Total Body Surface Area Research Articles

Esketamine use for primary intelligent analgesia in adults with severe burns: A double-blind randomized trial with effects on analgesic efficacy, gastrointestinal function and mental state

BackgroundOpioid consumption for analgesia in burn patients is enormous. Non-opioid analgesics for burn pain management may result in opioid sparing, reducing opioid-related adverse reactions and drug tolerance or addiction. MethodsA dual-center, randomized controlled trial assessed Esketamine for the perioperative period in patients with severe [20–50 % total body surface area (TBSA)] and extensive (≥ 50 % TBSA) burns, comparing analgesia with standard anesthesia. Sixty patients were randomly allocated (1:1 ratio) to two arms. In the Treatment Arm, patients received intra-operative Esketamine and postoperative intravenous primary intelligent analgesia pump with Esketamine. Patients in the Control Arm received the same intervention as Treatment Arm without Esketamine. The primary endpoint was subjective analgesic efficacy (SAE) evaluated on Day 28 or the day before hospital discharge. Secondary outcomes included the postoperative Numeric Pain Rating (NPR) Scale at rest (NPRr) and during movement (NPRm) and opioid consumption. Gastrointestinal dysfunction Scores (GIDS) and serum markers of intestinal injury [intestinal fatty acid-binding protein 2 (iFabp2) and apolipoproteinA2 (ApoA2)] were measured in the 1st and 4th post-injury weeks. Depression and sleep quality were assessed by relevant questionnaires. ResultsFifty-five patients were included in the analysis. Esketamine-treated Arm recorded a better analgesic efficacy than the Control Arm (proportion of patients with Grade 1 or 2 SAE scores, 67.9 % vs. 40.7 %, p = 0.022). Esketamine-treated patients had lower NPRm values (p = 0.033) and lower daily opioid consumption (p = 0.033) when compared with Controls. Esketamine-treated patients showed comparable gastrointestinal recovery to those in the Control Arm. The overall sleep quality might be improved in the Treatment Arm. ConclusionsEsketamine use is safe for perioperative primary intelligent analgesia of severe burns, resulting in improved resting pain control and lower opioid requirements. Trial registrationThe trial was registered at the Chinese Clinical Trial Registry (www.chictr.org.cn/) (ChiCTR2000034069).

THE OCCURRENCE OF CONTRACTURE AND THE SEVERITY OF BURN INJURIES AMONG BURN PATIENTS TREATED AT DR. SOETOMO GENERAL ACADEMIC HOSPITAL, SURABAYA, INDONESIA (2020-20220)

Highlights: A robust association was observed between total body surface area (TBSA) and burn injuries, except in the case of elderly individuals. The duration of hospitalization is significantly associated with the occurrence of contracture. Abstract: Introduction: Burn injuries are a worldwide issue and can happen for many reasons, often causing skin damage that leads to deformities and movement difficulties. Many burn patients, up to 50%, experience contractures, which limit movement in areas such as the shoulders, wrists, and torso. Proper management through medicine, surgery, and therapy is crucial for helping these patients. Research at Dr. Soetomo General Academic Hospital is focused on studying the frequency of contractures after burn injuries to improve treatment and prevention methods. Methods: The research used descriptive analytics and gathered data from the Burn Unit at Gedung Bedah Pusat Terpadu (GBPT) and the Plastic Surgery Polyclinic at Dr. Soetomo General Academic Hospital in Surabaya. The study examined 40 eligible patients and assessed variables including burn severity, affected body area, and hospitalization duration. Results: The results showed that the average age of patients was 26.30 years, with 70% of them being male. Only 5% of patients had other health problems, mainly related to hormones. Most burns were caused by fire (37.5%), and many were second-degree burns (42.5%). The percentage of the body affected by burns varied by age: children had around 9.86%, adolescents had around 15.96%, and adults had around 5.25%. Most injuries were on the left arm (67.5%), and many patients stayed in the hospital for a long time (67.5%). Conclusion: All patients developed contractures following burns, irrespective of burn severity. There was a correlation between burn size and severity, except among older patients. Additionally, a notable association was observed between contracture occurrence and prolonged hospitalization.

Acute healing outcomes in paediatric partial thickness burns using Epiprotect® and Biobrane®: A retrospective comparative study

To compare the acute healing outcomes of Biobrane® and Epiprotect® in paediatric partial thickness (PT) burns. All paediatric patients (age <18 years) with PT burns managed using either Biobrane® or Epiprotect® over a 5-year period at our burns unit were included. The primary outcome was time to complete healing. Secondary outcomes included adherence, infection rates, length of hospital stay, duration of acute follow-up and return to the theatre. Among the 99 patients included, 38 received Epiprotect® and 61 received Biobrane®. The mean total body surface area (TBSA) was 6% (range 1%-15%) and median age was 21 months (range 5-169 months). Median time to healing in the Epiprotect® group was 19.5 days and 16 days in the Biobrane® group (P=.14). The median hospitalisation length was the same for both products (2 days, P=.85). Infection rate was lower in the Epiprotect® group (2.6% vs 16.4%, P=.048). There was no difference in adherence rate. These trends were preserved when depth sub-groups were analysed. Adherence and infection rates were not affected by post-operative antibiotics (P>.99 and P=.65, respectively) in either group. The rate of return to the theatre for further surgery was 13.2% for both products (P> .99). Our findings demonstrate that acute healing outcomes with Epiprotect® in paediatric PT burns are comparable to those with Biobrane®, with significantly lower infection rates for Epiprotect®. These results suggest that Epiprotect® is a viable alternative to Biobrane®. Nevertheless, further prospective randomised studies are required to investigate the short- and long-term outcomes.

Inter-individual variability of aerobic capacity after rehabilitation exercise training in children with severe burn injury

IntroductionSevere burn trauma damages resting and exercise cardiac function that may affect long term cardiovascular health. The implementation of rehabilitation exercise training (RET) soon after hospital discharge improves cardiorespiratory fitness; however, it does not fully restore aerobic capacity and presents large inter-individual variability. We tested the hypothesis that the inter-individual variability of aerobic capacity for responders (R) compared to nonresponders (NR) would differ for exercise frequency and intensity. MethodsThirty-three children (11 female, [mean±SD] 12 ± 3 years, 145 ± 18 cm, 40 ± 11 kg, 49 ± 31 BMI percentile) with severe burns (49 ± 15 % total body surface area burned, with 35 ± 22 % third-degree burns) completed a 6-week RET program. Cardiorespiratory fitness (peak VO2) was measured before and after RET. Frequency (session days/week), intensity (% peak heart rate), time (min/session), and volume (min/week) were compared between responders and non-responders. Significance was set at p < 0.05. ResultsSixty-four percent of the study population improved peak VO2 after RET whereas 36 % showed no improvements. Using a 2-way factorial ANOVA (group [G] × week [WK]), we found that exercise frequency and session time were similar and increased slightly over 6 weeks between R and NR (main effect for WK; P < 0.002). Exercise volume was significantly lower on week 2 for NR compared to R (G × WK interaction, P < 0.028). Exercise intensity over 6-weeks was significantly lower in the NR compared to the R group (G × WK interaction, P < 0.022). ConclusionsExercise intensity and volume may be important contributors for improving the interindividual response to exercise training for peak VO2. These data suggest that the appropriate dose-response requirement for exercise intensity may be > 80 % peak heart rate and exercise volume of > 150 min per week. Further understanding of the exercise prescription will provide insights important for cardiovascular rehabilitation in children with severe burns. Subject codeInter-individual Variability, Exercise, Pediatrics, Exercise Training

The minimal important change (MIC) and minimal clinically important difference (MCID) of the patient and observer scar assessment scale (POSAS) 2.0

BackgroundThe Patient and Observer Scar Assessment Scale (POSAS) is frequently used to assess scar quality after burns. It is important to be aware of the minimal important change (MIC) and the minimal clinically important difference (MCID) to establish if a POSAS score represents a clinically relevant change or difference. The aim of this study is to explore the MIC and MCID of POSAS version 2.0. MethodsThis prospective study included 127 patients with deep dermal burns that underwent split thickness skin grafting with a mean age of 44 years (range 0 – 87) and total body surface area burned of 10 % (range 0.5 – 55). POSAS data was obtained for one burn scar area at three, six, and 12 months after split skin grafting. At the second and third visits, patients rated the degree of clinical change in scar quality in comparison to the previous visit. At 12 months, they completed the POSAS for a second burn scar area and rated the degree of clinical difference between the two scar areas. Two anchor-based methods were used to determine the MIC and MCID. ResultsMIC values of the patient POSAS ranged from − 0.59 to − 0.29 between three and six months and from − 0.75 to − 0.38 between six and 12 months follow-up. Both had a poor discriminatory value. MCID values ranged from − 0.39 and − 0.08, with a better discriminatory value. ConclusionResults suggest that patients consider minor differences (less than 0.75 on the 1–10 scale) in POSAS scores as clinically important scar quality changes. MCID values can be used to evaluate the effects of burn treatment and perform sample-size calculations.

Burn Mortality in an Appalachian Referral Center: An Examination of Mortality Prediction Scores in a 13-Year Retrospective Study.

Introduction Burn injuries have profound implications, prompting the use of various mortality scoring systems. This study aimed to evaluate their effectiveness within our Appalachian burn referral center, which serves as the sole burn center in the state of West Virginia. Given this unique status, understanding the efficacy of mortality scoring systems within our center is crucial for resource allocation and optimizing patient outcomes in our region. Methods A retrospective analysis of patients admitted to Cabell Huntington Hospital Burn Intensive Care Unit (BICU) from January 2010 to June 2023 was conducted, assessing Baux (B), revised Baux (rB), Belgian Outcome in Burn Injury (BOBI), and Abbreviated Burn Severity Index (ABSI) scores. Logistic regression and receiver operating characteristic analysis were employed to examine survival status and determine optimal cut points. Results Among 1,104 patients, 57 died (5% mortality rate). Deceased patients had significantly higher B/rB/BOBI scores (mean: 98/98/92) than survivors (45/46/4.19) (p < 0.001), with ABSI showing no significance (p = 0.079). Each one-point increase in B/rB/BOBI scores correlated with a 1.09/1.09/2.34 times higher mortality risk (p < 0.001). The AUC for B score in predicting mortality was 0.926 (95% CI: 0.890, 0.962), with sensitivity and specificity values of 0.789 and 0.92, respectively, and an optimal cutoff point of 79. The AUC for the rB score was 0.927 (95% CI: 0.892, 0.962), with sensitivity and specificity values of 0.789 and 0.926, respectively, and an optimal cutoff point of 80. The AUC for the BOBI score was 0.901 (95% CI: 0.865, 0.937), with sensitivity and specificity values of 0.895 and 0.775, respectively, and an optimal cutoff point of 2. For patients with B scores above 79, their odds of mortality were 42.6 times higher than those with B scores of 79 or lower (95% CI: 22.6, 85.6, p < 0.001). Similarly, for patients with rB scores exceeding 80, their odds of mortality were 42.9 times higher than those with rB scores of 80 or lower (95% CI: 22.9, 84.8, p < 0.001). Finally, for patients with BOBI scores greater than 2, their odds of mortality were 17.8 times higher than those with BOBI scores of 2 or lower (95% CI: 9.88, 33.4, p < 0.001). Conclusion Our study underscores the vital role of mortality scoring systems in guiding clinical decision-making and resource allocation for burn patients, particularly within the Appalachian region served by the Cabell Huntington Hospital BICU. By leveraging tools such as the Baux, revised Baux, and BOBI scores, healthcare providers can identify high-risk patients early in their treatment course, facilitating personalized interventions and improving overall patient outcomes. Moreover, our findings highlight the significance of age and total body surface area burned as key determinants of mortality risk, emphasizing the need for tailored approaches to care for elderly patients and those with extensive burns. Continued research and refinement of mortality scoring systems are essential to further enhance their effectiveness and ensure optimal patient care in the challenging field of burn management.

Increased serum levels of proNGF, mature NGF and interleukins in burn-injured children.

Burns are among the most common injuries in children. In burns of more than 20% of the total body surface area, a systemic inflammatory response involving several chemical mediators occurs. Among them, nerve growth factor (NGF) regulates the inflammatory response related to wound healing and promotes keratinocyte proliferation and angiogenesis. The aim of our study was to investigate the physiological response to injury in children with moderate-severe burns, assaying proNGF, mature NGF (mNGF), interleukins (IL)-1β, and Il-10 serum levels. This is a prospective observational study, including twelve children hospitalized for moderate-severe burns at the Gemelli Hospital (Rome). Their laboratory features were compared to those of patients with obstructive hydrocephalus who underwent surgery. Our results showed an increase in proNGF and mNGF serum levels. In burn patients, proNGF levels increased before mNGF, and serum concentrations of both were not correlated with burn extension and depth. The most significant levels of mNGF and proNGF were reported in scalds involving the face. Serum IL-1β and IL-10 peak levels were reached with a time-course pattern similar to proNGF. Our preliminary results validate the hypothesis that serum levels of proNGF and mNGF may represent inflammatory biomarkers useful for monitoring burn patients and defining new strategies for their treatment.

Health-Related Quality of Life Burden Among Adults with Vitiligo: Relationship to Disease Severity and Disease Location.

Vitiligo was historically regarded as a cosmetic disorder; however, it is an autoimmune disease. As a visible condition, it affects patient well-being. We assessed the impact of disease severity, lesion location, and body surface area (BSA) affected on patient health-related quality of life (HRQoL). Retrospective data were from the Adelphi Real World Vitiligo Disease Specific Programme: a cross-sectional survey of physicians and their patients with vitiligo (10/2021-07/2022). Patient-reported outcomes were assessed by the Vitiligo-Specific Quality of Life Instrument (VitiQoL), Hospital Anxiety and Depression Scale (HADS), and EQ-5D-5L. The Work Productivity and Impairment Questionnaire (WPAI) questionnaire was used to assess disease-related impairment of daily activities. Data were stratified by physician-reported disease severity, presence/absence of vitiligo on the face, and BSA percentage affected. In total, 1388 patients were included. Mean (SD) VitiQoL, HADS depression, and anxiety scores were higher for those with severe disease [40.5(26.1), 5.2(4.4), and 6.8(4.7)] than those with mild [24.8(18.8), 3.6(3.8), 4.2(3.8)] or moderate [27.1(22.6), 3.8(4.5), 4.3(4.4)] disease. Patients with face affected reported higher VitiQoL [30.0(22.3) versus 23.2(19.3)], and HADS scores [depression, 4.3(4.3) versus 3.2(3.9); anxiety, 5.0(4.3) versus 3.8 (3.9)] than those without. Patients with ≥ 5% BSA affected had higher VitiQoL, depression and anxiety scores [27.9(21.8), 4.0(4.4), and 4.5(4.2)] than those with 0-5% [24.6(19.7), 3.4(3.7), and 4.3(4.1)]. Patients with severe vitiligo, facial lesions, or ≥ 5% BSA reported higher activity impairment. Mean EQ-5D-5L-utility score was approximately 0.9 regardless of disease severity or total BSA affected. These data demonstrate the impact disease severity can have on HRQoL and daily activities for patients with vitiligo. Lesions that are more severe, on the face, or covering a greater BSA are more often associated with poorer outcomes and activity impairment. These data also highlight the potential insensitivity of commonly used HRQoL measures and a need for more sensitive disease-specific measures.

Outpatient Follow-Up and Reconstructive Surgery Rates in Massive Burn Survivors: Investigating the Social Determinants.

Burn care continues to improve and larger total body surface area (TBSA) burn survival is increasing. These survivors require more extensive care than smaller burns and are at higher risk for wound/scar-related complications. Prior work has shown low rates of follow-up for burn survivors linked to socioeconomic factors such as housing insecurity and substance use. There are limited studies that evaluate socioeconomic factors that contribute to follow-up and reconstructive surgery rates in massively burned patients. Patients who survived to discharge with >50% TBSA burns and planned return to the treating institution were included in the study. Univariate and multivariate analyses were performed on the data collected. Sixty-five patients were included with an average TBSA of 63.1%. Fifty-three patients (81.5%) attended at least one follow-up appointment with median of 4 follow-up appointments. Younger patients (33 ± 9 vs 44 ± 11; P = .0006), patients with larger TBSA burns (65 ± 13 vs 55 ± 5%; P = .02), those with private insurance, and those without housing insecurity (1.8% vs 45.4%; P = .003) were more likely to follow up. On multivariate regression analysis, patients with housing insecurity were independently associated with lack of follow-up (OR: 0.009; CI: 0.00001-0.57). Thirty-five patients had at least one reconstructive surgery and 31 patients had reconstructive surgery after discharge. No patients with housing insecurity underwent reconstructive surgery. Follow-up rates in massive burns were higher than reported for smaller TBSA burns and more than half received reconstructive surgery. Housing-insecure patients should be targeted for improved follow-up and access to reconstructive surgery.

Risk Factors of Mortality and Long-Term Survival in Burn Patients With/Without Extracorporeal Membrane Oxygenation: A 16 Year Real-World Study.

Burn patients face cardiopulmonary failure risks, with recent observational studies suggesting promising outcomes for extracorporeal membrane oxygenation (ECMO). However, the effectiveness and long-term survival remain unclear. Our study aims to assess mortality risk factors and long-term survival in burn patients with and without ECMO. This study used Taiwan's National Health Insurance Research Database and designed a case-control with onefold propensity score matching across variables including sex, age, total body surface area (TBSA) burned, and index date. We analyzed mortality and survival risk factors in each stratified group with/without ECMO. Finally, we analyze the mortality according to ECMO and TBSA burned, and the cause of death and long-term survival. From 2000 to 2015, 4,556 burn patients with ECMO compared to an equivalent number without ECMO. Primary mortality include male, age >65, TBSA ≥30%, escharotomy, hemodialysis, and bacteremia. The ECMO group showed lower survival across all stratified risk factors, with the primary cause of death being burn-related issues, followed by respiratory and heart failure. The overall mortality rate was 54.41% with ECMO and 40.94% without ECMO (p < 0.001). Additionally, long-term survival is lower in the group with ECMO. This research provides a valuable real-world gross report about ECMO efficacy and long-term survival among burn patients with/without ECMO.

Diagnosis and Management of Orbital Compartment Syndrome in Burn Patients-A Systematic Review.

Orbital compartment syndrome is a poorly understood complication of acute burns. The purpose of this systematic review is to summarize the literature describing orbital compartment syndrome in patients with burns to provide greater detail on risk factors and guide the management of this morbid condition. A systematic review of the PubMed, Embase, and Cochrane Library databases was performed in June 2023 according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Study quality was assessed using 2 validated scoring systems. After removing duplicates, 303 unique articles were reviewed and 8 met the inclusion criteria. All publications were retrospective. Most studies considered intraocular pressure >30-40 mmHg as diagnostic for orbital compartment syndrome. In total, 60 unique cases of orbital compartment syndrome were reported. Orbital compartment syndrome occurred most frequently within 24 h postburn. The mean total body surface area of burn was 58.7%; the mean 24-h resuscitation volume was 6.01 cc/kg/%total burn surface area; and 86.5% of cases had periorbital burns. Surgical decompression always starts with lateral canthotomy. When pressures were not immediately reduced, cantholysis was performed. Study quality per median Newcastle-Ottawa Scores ranged from 38.9% to 94.4% (median 66.7%). A precise threshold for surgical decompression of orbital compartment syndrome remains conflicted; however, increased intraocular pressure > 30-40 mmHg warrants intervention. Burn surgeons/intensivists should be aware of the risk factors for this vision-threatening complication and act appropriately.

Perception of Caregiver on Physical Therapy Management for Pediatric Burn Patients

Background: Burn injuries are among the most severe types of child injuries, leading to significant functional, social, and psychological disabilities. Physiotherapy plays a crucial role in the rehabilitation of pediatric burn patients, and caregivers are essential in facilitating the treatment process. Understanding caregivers' perceptions and adherence to physiotherapy treatment can inform better care strategies. Objective: This study aimed to assess the perceptions of caregivers towards physiotherapy treatment for pediatric burn patients and to evaluate adherence to prescribed exercise regimens. Methods: A descriptive cross-sectional study was conducted from June 2023 to December 2023. Data were collected from caregivers at two public hospitals and one private rehabilitation center using a non-probability convenience sampling method. The sample included 53 caregivers of children aged 1-5 years with burn injuries covering more than 20% of their total body surface area and who had been undergoing physiotherapy for 3-4 weeks. Exclusion criteria were caregivers not actively involved in daily care, those unable to communicate in English or Urdu, and patients without a caregiver. Data were collected using a semi-structured questionnaire based on the Measure of Processes of Care (MPOC). The questionnaire was validated and had a Cronbach’s alpha of 0.703. Data were analyzed using SPSS version 25, with descriptive statistics presented as frequencies, percentages, means, and standard deviations. Results: Among the caregivers, 64.2% were mothers, 15.1% were fathers, and 20.8% were other relatives. A total of 81.1% of caregivers agreed and 18.9% strongly agreed that the physiotherapist encouraged active participation in decision-making. Comfort in discussing concerns was reported by 69.3% agreeing and 18.9% strongly agreeing. Emotional and social aspects were adequately addressed according to 39.6% of caregivers, with 41.5% neutral and 15.5% disagreeing. Clear communication of treatment plans was reported by 75.5% agreeing and 24.5% neutral. Adherence to exercise routines varied, with 47.2% often, 32.1% always, and 20.8% sometimes helping with exercises. However, 39.6% reported that the child always refused to do exercises, and 64.2% noted the child always complained of pain during therapy. Conclusion: The study concluded that caregivers generally have a positive perception of physiotherapy for pediatric burn patients and actively participate in their care. Challenges such as pain during exercises and time constraints highlight the need for enhanced support and communication to improve adherence and outcomes.

Sex Differences, Age, and Burn Size Contribute to Risk of PTSD and Depression After Burn Injury.

The prevalence of psychological symptoms in burn survivors has been well documented; however, the role of biological sex requires further investigation. This study explored sex differences among burn survivors and examined the impact of sex, age, and total body surface area (TBSA) of the burn injury on (1) the risk of developing PTSD and depression and, subsequently, (2) the influence of initial risk on symptom outcomes 30 days post-injury. Participants included 374 adult patients enrolled in the Burn Behavioral Health program at a regional Burn Center. T-tests and chi-square tests were conducted to determine differences between sexes on outcome measures. A path analysis was conducted to evaluate relationships between variables of interest. Findings revealed significant sex discrepancies in risk and symptom outcomes. Compared to men, women reported greater total risk scores of developing PTSD and depression (p = .005) early after their burn injury. A subscale analysis showed that women reported greater risk scores on depression (p < .001), but not on PTSD. Women did not report higher depression scores 30 days post-injury compared to men but did report higher PTSD scores than men (p = .020). When sex, age, and TBSA were included in a path analysis, female sex (p=.001), younger age (p<.001), and larger TBSA of the burn injury (p=.024) were associated with greater risk. Additionally, risk scores significantly predicted PTSD (p<.001) and depression (p<.001) symptoms 30 days post-injury. Our research shows how sex, age, and TBSA affect the risk of PTSD and depression among burn survivors. It underscores the importance of accounting for sex and age differences in mental health risk, especially in women and younger patients. This emphasizes the urgency of early screening and intervention.

Insight on Pediatric Burn Morbidity and Mortality at a Tertiary Indian Burn Care Center: A Case For Burn Prevention.

Pediatric burns pose a significant health burden in LMICs. Despite efforts to address burn prevention and management, morbidity and mortality rates remain high, particularly among children. Understanding pediatric burn epidemiology and predictors of clinical outcomes is crucial for developing effective prevention strategies and improving patient-care. This retrospective cohort study analyzed pediatric burn patients admitted to a tertiary burn-center in India, between March-2022 and December-2023. Demographic date, burn characteristics, treatments, complications and outcomes were collected. Statistical analysis, including logistic and linear regression, was conducted to identify predictors of mortality, sepsis, and hospital stay length. Among 332 pediatric burn patients, median age was 3 years, with a male predominance. Scald burns were the most common, followed by electrical and flame burns. Median total body surface area burned was 20%, with upper and lower extremities most affected. The incidence of electrical burns increased with age and was associated with a longer length of stay. Mortality rate was 14.2%, with age >10 years, male gender, and TBSA >30% predicting mortality. Complications like sepsis significantly increased mortality risk, while deep burns were associated with longer hospital stays. This study underscores importance of targeted prevention efforts and specialized care. Scald burns among young children highlight the need for safer cooking practices, while the high incidence of electrical burns in older children suggests age-specific education interventions are necessary. Predictors of mortality identified can guide risk assessment and resource allocation, emphasizing the importance of infection control and wound management strategies in improving outcomes.

Limited debridement combined with ReCell® Techniques for deep second-degree burns.

The purpose of this article is to introduce a method that combines limited debridement and ReCell® autologous cell regeneration techniques for the treatment of deep second-degree burn wounds. A total of 20 patients suffered with deep second-degree burns less than 10% of total body surface area (TBSA) who were admitted to our department, from June 2019 to June 2021, participated in this study. These patients first underwent limited debridement with an electric/pneumatic dermatome, followed by the ReCell® technique for secondary wounds. Routine treatment was applied to prevent scarring after the wound healed. Clinical outcomes were scored using the Vancouver Scar Scale (VSS). All wounds of the patients healed completely. One patient developed an infection in the skin graft area and finally recovered by routine dressing changes. The average healing time was 12 days (range: 10-15 days). The new skin in the treated area was soft and matched the colour of the surrounding normal skin and the VSS score ranged from 3~5 for each patient. Of the 20 patients, 19 were very satisfied and 1 was satisfied. This article reports a useful treatment method that combines electric dermatome-dependent limited debridement and the ReCell® technique for the treatment of deep second-degree burn wounds. It is a feasible and effective strategy that is easy to implement and minimally invasive, and it is associated with a short healing time, mild scar formation and little damage to the donor skin area.

Associations of Diabetes and Hyperglycaemia with Extent and Outcomes of Acute Burn Injuries.

Severe burns may induce hyperglycaemia in the absence of diabetes, but how glucose trajectories relate to burns outcomes is unclear. To assess incidence of hyperglycaemia following acute burn injury, and associations with diabetes history and length of stay (LOS). Retrospective cohort study of adults admitted with acute burns to tertiary centres. Blood glucose level (BGL), hyperglycaemic episodes (BGL ≥ 11.1 mmol/L) and hyperglycaemic days were recorded. Stress hyperglycaemia was defined as BGL ≥ 11.1 mmol/L without a diabetes history. A total of 30 participants had a diabetes history and 260 did not. Participants with known diabetes had higher mean BGLs (9.7 vs. 9.0 mmol/L, p < 0.001), more hyperglycaemic episodes (28.0 vs. 17.2%, p < 0.001) and hyperglycaemic days (51 vs. 21%, p < 0.001), compared to those without diabetes, despite smaller burns (total body surface area 1.0 vs. 14.8%, p < 0.001). Fourteen participants with stress hyperglycaemia had similar BGLs (at admission 10.3 vs. 11.5 mmol/L; during inpatient stay 9.9 vs. 9.8 mmol/L), more severe burns (15.6% vs. 1.0% TBSA) and longer LOS (18 vs. 7 days, p < 0.001) compared to participants with known diabetes. Extent of burns, having NGT nutrition, age, having inpatient BGL monitoring in the setting of diabetes, or having inpatient BGL monitoring in the absence of diabetes were associated with longer LOS. In participants with known diabetes, small burn injuries were associated with hyperglycaemia. Stress hyperglycaemia can be triggered by major burn injuries, with early and sustained elevation of BGLs. Further research is warranted to improve inpatient management of BGL in patients with acute burn injury.

The Early Childhood Development of Pediatric Burn Patients

Our study aimed to provide a description of the early childhood development of pediatric burn patients relative to Dutch reference values, using both pre- and post-burn data from the Dutch Development Instrument and the D-score. Data from the Dutch Development Instrument were used to calculate the D-score and age-standardized D-score. Similar to a growth chart, the D-score was used to plot pediatric burn patients’ development relative to Dutch reference values for their age. Pediatric burn patients’ (n = 38) median age at the time of injury was 1.0 (1.0–2.0) years old. Burn size ranged from 1.0% to 36.0% of the total body surface area. Ninety-five percent (± 6.0%) of pediatric burn patients passed each of the age-appropriate developmental milestones at the target age. The mean age-standardized D-score was just above the Dutch average (+0.49 SD [0.18, 0.80]) and did not vary depending on sex (p = 0.06) or burn size (p = 0.41). In conclusion, among pediatric patients aged up to two-and-a-half years old, with non-full thickness burns, development was on track relative to the Dutch reference values. Our findings offer valuable first insights into the early childhood development of pediatric burn patients and may alleviate some parental concerns.

An Analysis of Hospitalized Burn Injuries in a Burn Care Unit of Northern Bangladesh

Introduction: Burn injuries remain a significant public health issue, especially in low- and middle-income countries where comprehensive data is scarce. This study provides a detailed analysis of burn injuries in Northern Bangladesh, focusing on epidemiological characteristics and factors influencing burn severity and incidents. Methods: This retrospective study analyzed 477 cases of acute, unintentional burns recorded between January 2022 and December 2022 at the Rangpur Medical College Hospital's Burn and Plastic Surgery unit. Data on demographics, burn types, etiology, and severity were collected from hospital registers. Statistical analysis, including chi-square tests and logistic regression, was used to identify predictors of burn severity. Result: Of the 477 documented cases, females represented 62.05% (296 cases) and males 37.95% (181 cases). Flame burns predominated, comprising 70% of incidents, significantly impacting females engaged in cooking activities. The data revealed a distinct seasonal trend with a significant peak in January, where 40% (191 cases) of annual burn incidents occurred due to campfire exposure. The analysis further demonstrated that burns covering more than 30% of total body surface area (TBSA) were significantly associated with higher morbidity and mortality, with third-degree burns occurring in 92.9% of females compared to 55.8% of males. Logistic regression identified age (OR = 1.28, CI [1.13-2.71]), gender (OR = 1.75, CI [1.11-1.47]), and the cause of ignition (OR = 0.56, CI [0.41-0.76]) as significant predictors of burn severity. Conclusion: The findings emphasize the need for targeted interventions to address the high incidence of burns among young to middle-aged women, particularly through safer cooking practices and awareness campaigns. Additionally, public health strategies should consider seasonal risks and promote safer heating methods during colder months. This study underlines critical areas for intervention and highlights the importance of culturally tailored public health strategies to reduce burn injuries in Northern Bangladesh.

Intraluminal release of citrullinated histone 3 from various cellular origins coincides with microvascular thrombosis in burn wounds.

Loss of perfusion in the burn wound might cause wound deepening and impaired healing. We previously showed persistent microvascular thrombosis coinciding with intraluminal neutrophils extracellular traps in human burned skin. This study investigates the presence of intraluminal citrullinated histone 3 (H3cit) from different cellular origins (neutrophils, monocytes, and lymphocytes) in relation to microvascular thrombosis of burn wounds. Eschar was obtained from burn patients (n = 18) 6-40 days postburn with a mean total burned body surface area of 23%. Microvascular presence of tissue factor (TF), factor XII (FXII) and thrombi was assessed by immunohistochemistry. Intramicrovascular cell death was analyzed via immunofluorescent microscopy, combining antibodies for neutrophils (MPO), monocytes (CD14), and lymphocytes (CD45) with endothelial cell markers CD31 and H3cit. Significantly increased microvascular expression of TF, FXII, and thrombi (CD31+) was found in all eschar samples compared with control uninjured skin. Release of H3cit from different cellular origins was observed in the lumen of the dermal microvasculature in the eschar tissue 7-40 days postburn, with release from neutrophilic origin being 2.7 times more abundant. Intraluminal presence of extracellular H3cit colocalizing with either MPO, CD14, or CD45 is correlated to increased microvascular thrombosis in eschar of burn patients.

Abstract PO2-20-07: A case report of a severe cutaneous adverse event in triple negative breast cancer treated with chemoimmunotherapy

Abstract Introduction Cutaneous adverse events related to immune checkpoint inhibitors (ICI) are common and most are mild. However, numerous case reports have documented severe ICI-related skin-toxicities such as Stevens-Johnsons Syndrome (SJS) most commonly among patients with melanoma and lung cancer as immunotherapy has now become a mainstay of treatment in these tumors. The use of ICIs in breast cancer treatment has only recently become standard of care for treatment of metastatic and high risk early-stage triple negative breast cancer with the publication of two landmark clinical trials, KEYNOTE-355 and KEYNOTE-522, respectively. While these trials report low rates of severe skin reactions, little is known about ICI-related severe skin toxicities in patients with breast cancer. Case description A 58-year-old female with clinical stage IIB (cT2N0M0) triple negative breast cancer was undergoing neoadjuvant treatment with pembrolizumab, an anti-programmed death (PD-1) monoclonal antibody, coupled with a chemotherapy back-bone of 12 weekly treatments of carboplatin and paclitaxel followed by 4 cycles of doxorubicin and cyclophosphamide. She developed an erythematous and itchy rash on the right breast and axilla approximately 61 days into her treatment course after having received her fourth dose of pembrolizumab. Over the next 10 days, she developed progression of the rash with painful red papules coalescing into reticulated plaques and dusky blistering of the skin involving the right arm, axilla, abdomen, inguinal folds, thigh, and back, totaling &amp;lt; 10% total body surface area. Notably, the rash did not have mucosal involvement. She was hospitalized for close monitoring and treatment. A punch biopsy of the rash revealed interface dermatitis with areas of full thickness skin necrosis consistent with erythema multiforme, SJS, toxic epidermal necrolysis (TEN), or a fixed drug eruption. Her skin continued to slough in the distribution of rash and a diagnosis of SJS was made. The patient had no response to initial treatment with high dose steroids. Cyclosporine was added, resulting in rapid improvement of her rash. The patient’s neoadjuvant treatment was stopped given the grade 3 SJS she experienced. Despite this truncated neoadjuvant treatment, she had excellent clinical response as her tumor was no longer palpable. She proceeded with a partial mastectomy and sentinel lymph node biopsy. Pathology revealed a pathological complete response. She did not receive any further systemic therapy in the adjuvant setting. Three months later, she was evaluated in clinic without evidence of SJS on physical exam. She was rapidly tapered off cyclosporine over one week without recurrence of her rash. Discussion Severe cutaneous adverse events related to ICIs remains an emerging area of study. In SJS, drug-specific CD8+ T lymphocytes utilize granulysin to mediate keratinocyte apoptosis. It is hypothesized that the blocking of the PD-1/PD-L1 interaction by ICIs results in the disruption of T-cell homeostasis leading to self-directed cytotoxic and inflammatory reactions and ultimately epidermal detachment. In contrast, Molina et al 2020 postulate that such ICI-related skin reactions may represent a separate clinical entity from SJS. In their case report of seven patients, they propose the term “progressive immunotherapy-related mucocutaneous eruption” (PIRME), which the authors suggest is characterized by delayed symptom onset, mild initial presentation, rare ocular involvement, benign clinical course, and favorable treatment response. Further characterization of ICI-related cutaneous adverse events is needed to understand the disease course, optimal treatment, and importantly, implications for re-challenging patients with immunotherapy. Clinicians taking care of breast cancer patients treated with ICIs need to be educated to recognize the associated skin toxicities as patients can rapidly worsen without appropriate treatment. Citation Format: Annie Zhang, Mara Beveridge, Bahar Moftakhar. A case report of a severe cutaneous adverse event in triple negative breast cancer treated with chemoimmunotherapy [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO2-20-07.