12-Year within-wound study of the effectiveness of custom pressure garment therapy.

Pressure garment therapy is standard of care for prevention and treatment of hypertrophic scarring after burn injury. Nevertheless there is little objective data that confirms effectiveness. The purpose of this study was to determine the effectiveness of pressure garment therapy with objective data obtained with a randomized within-wound comparison. We enrolled consecutive patients with forearm injuries over a 12-year period. The subjects wore custom garments with normal and low compression randomized to either the proximal or distal zones. Hardness, color and thickness of wounds were objectively measured using appropriate devices; clinical appearance was measured by a panel masked to the identity of the pressure treated area. Wounds treated with normal compression were significantly softer, thinner, and had improved clinical appearance. There was no interaction of any effect with patient ethnicity. However, these findings were clinically evident only with moderate to severe scarring. We conclude that pressure garment therapy is effective, but that the clinical benefit is restricted to those patients with moderate or severe scarring.

The WeeFIM [R] instrument--a paediatric measure of functional independence to predict longitudinal recovery of paediatric burn patients.

INTRODUCTION: Burns create a myriad of complications that affect the child's developmental, functional and aesthetic status. The WeeFIM is a standardized measure of functional performance developed for use in children 6-months to 8-years of age but with application through adolescence. It includes 18 domains of performance which are scored on a 7-point scale from 'total assistance' to 'complete independence'. In this study, the WeeFIM was used to evaluate the influence of burn size on functional independence and on time to recovery. METHODS: Children, 6 months to 16 years of age, with total body surface area (TBSA) bums of 10-100% burn injury were recruited for a 2-year longitudinal study. Due to unstable WeeFIM measurements on children 6 months to 6 years, analyses on normalized WeeFIM scores among subjects 6-16 years are presented. Children were evaluated at discharge from acute care, 6 months, 1 year and 2 years after burn injury. FINDINGS: In this analysis, 454 WeeFIM evaluations from 249 patients, 6-16 years of age, were reviewed. While mean WeeFIM scores varied significantly at discharge based on the size of burn, there were no significant differences in any of the WeeFIM scales at 24 months post-burn. At 24 months, the mean WeeFIM score for all children, independent of size of their bum, indicated full independence. Hands-on assistance was not required for performing activities of daily living (ADLs). The rates of improvement differed statistically by size of bum. Maximum improvement was attained by 6 months for 10-15% TBSA burns, 12 months for 16-30% burns, 12 months for 31-50% burns and 24 months for 51-100% TBSA. CONCLUSION: The WeeFIM can be utilized by burn centres to describe diminished functional capacity at discharge from acute care for severely burnt children. The tool can be used to track return to baseline independence after a major burn injury in a paediatric population.

Impairment after burns: a two-center, prospective report.

Impairment rating is regularly reported for trauma and other conditions but rarely for burns. The purposes of this study were: (1) to report impairment collected prospectively at our burn center, (2) to relate this impairment to measures of psychosocial and functional outcome, and (3) to compare these data to similar data from another burn center to verify that rating impairment is standardized and that the impairments are similar. We studied 139 patients from the University of Washington (UW) Burn Center and 100 patients from the University of Texas (UT) Southwestern Burn Center. The average whole person impairment (WPI) ratings at the University of Washington were 17% and this correlated with total body surface area burned and days off work. It did not correlate with Brief Symptom Inventory (BSI), Functional Independence Measure (FIM), Short-Form 36-Item Health Survey (SF-36), Satisfaction With Life Scale (SWLS), and the Community Integration Questionnaire (CIQ). Average whole person impairment ratings at UT Southwestern were similar at 19%. Several components of the impairment rating, however, differed at the two institutions. To minimize this variation, we recommend: (1) use the skin impairment definitions of the fifth edition of the Guides to the Evaluation of Permanent Impairment (or the most recent published versions of the Guide), and (2) include sensory impairment in healed burns and skin grafts in the skin impairment.

The methamphetamine burn patient.

Early aggressive fluid resuscitation has significantly decreased the morbidity and mortality associated with volume losses from large burns. Although most patients are adequately resuscitated using the Parkland formula, we noted increased fluid requirements for shock resuscitation in patients involved in methamphetamine laboratory explosions. Because predominant users are young healthy individuals in their 20s and 30s, we had not anticipated burn shock resuscitation failures in this patient group. We reviewed our experience with burn patients with documented methamphetamine use to determine whether this patient group presents new dilemmas to the burn surgeon. A 2-year retrospective study of 30 patients (15 methamphetamine users, 15 controls) revealed that the methamphetamine burn patient requires two to three times the standard Parkland formula resuscitation. In this study, methamphetamine burns larger than 40% TBSA had a 100% mortality.

Current management of purpura fulminans: a multicenter study.

Seven burn centers performed a 10-yr retrospective chart review of patients diagnosed with purpura fulminans. Patient demographics, etiology, presentation, medical and surgical treatment, and outcome were reviewed. A total of 70 patients were identified. Mean patient age was 13 yr. Neisseria meningitidis was the most common etiologic agent in infants and adolescents whereas Streptococcus commonly afflicted the adult population. Acute management consisted of antibiotic administration, volume resuscitation, ventilatory and inotropic support, with occasional use of corticosteroids (38%) and protein C replacement (9%). Full-thickness skin and soft-tissue necrosis was extensive, requiring skin grafting and amputations in 90% of the patients. One fourth of the patients required amputations of all extremities. Fasciotomies when performed early appeared to limit the level of amputation in 6 of 14 patients. Therefore, fasciotomies during the initial management of these patients may reduce the depth of soft-tissue involvement and the extent of amputations.

Dermatome setting for autografts to cover INTEGRA.

Using the INTEGRA Dermal Regeneration Template requires the outer silastic layer to be replaced with an autograft. We followed the manufacturer's directions for epidermal autografting and frequently obtained shredded, useless grafts, therefore, it seemed important to determine the proper dermatome setting. We evaluated dermatome settings from 0.002 to 0.012 inches. First, with feeler gauges, we verified the dermatome settings. Second, we harvested skin at various dermatome settings and measured the thickness histologically. We found that 1) the dermatome settings are reasonably accurate; 2) harvesting useful sheets at 0.002 and 0.004 inches is virtually impossible; 3) the variability of histologic graft thickness is enormous; and 4) a dermatome setting of 0.006 inches yields useful grafts. We no longer use the term epidermal autografting but rather ultrathin split-thickness grafting. To harvest these grafts, we now merely set the dermatome to 0.006 inches and make whatever midcourse corrections are necessary to obtain translucent grafts.

Cones of skin occur where hypertrophic scar occurs.

Hypertrophic scarring is devastating for the patient, however the pathophysiology and treatment remain unknown after decades of research. The process follows deep dermal injury, occurs only on certain body parts, does not occur in the early fetus or in animals, and is a localized event. This suggests that an anatomic structure in human, deep dermis may be involved. The dermis is a matrix perforated by cones containing many structures including skin appendages and fat domes. We hypothesized that studying the cones might reveal a structure related to scarring. We examined tangential wounds from various body parts on human cadavers along with skin histology from various human body parts, the early fetus, partial thickness burns, hypertrophic scars, and two other species-rats and rabbits. We found that the cones may in fact be the structure. They exist where hypertrophic scar occurs-cheek, neck, chest, abdomen, back, buttock, arm, forearm, dorsal hand, thigh, leg, dorsal foot, helix and ear lobe. They do not exist where hypertrophic scar does not occur-scalp, forehead, concha, eyelid, palm, early fetus, and in rat, or rabbit. It also became apparent that the cones have been omitted from most considerations of skin histology. We suggest that the cones need to be studied in relation to hypertrophic scarring and restored to skin diagrams.

Community integration after burn injuries.

Evaluation of community integration is a meaningful outcome criterion after major burn injury. The Community Integration Questionnaire (CIQ) was administered to 463 individuals with major burn injuries. The CIQ results in Total, Home Integration, Social Integration, and Productivity scores. The purposes of this study were to determine change in CIQ scores over time and what burn injury and demographic factors predict CIQ scores. The CIQ scores did not change significantly from 6 to 12 to 24 months postburn injury. Home integration scores were best predicted by sex and living situation; Social Integration scores by marital status; and Productivity scores by functional outcome, burn severity, age, and preburn work factors. The data demonstrate that individuals with burn injuries have significant difficulties with community integration due to burn and nonburn related factors. CIQ scores did not improve over time but improvement may have occurred before the initial 6-month postburn injury follow-up in this study.

Toxic epidermal necrolysis (TEN) in elderly patients.

Toxic epidermal necrolysis (TEN) is a severe exfoliative disease of the skin and mucous membranes that results in high mortality. As the elderly population increases, the number of elderly patients with TEN can also be expected to increase. Elderly patients with comparably sized burn wounds usually have a poor prognosis. Our purpose was to determine whether elderly TEN patients exhibit similarly high mortality. A retrospective review was conducted of 52 patients treated for TEN from October 1991 through September 1998. Eleven patients were older than 65 years. All patients were treated according to our TEN protocol. Eight of 11 patients recovered, and 3 died. The mean total body surface area (TBSA) involvement for the patients who recovered was 24%, compared with 66% for the nonsurvivors. The survival rate for elderly patients (73%) compares well with that for those younger than 65 years (89%). Therefore, we propose that we should be aggressive in treating elderly patients with TEN.

Barriers to employment among working-aged patients with major burn injury.

The purpose of this study was to examine the prevalence of preexisting and burn-related impairments and to describe their association with preburn employment status. Data gathered during the acute hospitalization were analyzed on a consecutive series of burn patients aged 16 to 64 years (N = 770) enrolled in a prospective, longitudinal, multicenter study. Patients who were unemployed before the injury were more likely than those who were employed to report being alcohol-dependent (36 vs 18%), abusing other drugs (22 vs 10%), having received psychiatric treatment in the past year (21 vs 6%), and having preexisting physical disability (23 vs 3%); all were significant at P < .001). Of the unemployed patients who received toxicologic screening at admission, 49% tested positive for alcohol and 39% positive for other drugs, percentages that were significantly higher than 26 and 31%, respectively, for the employed. With adjustment for age, sex, race, and education, variables that were most predictive of preinjury unemployment status were preexisting physical disability (odds ratio, 51.0; 95% confidence interval, 7.7-336.9) and being alcohol-positive at admission (odds ratio, 2.8; 95% confidence interval, 1.2-6.8). Unemployed and employed patients also differed significantly in injury patterns and clinical outcomes, with inhalation injury and psychiatric distress being more prevalent among the unemployed and both hand burns and hand surgery among the employed. The greater prevalence of preexisting impairments among survivors who were unemployed before the injury helps explain why preburn employment status is such a powerful determinant of postburn work outcomes, and suggests the need to include psychosocial services in a program of comprehensive rehabilitation.

Prospective trial of thick vs standard split-thickness skin grafts in burns of the hand.

For best function and appearance, thick skin grafts for hands are generally preferred to thinner grafts. But how thick is thick enough? This prospective randomized trial was designed to compare 0.015-inch skin grafts for burned hands to hand grafts that are 0.025 inches thick. Consecutive patients receiving skin grafts to hands were randomized to have sheet grafts using donor sites of 0.015-inch or 0.025-inch thickness. To prevent delayed healing and potential hypertrophic scarring, the thick graft donor sites were grafted with 0.008-inch grafts. There were no significant differences in range of motion, final appearance, or patient satisfaction between the two groups at 1 year. There were problems with donor site healing in both groups. We recommend that hand grafts for adults be at least 0.015 inches thick but do not see an advantage to the use of very thick (0.025-inch) grafts, even with thin split-thickness skin grafts to the donor site.

Time off work and return to work rates after burns: systematic review of the literature and a large two-center series.

The literature on time off work and return to work after burns is incomplete. This study addresses this and includes a systematic literature review and two-center series. The literature was searched from 1966 through October 2000. Two-center data were collected on 363 adults employed outside of the home at injury. Data on employment, general demographics, and burn demographics were collected. The literature search found only 10 manuscripts with objective data, with a mean time off work of 10 weeks and %TBSA as the most important predictor of time off work. The mean time off work for those who returned to work by 24 months was 17 weeks and correlated with %TBSA. The probability of returning to work was reduced by a psychiatric history and extremity burns and was inversely related to %TBSA. In the two-center study, 66% and 90% of survivors had returned to work at 6 and 24 months post-burn. However, in the University of Washington subset of the data, only 37% had returned to the same job with the same employer without accommodations at 24 months, indicating that job disruption is considerable. The impact of burns on work is significant.

Rates, trends, and severity of depression after burn injuries.

It is commonly assumed that patients hospitalized for burn treatment will experience some level of depression. However, little is known about the trends in severity of depression over time. The purpose of this study was to determine the rates and severity of depression over a 2-year period. The Beck Depression Inventory was administered at 1 month (N = 151), 1 year (N = 130), and 2 years (N = 125) after discharge. At 1 month, 54% of patients showed symptoms of moderate to severe depression, and at 2 years, 43% of the patients responding still reported moderate to severe depression. The average correlation between scores over time was high. Women had higher depression scores than men at each time period. An interaction between gender and having a head or neck injury was also observed at 1 month and 1 year after discharge. Results suggest that routine outpatient screening for depression is warranted.

Dexter: a tool to facilitate impairment ratings.

Calculating impairment in burn patients is crucial to understanding outcome. However, it is rarely reported after burns, presumably because the process of calculating impairment ratings is complicated and tedious. Computerized systems have been developed that facilitate the process, but it has not been established in burn patients that these systems reduce the time required to calculate impairment. We evaluated the Dexter Evaluation and Therapy System by Cedaron Medical Inc (Davis, CA). A sample of 10 manually recorded ratings was compared with 10 performed on the Dexter. Mean time for the manual technique was 65 +/- 35 minutes versus 37 +/- 13 minutes for the Dexter (P < .05, Mann-Whitney). The time taken to perform impairment ratings in burn survivors is significantly reduced by the use of the Dexter system. Time saving occurs primarily at three points: (1) electronic data entry directly from the measuring instruments, (2) compilation of data, and (3) rapid generation of reports.

The 2000 Clinical Research Award. Describing and predicting distress and satisfaction with life for burn survivors.

We investigated ratings of emotional distress and satisfaction with life at discharge from the hospital and at a 6-month follow-up in a multisite sample of 295 adults hospitalized for the care of a major burn injury. Several psychosocial variables (history of alcohol abuse, marital status, and previous mental health) and some medical variables (days of intensive care, pulmonary complications, and hand burns) accounted for significant variance in the prediction of outcomes. Brief Symptom Inventory (distress) scores were higher and Satisfaction With Life Scale scores were significantly lower than those of a normative population at both measurement points. The results show the utility of biosocial models in which psychological and physical variables interact to influence adjustment and quality of life.

Analysis of hypertrophic and normal scar gene expression with cDNA microarrays.

Hypertrophic scar is one form of abnormal wound healing. Previous studies have suggested that hypertrophic scar formation results from altered gene expression of extracellular matrix molecules. A broadscale evaluation of gene expression in hypertrophic scars has not been reported. To better understand abnormalities in hypertrophic scar gene expression, we compared messenger RNA expression in hypertrophic scars, normal scars, and uninjured skin with the use of complementary (c)DNA microarrays. Total RNA was extracted from freshly excised human hypertrophic scars, normal scars, or uninjured skin and reverse transcribed into cDNA with the incorporation of [33P] deoxycytidine triphosphate. The resulting radioactive cDNA probes were hybridized onto cDNA microarrays of 4000 genes. Hybridization signals were normalized and analyzed. In the comparison of tissue samples, mean intensities were calculated for each gene within each group (hypertrophic scars, normal scars, and uninjured skin). Ratios of the mean intensities of hypertrophic scars to normal scars, hypertrophic scars to uninjured skin, and normal scars to uninjured skin were generated. A ratio that was greater than 1 indicated upregulation of any particular gene and a ratio that was less than 1 indicated downregulation of any particular gene. Our data indicated that 142 genes were overexpressed and 50 genes were underexpressed in normal scars compared with uninjured skin, 107 genes were overexpressed and 71 were underexpressed in hypertrophic scars compared with uninjured skin, and 44 genes were overexpressed and 124 were underexpressed in hypertrophic scars compared with normal scars. Our analysis of collagen, growth factor, and metalloproteinase gene expression confirmed that our molecular data were consistent with published biochemical and clinical observations of normal scars and hypertrophic scars. cDNA microarray analysis provides a powerful tool for the investigation of differential gene expression in hypertrophic scar samples and either uninjured skin or normal scars. Our data validate the use of this technology for future studies on gene expression during repair processes of normal and abnormal wounds.

A biopsy of the use of the Baxter formula to resuscitate burns or do we do it like Charlie did it?

The Baxter formula is commonly used to calculate fluid requirements. Baxter reported that 12% of patients would require more than 4.3 mL/kg per percentage of total body surface area (%TBSA). We anecdotally observed that we frequently exceeded the predictions of the formula, and we wondered if this was unique to our practice. We studied our last 11 burn-related resuscitations and collected fluid resuscitation data from US burn centers. Twenty-eight centers were queried, and 6 centers shared data. We were therefore able to study the resuscitation data of 50 adult patients. For 29 patients (58%), 4.3 mL/kg/%TBSA was exceeded compared with the 12% reported by Baxter. These findings suggest that in actual practice, fluid volumes administered are larger than the Baxter formula predicts. This survey does not explain why. Possible reasons for the larger fluid volumes are as follows: (1) the sample is not representative; (2) the formula is used improperly; (3) burns have changed and require more fluids; (4) burn care has changed.

Transient exposure to tumor necrosis factor-alpha inhibits collagen accumulation by cultured hypertrophic scar fibroblasts.

BACKGROUND: Hypertrophic scars (HS) are frequent consequences of deep dermal injury, such as deep partial-thickness burns and abrasions, and are characterized by overproduction of collagen. In vitro studies have shown that cultured HS fibroblasts produce elevated levels of collagen and insulin-like growth factor-binding protein 3 (IGFBP-3). Additionally, histological studies have indicated HS contain fewer tumor necrosis factor alpha (TNF-alpha)-positive infiltrating cells and express lower levels of TNF-alpha mRNA, suggesting TNF-alpha, which can inhibit collagen expression in some systems, may function to deactivate the wound healing process in scars. HS also exhibit increased levels of transforming growth factor beta (TGF-beta), a factor that stimulates collagen and extracellular matrix deposition by fibroblasts and also stimulates IGFBP-3 expression. In some systems, IGFBP-3 mediates the effects of TGF-beta. The present study sought to determine the effects of continuous and transient TNF-alpha exposure on collagen and IGFBP-3 expression by cultured HS fibroblasts and to investigate the role of IGFBP-3 in collagen accretion by HS fibroblasts. MATERIALS AND METHODS: Superficial and deep dermal HS fibroblasts from four patients were cultured. Fibroblasts were cultured in serum-free medium and exposed to 0-2 ng/ml TNF-alpha for 0, 1, 4, or 72 h. After 72 h of culture, medium samples were processed for Western blot analysis of type I collagen accumulation or for ligand blot analysis of IGFBP-3 accumulation. The effects of an anti-IGFBP-3 neutralizing antibody on collagen accumulation were also assessed. RESULTS: Treatment of superficial and deep HS fibroblasts with TNF-alpha resulted in dose-dependent decreases in accumulation of both type I collagen and IGFBP-3 in the culture medium (P < 0.01). However, using the anti-IGFBP-3 neutralizing antibody, a causal relationship between decreased IGFBP-3 and decreased collagen accumulation could not be demonstrated. Transient exposure of cultured HS fibroblasts to TNF-alpha for as little as 1 h was as effective as continuous exposure to TNF-alpha for 72 h in inhibiting collagen accumulation. CONCLUSIONS: These results support the hypothesis that TNF-alpha functions as a wound healing deactivation signal that is deficient in HS. Although TNF-alpha inhibited accretion of both collagen and IGFBP-3, the role of IGFBP-3 in HS remains unresolved. This study suggests that transient TNF-alpha exposure may be used to inhibit collagen overaccumulation in HS and that the timing of TNF-alpha exposure following dermal injury may not be critical for this inhibition.

Methemoglobinemia secondary to topical silver nitrate therapy--a case report.

Methemoglobinemia is a rare complication in individuals exposed to nitrates or nitrites. Whereas methemoglobinemia is a recognized potential complication in burn patients treated with topical 0.5% silver nitrate solution, no report of methemoglobinemia in burn patients has been present in the literature for more than 15 years. We raise consciousness about this complication with a case report of a 12-month-old child with necrotizing fasciitis resulting from a cutaneous flank infection. The patient developed cyanosis 20 days after initiation of topical treatment with 0.5% silver nitrate solution. Intravenous injection of methylene blue can restore normal blood oxygenation.