Long-Term Outcomes in Patients Surviving Large Burns: The Skin:

REsource Support To Optimize REcovery (RESTORE) document study: Evaluating aftercare resources for burn survivors

INTRODUCTION

Burn survivors may face chronic adverse sequelae from burn injury and report a lack of resources during the aftercare phase of recovery after discharge. This study aimed to identify the resources provided by healthcare institutions to assist adult burn survivors in the post-discharge transition to living in their communities.

METHODS

A convenience sample of burn injury healthcare providers in the United States and Canada described resources provided to adult burn survivors and implementation processes. The World Health Organization (WHO) International Classification of Functioning, Disability, and Health (ICF) Core Set for burn injury provided a conceptual framework to categorize resources. Implementation documentation included who, when, where, and how the resources were provided.

RESULTS

In total, 14 (13 U.S., 1 Canadian) healthcare institutions provided information about 255 burn aftercare resources. Organizing resources through the ICF revealed that 49.0 % were related to Environmental Factors, 39.2 % to Activities and Participation, and 11.8 % to Body Functions. Important topics covered included health services, professionals, handling stress and emotional health, self-management of burn injury sequelae, and wound care. Some topics not covered included fatigue, sleep, respiratory functioning, and thermoregulation. Resource implementation was carried out largely by social workers, nurses, and therapists. Most resources were distributed as handouts, packets, or verbally, and were provided to inpatients, primarily as needed, on day of discharge, or at admission.

CONCLUSION

This study gives an overview of the burn aftercare resources currently provided in participating healthcare institutions. The ICF Core Set for burn injury provided useful strategies for examining resources to identify strengths and content gaps. Implementation trends can inform efforts to effectively provide resources.

Randomized, controlled, within-patient, single-blinded pilot study to evaluate the efficacy of 12-weeks of endermotherapy with adult burn survivors

BACKGROUND

Vacuum massage, or endermotherapy, is applied to scar tissue with the primary therapeutic goal of promoting structural or physiological changes. These changes are intended to enhance pliability, enabling the skin to possess the strength and elasticity required for normal mobility. The advantage of vacuum massage compared to therapist-generated manual massage is that it provides a standardized dosage using rollers and suction valves to mobilize the tissue. However, research documenting and supporting its impact on post-burn hypertrophic scar is lacking. Thus, this study was designed to objectively characterize the changes in scar elasticity, erythema, melanin, thickness, and transepidermal water loss immediately after a vacuum massage session and after a 12-week course of treatment compared to intra-individual matched control scars.

METHODS

We conducted a prospective, randomized, controlled, within-patient, single-blinded clinical trial, initially designed as a fully-powered study but limited to a pilot study due to COVID-19 restrictions. Nineteen burn survivors consented to participate and 16 completed the study. Two homogeneous, intra-individual scars were randomized to usual care control or vacuum massage therapy plus usual care. Vacuum massage interventions were provided by a certified massage therapist three times per week for 12 weeks. Scar characteristics were evaluated every four weeks immediately before and after mechanical massage treatment. The evaluations included measurements of elasticity (Cutometer), erythema and melanin (Mexameter), transepidermal water loss (TEWL) (Tewameter), and thickness (high-frequency ultrasound). Linear mixed-model analyses were performed to test for immediate and long-term treatment effects.

RESULTS

The ANOVA analyses revealed a non-significant time:treatment interaction for elasticity, erythema, melanin, thickness, or TEWL. There was a significant increase in elasticity and erythema and a decrease in TEWL in both the control and treatment sites over time with consistent standard care. However, there was no statistically significant immediate or long-term treatment effect for any of the skin characteristics. Nonetheless, the mean participant satisfaction was 4/5 (SD = 1.5) and the mean participant perception of effectiveness was 8/10 (SD = 1.9).

CONCLUSIONS

This pilot study did not find a treatment benefit of vacuum massage therapy for elasticity, erythema, melanin, thickness or TEWL, but it did find an improvement with time in elasticity, erythema and TEWL. Despite the lack of objective improvement of the treated scar site, participants were satisfied with the results and believed vacuum massage was very effective. Further high-quality research is required to better inform clinicians patient education and treatment decisions for this costly, burdensome treatment approach that has high participant satisfaction.

Assessing the Feasibility of Using Parents' Social Media Conversations to Inform Burn First Aid Interventions: Mixed Methods Study

BACKGROUND

Burns are common childhood injuries, which can lead to serious physical and psychological outcomes. Appropriate first aid is essential in managing the pain and severity of these injuries; hence, parents who need timely access to such information often seek it from the web. In particular, social media allow them to reach other parents, hence these conversations may provide insight to aid the design and evaluation of burn first aid interventions for parents.

OBJECTIVE

This study aims to determine the feasibility of finding, accessing, and analyzing parent burn first aid conversations on social media to inform intervention research.

METHODS

The initial choice of the relevant social media was made based on the results of a parent focus group and survey. We considered Facebook (Meta Platforms, Inc), Mumsnet (Mumsnet Limited), Netmums (Aufeminin Group), Twitter (subsequently rebranded as "X"; X Corp), Reddit (Reddit, Inc), and YouTube (Google LLC). To locate the relevant data on these platforms, we collated a taxonomy of search terms and designed a search strategy. A combination of natural language processing and manual inspection was used to filter out irrelevant data. The remaining data were analyzed manually to determine the length of conversations, the number of participants, the purpose of the initial post (eg, asking for or offering advice), burn types, and distribution of relevant keywords.

RESULTS

Facebook parenting groups were not accessed due to privacy, and public influencer pages yielded scant data. No relevant data were found on Reddit. Data were collected from Mumsnet, Netmums, YouTube, and Twitter. The amount of available data varied across these platforms and through time. Sunburn was identified as a topic across all 4 platforms. Conversations on the parenting forums Mumsnet and Netmums were started predominantly to seek advice (112/116, 96.6% and 25/25, 100%, respectively). Conversely, YouTube and Twitter were used mainly to provide advice (362/328, 94.8% and 126/197, 64%, respectively). Contact burns and sunburn were the most frequent burn types discussed on Mumsnet (30/94, 32% and 23/94, 25%, respectively) and Netmums (2/25, 8% and 14/26, 56%, respectively).

CONCLUSIONS

This study provides a suite of bespoke search strategies, tailored to a range of social media platforms, for the extraction and analysis of burn first aid conversation data. Our methodology provides a template for other topics not readily accessible via a specific search term or hashtag. YouTube and Twitter show potential utility in measuring advice offered before and after interventions and extending the reach of messaging. Mumsnet and Netmums present the best opportunity for informing burn first aid intervention design via an in-depth qualitative investigation into parents' knowledge, attitudes, and behaviors.

Effectiveness of Postburn Pruritus Treatment and Improvement of Insomnia-A Randomized Trial

Postburn pruritus is difficult to assess and treat. Antihistamines used in its treatment provide little relief. Identification of the itch neuronal pathway has inspired new alternatives, including gabapentin, for its management. The study compared the effectiveness of cetirizine, gabapentin, and a combination of gabapentin and cetirizine in treating postburn pruritus. Burn patients were randomly assigned to treatment with Cetirizine (n = 23), Gabapentin (n = 23), or Cetirizine plus Gabapentin (n = 23). A baseline assessment of the intensity or the severity of pruritus was evaluated, after which treatment commenced with standard doses of the 3 study regimens. Quality of sleep was assessed at baseline (day 0) and repeated on day 3, day 7, and day 14. Approximately 97% of participants presented with moderate or severe itch; 69% with acute itch; and the majority (94.2%) experienced pruritus between the first and fourth weeks. Gabapentin reduced itch by 92.9% in 14 days compared to cetirizine's 61.8%. The combined effect of cetirizine and gabapentin was comparable using gabapentin alone. When the itch became protracted over 6 weeks, the effectiveness of cetirizine in controlling itch worsened. It reduced itch intensity by only 37.7%, whilst gabapentin did so at 89.4%. Itch intensity correlated positively with insomnia, and controlling itch intensity improved sleep. Gabapentin was more effective for the treatment of postburn pruritus than cetirizine. Controlling itch intensity improved sleep. In acute and moderate itch, low-dose gabapentin could be added if cetirizine is the drug intended for its treatment.

Unmet needs in treating itch: reaching beyond eczema

PURPOSE

Pruritus is an unpleasant sensation that creates the urge to scratch. In many chronic conditions, relentless pruritus and scratching perpetuates a vicious itch-scratch cycle. Uncontrolled itch can detrimentally affect quality of life and may lead to sleep disturbance, impaired concentration, financial burden, and psychological suffering. Recent strides have been made to develop guidelines and investigate new therapies to treat some of the most common severely pruritic conditions, however, a large group of diseases remains underrecognized and undertreated. The purpose of this article is to provide a comprehensive review of the challenges hindering the treatment of pruritus.

METHODS

An online search was performed using PubMed, Web of Science, Google Scholar, and ClinicalTrials.gov from 1994 to 2024. Included studies were summarized and assessed for quality and relevance in treating pruritus.

RESULTS

Several barriers to treating pruritus emerged, including variable presentation, objective measurement of itch, and identifying therapeutic targets. Itch associated with autoimmune conditions, connective tissue diseases, genodermatoses, cutaneous T-cell lymphoma, and pruritus of unknown origin were among the etiologies with the greatest unmet needs.

CONCLUSION

Treating pruritus poses many challenges and there are many itchy conditions that have no yet been addressed. There is an urgent need for large-scale controlled studies to investigate potential targets for these conditions and novel therapies.

Malignant melanoma arising in a burn scar

Secondary malignancies are rare but devastating complications of longstanding burn scars. Squamous cell carcinoma is the most common, followed by basal cell carcinoma and melanomas. There are fewer than 50 total reported cases of malignant melanomas arising in burn scars. We report a case of malignant melanoma arising within a longstanding burn scar confirmed by histology, FISH, and PRAME staining to further characterize melanomas arising in burn scars and to illustrate the diagnostic challenges they present.

Comparison of Clinical Estimation and Stereophotogrammic Instrumented Imaging of Burn Scar Height and Volume

Descriptive clinical tools for characterizing burn scars are limited by between-user variability and unknown sensitivity to change over time. We previously described preclinical assessment of stereophotogrammetry as a valid measure of burn-related scars. Here, we compared the estimated vs. instrumented measurements of maximum height and total positive volume of 26 burn scars. The burn scars were imaged with the QuantifiCare LifeViz Micro 3D camera. Three experienced wound care therapists first estimated, then measured using 3D Track software, the imaged scars' height and volume. Two-factor analysis without replication was performed to calculate intraclass correlation coefficients (ICCs) between assessors' estimated scar height and volume, and measured height and volume. Two-sided Wilcoxon tests were performed comparing the mean estimated height and volume with the estimated and measured outputs. The estimated scar height's ICC was 0.595, and for volume, it was 0.531. The measured scar height's ICC was 0.933 and for volume, it was 0.890. The estimated and measured volume were significantly different (z = -2.87, p = 0.041), while the estimated and measured height were not (z = -1.39, p = 0.161). Stereophotogrammic measurement of scar height and volume is more reliable than clinical photograph assessment. Stereophotogrammetry should be utilized when assessing burn scar height and volume, rather than subjective estimates from clinical scar tools.

Burn size and environmental conditions modify thermoregulatory responses to exercise in burn survivors

This project tested the hypothesis that burn survivors can perform mild/moderate-intensity exercise in temperate and hot environments without excessive elevations in core body temperature. Burn survivors with low (23 ± 5%TBSA; N = 11), moderate (40 ± 5%TBSA; N = 9), and high (60 ± 8%TBSA; N = 9) burn injuries performed 60 minutes of cycle ergometry exercise (72 ± 15 watts) in a 25°C and 23% relative humidity environment (ie, temperate) and in a 40°C and 21% relative humidity environment (ie, hot). Absolute gastrointestinal temperatures (TGI) and changes in TGI (ΔTGI) were obtained. Participants with an absolute TGI of >38.5°C and/or a ΔTGI of >1.5°C were categorized as being at risk for hyperthermia. For the temperate environment, exercise increased ΔTGI in all groups (low: 0.72 ± 0.21°C, moderate: 0.42 ± 0.22°C, and high: 0.77 ± 0.25°C; all P < .01 from pre-exercise baselines), resulting in similar absolute end-exercise TGI values (P = .19). Importantly, no participant was categorized as being at risk for hyperthermia, based upon the aforementioned criteria. For the hot environment, ΔTGI at the end of the exercise bout was greater for the high group when compared to the low group (P = .049). Notably, 33% of the moderate cohort and 56% of the high cohort reached or exceeded a core temperature of 38.5°C, while none in the low cohort exceeded this threshold. These data suggest that individuals with a substantial %TBSA burned can perform mild/moderate intensity exercise for 60 minutes in temperate environmental conditions without risk of excessive elevations in TGI. Conversely, the risk of excessive elevations in TGI during mild/moderate intensity exercise in a hot environment increases with the %TBSA burned.

Preoperative expectations, postoperative satisfaction and patient directed priorities for clinical burn research

INTRODUCTION

Burn patients receiving split thickness skin grafting are left with scarring and chronically dysfunctional grafted skin. Given evidence that patients' preoperative expectations mediate postoperative outcomes and satisfaction, we described burn patients' experience, expectations, and satisfaction with their skin graft, their views towards a cell based clinical trial to improve their graft and identified graft outcome measures for use in future studies.

METHODS

Data were collected via questionnaires preoperatively, one, and three months postoperatively. Longitudinal analyses assessed change over time.

RESULTS

Expectations of graft function were consistent pre- and postoperatively. Expectations of graft appearance showed significant decrease over time (β1 = -0.290, p = 0.008). Significant improvements in skin function (β1 = 0.579, p = 0.000) and appearance (β1 = 0.247, p = 0.025) at the wound site during recovery were observed. Patients noted great difference between grafted and normal skin. Patient satisfaction with their graft did not change significantly over time. Patients were willing to participate in a cell based clinical trial to improve graft symptomology and prioritized improvements in scarring, redness, sensation, and elasticity.

CONCLUSIONS

Outcome measures in trials advancing skin grafting should reflect chronic, patient prioritized limitations. We recommend preoperative educational interventions for burn patients receiving grafting to improve postoperative satisfaction.

Burn Injury Complications Impacting Rehabilitation

Successful post-burn rehabilitation requires an understanding of a wide range of complications to maximize functional recovery. This article reviews a range of potential challenges including burn scar contracture, amputation, peripheral nerve injury, heterotopic ossification, dysphagia, altered skin physiology, pain, and pruritis. The overall focus is to serve as a guide for post-injury therapy and rehabilitation spanning the phases of care and considering evidence-based approaches, prevention, and treatment with an ultimate goal of aiding in the functional recovery and long-term quality of life for burn survivors.

Hypertrophic Scar

Hypertrophic scars frequently develop post-burn, and are characterized by their pruritic, painful, raised, erythematous, dyschromic, and contractile qualities. This article aims to synthesize knowledge on the clinical and molecular development, evolution, management, and measurement of hypertrophic burn scar for both patient and clinician knowledge.

Key Exercise Concepts in the Rehabilitation from Severe Burns

This article presents information on the benefits of exercise in counteracting the detrimental effects of bed rest, and/or severe burns. Exercise is key for maintaining physical function, lean body mass, metabolic recovery, and psychosocial health after major burn injuries. The details of an exercise training program conducted in severely burned persons are presented, as well as information on the importance of proper regulation of body temperature during exercise or physical activity. The sections on exercise and thermoregulation are followed by a section on the role of exercise in scarring and contractures. Finally, gaps in the current knowledge of exercise, thermoregulation, and contractures are presented.

Outcomes of Patients with Amputation following Electrical Burn Injuries

This study aimed to examine patients who sustained amputation as a result of electrical burns and to evaluate their long-term health outcomes compared to non-electrical burn patients with amputation. A retrospective analysis was conducted on burn patients from 1993 to 2021, utilizing the Burn Model System National Database, which includes the Veterans RAND 12-Item Health Survey and the Patient-Reported Outcomes Measurement Information System 29. The data was collected at discharge, 6 months, and 12 months after the burns occurred. The findings revealed that the rate of amputation was significantly higher in electrical burn patients (30.3%) compared to non-electrical burn patients (6.6%) (p < 0.0001). At the time of discharge, electrical burn patients with amputation exhibited significantly lower physical component scores (PCS = 34.00 ± 8.98) than electrical burn patients without amputation (PCS = 44.66 ± 9.90) (p < 0.05). However, there were no significant differences in mental component scores observed between patients, regardless of the burn type or amputation. Among all patient groups, non-electrical burn survivors with amputation faced the greatest challenges in terms of physical and social well-being, likely due to larger total body surface area burns. This study emphasizes the importance of early rehabilitation for electrical burn patients with amputation and highlights the need for ongoing support, both physically and socially, for non-electrical burn survivors with amputation. These findings, consistent with previous studies, underscore the necessity of providing psychological support to all burn survivors.

Long-Term Outcomes in Burn Patients

Better understanding of long-term outcomes after burn injury is essential for the burn clinician. Contractures are present in almost half of patients at discharge. Although less common, neuropathy and heterotopic ossification may be missed or go unaddressed. Close attention to psychological distress and to challenges with community reentry is essential. Obviously long-term problems with skin issues occur but other issues must be attended to maximize health and quality of life after injury. Facilitating access to community resources and providing long-term medical follow-up should be the standard of care.

Novel Design and Implementation of an Integrated Burn Rehabilitation Clinical Fellowship

ABSTRACT

Postgraduate medical burn rehabilitation training has been limited, with very few academic physiatrists specializing in burn rehabilitation. As a result, there are no existing models for postgraduate burn rehabilitation education. A 12-mo comprehensive clinical fellowship in burn rehabilitation was offered through a tertiary burn center with formal university accreditation. In this article, the clinical, educational, and skill-based goals developed and implemented for this novel fellowship was outlined to serve as a blueprint for future fellowships in burn rehabilitation, as well as reflections on the experience.

Long-term results of split-thickness skin grafting with and without additional dermal matrix in severe traumatic soft tissue defects of the lower limb

PURPOSE

Aim of this study was to compare the use of split-thickness skin graft (STSG) with and without additional MatriDerm^® application in a predominantly one-step procedure for the treatment of severe traumatic soft tissue defects of the lower limb.

METHODS

This retrospective study included patients treated in a European level I trauma center between June 2013 and July 2018 in terms of a severe traumatic soft tissue defect of the lower extremity using STSG alone or in combination with the acellular dermal substitute MatriDerm^®. The healing of the soft tissue defect was measured by assessment of the take rate. Outcome quality of the scar tissue was assessed using the Vancouver Scar Scale.

RESULTS

A total of 147 cases were included in this study. The overall healing rate (number of patients with take rate ≥ 75%) was 88/147 (60%) and did not demonstrate significant differences between the treatment groups (p = 0.15). Despite the difference in wound complexity between the treatment groups, there was no difference regarding the scar tissue quality 12 months postoperatively. In about 25% of all cases, a post-operative event was mentioned that had to be revised surgically.

CONCLUSION

Surgical treatment with STSG and additional MatriDerm^® application can be recommended as satisfactory alternative for dermis replacement in patients with severe skin defects, independent of age. The additional MatriDerm^® use allows for bridging of exposed ligaments, tendons, vessels or bones without relevant differences in cosmetical outcome.

Advances in Skin Tissue Engineering and Regenerative Medicine

There are an estimated 500,000 patients treated with full-thickness wounds in the United States every year. Fire-related burn injuries are among the most common and devastating types of wounds that require advanced clinical treatment. Autologous split-thickness skin grafting is the clinical gold standard for the treatment of large burn wounds. However, skin grafting has several limitations, particularly in large burn wounds, where there may be a limited area of non-wounded skin to use for grafting. Non-cellular dermal substitutes have been developed but have their own challenges; they are expensive to produce, may require immunosuppression depending on design and allogenic cell inclusion. There is a need for more advanced treatments for devastating burns and wounds. This manuscript provides a brief overview of some recent advances in wound care, including the use of advanced biomaterials, cell-based therapies for wound healing, biological skin substitutes, biological scaffolds, spray on skin and skin bioprinting. Finally, we provide insight into the future of wound care and technological areas that need to be addressed to support the development and incorporation of these technologies.

Evaluating parental knowledge of pediatric burns first aid in Ireland and the effectiveness of an educational intervention improving knowledge

AIM

Burns represent a large portion of injuries attending emergency departments each year, with children accounting for the biggest proportion. Appropriate first aid has been shown to help improve the outcome of burns, and decrease the need for surgical intervention. Several studies outside of Ireland demonstrate inadequate parental knowledge of burns first aid, but few evaluated interventions to improve knowledge. Consequently our aim was to assess parental/caregiver knowledge in Ireland, and determine if knowledge levels could be raised following a short educational video intervention.

METHODS

An educational video based on current European and British best practice guidelines was produced and shown to parents/caregivers waiting in the Pediatric Outpatients Department after a previously validated pre-intervention questionnaire was completed. A post intervention questionnaire was completed following the video. Questionnaires assessed demographics, previous experience and included scenarios to test parental knowledge.

RESULTS

112 parents/caregivers (81.3% female (n = 91), 18.8% male (n = 21)) were questioned. Baseline knowledge was found to be poor overall, however this significantly improved with a simple educational video (pre-score 31.9%, post-test mean score knowledge 92.1%). Pre- and post-test scores showed a statistical significance (x² = 71.117, P < 0.001, 95% CI).No other variables analysed were shown to be statistically significant predictors of pre- or post-test scores (all p > 0.05).

CONCLUSION

The study found poor parental knowledge of burns first aid in Ireland and shows the use of an educational video was effective in raising knowledge levels.

Edward F. Adolph Distinguished Lecture. It's more than skin deep: thermoregulatory and cardiovascular consequences of severe burn injuries in humans

Each year, within the United States, tens of thousands of individuals are hospitalized for burn-related injuries. The treatment of deep burns often involves skin grafts to accelerate healing and reduce the risk of infection. The grafting procedure results in a physical disruption between the injured and subsequently debrided host site and the skin graft placed on top of that site. Both neural and vascular connections must occur between the host site and the graft for neural modulation of skin blood flow to take place. Furthermore, evaporative cooling from such burn injured areas is effectively absent, leading to greatly impaired thermoregulatory responses in individuals with large portions of their body surface area burned. Hospitalization following a burn injury can last weeks to months, with cardiovascular and metabolic consequences of such injuries having the potential to adversely affect the burn survivor for years postdischarge. With that background, the objectives of this article are to discuss 1) our current understanding of the physiology and associated consequences of skin grafting, 2) the effects of skin grafts on efferent thermoregulatory responses and the associated consequences pertaining to whole body thermoregulation, 3) approaches that may reduce the risk of excessive hyperthermia in burn survivors, 4) the long-term cardiovascular consequences of burn injuries, and 5) the extent to which burn survivors can "normalize" otherwise compromised cardiovascular responses. Our primary objective is to guide the reader toward an understanding that severe burn injuries result in significant physiological consequences that can persist for years after the injury.

The development of burn scar contractures and impact on joint function, disability and quality of life in low- and middle-income countries: A prospective cohort study with one-year follow-up

OBJECTIVE

The aim of this study was to assess the development of burn scar contractures and their impact on joint function, disability and quality of life in a low-income country.

METHODS

Patients with severe burns were eligible. Passive range of motion (ROM) was assessed using lateral goniometry. To assess the development of contractures, the measured ROM was compared to the normal ROM. To determine joint function, the normal ROM was compared to the functional ROM. In addition, disability and quality of life (QoL) were assessed. Assessments were from admission up to 12 months after injury.

RESULTS

Thirty-six patients were enrolled, with a total of 124 affected joints. The follow-up rate was 83%. Limited ROM compared to normal ROM values was observed in 26/104 joints (25%) at 12 months. Limited functional ROM was observed in 55/115 joints (48%) at discharge and decreased to 22/98 joints (22%) at 12 months. Patients who had a contracture at 12 months reported more disability and lower QoL, compared to patients without a contracture (median disability 0.28 versus 0.17 (p = 0.01); QoL median 0.60 versus 0.76 (p = 0.001)). Significant predictors of developing joint contractures were patient delay and the percentage of TBSA deep burns.

CONCLUSION

The prevalence of burn scar contractures was high in a low-income country. The joints with burn scar contracture were frequently limited in function. Patients who developed a contracture reported significantly more disability and lower QoL. To limit the development of burn scar contractures, timely access to safe burn care should be improved in low-income countries.

Interaction of Exercise Intensity and Simulated Burn Injury Size on Thermoregulation

PURPOSE

This study aimed to test the hypothesis that the elevation in internal body temperature during exercise in a hot environment is influenced by the combination of exercise intensity and BSA burned.

METHODS

Ten healthy participants (8 males, 2 females; 32 ± 9 yr; 75.3 ± 11.7 kg) completed eight exercise trials on a cycle ergometer, each with different combinations of metabolic heat productions (low, 4 W·kg-1; moderate, 6 W·kg-1) and simulated BSA burn in a hot environmental chamber (39.9°C ± 0.3°C, 20.1% ± 1.5% RH). Burns were simulated by covering 0%, 20%, 40%, or 60% of participants' BSA with a highly absorbent, vapor-impermeable material. Gastrointestinal temperature (TGI) was recorded, with the primary analysis being the increase in TGI after 60 min of exercise.

RESULTS

We identified an interaction effect for the increase in TGI (P < 0.01), suggesting TGI was influenced by both intensity and simulated burn BSA. Regardless of the percentage BSA burn simulated, the increase in TGI was similar across low-intensity trials (0.70°C ± 0.26°C, P > 0.11 for all). However, during moderate-intensity exercise, the increase in TGI was greater for the 60% (1.78°C ± 0.38°C, P < 0.01) and 40% BSA coverage trials (1.33°C ± 0.44°C, P = 0.04), relative to 0% (0.82°C ± 0.36°C). There were no differences in TGI responses between 0% and 20% trials.

CONCLUSION

These data suggest that exercise intensity influences the relationship between burn injury size and thermoregulatory responses in a hot environment.

Exercise Training Improves Microvascular Function in Burn Injury Survivors

INTRODUCTION

Vasodilator function is impaired in individuals with well-healed burn injuries; however, therapeutic interventions that lessen or reverse this maladaptation are lacking. The purpose of this study was to test the hypothesis that a 6-month community-based exercise training program would increase microvascular dilator function in individuals with well-healed burn injuries, irrespective of the magnitude of the injured body surface area. Further, we hypothesize that macrovascular dilator function would remain unchanged posttraining.

METHODS

Microvascular function (forearm reactive hyperemia), macrovascular function (brachial artery flow-mediated dilation), and the maximal vasodilatory response after ischemic handgrip exercise (an estimate of microvascular remodeling) were assessed before and after exercise training in nonburned control subjects (n = 11) and individuals with burn injuries covering a moderate body surface area (26% ± 7%; n = 13) and a high body surface area (59% ± 15%; n = 19).

RESULTS

Peak vascular conductance and area under the curve during postocclusive reactive hyperemia increased from pretraining to posttraining in control and burn injury groups (both P < 0.05), the magnitude of which did not differ between groups (both P = 0.6). Likewise, the maximal vasodilatory response after ischemic handgrip exercise increased in all groups after exercise training (P < 0.05). Macrovascular dilator function did not differ across time or between groups (P = 0.8).

CONCLUSIONS

These data suggest that a community-based exercise training program improves microvascular function in individuals with well-healed burn injuries, which may be due in part to vascular remodeling.

Exercise Thermoregulation with a Simulated Burn Injury: Impact of Air Temperature

The U.S. Army's Standards of Medical Fitness (AR 40-501) states: "Prior burn injury (to include donor sites) involving a total body surface area of 40% or more does not meet the standard." However, the standard does not account for the interactive effect of burn injury size and air temperature on exercise thermoregulation.

PURPOSE

To evaluate whether the detrimental effect of a simulated burn injury on exercise thermoregulation is dependent on air temperature.

METHODS

On eight occasions, nine males cycled for 60 min at a fixed metabolic heat production (6 W·kg) in air temperatures of 40°C or 25°C with simulated burn injuries of 0% (Control), 20%, 40%, or 60% of total body surface area (TBSA). Burn injuries were simulated by covering the skin with an absorbent, vapor-impermeable material to impede evaporation from the covered areas. Core temperature was measured in the gastrointestinal tract via telemetric pill.

RESULTS

In 40°C conditions, greater elevations in core temperature were observed with 40% and 60% TBSA simulated burn injuries versus Control (P < 0.01). However, at 25°C, core temperature responses were not different versus Control with 20%, 40%, and 60% TBSA simulated injuries (P = 0.97). The elevation in core temperature at the end of exercise was greater in the 40°C environment with 20%, 40%, and 60% TBSA simulated burn injuries (P ≤ 0.04).

CONCLUSIONS

Simulated burn injuries ≥20% TBSA exacerbate core temperature responses in hot, but not temperate, air temperatures. These findings suggest that the U.S. Army's standard for inclusion of burned soldiers is appropriate for hot conditions, but could lead to the needless discharge of soldiers who could safely perform their duties in cooler training/operational settings.

The effects of cross-linking a collagen-elastin dermal template on scaffold bio-stability and degradation

MatriDerm is a collagen-elastin dermal template that promotes regeneration in full-thickness wound repair. Due to its noncross-linked status, MatriDerm biodegrades quickly in a wound. Facilitating vascularization and dermal repair, it is desirable for MatriDerm to remain present until the wound healing process is complete, optimizing tissue regeneration and reducing wound contraction. The aim of this study was to investigate the effect of cross-linking MatriDerm on its mechanical and biological properties and to enhance its regenerative functionality. MatriDerm was chemically cross-linked and characterized in comparison with noncross-linked MatriDerm. Scaffold properties including surface morphology, protein release and mechanical strength were assessed. Cell-scaffold interaction, cell proliferation and migration were examined using human dermal fibroblasts. Scaffold biodegradation and its impact on wound healing and contraction were studied in a mouse model. Results showed that cross-linked MatriDerm displayed a small reduction in pore size, significantly less protein loss and a threefold increase in tensile strength. A significant increase in fibroblast proliferation and migration was observed in cross-linked MatriDerm with reduced scaffold contraction in vitro. In the mouse model, noncross-linked MatriDerm was almost completely biodegraded after 14 days whereas cross-linked MatriDerm remained intact. No significant difference in wound contraction was found between scaffolds. In conclusion, cross-linked MatriDerm showed a significant increase in stability and strength, enhancing its durability and cell-scaffold interaction. in vivo analysis showed cross-linked MatriDerm had a reduced biodegradation rate with a similar host response. The extended structural integrity of cross-linked MatriDerm could potentially facilitate improved skin tissue regeneration, promoting the formation of a more pliable scar.

A Scoping Review on the Long-Term Outcomes in Persons with Adult-Acquired Burn Injuries

Adult-acquired burn injuries are a life-altering event that can lead to debilitating functional or psychological impairments. With advancements in health care resulting in decreased mortality rates, survivors of burn injuries can expect to live longer. This warrants a shift in focus to better understand what happens to adults once they are discharged from the hospital into the community. Therefore, the purpose of this scoping review was to map the literature regarding the long-term outcomes of community-dwelling adult-acquired burn survivors. A computer-assisted literature search was conducted on literature from January 1, 2000 to August 31, 2018 utilizing four large databases (MEDLINE, EMBASE, CINHAL, and PsycINFO). Articles were included if they had a minimum of five individuals with a burn injury as a result of an accidental injury who were at least 18 years of age at the time of injury. Fifty-four articles were found suitable for inclusion in this review. The majority of studies were conducted in the United States and were longitudinal in design. Four themes were apparent from the articles: postburn complications, psychosocial outcomes, quality of life, and community participation. Data are lacking with respect to outcomes more than 5 years postburn as well as qualitative research. Furthermore, more literature is needed to understand the impact of postburn complications, coping strategies, and posttraumatic growth as well as barriers to community participation. Overall, there is an emerging body of literature that describes the long-term outcomes of adult-acquired burn survivors up to 5 years postburn.

Social Interactions and Social Activities After Burn Injury: A Life Impact Burn Recovery Evaluation (LIBRE) Study

Social interactions and activities are key components of social recovery following burn injuries. The objective of this study is to determine the predictors of these areas of social recovery. This study provides a secondary analysis of a cross-sectional survey of adult burn survivors. The Life Impact Burn Recovery Evaluation-192 was administered to 601 burn survivors for the field-testing of the Life Impact Burn Recovery Evaluation Profile. Survivors aged 18 years and older with injuries ≥5% total BSA or burns to critical areas (hands, feet, face, or genitals) were eligible to participate. Multivariate linear regression analyses were used to determine predictors of the Social Activities and Social Interactions scale scores. A total of 599 people completed the Social Interactions and Social Activities scales. Of these, 77% identified as White Non-Hispanic, 55% were female, 55% were unmarried, and 80% had burns to critical areas. Participants had a mean age of 45 years, a mean time since burn injury of 15 years, and a mean burn size of 41% total BSA. Younger age (P < .01) and being married/living with a significant other (P ≤ .01) were associated with higher Social Activities and Social Interactions scale scores. Individual item responses reveal that survivors had lower scores on items related to participating in outdoor activities (30.4%) or feeling uncomfortable with their appearance (32.4% report dressing to avoid stares). Social interactions and activities are long-term challenges for burn survivors. It is important for clinicians to identify patients who may struggle with social recovery in order to focus on future community-based interventions.

An Examination of Follow-up Services Received by Vulnerable Burn Populations: A Burn Model System National Database Study

While disparities in healthcare outcomes and services for vulnerable populations have been documented, the extent to which vulnerable burn populations demonstrate disparities in long-term care is relatively underexplored. This study's goal was to assess for differences in long-term occupational or physical therapy (OT/PT) and psychological service use after burn injury in vulnerable populations. Data from the Burn Model System National Database (2006-2015) were analyzed. The vulnerable group included participants in one or more of these categories: 65 years of age or older, nonwhite, no insurance or Medicaid insurance, preinjury receipt of psychological therapy or counseling, preinjury alcohol and/or drug misuse, or with a preexisting disability. Primary outcomes investigated were receipt of OT/PT and psychological services. Secondary outcomes included nine OT/PT subcategories. Outcomes were examined at 6, 12, and 24 months postinjury. One thousand one hundred thirty-six burn survivors (692 vulnerable; 444 nonvulnerable) were included. The vulnerable group was mostly female, unemployed at time of injury, and with smaller burns. Both groups received similar OT/PT and psychological services at all time points. Adjusted regression analyses found that while the groups received similar amounts services, some vulnerable subgroups received significantly more services. Participants 65 years of age or older, who received psychological therapy or counseling prior to injury, and with a preexisting disability received more OT/PT and psychological or peer support services at follow-up. Overall, vulnerable and nonvulnerable groups received comparable OT/PT and psychological services. The importance of long-term care among vulnerable subgroups of the burn population is highlighted by this study. Future work is needed to determine adequate levels of follow-up services.

Adult Human Dermal Progenitor Cell Transplantation Modulates the Functional Outcome of Split-Thickness Skin Xenografts

Following full-thickness skin injuries, epithelialization of the wound is essential. The standard of care to achieve this wound "closure" in patients is autologous split-thickness skin grafting (STSG). However, patients living with STSGs report significant chronic impairments leading to functional deficiencies such as itch, altered sensation, fragility, hypertrophic scarring, and contractures. These features are attributable to the absence of functional dermis combined with the formation of disorganized fibrotic extracellular matrix. Recent work has demonstrated the existence of dermal progenitor cells (DPCs) residing within hair follicles that function to continuously regenerate mesenchymal tissue. The present work examines whether cultured DPCs could regenerate dermis within an STSG and improve overall graft function. Adult human DPCs were transplanted into a full-thickness skin wound in immune-compromised mice and closed with a human STSG. At 3 months, human DPCs (hDPCs) had successfully integrated into the xenograft and differentiated into various regionally specified phenotypes, improving both viscoelastic properties of the graft and mitigating pruritus.

One center's experience developing a burn outpatient registry

INTRODUCTION

Recent advances in burn care have resulted in the transition of care from inpatient to outpatient. There is a growing appreciation that with improved survival, meaningful markers of quality need to include recovery of form, function, and reconstruction. Capture of the data describing care delivered in the outpatient setting is being missed.

METHODS

Development of our outpatient database included providers, registrar, program manager, and outpatient nursing staff. Data points were included if they described the population, and epidemiology of our patients, were useful for programmatic changes and improvements as well as anticipated research focus areas.

RESULTS

The database platform chosen was Midas+™ because it was in use by hospital quality and integrated with the electronic medical record. Fields were customized based on changing program needs and are updated for new programs or outcomes measures. Reports can be easily built and both outpatients and inpatients are included. This allows for longitudinal tracking of burn patients. Ongoing additions to original data points include variables to track outcomes related to laser therapy for scar management, time to custom garment donning, and to track functional outcomes. Epidemiologic data collected is used to target high-risk populations for prevention and outreach efforts. Outcome data is used for evaluation of programs and care.

CONCLUSIONS

High quality databases serve to measure effectiveness of care and offer insight for areas of improvement. There is a clear need for inclusion of outpatient activity in the National Burn Registry (NBR).

Progressive exercise training improves maximal aerobic capacity in individuals with well-healed burn injuries

Long-term rehabilitative strategies are important for individuals with well-healed burn injuries. Such information is particularly critical because patients are routinely surviving severe burn injuries given medical advances in the acute care setting. The purpose of this study was to test the hypothesis that a 6-mo community-based exercise training program will increase maximal aerobic capacity (V̇o_2max) in subjects with prior burn injuries, with the extent of that increase influenced by the severity of the burn injury (i.e., percent body surface area burned). Maximal aerobic capacity (indirect calorimetry) and skeletal muscle oxidative enzyme activity (biopsy of the vastus lateralis muscle) were measured pre- and postexercise training in noninjured control subjects (n = 11) and in individuals with well-healed burn injuries (n = 13, moderate body surface area burned; n = 20, high body surface area burned). Exercise training increased V̇o_2max in all groups (control: 15 ± 5%; moderate body surface area: 11 ± 3%; high body surface area: 11 ± 2%; P < 0.05), though the magnitude of this improvement did not differ between groups (P = 0.7). Exercise training also increased the activity of the skeletal muscle oxidative enzymes citrate synthase (P < 0.05) and cytochrome c oxidase (P < 0.05), an effect that did not differ between groups (P = 0.2). These data suggest that 6 mo of progressive exercise training improves V̇o_2max in individuals with burn injuries and that the magnitude of body surface area burned does not lessen this adaptive response.

Identification of Merkel cells associated with neurons in engineered skin substitutes after grafting to full thickness wounds

Engineered skin substitutes (ESS), prepared using primary human fibroblasts and keratinocytes with a biopolymer scaffold, were shown to provide stable closure of excised burns, but relatively little is known about innervation of ESS after grafting. This study investigated innervation of ESS and, specifically, whether Merkel cells are present in healed grafts. Merkel cells are specialized neuroendocrine cells required for fine touch sensation in skin. We discovered cells positive for keratin 20 (KRT20), a general marker for Merkel cells, in the basal epidermis of ESS after transplantation to mice, suggesting the presence of Merkel cells. Cells expressing KRT20 were not observed in ESS in vitro. However, widely separated KRT20-positive cells were observed in basal epidermis of ESS by 2 weeks after grafting. By 4 weeks, these cells increased in number and expressed keratins 18 and 19, additional Merkel cells markers. Putative Merkel cell numbers increased further between weeks 6 and 14; their densities varied widely and no specific pattern of organization was observed, similar to Merkel cell localization in human skin. KRT20-positive cells co-expressed epidermal markers E-cadherin and keratin 15, suggesting derivation from the epidermal lineage, and neuroendocrine markers synaptophysin and chromogranin A, consistent with their identification as Merkel cells. By 4 weeks after grafting, some Merkel cells in engineered skin were associated with immature afferents expressing neurofilament-medium. By 8 weeks, Merkel cells were complexed with more mature neurons expressing neurofilament-heavy. Positive staining for human leukocyte antigen demonstrated that the Merkel cells in ESS were derived from grafted human cells. The results identify, for the first time, Merkel cell-neurite complexes in engineered skin in vivo. This suggests that fine touch sensation may be restored in ESS after grafting, although this must be confirmed with future functional studies.

Vasodilator function is impaired in burn injury survivors

The effect of severe burn injury on vascular health is unknown. We tested the hypothesis that, compared with nonburn control subjects, vasodilator function would be reduced and that pulse-wave velocity (a measure of arterial stiffness) would be increased in individuals with prior burn injuries, the extent of which would be associated with the magnitude of body surface area having sustained a severe burn. Pulse-wave velocity and macrovascular (flow-mediated dilation) and microvascular (reactive hyperemia) dilator functions were assessed in 14 nonburned control subjects and 32 age-matched subjects with well-healed burn injuries. Fifteen subjects with burn injuries covering 17-40% of body surface area were assigned to a moderate burn injury group, and 17 subjects with burn injuries covering >40% of body surface area were assigned to a high burn injury group. Pulse-wave velocity [ P = 0.3 (central) and P = 0.3 (peripheral)] did not differ between the three groups. Macrovascular dilator function was reduced in the moderate ( P = 0.07) and high ( P < 0.05) burn injury groups compared with the control group. Likewise, peak vascular conductance during postocclusive reactive hyperemia differed from the moderate burn injury group ( P = 0.08 vs. control) and the high burn injury group ( P < 0.05 vs. control). These data suggest that vasodilator function is impaired in well-healed burn injury survivors, with the extent of impairment not dependent on the magnitude of body surface area having sustained a severe burn injury.

First aid for children's burns in the US and UK: An urgent call to establish and promote international standards

INTRODUCTION

Appropriate first aid can reduce the morbidity of burns, however, there are considerable variations between international first aid recommendations. We aim to identify, and compare first aid practices in children who present to Emergency Departments (ED) with a burn.

METHODS

A prospective cross-sectional study of 500 children (0-16 completed years) presenting with a burn to a paediatric ED in the UK (Cardiff) and the USA (Denver, Colorado), during 2015-2017. The proportion of children who had received some form of first aid and the quality of first aid were compared between cities.

RESULTS

Children attending hospital with a burn in Cardiff were 1.47 times more likely (RR 1.47; CI 1.36, 1.58), to have had some form of first aid than those in Denver. Denver patients were 4.7 time more likely to use a dressing and twice as likely to apply ointment/gel/aloe vera than the Cardiff cohort. First aid consistent with local recommendations was only administered to 26% (128/500) of children in Cardiff and 6% (31/500) in Denver. Potentially harmful first aid e.g. application of food, oil, toothpaste, shampoo or ice was applied to 5% of children in Cardiff and 10% in Denver.

CONCLUSION

A low number of children received optimal burns first aid, with potentially harmful methods applied in a considerable proportion of cases. There is an urgent need for internationally agreed, evidence-based burn first aid recommendations.

Three Years After Black Saturday: Long-Term Psychosocial Adjustment of Burns Patients as a Result of a Major Bushfire

Despite increasing evidence that burn injuries can result in multiple psychological sequelae, little is known about the long-term psychosocial adjustment to burns sustained in a major bushfire. The aim of the present study was to assess long-term psychological distress and health-related quality of life in Australian burns patients as a result of the 2009 Black Saturday bushfires. Eight male and five female burns patients with a mean age of 53.92 (SD = 11.82) years who received treatment at a statewide burns service participated in the study. A battery of standardized questionnaires was administered to assess general psychological distress, burns-specific and generic health-related quality of life, alcohol use, and specific psychological symptoms of posttraumatic stress disorder, depression, and anxiety. The results revealed that more than 3 years after Black Saturday 33% of the burns patients still suffered "high" to "very high" levels of general distress, whereas 58% fulfilled partial or full criteria for posttraumatic stress disorder. Furthermore, participants still experienced significantly impaired physical health functioning as compared to their preinjury status including limitations in work-based activities, increased bodily pain, and lower vitality overall. The trajectory of distress varied for participants. Some individuals experienced little distress overall, whereas others displayed a decline in their stress levels over time. Notwithstanding, some patients maintained high levels of distress throughout or experienced an increase in distress at a later stage of recovery. The results point to the importance of psychosocial screening to identify distress early. Follow-up assessments are crucial to diagnose individuals with chronic or late onset of distress.

Long-Term Outcomes in Patients Surviving Large Burns: The Musculoskeletal System

The authors have previously described long-term outcomes related to the skin in patients surviving large burns. The objective of this study was to describe the long-term musculoskeletal complications following major burn injury. This is a cross-sectional descriptive study that includes a one-time evaluation of 98 burn survivors (mean age = 47 years; mean TBSA = 57%; and mean time from injury = 17 years), who consented to participate in the study. A comprehensive history and physical examination was conducted by a senior and experienced Physical Medicine and Rehabilitation physician. In addition to completing a Medical Problem Checklist, subjects also completed the Burn-Specific Health Scale (Abbreviated 80 item), a self-report measure used to review the level of functional adaptation. Joint pain, joint stiffness, problems walking or running, fatigue, and weak arms and hands are conditions that continue to be reported at an average of 17 years from the time of burn injury. Seventy-three percent (68 of 93) of the study sample were found to have a limitation of motion and areas most affected were the neck (47%), hands (45%), and axilla (38%). The global (Burn-Specific Health Scale-total) score for the overall sample was 0.78. Subjects with limitation of motion had significant difficulty in areas of mobility, self-care, hand function, and role activities. This study underscores the importance of long-term follow-up care and therapeutic interventions for survivors of major burn injury, as they continue to have significant and persistent burn-related impairments even several years following injury.

Burn care and rehabilitation in Australia: health professionals' perspectives

OBJECTIVE

To understand health professionals' perspectives of burn care and rehabilitation.

DESIGN

Qualitative and semi-structured interviews.

SETTING

Australian burn and rehabilitation units.

PARTICIPANTS

Twenty-two clinicians working in burns units across disciplines and healthcare settings.

RESULTS

The data portrayed the health professionals' perspectives of burn care and rehabilitation in Australia. Three themes were identified: (1) interprofessional collaboration; (2) integrated community care, and (3) empowering patients to self-care.

CONCLUSION

Burn care and rehabilitation remains a complex and a challenging area of care with limited access to burn services especially in rural and remote areas. Interprofessional training and education of health professionals involved with the complex care of burn injury remains a key element to support and sustain the long-term rehabilitation requirements for patients and their families. Empowering patients to develop independence early in their rehabilitation is fundamental to their ongoing recovery. A burns model of care that embraces a multidisciplinary collaboration and integrated care across the continuum has the potential to positively impact recovery and improve health outcomes. Implications for rehabilitation Burn care and rehabilitation remains a complex and challenging area of care. Managing the rehabilitation phase after burn injury can be as complex as managing the acute phase. Interprofessional collaboration, integrated community care, and empowering patients to self-care are key elements for sustaining the rehabilitation of adults with burn injuries.

Using biomaterials to rewire the process of wound repair

Wound healing is one of the most complex processes that our bodies must perform. While our ability to repair wounds is often taken for granted, conditions such as diabetes, obesity, or simply old age can significantly impair this process. With the incidence of all three predicted to continue growing into the foreseeable future, there is an increasing push to develop strategies that facilitate healing. Biomaterials are an attractive approach for modulating all aspects of repair, and have the potential to steer the healing process towards regeneration. In this review, we will cover recent advances in developing biomaterials that actively modulate the process of wound healing, and will provide insight into how biomaterials can be used to simultaneously rewire multiple phases of the repair process.

Near-death experiences, posttraumatic growth, and life satisfaction among burn survivors

Survivors of large burns may face positive and negative psychological after-effects from close-to-death injuries. This study is the first to examine their near-death experiences (NDEs) and posttraumatic growth (PTG) and life satisfaction afterwards. With an available sample of 92 burn survivors, half met the criteria for an NDE using an objective scale. Those who indicated religion was a source of strength and comfort had high scores on life satisfaction, PTG, and the NDE Scale. Individuals with larger burns reported greater PTG than those with smaller total body surface area burned (TBSA). There were no significant differences on life satisfaction, PTG, or NDEs when examined by gender or years since the burn injury. Elements of the NDE most frequently reported were: An altered sense of time, a sense of being out of the physical body, a feeling of peace, vivid sensations, and sense of being in an "other worldly" environment. Social workers and other health providers need to be comfortable helping burn survivors discuss any NDEs and process these through survivors' spirituality and religious belief systems as they recover.

The benefits of ultrasound-guided continuous sensory nerve blockade in the setting of burn injury: a case report of bilateral continuous superficial peroneal nerve blockade in a patient with severe sleep apnea

The management of pain after burn injuries is a clinical challenge magnified in patients with significant comorbidities. Presently, burn pain is treated via a wide variety of modalities, including systemic pharmacotherapy and regional analgesia. Although the latter can provide effective pain control in patients with burn injuries, it is relatively underused. Furthermore, the development of ultrasound guidance has allowed for novel approaches and sparing of motor nerve blockade with preference toward sensory-specific analgesia that has not been possible previously. This can result in decreased opiate use and shorter latency to initiation of rehabilitation. In this report, we describe a patient with chronic pain, morbid obesity, and severe sleep apnea who presented with uncontrolled pain resulting from a burn injury to the dorsum of his feet. The treatment consisted of multimodal analgesia and placement of bilateral continuous superficial peroneal nerve catheters, as he underwent skin grafting and postprocedural hydrotherapy. This novel approach allowed for sparing of postprocedural opiates with positive clinical results.

Patient opinion of scarring is multidimensional: An investigation of the POSAS with confirmatory factor analysis

INTRODUCTION

Scarring is a significant consequence for patients following a burn. Understanding how patients perceive the physiological scar and define scar severity may provide valuable information regarding how the scar influences quality of life after burn. The Patient and Observer Scar Assessment Scale was the first scar assessment tool validated to include the patients' evaluation of the scars physical qualities, following a burn. Validation studies of this tool have previously been conducted for a discrete scar-site after burn. The aim of this study was to assess the structural validity of the POSAS to capture the patients' evaluation of the total area of burn scar(s).

METHOD

Statistical analysis was based on 508 completed POSAS forms from 358 patients. Exploratory factor analysis (EFA) was used initially to identify the number of factors within the tool, then confirmatory factor analysis (CFA) using structural equation modelling explored areas of misfit within each factor and whether the model provided a predicable structure to capture patient perception of scar severity.

RESULTS/DISCUSSION

The CFA analysis confirmed that a two dimensional model was superior to a unidimensional model when assessing the patient opinion of their total burn scar. The two dimensions were the physical scar (color, stiffness, thickness and irregularity) and the sensory scar (pain and itch). Further strain analysis of the two factor model identified additional domains. Independent factors influenced the perception of color forming a separate subdomain within the physical domain. Color is a visual characteristic, whereas the other three are predominantly tactile characteristics. A significant relationship between thickness and irregularity suggested they may form another subdomain, however further research is required to confirm this. Both pain and itch were recognized as independent, multidimensional latent variables, which require assessment tools with multidimensional structures.

CONCLUSIONS

When assessing the entire burn scar, three independent dimensions influence patient perception: (1) the physical scar, (2) pain and (3) itch. Within the physical domain, color formed a visual subdomain separate to a tactile subdomain. Further development of these domains within a high-order multi-dimensional structure is recommended.

The construction and implementation of a novel postburn pruritus scale for infants and children aged five years or less: introducing the Toronto Pediatric Itch Scale

The authors' objectives were to design, refine, validate and implement a behavior-anchored postburn pruritus scale for children aged 5 years or less. We engaged a range of professionals involved in the care of children with burns. We used Q-methodology in interprofessional team exercises to identify and stratify itch behaviors into categories of increasing severity, and then iteratively refined these into a draft scale. We used a range of quantitative and qualitative techniques to assess the utility, feasibility, and validity of the scale and refined it accordingly. During the implementation phase we collected some preliminary reliability data. We generated a 4-point scale of itch severity with simple descriptors of each score. We also designed a separate guidance note and example behaviors that could be used to orientate new users without the need for rater training. End-user interviews revealed high levels of feasibility and content validity. The reliability data showed moderate inter-observer agreement, with a Cohen's kappa of 0.52 (P < .001). We have developed and implemented a behavioral post-burn pruritus scale for use in children aged less than 5 years and have demonstrated its utility, feasibility, validity, and reliability. The development of a validated symptom scoring scales will allow for the conduct of high-quality quantitative clinical trials and the subsequent implementation of evidence-based management protocols.

Race Does Not Predict Melanocyte Heterogeneous Responses to Dermal Fibroblast-Derived Mediators

Introduction

Abnormal pigmentation following cutaneous injury causes significant patient distress and represents a barrier to recovery. Wound depth and patient characteristics influence scar pigmentation. However, we know little about the pathophysiology leading to hyperpigmentation in healed shallow wounds and hypopigmentation in deep dermal wound scars. We sought to determine whether dermal fibroblast signaling influences melanocyte responses.

Methods and Materials

Epidermal melanocytes from three Caucasians and three African-Americans were genotyped for single nucleotide polymorphisms (SNPs) across the entire genome. Melanocyte genetic profiles were determined using principal component analysis. We assessed melanocyte phenotype and gene expression in response to dermal fibroblast-conditioned medium and determined potential mesenchymal mediators by proteome profiling the fibroblast-conditioned medium.

Results

Six melanocyte samples demonstrated significant variability in phenotype and gene expression at baseline and in response to fibroblast-conditioned medium. Genetic profiling for SNPs in receptors for 13 identified soluble fibroblast-secreted mediators demonstrated considerable heterogeneity, potentially explaining the variable melanocyte responses to fibroblast-conditioned medium.

Discussion

Our data suggest that melanocytes respond to dermal fibroblast-derived mediators independent of keratinocytes and raise the possibility that mesenchymal-epidermal interactions influence skin pigmentation during cutaneous scarring.

Aerobic Fitness Is Disproportionately Low in Adult Burn Survivors Years After Injury

A maximal aerobic capacity below the 20th percentile is associated with an increased risk of all-cause mortality (Blair 1995). Adult Adult burn survivors have a lower aerobic capacity compared with nonburned adults when evaluated 38 ± 23 days postinjury (deLateur 2007). However, it is unknown whether burn survivors with well-healed skin grafts (ie, multiple years postinjury) also have low aerobic capacity. This project tested the hypothesis that aerobic fitness, as measured by maximal aerobic capacity (VO2max), is reduced in well-healed adult burn survivors when compared with normative values from nonburned individuals. Twenty-five burn survivors (36 ± 12 years old; 13 females) with well-healed split-thickness grafts (median, 16 years postinjury; range, 1-51 years) covering at least 17% of their BSA (mean, 40 ± 16%; range, 17-75%) performed a graded cycle ergometry exercise to test volitional fatigue. Expired gases and minute ventilation were measured via a metabolic cart for the determination of VO2max. Each subject's VO2max was compared with sex- and age-matched normative values from population data published by the American College of Sports Medicine, the American Heart Association, and recent epidemiological data (Aspenes 2011). Subjects had a VO2max of 29.4 ± 10.1 ml O2/kg body mass/min (median, 27.5; range, 15.9-53.3). The use of American College of Sports Medicine normative values showed that mean VO2max of the subjects was in the lower 24th percentile (median, 10th percentile). A total of 88% of the subjects had a VO2max below American Heart Association age-adjusted normative values. Similarly, 20 of the 25 subjects had a VO2max in the lower 25% percentile of recent epidemiological data. Relative to nongrafted subjects, 80 to 88% of the evaluated skin-graft subjects had a very low aerobic capacity. On the basis of these findings, adult burn survivors are disproportionally unfit relative to the general U.S. population, and this puts them at an increased risk of all-cause mortality (Blair 1995).