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Hanan A Tanash,1 Thomas Ringbaek,2 Fredrik Huss,3,4 Magnus Ekström1 1Department of Respiratory Medicine, Skåne University Hospital, Lund University, Lund, Sweden; 2Respiratory Department, Hvidovre Hospital, Copenhagen, Denmark; 3Department of Surgical Sciences, Plastic Surgery, 4Department of Plastic and Maxillofacial Surgery, Burn Center, Uppsala University Hospital, Uppsala, Sweden Background: Long-term oxygen therapy (LTOT) increases life expectancy in patients with COPD and severe hypoxemia. Smoking is the main cause of burn injury during LTOT. Policy regarding smoking while on LTOT varies between countries. In this study, we compare the incidence of burn injury that required contact with a health care specialist, between Sweden (a country with a strict policy regarding smoking while on LTOT) and Denmark (a country with less strict smoking policy). Methods: This was a population-based, cohort study of patients initiating LTOT due to any cause in Sweden and Denmark. Data on diagnoses, external causes, and procedures were obtained from the Swedish and Danish National Patient Registers for inpatient and outpatient care. Patients were followed from January 1, 2000, until the first of the following: LTOT withdrawal, death, or study end (December 31, 2009). The primary end point was burn injury during LTOT. Results: A total of 23,741 patients received LTOT in Denmark and 7,754 patients in Sweden. Most patients started LTOT due to COPD, both in Sweden (74%) and in Denmark (62%). The rate of burn injury while on LTOT was higher in Denmark than in Sweden; 170 (95% confidence interval [CI], 126–225) vs 85 (95% CI, 44–148) per 100,000 person-years; rate ratio 2.0 (95% CI, 1.0–4.1). The risk remained higher after adjustment for gender, age, and diagnosis in multivariate Cox regression, hazard ratio 1.8 (95% CI, 1.0-3.5). Thirty-day mortality after burn injury was 8% in both countries. Conclusion: Compared to Sweden, the rate of burn injury was twice as high in Denmark where smoking is not a contraindication for prescribing LTOT. Keywords: burn injury, COPD, long-term oxygen therapy, smoking

Hanan A Tanash,1 Fredrik Huss,2,3 Magnus Ekström41Department of Respiratory Medicine and Allergology, Skåne University Hospital, Lund University, Lund, 2Department of Surgical Sciences, Plastic Surgery, Uppsala University, 3Burn Center, Department of Plastic and Maxillofacial Surgery, University Hospital of Uppsala, Uppsala, 4Department of Clinical Sciences, Division of Respiratory Medicine & Allergology, Lund University, Lund, SwedenBackground: Long-term oxygen therapy (LTOT) improves the survival time in hypoxemic chronic obstructive pulmonary disease. Despite warnings about potential dangers, a considerable number of patients continue to smoke while on LTOT. The incidence of burn injuries related to LTOT is unknown. The aim of this study was to estimate the rate of burn injury requiring health care contact during LTOT.Methods: Prospective, population-based, consecutive cohort study of people starting LTOT from any cause between January 1, 1992 and December 31, 2009 in the Swedish National Register of Respiratory Failure (Swedevox).Results: In total, 12,497 patients (53% women) were included. The mean (standard deviation) age was 72±9 years. The main reasons for starting LTOT were chronic obstructive pulmonary disease (75%) and pulmonary fibrosis (15%). Only 269 (2%) were active smokers when LTOT was initiated. The median follow-up time to event was 1.5 years (interquartile range, 0.55–3.1). In total, 17 patients had a diagnosed burn injury during 27,890 person-years of LTOT. The rate of burn injury was 61 (95% confidence interval, 36–98) per 100,000 person-years. There was no statistically significant difference in the rate of burn injury between ever-smokers and never-smokers, or between men and women.Conclusion: The rate of burn injuries in patients on LTOT seems to be low in Sweden. The strict requirements in Sweden for smoking cessation before LTOT initiation may contribute to this finding.Keywords: respiratory failure, oxygen, fire, burn, mortality, smoking

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The most common cited cause of split-thickness skin graft failure is infection and due to the association between bacterial findings in wound beds an attempt to decrease the bacterial burden before skin-grafting evolved. Thus, preoperative microbiology swabs of the wound bed became routine at some institutions prior to grafting. This is not standard practice in the Pietermaritzburg Burn Service. Emphasis is instead placed on a strict protocol of intraoperative wound bed preparation to promote adequate graft take. This pilot study aims to evaluate whether preoperative wound swabs are appropriate. We performed a prospective observational study to determine if positive wound cultures were associated with graft failure. All patients with a burn surface area of less than 10%, where delayed grafting (later than 28 days from the time of burn injury) was performed, from March to December 2021 were analyzed. Patient demographics, days from burn to graft, %TBSA burn, %TBSA grafted, whether sharp debridement prior to grafting in the same procedure was performed or not, use of topical gentamicin intraoperatively, graft outcome (% graft loss), need for regraft, and organism grown were recorded into an excel spreadsheet for analysis. The sample included 52 patients. Of these, 17 (31.5%) were female. The median %TBSA grafted was 8% (IQR 4%-13%) and similar in both groups. The median days from burn to grafting were 35 days. Thirty-nine patients (75%) had graft Take and 13 (25%) had graft Failure. In the failed group, the median % graft failure was 50% (30%-70%). Of the group with successful graft take, 90% were noted to have had a positive wound culture prior to grafting. A positive wound culture was not found to be a risk factor for graft failure (P = .993). Despite the positive wound cultures graft take was more than 90% in 75% of grafts performed and only 2/52 patients required supplementary grafting. We believe that this demonstrates that our local protocol is reasonable in this setting and that waiting for negative wound swabs prior to grafting should not be a reason to delay grafting., (© The Author(s) 2024. Published by Oxford University Press on behalf of the American Burn Association. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Background: Nitrous oxide (N 2 O) use in recreational settings has been increasing in Sweden and Europe and consequently, the related injuries are also increasing. We aimed to investigate the incidence, management, and surgical outcomes of frostbite injury (FI) related to N 2 O use., Material and Method: All patients in a 22-month period from 2021 to 2022 presenting with FI related to N 2 O abuse from 2 plastic surgery clinics (1 national burn center) were identified. Data regarding patient comorbidity, mechanism of injury, initial management, treatment, and follow-up were investigated. Complications following surgery were categorized into minor (treated in outpatient setting) and major (requiring reoperation) complications., Results: In total, 9 patients were identified; among them, 5 patients provided consent and were included in the study. Direct contact with the gas canister was the most common injury mechanism (n = 4). All but 1 patient contracted full-thickness injuries, and these 4 patients later required surgery. The medial thigh was the most common area of injury. Outpatient clinic visits were common (mean 4.8 visits/patient). Surgical complications were common and all operated patients were diagnosed with minor complications and half of them with major complications (wound dehiscence and scar contracture)., Conclusion: Frostbite injuries arising from recreational N 2 O use are complex and often require surgical intervention that may lead to complications. With the increasing incidence of N 2 O abuse in Sweden, further research is crucial to address this emerging public health concerns and optimize treatment strategies for these distinctive injuries., Competing Interests: None., (© 2024 The Author(s).)

Background: A person diagnosed with gender dysphoria who was assigned female at birth (AFAB) may request a vaginectomy as part of gender-affirming treatment. The aim of this study was to investigate the impact of vaginectomy on symptoms of pelvic floor dysfunction (PFD)., Methods: This is a cohort study on patient-reported symptoms of PFD in patients who were AFAB, diagnosed with gender dysphoria, and undergoing vaginectomy in a single surgical center. Patients responded to a questionnaire preoperatively and 1 year postoperatively. The questionnaire consisted of 33 questions, including a modified short-form version of the Pelvic Floor Distress Inventory (PFDI-20)., Results: Twenty-three consecutive patients were included in the study and 20 patients (87%) completed the 1-year follow-up. The preoperative median PFDI-20 score was 24 (0-114) compared with 32 (0-168) at the 1-year follow-up ( P  = 0.07). Patients who had previously undergone neophallus construction with a metoidioplasty (n = 15) had no significant change between the preoperative and the 1-year postoperative PFDI-20 score [median 17.5 (0-114) and 27.5 (0-145) ( P  = 0.65), respectively]; whereas those with a groin flap phalloplasty (n = 5) had a significant increase in reported symptoms [median 37 (10-95) and 124 (45-168), respectively ( P  = 0.04)]., Conclusions: Overall, vaginectomy could be performed without any major impact on symptoms of PFD. However, this seemed to be true mainly for patients with previous metoidioplasty, whereas patients with previous groin flap phalloplasty reported worsening of symptoms., Competing Interests: The authors have no financial interest to declare in relation to the content of this article. The study was funded by ALF grants from Region Östergötland., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Introduction: The Surviving Sepsis Campaign was developed to improve outcomes for all patients with sepsis. Despite sepsis being the primary cause of death after thermal injury, burns have always been excluded from the Surviving Sepsis efforts. To improve sepsis outcomes in burn patients, an international group of burn experts developed the Surviving Sepsis After Burn Campaign (SSABC) as a testable guideline to improve burn sepsis outcomes., Methods: The International Society for Burn Injuries (ISBI) reached out to regional or national burn organizations to recommend members to participate in the program. Two members of the ISBI developed specific "patient/population, intervention, comparison and outcome" (PICO) questions that paralleled the 2021 Surviving Sepsis Campaign [1]. SSABC participants were asked to search the current literature and rate its quality for each topic. At the Congress of the ISBI, in Guadalajara, Mexico, August 28, 2022, a majority of the participants met to create "statements" based on the literature. The "summary statements" were then sent to all members for comment with the hope of developing an 80% consensus. After four reviews, a consensus statement for each topic was created or "no consensus" was reported., Results: The committee developed sixty statements within fourteen topics that provide guidance for the early treatment of sepsis in burn patients. These statements should be used to improve the care of sepsis in burn patients. The statements should not be considered as "static" comments but should rather be used as guidelines for future testing of the best treatments for sepsis in burn patients. They should be updated on a regular basis., Conclusion: Members of the burn community from the around the world have developed the Surviving Sepsis After Burn Campaign guidelines with the goal of improving the outcome of sepsis in burn patients., Competing Interests: Declaration of Competing Interest Kevin Chung is Chief Medical Officer for SeaStar Medical, Denver, Colorado. No other author has declared a conflict of interest related to the publication., (Copyright © 2023 Elsevier Ltd and International Society of Burns Injuries. All rights reserved.)

Umbilical pilonidal sinus is a rare diagnosis which is characterized by an inflammatory granulomatous reaction to hair shafts penetrating the epidermis. It is most often seen in adolescent male with a hairy abdomen. The patients often present with a history of pain and umbilical discharge. Conservative treatment with hair extraction and personal hygiene is prioritized and surgery is only recommended in recurrent cases. Here one such case is presented, which was resistant to conservative treatment and where surgical excision and primary repair was indicated. No recurrence was observed 6 months postoperatively.

Background & Aims: Intensive nutritional therapy is an essential component of burn care. Regarding post-minor burn injuries, the literature is lacking. The aim of this study was to evaluate documented nutritional therapy in relation to international guidelines after both minor and major burn injuries. The secondary aim of this study was to evaluate the adequacy of energy and protein intake compared to individual nutritional goals post-burn injury., Methods: A retrospective observational single-centre study including patients admitted between 2017 and 2019 at a burn centre in Sweden was performed. The patients included in the study were ≥18 years old and in need of hospital care for ≥72 h post-burn injury. Information about patients' demographics, nutritional therapy, and clinical characteristics of burn injury was collected. The patients were divided according to total body surface area burnt (TBSA %) into minor burn injuries (TBSA <20%) and major burn injuries (TBSA ≥20%). Descriptive statistics were used to analyse data. Adherence to guidelines was established by comparing 24 nutritional therapy recommendations to documented treatment. If documented nutritional treatment were in accordance with guidelines, adherence was considered high (≥80%), moderate (60-79.9%) or low (<59.9%)., Results: One hundred thirty-four patients were included, 90 patients with minor burn injuries and 44 patients with major burn injuries. Documented adherence to the nutritional guideline was overall low. After minor burn injury, 8% (2/24) of nutritional therapy recommendations had a high adherence (fat intake <35% of total energy intake and enteral nutrition as prioritized feeding route), 17% (4/24) a moderate adherence, and 75% (18/24) a low adherence. In patients treated after a major burn injury, there were two recommendations with documented high adherence (Vitamin C and Zinc); 25% (6/24) had moderate adherence, and 67% (16/24) had low adherence. In addition, quite a large amount of missing data was found. Adequacy of documented nutritional intake, compared to the individual documented goal, was 78% (±23%) for energy and 66% (±22%) for protein after minor burn injury. After major burn injury, the adequacy was 89% (±21%) for energy and 78% (±19%) for protein, respectively., Conclusions: This study revealed low adherence to nutritional guidelines in patients treated for minor and major burn injuries. Compared to major burn injuries, lower documented adequacy for both energy and proteins was found in minor burn injuries. Given the disparity between guidelines and documented nutritional therapy, and the lack of specific guidelines for minor burn injuries, there could be a considerable risk of inadequate nutritional therapy post-burn injury., Competing Interests: Declaration of competing interest The authors declare no conflict of interest., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Assessment of burn extent and depth are critical and require very specialized diagnosis. Automated image-based algorithms could assist in performing wound detection and classification. We aimed to develop two deep-learning algorithms that respectively identify burns, and classify whether they require surgery. An additional aim assessed the performances in different Fitzpatrick skin types. Annotated burn (n = 1105) and background (n = 536) images were collected. Using a commercially available platform for deep learning algorithms, two models were trained and validated on 70% of the images and tested on the remaining 30%. Accuracy was measured for each image using the percentage of wound area correctly identified and F1 scores for the wound identifier; and area under the receiver operating characteristic (AUC) curve, sensitivity, and specificity for the wound classifier. The wound identifier algorithm detected an average of 87.2% of the wound areas accurately in the test set. For the wound classifier algorithm, the AUC was 0.885. The wound identifier algorithm was more accurate in patients with darker skin types; the wound classifier was more accurate in patients with lighter skin types. To conclude, image-based algorithms can support the assessment of acute burns with relatively good accuracy although larger and different datasets are needed., (© 2023. The Author(s).)

Objective: To describe the course of the outbreak and infection control measures to stop the spread of sequence type 15 OXA-23-producing Acinetobacter baumannii in the Burn Center of Uppsala University Hospital, between November 2014 and the end of April 2015., Methods: Compliance with hand hygiene, dress code, and cleaning routines were reviewed, the ward's environment was systematically investigated to identify potential environmental sources. Sampling routines for A. baumannii, from patients and environment, were established, and the epidemiological relationship was analysed for all carbapenem-resistant A. baumannii isolates using arbitrarily primed polymerase chain reaction (AP-PCR) and pulsed-field gel electrophoresis (PFGE)., Results: A total of 54 patients were treated at the burn intensive care unit during the studied, approximately five months period, and an OXA-23-producing A. baumannii was isolated from nine patients (9/54, 17%), whereof two died (2/9, 22.2%). All isolates shared identical PFGE-genotype patterns and belonged to sequence type 15; AP-PCR was eligible for prompt epidemiological investigations., Conclusions: Higher awareness and increased compliance with hand hygiene and dress code as well as intensified cleaning protocols of the environment and equipment were successfully established and likely to have led to stop the spread of sequence type 15 OXA-23-producing Acinetobacter baumannii., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Glutamine is thought to have beneficial effects on the metabolic and stress response to severe injury. Clinical trials involving patients with burns and other critically ill patients have shown conflicting results regarding the benefits and risks of glutamine supplementation., Methods: In a double-blind, randomized, placebo-controlled trial, we assigned patients with deep second- or third-degree burns (affecting ≥10% to ≥20% of total body-surface area, depending on age) within 72 hours after hospital admission to receive 0.5 g per kilogram of body weight per day of enterally delivered glutamine or placebo. Trial agents were given every 4 hours through a feeding tube or three or four times a day by mouth until 7 days after the last skin grafting procedure, discharge from the acute care unit, or 3 months after admission, whichever came first. The primary outcome was the time to discharge alive from the hospital, with data censored at 90 days. We calculated subdistribution hazard ratios for discharge alive, which took into account death as a competing risk., Results: A total of 1209 patients with severe burns (mean burn size, 33% of total body-surface area) underwent randomization, and 1200 were included in the analysis (596 patients in the glutamine group and 604 in the placebo group). The median time to discharge alive from the hospital was 40 days (interquartile range, 24 to 87) in the glutamine group and 38 days (interquartile range, 22 to 75) in the placebo group (subdistribution hazard ratio for discharge alive, 0.91; 95% confidence interval [CI], 0.80 to 1.04; P = 0.17). Mortality at 6 months was 17.2% in the glutamine group and 16.2% in the placebo group (hazard ratio for death, 1.06; 95% CI, 0.80 to 1.41). No substantial between-group differences in serious adverse events were observed., Conclusions: In patients with severe burns, supplemental glutamine did not reduce the time to discharge alive from the hospital. (Funded by the U.S. Department of Defense and the Canadian Institutes of Health Research; RE-ENERGIZE ClinicalTrials.gov number, NCT00985205.)., (Copyright © 2022 Massachusetts Medical Society.)

Background: Safe and effective methods for sedation and analgesia in pediatric burn patients are strongly warranted. This retrospective study of electronic health care records aims to evaluate the safety and efficacy of intranasal dexmedetomidine combined with rectal ketamine as procedural sedation for young children undergoing dressing changes and debridement of burn wounds., Methods: Documentation was analyzed from 90 procedures in 58 pediatric patients aged <5 years. Safety and efficacy of the method were assessed based on documentation for complications, adverse effects, pain level, level of sedation and preoperative and recovery time., Results: All 90 sedations were completed without significant adverse events with acute airway management or medical intervention. The combination of dexmedetomidine-ketamine produced acceptable analgesia during the procedure and effectively relieved postoperative pain. However, the approach was insufficient for 7/58 patients (7.8%); these patients were converted from the dexmedetomidine-ketamine combination to intravenous anesthesia. In 23% of the cases an extra dose of either ketamine of dexmedetomidine was administered. Moreover, there were two cases of delayed awakening with recovery time >120 min., Conclusion: The drug combination intranasal dexmedetomidine and rectal ketamine is a safe and reliable approach for procedural sedation and analgesia in pediatric patients undergoing burn wound procedures, producing a clinically stable sedative condition requiring only basic monitoring., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)