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Summary Background & aims Burn patients pose a number of clinical challenges for doctors and dietitians to achieve optimal nutrition practice. The objective of this study was to describe nutrition practices in burn center intensive care units (ICUs) compared to the most recent ESPEN and SCCM/ASPEN guidelines (hereafter referenced as “the Guidelines”) and highlight the variation in practice and what is “best achievable.” Methods In 2014–15, we prospectively enrolled 283 mechanically ventilated patients who were admitted to one of 14 burn ICUs for at least 72 h. Data collected included information on the estimation of energy and protein requirements, their actual delivery as well as route and time of feeding, and administration of micronutrients. We describe site practices and data per patient-day. Results Adherence to the Guidelines for the use of enteral nutrition (EN) over parenteral nutrition (PN) was 90.5% of patient-days (site range 79.2%–97.0%). However, adherence to the Guidelines for the measurement of energy requirements was 6.0% of patient-days (site range 0.0%–93.3%), supplementation with glutamine took place in 22.4% of patient-days (site range 0.0%–61.8%). Provision of 80% of energy requirements within 48–72 h was achieved in 35.3% of patients (site range 0.0%–80.0%), and provision of 80% of protein needs within 48–72 h was achieved in 34.3% of patients (site range 0.0%–80.0%). Average nutritional adequacy was 64.9 ± 40.0% for energy (best site: 80.2%, worst site: 42.0%) and 65.6 ± 42.1% for protein (best site: 87.3%, worst site: 43.6%). Conclusion The present findings indicate that despite high adherence to providing EN over PN, there is still a large gap between many recommendations and clinical practice, and the achievement of nutrition goals for patients in burn centers is suboptimal.

Healing of burn wounds is necessary for survival; however tracking progression or healing of burns is an inexact science. Recently, the relationship of mortality and wound healing has been documented with a software termed WoundFlow. The objective of the current study was to confirm various factors that impact burn wound healing, as well as to establish a timeline and rate of successful healing. A retrospective analysis was performed on adults (n=115) with at least 20% TBSA burn that had at least two computer-based wound mappings. The % open wound (%OW) was calculated over time to document healing trajectory until successful healing or death. Only 2% of patients in the group with successful wound healing died. A decrease in the %OW of 0.8 (IQR: 0.7-1.1) was associated with survival. Disparities in wound healing trajectories between survivors and non-survivors were distinguishable by 2weeks post-injury (P

Introduction Nutrition is crucial for recovery from burn injuries, as severe weight (wt.) loss can lead to impaired immunity and wound healing, infections, skin graft failure, and mortality. Previous studies recommended avoiding more than 10% wt. loss, as this level resulted in increased infection rates. However, wt. loss is often not quantifiable during the critical illness phase, with severe edema masking non-fluid related body wt. changes. Energy (kcal) deficits can be used to estimate wt. loss until the edema has resolved, but previous studies in non-burn patients indicate that actual wt. loss is less than the commonly used 3500 kcal per pound of fat (7700 kcal per kg of fat). The objective of this performance improvement project was to evaluate nutritional intake and the resulting dry wt. change in severely burned patients. Methods This performance improvement project was approved by our regulatory compliance division. We performed a retrospective evaluation on patients with at least 20% total body surface area (TBSA) burns admitted for initial burn care to our intensive care unit over a 7-year period. Patients who died or who had major fascial excisions or limb amputations were excluded. Patients who did not achieve a recorded dry wt. after wound healing were not included in this analysis. Retrospective data were collected, including sex, age, burn size, kcal intake, kcal goal per the Milner equation using activity factor of 1.4, admission dry wt., dry wt. after wound healing (defined as less than 10% TBSA open wound), and days to dry wt. after wound healing. Descriptive statistics and linear regression were performed using JMP. Significance was set at p< 0.05. Results The 30 included patients had the following characteristics: 90% male, 30 ± 11 years old, 45% ± 15% TBSA burn. They received 2720 ± 1092 kcal/day, meeting 68% ± 24% kcal goal, and took approximately 53 ± 30 days from injury to achieve dry wt. after wound healing. These patients had wt. loss of 8 ± 8 kg from the kcal deficit of 69,819 ± 51,704 during this time period. The kcal deficit was significantly associated with wt. change [p < 0.001, R2 = 0.49, wt. change in kg = (-0.000103 x kcal deficit) – 1]. This translates to one kg of body wt. loss resulting from 9709 kcal deficit. Conclusions This performance improvement project found that an energy deficit of approximately 9700 kcal in our patients equates to 1 kg of body mass loss (4400 kcal deficit equates to 1 pound of body mass loss). These findings are similar to wt. loss studies in other patient populations and contrary to the commonly used 3500 kcal per pound of fat (7700 kcal per kg of fat).

Introduction Nutrition is a core component of care for the critically ill burn patient. The Society for Critical Care Medicine recommends initiating enteral nutrition (EN) within 4–6 hours of injury for burn patients, while simultaneously recommending waiting until hemodynamic stability is achieved for critical care patients. The goal of this analysis was to evaluate tolerance of EN during periods of different pressor requirements and lactate levels. Methods We performed a retrospective evaluation on all burn patients admitted to our intensive care unit in 2018 who received EN. This performance improvement project was approved by our regulatory compliance division. Lactate levels and vasopressor use just prior to EN initiation, the highest EN rates and gastric residual volumes during the 24 hours after initiation, and ischemic bowel and aspiration after EN initiation were recorded. Significance was accepted at p< 0.05. Results EN was initiated at 30 ± 20 hours after admission in 58 patients with the following characteristics: 47 ± 19 years old, 29 ± 24% TBSA burn, 13 mechanical ventilator days (IQR: 5–30), 15% mortality. The highest EN rate reached was 100 ± 49 mL/hr during the first 24 hours after initiation. Lactate levels were 1.9 mmol/L at the time of EN initiation (IQR: 1.6–2.4 mmol/L), with a maximum of 4.9 mmol/L. Lactate levels did not have a significant correlation with gastric residual volumes (p=0.532). Most (59%) patients did not have vasopressor requirements, but 21% required vasopressin only, 2% required norepinephrine only, and 19% required a combination of vasopressin and norepinephrine. Those who received norepinephrine received 3.3 ± 1.7 mcg/min, with a maximum of 7 mcg/min. There was a significant difference in gastric residual volumes between patients who had no vasopressor requirements compared to those who required vasopressors [13 mL (IQR: 0–200 mL) vs. 240 mL (IQR: 21–430 mL), p=0.014)]; however, the number of patients with gastric residual volumes over 500 mL was not significantly different (3% vs. 17%, p=0.149). When examining patients receiving vasopressin alone, there was a significant but weak correlation between vasopressin dose and gastric residual volumes (p=0.047, R2=0.339); however, when examining only patients receiving norepinephrine, there was no correlation between norepinephrine dose and gastric residual volumes (p=0.905, R2=0.002). There was 1 episode of aspiration and 1 episode of ischemic bowel, both of which occurred 3 days after EN initiation. EN was initiated without vasopressors running and lactate levels were normal in both cases. Conclusions The majority of patients tolerated EN initiation with vasopressor dosing of norepinephrine up to 7 mcg/min and lactate up to 4.9 mmol/L. Applicability of Research to Practice We found no indication for holding EN for lactate levels under 5 mmol/L and norepinephrine under 8 mcg/min.

Nutrition is an essential component of the healing and recovery process after severe burn injury. For many burn patients, nutrition support is necessary to meet nutrition goals. The ratio of carbohydrates and fat is particularly important for burn patients, as an essential fatty acid deficiency can contribute to poor wound healing. However, there is evidence to suggest that diets containing more carbohydrates and less fat may result in better patient outcomes. A literature search was conducted to identify studies related to nutrition support and macronutrient ratios in burn patients. Eleven published papers were found that considered macronutrient use in enteral and parenteral nutrition therapies among 9 different burn patient samples. No negative outcomes associated with lower fat, higher carbohydrate nutrition for severely burned patients were found in the literature. Conversely, the literature review revealed improved outcomes among severely burned patients receiving lower fat, higher carbohydrate nutrition to include fewer incidences of pneumonia, wound infections, acute respiratory distress syndrome, fatty liver, and sepsis. These patients also experienced shorter hospital length of stay and shorter wound healing times, as well as lower spleen and kidney weights, lower urinary nitrogen losses, improved nitrogen balance, higher insulin levels, higher insulin-like growth factor-1, lower cortisol, and less muscle protein breakdown. The evidence available to date supports the clinical use of nutrition support providing ≤15% fat and ≥60% carbohydrate for critically ill burn patients.

The purpose of this project was to evaluate the relationships between nutrition, physical activity levels (PALs), severity of illness (SOI), and survival in critically ill burn patients. We conducted a retrospective evaluation of consecutively admitted adult patients who had an intensive care unit stay ≥8 days after ≥20% TBSA burns. Linear regression was used to assess the association between SOI (sequential organ failure assessment scores) and PALs as well as between SOI and nutritional intake. After univariate analysis comparing survivors and nonsurvivors, factors with P < .10 were analyzed with multiple logistic regression. Characteristics of the 45 included patients were: 42 ± 15 years old, 37 ± 17% TBSA burns, 22% mortality. Factors independently associated with survival were burn size (negatively) (P = .018), height (positively) (P = .006), highest PAL during the first eight intensive care unit days (positively) (P = .016), and kcal balance during the fifth through the eighth intensive care unit days (positively) (P = .012). Sequential organ failure assessment scores had a significant (P < .001) but weak association with nutrition intake (R2 = 0.05) and PALs (R2 = 0.25). Higher nutritional intake and activity were significantly associated with lower mortality in critically ill burn patients. Given the weak associations between both nutritional intake and PALs with SOI, the primary barrier in achieving nutrition and activity goals was not SOI. We recommend that physical rehabilitation and nutritional intake be optimized in an effort to improve outcomes in critically ill burn patients.

Introduction Early initiation of enteral nutrition (EN) for severely burned patients (pts) has been found to be associated with decreased catabolism, decreased wound infections, lower sepsis rates, shorter intensive care unit (ICU) days and hospital days, and improved mortality. The American Society for Parenteral and Enteral Nutrition (ASPEN) recommends initiating EN within 4–6 hrs of injury for critically ill adult burn pts; however, they also recommend waiting for hemodynamic stability to be achieved before starting EN in all critically ill pts. The objectives of this performance improvement project (PIP) were to evaluate the timing of EN initiation and reasons for delays in initiating EN in our critically ill burn pts. Methods We performed a retrospective evaluation on pts admitted to our ICU in 2019 with at least 20% TBSA burns. Exclusion criteria were death within 72 hrs of admission, oral nutrition, and admission over 1 calendar day after injury. This PIP was approved by our regulatory compliance division. We clinically defined hemodynamic stability as lactate levels less than 3 mmol/L with vasopressor requirements of less than 10 mcg/min norepinephrine. Demographic data were collected along with timing of EN and reasons for delays in EN initiation. Results EN was initiated 28 ± 17 hrs after admission for the 19 included pts with the following characteristics: 44 ± 16 years old, 38 ± 16% TBSA burn, all required mechanical ventilation on admission. These pts had 16 ± 10 mechanical ventilator days and 42% mortality. The shortest time to EN initiation was 9 hrs after admission. EN was delayed for initial hemodynamic instability for 10 ± 17 hrs after admission. Other delays in EN initiation after initially achieving hemodynamic stability included time to feeding tube placement (1 ± 2 hrs) and x-ray confirmation (4 ± 9 hrs), and time to EN orders (8 ± 10 hrs). EN was initiated 6 ± 6 hrs after the preceding events occurred. Some of the delays in placement of EN orders and for EN initiation after the above criteria were met included procedures (2 ± 2 hrs), becoming hemodynamically unstable again (5 ± 7 hrs), and placement of a small bore, post-pyloric feeding tube when an orogastric or nasogastric feeding tube was already available for use (2 ± 4 hrs). We were not able to retrospectively identify reasons for delays during 5 ± 6 hrs per patient. Conclusions As a result of this PIP, we found EN was not initiated in any of our critically ill burn pts within the timeline recommended by ASPEN/SCCM. The primary reasons for delays included hemodynamic instability, feeding tube placement and confirmation, adding a post-pyloric feeding tube, and procedures.

Introduction Pneumonia is a prominent cause of morbidity and mortality in burn patients. The European Society for Clinical Nutrition and Metabolism (ESPEN) recommends supplementing with intravenous copper, selenium, and zinc, as a randomized controlled trials on burn patients in Switzerland showed decreased pneumonia rates. The purpose of this performance improvement project was to determine whether the intravenous supplementation of copper, selenium, and zinc had an association with the incidence of pneumonia in patients with total body surface area (TBSA) burns over 20% in order to determine if this practice should be re-initiated. Methods Based on available randomized controlled trial evidence, we began the clinical practice of providing intravenous trace elements to our patients with burns over 20% TBSA who were admitted to the burn intensive care unit and who had a central line. This clinical practice ended after 2 years when there was a national shortage of these intravenous trace elements. We performed a retrospective evaluation on patients admitted for initial burn care to our intensive care unit who received an intravenous solution containing 4 mg copper, 500 mcg selenium, and 40 mg zinc daily for a goal duration of 14 days in patients with 20–40% TBSA burns and 21 days in patients with over 40% TBSA burns. Patients who survived less than two days were excluded. In order to compare the incidence of pneumonia within the first 30 hospital days in patients who received intravenous trace element supplementation to those who did not, we matched patients based on age, burn size, and gender. Matched subjects were admitted either before or after the time period of intravenous trace element supplementation and these subjects received oral zinc supplementation. Descriptive statistics and Chi-Square were performed using JMP. Significance was set at p< 0.05. Results Pneumonia within the first 30 hospital days occurred in 63% of the 52 included patients with the following characteristics: 71% male, 52 ± 18 years old, 43 ± 15% TBSA burn, 29 ± 25 mechanical ventilator days, and 44% mortality. A significant difference in the incidence of pneumonia during the first 30 hospital days was not found between groups (intravenous trace element group: 70%; comparison group: 56%, p=0.28). Conclusions Supplementation of intravenous copper, selenium, and zinc was not significantly associated with incidence of pneumonia in our severely burned patients, contrary to previous research findings.

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.

Introduction Multiple organizations have developed guidelines for nutritional support following burn trauma. These guidelines are based on low levels of evidence and largely on expert opinion. We sought to compile randomized controlled trials (RCTs) evaluating clinical outcomes from carbohydrate versus fat in enteral nutrition (EN) for burn patients and then analyze outcomes via meta-analysis and compare these outcomes to current available guidelines. Methods We performed a literature search to identify RCTs evaluating outcomes of burn patients with different proportions of carbohydrate versus fat interventions. Meta-analyses were conducted on outcomes reported by more than one RCT with the DerSimonian and Laird random effects model. Statistical significance was established at α less than 0.05. Meta-analysis results were then evaluated alongside the available guidelines from American Society for Parenteral and Enteral Nutrition (ASPEN) and Society of Critical Care Medicine (SCCM), the European Society for Parenteral and Enteral Nutrition (ESPEN), and the International Society for Burn Injury (ISBI). Results We identified 3 studies meeting our inclusion criteria for RCTs. Meta-analysis showed lower fat, higher carbohydrate EN to be associated with lower incidence of pneumonia (p=0.0005) as well as a reduction in mortality (p=0.04). The ASPEN/SCCM and ISBI guidelines do not specifically address this topic. ESPEN recommends less than 60% carbohydrates and less than 35% fat. However, this is not in accordance with the 46–65% carbohydrate and 12–27% fat with favorable outcomes studied in the 3 identified RCTs. Conclusions As current guidelines are often not based on high levels of evidence, it was important to collect and evaluate all of the available RCTs. Our meta-analysis results of these RCTs demonstrated mortality benefits with lower fat, higher carbohydrate EN in burn patients. Additionally, we found lower rates of pneumonia with lower fat, higher carbohydrate EN. Applicability of Research to Practice Consideration should be made for 12–27% fat, 46–65% carbohydrate EN in burn patients; however, multicentered trials are required before strong recommendations can be made.

Maintaining body temperature is a unique challenge with burn care. We sought to describe core temperature goals in the operating room (OR) and the methods used to achieve and maintain these goals, along with current methods of warming in the intensive care unit (ICU), the perception of effect of increased ambient temperature on work performance, and concerns with contamination of sterile fields due to increased ambient temperature. A 24 question survey was disseminated to burn centers in the United States and Canada. The questions included demographics, target core and ambient temperatures, warming methods, and beliefs on ambient temperature's effects. Of 121 burn centers, 52 questionnaires were completed (43% response rate). The majority of centers targeted a core temperature between 36 and 38°C in the OR and an ambient temperature between 75 and 95°F in the ICU. The most common methods for maintaining core temperature included warmed ambient temperature, forced air devices, and intravenous fluids. Although the majority of centers reported the belief that increased ambient temperature benefits patients, many also reported that there is a negative impact on staff performance and risk of staff perspiration contaminating sterile fields. Burn centers reported a range of target core temperatures and methods to reach target temperatures. More than a third of respondents perceived a negative impact work performance while more than half acknowledged the potential for contamination of sterile fields. A prospective observational study is needed to determine actual temperature regulation practice patterns and its impact on outcomes.

The aim of this study was to determine whether visceral protein levels increase under positive nitrogen balance during times of decrease in acute-phase reactant levels in patients with burn injury. This was a post hoc analysis of a prospective, interventional study approved by the local institutional review board. A total of 10 subjects between the ages of 18 and 72 with ≥ 20% total body surface area burn were enrolled over a 14-month period. Data were collected for five subjects (average age of 28 ± 8 years and total body surface area burn of 69 ± 15%) who met the inclusion criteria. Changes in visceral protein levels were examined along with nitrogen balance and acute-phase reactants when the subjects were on enteral nutrition, and the proteins were not examined during times of acute kidney injury. Descriptive statistics were performed, and linear regression was used to analyze the association of visceral proteins and nitrogen balance during times that acute-phase reactant levels were decreasing. The subjects received an average of 3044 ± 1613 kcal/day (39 ± 20 kcal/kg), meeting 72% of caloric goals and achieving positive nitrogen balance during 68% of the 40 weekly measurements, with 174 ± 85 g of protein intake per day (2.2 ± 1.1 g/kg). There was a weak relationship between nitrogen balance and changes in visceral protein levels during times that the acute-phase reactant levels were decreasing (P > .05). Visceral proteins were found to be poor markers of nutritional status. This study is unique because the subjects were able to achieve positive nitrogen balance despite severe burns.

Hypermetabolism is universal in the severely burned and is characterized by catabolism of lean mass and body fat with associated insulin resistance. Adipokines are likely to play a role in these changes but have not been identified to date in burn patients.From a single burn ICU, 17 burn patients with an expected stay14 days were studied. Study period began within 14 days of admission. Over 7 days, plasma samples were collected for measurement of leptin, adiponectin, resistin, ghrelin, insulin, and cortisol by ELISA. For comparison, samples from 15 healthy controls of similar age, BMI, and blood glucose were obtained.Mean age was 33±17 years and BMI 26±3.4. Average burn size was 45±20% TBSA and ISS 32±10 with 72% having inhalation injury; in-hospital mortality was 29%. Estimated energy needs were 3626±710 kcal, of which 84±21% were met by enteral feeding with intensive insulin treatment (glucose 80-110 mg/ml). Using the homeostasis model assessment of insulin resistance, burned subjects were more resistant than controls (17±11.3 and 8±10.0). Insulin levels were elevated (57±35.6 μU/ml in burned subject vs. 26±31.1 μU/ml in controls), and cortisol concentrations increased (50±41.2 μg/dl vs. 12±3.9 μg/dl). These traditional hormone changes were associated with increased resistin (16.6±5.5 ng/ml vs. 3.8±0.9 ng/ml) and decreased leptin (8.8±8.9 ng/ml vs. 19.4±23.5 ng/ml), adiponectin (9±3.5 ng/ml vs. 17±10.2 ng/ml), and ghrelin (0.37±0.14 ng/ml vs.0.56±0.26 ng/ml).Patients with burns, who are characteristically hypermetabolic with hypercortisolism and insulin resistant, have significant changes in adipokine levels that appear independent of the magnitude of initial injury or metabolic derangement. In addition, suppression of ghrelin in the presence of decreased leptin and adiponectin levels in combination with increased insulin and resistin levels represent unexpected changes in the metabolic milieu of the injured patient possibly due to dramatic activation of inflammatory pathways, indicating strategies for treatment.

Severe weight loss resulting from inadequate nutritional intake along with the hypermetabolism after thermal injury can result in impaired immune function and delayed wound healing. This observational study was conducted on adults admitted between October 2007 and April 2012 with at least 20% total body surface area burn requiring excision who previously tolerated gastric enteral nutrition at calorie goal and who returned from surgery hemodynamically stable (no new pressor requirement) and compared the effect of goal rate re-initiation versus slow re-initiation after the first excision and grafting. Demographic, intake, and tolerance data were collected during the 36h following surgery and were analyzed with descriptive and comparative statistics. Data were collected on 14 subjects who met the inclusion criteria. Subjects in the goal rate re-initiation group (n=7) met a significantly greater percentage of caloric goals (99±12% versus 58±21%, p=0.003) during the 36h following surgery than subjects in the slow re-initiation group (n=7). There were no incidences of emesis, aspiration, or ischemic bowel in either group. The goal rate re-initiation group had a 29% incidence of either stool output >1L (n=1) or gastric residual volumes >500mL (n=1), whereas these were not present in the slow re-initiation group (p=0.462). In conclusion, in this small pilot study, we found that enteral nutrition could be re-initiated after the first excision and grafting in those patients who previously tolerated gastric enteral nutrition meeting caloric goals who return from surgery hemodynamically stable without a significant difference in intolerance and with a significantly higher percentage of calorie goals achieved, but larger studies are required.

The aim of this study was to determine the prevalence of late defecation (absence of laxation for more than 6 days after admission) as an indicator of lower-gastrointestinal (GI) tract dysfunction in burn patients. In addition, the authors wanted to determine whether the addition of polyethylene glycol 3350 to the standard bowel regimen led to improvement in markers of lower-GI function and outcomes. The authors conducted a retrospective chart review of patients admitted to the burn intensive care unit during a 26-month period. Inclusion criteria were 20% or more TBSA burn, requirement for mechanical ventilation, and age over 18 years. Of 83 patients included, the prevalence of late defecation was 36.1% (n = 30). There was no association between late defecation and mortality. Patients with late defecation had more frequent episodes of constipation after first defecation (P =.03), of feeding intolerance (P =.007), and received total parenteral nutrition more frequently (P =.005). The addition of polyethylene glycol to the standard bowel regimen did not affect markers of lower-GI function. Late defecation occurs in more than one third of critically ill burn patients. Late defecation was associated with ongoing lower-GI dysfunction, feeding intolerance, and the use of total parenteral nutrition. The causal relationship between these problems has not been determined. A prospective study at the authors' institution is currently planned to attempt to validate late defecation as a marker of lower-GI tract dysfunction, determine its relationship to various outcomes, and determine risk factors for its development.

The purpose of this study was to evaluate the accuracy of nine predictive equations for calculating energy expenditure in severely burned adult subjects. The selected equations have been reported as commonly used or determined to be the most accurate. This prospective, observational study was conducted on adult subjects admitted between October 2007 and July 2010 with ≥ 20% TBSA full-thickness burns (excluding electrical burns or severe head injury). Indirect calorimetry measurements were conducted as a convenience sample during the first 30 days after injury. Demographic data were collected, and resting energy expenditure was calculated using the nine selected predictive equations and compared to measured energy expenditure (MEE) using descriptive and comparative statistics. Data were collected on 31 subjects with an average age of 46 ± 19 years and %TBSA burn of 48 ± 21%. For all equations, slopes and intercepts were significantly different from the line of identity when compared with MEE. A calorie-dependent bias was present for all equations, in that lower calorie range was overestimated and the higher calorie range was underestimated. Only the Carlson and Milner equations had results that were not significantly different from the MEE and mean differences that were not significant in all burn size ranges. None of the equations had a strong correlation with MEE. Of the equations available, the Milner and Carlson equations are the most satisfactory in predicting resting energy expenditure in severely burned adults when indirect calorimetry is unavailable.

Although there is no evidence that electromagnetic energy in the radio frequency radiation (RFR) band is mutagenic, there have been suggestions that RFR energy might serve as either a promoter or co-promoter in some animal models of carcinogenesis. Recent developments in electromagnetic technology have resulted in the manufacture of RFR sources capable of generating frequencies in the millimeter wave- length (MMW) range (30- 300 GHz). Because absorption of MMW energy occurs in the skin, it is to be expected that long-term detrimental health effects, if any, would most likely be manifest in the skin. In this study we investigated whether a single (1.0 W/cm2 for 10 s) or repeated (2 exposures/week for 12 weeks, 333 mW/cm2 for 10 s) exposure to 94 GHz RFR serves as a promoter or co-promoter in the 7,12-dimethylbenz[ a ]anthracene (DMBA)-induced SENCAR mouse model of skin carcinogenesis. Neither paradigm of MMW exposure significantly affected papilloma development, as evidenced by a lack of effect on tumor incidence and multiplicity. There was also no evidence that MMW exposure served as a co-promoter in DMBA-induced animals repeatedly treated with 12- O - tetradecanoylphorbol 13-acetate. Therefore, we conclude that exposure to 94 GHz RFR under these conditions does not promote or co-promote papilloma development in this animal model of skin carcinogenesis.