Journal of Burn Care & Research最新文献

Adipose-derived stem cells (ADSCs) have an important role in the modulation of burned tissue repair through the release of paracrine factors that stimulate the wound healing response. In this study, we tested the hypothesis that smoking status alters the profile of paracrine factors secreted from ADSCs isolated from damaged adipose tissue. Adipose tissue was collected from adult patients (N=8) with severe burn injuries (>20% total body surface area) at the index operation. ADSCs were extracted and cultured in vitro. Supernatants were harvested 30 hours after plating and used for cytokine determinations by Multiplex assay. Fluorescence activated single cell sorting (FACS) confirmed their phenotype with markers CD 90, CD 166, and CD 73. Univariate analyses were performed to compare the two cohorts (Smokers vs non smokers). Higher amounts of anti-inflammatory cytokines IL-4 (p=0.03) and IL-10 (p=0.04) and pro-inflammatory cytokines TNF-alpha (p=0.03), IL-8, and IFN-gamma (p=0.03) were detected in burn patients who were current everyday smokers when compared to nonsmokers, or former smokers. No significant differences in supernatant concentrations of IL-17, IL-1 beta, TGF-alpha, IL-6, and IL-13 were observed (p>0.05). Mortality was higher in the smoker group when compared to non-smokers. The results from this study suggest that smoking status in patients with a major burn injury may alter the paracrine factors secreted from ADSCs, and on-going studies will increase sample size and refine experimental approach. Furthermore, these results support the need for studies examining the systemic effects of smoking status of patients suffering burn injuries impacts the wound healing.

Background: Geographical access to pediatric burn centers in the US is not well described. Patients may receive care at American Burn Association (ABA)-verified burn centers, unverified burn centers, or non-burn centers. A recent study indicated that most US counties do not have an ABA-verified pediatric burn center within 100 miles. However, access to unverified burn centers that provide care to pediatric burn patients was not considered. We studied access to all pediatric burn centers across different US regions, using American College of Surgeons (ACS) Committee on Trauma-verified pediatric trauma centers as a benchmark.

Study design: An observational cohort study was conducted using 2022 US Census data. Individuals aged ≤14 years were included. Geographical location was determined by residence ZIP code. Pediatric burn centers were identified from the ABA directory. Pediatric trauma centers were identified by ACS verification status using the ACS Hospitals and Facilities directory. Population access to pediatric burn and trauma centers within 50, 100, and 300 miles of the home ZIP code was assessed.

Results: Of US children, 62.1%, 83.5%, and 98.6% live within 50, 100, and 300 miles of a pediatric burn center. Access to ABA-verified pediatric burn centers is lower compared to access to ACS-verified pediatric trauma centers.

Conclusions: Overall, the US population has limited access to pediatric burn centers compared to pediatric trauma centers. The services offered and outcomes should be studied to better understand differences in the quality of care provided by verified and unverified centers.

Burn injuries in patients with significant pre-existing medical conditions provide unique challenges in both medical management and surgical planning. Spasticity, if left untreated, can be one of the most disabling consequences of a neurologic injury. Treatment is largely dependent on pharmacologic management with anti-spasmodic agents such as baclofen. Baclofen's effectiveness when taken orally is often limited by its systemic side effects, which mostly affect the central nervous system (CNS). Intrathecal baclofen (ITB) can circumvent these intolerable adverse effects while achieving symptom relief via a more targeted therapeutic route. However, abrupt cessation of chronic baclofen use can precipitate an acute life-threatening withdrawal syndrome. We present a case of a 47-year-old female who sustained 54% total body surface area (TBSA) full-thickness flame burns to the circumferential bilateral lower extremities, left arm, left anterior and posterior trunk, flank, and perineum. She had a pre-morbid C5 spinal cord injury resulting in spastic paraplegia for which she had an ITB pump implanted into her left abdominal wall for symptom management. This pump was directly beneath her operative burn wounds. We discuss the complex issues that were encountered throughout her care related to medication reservoir supply, life-threatening risk of baclofen withdrawal, pain-specialist availability, medical-legal barriers, and the multi-staged surgical plan for coverage, balancing proper wound debridement with risk of device exposure and infection. To our knowledge, this is the only case report detailing the cohort of obstacles that may be associated with these devices, specifically with burn patients.

Serratia marcescens is an opportunistic nosocomial pathogen with significant implications for burn care due to its multidrug resistance, virulence, and ability to colonize hospital environments. This retrospective study, conducted at an American Burn Association Verified Burn Centre, reviewed 22 cases of S. marcescens infections from 2015 to 2020. Patients exhibited a mean total body surface area (TBSA) burned of 28% (range: 2-71%), with 68% sustaining burns >20% TBSA and 40.9% presenting with inhalation injuries. The pathogen was most commonly isolated from sputum (36%) and burn wound tissue (50%), with a mean time to positive culture of 8.7 days. Early-onset infections were associated with increased mortality, particularly in patients with major burns, as five out of seven such individuals succumbed to infection. The overall mortality rate was 23%, despite timely antibiotic administration. Targeted topical antimicrobials, such as Dakin's solution, nanocrystalline silver, and polyhexamethylene biguanide (PHMB), offer potential benefits but lack robust evidence for optimal use. Stronger clinical data are needed to guide their application and improve outcomes. These findings underscore the need for enhanced surveillance, refined treatment strategies, and research into S. marcescens management in burn care.

The aim of this registry-based cohort study was to quantify the prevalence, injury characteristics, and outcomes of alcohol exposure in burn-related injuries. All patients ≥ 18 years presenting to The Alfred Emergency & Trauma Centre, a major trauma centre in Victoria, Australia between January 1, 2019 and December 31, 2022 and included in the Victorian Adult Burns Service registry were included. An explicit chart review was performed to verify retrieved data with alcohol exposure coded when documented in medical records, laboratory evidence of a blood alcohol concentration > 2mmol/L, or recorded in discharge ICD-10-AM codes. Among 1587 eligible patients, 251 (15.8%) had been exposed to alcohol prior to injury. Patients with alcohol exposure at the time of burn-related injury had higher rates of admission to the ICU (28% vs 16.4%, p < 0.001) and longer median hospital admission (10.1 vs 7.7 days, p < 0.001). The significant impact of alcohol exposure on the overall health burden of burn injuries highlight the need for standardised and robust alcohol testing protocols to support targeted strategies to reduce the burden of alcohol-related burn injuries.

Severe burn injury poses significant clinical challenges, often necessitating the use of vasoactive agents to maintain perfusion. This narrative review explores the current landscape of vasoactive agents in acute burn shock resuscitation and severe burn-injured patients who develop septic shock, with a particular focus on the potential role of the novel vasoactive agent, synthetic angiotensin-II (AT-II), in these settings. While catecholamines and vasopressin remain cornerstone therapies, adverse effects, variable patient response, and a new understanding of burn injury pathophysiology highlight the potentially evolving role of vasoactive agents in these clinical scenarios. A key system involved in blood pressure regulation, the renin-angiotensin-aldosterone system (RAAS), is often dysregulated in acute burn and septic shock. Contributory mechanisms and potential benefits of synthetic AT-II are discussed here within and form the physiologic rationale behind exogenous administration of synthetic AT-II in the context of available safety and efficacy data. To date, administration of synthetic AT-II administration has shown promise in improving hemodynamics and clinical outcomes in distributive shock populations; however, data in acute burn shock and burn patients who develop septic shock are lacking. In addition, a comprehensive understanding of the potential and future areas of research in burn shock and severe burn-injured patients is provided.

Burn injury results in hypercoagulability and an increased venous thromboembolism risk. However, the most effective chemoprophylaxis for burn-injured patients has yet to be elucidated. Therefore, this study aims to identify the safety and efficacy of a burn center's venous thromboembolism protocol modification which increased the dose of enoxaparin from 40mg daily to 40mg twice daily with peak anti-Xa level adjustments. It was hypothesized that this change would not increase bleeding complications and would decrease venous thromboembolism rates. All adult, burn-injured patients admitted to a regional burn center were retrospectively reviewed one year before and after the implementation of this protocol modification. There were no differences in demographics, injury characteristics, or hospital length of stay between the pre- (n=432) and post-protocol modification (n=407) groups. Bleeding complications did not increase in the post-protocol group, including intraoperative blood loss (50 vs 25cc), the total number of transfusions (9.0 vs 6.0 units), and GI bleeding events (0.7 vs 0.2%) (all p>0.05). Most patients receiving enoxaparin 40mg twice daily achieved an initial therapeutic level based on peak anti-Xa measurements (46.5%), yet the rate of venous thromboembolisms between pre- and post-protocol groups was not statistically different (1.4 vs 0.7%, p=0.5072). Factors associated with an initial sub- or supratherapeutic peak anti-Xa level were percent total body surface area, weight, body mass index, and creatinine clearance. Overall, this study demonstrated that a higher dose of enoxaparin (40mg twice daily) with peak anti-Xa level adjustments was safe in burn-injured patients and necessary to obtain therapeutic levels of chemoprophylaxis.

Return to work (RTW) after burn injury is dependent on many variables, including type and location of burn injury, access to care, and pre-injury mental and physical health. Noting that prior studies were limited by small sample sizes, we aimed to use a large database to explore the associations between hand burn severity, functional hand outcomes, and RTW post-injury. Data from a multicenter longitudinal study were analyzed. Adults with burn injuries were classified into 6 groups ranking in severity of hand injury: (0) no hand burns, (1) single hand burn no grafting, (2) bilateral hand burn no grafting, (3) single hand burn requiring grafting, (4) bilateral hand burn requiring unilateral graft, (5) bilateral hand burn requiring bilateral grafts. Grafting was used as a proxy for burn severity. Self-reported employment status, Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE) scores and reported request for work accommodations were collected at discharge, 6-, 12-, and 24-months post-injury. Descriptive statistics and analysis of variance (ANOVA) with post-hoc Tukey Test were completed to examine differences in outcomes by hand injury severity. A total of 4,621 participants met inclusion criteria. Group 5, those with most severe burns, had significantly longer RTW times than Groups 0-3 (p< 0.005). Group 5's (bilateral burn/unilateral graft) average RTW was greater, however not significantly, compared to group 4. At 6 months, the mean PROMIS UE scores for grafted groups (Group 3, 40.6; Group 5, 35.4) were significantly worse than non-grafted groups (Group 1, 46.8; Group 2, 45.0; (p< 0.0001). At 12 and 24 months, mean PROMIS UE scores were worse for grafted groups, though differences were no longer significant compared to non-grafted groups. At every time point, the majority of respondents did not request accommodations for their injuries from their employers, regardless of severity. Burn severity plays a significant role in both RTW and hand function for participants with hand burns. Additionally, the lack of correlation between burn severity and request for work accommodations hints at the baseline vulnerability of these populations. These findings suggest a need for systematic improvements in the way these patients are cared for and re-integrated into the workforce.