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This prospective observational study was performed to analyze the clinical outcomes of patients with massive burns treated using cultured epithelial autografts (CEAs) and to determine the association of this treatment with survival outcomes. During 2006-2013, total 177 massive-burns subjects treated with (96 subjects) or without (81 subjects) CEAs. Data were analyzed using the independent t test or chi-square test. Multivariate logistic regression, Kaplan-Meier survival, and Cox regression analyses were performed to evaluate the factors that influenced mortality. Age, percentage of total body surface area burned, incidence of inhalation injury, allograft-application rate, Abbreviated Burn Severity Index score, length of hospital stay, and mortality significantly differed between the CEA and noncultured epithelial autograft groups. Mortality and other clinical parameters did not differ between the sheet-type and spray-type CEA groups. Allograft application (odds ratio, 4.44; p < 0.01) significantly influenced CEA application. The CEA group showed significantly higher survival rates (p = 0.05). Cultured epithelial autografting had a hazard ratio of 0.55 (p = 0.02) and 0.59 (p = 0.05) according to the uni- and multivariate Cox regression analysis, respectively. In conclusion, early and aggressive allograft application is required to facilitate CEA application. Furthermore, the use of CEAs was associated with a lower mortality, but this result should be interpreted with caution as the groups were not randomized., (© 2015 by the Wound Healing Society.)

Purpose: To determine epidemiological trends among burns patients admitted to our burns center during 2003-2012, and the usefulness of the Abbreviated Burns Severity Index (ABSI) for predicting burns-related mortality., Methods: We retrospectively reviewed the data of 4481 burns patients. We analyzed the epidemiological trends and ABSI scores using Student t-test and one-way analysis of variance (continuous variables), chi-square test (categorical variables) and stepwise logistic-regression analysis (predictors of mortality)., Results: The mean age and male-to-female ratio were 39.9±19.7 years and 2.88, respectively. ABSI scores decreased from 7.7±3.0 in 2003 to 6.9±3.0 in 2012. Mortality rate improved from 24.5% in 2003 to 15.8% in 2012. Burns were caused by flames (67.3%), scalding (22.0%) and electrical (7.5%), chemical (1.6%) and contact (1.5%) injuries. Scalding and flames were the most common causes in patients aged ≤20 years and ≥21 years, respectively. Female sex, inhalation injury, full-thickness burns, large total body surface area (TBSA) burned and old age predicted mortality. ABSI scores <4 and >14 were associated with 0.7% and >90% mortality, respectively., Conclusions: The mortality of major burns has decreased but remains high. ABSI scores predict burns-related mortality., (Copyright © 2014 Elsevier Ltd and ISBI. All rights reserved.)

Background: Major burn injuries induce inflammatory responses and changes in the levels of various cytokines. This study was conducted to assess early changes in the serum levels of inflammatory cytokines after burn injury, identify cytokines associated with mortality, and characterize correlations among cytokines., Methods: Blood samples of 67 burn patients were collected on days 1 and 3 after burn injury, and the concentrations of 27 cytokines were measured using the Bio-Plex Suspension Array System (Bio-Rad Laboratories, USA). Blood samples of 25 healthy subjects were used as controls. We analyzed statistical differences in the concentrations of each cytokine between the control and patient groups, between day 1 and day 3, and between survival and nonsurvival groups. Correlations among 27 cytokines were analyzed., Results: Median concentrations of granulocyte colony-stimulating factor (G-CSF), granulocyte macrophage colony-stimulating factor (GM-CSF), interleukin 1 receptor antagonist (IL-1RA), interleukin 6 (IL-6), interleukin 8 (IL-8), interleukin 10 (IL-10), interleukin 15 (IL-15), monocyte chemoattractant protein-1 (MCP-1), macrophage inflammatory protein 1β (MIP-1β), and vascular endothelial growth factor (VEGF) were significantly higher in burn patients than in controls. IL-1RA, IL-6, and MCP-1 levels were significantly higher in the nonsurvival group than in the survival group on day 1 after burn injury. Correlation analysis of 27 cytokines showed different relationships with one another. Stronger correlations among interferon γ (IFN-γ), IL-2, IL-4, IL-7, IL-12p70, and IL-17 were found., Conclusions: IL-1RA, IL-6, and MCP-1 may be used as prognostic indicators of mortality in burn patients and the increase in cytokine concentrations is induced by interactions within a complex network of cytokine-related pathways.

This study was to re-evaluate inhalation injury as a prognostic factor in burn patients and to determine the factors that should be considered when refining the definition of inhalation injury. A total of 192 burn patients (152 men, 40 women; mean age, 46.1±13.8 years) who were suspected to have an inhalation injury and underwent bronchoscopy between January 2010 and June 2012 were included in this prospective observational study. All patients underwent bronchoscopy within 24h of sustaining the burn. The bronchoscopic findings were classified as normal, mild, moderate, and severe. Mechanical ventilation was administered, when required. Age, percentage of TBSA burned, ABSI score, requirement of mechanical ventilation and PF ratio, but not inhalation injury, COHb level, and bronchoscopic grades, significantly differed between the survivors and non-survivors (p<0.05). Mechanical ventilation (adjusted odds ratio [OR]: 9.787) and severe inhalation injury on bronchoscopy (adjusted OR: 45.357) were independent predictors of mortality on multivariate logistic regression analysis. Inhalation injury diagnosed through history does not predict mortality from burns. Other components such as severity of inhalation injury determined using bronchoscopy, and administration of mechanical ventilation might help predict the morbidity and mortality of burn patients with inhalation injury and all of the factors should be considered when the definition of inhalation injury is refined., (Copyright © 2014 Elsevier Ltd and ISBI. All rights reserved.)

This study is a phase 1 and 2 clinical trial for investigating the safety profile, effective treatment dose and effectiveness of the newly developed thermosensitive hydrogel-type cultured epidermal allograft. For phase 1, the keratinocytes were divided into 3 groups as follows, with 5 patients in each group: (1) low-dose group (6.7×10(6)/1.5mL), (2) medium-dose group (2×10(7)/1.5mL), and (3) high-dose group (6.0×10(7)/1.5mL). The second phase of the trial proceeded with 10 cases after choosing the most effective dose based on the analysis of the first phase. When comparing re-epithelialization time, medium- and high-dose group showed significantly shorter re-epithelialization time than low-dose group (p=0.003 and p=0.002). A total of 15 cases, 5 cases selected from phase 1 and 10 cases test in phase 2 with the medium dose, were compared with the re-epithelialization period. The re-epithelialization period was 9.6±4.0 days in the test site and 12.4±4.8 days in the control site. In the test site, re-epithelialization was 2.8±1.8 days faster than in the control site (p<0.0001). There was no significant adverse reaction in our clinical trial. In conclusion, this new type of CEAllo accelerates wound healing time and shows the safety., (Copyright © 2014 Elsevier Ltd and ISBI. All rights reserved.)

Objective: To evaluate the effect of burn rehabilitation massage therapy on hypertrophic scar after burn., Method: One hundred and forty-six burn patients with hypertrophic scar(s) were randomly divided into an experimental group and a control group. All patients received standard rehabilitation therapy for hypertrophic scars and 76 patients (massage group) additionally received burn scar rehabilitation massage therapy. Both before and after the treatment, we determined the scores of visual analog scale (VAS) and itching scale and assessed the scar characteristics of thickness, melanin, erythema, transepidermal water loss (TEWL), sebum, and elasticity by using ultrasonography, Mexameter(®), Tewameter(®), Sebumeter(®), and Cutometer(®), respectively., Results: The scores of both VAS and itching scale decreased significantly in both groups, indicating a significant intragroup difference. With regard to the scar characteristics, the massage group showed a significant decrease after treatment in scar thickness, melanin, erythema, TEWL and a significant intergroup difference. In terms of scar elasticity, a significant intergroup difference was noted in immediate distension and gross skin elasticity, while the massage group significant improvement in skin distensibility, immediate distension, immediate retraction, and delayed distension., Conclusion: Our results suggest that burn rehabilitation massage therapy is effective in improving pain, pruritus, and scar characteristics in hypertrophic scars after burn., (Copyright © 2014 Elsevier Ltd and ISBI. All rights reserved.)

Background: The purpose of this study is to clarify the clinical significance of serum transthyretin (TTR) in massively burned patients in nutrition support and clinical severity., Methods: A retrospective study was performed with 204 patients admitted to Hangang Sacred Heart Hospital's Burn Center September 2010-September 2012 with burn wounds > 20% of total body surface area (TBSA) burned. Serum TTR, C-reactive protein (CRP), lactic acid, and an NST index (calculated by dividing real caloric intake by estimated caloric need for 7 days) were analyzed on a weekly basis for 5 weeks after admission., Results: When we classified patients with severity according to mortality, percentage of TBSA burned, serum lactic acid, and CRP, mean serum TTR level was significantly higher in the less severe patient group than in the severe patient group in each week for every severity index. And the serum TTR level did not show significant differences by NST index in both the severe patient group and the less severe patient group. In a multivariate logistic regression, percentage TBSA burned, TTR, and lactic acid had an independent association with mortality., Conclusion: Serum TTR did not show a significant difference by nutrition support in massively burned patients with >20% of TBSA burned. But serum TTR was significantly different by the severity of the patient and independently associated with mortality. Hence, serum TTR level can be 1 of the useful biomarkers for comprehending the severity of the illness in massively burned patients., (© 2013 American Society for Parenteral and Enteral Nutrition.)

Introduction: The reported mortality rates range from 28% to 100% in burn patients who develop acute kidney injury (AKI) and from 50% to 100% among such patients treated with renal replacement therapy. Recently, the serum cystatin C and plasma and urine neutrophil gelatinase-associated lipocalin (NGAL) levels have been introduced as early biomarkers for AKI; the levels of these biomarkers are known to increase 24 to 48 hours before the serum creatinine levels increase. In this study, we aimed to estimate the diagnostic utility of the cystatin C and plasma and urine NGAL levels in the early post-burn period as biomarkers for predicting AKI and mortality in patients with major burn injuries., Methods: From May 2011 to July 2012, 90 consecutive patients with a burn wound area comprising ≥ 20% of the total body surface area (TBSA) were enrolled in this study. Whole blood and urine samples were obtained for measuring the serum creatinine, serum cystatin C, and urine and plasma NGAL levels at 0, 3, 6, 12, 24, and 48 hours after admission. Receiver operating characteristic curve, area under the curve, and multivariate logistic regression analyses were performed to assess the predictive values of these biomarkers for AKI and mortality., Results: In the multivariate logistic regression analysis, all variables, including age, percentage TBSA burned, sex, inhalation injury, and serum creatinine levels, serum cystatin C levels, and plasma and urine NGAL levels were independently associated with AKI development. Moreover, age, sex, percentage TBSA burned, and plasma and urine NGAL levels were independently associated with mortality. However, inhalation injury and the serum creatinine and cystatin C levels were not independently associated with mortality., Conclusions: Massively burned patients who maintained high plasma and urine NGAL levels until 12 hours after admission were at the risk of developing early AKI and early mortality with burn shock. However, the plasma and urine NGAL levels in the early post-burn period failed to predict late AKI and non-burn shock mortality in this study. Nevertheless, the plasma and urine NGAL levels were independently associated with AKI development and mortality within 48 hours after admission.

Introduction: Pain management is an important aspect of burn management. We developed a routine pain monitoring system and pain management protocol for burn patients. The purpose of this study is to evaluate the effectiveness of our new pain management system., Methods: From May 2011 to November 2011, the prospective study was performed with 107 burn patients. We performed control group (n=58) data analysis and then developed the pain management protocol and monitoring system. Next, we applied our protocol to patients and performed protocol group (n=49) data analysis, and compared this to control group data. Data analysis was performed using the Numeric Rating Scale (NRS) of background pain and procedural pain, Clinician-Administered PTSD Scale (CAPS), Hamilton Depression Rating Scale (HDRS), State-Trait Anxiety Inventory Scale (STAIS), and Holmes and Rahe Stress Scale (HRSS)., Results: The NRS of background pain for the protocol group was significantly decreased compared to the control group (2.8±2.0 versus 3.9±1.9), and the NRS of procedural pain of the protocol group was significantly decreased compared to the control group (4.8±2.8 versus 3.7±2.5). CAPS and HDRS were decreased in the protocol group, but did not have statistical significance. STAIS and HRSS were decreased in the protocol group, but only the STAIS had statistical significance., Conclusion: Our new pain management system was effective in burn pain management. However, adequate pain management can only be accomplished by a continuous and thorough effort. Therefore, pain control protocol and pain monitoring systems need to be under constant revision and improvement using creative ideas and approaches., (Copyright © 2012 Elsevier Ltd and ISBI. All rights reserved.)

Background: Hypophosphatemia is relatively common phenomenon in patients with massive burn injury. Therefore, we check serum phosphate level routinely and try to supply phosphate in a timely manner. The purpose of this study was to investigate the change of the serum phosphate level of early postburn period and the impact of hypophosphatemia on the prognosis of patients., Methods: A total of 227 patients with burn injury were reviewed retrospectively. We performed analysis of serum phosphate level within 20 days from burn injury., Results: Patients' mean (SD) age was 47.0 (14.1) years, and mean (SD) percentage of total body surface area burned were 47.7 (21.9). Severe hypophosphatemia (phosphate < 1.0 mg/dL) was observed in 35 patients (15.8%), and moderate hypophosphatemia (1.0 ≤ phosphate < 2.0 mg/dL) was found in 115 patients (50.6%). Therefore, overall incidence of hypophosphatemia was 66.4%. There was no significant difference in serum phosphate level with survival, total body surface area burned, and mechanical ventilation. Age (odds ratio [OR], 3.180; 95% confidence interval [CI], 1.025-9.871; p = 0.045), total body surface area burned (OR, 20.934; 95% CI, 6.845-64.024; p = 0.000), and mechanical ventilation (OR, 5.581; 95% CI, 2.380-13.085; p = 0.002) were independently associated with mortality. However, serum phosphate level (OR, 0.828; 95% CI, 0.275-2.495; p = 0.737) does not have a statistical significance., Conclusion: Although multiple studies have evaluated the efficacy and safety of phosphate repletion regimens, the effect on mortality and morbidity is not well reported. However, our results show that patients with massive burn injury have high incidence of hypophosphatemia, and hypophosphatemia can result in many complications. Therefore, routine check and supply of phosphate can be suggested in patients with massive burn injury., Level of Evidence: Prognostic study, level II.

Background: Major burn injury induces an inflammatory response that is accompanied by the release of various cytokines. We investigated the gradual changes in the levels of pro-inflammatory and anti-inflammatory cytokines following burn injury and determined the relationship between these levels and burn size in adult Korean patients with burn injury., Methods: Blood samples from 9 healthy controls and 60 Korean burn patients were collected on days 1, 3, 7, 14, and 21 after burn injury, and concentrations of interleukin (IL)-6, IL-8, IL-10, tumor necrosis factor (TNF)-α, and granulocyte-colony stimulating factor (G-CSF) were measured. Burn patients were divided into 3 groups according to burn size (15-30%, 31-50%, >50% total body surface area), and the concentrations of the cytokines were compared between these groups and the control group over 3 weeks., Results: Compared to their levels in controls, IL-6, IL-8, IL-10, TNF-α, and G-CSF levels in burn patients were significantly higher during the observation period. Median concentrations of IL-8, IL-10, and G-CSF at each time point increased with burn size, although peak levels and time to peak levels of these cytokines differed from patient to patient., Conclusions: These findings indicate that IL-6, IL-8, IL-10, TNF-α, and G-CSF are important mediators in inflammatory changes after burn injury; however, various factors, including burn size, may influence the concentrations of these cytokines.

Background: We observed that serum transthyretin (TTR) levels consistently remain low when patients' general conditions are poor, despite adequate nutritional support. We conducted this study to analyze the changes of serum TTR over time from injury in massively-burned patients and verify the validity of prediction by clinical outcomes, which are assessed via serum TTR in the early postburn period., Methods: From January 2005 to December 2010, the samples of serum TTR from 471 burn patients (mean % total body surface area [TBSA] burned, 51% ± 20%) were analyzed with time frames from injury retrospectively., Results: Serum TTR significantly decreased during the period from day 5 to day 10 postinjury in both the survival group (n = 290, mean %TBSA burned, 42.9% ± 14.2%) and nonsurvival group (n = 181, mean %TBSA burned, 64.6% ± 20.8%). However, after this period, the serum TTR constantly increased in the survival group but remained low in nonsurvivors. At all time, the levels of serum TTR obtained from survivors were significantly higher than those of nonsurvivors. The serum TTR had weak correlation with the extent of the burn injury (r = -0.234). Survival rates of the patients increased significantly by the increase of the serum TTR of early postburn period. In multivariable model, age (odds ratio [OR], 1.054; 95% confidence interval [CI], 1.043-1.066; p = 0.000), TBSA burned (OR, 1.058; 95% CI, 1.051-1.066; p = 0.000), sex (OR, 0.720; 95% CI, 0.547-0.947; p = 0.019), and serum TTR during early postburn period (OR, 1.05; 95% CI, 0.873-0.972; p = 0.003) were independently associated with mortality., Conclusions: The serum TTR of early postburn period can be used as a prognostic markers, and low serum TTR can be used as a signal for screening out the patients at risk who need careful assessment and monitoring at an early stage.

We address the clinical application of the suspension type cultured epithelial autografts (CEAs), Keraheal™ (MCTT, Seoul, Korea), along with the effects, application method, merits and demerits thereof. From February 2007 to June 2010, 29 burn patients with extensive burns, participated in the suspension type of CEA clinical test. A widely meshed autograft (1:4-6 ratio) was applied to the wound bed and the suspension type CEA was sprayed with a Tissomat cell sprayer, followed by a Tissucol spray, a fibrin sealant. The patients' (men/women=26/3) median (interquartile ranges) age was 42 (30-49) years old, the burned TBSA was 55 (44-60) %, and the full thickness burn area was 40 (30-46.5) %. The area of Keraheal™ applied was 800 (400-1200) cm(2). The take rate was 96 (90.5-99) % and 100 (98.5-100) % at 2 and 4 weeks after treatment with Keraheal™, respectively. The Vancouver burn scar scale was 5 (4-6.5), 4 (3-6), and 3 (2-4) at 8, 12 and 24 weeks after the Keraheal™ application. Widely meshed autograft must be applied in massive burns but it's take rate is greatly reduced. The CEAs enhance the take rate of a wide meshed autograft in massive burns and allow for grafting wide meshed autograft together with acellular dermal matrix in some cases., (Copyright © 2011 Elsevier Ltd and ISBI. All rights reserved.)

In efforts to prevent and reduce joint contracture and scar formation after burn, we used the acellular human dermis (AlloDerm) as a dermal replacement in the acute stage. A total of 64 patients received AlloDerm graft selectively on joint areas during the study period from March, 2005 to July, 2007. From January to March, 2008, a total of 31 patients returned to our burn center to examine the functional results by measuring range of motion of joints. Additionally, the quality of grafted skin condition criteria of skin elasticity, scar thickness, trans-epidermal water loss, melanin and erythema level was measured in a total of 11 patients among them. By analyzing the limitation level of 55 joints excluding hand areas, we found that 24 joints (43.6%) showed no limitations, 12 joints (21.8%) showed limitations below 10%, 16 joints (29.1%) showed limitations between 10 and 19% and 3 joints (5.5%) showed limitations over 20%. The scar thickness of non-AlloDerm applied areas was 2.5+/-0.9 mm and AlloDerm applied areas was 1.8+/-0.7 mm (p = 0.396). Trans-epidermal water loss for non-AlloDerm applied areas was 20.9+/-7.7 g/h/m(2) and AlloDerm applied areas was 10.8+/-3.4 g/h/m(2) (p<0.001). Erythema value for non-AlloDerm applied areas was 436.1+/-65.8, whereas AlloDerm applied area was 394.4+/-61.2 (p<0.001). Acellular dermal matrix is a good option for treating major burns to prevent scar formation after burn and loss of joint function., (Copyright 2009 Elsevier Ltd and ISBI. All rights reserved.)

Pruritus (itching) constitutes a source of severe distress for burn patients. The authors administered naltrexone to burn patients suffering from itching that was refractory to treatment with antihistamine and anticonvulsant medications to examine the efficacy of this medication as a treatment for pruritus in burn patients. Nineteen burn patients admitted to the Hallym Burn Center at Hangang Sacred Heart Hospital in Seoul, Korea, with burns over 40.32% (+/-18.3) of their total body surface were recruited for this study. The mean number of postburn days before naltrexone treatment was 157.3 days (+/-114.7). The authors observed a significant decrease in itching sensations after 2 weeks of treatment with naltrexone (z = -3.32, P = .001). Scratching activity was also decreased in 44.5% (+/-20.5) of subjects. The authors propose that naltrexone constitutes a potential antipruritic medication for burn patients suffering from treatment-refractory itching.

The aim of this study was to estimate the pharmacokinetics (PK) of arbekacin in burn patients using a population-PK approach. Therapeutic drug monitoring data consisting of 126 plasma concentrations (including 17 values that were below the quantitation limit) from 47 burn patients were retrospectively analyzed using a mixed effect method (NONMEM, ver. 6.0). Covariates, such as burn index, age, sex, among others, were tested on the basic one-compartment model. In the basic model, positive correlations of body weight (WT) and creatinine clearance (CLcr) on total clearance (CL) and volume of distributions (V) were assumed. In the final model, V increased with burn index (BI). The final model was: CL(L/h) = 3.18x WT/ 70 + 4.49x CLcr/120; V(L) = 27.5x WT/70 + 0.28x (BI-23.5). Between-subject variability in terms of CL and V were 35 and 39%, respectively. The CL of our burn patients was significantly greater than that reported in unburned patients, and V increased proportionally with increasing BI.

This is a retrospective, epidemiological study of 19,157 acute burn patients admitted to the Hallym Burn Centre, Hangang Sacred Heart Hospital, Seoul, Korea, during the period 1986-2003. The study was conducted to identify characteristics of burn patients that could lead to development of preventive programs to reduce both the frequency and mortality of burn injury. The majority of patients admitted had relatively minor burns, which were treated conservatively. Males predominated in all age groups with a summer peak seasonal variation. Typical burn in the children <5 years of age was a scald injury, occurring at home, affecting upper limbs and resulting in a relatively short hospital stay. Electrical burns due to steel chopsticks and steam burns due to electric rice cookers were also found in this age group. Adult burns, affecting upper and lower limbs, were caused by flames, hot liquids or electricity. Burns were sustained at the workplace and outdoors. Flame accidents in males were the leading cause of death with overall mortality of 8.2%. 13.9% of admissions needed intensive care and average length of hospital stay was 32.6 days. The annual number of patients undergoing burn related surgery has continuously increased reflecting a more aggressive surgical management. Our ongoing efforts are to promote prevention program and look for changes in the incidence of burn injury based on these epidemiologic features. Further study for implications of changes in management protocols and policies on treatment outcomes would improve the provision of appropriate care for the patients.

Background: Acute renal failure (ARF) is not a rare occurrence in severe burns and is an important complication leading to an increase in mortality. The severity of the burn is largely determined by the burn size, and severe burns are likely to cause enough loss of extracellular fluid and albumin from plasma volume to produce shock and hypoalbuminemia., Hypothesis: We hypothesized that initial serum albumin level may be useful as an indicator of prognosis and severity of injury in burned patients., Methods: The clinical characteristics of 147 adult patients with second- and third-degree burns covering 30% or more of their body surface area were analyzed retrospectively. Logistic regression was used to estimate the relative risks of ARF and mortality associated with the larger burn size and the lower serum albumin level at admission., Results: Mean burned body surface was 60.0 +/- 21.8% (range 30-100%). Twenty-eight (19.0%) out of 147 patients experienced ARF, defined as a serum creatinine > or = 2 mg/dl, during the admission. The patients with ARF had larger burn size (79.5 +/- 15.4 vs. 55.3 +/- 20.5%, p < 0.0001) and lower serum albumin concentration at admission (1.92 +/- 0.66 vs. 2.48 +/- 0.82 g/dl, p < 0.0005) compared with those without ARF. All patients with ARF expired, whereas 29.4% (35/119) of the patients without ARF died. The burn size > or = 65% was associated with a risk of ARF that was 9.9 times and with a risk of death that was 14.2 times as high as that for the burn size <65%. The initial serum albumin level <2.5 g/dl was associated with a risk of death that was 2.7 times as high as that for the initial serum albumin level > or = 2.5 g/dl., Conclusions: When major burns are complicated by ARF, the mortality rate increases significantly. Burn size is an independent predictor of ARF occurring in major burns. Initially depressed serum albumin level is associated with an increase in mortality in the major burn patients., (Copyright 2003 S. Karger AG, Basel)