Journal of Burn Care & Research最新文献

Frailty is a clinical state characterized by increased vulnerability to stressors, leading to an increased risk of adverse health outcomes. The modified Frailty Index (mFI-5), based on five comorbidities-diabetes mellitus, heart failure, pulmonary disease, hypertension, and totally or partially dependent functional health status -has shown predictive value for treatment outcomes and mortality. The primary objective of this study was to evaluate differences in clinical outcomes between burn patients with mFI-5 scores of 0, 1, and ≥2. The secondary objective was to determine whether the mFI-5 score independently predicts adverse outcomes. A retrospective analysis of 644 burn patients treated between September 2018 and May 2022 was conducted. Data on comorbidities, complications, ventilation status, surgical procedures, length of stay, and discharge destination were analyzed. Statistical analyses included Pearson's chi-square test, Kruskal-Wallis test, and adjusted multivariate regression analysis. Higher mFI-5 scores were associated with worse overall outcomes, including longer hospital stay, higher rates of complications, more frequent need for mechanical ventilation, a greater number of skin grafts and necrectomies, and more frequent discharge to non-home settings. Multivariate analyses showed that a higher mFI-5 score compared to mFI-5=0 was independently associated with higher rates of urinary tract infections (mFI-5≥2: OR 2,41, 95% CI: 1.19-4.86, p=0.014) and non-home discharge (mFI-5=1: OR 2.34, 95% CI: 1.00-5.45, p=0.049). The mFI-5 is a strong predictor of complications and adverse outcomes in burn patients. Its quick, simple application makes it a valuable risk stratification tool in specialized burn centers.

Skin fibrosis, especially hypertrophic scars (HTS), remains understudied with few effective treatments. Studying HTS is challenging due to its natural tendency to improve over time, making it hard to separate intervention effects. This study evaluated fractional ablative laser treatment for symptomatic HTSs, focusing on variability in patient response. It was hypothesized that pain and itch would decrease post-treatment, and that demographic or injury characteristics might predict responders. A retrospective chart review analyzed pre-treatment and six post-laser sessions using the Patient Scar Assessment Scale (POSAS) for pain and itch (1 = low, 10 = high). Patients showing a ≥ 3 point improvement were classified as "responders" (n = 48 for pain, n = 62 for itch); those with ≤2 point improvement or worsening were "non-responders" (n = 62 for pain, n = 76 for itch). In total, 110 patients were analyzed for pain and 138 for itch. Most patients were non-responders for both pain (56.4%) and itch (55.1%). Responders experienced significant reductions in pain and itch after the first session, with stable scores thereafter (p<.0001). Non-responders showed no significant improvement in pain and, for itch, even a significant worsening after the first session. No significant differences were found between groups based on sex, skin type, race, scar age, scar size, or patient age. Responders had higher baseline pain and itch scores than non-responders. The greatest symptom relief occurred after the first treatment. Demographic and injury characteristics did not predict treatment response.

Frostbite injuries account for 2000-4000 hospital admissions annually in the U.S., with 30% of severe cases requiring amputation and up to 70% result in long-term sequelae or disability. Traditional practice following frostbite injury is to delay surgical intervention 4-6 weeks to preserve limb length, tissue coverage, and reduce complications. This study examines amputation timing among frostbite patients in the U.S. and identifies factors influencing early versus delayed amputation. This retrospective study used the Nationwide Readmission Database from 2016-2020 to identify frostbite admissions. Logistic regression models identified predictors of early amputation. Among 4786 patients with frostbite injury, 1422 (29.7%) underwent amputation. Of these, 977 (68.7%) had early amputations. Drug and alcohol use and housing insecurity were more prevalent among amputated patients, but was not associated with early amputation. Female sex, drug or alcohol use, comorbidities, infection or cellulitis, and mental health diagnoses were associated with a lower likelihood of early amputation. In adjusted models, infection/cellulitis was associated with lower odds of early amputation in the full cohort and not associated with timing in the non-elective subset. Across U.S. admissions captured in the NRD, amputations commonly occurred within 30 days of presentation, diverging from historical "watchful waiting" practices. Social drivers of health influence need for and timing of amputations. Infection and cellulitis, which may necessitate urgent intervention, was not associated with increased likelihood of early amputation timing. Future research should explore factors driving early amputation and assess the impact of amputation timing on functional outcomes.

The development of an autologous, full-thickness skin replacement remains the holy grail for the treatment of full thickness skin loss from burns, wounds, and trauma. With massive burn injury and limited donor-site, cultured epidermal autografts (CEAs) can be lifesaving, however they have significant limitations. Furthermore, reconstruction in such patients is challenging. We describe the compassionate use of an autologous, engineered, hydrogel skin graft with keratinocytes and fibroblasts (EHSG-KF), in the treatment of a pediatric patient with massive burn injury. A compassionate use exemption was obtained from the U.S. Food and Drug Administration allowing for up to 3 separate treatments using an EHSG-KF for a 3-year-old patient with a 90% TBSA burn. Grafts were based on plastically compressed collagen type I hydrogels with incorporated keratinocytes and fibroblasts. We retrospectively review our experience with two separate applications and early outcomes. A 2x2cm split thickness skin graft was harvested and shipped internationally for processing. At the same time, contracture releases were performed, and dermal matrices were applied. EHSG-KF were then applied approximately 4 weeks after contracture release. In some areas, EHSG-KF was applied without a dermal matrix, immediately post debridement. Grafts were secured for 7 days with staples and covered with silver foam and tie over bolsters or circumferential gauze wrapping. Graft take was >95%. This novel EHSG-KF was relatively easy to handle, apply, and care for, similar to a traditional autologous FTSG. Engraftment rate was >95% and the resulting healed skin appears to be durable. Our impression has been extremely positive, particularly when compared to traditional CEAs. Additional trials in Europe using this particular EHSG-KF are ongoing.

Skin graft complications may include pain, contractures, hypertrophic scars (HSc), hypersensitivity, and recurrent wounds. Complications involving grafts to the genitalia, perineum, and/or buttocks can be particularly challenging, directly affecting walking, sitting, voiding, bowel elimination, sexual function, and intimacy, ultimately diminishing quality of life. Perineal and pelvic floor rehabilitation (PPFR) is commonly used to treat various pelvic floor disorders; however, its application following burn injury or necrotizing fasciitis has not been previously described. This manuscript presents the evaluation and treatment outcomes of patients with necrotizing fasciitis or Fournier's gangrene. Initial evaluation was conducted approximately four months post-admission by a certified pelvic floor physiotherapist and occupational therapist. Treatment included pelvic floor rehabilitation, patient education, sensory re-education, bladder and bowel training, use of adapted pressure garments, gel application, cutaneous and myofascial stretching, and manual therapy. This report details the outcomes of two male patients (37 and 69 years old) who underwent skin grafting and reconstructive surgery following necrotizing fasciitis and Fournier's gangrene. Both presented with complex wounds that closed approximately four months post-admission, accompanied by contractures, HSc, altered sensory perception, incontinence, and sexual intimacy dysfunction. Following PPFR treatment, improvements were observed in pruritus, urinary and fecal retention capacity, sexuality-related fear avoidance, penile deviation, lower extremity range of motion, satisfaction with sexual function, and sensory perception. This is the first description of a standardized PPFR protocol in this context, demonstrating that specialized interdisciplinary rehabilitation can enhance sexual function, body image satisfaction, and overall quality of life in patients with genital, perineal, and/or buttock grafts.

Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) Syndrome are potentially fatal skin conditions frequently cared for in burn units. In a national database study, we studied the demographics and outcomes of this patient population. This retrospective cohort study included patient admissions for SJS/TEN. Patient demographics and outcomes were compared and adjusted for age, sex, inhalation injury, and percent total body surface area (TBSA). Logistical regression was used for binary outcomes, and linear regression was used for continuous outcomes. All outcomes were described in reference to the entire disease continuum (SJS/TEN) and each specific disease subcohort (SJS, SJS-TEN Overlap, and TEN). Of 271,971 patients queried within the Noncommercial Burn Research Dataset, 2,416 patients had a diagnosis of SJS/TEN. These patients were statistically more likely to be older (48±22 years vs. 36±22 years), housed (1% vs. 2%), females (57% vs. 34%), and have a higher mean TBSA (8±13% vs. 7±12%). In multivariable analysis, SJS/TEN was associated with increased risk of unplanned intubations (Odds Ratio [OR] 1.69) and pneumonia (OR 1.26), but not respiratory failure (OR 0.36). There was also an increased risk for sepsis (OR 1.43). Patients were significantly more likely to have a shorter hospital LOS (OR -3.7). There was no significant difference in mortality. In subcohort analysis, a stepwise increase in morbidity and mortality was observed when comparing SJS, SJS-TEN Overlap, and TEN. SJS/TEN is a rare but extremely morbid disease continuum that frequently involves female patients and results in increased respiratory and alternative complications.

Friction injury occurs when a patient slides across a surface at high velocity, resulting in mechanical abrasion, laceration, and thermal burn. Mechanical abrasion removes tissue to a variable depth depending on surface texture in contact, and thermal burn devitalizes tissue to a variable depth based on contact pressure and transfer of kinetic energy. In these heterogenous wounds, tangential excision can excise healthy tissue alongside devitalized tissue, and other debridement techniques like hydrosurgery or dermabrasion may not reach deeper crevasses created by abrasion and laceration. Additionally, traditional skin grafts create significant donor site morbidity. This case series presents an early experience with a novel approach using bromelain-based enzymatic debridement combined with autologous skin cell suspension. Bromelain-based enzymatic debridement acts uniformly on a wound surface despite its topography, optimizing removal of devitalized tissue while preserving healthy tissue. Autologous skin cell suspension reduces donor site morbidity. This combined strategy minimizes dressing changes, optimizing pain control and enabling outpatient management. We observe rapid healing and outstanding cosmetic outcomes, and no patients experienced wound infection or other complications or required secondary procedures for nonhealing.