Metabolic and Nutritional Support

Hypermetabolism is a hallmark of larger burn injuries. The hypermetabolic response is characterized by marked and sustained increases in catecholamines, glucocorticoids, and glucagon. There is an increasing body of literature for nutrition and metabolic treatment and supplementation to counter the hypermetabolic and catabolic response secondary to burn injury. Early and adequate nutrition is key in addition to adjunctive therapies, such as oxandrolone, insulin, metformin, and propranolol. The duration of administration of anabolic agents should be at minimum for the duration of hospitalization, and possibly up to 2 to 3 years postburn.

Novel Design and Implementation of an Integrated Burn Rehabilitation Clinical Fellowship

ABSTRACT

Postgraduate medical burn rehabilitation training has been limited, with very few academic physiatrists specializing in burn rehabilitation. As a result, there are no existing models for postgraduate burn rehabilitation education. A 12-mo comprehensive clinical fellowship in burn rehabilitation was offered through a tertiary burn center with formal university accreditation. In this article, the clinical, educational, and skill-based goals developed and implemented for this novel fellowship was outlined to serve as a blueprint for future fellowships in burn rehabilitation, as well as reflections on the experience.

Outbreak of Carbapenemase-Producing Enterobacteriaceae in a Regional Burn Center

Antimicrobial resistance is an increasing problem in hospitals worldwide; however, the prevalence of carbapenemase-producing Enterobacteriaceae (CPE) in our region is low. Burn patients are vulnerable to infection because of the loss of the protective skin barrier, thus burn centers prioritize infection prevention and control (IP&C). This report describes a CPE outbreak in a regional burn center. In a period of 2.5 months, four nosocomial cases of CPE were identified, three containing the Klebsiella pneumoniae carbapenemase (KPC) gene and one Verona integrin-encoded metallo-β-lactamase (VIM) gene. The first two cases were identified while there was no CPE patient source on the unit. CPE KPC gene was then isolated in sink drains of three rooms. In addition to rigorous IP&C practices already in place, we implemented additional outbreak measures including restricting admissions to patients with complex burns or burns ≥10% TBSA, admitting patients to other in-patient units, and not permitting elective admissions. We began cohorting patients using nursing team separation for CPE-positive and -negative patients and geographical separation on the unit. Despite aggressive IP&C measures already in place, hospital-acquired CPE colonization/infection occurred. Given that CPE contaminated sinks of the same enzyme were identified, we believe hospital sink drains may the source. This highlights the importance of sink design and engineering solutions to prevent the formation of biofilm and reduce splashing. CPE infections are associated with poor outcomes in patients and significant health system costs due to a longer length of stay and additional institutional resources.

Time to surgical closure of complex infectious wounds: a single-center retrospective cohort study

INTRODUCTION

Surgical management of NSTIs can result in complex wounds, and closure of these wounds is often difficult or complicated. Although surgical factors influencing mortality and LOS have been well described, little is known about patient, wound, and surgical factors associated with time to closure.

OBJECTIVE

The purpose of this study is to identify patient, wound, and surgical factors that may influence time to closure of NSTIs.

MATERIALS AND METHODS

The records of patients who presented to a tertiary care center over an 11-year period (2007-2017) with an NSTI requiring surgical closure were retrospectively reviewed.

RESULTS

Forty-seven patients met the inclusion criteria. The average time to closure was 31.1 days, with an average of 4.8 procedures. Most patients were middle aged (mean, 50.3 years; range, 20-81 years), immunocompetent, and nondiabetic upon admission. Closure was achieved mainly with autograft. The percent TBSA was described in 19 cases (40%). There was no association between substance use (alcohol, smoking, or other), anticoagulant medication use, or medical comorbidities and time to closure. On multivariable analysis, flap closure (P =.02) and increased number of surgical procedures (P =.003)-the latter reflecting the need for an increased number of debridements-were associated with increased time to closure.

CONCLUSIONS

The data in this study suggest that use of local flaps for wound closure and increased number of surgical procedures (particularly debridements) may be predictors of time to closure in patients with an NSTI.

700 Use of Antibiograms and Changes in Bacterial Resistance Patterns

Introduction

Infection is a leading cause of death in burn patients. With an increase in resistance patterns, management of these infections has become progressively difficult. Antibiograms, a summary of susceptibilities to bacteria in a given institution or area, are often used to guide empiric treatment of infections. However, inappropriate prescribing and use of empiric antimicrobials may greatly impact the incidence of resistance. Currently, we do not know the patterns of antibiotic use since the introduction of institutional antibiograms or associated changes in antibiotic resistance. The objective of this study is to describe trends in antibiotic susceptibilities in burn patients in Canada pre- (PrA) and post-introduction (PoA) of antibiograms.

Methods

We performed a retrospective review of patients admitted to an ABA-verified Burn Centre 2 years pre- (2013-2014) and post-introduction (2016-2017) of institutional antibiograms and started on broad-spectrum antibiotics (meropenem, piperacillin-tazobactam, and/or vancomycin).

Results

A total of 864 patients were admitted during the study period (n=420 PrA and n=444 PoA). Average age, % total body surface area (%TBSA), and length of stay were similar between cohorts. Administration of empiric meropenem increased (43.2% vs. 56.8%) and piperacillin-tazobactam decreased (60.6% vs. 39.4%), which was significant (p=0.002). The use of vancomycin was unchanged. There was a significant decrease in the overall use of empiric antibiotics (p=0.002) since the inception of antibiograms, with a significant improvement in culture and sensitivity (C&S) testing within 5 days of starting empiric antibiotics (p=0.002). There was no significant difference in use of targeted antibiotics pre- or post-antibiogram introduction.

Conclusions

Our study demonstrates that since the inception of antibiograms, there has been a significant decrease in overall use of empiric antibiotics and improvement in acquiring C&S within 5 days. However, these antibiotics were not always targeted to the appropriate organism and therefore may contribute to multi-drug resistant organisms in a burn population.

Use of a Fluorescence Imaging Device to Detect Elevated Bacterial Loads, Enhance Antimicrobial Stewardship, and Increase Communication Across Inpatient Complex Wound Care Teams

Introduction. Wounds are increasing in number and complexity within the hospital inpatient system, and coordinated and dedicated wound care along with the use of emerging technologies can result in improved patient outcomes. Objective. This prospective implementation study at 2 hospital inpatient sites examines the effect of bedside fluorescence imaging of wounds in the detection of elevated bacterial loads and its location in/around the wound on the inpatient wound population. Materials and Methods. Clinical assessment and fluorescence imaging assessments were performed on 26 wounds in 21 patients. Treatment plans were recorded after the clinical assessment and again after fluorescence imaging, and any alterations made to the treatment plans after imaging were noted. Results. Prior to fluorescence imaging, antimicrobial use in this patient population was common. An antimicrobial dressing, a topical antibiotic, or an oral antibiotic was prescribed in 23 wounds (88% of assessments), with antimicrobial dressings prescribed 73% of the time. Based on clinical assessment, more than half of the treated wounds were deemed negative for suspected infection. In 12 of 26 wounds, the fluorescence imaging information on bacterial presence had the potential to prompt a change in whether an antimicrobial dressing was prescribed. Five of these 12 wounds were fluorescence imaging-positive and an antimicrobial drug was not prescribed, whereas 7 of the 12 wounds were negative upon fluorescence imaging and clinical assessment but antimicrobial dressing was prescribed. Overall, fluorescence imaging detected 70% more wounds, with bacterial fluorescence indicating elevated bacterial loads, compared with clinical assessment alone, and use of imaging resulted in altered treatment plans in 35% of cases. Conclusions. Fluorescence imaging can aid in antimicrobial stewardship goals by supporting evidence-based decision-making at the point of care. In addition, use of such imaging resulted in increased communication, enhanced efficiency, and improved continuity of care between wound care providers and hospital sites.

Identifying risk factors that increase analgesic requirements at discharge among patients with burn injuries

Patients with burn injuries require large doses of opioids and gabapentinoids to achieve pain control and are often discharged from hospital with similar amounts. This study aimed to identify patient risk factors that increase analgesic requirements among patients with burn injuries and to determine the relationship between opioid and gabapentinoid use. Patient charts from July 1, 2015 - 2018 were reviewed retrospectively to determine analgesic requirements 24 hours before discharge. Linear mixed regression models were performed to determine patient risk factors (age, gender, history of substance misuse, total body surface area of burn, length of stay in hospital, history of psychiatric illness, or surgical treatment) that may increase analgesic requirements. This study found that patients with a history of substance misuse (p = 0.01) or who were managed surgically (p = 0.01) required higher doses of opioids at discharge. Similarly, patients who had undergone surgical debridement required more gabapentinoids (p < 0.001). For every percent increase in TBSA, patients also required 14 mg more gabapentinoids (p = 0.01). In contrast, older patients (p = 0.006) and those with a longer hospital stay (p = 0.009) required fewer amounts of gabapentinoids before discharge. By characterizing factors that increase analgesic requirements at discharge, burn care providers may have a stronger understanding of which patients are at greater risk of developing chronic opioid or gabapentinoid misuse. The quantity and duration of analgesics prescribed at discharge may then be tailored according to these patient specific risk factors.

Comparison of clinical outcomes of lower extremity burns in diabetic and non-diabetic patients: a retrospective analysis

Diabetes mellitus is an increasingly prevalent chronic disease that leads to long-term health consequences. Some long-term clinical sequelae of diabetes include coronary artery disease, peripheral vascular disease, peripheral neuropathy, and impaired wound healing. These can increase hospital stay and complications such as wound infections and amputations among patients with lower extremity burns. A retrospective analysis was performed of all isolated lower extremity burns from a single tertiary burn care centre from 2006-2017. Patients were stratified by diabetic status and the incidence of lower extremity amputations was the primary outcome. Multivariable regression was used to model the association between diabetes and amputations, adjusting for patient and injury characteristics. A total of 198 patients were identified as meeting inclusion criteria, 160 were non-diabetic and 38 were diabetic. Age was significantly different between non-diabetic and diabetic patients; mean age was 46 ± 18 years versus 62 ± 17 years (p<0.0001). Length of stay was also significantly different, median length of stay was 11 (IQR 7-15) versus 18 (IQR 12-24) (p<0.001), with diabetic patients staying longer. There was a significantly greater proportion of diabetic patients that had an amputation (control 4% versus diabetic 29%; p<0.0001). After adjustment for patient and injury characteristics, there was a significant association between diabetes and amputation (p=0.002). Among patients with isolated lower extremity burns, those with a pre-existing condition of diabetes had a longer hospitalization and increased amputations, despite similar size of burn. Diabetes is an important risk factor to acknowledge in patients with these injuries to optimize care.

Prescribing patterns of opioids and adjunctive analgesics for patients with burn injuries

PURPOSE

Large quantities of analgesics are prescribed to control pain among patients with burn injuries and may lead to chronic use and dependency. This study aimed to determine whether patients are overprescribed analgesics at discharge and to identify factors that influence prescribing patterns.

MATERIAL AND METHODS

A retrospective review of patient charts (n = 199) between July 1, 2015-2018 were reviewed from a registry at a single burn center. Opioid, neuropathic pain agent, acetaminophen, and ibuprofen quantities given before and at discharge were compared. Linear mixed regression models were used to identify factors that increased the amount of analgesics prescribed.

RESULTS

On average, patients were prescribed significantly more analgesics at discharge compared to what was consumed pre-discharge (p < 0.0001). Specifically, on average, providers did not overprescribe the daily dose, but overprescribed the duration of pain medications required. For every increase in percent TBSA, 14 MEQ more opioids, 203 mg more neuropathic pain agents, 843 mg more acetaminophen, and 126 mg more ibuprofen were prescribed (p < 0.05). Surgery was a predictor for higher opioid and neuropathic pain agent prescriptions (p = 0.03), while length of stay was associated with fewer neuropathic pain agents prescribed (p = 0.04). Fewer ibuprofen were given to patients with a history of substance misuse (p = 0.01).

CONCLUSIONS

The quantity of analgesics prescribed at discharge varied widely and often prescribed for long durations of time. Standardized prescribing guidelines should be developed to optimize how analgesics are prescribed at discharge.

Burn Infection and Burn Sepsis

Background: Infection is the most common complication and cause of death in patients suffering burn injuries. These patients are susceptible to infection and burn wound sepsis secondary to the alterations in their physiology. Diagnosis and management of infections rely on physical examination, cultures, and the pathology of the burn wound. Method: We performed an electronic search for articles in the Google Scholar and PubMed databases using the search terms "burn sepsis," "burn infection," and "burn critical care." Results: Multiple factors increase burn patients' risk of invasive infection and sepsis, including underlying factors and co-morbidities, the percent total body surface area of the burn, delays in burn wound excision, and microbial virulence/bacterial count. Organisms causing burn wound infection differ, depending on the time since injury and its location; and diagnosis is multi-factorial. The most common pathogens remain Staphylococcus and Pseudomonas spp. Conclusion: Overall, the recognition of burn sepsis is based on clinical findings. Treatment consists of a combination of local dressings, early burn excision, and systemic antimicrobial therapy. The mortality rate has decreased significantly over the past 10 years, but continued efforts at timely management and infection prevention are essential.

Anabolic and anticatabolic agents used in burn care: What is known and what is yet to be learned

Major thermal injury induces profound metabolic derangements secondary to an inflammatory "stress-induced" hormonal environment. Several pharmacological interventions have been tested in an effort to halt the hypermetabolic response to severe burns. Insulin, insulin growth factor 1, insulin growth factor binding protein 3, metformin, human growth hormone, thyroid hormones, testosterone, oxandrolone, and propranolol, among others, have been proposed to have anabolic or anticatabolic effects. The aim of this broad analysis of pharmacological interventions was to raise awareness of treatment options and to help establishing directions for future clinical research efforts. A PubMed search was conducted on the anabolic and anticatabolic agents used in burn care. One hundred and thirty-five human studies published between 1999 and 2017 were included in this review. The pharmacological properties, rationale for the treatments, efficacy considerations and side effect profiles are summarized in the article. Many of the drugs tested for investigational purposes in the severely thermally injured are not yet gold-standard therapies in spite of their potential benefit. Propranolol and oxandrolone have shown great promise but further evidence is still needed to clarify their potential use for anabolic and anticatabolic purposes.

Allogeneic mesenchymal stem cells for treatment of severe burn injury

The most important determinant of survival post-burn injury is wound healing. For decades, allogeneic mesenchymal stem cells (MSCs) have been suggested as a potential treatment for severe burn injuries. This report describes a patient with a severe burn injury whose wounds did not heal with over 18 months of conventional burn care. When treated with allogeneic MSCs, wound healing accelerated with no adverse treatment complications. Wound sites showed no evidence of keloids or hypertrophic formation during a 6-year follow-up period. This therapeutic use of allogeneic MSCs for large non-healing burn wounds was deemed safe and effective and has great treatment potential.

Management and prevention of drug resistant infections in burn patients

Introduction: Despite modern advances, the primary cause of death after burns remains infection and sepsis. A key factor in determining outcomes is colonization with multi-drug resistant (MDR) organisms. Infections secondary to MDR organisms are challenging due to lack of adequate antibiotic treatment, subsequently prolonging hospital stay and increasing risk of adverse outcomes. Areas covered: This review highlights the most frequent organisms colonizing burn wounds as well as the most common MDR bacterial infections. Additionally, we discuss different treatment modalities and MDR infection prevention strategies as their appropriate management would minimize morbidity and mortality in this population. We conducted a search for articles on PubMed, Web of Science, Embase, Cochrane, Scopus and UpToDate with applied search strategies including a combination of: "burns, 'thermal injury,' 'infections,' 'sepsis,' 'drug resistance,' and 'antimicrobials.' Expert opinion: Management and prevention of MDR infections in burns is an ongoing challenge. We highlight the importance of preventative over therapeutic strategies, which are easy to implement and cost-effective. Additionally, targeted, limited use of antimicrobials can be beneficial in burn patients. A promising future area of investigation within this field is post-trauma microbiome profiling. Currently, the best treatment strategy for MDR in burn patients is prevention.

The Impact of Time of Mobilization After Split Thickness Skin Graft on Lower Extremity Wound Healing-Systematic Review and Meta-analysis

Systematic Review registration

: Prospero CRD42017070990.

Sepsis criteria versus clinical diagnosis of sepsis in burn patients: A validation of current sepsis scores

BACKGROUND

Sepsis remains an ongoing diagnostic challenge in burns, especially with the signs of sepsis being ubiquitously present during the acute period after injury. We aimed to determine the predictive validity of 3 current sepsis criteria in the burn population. The criteria of interest included the American Burn Association sepsis criteria, Mann-Salinas et al predictors of sepsis, and the Sepsis-3 consensus definition.

METHODS

Adult patients with an acute burn injury who were diagnosed prospectively with sepsis by the burn team using specific clinical markers were included in this cohort study. Sepsis predictors were collected from patient charts and used to calculate the results of the 3 criteria, then subsequently compared to the clinical diagnosis.

RESULTS

Of the 418 patients in the study, which took place from 2000 until 2016, 88 (21%) were septic; the mean age was 50 ± 18 years with a mean percent total body surface area burn of 30% ± 17%. Inhalation injury was present in 50%, median length of stay was 49 (29-71) days, and mortality was 19%. The American Burn Association, Mann-Salinas, and Sepsis-3 criteria were positive in 59%, 28%, and 85% respectively, P < .05. The most reliable predictors included increased oxygen requirements, altered mental status, hypothermia, hyperthermia, tachycardia, and hypotension.

CONCLUSION

The Sepsis-3 criteria was the most predictive, followed by the American Burn Association and Mann-Salinas criteria. However, no criterion alone had the accuracy to be a diagnostic standard within this burn population. We recommend sepsis is clinically assessed, diagnosed, and documented prospectively by the burn team, and not by the application of retrospective criteria.

Review of Adult Electrical Burn Injury Outcomes Worldwide: An Analysis of Low-Voltage vs High-Voltage Electrical Injury

The aims of this article are to review low-voltage vs high-voltage electrical burn complications in adults and to identify novel areas that are not recognized to improve outcomes. An extensive literature search on electrical burn injuries was performed using OVID MEDLINE, PubMed, and EMBASE databases from 1946 to 2015. Studies relating to outcomes of electrical injury in the adult population (≥18 years of age) were included in the study. Forty-one single-institution publications with a total of 5485 electrical injury patients were identified and included in the present study. Fourty-four percent of these patients were low-voltage injuries (LVIs), 38.3% high-voltage injuries (HVIs), and 43.7% with voltage not otherwise specified. Forty-four percentage of studies did not characterize outcomes according to LHIs vs HVIs. Reported outcomes include surgical, medical, posttraumatic, and others (long-term/psychological/rehabilitative), all of which report greater incidence rates in HVI than in LVI. Only two studies report on psychological outcomes such as posttraumatic stress disorder. Mortality rates from electrical injuries are 2.6% in LVI, 5.2% in HVI, and 3.7% in not otherwise specified. Coroner's reports revealed a ratio of 2.4:1 for deaths caused by LVI compared with HVI. HVIs lead to greater morbidity and mortality than LVIs. However, the results of the coroner's reports suggest that immediate mortality from LVI may be underestimated. Furthermore, on the basis of this analysis, we conclude that the majority of studies report electrical injury outcomes; however, the majority of them do not analyze complications by low vs high voltage and often lack long-term psychological and rehabilitation outcomes after electrical injury indicating that a variety of central aspects are not being evaluated or assessed.

Comparison of two-dimensional methods versus three-dimensional scanning systems in the assessment of total body surface area estimation in burn patients

BACKGROUND

Accurate measurement of percent total body surface area (%TBSA) burn is crucial in the management of burn patients for calculating the estimated fluid resuscitation, determining the need to transfer to a specialized burn unit and probability of mortality. %TBSA can be estimated using many methods, all of which are relatively inaccurate. Three-dimensional (3D) systems have been developed to improve %TBSA calculation and consequently optimize clinical decision-making. The objective of this study was to compare the accuracy of percent total burn surface area calculation by conventional methods against novel 3D methods.

METHODS

This prospective cohort study included all acute burn patients admitted in 2016 who consented to participate. The staff burn surgeon determined the %TBSA using conventional methods. In parallel, a researcher determined 3D %TBSA using the BurnCase 3D program (RISC Software GmbH, Hagenberg, Austria). Demographic data and injury characteristics were also collected. Wilcoxon Signed Rank test was used to determine differences between each measure of %TBSA, with assessment of the influence of body mass index (BMI) and gender on accuracy.

RESULTS

Thirty-five patients were included in the study (6 female and 29 male). Average age was 47.5 years, with a median BMI of 26.6kg/m². %TBSA determined by BurnCase 3D program was statistically significantly different from conventional %TBSA assessment (p=0.007), with the %TBSA measured using Burn Case 3D being lower than the %TBSA determined using conventional means (Lund and Browder Diagram) by 1.3% (inter-quartile range -0.6% to 5.6%). BMI and gender did not have an impact on the estimation of the %TBSA.

CONCLUSION

The BurnCase 3D program underestimated %TBSA by 1.3%, as compared to conventional methods. Although statistically significant, this difference is not clinically significant as it has minimal impact on fluid resuscitation and on the decision to transfer a patient to a burn unit. 3D %TBSA evaluation systems are valid tools to estimate %TBSA, and should therefore be considered to improve %TBSA estimation at centers with no available experienced burn staff surgeon. Their use may ultimately prevent inappropriate transfers and allow for improved management of patients with acute burns.

A comparison of Biobrane™ and cadaveric allograft for temporizing the acute burn wound: Cost and procedural time

INTRODUCTION

In many circumstances early burn excision and autografting is unsafe or even impossible. In these situations, skin substitute dressings can be utilized for temporary wound coverage. Two commonly used dressings for this purpose are cadaveric allograft and Biobrane™.

MATERIALS AND METHODS

Five year retrospective cohort study evaluating upper extremity burns treated with temporary wound coverage (Biobrane™ or allograft). The primary outcome was to determine the impact choice of wound coverage had on operative time and cost. The secondary outcome was the need for revision of upper extremity debridement prior to definitive autografting.

RESULTS

45 patients were included in this study: 15 treated with cadaveric allograft and 30 treated with Biobrane™ skin substitute. Biobrane™ had a significantly lower procedure time (21.12 vs. 54.78 min per %TBSA excised, p=0.02) and cost (1.30 vs. 2.35 dollars per minute per %TBSA excised, p=0.002). Both techniques resulted in 2 revisions due to complications.

CONCLUSION

Biobrane™ is superior to cadaveric allograft as a temporizing skin substitute in the acute burn wound, both in terms of procedure time and associated cost. We believe that this is largely due to the relative ease of application of Biobrane™. Furthermore, given its unique characteristics, Biobrane™ may serve as a triage and transport option for severe burns in the military and mass casualty settings.

The use of dermal substitutes in burn surgery: acute phase

Major burns represent a challenge in autologous skin coverage and may lead to severe functional and cosmetic sequelae. Dermal substitutes are increasingly becoming an essential part of burn care during the acute phase of treatment. In the long term dermal substitutes improve functional and cosmetic results and thus enhance quality of life. In the chronic wound setting, dermal substitutes are used to reconstruct and improve burn scars and defects. Despite the potential of dermal substitutes, further research is required to strengthen scientific evidence regarding their effects and also to develop new technologies and products. Furthermore, dermal substitutes have a pivotal role in future research strategies as they have the potential to provide adequate scaffold for stem cells, tissue engineering, and regenerative medicine with conceivable application of obtaining long-lasting and scarless artificial skin. This review discusses the status quo of dermal substitutes and novel strategies in the use of dermal substitutes with a focus on burn care.

Management of adult patients with buttock and perineal burns: The Ross Tilley Burn Centre experience

BACKGROUND

Perineal and buttock burns are challenging wounds to heal for several reasons because of the contamination risk and shear stress that is always present. Because of the nature of the wound bed, pathogens can have ready access to create systemic infections and complications. Prolonged healing times also delay the recovery for patients and add to their discomfort and psychological stress from the injury. The ideal treatment approach is not well defined, and the aims of this study were to conduct a literature review of current treatment suggestions and to look at our own patient population to determine how our center treated these challenging patients.

METHODS

This is a retrospective review of all patients treated between 2010 and 2013 at our center. Patients that received care for burns to the perineum or buttocks were evaluated. Mortalities within 24 hours of admission and transfers before completion of their care were excluded. All patients older than 18 years were included in the study. The primary outcome studied was a cause for graft revision. Secondary outcomes included benefits and risks of fecal management devices, risk of infection, and mortality.

RESULTS

The literature review did not show consensus on how to best manage this patient population. Our results however demonstrated that patients treated with the fecal management device Flexi-seal (Convatec, Skillman, NJ) were at increased risk of developing an infection involving an enteric pathogen and requiring revision procedures. The patient population that was treated with this device was also older and had larger burns. The patients within this group that were treated initially with allograft required fewer revisions when compared with patients that received autograft in this group (23% vs. 34%, p > 0.05).

CONCLUSION

After our data and the literature had been reviewed, the lack of evidence-based treatment protocols led us to create recommendations for burn surgeons with regard to the initial management of this complicated area. Certain key features include avoiding autograft at the primary excision if they have an increased revised Baux score and minimizing the amount of liquid stool contaminating the wound bed to increase success.

LEVEL OF EVIDENCE

Epidemiologic study, level IV. Therapeutic study, level V.

Wound coverage technologies in burn care: novel techniques

Improvements in burn wound care have vastly decreased morbidity and mortality in severely burned patients. Development of new therapeutic approaches to increase wound repair has the potential to reduce infection, graft rejection, and hypertrophic scarring. The incorporation of tissue-engineering techniques, along with the use of exogenous proteins, genes, or stem cells to enhance wound healing, heralds new treatment regimens based on the modification of already existing biological activity. Refinements to surgical techniques have enabled the creation of protocols for full facial transplantation. With new technologies and advances such as these, care of the severely burned will undergo massive changes over the next decade. This review centers on new developments that have recently shown great promise in the investigational arena.

Infections in Burns

Infections remain a leading cause of death in burn patients. This is as a result of loss of the environmental barrier function of the skin predisposing these patients to microbial colonization leading to invasion. Therefore, reconstitution of the environmental barrier by debriding the devitalized tissue and wound closure with application of allograft versus autograft is of optimal importance.

Enteral nutrition support in burn care: a review of current recommendations as instituted in the Ross Tilley Burn Centre

Failure to adequately address the increased levels of inflammatory mediators, catecholamines and corticosteroids central to the hypermetabolic response post burn injury can lead to catastrophic results. One of the most important perturbations is provision of adequate and early nutrition. The provision of the right balance of macro and micronutrients, along with additional antioxidants is essential to mitigating the hypermetabolic and hypercatabolic state that results following a burn injury. As it is now widely accepted that enteral feeding is best practice for the burn population research has been more closely examining the individual components of enteral nutrition support. Recently fat to carbohydrate ratios, glutamine and antioxidants have made up the balance of this focus. This paper provides a review of the most recent literature examining each of these components and discusses the practices adopted in the Ross Tilley Burn Centre at Sunnybrook Health Sciences Centre.

Three components of education in burn care: surgical education, inter-professional education, and mentorship

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

Evaluation of the Quit and Win contest for smoking cessation in the Islamic Republic of Iran

Quit and Win is an international biannual smoking cessation contest. Although more than 70 countries participate, few are from the Eastern Mediterranean Region. This study evaluated 4 Quit and Win campaigns in Isfahan province, Islamic Republic of Iran, from 1998 to 2004, documenting participation rates, self-reported 1-month and 1-year abstinence rates and related factors. Participation rates among smokers ranged from 0.7%-2.4% of the smokers in Isfahan. One-month quit rates varied from 41.8% in 1998 to 92.8% in 2004. At 1-year follow-up, self-reported quit rates varied from 22.5% in 1998 to 91.2% in 2004. This model was found to be feasible and successful in our community, and can be implemented in other low- and middle-income countries.