The development of an educational web site for burn care: burnsurgery.org.

Advances in burn care are well documented in the literature but often do not reach health care professionals who treat burn patients. The World Wide Web provides instant access to a wide variety of information globally. We describe the development of www.burnsurgery.org, a nonprofit Web site dedicated to the education of burn care professionals. Internet-based medical education is becoming a dominant method of information transfer and we believe that it will help to standardize and improve burn care throughout the world.

The rate of restoration of body weight after burn injury, using the anabolic agent oxandrolone, is not age dependent.

We determined the effect of age on the restoration of lost body weight and lean mass after burn injury, using the anabolic steroid oxandrolone. Patients with deep burns of 30-55% of body surface were studied when entering the recovery phase of injury, defined as resolution of the hypermetabolic, catabolic state. Patients were provided optimum nutrition and exercise alone or with the addition of oxandrolone. The rate of body weight and lean mass gain and improvement in physical function were measured over a 4-week period. Four groups were studied. A younger group, mean age of 34 years and burn size of 47+/-7% versus an older group, mean age 60 years and burn size 36+/-5%. The mean loss of body weight in the younger and older groups was 10+/-2 and 11+/-2% of total. Both groups were randomly divided into a control and oxandrolone study group. Weight restoration, 74+/-5% of which was lean mass, averaged 1.7+/-0.4 kg and 1.6+/-0.3 kg per week in the young and older oxandrolone groups. This rate was compared with 0.7+/-0.2 kg and 0.5+/-0.2 kg in the young and older control groups, with only 55% of weight gain being lean mass. These differences were statistically significant. The increase in the rate of weight gain with oxandrolone corresponded with a 30% decrease in length of stay in the burn rehabilitation unit. We concluded that the ability of an anabolic steroid to restore lean mass and physical function after burn surgery is not related to age.

Effect of a hypocaloric diet, increased protein intake and resistance training on lean mass gains and fat mass loss in overweight police officers.

We compare the effects of a moderate hypocaloric, high-protein diet and resistance training, using two different protein supplements, versus hypocaloric diet alone on body compositional changes in overweight police officers. A randomized, prospective 12-week study was performed comparing the changes in body composition produced by three different treatment modalities in three study groups. One group (n = 10) was placed on a nonlipogenic, hypocaloric diet alone (80% of predicted needs). A second group (n = 14) was placed on the hypocaloric diet plus resistance exercise plus a high-protein intake (1.5 g/kg/day) using a casein protein hydrolysate. In the third group (n = 14) treatment was identical to the second, except for the use of a whey protein hydrolysate. We found that weight loss was approximately 2.5 kg in all three groups. Mean percent body fat with diet alone decreased from a baseline of 27 +/- 1.8 to 25 +/- 1.3% at 12 weeks. With diet, exercise and casein the decrease was from 26 +/- 1.7 to 18 +/- 1.1% and with diet, exercise and whey protein the decrease was from 27 +/- 1.6 to 23 +/- 1.3%. The mean fat loss was 2. 5 +/- 0.6, 7.0 +/- 2.1 and 4.2 +/- 0.9 kg in the three groups, respectively. Lean mass gains in the three groups did not change for diet alone, versus gains of 4 +/- 1.4 and 2 +/- 0.7 kg in the casein and whey groups, respectively. Mean increase in strength for chest, shoulder and legs was 59 +/- 9% for casein and 29 +/- 9% for whey, a significant group difference. This significant difference in body composition and strength is likely due to improved nitrogen retention and overall anticatabolic effects caused by the peptide components of the casein hydrolysate.

Enteral glutamine administration prevents the decrease in cell energy charge potential produced in ileum after a skin burn in the rat.

A skin burn produces a decrease in cell energy charge potential (ECP), a marker of cell function, in the liver and other organs. The process appears to be oxidant induced because reduced glutathione (GSH) appears to be protective. The gut mucosal barrier is also known to be altered after burns and appears to be improved by glutamine, which is a source of energy and GSH production. Neither the relationship between the gut barrier change and the ECP of the gut barrier nor the mechanism of glutamine protection has been defined. The effect of a 20% total body surface area, full-thickness burn in a rat on ECP and GSH content in the ileum and the liver and the effect of oral glutamine (1 g/kg/d) on any changes were studied. Three groups of rats (14 rats per group) were studied: a control group, a group with burns alone, and a group with burns that were given glutamine. Half of the rats were killed 1 day after the burn, and the other half were killed 6 days after the burn. ECP did not decrease 1 day after the burn, but 6 days after the burn, ECP decreased from a control of 0.53+/-0.06 to 0.41+/-0.01 in the liver and from 0.64+/-0.04 to 0.29+/-0.04 in the ileum. In the ileum, glutamine prevented the decrease of the ECP (which increased to 0.58+/-.03), but in the liver, glutamine did not alter the ECP (which remained at 0.42+/-0.05). The GSH content was unchanged after the burn injury in both organs compared with the value before the burn injury. It can be concluded that a delayed decrease in ECP in the ileum occurs after a burn injury. Orally administered glutamine prevents the decrease in ECP, probably by providing cell energy rather than by increasing gut GSH (antioxidant) activity.

Pulmonary artery catheterization and clinical outcomes: National Heart, Lung, and Blood Institute and Food and Drug Administration Workshop Report. Consensus Statement.

OBJECTIVE: The efficacy and safety of the pulmonary artery catheter are under scrutiny because of its association with increased morbidity and mortality in observational studies. In response, the National Heart, Lung, and Blood Institute (NHLBI) and the US Food and Drug Administration (FDA) conducted the Pulmonary Artery Catheterization and Clinical Outcomes workshop in Alexandria, Va, on August 25 and 26, 1997, to develop recommendations regarding actions to improve pulmonary artery catheter utility and safety. PARTICIPANTS: The NHLBI and FDA planning task force selected a workshop chairperson, subcommittee chairs, and participants. Approximately 85 participants were selected for their collective expertise in critical care, pulmonary medicine, cardiovascular medicine and surgery, pediatrics, nursing, biostatistics, and medical economics. The meeting was open to industry representatives and other government and lay observers. This workshop was funded by the NHLBI and the FDA's Division of Devices. EVIDENCE: Published reports relating to the efficacy and safety of the pulmonary artery catheter, especially consensus documents developed by professional societies. CONSENSUS PROCESS: The planning task force disseminated materials, held teleconferences, and developed draft position papers prior to the workshop. These were modified during the workshop and thereafter in the course of several teleconferences, and presented to the entire group for final modifications and approval. CONCLUSIONS: A need exists for collaborative education of physicians and nurses in performing, obtaining, and interpreting information from the use of pulmonary artery catheters. This effort should be led by professional societies, in collaboration with federal agencies, with the purpose of developing and disseminating standardized educational programs. Areas given high priority for clinical trials were pulmonary artery catheter use in persistent/refractory congestive heart failure, acute respiratory distress syndrome, severe sepsis and septic shock, and low-risk coronary artery bypass graft surgery. JAMA. 2000;283:2568-2572

Oxandrolone, an anabolic steroid, enhances the healing of a cutaneous wound in the rat.

The effect of the anabolic steroid oxandrolone on the healing rate of a standardized full thickness linear wound on the back of the rat was studied. Oxandrolone was given orally by gavage in peanut oil at a dose of 0.1 mg/kg/day. A placebo powder in peanut oil was given at the same dose to a control group. Parameters monitored were time to complete wound closure, wound hydroxyproline content and tensile strength, as well as histology. We found that wounds closed completely in 12+/-3 days with oxandrolone, compared to 18+/-3 days for a placebo, a statistically significant difference. The rate of body weight gain was identical in both groups. Hydroxyproline content of the healed incision site was 23+/-4 mg/g tissue vs. 17+/-3 mg/g tissue, while the tensile strength increased to 185+/-13 g/mm2 vs. 102+/-18 g/mm2 in the oxandrolone and placebo groups, respectively. Both parameters were significantly increased with the anabolic steroid. Histologic examination showed a wound that contained more mature and densely packed collagen and was also hypercellular with oxandrolone treatment. We conclude that the anabolic steroid oxandrolone significantly enhanced wound healing unrelated to any generalized increase in protein mass as would be reflected in body weight.

The anticatabolic and wound healing effects of the testosterone analog oxandrolone after severe burn injury.

PURPOSE: Severe burn injury leads to marked catabolism and decreased lean mass, which can impair healing. Anabolic agents can attenuate net catabolism. Our purpose was to determine whether the testosterone analog, oxandrolone, given during the acute post burn period decreased the degree of nitrogen loss and loss of body weight while also increasing the healing rate of a skin donor site. MATERIALS AND METHODS: Patients with burns between 40% and 70% of body surface were studied. A randomized double-blinded placebo-controlled study design was used. Patients were given oxandrolone 20 mg/day (n = 11) or a placebo 20 mg/day (n = 9) beginning between days 2 and 3 post burn. Net nitrogen balance and the healing time of a standardized donor site were measured. Patients were monitored until transferred to a burn rehabilitation facility, an average time period of 33 +/- 9 days. RESULTS: Mean burn size was 49 +/- 8% for placebo and 53 +/- 9% of total body surface for the oxandrolone group. Smoke inhalation was present in approximately 50% of patients in both groups. All patients survived the burn injury. Net weight loss was 8 +/- 3.1 kg in the placebo group compared with 3 +/- 1.9 kg in the oxandrolone group, a statistically significant decrease. Net daily nitrogen loss over a 3-week period (days 7 to 28) was 13 +/- 4 g in placebo treated compared with 4 +/- 1.9 g for the oxandrolone group, a statistically significant decrease. The healing time of a standardized donor site, decreased from the placebo group value of 13 +/- 3 days to 9 +/- 2 days for oxandrolone treated patients, a significant improvement. No major liver dysfunction, or other complication attributable to an anabolic steroid was seen in either group. CONCLUSION: We found the anabolic agent, oxandrolone, significantly decreased weight loss and net nitrogen loss and increased donor site wound healing compared with placebo controls. We noted no complications with the use of oxandrolone.

Metabolic management of patients with severe burns.

Burn injury results in profound metabolic abnormalities perpetuated by an exaggerated stress response to injury. Hypermetabolism and marked catabolism, with rapid erosion of lean body mass, becomes evident shortly after injury. Much of the morbidity and mortality of a major burn can be attributed to this process, which increases infection risks, decreases the healing rate, and alters cell function. Rapid removal of devitalized burn tissue combined with early aggressive nutritional support significantly attenuates this autodestructive process. The addition of anabolic agents decreases the degree of lean mass loss and increases the rate of restoration. Immediate attention to the metabolic response to a severe burn significantly decreases complications and improves outcome.

Involuntary weight loss and the nonhealing wound: the role of anabolic agents.

Endocrine responses to trauma result in a net catabolic state and exaggerated hepatic gluconeogenesis, with losses in lean body mass that can compromise wound healing. With proper nutrition, reduction of stress, resistance exercise, and the addition of certain anabolic agents, lean body mass can be restored and wound healing promoted.

Comparison of the anabolic effects and complications of human growth hormone and the testosterone analog, oxandrolone, after severe burn injury.

This study compared the anticatabolic and wound healing effects of the anabolic agents human growth hormone, HGH, and the testosterone analogue, oxandrolone, after severe burn injury. A randomized prospective study design was used. Patients were given HGH at a dose of 0.1 mg/kg/day (n = 20) or oxandrolone, 20 mg/day (n = 16), beginning between days 7-10 post-burn. Data was compared to burn patients not placed on either agent (n = 24). Patients were monitored until they were sufficiently healed to be transferred to a rehabilitation center. The results of our study were as follows. All patients survived. Net weight loss was 8 +/- 2.1 kg in the control group compared with 4 +/- 1.8 kg with HGH and 3 +/- 1.2 kg with oxandrolone, a significant decrease. Net daily nitrogen loss was 12 +/- 3 g in non-treated compared to 3 g or less for each of the anabolic groups, a significant decrease. The metabolic rate in untreated burns was 155 + 25% of predicted normal, compared to 178 +/- 28% for HGH and 156 +/- 20% for oxandrolone treated patients. The complete healing time of a standardized donor site, decreased from the control value of 14 +/- 2 days to 10 +/- 3 days for HGH and 10 +/- 2 days for oxandrolone treated patients, a significant improvement. Hyperglycemia (glucose over 225 mg/dl 12.5 mM) was present in 100% of HGH patients compared to 55% for control and 50% for oxandrolone treated. We found that both anabolic agents significantly decreased weight and nitrogen loss and increased healing with nearly identical benefits. However HGH resulted in the significant complications of hyperglycemia and accentuated hypermetabolism. We noted no side effects with oxandrolone.

Management of partial thickness facial burns (comparison of topical antibiotics and bio-engineered skin substitutes).

This study compared the effect of standard topical antibiotic management versus a biological skin substitute wound closure for mid-partial thickness burns of the face. Adult patients with mid-dermal facial burns produced by flash flames or flame exposure were studied using a randomized prospective study design. Total daily burn care time, pain (0-10 scale) and healing time were monitored. Immediately after partial thickness debridement, the entire face burn, including ears, was closed with a bioengineered skin substitute coated with fibronectin (TransCyte) or treated by the open technique using bacitracin ointment applied 2-3 times daily. 21 patients were studied, with 10 patients in the skin substitute group. We found a significant decrease in wound care time 0.35 +/- 0.1 versus 1.9 +/- 0.5 h, decrease in pain of 2 +/- 1 versus 4 +/- 2 and re-epithelialization time 7 +/- 2 versus 13 +/- 4 days in the skin substitute group compared to topical antibiotics. We can conclude that a bioengineered skin substitute significantly improves the management and healing rate of partial thickness facial burns, compared to the standard open topical ointment technique.

Closure of the "non-healing wound" corresponds with correction of weight loss using the anabolic agent oxandrolone.

We studied the relationship between restoration of weight loss and healing of the "non-healing wound." Eight consecutive patients with large "non-healing wounds" of an average of 12 months duration, despite good local wound care, were studied. All had a weight loss of 10 percent or more of body weight, mainly lean body mass. Optimizing nutrition (4 weeks) did not significantly increase weight or healing. The addition of the oral anabolic agent oxandrolone increased restoration of weight (4 lbs/week) over a 12-week period. Five wounds completely closed and three closed by 75 percent during this period. We noted a significant correlation (r = 0.67) between restoration of weight loss and closure of the previously "non-healing wound." The rate of wound healing was most prominent after 50 percent of weight loss had been restored. This finding reflects the key relationship between restoring body weight, body protein stores, and wound healing.

Recombinant human growth hormone decreases lung and liver tissue lipid peroxidation and increases antioxidant activity after thermal injury in rats.

The combination of increased oxidant with decreased endogenous polypeptide and protein antioxidant activity corresponds to a decrease in cellular energetics and cell membrane lipid peroxidation. Providing large doses of growth hormone has been shown to preserve cell mass and organ function after burn injury. The role of growth hormone in oxidant injury has not been defined. We determined whether growth hormone altered the degree of lung and liver lipid peroxidation and the activity of glutathione and catalase in lung and liver tissue after burn injury. Four groups of 40 rats each were studied for 48 hours, with 1 group receiving a 20% full-thickness burn, 1 group treated with growth hormone after 20% full-thickness burn injury, a control group, and a growth hormone alone-treated group. We found increased lipid peroxidation, measured as malondialdehyde, in lung and liver tissue, and a decrease in glutathione and catalase activities during the 48-hour post-burn period. The addition of growth hormone prevented the lipid peroxidation and significantly increased tissue glutathione and catalase activities with respect to control values. Growth hormone alone also increased endogenous antioxidant levels. We conclude that growth hormone given after burn injury decreases oxidant stress by producing a significant increase in the endogenous antioxidants glutathione and catalase.

Development of a burn rehabilitation unit: impact on burn center length of stay and functional outcome.

In 1995 we initiated the development of a specialized burn rehabilitation unit within an acute rehabilitation hospital, geographically separated from our burn center. The purpose was to allow an earlier initiation of an intensive rehabilitation program while still maintaining optimal burn wound care and nutritional support. The unit was directed by a burn center nurse coordinator who spent 50% of the time in the burn center and 50% in the rehabilitation unit training and supervising care. By 1996 the unit was able to manage open wounds, including skin substitutes of as much as 18% total body surface area, with 2- to 3-day returns to the center for wound coverage (2.5 +/- 0.5 procedures/patient). Our length of stay in 1996 for burns requiring inpatient rehabilitation (mean size 54% +/- 7% total body surface area) decreased by 21 +/- 5 days with respect to those in 1994 and 1995, with no increased morbidity. This length of stay was also significantly shorter (24%) than that predicted by the American Burn Association Registry formula. In addition, the rehabilitation unit length of stay required to restore the same degree of function according to a standardized measurement was significantly shorter (by 9 +/- 3 days) than for patients referred to other rehabilitation facilities in 1996. We conclude that the benefits of a burn rehabilitation unit include not only a decreased burn center length of stay but also a more rapid restoration of function.

Anticatabolic and anabolic strategies in critical illness: a review of current treatment modalities.

Critically ill patients characteristically exhibit a pronounced catabolism in addition to a down-regulation of normal anabolic activity, leading to major complications from loss of body protein stores. The marked decrease in lean body mass and protein stores leads to the loss of essential structural and functional proteins required for restoring and maintaining homeostasis. The standard management of the catabolic response to injury and illness has centered on optimizing nutrient intake that modulates but does not reverse the process. Complications of ongoing catabolism therefore remain a major cause of morbidity. Addition of anticatabolic and anabolic agents that may counteract "the stress response to injury or illness" may be of significant clinical benefit. Agents currently available for clinical use, which will be described, can be divided into two groups. The first group are nutrients and nutrient metabolites, namely protein and the specific amino acids, glutamine, arginine, and branched chain amino acids, especially leucine. The second group are anabolic hormones, namely growth hormone, testosterone, and the testosterone analog oxandrolone. The pros and cons of these agents, as to their anabolic and anticatabolic value, are described.

Increased protein intake during the recovery phase after severe burns increases body weight gain and muscle function.

We determined the effect of protein intake on weight gain and muscle function in the recovery phase after severe burns. Fifteen patients with deep burns between 30% to 50% of total body surface were studied over a 3 week period-after resolution of the hypermetabolic, catabolic state. All patients were studied in an acute rehabilitation hospital affiliated with the burn center. Nutritional profiles; weight gain; and muscle strength, measured by a physical therapy index (0 to 10)--10 being the greatest progress-were measured. All patients were provided a high-calorie, high-protein diet. Group 1 patients (n=8) also were provided a standard nutrient supplement to maintain caloric intake at 30 to 35 kcal/kg/day and to maintain protein intake at 1.3 to 1.5 g/kg/day. Group 2 patients (n=7) were provided a high-calorie, high-protein diet plus a protein hydrolysate (70 g/day) that provided a protein intake of 1.7 to 2 g/kg/day. Group 1 patients averaged a 1 to 1.5 pound weight gain per week or four pounds during three weeks. Their physical therapy index at three weeks of 4+/-0.5 indicated adequate improvement in strength and endurance. Group 2 patients averaged 2.5 to 3 pounds weight gain per week or 8.5 pounds during three weeks. Their physical therapy index of 7+/-0.7 indicated marked gains in muscle strength. Both measurements were significantly higher than those of Group 1. We conclude that increased protein intake by means of adding a protein hydrolysate increases the rate of restoration of body weight and muscle function.

Energy charge potential and glutathione levels as predictors of outcome following burn injury complicated by endotoxemia.

We studied the effect of water-soluble antioxidants geared at restoring glutathione levels on oxygen consumption, cell energetics as measured by energy charge potential (ECP), glutathione levels, and mortality, in response to a 20% total body surface area (TBSA) third degree burn injury combined with endotoxemia, five days after burn in a rat model. The 20% TBSA third degree burn injury was not fatal for the six day study period. Oxygen consumption as well as red blood cell ECP remained unchanged from control values. Liver ECP was significantly reduced; however, liver glutathione was significantly increased. The 20% TBSA burn injury combined with endotoxemia produced a 60% mortality rate. Twenty-four hour survivors (40%) demonstrated a significant decrease in oxygen consumption, red blood cell ECP, and liver ECP. Liver glutathione was significantly decreased compared with burn but was not significantly decreased compared with control. Nonsurvivors of the burn injury combined with endotoxin (60%) demonstrated a significant reduction in liver glutathione levels compared with survivors. Oxygen consumption and ECP could not be measured in the nonsurvivors due to the rapid loss of ATP in the moribund state that occurred by 4 h postinjury. Antioxidants produced 100% survival, attenuated in the fall in liver ECP, and restored red blood cell ECP and liver glutathione levels to normal values. We conclude that a modest burn injury combined with endotoxemia produces a liver glutathione debt, oxygen debt, an energy deficit, and 60% mortality. The mechanism of injury is oxidant related as antioxidants prevented mortality restored liver glutathione levels, and prevented or attenuated the decrease in ECP. A decrease in ECP and glutathione levels appear to be more sensitive indicators of outcome than the presence of an oxygen debt. The survivors, in both burn plus endotoxin groups treated with or without antioxidants was comparable, indicating a critical value for oxygen consumption exists before death occurs.