OBJECTIVE: Tracheal transplantation is an ideal option for the reconstruction of long-segment circumferential tracheal defects. Our group performed the first successful vascularized single-staged tracheal transplantation in January 2021. Although a rigid biocompatible structure is necessary for a functioning tracheal replacement, the importance of ciliated epithelium, which allows for critical mucociliary clearance, is now being appreciated. Here, we examined the histological changes of the first single-staged human tracheal transplant from serial endoscopic biopsies.
METHODS: Biopsies of the tracheal mucosa were serially obtained since the time of the tracheal transplantation. Samples were examined via hematoxylin and eosin, electron microscopy, and immunohistochemistry.
RESULTS: One week after transplantation, there is loss of ciliated epithelium and seromucinous cells, with only a basal layer of epithelium remaining. By 2 weeks, however, the epithelium begins to recover, albeit differently depending on the location of the biopsy. Near the site of tracheal anastomosis, there is epithelial proliferation, with the appearance of early ciliated cells. However, in the midgraft, there appears to be evidence of squamous metaplasia. Over time, however, normal ciliated epithelium and mucous cells appear without signs of chronic inflammation.
CONCLUSIONS: Critically, the tracheal allograft regained normal appearing respiratory epithelium after initial ischemic injury. The histologic differences at the midgraft versus anastomosis may suggest unique mechanisms of reepithelialization. At the recipient-donor interface, there may be a faster direct migration of recipient-derived epithelial cells, in line with preclinical studies. The midgraft, in contrast, responds with epithelial proliferation from the donor basal cells or dedifferentiated mucous cells.
METHODS: N/A Laryngoscope, 134:2664-2671, 2024.

There are many types of dressings available for the management of hard-to-heal (chronic) wounds. This case report illustrates the efficacy of bioelectric dressings in healing hard-to-heal wounds in five patients. Of the patients, four had diabetic foot ulcers (DFUs) and one had a surgical site infection. Wounds were examined using the TIMES concept and debridement was carried out if needed. Amorphous hydrogel was used as conduction fluid before the application of the bioelectric wound dressings. The wound was covered with foam dressing and crepe bandage. In this case report, among all five wounds, one wound healed completely while the other four reduced in size, with the presence of more granulation and re-epithelialisation. In this case report, bioelectric wound dressings were effective in managing infection and promoting wound healing.

Previous studies have evaluated the effectiveness of bacterial nanocellulose (BNC) for the treatment of thermal injuries, but the synergic effect of platelet-rich plasma (PRP) with BNC-based dressing for burns still requires further investigation. Herein, we evaluated the effectiveness of BNC dressings in the management of facial burns using PRP. Patients with second-degree facial burns were treated with BNC-based wound dressings after debridement. The burn\'s depth and epithelialization were evaluated by clinical assessment. Besides using the dressings, we injected PRP subcutaneously into the left-hemifacial burns. The right hemiface was only treated with the dressings. Scar quality was assessed using the Patient and Observer Scar Assessment Scale (POSAS). Eight patients were included with superficial second-degree burns in 75% of the cases and deep second-degree burns in 25%. Overall, dressings were placed 3.25 days after the initial insult. None of the patients presented with complications after dressing placement. Dressing changes were not required, and no further surgical management was necessary. The mean time for epithelialization was 11.4 days. During subgroup analysis, we did not find a significant difference in the epithelialization time when comparing BNC-based dressings (11.8 days) to BNC-based dressings + PRP (11 days, p = 0.429). The mean POSAS scores from a patient (17 vs. 12.3, p = 0.242) and surgeon (13.5 vs. 11.3, p = 0.26) standpoint were not significantly different using BNC-based dressings versus BNC-based dressings + PRP. Nanocellulose-based dressings are effective to treat second-degree facial burns. It enhances reepithelialization with optimal esthetic outcomes with or without PRP.

OBJECTIVE: To assess safety and efficacy of corneal collagen crosslinking (CXL) for advanced bullous keratopathy (BK).
METHODS: Eight eyes of eight patients subjected to Dresden CXL protocol.
METHODS: BK history of at least one year, severe pain and no indication for keratoplasty due to poor visual prognosis.
METHODS: best corrected visual acuity (BCVA), pain (decimal visual scale), central corneal thickness (CCT) by tomography (Pentacam®, Oculus Inc, Germany), corneal bullae and complications.
RESULTS: Seven women and one man of median age 77.00 (range 58-79) years. The median follow-up was 7 (range 5-7) months. BCVA remained unchanged through follow-up. A significant decrease in pain was observed at the end of the follow-up period (median 6, range 5-6 vs. median 0, range 0-4, P=0.05). Corneal tomography could only be performed in three cases, due to poor vision or image quality. A reduction in mean CCT was observed in the first post procedural month (from 708.33±140.48 to 627±136.89μm). In all eight cases, the absence of corneal bullae only persisted for two months after CXL. In six patients, corneal re-epithelialization after CXL was poor; in four of these eyes, the problem was resolved with topical treatment, but in the remaining two eyes, amniotic membrane transplant and mechanical debridement were required.
CONCLUSIONS: In this uncontrolled small case series, CXL treatment improved pain in patients with advanced BK. However, the high rate of poor re-epithelialization requiring surgical treatment observed in one third of cases makes this treatment controversial.

Corneal ectasia can be a complication of Stevens-Johnson syndrome. When detected in a timely manner, corneal crosslinking can be a safe treatment. This is an important association to highlight that early diagnosis and treatment can prevent the need for invasive surgical procedures such as keratoplasty.
This study aimed to report a successful accelerated epithelium-off corneal crosslinking in a rare case of corneal ectasia secondary to Stevens-Johnson syndrome.
A 25-year-old Indian man presented with a progressive visual acuity decline 5 years after an acute episode of Stevens-Johnson syndrome secondary to penicillin ingestion. Serial tomography scans confirmed the diagnosis of corneal ectasia. After the preparation of the ocular surface, which was deemed to have a mild degree of limbal stem cell deficiency, with frequent preservative-free lubrication and steroid use, accelerated epithelium-off crosslinking was performed with 4 minutes of continuous ultraviolet-A exposure at 30 mW/cm2 and a total energy dose of 7.2 J/cm2. Complete re-epithelialization was observed at 72 hours after crosslinking with no complications. Corneal tomography 15 months after treatment showed stabilization of ectasia, with improvement in visual acuity.
Corneal ectasia is a rare but important complication of Stevens-Johnson syndrome. Accelerated epithelium-off crosslinking treatment can be considered in patients with a compromised ocular surface after Stevens-Johnson syndrome. Pre-operative optimization of the ocular surface and vigilant monitoring in the early post-operative period are recommended for the prevention of complications.

OBJECTIVE: To report a case of Gundersen flap removal where the ocular surface was restored without the need for additional limbal stem cell transplantation.
METHODS: We describe a case of 57-year-old man who underwent Gundersen flap for a nonhealing corneal ulcer in right eye 17 years ago. He recently lost eyesight in left eye after blunt trauma. Gundersen flap removal was performed in right eye along with amniotic membrane transplantation.
RESULTS: The ocular surface recovered completely after surgery without any evidence of limbal stem cell deficiency. His corrected distance visual acuity improved to 20/60 along with a stable ocular surface, which was maintained till last follow-up of 12 months.
CONCLUSIONS: A normal ocular surface can be restored after Gundersen flap surgery if removal of limbal epithelium is not performed during the primary procedure. Additional corneal surgery might be required depending on corneal clarity.

BACKGROUND: Toxic epidermal necrolysis (TEN) is a severe, potentially lethal drug reaction for which no standard treatment is available.
OBJECTIVE: To describe 17 consecutive TEN patients treated with a single dose of etanercept, a TNF-alpha inhibitor.
METHODS: Comorbidities and any drug treatment initiated within the previous month were recorded on admission. Patients received 50 mg etanercept in a single subcutaneous injection. The clinical severity of the disease was computed using the SCORTEN scale. The expected number of deaths was calculated based on the probability of death associated with each SCORTEN score level. Healing was defined as complete re-epithelialization. Time to healing was analysed using the Kaplan-Meier estimator.
RESULTS: The lowest SCORTEN score was 2, and seven patients scored in the most severe risk category (i.e., =>5). A comparison between observed (2/17) vs. expected deaths (10/17) was statistically significant (p=0.012). Fifteen patients promptly responded to treatment and achieved complete re-epithelization (median time to healing: 8.5 days), without complications or side effects. The two observed deaths were due to other causes, although re-epithelization had initiated in both patients.
CONCLUSIONS: These preliminary results add to our initial observations indicating that etanercept may effectively control TEN, a potentially lethal skin condition for which there is currently no effective cure. Where funding is available, randomized controlled trials on etanercept for TEN should be conducted.

UNASSIGNED: To assess the safety and efficacy of a surfactant-based technology for the management of burns.
UNASSIGNED: In a retrospective review, paediatric patients with different types of burns were treated with the gel technology. In some patients, the treatment was combined with a topical antimicrobial agent. Primary objectives of the review were the assessment of healing, healing times and ease of use of the material.
UNASSIGNED: The wounds of 15 paediatric patients with different types of burns, particularly with regard to depth and anatomical location, were evaluated using a retrospective chart review. It was found that the surfactant gel technology, with or without the topical antimicrobial agent, assisted in autolytic debridement, and that time to re-epithelialisation was short and within the range of those obtained with other established treatments.
UNASSIGNED: The number of patients and wounds in this evaluation is small but the study indicates that the gel technology provides a safe and effective way to treat smaller burns in paediatric patients.

OBJECTIVE: Children are at high risk of injuries and wounds. The application of medical grade honey is a promising approach to improving the healing of wounds of various origin and severity. However, the use of medical grade honey in young paediatric patients remains limited. The aim of this study is to show the safety, efficacy and usefulness of medical grade honey in abdominal wounds, of different causes, in paediatric patients.
METHODS: This was a prospective, observational case series evaluating five young infants with abdominal wounds at the General Hospital in Thessaloniki. All wounds were treated in the same manner with daily medical grade honey applied to the wound area and closely monitored.
RESULTS: All treated wounds rapidly presented granulation tissue formation and underwent re-epithelialisation. Peripheral oedema and inflammation decreased upon initial application. Necrotic tissue was effectively debrided when present. Slough was removed and no signs of infection were detected, irrespective of initial wound presentations. Scar formation was minimal and the full range of motion was preserved in all cases.
CONCLUSIONS: Based on this case study, medical grade honey is safe and effective in treating different abdominal wounds, including infected or dehisced wounds as well as burns. The easy application and broad applicability make medical grade honey recommendable as a first-line treatment in paediatric patients.

BACKGROUND: Several reports state that negative pressure wound therapy (NPWT) with instillation and dwell time (NPWTi-d) is useful in the management of intractable ulcers. However, reports comparing the effects of NPWT and NPWTi-d in the same patient are lacking.
METHODS: A 76-year-old man with intractable skin ulcers on both lateral malleoli presented to an outpatient clinic. Conservative treatment over a 3-month period had not been effective. The authors applied NPWT to the left leg and NPWTi-d to the right leg with fibular osteomyelitis to encourage granulation for 28 days. Thereafter, they covered both ulcers with split-thickness skin grafts. Negative pressure wound therapy was applied to the both legs for 1 week postoperatively. During periods in which NPWT and NPWTi-d were utilized, the patient received intravenous cefazolin sodium (1 g twice daily), lasting 7 days after skin grafting. Epithelization was completed in the NPWTi-d-treated ulcer in about 3 weeks and in the NPWT-treated ulcer in about 8 weeks due to the difficulty in healing his residual ulcers. In terms of the efficacy of granulation and debridement of infected granulation tissue, NPWTi-d demonstrated better results with increments in the washing amount. Also, NPWTi-d proved superior in terms of the survival status of the skin graft, the time until the residual ulcer disappeared, and the removal of latent bacteria.
CONCLUSIONS: From this case report, the authors believe NPWTi-d may be more effective in cases with intractable ulcers associated with infection that need better granulation.