Burn size and survival probability in paediatric patients in modern burn care: a prospective observational cohort study

Selective Deletion of HLA-B, and -C Class I Genes Promotes Immunocompatibility of Humanized Skin Graft Model

Background

The treatment of extensive burns requires rapid allogeneic skin transplantation, but HLA diversity poses a significant challenge in finding histocompatible donor-recipient matches.

Methods

In this study, we developed a humanized skin graft model using HLA class I transgenic mice to closely examine the HLA-mediated immune response in skin transplantation. Additionally, this model was used to analyse the response against a human lymphoblastoid cell line, JY, with HLA-B and -C genes knocked out by a single-step CRISPR-Cas9 strategy, retaining the most common HLA class I allele, HLA-A*02:01.

Results

Mice expressing the HLA-A02:01 allele alone or in combination with HLA-B07:02 do not reject the skin of animals expressing only HLA-A02:01. However, skin from HLA-A02:01/B07:02 mice transplanted into HLA-A02:01 mice is rejected, triggering a strong specific CD8 T cell response mediated by the HLA-B*07:02 molecule. In these latter mice, unlike the parental JY cell line, the edited cells did not induce a CD8 T cell response in vitro, suggesting that the selective deletion of HLA-B and -C may contribute to improve skin graft compatibility.

Conclusion

This genetic engineering approach, repeated without modification for the five HLA-A class I most common alleles known to be associated with HLA-B7 and -C7 in the same haplotype, would cover 83.4% of the world population. Our findings offer a scalable HLA-compatible skin graft model, potentially improving practices in burn units worldwide.

Early extubations in children intubated prior to arrival in Paediatric Burn ICU: A single center retrospective study over 1520 admissions

BACKGROUND

In adult burns intensive care units, more than 30% of patients arriving intubated, are extubated within 2 days (potentially unnecessary intubation, PUNI). Such data are lacking in paediatric populations. Exploring this paediatric PUNI rate was the primary aim of the study.

METHODS

Data from all the admissions to our paediatric burn intensive care unit were retrospectively analyzed over an 8-years period. Extubations within the first two days among patients arriving intubated were assessed as the primary outcome (PUNI rate). Using a univariate logistic regression and a multivariate model, we analyzed factors associated with intubation lasting more than 2 days (potentially necessary intubation, PNI). Finally, we developed a score to predict the probability of PNI.

RESULTS

Among the 1520 admitted children (age: 0-17; Percentage of Total Body Surface Area (%TBSA): 1%-97%), 56 (4%) arrived intubated, 20 (36%) of whom were considered PUNI. These patients had smaller %TBSA burned compared to those having PNI (24% ± 17% vs. 48% ± 24%, p = 0.002). We developed a score based on factors independently associated with PNI: %TBSA burned (OR = 1.12 [1.09-1.15] for each additional per cent), flame burns (OR = 4.43 [1.64-11.6]) and facial burns (OR = 12.28 [3.41-67.4]). Seven children (<0.5%) were intubated after admission.

CONCLUSION

Intubation before admission to a burn intensive care unit was less frequent in children. The paediatric rate of PUNI, however, was close to findings reported in adults: approximately one-third of intubated children were extubated within 2 days.

A Systematic Review of Simulation in Burn Care: Education, Assessment, and Management

Assessment and management of burns require nuanced, timely interventions in high-stake settings, creating challenges for trainees. Simulation-based education has become increasingly popular in surgical and nonsurgical subspecialties to supplement training without compromising patient safety. This study aimed to systematically review the literature on existing burn management-related simulations. A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Articles describing burn-specific surgical and nonsurgical simulation models were included. The model type, study description, simulated skills, assessment methods, fidelity, cost, and outcomes were collected. Of 3472 articles, 31 met the inclusion criteria. The majority of simulations were high-fidelity (n = 17, 54.8%). Most were immersive (n = 17, 54.8%) and used synthetic benchtop models (n = 13, 41.9%), whereas none were augmented reality (AR)/virtual reality (VR). Simulations of acute and early surgical intervention techniques (n = 16, 51.6%) and burn wound assessments (n = 15, 48.4%) were the most common, whereas burn reconstruction was the least common (n = 3, 9.7%). Technical skills were taught more often (n = 29, 93.5%) than nontechnical skills (n = 15, 48.4%). Subjective assessments (n = 18, 58.1%) were used more often than objective assessments (n = 23, 74.2%). Of the studies that reported costs, 91.7% (n = 11) reported low costs. This review identified the need to expand burn simulator options, especially for burn reconstruction, and highlighted the paucity of animal, cadavers, and AR/VR models. Developing validated, accessible burn simulations to supplement training may improve education, patient safety, and outcomes.

Predictors of Prolonged Hospitalization in Pediatric Burn Patients: Insights From a Rural Burn Intensive Care Unit (BICU) in Appalachia

INTRODUCTION

Burn injuries are the fifth most common cause of non-fatal injuries among children worldwide. Pediatric burn patients require complex management due to their distinct physiology compared to adults. The purpose of this study is to investigate demographic and clinical factors contributing to a prolonged total hospital duration among pediatric burn patients in a rural, Level 2 Trauma Center and Burn Intensive Care Unit (BICU) located in the Appalachian region.

METHODS

Data were collected from 2017 to 2023 and included all patients 18 years and younger who were admitted to the Cabell Huntington Hospital BICU. Patient demographics were analyzed using descriptive statistics. One-way ANOVA assessed the differences between gender and length of stay (LOS) and source of burn and LOS. A chi-square test analyzed the effect of an inhalation injury on LOS. Pearson correlation was used to assess the relationship between BMI and LOS and between total ventilation days (TVD) and LOS.

RESULTS

A total of 232 patients were included in this study, consisting of 102 (44%) females and 130 (56%) males. The average patient age was 6.9 years (SD ± 6.2). The mean LOS was 3.1 (SD ± 4.4) among this cohort. The most common sources of burn injuries within this cohort were flame (43%), scald (35%), and other (chemical/electric/radiation) comprising 22%. Flame burns were found to have a significant impact on LOS (p = 0.039), requiring longer hospital stays compared to other burn sources. Age was a significant predictor, with each additional year of age associated with an increase of 0.15 days in LOS (95% CI: 0.05 to 0.25, p < 0.001). Similarly, the total body surface area (TBSA) showed a significant positive association, with larger burn areas strongly predicting longer hospital stays (p < 0.001). The median TBSA was 5.5% (SD ± 6.7). For every 1% increase in TBSA burns, the hospital stay increased by approximately 0.13 days (95% CI: 0.05 to 0.22, p < 0.05). However, variables such as inhalation injury (p = 0.748) and BMI (p = 0.058) did not significantly predict hospital duration.

CONCLUSION

The results of this study demonstrated that age, burn severity, and the source of the burn are significant predictors of prolonged hospital stay in pediatric burn patients. Recognizing these key predictors of LOS will allow providers to identify high-risk patients early and initiate prompt stabilization, management, and timely referral to tertiary centers when necessary. Further, the results of this study may serve as the framework for the development of preventative efforts and regional care guidelines for rural, underserved healthcare providers.

A 10-year mono-center study on patients with burns ≥70% TBSA: prediction model construction and multicenter validation - retrospective cohort

BACKGROUND

Burn injuries with ≥70% total body surface area (TBSA) are especially acute and life-threatening, leading to severe complications and terrible prognosis, while a powerful model for the prediction of overall survival (OS) is lacking. The objective of this study is to identify prognostic factors for the OS of patients with burn injury ≥70% TBSA and construct and validate a feasible predictive model.

MATERIALS AND METHODS

Patients diagnosed with burns ≥70% TBSA admitted and treated between 2010 and 2020 in our hospital were included. A cohort of the patients from the Kunshan explosion were assigned as the validation set. The χ2 test and K-M survival analysis were conducted to identify potential predictors for OS. Then, multivariate Cox regression analysis was performed to identify the independent factors. Afterward, we constructed a nomogram to predict OS probability. Finally, the Kunshan cohort was applied as an external validation set.

RESULTS

Sex, the percentage of third-degree and fourth-degree burns as well as organ dysfunction were identified as significant independent factors. A nomogram only based on the factors of the individuals was built and evidenced to have promising predictive accuracy, accordance, and discrimination by both internal and external validation.

CONCLUSIONS

This study recognized significant influencing factors for the OS of patients with burns ≥70% TBSA. Furthermore, our nomogram proved to be an effective tool for doctors to quickly evaluate patients' outcomes and make appropriate clinical decisions at an early stage of treatment.

Characteristics, treatments and outcomes in patients with severe burn wounds; a 10 year cohort study on acute and reconstructive treatment

Reports on treatment characteristics and long term outcomes for severe burns are scarce, while the need to compare outcomes of novel treatment modalities to standard of care is increasing. Our national database on burn treatment enabled analysis of patient as well as treatment characteristics during acute treatment and following reconstructive procedures. Furthermore, outcome data of longitudinal scar assessments were analysed from a single burn centre database. Acute and reconstructive data were analysed for patients admitted to the three Dutch burn centres with total body surface area burned of ≥ 20% TBSA. Long term outcome was analysed from a single centre scar database, both for a period of 2009-2019. Treatment characteristics from 396 surviving acute burn patients were analysed. Surgical treatment was required in 89.6% of these patients and 110 patients (27.8%) needed reconstructive surgery in the years after the burn incident, with a mean of 4.4 reconstructive procedures per patient. Main indications were contractures (70.5%) and arms (45.0%) and head and neck region (41.2%) were most frequently affected. Techniques used for reconstructive corrections were predominantly excision, release and flaps (54.7%), followed by skin transplants (32.4%). Scar quality was significantly worse in patients with more severe burns compared to those with TBSA < 20% during prolonged times. These data provide insight into health care utilization, treatment characteristics and outcomes in severely burned patients. These real-world data can guide future development of improved treatment strategies for at risk patients as well as anatomical locations.

A Nomogram of Predicting Healthcare-Associated Infections in Burned Children

BACKGROUND

Healthcare-associated infections (HAIs) are a common clinical concern associated with adverse prognosis and mortality in burned children. This study aimed to construct a predictive nomogram of the risk of HAIs in burned children.

METHODS

Children admitted to the burn unit of Wuhan Third Hospital between 2020 and 2022 were included. The univariate and multivariate logistic regression analyses were adopted to ascertain predictors of HAIs. A nomogram was developed to predict the HAI risk of each patient, with receiver operating characteristic curves and calibration curves being generated to assess its predictive ability. Furthermore, decision and impact curves were used to assess the clinical utility.

RESULTS

Of 1122 burned children, 61 (5.5%) patients experienced HAIs. The multivariate analysis indicated that total burn surface area, length of stay, surgery, central venous catheter use and urinary catheter use were the independent risk factors of HAIs. Using these variables, we developed a predictive nomogram of the occurrence of HAIs in burned children, and the internal validation results demonstrated good discrimination and calibration of the nomogram. The area under the curve values of the nomogram was 0.926 (95% CI, 0.896-0.957). The calibration curve showed high consistency between the actual and predicted HAIs. The decision and impact curve indicated that the nomogram was of good clinical utility and more credible net clinical benefits in predicting HAIs.

CONCLUSIONS

The present study constructed a nomogram for predicting the risk of HAIs in burned children. This nomogram may strengthen the effective screening of patients at high risk of HAIs.

A Survival Prediction Model of Self-Immolation Based on Machine Learning Techniques

Background

Self-immolation is one of the violent methods of suicide in developing countries. Predicting the survival of self-immolation patients helps develop therapeutic strategies. Today, machine learning is widely used in diagnosing diseases and predicting the survival of patients. This study aims to provide a model to predict the survival of self-immolation patients using machine learning techniques.

Materials and Methods

A retrospective cross-sectional study was conducted on 445 hospitalized self-immolated patients admitted to a burn hospital between March 2008 and 2019. Python programming language version 3.7 was used for this goal. All possible machine-learning algorithms were used. Gradient Boosting, support vector machine (SVM), random forest, multilayer perceptron (MLP), and k-nearest neighbors algorithm (KNN) were selected as the high-performance machine learning technique for survival prediction, and then they were compared by evaluation metrics such as F1 score, accuracy, sensitivity, specificity, and area under the receiver operating characteristic (ROC) curve (AUC). Based on this comparison, the best model was reported.

Results

SVM was the best algorithm. F1 score, accuracy, and AUC for this machine-learning model were 91.8%, 91.9%, and 0.96, respectively. The machine learning model results revealed that surgical procedures, score, length of stay, anatomical region, and gender obtained the most important and had more impact than other factors on patients' survival prediction.

Conclusion

In this paper, machine learning algorithms were used to create a model for survival of self-immolation patients. The results of this study can be used as a model for predicting self-immolation patients' survival, better treatment management, and setting up policies and medical decision-making in burn centers.

Update on Hypermetabolism in Pediatric Burn Patients

Despite advancements in pediatric burn care, the profound hypermetabolic response associated with severe burns remains a multifaceted challenge throughout the continuum of care. Understanding the various physiologic disturbances that constitute hypermetabolism is crucial for a thorough evaluation and for implementing appropriate surgical and nonsurgical interventions. In this article, we describe the pathophysiology and treatment of hypermetabolism in pediatric burn patients with a focus on reducing resting energy requirements, minimizing infection, and optimizing nutrition for patients undergoing frequent surgical intervention.

Stomatin promotes neutrophil degranulation and vascular leakage in the early stage after severe burn via enhancement of the intracellular binding of neutrophil primary granules to F-actin

BACKGROUND

The pathophysiology of severe burn injuries in the early stages involves complex emergency responses, inflammatory reactions, immune system activation, and a significant increase in vascular permeability. Neutrophils, crucial innate immune cells, undergo rapid mobilization and intricate pathophysiological changes during this period. However, the dynamic alterations and detailed mechanisms governing their biological behavior remain unclear. Stomatin protein, an essential component of the cell membrane, stabilizes and regulates the membrane and participates in cell signal transduction. Additionally, it exhibits elevated expression in various inflammatory diseases. While Stomatin expression has been observed in the cell and granule membranes of neutrophils, its potential involvement in post-activation functional regulation requires further investigation.

METHODS

Neutrophils were isolated from human peripheral blood, mouse peripheral blood, and mouse bone marrow using the magnetic bead separation method. Flow cytometry was used to assess neutrophil membrane surface markers, ROS levels, and phagocytic activity. The expression of the Stomatin gene and protein was examined using quantitative real-time polymerase chain reaction and western blotting methods, respectively. Furthermore, the enzyme-linked immunosorbent assay was used to evaluate the expression of neutrophil-derived inflammatory mediators (myeloperoxidase (MPO), neutrophil elastase (NE), and matrix metalloproteinase 9 (MMP9)) in the plasma. Images and videos of vascular leakage in mice were captured using in vivo laser confocal imaging technology, whereas in vitro confocal microscopy was used to study the localization and levels of the cytoskeleton, CD63, and Stomatin protein in neutrophils.

RESULTS

This study made the following key findings: (1) Early after severe burn, neutrophil dysfunction is present in the peripheral blood characterized by significant bone marrow mobilization, excessive degranulation, and impaired release and chemotaxis of inflammatory mediators (MPO, NE, and MMP9). (2) After burn injury, expression of both the stomatin gene and protein in neutrophils was upregulated. (3) Knockout (KO) of the stomatin gene in mice partially inhibited neutrophil excessive degranulation, potentially achieved via reduced production of primary granules and weakened binding of primary granules to the cell skeleton protein F-actin. (4) In severely burned mice, injury led to notable early-stage vascular leakage and lung damage, whereas Stomatin gene KO significantly ameliorated lung injury and vascular leakage.

CONCLUSIONS

Stomatin promotes neutrophil degranulation in the early stage of severe burn injury via increasing the production of primary granules and enhancing their binding to the cell skeleton protein F-actin in neutrophils. Consequently, this excessive degranulation results in aggravated vascular leakage and lung injury.

Health-related quality of life after burn injury due to bioethanol-fueled fireplaces

OBJECTIVE

Commercially available bioethanol-fueled fireplaces are a potential source of burns and are commonly used for home use. The present study aimed to evaluate the quality of life following burn injuries that were caused by bioethanol-related accidents.

METHODS

Burned patients who were admitted to our burn unit with burn injury due to bio-ethanol fueled fire places between January 2010 and December 2021 were contacted to ask for their willingness to participate in this study. They were asked to answer questions regarding the circumstances of the accident and three questionnaires to capture burn specific and general health related quality of life (Burn Specific Health Scale-Brief (BSHS-B), Short-Form Health Survey 36 (SF-36)) and general information about the accident. Patients were matched and compared to a group of patients suffering comparable burns from other burn mechanisms, which were also admitted to our burn unit at the same time.

RESULTS

Of 35 patients that met the inclusion criteria, 19 answered the questionnaire and were compared to 38 patients with other burn mechanisms. There were no statistical differences regarding age (bioethanol: 37.4 ± 14.7 years vs. control: 36.2 ± 14.3 years, p = 0.777), TBSA (9.9 ± 6.8% vs. 8.9 ± 10.4, p = 0.715), and sex (42.1% females vs. 36.8% females, p = 0.882). Most patients in the bioethanol-group reported that they did not follow the manual instructions (68.4%) and that the accident happened during the refilling process (52.6%). There was no significant difference in any subscale of the BSHS-B or the SF-36.

DISCUSSION

Burns related to bioethanol-fueled fireplaces are rare compared to other typical burn mechanisms. However, as they are used for personal pleasure and interior design, psychological impairment following burn may be even more critical. Detailed education on the use of these fireplaces needs to take place in order to reduce the risk of accidents.

Exploration of risk analysis and elimination methods for a Cr(VI)-removal recombinant strain through a biosafety assessment in mice

Though recombinant strains are increasingly recognized for their potential in heavy metal remediation, few studies have evaluated their safety. Moreover, biosafety assessments of fecal-oral pathway exposure at country as well as global level have seldom analyzed the health risks of exposure to microorganisms from a microscopic perspective. The present study aimed to predict the long-term toxic effects of recombinant strains by conducting a subacute toxicity test on the chromium-removal recombinant strain 3458 and analyzing the gut microbiome. The available disinfection methods were also evaluated. The results showed that strain 3458 induced liver damage and affected renal function and lipid metabolism at 1.0 × 1011 CFU/mL, which may be induced by its carrier strain, pET-28a. Strain 3458 poses the risk of increasing the number of pathogenic bacteria under prolonged exposure. When 500 mg L-1 chlorine-containing disinfectant or 250 mg L-1 chlorine dioxide disinfectant was added for 30 min, the sterilization rate exceeded 99.9 %. These findings suggest that existing wastewater disinfection methods can effectively sterilize strain 3458, ensuring its application value. The present study can serve a reference for the biosafety evaluation of the recombinant strain through exposure to the digestive tract and its feasibility for application in environmental pollution remediation.

Analysis of the Epidemiological Features and Treatment Results of Burn Injuries in a Burn Center in Turkey

The aim of the study was to reveal the epidemiological characteristics and clinical course of burn patients who were hospitalized in our burn center between 2015 and 2020 and to compare the results between nationalities. The data were retrospectively evaluated in terms of age, gender, time of admission, the total body surface area burned, the degree of burn, the accident location, the presence of wound infection, surgical intervention, length of hospital stay, mortality, educational status of the parents, and nationality; 59.8% of 1496 cases were male, mean age was 40.38 months. The most common age range was 0-2 years. 78.4% were admitted within the first 24 hours; 50.5% of the admissions were from İzmir and its districts. Burn trauma most commonly occurred indoors in all age groups. The most common cause was scalding. Isolation of microorganism in wound cultures was most commonly detected in second degree burns. The most common infection agent was Pseudomonas aeruginosa. The surgical intervention rate was 19%. The mean length of hospitalization was 14.46 ± 12.17 days. Total burned surface, hospitalization time, the infection, and mortality rate were higher in patients who underwent surgical intervention. Parents were mostly primary school graduates. 11.6% of the patients were of foreign nationality. No significant difference was found in the analyzed parameters between nationalities. In conclusion; burn trauma is most commonly seen in the 0-2 age group, regardless of parental education levels. Therefore, it is of great importance to provide training on burns to families and those responsible for the care of children.

Chinese expert consensus on the Management of Pediatric Deep Partial-Thickness Burn Wounds (2023 edition)

Burns are a main cause of accidental injuries among children in China. Because of the unique wound repair capacity and demand for growth in pediatric patients, the management of pediatric deep partial-thickness burn wounds involves a broader range of treatment options and controversy. We assembled experts from relevant fields in China to reach a consensus on the key points of thermal-induced pediatric deep partial-thickness burn-wound management, including definition and diagnosis, surgical treatments, nonsurgical treatment, choice of wound dressings, growth factor applications, infectious wound treatment, scar prevention and treatment. The committee members hope that the Expert Consensus will provide help and guiding recommendations for the treatment of pediatric deep partial-thickness burn wounds.

[Expert consensus on the management of deep partial-thickness burn wounds in pediatric patients (2023 version)]

Burns are the leading cause of accidental injuries among Chinese children. Due to the strong wound repair ability and the demand for growth and development in pediatric patients, there are many options for the treatment of deep partial-thickness burn wounds in pediatric patients, while many controversies about the strategies for treatment of this kind of wounds also exist. This article assembled the consensus reached by experts in burns and relevant fields in China and abroad on the management of thermal-induced deep partial-thickness burn wounds in pediatric patients aged 1-6 years, including definition and diagnosis, surgical treatment, non-surgical treatment, wound dressings, application of growth factors, treatment of infectious wounds, prevention and treatment of scar, to provide guiding recommendations for the diagnosis and treatment of deep partial-thickness burn wounds in pediatric patients in China.

Exploration of Maternal and Fetal Toxicity Risks for Metronidazole-Related Teratogenicity and Hepatotoxicity through an Assessment in Albino Rats

Metronidazole is the primary antimicrobial drug for treating acute and chronic vaginal pathogens during pregnancy; however, there has been insufficient research on placental disorders, early pregnancy loss, and preterm birth. Here, the potential activity of metronidazole on pregnancy outcomes was investigated. 130 mg/kg body weight of metronidazole was orally given individually to pregnant rats on gestation days 0-7, 7-14, and 0-20. Pregnancy outcome evaluations were carried out on gestation day 20. It was demonstrated that metronidazole could induce maternal and fetal hepatotoxicity. There is a significant increase in the activities of maternal hepatic enzymes (ALT, AST, and ALP), total cholesterol, and triglycerides compared with the control. These biochemical findings were evidenced by maternal and fetal liver histopathological alterations. Furthermore, metronidazole caused a significant decrease in the number of implantation sites and fetal viability, whereas it caused an increase in fetal lethality and the number of fetal resorptions. In addition, a significant decrease in fetal weight, placental weight, and placental diameter was estimated. Macroscopical examination revealed placental discoloration and hypotrophy in the labyrinth zone and the degeneration of the basal zone. The fetal defects are related to exencephaly, visceral hernias, and tail defects. These findings suggest that the administration of metroniazole during gestation interferes with embryonic implantation and fetal organogenesis and enhances placental pathology. We can also conclude that metronidazole has potential maternal and fetal risks and is unsafe during pregnancy. Additionally, it should be strictly advised and prescribed, and further consideration should be given to the associated health risks.

European Burns Association guidelines for the management of burn mass casualty incidents within a European response plan

BACKGROUND

A European response plan to burn mass casualty incidents has been jointly developed by the European Commission and the European Burn Association. Upon request for assistance by an affected country, the plan outlines a mechanism for coordinated international assistance, aiming to alleviate the burden of care in the affected country and to offer adequate specialized care to all patients who can benefit from it. To that aim, Burn Assessment Teams are deployed to assess and triage patients. Their transportation priority recommendations are used to distribute outnumbering burn casualties to foreign burn centers. Following an appropriate medical evacuation, these casualties receive specialized care in those facilities.

METHODS

The European Burns Association's disaster committee developed medical-organizational guidelines to support this European plan. The experts identified fields of interest, defined questions to be addressed, performed relevant literature searches, and added their expertise in burn disaster preparedness and response. Due to the lack of high-level evidence in the available literature, recommendations and specially designed implementation tools were provided from expert opinion. The European Burns Association officially endorsed the draft recommendations in 2019, and the final full text was approved by the EBA executive committee in 2022.

RECOMMENDATIONS

The resulting 46 recommendations address four fields. Field 1 underlines the need for national preparedness plans and the necessary core items within such plans, including coordination and integration with an international response. Field 2 describes Burn Assessment Teams' roles, composition, training requirements, and reporting goals. Field 3 addresses the goals of specialized in-hospital triage, appropriate severity criteria, and their effects on priorities and triage. Finally, field 4 covers medical evacuations, including their timing and organization, the composition of evacuation teams and their assets, preparation, and the principles of en route care.

Establishment of the German Burn Registry - five years of prospective data collection

BACKGROUND

From 1991-2014, all major burn centers of the German-speaking countries participated in a multicenter study in which essentially demographic data were collected. Individual patient data was located at the particular burn centers and only cumulated data were summarized annually for presentation. Retrospective statistical analysis of the entire data collection and identification of subgroups was not possible. In 2015 the German Burn Registry was established for prospective collection of individual patient data as a tool for quality management (QM) and for scientific analyses.

METHODS

A working group was formed to ensure the development and administration of the registry. From the official start of the German Burn Registry at the beginning of the year 2015 prospective data collection was realized with an individualized, web-based data collection software in a pseudonymized way. Selected data analysis was performed for the first 5 years of data collection. Severely burned adults and all hospitalized children with burn injuries were documented in the registry.

RESULTS

The German Burn Registry was successfully established. 64 burn divisions have already been registered. 18,891 patients were documented over 5 years, of which 58% where children (<16 years). Mean ABSI Score was 4 (children: 3, adults: 6) with a mortality rate of 3.8.0% (children: 0.2%, adults: 9.3%). Children were hospitalized for an average of 7 days, whereas adults were discharged after 18 days.

CONCLUSION

A registry is mandatory for quality assurance in burn medicine, since realization of randomized studies is difficult due to the heterogeneity of burn injuries. The German Burn Registry already is one of the biggest burn registries in Europe. Several scientific projects, based on the registry database, are in working process or have already been published.

Acute burn care and outcomes at the Hospital Nacional Guido Valadares (HNGV), Timor-Leste: A 7-year retrospective study

The purpose of this study was to describe the epidemiology of patients presenting with acute burns and undergoing admission at Hospital Nacional Guido Valadares (HNGV) in Dili, Timor-Leste in the period 2013 to 2019. HNGV is the only tertiary referral hospital in Timor-Leste. This was a retrospective study involving all acute burn patients admitted to the surgical wards of HNGV from 2013 to 2019. The data was collected from patient charts and hospital medical archives. Data were reviewed and analyzed statistically in terms of age, gender, residence, cause, total body surface area (TBSA), burns depth, length of stay (LOS), and mortality. The outcomes were analyzed using logistic regression. Over the 7-year period, there were 288 acute burn patients admitted to the surgical wards of HNGV. Most patients were children (55%), male (65%) and from the capital city of Dili or surrounding areas (59%). The most common cause of burns in children was scalds and the most common cause among adults was flames. Of the admitted patients 59% had burns affecting >10% of the TBSA and 41% had full thickness burns. The median LOS was 17 days (1-143) and the average mortality for admitted burn patients in HNGV was 5.6% (annual mortality 0-17%). The odds ratio for extended LOS was 1.9 (95% confidence interval 1.1-3.2) in female compared with male patients. The odds ratio for mortality was 14.6 (95% confidence interval 2.7-80.6) in the older adults when compared with younger adults. Higher TBSA, full thickness burns, and flame burns were also significantly associated with longer LOS and higher mortality. Children and male patients were disproportionately overrepresented among patients admitted to HNGV, while female patients had longer LOS and older adults had more severe injury and a higher risk of mortality. Establishment of a national program for the prevention of burns is essential.

Oral to nasal endotracheal tube exchange using tracheal tube guide and video laryngoscope in a pediatric patient with facial burns: a case report

Background

Airway management in children with severe burns is difficult because of airway edema and prolonged duration of ventilatory management. There is insufficient evidence to suggest that tracheostomy is beneficial for children.

Case presentation

A male child aged 1 year and 4 months was injured when he accidentally fell into a bathtub filled with boiling water. Furthermore, 85% of the burnt area, including the face and neck, consisted of second-degree burns; hence, oral tracheal intubation and resuscitative infusion were required. In this case, the patient was safely switched from oral to nasotracheal intubation using a tracheal tube guide and video laryngoscope, without the use of a bronchoscope, and ventilatory management could be continued for 2 weeks.

Conclusion

Oral to nasal endotracheal tube exchange using a tracheal tube guide and video laryngoscope may be useful not only for pediatric burn patients but also for adult patients who need to be safely switched from oral to nasotracheal intubation.

Characteristics and prognosis of Herpesviridae-related pneumonia in critically ill burn patients

BACKGROUND

The aim of this study was to describe the prevalence, characteristics and outcome of critically burn patients with pulmonary HSV reactivation.

METHODS

Retrospective, single-center cohort study in a burn critical care unit in a tertiary center, including all consecutive severely burn patients with bronchoalveolar lavage performed for pneumoniae suspicion and screened for HSV from January 2013 and April 2017. We used logistic regression to identify factors associated with HSV reactivation and outcomes.

RESULTS

94 patients were included, mean age was 51 (39-64) years; median total body surface area burned was 36 (25-54)% and ICU mortality 38%. Fifty-five patients (59%) had pulmonary HSV reactivation and 30 (55%) were treated with acyclovir. Patients with HSV reactivation were more severely ill with higher SOFA score at admission compared to patient without HSV reactivation (6 [3-8] vs. 2 [1-4], p < 0.0001 respectively). In multivariate analysis, sex, SOFA score at admission and smoke inhalation were significantly associated with HSV reactivation. Only septic shock was associated with 90-day mortality when HSV reactivation was not.

CONCLUSIONS

Pulmonary HSV reactivation is frequent among severely ill burn patients. Initial severity and smoke inhalation are risk factors. Antiviral treatment was not associated with outcome.

Tranexamic acid reduced blood transfusions in acute burn surgery: A retrospective case-controlled trial

OBJECTIVE

Early excision and grafting of burn wounds are key for reducing prevalence of infection and sepsis. However, it is associated with massive blood loss and patients frequently require large numbers of blood transfusions. This study aimed to evaluate the effect of tranexamic acid (TXA) on blood transfusion requirements in acute burn surgery.

METHODS

Patients admitted to the burn intensive care unit between January 2018 and May 2021 and received TXA before first surgery for wound excision and grafting were matched in a 1:2 ratio to patients that did not receive TXA (confounders age,sex,total body surface area (TBSA) burned). Primary endpoint of the analysis was the total number of transfused units of red blood cells (RBC) intra- and postoperatively up to 48 h. Fresh frozen plasma (FFP) and platelets were evaluated. Endpoints were compared between groups using van Elteren tests adjusting for strata variable age, gender, TBSA.

RESULTS

Twenty-six TXA patients were matched with 52 control patients resulting in similar distributions of gender (77.9%(TXA)vs. 82.7%(control) males, p=0.542), age (51.7±21.3vs.48.3 ±17.4years,p = 0.459) and %TBSA burned (33.5%(IQR34)vs. 38.5% (IQR 30.5),p = 1.000). TXA group received significantly less RBC units intraoperatively (2.5(IQR 2.0)vs.4.0 units (IQR4.0), p = 0.038) and in total (4.0(IQR3.0)vs.6.0(IQR4.0),p = 0.017). TXA patients also received less blood products in general (RBC, FFP, platelets) in each period and in total. We found no significant difference in length of stay (24.0(IQR26.0)vs.33.0 days (IQR 0.5),p = 0.367) or mortality (15.4%vs.21.2%, p = 0.542).

DISCUSSION

This study shows that necessity for blood transfusions in acute burn surgery may be reduced significantly by administration of TXA perioperatively. Randomized-controlled trials are needed to prove these findings.

Sociodemographic Patterns of Pediatric Patients in Specialized Burn Care in Sweden

Trauma is a leading cause of mortality in children. Burns affect children disproportionally. Although burn incidence and mortality are decreasing, differences in the risk depend on socioeconomic status. The present study aimed to investigate the sociodemographic patterns of pediatric patients (0-17 years) managed at the two burn centers in Sweden, Uppsala, and Linköping, between 2010 and 2020.

METHOD

This retrospective register-based study used hospital records from the two burn centers combined with information from Statistics Sweden plus data regarding number of asylum seekers from the Swedish Migrations Agency. Choropleth maps representing the patients' geographical distribution were created. Information about income levels per geographic area was added. A Wilcoxon signed-rank test was performed to investigate differences in median income levels between the areas where the patients lived, related to Sweden's median income.

RESULTS

The study included 2455 patients. Most of the children aged below 5 years (76%) and were boys (60%). The mean percentage of total skin area was 4.2%. There was no significant increment or decrease in the incidence of pediatric burns during the study. Most patients with recorded zip codes lived in areas with an income level below the national median (n = 1974, 83%). Children with asylum status were over-represented compared with residents and/or Swedish citizens.

CONCLUSIONS

In Sweden, most pediatric burns occur in families that live in areas with low-income levels. Pediatric burns affect children with asylum status disproportionally compared with those who are residents in and/or citizens of Sweden. Prevention strategies should be designed and implemented to alleviate this health inequity.

Aging Impairs the Cellular Interplay between Myeloid Cells and Mesenchymal Cells during Skin Healing in Mice

Impaired wound healing is a major issue in the elderly population and is associated with substantial health and economic burden, which is exponentially increasing with the growing aging population. While the underlying pathobiology of disturbed skin healing by aging is linked to several genetic and epigenetic factors, little is known about the cell-cell interaction during the wound healing process in aged individuals, particularly the mesenchymal stem cell (MSCs)-macrophages axis. In this study, by using a thermal injury animal model in which we compared the wound healing process of adult and young mice, we found that the insufficient pool of MSCs in adult animals are deficient in migrating to the wound bed and instead are restricted to the wound edge. We identified a deficiency of a CD90-positive MSC subpopulation in the wounds of adult animals, which is positively correlated with the number of F4/80+ macrophages. In vitro, we found that CD90+ cells preferentially adhere to the myeloid cells forming doublet cells. Thus, our findings highlight that in adult mice subjected to a thermal injury, impaired wound healing is likely mediated by a disturbed cellular interplay between myeloid cells and mesenchymal cells.

Identifying changes in immune cells and constructing prognostic models using immune-related genes in post-burn immunosuppression

BACKGROUND

Burn patients are prone to infection as well as immunosuppression, which is a significant cause of death. Currently, there is a lack of prognostic biomarkers for immunosuppression in burn patients. This study was conducted to identify immune-related genes that are prognosis biomarkers in post-burn immunosuppression and potential targets for immunotherapy.

METHODS

We downloaded the gene expression profiles and clinical data of 213 burn patients and 79 healthy samples from the Gene Expression Omnibus (GEO) database. Immune infiltration analysis was used to identify the proportion of circulating immune cells. Functional enrichment analyses were carried out to identify immune-related genes that were used to build miRNA-mRNA networks to screen key genes. Next, we carried out correlation analysis between immune cells and key genes that were then used to construct logistic regression models in GSE77791 and were validated in GSE19743. Finally, we determined the expression of key genes in burn patients using quantitative reverse transcription polymerase chain reaction (qRT-PCR).

RESULTS

A total of 745 differently expressed genes were screened out: 299 were up-regulated and 446 were down-regulated. The number of Th-cells (CD4+) decreased while neutrophils increased in burn patients. The enrichment analysis showed that down-regulated genes were enriched in the T-cell activation pathway, while up-regulated genes were enriched in neutrophil activation response in burn patients. We screened out key genes (NFATC2, RORA, and CAMK4) that could be regulated by miRNA. The expression of key genes was related to the proportion of Th-cells (CD4+) and survival, and was an excellent predictor of prognosis in burns with an area under the curve (AUC) value of 0.945. Finally, we determined that NFATC2, RORA, and CAMK4 were down-regulated in burn patients.

CONCLUSION

We found that NFATC2, RORA, and CAMK4 were likely prognostic biomarkers in post-burn immunosuppression and potential immunotherapeutic targets to convert Th-cell dysfunction.

Hepatic functional pathophysiology and morphological damage following severe burns: a systematic review and meta-analysis

INTRODUCTION

Severe burns are devastating injuries affecting multiple organ systems. Little is known about the influence on the hepatic system and its physiology. This systematic review aimed to assess the current state of research on morphologic liver damage following severe burns.

METHODS

A search was conducted in Pubmed, Web of Science and Cochrane databases using PRISMA guidelines. Outcomes included serum levels of transaminases, fatty infiltration and necrosis. Weighted individual study estimates were used to calculate pooled transaminase levels and necrosis/fatty infiltration rates using a random-effects approach. Risk ratios (RRs) or Odds ratios (ORs) and 95% confidence intervals (CIs) were used to describe pooled estimates for risk factors.

RESULTS

The literature search retrieved 2548 hits, of which 59 studies were included into qualitative synthesis, and finally ten studies were included into meta-analysis. Studies were divided into those reporting autopsies and those reporting changes of serum transaminase levels. The majority of liver autopsies showed fatty infiltration 82% (95% CI39%-97%) or necrosis of the liver 18% (95% CI13%-24%).

DISCUSSION

Heterogeneity in studies on hepatic functional damage following severe burns was high. Only few were well-designed and published in recent years. Many studies could not be included because of insufficient numerical data. There is a high number of patients deceasing from burns that present with fatty infiltration or necrosis of hepatic tissue. Transaminases were elevated during the first days after burn. Further research on how severe burns affect the hepatic function and outcome, especially long-term, is necessary.

Edward F. Adolph Distinguished Lecture. It's more than skin deep: thermoregulatory and cardiovascular consequences of severe burn injuries in humans

Each year, within the United States, tens of thousands of individuals are hospitalized for burn-related injuries. The treatment of deep burns often involves skin grafts to accelerate healing and reduce the risk of infection. The grafting procedure results in a physical disruption between the injured and subsequently debrided host site and the skin graft placed on top of that site. Both neural and vascular connections must occur between the host site and the graft for neural modulation of skin blood flow to take place. Furthermore, evaporative cooling from such burn injured areas is effectively absent, leading to greatly impaired thermoregulatory responses in individuals with large portions of their body surface area burned. Hospitalization following a burn injury can last weeks to months, with cardiovascular and metabolic consequences of such injuries having the potential to adversely affect the burn survivor for years postdischarge. With that background, the objectives of this article are to discuss 1) our current understanding of the physiology and associated consequences of skin grafting, 2) the effects of skin grafts on efferent thermoregulatory responses and the associated consequences pertaining to whole body thermoregulation, 3) approaches that may reduce the risk of excessive hyperthermia in burn survivors, 4) the long-term cardiovascular consequences of burn injuries, and 5) the extent to which burn survivors can "normalize" otherwise compromised cardiovascular responses. Our primary objective is to guide the reader toward an understanding that severe burn injuries result in significant physiological consequences that can persist for years after the injury.

Burn Center Organization and Cellular Therapy Integration: Managing Risks and Costs

The complex management of severe burn victims requires an integrative collaboration of multidisciplinary specialists in order to ensure quality and excellence in healthcare. This multidisciplinary care has quickly led to the integration of cell therapies in clinical care of burn patients. Specific advances in cellular therapy together with medical care have allowed for rapid treatment, shorter residence in hospitals and intensive care units, shorter durations of mechanical ventilation, lower complications and surgery interventions, and decreasing mortality rates. However, naturally fluctuating patient admission rates increase pressure toward optimized resource utilization. Besides, European translational developments of cellular therapies currently face potentially jeopardizing challenges on the policy front. The aim of the present work is to provide key considerations in burn care with focus on architectural and organizational aspects of burn centers, management of cellular therapy products, and guidelines in evolving restrictive regulations relative to standardized cell therapies. Thus, based on our experience, we present herein integrated management of risks and costs for preserving and optimizing clinical care and cellular therapies for patients in dire need.

Clinical therapeutic effects of platelet-rich plasma in patients with burn wound healing: A protocol for systematic review and meta-analysis

BACKGROUND

In clinical settings, burn wounds are frequently encountered. Since burn wounds are a form of physical injury, they can have long-term adverse effects on the human body. It has been a significant challenge to treat burn wounds completely. Since traditional treatment strategies have been unable to heal burn wounds completely, they lack the efficacy to cure the wounds without long-term effects, such as heavy scarring. Reportedly, platelet-rich plasma (PRP) has shown potential to accelerate wound healing. Yet, there are no conclusive reports on a methodological comparative study of research that has assessed the medical benefits of PRP for treating individuals carrying burn wounds. Thus, the present meta-analysis and systematic study aims to assess the medical benefits of PRP for treating patients carrying burn wounds.

METHODS

The authors will conduct a comprehensive search for randomized controlled trials that evaluate the safeness and efficiency of PRP to treat burn wounds. The search includes 3 Chinese language databases (WanFang database, Chinese BioMedical Literature database, and China National Knowledge Infrastructure) and 4 English language databases (Cochrane Library, EMBASE, Web of Science, and MEDLINE). These electronic databases will be searched from their establishment till May 2021. A pair of independent authors will be selecting eligible studies for extracting data. The same authors will employ the Cochrane risk of bias tool to evaluate the bias risk. We will make use of RevMan (version: 5.3) software to complete data synthesis.

RESULTS

The present protocol will establish practical and targeted results evaluating the efficacy and safeness of using PRP to treat burn wounds. The current study also provides a reference for clinical use of PRP.

CONCLUSION

Stronger evidence about the effectiveness and safety of using PRP to treat and heal burn wounds will be provided for clinicians to refer.

ETHICS AND DISSEMINATION

Ethics approval is unrequired.

REGISTRATION NUMBER

March 31, 2021.osf.io/whauj. (https://osf.io/whauj/).

Concomitant Pediatric Burns and Craniomaxillofacial Trauma

ABSTRACT

This study is the first to investigate pediatric craniomaxillofacial (CMF) trauma patients that present with concomitant burns. The authors aim to identify differing etiologies, presentations, facial fracture patterns, interventions, and outcomes between pediatric CMF trauma patients with versus without concomitant burns. In this retrospective cohort study of a tertiary care center between the years 1990 and 2010, concomitant burns were identified among pediatric patients presenting with CMF fractures. Patient charts were reviewed for demographics, presentation, burn characteristics (total body surface area %, location, and degree), imaging, interventions, involvement of child protective services, and long-term outcomes. Data were analyzed using two-tailed Student t tests and chi-square analysis. Of the identified 2966 pediatric CMF trauma patients (64.0% boys; age 7 ± 4.7 years), 10 (0.34%) patients presented with concomitant burns. Concomitant burn and CMF traumas were more likely to be due to penetrating injuries (P < 0.0001) and had longer hospital lengths of stay (13 ± 18.6 versus 4 ± 6.2 days, P < 0.0001). 40% were due to child abuse, 40% due to motor vehicle collisions, and 20% due to house fires. All four child abuse patients presented in a delayed fashion; operative burn care was prioritized and 70% of the CMF fractures were managed nonoperatively. Concomitant burn and CMF trauma is a rare injury pattern in pediatrics and warrants skeletal surveys with suspicious injury patterns. Future research is necessary to develop practice guidelines.

Characteristics of Burn-Injured Children in 117 U.S. PICUs (2009-2017): A Retrospective Virtual Pediatric Systems Database Study

OBJECTIVES

To describe characteristics and outcomes of children with burn injury treated in U.S. PICUs.

DESIGN

Retrospective study of admissions in the Virtual Pediatric Systems, LLC, database from 2009 to 2017.

SETTING

One hundred and seventeen PICUs in the United States.

PATIENTS

Patients less than 18 years old admitted with an active diagnosis of burn at admission.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 2,056 patients were included. They were predominantly male (62.6%) and less than 6 years old (66.7%). Cutaneous burns were recorded in 92.1% of patients, mouth/pharynx burns in 5.8%, inhalation injury in 5.1%, and larynx/trachea/lung burns in 4.5%. Among those with an etiology recorded (n = 861), scald was most common (38.6%), particularly in children less than 2 years old (67.8%). Fire/flame burns were most common (46.6%) in children greater than or equal to 2 years. Multiple organ failure was present in 26.2% of patients. Most patients (89%) were at facilities without American Burn Association pediatric verification. PICU mortality occurred in 4.5% of patients. On multivariable analysis using Pediatric Index of Mortality 2, greater than or equal to 30% total body surface area burned was significantly associated with mortality (odds ratio, 5.40; 95% CI, 2.16-13.51; p = 0.0003). When Pediatric Risk of Mortality III was used, greater than or equal to 30% total body surface area burned (odds ratio, 5.45; 95% CI, 1.95-15.26; p = 0.001) and inhalation injury (odds ratio, 5.39; 95% CI, 1.58-18.42; p = 0.007) were significantly associated with mortality. Among 366 survivors (18.6%) with Pediatric Cerebral Performance Category or Pediatric Overall Performance Category data, 190 (51.9%) had a greater than or equal to 1 point increase in Pediatric Cerebral Performance Category or Pediatric Overall Performance Category disability category and 80 (21.9%) had a new designation of moderate or severe disability, or persistent vegetative state.

CONCLUSIONS

Burn-injured patients in U.S. PICUs have a substantial burden of organ failure, morbidity, and mortality. Coordination among specialized facilities may be particularly important in this population, especially for those with higher % total body surface area burned or inhalation injury.

Non-Survival Distributions in Paediatric Burn Patients; A Comparative Study of Two National Databases

A contemporary, age-specific model for the distribution of burn mortality in children has not been developed for over a decade. Using data from TriNetX, a global federated health research network, and the American Burn Association's Nation Burn Repository (NBR), we investigated non-survival distributions for paediatric burns in the United States. Paediatric burn patients ages 0-20 between 2010-2020 were identified in TriNetX from 41 Health Care Organizations using ICD-10 codes (T.20-T.30) and identified as lived/died. These were compared to the non-survival data from 90 certified burn centers in NBR database between 2016-2018. The patient population was stratified by age into subgroups of 0-4, 5-9, 10-14, 15-20 years. Overall, mortality rates for paediatric burn patients were found to be .62% in NBR and .52% in TrinetX. Boys had a higher incidence of mortality than girls in both databases (0.34% vs. 0.28% NBR, p = 0.13; 0.31% vs. 0.21% TriNetX, p = <0.001). Comparison of ethnic cohorts between 2010-2015 and 2016-2020 subgroups showed that non-survival rates of African American children increased relative to White children (TriNetX, p = <0.001), however, evidence was insufficient to conclude that African American children die more frequently than other ethnicities (NBR, p=0.054). When analyzing subgroups in TriNetX, burned children ages 5-9 had significantly increased frequency of non-survival, (p = <0.001). However, NBR data suggested that children 0-4 experience the highest frequency of mortality (p = <0.001). The non-survival distributions between these two large databases accurately reflects non-survival rates in burned children.

Development of a framework for managing severe burns through a 17-year retrospective analysis of burn epidemiology and outcomes

Burns are one of the most common injuries in daily life for all ages of population. This study was to investigate the epidemiology and outcomes among burn patients in one of the largest burn centers in the southwest of China. The study was performed at the Institute of Burn Research in the first affiliated with the Army Medical University (AMU). A total of 17,939 burn patients were included in this retrospective study. Information regarding burn epidemiology and outcomes in 17 years were collected, calculated and compared. The age ranged from 257 days to 95 years old. Scalding and flame were the two most common causes to burn injuries, comprising of 91.96% in total. Limbs, head/face/neck, and trunk were the most frequently occurred burn sites, with the number and the percent of 12,324 (68.70%), 7989 (44.53%), and 7771 (43.32%), respectively. The average total body surface area (TBSA) was 13.64 ± 16.83% (median 8%) with a range of 0.1–100%. A total of 874 (4.9%) patients had TBSA > 50%. The presence of a burn with an inhalation injury was confirmed in 543 patients (3.03%). The average LOS was 32.11 ± 65.72 days (median: 17 days). Eventually, the retrospective analysis resulted in the development of a burn management continuum used for developing strategies to prevent and manage severe burns. The annual number of burn injuries has kept decreasing, which was partially attributed to the increased awareness and education of burn prevention and the improved burn-preventative circumstances. However, the burn severity and the economic burden were still in a high level. And the gender difference and age difference should be considered when making individualized interventions and rehabilitative treatments.

Severe Altered Immune Status After Burn Injury Is Associated With Bacterial Infection and Septic Shock

Introduction: Burn injury is associated with a high risk of death. Whether a pattern of immune and inflammatory responses after burn is associated with outcome is unknown. The aim of this study was to explore the association between systemic immune and inflammatory responses and outcome in severely-ill burn patients.

Materials and Methods: Innate immunity, adaptive immunity, activation and stress and inflammation biomarkers were collected at admission and days 2, 7, 14, and 28 in severely-ill adult burn patients. Primary endpoint was mortality at day 90, secondary endpoint was secondary infections. Healthy donors (HD) served as controls. Multiple Factorial Analysis (MFA) was used to identify patterns of immune response.

Results: 50 patients were included. Age was 49.2 (44.2–54.2) years, total burn body surface area was 38.0% (32.7–43.3). Burn injury showed an upregulation of adaptive immunity and activation biomarkers and a down regulation of innate immunity and stress/inflammation biomarkers. High interleukin-10 (IL-10) at admission was associated with risk of death. However, no cluster of immune/inflammatory biomarkers at early timepoints was associated with mortality. HLA-DR molecules on monocytes at admission were associated with bacterial infections and septic shock. Later altered immune/inflammatory responses in patients who died may had been driven by the development of septic shock.

Conclusion: Burn injury induced an early and profound upregulation of adaptive immunity and activation biomarkers and a down regulation of innate immunity and stress/inflammation biomarkers. Immune and inflammatory responses were associated with bacterial infection and septic shock. Absence of immune recovery patterns was associated with poor prognosis.

Investigation and assessment of neutrophil dysfunction early after severe burn injury

BACKGROUND

Extensive burn injury results in a complex immune response that is associated with mortality and prognosis. Studies on acquired immune and the development of sepsis in burn patients have been reported. However, one of the main cells in innate immune, neutrophil dysfunction in the burn shock stage has not been thoroughly characterized.

METHODS

Neutrophil chemotaxis, expression of neutrophil surface markers (P2X1 receptor, [P2RX1]), degranulation (myeloperoxidase [MPO], heparin-binding protein [HBP], matrix metalloproteinase-9 [MMP-9] and neutrophil elastase [NE]), oxidative burst capacity, neutrophil extracellular trap (NET) generation, phagocytosis and apoptosis were measured in 18 patients with major burns (≥30% total body surface area [TBSA]) within 48 h after burn injury. In addition, circulating neutrophils and vascular permeability in mice model with 30% TBSA third-degree burns were also observed and investigated.

RESULTS

Neutrophil functions were reduced considerably in burn shock stage, which was characterized by decreased chemotaxis, phagocytosis and abnormal bactericidal function. Increased release of heparin-binding protein (HBP) and the expression of P2RX1 on the neutrophil surface are related to fluid leakage and decreased chemotaxis during burn shock stage, respectively. The combination of HBP concentration in plasma and P2RX1 expression on neutrophils gives a better prediction of neutrophil dysfunction in burn-injured patients.

CONCLUSION

Neutrophil dysfunction plays a key role in the development of burn injury. Targeting the restoration of neutrophil function may be a feasible therapeutic intervention to help reduce fluid loss during shock and the severity of subsequent infection.

Overexpressing of caveolin-1 in mesenchymal stem cells promotes deep second-degree burn wound healing

Burn injury is one of the most common physical injuries in clinic. It is a big challenge to find an ideal treatment for burn injury. Mesenchymal stem cells (MSCs) have been suggested as a promising candidate for wound healing. However, it is critical to improve the therapeutic efficiency of MSCs for treatment of burn injury. Here, we demonstrated that overexpression of caveolin-1, the main component of the caveolae plasma membranes, promoted the proliferation of MSCs both in vitro and in vivo. Moreover, transplantation of MSCs overexpressing caveolin-1 facilitated the expression of various growth factors and immunoregulatory cytokines and accelerated deep second-degree burn wound healing in a rat model of burn injury. Our results suggest that overexpression of caveolin-1 can improve the therapeutic efficiency of MSCs, which may be a promising strategy for the treatment of deep second-degree burn injury in clinic.

Umbilical cord-derived mesenchymal stem cells preconditioned with isorhamnetin: potential therapy for burn wounds

BACKGROUND

Impaired wound healing can be associated with different pathological states. Burn wounds are the most common and detrimental injuries and remain a major health issue worldwide. Mesenchymal stem cells (MSCs) possess the ability to regenerate tissues by secreting factors involved in promoting cell migration, proliferation and differentiation, while suppressing immune reactions. Preconditioning of MSCs with small molecules having cytoprotective properties can enhance the potential of these cells for their use in cell-based therapeutics.

AIM

To enhance the therapeutic potential of MSCs by preconditioning them with isorhamnetin for second degree burn wounds in rats.

METHODS

Human umbilical cord MSCs (hU-MSCs) were isolated and characterized by surface markers, CD105, vimentin and CD90. For preconditioning, hU-MSCs were treated with isorhamnetin after selection of the optimized concentration (5 µmol/L) by cytotoxicity analysis. The migration potential of these MSCs was analyzed by the in vitro scratch assay. The healing potential of normal, and preconditioned hU-MSCs was compared by transplanting these MSCs in a rat model of a second degree burn wound. Normal, and preconditioned MSCs (IH + MSCs) were transplanted after 72 h of burn injury and observed for 2 wk. Histological and gene expression analyses were performed on day 7 and 14 after cell transplantation to determine complete wound healing.

RESULTS

The scratch assay analysis showed a significant reduction in the scratch area in the case of IH + MSCs compared to the normal untreated MSCs at 24 h, while complete closure of the scratch area was observed at 48 h. Histological analysis showed reduced inflammation, completely remodeled epidermis and dermis without scar formation and regeneration of hair follicles in the group that received IH + MSCs. Gene expression analysis was time dependent and more pronounced in the case of IH + MSCs. Interleukin (IL)-1β, IL-6 and Bcl-2 associated X genes showed significant downregulation, while transforming growth factor β, vascular endothelial growth factor, Bcl-2 and matrix metallopeptidase 9 showed significant upregulation compared to the burn wound, showing increased angiogenesis and reduced inflammation and apoptosis.

CONCLUSION

Preconditioning of hU-MSCs with isorhamnetin decreases wound progression by reducing inflammation, and improving tissue architecture and wound healing. The study outcome is expected to lead to an improved cell-based therapeutic approach for burn wounds.

Incidence of Laryngotracheal Stenosis after Thermal Inhalation Airway Injury

Inhalation injury is independently associated with burn mortality, yet little information is available on the incidence, risk factors, or functional outcomes of thermal injury to the airway. In patients with thermal inhalation injury, we sought to define the incidence of laryngotracheal stenosis (LTS), delineate risk factors associated with LTS development, and assess long-term tracheostomy dependence as a proxy for laryngeal function. Retrospective cohort study of adult patients treated for thermal inhalation injury at a single institution burn critical care unit from 2012 to 2017. Eligible patients' records were assessed for LTS (laryngeal, subglottic, or tracheal stenosis). Patient characteristics, burn injury characteristics, and treatment-specific covariates were assessed. Descriptive statistics, Mann-Whitney U-tests, odds ratio, and chi-square tests compared LTS versus non-LTS groups. Of 129 patients with thermal inhalation injury during the study period, 8 (6.2%) developed LTS. When compared with the non-LTS group, patients with LTS had greater mean TBSA (mean 30.3, Interquartile Range 7-57.5 vs 10.5, Interquartile Range 0-15.12, P = .01), higher grade of inhalation injury (mean 2.63 vs 1.80, P = .05), longer duration of intubation (12.63 vs 5.44; P < .001), and greater inflammatory response (mean white blood cell count on presentation 25.8 vs 14.9, P = .02, mean hyperglycemia on presentation 176.4 vs 136.9, P = .01). LTS patients had a significantly higher rate of tracheostomy dependence at last follow-up (50 vs 1.7%, P < .001). Six percent of patients with thermal inhalation injury develop LTS. LTS was associated with more severe thermal airway injury, longer duration of intubation, and more severe initial host inflammation. Patients with inhalation injury and LTS are at high risk for tracheostomy dependence. In burn patients with thermal inhalation injury, laryngeal evaluation and directed therapy should be incorporated early into multispecialty pathways of care.

Clinical features and mortality-related factors of extensive burns among young adults: the Kunshan disaster experience

Background

The aim of the study was to identify the clinical features and the factors associated with burn induced mortality among young adults after exposure to indoor explosion and fire.

Methods

This is an observational study which included burn patients who were admitted to eighteen ICUs after a fire disaster. Epidemiologic and clinical characteristics, as well as therapy were recorded. The primary outcome was 90-day mortality. The mortality-related factors were also analyzed.

Results

There were 167 burn patients enrolled in the study, the median age was 38 years, 62 (37.1%) patients died within 90 days. Seventy-one percent of patients had a burn size ≥90% TBSA, and 73.7% of patients had a full-thickness burn area above 50% TBSA. The survivors had lower Baux scores, and received earlier escharectomy and autologous skin grafts. The 50% mortality rates (LA50s) for burn size and full-thickness burn area were 95.8% and 88.6% TBSA, respectively. The multivariate analysis showed that full-thickness burn area over 50% TBSA and residual burned surface area (RBSA)/TBSA at 28 days were strong predictors of mortality among burn patients (odds ratio 2.55; 95% CI, 1.01 to 6.44, P=0.047; odds ratio 1.07; 95% CI, 1.04 to 1.09, P<0.001). The ROC curve-based cut-off values of RBSA/TBSA at 28 days for predicting 90-day mortality were 62.5%.

Conclusions

Burn size and full-thickness burn area were the main risk factors for poor outcome in patients with extensive burns. Earlier escharectomy and autologous skin grafts may improve outcomes.

Management of paediatric burns in low- and middle-income countries: assessing capacity using the World Health Organization Surgical Assessment Tool

BACKGROUND

Burns are a leading cause of global disease burden, with children in low- and middle-income countries (LMICs) disproportionately affected. Effective management improves outcomes; however, the availability of necessary resources in LMICs remains unclear. We evaluated surgical centres in LMICs using the WHO Surgical Assessment Tool (SAT) to identify opportunities to optimize paediatric burn care.

METHODS

We reviewed WHO SAT database entries for 2010-2015. A total of 1121 facilities from 57 countries met the inclusion criteria: facilities with surgical capacity in LMICs operating on children. Human resources, equipment and infrastructure relevant to paediatric burn care were analysed by WHO Regional and World Bank Income Classifications and facility type.

RESULTS

Facilities had an average of 147 beds and performed 485 paediatric operations annually. Discrepancies existed between procedures performed and resource availability; 86% of facilities performed acute burn care, but only 37% could consistently provide intravenous fluids. Many, particularly tertiary, centres performed contracture release and skin grafting (41%) and amputation (50%).

CONCLUSIONS

LMICs have limited resources to provide paediatric burn care but widely perform many interventions necessary to address the burden of burns. The SAT may not capture innovative and traditional approaches to burn care. There remains an opportunity to improve paediatric burn care globally.

Changing of serum metabolic hormone and liver size during acute phase of severe adult burn patients

The aims of this study were to determine characteristics and factors influencing metabolic hormones including serum catecholamines, cortisol level and liver size in severe adult burn patients. A prospective study was conducted on 44 adult burn patients with burn extent from and over 20% TBSA admitted during 72 h after burn to burn intensive care unit, National Burn Hospital, Vietnam. Serum levels of epinephrine, norepinephrine and cortisol were measured on admission and 7^th day after burn. Liver size was measured by ultrasound on admission and 21^st day after burn. The results indicated that norepinephrine level did not significantly change along the time meanwhile epinephrine concentration significantly increased after 1 week (P < 0.01). Serum cortisol level was higher than normal physiological value and then significantly reduced at 7^th day post burn (P < 0.05). Significantly increased liver size was seen at the 21^st day postburn (P < 0.01). Age, gender, burn severity, inhalation injury and death did not affect concentration of catecholamines and liver size. Meanwhile, cortisol level was significantly higher in patients with deep burn area ≥ 20% TBSA at 7^th day after burn and in non-survivors (P < 0.05). Further studies are necessary to understand clearly metabolic state in severe adult burn patients.

The Effect of β-Blockers for Burn Patients on Clinical Outcomes: Systematic Review and Meta-Analysis

OBJECTIVES

To assess the effects and safety of β-blockers in hospitalized patients with burns.

METHODS

A systematic review and meta-analysis of the literature. A broad search was conducted to identify all randomized controlled trials (RCTs) comparing β-blockers to control in hospitalized patients with burns. The primary outcome was 3-month all-cause mortality. Secondary outcomes were clinical patient-relevant end points. We subgrouped results by children/adults and burn severity. Risk of bias was assessed using the individual domain approach.

RESULTS

Four RCTs reported in 11 publications were included. Primary outcome of mortality was assessed in children (2 trials, n = 424) and adults (2 trials, n = 148) with severe burns. No significant difference was found between propranolol and control for mortality (risk ratio [RR] = 0.82, 95% CI = 0.48-1.39, 4 trials with broad confidence intervals in adults and children), sepsis (RR = 0.81, 95% CI = 0.46-1.43, 2 trials), and survivors' length of stay (absolute mean difference = 2.53, 95% CI = -2.58-7.63, 3 trials). There was no significant difference in bradycardia (RR = 1.33, 95% CI = 0.77-2.3, 2 trials), hypotension (RR = 1.26, 95% CI = 0.73-2.17, 3 trials), or cardiac arrhythmia (RR: 2.97, 95% CI: 0.12-71.87, 1 trial). The evidence was graded as very low certainty, due to trial's internal risk of bias, imprecision, and possible selective reporting.

CONCLUSIONS

No sufficient evidence was found to support or refute an advantage for β-blocker use in children or adults after burns. Additional studies are needed to create a consensus and formulate practice guidelines on the optimal β-blocker to use, indications for initiation, and duration of treatment.

Mortality following combined burn and traumatic brain injuries: An analysis of the national trauma data bank of the American College of Surgeons

BACKGROUND

Severe burn and traumatic brain injuries (TBI) lead to significant mortality, and combined burn-TBI injuries may predispose towards even worse outcomes. The purpose of this study was to investigate the mortality of patients with burn, burn with non-TBI trauma, and combined burn/TBI to determine if combined injury portends a worse outcome.

METHODS

We obtained the National Trauma Data Bank from 2007 to 2012, identifying 32,334 patients with burn related injuries, dividing this cohort into three injury types: BURN ONLY, BURN with TRAUMA/NO TBI, and BURN with TBI. For each patient, demographic data was obtained, including age, gender, presence of trauma, TBI, or inhalation injury, burn total body surface area (TBSA), Glasgow Coma Scale, Injury Severity Score, and mortality. Multivariable logistic regression was performed.

RESULTS

Age, gender, and TBSA were similar across the three injury groups, but the incidence of inhalation injury was doubled in the BURN with TRAUMA/NO TBI (15.4 %) and BURN with TBI (15.3 %) groups when compared to the BURN ONLY (7.2 %) group. Mortality differed across injury categories after adjusting for age, TBSA, and inhalation injury. Increased mortality was seen in BURN with TRAUMA/NO TBI versus BURN ONLY (OR = 1.27 [1.06, 1.53]) and was higher when comparing BURN with TBI versus BURN ONLY (OR = 4.22 [2.85, 6.18]). BURN with TBI also had higher mortality when compared to BURN with TRAUMA/NO TBI (OR = 3.33 [2.30, 4.82]). The logs odds of mortality also increased with increasing age, TBSA and presence of inhalation injury.

DISCUSSION

This analysis of the NTDB suggests that mortality following burn-related injuries may be higher when burn injury is combined with TBI when compared to burns with other trauma, even after correcting for age, TBSA, and inhalation injury. Further clinical and laboratory research is needed to validate these findings and better understand how to optimize combined TBI and burn injury treatment.

An Invertebrate Burn Wound Model That Recapitulates the Hallmarks of Burn Trauma and Infection Seen in Mammalian Models

The primary reason for skin graft failure and the mortality of burn wound patients, particularly those in burn intensive care centers, is bacterial infection. Several animal models exist to study burn wound pathogens. The most commonly used model is the mouse, which can be used to study virulence determinants and pathogenicity of a wide range of clinically relevant burn wound pathogens. However, animal models of burn wound pathogenicity are governed by strict ethical guidelines and hindered by high levels of animal suffering and the high level of training that is required to achieve consistent reproducible results. In this study, we describe for the first time an invertebrate model of burn trauma and concomitant wound infection. We demonstrate that this model recapitulates many of the hallmarks of burn trauma and wound infection seen in mammalian models and in human patients. We outline how this model can be used to discriminate between high and low pathogenicity strains of two of the most common burn wound colonizers Pseudomonas aeruginosa and Staphylococcus aureus, and multi-drug resistant Acinetobacter baumannii. This model is less ethically challenging than traditional vertebrate burn wound models and has the capacity to enable experiments such as high throughput screening of both anti-infective compounds and genetic mutant libraries.