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Introduction Residential fires account for the majority of burn-related injuries and fatalities. Established risk factors for burn injury include male gender, racial minority, children and elderly individuals, poverty, and substandard housing characteristics. In North Carolina, the rate of residential fire injuries and deaths is higher than the national average. Therefore, we sought to describe residential fire hospitalizations at a large regional burn center and describe the neighborhoods in which they live. We hypothesized that patients living in areas with higher Area Deprivation Index (ADI) are more likely to have major residential burns. Methods We conducted a retrospective analysis of burn admissions from January 2002 to December 2015. We dichotomized patients into two cohorts: residential and non-residential burns and performed a bivariate analysis. Multivariate Poisson regression models were utilized to determine if ADI was associated with inhalation injury and ≥20% total body surface area burn. Results Of the 10,506 patients presented during the study period. Of these, 10,016 (95.3%) patients resided in North Carolina, and 7894 (78.8%) had a residential burn. Of the overall cohort, 6.0% (n = 458) of patients had ≥20% TBSA burns and 6.4% (n = 506) had inhalation injury. The majority of patients were in the highest (most disadvantaged) ADI quartile (n = 3050, 39.5%), and only 6.8% of patients (n = 525) were in the lowest (least disadvantaged) ADI quartile. In the Poisson multivariate regressions to determine if the ADI was associated with severe burns, patients in the highest ADI quartile had an increased relative risk of ≥20% TBSA burn (RR 1.31, 95% CI 1.02–1.68) and inhalation injury (RR 1.39, 95% CI 1.09–1.76) when compared to patients in the second-lowest ADI quartile when controlled for pertinent covariates. Conclusion Residential structure fires represent the major source of burns and fatalities. People who reside in the highest ADI quartile are more like to present with higher burn injury severity in terms of burn size and the presence of inhalation injury. The use of the ADI to target neighborhoods for burn prevention is imperative.

Traumatic brain injury (TBI) has a bimodal age distribution with peak incidence at age 24 and age 65 with worse outcomes developing in aged populations. Few studies have specifically addressed age at the time of injury as an independent biologic variable in TBI-associated secondary pathology. Within the framework of our published work, identifying age related effects of TBI on neuropathology, cognition, memory and motor function we analyzed fecal pellets collected from young and aged TBI animals to assess for age-induced effects in TBI induced dysbiosis. In this follow up, work we hypothesized increased dysbiosis after TBI in aged (80-week-old, N=10) versus young (14-week-old, N=10) mice. C57BL/6 males received a sham incision or TBI via open-head controlled cortical impact. Fresh stool pellets were collected 1-day pre-TBI, then 1, 7, and 28-days post-TBI for 16S rRNA gene sequencing and taxonomic analysis. Data revealed an age induced increase in disease associated microbial species which were exacerbated by injury. Consistent with our hypothesis, aged mice demonstrated a high number of disease associated changes to the gut microbiome pre- and post-injury. Our data suggest divergent microbiome phenotypes in injury between young and aged reflecting a previously unknown interaction between age, TBI, and the gut-brain axis implying the need for different treatment strategies.

Objective This open-label, controlled, randomized study assessed the safety, tolerability, and efficacy of StrataGraft tissue compared to autograft in the treatment of deep partial-thickness (DPT) burns. Methods Thirty subjects with DPT thermal burns (3%–43% total body surface area) were treated with StrataGraft tissue as follows: cohort 1, ≤220 cm2 refrigerated tissue; cohort 2, ≤440 cm2 refrigerated tissue; and cohort 3, ≤440 cm2 cryopreserved tissue. On each subject, two comparable areas of DPT burn were randomized to receive StrataGraft tissue or autograft. Coprimary end points were the percent area of the StrataGraft tissue treatment site undergoing salvage autografting by Day 28 and wound closure of treatment sites by 3 months. Results By Day 28, no StrataGraft tissue treatment sites underwent autografting. By 3 months, 93% and 100% of the StrataGraft tissue and autograft treatment sites achieved complete wound closure, respectively. No significant differences in observer total and overall opinion POSAS scores between StrataGraft tissue and autograft treatment sites were observed at any timepoint. The most common adverse event was pruritus (17%). Conclusions StrataGraft tissue treatment of DPT thermal burns reduced the need for autograft, resulted in wound closure and treatment-site cosmesis comparable to that of autograft, and was well tolerated.

Introduction Split-thickness skin grafts (STSG) are the standard of care (SOC) for burns undergoing autografting but are associated with donor skin site morbidity and limited by the availability of uninjured skin. The RECELL® Autologous Cell Harvesting Device (RECELL® System, or RECELL) was developed for point-of-care preparation and application of a suspension of non-cultured, disaggregated, autologous skin cells, using 1 cm2 of the patient’s skin to treat up to 80 cm2 of excised burn. Methods A multi-center, prospective, within-subject controlled, randomized, clinical trial was conducted with 30 subjects to evaluate RECELL in combination with a more widely meshed STSG than a pre-defined SOC meshed STSG (RECELL treatment) for the treatment of mixed-depth burns, including full-thickness. Treatment areas were randomized to receive standard meshed STSG (Control treatment) or RECELL treatment, such that each subject had 1 Control and 1 RECELL treatment area. Effectiveness measures were assessed and included complete wound closure, donor skin use, subject satisfaction, and scarring outcomes out to one year following treatment. Results At 8 weeks, 85% of the Control-treated wounds were healed compared with 92% of the RECELL-treated wounds, establishing the non-inferiority of RECELL treatment for wound healing. Control-treated and RECELL-treated wounds were similar in mean size; however, mean donor skin use was significantly reduced by 32% with the use of RECELL (p Conclusions In combination with widely meshed STSG, RECELL is a safe and effective point-of-care treatment for mixed-depth burns without confluent dermis, achieving short- and long-term healing comparable to standard STSG, while significantly decreasing donor skin use.

Objectives Studies suggest that a restrictive transfusion strategy is safe in burns, yet the efficacy of a restrictive transfusion policy in massive burn injury is uncertain. Our objective: compare outcomes between massive burn (≥60% total body surface area (TBSA) burn) and major (20–59% TBSA) burn using a restrictive or a liberal blood transfusion strategy. Methods Patients with burns ≥20% were block randomized by age and TBSA to a restrictive (transfuse hemoglobin Results Three hundred and forty-five patients received 7,054 units blood, 2,886 in massive and 4,168 in restrictive. Patients were similar in age, TBSA, and inhalation injury. The restrictive group received less blood (45.57 ± 47.63 vs. 77.16 ± 55.0, p < 0.03 massive; 11.0 ± 16.70 vs. 16.78 ± 17.39, p < 0.001) major). In massive burn, the restrictive group had fewer ventilator days (p < 0.05). Median ICU days and LOS were lower in the restrictive group; wound healing, mortality, and infection did not differ. No significant outcome differences occurred in the major (20–59%) group (p > 0.05). Conclusions: A restrictive transfusion strategy may be beneficial in massive burns in reducing ventilator days, ICU days and blood utilization, but does not decrease infection, mortality, hospital LOS or wound healing.

A major burn is a severe injury with a global impact. Our system of medical evacuation has led to the survival of many severely injured service members. Burn rehabilitation is a complex and dynamic process and will not be linear. Recovery requires a comprehensive, interdisciplinary team-based approach, individually designed to maximize function, minimize disability, promote self-acceptance, and facilitate survivor and family reintegration into the community.

Background and Objectives: Porcine xenografts have been used successfully in partial thickness burn treatment for many years. Their disappearance from the market led to the search for effective and efficient alternatives. In this article, we examine the synthetic epidermal skin substitute Suprathel® as a substitute in the treatment of partial thickness burns. Materials and Methods: A systematic review following the PRISMA guidelines has been performed. Sixteen Suprathel® and 12 porcine xenograft studies could be included. Advantages and disadvantages between the treatments and the studies’ primary endpoints have been investigated qualitatively and quantitatively. Results: Although Suprathel had a nearly six times larger TBSA in their studies (p < 0.001), it showed a significantly lower necessity for skin grafts (p < 0.001), and we found a significantly lower infection rate (p < 0.001) than in Porcine Xenografts. Nonetheless, no significant differences in the healing time (p = 0.67) and the number of dressing changes until complete wound healing (p = 0.139) could be found. Both products reduced pain to various degrees with the impression of a better performance of Suprathel® on a qualitative level. Porcine xenograft was not recommended for donor sites or coverage of sheet-transplanted keratinocytes, while Suprathel® was used successfully in both indications. Conclusion: The investigated parameters indicate that Suprathel® to be an effective replacement for porcine xenografts with even lower subsequent treatment rates. Suprathel® appears to be usable in an extended range of indications compared to porcine xenograft. Data heterogeneity limited conclusions from the results.

Highlights • Shelter-in-place mandate for COVID-19 led to an increase in pediatric burn admissions. • School-age children burn admissions increased 28% for our burn center. • Prevention strategies must target at-risk children if there is another shelter-in-place mandate., The ramifications from the 2019 severe acute respiratory syndrome coronavirus 2 (COVID-19) pandemic caused by the novel corona virus will be felt globally for years to come. Mandates to shelter-in-place were called in nearly every state to limit viral exposure. The impact of the mandate on acute burn admissions was unknown. Our objective was to assess the impact of a shelter-in-place order on acute burn admissions at our burn center. All patients admitted to the burn center with burn injuries– including inhalation injury only– and desquamating skin disorders between March 10th to May 22nd, 2020 were eligible for inclusion. We compared all burn center admissions to a month-matched historical cohort from 2019, and summertime admissions for the last five years. Statistical significance was accepted as p

Management of wartime burn casualties can be very challenging. Burns frequently occur in the setting of other blunt and penetrating injuries. This clinical practice guideline provides a manual for burn injury assessment, resuscitation, wound care, and specific scenarios including chemical and electrical injuries in the deployed or austere setting. The clinical practice guideline also reviews considerations for the definitive care of local national patients, including pediatric patients, who are unable to be evacuated from theater. Medical providers are encouraged to contact the US Army Institute of Surgical Research (USAISR) Burn Center when caring for a burn casualty in the deployed setting.

Early excision and autografting are standard care for deeper burns. However, donor sites are a source of significant morbidity. To address this, the ReCell® Autologous Cell Harvesting Device (ReCell) was designed for use at the point-of-care to prepare a noncultured, autologous skin cell suspension (ASCS) capable of epidermal regeneration using minimal donor skin. A prospective study was conducted to evaluate the clinical performance of ReCell vs meshed split-thickness skin grafts (STSG, Control) for the treatment of deep partial-thickness burns. Effectiveness measures were assessed to 1 year for both ASCS and Control treatment sites and donor sites, including the incidence of healing, scarring, and pain. At 4 weeks, 98% of the ASCS-treated sites were healed compared with 100% of the Controls. Pain and assessments of scarring at the treatment sites were reported to be similar between groups. Significant differences were observed between ReCell and Control donor sites. The mean ReCell donor area was approximately 40 times smaller than that of the Control (P < .0001), and after 1 week, significantly more ReCell donor sites were healed than Controls (P = .04). Over the first 16 weeks, patients reported significantly less pain at the ReCell donor sites compared with Controls (P ≤ .05 at each time point). Long-term patients reported higher satisfaction with ReCell donor site outcomes compared with the Controls. This study provides evidence that the treatment of deep partial-thickness burns with ASCS results in comparable healing, with significantly reduced donor site size and pain and improved appearance relative to STSG.

Heavy use of alcohol can lead to addictive behaviors and to eventual alcohol-related tissue damage. While increased consumption of alcohol has been attributed to various factors including level of alcohol exposure and environmental factors such as stress, data from behavioral scientists and physiological researchers are revealing roles for the circadian rhythm in mediating the development of behaviors associated with alcohol use disorder as well as the tissue damage that drives physiological disease. In this work, we compile recent work on the complex mutually influential relationship that exists between the core circadian rhythm and the pharmacodynamics of alcohol. As we do so, we highlight implications of the relationship between alcohol and common circadian mechanisms of effected organs on alcohol consumption, metabolism, toxicity, and pathology.

On November 18th, 2016 the 21st annual Alcohol and Immunology Research Interest Group (AIRIG) meeting was held at the Center for Translational Research and Education at Loyola University Chicago’s Health Sciences Campus in Maywood, IL. The 2016 meeting focused broadly on alcohol and inflammation, epigenetics, and the microbiome. The four plenary sessions of the meeting were: Alcohol, Inflammation, and Immunity; Alcohol and Epigenetics; Alcohol, Transcriptional Regulation, and Epigenetics; and Alcohol, Intestinal Mucosa, and the Gut Microbiome. Presentations in all sessions of the meeting explored putative underlying causes for chronic diseases and mortality associated with alcohol consumption, shedding light on future work and potential therapeutic targets to alleviate the negative effects of alcohol misuse.

The CDC estimate that nearly 3 million Americans sustain a traumatic brain injury (TBI) each year. Even when medical comorbidities are accounted for, age is an independent risk factor for poor outcome after TBI. Nonetheless, few studies have examined the pathophysiology of age-linked biologic outcomes in TBI. We hypothesized that aged mice would demonstrate more severe neuropathology and greater functional deficits as compared to young adult mice after equivalent traumatic brain injuries. Young adult (14-week-old) and aged (80-week-old) C57BL/6 male mice underwent an open-head controlled cortical impact to induce TBI or a sham injury. At 30-days post-injury groups underwent behavioral phenotyping, magnetic resonance imaging, and histologic analyses. Contrary to our hypothesis, young adult TBI mice exhibited more severe neuropathology and greater loss of white matter connectivity as compared to aged mice after TBI. These findings correlated to differential functional outcomes in anxiety response, learning, and memory between young adult and aged mice after TBI. Although the mechanisms underlying this age-effect remain unclear, attenuated signs of secondary brain injury in aged TBI mice point towards different inflammatory and repair processes between age groups. These data suggest that age may need to be an a priori consideration in future clinical trial design.

The US Army Institute of Surgical Research (USAISR) Burn Center is among the first and largest burn centers in the world and is the only US military burn center. This American Burn Association-verified facility is located on the Fort Sam Houston military base, in San Antonio, TX. It has provided comprehensive burn care to both military personnel and civilians in the South Texas area since the end of World War II. The global mission of the USAISR is to optimize combat casualty care, including care for major thermal injuries. This optimization of combat casualty care is executed clinically in the USAISR Burn Center through interdisciplinary teamwork and by advancing the care provided based on leading edge research. This article focuses on clinical lessons learned in the area of burn nutrition over the last decade at this facility during the support of the combat casualties from Operation Iraqi Freedom and Operation Enduring Freedom; it also provides a review of current evidence-based nutritional medicine practices for treating patients with thermal injuries. The extreme nutritional demand and metabolic changes associated with severe burns have been well described. This hypermetabolic, hypercatabolic response can lead to lean body mass and strength loss, resulting in the lack of ability to perform activities of daily living, as well as infection, wound healing failure, and death. Nutrition is an essential tool to avoid these catastrophic results, but monitoring the nutrition status is complicated by the whole body volume overload, resulting from the initial massive fluid resuscitation, which is required to prevent cardiovascular collapse. Techniques such as estimating weight loss from the caloric deficit must be utilized in place of actual weight loss until the interstitial fluid is reclaimed and a dry weight is achieved. Replenishing the extreme caloric expenditure and nitrogen loss is challenging; hence, careful monitoring of the nutrition intake is an essential component of burn treatment. In addition, there are a number of potential adverse effects of nutritional therapy that must also be factored into the complex decision-making regarding the initiation and delivery of nutrition in the critically ill burn population.

Fluid resuscitation is the foundation of management in burn patients and is the topic of considerable research. One adjunct in burn resuscitation is continuous, high-dose vitamin C (ascorbic acid) infusion, which may reduce fluid requirements and thus decrease the risk for over resuscitation. Research in preclinical studies and clinical trials has shown continuous infusions of high-dose vitamin C to be beneficial with decrease in resuscitative volumes and limited adverse effects. However, high-dose and low-dose vitamin C supplementation has been shown to cause secondary calcium oxalate nephropathy, worsen acute kidney injury, and delay renal recovery in non-burn patients. To the best of our knowledge, the authors present the first case series in burn patients in whom calcium oxalate nephropathy has been identified after high-dose vitamin C therapy.

Objectives Major trials examining storage age of blood transfused to critically ill patients administered relatively few blood transfusions. We sought to determine if the storage age of blood affects outcomes when very large amounts of blood are transfused. Design A secondary analysis of the multicenter randomized Transfusion Requirement in Burn Care Evaluation study which compared restrictive and liberal transfusion strategies. Setting Eighteen tertiary-care burn centers. Patients Transfusion Requirement in Burn Care Evaluation evaluated 345 adults with burns greater than or equal to 20% of the body surface area. We included only the 303 patients that received blood transfusions. Interventions The storage ages of all transfused red cell units were collected during Transfusion Requirement in Burn Care Evaluation. A priori measures of storage age were the the mean storage age of all transfused blood and the proportion of all transfused blood considered very old (stored ≥ 35 d). Measurements and main results The primary outcome was the severity of multiple organ dysfunction. Secondary outcomes included time to wound healing, the duration of mechanical ventilation, and in-hospital mortality. There were 6,786 red cell transfusions with a mean (± SD) storage age of 25.6 ± 10.2 days. Participants received a mean of 23.4 ± 31.2 blood transfusions (range, 1-219) and a mean of 5.3 ± 10.7 units of very old blood. Neither mean storage age nor proportion of very old blood had any influence on multiple organ dysfunction severity, time to wound healing, or mortality. Duration of ventilation was significantly predicted by both mean blood storage age and the proportion of very old blood, but this was of questionable clinical relevance given extreme variability in duration of ventilation (adjusted r ≤ 0.01). Conclusions Despite massive blood transfusion, including very old blood, the duration of red cell storage did not influence outcome in burn patients. Provision of the oldest blood first by Blood Banks is rational, even for massive transfusion.

ObjectiveOur objective was to compare outcomes of a restrictive to a liberal red cell transfusion strategy in 20% or more total body surface area (TBSA) burn patients. We hypothesized that the restrictive group would have less blood stream infection (BSI), organ dysfunction, and mortality.BackgroundPatients with major burns have major (>1 blood volume) transfusion requirements. Studies suggest that a restrictive blood transfusion strategy is equivalent to a liberal strategy. However, major burn injury is precluded from these studies. The optimal transfusion strategy in major burn injury is thus needed but remains unknown.MethodsThis prospective randomized multicenter trial block randomized patients to a restrictive (hemoglobin 7-8 g/dL) or liberal (hemoglobin 10-11 g/dL) transfusion strategy throughout hospitalization. Data collected included demographics, infections, transfusions, and outcomes.ResultsEighteen burn centers enrolled 345 patients with 20% or more TBSA burn similar in age, TBSA burn, and inhalation injury. A total of 7054 units blood were transfused. The restrictive group received fewer blood transfusions: mean 20.3 ± 32.7 units, median = 8 (interquartile range: 3, 24) versus mean 31.8 ± 44.3 units, median = 16 (interquartile range: 7, 40) in the liberal group (P < 0.0001, Wilcoxon rank sum). BSI incidence, organ dysfunction, ventilator days, and time to wound healing (P > 0.05) were similar. In addition, there was no 30-day mortality difference: 9.5% restrictive versus 8.5% liberal (P = 0.892, χ test).ConclusionsA restrictive transfusion strategy halved blood product utilization. Although the restrictive strategy did not decrease BSI, mortality, or organ dysfunction in major burn injury, these outcomes were no worse than the liberal strategy (Clinicaltrials.gov identifier NCT01079247).

Background Fungal wound infection is a leading cause of burn wound infections, and diagnosis is often delayed as it conventionally requires culture and histopathology. Fungal screening assays have sped diagnosis of invasive fungal infections in other populations. Few studies have evaluated the performance of fungal screening assays outside of the hematologic malignancy and hematopoietic stem cell transplant populations. Methods We performed a three year retrospective analysis of all fungal screening assays in burn patients in the ICU between 2008 and 2011. The primary goal was to evaluate the correlation between the two available fungal screening assays, (1 → 3)-β- d -glucan (BG) and galactomannan (GM) assay, and fungal wound colonization (FWC) and infection (FWI). We also evaluated previously hypothesized causes of false positives and their associations with false positives in the burn population. Results We identified 53 patients [median 29% total body surface area burned (TBSA), IQR 17–51] with BG or GM serological tests available, of which 15 had a FWI or FWC. FWC/FWI was associated with higher TBSA ( p = 0.02). BG and GM correlated with TBSA (BG 0.57, p p = 0.02), but neither assay was associated with FWI/FWC or species of fungus involved when FWI/FWC was diagnosed. Conclusions Positive BG and GM fungal screening assays are not associated with FWI/FWC, or with species of fungus when FWC/FWI is present. BG false positives are common and associated with higher TBSA burns.

Burn injury affects a half million people in the United States annually. The severe thermal injury can have long-term debilitating effects. The management of burn patients in austere and operational environments is more complex. Mass casualty incidents can result in a large number of patients with multiple traumatic injuries, which often include burn injury. Appropriate triage of casualties is essential. Severely burned patients should be evacuated to a burn center if possible. Airway management and fluid resuscitation of burn patients present unique challenges. Supplies, resources, and expertise to maintain a definitive airway may not be readily available. Airway adjuncts can be helpful but judicious use of resources is warranted in the austere setting. Traditional resuscitation of severe thermal injury is not practical in the austere environment. Oral resuscitation and in rare cases rectal hydration may be utilized until the patient can be transported to a medical facility. Much has been learned about the management of burn and polytraumatized patients after mass casualty incidents such as the September 11, 2001 terror attacks and the Pope Air Force Base disaster. A well-coordinated emergency preparedness plan is essential. The care of burn patients in austere, operational, and mass casualty situations can tax resources and manpower. The care of these patients will require creativity and ingenuity. Burn patients can be difficult to manage under normal circumstances but the care of these patients under the above situations complicates the management severalfold.

Burn injury comprises 5–20 % of injuries on the battlefield depending on operational tempo. The management of these injuries can pose significant challenges to the medical provider and care of these patients can be resource and labor intense. Coalition forces may present with poly-traumatic injuries in addition to burn and this will further complicate the care of these patients. Medical facilities supporting these mission must also be prepared to care for thermally injured host nationals as local medical resources will not likely be able to render appropriate level of care acutely. Unlike coalition casualties who are usually evacuated expeditiously, local nationals with burn injury will require prolonged care at field medical hospitals. Expectant care of host nationals with severe burn injury (>40–50 % total body surface area) should be considered since mortality is extremely high in this patient population.

Battlefield care given to a casualty before hospital arrival impacts clinical outcomes. To date, the published data regarding care given in the prehospital setting of a combat zone are limited. The purpose of this study was to describe the incidence and efficacy of specific prehospital lifesaving interventions (LSIs; interventions that could affect the outcome of the casualty), consistent with the Tactical Combat Casualty Care paradigm, performed during the resuscitation of casualties in a combat zone.We performed a prospective observational study between November 2009 and November 2011. Casualties were enrolled as they were treated at six US surgical facilities in Afghanistan. Descriptive data were collected on a standardized data collection form and included mechanism of injury, airway management, chest and hemorrhage interventions, vascular access, type of fluid administered, and hypothermia prevention. On arrival to the military hospital, the treating physician determined whether an intervention was performed correctly and whether an intervention was not performed that should have been performed (missed LSI).A total of 1,003 patients met the inclusion criteria. Their mean (SD) age was 25 (8.5) years and 97% were male. The mechanism of injury was explosion in 60% of patients, penetrating in 24% of patients, blunt in 15% of patients, and burn in 0.8% of patients. The most commonly performed LSIs included hemorrhage control (n = 599), hypothermia prevention (n = 429), and vascular access (n = 388). Of the missed LSIs, 252 were identified with the highest percentage of missed opportunities being composed of endotracheal intubation, chest needle decompression, and hypotensive resuscitation. In contrast, tourniquet application had the lowest percentage of missed opportunities.In our prospective study of prehospital LSIs performed in a combat zone, we observed a higher rate of incorrectly performed and missed LSIs in airway and chest (breathing) interventions than hemorrhage control interventions. The most commonly performed LSIs had lower incorrect and missed LSI rates.

The care of host nation burn victims in Iraq and Afghanistan has been a significant challenge to US military healthcare providers. To provide burn care in an austere environment is more challenging by limitations in resources such as inadequate medical supplies, infection control issues, and a lack of blood or tissue banking capabilities. Large full thickness burns pose a significant obstacle due to limitations in the casualties’ available donor skin, which can be used to achieve wound coverage. In US burn centers, allograft stored in skin banks provides temporary coverage during donor site healing in the management of large total body surface area burns.This report is a study of two severely burned Iraqi children with inadequate donor site surface area to achieve wound coverage that were managed with close-relative allograft harvested from their fathers to achieve temporary wound closure. A brief literature review and future recommendations are included.

Recent data demonstrate a possible mortality benefit in traumatically injured patients when given subcutaneous recombinant human erythropoietin (rhEPO). The purpose of this report is to examine the effect of rhEPO on mortality and transfusion in burn patients. We conducted a review of burn patients (greater than 30% total body surface area, intensive care unit [ICU] days greater than 15) treated with 40,000u rhEPO over an 18-month period (January 2007 to July 2008). Matched historical controls were identified and a contemporaneous cohort of subjects not administered rhEPO was used for comparison (NrhEPO). Mortality, transfusions, ICU and hospital length of stay were assessed. A total of 105 patients were treated (25 rhEPO, 53 historical control group, 27 NrhEPO). Hospital transfusions (mean 13,704 ± mL vs 13,308 ± mL; P = 0.42) and mortality (29.6 vs 32.0%; P = 0.64) were similar. NrhEPO required more blood transfusions (13,308 ± mL vs 6,827 ± mL; P = 0.004). No difference in mortality for the rhEPO and NrhEPO (32.0 vs 22.2%; P = 0.43) was found. Thromboembolic complications were similar in all three groups. No effect was seen for rhEPO treatment on mortality or blood transfusion requirements in the severely burned.

Acute lung injury (ALI) is a syndrome consisting of noncardiogenic acute hypoxemic respiratory failure with the presence of bilateral pulmonary infiltrates and occurs in up to 33% of critically ill trauma patients. Retrospective and observational studies have suggested that a blood component resuscitation strategy using equal ratios of packed red blood cells (PRBCs) and fresh frozen plasma (FFP) may have a survival benefit in combat casualties. The purpose of this study was to determine whether this strategy is associated with an increased incidence of ALI.We performed a prospective observational study of all injured patients admitted to an intensive care unit (ICU) at a combat support hospital who required5 units of blood transfusion within the first 24 hours of admission. Baseline demographic data along with Injury Severity Score (ISS), pulmonary injury, presence of long bone fracture, blood products transfused, mechanical ventilation data, and arterial blood gas analysis were collected. The primary endpoint of the study was the development of ALI at 48 hours after injury. Those who did not survive to ICU admission were excluded from analysis. Follow-up (including mortality) longer than 48 hours was unavailable secondary to rapid transfer out of our facility. A multivariate logistic regression was performed to determine the independent effects of variables on the incidence of early ALI.During a 12-month period (from January 2008 to December 2008), 87 subjects were studied; of these, 66 patients met inclusion criteria, and 22 patients developed ALI at 48 hours (33%). Overall, the ratio of FFP to PRBC was 1:1.1. Those who developed ALI had a higher ISS (32 +/- 15 vs. 26 +/- 11; p = 0.04) and received more units of FFP (22 +/- 15 vs. 12 +/- 7; p0.001), PRBCs (22 +/- 16 vs. 13 +/- 7; p = 0.008), and platelets (5 +/- 11 vs. 1 +/- 2; p = 0.004) compared with those who did not develop ALI. Multivariate logistic regression analysis revealed that presence of pulmonary injury (odds ratio, 5.4; 95% confidence interval, 1.3-21.9) and volume of FFP transfused (odds ratio, 1.2; 95% confidence interval, 1.1-1.3) had independent effects on ALI at 48 hours.On the basis of this small, prospective, descriptive study of severely injured patients admitted to the ICU, we determined that the presence of pulmonary injury had the greatest impact on the incidence of early ALI. There was also an independent relationship between the amount of FFP transfused and the incidence of early ALI. Further studies are required to determine the effects of the development of early ALI from FFP transfusion on short- and long-term survival.

Introduction: Several relatively new technologies have served as valuable adjuncts to clinical judgment in burn wound depth assessment. Among these technologies, laser Doppler imaging and indocyanine green videoangiography have improved accuracy of burn depth assessment. However, an objective way to monitor improvement and changes in blood flow after hyperbaric oxygen treatment is not well documented. Methods: We present a case of a 43 year-old African American female patient whose burns we evaluated with laser Doppler imaging and indocyanine green videoangiography prior to and after hyperbaric oxygen therapy (HBOT). Results: These imaging modalities documented an improvement in perfusion of the burned tissues in our patient. Conclusions: Though we need more comparative data in the form of prospective studies with large cohorts to make concrete recommendations, we suggest with our case report that laser Doppler imaging and indocyanine green videoangiography can be used to monitor improvement and document blood flow after HBOT.

Background: Several studies have reported the utility of Pulse Dye Laser (PDL) therapy in the management of hypertrophic burn scars. Among the potential benefits including improvement in pruritis, pain, stiffness and surface irregularities, its effect on erythema reduction has been most frequently reported. However, few studies have used quantitative methods to document the degree of erythema reduction in hypertrophic burn scars. Methods: A retrospective review of patients who received PDL therapy at our burn center was performed. The anatomic area, date, settings and number of treatments were tabulated as were the skin type, and the erythema measurements of the treated areas. Results: 61 patients received PDL therapy from a period of Mar 2012 to Jul 2013. Among them, 45 patients had enough data for analysis. The average age was 33 (range 18-66) with a 2:1 female to male ratio. The most common mechanism of injury was flame (55%) followed by blast (17.7%). The average TBSA was 16.55% (range 1-65%). The mean fluences used were 7.3 J/cm2 (range 6-9 J/cm2) and 5.1 J/cm2 (range 3.75-6.5 J/cm2) for the 7 mm and 10 mm spot sizes respectively. An average of 10.7 months elapsed (range 0.75-81 months) prior to treatment initiation. An average of 2.2 treatments were rendered (range 1-5). The average follow up period was 4.6 months with a range of 1 – 14.2 months. Erythema reduction of 5.8% percent (p=0.045) was observed. Subgroup analysis based on Fitzpatrick skin types revealed a 15.3% reduction in type I skin (p=0.047), 7.4% reduction in type II skin (p= 0.036), -5.5% reduction in type III skin (p=0.081) and -2.2% reduction type IV skin (p=0.084). Conclusion: Pulse dye laser treatment for the management of hypertrophic burn scars resulted in a modest decrease in erythema, with the greatest degree of erythema reduction observed in patients with Fitzpatrick skin types I and II.

Seven hundred one patients were treated at and 394 were admitted to the 212th Mobile Army Surgical Hospital in Central Iraq during the combat phase of Operation Iraqi Freedom. Ninety of those patients underwent 100 operations, with 187 procedures in 19 days. At the peak of hostilities, 48 patients were admitted, 15 operations were performed, and 56 patients were medically evacuated during different 24-hour periods. Thirty-three patients required the surgical expertise of a general or thoracic surgeon. Although 82% of injuries and 70% of the procedures were orthopedic in nature, orthopedic operating room utilization was only 60% of total operating room time (156 hours). The general and thoracic injuries were laborintensive, frequently requiring two surgeons. Although orthopedic injury remains the predominant reason for surgical intervention on the battlefield, there remains a need to forwarddeploy general and thoracic surgeons, because of the presence and complexity of nonorthopedic trauma.

Toxic epidermal necrolysis (TEN) is a rare condition affecting an estimated 1 to 2 cases per million per year, with reported mortality between 30% and 50% typically because of multiorgan failure or sepsis. Acute pulmonary complications from this disorder include bronchial mucosal sloughing, pulmonary edema, and infectious pneumonitis. Pulmonary complications in TEN occurred in 46% of patients in one series. Use of extracorporeal life support (ECLS) in adults with acute respiratory distress syndrome (ARDS) has increased markedly during the past few years after successful treatment in adults with swine flu (H1N1) and publication of the CESAR (conventional ventilation or ECMO for severe adult respiratory failure) trial, which demonstrated a lower mortality and disability at 6 months for patients referred to an ECLS center. The suggested ideal candidate for ECLS would be one with an acute, reversible, survivable illness if not for associated ARDS, no significant comorbidities, no contraindication to systemic anticoagulation, less than 8 days on mechanical ventilation, and younger than 65 years of age.

A large portion of the casualties admitted to military hospitals on the battlefield in Iraq consists of children, of whom 13% had burns. The U.S. Army Combat Support Hospital (CSH) in Baghdad, faced with an influx of such patients, successfully transferred selected burned children by commercial airlines to the Shriners Hospital for Children in Boston, Massachusetts (SHC-B). The authors aimed to document this process, from both an ethical and a procedural standpoint. Care was conducted in six phases: (1) admission to the CSH; (2) selection for transfer; (3) burn care at the CSH; (4) travel to the United States; (5) burn care at the SHC-B; (6) return to Iraq. Transfer and SHC-B care were funded by charitable organizations. A review of patient records was performed. Eight acutely burned pediatric patients participated in this program. All were successfully transferred, treated at SHC-B, and returned to Iraq. They ranged in age from 1.7 to 17 years and in burn size from 6 to 53% of the TBSA. At SHC-B, the hospital length of stay was 14 to 132 days; up to 23 visits to the operating room were performed for acute and reconstructive burn surgery. The cost of war includes the care of injured civilians, and includes burned children. For selected patients, transfer out of the combat zone is one method of fulfilling this obligation.

The objective of this study was to identify the 100 most cited, peer-reviewed burn-related articles over the past half century. Burn care presents ongoing challenges to both U.S. civilian and military healthcare personnel. Improvements in burn survival and quality of life are the result of advances in burn research. The Web of Science (including Science Citation Index) was searched for the most cited articles related to burn care, published from 1955 to the present. The most cited article was Permanent coverage of large burn wounds with autologous cultured human epithelium, by G.G. Gallico et al, New England Journal of Medicine, 1984 (711 citations). Between the 1970s and the 1990s, there was a near doubling of the number of highly cited publications with each subsequent decade. A total of 85% of the articles were on the topics of pathophysiology (37%), wounds, tissue, or dressings (31%), or organ failure/sepsis (17%). B.A. Pruitt Jr. (2320 citations), D.N. Herndon (1972 citations), and A.D. Mason Jr. (1435 citations) were the most cited authors. This study identified some of the most important contributions to burn research and the areas of greatest scientific interest to the specialty during the past five decades, and highlights key research that has contributed to the evolution of modern burn care.

Accurate burn estimation affects the use of burn resuscitation formulas and treatment strategies, and thus can affect patient outcomes. The objective of this process-improvement project was to compare the accuracy of a computer-based burn mapping program, WoundFlow (WF), with the widely used hand-mapped Lund-Browder (LB) diagram. Manikins with various burn representations (from 1% to more than 60% TBSA) were used for comparison of the WF system and LB diagrams. Burns were depicted on the manikins using red vinyl adhesive. Healthcare providers responsible for mapping of burn patients were asked to perform burn mapping of the manikins. Providers were randomized to either an LB or a WF group. Differences in the total map area between groups were analyzed. Also, direct measurements of the burn representations were taken and compared with LB and WF results. The results of 100 samples, compared using Bland-Altman analysis, showed no difference between the two methods. WF was as accurate as LB mapping for all burn surface areas. WF may be additionally beneficial in that it can track daily progress until complete wound closure, and can automatically calculate burn size, thus decreasing the chances of mathematical errors.

Adrenal masses are often found on abdominal imaging studies that were performed to evaluate other diagnoses or nonspecific symptoms. Various opinions on the workup and treatment of these adrenal incidentalomas are readily found in the literature. We report a case of a young woman whose workup for symptoms of biliary colic led to the discovery of such a mass. The mass was found to be an adrenal cortical carcinoma with no evidence of lymphatic or capsular invasion.

Since 1952, the US Army Institute of Surgical Research (USAISR) Burn Center has provided comprehensive care for patients who have sustained severe thermal trauma, inhalation injury, and other diseases related to burn trauma. The Army Burn Center serves the entire population encompassed by the military health care system as well as veterans and civilian emergency patients requiring burn center care within the 26,000-sq mi trauma service area surrounding San Antonio, Texas. US military engagement following the events of 9/11 markedly changed the number and type of patients with burn injury treated at our center and the system used to care for them. We report our experience and summarize the most noteworthy changes in practice implemented during these 10 years of war. As the number of patients admitted to our center rose during the decade of combat operations, the mix of military versus civilian patients varied considerably (Fig. 1). The first military casualty from overseas contingency operations, initially referred to as the Global War on Terrorism, arrived at our burn center in March 2003; between the start of Operation Enduring Freedom in October 2001 and March 2003, there were no combat-related injuries warranting burn center care1 (Table 1). The mechanism of thermal injury among those evacuated from Iraq and Afghanistan was predominantly from fire and flame injury related to effects of explosives; however, other noncombat-related injuries predominated during the early part of the engagement.2 Explosions represent the single largest mechanism of injury for combat-related burn casualties3 (Fig. 2).

The purpose of this article is to provide a descriptive study of the management of burns in the prehospital setting of a combat zone.A retrospective chart review was performed of U.S. casualties with20% total-body-surface-area thermal burns, transported from the site of injury to Ibn Sina Combat Support Hospital (CSH) between January 1, 2006, and August 30, 2009.Ibn Sina CSH received 225 burn casualties between January 2006 and August 2009. Of these, 48 met the inclusion criteria. The mean Injury Severity Score was 31.7 (range 4 to 75). Prehospital vascular access was obtained in 24 casualties (50%), and 20 of the casualties received fluid resuscitation. Out of the 48 casualties enrolled, 28 (58.3%) did not receive prehospital fluid resuscitation. Of the casualties who received fluid resuscitation, nearly all received volumes in excess of the guidelines established by the American Burn Association and those recommended by the Committee for Tactical Combat Casualty Care. With regard to pain management in the prehospital setting, 13 casualties (27.1%) received pain medication.With regard to the prehospital fluid resuscitation of primary thermal injury in the combat zone, two extremes were noted. The first group did not receive any fluid resuscitation; the second group was resuscitated with fluid volumes higher than those expected if established guidelines were utilized. Pain management was not uniformly provided to major burn casualties, even in several with vascular access. These observations support improved education of prehospital personnel serving in a combat zone.