centres from the period 2009 to 2015 were included in the analysis.Burn patients were considered as elderly when≥65 years of age,and were then further subdivided into three age categories:65–74,75–85 and 85+years.Younger adults in the age category 18–64 years were used as the reference group.Surgical managementwas studied comprehensively and included timing of surgery,the number of procedures and details on the surgical technique,especially the technique used for debridement and the grafting technique that was applied.For the comparison of clinical outcome,the following parameters were included:mortality,wound infections,length of stay/TBSA(total body surface area)burned,discharge disposition and secondary reconstructions.Results:During the study period,3155 adult patients were included(elderly,n=505).Burn severity,reflected by the median TBSA,varied between 3.2–4.0%and was comparable,but aetiology and pre-hospital care were different between elderly and the younger adult reference group.Surgical treatment was initiated significantly faster in elderly burn patients(p<0.001).Less selective techniques for surgical debridement were used in the elderly burns patients(hydrosurgery,42.0%vs 23.5–22.6%),and on the other hand more avulsion(5.3%vs 7.3–17.6%)and primary wound closure(6.7%vs 24.5%).The most frequently used grafting technique was meshed skin grafts(79.2–88.6%);this was not related to age.Mortality increased rapidly with a higher age and showed a high peak in the 85+category(23.8%).Furthermore,considerable differences were found in hospital discharge disposition between the elderly and the reference group.Conclusions:In conclusion,elderly burn patients who require specialized burn care are vulnerable and medically challenging.Differences in aetiology,comorbidity,physiology and the management prior to admission possibly affect the initial surgical management and result in significantly worse outcomes in elderly.Elderly patients need optimal,timely and specialized burn care to enhance survival after burn injuries.

Clinical-based phenotypes in children with pediatric post-COVID-19 condition

Background Pediatric post coronavirus disease 2019(COVID-19)condition(PPCC)is a heterogeneous syndrome,which can significantly affect the daily lives of children.This study aimed to identify clinically meaningful phenotypes in children with PPCC,to better characterize and treat this condition.Methods Participants were children with physician-diagnosed PPCC,referred to the academic hospital Amsterdam UMC in the Netherlands between November 2021 and March 2023.Demographic factors and information on post-COVID symptoms,comorbidities,and impact on daily life were collected.Clinical clusters were identified using an unsupervised and unbiased approach for mixed data types.Results Analysis of 111 patients(aged 3–18 years)revealed three distinct clusters within PPCC.Cluster 1(n=62,median age=15 years)predominantly consisted of girls(74.2%).These patients suffered relatively more from exercise intolerance,dyspnea,and smell disorders.Cluster 2(n=33,median age=13 years)contained patients with an even gender distribution(51.5%girls).They suffered from relatively more sleep problems,memory loss,gastrointestinal symptoms,and arthralgia.Cluster 3(n=16,median age=11 years)had a higher proportion of boys(75.0%),suffered relatively more from fever,had significantly fewer symptoms(median of 5 symptoms compared to 8 and 10 for clusters 1 and 2 respectively),and experienced a lower impact on daily life.Conclusions This study identified three distinct clinical PPCC phenotypes,with variations in sex,age,symptom patterns,and impact on daily life.These findings highlight the need for further research to understand the potentially diverse underlying mechanisms contributing to post-COVID symptoms in children.

Children’s growth and motor development following a severe burn:a systematic review

Background:The epidemiological data on post-burn growth,body composition and motor devel-opment is ambiguous and scattered.The aim of this systematic review was therefore to summarize the current body of evidence on post-burn growth,body composition and motor development in children.Methods:A literature search was conducted in PubMed,EMBASE and Web of Science up to March 2021.We considered observational studies that reported(1)metrics on weight,height,body composition,bone mineral content,bone mineral density or motor development,in(2)paediatric burn patients and(3)published in a peer-reviewed journal.Results:A total of 16 studies were included.Each of the included studies used quantitative methods,but with differing methodology:prospective cohort studies(n=8),retrospective chart reviews(n=3),case-control studies(n=2),cross sectional studies(n=2)and a retrospective cohort study(n=1).When combined,the included studies represented 2022 paediatric burn patients,with a mean age of 7.7(±3.2)years.The average burn sizewas 52.8%(±12.7)of the total body surface area.Identified outcome measures included weight(n=12),height(n=7),muscular strength(n=4),bone mineral content(n=5),bone mineral density(n=5),body mass index(n=3),fat mass(n=5),lean body mass(n=7)and fine and gross motor development(n=1).Conclusions:Following an initial decline,patients’growth and motor development started to recover during the first or second year post-burn.Nonetheless,burns may have a profound and prolonged effect on the paediatric burn patients’muscular strength,bone mineral content and lean body mass.It should be noted that the vast majority of studies included only patients with burns covering≥30%total body surface area.The evidence presented in this review may thus not be representative of the whole paediatric burn population.