A Cross-Sectional Study of Sex, Race, and Ethnic Representation in Burn Registered Clinical Trials.

PURPOSE: The demographic proportions of plastic surgery trials approximating real-world disease have not well been studied. Judicious trial representation is essential in evaluation of treatments across diverse patient populations. Herein, we investigate sex, racial, and ethnic disparities in patient enrollment across burn trials. METHODS: Cross-sectional analysis of participants enrolled in high-quality, with reduced risk of bias, randomized controlled trials (RCT) on burns registered on clinicaltrials.gov under the query "burn." Completed RCTs reporting at least two demographic groups, employing double masking or greater, and with results accessible through the registry or publications were included. Trial characteristics (sponsor country, site location, initiation year, study phase, masking) and demographic data (sex, race, ethnicity per US reporting guidelines) were collected. The Global Burden of Disease database provided sex-based burn disease burdens. The primary outcome was the population-to-prevalence ratio of enrolled female participants. Secondary outcomes included representation of racial and ethnic populations as related to study blinding, phase, and study/sponsor locations. RESULTS: Of 546 records, 39 trials met the inclusion criteria (2919 participants). All trials reported sex demographics, with females comprising 37.02% of all participants (PPR = 0.71, 95% CI [0.59, 0.82], likely indicating underrepresentation against their empiric disease burden). Only 7 and 9 trials reported ethnicity and race, respectively, although not comprehensively. Among trials reporting race or ethnicity, Caucasians and Black persons comprised 57.52% and 21.80% of participants, respectively, while only 9.80% had Hispanic/Latino ethnicity. Severe underreporting of race and ethnicity precluded much of secondary significance testing across study variables. CONCLUSIONS: Females are likely underrepresented in high-quality, US-registered burn trials, unreflective of their real-world disease burden. Further, severe underreporting of race and ethnicity was noted. Future trials should enroll diverse demographics and equitable populations for promotion of study generalizability.

Adherence to Burn Resuscitation Guidelines Reduces Resuscitation Fluids and Mortality.

In our province, regional recommendations for optimal fluid resuscitation were published in 2011 to improve the management of acute burn patients prior to transfer to a specialized burn center. The purpose of this study was to determine compliance with these provincial burn resuscitation guidelines and their subsequent impact on patient outcomes. A retrospective review of patients transferred to the provincial burn center after being initially managed at peripheral sites was performed from 2011 to 2019. Patients were included if their burn injury was greater than 20% TBSA and they were transferred within 24 hours postburn injury. Charts were reviewed for the amount of fluid patients received and resuscitation associated outcomes. A total of 72 patients met the inclusion criteria, 37 of which were treated in accordance with the 2011 guidelines. For patients that followed the 2011 provincial guidelines, they received on average 3.2 cc/kg/TBSA of fluid during the first 24 hours postburn injury. Significantly more fluids were given when guidelines were not followed with an average of 4.4 cc/kg/TBSA (P = .03). Mortality rates were found to be significantly lower during the primary admission with guidelines compliance (16.2% vs 2.7%, P = .04). No significant differences were found between the remaining evaluated complications including abdominal compartment syndrome (8.1% vs 2.7%) and need for escharotomy (35.2% vs 21.6%). The use of clinical practice guidelines decreased excess IV fluid administration in additional to decreasing mortality rates for patients initially assessed in peripheral low volume centers.

Adult kitchen-related burn injuries: The impact of COVID-19.

INTRODUCTION: Kitchen-related burn injuries are common and preventable. To limit the spread of COVID-19, public health orders encouraged the public to stay at home which may have led to an increase in kitchen-related burn injuries. OBJECTIVE: To assess adult kitchen-related burns treated in an outpatient setting in general, and especially looking at the impact of the COVID-19 pandemic on the incidence and epidemiology of these burns. METHODS: For this retrospective, population-based study, data were obtained for adult patients who suffered burn injuries resulting in a visit to a Canadian tertiary Burn Clinic between April 2016 and March 2021 specifically looking at demographics, burn etiology, severity and anatomical location and the need for surgery. Separately, we compared the patients before and after the beginning of the COVID-19 pandemic (April 1, 2020). RESULTS: A total of 1380 burn patients were identified. Of these, 38 % (N = 521) sustained a kitchen-related burn. The median patient age was 40 years (range 18-95) and 282 (54.1 %) were female. The most common etiology and location were scald (76.8 %) and anterior arm (28.5 %), respectively. Thirty-two (6.1 %) patients required admission to the Burn Unit and 26 of these had surgeries. Additionally, 72 (13.8 %) patients had surgery as an outpatient. During the COVID-19 pandemic, East Asian patients saw a significant increase in kitchen burns (p < 0.01). CONCLUSION: Over 1/3 of burns at the outpatient burn clinic were kitchen-related. About 94 % of these were treated as outpatient only. The incidence of kitchen-related burns did not change during the COVID-19 pandemic, but we found significant differences in ethnic distribution. These results provide a unique opportunity to focus on communication and education and set up preventative measures.

Sulfaphenazole reduces thermal and pressure injury severity through rapid restoration of tissue perfusion.

Pressure injuries, also known as pressure ulcers, are regions of localized damage to the skin and/or underlying tissue. Repeated rounds of ischemia-reperfusion (I/R) have a major causative role for tissue damage in pressure injury. Ischemia prevents oxygen/nutrient supply, and restoration of blood flow induces a burst of reactive oxygen species that damages blood vessels, surrounding tissues and can halt blood flow return. Minimizing the consequences of repeated I/R is expected to provide a protective effect against pressure injury. Sulfaphenazole (SP), an off patent sulfonamide antibiotic, is a potent CYP 2C6 and CYP 2C9 inhibitor, functioning to decrease post-ischemic vascular dysfunction and increase blood flow. The therapeutic effect of SP on pressure injury was therefore investigated in apolipoprotein E knockout mice, a model of aging susceptible to ischemic injury, which were subjected to repeated rounds of I/R-induced skin injury. SP reduced overall severity, improved wound closure and increased wound tensile strength compared to vehicle-treated controls. Saliently, SP restored tissue perfusion in and around the wound rapidly to pre-injury levels, decreased tissue hypoxia, and reduced both inflammation and fibrosis. SP also demonstrated bactericidal activity through enhanced M1 macrophage activity. The efficacy of SP in reducing thermal injury severity was also demonstrated. SP is therefore a potential therapeutic option for pressure injury and other ischemic skin injuries.

Predicting and Estimating Burn Outcomes: An Institutional Analysis of 4622 Cases.

Advances in burn care have improved patient outcomes, and independently validated indices and predictors of burn outcomes warrant re-evaluation. The purpose of this study is to consolidate predictors of burn outcomes and determine the factors that significantly contribute to length-of-stay (LOS) and mortality. A retrospective review was conducted of all burn patients (n = 5778) admitted to a quaternary provincial burn unit from 1973 to 2017. Our inclusion criteria yielded 4622 independent cases. Multivariate linear and logistic regression models were generated, and area-under-receiver-operator-curve (AUROC) analysis was performed. Burn predictors included %TBSA, Baux (classic and revised) index, Abbreviated Burn Severity Index (ABSI), and Ryan score. Primary outcomes were mortality and LOS. Multivariate logistic regression for mortality showed the Baux index to be the best predictor for mortality (OR = 1.11, P < 0.001). The AUROC for Baux index was 0.95. With regard to LOS, ABSI was the best predictor for LOS (P < 0.001). ICU stay, ventilator use, alcoholism, and age are significantly associated with increased LOS. Interestingly, hypertension had a protective effect for LOS (P < 0.01) and trended towards a protective effect in mortality. Lethal score 50% (LS50) improved over the study period. The regressions show that burn mortality and LOS are best predicted with the Baux index and ABSI, respectively. Hypertension may have a protective effect on burn outcomes and may be attributed to increased perfusion to the periphery. These predictive scores are useful in determining institutional outcomes in burn surgery. Objective benchmarking of improvement in burn care outcomes can be established using LS50 trends.

Safety and Cost-Effectiveness of Outpatient Surgery in Acute Burn Care.

Outpatient burn surgery is increasingly used in acute burn care. Reports of its safety and efficacy are limited. This study aims to evaluate the safety and cost reduction associated with outpatient burn surgery and to describe our center's experience. This was a single-center, retrospective cohort study of consecutive patients who underwent outpatient burn surgery requiring split-thickness skin graft or dermal regenerative template from January 2010 to December 2018. Patient demographics, comorbidities, burn etiologies, operative data, and postoperative care were reviewed. The primary outcome is complications involving major graft loss requiring reoperation. One hundred and sixty-five patients and 173 procedures met the inclusion criteria. The average age was 44 years and 60.6% (100/165) were male. Annual outpatient procedure volume increased 48% from 23 to 34 cases over the 9-year period. The median (interquartile range) grafted percentage total body surface area was 1.0 (1.0)%. Rate of major graft loss requiring reoperation was 5.2% (9/172) and the most common site was the lower extremity (8/9, 88.9%). Age, sex, comorbidities, total body surface area, and procedure types were not significantly associated with postoperative complication rates. The outpatient burn surgery model was estimated to save CA$8170 per patient from inpatient costs. Demonstration of the safety and cost savings associated with outpatient acute burn surgery is compelling for further utilization. Our experience found the adoption of improved dressing care, appropriate patient selection, increased patient education, adequate pain control, and regimented outpatient multidisciplinary care to be fundamental for effective outpatient surgical burn care.

Granzyme B mediates impaired healing of pressure injuries in aged skin.

Pressure injuries (PIs), also known as bedsores or pressure ulcers, are a major cause of death and morbidity in the elderly. The serine protease, Granzyme B (GzmB), contributes to skin aging and impaired wound healing. Aging is a major risk factor for PIs; thus, the role of GzmB in PI pathogenesis was investigated. GzmB levels in human PI tissue and wound fluids were markedly elevated. A causative role for GzmB was assessed in GzmB knockout (GzmB-/-) and wild-type (WT) mice using a murine model of PI. An apolipoprotein E knockout (ApoE-/-) model of aging and vascular dysfunction was also utilized to assess GzmB in a relevant age-related model better resembling tissue perfusion in the elderly. PI severity displayed no difference between young GzmB-/- and WT mice. However, in aged mice, PI severity was reduced in mice lacking GzmB. Mechanistically, GzmB increased vascular wall inflammation and impaired extracellular matrix remodeling. Together, GzmB is an important contributor to age-dependent impaired PI healing.

Community acquired pressure injuries in a work-related spinal cord injury population: Problem characterization and assessment of a working solution.

BACKGROUND: To characterize the problem of community-acquired pressure injuries (CAPIs) in a work-related spinal cord injury (SCI) population in Canada and assess the benefits of a person-centered solution. Characterization of the problem and a solution, albeit in an insured Worker's Compensation Board of British Columbia (WorkSafeBC) cohort, may inform the supply of solutions in the larger SCI population with disparate access to healthcare. METHODS: For this observational study, data on 244 WorkSafeBC clients, who received an intervention featuring pressure injury (PI) assessment between 2011 and 2015, were used to characterize the problem. Data on observed injuries, risk, referrals, and outcomes were linked to healthcare service claims. Employing an activity-based costing methodology, total expenditures on attributed services were calculated for clients with 1 or more PIs. Intervention cost and benefits from the insurer's perspective are considered. RESULTS: 84 of 244 clients had 1 or more PIs at assessment, with attributed mean cost of $56,092 in 2015 Canadian dollars (CAD). Mean cost by PI severity range from $9580 to $238,736. At an intervention cost of $820,618, detection of less severe injuries provided an opportunity to prevent progression and achieve $3 million in cost avoidance. Follow-up data suggest reasonable returns. Reductions in the incidence, number, and risk of pressure injuries were also observed. CONCLUSIONS: The analysis establishes the cost of CAPIs in a Canadian-based work-related SCI population and suggests preventative and early intervention is not only feasible but also practical. Results are relevant to decisions regarding the use of proactive prevention-based treatment models as opposed to reactive, solutions in the larger SCI population.

Demographics and clinical outcomes of adult burn patients admitted to a single provincial burn centre: A 40-year review.

INTRODUCTION: This study evaluated trends in demographics and outcomes of cutaneous burns over a forty-year period at a Canadian burn centre. METHODS: Retrospective review was performed of all consecutive adult burn admissions to the Vancouver General Hospital (VGH) between 1976 and 2015. Comparison was made to the 2016 American Burn Association - National Burn Repository. RESULTS: There were 4105 admissions during study period. Both overall admissions and admissions per 100,000 BC residents declined (p < 0.0001). Males represented three quarters of admissions. There was a decrease in large burns (p < 0.05). Flame burns were most commonly associated with larger TBSA, ICU stays, and mortality. Mortality decreased from 11.3% to 2.8% (p < 0.05). Factors found to affect mortality included: increased length of stay, age and burn size, male gender, and number of complications. Baux50 and rBaux50 increased, from 102.8 to 116.7 and 112.2 to 125.3 respectively (p < 0.05, respectively). CONCLUSIONS: This study represents the largest report on burn epidemiology in Canada. The incidence of burns has decreased significantly over the last forty years. Mortality has improved over this time frame, as evident by increases in Baux50 and rBaux50 scores. Further data is largely in concurrence with that of the National Burn Repository's amalgamation of US centres.

The relation between positive screening results and MRSA infections in burn patients.

INTRODUCTION: Methicillin-resistant Staphylococcus aureus (MRSA) is a key pathogen in burn patients. Several factors put them at increased risk of MRSA infection: partial loss of the skin barrier, the immune-compromising effects of burns, prolonged hospital stays, and invasive procedures. This study aims to find the relation between MRSA screening swab cultures taken within 48 h of admission, weekly surveillance cultures, and MRSA infection secondary to colonization. METHODS: The data of all burns patients admitted to the referral centre for burns from 2012 to 2016 were reviewed. MRSA cultures taken at admission and on weekly surveillance screening, including nasal, perianal, and wound swabs, were reviewed. To determine associations between MRSA colonization and infection rates, both MRSA-positive and MRSA-negative swab cultures were included in the analysis. Several risk factors were considered: age, gender, ethnicity, %TBSA, BAUX index, inhalational injury, ICU admission and days, need for ventilator support and days, length of stay (LOS) in hospital, and complications. Univariate and multiple logistic regression analyses were used to predict correlations between positive swab cultures and risk factors. RESULTS: Data from 396 patients were reviewed. The median age at admission for the burn patients was 46 (IQR: 31-59) years. On admission, 2.5% of patients were MRSA positive, whereas 17.9% were found to be MRSA positive on weekly surveillance screening. At surveillance, 60.6% developed an infection secondary to MRSA colonization. An MRSA infection was not identified for any patient who did not have at least one positive admission or surveillance swab. A statistically significant association was found between any positive swab and MRSA infection (P < 0.001). The median number of complications reported in the MRSA-positive group was 2 (IQR: 1-3) versus 0 (IQR: 0-1) in the MRSA-negative group and the median length of hospital stay in the MRSA-positive group was 34.5 (IQR: 20.25-56.25) days versus 7 (IQR: 3-16) days in the MRSA-negative group (P < 0.001). CONCLUSION: Nosocomial MRSA colonization rates are high, and patients incurring infections experience a greater than average LOS in hospital and complications. Over 60% of patients who had a positive swab culture at surveillance developed an infection, whereas, no patient with a negative MRSA swab status developed an infection. Hence, pragmatic prevention strategies have to be implemented.

Improved outcomes of renal injury following burn trauma.

BACKGROUND: Acute kidney injury (AKI) is common in major burn injuries and associated with increased mortality. With advances in surgical and critical care it is unclear if mortality in this population remains this high. This study aims to describe incidence and outcomes of patients admitted to intensive care (ICU) with a burn injury who develop AKI. We additionally sought to determine risk factors for developing AKI. METHODS: A historical cohort study of patients admitted to ICU from 2010 to 2016 with major burn injury was conducted. Demographic, laboratory, and clinical information was collected. AKI was defined by Acute Kidney Injury Network (AKIN) classification. Multivariable logistic regression was used to model association between baseline risk factors and risk of AKI. RESULTS: Of the 151 patients included, 64 people developed AKI (42%) defined by stages 1-3 of AKIN criteria. The median TBSA was 20% (IQR 9-41). Renal replacement therapy was required in 18/64 (28%) who developed AKI. Multivariable logistic regression demonstrated association between AKI and the following variables: APACHE II score (OR 1.2, 95%CI 1.1-1.3, P = 0.001), age (OR 1.8 per 10-year increase, 95%CI: 1.2-2.5, P = 0.002) and log(TBSA). Fractional polynomial regression analysis demonstrates that the best functional form of TBSA was in the natural logarithm (OR 2.7, 95%CI: 1.5-4.7, p = 0.001). Compared to those without AKI, patients with AKI had longer duration of mechanical ventilation, (median 11 [IQR 6-19] vs. 4 [IQR 2-9] days), ICU stay (15 [IQR 9-22] vs. 6 [IQR 3-10] days), and increased mortality (14 of 64(22%) vs. 4 of 87(5%). CONCLUSIONS: AKI is common in patients with a major burn injury. However, mortality is lower than described in the literature, particularly for those who required renal replacement therapy.

Incisional negative pressure therapy reduces complications and costs in pressure ulcer reconstruction.

Complications after pressure ulcer reconstruction are common. A complication rate of 21% to 58% and a 27% wound recurrence has been reported. The aim of this study was to decrease postoperative wound-healing complications with incisional negative pressure wound therapy (iNPWT) postoperatively. This was a prospective non-randomised trial with a historic control. Surgically treated pressure ulcer patients receiving iNPWT were included in the prospective part of the study (Treatment group) and compared with the historic patient cohort of all consecutive surgically treated pressure ulcer patients during a 2-year period preceding the initiation of iNPWT (Control). There were 24 patients in the Control and 37 in the Treatment groups. The demographics between groups were similar. There was a 74% reduction in in-hospital complications in the Treatment group (10.8% vs 41.7%, P = 0.0051), 27% reduction in the length of stay (24.8 vs 33.8 days, P = 0.0103), and a 78% reduction in the number of open wounds at 3 months (5.4 vs 25%, P = -0.0481). Recurrent wounds and history of previous surgery were risk factors for complications. Incisional negative pressure wound therapy shortens hospital stay, number of postoperative complications, and the number of recurrent open wounds at 3 months after reconstructive pressure ulcer surgery, resulting in significant cost savings.

Granzyme K Expressed by Classically Activated Macrophages Contributes to Inflammation and Impaired Remodeling.

Granzyme K (GzmK), traditionally described as a pro-apoptotic, granule-secreted serine protease, has been proposed to promote inflammation. Found at low levels in the plasma of healthy individuals, GzmK is markedly elevated in response to sepsis and infection. In this study we investigated the role of GzmK in inflammation and remodeling in response to thermal injury. In human burn tissue, GzmK was elevated compared with normal skin, with expression predominantly found in macrophages. GzmK was expressed and secreted by cultured human classically activated macrophages. To assess the role of GzmK in response to skin wounding, wild-type or GzmK-/- mice were subjected to grade 2 thermal injury. GzmK-/- mice exhibited improved wound closure, matrix organization, and tensile strength compared with wild-type mice. Reduced proinflammatory IL-6, ICAM-1, VCAM-1, and MCP-1 expressions were observed at 3 days after injury. Additionally, GzmK induced IL-6 expression in keratinocytes and skin fibroblasts that was dependent on PAR-1 activation. Re-epithelialization showed the greatest degree of improvement of all healing parameters, suggesting that keratinocytes are sensitive to GzmK-mediated proteolysis. In support, keratinocytes, but not skin fibroblasts, exposed to GzmK showed impaired wound healing in vitro. In summary, GzmK influences wound healing by augmenting inflammation and impeding epithelialization.

The development of a treatment pathway for dermal regenerative matrix (DRM).

The process of standardising burn care and creating protocols within burn centres has, at its core, evidence-based practice principles combined with the clinical experiences of burn care specialists. Although protocols and pathways have been created for certain topics of burn care, they tend to be tailored to the local individual needs of each burn centre, which is a limiting factor for consideration of larger/nationwide approaches. In order to continue to improve the short and long term outcomes after burn injuries, such as increasing the survival rate, reduction in the incidence of sepsis and organ failure, and improving wound healing and scarring, more generalised care pathways combining the recommendations of a nationwide working group of burn care specialists should be created around the topics of interest to ultimately improve patients' outcomes. We describe the steps put in place in Canada to design and adopt a nationwide protocol from a single burn centre on the topic of wound healing and dermal substitutes as the initial exemplary process. This report summarizes the Canadian experience for this type of initiative, which can be used as framework for developing additional guidelines/protocols in other relevant burn care related topics in Canada or other countries.

Topical small molecule granzyme B inhibitor improves remodeling in a murine model of impaired burn wound healing.

Granzyme B (GzmB) is a serine protease that has long been thought to function exclusively in lymphocyte-mediated apoptosis. In recent years, this paradigm has been revisited due to the recognition that GzmB accumulates in the extracellular milieu in many autoimmune and chronic inflammatory disorders, and contributes to impaired tissue remodeling due to the cleavage of extracellular matrix proteins. Knockout studies suggest that GzmB-mediated cleavage of decorin (DCN) contributes to impaired collagen fibrillogenesis and remodeling. As DCN is anti-fibrotic and contributes to reduced hypertrophic scarring, GzmB-induced DCN cleavage could play a role in wound healing following burn injury. In the present study, a novel, gel-formulated, first-in-class small-molecule inhibitor of GzmB, VTI-1002, was assessed in a murine model of impaired, diabetic burn wound healing. VTI-1002 exhibited high specificity, potency, and target selectivity. Gel-formulated VTI-1002 was able to penetrate the stratum corneum and was retained in the skin with minimal systemic absorption. Daily topical administration of VTI-1002 gel for 30 days following thermal injury showed significantly accelerated wound closure, increased DCN protein levels, and collagen organization that was translated into significantly increased wound tensile strength compared to controls. Overall, VTI-1002 gel was well-tolerated in vivo and no adverse events were observed. Topical application of VTI-1002 represents a novel therapeutic approach for the treatment of cutaneous burn wounds.

Treatment of toxic epidermal necrolysis by a multidisciplinary team. A review of literature and treatment results.

BACKGROUND: Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) are mucocutaneous hypersensitivity reactions, usually to drugs or their metabolites. TEN is the most severe involving greater than 30% of the total body surface area (TBSA). Management of these patients usually benefits from a large multidisciplinary team for both wound and medical management. Treatment of these patients varies between centers and physicians and there is lack of a standardized treatment protocol in the medical literature. OBJECTIVES: To review the literature and complete a retrospective review of patients treated at Vancouver General Hospital over a 11-year period. METHODS: A retrospective chart review of all patients diagnosed with SJS/TEN and treated at Vancouver General Hospital from 2001 to 2011 was completed. Data collected include patient demographics, time to transfer to a burn center, SCORTEN calculation, suspected cause of TEN, %TBSA involved, length of stay in hospital and ICU, medications, dressings, infections/cultures, fluids, mucosal involvement, teams involved, associated complications, morbidity and mortality. Data is reported quantitatively. RESULTS: A total of 67 patients were identified (28 SJS, 21 SJS/TEN overlap, 18 TEN). In SJS/TEN overlap and TEN patients, oral mucosa and trunk were the primary sites involved. SCORTEN calculations were highest in the TEN group. Plastic surgery was consulted in 53% of TEN cases, 52% of SJS/TEN cases and 25% of SJS cases. Patients were admitted to a burn unit in 74% of TEN cases, 57% of TEN/SJS cases and 21% of SJS cases. Time from symptoms to diagnosis and transfer to a burn unit was highest for TEN patients. Time from presentation to diagnosis was highest in SJS/TEN overlap. Triggers were identified in 67-82% of cases. Treatment varied widely. Patients were treated conservatively, with steroids, IVIg, and cyclosporine alone or in combination. Observed mortality was higher than predicted by SCORTEN for patients treated with IVIg and lower for those treated with Cyclosporin. Dressings varied greatly and were often changed throughout a patients stay. Total mortality was 20.9% being the highest in the TEN group (35%). CONCLUSIONS: SJS and TEN are a spectrum of severe mucocutaneous reactions that have unclear treatment recommendations within the literature and within our Level 1 hospital. Information gleaned from this research will help educate physicians involved in the treatment and management of patients with these diagnoses and has resulted in development of treatment guidelines in our hospital.

The Safety and Tolerability of Topically Delivered Kynurenic Acid in Humans. A Phase 1 Randomized Double-Blind Clinical Trial.

Scarring is a consequence of biological tissue repair following trauma. Currently, there are no generally agreed ways to prevent scarring. Recently, kynurenic acid has shown to be a potent modulator of extracellular matrix deposition and remodeling. Kynurenic acid can reduce matrix deposition and other fundamental characteristics of fibrosis in vitro and in vivo. Specifically, kynurenic acid has shown to increase matrix metalloproteinase-1 activity and subsequently reduce collagen deposition in a rabbit ear scar model. In the present study kynurenic acid cream in different concentrations was topically applied on healthy skin on volunteers to assess skin reactions and skin sensitivity in both acute and chronic application settings. Skin reactions were assessed, and concentrations for kynurenic acid were assessed both form serum and urine. Results showed to acute or delayed skin reactions. Kynurenic acid was not detectable in blood at any time point, and only trace elements of kynurenic acid were found in urine. This study supports safety and tolerability of topically administered FS2 when using a liposomal, compounding base carrier.

Accelerant-related burns and drug abuse: Challenging combination.

BACKGROUND: Accelerants are flammable substances that may cause explosion when added to existing fires. The relationships between drug abuse and accelerant-related burns are not well elucidated in the literature. Of these burns, a portion is related to drug manufacturing, which have been shown to be associated with increased burn complications. OBJECTIVES: 1) To evaluate the demographics and clinical outcomes of accelerant-related burns in a Provincial Burn Centre. 2) To compare the clinical outcomes with a control group of non-accelerant related burns. 3) To analyze a subgroup of patients with history of drug abuse and drug manufacturing. METHODS: Retrospective case control study. Patient data associated with accelerant-related burns from 2009 to 2014 were obtained from the British Columbia Burn Registry. These patients were compared with a control group of non-accelerant related burns. Clinical outcomes that were evaluated include inhalational injury, ICU length of stay, ventilator support, surgeries needed, and burn complications. Chi-square test was used to evaluate categorical data and Student's t-test was used to evaluate mean quantitative data with the p value set at 0.05. A logistic regression model was used to evaluate factors affecting burn complications. RESULTS: Accelerant-related burns represented 28.2% of all burn admissions (N=532) from 2009 to 2014. The accelerant group had higher percentage of patients with history of drug abuse and was associated with higher TBSA burns, ventilator support, ICU stay and pneumonia rates compared to the non-accelerant group. Within the accelerant group, there was no difference in clinical outcomes amongst people with or without history of drug abuse. Four cases were associated with methamphetamine manufacturing, all of which underwent ICU stay and ventilator support. CONCLUSIONS: Accelerant-related burns cause significant burden to the burn center. A significant proportion of these patients have history of drug abuse.

Venous thromboembolism in burn patients is not prevented by chemoprophylaxis.

BACKGROUND: Venous thromboembolisms (VTE) including deep venous thrombosis and pulmonary embolism are serious complications following burn trauma. There are inconsistencies in the literature regarding thromboembolic prevention strategies and data suggests that complications occur despite chemoprophylaxis. OBJECTIVE: To determine the prevalence of deep venous thromboembolism and pulmonary embolism in burn patients who are actively being treated with VTE prophylaxis and to determine factors that help predict which anti-coagulated patients are at risk for VTE and may benefit from further treatment. MATERIALS AND METHODS: Retrospective analysis of burn data registry and patient Charts 1980-2012. RESULTS: Out of 1549 burn patients in the registry fifty patients (3.2%) had a VTE but charts were only available for 26 of these for further analysis. Of these, 12 patients (46%) had a VTE while on chemoprophylaxis and 14 (54%) without chemoprophylaxis. There were no differences between groups, but 90% of DVT complications occurred to Caucasian patients and none to Asians. The VTE group had significantly higher rate of inhalation injury, higher TBSA, longer hospital stay and ICU stay than matched controls. CONCLUSIONS: Chemoprophylaxis does not prevent VTEs. Burn severity predisposes to venous thromboembolic complications.

Split thickness skin graft meshing ratio indications and common practices.

BACKGROUND: Split thickness skin grafting is a commonly used technique in burn surgery for resurfacing wounds that are unlikely to heal without scarring. Meshing and expanding skin grafts allow for reconstruction of larger wounds with smaller donor sites. METHODS: A retrospective chart review was performed of 210 patients with burns equal to or greater than 20% total body surface area admitted to Vancouver General Hospital between 1998 and 2014. Charts were reviewed to collect data on patient and burn demographics. A survey was sent to Canadian plastic surgeons registered with the CSPS to collect data on common practices in burn surgery nationwide. RESULTS: The patients that received 3:1 or higher meshed grafts were all flame burns, had a significantly higher average TBSA (51.89%±14.87 vs 29.13%±9.48, p=0.001), and a significantly higher full thickness burn TBSA (25.76%±21.97 vs 6.20%±9.04, p=0.001). We found no significant differences in gender, age, or burn location between the less than 2:1 and 3:1 or greater meshing ratio groups. The survey of plastic surgeons performing burn surgery in Canada revealed that 60% of responders had experience with skin grafts using meshing ratios of 3:1 or higher. Of these surgeons, 100% felt that burn size and 36% felt that burn location would influence their decision to use a 3:1 or higher meshing ratio. CONCLUSIONS: A larger burn size is the major influencing factor for the use of higher skin graft meshing ratios by Canadian burn surgeons. Furthermore, burn location determines the choice of donor and recipient sites in these cases.