Fractional CO2 Laser for Burn Scars: A Comparison of Patient Reported Outcomes Between Those With and Without Laser Treatment.

Burn reconstruction outcomes are an area of growing investigation. Although there is evidence of measured physical improvements in scar characteristics after laser treatment, there is little information on patient reported outcomes. The purpose of this study is to compare patient reported outcomes between burn survivors with and without laser treatment. The study included participants in the Burn Model Systems National Database at a single center; participants that received outpatient laser treatment for burn scars were compared to a matched group of burn survivors that did not receive laser. The following outcomes were examined: Satisfaction With Life Scale, Mental and Physical Component Summary of the Veterans Rand Survey, and the PROMIS Pain Intensity Scale. Regression analyses examined the associations between laser treatment and each outcome at 12 and 24 months. The study population included 287 adult burn survivors (65 laser group, 222 control group). The significant differences found between the two groups included: burn size (laser: 14.9, 13.5 SD, control: 8.9, 11.1 SD; p<0.001), insurance type (p=0.036), inhalation injury (laser: 17.2%, control: 2.7%; p<0.001), and ventilator requirement (laser: 27.7%, control: 13.5%; p=0.013). Laser treatment was not associated with any of the outcomes at both follow-up time points. Further research is needed to develop patient reported outcome measures that are more sensitive to the clinical changes experienced by burn survivors receiving laser treatment.

Update on Cold-Induced Injuries.

Cold-induced injuries are a major challenge for burn surgeons, leading to significant sequelae for the patients including amputations, long-term disability, and death. Rapid assessment and diagnosis are essential for optimal outcomes. Various therapies have emerged to improve outcomes. Topical, oral, and intravenous agents have shown to minimize the impact of cold-induced injuries. Thrombolytics have shown the greatest promise in improving tissue perfusion outcomes in cold-induced injuries. This article provides an update on the evidence-based assessment and management of cold-induced injuries, as well as reviews outcomes and future directions of this challenging pathology.

A PREVENTIVE TOOL FOR PREDICTING BLOODSTREAM INFECTIONS IN CHILDREN WITH BURNS.

ABSTRACT: Introduction: Despite significant advances in pediatric burn care, bloodstream infections (BSIs) remain a compelling challenge during recovery. A personalized medicine approach for accurate prediction of BSIs before they occur would contribute to prevention efforts and improve patient outcomes. Methods: We analyzed the blood transcriptome of severely burned (total burn surface area [TBSA] ≥20%) patients in the multicenter Inflammation and Host Response to Injury ("Glue Grant") cohort. Our study included 82 pediatric (aged <16 years) patients, with blood samples at least 3 days before the observed BSI episode. We applied the least absolute shrinkage and selection operator (LASSO) machine-learning algorithm to select a panel of biomarkers predictive of BSI outcome. Results: We developed a panel of 10 probe sets corresponding to six annotated genes ( ARG2 [ arginase 2 ], CPT1A [ carnitine palmitoyltransferase 1A ], FYB [ FYN binding protein ], ITCH [ itchy E3 ubiquitin protein ligase ], MACF1 [ microtubule actin crosslinking factor 1 ], and SSH2 [ slingshot protein phosphatase 2 ]), two uncharacterized ( LOC101928635 , LOC101929599 ), and two unannotated regions. Our multibiomarker panel model yielded highly accurate prediction (area under the receiver operating characteristic curve, 0.938; 95% confidence interval [CI], 0.881-0.981) compared with models with TBSA (0.708; 95% CI, 0.588-0.824) or TBSA and inhalation injury status (0.792; 95% CI, 0.676-0.892). A model combining the multibiomarker panel with TBSA and inhalation injury status further improved prediction (0.978; 95% CI, 0.941-1.000). Conclusions: The multibiomarker panel model yielded a highly accurate prediction of BSIs before their onset. Knowing patients' risk profile early will guide clinicians to take rapid preventive measures for limiting infections, promote antibiotic stewardship that may aid in alleviating the current antibiotic resistance crisis, shorten hospital length of stay and burden on health care resources, reduce health care costs, and significantly improve patients' outcomes. In addition, the biomarkers' identity and molecular functions may contribute to developing novel preventive interventions.

Microsurgical Techniques and Postoperative Outcomes After Total and Subtotal Nasal Reconstruction: A Systematic Review.

BACKGROUND: Multiple microsurgical techniques for nasal reconstruction have been described in the literature. Given the gaps in the literature regarding evidence-based reviews for total and subtotal nasal reconstruction using microsurgical techniques, the purpose of this study was to provide a thorough presentation of the most popular microvascular techniques and their outcomes (functional and aesthetic) for total or subtotal nasal defects. METHODS: A systematic search was performed using PubMed, Google Scholar, and Cochrane Library on free flap techniques for restoration of nasectomy defects. The keywords were "nasal reconstruction," "nose," "nasectomy," "rhinectomy," and "microvascular." Inclusion criteria for analysis in the study were the largest clinical case series published in English within the past 15 years with more than 8 patients.Studies were analyzed for patient demographics, etiology of nasal loss, surgical approaches to reconstruction, outcomes, and complications. The current study was registered at the International Prospective Register of Systematic Reviews and conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. RESULTS: The initial search yielded 302 results. Eleven articles with a total of 232 patients met the inclusion criteria. The radial (n = 85) and ulnar forearm flaps (n = 20), auricular helical rim (n = 87), and anterolateral thigh flap (n = 30) were the most commonly reported free flaps in nasal reconstruction. The main etiologic factors were malignancy and trauma. The most common complication was partial flap necrosis. CONCLUSIONS: The auricular helical and radial forearm flaps represent the most used free flaps for total and/or subtotal nasal defects with satisfactory patient outcomes.

Lower Extremity Salvage in the Setting of Bullous Pemphigoid Exacerbation: A Case Report.

Bullous pemphigoid is an autoimmune blistering disease where patients suffer from painful bullae, often covering large portions of the skin and requiring management with immune-suppression. Our case report of recurring bullous pemphigoid illustrates the importance of considering immunosuppressive perioperative management in patients with a history of autoimmune blistering even when the disease has been quiescent for some time. With multidisciplinary care and immune suppressive therapies in the perioperative period, a free flap complicated by recurrent bullous pemphigoid can be salvaged.

Evaluation of Patient-Reported Outcomes in Burn Survivors Undergoing Reconstructive Surgery in the Rehabilitative Period.

BACKGROUND: Health-related quality of life is decreased in burn survivors, with scars implicated as a cause. The authors aim to characterize the use of reconstructive surgery following hospitalization and determine whether patient-reported outcomes change over time. The authors hypothesized improvement in health-related quality of life following reconstructive surgery. METHODS: Adult burn survivors undergoing reconstructive surgery within 24 months after injury were extracted from a prospective, longitudinal database from 5 U.S. burn centers (Burn Model System). Surgery was classified by problem as follows: scar, contracture, and open wound. The authors evaluated predictors of surgery using logistic regression. Short Form-12/Veterans RAND 12 health survey outcomes at 6, 12, and 24 months were compared at follow-up intervals and matched with nonoperated participants using propensity score matching. RESULTS: Three hundred seventy-two of 1359 participants (27.4 percent) underwent one or more reconstructive operation within 24 months of injury. Factors that increased the likelihood of surgery included number of operations during index hospitalization (p < 0.001), hand (p = 0.001) and perineal involvement (p = 0.042), and range-of-motion limitation at discharge (p < 0.001). Compared to the physical component scores of peers who were not operated on, physical component scores increased for participants undergoing scar operations; however, these gains were only significant for those undergoing surgery more than 6 months after injury (p < 0.05). Matched physical component scores showed nonsignificant differences following contracture operations. Mental component scores were unchanged or lower following scar and contracture surgery. CONCLUSIONS: Participants requiring more operations during index admission were more likely to undergo reconstructive surgery. There were improvements in Short Form-12/Veterans RAND 12 scores for those undergoing scar operations more than 6 months after injury, although contracture operations were not associated with significant differences in Short Form-12/Veterans RAND 12 scores.

Geographic Variation in Outcomes After Burn Injury: A Burn Model System National Database Study.

BACKGROUND: Geography is an important yet underexplored factor that may influence the care and outcomes of burn survivors. This study aims to examine the impact of geography on physical and psychosocial function after burn injury. METHODS: Data from the Burn Model Systems National Database (1997-2015) were analyzed. Individuals 18 years and older who were alive at discharge were included. Physical and psychosocial functions were assessed at 6, 12, and 24 months postinjury using the following patient-reported outcome measures: Community Integration Questionnaire, Physical Composite Scale and Mental Composite Scale of the 12-Item Short Form Health Survey, Satisfaction with Appearance Scale, and Satisfaction with Life Scale. Descriptive statistics were generated for demographic and medical data, and mixed regression models were used to assess the impact of geography on long-term outcomes. RESULTS: The study included 469 burn survivors from the Centers for Medicare and Medicaid Services regions 10, 31 from region 8, 477 from region 6, 267 from region 3, and 41 from region 1. Participants differed significantly by region in terms of race/ethnicity, burn size, burn etiology, and acute care length of stay (P < 0.001). In adjusted mixed model regression analyses, scores of all 5 evaluated outcome measures were found to differ significantly by region (P < 0.05). CONCLUSIONS: Several long-term physical and psychosocial outcomes of burn survivors vary significantly by region. This variation is not completely explained by differences in population characteristics. Understanding these geographical differences may improve care for burn survivors and inform future policy and resource allocation.

Beneath the Surface: A Review of Laser Remodeling of Hypertrophic Scars and Burns.

Significance: Hypertrophic scars, keloids, and burn injuries of the skin have a significant impact on patients' lives and impact the health care system tremendously. Treating skin wounds and lesions can be challenging, with a variety of choices available for treatment. Scar and burn managements range from invasive, surgical options such as scar excision to less invasive, nonsurgical alternatives such as laser therapy or topical drug application. Recent Advances: Laser treatment has become increasingly popular, with a growing body of research supporting its use for scars and burns. Numerous methods are available for the treatment of these skin diseases, including different nonsurgical laser therapies. Critical Issues: To date, the optimal treatment method for scars, keloids, and burn injuries of the skin has not yet been established, although it is an area of increasing clinical concern. Future Directions: This review provides an updated summary of the treatment of scars and burn wounds of the skin using different laser treatments, including the most recent technologies. It addresses their indications, mechanisms of action, differences, efficacies, and complications.

Investigation into Possible Association of Oxandrolone and Heterotopic Ossification Following Burn Injury.

Oxandrolone, a testosterone analog, is used to counteract the catabolic effects of burn injury. Recent animal studies suggest a possible hormonal association with heterotopic ossification (HO) development postburn. This work examines oxandrolone administration and HO development by exploring historical clinical data bridging the introduction of oxandrolone into clinical practice. Additionally, we examine associations between oxandrolone administration and HO in a standardized mouse model of burn/trauma-related HO. Acutely burned adults admitted between 2000 and 2014, survived through discharge, and had a HO risk factor of 7 or higher were selected for analysis from a single burn center. Oxandrolone administration, clinical and demographic data, and elbow HO were recorded and were analyzed with logistic regression. Associations of oxandrolone with HO were examined in a mouse model. Mice were administered oxandrolone or vehicle control following burn/tenotomy to examine any potential effect of oxandrolone on HO and were analyzed by Student's t test. Subjects who received oxandrolone had a higher incidence of elbow HO than those that did not receive oxandrolone. However, when controlling for oxandrolone administration, oxandrolone duration, postburn day oxandrolone initiation, HO risk score category, age, sex, race, burn size, and year of injury, there was no significant difference between rates of elbow HO between the two populations. In agreement with the review, in the mouse model, while there was a trend toward the oxandrolone group developing a greater volume of HO, this did not reach statistical significance.

LIBERTI: A SMART study in plastic surgery.

BACKGROUND/AIMS: Laser treatment of burns scars is considered by some providers to be standard of care. However, there is little evidence-based research as to the true benefit. A number of factors hinder evaluation of the benefit of laser treatment. These include significant heterogeneity in patient response and possible delayed effects from the laser treatment. Moreover, laser treatments are often provided sequentially using different types of equipment and settings, so there are effectively a large number of overall treatment options that need to be compared. We propose a trial capable of coping with these issues and that also attempts to take advantage of the heterogeneous response in order to estimate optimal treatment plans personalized to each individual patient. It will be the first large-scale randomized trial to compare the effectiveness of laser treatments for burns scars and, to our knowledge, the very first example of the utility of a Sequential Multiple Assignment Randomized Trial in plastic surgery. METHODS: We propose using a Sequential Multiple Assignment Randomized Trial design to investigate the effect of various permutations of laser treatment on hypertrophic burn scars. We will compare and test hypotheses regarding laser treatment effects at a general population level. Simultaneously, we hope to use the data generated to discover possible beneficial personalized treatment plans, tailored to individual patient characteristics. RESULTS: We show that the proposed trial has good power to detect laser treatment effect at the overall population level, despite comparing a large number of treatment combinations. The trial will simultaneously provide high-quality data appropriate for estimating precision-medicine treatment rules. We detail population-level comparisons of interest and corresponding sample size calculations. We provide simulations to suggest the power of the trial to detect laser effect and also the possible benefits of personalization of laser treatment to individual characteristics. CONCLUSION: We propose, to our knowledge, the first use of a Sequential Multiple Assignment Randomized Trial in surgery. The trial is rigorously designed so that it is reasonably straightforward to implement and powered to answer general overall questions of interest. The trial is also designed to provide data that are suitable for the estimation of beneficial precision-medicine treatment rules that depend both on individual patient characteristics and on-going real-time patient response to treatment.

Thermal injuries from exploding electronic cigarettes.

INTRODUCTION: There are an estimated 2.75 million electronic cigarette (EC) users in the United States. ECs have become the most commonly used nicotine-containing product in young adults ages 18-24 years. Thermal, blast, and missile injuries from EC explosions has grown rapidly in recent years. Burn surgeons must remain up to date regarding management and treatment of burn injuries related to EC device ignition. METHODS: An IRB approved retrospective review of all patients admitted to the Massachusetts General Hospital Burn Center from January 2015 to April 2017 was performed. Fourteen patients with injuries associated with EC use were identified. Patient demographics, injury location, size and degree of burn, treatments required, length of stay (LOS), time to 95% closure, associated complications and injuries, and the circumstances that led to the injury were identified. RESULTS: The mean age was 28.6±8.6 years with a range of 19-50 years (n=14). EC burns occurred in males 93% (13/14) of the time. The majority of EC explosions caused 2nd and 3rd degree burns (57%) within the same wound bed, followed by deep 2nd degree (29%), and superficial 2nd degree (14%). The average TBSA from EC burns was 4.7±2.4% with a range of 1-10%. The most common location of the device or battery at the time of the injury was a pant pocket 86% (12/14), followed by 7% hand (1/14) and 7% purse (1/14). Isolated lower extremity burns occurred in 43% (6/14) of patients, while lower extremity and hand burns occurred in 21% (3/14) of patients. Nine of 14 patients required an operating room encounter under general anesthesia. Eight of 14 patients required skin grafting for definitive wound closure. The mean hospital length of stay was 6.6±4.7 days with a range of 0-15 days. Time to 95% wound closure was 18.4±10.8 with a range of 8-40 days. CONCLUSION: Thermal and blast injuries associated with EC device failure tend to cause small TBSA burns that are deep 2nd and 3rd degree wounds. The most common location for EC device storage among males was the front pants pocket. EC device users should be made aware of the dangers associated with EC use and advised to carry EC devices away from their body in dedicated carrying cases without loose metallic items.

Microsurgical Burn Reconstruction.

The treatment of burn-related wounds requires consideration of several factors, including defect size, available donor sites, exposure of critical structures, and the ultimate functional and aesthetic result of reconstruction. Although skin grafts and locoregional flaps are workhorses in burn reconstruction, they have inherent limitations that can directly impact reconstructive outcomes. Microsurgical free tissue transfer represents a viable option for the reconstruction of burn-related wounds in certain patients. Each anatomic region of the body has unique challenges that must be addressed to achieve a successful reconstruction. Therefore, the choice of free flap must be individualized to the wound and patients.

Outcome Metrics After Burn Injury: From Patient-Reported Outcome Measures to Value-Based Health Care.

Outcomes research is important because it allows us to critically evaluate our results and strive for quality improvement, share our experiences with our colleagues, and improve the care and results delivered to the patient. This article focuses on outcomes research in burns from a historical perspective, highlights some of the current innovations, and previews future directions for outcomes-based research in burn care.

Lessons Learned from Burn Disasters in the Post-9/11 Era.

Although every disaster scenario is unique, certain themes have emerged repeatedly during management of burn disasters. These lessons learned are useful when planning an individual burn unit's role in future disaster response.

Chemical, Electrical, and Radiation Injuries.

This article reviews the unique challenges presented by chemical, electrical, and radiation injuries. The authors discuss pathophysiology and diagnosis of these injuries and provide recommendations for management.

Simultaneous vascularized bony reconstruction of the maxilla and mandible using a single fibula: A case report.

Simultaneous maxillary and mandibular reconstruction is exceedingly rare. These are complicated cases, requiring consideration of multiple variables: defect components, donor site morbidity, recipient vessels, and so forth. We describe a unique case of secondary maxillary/mandibular reconstruction in a 59-year-old male. The original defect was created after removal of a buccal squamous cell carcinoma, involving the external cheek skin, buccal mucosa, right mandibular body, and right inferior maxilla; a free vertical rectus abdominis musculocutaneous flap was used for the initial reconstruction. At the time of presentation to our clinic, the patient was tube-feed-dependent, unable to speak, and distressed regarding his appearance. We revised his reconstruction, rebuilding his maxilla and hemimandible using two free fibula flaps from a single fibula. The fibulae were vascularized via vein grafts and an ALT flap was used for external cheek resurfacing. All flaps survived and there were no complications at seven months since his surgery (when this report was written). The patient had intelligible speech and maintained adequate nutrition with a soft diet. Simultaneous vascularized bony reconstruction of the maxilla and mandible using a single fibula flap may be performed safely and with good outcomes.

Efficacy of intense pulsed light for the treatment of burn scar dyschromias: a pilot study to assess patient satisfaction, safety, and willingness to pay.

INTRODUCTION: No treatment algorithms exist to reliably treat burn scar dyschromias. Intense pulsed light (IPL) has been used successfully to treat hyperpigmentation disorders, but has not been studied extensively in the treatment of burn scars. The purpose of this investigation was to assess clinical efficacy and patient satisfaction with IPL for the treatment of burn scar dyschromia. METHODS: Patients with burn scar dyschromias were treated using the Lume 1 platform (Lumenis) to target pigmented lesions, using fluences between 10 and 22 joules/cm and filters ranging from 560 to 650 nm. At the conclusion of the study, providers assessed changes in burn scar dyschromia, whereas patients were queried regarding satisfaction and perceived efficacy, using a 1 to 5 Likert scale. The patients, who were not charged for the IPL treatment, were queried regarding willingness to pay. RESULTS: Twenty patients (mean age, 35.4 years; mean total body surface area, 27.6%; mean composite Fitzpatrick score, 3.9) underwent IPL treatment of burn scar dyschromias, an average of 3.2 years after injury. Mean fluence was 15.4 J/cm (range, 10-22 J/cm), and the most common filter used was 590 nm (range, 560-650 nm). Mean area treated was 90.7 cm, with a range of 4 to 448 cm. Complications included pain (4), hyperpigmentation (1), and blistering (2). Sixteen patients noted mild to moderate improvement, reporting a 4.5 for efficacy and a 4.4 for satisfaction. Regarding willingness to pay, patients would spend a mean of U.S. $7429 to completely remove their scars, but only a median of U.S. $350 to get the actual results that they received. Mean length of follow-up was 3.8 months, with a standard deviation of 2.2 months. CONCLUSIONS: Patients perceived IPL as an efficacious modality in the treatment of burn scar dyschromia, with a high level of satisfaction, despite the potential for morbidity. However, we are reluctant to recommend IPL for routine treatment of burn scar dyschromias, given only minimal improvement observed, potential for complications, and a willingness to pay that is lower than the cost of providing care.

Discrepancy in Initial Pediatric Burn Estimates and Its Impact on Fluid Resuscitation.

One of the fundamental aspects of initial burn care is the ability to accurately measure the TBSA of injured tissue. Discrepancies between initial estimates of burn size and actual TBSA (determined at the burn unit) have long been reported. These inconsistencies have the potential for unnecessary patient transfer and inappropriate fluid administration which may result in morbidity. In an effort to study these inconsistencies and their impact on initial care, we evaluated the differences between initial TBSA estimates and its impact on fluid resuscitation at an American Burn Association-verified pediatric burn center. A prospective observational study of 50 consecutive burn patients admitted to Shriner's Hospital for Children in Boston, Massachusetts, between October 2011 and April 2012 was performed. Data collected included age, mechanism of burn injury, type of referral center, referring hospital TBSA, and volume of fluid administration as well as admission TBSA and volume of fluid administration. Determination of over or under resuscitation was based on comparing the amount of fluids received at the referral center to that received at the pediatric burn center. A total of 50 patients were admitted during the 7-month study period. The average age was 4.1 years old (25 days-16 years) and the average TBSA was 2.5% (0.25-55%). There were significant differences in the TBSA calculations between referring centers and the pediatric burn center. Overestimation of scald and contact burn size (P < .05) was noted with no difference in flame burn size estimation. Community referrals were more likely than tertiary centers to overestimate TBSA (P < .05 vs P = .29). Overall, 59% of study patients were administered more fluid at the referring hospital than would have been expected by the burn size calculated at our facility. Inconsistencies with the estimation of TBSA burn between referring hospitals and tertiary referral centers remains a problem in pediatric patients and may lead to inappropriate resuscitation. This study highlights the continued need for educational outreach programs and for the provision of novel resources to initial burn providers. Additional support through online resources (eg, Lund-Browder diagram) and remotely assisting providers during their TBSA measurements are potential options which may help to improve the initial care of burn patients.