High-Carbohydrate vs High-Fat Nutrition for Burn Patients

Nutrition is an essential component of the healing and recovery process after severe burn injury. For many burn patients, nutrition support is necessary to meet nutrition goals. The ratio of carbohydrates and fat is particularly important for burn patients, as an essential fatty acid deficiency can contribute to poor wound healing. However, there is evidence to suggest that diets containing more carbohydrates and less fat may result in better patient outcomes. A literature search was conducted to identify studies related to nutrition support and macronutrient ratios in burn patients. Eleven published papers were found that considered macronutrient use in enteral and parenteral nutrition therapies among 9 different burn patient samples. No negative outcomes associated with lower fat, higher carbohydrate nutrition for severely burned patients were found in the literature. Conversely, the literature review revealed improved outcomes among severely burned patients receiving lower fat, higher carbohydrate nutrition to include fewer incidences of pneumonia, wound infections, acute respiratory distress syndrome, fatty liver, and sepsis. These patients also experienced shorter hospital length of stay and shorter wound healing times, as well as lower spleen and kidney weights, lower urinary nitrogen losses, improved nitrogen balance, higher insulin levels, higher insulin-like growth factor-1, lower cortisol, and less muscle protein breakdown. The evidence available to date supports the clinical use of nutrition support providing ≤15% fat and ≥60% carbohydrate for critically ill burn patients.

The Interplay of Nutrition, Physical Activity, Severity of Illness, and Mortality in Critically Ill Burn Patients: Is There a Connection?

The purpose of this project was to evaluate the relationships between nutrition, physical activity levels (PALs), severity of illness (SOI), and survival in critically ill burn patients. We conducted a retrospective evaluation of consecutively admitted adult patients who had an intensive care unit stay ≥8 days after ≥20% TBSA burns. Linear regression was used to assess the association between SOI (sequential organ failure assessment scores) and PALs as well as between SOI and nutritional intake. After univariate analysis comparing survivors and nonsurvivors, factors with P < .10 were analyzed with multiple logistic regression. Characteristics of the 45 included patients were: 42 ± 15 years old, 37 ± 17% TBSA burns, 22% mortality. Factors independently associated with survival were burn size (negatively) (P = .018), height (positively) (P = .006), highest PAL during the first eight intensive care unit days (positively) (P = .016), and kcal balance during the fifth through the eighth intensive care unit days (positively) (P = .012). Sequential organ failure assessment scores had a significant (P < .001) but weak association with nutrition intake (R2 = 0.05) and PALs (R2 = 0.25). Higher nutritional intake and activity were significantly associated with lower mortality in critically ill burn patients. Given the weak associations between both nutritional intake and PALs with SOI, the primary barrier in achieving nutrition and activity goals was not SOI. We recommend that physical rehabilitation and nutritional intake be optimized in an effort to improve outcomes in critically ill burn patients.

A Review of Adjunctive Therapies for Burn Injury Pain During the Opioid Crisis

Opioids are the mainstay of pain management after burn injury. The United States currently faces an epidemic of opioid overuse and abuse, while simultaneously experiencing a nationwide shortage of intravenous narcotics. Adjunctive pain management therapies must be sought and utilized to reduce the use of opioids in burn care to prevent the long-term negative effects of these medications and to minimize the dependence on opioids for analgesia. The purpose of this review was to identify literature on adjunctive pain management therapies that have been demonstrated to reduce pain severity or opioid consumption in adult burn patients. Three databases were searched for prospective studies, randomized controlled trials, and systematic reviews that evaluated adjunctive pain management strategies published between 2008 and 2019 in adult burn patients. Forty-six studies were analyzed, including 24 randomized controlled trials, six crossover trials, and 10 systematic reviews. Various adjunctive pain management therapies showed statistically significant reduction in pain severity. Only one randomized controlled trial on music therapy for acute background pain showed a reduction in opioid use. One cohort study on hypnosis demonstrated reduced opioid use compared with historical controls. We recommend the development of individualized analgesic regimens with the incorporation of adjunctive therapies in order to improve burn pain management in the midst of an abuse crisis and concomitant national opioid shortage.

Relationship Between Burn Wound Location and Outcomes in Severely Burned Patients: More Than Meets the Size

We hypothesized that burn location plays an important role in wound healing, mortality, and other outcomes and conducted the following study to test this multifold hypothesis. We conducted a study to retrospectively look at patients with burns ≥10% TBSA. Demographics, TBSA, partial/full thickness burns (PT/FT) in various wound locations, fluids, inhalation injury, mortality, ICU duration, and hospital duration were considered. Initial wound healing rates (%/d) were also calculated as a slope from the time of the first mapping of open wound size to the time of the third mapping of open wound size. Multivariate logistic regression and operating curves were used to measure mortality prediction performance. All values were expressed as median [interquartile range]. The mortality rate for 318 patients was 17% (54/318). In general, patients were 43 years [29, 58 years] old and had a TBSA of 25% [17, 39%], PT of 16% [10, 25%], and FT of 4% [0, 15%]. Between patients who lived and did not, age, TBSA, FT, 24-hour fluid, and ICU duration were statistically different (P < .001). Furthermore, there were statistically significant differences in FT head (0% [0, 0%] vs 0% [0, 1%], P = .048); FT anterior torso (0% [0, 1%] vs 1% [0, 4%], P < .001); FT posterior torso (0% [0, 0%] vs 0% [0, 4%], P < 0.001); FT upper extremities (0% [0, 3%] vs 2% [0, 11%], P < .001); FT lower extremities (0% [0, 2%] vs 6% [0, 17%], P < .001); and FT genitalia (0% [0, 0%] vs 0% [0, 2%], P < .001). Age, presence of inhalation injury, PT/FT upper extremities, and FT lower extremities were independent mortality predictors and per unit increases of these variables were associated with an increased risk for mortality (P < .05): odds ratio of 1.09 (95% confidence interval [CI] = 1.61–1.13; P < .001) for mean age; 2.69 (95% CI = 1.04–6.93; P = .041) for inhalation injury; 1.14 (95% CI = 1.01–1.27; P = .031) for mean PT upper extremities; 1.26 (95% CI = 1.11–1.42; P < .001) for mean FT upper extremities; and 1.07 (95% CI = 1.01–1.12; P = .012) for mean FT lower extremities. Prediction of mortality was better using specific wound locations (area under the curve [AUC], AUC of 0.896) rather than using TBSA and FT (AUC of 0.873). Graphs revealed that initial healing rates were statistically lower and 24-hour fluids and ICU length of stay were statistically higher in patients with FT upper extremities than in patients without FT extremities (P < .001). Burn wound location affects wound healing and helps predict mortality and ICU length of stay and should be incorporated into burn triage strategies to enhance resource allocation or stratify wound care.

Burn Casualty Care in the Deployed Setting

Management of wartime burn casualties can be very challenging. Burns frequently occur in the setting of other blunt and penetrating injuries. This clinical practice guideline provides a manual for burn injury assessment, resuscitation, wound care, and specific scenarios including chemical and electrical injuries in the deployed or austere setting. The clinical practice guideline also reviews considerations for the definitive care of local national patients, including pediatric patients, who are unable to be evacuated from theater. Medical providers are encouraged to contact the US Army Institute of Surgical Research (USAISR) Burn Center when caring for a burn casualty in the deployed setting.

Predicting wound healing rates and survival with the use of automated serial evaluations of burn wounds

Healing of burn wounds is necessary for survival; however tracking progression or healing of burns is an inexact science. Recently, the relationship of mortality and wound healing has been documented with a software termed WoundFlow. The objective of the current study was to confirm various factors that impact burn wound healing, as well as to establish a timeline and rate of successful healing. A retrospective analysis was performed on adults (n=115) with at least 20% TBSA burn that had at least two computer-based wound mappings. The % open wound (%OW) was calculated over time to document healing trajectory until successful healing or death. Only 2% of patients in the group with successful wound healing died. A decrease in the %OW of 0.8 (IQR: 0.7-1.1) was associated with survival. Disparities in wound healing trajectories between survivors and non-survivors were distinguishable by 2weeks post-injury (P<0.05). When %TBSA was stratified by decile, the 40-49% TBSA group had the highest healing rate. Taken together, the data indicate that wound healing trajectory (%OW) varies with injury severity and survival. As such, automated mapping of wound healing trajectory may provide valuable information concerning patient/prognosis, and may recommend early interventions to optimize wound healing.

Recurrent bacteremia: A 10-year retrospective study in combat-related burn casualties

INTRODUCTION

Surviving the first episode of bacteremia predisposes burn casualties to its recurrence. Herein, we investigate the incidence, mortality, bacteriology, and source of infection of recurrent bacteremia in military burn casualties admitted to the U.S. Army Institute of Surgical Research Burn Center over a 10year period.

METHODS

Bacteremia was defined as the growth of Gram-positive or Gram-negative organisms in a blood culture that excluded probable skin contaminants. Recurrent bacteremia was defined as a subsequent episode of bacteremia ≥7 days after the first episode. Polymicrobial bacteremia was the presence of more than one pathogen in the same blood culture. Bacteremia was attributed to UTI, pneumonia, or wound sepsis. All other bacteremias were considered non-attributable bloodstream infections. Univariate and multivariate analyses determined factors predictive of clinical outcome.

RESULTS

Out of 952 combat-related burn casualties screened, 166 cases were identified; 63% (non-recurrent) and 37% (recurrent) with median time to recurrence of 20 days. Univariate and multivariate analysis showed that the mortality rate was two and nine-fold, respectively, higher with recurrent bacteremia. Univariate analysis found that except for urinary tract infection, large burn size (>20%), 3rd degree burns, increased injuiry severity, perineal burns, and mechanical ventilator days were independent factors predictive of recurrence of bacteremia as well as increased mortality in the recurrent bacteremia cohort. Acinetobacter baumannii complex (63%) was prevalent in the non-recurrent group, while Klebsiella pneumoniae (46% vs. 30%) and Pseudomonas aeruginosa (35% vs. 26%) were prevalent in recurrent bacteremia. Half of the recurrent bacteremia cases were polymicrobial, compared to 9% in non-recurrent bacteremia. Pneumonia was prevalent in non-recurrent bacteremia (38%) and a combination of pneumonia and wound sepsis (29%) in recurrent bacteremia casualties.

CONCLUSIONS

Recurrent bacteremia increases mortality in military burn casualties. Additional research is needed to address and mitigate the underlying causes, thereby improving survival.

Advancements in Regenerative Strategies Through the Continuum of Burn Care

Burns are caused by several mechanisms including flame, scald, chemical, electrical, and ionizing and non-ionizing radiation. Approximately half a million burn cases are registered annually, of which 40 thousand patients are hospitalized and receive definitive treatment. Burn care is very resource intensive as the treatment regimens and length of hospitalization are substantial. Burn wounds are classified based on depth as superficial (first degree), partial-thickness (second degree), or full-thickness (third degree), which determines the treatment necessary for successful healing. The goal of burn wound care is to fully restore the barrier function of the tissue as quickly as possible while minimizing infection, scarring, and contracture. The aim of this review is to highlight how tissue engineering and regenerative medicine strategies are being used to address the unique challenges of burn wound healing and define the current gaps in care for both partial- and full-thickness burn injuries. This review will present the current standard of care (SOC) and provide information on various treatment options that have been tested pre-clinically or are currently in clinical trials. Due to the complexity of burn wound healing compared to other skin injuries, burn specific treatment regimens must be developed. Recently, tissue engineering and regenerative medicine strategies have been developed to improve skin regeneration that can restore normal skin physiology and limit adverse outcomes, such as infection, delayed re-epithelialization, and scarring. Our emphasis will be centered on how current clinical and pre-clinical research of pharmacological agents, biomaterials, and cellular-based therapies can be applied throughout the continuum of burn care by targeting the stages of wound healing: hemostasis, inflammation, cell proliferation, and matrix remodeling.

Thermal stability of mafenide and amphotericin B topical solution

OBJECTIVE

Fungal infections remain a major cause of mortality in the burned population. Mafenide acetate/amphotericin B solution (SMAT) has been used topically for prophylaxis and treatment of these infections. Current manufacturer guidelines only guarantee the stability of mafenide solution and amphotericin B at room temperature. Additionally, the recommended maximum storage time for mafenide solution is 48h, leading to significant financial and material loss when unused solutions are discarded. The purpose of this study was to characterize the chemical stability, structure and bioactivity of SMAT stored at 2°C, 25°C, and 40°C for up to 90 days.

METHODS

Stability analyses of SMAT solutions containing 2.5% or 5% mafenide plus 2μg/mL amphotericin B were performed using high performance liquid chromatography. Chemical structure was assessed using Fourier-transform infrared spectroscopy. Bioactivity against clinically relevant species was examined.

RESULTS

The chemical structure and stability of mafenide did not change over 90days at all temperatures. Amphotericin B was undetectable in SMAT solutions after two days at high temperatures, which was slowed by refrigerated storage. Against Staphylococcus aureus, SMAT activity began to decrease generally between two and seven days. Against Pseudomonas aeruginosa, activity slowly tapered and was gone by day 90. SMAT retained high bioactivity against Candida albicans for over 40days and was not affected by temperature.

CONCLUSIONS

The amphotericin B component of SMAT is degraded within 2days under warm storage. While mafenide was stable over 90 days, the bioactivity of SMAT solution may be lost within 2days as well.

Transfer of innovation on allergic rhinitis and asthma multimorbidity in the elderly (MACVIA-ARIA) - EIP on AHA Twinning Reference Site (GARD research demonstration project)

The overarching goals of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA) are to enable European citizens to lead healthy, active and independent lives whilst ageing. The EIP on AHA includes 74 Reference Sites. The aim of this study was to transfer innovation from an app developed by the MACVIA-France EIP on AHA reference site (Allergy Diary) to other reference sites. The phenotypic characteristics of rhinitis and asthma multimorbidity in adults and the elderly will be compared using validated information and communication technology (ICT) tools (i.e. the Allergy Diary and CARAT: Control of Allergic Rhinitis and Asthma Test) in 22 Reference Sites or regions across Europe. This will improve the understanding, assessment of burden, diagnosis and management of rhinitis in the elderly by comparison with an adult population. Specific objectives will be: (i) to assess the percentage of adults and elderly who are able to use the Allergy Diary, (ii) to study the phenotypic characteristics and treatment over a 1-year period of rhinitis and asthma multimorbidity at baseline (cross-sectional study) and (iii) to follow-up using visual analogue scale (VAS). This part of the study may provide some insight into the differences between the elderly and adults in terms of response to treatment and practice. Finally (iv) work productivity will be examined in adults.

Wound Penetration of Cefazolin, Ciprofloxacin, Piperacillin, Tazobactam, and Vancomycin During Negative Pressure Wound Therapy

Objective: Negative pressure wound therapy (NPWT) uses subatmospheric pressure as a noninvasive adjunct to treat wounds and has demonstrated clinical efficacy by accelerating healing of a variety of acute and chronic wounds. NPWT may also play a role in preventing or treating wound infections, possibly by increasing wound penetration of antibiotics. However, clinical data in patients undergoing antibiotic and NPWT treatment are limited. Approach: To evaluate the wound penetration of antibiotics in NPWT patients, we conducted a prospective, observational study of burn and trauma patients treated with NPWT and systemic antibiotics. We evaluated the plasma pharmacokinetic profile of systemic vancomycin, ciprofloxacin, cefazolin, and piperacillin/tazobactam, as well as total and unbound antibiotic concentrations in wound exudate from the same patients. Results: Data from 32 patients with 37 wounds undergoing NPWT demonstrated that vancomycin, ciprofloxacin, and piperacillin/tazobactam all penetrated wounds with exudate to plasma concentration ratios more than 0.8. Cefazolin did not penetrate wounds in patients undergoing NPWT as effectively, with an average exudate to plasma concentration ratio of 0.51. Innovation: Clinical data on the wound penetration of antibiotics in patients undergoing NPWT are limited, but these data suggest that antibiotics have different capacities for wound penetration during NPWT that should be considered when making clinical decisions. Conclusion: This initial report suggests that (1) vancomycin, ciprofloxacin, and piperacillin/tazobactam effectively penetrate wounds during NPWT and (2) cefazolin as well as other antibiotics may not penetrate wounds during NPWT.

Thermal injury patterns associated with electronic cigarettes

E-cigarettes are typically lithium-ion battery-operated devices that simulate smoking by heating a nicotine-solution into a vapor that the user inhales. E-cigarette use is becoming rapidly popular as an alternative to traditional cigarette smoking. This report describes an emerging problem associated with e-cigarettes, consisting of 10 thermally injured patients seen at a single burn center over a 2-year period from 2014 to 2016. Our cohort was comprised mainly of young adults who sustained mixed partial and full thickness burns as a result of e-cigarette-related explosions. In many documented scenarios, a malfunctioning or over-heated battery is the cause. Our data support the need for increased awareness among healthcare providers and the general public of the potential harms of e-cigarette use, modification, storage, and charging.

Elevations in growth hormone and glucagon-like peptide-2 levels on admission are associated with increased mortality in trauma patients

BACKGROUND

Burn and trauma patients present a clinical challenge due to metabolic derangements and hypermetabolism that result in a prolonged catabolic state with impaired healing and secondary complications, including ventilator dependence. Previous work has shown that circulating levels of growth hormone (GH) are predictive of mortality in critically ill adults, but few studies have examined the prognostic potential of GH levels in adult trauma patients.

METHODS

To investigate the utility of GH and other endocrine responses in the prediction of outcomes, we conducted a prospective, observational study of adult burn and trauma patients. We evaluated the serum concentration of GH, insulin-like growth factor 1 (IGF-1), IGF binding protein 3 (IGFBP-3), and glucagon-like peptide-2 (GLP-2) weekly for up to 6 weeks in 36 adult burn and trauma patients admitted between 2010 and 2013.

RESULTS

Non-survivors had significantly higher levels of GH and GLP-2 on admission than survivors.

DISCUSSION

This study demonstrates that GH has potential as a predictor of mortality in critically ill trauma and burn patients. Future studies will focus on not only the role of GH, but also GLP-2, which was shown to correlate with mortality in this study with a goal of offering early, targeted therapeutic interventions aimed at decreasing mortality in the critically injured.

CONCLUSIONS

GH and GLP-2 may have clinical utility for outcome prediction in adult trauma patients.

Vitamin C in Burn Resuscitation

The inflammatory state after burn injury is characterized by an increase in capillary permeability that results in protein and fluid leakage into the interstitial space, increasing resuscitative requirements. Although the mechanisms underlying increased capillary permeability are complex, damage from reactive oxygen species plays a major role and has been successfully attenuated with antioxidant therapy in several disease processes. However, the utility of antioxidants in burn treatment remains unclear. Vitamin C is a promising antioxidant candidate that has been examined in burn resuscitation studies and shows efficacy in reducing the fluid requirements in the acute phase after burn injury.

Pediatric Toxic Epidermal Necrolysis: Experience of a Tertiary Burn Center

BACKGROUND

Pediatric toxic epidermal necrolysis (TEN) is a rare and potentially fatal skin disease with a multitude of causative factors and no consensus on treatment guidelines and, as a result, it has a variety of short- and long-term outcomes. We present the experience of a large specialty burn center to share our diagnostic and treatment principles.

METHODS

A retrospective review from 1989 to 2010 at the Joseph M. Still Burn Center was performed to find patients with a diagnosis of Steven-Johnson syndrome (SJS) or TEN. Information was obtained on demographic and physiologic parameters such as age, race, total body surface area involved, treatments, hospital stay, and need for ventilator support.

RESULTS

We identified SJS or TEN in 21 patients. Prescription drugs were the most common etiology (in 15 patients), with antibiotics as the most common causative agent. Histology confirmed the clinical diagnosis of TEN in 14 patients. Our treatment plan included a multidisciplinary team, early initiation of intravenous immunoglobulin, bronchoscopy, strict management of electrolyte and fluid balances, and meticulous surgical wound care. Mortality was 9.5%.

CONCLUSION

Our experience in treating this rare but devastating disease affords us the opportunity to share the diagnostic dilemmas we faced and the treatment principles we used to treat this unique patient population successfully.

Children and adolescents infected withWuchereria bancroftiin Greater Recife, Brazil: a randomized, year-long clinical trial of single treatments with diethylcarbamazine or diethylcarbamazine–albendazole

In filariasis-endemic areas beyond sub-Saharan Africa, the World Health Organization's recommended strategy for interrupting transmission of the causative parasites is annual, single-dose, mass treatment with a combination of diethylcarbamazine (DEC; given at 6 mg/kg) and albendazole (ALB; given at 400 mg) for 4-6 years (the minimum estimated life-span of the adult parasites). In an open, hospital-based, randomized and controlled trial, with a blinded evaluation of outcome, 82 children and adolescents from Recife, all with Wuchereria bancrofti microfilaraemias, were given either DEC alone (6 mg/kg) or the same dose of DEC combined with ALB (at 400 mg/patient). Every 90 days for 1 year after the single treatment, each patient was checked for microfilaraemia by the filtration of up to 5 ml of venous blood collected at night. One year post-treatment, 16 (39%) of the 41 patients given DEC alone and 20 (49%) of the 41 given DEC-ALB were found microfilaraemic (relative risk=0.8, with a 95% confidence interval of 0.49-1.31) and the corresponding geometric mean levels of microfilaraemia were 2.0% and 1.8% of the levels recorded immediately pre-treatment, respectively (P>0.05). In terms of the prevalences and intensities of microfilaraemia, therefore, the addition of ALB to the DEC appeared to offer no significant benefit.

Somatotype analysis of physically active individuals

AIM

The present study aimed at comparing demographic variables, physical activity level, and health-related anthropometric indicators according to somatotype among physically active individuals.

METHODS

This is a descriptive cross-sectional study, in which the sample consisted of 304 individuals, who are users of the jogging track at the Federal University of Pernambuco (UFPE) in Recife, state of Pernambuco, northeastern Brazil. Somatotypes were analyzed using the anthropometric technique proposed by Heath & Carter (1990). To assess physical activity level, we used the short version of the International Physical Activity Questionnaire (IPAQ). We used as health-related anthropometric indicators: body mass index (BMI), waist circumference (WC), waist-hip ratio (WHR), and conicity index (CI). We used descriptive statistics to characterize the sample, and then used a multivariate analysis of variance (a = 0.05) to test for differences.

RESULTS

In the somatotype analysis, we observed among women significant predominance of the endomorphy and lower predominance of the ectomorphy in comparison to men. In the age group ≤ 29 years significantly lower values were found for endomorphy than in other age groups. Irregularly active individuals had significantly lower values of endomorphy. We observed that individuals with obesity and risk in WHR, WC and CI had higher scores of endomorphy and mesomorphy and lower scores of ectomorphy.

CONCLUSION

The somatotype of physically active individuals in the present study raises health concern, mainly related to high relative adiposity represented by endomorphy.

Moderate systemic hypothermia decreases burn depth progression

BACKGROUND

Therapeutic hypothermia has been proposed to be beneficial in an array of human pathologies including cardiac arrest, stroke, traumatic brain and spinal cord injury, and hemorrhagic shock. Burn depth progression is multifactorial but inflammation plays a large role. Because hypothermia is known to reduce inflammation, we hypothesized that moderate hypothermia will decrease burn depth progression.

METHODS

We used a second-degree 15% total body surface area thermal injury model in rats. Burn depth was assessed by histology of biopsy sections. Moderate hypothermia in the range of 31-33°C was applied for 4h immediately after burn and in a delayed fashion, starting 2h after burn. In order to gain insight into the beneficial effects of hypothermia, we analyzed global gene expression in the burned skin.

RESULTS

Immediate hypothermia decreased burn depth progression at 6h post injury, and this protective effect was sustained for at least 24h. Burn depth was 18% lower in rats subjected to immediate hypothermia compared to control rats at both 6 and 24h post injury. Rats in the delayed hypothermia group did not show any significant decrease in burn depth at 6h, but had 23% lower burn depth than controls at 24h. Increased expression of several skin-protective genes such as CCL4, CCL6 and CXCL13 and decreased expression of tissue remodeling genes such as matrix metalloprotease-9 were discovered in the skin biopsy samples of rats subjected to immediate hypothermia.

CONCLUSIONS

Systemic hypothermia decreases burn depth progression in a rodent model and up-regulation of skin-protective genes and down-regulation of detrimental tissue remodeling genes by hypothermia may contribute to its beneficial effects.