Squamous Cell Carcinoma of the Foot Occurring in a Wart.

Verrucous carcinoma is a rare form squamous cell carcinoma which appears similar to a wart. When it occurs in the feet, it can be easily misdiagnosed. It rarely metastasizes or recurs posttreatment. We report a case of a septuagenarian with recurrence of verrucous carcinoma diagnosed within 6 months at the site of previous treatment. Unique features in our patient's clinical presentation include his advanced age, being nondiabetic, and the rapid recurrence of carcinoma.Level of Evidence: Level IV: Case report.

Kidney Injury in Critically Ill Patients Treated with Vancomycin and Zosyn or an Alternative: A Systematic Review and Meta-Analysis.

Background: Zosyn® (piperacillin-tazobactam; Pfizer Medical, New York, NY), a valuable antibiotic against gram-negative bacteria, combined with vancomycin (Z+V) is known for its high incidence of acute kidney injury (AKI), particularly in the intensive care unit (ICU), leading to the frequent use of alternatives for gram-negative coverage (Alt+V). Because there are limited data describing AKI on these alternative antibiotic agents, a systematic review and meta-analysis was conducted to determine if these regimens were indeed associated with decreased rates of AKI. Patients and Methods: A literature review was performed electronically from its inception to November 1, 2018, screening for relevant literature by title, abstract and full text according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines within the following databases: PubMed/Medline, CINAHL, Scopus, and Cochrane Central Register of Controlled Trials. Studies were included if they contained adults who had been admitted to the ICU for treatment and had received a combination of intravenous Z + V or Alt+V as well as had AKI measured during administration of these antibiotic agents. Studies were excluded if they represented pediatric populations, did not receive care in an ICU during their hospital admission, only received monotherapy for antibiotic treatment or received antibiotic treatment for less than 48 hours. Independent extraction was performed by two reviewers. Risk of bias was assessed using the Risk of Bias in Non-randomised Studies of Interventions (ROBINS-I) methodology for retrospective studies. Random-effects models were used to calculate any differences between rates of AKI after Z + V or Alt + V. Results: Fourteen articles (totaling 30,399 patients) were included. All studies available were retrospective in design. Compared with Alt + V, Z + V was associated with a higher risk ratio of AKI (1.79; 95% confidence interval [CI], 1.46-2.19; p < 0.001). Cefepime (C + V) was the most common alternative to Zosyn, and Z + V was associated with higher rates of kidney injury compared with C + V (1.70; 95% CI, 1.36-2.12; p < 0.00001). However, there was substantial heterogeneity in the data collected as well as high risk of bias. Conclusions: Zosyn plus vancomycin is associated with more risk of AKI compared with Alt+V coverage in ICU adult populations. However, the conclusions were limited by the retrospective nature of the studies, high bias of included articles, and heterogeneity of the included studies.

Energy-based devices for the treatment of Acne Scars: 2022 International consensus recommendations.

BACKGROUND AND OBJECTIVES: Acne scars are one of the most distressing and long-term consequences of acne vulgaris, with damaging effect on a person's physical, mental, and social well-being. Numerous treatment options are available including surgical and nonsurgical techniques, depending on the clinical presentation. Although considerable advances in the development of new treatment technologies and applications have been made in the last decade, international treatment guidelines and reimbursement schemes have not yet caught up with current knowledge and practice in many centers. The authors intend to highlight the potential utility of energy-based devices (EBDs) for acne scarring, offer recommendations for safe and efficacious treatment, and provide consensus-based EBD treatment options based on varying presentations demonstrated in a series of real-life clinical photographs. STUDY DESIGN/MATERIALS AND METHODS: An international panel of 24 dermatologists and plastic surgeons from 12 different countries and a variety of practice backgrounds was self-assembled to develop updated consensus recommendations for the treatment of acne scars. A two-step modified Delphi method took place between March 2020 and February 2021 consisting of two rounds of emailed questionnaires. The panel members approved the final manuscript via email correspondence. RESULTS: The manuscript includes a comprehensive discussion and panel recommendations regarding the following topics: 1. the role of EBD in mitigating and treating acne scars in a patient with active acne, 2. the use of various EBDs for the treatment of different acne scar types with special focus on commonly used laser platform such as vascular lasers, ablative fractional lasers (AFLs) and non-AFLs (NAFLs), 3. treatment combinations, and 4. acne scar treatments in skin of color. The last part comprised of 10 photos of real-life clinical cases with the panel recommendation treatment plan to achieve best aesthetic outcome. CONCLUSION: Panel members were unanimous in their view that EBDs have a role in the management of acne scars, with AFLs, NAFLs, vascular lasers, and RF devices preferentially selected by most of the panel experts. EBDs are considered a first-line treatment for a variety of acne scar types and patients without access to these treatments may not be receiving the best available care for optimal cosmetic results. Future high-quality research and updated international treatment guidelines and reimbursement schemes should reflect this status.

Vascularized Composite Allotransplantation in Burn Reconstruction: Systematic Review and Meta-analysis.

Vascularized composite allotransplantation has been successfully employed for burn reconstruction since 2003. However, its safety in this population has been questioned due to high levels of alloimmunization from burn care-related tissue exposures. To investigate this, a systematic review of vascularized composite allotransplantation employed for burn reconstruction was conducted, evaluating literature from January 2000 to September 2019. Articles containing vascularized composite allotransplantation, composite tissue allotransplantation, and burn reconstructive surgery were included; articles without published outcomes were excluded. Observational meta-analysis of pooled mortality and acute rejection episodes relative to allograft type (face vs extremity) and reconstruction type (burn vs non-burn) was performed. Twenty-four of the 63 identified articles met the criteria for inclusion, with 5 more articles added after secondary review. To date, 152 allotransplantations have been performed in 117 patients: 45 face transplants and 107 extremity transplants. Of these, 34 (22%) were performed for burn reconstruction in 25 patients (21%) with an overall higher 1-year mortality rate (12.0% vs 1.1%, P = .030). Of these deaths, 75% received three or more simultaneous allografts. Additionally, more episodes of acute rejection occurred compared to non-burn patients (4.4 vs 2.4, P = .035). Vascularized composite allotransplantation performed for burn reconstruction was found to be associated with a greater risk of 1-year mortality and nearly twice the number of episodes of acute rejection. Future studies should seek to identify unique risk factors of burn patients undergoing this operation and evaluate the relationship between antigenic burden and surgical outcomes.

Laser Treatment of Traumatic Scars and Contractures: 2020 International Consensus Recommendations.

BACKGROUND AND OBJECTIVES: There is currently intense multidisciplinary interest and a maturing body of literature regarding laser treatments for traumatic scars, but international treatment guidelines and reimbursement schemes have not yet caught up with current knowledge and practice in many centers. The authors intend to highlight the tremendous potential of laser techniques, offer recommendations for safe and efficacious treatment, and promote wider patient access guided by future high-quality research. STUDY DESIGN/MATERIALS AND METHODS: An international panel of 26 dermatologists and plastic and reconstructive surgeons from 13 different countries and a variety of practice backgrounds was self-assembled to develop updated consensus recommendations for the laser treatment of traumatic scars. A three-step modified Delphi method took place between March 2018 and March 2019 consisting of two rounds of emailed questionnaires and supplementary face-to-face meetings. The panel members approved the final manuscript via email correspondence, and the threshold for consensus was at least 80% concurrence among the panel members. RESULTS: The manuscript includes extensive detailed discussion regarding a variety of laser platforms commonly used for traumatic scar management such as vascular lasers and ablative and non-ablative fractional lasers, special considerations such as coding and laser treatments in skin of color, and 25 summary consensus recommendations. CONCLUSIONS: Lasers are a first-line therapy in the management of traumatic scars and contractures, and patients without access to these treatments may not be receiving the best available care after injury. Updated international treatment guidelines and reimbursement schemes, additional high-quality research, and patient access should reflect this status. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc.

Effects of a restrictive blood transfusion protocol on acute pediatric burn care: Transfusion threshold in pediatric burns.

BACKGROUND: Blood transfusion is costly and associated with various medical risks. Studies in critically ill adult and pediatric patients suggest that implementation of more restrictive transfusion protocols based on lower threshold hemoglobin concentrations can be medically and economically advantageous. The purpose of this study was to evaluate the implications of a hemoglobin threshold change in pediatric burn patients. METHODS: We implemented a change in hemoglobin threshold from 10 g/dL to 7 g/dL and compared data from patients before and after this protocol change in a retrospective review. Primary endpoints were hemoglobin concentration at baseline, before transfusion, and after transfusion; amount of blood product administered; and mortality. Secondary endpoints were the incidence of sepsis based on the American Burn Association physiological criteria for sepsis and mean number of septic days per patient. All endpoint analyses were adjusted for relevant clinical covariates via generalized additive models or Cox proportional hazard model. Statistical significance was accepted at p less than 0.05. RESULTS: Patient characteristics and baseline hemoglobin concentrations (pre, 13.5 g/dL; post, 13.3 g/dL; p > 0.05) were comparable between groups. The group transfused based on the more restrictive hemoglobin threshold had lower hemoglobin concentrations before and after transfusion throughout acute hospitalization, received lower volumes of blood during operations (pre, 1012 mL; post, 824 mL; p < 0.001) and on days without surgical procedures (pre, 602 mL; post, 353 mL; p < 0.001), and had a lower mortality (pre, 8.0%; post, 3.9%; mortality hazard decline, 0.55 [45%]; p < 0.05). Both groups had a comparable incidence of physiological sepsis, though the more restrictive threshold group had a lower number of sepsis days per patient. CONCLUSION: More restrictive transfusion protocols are safe and efficacious in pediatric burn patients. The associated reduction of transfused blood may lessen medical risks of blood transfusion and lower economic burden. LEVEL OF EVIDENCE: Therapeutic, level IV.

Co-administration of vancomycin and piperacillin-tazobactam is associated with increased renal dysfunction in adult and pediatric burn patients.

BACKGROUND: Burn patients are prone to infections which often necessitate broad antibiotic coverage. Vancomycin is a common antibiotic after burn injury and is administered alone (V), or in combination with imipenem-cilastin (V/IC) or piperacillin-tazobactam (V/PT). Sparse reports indicate that the combination V/PT is associated with increased renal dysfunction. The purpose of this study was to evaluate the short-term impact of the three antibiotic administration types on renal dysfunction. METHODS: All pediatric and adult patients admitted to our centers between 2004 and 2016 with a burn injury were included in this retrospective review if they met the criteria of exposition to either V, V/IC, or V/PT for at least 48 h, had normal baseline creatinine, and no pre-existing renal dysfunction. Creatinine was monitored for 7 days after initial exposure; the absolute and relative increase was calculated, and patient renal outcomes were classified according to the Kidney Disease Improving Global Outcomes (KDIGO) criteria depending on creatinine increases and estimated creatinine clearance. Secondary endpoints (demographic and clinical data, incidences of septicemia, and renal replacement therapy) were analyzed. Antibiotic doses were modeled in logistic and linear multivariable regression models to predict categorical KDIGO events and relative creatinine increase. RESULTS: Out of 1449 patients who were screened, 718 met the inclusion criteria, 246 were adults, and 472 were children. Between the study cohorts V, V/IC, and V/PT, patient characteristics at admission were comparable. V/PT administration was associated with a statistically higher serum creatinine, and lower creatinine clearance compared to patients receiving V alone or V/IC in adults and children after burn injury. The incidence of KDIGO stages 1, 2, and 3 was higher after V/PT treatment. In children, the incidence of KDIGO stage 3 following administration of V/PT was greater than after V/IC. In adults, the incidence of renal replacement therapy was higher after V/PT compared with V or V/IC. Multivariate modeling demonstrated that V/PT is an independent predictor of renal dysfunction. CONCLUSION: Co-administration of vancomycin and piperacillin-tazobactam is associated with increased renal dysfunction in pediatric and adult burn patients when compared to vancomycin alone or vancomycin plus imipenem-cilastin. The mechanism of this increased nephrotoxicity remains elusive and warrants further scientific evaluation.

Predicting and managing sepsis in burn patients: current perspectives.

Modern burn care has led to unprecedented survival rates in burn patients whose injuries were fatal a few decades ago. Along with improved survival, new challenges have emerged in the management of burn patients. Infections top the list of the most common complication after burns, and sepsis is the leading cause of death in both adult and pediatric burn patients. The diagnosis and management of sepsis in burns is complex as a tremendous hypermetabolic response secondary to burn injury can be superimposed on systemic infection, leading to organ dysfunction. The management of a septic burn patient represents a challenging scenario that is commonly encountered by providers caring for burn patients despite preventive efforts. Here, we discuss the current perspectives in the diagnosis and treatment of sepsis and septic shock in burn patients.

Management of Acute Pediatric Hand Burns.

Worldwide, approximately 500,000 children are admitted to the hospital with burn injuries every year. Referral to an accredited burn center is required for burns that involve the hand regardless of age. As with most burn injuries, a multidisciplinary approach is important; however, in the younger pediatric patient, extra resources such as child life services, pediatric psychotherapy, and music therapy all play major roles alongside the nurse, physical therapists, and psychiatrists so that together with the appropriate support for the family involved, a successful outcome can be achieved.

Accuracy of Currently Used Paper Burn Diagram vs a Three-Dimensional Computerized Model.

Burn units have historically used paper diagrams to estimate percent burn; however, unintentional errors can occur. The use of a computer program that incorporates wound mapping from photographs onto a three-dimensional (3D) human diagram could decrease subjectivity in preparing burn diagrams and subsequent calculations of TBSA burned. Analyses were done on 19 burned patients who had an estimated TBSA burned of ≥20%. The patients were admitted to Shriners Hospitals for Children or the University of Texas Medical Branch in Galveston, Texas, from July 2012 to September 2013 for treatment. Digital photographs were collected before the patient's first surgery. Using BurnCase 3D (RISC Software GmbH, Hagenberg, Austria), a burn mapping software, the user traced partial- and full-thickness burns from photographs. The program then superimposed tracings onto a 3D model and calculated percent burned. The results were compared with the Lund and Browder diagrams completed after the first operation. A two-tailed t-test was used to calculate statistical differences. For partial-thickness burns, burn sizes calculated using Lund and Browder diagrams were significantly larger than those calculated using BurnCase 3D (15% difference, P < .01). The opposite was found for full-thickness burns, with burn sizes being smaller when calculated using Lund and Browder diagrams (11% difference, P < .05). In conclusion, substantial differences exist in percent burn estimations derived from BurnCase 3D and paper diagrams. In our studied cohort, paper diagrams were associated with overestimation of partial-thickness burn size and underestimation of full-thickness burn size. Additional studies comparing BurnCase 3D with other commonly used methods are warranted.

Transpulmonary Thermodilution Versus Transthoracic Echocardiography for Cardiac Output Measurements in Severely Burned Children.

INTRODUCTION: Severe burns trigger a hyperdynamic state, necessitating accurate measurement of cardiac output (CO) for cardiovascular observation and guiding fluid resuscitation. However, it is unknown whether, in burned children, the increasingly popular transthoracic echocardiography (TTE) method of CO measurement is as accurate as the widely used transpulmonary thermodilution (TPTD) method. PATIENTS AND METHODS: We retrospectively compared near-simultaneously performed CO measurements in severely burned children using TPTD with the Pulse index Continuous Cardiac Output (PiCCO) system or TTE. Outcomes were compared using t tests, multiple linear regression, and a Bland-Altman plot. RESULTS: Fifty-four children (9 ±â€Š5 years) with 68 ±â€Š18% total body surface area burns were studied. An analysis of 105 data pairs revealed that PiCCO yielded higher CO measurements than TTE (190 ±â€Š39% vs. 150 ±â€Š50% predicted values; P < 0.01). PiCCO- and TTE-derived CO measurements correlated moderately well (R = 0.54, P < 0.01). A Bland-Altman plot showed a mean bias of 1.53 L/min with a 95% prediction interval of 4.31 L/min. CONCLUSIONS: TTE-derived estimates of CO may underestimate severity of the hyperdynamic state in severely burned children. We propose using the PiCCO system for objective cardiovascular monitoring and to guide goal-directed fluid resuscitation in this population.

The effect of ketoconazole on post-burn inflammation, hypermetabolism and clinical outcomes.

BACKGROUND: Hypercortisolemia has been suggested as a primary hormonal mediator of whole-body catabolism following severe burn injury. Ketoconazole, an anti-fungal agent, inhibits cortisol synthesis. We, therefore, studied the effect of ketoconazole on post-burn cortisol levels and the hyper-catabolic response in a prospective randomized trial (block randomization 2:1). METHODOLOGY/PRINCIPAL FINDINGS: Fifty-five severely burned pediatric patients with >30% total body surface area (TBSA) burns were enrolled in this trial. Patients were randomized to receive standard care plus either placebo (controls, n = 38) or ketoconazole (n = 23). Demographics, clinical data, serum hormone levels, serum cytokine expression profiles, organ function, hypermetabolism measures, muscle protein synthesis, incidence of wound infection sepsis, and body composition were obtained throughout the acute hospital course. Statistical analysis was performed using Fisher's exact test, Student's t-test, and parametric and non-parametric two-way repeated measures analysis of variance where applicable. Patients were similar in demographics, age, and TBSA burned. Ketoconazole effectively blocked cortisol production, as indicated by normalization of the 8-fold elevation in urine cortisol levels [F(1, 376) = 85.34, p<.001] with the initiation of treatment. However, there were no significant differences in the inflammatory response, acute-phase proteins, body composition, muscle protein breakdown or synthesis, or organ function between groups. CONCLUSIONS: Both groups were markedly hypermetabolic and catabolic throughout the acute hospital stay. Normalization of hypercortisolemia with ketoconazole therapy had no effect on whole-body catabolism or the post-burn inflammatory or hypermetabolic response, suggesting that hypercortisolemia does not play a central role in the post-burn hypermetabolic catabolic response. TRIAL REGISTRATION: ClinicalTrials.gov NCT00675714; and NCT00673309.

Fibrin sealant improves graft adherence in a porcine full-thickness burn wound model.

INTRODUCTION: Autograft take and rapid wound closure is essential for the survival of severely burned patients. Loss of skin grafts typically occurs during the first few days after coverage, mainly due to shear forces and inadequate contact with the wound bed. Slow-clotting fibrin sealant, applied with a spray-on device, has been shown to improve healing of skin grafts in large wounds. However, its use in burn wounds has not been studied so far. STUDY AIM: To evaluate the effectiveness of sprayed fibrin sealant in excised and grafted full-thickness burns. MATERIAL AND METHODS: Ten female Yorkshire pigs (30-45 kg) received a full-thickness contact burn of approximately 15% total body surface area. The burns were excised to the level of the muscular fascia after 24 h and covered with meshed skin autograft (mesh ratio 1:3). Wounds were randomized to either fibrin sealant (n=20) or standard skin staples (n=16) for graft fixation. Fibrin sealant was used as a slow-clotting spray (4 IU thrombin/ml). Outcome measurements included clinical scoring at days 2, 5, 9 and 14 postoperatively, planimetric analysis of wound closure, and histological examination of epidermal and dermal thickness 14 days after autografting. RESULTS: In the fibrin sealant group, graft adherence scores were significantly increased (p<0.02) and graft dislocation scores significantly decreased (p<0.01) at days 2 and 5 postoperatively, when compared to controls. Planimetric analysis of remaining open mesh interstices showed acceleration of wound closure in the fibrin sealant group but did not reach statistical significance (day 14 p=0.04 at significance level p<0.025). Wound contraction, occurrence of hematoma, and dermal as well as epidermal thickness were not different between the groups at 14 days postoperatively. CONCLUSION: The results indicate that the use of slow-clotting fibrin sealant spray for autograft fixation is advantageous over skin staples. Easy handling and reduced graft dislocation at early time points are key qualities of this method.

Changes in cardiac physiology after severe burn injury.

Cardiac stress, mediated by increased catecholamines, is the hallmark of severe burn injury typified by marked tachycardia, increased myocardial oxygen consumption, and increased cardiac output (CO). It remains one of the main determinants of survival in large burns. Currently, it is unknown for how long cardiac stress persists after a severe injury. Therefore, the aim of this study was to determine the extent and duration of cardiac stress after a severe burn. To determine persistence of cardiac alteration, the authors determined cardiac parameters of all surviving patients with burns ≥ 40% TBSA from 1998 to 2008. One hundred ninety-four patients were included in this study. Heart rate, mean arterial pressure, CO, stroke volume, cardiac index, and ejection fractions were measured at regular intervals from admission up to 2 years after injury. Rate pressure product was calculated as a correlate of myocardial oxygen consumption. All values were compared with normal nonburned children to validate the findings. Statistical analysis was performed using log transformed analysis of variance with Bonferroni correction and Student's t-test, where applicable. Heart rate, CO, cardiac index, and rate pressure product remained significantly increased in burned children for up to 2 years when compared with normal ranges (P < .05), indicating vastly increased cardiac stress. Ejection fraction was within normal limits for 2 years. Cardiac stress persists for at least 2 years postburn, and the authors suggest that attenuation of these detrimental responses may improve long-term morbidity.

Neonate twin with staphylococcal scalded skin syndrome from a renal source.

OBJECTIVE: To understand the underlying mechanism of exfoliative toxins causing staphylococcal scalded skin syndrome or Ritter's Disease that predominantly affects newborns and infants, although it is sometimes found in adults. Staphylococcal scalded skin syndrome is typically diagnosed by the characteristic fluid-filled bullae together with superficial skin loss. A histopathological diagnosis may be made by looking for subcorneal acantholytic cleavage with minimal inflammation on biopsy, although this is not normally required. Exfoliative toxin A and B are both responsible for the "acantholytic" infection of Staphylococcus aureus as they target desmoglein-1 leading to loss of cell-to-cell cohesion and subsequent spread of infection. Other factors produced by S. aureus can cause a myriad of other problems including neutralization of antimicrobial peptides, inactivation of neutrophils, proteolysis, T-cell anergy, and immunosuppression. DESIGN: Individual care report. SETTING: Pediatric intensive care unit. PATIENT: We describe a normal male infant who was born at term and developed 100% total body surface area staphylococcal scalded skin syndrome on the 14 day of life with associated renal sepsis. INTERVENTIONS: After cultures from the lesions, bloodstream, and urine were obtained, intravenous Vancomycin and Ceftriaxone were commenced. The initial lesions increased in size over a 36-hr period to cover the entire body surface; this was associated with a decline in hemodynamic status. MEASUREMENTS AND MAIN RESULTS: Cultures from the urine and blood grew coagulase-positive S. aureus. An ultrasound scan revealed bilateral pyonephroses, which necessitated the placement of percutaneous nephrostomies with subsequent decompression of the collecting system. CONCLUSIONS: After the decompression hemodynamic status stabilized and over the ensuing 10 days, the patient made a full recovery with no scarring. No similar lesions were noticed on the infant's twin brother. We discuss the recent developments in understanding the underlying mechanism of exfoliative toxins causing staphylococcal scalded skin syndrome, review current treatment guidelines, and outline the need for new therapeutic options.

Measurement of body composition in burned children: is there a gold standard?

BACKGROUND: Maintaining lean body mass (LBM) after a severe burn is an essential goal of modern burn treatment. An accurate determination of LBM is necessary for short- and long-term therapeutic decisions. The aim of this study was to compare 2 measurement methods for body composition, whole-body potassium counting (K count) and dual x-ray absorptiometry (DEXA), in a large prospective clinical trial in severely burned pediatric patients. METHODS: Two-hundred seventy-nine patients admitted with burns covering 40% of total body surface area (TBSA) were enrolled in the study. Patients enrolled were controls or received long-term treatment with recombinant human growth hormone (rhGH). Near-simultaneous measurements of LBM with DEXA and fat-free mass (FFM) with K count were performed at hospital discharge and at 6, 9, 12, 18, and 24 months post injury. Results were correlated using Pearson's regression analysis. Agreement between the 2 methods was analyzed with the Bland-Altman method. RESULTS: Age, gender distribution, weight, burn size, and admission time from injury were not significantly different between control and treatment groups. rhGH and control patients at all time points postburn showed a good correlation between LBM and FFM measurements (R(2) between 0.9 and 0.95). Bland-Altman revealed that the mean bias and 95% limits of agreement depended only on patient weight and not on treatment or time postburn. The 95% limits ranged from 0.1 +/- 2.9 kg for LBM or FFM in 7- to 18-kg patients to 16.3 +/- 17.8 kg for LBM or FFM in patients >60 kg. CONCLUSIONS: DEXA can provide a sufficiently accurate determination of LBM and changes in body composition, but a correction factor must be included for older children and adolescents with more LBM. DEXA scans are easier, cheaper, and less stressful for the patient, and this method should be used rather than the K count.

Pathophysiologic response to severe burn injury.

OBJECTIVE: To improve clinical outcome and to determine new treatment options, we studied the pathophysiologic response postburn in a large prospective, single center, clinical trial. SUMMARY BACKGROUND DATA: A severe burn injury leads to marked hypermetabolism and catabolism, which are associated with morbidity and mortality. The underlying pathophysiology and the correlations between humoral changes and organ function have not been well delineated. METHODS: Two hundred forty-two severely burned pediatric patients [>30% total body surface area (TBSA)], who received no anabolic drugs, were enrolled in this study. Demographics, clinical data, serum hormones, serum cytokine expression profile, organ function, hypermetabolism, muscle protein synthesis, incidence of wound infection sepsis, and body composition were obtained throughout acute hospital course. RESULTS: Average age was 8 +/- 0.2 years, and average burn size was 56 +/- 1% TBSA with 43 +/- 1% third-degree TBSA. All patients were markedly hypermetabolic throughout acute hospital stay and had significant muscle protein loss as demonstrated by a negative muscle protein net balance (-0.05% +/- 0.007 nmol/100 mL leg/min) and loss of lean body mass (LBM) (-4.1% +/- 1.9%); P < 0.05. Patients lost 3% +/- 1% of their bone mineral content (BMC) and 2 +/- 1% of their bone mineral density (BMD). Serum proteome analysis demonstrated profound alterations immediately postburn, which remained abnormal throughout acute hospital stay; P < 0.05. Cardiac function was compromised immediately after burn and remained abnormal up to discharge; P < 0.05. Insulin resistance appeared during the first week postburn and persisted until discharge. Patients were hyperinflammatory with marked changes in IL-8, MCP-1, and IL-6, which were associated with 2.5 +/- 0.2 infections and 17% sepsis. CONCLUSIONS: In this large prospective clinical trial, we delineated the complexity of the postburn pathophysiologic response and conclude that the postburn response is profound, occurring in a timely manner, with derangements that are greater and more protracted than previously thought.

A porcine model of full-thickness burn, excision and skin autografting.

Acute burn wounds often require early excision and adequate coverage to prevent further hypothermia, protein and fluid losses, and the risk of infection. Meshed autologous skin grafts are generally regarded as the standard treatment for extensive full-thickness burns. Graft take and rate of wound healing, however, depend on several endogenous factors. This paper describes a standardized reproducible porcine model of burn and skin grafting which can be used to study the effects of topical treatments on graft take and re-epithelialization. Procedures provide a protocol for successful porcine burn wound experiments with special focus on pre-operative care, anesthesia, burn allocation, excision and grafting, postoperative treatment, dressing application, and specimen collection. Selected outcome measurements include percent area of wound closure by planimetry, wound assessment using a clinical assessment scale, and histological scoring. The use of this standardized model provides burn researchers with a valuable tool for the comparison of different topical drug treatments and dressing materials in a setting that closely mimics clinical reality.

Gender differences in pediatric burn patients: does it make a difference?

OBJECTIVE: There is evidence that females have a better outcome in intensive care units (ICUs) when compared with males. The aim of the present study was to compare hospital course and physiologic markers between severely burned pediatric females and males. SUMMARY BACKGROUND DATA: One-hundred eighty-nine children sustaining a >or=40% total body surface area burn were divided into females (n = 76) and males (n = 113). METHODS: : Patient demographics, clinical parameters, and mortality were noted. Muscle protein synthesis was determined by stable isotope technique. Resting energy expenditure (REE) was measured by indirect calorimetry and body composition by dual x-ray absorptiometry. Serum hormones, proteins, and cytokines were determined. Cardiac function and liver size were determined by repeated ultrasound measurements. RESULTS: There were no significant differences between females and males for mortality, demographics, burn size, nutritional intake, or concomitant injuries. ICU stay was in females: 29+/-3 days whereas the stay in males was 38+/-3 days, P < 0.05. Females had a significant attenuated loss in muscle protein net balance (females: -0.028+/-0.001% vs. males: -0.05+/-0.007%) and an increase in lean body mass (Delta females: 5+/-4% vs. Delta males: -1+/-3%), P < 0.05. Percent-predicted REE was significantly decreased in females compared with males, P < 0.05. Systemic inflammatory markers and stress hormone levels were significantly decreased in females, P < 0.05. Cardiac and liver dysfunction were significantly attenuated in females compared with males, P < 0.05. CONCLUSIONS: Female burned patients exert an attenuated inflammatory and hypermetabolic response compared with males. This decrease is reflected in improved muscle protein net balance and preservation of lean body mass, which are associated with shortened hospital stay.

Age differences in inflammatory and hypermetabolic postburn responses.

OBJECTIVE: The aim of this study was to identify contributors to morbidity and death in severely burned patients <4 years of age. METHODS: A total of 188 severely burned pediatric patients were divided into 3 age groups (0-3.9 years, 4-9.9 years, and 10-18 years of age). Resting energy expenditure was measured through oxygen consumption, body composition through dual-energy x-ray absorptiometry, liver size and cardiac function through ultrasonography, and levels of inflammatory markers, hormones, and acute-phase proteins through laboratory chemistry assays. RESULTS: Resting energy expenditure was highest in the 10- to 18-year-old group, followed by the 4- to 9.9-year-old group, and was lowest in the 0- to 3.9-year-old group. Children 0 to 3.9 years of age maintained lean body mass and body weight during acute hospitalization, whereas children >4 years of age lost body weight and lean body mass. The inflammatory cytokine profile showed no differences between the 3 age groups, whereas liver size increased significantly in the 10- to 18-year-old group and was lowest in the 0- to 3.9-year-old group. Acute-phase protein and cortisol levels were significantly decreased in the toddler group, compared with the older children. Cardiac data indicated increased cardiac work and impaired function in the toddler group, compared with the other 2 age groups. CONCLUSIONS: Increased mortality rates for young children are associated with increased cardiac work and impaired cardiac function but not with the inflammatory and hypermetabolic responses.