IL-1/MyD88-Dependent G-CSF and IL-6 Secretion Mediates Postburn Anemia.

The anemia of critical illness (ACI) is a nearly universal pathophysiological consequence of burn injury and a primary reason burn patients require massive quantities of transfused blood. Inflammatory processes are expected to drive postburn ACI and prevent meaningful erythropoietic stimulation through iron or erythropoietin supplementation, but to this day no specific inflammatory pathways have been identified as a critical mechanism. In this study, we examined whether secretion of G-CSF and IL-6 mediates distinct features of postburn ACI and interrogated inflammatory mechanisms that could be responsible for their secretion. Our analysis of mouse and human skin samples identified the burn wound as a primary source of G-CSF and IL-6 secretion. We show that G-CSF and IL-6 are secreted independently through an IL-1/MyD88-dependent mechanism, and we ruled out TLR2 and TLR4 as critical receptors. Our results indicate that IL-1/MyD88-dependent G-CSF secretion plays a key role in impairing medullary erythropoiesis and IL-6 secretion plays a key role in limiting the access of erythroid cells to iron. Importantly, we found that IL-1α/ß neutralizing Abs broadly attenuated features of postburn ACI that could be attributed to G-CSF or IL-6 secretion and rescued deficits of circulating RBC counts, hemoglobin, and hematocrit caused by burn injury. We conclude that wound-based IL-1/MyD88 signaling mediates postburn ACI through induction of G-CSF and IL-6 secretion.

Bupivacaine Extended-Release Liposomal Injection Versus Bupivacaine HCl for Early Postoperative Pain Control Following Wrist Operations: A Prospective, Randomized Control Trial.

PURPOSE: This study evaluated pain control after wrist operations using a long-acting local anesthetic, liposomal bupivacaine, compared with the standard local anesthetic, bupivacaine HCl. METHODS: Patients undergoing elective carpometacarpal joint arthroplasty and proximal row carpectomy were eligible. Those meeting inclusion criteria were enrolled before surgery and were randomized to receive an intraoperative injection of liposomal bupivacaine or bupivacaine HCl. Primary outcomes included intraoperative and postoperative opioid requirements and pain levels. On the first 4 postoperative days, phone contact assessed pain level by numeric rating scale, number of opioids taken in each 24-hour period, and efficacy of anesthesia and opioid side effects with overall benefit of analgesia score. RESULTS: Postoperative pain scores for 52 patients measured by numeric rating scale demonstrated that liposomal bupivacaine and bupivacaine HCl were similar for pain control. Pain scores and opioid use were similar during the first 4 postoperative days. Opioid use on day 1 was slightly lower with liposomal bupivacaine. There were no statistically significant differences in any postoperative outcome between groups. CONCLUSIONS: Liposomal bupivacaine and bupivacaine HCl have similar effects in the treatment of early postoperative pain after trapeziometacarpal suspension arthroplasty and proximal row carpectomy. Neither drug demonstrated a clear advantage in this study. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Palate Fracture Repair With Light-Cured Resin Splint: Technical Note.

Palate fractures are rare, and their treatment is a matter of debate. Although some investigators have favored rigid plate fixation, others have reported successful treatment without it. Sagittal split and comminuted fractures can require rigid fixation to reduce the maxillary width; however, additional stabilization is needed. Also, palate repair without a splint is complicated by prolonged intermaxillary fixation (IMF), causing stiffness to the temporomandibular joint. We introduce a technique using a rapid light-cured resin (TRIAD TranSheet) frequently used by orthodontists for making dental retainers. Its use is similar to the splints traditionally created preoperatively, but obviates the need for making impressions, a model, and a molded splint. A series of 13 patients treated with this technique during a 5-year period is presented. The average duration of IMF was 4.7 weeks (range 3 to 6). The average duration of the palate splint was 8.4 weeks (range 5 to 12). One patient had malocclusion, but none had malunion, infection, or oronasal fistula. Our series has demonstrated a simple, cost-effective, and successful technique. It can be used alone or combined with rigid fixation and allows for a shortened duration of maxillomandibular fixation.

Orbital reconstruction for pulsatile exophthalmos secondary to sphenoid wing dysplasia.

Sphenoid wing dysplasia or absence of the greater sphenoid wing is a rare condition that is considered pathopneumonic for neurofibromatosis type 1 (NF1). It occurs in 4% to 11% of NF1 patients, and its precise cause is unclear. Some cases appear to be congenital, while others have demonstrated it to be a progressive degeneration of the orbital wall. In about half of cases, associated adjacent neurofibromas are described. Consistently, however, the clinical sequelae is herniation of the temporal lobe into the orbit, causing progressive proptosis and pulsatile exophthalmos. Reconstruction of the orbit has traditionally been with bone grafts, but due to problems with bone resorption and recurrence, titanium plates in conjunction with bone grafts have been reported. We present a case of a 6-year-old male patient who was first diagnosed with NF1 and associated absence of the greater sphenoid wing at the age of 2. Four years later, he was referred for reconstruction after the development of pulsatile exophthalmos. Surgical management included dissection of the dura of the temporal lobe off of the periorbita and skull base reconstruction with a combination of radial-shaped titanium mesh and split calvarial bone grafts. Postoperatively, there was near immediate resolution of the pulsatile exophthalmos, and follow-up at 1 year showed no recurrence.

Mortality From Burns Sustained on Home Oxygen Therapy Exceeds Predicted Mortality.

The Boston Criteria and the Abbreviated Burn Severity Index are two widely accepted models for predicting mortality in burn patients. We aimed to elucidate whether these models are able to predict the risk of mortality in patients who sustain burns while smoking on home oxygen given their clinical fragility. We conducted a retrospective chart review of 48 patients admitted to our burn center from November 2013 to September 2017 who sustained a burn while smoking on home oxygen. Yearlong mortality was the primary outcome of the investigation; secondary outcomes included discharge to facility, length of stay, and need for tracheostomy. We calculated the expected mortality rate for each patient based on Boston Criteria and Abbreviated Burn Severity Index and compared the mortality rate observed in our cohort. Patients in our cohort suffered a 54% mortality rate within a year of injury, compared to a 23.5% mortality predicted by Boston Criteria, which was found to be statistically significant by chi-square analysis (P < .05). Abbreviated Burn Severity Index predicted mortality was 19.7%. While the absolute value of the difference in mortality was greater, this was not significant on chi-square analysis due to sample size. Our secondary outcomes revealed 42% discharge to facility, the average length of stay of 6.2 days, and 6.25% required tracheostomy. Patients whose burns are attributable to smoking on home oxygen may have an increased risk of mortality than prognostication models would suggest. This bears significant clinical impact, particularly regarding family and provider decision making in pursuing aggressive management.

Prevalence and Risk Factors for Hypertrophic Scarring of Split Thickness Autograft Donor Sites in a Pediatric Burn Population.

TITLE: Prevalence and Risk Factors for Hypertrophic Scarring of Split Thickness Autograft Donor Sites in a Pediatric Burn Population. OBJECTIVE: The split-thickness autograft remains a fundamental treatment for burn injuries; however, donor sites may remain hypersensitive, hyperemic, less pliable, and develop hypertrophic scarring. This study sought to assess the long-term scarring of donor sites after pediatric burns. METHODS: A retrospective review of pediatric burn patients treated at a single institution (2010-2016) was performed. Primary outcomes were prevalence of donor site hypertrophic scarring, scarring time course, and risk factor assessment. RESULTS: 237 pediatric burn patients were identified. Mean age at burn was 7 yrs., mean %TBSA was 26% with 17% being Full Thickness. Mean follow-up was 2.4 yrs. Hypertrophic scarring was observed in 152 (64%) patients with 81 (34%) patients having persistent hypertrophic scarring through long-term follow-up. Patient-specific risk factors for hypertrophic scarring were Hispanic ethnicity (P=0.03), increased %TBSA (P=0.03), %Full Thickness burn (P=0.02) and total autograft amount (P=0.03). Donor site factors for hypertrophic scarring were longer time to epithelialization (P<0.0001), increased donor site harvest depth (P<0.0001), autografts harvested in the acute burn setting (P=0.008), and thigh donor site location (vs. all other sites; P<0.0001). The scalp, arm, foot, and lower leg donor sites (vs. all other sites) were less likely to develop HTS (P<0.0001, 0.02, 0.005, 0.002, respectively), along with a history of previous donor site harvest (P=0.04). CONCLUSIONS: Hypertrophic scarring is a prominent burden in donor site wounds of pediatric burn patients. Knowledge of pertinent risk factors can assist with guiding management and expectations.

Patient Safety in Burn Care: Application of Evidence-based Medicine to Improve Outcomes.

This article reviews 5 areas in burn care that increasingly use evidence-based medicine to optimize quality and safety: resuscitation protocols, transfusion practices, vascular access, venous thromboembolic prophylaxis, and rational use of antibiotics.

Epidemiology of operative burns at Kijabe Hospital from 2006 to 2010: pilot study of a web-based tool for creation of the Kenya Burn Repository.

INTRODUCTION: In order to implement effective burn prevention strategies, the WHO has called for improved data collection to better characterize burn injuries in low and middle income countries (LMIC). This study was designed to gather information on burn injury in Kenya and to test a model for such data collection. METHODS: The study was designed as a retrospective case series study utilizing an electronic data collection tool to assess the scope of burn injuries requiring operation at Kijabe Hospital from January 2006 to May 2010. Data were entered into a web-based tool to test its utility as the potential Kenya Burn Repository (KBR). RESULTS: 174 patients were included. The median age was 10 years. There was a male predominance (59% vs. 41%). Findings included that timing of presentation was associated with burn etiology (p=0.009). Length of stay (LOS) was associated with burn etiology (p<0.001). Etiology differed depending on the age group, with scald being most prominent in children (p=0.002). CONCLUSIONS: Burn injuries in Kenya show similarities with other LMIC in etiology and pediatric predominance. Late presentation for care and prolonged LOS are areas for further investigation. The web-based database is an effective tool for data collection and international collaboration.