Pediatric Emergency Department Visits Associated with Mental Health Conditions Before and During the COVID-19 Pandemic - United States, January 2019-January 2022.

In 2021, a national emergency* for children's mental health was declared by several pediatric health organizations, and the U.S. Surgeon General released an advisory† on mental health among youths. These actions resulted from ongoing concerns about children's mental health in the United States, which was exacerbated by the COVID-19 pandemic (1,2). During March-October 2020, among all emergency department (ED) visits, the proportion of mental health-related visits increased by 24% among U.S. children aged 5-11 years and 31% among adolescents aged 12-17 years, compared with 2019 (2). CDC examined changes in U.S. pediatric ED visits for overall mental health conditions (MHCs) and ED visits associated with specific MHCs (depression; anxiety; disruptive behavioral and impulse-control disorders; attention-deficit/hyperactivity disorder; trauma and stressor-related disorders; bipolar disorders; eating disorders; tic disorders; and obsessive-compulsive disorders [OCD]) during 2019 through January 2022 among children and adolescents aged 0-17 years, overall and by sex and age. After declines in weekly visits associated with MHCs among those aged 0-17 years during 2020, weekly numbers of ED visits for MHCs overall and for specific MHCs varied by age and sex during 2021 and January 2022, when compared with corresponding weeks in 2019. Among adolescent females aged 12-17 years, weekly visits increased for two of nine MHCs during 2020 (eating disorders and tic disorders), for four of nine MHCs during 2021 (depression, eating disorders, tic disorders, and OCD), and for five of nine MHCs during January 2022 (anxiety, trauma and stressor-related disorders, eating disorders, tic disorders, and OCD), and overall MHC visits during January 2022, compared with 2019. Early identification and expanded evidence-based prevention and intervention strategies are critical to improving children's and adolescents' mental health (1-3), especially among adolescent females, who might have increased need.

The effect of intra-operative hypotension on acute kidney injury, postoperative mortality and length of stay following emergency hip fracture surgery.

The association between intra-operative hypotension and postoperative acute kidney injury, mortality and length of stay has not been comprehensively evaluated in a large single-centre hip fracture population. We analysed electronic anaesthesia records of 1063 patients undergoing unilateral hip fracture surgery, collected from 2015 to 2018. Acute kidney injury, 3-, 30- and 365-day mortality and length of stay were evaluated to assess the relationship between intra-operative hypotension absolute values (≤ 55, 60, 65, 70 and 75 mmHg) and duration of hypotension. The rate of acute kidney injury was 23.7%, mortality at 3-, 30- and 365 days was 3.7%, 8.0% and 25.3%, respectively, and median (IQR [range]) length of stay 8 (6-12 [0-99]) days. Median (IQR [range]) time ≤ MAP 55, 60, 65, 70 and 75 mmHg was 0 (0-0.5[0-72.1]); 0 (0-4.4 [0-104.9]); 2.2 (0-8.7 [0-144.2]); 6.6 (2.2-19.7 [0-198.8]); 17.5 (6.6-37.1 [0-216.3]) minutes, and percentage of surgery time below these thresholds was 1%, 2.5%, 7.9%, 12% and 21% respectively. There were some univariate associations between hypotension and mortality; however, these were no longer evident in multivariable analysis. Multivariable analysis found no association between hypotension and acute kidney injury. Acute kidney injury was associated with male sex, antihypertensive medications and cardiac/renal comorbidities. Three-day mortality was associated with delay to surgery ? 48 hours, whilst 30-day and 365-day mortality was associated with delay to surgery ≥ 48 hours, impaired cognition and cardiac/renal comorbidities. While the rate of acute kidney injury was similar to other studies, use of vasopressors and fluids to reduce the time spent at hypotensive levels failed to reduce this complication. Intra-operative hypotension at the levels observed in this cohort may not be an important determinant of acute kidney injury, postoperative mortality and length of stay.

Mesenchymal Stem/Stromal Cells and Their Derivates in Acute Diseases: Emergency in the Post-COVID-19 Times.

The current coronavirus disease-19 (COVID-19) pandemic has strongly revived the pressing need to incorporate new therapeutic alternatives to deal with medical situations that result in a dramatic breakdown in the body's normal homeostasis [...].

How the COVID-19 Wave Changed Emergency Urology: Results From an Academic Tertiary Referral Hospital in the Epicentre of the Italian Red Zone.

OBJECTIVE: To quantify and characterize the burden of urological patients admitted to emergency department (ED) in Lombardy during Italian COVID-19 outbreak, comparing it to a reference population from 2019. METHODS: We retrospectively analysed all consecutive admissions to ED from 1 January to 9 April in both 2019 and 2020. According to the ED discharge ICD-9-CM code, patients were grouped in urological and respiratory patients. We evaluated the type of access (self-presented/ambulance), discharge priority code, ED discharge (hospitalization, home), need for urological consultation or urgent surgery. RESULTS: The number of urological diagnoses in ED was inversely associated to COVID-19 diagnoses (95% confidence interval -0.41/-0.19; Beta = -0.8; P < .0001). The average access per day was significantly lower after 10 March 2020 (1.5 ± 1.1 vs 6.5 ± 2.6; P < .0001), compared to reference period. From 11 March 2020, the inappropriate admissions to ED were reduced (10/45 vs 96/195; P = .001). Consequently, the patients admitted were generally more demanding, requiring a higher rate of urgent surgeries (4/45 vs 4/195; P = .02). This reflected in an increase of the hospitalization rate from 12.7% to 17.8% (Beta = 0.88; P < .0001) during 2020. CONCLUSION: Urological admissions to ED during lockdown differed from the same period of 2019 both qualitatively and quantitatively. The spectrum of patients seems to be relatively more critical, often requiring an urgent management. These patients may represent a challenge due to the difficult circumstances caused by the pandemic.

Experiencia desde el punto de vista de un traumatólogo en el Hospital COVID-IFEMA en Madrid durante la pandemia del coronavirus en España / An orthopaedic surgeon's experience at COVID-IFEMA Hospital during coronavirus pandemic in Spain

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Reintegrating droperidol into emergency medicine practice.

PURPOSE: After a long period of low utilization, droperidol has become easier to obtain in the US market. This comprehensive review discusses the safety, indications, clinical efficacy, and dosing of droperidol for use in the emergency department (ED) setting. SUMMARY: In 2001 the US Food and Drug Administration (FDA) mandated a boxed warning in the labeling of droperidol after reports of QT interval prolongation associated with droperidol use. Since that time, it has been difficult to access droperidol in the United States; as a result, many practicing clinicians lack experience in its clinical use. Multiple studies have been conducted to assess the clinical efficacy and safety of droperidol use in ED patients. Results consistently show the safety of droperidol and its clinical efficacy when used as an analgesic, antiemetic, and sedative. Now that droperidol is more widely available for use in the US market, pharmacists and prescribers need to reliably translate safety and efficacy data compiled since 2001 to help ensure appropriate and effective use of the medication. CONCLUSION: Droperidol is an effective and safe option for the treatment of acute agitation, migraine, nausea, and pain for patients in the ED setting. Healthcare professionals can adopt droperidol for use in clinical practice, and they should become familiar with how to dose and monitor droperidol for safe and effective use.

National trends in ventral hernia repairs for patients with intra-abdominal metastases.

BACKGROUND: Ventral hernias in patients with intra-abdominal metastases may not be addressed owing to other oncologic priorities, but they can affect quality of life and lead to sequelae necessitating an emergency operation. We compared the national trends and perioperative outcomes for elective and nonelective ventral hernia repairs for patients with intra-abdominal metastases. METHODS: Patients were identified from the National Inpatient Sample (2003-2015). Temporal trends were described using average annual percent change. Perioperative outcomes between elective and nonelective ventral hernia repairs were compared using multivariable regressions. RESULTS: An estimated 947,112 ventral hernia repairs were performed nationally, including 5,602 (0.6%) in patients with intra-abdominal metastases. Among patients with intra-abdominal metastases, 40.1% had a nonelective ventral hernia repair, mean (standard deviation) age was 64 (12) years, and 65.1% were women. Between 2003 and 2015, the total number of ventral hernia repairs performed nationally did not change (average annual percent change 0.062, P = .84). For patients with intra-abdominal metastases, although there was no change in the number of elective ventral hernia repairs (average annual percent change 0.65, P = .59), the number of nonelective ventral hernia repairs increased significantly (average annual percent change 2.7, P = .025). By multivariable analyses, patients with intra-abdominal metastases who underwent a nonelective repair were more likely to experience complications (odds ratio 1.76, P = .001), nonroutine discharge (odds ratio 1.93, P < .001), and mortality (odds ratio 2.27, P = .035). Nonelective ventral hernia repairs was also associated with a 38.5% (P < .001) longer hospital stay and 24.4% (P < .001) higher charges. CONCLUSION: The number of nonelective ventral hernia repairs, which is associated with substantial perioperative morbidity, has increased significantly among patients with intra-abdominal metastases. Surgeons should consider a nonemergency operation for select patients to mitigate the burden of nonelective ventral hernia repairs.

30-Day Recurrence, Readmission Rate, and Clinical Outcome After Emergency Lumbar Discectomy.

STUDY DESIGN: A retrospective cohort study. OBJECTIVE: To investigate the 30-day recurrence rate after emergency lumbar discectomy. Secondary aims were to investigate the factors affecting the 30-day recurrence and readmission rates and clinical outcome. SUMMARY OF BACKGROUND DATA: Excluding cauda equine syndrome (CES) due to massive intervertebral disc herniation, emergency surgery for lumbar disc herniation (LDH) is rarely required. The operation may, however, be performed for other reasons such as persistent or progressive motor paresis associated with radiculopathy or uncontrolled pain. Literature on these topics is scarce. METHODS: All patients admitted for inpatient care after a visit to the emergency department (ED) due to acute low back pain and who had subsequently undergone an emergency lumbar discectomy during the 4-year study period were included in the study. Patients attending the ED who subsequently had a delayed discectomy formed the control group. Recurrence and readmission rates were analyzed and clinical outcome at 30 days post-surgery was assessed with the Oswestry Disability Index (ODI) and the visual analog pain scale (VAS). RESULTS: One hundred thirty patients were admitted to the hospital after visiting the ED and underwent an emergency discectomy after a median of 1.0 days from admittance. Six patients in the study group [4.6% (95% CI: 2.1-9.7)] had recurrent LDH and nine patients in total [6.9% (95% CI: 3.9-12.6)] were readmitted within 30 days. None of the baseline variables clearly predicted recurrence. Mean ODI difference between the study group and controls was 8.1 (95% CI: -6.7-23.2). BMI and surgery by a non-spine surgeon were associated with higher ODI values. CONCLUSION: An emergency discectomy is associated with a higher rate than expected of both recurrent LDHs and 30-day readmissions. Surgeon experience and patient-related factors had minor effects on the 30-day clinical outcome. LEVEL OF EVIDENCE: 4.

Changes in Emergency Department Care Intensity from 2007-16: Analysis of the National Hospital Ambulatory Medical Care Survey.

INTRODUCTION: Emergency departments (ED) in the United States (US) have increasingly taken the central role for the expedited diagnosis and treatment of acute episodic illnesses and exacerbations of chronic diseases, allowing outpatient management to be possible for many conditions that traditionally required hospitalization and inpatient care. The goal of this analysis was to examine the changes in ED care intensity in this context through the changes in ED patient population and ED care provided. METHODS: We analyzed the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2007-2016. Incorporating survey design and weight, we calculated the changes in ED patient characteristics and ED care provided between 2007 and 2016. We also calculated changes in the proportion of visits with low-severity illnesses that may be safely managed at alternative settings. Lastly, we compared ED care received and final ED dispositions by calculating adjusted relative risk (aRR) comparing ED visits in 2007 to 2016, using survey weighted multivariable logistic regression. RESULTS: NHAMCS included 35,490 visits in 2007 and 19,467 visits in 2016, representing 117 million and 146 million ED visits, respectively. Between 2007 and 2016, there was an increase in the proportion of ED patients aged 45-64 (21.0% to 23.6%) and 65-74 (5.9% to 7.5%), while visits with low-severity illnesses decreased from 37.3% to 30.4%. There was a substantial increase in the proportion of Medicaid patients (22.2% to 34.0%) with corresponding decline in the privately insured (36.2% to 28.3%) and the uninsured (15.4% to 8.6%) patients. After adjusting for patient and visit characteristics, there was an increase in the utilization of advanced imaging (aRR 1.29; 95% confidence interval [CI], 1.17-1.41), blood tests (aRR 1.16; 95% CI, 1.10-1.22), urinalysis (aRR 1.22; 95% CI, 1.13-1.31), and visits where the patient received four or more medications (aRR 2.17; 95% CI, 1.88-2.46). Lastly, adjusted hospitalization rates declined (aRR 0.74; 95% CI, 0.64-0.84) while adjusted discharge rates increased (aRR 1.06; 95%CI 1.03-1.08). CONCLUSION: From 2007 to 2016, ED care intensity appears to have increased modestly, including aging of patient population, increased illness severity, and increased resources utilization. The role of increased care intensity in the decline of ED hospitalization rate requires further study.

Trends in Regionalization of Emergency Care for Common Pediatric Conditions.

BACKGROUND: For children who cannot be discharged from the emergency department, definitive care has become less frequent at most hospitals. It is uncertain whether this is true for common conditions that do not require specialty care. We sought to determine how the likelihood of definitive care has changed for 3 common pediatric conditions: asthma, croup, and gastroenteritis. METHODS: We used the Nationwide Emergency Department Sample database to study children <18 years old presenting to emergency departments in the United States from 2008 to 2016 with a primary diagnosis of asthma, croup, or gastroenteritis, excluding critically ill patients. The primary outcome was referral rate: the number of patients transferred among all patients who could not be discharged. Analyses were stratified by quartile of annual pediatric volume. We used logistic regression to determine if changes over time in demographics or comorbidities could account for referral rate changes. RESULTS: Referral rates increased for each condition in all volume quartiles. Referral rates were greatest in the lowest pediatric volume quartile. Referral rates in the lowest pediatric volume quartile increased for asthma (13.6% per year; 95% confidence interval [CI] 5.6%-22.2%), croup (14.8% per year; 95% CI 2.6%-28.3%), and gastroenteritis (16.4% per year; 95% CI 3.5%-31.0%). Changes over time in patient age, sex, comorbidities, weekend presentation, payer mix, urban-rural location of presentation, or area income did not account for these findings. CONCLUSIONS: Increasing referral rates over time suggest decreasing provision of definitive care and regionalization of inpatient care for 3 common, generally straightforward conditions.

En respuesta a la pregunta: «¿Jugamos todos en el mismo equipo?» / In reply to the question: "Are we really playing together in the same team?"

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Desarrollo de solución inyectable de ribavirina en el Centro Militar de Farmacia de la Defensa como tratamiento de urgencia frente a agentes víricos altamente infecciosos. Cobertura de una laguna terapéutica / Development of the injectable ribavirin solution at the Military Defense Pharmacy Center as an emergency treatment against highly infectious agents. Coverage of a therapeutic lagoon

Antecedentes: España por su situación geopolítica no está exenta de amenazas y desafíos asociados a enfermedades infecciosas víricas como las «fiebres hemorrágicas víricas». Implementar acciones para disminuir estos riesgos frente a agentes víricos con el desarrollo de un tratamiento de urgencia por vía intravenosa resulta de gran interés. Objetivos: Desarrollar dos formulaciones de Ribavirina 100 mg/ml con distintos excipientes y condiciones de fabricación para buscar la formulación más estable. Material y métodos: Se ha utilizado ribavirina, distintos tampones y agua para inyectables. Se ha evaluado alteraciones físicas, riqueza y pH siguiendo especificaciones de la monografía de la Farmacopea Europea. Resultados: Se exponen resultados de pH y riqueza de ambas formulaciones con y sin esterilización terminal. Conclusiones: Los resultados obtenidos cumplen especificaciones para ambas formulaciones, demostrando una estabilidad química tras su conservación en condiciones de estudios a largo plazo durante 12 meses y acelerados durante 6 meses. El desarrollo de la ribavirina 100 mg/ml (10% w/v) inyectable satisface una necesidad terapéutica relacionada con el tratamiento de primera elección en enfermedades víricas altamente contagiosas que carecen de tratamientos eficaces

Background: Spain, due to its geopolitical situation, is not exempt from the threats and challenges associated with viral infectious diseases such as the «viral hemorrhagic fevers». Implementing actions to reduce these risks with the development of an emergency treatment against these viral agents for intravenous is of great interest. Objective: Develop two formulations of Ribavirin 100 mg/ml with different excipients and manufacturing conditions to look for the most stable formulation. Material and methods: Ribavirin, various buffers and water for injections have been used. Physical alterations, richness and pH have been evaluated following specifications of European Pharmacopoeia monograp. Results: Results of pH and richness of both formulations are exposed with and without terminal sterilization. Conclusions: The results obtained meet specifications for both formulations, demonstrating chemical stability after preservation under long-term study conditions for 12 months and accelerated for 6 months. The development of injectable 100 mg/ml ribavirin (10% w/v) satisfies a therapeutic need related to the treatment of first choice in highly contagious viral diseases that lack treatments

Emergent and Urgent Craniotomies in Pediatric Patients: Resource Utilization and Cost Analysis.

BACKGROUND: Pediatric neurosurgeons are occasionally tasked with performing surgery expeditiously to preserve a child's neurologic faculties and life. OBJECTIVE: This study examines the etiologies, outcomes, and costs for urgent or emergent craniotomies at a Level I Pediatric Trauma center over a 7-year time period. METHODS: A retrospective review was conducted for each patient who underwent an emergent or urgent craniotomy within 24 hours of presentation between January 2010 and April 2017. Demographic, clinical, and surgical details were recorded for a total of 48 variables. Any readmission within 90 days was analyzed. Hospital charges for each admission and readmission were collected and adjusted for inflation to October 2018 values. RESULTS: Among the 223 children who underwent urgent or emergent craniotomies, the majority were admitted for traumatic injuries (n = 163, 73.1%). The most common traumatic mechanism was fall (n = 51, 22.9%), and the most common non-traumatic cause was tumor (n = 21, 9.4%). Overall, craniotomies were typically performed for hematoma evacuation of one type or combination (n = 115, 51.6%) during off-peak times (n = 178, 79.8%). Seventy-seven (34.5%) subjects experienced 1 or more postoperative events, 22 of whom returned to the operating room. There were 13 (5.8%) and 33 (14.8%) readmissions within 30 days and 90 days of discharge, respectively. Non-trauma patients (compared with trauma patients) and polytrauma (compared with isolated head injury) had greater healthcare needs, resulting in higher charges. CONCLUSION: Most urgent or emergent pediatric craniotomies were performed for the treatment of traumatic injuries involving hematoma evacuation, but non-traumatic patients were more complex requiring greater resources.

Perceptions and expectations of health-related quality of life among geriatric patients seeking emergency care: a qualitative study.

BACKGROUND: Health-related quality of life (HRQoL), encompassing social, emotional, and physical wellbeing is an important clinical outcome of medical care, especially among geriatric patients. It is unclear which domains of HRQoL are most important to geriatric patients and which domains they hope to address when using the Emergency Department (ED). The objective of this study was to understand which aspects of HRQoL are most valued by geriatric patients in the ED and what expectations patients have for addressing or improving HRQoL during an ED visit. METHODS: This was a qualitative focus group study of geriatric ED patients from an urban, academic ED in the United States with > 16,500 annual geriatric visits. Patients were eligible if they were age > =65 years and discharged from the ED within 45 days of recruitment. Semi-structured pilot interviews and focus groups were conducted several weeks after the ED visit. Participants shared their ED experiences and to discuss their perceptions of the subsequent impact on their quality of life, focusing on the domains of physical, mental, and social health. Latent content and constant comparative methods were used to code focus group transcripts and analyze for emergent themes. RESULTS: Three individuals participated in pilot interviews and 31 participated in six focus groups. Twelve codes across five main themes relating to HRQoL were identified. Patients recalled: (1) A strong desire to regain physical function, and (2) anxiety elicited by the emotional experience of seeking care in the emergency department, due to uncertainty in diagnosis, treatment, and prognosis. In addition, patients noted both (3) interpersonal impacts of health on quality of life, primarily mediated primarily by social interaction, and (4) an individual experience of health and quality of life mediated primarily by mental health. Finally, (5) patients questioned if the ED was the right place to attempt to address HRQoL. CONCLUSIONS: Patients expressed anxiety around the time of their ED visit related to uncertainty, they desired functional recovery, and identified both interpersonal effects of health on quality of life mediated by social health, and an individual experience of health and quality of life mediated by mental health.

Age is associated with increased mortality in the RETTS-A triage scale.

BACKGROUND: Triage is widely used in the emergency department (ED) in order to identify the patient's level of urgency and often based on the patient's chief complaint and vital signs. Age has been shown to be independently associated with short term mortality following an ED visit. However, the most commonly used ED triage tools do not include age as an independent core variable. The aim of this study was to investigate the relationship between age and 7- and 30-day mortality across the triage priority level groups according to Rapid Emergency Triage and Treatment System - Adult (RETTS-A), the most widely used triage tool in Sweden. METHODS: In this cohort, we included all adult patients visiting the ED at the Karolinska University Hospital, Sweden, from 1/1/2010 to 1/1/2015, n = 639,387. All patients were triaged according to the RETTS-A and subsequently separated into three age strata: 18-59, 60-79 and ≥ 80 years. Descriptive analyses and logistic regression was used. The primary outcome measures were 7- and 30-day mortality. RESULTS: We observed that age was associated with both 7 and 30-day mortality in each triage priority level group. Mortality was higher in older patients across all triage priority levels but the association with age was stronger in the lowest triage group (p-value for interaction = < 0.001). Comparing patients ≥80 years with patients 18-59 years, older patients had a 16 and 7 fold higher risk for 7 day mortality in the lowest and highest triage priority groups, respectively. The corresponding numbers for 30-d mortality were a 21- and 8-foldincreased risk, respectively. CONCLUSION: Compared to younger patients, patients above 60 years have an increased short term mortality across the RETTS-A triage priority level groups and this was most pronounced in the lowest triage level. The reason for our findings are unclear and data suggest a validation of RETTS-A in aged patients.

Ambulatory care sensitive conditions hospitalization for emergencies rates in Colombia.

OBJECTIVE: To analyze the emergency hospitalizations trend for ambulatory care sensitive conditions between 2011 and 2015 in a health insureance company of the Colombian Social Security General System. METHODS: A log-linear analysis based on age-adjusted hospitalization rates for ambulatory care sensitive conditions in the Entidad Promotora de Salud Sanitas was used to estimate the annual percentage change in these rates and to identify joinponts of the rates. Data was collected from administrative sources. RESULTS: There were 38,530 hospitalizations for ambulatory care sensitive conditions in 26,501 Entidad Promotora de Salud Sanitas enrollees, with a significant decrease in hospitalization rates. The annual percentage change estimated for the period was -9.5% with no significant joinpoints throughout the time interval. CONCLUSIONS: A significant reduction in hospital admissions due to ambulatory care sensitive conditions in Entidad Promotora de Salud Sanitas enrollees were reported for the last five years in this study.

Neurosurgical Oncology in Vietnam.

BACKGROUND: In conjunction with Vietnam's unparalleled economic growth over the past 20 years, our scope of neurosurgical interventions has considerably diversified throughout this time period. METHODS: Although still appreciably limited, healthcare resources and infrastructure have expanded and shifted the focus within neurosurgery at Ho Chi Minh City's Cho Ray Hospital from head trauma (which remains highly prevalent) to an equal proportion of elective cases for vascular lesions, tumors, and degenerative spine disease. Arguably the most significant progress throughout the new millennium has been achieved in the realm of neurosurgical oncology. RESULTS: About 1000 craniotomies are performed annually for brain tumors at our institution, most of which are for lower-grade lesions that result in excellent surgical outcomes. We continue to strive to improve the standard of care for patients with malignant brain tumors, as the first multidisciplinary neuro-oncology care team was founded recently in 2016. CONCLUSIONS: This article is the first in the English neurosurgical literature to report on the current state and outcomes of neuro-oncology in Vietnam, as we highlight our experiences in caring for patients with brain tumors at Cho Ray Hospital.

[A brief history of burn rehabilitation medicine in China].

Objective: Burn rehabilitation medicine in China has made great progress in recent years. This article reviews the development history of burn rehabilitation medicine in China from three stages of the initial period, the starting stage, and the development period by looking back to the history. Besides, the article is written according to the milestone events in the development of burn rehabilitation medicine, such as article publishing, guideline making, monograph publication, establishment of rehabilitation association, rehabilitation conference holding. By summarizing successful experience in the past and analyzing the challenge we face, the authors wish all the colleagues committed to burn prevention and treatment work together to make the burn rehabilitation medicine in China better in the future.