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The importance of a published paper to a particular area is reflected in the quantity of citations obtained from peers. In burns, it is unknown which papers have been the most influential on this specialty. The purpose of our study was to identify the 100 most cited papers in burns and to analyze their characteristics. Twenty-seven journals were chosen for analysis. These included high impact factor scientific journals and journals dedicated to burns and trauma. Only twelve of these journals contributed to the 100 most cited papers in burns and we analyzed each paper individually looking at its subject matter, authorship, article type, institution, country and year of publication. Our citation analysis revealed an interesting mix of clinical and scientific papers that documents the key landmarks in burn care over the past 66 years.

Purpose To evaluate the efficacy of mannitol solution as a decontamination agent on the chemical burn of the human corneas. Methods Eight donor corneas from an eye bank were exposed to 25 μl of 2.5% hydrofluoric acid (HF) solution on a filter paper for 20 s. Three eyes were rinsed with 1000 ml of mannitol 20% for 15 min immediately after removal of the filter paper, 3 other were rinsed with sodium chloride (NaCl) 0.9% (1000 ml for 15 min) and two eyes were not rinsed. Microstructural changes were monitored in the time domain by optical coherence tomography (OCT) imaging for 75 min. Results NaCl reduced the penetration depth to approximately half the thickness of the cornea at 15 min; scattering within the anterior cornea was higher than that for the unrinsed eye. With mannitol, no increased scattering was observed in the posterior part of the corneal stroma within a time period of 1 h after rinsing. OCT images revealed low-scattering intensity within the anterior stroma at the end of the rinsing period. Conclusion In eye bank human corneas, mannitol proved to be an efficient agent to decontaminate HF burn.

Hot-bitumen burn is a unique case in all types of burns. This melting substance is difficult to remove when it adheres to the skin and solidifies. It causes burns and sticks to the skin when it is cooled to the skin temperature. Some reports are available on many kinds of solvents for the removal of solid bitumen. However, there have thus far been no comparative studies. It is necessary to seek for an optimum method to remove bitumen without consuming so much time and with minimum injury to the skin. The selected solvents in this study were petrolatum, olive oil, salad oil, butter, Neosporin ointment and De-solv-it. They were often reported as being effective for hot-bitumen burn injuries with little irritation for a damaged skin. It is easy to purchase them commercially. Each solvent was poured over the bitumen in a test tube. Afterwards, the concentrations of the bitumen in the solvents were quantified with the fluorescence measurement technique. We consider De-solv-it is the one of the best solvent for the removal of bitumen and highly recommended for hot-bitumen burns. The results of this study suggest that dressing change should be done every 4 to 8 h or as frequently as needed until the bitumen is entirely removed.

Also on behalf of my co-authors, we want to thank Mr. Timothy Stuart Burges for his comment on our article ‘‘Optimal treatment of partial thickness burns in children: A systematic review’’ [1]. For our research we reviewed an extensive series of articles, obtained via a structured literature search using the Medline and Embase search engines, and Mr. Burges’ paper was not found. In fact, Mr. Burges describes the paper as ‘‘a presentation abstract’’ which is different from a full paper and, by nature, cannot not be considered as such for a review article. A search on the site of The Journal of the Royal Army Medical Corps finds the article indeed [2]. However, this was only available through a paid download which is not in the current spirit of the scholarly literature. From Mr. Burges’ letter we understand that his presentation seems to be in line with the findings in our review: for these types of burns, membranous dressings perform better on various wound healing parameters than cream based [1] Vloemans AFPM, Hermans MHE, van der Wal MBA, Liebregts J, Middelkoop E. Optimal treatment of partial thickness burns in children: a systematic review. Burns 2014;40:177–90. [2] Atun AR, Burges TS, Kay AR, Estela C. Combined Services Plastic Surgery Society – biobrane experience in Bristol. J R Army Med Corps 2006;152:37–43.

Ten patients with 20 per cent burns were studied for total serum proteins and differential serum protein by paper electrophoresis and polyacrylamide disc gel electrophoresis. The study was carried out for 3 weeks. Total serum protein and albumin levels showed gradual decline in all the patients. Differential serum protein showed decreased albumin on days 4, 12 and 22. Beta-globulin was increased on days 4 and 22, but decreased on day 12. The changes in the group specific protein were indefinite and inconclusive. In all the cases, gamma-globulin was slightly decreased on day 4, but gradually increased on days 12 and 22 post burn. Thickness and intensity of gamma-globulin bands were more marked in the patients with superficial burns as compared to deep burns.

Introduction: Autologous split thickness skin grafting is the standard-of-care for the majority of deep dermal and full thickness burns: Meshed grafting is most commonly used. Patients with extensive burn injuries have limited donor site availability. Meek micrografting is a well-known technique to enable larger expansions. A review was conducted on the outcomes of the Meek micrograft technique. Method: A database search in PubMed, Web of Science, Google Scholar and the Cochrane Library was conducted from the first Meek micrografting report in 1958 until 2021, including terms ‘burns’, ‘micrografting’ and/or ‘Meek’. Original papers reporting outcomes of Meek micrografting were included. Results: 1529 papers were identified and eventually 15 articles were included, the majority classified as poor quality according to Chambers criteria. 310 patients with 56% mean TBSA were described. Weighted averages were calculated for ‘graft take’ 82 ± 7%, ‘time to wound closure’ 53 ± 20 days and ‘length of hospital stay’ 61 ± 31 days. Scar quality was minimally described and often poorly assessed. Limited data were available on outcomes ‘donor site size’, ‘number of operations’, ‘cost effectiveness’ and ‘bacterial load/wound infection rate’. Conclusion: Overall poor study quality and the specific lack of data on scar quality, made it impossible to draw conclusions on the outcomes of Meek micrografting. A randomized controlled trial is required to further investigate the performance of the Meek micrograft technique.

Background Much of the recent literature on bromelain based enzymatic debridement of burn injury has focused on its use in smaller burn injury and specialist areas such as the hands or genitals (Krieger et al., 2012; Schulz et al., 2017a,b,c,d). This is despite the original papers describing its use in larger burn injury (Rosenberg et al., 2004, 2014). The current EMA license for Nexobrid™ advises that it should not be used for burn injuries of more than 15% TBSA and should be used with caution in patients with pulmonary burn trauma and suspected pulmonary burn trauma. The original safety and efficacy trial of NexoBrid™ limited its use to 15% TBSA aliquots with concern regarding the effect of bromelain on coagulation. In a European consensus paper of experienced burns clinicians, now on its second iteration, 100% of respondents agreed that “up to 30% BSA can be treated by enzymatic debridement based on individual decision” (Hirche et al., 2017). Hofmaenner et al.’s recent study on the safety of enzymatic debridement in extensive burns larger than 15% provides some further evidence that “bromelain based enzymatic debridement can be carried out safely in large-area burns” (Hofmaenner et al., 2020) but the literature is scant in these larger debridement areas. In our centre we have been using enzymatic debridement for resuscitation level burn injury since 2016. We have gained significant learning in this time; this article aims to describe our current protocol for enzymatic debridement in this patient population and highlight specific learning points that might aid other centres in using enzymatic debridement for larger burn injury. Method We performed a search of the IBID database to identify all adult patients who satisfied the inclusion criteria of resuscitation level burn injury (defined as total burn surface area (TBSA) ≥15% in patients aged >16 years), or level 3 admission following burn injury and who underwent Enzymatic Debridement. A case note review was completed, and details comprising patient demographics, TBSA, mechanism of burn, presence of inhalation injury, sequencing of debridement, length of ICU and hospital stay, blood product utilisation and the need for autografting were recorded. No ethical approval has been sought for this retrospective review. Results We identified 29 patients satisfying the inclusion criteria (Table 1). Between June 2016 and June 2020 the average total burn size of patients who had at least some of their burn treated by enzymatic debridement increased from 21.4% in 2016/17 to 34.7% in 2019/20. In these patients the actual area treated by enzymatic debridement also increased from 11.9% TBSA to 20.3% TBSA. 19 patients (66%) had enzymatic debridement performed within 24 h of injury, a further 2 patients (7%) within 48 h after injury. Patients were more likely to have enzymatic debridement commenced in the first 24 h after injury if they had circumferential limb injury (39% vs 9%) or were planned for enzyme only debridement (78% vs 28%). Those who were planned for combination enzyme and surgical debridement were more likely to have enzymatic debridement commenced after the first 48 h (75%). We have performed enzymatic debridement overnight on one occasion, for a patient who presented with circumferential limb injury and was determined to undergo urgent debridement. Conclusion Much of the literature has described the use of enzymatic debridement in smaller burns, and specialist areas. However, it is our opinion that the advantages of enzymatic debridement appear to be greater in larger burns with a facility for whole burn excision on the day of admission in the ICU cubicle. We have demonstrated significantly reduced blood loss, improved dermal preservation, reduced need for autografting, and a reduction in the number of trips to theatre. We would advocate that both the team and the patient need to be as prepared as they would be for a traditional surgical excision. The early part of our learning curve for enzymatic debridement in resuscitation level injuries was steep, and we were able to build on experience from managing smaller injuries. We recommend any team wishing to using enzymatic debridement gain experience in the same way and develop robust local pathways prior to attempting use in larger burn injuries.

Highlights • Quality improvement requires a comprehensive integrated approach. • Clinical standards are a vital first step in improving outcomes for LMICs. • Capacity building needs a range of educational courses from basic to advanced. • Evaluation tools are needed to measure progress., Consistent evidence has emerged over many years that the mortality and morbidity outcomes for burn patients in low and middle-income countries (LMICs) lag behind those in more resource rich countries. Interburns is a charity that was set up with the aim of working to reduce the disparity in the number of cases of burns as well as the outcomes for patients in LMICs. This paper provides an overview of a cyclical framework for quality improvement in burn care for use in LMICs that has been developed using an iterative process over the last 10 years. Each phase of the process is outlined together with a description of the tools used to conduct a gap analysis within the service, which is then used to frame a programme of capacity enhancement. Recent externally reviewed projects have demonstrated sustained improvement with the use of this comprehensive and integrated approach over a three-year cycle. This overview paper will be supported by further publications that present these results in detail.