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Burn care continues to improve and larger total body surface area (TBSA) burn survival is increasing. These survivors require more extensive care than smaller burns and are at higher risk for wound/scar-related complications. Prior work has shown low rates of follow-up for burn survivors linked to socioeconomic factors such as housing insecurity and substance use. There are limited studies that evaluate socioeconomic factors that contribute to follow-up and reconstructive surgery rates in massively burned patients. Patients who survived to discharge with >50% TBSA burns and planned return to the treating institution were included in the study. Univariate and multivariate analyses were performed on the data collected. Sixty-five patients were included with an average TBSA of 63.1%. Fifty-three patients (81.5%) attended at least one follow-up appointment with median of 4 follow-up appointments. Younger patients (33 ± 9 vs 44 ± 11; P = .0006), patients with larger TBSA burns (65 ± 13 vs 55 ± 5%; P = .02), those with private insurance, and those without housing insecurity (1.8% vs 45.4%; P = .003) were more likely to follow up. On multivariate regression analysis, patients with housing insecurity were independently associated with lack of follow-up (OR: 0.009; CI: 0.00001-0.57). Thirty-five patients had at least one reconstructive surgery and 31 patients had reconstructive surgery after discharge. No patients with housing insecurity underwent reconstructive surgery. Follow-up rates in massive burns were higher than reported for smaller TBSA burns and more than half received reconstructive surgery. Housing-insecure patients should be targeted for improved follow-up and access to reconstructive surgery., (Published by Oxford University Press on behalf of the American Burn Association 2024.)

Previous iterations of burn severity (mild, moderate, and severe) were not data-driven and were outdated. Clustering analyses have gained popularity for identifying homogenous subgroups from heterogeneous medical conditions, such as asthma, sepsis, and lung disease. There is no consensus in burn literature regarding what constitutes massive burns. The current classification includes a 20% total body surface area (TBSA) burn and a 95% TBSA burn as severe. Latent class and hierarchical clustering analyses were applied to the American Burn Association National Burn Research Dataset. Cluster variables included length of stay, length of stay, intensive care unit length of, number and type of procedures, and number and type of complications. Non-clustering variables were evaluated after clustering, including burned TBSA, inhalation injury, mortality, discharge disposition, age, sex, and race. Latent class analysis suggested three clusters. Hierarchical clustering analysis was applied to the most severe latent class, creating four total burn severity groups. In total, 112,297 patients were included in the final analysis. The mean TBSA burned for each class is 4.26±4.91 for minor, 8.07±8.39 for moderate, 22.76±17.31 for severe and 36.72±21.61 for massive. The age and sex proportions were similar among all clusters. The clustering variables steadily increased for each severity cluster. Mortality was the highest in the massive cluster (18.2%). Data informed categories of burn severity were formed using clustering analyses, which will be helpful for triage, data-benchmarking, and class-specific research., (Published by Oxford University Press on behalf of the American Burn Association 2024. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Physical, social, and psychological outcomes have been identified as relevant to the rehabilitation process of children with burn injuries. Existing legacy measures are limited in item content and only cover a few constructs. Condition-specific outcomes are highly relevant to gauge early growth and development. Computerized adaptive tests (CATs) leveraging advanced psychometric technologies minimize respondent burden. This project developed PS-LIBRE1-5 Profile CAT (Preschool Life Impact Burn Recovery Evaluation) to measure relevant postburn outcomes in children aged one to five. Responses to the field-tested PS-LIBRE1-5 Profile (188 items) were measured on a scale of frequency or ability. Scores were coded from 0 to 4 where higher scores reflected better functioning. Factor analysis identified the items retained in the final item bank of each scale. CAT simulations were conducted to estimate the mean score of each scale. The simulated CAT score and full item bank scores were compared based upon the score range, ceiling and floor effects, and marginal reliabilities. The child mean age was 3.0 ± 1.5 years (n = 500). Average burn size and time since burn injury were 4.2% TBSA and 1.1 years, respectively. Psychometric analysis resulted in eight scales: Physical, Communication and Language, Emotional Wellbeing, Mood, Anxiety, Peer Acceptance, Play, and Peer Relations. Ceiling effects were acceptable at <13% for all scales. Marginal reliabilities of the CATs were credible. The PS-LIBRE1-5 Profile CAT contains 111 items, and is a comprehensive measure that captures physical, communication and language, psychological, and social functioning of preschool burn survivors., (© The Author(s) 2023. Published by Oxford University Press on behalf of the American Burn Association. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Intensive care for massively burn patients has increased survival and highlights the need for a solution to the problem of insufficient donor sites for autologous skin coverage. In this case series, we present 10 patients with average burn size of 81% TBSA and mean age of 24 years old, who underwent burn excision followed by either immediate or delayed biodegradable temporizing matrix (BTM) placement. After an integration period, the BTM was delaminated either the day before or immediately prior to placement of cultured epithelial autografts over a widely meshed (4:1 or 6:1) split thickness skin graft. One patient had cultured epithelial autografts alone, without split thickness skin graft, placed on integrated BTM and had successful take. Seven patients survived to discharge and had average 95% wound closure at 135 ± 35 days. The patients had on average 10.4 total operations and 8.7 excision and grafting operations. Five patients had complications related to the BTM requiring removal or replacement including three fungal infections, one bacterial infection and one with bleeding and a large clot burden. In conclusion, this surgical strategy is a viable option for patients with massive burns and insufficient donor for autologous skin grafting., (© The Author(s) 2023. Published by Oxford University Press on behalf of the American Burn Association. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: The Surviving Sepsis Campaign was developed to improve outcomes for all patients with sepsis. Despite sepsis being the primary cause of death after thermal injury, burns have always been excluded from the Surviving Sepsis efforts. To improve sepsis outcomes in burn patients, an international group of burn experts developed the Surviving Sepsis After Burn Campaign (SSABC) as a testable guideline to improve burn sepsis outcomes., Methods: The International Society for Burn Injuries (ISBI) reached out to regional or national burn organizations to recommend members to participate in the program. Two members of the ISBI developed specific "patient/population, intervention, comparison and outcome" (PICO) questions that paralleled the 2021 Surviving Sepsis Campaign [1]. SSABC participants were asked to search the current literature and rate its quality for each topic. At the Congress of the ISBI, in Guadalajara, Mexico, August 28, 2022, a majority of the participants met to create "statements" based on the literature. The "summary statements" were then sent to all members for comment with the hope of developing an 80% consensus. After four reviews, a consensus statement for each topic was created or "no consensus" was reported., Results: The committee developed sixty statements within fourteen topics that provide guidance for the early treatment of sepsis in burn patients. These statements should be used to improve the care of sepsis in burn patients. The statements should not be considered as "static" comments but should rather be used as guidelines for future testing of the best treatments for sepsis in burn patients. They should be updated on a regular basis., Conclusion: Members of the burn community from the around the world have developed the Surviving Sepsis After Burn Campaign guidelines with the goal of improving the outcome of sepsis in burn patients., Competing Interests: Declaration of Competing Interest Kevin Chung is Chief Medical Officer for SeaStar Medical, Denver, Colorado. No other author has declared a conflict of interest related to the publication., (Copyright © 2023 Elsevier Ltd and International Society of Burns Injuries. All rights reserved.)

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., (Published by Oxford University Press on behalf of the American Burn Association 2022.)

The purpose of this study was to determine the relationship between frailty and poverty in burn patients ≥50 years old, and their association with patient outcomes. This was a single-center retrospective chart review from 2009 to 2018 of patients ≥50 years old admitted with acute burn injuries. Frailty was assigned using the Canadian Study of Health and Aging Clinical Frailty Scale. Poverty was defined as a patient from a zip code that had >20% of people living in poverty. The relationship between frailty and poverty, as well as each variable independently on mortality, length of stay (LOS), and disposition location, was examined. Of 953 patients, the median age was 61 years, 70.8% were male, and the median total body surface area burn was 6.6%. Upon admission, 26.4% and 35.2% of patients were frail and from impoverished neighborhoods, respectively. The mortality rate was 8.8%. Univariate analysis demonstrated that nonsurvivors had significantly higher chances of living in poverty (P = .02) and were more likely to be frail compared to survivors. There was no significant correlation between poverty and frailty (P = .08). Multivariate logistic regression confirmed the relationship between lack of poverty and mortality (OR .47, 95% CI 0.25-0.89) and frailty and mortality (OR 1.62, 95% CI 1.24-2.12). Neither poverty (P = .26) nor frailty (P = .52) was associated with LOS. Both poverty and frailty were associated with a patient's discharge location (P = .03; P < .0001). Poverty and frailty each independently predict mortality and discharge destination in burn patients ≥50, but they are not associated with LOS nor each other., (© The Author(s) 2023. Published by Oxford University Press on behalf of the American Burn Association. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Advances in the care of burn-injured pediatric patients have improved mortality over the last 20 years. However, massive burn injuries (50% TBSA or greater) in pediatric patients, while overall rare, have a significant morbidity and mortality. The primary aim for this study is to analyze treatment and outcomes in massive pediatric burn injuries. A retrospective study of children with burn injuries 50% TBSA or greater who were admitted to Shriners Hospital for Children Northern California, from May 1, 2009 to May 22, 2020, was conducted. Data were collected from the electronic health records through a comprehensive chart review that included: patient demographics, past medical history, treatment interventions, and outcomes. This study included 69 patients (59.4% male) with a mean age of 8.7 ± 6 years. The median time from injury to admission was 2 (1-4) days. In this study, 63.8% of patients were from Mexico, 34.8% were from the United States, and 1% patient was from American Samoa. The median time from injury to admission was 2 (1-4) days. Mean TBSA was 66% ± 12%. The median TBSA of second-degree burns was 0 (0-6) %, and the mean TBSA of third-degree burns was 60% ± 16%. Forty percent of patients suffered an inhalation injury and 83% of patients received a tracheostomy. The median number of days requiring ventilator assistance was 26 (12-58) days. Mean length of hospitalization was 90 ± 60 days, with 61 ± 41 days spent in the intensive care unit. The mean number of surgical procedures was 6 ± 4. The time between surgical procedures was 12 ± 6 days. The median time from admission to the first surgical procedure was 1 (0-2) day. At the first procedure, a mean of 42% ± 15% TBSA of the burn injury was excised. Sixty-two percent of patients received autografting (22% ± 11% TBSA) and 52% of patients received allografting (27% ± 17% TBSA) during the first procedure. For survivors, the median number of inpatient occupational therapy encounters was 143.5 (83-215) and inpatient physical therapy encounters was 139.5 (81-215). Twenty-five percent of the patients included in this study died as a result of their burn injury. Multivariate regression revealed that sustaining an inhalation injury was a significant and independent predictor of death (odds ratio: 3.4, 95% confidence interval: 1.05 to 11, P = .04). Massive burn injuries in children required a very high number of surgical procedures and hospital resources. Most children who died as a result of their massive burn injury died within the first month of admission. Inhalation independently increases the risk of dying in pediatric patients with a massive burn injury., (© The Author(s) 2021. Published by Oxford University Press on behalf of the American Burn Association. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Burn injuries are a leading cause of morbidity that can result in devastating disability and poor quality of life for survivors. This systematic review aimed to synthesise evidence regarding the effect of 20 minutes of cool running water (CRW) within three hours of injury on outcomes of patients with thermal burn injuries., Methods: This systematic review was conducted in reference to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Multiple databases (PubMed, EMBASE, CENTRAL, CINAHL Complete via EBSCO, PROQUEST Dissertations and Theses), and the Australia New Zealand Clinical Trial Registry were searched for eligible studies published in English and Chinese, without date restriction. Meta-analyses were undertaken Methodological quality of studies was assessed by using Downs and Black Checklist., Results: Of 323 records, seven studies were included. The majority (67%) of studies were conducted in Australia and New Zealand. The methodological quality was ranked between 'fair' and 'good'. Twenty minutes of CRW within the first three hours of burn injury significantly decreased the odds of patients requiring skin grafting and surgical intervention for wound management., Conclusions: There is considerable evidence suggesting the application of 20 min of CRW within the first three hours of injury improves outcomes for patients with burn injury. Consensus between burn organisations and collaborative efforts to translate evidence into practice are needed to optimise burn first aid care which can improve patient outcomes globally., Competing Interests: Conflict of interest We have no conflicts of interest to declare., (Copyright © 2022. Published by Elsevier Ltd.)

The increase life expectancy led to an expected increase in skin cancer incidence in older patients. Their treatment can require a complex decision-making process. Limited data are available on characteristics, management and outcome of skin tumours in nonagenarian and centenarian patients. The aim of our study was to describe epidemiology, clinical-pathological features and treatment strategies of skin cancers in a cohort of patients aged ≧95 years. A total of 116 patients ≧95 years of age presented for the evaluation of 225 skin lesions (mean of 1.94 lesions per patient). The mean age was 97.4 years, 57.8% were women. Most patients had an ECOG score of 3 (49.3%) or 4 (32%). Lesions were mainly located on the head and neck area (74.2%), upper (7.1%) and lower (6,2%) limbs. The majority of patients presented with non-melanoma skin cancers (183/225; 81.3%), 25/225 (11.1%) had actinic keratosis, 5 (2.2%) melanoma and 2 (0.9%) atypical fibroxanthoma. Forty-eight lesions (21.3%) were treated with surgery, 58 (25.8%) with radiotherapy. The management of 73 lesion (32.4%) was discussed at the multidisciplinary tumour board meeting. One patient died for the progression of a squamous cell carcinoma; 74 patients died for causes unrelated to skin tumours, 36 are still alive after a mean follow-up of 27.27 months. This cohort study confirms that age is not per se a contraindication for treatment of skin cancers in elderly patients. Our results support the importance of a patient-centred care approach that should take into consideration patient's preferences, comorbidities, compliance and possible adverse events., (© 2022 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background: Cooling thermal burns with running water is a recommended first aid intervention. However, guidance on the ideal duration of cooling remains controversial and inconsistent across organisations., Aim: To perform a systematic review of the evidence for the question; Among adults and children with thermal burn, does active cooling using running water as an immediate first aid intervention for 20 min or more, compared with active cooling using running water for any other duration, change the outcomes of burn size, burn depth, pain, adverse outcome (hypothermia) or complications?, Method: We searched Medline, Embase, Cochrane Database of Systematic Reviews and used ROBINS-I to assess for risk of bias. We used Grading of Recommendations, Assessment, Development and Evaluation methodology for determining the certainty of evidence. We included all studies that compared the selected outcomes of the duration of cooling of thermal burns with water in all patient ages. (PROSPERO registration number: CRD42021180665). From 560 screened references, we included four observational studies. In these studies, 48% of burns were cooled for 20 min or more. We found no benefit for a duration of 20 min or more of cooling when compared with less than 20 min of cooling for the outcomes of size and depth of burn, re-epithelialization, or skin grafting. The evidence is of very low certainty owing to limitations in study design, risk of bias and indirectness., Conclusion: The optimal duration of cooling for thermal burns remains unknown and future prospective research is indicated to better define this treatment recommendation., Competing Interests: Declaration of Competing Interest The authors and members of the Task Force collaborating or acknowledged have no conflicts of interest relevant to this article to disclose., (Copyright © 2021 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: It is unknown whether lung-protective ventilation is applied in burn patients and whether they benefit from it. This study aimed to determine ventilation practices in burn intensive care units (ICUs) and investigate the association between lung-protective ventilation and the number of ventilator-free days and alive at day 28 (VFD-28)., Methods: This is an international prospective observational cohort study including adult burn patients requiring mechanical ventilation. Low tidal volume ( V T ) was defined as V T  ≤ 8 mL/kg predicted body weight (PBW). Levels of positive end-expiratory pressure (PEEP) and maximum airway pressures were collected. The association between V T and VFD-28 was analyzed using a competing risk model. Ventilation settings were presented for all patients, focusing on the first day of ventilation. We also compared ventilation settings between patients with and without inhalation trauma., Results: A total of 160 patients from 28 ICUs in 16 countries were included. Low V T was used in 74% of patients, median V T size was 7.3 [interquartile range (IQR) 6.2-8.3] mL/kg PBW and did not differ between patients with and without inhalation trauma ( p  = 0.58). Median VFD-28 was 17 (IQR 0-26), without a difference between ventilation with low or high V T ( p  = 0.98). All patients were ventilated with PEEP levels ≥5 cmH 2 O; 80% of patients had maximum airway pressures <30 cmH 2 O., Conclusion: In this international cohort study we found that lung-protective ventilation is used in the majority of burn patients, irrespective of the presence of inhalation trauma. Use of low V T was not associated with a reduction in VFD-28., Trial Registration: Clinicaltrials.gov NCT02312869. Date of registration: 9 December 2014., (© The Author(s) 2021. Published by Oxford University Press.)

Elderly suffer worse outcomes from burns; thus, it is important to identify the causes of burns in the elderly to develop burn prevention campaigns. We performed a 10-year review of burns that were registered in the NEISS database. We included patients at least 65 years old and analyzed the top five products that caused burn injury. In adults 65 to 74 years old, hot water was the most common cause of burns. Women suffered more burns by candles and cookware. Heaters/heating systems and gasoline were among the top five causes of burns in only men. For the age group 75 to 84 years old, the most common burn was from hot water in women and gasoline in men. For women, the top five included candles, nightwear, and cookware. Only men suffered gasoline burns. The majority of daywear, home/room fire, and ranges/ovens caused burns occurred in men. The majority of burns from hot water, ranges/ovens, electric heating pads, and bathtubs/showers occurred in women. For men, burns from gasoline, structural fires, and heaters are more prevalent. This data can be used to develop age- and gender-specific prevention campaigns to reduce the risk of burn injury., (© The Author(s) 2020. Published by Oxford University Press on behalf of the American Burn Association. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Vitamin D synthesis by exposure of skin to solar ultraviolet radiation (UVR) provides the majority of this hormone that is essential for bone development and maintenance but may be important for many other health outcomes. This process, which is the only well-established benefit of solar UVR exposure, depends on many factors including genetics, age, health, and behavior. However, the most important factor is the quantity and quality of UVR reaching the skin. Vitamin D synthesis specifically requires ultraviolet B (UVB) radiation that is the minority component (<5%) of solar UVR. This waveband is also the most important for the adverse effects of solar exposure. The most obvious of which is sunburn (erythema), but UVB is also the main cause of DNA damage to the skin that is a prerequisite for most skin cancers. UVB at the Earth's surface depends on many physical and temporal factors such as latitude, altitude, season, and weather. Personal, cultural, and behavioral factors are also important. These include skin melanin, clothing, body surface area exposed, holiday habits, and sunscreen use. There is considerable disagreement in the literature about the role of some of these factors, possibly because some studies have been done by researchers with little understanding of photobiology. It can be argued that vitamin D supplementation obviates the need for solar exposure, but many studies have shown little benefit from this approach for a wide range of health outcomes. There is also increasing evidence that such exposure offers health benefits independently of vitamin D: the most important of which is blood-pressure reduction. In any case, public health advice must optimize risk versus benefit for solar exposure. It is fortunate that the individual UVB doses necessary for maintaining optimal vitamin D status are lower than those for sunburn, irrespective of skin melanin. © 2020 The Authors. JBMR Plus published by Wiley Periodicals LLC. on behalf of American Society for Bone and Mineral Research., (© 2020 The Authors. JBMR Plus published by Wiley Periodicals LLC. on behalf of American Society for Bone and Mineral Research.)

Elucidating the carrier density at which strongly bound excitons dissociate into a plasma of uncorrelated electron-hole pairs is a central topic in the many-body physics of semiconductors. However, there is a lack of information on the high-density response of excitons absorbing in the near-to-mid ultraviolet, due to the absence of suitable experimental probes in this elusive spectral range. Here, we present a unique combination of many-body perturbation theory and state-of-the-art ultrafast broadband ultraviolet spectroscopy to unveil the interplay between the ultraviolet-absorbing two-dimensional excitons of anatase TiO&#95;{2} and a sea of electron-hole pairs. We discover that the critical density for the exciton Mott transition in this material is the highest ever reported in semiconductors. These results deepen our knowledge of the exciton Mott transition and pave the route toward the investigation of the exciton phase diagram in a variety of wide-gap insulators.

As many as one third of patients undergoing minimally invasive thoracic surgery and one half undergoing thoracotomy will have chronic pain, defined as pain lasting 2 to 3 months. There is limited information regarding predictors of chronic pain and even less is known about its impact on health-related quality of life, known as pain interference. Currently, there is a focus on decreased opioid prescribing after surgery. Interestingly, thoracic surgical patients are the least likely to be receiving opioids before surgery and have the highest rate of new persistent opioid use after surgery compared with other surgical cohorts. These studies of opioid use have identified important predictors of new persistent opioid use, but their findings are limited by failing to correlate opioid use with pain. The objectives of this invited review are to present the findings of pertinent studies of chronic pain and opioid use after thoracic surgery, "where we are," and to discuss gaps in our knowledge of these topics and opportunities for research to fill those gaps, "where we need to go.", (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

In a seminal paper, Mahan predicted that excitonic bound states can still exist in a semiconductor at electron-hole densities above the insulator-to-metal Mott transition. However, no clear evidence for this exotic quasiparticle, dubbed Mahan exciton, exists to date at room temperature. In this work, we combine ultrafast broadband optical spectroscopy and advanced many-body calculations to reveal that organic-inorganic lead-bromide perovskites host Mahan excitons at room temperature. Persistence of the Wannier exciton peak and the enhancement of the above-bandgap absorption are observed at all achievable photoexcitation densities, well above the Mott density. This is supported by the solution of the semiconductor Bloch equations, which confirms that no sharp transition between the insulating and conductive phase occurs. Our results demonstrate the robustness of the bound states in a regime where exciton dissociation is otherwise expected, and offer promising perspectives in fundamental physics and in room-temperature applications involving high densities of charge carriers.

Controlling the excitonic optical properties of room temperature semiconductors using time-dependent perturbations is key to future optoelectronic applications. The optical Stark effect in bulk and low-dimensional materials has recently shown exciton shifts below 20 meV. Here, we demonstrate dynamical tuning of the exciton properties by photoinduced coherent acoustic phonons in the cheap and abundant wide-gap semiconductor anatase titanium dioxide (TiO 2 ) in single crystalline form. The giant coupling between the excitons and the photoinduced strain pulses yields a room temperature exciton shift of 30 to 50 meV and a marked modulation of its oscillator strength. An advanced ab initio treatment of the exciton-phonon interaction fully accounts for these results, and shows that the deformation potential coupling underlies the generation and detection of the giant acoustic phonon modulations., (Copyright © 2019 The Authors, some rights reserved; exclusive licensee American Association for the Advancement of Science. No claim to original U.S. Government Works. Distributed under a Creative Commons Attribution NonCommercial License 4.0 (CC BY-NC).)

This is a recommended management algorithm from the Western Trauma Association addressing the management of victims of burn injury. Because there is a paucity of published prospective randomized clinical trials that have generated Class I data, these recommendations are based primarily on published retrospective studies, clinical guidelines, and the expert opinion of members of the Western Trauma Association in conjunction with partner members of the American Burn Association. The algorithm and accompanying comments represent one safe and sensible approach that can be followed at most trauma centers. We recognize that there may be patient or institutional factors that warrant deviation from the published algorithm. We would encourage institutions to use this document as a starting point toward a dialog with local burn centers to collaboratively create a patient-centered care experience for the victims of minor burn injuries arriving at local trauma centers.

IN BRIEF Treatment of lower-extremity burn injuries in adults with diabetes can be complex, and some diabetes-related factors can lead to impaired healing of such wounds, putting patients at risk of amputation. In this retrospective review of adult patients with lower-extremity burns, patients with pre-injury neuropathy and higher A1C levels were more likely to require amputations after their burn injury. The authors conclude that lower-extremity burn injuries in patients with diabetes require close follow-up and possibly referral to a burn specialist for interventions and treatment strategies to offset more serious complications., (© 2019 by the American Diabetes Association.)

Objective: Elderly burn patients vary in physiologic age and frailty. While previous evidence suggests that frailty on admission is associated with poor outcomes, changes in frailty during hospitalization for a burn injury have not been reported., Methods: We performed a two-year retrospective review of all elderly (≥65years) burn-patients admitted to our burn center. Patients who died during admission were excluded. Data collected include: demographics, injury characteristics, outcomes, and discharge disposition. Canadian Study on Health and Aging Clinical Frailty Scores (CFS) were calculated on admission and at discharge. Change in frailty was calculated for each patient. Mean values are represented as mean±standard deviation, median values are represented as median (IQR)., Results: Seventy-nine patients, mean age of 75±8years, with a mean admission CFS was 4.3±1.2 and discharge CFS was 5.1±1.2 were included in the study. The mean change in CFS was -0.55±0.93. Forty-six patients (59%) had no change or an improvement in frailty during hospitalization while 32 (41%) had worsened CFS at discharge. Patients whose CFS was worse at discharge had larger burns (12.8±10.7% vs. 6.28±5.7%), lower admission CFS (3.88±1.5 vs. 4.93±1.0), and longer ICU stays (15.6±18.9 vs. 7.64± 10.6 days) than patients without change in CFS. On multivariate regression analysis TBSA (OR 1.2 (1.07-1.3)) and admission CFS of 1-4 (OR 7.9 (2.2-28)) were significant predictors of worsened CFS at discharge., Conclusions: In our study population, patients with low admission frailty scores are at greatest risk for worsened frailty at discharge and should be targeted for the development of future frailty prevention programs., (Copyright © 2018 Elsevier Ltd and ISBI. All rights reserved.)

Introduction: Following a severe burn injury, significant hematologic changes occur that are reflected in complete blood count (CBC) measurements. Our aim for this study was to examine trend in the components of the CBC in severely burned patients over the first week after injury and compare differences in CBC components between survivors and non-survivors., Methods: A 5-year retrospective review was performed of adult (≥18years) burn patients with a TBSA≥15%. Age, TBSA, gender, mortality, length of hospital stay, ventilator days, and CBC were collected., Results: Over the first week after injury, HBG and HCT decreased. This decrease was due to loss of red blood cells. WBC counts was initially elevated but decreased over the first 4days. PLT also decreased over the first 4days. Non-survivors had lower HBG, HCT, RCC, and PLT over the first week compared to survivors. Non-survivors had higher WBC compared to survivors. RDW was elevated during the first week in non-survivors. MPV was elevated at the end of the first week in non-survivors and MPV on day 7 was independently associated with mortality (O.R. 2.01 (1.1-3.7)). Compared to survivors non-survivors received more transfusions of blood products during the first week after injury., Conclusion: Burn-injury specific trends in CBC measurements can be used as references to determine expected clinical course of burn patients. Non-survivors have early hematologic differences compared to survivors., (Copyright © 2018 Elsevier Ltd and ISBI. All rights reserved.)

The Network of Cancer Genes (NCG) is a manually curated repository of 2372 genes whose somatic modifications have known or predicted cancer driver roles. These genes were collected from 275 publications, including two sources of known cancer genes and 273 cancer sequencing screens of more than 100 cancer types from 34,905 cancer donors and multiple primary sites. This represents a more than 1.5-fold content increase compared to the previous version. NCG also annotates properties of cancer genes, such as duplicability, evolutionary origin, RNA and protein expression, miRNA and protein interactions, and protein function and essentiality. NCG is accessible at http://ncg.kcl.ac.uk/ .

There is a clinical trend toward "early mobilization" of patients with burn injury, however mobility is not well defined in burn care. Burn injuries result in various extents of injury, body areas affected, and types of skin graft surgeries needed-all of which may influence the type, timing, safety, and outcome of mobilization activities. This study surveyed burn clinicians to determine current mobility practices and the influence of skin graft surgery on clinical decisions to mobilize patients. A 32-question survey was electronically distributed to burn clinicians and included questions about postoperative range of motion (ROM) and out of bed (OOB) mobility practices for various skin graft types and locations. For all types of grafts on all body locations, the average time after skin graft surgery that patients resumed ROM activities was postoperative day (POD) 3.87 (±2.04) while OOB mobility resumed on POD 2.54 (±1.38). There was significantly greater variability for OOB mobility compared to ROM (coefficient of variation [CV] 0.71 ± 0.8 vs 0.5 ± 0.05). Time to postoperative ROM was significantly different depending on the type of skin graft placed with sheet skin grafts resuming ROM the earliest. Time to OOB mobility after surgery was significantly different for different body locations with grafts placed above the waist resuming OOB mobility earliest. This study provides a summary of current mobility practices and serves as a foundation for future studies investigating the optimal timing and practical application of mobility protocols that may influence safety and outcome of burn survivors.

High dose ascorbic acid (HDAA) has been touted to ameliorate inflammation and reduce fluid requirements during burn shock resuscitation (BSR). Whether this leads to improved outcomes is not known. The authors' aim for this study was to compare ventilator days, ventilator-associated pneumonia, and mortality between patients who did and did not receive HDAA during BSR.The authors performed a retrospective case control study from 2012 to 2015. They identified 38 patients (HDAA) who received HDAA during BSR. Using age and %TBSA, the authors identified and matched 42 control patients (CTL) who did not receive HDAA for BSR during that same time period. The authors collected data for age, %TBSA, hospital days (LOS), ventilator days (VENT), inhalation injury (INH), ventilator-associated pneumonia (VAP), and mortality (MORT).There were no differences in age and %TBSA or %TBSA of third-degree burn injury between groups. There was no significant difference in the incidence of INH (HDAA-52% vs CTL-36%, P = .17) and the groups had similar LOS and VENT. Additionally, there was no significant difference in VAP incidence (HDAA-29% vs CTL-14%, P = .13) or mortality (HDAA-26% vs CTL-23%, P = .8). HDAA patients had a numerically higher incidence of acute renal failure requiring dialysis (23 vs 7%, P = .06) which was confirmed in a multivariate analysis (odds ratio 5.4; 95% confidence interval 1.1-26). HDAA, while potentially reducing inflammation and fluid requirements during BSR, may not improve any meaningful outcomes such as ventilator requirements, ventilator-associated pneumonia, and mortality.

The way nuclear motion affects electronic responses has become a very hot topic in materials science. Coherent acoustic phonons can dynamically modify optical, magnetic, and mechanical properties at ultrasonic frequencies, with promising applications as sensors and transducers. Here, by means of ultrafast broadband deep-ultraviolet spectroscopy, we demonstrate that coherent acoustic phonons confined in anatase TiO 2 nanoparticles can selectively modulate the oscillator strength of the two-dimensional bound excitons supported by the material. We use many-body perturbation-theory calculations to reveal that the deformation potential is the mechanism behind the generation of the observed coherent acoustic wavepackets. Our results offer a route to manipulate and dynamically tune the properties of excitons in the deep-ultraviolet at room temperature.

Long-term functional outcomes in young adults with facial burns remain poorly studied. This 5-year (2003-2008) prospective multicenter study includes burn survivors (age 19-30 years) who completed the Young Adult Burn Outcome Questionnaire (YABOQ) from 0 to 36 months after baseline survey administration. A composite canonical score was developed from 15 YABOQ domains using discriminant analysis, maximizing the difference at the baseline between burn-injured patients with face involved and not involved. A generalized linear model with the generalized estimation equation technique was used to track the changing pattern of the composite score over time. Individual domain scores with high correlation to the canonical score were used to evaluate recovery patterns in facial burns. A total of 153 burned (31% with face burns) and 112 nonburned subjects completed 620 questionnaires. Canonical analysis showed that early postburn, facial burns were associated with a difference in outcome, but this overall difference diminished over time. Regression analysis showed that for survivors with facial injury, Emotion and Sexual Function scores were persistently lower (worse), while Religion scores were persistently higher. Satisfaction with Role was initially better than the nonface burned group, but over time got worse, while Perceived Appearance was initially worse in the face burned group but this difference diminished over time. Social Function Limited by Appearance was initially similar between the groups, but over time the group with face burns scored lower. The overall difference in recovery between survivors with and without facial burns diminished over time while the individual domains had various patterns of recovery.

Background: There has been little systematic examination of variation in pediatric burn care clinical practices and its effect on outcomes. As a first step, current clinical care processes need to be operationally defined. The highly specialized burn care units of the Shriners Hospitals for Children system present an opportunity to describe the processes of care. The aim of this study was to develop a set of process-based measures for pediatric burn care and examine adherence to them by providers in a cohort of pediatric burn patients., Methods: We conducted a systematic literature review to compile a set of process-based indicators. These measures were refined by an expert panel of burn care providers, yielding 36 process-based indicators in four clinical areas: initial evaluation and resuscitation, acute excisional surgery and critical care, psychosocial and pain control, and reconstruction and aftercare. We assessed variability in adherence to the indicators in a cohort of 1,076 children with burns at four regional pediatric burn programs in the Shriners Hospital system. The percentages of the cohort at each of the four sites were as follows: Boston, 20.8%; Cincinnati, 21.1%; Galveston, 36.0%; and Sacramento, 22.1%. The cohort included children who received care between 2006 and 2010., Results: Adherence to the process indicators varied both across sites and by clinical area. Adherence was lowest for the clinical areas of acute excisional surgery and critical care, with a range of 35% to 48% across sites, followed by initial evaluation and resuscitation (range, 34%-60%). In contrast, the clinical areas of psychosocial and pain control and reconstruction and aftercare had relatively high adherence across sites, with ranges of 62% to 93% and 71% to 87%, respectively. Of the 36 process indicators, 89% differed significantly in adherence between clinical sites (p < 0.05). Acute excisional surgery and critical care exhibited the most variability., Conclusion: The development of this set of process-based measures represents an important step in the assessment of clinical practice in pediatric burn care. Substantial variation was observed in practices of pediatric burn care. However, further research is needed to link these process-based measures to clinical outcomes., Level of Evidence: Therapeutic/care management, level IV.

Ultrafast interfacial electron transfer in sensitized solar cells has mostly been probed by visible-to-terahertz radiation, which is sensitive to the free carriers in the conduction band of the semiconductor substrate. Here, we demonstrate the use of deep-ultraviolet continuum pulses to probe the interfacial electron transfer, by detecting a specific excitonic transition in both N719-sensitized anatase TiO 2 and wurtzite ZnO nanoparticles. Our results are compared to those obtained on bare nanoparticles upon above-gap excitation. We show that the signal upon electron injection from the N719 dye into TiO 2 is dominated by long-range Coulomb screening of the final states of the excitonic transitions, whereas in sensitized ZnO it is dominated by phase-space filling. The present approach offers a possible route to detecting interfacial electron transfer in a broad class of systems, including other transition metal oxides or sensitizers.

We describe the facilities for ultraviolet studies in the femtosecond to nanosecond time domain. These facilities consist of: i) a set-up for deep-ultraviolet spectroscopy in the 260-380 nm range in both pump and probe pulses for transient absorption/reflectivity or two-dimensional spectroscopy studies; ii) a set-up for ultrafast fluorescence measurements with detection down to 300 nm. The capabilities of these set-ups are demonstrated by examples on molecular systems, biosystems, nanoparticles and solid materials.

Cutaneous functional units (CFUs) are fields of skin that functionally contribute to range of motion (ROM) at an associated joint. When replaced with scar tissue, the skin is less extensible and may result in loss of movement at the joint. Consideration of the amount of CFU affected by burn injury is increasingly being used to predict the development of burn scar contracture (BSC) in burn survivors. Previous work established that, in adults, burn rehabilitation time per CFU was the greatest predictor of preventing BSC. Our study aimed to examine the direct relationship between percent involvement of CFU and ROM achieved in children with BSC who received 6 months of rehabilitation therapy services. ROM was measured at baseline and throughout the study period using traditional methods of goniometry as well as three-dimensional motion capture during the performance of functional tasks. Burn extent and distribution were mapped using an electronic diagram to calculate the percentage of CFU affected by scarring or skin grafts. Pearson's correlations and multivariate linear regression analyses were performed to determine associations between variables. Results showed that percent CFU involvement was negatively correlated with maximal goniometric and functional shoulder ROM achieved. That is, the amount of a given CFU scarred was predictive of less ROM achieved in the associated area. Percentage of CFU involved did not significantly correlate with baseline shoulder ROM, suggesting that other factors may be associated with initial limitations in ROM. Evaluation of the percentage of CFU scarred is useful for predicting shoulder ROM recovery with rehabilitation and may be used to help guide clinical decision making and allocation of time and resource for therapy services.

Restorative sleep is an important component of quality of life. Disturbances in sleep after burn injury were reported but all based on uncontrolled or nonstandardized data. The occurrence and the effect of long-term sleep problems in young adult burn survivors have not been well defined. This 5-year (2003-2008) prospective multicenter longitudinal study included adults with burn injuries ages 19 to 30 years who completed the Young Adult Burn Outcome Questionnaire (YABOQ) up to 36 months after injury. The items measured 15 patient-reported outcomes including physical, psychological, and social statuses and symptoms such as itch and pain. Scores of these 15 YABOQ outcome domains were standardized to a mean of 50 and a SD of 10 based on an age-matched nonburned reference group of young adults. Sleep quality was assessed using the item 'How satisfied are you now with your sleep,' rated by a 5-point Likert scale. Patients responding with very and somewhat dissatisfied were classified as having sleep dissatisfaction and the remaining as less or not dissatisfied. The associations between sleep dissatisfaction (yes/no) and YABOQ outcome domains were analyzed longitudinally using mixed-effect generalized linear models, adjusted for %TBSA burned, age, gender, and race. Generalized estimating equations were used to take into account correlated error resulting from repeated surveys on each patient over time. One hundred and fifty-two burn survivors participated in the YABOQ survey at baseline and during the follow-up who had at least one survey with a response to the sleep item. Among them, sleep dissatisfaction was twice as prevalent (76/152, 50%) when compared with the nonburned reference group (29/112, 26%). The likelihood of a burn survivor being dissatisfied with sleep was reduced over time after the burn injury. Sleep dissatisfaction following burns was significantly associated, in a dose-dependent manner, with increasing burn size (P = .001). Better sleep was associated with better outcomes in all domains (P < .05) except Fine Motor Function, and this association was significantly more apparent in the longer term compared with the shorter term with the same domains (P < .05). Dissatisfaction with sleep is highly prevalent following burn injuries in young adults. Lower satisfaction with sleep is associated with poorer scores in nearly all quality of life measures. Satisfaction with sleep should be addressed during the long-term clinical follow-up of young adults with burn injuries. Further research should be undertaken to understand the components of sleep quality that are important to burn survivors and which ones might be modified and tested in future intervention studies.

Importance: Patient-reported outcomes serving as benchmarks for recovery of pediatric burn survivors are lacking, and new approaches using longitudinal cohorts for monitoring their expected recovery based on statistical models are needed for patient management during the early years following the burn., Objective: To describe multidimensional patient-reported outcomes among pediatric burn survivors younger than 5 years to establish benchmarks using recovery curve methods., Design, Setting, and Participants: Prospective cohort study of pediatric burn survivors younger than 5 years at 12 burn centers. Age-matched nonburned reference groups were studied to define expected results in normal growth and development. The Burn Outcomes Questionnaire for children aged 0 to 5 years (BOQ0-5) was administered to parents of children who had burns and were younger than 5 years. Mixed models were used to generate 48-month recovery curves for each of the 10 BOQ0-5 domains. The study was conducted between January 1999 and December 2008., Main Outcomes and Measures: The 10 BOQ0-5 domains including play, language, fine motor skills, gross motor skills, emotional behavior, family functioning, pain/itching, appearance, satisfaction with care, and worry/concern up to 48 months after burn injury., Results: A total of 336 pediatric burn survivors younger than 5 years (mean [SD] age, 2.0 [1.2] years; 58.4% male; 60.2% white, 18.6% black, and 12.0% Hispanic) and 285 age-matched nonburned controls (mean [SD] age, 2.4 [1.3] years; 51.1% male; 67.1% white, 8.9% black, and 15.0% Hispanic) completed the study. Predicted scores improved exponentially over time for 5 of the BOQ0-5 domains (predicted scores at 1 month vs 24 months: play, 48.6 vs 52.1 [P = .03]; language, 49.2 vs 54.4 [P < .001]; gross motor skills, 48.7 vs 53.0 [P = .002]; pain/itching, 15.8 vs 33.5 [P < .001]; and worry/concern, 31.6 vs 44.9 [P < .001]). Pediatric burn survivors had higher scores in language, emotional behavior, and family functioning domains compared with healthy children in later months., Conclusions and Relevance: This study demonstrates significant deficits in multiple functional domains across pediatric burn survivors compared with controls. Recovery curves can be used to recognize deviation from the expected course and tailor care to patient needs.

Cardiac fatalities are the leading cause of death among all firefighters. Increasing age has been linked to increased cardiac fatalities in firefighters; however, circumstances surrounding in-line-of-duty cardiac firefighter deaths can also increase the risk of a cardiac death. The authors hypothesize that cardiac fatalities among firefighters will be related to the type of duty and level of physical exertion. The authors analyzed the Firefighter Fatalities and Statistics data collected by the U.S. Fire Administration (http://apps.usfa.fema.gov/firefighter-fatalities/fatalityData/statistics) from January 2002 to December 2012. Data were analyzed for associations between age, firefighter classification, duty-type, and cause of fatal cardiac event. A total of 1153 firefighter fatalities occurred during the 10-year period reviewed. Of these, 47% were cardiac fatalities. Mean age was significantly higher in firefighters who suffered a cardiac fatality (52.0 ± 11.4 ± 40.8 ± 14.7 years; P < .05). Volunteer firefighters suffered significantly higher proportion of cardiac fatalities (62%; P < .05) followed by career firefighters (32%). Additionally, cardiac fatalities were the leading cause of death for volunteer firefighters (54%; P < .05). The highest proportion of cardiac fatalities occurred on-the-scene (29%; P < .05) followed by after-duty fatalities (25%). Stress and overexertion accounted for 98% of the cause of cardiac fatalities. Adjusting for rank and firefighter classification, age (odds ratio, 1.06; 95% confidence interval, 1.05-1.08) and stress or overexertion (odds ratio, 11.9; 95% confidence interval, 1.7-83.4) were independent predictors of a firefighter cardiac fatality. Both career and volunteer firefighters are at significantly higher risk of a fatal cardiac event as they age. These fatalities occur in a significant proportion on-the-scene. National efforts should be aimed at these high-risk populations to improve cardiovascular health.

Ventilator-associated pneumonia (VAP) is a common cause of morbidity and mortality for critically ill burn patients. Prevention of VAP through bundled preventative measures may reduce the risk and incidence of VAP in burn patients. A retrospective chart review was performed of all mechanically ventilated adult (age ≥ 18 years) burn patients before and after VAP prevention bundle implementation. Data collected included age, TBSA, gender, diagnosis of inhalation injury, mechanism of injury, comorbid illnesses, length of mechanical ventilation, length of hospital stay, development of VAP, discharge disposition, and mortality. Burn patients with VAP had larger burn injuries (47.6 ± 22.2 vs 23.9 ± 23.01), more inhalation injuries (44.6% vs 27%), prolonged mechanical ventilation, and longer intensive care unit (ICU) and hospital stays. Mortality was also higher in burn patients who developed VAP (34% vs 19%). On multivariate regression analysis, TBSA and ventilator days were independent risk factors for VAP. In 2010, a VAP prevention bundle was implemented in the burn ICU and overseen by a nurse champion. Compliance with bundle implementation was more than 95%. By 2012, independent of age, TBSA, inhalation injury, ventilator days, ICU and hospital length of stay, VAP prevention bundles resulted in a significantly reduced risk of developing VAP (odds ratio of 0.15). Burn patients with an inhalation injury and a large burn injury are at increased risk of developing VAP. The incidence and risk of VAP can be significantly reduced in burn patients with VAP prevention bundles.

Background: Radiotherapy is an established treatment for some types of patients with nonmelanoma skin cancer. A hypofractionated schedule has been proposed as a valuable option for elderly disabled patients to minimize the number of hospital visits., Objective: We sought to compare a weekly hypofractionated orthovoltage radiotherapy regimen with a standard daily one for the treatment of nonmelanoma skin cancer., Methods: A retrospective cohort study was performed on 436 tumors. Overall survival, disease-free survival, and cosmetic outcome were measured. Life-table analysis, Kaplan-Meier survival analysis, and multivariate Cox regression model were performed., Results: The hypofractionated regimen was not associated with increased recurrence rates and mortality, or with a poorer cosmetic outcome, when compared with the daily schedule., Limitations: Absence of complete information about acute treatment toxicity and a shorter follow-up time for patients receiving the weekly schedule are limitations of this study., Conclusions: A weekly hypofractionated regimen of orthovoltage radiotherapy seems to be the most appropriate approach in elderly disabled patients with nonmelanoma skin cancers., (Copyright © 2015 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

The goal of this study is to quantify the number of medications administered to burn patients and identify potential drugs interfering with laboratory testing. The authors reviewed the medical records of 12 adult (age ≥ 18 years) burn patients with more than 20% TBSA burns from an existing glucose control database at our institution. Dose, interval, and route of medications administered from admission to discontinuation of intensive insulin therapy were recorded. Interfering drugs were identified based on established clinical chemistry literature. The retrospective cohort of adult burn patients exhibited a mean (SD) age of 37.9 (3.0) years. Mean TBSA burn was 51.3 (9.3)%. Disease severity determined by the average multiple organ dysfunction score was 5.4 (0.2). Mean and median medications administered per day were 42.1 (9.5) and 49 (with a daily range of 0-65), respectively. A total of 666 potential laboratory test interferences caused by medications were identified. There were 261 different effects (eg, increased glucose, decreased potassium). Multiple interferences, 71.0% (475/666), were caused by more than one medication. Investigation of the number of medications administered to a burn patient and delineation of potential laboratory test interferences has not been conducted in burn patients. Given the substantial number of medications administered to burn patients, physicians and laboratory personnel should work together to identify potential interferences and define appropriate countermeasures while enhancing the laboratorians understanding of this unique population. This synergistic partnership can lead to intelligent support tools and potentially autocorrecting instruments.

The dermoscopic findings of basal cell carcinoma (BCC) were first described more than a decade ago and the list of BCC-related criteria has been several times updated and enriched. Today, the dermatoscope is considered the key tool for the diagnosis of BCC, since it allows its early detection and enables its discrimination from other pigmented and nonpigmented skin tumors. The dermoscopic pattern of BCC results from several combinations of well-known BCC criteria, depending on several factors, including histopathologic subtype, location, gender, age and pigmentary trait. In addition, recent evidence highlighted that dermoscopy is also useful in the management of BCC, since it provides information on the tumor subtype, the presence of pigmentation or ulceration and the response to nonablative treatments.

Management of burn injuries requires treatments and interventions from many disciplines. Worldwide, burn patients suffer from physical and psychological challenges that impact their lives socially and economically. In this review, we will highlight a handful of the numerous articles published in multiple areas of burn care. The areas of burn care addressed in the article are: epidemiology; burn resuscitation, critical care, and infection; nutrition and metabolism; pain and rehabilitation; prevention and firefighter safety; psychology; and reconstruction and wounds.

Background: Early detection of acute kidney injury (AKI) in severely burn-injured patients can help alter treatment to prevent progression to acute failure and reduce the need for renal replacement therapy. We hypothesized that whole blood neutrophil gelatinase-associated lipocalin (NGAL) will be increased in severely burn-injured patients who develop AKI during acute resuscitation., Materials and Methods: We performed a prospective observation study of adult burn patients with a 20% total body surface area (TBSA) burned or greater burn injury. Two-hour serial measurements of NGAL, serum creatinine (Cr), and hourly urine output (UO) were collected for 48 h after admission. Our primary goal was to correlate the risk of AKI in the first week after burn injury with serial NGAL levels in the first 48 h after admission. Our secondary goal was to determine if NGAL was an earlier independent predictor of AKI compared with Cr and UO., Results: We enrolled 30 adult (age ≥ 18 y) burn patients with the mean ± standard deviation age of 40.9 ± 15.4 and mean TBSA of 46.4 ± 22.4. Fourteen patients developed AKI within the first 7 d after burn injury. There were no differences in age, TBSA, fluid administration, mean arterial pressure, UO, and Cr between AKI and no-AKI patients. NGAL was significantly increased as early as 4 h after injury (182.67 ± 83.3 versus 107.37 ± 46.15) in the AKI group. Controlling for age, TBSA, and inhalation injury, NGAL was a predictor of AKI at 4 h after injury (odds ratio, 1.02) and remained predictive of AKI for the period of more than the first 24 h after admission. UO and Cr were not predictive of AKI in the first 24 h after admission., Conclusions: Whole blood NGAL is markedly increased in burn patients who develop AKI in the first week after injury. In addition, NGAL is an early independent predictor of AKI during acute resuscitation for severe burn injury. UO and Cr are not predictive of AKI during this time period., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Adequate resuscitation is paramount to burn patient survival and recovery. Novel biomarkers of intravascular volume and renal perfusion may augment resuscitation strategies. The purpose of this study is to characterize serum B-type natriuretic peptide (BNP) and neutrophil gelatinase-associated lipocalin (NGAL) during burn resuscitation and correlate to clinical assessments of volume status. We hypothesize that BNP and NGAL will help predict inadequate resuscitation during the first 48 hours following burn injury. We conducted a pilot observational study recruiting 15 adult (age ≥18 years) patients with ≥20% TBSA burns. Paired serial BNP, NGAL, and creatinine measurements were performed using point-of-care testing. Samples were tested every 4 hours for the first 48 hours following admission. Acute kidney injury (AKI) was defined by the RIFLE criteria. Over-resuscitation was defined as developing compartment syndrome. Demographics and TBSA were similar between AKI (n = 7) vs non-AKI (n = 8), and over-resuscitated (n = 5) vs adequately resuscitated groups (n = 10). NGAL (184.9 ± 72.2 vs 110.8 ± 35.8 ng/ml, P = .004) and BNP (25.3 ± 17.3 vs 8.8 ± 5.2 pg/ml, P = .033) values were significantly higher in AKI patients. Creatinine values were similar between AKI and non-AKI patients. NGAL levels suggested presence of AKI 12 hours earlier than creatinine levels. BNP values (23.1 ± 21.9 vs 13.9 ± 13.4 pg/ml, P < .001) were significantly higher in over-resuscitated patients. Point-of-care BNP, NGAL, and creatinine measurements aid in the assessment of vascular volume and renal function during acute burn resuscitation. Further studies are warranted to determine BNP and NGAL cut-offs for guiding burn resuscitation.

There is an emerging mechanism of burn injury as a result of the ignition of butane, during the manufacture of a tetrahydrocannabinol concentrate known as butane honey oil. The authors report of a series of patients who presented with this mechanism of injury and a description of the process that causes these burns. Patient data were gathered from the medical records of eight patients treated at the University of California Davis Medical Center and Shriners Hospital of Northern California. Information on the manufacturing process of butane honey oil was gathered from Internet searches and published literature on the topic. The burns witnessed at the abovementioned institutions ranged from 16 to 95% TBSA, with an average of 49.9%. The average length of stay for the patients was 118.3 hospital days and 114.4 intensive care unit days, with an average of 43.8 days spent on mechanical ventilation. The average age of patients was 22 years, with only one patient above the age of 30 years. Accidents during honey oil production have resulted in a surge of burn injuries in our community during the past year. The manufacture of this product, which involves the use of volatile butane gas, is gaining in popularity. Although considered to be safer than previous methods, multiple casualties with extensive burn injuries have resulted from this process. Associated injuries from blast trauma or chemical burns are not likely to occur in these types of explosions and have not been observed in the series reported in this article. In light of the increasing popularity of honey oil, it is important for burn care providers to gain awareness and understanding of this problem and its growing presence in the community.

Background: Tracheostomy is often performed in the pediatric burn population to establish secure airways. Tracheostomy is safe in this population, but the duration of tracheostomy may be related to age and extent and severity of burn. We hypothesized that burn related factors and not age determine the time to removal of a tracheostomy in pediatric burn patients., Methods: A 5-year retrospective review was performed for pediatric burn patients (age ≤18 years) who underwent tracheostomy. Patients were divided into three groups by age (group 1: 0 to ≤2 years, group 2: >2 to ≤12 years, group 3: >12 to ≤18 years). Data collected included: age, total body surface area burn injured (TBSA), gender, mechanism of injury, diagnosis of inhalation injury, mortality, time from injury to admission, time from admission to placement of tracheostomy, time of injury to placement of tracheostomy, duration of tracheostomy, days of mechanical ventilation, and tracheostomy related complications., Results: 45 patients were reviewed. There were no differences in TBSA, length of ICU stay, length of hospital stay, and mortality between the three groups. Additionally, there were no differences in ventilator days and duration of tracheostomy. Multivariate linear regression analysis indicated that TBSA and not age independently increased the duration of tracheostomy., Conclusion: Tracheostomy duration is dependent on the extent of burn in pediatric burn patients., (Copyright © 2014 Elsevier Ltd and ISBI. All rights reserved.)

Glass fronted gas fireplaces (GFGFs) have exterior surfaces that can reach extremely high temperatures. Burn injuries from contact with the glass front can be severe with long-term sequelae. The Consumer Product Safety Commission reported that these injuries are uncommon, whereas single-center studies indicate a much higher frequency. The purpose of this multi-institutional study was to determine the magnitude and severity of GFGF injuries in North America. Seventeen burn centers elected to participate in this retrospective chart review. Chart review identified 402 children ≤10 years of age who sustained contact burns from contact with GFGF, who were seen or admitted to the study hospitals from January 2006 to December 2010. Demographic, burn, treatment, and financial data were collected. The mean age of the study group was 16.8 ± 13.3 months. The majority suffered burns to their hands (396, 98.5%), with burns to the face being the second, much less common site (14, 3.5%). Two hundred and sixty-nine required rehabilitation therapy (66.9%). The number of GFGF injuries reported was 20 times greater than the approximately 30 injuries estimated by the Consumer Product Safety Commission's 10-year review. For the affected children, these injuries are painful, often costly and occasionally can lead to long-term sequelae. Given that less than a quarter of burn centers contributed data, the injury numbers reported herein support a need for broader safety guidelines for gas fireplaces in order to have a significant impact on future injuries.

The 1800s show a wide range of both understanding and misinterpretation of the pathophysiology and treatment of burns. The objective of this paper was to describe the key advancements in the study and treatment of burns in the 1800s. We reviewed primary and secondary sources of ancient to modern burn care manuscripts. Prior to the 1800s, burn care was different iterations of poultices and oils placed over acute burns in the hope the patient would survive. The 1800s showed the discoveries of the Curling and Marjolin's ulcers as well as the first understanding of inhalation injury and advancements in skin grafting, leading to further understanding of the disease process.

The impact of burn size on mortality is well known, but the association of burn size with the trajectories of long-term functional outcomes remains poorly studied. This prospective multi-center study included burned adults ages 19 to 30 years who completed the Young Adult Burn Outcome Questionnaire at initial baseline contact, 2 weeks, and at 6 and 12 months after initial questionnaire administration. Non-burned adults of comparable ages also completed the questionnaire as a reference group. The association between functional recovery and TBSA burned was analyzed longitudinally using generalized linear models with the generalized estimation equation technique. Functional status was characterized in 15 domains: physical function, fine motor function, pain, itch, social function limited by physical function, perceived appearance, social function limited by appearance, sexual function, emotion, family function, family concern, satisfaction with symptom relief, satisfaction with role, work reintegration, and religion. Scores were standardized to a mean of 50 and a SD of 10 based on non-burned controls. There were 153 burned and 112 non-burned subjects with a total of 620 questionnaires. TBSA burned was 11 ± 14% (mean ± SD); 31% had face involvement and 57% had hand involvement. The lag time from burn injury to questionnaire administration was on average 7 ± 7.7 months, with a maximum of 36 months. Lower recovery levels were associated with increasing burn size for physical function, pain, itch, work reintegration, emotion, satisfaction with symptom relief, satisfaction with role, family function, and family concern (P value ranged from .04-<.0001). No significant differences in recovery levels were found with increasing burn size for fine motor function, social function limited by physical function, sexual function, and religion; these areas tracked toward the age-matched non-burned group regardless of burn size. Perceived appearance and social function limited by appearance remained below the non-burn levels throughout the 3-year period regardless of burn size. Three-year recovery trajectories of survivors with larger burn size showed improvements in most areas, but these improvements lagged behind those with smaller burns. Poor perceived appearance was persistent and prevalent regardless of burn size and was found to limit social function in these young adult burn survivors. Expectations for multidimensional recovery from burns in young adults can be benchmarked based on burn size with important implications for patient monitoring and intervening in clinical care.

Aims: The efficacy of paclitaxel-coated balloons (PCB) for the treatment of superficial femoral artery (SFA) disease has been demonstrated in the clinical setting. Due to the high frequency of arterial calcification found in this vascular territory, the adjunctive use of atherectomy plus PCB has been proposed. In this study, we aimed to evaluate the biological effect on vascular healing and drug retention of this combination approach in the familial hypercholesterolaemic swine (FHS) model of femoral artery stenosis., Methods and Results: Eleven femoral arteries (six superficial and five profunda arteries) were included. Vessels were injured (x2) over a 28-day period and all animals were maintained on a high cholesterol diet for 60 days following initial injury. Vessels were randomised to PCB (n=5) or orbital atherectomy system (OAS) plus PCB (n=6). At 28 days following therapy, vessels were followed with angiography, intravascular ultrasound (IVUS) and optical coherence tomography (OCT). Vessels were harvested for histological and pharmacokinetic analysis. Angiographic findings were comparable at termination between both groups. The OCT findings were comparable at termination. There were no differences in the vascular healing profile between both groups. The paclitaxel levels at termination were comparable between both groups (PCB=5.16 vs. OAS+PCB=3.03 ng/mg)., Conclusions: In the experimental setting, the combination of OAS+PCB appears to be safe by demonstrating a vascular healing profile and drug tissue levels comparable to PCB only. The vascular effect of PCB may be enhanced by the use of OAS by decreasing plaque burden and cholesterol crystals.