Peritraumatic Plasma Omega-3 Fatty Acid Concentration Predicts Chronic Pain Severity Following Thermal Burn Injury.

Chronic pain is a significant comorbidity of burn injury affecting up to 60% of survivors. Currently, no treatments are available to prevent chronic pain after burn injury. Accumulating evidence suggests that omega-3 fatty acids (O3FAs) improve symptoms across a range of painful conditions. In this study, we evaluated whether low peritraumatic levels of O3FA predict greater pain severity during the year after burn injury. Burn survivors undergoing skin autograft were recruited from three participating burn centers. Plasma O3FA (n = 77) levels were assessed in the early aftermath of burn injury using liquid chromatography/mass spectrometry, and pain severity was assessed via the 0 to 10 numeric rating scale for 1 year following burn injury. Repeated-measures linear regression analyses were used to evaluate the association between peritraumatic O3FA concentrations and pain severity during the year following burn injury. Peritraumatic O3FA concentration and chronic pain severity were inversely related; lower levels of peritraumatic O3FAs predicted worse pain outcomes (ß = -0.002, P = .020). Future studies are needed to evaluate biological mechanisms mediating this association and to assess the ability of O3FAs to prevent chronic pain following burn injury.

Peritraumatic Vitamin D Levels Predict Chronic Pain Severity and Contribute to Racial Differences in Pain Outcomes Following Major Thermal Burn Injury.

Major thermal burn injuries result in approximately 40,000 hospitalizations in the United States each year. Chronic pain affects up to 60% of burn survivors, and Black Americans have worse chronic pain outcomes than White Americans. Mechanisms of chronic pain pathogenesis after burn injury, and accounting for these racial differences, remain poorly understood. Due to socioeconomic disadvantage and differences in skin absorption, Black Americans have an increased prevalence of Vitamin D deficiency. We hypothesized that peritraumatic Vitamin D levels predict chronic pain outcomes after burn injury and contribute to racial differences in pain outcomes. Among burn survivors (n = 77, 52% White, 48% Black, 77% male), peritraumatic Vitamin D levels were more likely to be deficient in Blacks vs Whites (27/37 [73%] vs 14/40 [35%], P < .001). Peritraumatic Vitamin D levels were inversely associated with chronic post-burn pain outcomes across all burn injury survivors, including those who were and were not Vitamin D deficient, and accounted for approximately one-third of racial differences in post-burn pain outcome. Future studies are needed to evaluate potential mechanisms mediating the effect of Vitamin D on post-burn pain outcomes and the potential efficacy of Vitamin D in improving pain outcomes and reducing racial differences.

Work-Related Burn Injuries in a Tertiary Care Burn Center, 2013 to 2018.

The features of work-related burn (WRB) injuries are not well defined in the literature and they vary depending on geographical location. We wanted to describe these characteristics among patients treated in the UNC Burn Center to evaluate the potential impact of commonly accepted prevention efforts. Adults of working age, admitted between January 1, 2013, and December 31, 2018, were identified using our Burn Center Registry. Demographic data, characteristics of injury, course of treatment, and patients' outcomes were described. Differences between work-related and non-work-related injuries were evaluated using the Chi-square test and Student t-test where appropriate. Three thousand five hundred and forty-five patients were included. WRB cases constituted 18% of the study population, and this proportion remained relatively stable during the study timeframe. Young white males were the majority of this group. When compared with non-WRB patients, they were characterized by fewer co-morbidities, decreased TBSA burns, decreased risk of inhalation injury, shorter time of intensive care treatment, shorter lengths of hospital stay, and lower treatment cost. In contrast to non-WRB, among which flame injuries were the main reason for admission, work-related patients most often suffered scald burns. They also had a dramatically increased proportion of chemical and electrical burns, making the latter the most common cause of death in that group. WRB are characterized by a characteristic patient profile, burn etiologies, and outcomes. Learning specific patterns at this group may contribute to optimize work safety regulations and medical interventions.

Osteomyelitis Increases the Rate of Amputation in Patients With Type 2 Diabetes and Lower Extremity Burns.

In patients with diabetes mellitus (DM), amputation rates exceed 30% when lower extremity osteomyelitis is present. We sought to determine the rate of osteomyelitis and any subsequent amputation in our patients with DM and lower extremity burns. We performed a single-site, retrospective review at our burn center using the institutional burn center registry, linked to clinical and administrative data. Adults (≥18 years old) with DM admitted from January 1, 2014 to December 31, 2018 for isolated lower extremity burns were eligible for inclusion. We evaluated demographics, burn characteristics, comorbidities, presence of radiologically confirmed osteomyelitis, length of stay (LOS), inpatient hospitalization costs, and amputation rate at 3 months and 12 months after injury. We identified 103 patients with DM and isolated lower extremity burns. Of these, 88 patients did not have osteomyelitis, while 15 patients had radiologically confirmed osteomyelitis within 3 months of the burn injury. Compared to patients without osteomyelitis, patients with osteomyelitis had significantly increased LOS (average LOS 22.7 days vs 12.1 days, P = .0042), inpatient hospitalization costs (average $135,345 vs $62,237, P = .0008), amputation rate within 3 months (66.7% vs 5.70%, P < .00001), and amputation rate within 12 months (66.7% vs 9.1%, P < .0001). The two groups were otherwise similar in demographics, burn injury characteristics, access to healthcare, and preexisting comorbidities. Patients with DM and lower extremity burns incurred increased LOS, higher inpatient hospitalization costs, and increased amputation rates if radiologically confirmed osteomyelitis was present within 3 months of the burn injury.

Death Due to Fractal Wood Burning: An Emerging Public Health Problem.

The art of pyrography, burning designs in wood, dates back to prehistory. Risks of traditional techniques included cutaneous burns and airway injury. Fractal wood burning is a niche technique using a high-voltage electrical source to burn branched designs into wood. While this technique has grown in popularity, the associated risks are not well understood. We describe a patient who presented to our burn center after sustaining high-voltage electrical injuries while making fractal wood art using an improvised a high-voltage transformer. During the wood-burning process, he contacted the electrodes and suffered full-thickness electrical burns to the neck, chest, and bilateral upper extremities. Bilateral upper extremity fasciotomies were performed on admission. Multiple subsequent operations culminated with autografting to most of the wounds and complex reconstruction of the left thumb. In evaluating online news reports, we found 25 unique individuals with death or injury attributed to fractal wood burning from July 2016 to January 2020. Five sustained substantial injuries, while 20 reportedly died. Ages ranged from 17 years old to the 60s. One death and one injury occurred in females, with the remainder of reports involving males. Of the survivors, four sustained significant upper extremity electrical injuries and three suffered cardiac arrest at the time of injury. Fractal wood burning is associated with devastating high-voltage electrical injuries and death. Prevention efforts should be focused on education about the potential for death and permanently disabling injuries from this art form.

Improved Intraoperative Hemodynamics in Burn Surgery: An Institutional Change to Pediatric-Specific Hemostasis Solutions.

A cornerstone of burn surgery hemostasis is infiltration of tumescent vasopressor solutions and topical vasoconstrictor-soaked compresses. Studies detailing pediatric-specific concentrations of these solutions are lacking. Our aim was to assess hemodynamic changes after an institutional change in tumescent vasopressor solution and vasopressor-soaked topical compresses for hemostasis management during pediatric burn surgery. Once the institutional change was implemented, cases performed before and after the intervention were reviewed; inclusion criteria included age 0 to 18 years, burn TBSA ≥ 10%, and surgery length > 50 minutes. Primary outcomes included changes in intraoperative mean arterial pressure, maximum inhaled anesthetic concentration, need for direct-acting vasodilators, estimated blood loss, and need for blood transfusions. Thirty patients were included in the intervention group, and 31 in the control group. There was a significant difference in peak intraoperative blood pressure in the intervention group (21.4%) compared with the control group (48.0%, P = .005). Maximum inhaled anesthetic concentrations were lower in the intervention group (2.5% vs 2.8%, P = .02). Estimated blood loss per TBSA decreased significantly (8.2 ml/1% TBSA vs 1.7, P = .008), as well as blood transfusion rates, with a transfusion rate of 16.7% in the intervention group vs 45.2% in the control group (P = .03). The changes instituted in type and concentration of tumescent solution and vasopressor-soaked topical compresses were associated with improved hemodynamic changes and decreased transfusion rates intraoperatively.

Acuity Is Seasonal in a Tertiary Care Burn Center.

Supply and demand dictate resource allocation in large academic institutions. Classic teaching is that burns is a seasonal specialty with winter being the "busiest" time of year. Resident allocation during the winter and summer months, however, is traditionally low due to the holidays and travel peaks. Our objective was to evaluate our acuity-defined as patient complexity-based on seasons, in order to petition for appropriate mid-level provider allocation. We performed a retrospective review of all admissions to an accredited, large academic burn center. All patients admitted between January 1, 2009 and December 31, 2018 were eligible for inclusion. Demographics, length of stay, injury characteristics, and mortality were evaluated. Thirteen thousand four hundred fifty-eight patients were admitted during this study period. Most patients were admitted during the summer. Patients admitted to the intensive care unit were more likely to be admitted in the winter, although this was not statistically significant. Winter admissions had the longest lengths of stay, and the highest incidence of inhalation injury. Female and elderly patients were more likely admitted during the winter. There was a significant difference in mortality between summer and winter seasons. Acuity is seasonal in our large academic burn center and resource allocation should align with the needs of the patients. This data may help large centers petition their institutions for more consistent experienced mid-level providers, specifically during critical seasons.

Sex-Based Differences in Inpatient Burn Mortality.

BACKGROUND: Among burn patients, research is conflicted, but may suggest that females are at increased risk of mortality, despite the opposite being true in non-burn trauma. Our objective was to determine whether sex-based differences in burn mortality exist, and assess whether patient demographics, comorbid conditions, and injury characteristics explain said differences. METHODS: Adult patients admitted with burn injury-including inhalation injury only-between 2004 and 2013 were included. Inverse probability of treatment weights (IPTW) and inverse probability of censor weights (IPCW) were calculated using admit year, patient demographics, comorbid conditions, and injury characteristics to adjust for potential confounding and informative censoring. Standardized Kaplan-Meier survival curves, weighted by both IPTW and IPCW, were used to estimate the 30-day and 60-day risk of inpatient mortality across sex. RESULTS: Females were older (median age 44 vs. 41 years old, p < 0.0001) and more likely to be Black (32% vs. 25%, p < 0.0001), have diabetes (14% vs. 10%, p < 0.0001), pulmonary disease (14% vs. 7%, p < 0.0001), heart failure (4% vs. 2%, p = 0.001), scald burns (45% vs. 26%, p < 0.0001), and inhalational injuries (10% vs. 8%, p = 0.04). Even after weighting, females were still over twice as likely to die after 60 days (RR 2.87, 95% CI 1.09, 7.51). CONCLUSION: Female burn patients have a significantly higher risk of 60-day mortality, even after accounting for demographics, comorbid conditions, burn size, and inhalational injury. Future research efforts and treatments to attenuate mortality should account for these sex-based differences. The project was supported by the National Institutes of Health, Grant Number UL1TR001111.

Burn recidivism: a 10-year retrospective study characterizing patients with repeated burn injuries at a large tertiary referral burn center in the United States.

BACKGROUND: Psychiatric and substance use disorders are common among trauma and burn patients and are known risk factors for repeat episodes of trauma, known as trauma recidivism. The epidemiology of burn recidivism, specifically, has not been described. This study aimed to characterize cases of burn recidivism at a large US tertiary care burn center and compare burn recidivists (RCs) with non-recidivists (NRCs). METHODS: A 10-year retrospective descriptive cohort study of adult burn patients admitted to the North Carolina Jaycee Burn Center was conducted using data from an electronic burn registry and the medical record. Continuous variables were reported using medians and interquartile ranges (IQR). Chi-square and Wilcoxon-Mann-Whitney tests were used to compare demographic, burn, and hospitalization characteristics between NRCs and RCs. RESULTS: A total of 7134 burn patients were admitted, among which 51 (0.7%) were RCs and accounted for 129 (1.8%) admissions. Of the 51 RCs, 37 had two burn injuries each, totaling 74 admissions as a group, while the remaining 14 RCs had between three and eight burn injuries each, totaling 55 admissions as a group. Compared to NRCs, RCs were younger (median age 36 years vs. 42 years, p = 0.02) and more likely to be white (75% vs. 60%, p = 0.03), uninsured (45% vs. 30%, p = 0.02), have chemical burns (16% vs. 5%, p <  0.0001), and have burns that were ≤ 10% total body surface area (89% vs. 76%, p = 0.001). The mortality rate for RCs vs. NRCs did not differ (0% vs. 1.2%, p = 0.41). Psychiatric and substance use disorders were approximately five times greater among RCs compared to NRCs (75% vs. 15%, p <  0.001). Median total hospital charges per patient were nearly three times higher for RCs vs. NRCs ($85,736 vs. $32,023, p <  0.0001). CONCLUSIONS: Distinct from trauma recidivism, burn recidivism is not associated with more severe injury or increased mortality. Similar to trauma recidivists, but to a greater extent, burn RCs have high rates of comorbid psychiatric and medical conditions that contribute to increased health care utilization and costs. Studies involving larger samples from multiple centers can further clarify whether these findings are generalizable to national burn and trauma populations.

Hypertrophic Scar Severity at Autograft Sites Is Associated With Increased Pain and Itch After Major Thermal Burn Injury.

Approximately three quarters of major thermal burn injury (MThBI) survivors suffer from hypertrophic scarring (HTS) and over half experience chronic pain or itch. In survivors of MThBI, HTS and chronic pain or itch are considered one of the greatest unmet challenges of postburn injury care and psychosocial reintegration. Although scarring, itch, and pain have been clinically associated, there are no prospective, multisite studies examining tissue autograft site pain or itch and scar outcomes. The authors collected a representative cohort (n = 56) of MThBI survivors who received autografting within 14 days of injury and evaluated graft-site pain or itch severity (0-10 Numeric Rating Scale) and HTS using a validated scar photograph assessment scale 6 months following MThBI. Given that stress is known to influence wound healing, the authors also assessed the relationship between previous trauma exposure, peritraumatic stress, preburn overall health (SF-12), scarring, and chronic pain or itch severity using Spearman's correlation. Association between HTS and chronic pain or itch was significant in a linear regression model adjusted for age, sex, and ethnicity (ß = 0.2, P = .033 for pain, ß = 0.2, P = .019 for itch). Results indicate that prior trauma exposure is inversely correlated (r = -.363, P = .030) with scar severity, but not pain or itch severity 6 months after MThBI. Study results suggest that preburn chronic pain or itch is associated with pathological scarring 6 months following MThBI. Results also indicate that stress may improve scarring after MThBI. Further work to understand the mechanisms that underlie both HTS and chronic pain or itch and their relationship to chronic stress is critical to the development of novel therapies to assist burn survivors recover.

HMGB1/IL-1ß complexes in plasma microvesicles modulate immune responses to burn injury.

Modulating immune responses to sepsis and trauma remain one of the most difficult challenges in modern medicine. Large burn injuries (LBI) are a severe form of trauma associated with sepsis, immune impairment, and mortality. Immune dysfunction after LBI is complex, involving both enhanced and impaired immune activation. The release of Damage-Associated Molecular Patterns (DAMPs), such as HMGB1, and cytokines (e.g. IL-1ß) creates an environment of immune dysfunction often leading to end organ failure and death. Both HMGB1 and IL-1ß have been found to play critical roles in sepsis and post-burn immune dysfunction. HMGB1 and IL-1ß have been shown previously to form potent complexes in vitro. We recently identified the presence of HMGB1/IL-1ß heterocomplexes in human tissue. We now find HMGB1/IL-1ß complexes in human and mouse plasma, and identify a synergistic role of HMGB1/IL-1ß complexes in post-burn immune dysfunction. In both humans and mice, we found that HMGB1 was enriched in plasma microvesicles (MVs) after LBI. HMGB1 was found form complexes with IL-1ß. Using flow cytometry of mouse plasma MVs, we identified an increase in an HMGB1+/IL-1ß+ MVs. Using co-IP, HMGB1 was found to bind the pro-form of IL-1ß in mouse and human plasma. Pro-IL-1ß, which is traditionally considered inactive, became active when complexed with HMGB1. Human THP-1 monocytes treated with HMGB1-pro-IL-1ß complexes showed increased transcription of LBI associated cytokines IL-6 and IFNß along with suppression of iNOS, mimicking findings associated with LBI. These findings identify that HMGB1/IL-1ß complexes released after burn injuries can modulate immune responses, and microvesicles are identified as a novel reservoir for these immune mediators. These complexes might serve as novel immune targets for the treatment of systemic immune responses due to LBI or other causes of sepsis.

Blocking CXCL1-dependent neutrophil recruitment prevents immune damage and reduces pulmonary bacterial infection after inhalation injury.

Smoke inhalation associated with structural fires, wildfires, or explosions leads to lung injury, for which innovative and clinically relevant animal models are needed to develop effective therapeutics. We have previously reported that damage-associated molecular patterns (DAMPs) and anti-inflammatory cytokines correlate with infectious complications in patients diagnosed with inhalational injury. In this study, we describe a novel and translational murine model of acute inhalational injury characterized by an accumulation of protein and neutrophils in the bronchoalveolar space, as well as histological evidence of tissue damage. Mice were anesthetized, and a cannula was placed in the trachea and exposed to smoldering plywood smoke three times for 2-min intervals in a smoke chamber. Here we demonstrate that this model recapitulates clinically relevant phenotypes, including early release of double-stranded DNA (dsDNA), IL-10, monocyte chemoattractant protein (MCP)-1, and CXCL1 along with neutrophilia early after injury, accompanied by subsequent susceptibility to opportunistic infection with Pseudomonas aeruginosa. Further investigation of the model, and in turn a reanalysis of patient samples, revealed a late release of the DAMP hyaluronic acid (HA) from the lung. Using nitric oxide synthase-deficient mice, we found that Nos2 was required for increases in IL-10, MCP-1, and HA following injury but not release of dsDNA, CXCL1 expression, early neutrophilia, or susceptibility to opportunistic infection. Depletion of CXCL1 attenuated early neutrophil recruitment, leading to decreased histopathology scores and improved bacterial clearance in this model of smoke inhalation. Together, these data highlight the potential therapeutic benefit of attenuating neutrophil recruitment in the first 24 h after injury in patients.

Correction: Differential regulation of innate immune cytokine production through pharmacological activation of Nuclear Factor-Erythroid-2-Related Factor 2 (NRF2) in burn patient immune cells and monocytes.

[This corrects the article DOI: 10.1371/journal.pone.0184164.].

Risk Factors for Healthcare-Associated Infections in Adult Burn Patients.

OBJECTIVE Burn patients are particularly vulnerable to infection, and an estimated half of all burn deaths are due to infections. This study explored risk factors for healthcare-associated infections (HAIs) in adult burn patients. DESIGN Retrospective cohort study. SETTING Tertiary-care burn center. PATIENTS Adults (≥18 years old) admitted with burn injury for at least 2 days between 2004 and 2013. METHODS HAIs were determined in real-time by infection preventionists using Centers for Disease Control and Prevention criteria. Multivariable Cox proportional hazards regression was used to estimate the direct effect of each risk factor on time to HAI, with inverse probability of censor weights to address potentially informative censoring. Effect measure modification by burn size was also assessed. RESULTS Overall, 4,426 patients met inclusion criteria, and 349 (7.9%) patients had at least 1 HAI within 60 days of admission. Compared to 6 times as likely to acquire an HAI (HR, 6.38; 95% CI, 3.64-11.17); and patients with >20% TBSA were >10 times as likely to acquire an HAI (HR, 10.33; 95% CI, 5.74-18.60). Patients with inhalational injury were 1.5 times as likely to acquire an HAI (HR, 1.61; 95% CI, 1.17-2.22). The effect of inhalational injury (P=.09) appeared to be larger among patients with ≤20% TBSA. CONCLUSIONS Larger burns and inhalational injury were associated with increased incidence of HAIs. Future research should use these risk factors to identify potential interventions. Infect Control Hosp Epidemiol 2017;38:1441-1448.

Systems-based Practice in Burn Care: Prevention, Management, and Economic Impact of Health Care-associated Infections.

Health care-associated infections in burn patients, from ventilator-associated pneumonia to skin and soft tissue infections, can substantially compromise outcomes, because these complications are associated with longer lengths of stay, increased morbidity and mortality, and greater direct medical costs. Health care-associated infections are largely preventable, through surveillance, education, appropriate hand hygiene, and culture change, especially for device-related infections. Systems-based practice, which allows individuals and clinical microsystems to navigate and improve the macro health care system, may be one of the most powerful skill sets to effect change, permitting a shift in culture toward patient safety and quality improvement.

Differential regulation of innate immune cytokine production through pharmacological activation of Nuclear Factor-Erythroid-2-Related Factor 2 (NRF2) in burn patient immune cells and monocytes.

Burn patients suffer from immunological dysfunction for which there are currently no successful interventions. Similar to previous observations, we find that burn shock patients (≥15% Total Burn Surface Area (TBSA) injury) have elevated levels of the innate immune cytokines Interleukin-6 (IL-6) and Monocyte Chemoattractant Protein-1 (MCP-1)/CC-motif Chemokine Ligand 2(CCL2) early after hospital admission (0-48 Hours Post-hospital Admission (HPA). Functional immune assays with patient Peripheral Blood Mononuclear Cells (PBMCs) revealed that burn shock patients (≥15% TBSA) produced elevated levels of MCP-1/CCL2 after innate immune stimulation ex vivo relative to mild burn patients. Interestingly, treatment of patient PBMCs with the Nuclear Factor-Erythroid-2-Related Factor 2 (NRF2) agonist, CDDO-Me(bardoxolone methyl), reduced MCP-1 production but not IL-6 or Interleukin-10 (IL-10) secretion. In enriched monocytes from healthy donors, CDDO-Me(bardoxolone methyl) also reduced LPS-induced MCP1/CCL2 production but did not alter IL-6 or IL-10 secretion. Similar immunomodulatory effects were observed with Compound 7, which activates the NRF2 pathway through a different and non-covalent Mechanism Of Action (MOA). Hence, our findings with CDDO-Me(bardoxolone methyl) and Compound 7 are likely to reflect a generalizable aspect of NRF2 activation. These observed effects were not specific to LPS-induced immune responses, as NRF2 activation also reduced MCP-1/CCL2 production after stimulation with IL-6. Pharmacological NRF2 activation reduced Mcp-1/Ccl2 transcript accumulation without inhibiting either Il-6 or Il-10 transcript levels. Hence, we describe a novel aspect of NRF2 activation that may contribute to the beneficial effects of NRF2 agonists during disease. Our work also demonstrates that the NRF2 pathway is retained and can be modulated to regulate important immunomodulatory functions in burn patient immune cells.

Improving Research Enrollment of Severe Burn Patients.

Enrolling severely burn injured patients into prospective research studies poses specific challenges to investigators. The authors describe their experience of recruiting adults with ≥20% TBSA burns or inhalation injury admitted to a single academic burn unit into observational research with minimally invasive specimen collection. The authors outline iterative changes that they made to their recruitment processes in response to perceived weaknesses leading to delays in enrollment. The primary outcome was the change in days to consent for enrolled patients or cessation of recruitment for nonenrolled patients before and after the interventional modifications. The authors assessed change in overall enrollment as a secondary outcome. Study enrollment was approximately 70% in both 4-month study periods before and after the intervention. Following the intervention, time to consent by surrogate decision maker decreased from a median of 26.5 days (interquartile range [IQR] 14-41) to 3 days (IQR 3-6) (P = .004). Time to initial consent by patient changed from a median of 15 days (IQR 2-30) to 3 days (IQR 2-6) (P = .27). Time to decline for nonenrolled patients decreased from a median of 12 days (IQR 6.5-27) to 1.5 days (IQR 1-3.5) (P = .026). Both the findings of the study and a brief literature review suggest that careful design of the recruitment protocol, increased experience of the study team, and broad time windows for both approach and enrollment improve the efficiency of recruiting critically injured burn patients into research.

Pain and itch outcome trajectories differ among European American and African American survivors of major thermal burn injury.

More than half of individuals experiencing major thermal burn injury (MThBI) receive an autologous skin graft (autograft), in which skin is removed from a healthy "donor" site and transplanted to the burn site. Persistent pain and itch at the graft site are major causes of suffering and disability in MThBI survivors. African Americans have a higher risk of MThBI, and in other clinical settings African Americans experience a greater burden of pain and itch relative to European Americans. However, to our knowledge, ethnic differences in skin graft site pain and itch outcomes after MThBI have not been assessed. We evaluated skin graft site pain and itch severity (0-10 Numeric Rating Scale [NRS]) over 1 year in a prospective multicenter cohort sample of African Americans and European Americans. In adjusted linear mixed models, African Americans experienced a slower rate of pain resolution in the acute phase of recovery (ß = -0.05 vs -0.08 NRS points per day, P < 0.001), which resulted in a higher pain severity in the persistent phase of recovery (NRS mean difference = 1.21, 95% confidence interval [0.12-2.29]), although not statistically significant after correction for multiple comparisons. African Americans also experience greater itch severity in 6 weeks to 12 months after burn injury compared with European Americans (NRS mean difference = 1.86 [0.80-2.93]), which results from a faster rate of itch development in African Americans in the acute recovery phase after burn injury. Future studies may improve outcomes in African Americans and lead to new pathogenic insights that benefit all burn injury survivors.

Inhalation Injury: Pathophysiology, Diagnosis, and Treatment.

The classic determinants of mortality from severe burn injury are age, size of injury, delays of resuscitation, and the presence of inhalation injury. Of the major determinants of mortality, inhalation injury remains one of the most challenging injuries for burn care providers. Patients with inhalation injury are at increased risk for pneumonia (the leading cause of death) and multisystem organ failure. There is no consensus among leading burn care centers in the management of inhalation injury. This article outlines the current treatment algorithms and the evidence of their efficacy.

Even Better Than the Real Thing? Xenografting in Pediatric Patients with Scald Injury.

This article reviews a single burn center experience with porcine xenografts to treat pediatric scald injuries, over a 10-year period. The authors compare xenografting to autografting, as well as wound care only, and provide outcome data on length of stay, incidence of health care-associated infections, and need for reconstructive surgery.