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This was the first study to analyse patients who sustained severe self-induced burns from this common Asian practice. There is a need to raise public awareness and physician attention about the consequences of preventable burn injuries and the importance of first aid in patients with diabetic neuropathy. Retrospective data on 16 consecutive patients who had diabetes and neuropathy admitted to the plastic surgery ward at the Tri-Service General Hospital from January 1, 2015, to February 2, 2021 with burn injuries because of heat applications were collected and analysed for this study. Age, gender, season, first aid adequacy, comorbidity, interventions, total body surface area (TBSA), degree of burn, aetiology, length of stay (LOS), and status at discharge were reviewed. The mean age of the 16 patients was 65.13 years. The most common burn aetiology was contact (50%), followed by scald (37.5%) and radiation burns (12.5%). TBSA burn averaged ± standard deviation 1.54 ± 1.22. Seven patients (44%) had wound infections, and three patients underwent amputations. The average LOS was 28.2 days. Asian practice of heat application is the common aetiology of severe and preventable burn injuries. Education about neuropathy and the consequences of a burn injury should be provided to patients with diabetes., (© 2021 The Authors. International Wound Journal published by Medicalhelplines.com Inc (3M) and John Wiley & Sons Ltd.)

Background and Objective: To deal with burn mass casualty incidents (BMCIs), various countries have established national or regional BMCI emergency response plans (ERPs). A burn care capacity ranking model for hospitals can play an integral role in ERPs by providing essential information to emergency medical services for distributing and handling mass burn patients. Ranking models vary across countries and contexts. However, Taiwan has had no such model. The study aims to develop a ranking model for classifying hospitals' burn care capacity in preparation for the development of a national BMCI ERP., Methods: Multiple methods were adopted. An expert panel provided consultations on data selection and clustering validation. Data on 116 variables from 535 hospitals were collected via open data platforms under the Ministry of Health and Welfare. Data selection and streamlining was conducted to determine 42 variables for cluster analysis. SAS 9.4 was used to analyze the data set -via a hierarchical cluster analysis using Ward's method, followed by a tree-based model analysis to identify the criteria for each cluster. Both internal and external cluster validation were performed., Results: Four clusters of burn care capacity were determined to be a suitable number of clusters. All hospitals were arranged into capacity levels accordingly. Results of the Kruskal-Wallis test showed that the difference between clusters were significant. Tree-based model analysis revealed four determining variables, among which the refined level of emergency care responsibility hospital was found to be most influential on the clustering process. Responses from the questionnaire were used as an external validation tool to corroborate with the cluster analysis results., Conclusion: The use of open government data and cluster analysis was suitable for developing a ranking model to determine hospitals' burn care capacity levels in Taiwan. The proposed ranking model can be used to develop a BMCI emergency response plan and can also serve as a reference for using cluster analysis with open government data to rank care capacity or quality in other domains., Competing Interests: Declaration of Competing Interest None of the authors have any conflicts of interest to disclose., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Introduction: Proper wound care along with the use of skin grafts over deep burn wounds has been the standard treatment. However, the goal in burn wound care has shifted from achieving a satisfactory survival rate to improving long-term form and function of the healed wound, which is sometimes hindered by scar contracture. This has prompted surgeons to find alternative ways to treat burn wounds without compromising function. Among burn cases, hand injuries are the most problematic when it comes to delicate function recovery., Methods: This study presents the results of conjunctive use of a bilayer artificial dermis, negative pressure wound therapy, and split-thickness skin grafts for grafting over acute burn wounds and scar-releasing defects after severe hand burns., Results: Three months after the operation, the scar was soft and pliable, the aesthetic outcome was good, and the patients gained much improvement in hand function and quality oflife., Conclusions: The combined technique achieved a good scar quality and aesthetic effect on burned hands as well as excellent functional outcome, which resulted in major improvements and an independent life for the patient., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To study outcomes among survivors of the mass-casualty powder explosion on 27 June 2015, at Formosa Fun Coast Waterpark, New Taipei City, Taiwan., Methods: Using retrospective data on Taiwanese survivors, we analyzed prehospital management, burns assessment and prognosis, functional recovery, and medical costs, followed-up through 30 June 2017. We related outcomes to burn extent, categorized according to the percentages of total body surface area with second/third-degree burns (%TBSA) or autologous split-thickness skin grafts (%STSG), and an investigational scale: f{SASG} = (%TBSA + %STSG)/2, stratified by %STSG. Analyses included casualty dispersal, comparisons between %TBSA, %STSG and f{SASG}, and their relationships with length of hospitalization, times to rehabilitation and social/school re-entry, physical/mental disability, and medical costs. We also investigated how burn scars restricting joint mobility affected rehabilitation duration., Results: 445 hospitalized casualties (excluding 16 foreigners, 23 with 0% TBSA and 15 fatalities) aged 12-38 years, had mean TBSA of 41.1%. Hospitalization and functional recovery durations correlated with %TBSA, %STSG and f{SASG} - mean length of stay per %TBSA was 1.5 days; more numerous burn scar contractures prolonged rehabilitation. Females had worse burns than males, longer hospitalization and rehabilitation, and later school/social re-entry; at follow-up, 62.3% versus 37.7% had disabilities and 57.7% versus 42.3% suffered mental trauma (all p ≤ 0.001). Disabilities affecting 225/227 people were skin-related; 34 were severely disabled but 193 had mild/moderate impairments. The prevalence of stress-related and mood disorders increased with burn extent. Treatment costs (mean USD-equivalents ∼$48,977/patient, ∼$1192/%TBSA) increased with burn severity; however, the highest %TBSA, %STSG and f{SASG} categories accounted for <10% of total costs, whereas TBSA 41-80% accounted for 73.2%., Conclusions: Besides %TBSA, skin-graft requirements and burn scar contractures are complementary determinants of medium/long-term outcomes. We recommend further elucidation of factors that influence burn survivors' recovery, long-term physical and mental well-being, and quality of life., (Copyright © 2020 The Authors. Published by Elsevier Ltd.. All rights reserved.)

A mass casualty incident (MCI) can have an enormous impact on an already crowded emergency department (ED), affecting the quality of health care provided to non-MCI ED patients. On June 26, 2015, a burn MCI (BMCI) occurred due to a cornstarch explosion at a party at a water park. The competing needs of the BMCI patients might have crowded out the needs of the non-BMCI patients. Although crowd-out effects have been previously documented in a variety of health care situations, they have not been extensively evaluated during MCIs. We aimed to determine whether the outcomes of the non-MCI patients were compromised during this incident.We conducted a retrospective observational study comparing several health care parameters and outcomes between non-BMCI patients and historical controls during the designated period using institutional electronic records and the National Health Insurance Research Database.On the night of the incident, 53 patients were sent to our ED; most of them arrived within 3 hours after the BMCI. There was a significant increase in the wait time for ICU beds among non-BMCI patients compared to the wait times during the corresponding week of the previous year (8.09 ± 4.21 hours vs 3.77 ± 2.15 hours, P = .008). At the hospital level, there was a significantly increased length of hospital stay (LOS) in the ICU after the MCI compared with the LOS in the ICU in the same week of the preceding year (median days: 15 vs 8, P ≤ .001). At the regional level, there were no significant differences between the 2 periods in the LOS in acute care, LOS in the ICU or mortality rates at the involved medical centers.Crowd-out effects from the MCI occurred in the ED and at the institutional level. Although there was an increased wait time for admission to the ICU and a longer LOS in the ICU, the LOS in acute care beds, treatment of time-sensitive diseases, and mortality rates were not compromised by the current MCI protocol at either the institutional or regional levels.

Early initiation of enteral nutrition improves clinical outcomes in critical patients with serious burns. Post-pyloric tube feeding is a valuable therapeutic option for severely burned patients with poor gastric emptying. How early post-pyloric feeding can be initiated to provide more benefits to patients has not yet been examined. A fire erupted at a recreational water park in New Taipei City, Taiwan, on June 27, 2015. The results of early initiation versus delayed post-pyloric feeding in severely burned patients in this mass-casualty incident were compared. Door-to-post-pyloric feeding time ≤ 24 h was considered as early post-pyloric feeding (EPF) and that > 24 h was considered as delayed post-pyloric feeding (DPF). Thirteen patients with severe burn injuries (> 40% of the total body surface area) were assigned to undergo either EPF (five patients) or DPF (eight patients). This study is a "fortuitously controlled" study, and the authors were able to formulate and test whether EPF is better than DPF by comparing the two groups. In patients in the EPF, the intake of calories increased rapidly and was maintained throughout the study period. In addition, rapid restoration of plasma magnesium concentrations as well as pronounced recovery of platelet count in the EPF group was observed. In conclusion, our findings indicate that the time from injury to the onset of post-pyloric feeding is crucial, and EPF allows for the administration of calculated caloric needs. Therefore, EPF can be successfully initiated with beneficial outcomes of nutritional reconstruction in severely burned patients.

Platelet-rich plasma (PRP) is a kind of plasma that is rich in platelets after processing. It includes various growth factors and cytokines, which speed up the process of wound healing and hemostasis. The PRP solution used in this study is diluted from lyophilized PRP powder, which decreased the possibility of contamination, facilitated the storage, and prolonged the storage life. From in vitro fibroblast proliferation testing, the numbers of PRP supplement were performed for 1, 4, and 7 times by continuous replacement of culture medium each day. Four times of lyophilized PRP supplement was selected for clinical study due to sufficient promotion of fibroblast proliferation. Next, 27 patients of deep second-degree burn wound were included in this study. Patients were assigned to two groups: PRP group (n = 15) and control group (n = 12). A concentration of 1.0 × 10 platelets/cm (wound area) according to wound size was sprayed on the wound evenly. Function was mainly assessed by the percentage of wound closure and bacteria picking out rate in 2 and 3 weeks. The wound closure at 3 weeks showed a significant difference in PRP group (P < 0.05). The healing rate of PRP group reached nearly 80% and made a breakthrough of 90% in 3 weeks, showing a significant difference compared with the control group (P < 0.05). Lyophilized PRP can be considered as an effective treatment to increase healing rate in patients with deep second-degree burn injury.

Background: Adequate fluid titration during the initial resuscitation period of major burn patients is crucial. This study aimed to evaluate the feasibility and efficacy of a goal-directed fluid resuscitation protocol that used hourly urine output plus the arterial waveform analysis FloTrac (Edwards LifeSciences, Irvine, Calif) system for major burns to avoid fluid overload., Methods: We conducted a retrospective cohort study of 43 major burn patients at the Tri-Service General Hospital after the Formosa Fun Coast Dust Explosion on June 27, 2015. Because of the limited capacity of intensive care units (ICUs), 23 intubated patients were transferred from the burn wards or emergency department to the ICU within 24 hours. Fluid administration was adjusted to achieve a urine output of 30 to 50 mL/h, cardiac index greater than 2.5 L/min/m, and stroke volume variation (SVV) less than 12%. The hourly crystalloid fluid infusion rate was titrated based on SVV and hourly urine output., Results: Of the 23 critically burned patients admitted to the ICU, 13 patients who followed the goal-directed fluid resuscitation protocol within 12 hours postburn were included in the analysis. The mean age (years) was 21.8, and the mean total body surface area (TBSA) burned (%) was 68.0. The mean Revised Baux score was 106.8. All patients sustained inhalation injury. The fluid volumes administered to patients in the first 24 hours and the second 24 hours (mL/kg/% total body surface area) were 3.62 ± 1.23 and 2.89 ± 0.79, respectively. The urine outputs in the first 24 hours and the second 24 hours (mL/kg/h) were 1.13 ± 0.66 and 1.53 ± 0.87, respectively. All patients achieved the established goals within 32 hours postburn. In-hospital mortality rate was 0%., Conclusions: The SVV-based goal-directed fluid resuscitation protocol leads to less unnecessary fluid administration during the early resuscitation phase. Clinicians can efficaciously manage the dynamic body fluid changes in major burn patients under the guidance of the protocol.

Significant skin pigmentation changes occur when patients suffer deep burn injuries. These pigmentation disorders may cause not only cosmetic and psychological issues, but more importantly it increases the risk of skin cancer or photoaging. Severe burns significantly effect on the process of repigmentation as the pigmentation is tightly regulated by cell proliferation and differentiation of melanocytes and melanocyte stem cells which are housing in the epidermis and hair follicles of the skin. In the present review, we discuss the possible mechanisms to replenish the melanocytes from the healthy epidermis and hair follicles surrounding burn wounds. The molecular mechanisms of skin repigmentation following healing of burn injuries includes the differentiation of melanoblasts into melanocytes, the distribution and responses of melanocytes and melanocyte stem cells after burn injury, and the regulation of melanin production. We also reviewed advanced therapeutic strategies to treat pigmentation disorders, such as convectional surgery, laser, UV treatment and emerging concepts in skin tissue-engineering., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Alginate is a natural rich anionic polysaccharide (APS), commonly available as calcium alginate (CAPS). It can maintain a physiologically moist microenvironment, which minimises bacterial infection and facilitates wound healing at a wound site. Patients with burn injuries suffer from pain and an inflammatory response. In this study, we evaluated the CAPS dressing and traditional dressing containing carboxymethyl cellulose (CMC) for wound healing and scar tissue formation in a burn model of rat and swine. In our pilot study of a burn rat model to evaluate inflammatory response and wound healing, we found that the monocyte chemoattractant protein (MCP)-1 and transforming growth factor (TGF)-β were up-regulated in the CAPS treatment group. Next, the burn swine models tested positive for MCP-1 in a Gram-positive bacterial infection, and there was overproduction of TGF-β during the burn wound healing process. Rats were monitored daily for 1 week for cytokine assay and sacrificed on day 28 post-burn injury. The swine were monitored over 6 weeks. We further examined the pain and related factors and inflammatory cytokine expression in a rodent burns model monitored everyday for 7 days post-burn. Our results revealed that the efficacy of the dressing containing CAPS for wound repair post-burn was better than the CMC dressing with respect to natural wound healing and scar formation. The polysaccharide-enriched dressing exerted an antimicrobial effect on burn wounds, regulated the inflammatory response and stimulated anti-inflammatory cytokine release. However, one pain assessment method showed no significant difference in the reduction in levels of adenosine triphosphate in serum of rats after wound dressing in either the CAPS or CMC group. In conclusion, a polysaccharide-enriched dressing outperformed a traditional dressing in reducing wound size, minimising hypertrophic scar formation, regulating cytokines and maximising antimicrobial effects., (© 2017 Medicalhelplines.com Inc and John Wiley & Sons Ltd.)

Background: Despite major advances in therapeutic strategies for the management of patients with severe burns, significant morbidity and mortality is observed. Hyperbaric oxygen therapy (HBOT) increases the supply of oxygen to burn areas. The aim of this study was to determine whether HBOT is effective in the treatment of major thermal burns., Methods: On June 27, 2015 in New Taipei, Taiwan, a mass casualty disaster occurred as fire erupted over a large crowd, injuring 499 people. Fifty-three victims (20 women and 33 men) were admitted to Tri-Service General Hospital. Thirty-eight patients underwent adjunctive HBOT (HBOT group), and 15 patients received routine burn therapy (control group). Serum procalcitonin (PCT) level, a sepsis biomarker, was measured until it reached normal levels (<0.5μg/L). The records of all patients from June 2015 to March 2016 were analyzed retrospectively. Outcome measures that were compared between the groups included the use of tracheostomy and hemodialysis, total body surface area (TBSA) and the number of skin graft operations, length of hospital stay, infection status, and mortality., Results: The mean age of the patients was 22.4 years, and the mean TBSA was 43%. All the patients survived and were discharged without requiring limb amputation or being permanently disabled. Patient characteristics did not differ significantly between the groups. PCT levels returned to normal significantly faster (p=0.007) in the HBOT group., Conclusion: Multidisciplinary burn care combined with adjunctive HBOT improves sepsis control compared with standard treatment without HBOT. Prospective studies are required to define the role of HBOT in extensive burns., (Copyright © 2016 Elsevier Ltd and ISBI. All rights reserved.)

Introduction: Explosion injury is very common on the battlefield and is associated with major burn and inhalation injuries and subsequent high mortality and morbidity rates. Here we report six victims who suffered from explosion injuries caused by stun grenade; all were treated with extracorporeal membrane oxygenation (ECMO) as salvage therapy. This study was aimed to evaluate the indications and efficacy of ECMO in acute and critically ill major burn patients., Methods: This was a retrospective analysis of six patients from Tri-Service General Hospital, National Defense Medical Center in Taiwan. All suffered from major burns with 89.0±19.1% average of total body surface area over second degree (TBSA; range, 50-99%). ECMO was used due to inhalation injury in five patients and cardiogenic shock in one patient. The average interval to start ECMO was 26.5±19.0h (range, 14-63h). Venoarterial ECMO was used on in four patients due to unstable hemodynamic status, whereas venovenous ECMO was used in two patients for sustained hypoxemia., Results: All patients had rhabdomyolysis with acute renal failure. The average duration of ECMO was 169.6±180.9h (range, 27-401h). All patients developed coagulopathy and needed debridement surgery during ECMO support, and five underwent torso escharotomy due to inspiratory compromise. Only one patient whose second and third degree burns covered 50% TBSA was successfully weaned from ECMO and survived; he was discharged after 221 hospital days. All patients who died had second and third degree burns covering over 90% of their TBSA. Three patients died of multiple organ failure, one died of septic shock, and the other died of cardiogenic shock. Overall survival rate was 16.7%., Conclusions: In acute and critically ill major burn patients, ECMO could be considered as a salvage therapy, particularly in those with inhalation injury and burn-related acute respiratory distress syndrome. However, ECMO does not seem to provide benefits for circulatory support in those with hemodynamic compromise. The use of ECMO in these patients is still investigational, as our data provided no benefit in terms of the outcomes or survival, particularly in those with more than 90% TBSA burns., (Copyright © 2016 Elsevier Ltd and ISBI. All rights reserved.)

Purpose: Firewalking is a common Taoist cleansing ceremony in Taiwan, but burns associated with the practice have rarely been reported. We analyzed the patients with plantar burns from one firewalking ceremony., Materials and Methods: In one firewalking ceremony, 12 Taoist disciples suffered from contact burns to the soles of their feet while walking over burning coals. Eight of them had at least second-degree burns over areas larger than 1% of their total body surface areas (TBSAs). The age, sex, medical history, date of injury, time taken to traverse the fire pit, depth and TBSA of the burns, treatment, length of stay, and outcome were recorded and analyzed., Results: Deep, disseminated second- to third-degree burns were noted and healing took as long as three weeks in some patients. Because disseminated hypertrophic scars form after burns, the soles involved regain much of their tensile strength while walking. The patients experienced only a few difficulties in their daily lives three months after injury., Conclusion: From our experience treating patients with deep disseminated second- to third-degree plantar burns caused by firewalking, we conclude that they should be treated conservatively, with secondary healing rather than a skin graft., (Copyright © 2011 Elsevier Ltd and ISBI. All rights reserved.)

Accurate estimates of the surface area of burns are important for initial fluid resuscitation and prognosis of burn victims. The area of the surface of the open hand is often used to estimate the area of a burn. Although it is accepted that hand surface area is generally equal to 1% of total body surface area among Caucasians, this ratio has not been verified for Chinese people. We used two-dimensional projection to estimate the hand surface areas of Chinese adults. The area of the palm was 0.44% of total body surface area among men and 0.42% among women. The area of the hand, including that of the thumb and fingers, was 0.76% of total body surface area among men and 0.73% among women. We conclude that the ratio between hand and total body surface area among Chinese adults differs from the ratio among Caucasians, and suggest an adjustment of the ratio for use with Chinese people.

Over the last half century, advances in treatment have changed the principal cause of death in burn patients from burn shock and wound sepsis to pulmonary sepsis, of which inhalation injury has always played a key role in morbidity and mortality. Even though Navar et al., Am. J. Surg. 1985;150:716-720 have noted that patients with inhalation injury had a mean fluid requirement of 5.8 ml/kg/% burn to achieve resuscitation from early burn shock, while patients without inhalation injury required only a mean fluid of 4.0 ml/kg/% burn, to achieve successful resuscitation in inhalation injured patients with minimum but adequate fluid has always been a challenge. To further define the difference of early fluid therapy between inhalation and noninhalation in extensively burned patients, a retrospective analysis was carried out in the Tri-Service General Hospital. Sixty-two flame burned patients (aged from 16 to 81 years-old with a mean age of 33.2+/-15.1 years: with burn size ranging from 30% to 98% TBSA with a mean burn size of 60.5+/-22.7%; 26 with inhalation injury; noninhalation 36) were reviewed during a 5-year period. The Parkland formula is the initial choice of fluid regimen with 4 ml/kg/% burn and the amount of replacement is monitored by urine output and is titrated to maintain urine output between 0.5 and 1.0 ml/kg/h. The mean amounts of fluid requirements of both inhalation and noninhalation burned patients were 3.1 +/- 1.0 and 2.3+/-0.8 ml/kg/% burn respectively (p < 0.05). Our study showed less fluid requirement for both inhalation and noninhalation injured patients in comparison with the Navar study and Parkland predictions in the first 24 h postburn. Furthermore, the inhalation injured patients definitely required volumes of fluid in excess of those required in noninhalation injured cases.