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This study aims to develop an experimental treatment model effective against oxidative stress in the acute period of severe burns and to analyze the mechanisms of healing large wound defects. Five rats, including 2 females and 3 males, were used as donors to obtain adipose-derived stem cells (ADSC) from the inguinal fat pad. The stem cells were labeled with green fluorescent protein. The study included four groups of 17 rats, each with grade 3 scalding burns on 30 % of their body surface, and a control group of 10 rats with an equal number of males and females. After early excision, 106 ADSC-derived stem cells were administered subdermally to the burned wound and autografted to the stem cell group (n = 17). The early excision group (n = 17) received early excision and autograft, with 2 ml of normal saline injected subdermally into the burn wound edge. The PLM group (n = 17) was treated with a polylactic membrane (PLM) dressing after the burn. No treatment was given to the burn group (n = 17). Ten rats from all groups were sacrificed on the 4th day post-burn for oxidative stress evaluation. The control group (n = 10) was sacrificed on day 4. Blood and tissue samples were collected post-sacrifice. Oxidative stress and inflammation in the blood, as well as cell damage in the skin, liver, kidneys, and lungs, were investigated histopathologically and biochemically on the 4th day post-burn. On the 70th day after burn, wound healing was examined macroscopically and histopathologically. On the 4th day, oxidative stress results showed that the levels of Total Oxidative Capacity (TOC) in the blood were lowest in the stem cell (7.4 [6–8.8]), control (6.7 [5.9–7.6]), and early excision (7.5 [6.6–8.5]) groups, with no significant difference between them. The burn group (14.7 [12.5–16.9]) had the highest TOC levels. The PLM group (9.7 [8.6–10.7]) had lower TOC levels than the burn group but higher levels than the other groups. Histopathological examination on the 4th day revealed low liver caspase-3 immunoreactivity in the stem cell and early excision groups among the burn groups. Caspase-3 immunoreactivity levels were as follows: stem cell group (20 [10–30]), early excision group (25 [15–50]), PLM group (70 [50–100]), control group (0), and burn group (80 [60–120]). Other oxidative stress and end-organ damage outcomes were consistent with these results. All rats in the stem cell group had burn wounds that healed completely by the 70th day. Examination of the skin and its appendages from the stem cell group with an immunofluorescence microscope demonstrated green coloration, indicating incorporation of stem cells. Stem cells may have the potential to form new skin and its appendages, providing better healing for large skin defects. Early excision treatment, by removing local necrotic tissues after extensive and deep burns, can prevent end-organ damage due to systemic oxidative stress and inflammation. We also believe that when these two treatments are used together, they can achieve the best results. • Systemic inflammation and oxidative stress occur during the acute phase of severe burns, causing damage to end organs. • Wound healing is an important problem in patients with severe burns if there is not enough space to harvest the skin autograft. • Early excision treatment, which involves clearing local necrotic tissue after extensive and deep severe burns, can prevent end-organ damage. • The stem cells may have the potential to form new skin and its appendages providing better healing for large skin defects. • Combining these two treatments may yield the best results. [ABSTRACT FROM AUTHOR]

Burn disasters and mass casualty events constitute potential scenarios which require separate response plans. The sources provide several triage methods that govern burn casualty triage and evacuation from the incident. However, there are limited data with regard to the patient selection, timing of early burn excision, and surgical technique applied in the case of mass burn casualty events. The majority of burn response plans allow for the postponement of burn surgery for up to a few days, until a secondary triage is performed and the patient is transferred to a specialist burn centre as soon as possible. Tangential excision is preferred in intermediate thickness burns, whereas excision to the fascia is preferable in the cases of full thickness burns. It is recommended that a surgeon with at least three years' experience in a burn unit should perform the surgery. Enzymatic eschar removal might also be an alternative to early surgery. The aim of this overview was to analyze data available in the scientific literature and search for indications, or recommendations concerning early burn wound excision in cases of mass casualty. An internationally standardized training plan for general surgeons, anesthesiologists, and nurses should be created to facilitate the development of local burn-response teams that would be adequately trained to provide first aid and early wound excision. [ABSTRACT FROM AUTHOR]

Background: Burns are one of the most prevalent forms of wound in children and adults, although timing of surgical excision for deep partial or full thickness burns remains controversial. Objectives: To determine if early surgical intervention (excision and grafting within 7 days) improves outcomes when compared to delayed surgical intervention (excision and grafting after 7 days) in adults with thermal burns. Methods: We searched the following electronic databases: Cochrane Wound Group Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and CINAHL. We hand searched the references of included studies and major review articles. We contacted authors of included trials for information about any ongoing trials or unpublished studies. Selection criteria: We included randomized controlled trials, both published and unpublished, comparing early versus delayed surgical intervention for treatment of thermal burns of all degrees and percent total body surface areas (%TBSA) in adult patients. Data collection and analysis: Two authors independently, and in duplicate, screened the titles abstracts and then full texts of all citations for possible inclusion. Data from eligible studies were extracted independently and in duplicate using Microsoft Excel. We pooled outcome data according to the guidelines of the Cochrane Collaboration using Review Manager 5.3 software and random effects model. We assessed Risk of Bias (RoB) in individual studies using the Cochrane Collaboration’s tool and overall certainty of evidence for each outcome using the GRADE framework. Main results: A total of 9 RCTs were included in the systematic review; 6 in the quantitative meta-analysis. Early surgical intervention may result in a small albeit imprecise reduction in mortality (risk ratio (RR) 0.78, 95% confidence interval (CI) 0.53 to 1.14, I2 = 46%, very low certainty) and a reduction in length of hospital stay (days) (mean difference (MD) 12.66 days fewer; 95% CI 9.80 days fewer to 15.53 days fewer, I2 = 88%, low certainty), but increased need for red blood cell (RBC) units (MD 27.11; 95% CI 20.17 to 34.06 units, I2 = 99%, low certainty) compared to delayed surgical intervention. Additionally, early excision and grafting may result in better functional and cosmetic outcomes; both based on low certainty evidence. However, no difference in scar quality and proportion of burns requiring re-operation was found (both low certainty). Conclusion: Early excision and grafting may reduce mortality and improve other patient important outcomes in adults with thermal burns, however most outcomes are based on low or very low certainty evidence. Higher quality, methodologically rigorous studies examining health-related quality of life are warranted in order to best inform this clinical question.

Advances in burn care have led to an overall improvement in mortality in high-income countries, but in low-middle income countries mortality remains relatively high. In a limited resource setting where temporary wound closure options were unavailable, it was determined whether early excision as a preliminary treatment could improve prognosis. A retrospective cohort study was conducted in Cipto Mangunkusumo Hospital Burn Unit to evaluate the outcomes of acute burn patients admitted from January 2013 to December 2018 using mortality and lethal area 50 (LA50), and to compare the outcomes between groups who underwent early excision without skin graft (EEWG), early excision with skin graft (EESG), delayed excision without skin graft (DEWG), or delayed excision with skin graft (DESG). Out of 390 patients available for screening, 256 were eligible for further study. The overall mortality was 17.9% with an increase linear with age and total body surface area (TBSA). The overall LA50 was 49%. Preliminary data showed the highest percentage of deaths in the no treatment group, with no deaths seen in treatment groups EESG and DESG. The odds ratio for mortality in the EEWG group was 2.11 (p-value 0.201, CI95% = 0.65-6.80) compared to the DEWG group. LA50 is more objective compared to crude mortality and enables future internal and external comparison. The highest mortality was in the no treatment group with mortality in the EEWG group higher than in the DEWG, but not statistically different. Early excision without skin grafting as a preliminary procedure may still be considered in a limited resource setting. [ABSTRACT FROM AUTHOR]

Introduction: While the benefits of early excision in burn surgery are clear, the advantages may be lost in low income countries with limited resources. It is important to identify the right timing of excision in different groups of patients, particularly those in low-income countries (LIC), as the burden of disease contributes to the highest global mortality and has the least resources. This systematic review and meta-analysis aims to determine the timing of excision in LICs and the outcomes associated with surgery: (1) mortality, (2) sepsis and (3) length of stay (LOS) compared to high income countries (HICs).Methodology: The PRISMA guidelines and MOOSE checklist were followed for this review. Publications in English from year 1990 to 2017 that included data on the timing and type of burn surgery and outcomes were included. Searches were done using Web of Science, Cochrane collaboration and Pubmed using keywords "Burn and surgery", "Burn and excision", "Burn and excision and grafting" and "burn and skin grafting". Trial quality was evaluated using the Newcastle-Ottawa scale. Outcomes compared for early and late excisions were length of stay (LOS), sepsis and mortality between LICs and HICs.Results: From 278 citations, we selected 41 for full text evaluation, and identified 16 eligible trials. LOS is shorter in early excision compared to late excision in both LICs and HICs. Mortality is lower in late excision compared to early excision in both LICs and HICs. Further subgroup analysis of elderly patients in HICs confirmed that mortality is lower in late excision and unchanged if the elderly are excluded. Early excision reduces sepsis in both LIC and HIC.Discussion: The variable definitions of age, timing of excision, variable nature of % TBSA comparison, mixed inclusion of inhalation injury, co-morbidities and unquantified access to resources make the data difficult to interpret and it is not possible to draw accurate conclusions on the role of early excision for burns in low-middle income countries. A prospective study is needed in order to answer this question. [ABSTRACT FROM AUTHOR]

Background: There is a common, well-known and established recommendation to excise burn wounds within 24-72 h in order to mitigate the systemic inflammatory and immunomodulatory response, shorten length of hospitalization through early grafting and optimize patient survival. Despite this apparent consensus, surprisingly few systematic studies have evaluated the actual adherence to this practice and its implications on patient outcomes. In this registry study, we sought to objectify the current status of early burn wound excision, its influencing factors and impact on patient outcomes for all German burn centers.Methods: The German burn registry ('Deutsches Verbrennungsregister') was queried for 3 consecutive years for all patients, who received at least one surgical intervention. Patients were stratified based on whether the first surgical procedure was performed early (EE, within 72 h) or late (LE, after 72 h) post-burn. Descriptive statistics and univariate regressions were performed to quantify fraction of EE vs. LE and to evaluate factors which might favor one over the other (i.e. age, inhalation injury, burn severity by total body surface area (TBSA), scald vs. other burns, obesity, time of admission). Key patient outcomes were analyzed for each group (i.e. mortality, length of hospitalization, number of surgeries) and multifactorial regression analyses were carried out to model the impact of EE on mortality. Statistical significance was accepted at p < 0.05.Results: After initial screening, 1494 complete records were included for final analysis and were stratified into EE and LE. Only 670 (44%) underwent EE within 72 h. Increasing TBSA burned (i.e. [TBSA > 30%]: 53.8% EE, [TBSA < 30%]: 43.5% EE, p < 0.01) and admission on a weekday between Sunday and Wednesday were associated with higher probability of EE (51.5% EE) versus Thursday to Sunday (37.3%, p < 0.001). Age, inhalation injury, cause of burn, and obesity had no effect on EE vs. LE. Patients with EE had significantly shorter median lengths of hospitalization (EE: 18 d, LE: 21 d, p < 0.01). The median number of operations was comparable for both groups. Gross mortality appeared higher in the EE group, but turned out to be comparable to LE after correction for age, TBSA and sex in multifactorial regression analysis.Conclusion: Despite apparent consensus among burn physicians, early excision of burn wounds is performed in less than 50% of cases in German burn centers. The relationship of EE to TBSA burned is expected and clinically sound, while a dependence on admission weekday raises administrative and infrastructural questions, especially when patients who receive EE have significantly shorter hospital stays. More analyses from other burn repositories are needed to compare and benchmark the international status quo of early burn wound excision. [ABSTRACT FROM AUTHOR]

Background: Severe burns are accompanied by an acute and prolonged hypermetabolic response typified by elevated levels of proinflammatory cytokines and acute phase proteins. When persistent, this inflammatory response can result in multi-organ dysfunction and death. Regarded as the standard of care, early removal of devitalised tissue and eschar mitigates this hypermetabolic response. Ascertaining the optimal time point for early excision, which remains controversial, has several clinical implications.Methods: This retrospective observational study included 836 adult thermal burns patients with total burned surface area ≥20% from all Burns Registry of Australia and New Zealand (BRANZ) Hospital sites, including the Victorian Adult Burns Service (VABS), from July 1 2009 to June 30 2018. Patients were divided into two groups, "early" and "delayed", based on a 24-hour excision cut-off from when the injury occurred. Outcome measurements included mortality, hospital length of stay, intensive care unit length of stay, ventilation requirements and the incidence of positive blood cultures.Results: Among all patients at BRANZ sites, excision within 24 h was associated with reduced mean length of ICU stay (6.6 ± 8.1 vs. 9.2 ± 10.6 days; p = 0.008) and lower mean mechanical ventilator hourly use (94.9 ± 160.8 vs. 159.2 ± 219.1 h; p = 0.001) in the 20-29% TBSA sub-group. Beyond this, no significant differences were observed in outcome measurements.Conclusions: While it is physiologically important to perform early burn wound excision to mitigate the inflammatory response, delaying excision beyond 24 h for surgical planning, possibly up to 72 h after injury, may be a reasonable approach for certain patient groups. [ABSTRACT FROM AUTHOR]

Objectives: To compare the outcomes of early excision and grafting between pediatric and adult patients with deep burns of less than 40% total body surface area burns (TBSA).Methods: This is a prospective comparative study. Overall, 106 patients admitted to Ghotbodin Burn Center in Shiraz, Iran from September 2012 to September 2013, were included in the study. All patients had less than 40% TBSA burn and had excision and grafting under 14 days from their injury. Patients were divided into two age groups of younger than 14 (n=49) and older than 14 (14-65) years old (n=57). During a 6-month follow-up period, the two groups were compared regarding mean percentage of graft take, total scar score, duration of hospital stay and itching score.Results: During follow-up, the two groups did not show a significant difference in graft take, total scar score and itching score (p=0.461, p=0.363 and p=0.637, respectively). Clinically, the pediatric group showed less hospital stay (12.25±9.1 vs. 16±12.9), however this was not statistically significant (p=0.091). Conclusion: Adults and elderly patients (14–65 years old) compared to pediatric patients (less than 14 years old) with less than 40% TBSA burns, can expect similar results regarding scar score, graft take, itch score and hospital stay, after excision and grafting performed less than two weeks from their initial injury.

The study of burn flora is helpful in determining current antibiotic susceptibilities and locating development of multidrug resistant bacterial strains among the unit's usual flora. In this study, we aimed to determine the bacteriological pattern of blood, urine and sputum infections and their correlation with burn wound infections. We used data from our burn registry program. All data on demographics, burn wounds and burn wound infection, bacteria isolated, sensitivity to different antibiotics, burn wound culture, sputum culture, urine culture and catheter tip culture were recorded. We had 1721 hospitalized burn patients. Mean age was 26.3+/-20.25 years old. Mean hospital stay was 14.41 days (range 0-64 days). Mean (SD) TBSA was 16.48 (20.67) years. Mortality rate was 5.9%. Burn wound infection was present in 38.54%. The most frequent species was Staphylococcus spp. (55.1%), followed by Pseudomonas (14.29%), Enterococcus (12.24%), E. coli (4%), Klebsiella and Proteus (both 2%). Urine culture was positive in 27.9%, sputum culture was positive in 1.14%, catheter tip culture was positive in 12.3% and blood culture was positive in 7.6% of the cases. There were correlations between positive wound culture and blood and urine culture, most of them with one bacteria species. The most frequent disseminated bacteria was Pseudomonas aeruginosa and the most sensitive antibiotic was Amikacin. More than 39.2% of our positive culture patients had 3 or more positive cultures, and 36.5% had similar culture results for one bacteria, which was a sign of disseminated infection. [ABSTRACT FROM AUTHOR]

Response plans for mass burn casualty events should include clear guidelines for early burn excision or debridement. Keywords: Burn wound; Early excision; Enzymatic debridement EN Burn wound Early excision Enzymatic debridement 1 2 2 09/26/22 20220809 NES 220809 Dear Editor, The aim of the letter is to stress the need of creating unified recommendations concerning early burn wound excision in cases of mass casualty burns exclusively. [Extracted from the article]

Background Post-traumatic heterotopic ossification (HO) around the elbow may severely impair joint function. Although surgical excision is effective at restoring range of motion (ROM), traditional surgical treatment is postponed for at least 1 year to prevent recurrence, which leads to secondary contracture of the elbow. Because the optimal timing of resection is controversial, our study was performed to compare recurrence and elbow function between early and late excision in our patients to determine whether the delay is necessary. Methods We retrospectively reviewed 164 patients during a 4-year period. In the control group (112 patients), HO was excised at an average of 23.0 months after initial injury (range, 9-204 months); in the early excision group (52 patients), resection was performed at an average of 6.1 months (range, 3-8 months). HO recurrence was assessed by the Hastings classification system. Final ROM and Mayo Elbow Performance Scores were also evaluated. Results Recurrent HO was observed in 30 of 112 patients (26.8%) in the control group and 15 of 52 (28.9%) in early excision group. No significant difference in HO recurrence was found between the 2 groups ( P = .942). Moreover, there were no notable differences regarding ROM, Mayo Elbow Performance Scores, and complications postoperatively. Conclusions Early excision associated with early exercise is effective for the treatment of HO aiming at a low recurrence rate and satisfactory function. The conventional surgical delay of more than 1 year may be shortened. [ABSTRACT FROM AUTHOR]

Advances in burn care have led to an overall improvement in mortality in high-income countries, but in low-middle income countries mortality remains relatively high. In a limited resource setting where temporary wound closure options were unavailable, it was determined whether early excision as a preliminary treatment could improve prognosis. A retrospective cohort study was conducted in Cipto Mangunkusumo Hospital Burn Unit to evaluate the outcomes of acute burn patients admitted from January 2013 to December 2018 using mortality and lethal area 50 (LA50), and to compare the outcomes between groups who underwent early excision without skin graft (EEWG), early excision with skin graft (EESG), delayed excision without skin graft (DEWG), or delayed excision with skin graft (DESG). Out of 390 patients available for screening, 256 were eligible for further study. The overall mortality was 17.9% with an increase linear with age and total body surface area (TBSA). The overall LA50 was 49%. Preliminary data showed the highest percentage of deaths in the no treatment group, with no deaths seen in treatment groups EESG and DESG. The odds ratio for mortality in the EEWG group was 2.11 (p-value 0.201, CI95% = 0.65-6.80) compared to the DEWG group. LA50 is more objective compared to crude mortality and enables future internal and external comparison. The highest mortality was in the no treatment group with mortality in the EEWG group higher than in the DEWG, but not statistically different. Early excision without skin grafting as a preliminary procedure may still be considered in a limited resource setting., (Copyright © 2022 Euro-Mediterranean Council for Burns and Fire Disasters.)

The study of burn flora is helpful in determining current antibiotic susceptibilities and locating development of multidrug resistant bacterial strains among the unit's usual flora. In this study, we aimed to determine the bacteriological pattern of blood, urine and sputum infections and their correlation with burn wound infections. We used data from our burn registry program. All data on demographics, burn wounds and burn wound infection, bacteria isolated, sensitivity to different antibiotics, burn wound culture, sputum culture, urine culture and catheter tip culture were recorded. We had 1721 hospitalized burn patients. Mean age was 26.3+/-20.25 years old. Mean hospital stay was 14.41 days (range 0-64 days). Mean (SD) TBSA was 16.48 (20.67) years. Mortality rate was 5.9%. Burn wound infection was present in 38.54%. The most frequent species was Staphylococcus spp. (55.1%), followed by Pseudomonas (14.29%), Enterococcus (12.24%), E. coli (4%), Klebsiella and Proteus (both 2%). Urine culture was positive in 27.9%, sputum culture was positive in 1.14%, catheter tip culture was positive in 12.3% and blood culture was positive in 7.6% of the cases. There were correlations between positive wound culture and blood and urine culture, most of them with one bacteria species. The most frequent disseminated bacteria was Pseudomonas aeruginosa and the most sensitive antibiotic was Amikacin. More than 39.2% of our positive culture patients had 3 or more positive cultures, and 36.5% had similar culture results for one bacteria, which was a sign of disseminated infection.

Objectives: To compare the outcomes of early excision and grafting between pediatric and adult patients with deep burns of less than 40% total body surface area burns (TBSA)., Methods: This is a prospective comparative study. Overall, 106 patients admitted to Ghotbodin Burn Center in Shiraz, Iran from September 2012 to September 2013, were included in the study. All patients had less than 40% TBSA burn and had excision and grafting under 14 days from their injury. Patients were divided into two age groups of younger than 14 (n=49) and older than 14 (14-65) years old (n=57). During a 6-month follow-up period, the two groups were compared regarding mean percentage of graft take, total scar score, duration of hospital stay and itching score., Results: During follow-up, the two groups did not show a significant difference in graft take, total scar score and itching score ( p =0.461, p =0.363 and p =0.637, respectively). Clinically, the pediatric group showed less hospital stay (12.25±9.1 vs. 16±12.9), however this was not statistically significant ( p =0.091)., Conclusion: Adults and elderly patients (14-65 years old) compared to pediatric patients (less than 14 years old) with less than 40% TBSA burns, can expect similar results regarding scar score, graft take, itch score and hospital stay, after excision and grafting performed less than two weeks from their initial injury., Competing Interests: None of the authors have any commercial and financial conflicts of interest to be declared regarding the manuscript.