Enhanced inflammatory hyperalgesia after recovery from burn injury

Treatment of Chronic Hypertrophic Burn Scars With a Fractional CO 2 Laser Is Well Tolerated in an Outpatient Clinic Setting

INTRODUCTION

The necessity of treating hypertrophic burn scars has expanded significantly with increased burn survivorship. Ablative lasers, such as carbon dioxide (CO 2 ) lasers, have been the most common nonoperative option for improving functional outcomes in severe recalcitrant hypertrophic burn scars. However, the overwhelming majority of ablative lasers used for this indication require a combination of systemic analgesia, sedation, and/or general anesthesia due to the painful nature of the procedure. More recently, the technology of ablative lasers has advanced and is more tolerable than their first-generation counterparts. Herein, we hypothesized that refractory hypertrophic burn scars can be treated by a CO 2 laser in an outpatient clinic.

METHODS

We enrolled 17 consecutive patients with chronic hypertrophic burn scars that were treated with a CO 2 laser. All patients were treated in the outpatient clinic with a combination of a topical solution (23% lidocaine and 7% tetracaine) applied to the scar 30 minutes before the procedure, Cryo 6 air chiller by Zimmer, and some patients received a mixture of N 2 O/O 2 . Laser treatments were repeated every 4 to 8 weeks until the patient's goals were met. Each patient completed a standardized questionnaire to assess tolerability and patient satisfaction of functional results.

RESULTS

All patients tolerated the laser well in the outpatient clinic setting, with 0% indicating "not tolerable," 70.6% "tolerable," and 29.4% "very tolerable." Each patient received more than 1 laser treatment for the following complaints: decreased range of motion (n = 16, 94.1%), pain (n = 11, 64.7%), or pruritis (n = 12, 70.6%). Patients were also satisfied with the results of the laser treatments ("no improvement or worsened" = 0%, "improved" = 47.1%, and "significant improvement" = 52.9%). The age of patient, type of burn, location of burn, presence of skin graft, or age of scar did not significantly affect the tolerability of treatment or satisfaction of outcome.

CONCLUSIONS

The treatment of chronic hypertrophic burn scars with a CO 2 laser is well tolerated in an outpatient clinic setting in select patients. Patients reported a high level of satisfaction with notable improvement in functional and cosmetic outcomes.

Comparing the Effect of Gabapentin, Ketamine, Dexmedetomidine, and Entonox on Pain Control in Burn Wound Dressing

This study aimed to evaluate differences in the experience of pain, nausea, and vomiting, as well as the hemodynamic parameters including heart rate (HR) and blood pressure (BP) in burn patients across four pain treatment groups-i.e., gabapentin, ketamine, dexmedetomidine, and entonox. In a single blinded randomized comparative study, 25 burn patients with second- or third-degree burns between 20% and 50% of their body surface were assigned to different treatment groups by using block randomization, while keeping the investigator blind to the size of the block. We recorded demographics, the hemodynamics, adverse effects, and pain levels before the treatment and again 5, 10, 15, 30, 60, 120, 240, and 360 minutes postadministration of pain medication (after-treatment). Gabapentin ketamine, dexmedetomidine, and entonox had significant effects in treatment of pain in burn patients. Entonox had the best analgesic effect with the least adverse effects and hemodynamic changes. Gabapentin also had good pain management effects; however, it showed less desirable effects on hemodynamic variables. Entonox caused the least amount of hemodynamic changes and the least adverse reactions, but since the medication is delivered by a facemask it limited its application with our patients. Gabapentin offered good benefits but caused a gradual drop in BP and HR and had some unfavorable reactions. However, since it is administered orally and often is cheaper, it could be considered as the drug of choice.

Autologous fat grafting for nerve regeneration and neuropathic pain: current state from bench-to-bedside

Despite recent advances in microsurgical techniques, functional recovery following peripheral nerve injury remains slow and inadequate. Poor peripheral nerve regeneration not only leaves patients with significant impairments, but also commonly leads to the development of debilitating neuropathic pain. Recent research has demonstrated the potential therapeutic benefits of adipose-derived stem cells, to enhance nerve regeneration. However, clinical translation remains limited due to the current regulatory burdens of the US FDA. A reliable and immediately translatable alternative is autologous fat grafting, where native adipose-derived stem cells present in the transferred tissue can potentially act upon regenerating axons. This review presents the scope of adipose tissue-based therapies to enhance outcomes following peripheral nerve injury, specifically focusing on their role in regeneration and ameliorating neuropathic pain.

Effectiveness of a hydrogel dressing as an analgesic adjunct to first aid for the treatment of acute paediatric thermal burn injuries: study protocol for a randomised controlled trial

Background

Burns are a painful and traumatic experience, particularly in children. Reduced pain and anxiety positively influences re-epithelialisation rates in paediatric burn patients, however current literature fails to fully explain the effects of pain and anxiety and their links with wound healing. This study will determine if Burnaid® hydrogel dressing is an effective treatment for reducing pain in the acute period of a burn injury. It is hypothesised that a reduction in pain will then improve re-epithelialisation time in comparison to plastic wrap, which is standard practice at our institution — a metropolitan tertiary paediatric hospital located in Brisbane, Australia.

Methods/design

A randomised controlled trial will be conducted to assess the effectiveness of Burnaid® as an analgesic adjunct to cold running water first aid for the treatment of paediatric burns. Participants will include children aged between 0 and 16 years with an acute thermal burn injury (total burn surface area < 20%) presenting to the Department of Emergency within 24 h of the burn occurring. Participants will be randomised into one of two groups: (1) Burnaid® hydrogel (intervention arm) or (2) plastic wrap (control arm). Participants will also be stratified into one of two groups based on factors that influence pain intensity: (1) high pain risk or (2) low pain risk. High pain risk factors include foot burns, hot coal/ash/fire pit burns, burn area greater than 5%, and circumferential burns. The primary outcome is the intervention’s effect on reducing acute pain. Secondary outcomes include days to re-epithelialisation, pulse rate, temperature, salivary cortisol and α-amylase, anxiety, and cost-effectiveness. Sample size calculations have shown that 36 participants will be recruited into each group.

Discussion

This study will provide comprehensive data on the analgesic properties of Burnaid® as an adjunct to first aid for the treatment of acute paediatric thermal burns. If the intervention is effective in reducing pain, Burnaid® will be integrated as standard practice within the hospital’s Department of Emergency. This study replicates a real-world scenario in order to identify clinically significant analgesic and wound-healing effects.

Trial registration

Australian New Zealand Clinical Trials Registry, ACTRN12617001274369. Prospectively registered on 5 Sept 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-3057-x) contains supplementary material, which is available to authorized users.

Effects of transdermal flunixin meglumine on pain biomarkers at dehorning in calves

The objective of this study was to evaluate the analgesic properties of transdermal flunixin meglumine when given at the time of dehorning on pain biomarkers. Twenty-four weaned male Holstein calves, 6 to 8 wk of age were enrolled into the study. The calves were randomly assigned to 1 of 3 treatment groups: 1) transdermal flunixin and dehorn (DH-FLU); 2) transdermal flunixin and sham dehorn (SHAM-FLU); and 3) placebo and dehorn (DH-PLBO). Transdermal flunixin at a label dose of 3.33 mg/kg (or placebo at an equivalent volume) was administered as a pour-on along the top-line of the calves in each treatment group concurrently with electrocautery dehorning or sham dehorning. Biomarker parameters collected and analyzed included: infrared thermography (IRT), mechanical nociception threshold (MNT), plasma cortisol, and substance P (SP). There were no differences in maximal temperatures detected for the IRT measurements of the medial canthus of the eye for the DH groups. Mean control point MNT measurements at 48 h were 3.14 kgF, 3.46 kgF, and 1.43 kgF for the DH-FLU, Sham-FLU, and DH-PLBO groups, respectively (P = 0.0001). No other differences of MNT were detected between the dehorned groups for the other test sites and time points. Plasma cortisol reached peak concentration at 20 min postdehorning for the DH-FLU and DH-PLBO groups and 10 min for SHAM-FLU group. Peak plasma cortisol concentrations were 32.0 ng/mL, 12.7 ng/mL, and 28.8 ng/mL for the DH-FLU, SHAM-FLU, and DH-PLBO groups, respectively. Cortisol concentrations were lower for the DH-FLU group at 90 min postdehorning compared to the SHAM-FLU and DH-PLBO groups ( = 0.04). Area under the effect curve (AUEC) were similar for all groups ( = 0.93). No statistical differences in SP concentrations between groups were detected for any of the time points. In conclusion, transdermal flunixin meglumine given at the time of dehorning did not provide substantial analgesia based on the pain biomarkers investigated. Further investigation into its role as part of a multimodal analgesic plan is warranted.

Impact of carprofen administration on stress and nociception responses of calves to cautery dehorning

The objective of this study was to investigate the effects of carprofen administered immediately before cautery dehorning on nociception and stress. Forty Holstein calves aged approximately 6 to 8 wk old were either placebo treated and sham dehorned ( = 10) or cautery dehorned following administration of carprofen (1.4 mg/kg) subcutaneously ( = 10) or orally ( = 10) or a subcutaneous and oral placebo ( = 10) in a randomized, controlled trial. All animals were given a cornual nerve block using lidocaine before dehorning. Response variables including mechanical nociception threshold, ocular temperature, heart rate, and respiratory rate were measured before and following cautery dehorning for 96 h. Blood samples were also collected over 96 h following dehorning and analyzed for plasma cortisol and substance P concentrations by RIA. Plasma carprofen concentration and ex vivo PGE concentrations were also determined for this time period. Average daily gain was calculated for 7 d after dehorning. Data were analyzed using a linear mixed effects model with repeated measures, controlling for baseline values by their inclusion as a covariate in addition to planned contrasts. Dehorning was associated with decreased nociception thresholds throughout the study and a stress response immediately after dehorning, following the loss of local anesthesia, and 48 h after dehorning compared with sham-dehorned calves. Carprofen was well absorbed after administration and reached concentrations that inhibited ex vivo PGE concentrations for 72 h (subcutaneous) and 96 h (oral) compared with placebo-treated calves ( < 0.05). Carprofen-treated calves tended to be less sensitive ( = 0.097) to nociceptive threshold tests. Overall, at the dosing regimen studied, the effect of carprofen on sensitivity and stress following cautery dehorning was minimal. Consideration of route of administration and dose determination studies may be warranted.

Intrathecal Injection of Resveratrol Attenuates Burn Injury Pain by Activating Spinal Sirtuin 1

Objective:

The present study sought to detect spinal sirtuin 1 (SIRT1) and acetylation of histone H3 (Ac-H3) expression in rats with burn injury pain (BIP model).

Procedures and Results:

A BIP model was first established. BIP rats showed lower paw withdrawal threshold (PWT) from day 1, which persisted for 21 days following the burn injury. Spinal SIRT1/Ac-H3 expression increased following burn injury. The intrathecal use of resveratrol increased PWT and SIRT1 expression but induced down-regulation of Ac-H3 expression. We first demonstrated that the inhibition of SIRT1 significantly induced mechanical allodynia in naïve rats. The preinjection of SIRT1 inhibitor partly antagonized the analgesic effects of resveratrol in BIP rats.

Conclusion:

Inhibition of SIRT1 produces pain facilitation in the naïve rats. The expression of spinal SIRT1 increased after burn injury in the BIP model. The activation of spinal SIRT1 might mediate the resveratrol-induced analgesic effects.

SUMMARY

Burn injury resulted in pain facilitation

Resveratrol attenuates pain facilitation induced by burn injury

Intrathecal injection of resveratrol attenuates burn injury pain by increasing spinal sirtuin 1 (SIRT1) expression

Inhibition of SIRT1 by selisistat, an SIRT1 inhibitor attenuated analgesic effects of resveratrol

Abbreviations used: SIRT1: Sirtuin 1, Ac-H3: Acetylation of histone H3, SD: Sprague-Dawley, EX527: Selisistat, an SIRT1 inhibitor, BIP: Burn injury pain, DMSO: Dimethyl sulfoxide, PWTs: Paw withdrawal thresholds

Progress of clinical practice on the management of burn-associated pain: Lessons from animal models

Opioid-based analgesics provide the mainstay for attenuating burn pain, but they have a myriad of side effects including respiratory depression, nausea, impaired gastrointestinal motility, sedation, dependence, physiologic tolerance, and opioid-induced hyperalgesia. To test and develop novel analgesics, validated burn-relevant animal models of pain are indispensable. Herein we review such animal models, which are mostly limited to rodent models of burn-induced, inflammatory, and neuropathic pain. The latter two are pain syndromes that provide insight into the pain caused by systemic pro-inflammatory cytokines and direct injury to nerves (e.g., after severe burn), respectively. To date, no single animal model optimally mimics the complex pathophysiology and pain that a human burn patient experiences. No currently available burn-pain model examines effects of pharmacological intervention on wound healing. As cornerstones of pain and wound healing, pro-inflammatory mediators may be utilized for insight into both processes. Moreover, common clinical concerns such as systemic inflammatory response syndrome and multiple organ dysfunction remain unaddressed. For development of analgesics, these aberrations can significantly alter the potential efficacy and/or adverse effects of a prescribed analgesic following burn trauma. We therefore suggest that a multi-model strategy would be the most clinically relevant when evaluating novel analgesics for use in burn patients.

Autologous fat grafting alleviates burn-induced neuropathic pain in rats

BACKGROUND

The management of neuropathic pain after burn injury is a critical clinical issue. Autologous fat grafting has been shown to alleviate neuropathic pain in certain cases, but has not been shown to alleviate the pain associated with burn-induced scars. The authors assessed the effectiveness of autologous fat grafting for the management of pain in burn-induced scars.

METHODS

One paw of the experimental rats received a third-degree burn using a heated metal block. Neuropathic pain in the affected paw was assessed based on behavioral responses to thermal and mechanical stimuli. A graft (0.4 ml of autologous fat or a sham graft) was administered by injection to the burn scar and sham-burned paw. The animals were killed 4 weeks after the fat graft treatments; Masson trichrome stain of hind-paw skin and expression of phosphorylated p38 and OX42 in the dorsal horns of the spinal cords were examined.

RESULT

The third-degree burns were completely healed at 4 weeks. Burn-induced scarring caused mechanical allodynia and increased the expression of phosphorylated p38 and OX42 in spinal cord dorsal horn microglial cells. Autologous fat grafting significantly alleviated mechanical allodynia (p < 0.05), and immunohistochemistry showed that the expression of phosphorylated p38 and OX42 was significantly lower in spinal cord dorsal horn microglial cells 4 weeks after fat grafting (p < 0.05).

CONCLUSIONS

Autologous fat grafting is used daily in clinical practice. It is an effective treatment for the relief of burn-induced mechanical allodynia in rats. Further investigation of the clinical use of autologous fat grafting in burn patients is warranted.

Pain mediators and wound healing--establishing the connection

Pain accompanies every disruption of the skin surface in a normal sensate individual. The intensity and duration of the pain varies depending on the nature of trauma, the healing trajectory and various host factors. Pain mediator release is the mechanism for pain perception following peripheral stimulus and central interpretation. The various mediators may have promoting effects on wound healing in the short term, but it appears that protracted release of these mediators may well have detrimental effects on wound healing. The exaggerated release of pain mediators may result in nociceptor hypersensitization, hyperinflammatory cellular and extracellular matrix (ECM) changes, and in some cases, the potential for a fibrotic healing pattern. This relates to an imbalance between mediators with differing healing characteristics arising in certain pathological conditions. In this respect, it may be worth examining pain mediator agonists or antagonists, not only on compassionate grounds of pain control, but relating to the potential effects on overall wound healing.

Analgesia effect of a fixed nitrous oxide/oxygen mixture on burn dressing pain: study protocol for a randomized controlled trial

Background

Procedural burn pain is the most intense acute pain and most likely type of burn injury pain to be undertreated due to the physician’s fear of the adverse effect of analgesia and lack of anesthetist present. At our institution, in most of the cases, local burn detersion and debridement were performed at the ward level without any analgesics. This article describes a study designed to test the analgesia effect of a fixed nitrous oxide/oxygen mixture on burn dressing pain.

Methods/design

The experiment was carried out in three centers. The patients were given a number from 1 to 240. A randomization list was produced by a statistician according to our preliminary study. Due to the severity of the pain suffered, ethically it was decided to help as many as possible, so patients given the letters A, B or C were treated using a canister with the appropriate letter containing preprepared nitrous oxide/oxygen mixture (NOOM). Those with D were given oxygen only, from an identical-looking canister labeled D. Neither patients, nor doctors, nor nurses, nor data collector knew what was in each canister, thus they were all blind. The nursing officer who implemented the intervention handed the doctors envelopes containing the patients’ name and allocation of A, B, C or D. Thus, patients receiving NOOM or oxygen were in the ratio 3:1. Parameters, including pain severity, blood pressure, heart rate, digital oxygen saturation and the Chinese version of the burn specific pain anxiety scale (C-BSPAS), were taken before, during and after dressing for each group. A video and audio record was taken individually for later communication coding and outcome analysis. Rescue analgesic was recorded.

Discussion

Based on the findings from our previous qualitative study that physician’s reluctance to order narcotic analgesia is due to its adverse effect and from our pilot experiment, this study aims to test the hypothesis that a fixed nitrous oxide/oxygen mixture will promote better burn dressing pain alleviation and outcomes. Analyses will focus on the effects of the experimental intervention on pain severity during dressing (primary outcomes); physiological parameters, C-BSPAS and acceptance of both health care professionals and patients (secondary outcomes). If this model of analgesia for burn pain management implemented by nurses proves successful, it could potentially be implemented widely in hospital and prehospital settings and improve patients’ satisfaction and quality of life.

Trial registration

(Clinical Trials Identifier: CHICTR-TRC11001690).

Burn patients' experience of pain management: a qualitative study

Pain is a major problem after burns and researchers continue to report that pain from burns remains undertreated. The inadequate pain control results in adverse sequalae physically and psychologically in the burn victims. A better understanding of a burn patient's experience is important in identifying the factors responsible for undertreated pain and establishing effective pain management guidelines or recommendation in the practice of pain relief for burn injuries. This study sought to explore and describe the experience that patients have about pain related to burn-injury during hospitalization. Semi-structured interviews were conducted on eight patients with moderate to severe pain from burn injuries recruited from a Burn Centre in Northwest China. Data was collected by in-depth interviews and qualitative description after full transcription of each interview. Analysis involved the identification of themes and the development of a taxonomy of patients' experience of burn pain and its management. Three themes were indentified: (1) patients' experience of pain control, (2) patients' perception on burn pain management, and (3) patients' expectation of burn pain management. Findings from this study suggested that patients experience uncontrolled pain both physically and psychologically which may serve as an alert for awareness of health professionals to recognize and establish a multidisciplinary pain management team for burn victims, including surgeons, critical care specialists, anesthesiologists, nurses, psychologists, and social workers to accomplish safe and effective strategies for pain control to reach an optimal level of pain management in burn patients. It also provides insights and suggestions for future research directions to address this significant clinical problem.

Painful pathways induced by TLR stimulation of dorsal root ganglion neurons

We hypothesize that innate immune signals from infectious organisms and/or injured tissues may activate peripheral neuronal pain signals. In this study, we demonstrated that TLRs 3, 7, and 9 are expressed by human dorsal root ganglion neurons (DRGNs) and in cultures of primary mouse DRGNs. Stimulation of murine DRGNs with TLR ligands induced expression and production of proinflammatory chemokines and cytokines CCL5 (RANTES), CXCL10 (IP-10), IL-1α, IL-1β, and PGE(2), which have previously been shown to augment pain. Further, TLR ligands upregulated the expression of a nociceptive receptor, transient receptor potential vanilloid type 1 (TRPV1), and enhanced calcium flux by TRPV1-expressing DRGNs. Using a tumor-induced temperature sensitivity model, we showed that in vivo administration of a TLR9 antagonist, known as a suppressive oligodeoxynucleotide, blocked tumor-induced temperature sensitivity. Taken together, these data indicate that stimulation of peripheral neurons by TLR ligands can induce nerve pain.

Comparative population pharmacokinetics of fentanyl using non-linear mixed effect modeling: burns vs. non-burns

OBJECTIVE

Fentanyl is a commonly used analgesic and sedative for the burned in the operating theater as well as the burn care units. The aim of this study was to characterize fentanyl population pharmacokinetics in burns and to identify clinically significant covariates.

METHOD

Twenty adults, aged 37+/-3 years, with 49+/-4% (mean+/-S.E.) total body surface area burn, were enrolled at 17+/-3 days after the injury. Twenty non-burn adults served as controls. After an intravenous bolus of 200 mcg fentanyl, the plasma concentrations were sequentially determined up to 4.5 h. Concentration-time profiles were subjected to non-linear mixed effect modeling. Cardiac indices were estimated with esophageal Doppler monitor.

RESULTS

Burned patients have higher cardiac index than the non-burned. Three-compartment model was the best fit. The volumes of distribution were considerably expanded in all three compartments (27.9 L vs. 63.4 L, 64.7 L vs. 92.9 L, 153 L vs. 301 L, respectively) compared to the non-burned. BURN was the single most important covariate significantly improving the model.

CONCLUSION

The primary effect of burn trauma on fentanyl pharmacokinetics is substantially expanded volumes of distribution, i.e., dilutional. Difference in simulation, however, was insufficient to explain the augmented resistance to fentanyl, implying the importance of titrating analgesics to the clinical effect.

TRPC1 and TRPC6 channels cooperate with TRPV4 to mediate mechanical hyperalgesia and nociceptor sensitization

The transient receptor potential vanilloid 4 (TRPV4) contributes to mechanical hyperalgesia of diverse etiologies, presumably as part of a mechanoreceptor signaling complex (Alessandri-Haber et al., 2008). To investigate the hypothesis that a functional interaction between TRPV4 and stretch-activated ion channels (SACs) is involved in this mechanical transduction mechanism, we used a selective SACs inhibitor, GsMTx-4. Intradermal injection of GsMTx-4 in the rat hindpaw reversed the mechanical hyperalgesia induced by intradermal injection of inflammatory mediators. In vivo single fiber recordings showed that GsMTx-4 reversed inflammatory mediator-induced decrease in mechanical threshold in half of sensitized C-fibers. Furthermore, GsMTx-4 reduced hyperalgesia to both mechanical and hypotonic stimuli in different models of inflammatory and neuropathic pain, although it had no effect on baseline mechanical nociceptive thresholds. TRPC1 and TRPC6, two GsMTx-4-sensitive SACs, are expressed in dorsal root ganglion (DRG) neurons. Single-cell reverse transcription-PCR showed that messenger RNAs for TRPV4, TRPC1, and TRPC6 are frequently coexpressed in DRG neurons. Spinal intrathecal administration of oligodeoxynucleotides antisense to TRPC1 and TRPC6, like that to TRPV4, reversed the hyperalgesia to mechanical and hypotonic stimuli induced by inflammatory mediators without affecting baseline mechanical nociceptive threshold. However, antisense to TRPC6, but not to TRPC1, reversed the mechanical hyperalgesia induced by a thermal injury or the TRPV4-selective agonist 4alpha-PDD (4 alpha-phorbol 12,13-didecanoate). We conclude that TRPC1 and TRPC6 channels cooperate with TRPV4 channels to mediate mechanical hyperalgesia and primary afferent nociceptor sensitization, although they may have distinctive roles.

Burns: what are the pharmacological treatment options?

BACKGROUND

Many advances have been made in the understanding and management of burn injury, dramatically increasing pharmacological decision options for burn care professionals. Since burn injury is so multi-faceted, these advances cross many injury processes, both acute and chronic.

OBJECTIVE

The purpose of this review was to highlight the advances and decision options across the entire scope of the burn injury process. The burn-related processes with the most significant pharmacological options of approved products are highlighted.

METHODS

The scope of the current research is the most pertinent literature, which has been summarized with the addition of a personal perspective.

RESULTS/CONCLUSIONS

Many advances over the past decade in multiple fields have made pharmacological options plentiful in burn care. That said, there are many problems for the burn patient which persist, making burn injury still the most severe form of trauma. These issues range from management of a catabolic state with involuntary weight loss in the critical burn to severe itching in the rehabilitating patient. There are also many more treatment options available today. Two key reasons stand out as the most prominent. One reason is the fact that burn care has become much more proactive, by searching out new approaches to solve old problems. Now the treatment approach is altering its focus on manipulating the course of a burn. Examples include the use of temporary skin substitutes in partial thickness or second degree burns, decreasing pain and increasing the healing rate. Another is the use of slow release silver dressing as the topical burn wound antimicrobial of choice, markedly reducing discomfort, the need for dressing changes and an overall decrease in infection. In larger, deeper burns, the approach has changed from the chronic management of an open burn wound to rapid excision and wound closure, eliminating the burn as a source of complications. In addition, there has been a very aggressive approach to controlling the profound hypermetabolic, catabolic response to burns, rather than simply treating the outcome of this predictable post-burn complication. Approaching psychosocial stress again by prevention rather than treatment of established problems is another example. The second reason for increased options and differences in management involves the mindset of those individuals taking care of burns. Tremendous differences in experience are involved in decision-making. Different opinions are based on the expertise and also the personal preferences of those managing the burn.