Burns - Articles in Press

Biodegradable staples, a needed revolution in burn future - Corrected Proof

Ali Akbar Mohammadi, Seyed Morteza Seyed Jafari — 2012-05-14

Although among available different methods of skin graft fixation, skin stapling is the method of choice in many burn centers , skin staples have a number of problems. The pain associated with removal of staples may provoke fear in patients.

Methylated spirit burns: An ongoing problem - Corrected Proof

J.R.H. Jansbeken, A.F.P.M. Vloemans, F.R.H. Tempelman, R.S. Breederveld — 2012-05-14

Abstract: Objective: Despite many educational campaigns we still see burns caused by methylated spirit every year. We undertook a retrospective study to analyse the impact of this problem.Methods: We retrospectively collected data of all patients with burns caused by methylated spirit over twelve years from 1996 to 2008. Our main endpoints were: incidence, age, mechanism of injury, total body surface area (TBSA) burned, burn depth, need for surgery and length of hospital stay.Results: Ninety-seven patients with methylated spirit burns were included. During the study period there was no decrease in the number of patients annually admitted to the burn unit with methylated spirit burns. 28% of the patients (n=27) were younger than eighteen years old, 15% (n=15) were ten years old or younger. The most common cause of burns was carelessness in activities involving barbecues, campfires and fondues. Mean TBSA burned was 16% (SD 12.4). 70% (n=68) had full thickness burns. 66% (n=64) needed grafting. Mean length of hospital stay was 23 days (SD 24.7).Conclusions: The use of methylated spirit is an ongoing problem, which continues to cause severe burns in adults and children. Therefore methylated spirit should be banned in households. We suggest sale only in specialised shops, clear labelling and mandatory warnings.

Antimicrobial resistance patterns and their encoding genes among Acinetobacter baumannii strains isolated from burned patients - Corrected Proof

2012-05-11

Abstract: The purpose of this study was to determine the mechanisms and patterns of antimicrobial resistance among the isolates obtained from burned patients with wound infections at a teaching hospital in Tehran, Iran. A total of 23 Acinetobacter baumannii isolates were collected from patients with burn wound infections between August 2009 and July 2010 from a hospital in Tehran. The susceptibility of these strains against 11 antimicrobial agents was determined by E-test according to the CLSI guidelines. All the resistant strains were then subjected to PCR assay for 28 distinct resistance genes. The most active antimicrobial agent was colistin with 100% sensitivity followed by gentamicin, amikacin and imipenem with 69.5%, 52.1% and 51.1% sensitivity, respectively. The most frequent resistance genes detected were blaOXA-51-like genes (n=23; 100%) that was intrinsic to A. baumannii isolates, gyrA (n=23; 100%), carO (n=23; 100%), tetA (n=22; 95.5%), tetB (n=15; 65.2%), intI (n=13; 56.5%) and PER (n=12; 52.1%), respectively. In order to make a proper choice of antibiotic for burn patients, it would be beneficial to physicians to identify drug resistance patterns in A. baumannii isolates.

The use of a frailty scoring system for burns in the elderly - Corrected Proof

D. Masud, S. Norton, S. Smailes, O. Shelley, B. Philp, P. Dziewulski — 2012-05-10

Abstract: Introduction: Burn in the elderly has a high mortality. Scoring systems incorporating age, and/or co-morbidities have been developed to assist in predicting outcomes in this high risk group. Life expectancy has increased in the general population and within the elderly age group medical co morbidity, physiological response to injury and socioeconomic factors give rise to the concept of biological versus chronological age. For a given age, baseline pre morbid state can vary. It is more valid to consider biological rather than chronological age when calculating risk. The Canadian Study of Health and Aging (CSHA) clinical frailty scale, incorporating fitness, co-morbidities and level of dependence was used to analyse our elderly burn patients admitted to Burns ITU, their surgical management and one-year survival.Method: Data from patients with burns greater than 10% and aged over 65years managed on the Burns ITU between 2005 and 2009 were obtained. A frailty score (1–7) was assigned to each patient based on the records of their admission assessment.42 patients met the study criteria for analysis. 18 (42.9%) patients, with mean age 74.9years (range 65–95years) survived (S) their ITU stay and of these, 83.3% survived at 1year. 24 (57.2%) patients, mean age 78.4years (range 66–95years) died (D) whilst on ITU. There was no significant difference between the two groups with regard to age, percentage burn (30% TBSA range 10–85%) (P>0.05 using T Test) or inhalational injury (p>0.05 using Z test).Using Mann–Whitney U test analysis, the frailty score between the two groups showed a significant difference at p=0.0001 (Mann–Whitney U test=78), median=3 (S) and median=5 (D). This suggests patients with better pre-morbid capacity, as evaluated by the frailty scoring system, were more likely to survive their burn insult and treatment. Significantly, more patients in the group that survived underwent surgical debridement (Mann–Whitney U test=111, p=0.02).Conclusion: Frailty scoring system appears to be a useful adjunct in predicting outcome in burns requiring admission to HDU/ITU in the senior population. The frailty score may predict which patients will benefit from surgery which also continues to be an important determinant of outcome in these patients.

The properties of an “ideal” burn wound dressing – What do we need in daily clinical practice? Results of a worldwide online survey among burn care specialists - Corrected Proof

2012-05-10

Abstract: Objective: Using Internet polling to classify characteristics of a burn wound dressing considered as “ideal” by burn care specialists for small sized burns (<20% TBSA).Methods: Open, voluntary Internet-based cross-sectional survey with twenty non-compulsory questions and collection of information related to profession, staff grade, work location.Results: In total one-hundred and twenty-one participants from 39 countries were included (response rate: 121/1000=12.1%) within the one month survey period (1–31st December 2011). The majority of respondents were surgeons (72.1%; 88/121), and most participants were from Europe 59.4% (72/121). According to the survey the following are the properties of an “ideal” burn wound dressing: non-adhesion (“essential”: 55/120, 45.8%; “desirable”: 50/120, 41.7%), absorbency (“essential”: 41/120, 34.2%; “desirable”: 64/120, 53.3%) and antimicrobial activity (“essential”: 52/121, 43.0%; “desirable”: 49/121, 40.5%). In addition, ease of removal, which would produce more pain-free dressing changes, was also considered to be an asset – ideally requiring dressing changes twice per week with a range of different dressing sizes available. As polled directly, most of the respondents thought that such a dressing was currently not available.Conclusion: This Internet-based survey provides a first insight into a ‘wish list’ of properties for burn wound dressings required by specialists in burn care from around the world. As with any kind of idealism, to date, no such burn wound dressing seems to be available in clinical practice according to the poll. Future scientific efforts need to focus on designing materials, which feature at least some of the properties revealed by this analysis.

Cooling properties of everyday liquids - Corrected Proof

Robert M. Warner, Yvonne Wilson, Darren L. Chester — 2012-05-04

Abstract: Objective: To examine the cooling properties of a variety of ‘everyday’ hot liquids within the context of scald injuries in the United Kingdom.Methods: The temperature of common hot liquids, including water, tea, coffee and various other liquids (i.e. takeaway coffees, “Indian tea”, chicken curries, hot milk and oil) were recorded over a time period, using digital cooking thermometers.Results: Minimal difference was detected between the cooling rates of hot water, coffee and tea. Indian tea cooled at a slower rate. The speed at which milk cooled was less than other liquids and the higher the fat content the slower it cooled. Takeaway beverages had a lower starting temperature and retained heat for substantially longer periods. The assessment of cooking oil revealed intense heat production and prolonged cooling.Conclusion: The authors propose that if a patient is exposed to a ‘common’ scalding agent that has been cooling for 10min or less then the temperature of that fluid is likely to be greater than 60°C and therefore capable of causing a burn within seconds of exposure. Furthermore, most liquids tested take between 15 and 30min to reach a “safe temperature” below 53°C.

Assault by burning in Dhaka, Bangladesh - Corrected Proof

2012-05-03

Abstract: Assault by burning in Dhaka, Bangladesh, occurs in a variety of forms, resulting from various causes and motives. A total of 311 cases of intentional burns from the Burn Unit of Dhaka Medical College Hospital from April 2004 to May 2011 (6years) were studied by retrospective and prospective observational review. The majority of victims (68%) were female. Concentrated sulphuric acid was the most commonly used chemical for attack. Disfigurement was the principal complication (mortality, 4%). Dowry-related issues, divorce and other marital quarrels were frequent backgrounds for assault by burning. Kerosene oil was used to ignite 78 girls or young women, most often related to conflicts over dowry (mortality 97%). A total of 102 victims (32%) in all burn groups were attacked because of dowry-related issues. Intentional contact burns were often inflicted on domestic servants. Although physical morbidity and mortality were not reported in contact and other types of burns, psychological disturbances were reported in all victims. A few victims had been assaulted prior to receiving burns, and fractures and deformities were also present on examination at the time of presentation for burn treatment. Ophthalmic injury, with frequent visual impairment, was very common in cases of chemical attack. Legal and social support for victims and their families are frequently inadequate to compensate for losses. Clearly, more attention in our community should be focussed on the prevention of burn assaults, adequate compensation and medical care for victims, as well as speedy retribution for perpetrators.

Are there predicting factors for burn patients that transfer to a rehabilitation center upon completion of acute care? - Corrected Proof

2012-04-30

Abstract: Introduction: Choosing the right burn patient that transfers to a rehabilitation facility following acute hospitalization is a difficult decision. In our study we characterize demographic, injury and hospitalization related variables that predict a burn patient's transfer to a rehabilitation facility.Methods: We analyzed the data of 974 burn patients with burns of the second degree and deeper, spanning 20% TBSA (total body surface area) or more, that were admitted to all 5 hospitals that operate a burn unit in Israel, between the years 1998 and 2005.Results: The results of the multivariate logistical regression model in which the predicted variable is discharge to rehabilitation showed that the most predictive variables were inhalation injury, surgical procedures and hospitalization period. Execution of a surgical procedure was the most influential factor over discharge to rehabilitation (odds ratio=6.202) followed by inhalation injury (OR=4.706) and finally, the hospitalization period (OR=1.026) (an increase of 1.026 times in the likelihood to be sent to rehabilitation with any additional day of hospitalization).Discussion: In this study we examined patients who were sent to a rehabilitation facility upon completion of their acute care in an attempt to evaluate common initial clinical variables that assist in making an educated decision regarding the patient rehabilitation transfer. This is one of the first attempts at examining and revealing evidence based parameters that might determine the correct burn patient to send to rehabilitation after his hospitalization.

Resurgence of methamphetamine related burns and injuries: A follow-up study - Corrected Proof

2012-04-30

Abstract: Purpose: Legislation enacted to curb methamphetamine production has only temporarily succeeded. Experiencing a recent increase in burns as a result of the new one-pot method, we compared methamphetamine related burn patients who utilized the previous anhydrous ammonia method of production to current patients who largely used the new one-pot method of production.Basic procedures: Patients who were burned as a result of methamphetamine production were retrospectively reviewed. Comparisons were made including demographics, length of stay, injury severity score, hospital charges, total body surface area burned, inhalation injury, intubation, ventilator days, toxicology, fluid volumes, surgeries and complications.Main findings: Eighteen current study patients (88.9% male) were compared to twenty-nine (86.2% male) previous study patients. The groups were similar in age, pattern of burn injury and intubation. Total body surface area burned, injury severity score, inhalation injuries, and ventilator days were not significantly increased in the current study. Longer length of stay and greater hospital charges were incurred by the current group. Burn surgeries per patient were significantly increased in the current group.Principal conclusions: A new one-pot method has emerged despite legislative attempts to curtail methamphetamine production, and burns have also increased. The reason for more extensive burn surgeries in the current METH related burn patients remains enigmatic. Severity of injury and cost to society remain high.

Noise levels in a burn intensive care unit - Corrected Proof

2012-04-30

Abstract: Introduction: Increased noise levels in hospitals, critical care units, and peri-operative areas have been associated with higher levels of sleep deprivation and patient stress. The World Health Organization (WHO) guidelines stipulate a limit of 35 decibels (dB(A)) equivalent continuous sound level (LEq) during the day and 30 dB(A) LEq at night in patients’ rooms. To date, no quantitative studies of noise levels have been performed in burn units. The objective of this study was to quantify noise levels in a burn critical care unit to ascertain compliance with guidelines in order to minimize this potential insult.Methods: An A-weighted sound pressure level meter was used to measure the ambient noise levels in a burn intensive care unit. Maximum and minimum sound pressure levels were measured at 30-min intervals on 10 days over a 1 month period. Measurements were obtained during shift changes and random times during the day and night-time. Descriptive statistical analyses were performed, to calculate means and standard deviations. Noise measurements at specified times were compared using analysis of variance (ANOVA).Results: Mean dB(A) LEq values for shift changes, day, and night-time were 65.9±2.8, 65.7±2.6, and 60.9±5.2 dB(A), respectively. There was no significant difference in dB(A)max or dB(A)min between shift changes, day or night-time (p>0.05). However, night-time minimum values were consistently lower. There was no significant difference between sound pressure level (SPL) inside and outside patients’ rooms (p>0.05) at any time.Conclusions: Irrespective of time or location, the mean dB(A) LEq in the burn unit was significantly greater than World Health Organization (WHO), National Institute for Occupational Safety and Health (NIOSH), and the Environmental Protection Agency (EPA) recommendations. Guidelines for decreasing noise exposure are necessary to reduce potential negative effects on patients, visitors, and staff.

Exercise training to improve health related quality of life in long term survivors of major burn injury: A matched controlled study - Corrected Proof

T.L. Grisbrook, S.L. Reid, D.W. Edgar, K.E. Wallman, F.M. Wood, C.M. Elliott — 2012-04-26

Abstract: Objective: Patients often experience reduced health-related quality of life (HRQOL) following burn injury. Exercise training has been demonstrated to improve HRQOL in a number of clinical populations, yet it is unknown whether exercise can improve HRQOL in burns patients.Procedures: Nine burn-injured participants (42±18.38%TBSA: 6.56±3.68 years after injury) and 9 matched controls participated in a 12-week exercise programme. HRQOL was assessed via the Burn Specific Health Scale-Brief (BSHS-B) and the Medical Outcomes Study 36-Item Short Form (SF-36). Activity limitation was measured using the quick Disabilities of the Arm, Shoulder and Hand (QuickDASH).Results: The burns group had decreased HRQOL compared to the controls at baseline, as reported by the BSHS-B (t (16)=3.51, p=0.003) and some domains of the SF-36 including role physical (t (16)=3.79, p=0.002). Burned participants reported decreased activity levels compared to the controls as measured by the QuickDASH (t (16)=2.19, p=0.044). Exercise training improved SF-36 scores in both burn (t (8)=3.77, p=0.005) and control groups (t (8)=2.71, p=0.027). Following training there was no difference between the groups on the SF-36 or QuickDASH.Conclusion: Exercise training improves HRQOL and activity limitations in burn-injured patients to a level that is equivalent to that of their uninjured counterparts.

An electrocardiogram for a patient with Biobrane® dressing - Corrected Proof

A. Farroha, M. Syed, P. Dziewulski — 2012-04-17

Biobrane® is a flexible biosynthetic dressing firmly adhere to wounds. Biobrane® has reduced the hospital stay, wound healing time and pain . Therefore, it is widely used in pediatric partial-thickness scald burns.

Epidemiology of fungal infection in burns: Therapeutic implications - Corrected Proof

Jean-Vivien Schaal, Thomas Leclerc, Pierre Pasquier, Laurent Bargues — 2012-04-12

We are very interested in the study of Sarabahi and colleagues on epidemiology of invasive fungal burn wound infections. Fungal infections now represent a serious problem in burn units, because they are associated with a high morbidity and mortality. This article emphasizes an important problem in burns: the changing epidemiology in fungal wound infections, and the necessity for clinicians to adapt empirical antifungal therapy. In the author's unit, nonalbicans Candida species become the predominant fungal agents causing wound infections in burned patients (66–93% of all fungal infections) .

Fixation of ProSeal™ laryngeal mask airway in a child with facial burns - Corrected Proof

Rupesh Yadav, Sohan Lal Solanki — 2012-04-12

An eight-year-old female child was posted for skin grafting of chest and upper limbs. She was a victim of 45%, second degree skin burn over whole face, scalp, chest and both upper limbs. On examination she was 24kg in weight. Cardiovascular and respiratory system revealed no abnormality. Airway examination revealed a mouth opening of 3cm and she was Mallampatti class II airway with limited neck flexion. Her preoperative routine laboratory investigations, chest X-ray and ECG were normal. A 20 G intravenous cannula was secured in lower limb and baseline normal saline infusion was started. 5-lead electrocardiography equipment was applied to the lower abdomen. Pulse oximetry and non invasive blood pressure monitoring were applied on lower limbs. Facemask was applied after securing vaseline impregnated gauze around and beneath the mask and she was preoxygenated with 100% oxygen for 3min. Anesthesia was induced with fentanyl 3mcgkg−1 and propofol 2.5mgkg−1. A size 2 ProSeal™ laryngeal mask airway (PLMA) was inserted and fixed with No. 1 Vicryl surgical suture. The PLMA was first tightly fixed with 2 rounds of Vicryl and 2 surgical knots. Both free ends of suture then fixed in lateral groves of upper incisors and 2 rounds was taken around incisors and tightened by 2 surgical knots (). Anesthesia was maintained on isoflurane in oxygen and nitrous oxide (30:70). Surgery lasted for 3h and at the end of surgery suture was cut and PLMA was removed when the patient was fully awake. The same procedure and method of fixation of PLMA was repeated in same patient on 2nd operation 1 week later.

Reduction in skin grafting after the introduction of hydrofiber dressings in partial thickness burns: A comparison between a hydrofiber and silver sulphadiazine - Corrected Proof

J. Dokter, H. Boxma, I.M.M.H. Oen, M.E. van Baar, C.H. van der Vlies — 2012-04-06

Abstract: Aim/purpose: The aim of this study was to compare clinical outcome of children with scald burns treated with a hydrofiber dressing (Aquacel®, Convatec Inc.) with the former standard of care with silver sulfadiazine (Flammazine®; Solvay Pharmaceuticals), considering surgical intervention and length of stay (LOS).Methods: A retrospective study of all consecutive children from zero to four years with primary scald burns up to 10% admitted to the Burn Centre of the Maasstad Hospital Rotterdam between January 1987 and January 2010 were reviewed. For data collection a prospective computerized database was used. For comparison the study period was divided into two periods representing the period before and after the introduction of the hydrofiber dressing (HFD), respectively 1987–1999 (period 1) and 1999–2010 (period 2).Results: Over the whole study period 27.3% of 502 patients treated with silver sulfadiazine (Ag-SD) underwent surgery, while before the introduction of HFD 30.5% of 338 Ag-SD treated patients were operated upon. After the introduction of the HFD 20.7% of 164 patients treated with Ag-SD eventually underwent skin grafting, a significant difference with the 11.6% of 302 patients whose wounds were dressed with HFD (p<0.01).Conclusions: Compared to silver sulfadiazine treatment a reduced number of surgical interventions was observed in mixed partial thickness scald burns up to 10% TBSA burned in children aged 0–4 years after the introduction of hydrofiber dressings. The mode of treatment with this wound dressing also limited hospital length of stay.

Prognostic factors for amputation in severe burn patients - Corrected Proof

C.A. Soto, C.R. Albornoz, V. Peña, C. Arriagada, J.P. Hurtado, J. Villegas — 2012-04-05

Abstract: Introduction: Amputation is a rare procedure among burned patients. However, it has significant physical and psychological consequences which impact quality of life.Objective: To study the incidence, etiology and prognostic factors associated with amputation among burned patients in Chile.Methods: Cohort study of patients admitted to the Reference Burn Center of Chile from 2006 to 2011. Association of demographic, event and injury variables with the likelihood of amputation were evaluated by using multivariable analysis.Results: Amputation incidence was 5.8% in 1090 admitted patients. Male amputee patients were significantly more frequent (p=0.01), with more electrical and high voltage burns (p<0.01) and had greater frequency of impaired consciousness (p=0.03). Multivariable analysis identified electrical burns (OR 13.7; 95% CI 6.7–28.1) and impaired consciousness (OR 2.8; 95% CI 1.4–5.7) as prognostic factors for amputation.Conclusion: Amputation is a low incidence procedure among burned patients. Patients who underwent amputations are frequently at working age. Patients with high-voltage electrical burns and impaired consciousness are more likely to undergo amputation. Since these are highly incapacitating injuries, it is very important to implement preventive measures.

β-Glucan treatment prevents progressive burn ischaemia in the zone of stasis and improves burn healing: An experimental study in rats - Corrected Proof

2012-04-02

Abstract: Saving the zone of stasis is one of the major goals of burn specialists. Increasing the tissue tolerance to ischaemia and inhibiting inflammation have been proposed to enable salvage of this zone. After a burn, excessive inflammation, including increased vascular permeability, local tissue oedema and neutrophil activation, causes local tissue damage by triggering vascular thrombosis and blocking capillaries, resulting in tissue ischaemia and necrosis. Oxygen radicals also contribute to tissue damage after a burn. However, macrophages play a pivotal role in the response to burn. We studied β-glucan because of its many positive systemic effects that are beneficial to burn healing, including immunomodulatory effects, antioxidant effects (free-radical scavenging activity) and effects associated with the reduction of the inflammatory response.There were four test groups in this study with eight rats in each group. Group 1 was the control group, group 2 was administered a local pomade (bacitracin+neomycin sulphate), group 3 received β-glucan (50mgkg–1, orally)+the local pomade and group 4 received β-glucan. Burns were created using a brass comb model. Macroscopic, histopathological and statistical assessments were performed. Samples were harvested on the 3rd, 7th and 21 days for analysis. The neutrophilic infiltration into the zone of stasis was analysed on day 3. Macrophage infiltration, fibroblast proliferation, angiogenesis and re-epithelialisation ratios in the zone of stasis were analysed on days 7 and 21.The β-glucan groups (groups 3 and 4) exhibited lower neutrophil counts on the 3rd day, and macrophage infiltration, fibroblast proliferation, angiogenesis and re-epithelialisation were very high in these groups on the 7th day. In particular, re-epithelialisation on the 21st day was significantly better in the β-glucan groups.This study demonstrated that β-glucan may prevent neutrophil-dependent tissue damage and burn-induced oxidative injury through its anti-inflammatory and antioxidant properties. We speculate that the inhibition of neutrophil activation preserves vascular patency by preventing capillary blockage. β-Glucan is also a powerful macrophage stimulator, and is therefore very effective in saving the zone of stasis.

Development of a long-term ovine model of cutaneous burn and smoke inhalation injury and the effects of early excision and skin autografting - Corrected Proof

2012-03-29

Abstract: Smoke inhalation injury frequently increases the risk of pneumonia and mortality in burn patients. The pathophysiology of acute lung injury secondary to burn and smoke inhalation is well studied, but long-term pulmonary function, especially the process of lung tissue healing following burn and smoke inhalation, has not been fully investigated. By contrast, early burn excision has become the standard of care in the management of major burn injury. While many clinical studies and small-animal experiments support the concept of early burn wound excision, and show improved survival and infectious outcomes, we have developed a new chronic ovine model of burn and smoke inhalation injury with early excision and skin grafting that can be used to investigate lung pathophysiology over a period of 3 weeks.Materials and methods: Eighteen female sheep were surgically prepared for this study under isoflurane anesthesia. The animals were divided into three groups: an Early Excision group (20% TBSA, third-degree cutaneous burn and 36 breaths of cotton smoke followed by early excision and skin autografting at 24h after injury, n=6), a Control group (20% TBSA, third-degree cutaneous burn and 36 breaths of cotton smoke without early excision, n=6) and a Sham group (no injury, no early excision, n=6). After induced injury, all sheep were placed on a ventilator and fluid-resuscitated with Lactated Ringers solution (4mL/% TBS/kg). At 24h post-injury, early excision was carried out to fascia, and skin grafting with meshed autografts (20/1000in., 1:4 ratio) was performed under isoflurane anesthesia. At 48h post-injury, weaning from ventilator was begun if PaO2/FiO2 was above 250 and sheep were monitored for 3 weeks.Results: At 96h post-injury, all animals were weaned from ventilator. There are no significant differences in PaO2/FiO2 between Early Excision and Control groups at any points. All animals were survived for 3 weeks without infectious complication in Early Excision and Sham groups, whereas two out of six animals in the Control group had abscess in lung. The percentage of the wound healed surviving area (mean±SD) was 74.7±7.8% on 17 days post-surgery in the Early Excision group. Lung wet-to-dry weight ratio (mean±SD) was significantly increased in the Early Excision group vs. Sham group (p<0.05). The calculated net fluid balance significantly increased in the early excision compared to those seen in the Sham and Control groups. Plasma protein, oncotic pressure, hematocrit of % baseline, hemoglobin of % baseline, white blood cell and neutrophil were significantly decreased in the Early Excision group vs. Control group.Conclusions: The early excision model closely resembles practice in a clinical setting and allows long-term observations of pulmonary function following burn and smoke inhalation injury. Further studies are warranted to assess lung tissue scarring and measuring collagen deposition, lung compliance and diffusion capacity.

A burn center paradigm to fulfill deferred consent public disclosure and community consultation requirements for emergency care research - Corrected Proof

Martha G. Blackford, Lynn Falletta, David A. Andrews, Michael D. Reed — 2012-03-29

Abstract: Introduction: To fulfill Food and Drug Administration and Department of Health and Human Services emergency care research informed consent requirements, our burn center planned and executed a deferred consent strategy gaining Institutional Review Board (IRB) approval to proceed with the clinical study. These federal regulations dictate public disclosure and community consultation unique to acute care research.Objective: Our regional burn center developed and implemented a deferred consent public notification and community consultation paradigm appropriate for a burn study.Methods: Published accounts of deferred consent strategies focus on acute care resuscitation practices. We adapted those strategies to design and conduct a comprehensive public notification/community consultation plan to satisfy deferred consent requirements for burn center research.Results: To implement a robust media campaign we engaged the hospital's public relations department, distributed media materials, recruited hospital staff for speaking engagements, enlisted community volunteers, and developed initiatives to inform “hard-to-reach” populations. The hospital's IRB determined we fulfilled our obligation to notify the defined community.Conclusion: Our communication strategy should provide a paradigm other burn centers may appropriate and adapt when planning and executing a deferred consent initiative.

Protective effects of ulinastatin on pulmonary damage in rats following scald injury - Corrected Proof

Chengjin Gao, Yuhao Liu, Lijie Ma, Sheng Wang — 2012-03-28

Abstract: Organ protection is desirable in severe burn/scald injuries, and damage mechanisms and thus effective therapies following scald injury have not been fully elucidated. Our aim was to examine the beneficial effects of ulinastatin on pulmonary damage associated with scald injury. Lewis rats were subjected to 30% total body surface area (TBSA) scald injury and were randomly divided into a burn control (S group) and an ulinastatin-treated group (U group). Lung malondialdehyde (MDA) and superoxide dismutase (SOD) levels were determined, and the lungs were examined histologically with immunohistochemistry (IHC) as well for the major histocompatibility complex (MHC) class I chain-related antigen A (MICA) and Bcl-2 at 24, 48 and 72h after the injury. The expression of spleen human leucocyte antigen-DR (HLA-DR) was detected by immunohistochemistry analysis. Selectins and adhesion molecules in lungs and serum were also detected. The lung injury degree was represented as wet/dry (W/D) values and alveolar thickness.Ulinastatin decreased MDA levels and ameliorated the down-regulation of SOD activity. MICA was up-regulated after the scald, and this up-regulation was greatly diminished by ulinastatin. Bcl-2 was up-regulated after the scald, especially in the U group. The spleen HLA-DR expression demonstrated the immunoregulatory effects of ulinastatin, which effectively protected the pulmonary tissues from scald-induced injury.Our results demonstrated that pulmonary damage was associated with autoimmunity and oxidant attack after severe scald. Ulinastatin exhibits significant protective effects on these effects.

Extracorporeal shock waves improve angiogenesis after full thickness burn - Corrected Proof

2012-03-26

Abstract: Objective: Extensive wounds of burn patients remain a challenge due to wound infection and subsequent septicemia. We wondered whether extracorporeal shock wave application (ESWA) accelerates the healing process. The aim of the study was to analyze microcirculation, angiogenesis and leukocyte endothelium interaction after burns by using ESWA with two types of low intensity.Methods: Full-thickness burns were inflicted to the ears of hairless mice (n=51; area: 1.3mm2). The mice were randomized into five groups: (A) low-energy shock waves after burn injury (0.04mJ/mm2); (B) very low-energy shock waves after burn injury (0.015mJ/mm2); (C) mice received burns but no ESWA (control group); (D) mice without burn were exposed to low-energy shock waves; (E) mice without burns and with no shock wave application. Intravital fluorescent microscopy was used to assess microcirculatory parameters, angiogenesis and leukocyte behavior. ESWA was performed on day 1, 3 and 7 (500 shoots, 1Hz). Values were obtained straight after and on days 1, 3, 7 and 12 post burn.Results: Group A showed accelerated angiogenesis (non-perfused area at day 12: 5.3% vs. 9.1% (group B) and 12.6% (group C), p=0.005). Both shock wave groups showed improved blood flow after burn compared to group C. Shock waves significantly increased the number of rolling leukocytes compared to the non-ESWA-treated animals (group D: 210.8% vs. group E: 83.3%, p=0.017 on day 7 and 172.3 vs. 90.9%, p=0.01 on day 12).Conclusion: Shock waves have a positive effect on several parameters of wound healing after burns, especially with regard to angiogenesis and leukocyte behaviour. In both ESWA groups, angiogenesis and blood flow outmatched the control group. Within the ESWA groups the higher intensity (0.04mJ/mm2) showed better results than the lower intensity group. Moreover, shock waves increased the number of rolling and sticking leukocytes as a part of an improved metabolism.

Documenting thermoregulatory system activity in burn patients - Corrected Proof

J. Bracher, D.B. Saleh, F. Urso-Baiarda, N. Brierley, J. Rawlins, S. Bhandari — 2012-03-22

We describe a useful method of recording Thermogard XP™ system (Zoll Medical Corporation) activity on observation charts, which can be applied in any Burns care setting. Thermoregulatory systems are well established in critical care units. The intravascular Thermogard XP™ has been used in our Regional Burns Centre since 2008. Although such systems are effective in regulating labile core body temperatures associated with severe burns, documentation of an artificially maintained temperature on an observation chart may be misleading and misrepresentative of underlying pathophysiology. This has implications for both immediate patient management and retrospective review of observation charts, for audit and/or medico-legal purposes. We have devised a qualitative method of charting Thermogard XP™ activity, allowing the burns team to determine the extent to which the system is influencing core body temperature, and providing a more accurate reflection of true underlying physiology.

Response to Letter to the Editor: ‘Epidemiology of Fungal Infection in Burns’ - Corrected Proof

Sujata Sarabahi, V.K. Tiwari, Savita Arora, Malini R. Capoor, Anurag Pandey — 2012-03-21

This is with reference to the letter to editor entitled ‘Epidemiology of fungal infection in burns’ by Jean Vivien Schaal et al. who have stated that in their unit the incidence of fungal isolates in burn patients is 17.2% without any candidemia. This is comparable to our study where the incidence of fungal infection in burn patients is 12%. However candidemia was seen in 4% of total patients who were critically ill .

Bacteriology of infected burn wounds in the burn wards of a teaching hospital in Southwest Nigeria - Corrected Proof

2012-03-05

Abstract: Background: Burns are characterized by the loss of varying proportions of the protective layers of the skin, depression of immune responses, and increased wound susceptibility to infection. Wound infection is a major cause of morbidity and mortality in burn cases. This study characterizes those factors that predispose burn wounds to infection and the bacteriology of the microorganisms in our environment.Patients and methods: Prospective study of burns patients that were admitted and treated at the Lagos State University Teaching Hospital (LASUTH), Ikeja-Lagos, Nigeria between January 1 and May 31, 2010 was carried out. Information about the demographics, aetiology/mechanism of burns, interval between the time of injury and admission, microbial studies, and antibiotic therapy were collected and analyzed.Results: A total of 74 patients consisting of 43 males and 31 females were seen. The ages range between one week and 95±22.42 years. Wound infections were confirmed in 28 patients (infection rate of 37.84 per 100 patients). Delayed presentation at LASUTH and length of hospital stay were significantly related to the development of wound infection. Pseudomonas aeruginosa and Proteus mirabilis were the most common infective organisms occurring in 53.6 and 10.7 percentages respectively. The isolated organisms were resistant to the beta-lactam antibiotics and mostly sensitive to carbapenem and aztreonam preparations.Conclusion: Factors predisposing to invasive wound infections in our environment were highlighted and suggestions made on methods that could reduce the infections and thus reduce morbidity and mortality in burns.

Effect of whole body vibration on leg muscle strength after healed burns: A randomized controlled trial - Corrected Proof

2012-03-05

Abstract: Objective: To investigate the effects of eight weeks whole body vibration training program on leg muscle strength (force-producing capacity) in adults after healed burns.Design: Randomized controlled trial.Setting: Faculty of Physical Therapy, Cairo University.Subjects: Thirty-one burned patients participated in the study and were randomized into whole body vibration group and control group. Non-burned healthy adults were assessed similarly to burned subjects and served as matched healthy controls.Methods: The whole body vibration group performed an eight weeks vibration program three times a week on a vibration platform; the control group received home based physical therapy program without vibration training.Main measures: Assessment of knee extensors and ankle planter flexor strength by isokinetic dynamometer at 150°/s were performed at the beginning of the study and at the end of the training period for both groups.Results: Subjects with burns more than 36% TBSA produced significantly less torque in the quadriceps and calf muscle than non-burned healthy subjects. Patients in whole body vibration group showed a significant improvement in knee extensor and ankle planter flexor strength as compared with those in the control group. Knee extensor strength and percent improvement was 233.40±5.74 (64.93±3.03 change score) and 38.54% for the vibration group and 190.07±3.99 (21.66±4.41 change score) and 12.86% for the control group, ankle plantar flexor strength and percent improvement was 156.27±5.95 (54.53±6.16 change score) and 53.70% for the vibration group and 116.13±3.24 (14.66±2.71 change score) and 14.52% for the control group.Conclusions: Participation in whole body vibration program resulted in a greater improvement in quadriceps and calf muscle strength in adults with healed thermal burn compared to base line values; a WBV program is an effective for strength gain in rehabilitation of burned patients.

Quality evaluation of meshed split-thickness skin grafts stored at 4°C in isotonic solutions and nutrient media by cell cultures - Corrected Proof

Zhe Li, Christine Overend, Peter Maitz, Peter Kennedy — 2012-03-02

Abstract: Objective: Excess split-skin autografts harvested and meshed during burn surgery are often stored at 4°C temporarily for later use. The quality of the stored skin is critical to clinical outcome and needs to be assured.Methods: Meshed split-thickness skin graft (mSSG) stored in saline, Hartmann's solution and two cell culture media, Dulbecco's Modified Eagle Medium (DMEM) and DMEM/Ham F12 (DMEM/F12, 3:1 mixture) were analyzed by trypan blue staining, cell culture and microbiological testing through a 28-day time course for cell viability and microbial contamination.Results: mSSG samples in all groups showed a progressive decrease of cell viability and colony forming efficiency through the time course of storage at 4°C. Cell culture media were better than saline and Hartmann's solution in maintaining the viability and growth capability of skin cells. The viability observed by trypan blue staining did not truly reflect the cell growth capacity after storage. mSSG in saline and Hartman's solution retained minimal keratinocyte growth potency after 7 days. mSSG in cell culture media had significant loss of keratinocyte colony growth potency after 7 days and minimal keratinocyte growth after 14 days. Dermal fibroblasts of all groups were less tolerant than keratinocytes to the storage. Microbial contaminations were common in mSSG harvested from burn surgery.Conclusions: Culture media instead of saline or Hartman's solution should be used for temporary storage of mSSG at 4°C. The stored mSSS should be used within seven days to have sufficient viable number and cell growth efficiency. After then, the efficacy of stored mSSG as a source of living cells for wound closure could be full of uncertainty due to significant decrease of keratinocyte colony forming efficiency. Precaution should be taken during skin harvest and storage to minimize the risk of sample contamination. Inclusion of antimicrobial agents in storage solution and microbiological testing are advisable to ensure the quality and clinical outcome.

Selectivity of a bromelain based enzymatic debridement agent: A porcine study - Corrected Proof

2012-03-02

Abstract: Background: Debridement of the burn eschar is a cornerstone of burn wound care. Rapid enzymatic debridement with a bromelain-based agent (Debriding Gel Dressing-DGD) has recently been investigated. The current study was designed to further investigate the selectivity of DGD to burned eschar in a larger number and more varied types of wounds.Methods: A systematic animal experiment was conducted to determine the effects of DGD on normal, non-injured skin, burns, exposed dermis of donor sites, and skin punch biopsy wells. Partial thickness dermal burns and partial thickness skin graft donor sites were created on a pig and treated with a 4-h application of DGD or its control hydrating vehicle that does not have any activity except hydration. Punch biopsy samples were taken before and after treatment and microscopically assessed for evidence of tissue viability and its respective components thickness.Results: Rapid dissolution of the burn eschar was noted in all DGD but not vehicle treated burns. There was no apparent damage to the underlying sub eschar dermis, donor sites, normal skin or punch biopsy wells after exposure to DGD. While the thickness of the treated tissues slightly increased due to edema, the increase in dermal thickness was similar after treatment with DGD or its vehicle. The increase in the cross section surface area of the treated punch biopsy wells was similar after treatment with DGD and its control vehicle.Conclusions: Exposure of the burn eschar to DGD results in its rapid dissolution. Exposure of normal skin or non-burned dermis to DGD has no effects demonstrating its selectivity to eschar.

Treatment outcomes for keloid scar management in the pediatric burn population - Corrected Proof

P.A. Patel, J.K. Bailey, K.P. Yakuboff — 2012-02-27

Abstract: Introduction: Keloids scars are challenging problems facing many reconstructive surgeons and have proven to be resistant to many treatments. This is evident by the broad range of treatments available and implemented with inconsistent results. We reviewed our experience to better define the disorder and to evaluate the impact of specific treatment options as related to our patient population.Methods: After obtaining Institutional Review Board approval, we examined the medical records of pediatric patients who were evaluated at our pediatric burn center between 2000 to 2008. All study subjects were identified as having keloid scars confirmed by clinical evaluation (raised scar extending beyond the margins of the original wound ). Treatments included excision and grafting [split thickness autograft (STAG) or full thickness autograft (FTAG)], excision and grafting with steroid injection, excision and primary closure, or excision and primary closure with steroid injection. Patients were included only if there was follow-up of 12 months or greater.Results: One hundred and ten subjects with a diagnosis of a keloid scar were identified. Twenty-six were treated with excision and skin grafting and 8 were treated with a steroid and surgery regimen. Of the patients treated with surgery and steroids, the treatment varied from an intra-operative injection to post-operative injections at 6-week intervals. The number of injections was determined by the administering surgeon and varied from one to three. Clinical end points were determined by the administering surgeon and included: (1) no further improvement in scar maturation or (2) absence of improvement. Recurrence was defined as return of a raised scar consistent with a keloid scar. The recurrence rate was 87.5% for patients treated with surgery and steroids and 80.0% for surgery only. This difference was not statistically significant.Conclusions: Our data demonstrate that steroids do not significantly decrease recurrence in pediatric burn related keloids as compared to previously published series involving non-burn related keloids . This further emphasizes that burn related keloids respond differently to conventional treatments that have proven successful in keloid scars from other mechanisms of injury. A consistent and effective treatment algorithm should be implemented in treating keloid scars from burn wounds.

A randomised prospective study of split skin graft donor site dressings: AWBAT-D™ vs. Duoderm® - Corrected Proof

N.S. Solanki, I.P. Mackie, J.E. Greenwood — 2012-02-24

Abstract: Objective: To assess patient comfort and wound-healing efficacy of a new, purpose-designed biosynthetic material (AWBAT-D™) in the healing of split-skin graft donor sites in comparison with our standard dressing, Duoderm®.Materials and methods: We conducted a prospective randomised controlled trial of donor site dressings, comparing AWBAT-D™ with our standard dressing, Duoderm®. Patients were randomly allocated to have their donor site dressed with one of these materials. Outcome measures included pain scores at rest and during dressing changes, time to re-epithelialisation, time to discharge, scarring and infection. Results were assessed for significance using the Mann–Whitney U-test (non-parametric data) and the Chi-Square test (parametric data).Results: Fourteen patients were recruited with 8 donor sites in each group. The mean pain scores at rest and during dressing changes were not found to be significantly different between the two groups (P=0.99 and P=0.90 respectively). The median time to re-epithelialisation was shorter in the Duoderm® group at 11 days compared to 17 days in the AWBAT-D™ group (P=0.007). The median time to discharge was not significantly different (P=0.38). No infection or scarring has been observed.Conclusions: Based on these early results, AWBAT-D™ appears to have slower donor site healing and does not provide significant improvements in postoperative pain or discharge time compared to Duoderm®. There is no evidence at this stage that our standard donor site dressing should be changed.

Three components of education in burn care: Surgical education, inter-professional education, and mentorship - Corrected Proof

Shahriar Shahrokhi, Kunaal Jindal, Marc G. Jeschke — 2012-02-24

Abstract: Education in burn care can be divided into three main components: surgical education, inter-professional education, e.g. critical care education and mentorship. To date these components have been used in varying degrees in most health institutions and to even lesser extent in burn care. The aim of this paper is to highlight each component and how these have been utilized in other fields to develop teams and foster education, and how they can be translated for burn teams. These ideas are not novel; however, this paper aims to shed light on how these concepts can be implemented in burn care, thus not only improving education, but also enabling recruitment and retention of health care providers in this field.

Management of 2nd-degree facial burns using the Versajet® hydrosurgery system and xenograft: A prospective evaluation of 20 cases - Corrected Proof

Franck Duteille, Pierre Perrot — 2012-02-23

Abstract: Introduction: There is no single therapeutic scheme for the management of intermediary 2nd-degree facial burns, which can cause problems because of their uncertain course. It is preferable to obtain optimal healing of the face in order to avoid functional or cosmetic sequelae. Some practitioners recommend early excision (first week) of these burns, whereas others prefer to wait and perform surgery later (after 2 weeks). The practice in our burns unit is early surgery (from the first week) associated with hydrosurgical excision and application of a biosynthetic dressing (xenograft). A prospective follow-up of 20 cases was carried out to evaluate the efficacy of our protocol.Patients and methods: The prospective evaluation was performed with follow-up at 2 weeks and 3, 6 and 12 months. The patients included had intermediary 2nd-degree burns on at least 15% of the face and no life-threatening prognosis. The mean age in our series was 40.5 years (16–72), the mean percentage of burn surface area was 27.75% and the mean percentage of facial burn was 60.75%. Early excision was performed (day 5–10) using the Versajet® system, which allows tangential water-dissection. Porcine xenograft (E-Z Derm®) was applied immediately afterwards. Patients whose healing process was not complete at 2 weeks were then scheduled to receive a thin autograft. Patients were followed up 2 weeks, 3, 6 and 12 months after discharge.Results: Excision was performed at a mean 7.6 days, and mean initial healing time was 13.4 days. In three cases, a full-thickness skin graft was used, whereas healing occurred in the other patients without further grafts. Two patients had functional sequelae (ectropion) corrected later by repair surgery. The course of healing for the other patients proceeded normally.Discussion: There is no consensus about the management of intermediate depth 2nd-degree facial burns. We chose to perform early surgery using the Versajet® system, which allows fine, precise excision, leaving nearly all of the healthy tissue in place. The Versajet® is particularly adapted to facial contours and is clearly more efficacious than the customary dermatomes. The use of a xenograft may augment facial healing while reducing the number of dressings and lessening patient discomfort. Our protocol provides the advantages of early management (limitation of functional sequelae, reduced hospitalization time), while avoiding too extensive or deep an excision through use of the Versajet®.

A potential skin substitute constructed with hEGF gene modified HaCaT cells for treatment of burn wounds in a rat model - Corrected Proof

2012-02-23

Abstract: 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.

Resurfacing large skin defects of the face and neck with expanded subclavicular flaps pedicled by the thoracic branch of the supraclavicular artery - Corrected Proof

Feng Xie, Jing Wang, Qingfeng Li, Shuangbai Zhou, Tao Zan, Bin Gu, Kai Liu — 2012-02-23

Abstract: Background: Supraclavicular flaps had been widely used as pedicled flaps to reconstruct face and neck defects. However, the size of this traditional flap was limited even after expansion. In this study, we present a flap pedicled by the thoracic branch of supraclavicular artery (TBSA). The flap is located at the subclavicular region, and has the advantage of large dimension, matching colour and thin thickness.Methods: In this series, 24 patients with ages ranging between 3 and 49 years (30 flaps with six patients in bilateral fashion) were treated in the authors’ institution.Results: The maximum size of the flap was 25cm×25cm, whereas the minimum size was 15cm×10cm. The average size of the flaps was 241.1±95.7cm2. Twenty-six flaps (86.7%) survived completely. Total flap loss was seen in one patient (3.3%) and was treated with reverse harvesting skin graft. Partial flap necrosis occurred in three flaps (10.0%). Through a mean time of 10-month follow-up, the colour and the texture of the flaps matched with the recipient area. No conspicuous flap contracture was observed.Conclusion: This expanded subclavicular flap pedicled by the TBSA has proved to be a promising method with satisfactory outcome and high success rate.

Reconstruction of extensive upper extremity defects using pre-expanded oblique perforator-based paraumbilical flaps - Corrected Proof

Mengqing Zang, Shan Zhu, Bin Song, Ji Jin, Donghong Liu, Qiang Ding, Yuanbo Liu — 2012-02-23

Abstract: The pedicled paraumbilical flap is a reliable tissue transfer for hand and forearm reconstruction. However, its size, pedicle length and/or thickness limit its application in resurfacing of extensive defects of the upper limb. To conquer those limitations, this flap was pre-expanded for 10–24 weeks prior to transfer in 25 patients and used as a pedicle flap to cover upper extremity defects. Extensive defects of upper limb were reconstructed by the pre-expanded paraumbilical flaps. The flaps ranged in size from 10cm×8cm to 30cm×14cm. The donor sites were closed directly in all cases. All flaps survived, but two had partial flap necrosis due to venous congestion or infection. With pre-transfer expansion, a large, well-perfused abdominal pedicle flap can be raised and transferred based on the paraumbilical perforators. This pre-expanded flap might be useful in the patients who have the extensive upper limb defects and sufficient time to allow tissue expansion.

Madecassoside suppresses migration of fibroblasts from keloids: involvement of p38 kinase and PI3K signaling pathways - Corrected Proof

2012-02-23

Abstract: Keloid is a specific skin scar that expands beyond the boundaries of the original injury as it heals. The invasive nature of keloid and notable migratory activity of fibroblasts are a hallmark, which distinguishes keloids from other common scars. Madecassoside, a triterpenoid saponin occurring in Centella asiatica herbs, possesses unique pharmacological properties to enhance wound-healing and diminish keloid formation. However, the effects of madecassoside on the formation of keloid scars have been poorly understood. Here, we focused on the potential of madecassoside on the migration of keloid-derived fibroblasts (KFs) and its mechanism. Primary KF, originating from human earlobe keloids, were purified and cultured, and then treated with madecassoside (10, 30, and 100μM). In both transwell migration assays and scratch-wound-closure assays, KF migration was considerably suppressed by madecassoside pretreatment. Furthermore, KFs treated with madecassoside showed decreased F-actin filaments, as revealed by fluorescein isothiocyanate (FITC)-phalloidin staining and confocal microscopy. By Western blot analysis, madecassoside was shown to remarkably attenuate the phosphorylation of cofilin, p38 MAPK and phosphatidylinositol-3-kinase (PI3K)/AKT signaling, but only exhibited a minor effect on MMP-13 and little effect on ERK1/2 phosphorylation. It was concluded that madecassoside could be of great use in the treatment and/or prevention of hypertrophic scars and keloids.

Microvessel networks in pre-formed in artificial clinical grade dermal substitutes in vitro using cells from haematopoietic tissues - Corrected Proof

2012-02-23

Abstract: Forming a microcirculation is critical for vascularisation of artificial skin substitutes. One strategy to improve speed of grafting is to pre-form microvascular networks in the substitute before applying to a wound. For clinical application, this requires sufficient functional endothelial cell numbers. In vitro endothelial colony forming cells (ECFCs) derived cells were expanded from cord and adult blood donations and co-cultured with human dermal fibroblasts or bone marrow mesenchymal stem/stromal cells to form microvascular networks in the presence or absence of dermal substitutes which are in clinical use. The number of endothelial cells generated ranged from 1.03×109 to 2.18×1011 from 10 adult blood donations and 1×1012 to 1.76×1013 from 6 cord blood units after 50 days in culture. Two adult donations failed to generate ECFCs. Both cord and adult blood cells formed 2D microvascular networks in vitro, although there was a significant difference in the functional capacity of adult and cord blood ECFCs. While co-culture of the latter within dermal substitutes Matriderm or Integra demonstrated the formation of 3D microvascular networks penetrating 100μm, enhanced expansion, while maintaining functional capacity, of adult blood cells is required for fully pre-vascularising the clinical grade acellular dermal substitutes used here prior to applying these to burns.

Molecular epidemiologic analysis of Staphylococcus aureus isolated from four burn centers - Corrected Proof

2012-02-23

Abstract: Staphylococcus aureus has been a major cause of hospital-acquired infections. Methicillin-resistant Staphylococcus aureus (MRSA) has emerged since 1980s as an epidemiologic problem in hospitals. This old pathogen brings a new challenge to all physicians and bacteriologists. Hence, effective measures of MRSA control are in critical need. S. aureus or MRSA is one of the leading causes of infection among burn centers, resulting in a number of poor outcomes and even death. The present study performed a molecular epidemiologic analysis of S. aureus isolated from four burn centers in the southeast of China. A total of 85 isolates were collected, and molecular characters were determined for further investigation. In this study, the prevalent clone of MRSA among four burn centers was found to be SCCmec III (spa-type t030, agr I), which is resistant to 4 kinds of antimicrobials including erythromycin, clindamycin, kanamycin and mupirocin. Discrepancy between mecA detection and conventional tests used for MRSA identification was observed unintentionally. Our data demonstrated that the overall prevalence rate of MRSA was 55.3%, and drugs such as sulfamethoxazole/trimethoprim, linezolid and fusidic acid are efficient antibiotic options for treating S. aureus or MRSA infections among four burn centers studied in present investigation.

Effects of Ligustrazine on pulmonary damage in rats following scald injury - Corrected Proof

Chengjin Gao, Yuhao Liu, Lijie Ma, Xiangyu Zhang, Sheng Wang — 2012-02-23

Abstract: Organ protection is a routine therapy in severe burn/scald injuries, and damage mechanisms following early scald injury was not been fully elucidated. Our aim was to verify the beneficial effects of Ligustrazine on pulmonary damage associated with scald injury.Lewis rats were subjected to 30% total body surface area (TBSA) scald injury, and were randomly divided into a burn control (S group) and an Ligustrazine-treated group (L group). Lung malondialdehyde (MDA) and superoxide dismutase (SOD) levels were determined and the lungs were examined histologically with immunohistochemistry (IHC) as well for the MHC class I chain-related antigen A (MICA) and Bcl-2 at 24, 48 and 72h after the injury. The expression of spleen HLA-DR was detected by immunohistochemistry analysis. Selectins and adhesion molecules in lungs and serum as well as pulmonary interleukins were also detected. The lung injury degree was represented as wet/dry (W/D) values and alveolar thickness.Ligustrazine decreased MDA levels and ameliorated the down-regulation of SOD activity. MICA was up-regulated after the scald, and this up-regulation was greatly diminished by Ligustrazine. Bcl-2 was up-regulated after the scald, especially in the L group. The spleen HLA-DR expression demonstrated the immunoregulatory effects of Ligustrazine, which effectively protected pulmonary tissues from scald-induced injury.Our results demonstrated that pulmonay damage associated with autoimmunity and oxidant attack occurred after severe scald. Ligustrazine exhibits significant protective effects on these effects.

Suicidal burn in Hong Kong - Corrected Proof

R.C. Chan, A. Burd — 2012-02-23

Abstract: The aim of our study is to review our experience in the management of patients who sustained burns associated with suicidal attempts over a 10-year period. In particular, we look into the outcome and incidence of self-harm/suicide after discharge among the survivors.Thirty-one patients with median age 36years, ranging from 10 to 74, were included. Twenty-three (74%) were males and eight (26%) were females. Nearly three quarters (74%) of our patients had a known history of psychiatric illness: 11 had known history of substance abuse; 3 of them had drug-induced psychosis; 6 had schizophrenia; 5 had depression; 4 had personality disorders; 1 had pathological gambling and another one had adjustment disorder. Relationship problems and work/financial difficulties were the commonest reason for the suicidal attempts. Self-inflicted flame burn was the most frequent (39%; 12 patients) method of burning.Six patients (19%) died. The remaining 25 patients healed and were discharged. Seventeen patients required ICU care. The median length of stay in ICU was 7days. The overall median length of stay was 35days. The median follow up time for those survived is 63months. Only 4 of these patients had further suicidal/parasuicidal attempts.Despite the high mortality, once these patients survived the initial injury, they are unlikely to commit suicide again. Thus, we believe that aggressive resuscitation should therefore be advocated for all suicidal burn patients.

Complex chemical burns following a mass casualty chemical plant incident: How optimal planning and organisation can make a difference - Corrected Proof

Tomás B. O’Neill, Jeremy Rawlins, Suzanne Rea, Fiona Wood — 2012-02-22

Abstract: Introduction: Four employees at a chemical plant sustained extensive chemical burns following the explosion of a pipeline containing 100% sulphuric acid. We describe the management of these patients from the initial ED triage through to discharge from hospital in life and limb threatening chemical burns.Methods: Four patients who sustained chemical burns to the torso and extremities are reviewed. Data was retrieved from patient case notes and operating theatre logbooks.Results: Four patients sustained chemical burns during the blast and were immediately transferred to a local ED where a prompt referral was made to the burns service. All patients were male aged 25–59 years (mean 46.5). Burn size was 2–50% BSA (mean 22.5). Following RFDS transfer to the state burns service two patients required immediate excisional surgery. In these patients the chemical burn involved full thickness skin loss with extensive underlying muscle and neurovascular damage. One patient required immediate above knee amputation of one leg and fascial burn excision of the other. The other patient required fascial burn excision of both legs followed by Integra placement 24h later. Both patients had prolonged hospital stays due to the complex nature of their injuries requiring multiple trips to theatre and lengthy rehabilitation. The two patients with smaller burns had straightforward surgery and an unremarkable recovery.Conclusion: Early communication following this mass casualty incident allowed for organisation of tertiary services and early radical surgery which was life saving. Management lessons were learnt following this mass casualty chemical burn incident.

The epidemiology of pediatric burns undergoing intensive care in Burn Centre Brno, Czech Republic, 1997–2009 - Corrected Proof

2012-02-22

Abstract: The aim of this study was to determine the basic epidemiological characteristics of severely burned children who were admitted to the intensive care unit (ICU), Department of Burns and Reconstructive Surgery Faculty Hospital Brno, Czech Republic in the years 1997–2009.Methods: We collected and evaluated epidemiological data such as age, sex, burn etiology, length of hospitalization, duration of the ICU stay, surgical or conservative therapeutic strategies, the use of mechanical ventilation and its duration, day and month of injury and the extent of burned area.Results: In total 383 children (253 boys, 130 girls) aged 0–14 years, underwent intensive care for at least 48h. Male to female ratio was 1.95:1. The average range of burn area in the group was 16.43±12.86% TBSA (total body surface area). During the reporting period, 16 children were admitted with burns over 50% TBSA. 328 children suffered burns indoors, with 55 children being burned outdoors. Indoor/outdoor ratio was set at 5.96:1. The most frequent etiological agent was scalding (hot water, soup, coffee, oil, tea). The total number of scalded children in this group was 312 (81.46%). Mechanical ventilation was used in 96 cases (25.07% of all the admitted patients). The duration of mechanical ventilation in these patients was 8.03±5.67 days in average. The average length of stay in ICU was 10.71±10.92 days and total length of hospital stay was an average of 21.55±14.55 days. A total of 184 patients (48.04%) were treated surgically and therefore required necrectomy and skin grafting. The other 199 (51.96%) patients were treated conservatively. During the reporting period 3 children died (0.78%).Conclusion: In our report we identify basic epidemiological data defined in the aim of this study for burned children requiring intensive care.

Lycopene inhibits caspase-3 activity and reduces oxidative organ damage in a rat model of thermal injury - Corrected Proof

2012-02-22

Abstract: Oxidative stress has been implicated in various pathological processes including burn induced multiple organ damage. This study investigated the effects of lycopene treatment against oxidative injury in rats with thermal trauma. Under ether anesthesia, shaved dorsum of the rats was exposed to 90°C bath for 10s to induce burn and treated either vehicle (olive oil) or lycopene (50mg/kg orally). Rats were decapitated 48h after injury and the tissue samples from lung and kidney were taken for histological analysis and the determination of malondialdehyde (MDA) and glutathione (GSH) levels, myeloperoxidase (MPO), superoxide dismutase (SOD), catalase (CAT) and caspase-3 activities. Proinflammatory cytokines, TNF-α and IL-1β, were assayed in blood samples. Severe skin scald injury caused a significant decrease in GSH levels, SOD and CAT activities, and significant increases in MDA levels, MPO and caspase-3 activities of tissues. Similarly, plasma TNF-α and IL-1β were elevated in the burn group as compared to the control group. Lycopene treatment reversed all these biochemical indices. According to the findings of the present study, lycopene possesses antiinflammatory, antiapoptotic and antioxidant effects that prevents burn-induced oxidative damage in remote organs.

Distribution of Ambler class A, B and D β-lactamases among Pseudomonas aeruginosa isolates - Corrected Proof

2012-02-21

Abstract: Objectives: We determined the prevalence rate of classes A, B and D β-lactamases among extended-spectrum cephalosporin (ESC)-non-susceptible Pseudomonas aeruginosa clinical isolates from burned patients.Methods: Disc susceptibility testing was performed on 156 P. aeruginosa isolates collected during 2010 at Prince Salman Hospital in Riyadh, Saudi Arabia. Phenotypic screening of ESBLs and MBLs in the isolates resistant to ceftazidime (MIC>8mg/L) was carried out. Genes encoding ESBLs and MBL were sought by PCR in ESBL- and MBL-producing isolates.Results: The resistance rate to ceftazidime was 22.43%. The resistance rates for ESC-non-susceptible P. aeruginosa isolates to piperacillin, piperacillin/tazobactam, cefepime, aztreonam, imipenem, amikacin, gentamicin and ciprofloxacin were 100%, 71.14%, 88.57%, 48.57%, 70.0%, 82.5%, 87.5%, and 90.0% respectively. No resistance was detected to polymyxine B. The prevalence of ESBL and MBL in ESC-non-susceptible P. aeruginosa was 69.44% and 42.85%, respectively. The prevalence of structural genes for VEB-1, OXA-10 and GES ESBLs in P. aeruginosa was 68%, 56% and 20%, respectively. VIM gene was detected in 15 (100%) of MBL-producing isolates. OXA-10 like gene was concomitant with VEB, GES and/or VIM. Eight isolates harbored OXA-10 with VEB (imipenem MIC 6–8mg/L), while five isolates harbored OXA-10 with VIM (imipenem MIC≥32mg/L) and one isolate contained OXA-10, VEB and GES (imipenem MIC 8mg/L). PER was not detected in this study.Conclusion: VEB-1 and OXA-10 are the predominant ESBL genes and blaVIM is the dominate MBL gene in ESC-non-sensitive P. aeruginosa isolates in Saudi Arabia. VEB, OXA-10 and GES ESBLs have not been reported previously in Saudi Arabia and GES has not been reported previously in Middle East and North Africa.

Characteristics of fatal and hospital admissions for burns in Fiji: A population-based study (TRIP Project-2) - Corrected Proof

2012-02-20

Abstract: Background: Over 95% of burn deaths are estimated to occur in low-and-middle-income countries. However, the epidemiology of burn-related injuries in Pacific Island Countries is unclear. This study investigated the incidence and demographic characteristics associated with fatal and hospitalised burns in Fiji.Methods: This cross-sectional study utilised the Fiji Injury Surveillance in Hospital database to estimate the population-based incidence and contextual characteristics associated with burns resulting in death or hospital admission (≥12h) during a 12-month period commencing 1st October 2005.Results: 116 people were admitted to hospital or died as a result of burns during the study period accounting for an overall annual incidence of 17.8/100,000 population, and mortality rate of 3.4/100,000. Most (92.2%) burns occurred at home, and 85.3% were recorded as unintentional. Burns were disproportionately higher among Fijian children compared with Fijian–Indian children with the converse occurring in adulthood. In adults, Indian women were at particularly high risk of death from self-inflicted burns as a consequence of ‘conflict situations’.Conclusion: Burns are a significant public health burden in Fiji requiring prevention and management strategies informed by important differences in the context of these injuries among the major ethic groups of the country.

Risk factors of burns among children in Mongolia - Corrected Proof

Tseren-Ochir Khandarmaa, Md. Harun-Or-Rashid, Junichi Sakamoto — 2012-02-20

Abstract: Burn is one of the leading causes of under-5 childhood injuries. Identification of risk factors and awareness level of caregivers could help reduction of burn-related morbidity. The objectives of this study were to identify general perceptions of risk factors of childhood burns, prevalence of burns among under-five Mongolian children, and to assess knowledge and practice of burn care and care seeking behaviors for care givers of those children. A household-based cross-sectional survey was conducted from September to October 2010 including 865 households with 1154 under-5 children. Data were collected by face-to-face interview using semi-structured questionnaire. Of total 1154 children, 291 (25.2%) had burn injury in their life-time. Above half of them had suffered a scald. Majority of burns occurred at home and urban children were at higher risk. The age up to 36 months, boys, and fewer children (<3) in the household were found as significant risk factors for childhood burns. Caregivers’ knowledge and practices on childhood burns were generally insufficient; most of them indicated the importance of physical environment at home. We concluded that burns were common among under-5 children, and caregivers’ knowledge and practices on burns was inadequate. Specific interventions like “Caregivers education program” encouraging safe domestic environmental conditions should be undertaken to increase their awareness on burn-related issues to reduce childhood burns in Mongolia.

Virtual reality for acute pain reduction in adolescents undergoing burn wound care: A prospective randomized controlled trial - Corrected Proof

Belinda Kipping, Sylvia Rodger, Kate Miller, Roy M. Kimble — 2012-02-20

Abstract: Background: Effective pain management remains a challenge for adolescents during conscious burn wound care procedures. Virtual reality (VR) shows promise as a non-pharmacological adjunct in reducing pain.Aims: This study assessed off-the-shelf VR for (1) its effect on reducing acute pain intensity during adolescent burn wound care, and (2) its clinical utility in a busy hospital setting.Methods: Forty-one adolescents (11–17 years) participated in this prospective randomized controlled trial. Acute pain outcomes including adolescent self-report, nursing staff behavioral observation, caregiver observation and physiological measures were collected. Length of procedure times and adolescent reactions were also recorded to inform clinical utility.Results: Nursing staff reported a statistically significant reduction in pain scores during dressing removal, and significantly less rescue doses of Entonox given to those receiving VR, compared to those receiving standard distraction. For all other pain outcomes and length of treatment, there was a trend for lower pain scores and treatment times for those receiving VR, but these differences were not statistically significant.Conclusion: Despite only minimal pain reduction achieved using off-the-shelf VR, other results from this trial and previous research on younger children with burns suggest a customized, adolescent and hospital friendly device may be more effective in pain reduction.

Characteristics of bloodstream infections in burn patients: An 11-year retrospective study - Corrected Proof

2012-02-20

Abstract: Aims: The principal aim of this study was to describe infection related characteristics of blood stream infections (BSI) in patients with burns. We sought to determine the organisms that caused BSI and factors that could predict the outcome of BSI.Methods: Data was collected on admitted patients with burns from January 1998 to December 2008. Selected information from databases was analysed using SPSS version 17 (SPSS Inc., Chicago). Descriptive, univariate and multivariate analysis was undertaken to determine factors predictive of clinical outcome. The factors analysed by univariate analysis were selected on clinical plausibility. Multivariate analysis used a crosstabs procedure initially to estimate maximum likelihood. Factors that were associated with a p value <0.15 were entered into a binary logistic regression to detect which factors were independent predictors of mortality in BSI and outcome according to specific organisms.Results: Ninety-nine out of 2364 (4%) patients developed 212-documented BSI. The median time from burn to BSI was 7 (interquartile range 3–16) days. Gram-positive organisms, in particular Methicillin resistant Staphylococcus aureus and Coagulase negative Staphylococci, were the most common bacteria associated with BSI in the first week of hospital admission. The mortality rate for all admissions over the data collection period was 3%. Of the 99 patients with BSI, 13 died giving a mortality rate, in the presence of BSI, of 13%. Univariate analysis found that the factors predictive of P. aeruginosa mortality were inhalational injury, higher total body surface area burns, total days of antibiotic treatment and elevated Acute Physiological and Chronic Health Evaluation (APACHE) II scores. Multivariate analysis identified inhalational injury to be the only factor associated with BSI-related mortality.Conclusion: Whilst the overall mortality in our cohort was low, the presence of BSI increased this four-fold. Whilst infections caused by Gram-positive pathogens occurred earlier in the patient stay than Gram-negative organisms, the highest mortality was associated with P. aeruginosa infections. This study highlights the negative effects of BSI on clinical outcomes in burn patients.

Protective effect of glucose–insulin–potassium (GIK) on intestinal tissues after severe burn in experimental rats - Corrected Proof

2012-02-16

Abstract: Intestinal barrier damage after scald and burns, other trauma or major operations result in severe intestinal infections that cause serious consequences. Therefore, it is important to develop methods to protect intestinal barrier after severe burns. This study used rats that had full-thickness burn of approximately 30% of the total body surface area to investigate the effect and mechanism of glucose–insulin–potassium (GIK) and provide experimental evidence for application of GIK in protecting the intestine after burns or other trauma and major surgeries. The results show that the degree of intestinal damage and plasma diamine oxidase (DAO) levels in GIK (the concentrations of glucose, insulin, sodium chloride and potassium chloride were 100gl−1, 70Ul−1, 9gl−1 and 5gl−1, respectively) and insulin (30IUl−1) treatment groups were significantly lower than that in control group; the status of anti-inflammatory and pro-inflammatory cytokines and the ratio between them in GIK and insulin groups also significantly improved compared to those in control group; intestinal tumour necrosis factor-alpha (TNFα), nuclear factor-kappaB (NF-κB) and interleukin-10 (IL-10) messenger RNA (mRNA) expression and IL10/TNFα in GIK and insulin groups 2 days after the injury were also improved significantly compared to those in control group. All the indices including body weight detected in GIK group were improved to those in insulin group. Taken together, these results show that GIK and insulin show protective effect on intestine after severe burn, which may relate to controlling hyperglycaemia and regulating intestinal expression of NFκB and pro-inflammatory and anti-inflammatory cytokine genes by GIK and insulin; the protective effect of GIK on intestinal tissue after severe burn is superior to that of using insulin alone, which may attribute to improving the nutritional status by glucose supplement and the relatively higher dose of insulin in the GIK group.

The effects of splinting on shoulder function in adult burns - Corrected Proof

Alison M. Kolmus, Anne E. Holland, Martin J. Byrne, Heather J. Cleland — 2012-02-15

Abstract: Introduction: Exercises are commonly prescribed to improve shoulder range following axillary burns, but the effect of additional splinting is unclear.Aim: To compare splinting and exercise to exercise alone in adults with axillary burns.Method: Prospective randomised study allocating participants to a splinting (n=27) or no splinting group (n=25). Outcomes measured at six and twelve weeks were shoulder abduction and flexion range, quality of life using the Burn Specific Health Scale-Brief (BSHS-B) questionnaire and upper limb function using the Upper Extremity Functional Index (UEFI) and the Grocery Shelving Task (GST).Results: At week twelve, there was no difference between groups for shoulder abduction (mean difference 0°, 95% CI −22 to 22°), flexion (mean difference 2°, 95% CI −18 to 23°), BSHS-B (mean difference −2 points, 95% CI −23 to 18 points), UEFI (mean difference −3 points, 95% CI −19 to 14 points) and GST (mean difference −9s, 95% CI −20 to 3s). Adherence to splinting decreased from 77% of participants at week one to 16% at week twelve.Conclusion: Shoulder splints did not improve clinical outcomes in this study population and low adherence rates suggest splinting may be unacceptable to patients and makes drawing firm conclusions difficult.

Burn mortality in Iraq - Corrected Proof

Ari Raheem Qader — 2012-02-13

Abstract: Mortality rates are important outcome parameters after burn, and can serve as objective end points for quality control. Causes of death after severe burn have changed over time. In a prospective study, eight hundred and eighty-four burn patients were admitted to the Burns and Plastic surgery Hospital in Sulaimani–Kurdistan region of Iraq in 2009. Age, gender, nationality, cause of burn, extent of injury, cause of death and mortality rate were tabulated and analyzed, 338 (38.2%) were male and 546 (61.8%) were female. The highest number of cases occurred in January, with the highest short period incidence occurring in April. Out of 884 cases, 260 persons died. Burn injuries were more frequent and larger with higher mortality in females than in males. Flame was the major cause of burns. Self-inflicted burns were noted mainly in young women. A large number of burns which affect children and females, occur in the domestic setting and could have been prevented. Therefore, it is necessary to implement programs for health education relating to prevention of burn injuries focusing on the domestic setting.