Update on the critical care management of severe burns

Cohort analysis of 50% lethal area (LA50) and associating factors in burn patients based on quality improvements and health policies

Burn injuries are among the common traumatic injuries, which can be accompanied with lifelong morbidity and mortality. The Lethal Area Fifty Percent (LA50) index is another reliable outcome measurement tool that assesses the standard of medical care at burn centers. It is widely used as a benchmark for assessing the quality of burn care and is considered the percentage at which 50% of burn patients are expected to die because of burn-related injuries. We aimed to determine and compare the LA50 in burn patients admitted to Shiraz Burn Referral Centers in 2018-2021 and 2011-2018 with regard to improving the quality of special care and infection control in the new hospital. We conducted a retrospective cohort analysis on patients admitted to Amir al-Momenin Burn Injury Hospital in Shiraz, Fars, Southern Iran. Data were retrospectively gathered from March 2011 to January 2022, and subsequently analyzed with standard statistical analysis, and also multivariate and probability analysis. A total of 7382 patients with acute burns injuries were identified. Among them, 4852 (65.7%) patients were men, and the median age was 27 years [Q1-Q3 7-40; range 1-98]. Most of the patients were in the pediatric and early adulthood age range, with 76.2% being younger than 40 years old. The median TBSA was 24% [IQR 14, 43], and the median duration of hospitalization was 11 [IQR 11] days. Most injuries were secondary to flame and fire (33.5%; n = 2472). The mortality rate in our study was 19.0% (n = 1403). We evaluated our patients based on two main time intervals: March 2011 till February 2018 (n = 3409; 46.2%), and March 2018 to January 2022 (n = 3973; 53.8%). Based on multivariate analysis, the second interval of our study was significantly correlated with a more female patients, higher age, lower TBSA, less burn injuries due to scald, contact, but more frequent fire and flame injuries, and also lower mortality rate. Factors correlated with higher mortality included male gender, older age, shorter hospitalization duration, higher TBSA, etiology of fire and flame, and accidental burn injuries. A Baux score of 76.5 had a sensitivity of 81.1%, specificity of 87.3%, accuracy of 86.1% in predicting mortality among our patients. The mortality probability for the study intervals were 20.67% (SD 33.0%) for 2011-2018, and 17.02% (SD 29.9%) for 2018-2022 (P < 0.001). The LA50 was 52.15 ± 2 for all patients. This ammount was 50 ± 2% in 2011-2018, and 54 ± 2 in 2018-2022 (P < 0.001). The mean LA50 values showed significant improvements following significant modifications in our critical care for burn victims, including augmented intensive care unit capacity, prompt relocation of inhalation burn cases to the intensive care unit, establishing a well-trained multidisciplinary team, and improved infection control. To improve outcomes for burn patients in developing countries, major changes should be made in the management of burn patients and LA50 is a reliable assessment tool for evaluating the how these changes affect patient's outcomes.

Massive Burn Injuries: Characteristics and Outcomes From a Single Institution

Massive burn injuries are a unique patient population with unique treatment paradigms. Data from 155 adult patients, admitted from 2009 to 2019, with >50% total body surface area burns (TBSA) were collected and analyzed. Average burn size was 70% TBSA and 63% had a concomitant inhalation injury. Approximately 30% of patients (46/155) transitioned to comfort care-only measures within 24 hours of admission. Standard treatment patients were younger (37 ± 13 vs 60 ± 19 years; p < .00001), male (94% vs 28%; p = .001) and had smaller TBSA (66 ± 13 vs 80 ± 16; p < .00001). Of the standard treatment group, 72 (66%) survived to discharge. Survivors had smaller TBSA (64 ± 13 vs 71 ± 13; p = .003), less third-degree TBSA (48 ± 25 vs 71 ± 13; p = .003) and lower incidence of renal failure requiring dialysis (22% vs 73%, p < .00001). Multivariate regression analysis showed that age (OR 1.05; p = .025), total TBSA (OR 1.07; p = .005), and renal failure (OR 10.2; p = .00005) were independently associated with mortality. Inhalation injury was not significantly associated with mortality. About 23% (35/155) of patients had a psychiatric condition on admission and 19% (30/155) of patients were burned attempting suicide. Patients with psychiatric conditions spent more time in the hospital (62 vs 30 days; p = .004), more time on ventilator (31 vs 12 days; p = .046), underwent more surgery (4 vs 2 operations, p = .03), and were less likely to die (34% vs 59%; p = .02). In summary, age, burn size, and renal failure were independently associated with mortality, with renal failure being the strongest factor. Psychiatric conditions are prevalent pre-injury and tend to require more inpatient care.

Six-minute walk test in burned subjects: Applicability, reproducibility and performance at hospital discharge

INTRODUCTION

Despite its clinical relevance in several populations, there is no evidence on applicability of the 6-min walk test (6MWT) in burned subjects.

OBJECTIVES

To verify the applicability and reproducibility of the 6MWT in burned individuals and to analyze patients' performance in this test at hospital discharge.

METHODS

In a cross-sectional study, burned individuals performed two 6MWT at hospital discharge, according to international standardization. In addition to walked distance, physiological and symptomatic variables were collected. Clinical history and demographic data were also recorded.

RESULTS

One hundred individuals were evaluated (70 men, 10 [6-18]% total body surface area burned). There was excellent agreement between the two 6MWT (ICC = 0.97). However, 73% of subjects increased the walked distance in the second test (23 [-9-47]m or 5 [-2-10]%; P = 0.001). Considering the best 6MWT, the walked distance was 488 [396-718]m (80 [65-92]%pred), and 51% of the individuals had limited functional exercise capacity. Additionally, participants without lower limb involvement presented better 6MWT than others (P < 0.0001).

CONCLUSION

The 6MWT was applicable, well tolerated and reproducible at hospital discharge in burned individuals. However, there was considerable learning effect between the first and second test. Finally, the reduced exercise capacity observed reinforces need for early rehabilitation in this population.

Triage and Transfer to a Regional Burn Center—Impact of a Mobile Phone App

Telemedicine technology can be used to facilitate consultations from nonburn-trained referring providers. However, there is a paucity of evidence indicating these technologies influence transfer decisions and follow-up care. In 2016, our regional burn center implemented a mobile phone app, which allows a referring provider to send photos of the wound along with basic demographic and clinical data to the burn specialist. A retrospective review was performed on consults to our regional burn center from a Level I trauma center approximately 70 miles away with a shared electronic medical record. Patients were considered to be “down-triaged” if they could be managed locally or if the transfer could occur via personal vehicle instead of ground or air ambulance transport. During the 2-year study period, 126 consultations were made for thermal injuries. Eighty-seven patients (69%) were referred using the Burn App. Overall, 49 patients (39%) were transferred. When the subset of intermediate size (1–10% TBSA) burns were considered (n = 48), the Burn App allowed for successful “down-triage” of 12 patients (33%) referred through the app. No patient referred without the app could be “down-triaged” (P = .02). Although 57 patients (44%) were recommended for outpatient follow-up, only 42% followed up. A mobile app can be used to successfully triage patients with intermediate size burn injuries to a lower acuity of follow-up and transfer mode. However, only a minority of patients triaged to outpatient management actually follow up with a regional burn center. Telemedicine efforts should focus on improving not only initial triage, but also aftercare.

Burn wound care of civilians in Sahel region by French military surgical teams: ethical challenges and future training requirements

The primary mission of the French military surgical teams deployed in external operations in the Sahel is to provide support for combatants. However, many of their activities and of the limited human and material resources allocated to them are devoted to providing free medical assistance to the local population. The French military surgical teams are very often expected to take care of serious burns for the benefit of civil populations because of the absence of dedicated civilian medical structures. Surgical teams are faced with a necessary triage of patients to be taken care of because of the discrepancy between the high demand for care and the means at their disposal. But the triage can lead to ethical dilemmas when the values that come into play in the decision contradict each other or when they run up against the quota of available human and material resources, as well as the interests of the military institution. The challenge is then to become aware of these dilemmas in this particular context. A discussion of these ethical dilemmas would help carers to avoid developing fatalistic attitudes or developing chronic pathologies due to unresolved or unconscious predicaments. Solutions are proposed that place ethical reflection at the heart of the practices during external operations by the French surgical teams. The ethics of discussion must bring together all players in care management and also the military authorities, before, during and after the missions. Training programmes for ethical reflection would benefit surgical teams and help them approach and become aware of the dilemmas they will necessarily face.

Nano-drug delivery systems in wound treatment and skin regeneration

Skin damages are defined as one of most common lesions people suffer from, some of wounds are notoriously difficult to eradicate such as chronic wounds and deep burns. Existing wound therapies have been proved to be inadequate and far from satisfactory. The cutting-edge nanotechnology offers an unprecedented opportunity to revolutionize and invent new therapies or boost the effectiveness of current medical treatments. In particular, the nano-drug delivery systems anchor bioactive molecules to applied area, sustain the drug release and explicitly enhance the therapeutic efficacies of drugs, thus making a fine figure in field relevant to skin regeneration. This review summarized and discussed the current nano-drug delivery systems holding pivotal potential for wound healing and skin regeneration, with a special emphasis on liposomes, polymeric nanoparticles, inorganic nanoparticles, lipid nanoparticles, nanofibrous structures and nanohydrogel.

Intraoperative Feeding Improves Calorie and Protein Delivery in Acute Burn Patients

Enteral nutrition support is a critical component of modern burn care for severely burned patients. However, tube feeds are frequently withheld during the perioperative period because of aspiration concerns. As a result, patients requiring multiple operative procedures risk accumulating significant protein-calorie deficits. The objective of this study was to describe our American Burn Association-certified burn center's experience implementing an intraoperative feeding protocol in severely burned patients defined as a cutaneous burn ≥20% TBSA. A retrospective review of patients with major thermal injuries (2008-2013). Thirty-three patients with an average of seven operating room trips (range, 2-21 trips) were evaluated. Seventeen patients received intraoperative enteral feeds (protocol group) and 16 patients did not (standard group). Feeding was performed using an enteral feeding tube placed postpylorically and was continued intraoperatively, regardless of operative positioning. There was no statistically significant difference in mortality between the groups (P = .62). No intraoperative aspiration or regurgitation events were recorded. The protocol group received significantly more calculated protein and caloric requirements, 98.06 and 98.4%, respectively, compared with 70.6 and 73.2% in the standard group (P < .001). Time to goal tube feed infusion rate was achieved on average 3 days sooner in the protocol group compared with the standard group (3.35 vs 6.18 days, P = .008). Early initiation and continuation of enteral feeds in severely burned patients led to higher percentages received of prescribed goal protein and caloric needs without increased rates of aspiration, regurgitation, or mortality.

Pediatric Trauma Care in Low Resource Settings: Challenges, Opportunities, and Solutions

Trauma constitutes a significant cause of death and disability globally. The vast majority -about 95%, of the 5.8 million deaths each year, occur in low-and-middle-income countries (LMICs) 3-6. This includes almost 1 million children. The resource-adapted introduction of trauma care protocols, regionalized care and the growth specialized centers for trauma care within each LMIC are key to improved outcomes and the lowering of trauma-related morbidity and mortality globally. Resource limitations in LMICs make it necessary to develop injury prevention strategies and optimize the use of locally available resources when injury prevention measures fail. This will lead to the achievement of the best possible outcomes for critically ill and injured children. A commitment by the governments in LMICs working alone or in collaboration with international non-governmental organizations (NGOs) to provide adequate healthcare to their citizens is also crucial to improved survival after major trauma. The increase in global conflicts also has significantly deleterious effects on children, and governments and international organizations like the United Nations have a significant role to play in reducing these. This review details the evaluation and management of traumatic injuries in pediatric patients and gives some recommendations for improvements to trauma care in LMICs.

Fetal Bovine Collagen Matrix in the Treatment of a Full Thickness Burn Wound: A Case Report With Long-Term Follow-Up

The treatment of full thickness skin wounds commonly associated with large burns continues to represent a challenging clinical entity. The current treatment for large TBSA burns is split thickness autologous skin grafting; however, this treatment often results in poor textural durability, hypertrophic scarring, and fibrotic contractures. In this case report, we describe our experience and long-term follow-up results after the application of fetal bovine collagen (FBC) matrix (PriMatrix, TEI Biosciences, Boston, MA) to burn wounds clinically assessed as full thickness that healed without the need for subsequent skin grafting. The patient presented with 25% TBSA burns and was debrided and covered with FBC on postburn day 7. By postoperative day 12, the patient had large areas of reepithelialization distributed throughout the wound bed. By postoperative day 26, the patient had significantly more areas of wound closure and was discharged. Reepithelialization and repigmentation continued, and long-term follow-up after 26 months demonstrated complete reepithelialization and nearly complete repigmentation, without the appearance of contractures or hypertrophic scarring. This case report highlights the use of FBC as a scaffold capable of dermal regeneration and spontaneous reepithelialization with an excellent long-term functional and cosmetic outcome.

Creation of Nepal's First Skin Bank: Challenges and Outcomes

Background

In Nepal, burn trauma causes more than 55,000 injuries each year. Burn-related mortality is high in Nepal, in part due to lack of allograft, leading to high infection rates. To address this challenge, our collaboration between Kirtipur Hospital, America Nepal Medical Foundation, Stanford University, and ReSurge International established Nepal's first skin bank.

Methods

We identified 3 major tasks to create a sustainable skin banking program: 1) identify and acquire the equipment and personnel needed to collect, process, store, and graft cadaveric skin for burn injuries; 2) develop safe donation protocols and documentation tools that remain feasible for low-resource settings; and 3) develop a long-term awareness program to educate the Nepali people on skin donation, a previously foreign concept.

Results

Kirtipur Hospital acquired the necessary equipment and materials for the skin bank through a combination of local and international fundraising efforts. Existing U.S. skin banking protocols were adapted for the Nepali setting and piloted on potential patients, donors, and physicians. For the first time in the hospital's history, patients with > 40% total body surface area burns were successfully treated with extensive allografts.

Conclusions

It is feasible to create a skin bank in a country with no tradition of allograft skin use. Long-term sustainability now depends on spreading awareness and education in the Kathmandu Valley to overcome religious and cultural barriers that have hindered donor recruitment. Our low-cost and high-impact skin bank provides a model to expand this system to other hospitals both within Nepal and beyond.

Qualitative analysis of a psychological supportive counseling group for burn survivors and families in Malawi

OBJECTIVE

While psychological care, including supportive group therapy, is a mainstay of burn treatment in the developed world, few reports of support groups for burn survivors and their caregivers in the developing world exist. This study records the findings of a support group in Malawi and provides a qualitative analysis of thematic content discussed by burn survivors and caregivers.

MATERIALS AND METHODS

We established a support group for burn survivors and caregivers from February-May 2012 in the burn unit at Kamuzu Central Hospital in Lilongwe, Malawi. Sessions were held weekly for twelve weeks and led by a Malawian counselor. The group leader compiled transcripts of each session and these transcripts were qualitatively analyzed for thematic information.

RESULTS

Thematic analysis demonstrated a variety of psychological issues discussed by both survivors and caregivers. Caregivers discussed themes of guilt and self-blame for their children's injuries, worries about emotional distance now created between caregiver and survivor, fears that hospital admission meant likely patient death and concerns about their child's future and burn associated stigma. Burn survivors discussed frustration with long hospitalization courses, hope created through interactions with hospital staff, the association between mental and physical health, rumination about their injuries and how this would affect their future, decreased self-value, increased focus on their own mortality and family interpersonal difficulties.

CONCLUSIONS

The establishment of a support group in our burn unit provided a venue for burn survivors and their families to discuss subjective experiences, as well as the dissemination of various coping techniques. Burn survivors and their caregivers in Malawi would benefit from the establishment of similar groups in the future to help address the psychological sequelae of burns.

Comparative Population Plasma and Tissue Pharmacokinetics of Micafungin in Critically Ill Patients with Severe Burn Injuries and Patients with Complicated Intra-Abdominal Infection

Severely burned patients have altered drug pharmacokinetics (PKs), but it is unclear how different they are from those in other critically ill patient groups. The aim of the present study was to compare the population pharmacokinetics of micafungin in the plasma and burn eschar of severely burned patients with those of micafungin in the plasma and peritoneal fluid of postsurgical critically ill patients with intra-abdominal infection. Fifteen burn patients were compared with 10 patients with intra-abdominal infection; all patients were treated with 100 to 150 mg/day of micafungin. Micafungin concentrations in serial blood, peritoneal fluid, and burn tissue samples were determined and were subjected to a population pharmacokinetic analysis. The probability of target attainment was calculated using area under the concentration-time curve from 0 to 24 h/MIC cutoffs of 285 for Candida parapsilosis and 3,000 for non-parapsilosis Candida spp. by Monte Carlo simulations. Twenty-five patients (18 males; median age, 50 years; age range, 38 to 67 years; median total body surface area burned, 50%; range of total body surface area burned, 35 to 65%) were included. A three-compartment model described the data, and only the rate constant for the drug distribution from the tissue fluid to the central compartment was statistically significantly different between the burn and intra-abdominal infection patients (0.47 ± 0.47 versus 0.15 ± 0.06 h(-1), respectively; P < 0.05). Most patients would achieve plasma PK/pharmacodynamic (PD) targets of 90% for non-parapsilosis Candida spp. and C. parapsilosis with MICs of 0.008 and 0.064 mg/liter, respectively, for doses of 100 mg daily and 150 mg daily. The PKs of micafungin were not significantly different between burn patients and intra-abdominal infection patients. After the first dose, micafungin at 100 mg/day achieved the PK/PD targets in plasma for MIC values of ≤0.008 mg/liter and ≤0.064 mg/liter for non-parapsilosis Candida spp. and Candida parapsilosis species, respectively.

Pediatric Trauma Care in Low- and Middle-Income Countries: A Brief Review of the Current State and Recommendations for Management and a Way Forward

Traumatic injuries are a significant cause of death and disability worldwide. The vast majority of these injuries occur in low- and middle-income countries (LMICs). Attention to protocolized care and adaptations to treatments based on availability of resources, regionalization of care, and the development of centers of excellence within each LMIC are crucial to improving outcomes and lowering trauma-related morbidity and mortality worldwide. Given limitations in the availability of the resources necessary to provide the levels of care found in high-income countries, strategies to prevent trauma and make the best use of available resources when prevention fails, and thus achieve the best possible outcomes for injured and critically ill children, are vital. Overall, a commitment on the part of governments in LMICs to the provision of adequate health care services to their populations will improve the outcomes of injured children. This review details the evaluation and management of traumatic injuries in pediatric patients and gives some recommendations for improvements to trauma care in LMICs.

Modified first world mortality scores can be used in a regional South African burn service with resource limitations

INTRODUCTION

Survival following a major burn is highly dependent on the availability of scare and expensive resources such as critical care services, modern dressings and access to operating theatres. Scoring systems, which predict mortality have been developed and can be used to identify patients in whom the outlay of these resources is futile. The aim of this study was to analyse the mortality at a regional South African burn service and to see if these scoring models developed in a resource rich environment were applicable to our setting.

METHODS

Consecutive admissions to the Edendale burn service, South Africa were collected from patient records over a 2-year period from July 2013 to June 2015. Demographic, burn details and final outcome (lived or died) were captured for statistical analysis. Each patient was scored using the Modified Baux, Coste et al., Belgian Outcome of Burn Injury (BOBI) and Abbreviated Burn Severity Index (ABSI) scores. Validation of models and inferential statistics were done to determine new breakpoints more applicable to our sample.

RESULTS

A total of 748 patients were included in the sample, with a mortality rate of 7.1%. The mean Modified Baux score was 27 (range 1-134), with the new breakpoint of 40 predicting 74% of the mortalities compared to the 42% predicted by the old breakpoint of 75. The mean ABSI score was 4 (range 2-15), with a lower break point of 6 predicting 75% of deaths compared to 42% with the old breakpoint of 8. The mean Coste score for the sample was 12 (range 0-100). With a suggested break point of 85 (predicting 50% mortality), only 6% of mortalities were predicted. The new break point of 17 predicted 91% of deaths. The original break point for the BOBI score was 6 (range 0-7). This included 42% of deaths. With a new breakpoint of 1, 74% of deaths were predicted.

DISCUSSION

Our data has shown that in our environment a significant number of fatalities occur in patients with potentially salvageable burns, and the breakpoints for the mortality prediction scores such as, the Modified Baux score, Coste et al. score, BOBI and ABSI scores are much lower than high-income countries. However these mortality predictive scores can be used in a resource scarce South African setting to triage patients into risk categories by lowering the breakpoints. This may facilitate early and more aggressive management of high-risk burn patients, improving survival rates, as well as efficient and judicious use of critical care and other resources.

Standardised mortality ratio based on the sum of age and percentage total body surface area burned is an adequate quality indicator in burn care: An exploratory review

Standardised Mortality Ratio (SMR) based on generic mortality predicting models is an established quality indicator in critical care. Burn-specific mortality models are preferred for the comparison among patients with burns as their predictive value is better. The aim was to assess whether the sum of age (years) and percentage total body surface area burned (which constitutes the Baux score) is acceptable in comparison to other more complex models, and to find out if data collected from a separate burn centre are sufficient for SMR based quality assessment. The predictive value of nine burn-specific models was tested by comparing values from the area under the receiver-operating characteristic curve (AUC) and a non-inferiority analysis using 1% as the limit (delta). SMR was analysed by comparing data from seven reference sources, including the North American National Burn Repository (NBR), with the observed mortality (years 1993-2012, n=1613, 80 deaths). The AUC values ranged between 0.934 and 0.976. The AUC 0.970 (95% CI 0.96-0.98) for the Baux score was non-inferior to the other models. SMR was 0.52 (95% CI 0.28-0.88) for the most recent five-year period compared with NBR based data. The analysis suggests that SMR based on the Baux score is eligible as an indicator of quality for setting standards of mortality in burn care. More advanced modelling only marginally improves the predictive value. The SMR can detect mortality differences in data from a single centre.

Biphasic changes (overreduction and overoxidation) of plasma redox status and clinical implications in early stage of severe burns

PURPOSE

Although the changes of redox status in the early stage of severe burns are considered to be associated with the disease progression, whereas antioxidant therapy cannot improve the prognosis, the characteristics and mechanisms of dynamic change of redox status related with the disease progression deserve further study.

METHODS

Blood redox potential (ORP) values (ΔORP value was adopted), plasma uric acid (UA) levels, and the inflammation-related indicators of 67 burn patients were dynamically monitored in the early stage.

RESULTS

Compared with healthy persons, the results revealed the biphasic changes of redox status in the early stage after burns, and both of them were closely related to the prognosis of severe burns. Overreduction status and overoxidation status were related to the dynamic changes of plasma UA level and the inflammation-related indicators of severe burns. In addition, the change of ΔORP value was found to associate with the traditional prognostic markers.

CONCLUSIONS

This study firstly revealed the excessive, biphasic changes of redox status and clinical implications in the early stage of severe burns, providing a new viewpoint for early pathological changes of severe burns and will be helpful for corresponding early treatment. ΔORP value also appears to be a potential early prognostic marker.

Management of Burns and Anesthetic Implications

Burn injuries are highly complex and affect almost every major organ system in the body. The treatment of burn patients requires the presence of a well-organized team of caregivers who understand the multifaceted consequences of burn injuries and who are adept at coordinating care. An understanding of the multitude of abnormalities that must be addressed helps to guide therapy in these patients. Careful anesthetic and perioperative management of these patients carries special importance in this fragile patient population as a part of their often lengthy recovery and rehabilitation.

Survival after burn in a sub-Saharan burn unit: challenges and opportunities

BACKGROUND

Burns are among the most devastating of all injuries and a major global public health crisis, particularly in sub-Saharan Africa. In developed countries, aggressive management of burns continues to lower overall mortality and increase lethal total body surface area (TBSA) at which 50% of patients die (LA50). However, lack of resources and inadequate infrastructure significantly impede such improvements in developing countries.

METHODS

This study is a retrospective analysis of patients admitted to the burn center at Kamuzu Central Hospital in Lilongwe, Malawi between June 2011 and December 2012. We collected information including patient age, gender, date of admission, mechanism of injury, time to presentation to hospital, total body surface area (TBSA) burn, comorbidities, date and type of operative procedures, date of discharge, length of hospital stay, and survival. We then performed bivariate analysis and logistic regression to identify characteristics associated with increased mortality.

RESULTS

A total of 454 patients were admitted during the study period with a median age of 4 years (range 0.5 months to 79 years). Of these patients, 53% were male. The overall mean TBSA was 18.5%, and average TBSA increased with age--17% for 0-18 year olds, 24% for 19-60 year olds, and 41% for patients over 60 years old. Scald and flame burns were the commonest mechanisms, 52% and 41% respectively, and flame burns were associated with higher mortality. Overall survival in this population was 82%; however survival reduced with increasing age categories (84% in patients 0-18 years old, 79% in patients 19-60 years old, and 36% in patients older than 60 years). TBSA remained the strongest predictor of mortality after adjusting for age and mechanism of burn. The LA50 for this population was 39% TBSA.

DISCUSSION

Our data reiterate that burn in Malawi is largely a pediatric disease and that the high burn mortality and relatively low LA50 have modestly improved over the past two decades. The lack of financial resources, health care personnel, and necessary infrastructure will continue to pose a significant challenge in this developing nation. Efforts to increase burn education and prevention in addition to improvement of burn care delivery are imperative.

Protective effects of enalapril, an angiotensin-converting enzyme inhibitor, on multiple organ damage following scald injury in rats

The aim of this study is to investigate the effects of enalapril, an angiotensin-converting enzyme inhibitor, on multiple organ damage after scald injury. Healthy adult rats (half male and half female; 8-12 weeks old) were randomly assigned to the following treatments: sham operation, scald injury, and intraperitoneal enalapril (1, 2, and 4 mg/kg body weight) treatment after scalding. At 1, 12, and 24 H postscald, left ventricular and aortic hemodynamics were measured using a multichannel physiological recorder. Functional and pathological changes of the heart, liver, and kidney were examined by biochemical and histological methods. Compared with sham controls, untreated scalded animals showed decreased hemodynamic parameters and increased myocardial angiotensin II, serum creatine kinase heart isoenzyme, and serum cardiac troponin I and histopathological inflammation in the myocardium 12 H postscald. These hemodynamic, functional, and pathological changes were attenuated by 1 mg/kg enalapril. Enalapril reversed scald-induced elevations in aspartate aminotransferase, alanine aminotransferase, blood urea nitrogen, and blood creatinine 12 H postscald, and ameliorated focal necrosis in the liver and erythrocyte cast formation in renal tubules. However, higher doses of enalapril yielded less or no improvement in organ dysfunction. Enalapril at 1 mg/kg attenuates scald-induced multiple organ damage in rats.

Virtually naked: virtual environment reveals sex-dependent nature of skin disclosure

The human tendency to reveal or cover naked skin reflects a competition between the individual propensity for social interactions related to sexual appeal and interpersonal touch versus climatic, environmental, physical, and cultural constraints. However, due to the ubiquitous nature of these constraints, isolating on a large scale the spontaneous human tendency to reveal naked skin has remained impossible. Using the online 3-dimensional virtual world of Second Life, we examined spontaneous human skin-covering behavior unhindered by real-world climatic, environmental, and physical variables. Analysis of hundreds of avatars revealed that virtual females disclose substantially more naked skin than virtual males. This phenomenon was not related to avatar hypersexualization as evaluated by measurement of sexually dimorphic body proportions. Furthermore, analysis of skin-covering behavior of a population of culturally homogeneous avatars indicated that the propensity of female avatars to reveal naked skin persisted despite explicit cultural norms promoting less revealing attire. These findings have implications for further understanding how sex-specific aspects of skin disclosure influence human social interactions in both virtual and real settings.

Shaking stress aggravates burn-induced cardiovascular and renal disturbances in a rabbit model

The aim of this study was to address the effects of shaking stress (a.k.a. physical agitation) on burn-induced remote organ injury and to evaluate the application of delayed fluid resuscitation to treat severe burns under shaking conditions. Healthy adult male rabbits, weighing 2.50±0.40 kg, were randomly assigned to the following groups: control group, burn group, and burn+shaking group. One half of burned animals received a 6-h delayed fluid resuscitation and the other half remained untreated. Cardiovascular hemodynamics and functional and pathological changes of the heart and kidney were examined. Compared to normal controls, untreated burned animals showed decreased hemodynamic parameters, increased serum lactic acid, and severe myocardial inflammation. The burn-induced hemodynamic abnormalities and cardiac injury were aggravated by shaking stress. Burn injury led to reduced urine volume, elevated serum creatinine and blood urea nitrogen, and formation of erythrocyte casts in renal tubules. Shaking stimulation worsened the burn-associated functional and pathological changes of the kidney. Fluid resuscitation markedly mitigated cardiac and renal injury in burned animals, and, to a lesser extent, in the presence of shaking stimulation. Shaking stimulation aggravates burn-induced cardiovascular and renal disturbances. Delayed fluid resuscitation attenuates cardiac and renal damages in burn injury under shaking conditions.

Photographic assessment of burn wounds: a simple strategy in a resource-poor setting

OBJECTIVE

To validate the use of photographic burn wound assessment in evaluation of burn size and wound characteristics.

METHODS

Feasibility study of agreement between methods of measurement of burn size and characteristics, in patients admitted to the burn unit at Kamuzu Central Hospital (KCH), Malawi, over two months in 2011. Burn wounds were photographed and assessed clinically, concurrently, by an experienced clinician. Photographs reviewed by two blinded burn clinicians after 4-6 weeks. Correlation between clinical assessment and photographic evaluation was calculated using kappa score and Pearson's correlation coefficient.

RESULTS

Thirty-nine patients were included in evaluation of TBSA, and fifty wounds assessed for their characteristics. Pearson's correlation coefficient for agreement of TBSA between clinical exam and photograph review by expert#1, and #2, was 0.96, 0.93 (p<0.001), respectively. Pearson's correlation coefficients comparing expert#1 and #2 to the gold standard were: proportion of full-thickness burn (0.88 and 0.81, p<0.001), and epithelialized superficial burn (0.89 and 0.55, p<0.001). Kappa scores were significant for wound evolution (expert#1 0.57, expert#2 0.64, p<0.001), and prognosis (expert#1 0.80, expert#2 0.80, p<0.001).

CONCLUSIONS

Burn assessment with digital photography is a valid and affordable alternative to direct clinical exam, alleviating access issues to burn care in developing countries.