Chronic wounds occur as a consequence of a prolonged inflammatory phase during the healing process, which precludes skin regeneration. Typical treatment for chronic wounds includes application of autografts, allografts collected from cadaver, and topical delivery of antioxidant, anti-inflammatory, and antibacterial agents. Nevertheless, the mentioned therapies are not sufficient for extensive or deep wounds. Moreover, application of allogeneic skin grafts carries high risk of rejection and treatment failure. Advanced therapies for chronic wounds involve application of bioengineered artificial skin substitutes to overcome graft rejection as well as topical delivery of mesenchymal stem cells to reduce inflammation and accelerate the healing process. This review focuses on the concept of skin tissue engineering, which is a modern approach to chronic wound treatment. The aim of the article is to summarize common therapies for chronic wounds and recent achievements in the development of bioengineered artificial skin constructs, including analysis of biomaterials and cells widely used for skin graft production. This review also presents attempts to reconstruct nerves, pigmentation, and skin appendages (hair follicles, sweat glands) using artificial skin grafts as well as recent trends in the engineering of biomaterials, aiming to produce nanocomposite skin substitutes (nanofilled polymer composites) with controlled antibacterial activity. Finally, the article describes the composition, advantages, and limitations of both newly developed and commercially available bioengineered skin substitutes.

A Concise Review on Tissue Engineered Artificial Skin Grafts for Chronic Wound Treatment: Can We Reconstruct Functional Skin Tissue In Vitro?

According to the World Health Organization (WHO), it is estimated that each year approximately 11 million people suffer from burn wounds, 180,000 of whom die because of such injuries. Regardless of the factors causing burns, these are complicated wounds that are difficult to heal and are associated with high mortality rates. Medical care of a burn patient requires a lot of commitment, experience, and multidirectional management, including surgical activities and widely understood pharmacological approaches. This paper aims to comprehensively review the current literature concerning burn wounds, including classification of burns, complications, medical care, and pharmacological treatment. We also overviewed the dressings (with an emphasis on the newest innovations in this field) that are currently used in medical practice to heal wounds.

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Burn Wound Healing: Clinical Complications, Medical Care, Treatment, and Dressing Types: The Current State of Knowledge for Clinical Practice

Background
Keratinocyte or nonmelanoma skin cancer (NMSC) is the commonest malignancy worldwide. The usual treatment is surgical excision. Current guidelines underestimate incomplete excision rates.

Objectives
We aimed to determine the risk of incomplete excision of NMSCs through a systematic review and meta-analysis of primary clinical studies.

Methods
A PRISMA-compliant systematic review and meta-analysis was performed using methodology proposed by Cochrane (PROSPERO CRD42019157936). A comprehensive search strategy was applied to MEDLINE, Embase, Scopus, CINAHL, EMCare, Cochrane Library and the grey literature (January 2000–27 November 2019). All studies were included except those on Mohs micrographic surgery, frozen section or biopsies. Abstract screening and data extraction were performed in duplicate. Risk of bias was assessed using a tool for prevalence/incidence studies. The primary outcome was the proportion of incomplete surgical excisions. A random-effects model for pooling of binomial data was used. Differences between proportions were assessed by subgroup meta-analysis and meta-regression, which were presented as risk ratios (RRs).

Results
Searching identified 3477 records, with 110 studies included, comprising 53 796 patients with 106 832 basal cell carcinomas (BCCs) and 21 569 squamous cell carcinomas (SCCs). The proportion of incomplete excisions for BCC was 11·0% [95% confidence interval (CI) 9·7–12·4] and for SCC 9·4% (95% CI 7·6–11·4). Proportions of incomplete excisions by specialty were: dermatology, BCCs 6·2% and SCCs 4·7%; plastic surgery, BCCs 9·4% and SCCs 8·2%; general practitioners, BCCs 20·4% and SCCs 18·9%. The risk of incomplete excision for general practitioners was four times that of dermatologists for both BCCs (RR 3·9, 95% CI 2·0–7·3) and SCCs (RR 4·8, 95% CI 1·0–22·8). Studies were heterogeneous (I2 = 98%) and at high risk of bias.

Conclusions
The proportion of incomplete excisions is higher than previously reported. Excisions performed by specialists may lower the risk of incomplete excision.

Incomplete surgical excision of keratinocyte skin cancers: a systematic review and meta-analysis.

Vibrios are ubiquitous bacteria in aquatic systems, especially marine ones, and belong to the Gammaproteobacteria class, the most diverse class of Gram-negative bacteria. The main objective of this review is to update the information regarding the ecology of Vibrio species, and contribute to the discussion of their potential risk in a changing environment. As heterotrophic organisms, Vibrio spp. live freely in aquatic environments, from marine depths to the surface of the water column, and frequently may be associated with micro- and macroalgae, invertebrates, and vertebrates such as fish, or live in symbiosis. Some Vibrio spp. are pathogenic to humans and animals, and there is evidence that infections caused by vibrios are increasing in the world. This rise may be related to global changes in human behavior (increases in tourism, maritime traffic, consumption of seafood, aquaculture production, water demand, pollution), and temperature. Most likely in the future, Vibrio spp. in water and in seafood will be monitored in order to safeguard human and animal health. Regulators of the microbiological quality of water (marine and freshwater) and food for human and animal consumption, professionals involved in marine and freshwater production chains, consumers and users of aquatic resources, and health professionals will be challenged to anticipate and mitigate new risks.

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Vibrio spp.: Life Strategies, Ecology, and Risks in a Changing Environment

Recurrent arachnoid cysts secondary to spinal adhesive arachnoiditis successfully treated with a ventriculoperitoneal shunt.

Seasonal Impact in Burn Profiles in a Dedicated Burn Unit

BACKGROUND Trapezoid fractures are very uncommon, accounting for less than 1% of all wrist fractures. Isolated fractures of this bone are even more rare, with just a few reports in the literature. The trapezoid bone has a very stable position within the wrist, forming a relatively immobile joint with the second metacarpal base distally. It is also connected by very strong ligaments to the trapezium, capitate and, scaphoid. Trapezoid fractures occur when a strong bending or axial force is applied to the second metacarpal base. CASE REPORT We present a clinical case of an isolated, non-displaced, trapezoid fracture in a young white male, which was treated with cast immobilization for 4 weeks and physical therapy. Complete functional recovery was achieved 3 months after the injury, without any pain or tenderness. CONCLUSIONS Fractures of the trapezoid bone usually have a good clinical outcome. Nonetheless, we need to be very suspicious about this diagnosis since radiography is apparently normal in almost all such cases and clinical examination results may not be entirely clear.

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Isolated Trapezoid Fracture in a Boxer.

Necrotizing fasciitis is a severe soft tissue infection with a high mortality rate and therefore requires emergent surgical treatment. Several microorganisms can cause this infection, Photobacterium damselae being one of them, with only eight cases previously published in the literature. We report the first ever case of necrotizing fasciitis, caused by this microorganism, in Portugal. In this case report the patient survived after several debridement procedures and reconstruction of the upper limb with acellular dermal matrix and skin graft. A brief review of the Photobacterium damselae soft tissue infection reports as well as the clinical presentation, diagnosis, pathophysiology and treatment of necrotizing fasciitis can also be found in this paper.

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Necrotizing Fasciitis Caused by Photobacterium damselae: The First Case in Portugal.

Third-degree burns of the lower extremities are among the most difficult burn injuries to treat as they frequently expose bone, tendons or articular surfaces. Coverage with a flap is the ideal treatment, but local tissue is often unavailable, and free flaps require sophisticated equipment and perfect microsurgical technique. We demonstrate a treatment option to obtain a stable cutaneous coverage for this kind of injury, consisting in an association of skin grafts, amniotic membrane and bilaminar dermal matrix templates. This combined treatment proved to be an excellent option to cover a wide area of tibial exposure with low donor site morbidity and good functional and aesthetic results. This shows that artificial dermis is a good alternative for treating bone exposure, especially in patients for whom a classic flap reconstruction is not suitable.

Bilateral third-degree burn of the legs: lower limb salvage with dermal regenerative matrix.

The management of burn sequelae is a major challenge for every plastic surgeon. The benefits of Integra® Dermal Regeneration Template in the management of burn injuries have been well documented but there is still a paucity of data regarding its use in reconstructive procedures. The aim of this study is to evaluate its effectiveness in the surgical treatment of post-burn scars. We performed a retrospective review of burn patients with major burn sequelae treated with Integra® at our hospital during 2016–2017 period. A modified Vancouver Scar Scale (mVSS) was used to provide a more objective measurement of burn scars. All patients were submitted to a two-stage procedure. The first one consisted in complete excision of the lesions and implantation of Integra and the second one in resurfacing the neodermis with a split thickness skin graft. The average wound size covered with Integra was 741.6 cm2. Follow-up ranged from 9 to 16 months. There were no early complications. In all cases, we achieved satisfactory cosmetic results with significant improvements in functionality and quality of life. mVSS score post-op was significantly lower than pre-op in all patients. Our results suggest that Integra is a very versatile tool for the treatment of burn sequelae. It yields good cosmetic and functional results in most cases with very little donor site morbidity. We believe that Integra should be viewed as one of the best current options for reconstructive procedures in burn patients. Level of Evidence: Level IV, therapeutic study.

Luís Mata Ribeiro

Papers

Seasonal Impact in Burn Profiles in a Dedicated Burn Unit

Isolated Trapezoid Fracture in a Boxer.

Necrotizing Fasciitis Caused by Photobacterium damselae: The First Case in Portugal.

Bilateral third-degree burn of the legs: lower limb salvage with dermal regenerative matrix.

Versatility of dermal regeneration templates in the treatment of burn sequelae