Sepsis in the burn patient: a different problem than sepsis in the general population

Comparison of the diagnostic accuracies of various biomarkers and scoring systems for sepsis: A systematic review and Bayesian diagnostic test accuracy network meta-analysis

PURPOSE

Sepsis affects approximately 50 million people worldwide, resulting in 11 million deaths annually. Conflicting results and insufficient evidence comparing performance biomarkers exist. The study aimed to comprehensively compare available biomarkers and clinical scores for detecting sepsis since its redefinition in 2016 with this systematic review and Bayesian diagnostic test accuracy network meta-analysis.

MATERIALS AND METHODS

We conducted searches in the PubMed, EMBASE, and Scopus databases between January 2016 and December 2023. Eligible studies assessed the diagnostic accuracies of biomarkers, the quick Sequential Organ Failure Assessment (qSOFA) score, or Systemic Inflammatory Response Syndrome (SIRS) criteria in detecting sepsis. Bivariate hierarchical random effects arm-based beta-binomial models were used for quantitative synthesis (PROSPERO Registration Number: CRD42018086545).

RESULTS

We included 78 studies representing 34,234 patients and compared qSOFA score, SIRS criteria alongside seven of the most studied biomarkers: procalcitonin, C-reactive protein (CRP), interleukin-6 (IL-6), presepsin (cluster of differentiation 14 subtypes), CD64, soluble triggering receptor expressed on myeloid cells-1 (sTREM-1), and lipopolysaccharide-binding protein (LBP). CD64 demonstrated the highest superiority index, followed by sTREM-1 and presepsin (diagnostic odds ratio: 20.17 vs 18.73 and 10.04, 95 % credible interval [CrI]: 8.39-38.61 vs 1.31-83.98 and 6.71-14.24; quality of evidence: moderate vs low and low). Multivariable meta-regression analysis identified significant sources of heterogeneity, including study design, proportion of sepsis, sample size, and the risk of bias (patient selection).

CONCLUSIONS

The best diagnostic accuracy for sepsis was shown by CD64, with a moderate quality of evidence. Compared to CD64, sTREM-1 and presepsin provided suboptimal and low evidence. These biomarkers were more effective at identifying updated sepsis than clinical scores. We recommend re-considering the addition of biomarkers in screening for sepsis or sepsis-related conditions, as this could lead to more accurate and timely decisions for future clinical interventions.

Metabolic and Hormonal Changes in Pediatric Burn Patients: Mechanisms, Evidence, and Care Strategies

BACKGROUND

Burn injuries constitute a significant global health challenge, especially in pediatric populations, where they are a leading cause of morbidity and mortality. Pediatric burns require particular attention due to their unique pathophysiology, long-term consequences on growth and development, and psychological impacts.

METHODS

We propose a comprehensive review of recent advancements in understanding the key aspects of hormonal and metabolic changes in burned children, aiming to guide therapeutic interventions, improve outcomes, and reduce the global burden of these injuries.

RESULTS

Effective management of the physiological stress response in pediatric burn patients necessitates a multidisciplinary approach integrating medical, nutritional, and rehabilitative strategies. Timely nutritional support and individualized plans preserve muscle mass, promote wound healing, and reduce complications and organ dysfunction risk. Advances in pharmacological interventions, such as beta-blockers, anabolic agents, and hormonal treatment, offer promising pathways to improve recovery and mitigate long-term complications. Early mobilization and physiotherapy are essential for preventing complications of prolonged immobility, including muscle wasting, joint contractures, and functional decline; their effectiveness is closely tied to advancements in minimally invasive procedures, regenerative medicine, and reconstructive techniques, particularly for pediatric patients.

CONCLUSIONS

While current strategies have significantly improved survival and outcomes for pediatric burn patients, ongoing research is critical to refine these new care strategies.

Early appropriate therapy with polymyxin B reduces the mortality in burn sepsis caused by carbapenem-resistant gram-negative bacteria: a retrospective analysis

OBJECTIVE

The prevalence of Carbapenem-Resistant Gram-Negative Bacteria (CR-GNB) is rapidly escalating, presenting a significant global public health concern. This study aims to evaluate the survival rate of early appropriate therapy with polymyxin B (PMB), and adverse drug reactions of PMB in treating severe burn sepsis caused by CR-GNB infections.

METHODS

We retrospectively analyzed 72 patients with severe burn sepsis caused by CR-GNB infections from January 1, 2018, to December 30, 2023. These patients received a treatment regimen based on PMB for at least three days. We collected data on the patient's clinical characteristics, microbiological results, details of PMB treatment, adverse drug reactions with PMB, and mortality. We compared the 30-day mortality rates between patients who received early appropriate therapy (the timely administration of an active antimicrobial agent within 48 h after the onset of infection) and those who underwent non-early appropriate therapy, multivariate Cox regression analysis was employed to evaluate factors impacting the 30-day survival rate of patients, and the adverse drug reactions caused by PMB were also analyzed.

RESULTS

Among the 72 patients with severe burn sepsis, the clinical effective rate was 69.4% (50/72), the 30-day all-cause mortality rate was 31.9% (23/72) and the 30-day sepsis-associated mortality rate was 27.8% (20/72). The adverse drug reactions of PMB included nephrotoxicity and skin pigmentation, with an incidence of 19.4% (14/72) and 15.3% (11/72), respectively. The patients who received early appropriate therapy had a lower mortality rate, lower SOFA scores and more wound infections compared to those who underwent non-early appropriate therapy (all P < 0.05). The univariate Cox regression analysis showed that age, hypertension, SOFA score at the time of sepsis diagnosis, and early appropriate therapy with PMB were associated with both 30-day all-cause mortality and sepsis-associated mortality in severely burned patients (all P < 0.05). Additionally, In the multivariate Cox regression analysis, early appropriate therapy with PMB was identified as an independent protective factor for both 30-day all-cause mortality (HR = 0.183 [95% CI 0.071-0.468], P < 0.001) and sepsis-associated mortality (HR = 0.150 [95% CI 0.054-0.414], P < 0.001) in severely burned patients.

CONCLUSIONS

Polymyxin B is an effective option for burn sepsis patients in treating CR-GNB infections. Early appropriate therapy with PMB significantly improved the survival rate of severe burn sepsis patients infected with CR-GNB.

Insights into bloodstream infections in South African paediatric burn patients: implications for antimicrobial stewardship

INTRODUCTION

Bloodstream infections (BSIs) significantly contribute to the morbidity and mortality in paediatric burn patients from low- and middle-income countries; with common pathogens like Staphylococcus aureus, Escherichia coli, and Pseudomonas aeruginosa frequently being multidrug resistant (MDR). Due to the growing prevalence of MDR BSIs, antimicrobial stewardship needs to be improved with perhaps more targeted initial antimicrobial use. The study describes the aetiology, and timing of burn-associated BSIs and MDR infections in paediatric burn patients admitted to two paediatric surgery units in Tshwane District, South Africa.

METHODS

This multi-centre retrospective review analysed paediatric burn patients (ages 0-12 years) admitted between January 2020 and December 2022 to two public hospitals in Tshwane District, South Africa. Collected data was from patient records and the National Health Laboratory System TrakCare database. BSIs were defined according to the CDC criteria.

RESULTS

Of 245 burn patients admitted, 18.8% (n = 46) developed BSIs. From 63 positive blood cultures, the most common isolates were S. aureus (n = 19; 30%), Acinetobacter baumannii (n = 18; 29%), and P. aeruginosa (n = 10; 16%). Collectively, gram negative bacteria were responsible for most BSIs (n = 41; 65%). Candida spp accounted for 9% (n = 5). Thirty-five pathogens (56%) were MDR; this included methicillin-resistant S. aureus (MRSA) (n = 7; 11%), carbapenem-resistant A. baumannii (n = 16; 25%), and P. aeruginosa (n = 6; 10%). The median time to the first positive blood culture was 5 days (IQR: 3-12) (gram positive organisms: median: 5 days [IQR: 3-15}); gram negative organisms: median: 8 days [IQR: 4-20]; Fungal: median: 9 days [IQR: 8-27]; p-value 0.37). In the first week, S. aureus caused 32% of infections, including five MRSA cases. Gram negative bacteria dominated weeks two and three, with fungal and polymicrobial infections mainly in weeks two and four.

CONCLUSION

Our findings show that as gram positive and gram negative infections predominantly occurred early in the admission period, while polymicrobial infections are more frequently observed later. Consequently, initial targeted narrow-spectrum antimicrobial use is not possible. Instead, antimicrobial de-escalation should be prioritized once culture results are available. Efforts should shift from a focus on treating BSIs to preventing them through wound care and infection control measures. Broad-spectrum antibiotics should be used judiciously and quickly de-escalated to minimise antimicrobial resistance development.

Semi-Supervised Burn Depth Segmentation Network with Contrast Learning and Uncertainty Correction

Burn injuries are a common traumatic condition, and the early diagnosis of burn depth is crucial for reducing treatment costs and improving survival rates. In recent years, image-based deep learning techniques have been utilized to realize the automation and standardization of burn depth segmentation. However, the scarcity and difficulty in labeling burn data limit the performance of traditional deep learning-based segmentation methods. Mainstream semi-supervised methods face challenges in burn depth segmentation due to single-level perturbations, lack of explicit edge modeling, and ineffective handling of inaccurate predictions in unlabeled data. To address these issues, we propose SBCU-Net, a semi-supervised burn depth segmentation network with contrastive learning and uncertainty correction. Building on the LTB-Net from our previous work, SBCU-Net introduces two additional decoder branches to enhance the consistency between the probability map and soft pseudo-labels under multi-level perturbations. To improve segmentation in complex regions like burn edges, contrastive learning refines the outputs of the three-branch decoder, enabling more discriminative feature representation learning. In addition, an uncertainty correction mechanism weights the consistency loss based on prediction uncertainty, reducing the impact of inaccurate pseudo-labels. Extensive experiments on burn datasets demonstrate that SBCU-Net effectively leverages unlabeled data and achieves superior performance compared to state-of-the-art semi-supervised methods.

Early Detection, Diagnosis, Prevention, and Treatment of Infection to Avoid Sepsis and Septic Shock in Severely Burned Patients: A Narrative Review

The early detection, diagnosis, anticipation, and therapy of infections to prevent sepsis and septic shock remain significant challenges in cases of grave burns. This narrative review explores various tools for early infection detection, including emerging biomarkers, the American Burn Association's clinical criteria, and traditional blood parameters. A comparative study of the American Burn Association, Mann-Salinas, and Sepsis-3 criteria highlights the superior early detection capabilities of the Sepsis-3 criteria. However, the authors recommend that sepsis should be prospectively evaluated, identified, and classified by the intensive care group, rather than by relying solely on retrospective items, though the latter may still be necessary in certain cases. Advances in biomarker identification, including polymerase chain reaction (PCR) and gene expression (mRNA) profiling, offer diagnostic advantages over current methods, enabling early detection within 4 to 6 h of intensive care unit admission. Mass spectrometry also shows promise for the rapid determination of bacteria, yeast, and fungi based on bacteria protein profiles. Source control remains crucial, and the use of antibacterial topical agents has significantly improved the survival rates of severely burned patients. However, antibiotic selection must be made judiciously to avoid resistance. Despite these advancements, significant progress is still needed to improve the rapid identification, actual presence, prevention, and therapy of infections to reduce the incidence of sepsis and septic shock in this patient subgroup.

Use of Cefiderocol in Management of Resistant Gram-Negative Infections in Patients Admitted to a Burn Center

Cefiderocol is a novel cephalosporin antibiotic approved for urinary tract infections and hospital-acquired or ventilator-associated pneumonias caused by difficult-to-treat Gram-negative pathogens. To date, its use in treating difficult-to-treat Gram-negative infections in burn patients has been minimally described in the literature. Our aim was to evaluate cefiderocol use in a population of burn patients initiated on cefiderocol for resistant Gram-negative infections. A retrospective chart review of nine patients was conducted. Two patients were treated for pneumonia; five for bacteremia, three of which had coexisting burn wound infections or pneumonia; one was treated for a burn wound infection alone; and one patient was treated for a simultaneous burn wound infection, pneumonia, and bacteremia. The pathogens treated included the following: multidrug-resistant Pseudomonas aeruginosa, carbapenem-resistant Acinetobacter baumannii, and carbapenem-resistant Enterobacterales. Three isolates were confirmed as New Delhi metallo-beta-lactamase (NDM) producers, though this was likely an underestimate as genetic testing is not routinely performed at our institution and not all the isolates were tested. One of the nine patients in this study succumbed to their infection. Of note, the multidrug-resistant Pseudomonas aeruginosa in this patient tested intermediate to cefiderocol. The patients were treated with cefiderocol for a median of 14 days, most commonly in combination with other antimicrobial therapies. Treatment with cefiderocol appeared to be efficacious in this population of burn patients when other antibiotics routinely used for complicated infections caused by multidrug-resistant (MDR) Gram-negative pathogens showed treatment failure or resistance.

Epidemiology of elderly burn patients in the United States: Mortality patterns and risk factors revealed by CDC WONDER database

INTRODUCTION

Burn-related fatalities pose a significant global public health challenge, with a substantial impact on the elderly population. This study examines two decades of burn-related mortality data in the United States, aiming to understand the trends, disparities, and contributing factors among adults aged 65 and older.

OBJECTIVES

The primary objectives of this study are to (1) analyze the trends in burn-related mortality rates among older adults, (2) investigate disparities based on gender, race and geographic regions, and (3) identify comorbidities and complications associated with burn-related deaths in this demographic.

METHODS

Data were obtained from the Centers for Disease Control and Prevention (CDC) using the National Center for Health Statistics database. The study cohort consists of individuals aged 65 and older who experienced burn-related deaths between 1999 and 2020. Various demographic variables, including age, sex, race/ethnicity, and location of death, were considered. The study also examined urban-rural classifications and regional differences. Mortality rates were calculated and adjusted for age. Joinpoint regression analysis was employed to assess trends in age-adjusted mortality rates over time. Modes of death and common comorbidities and complications were analyzed.

RESULTS

Between 1999 and 2020, a total of 96,498 older adults succumbed to burn injuries in the United States. Analysis revealed a concerning increase in burn-related mortality rates from 2012 onwards. Demographic disparities were evident, with older men consistently exhibiting higher mortality rates compared to women. Racial disparities were observed, with Black individuals experiencing the highest mortality burden. Geographic analysis indicated elevated mortality rates in Western states and rural areas. Accidents emerged as the leading cause of death, with ischemic heart disease and hypertensive diseases being prevalent comorbidities. Complications, with septicemia being the most common, contribute significantly to mortality.

CONCLUSION

Our analysis of 20 years of burn-related mortality data from the CDC reveals alarming trends in the United States. Unlike global trends, mortality rates have stagnated from 1999 to 2020, indicating a persistent public health challenge. Black individuals aged over 65 bear the brunt of burn-related mortality, facing the highest age-adjusted rates among all racial groups. Regional disparities are stark, with states in the top 90 % exhibiting significantly higher age-adjusted mortality rates compared to those in the bottom 10 %. Moreover, rural areas consistently report higher mortality rates than urban areas. Ischemic heart disease, hypertensive diseases, and other heart-related conditions emerge as prevalent comorbidities. To effectively reduce burn-related injuries and fatalities, targeted public health policies are imperative. These interventions must prioritize high-risk populations and adopt culturally sensitive approaches to promote safety. Additionally, enhancing access to healthcare and fire safety education is vital for mitigating the burden of burn-related mortality among the elderly population.

Self-Assembled Pt/Honokiol Nanomicelles for the Treatment of Sepsis-Associated Acute Kidney Injury

Sepsis is a severe and complex systemic infection that can result in multiple organ dysfunction. Sepsis-associated acute kidney injury (SAKI), caused by inflammatory response, oxidative stress, and cellular apoptosis, is a common complication that seriously impacts patient survival rates. Herein, a potent and novel metal-polyphenol nanomicelle can be efficiently self-assembled with Pt4+ and honokiol (HK) by the chelation, π-π conjugation, hydrophobic action, and the surfactant properties of Tween-80. These nanomicelles not only enhance drug bioavailability (encapsulation rates: Pt─49%, HK─70%) and reduce drug toxicity (safety dose: <20 μg/g) but also improve targeting toward damaged renal tissues. Furthermore, Pt4+ and HK in the nanomicelles exert a synergistic physiological effect by scavenging free radicals to alleviate oxidative damage, inhibiting macrophage activation and the release of inflammatory factors to regulate inflammation, and displaying broad-spectrum antimicrobial activity to control infection. These actions collectively protect renal tissue and restore its functionality. Here, we constructed metal-polyphenol nanomicelles (Pt/HK-NMs) via ingenious and efficient self-assembly, providing a new strategy to compensate for deficiencies in the hemodialysis and antibiotic treatment of SAKI.

"Diya"-Related Burn Injuries during the Diwali Period: A 5-Year Retrospective Review from a Tertiary Care Hospital in India

Background  Diwali is a festival that is passionately celebrated by Indians all across the globe. Fire hazards associated with this festival are well known. Our hospital is a tertiary care burn center and caters to a patient population from all over North India. Firecracker burns and diya burns constitute two major causes of burn injuries during the festival of Diwali. Since, diya-related burn injuries have been overlooked in the past, this study was primarily designed to study the demographical data of "diya burns" during Diwali. Materials and Methods  The departmental records were analyzed for 3 days around Diwali festival over a period of 5 years from 2018 to 2022. Results  The results indicated that almost a third of all Diwali-related burns were caused by diyas (32.5%). A "burning diya left on floor" was the main reason for these injuries. Females were the most affected (70.4%). Additionally, one-third of these patients required admission. Conclusion  This study emphasizes the need for raising awareness regarding the proper use of "diyas" to bring down the incidence of such preventable burn injuries.

Delayed admission to hospital with proper prehospital treatments prevents severely burned patients from sepsis in China: A retrospective study

BACKGROUND

Sepsis is one of the major causes of morbidity and mortality in burn patients. However, the optimal timing of admission which can minimize the probability of sepsis is still unclear. This study aims to determine the optimal time period of admission for severely burned patients and find out the possible reasons for it.

METHOD

185 victims to the Kunshan factory aluminum dust explosion accident, which happened on August 2nd, 2014, were studied. The optimal cutpoint for continuous variables in survival models was determined by means of the maximally selected rank statistic. Univariate and multivariate analyses were further conducted to verify that admission time was not a risk factor for sepsis. Subgroup analyses were performed to find out possible contributing factors for the result.

RESULT

The cutoff point for admission time was determined as seven hours, which was supported by the survival curve (p < 0.001). Multivariate analysis showed that, in our study population, delayed admission time was not a risk factor for sepsis (HR = 0.610, 95 %CI = 0.415 - 0.896, p = 0.012). Subgroup analyses showed that "Tracheotomy before admission" (p = 0.002), "Whole blood transfusion" (p < 0.001), "Hemodynamic instability before admission" (p = 0.02), "Has a burn department in the hospital" (p = 0.009), "Has a burn ICU in the hospital" (p < 0.001), "Acute heart failure (AHF)" (p = 0.05), "acute respiratory distress syndrome (ARDS)" (p = 0.05) and "GI bleeding" (p = 0.04) were all statistically significant.

CONCLUSION

In our study population, we found that delayed admission time was not a risk factor associated with a reduced incidence of sepsis among severely burned patients. This might be attributed to variations in prehospital treatments (whole blood transfusion and tracheotomy), whether the hospital had a burn department/ICU, and certain complications (AHF, ARDS and GI bleeding). It can be inferred that early prehospital care plays a crucial role in reducing sepsis risk among severe burn patients.

Gram-Negative Bacilli Blood Stream Infection in Patients with Severe Burns: Microbiological and Clinical Evidence from a 9-Year Cohort

Bloodstream infection is one of the most important and increasing complications in patients with severe burns. Most of the species affecting this population are Gram-negative bacilli that exhibit antimicrobial resistance. We conducted this study to determine the antimicrobial susceptibility profile and resistance mechanisms of these bacterial infections and their clinical associations on morbidity and mortality. We analyzed a retrospective cohort of burn patients. All patients included in this study had monobacterial blood stream infections during their hospital stay. We performed phenotypic and genotypic tests to determine the antimicrobial resistance mechanism and profile of each strain. Univariate and multivariate logistic regression analysis was performed between variables. We found 109 patients with monobacterial bacteremia. Pseudomonas spp. (50.7%), A. baumannii (46.4%), and Klebsiella spp. (13.8%) were the most common causative microorganisms. The Pseudomonas spp. isolates showed resistance to imipenem (81.5%), mainly by class A and class B carbapenemases. The A. baumannii isolates conferred resistance to imipenem (56.2%), mainly by class D carbapenemases. One quarter of Klebsiella spp. showed resistance to 3rd generation cephalosporins. We also observed that a total body surface area greater than 40% and three or more different types of invasive procedures might be related to increased mortality. Multidrug resistance is highly present. The extent of the burned area and a high number of different types of invasive procedures had an impact in decreasing survivorship in burn patients with bacteremia.

Diagnosis and Treatment of Infections in the Burn Patient

Infection is very common in burn patients because they lose the primary barrier from microorganism invasion, the skin. While there are attempts to prevent infections, topical antimicrobials and systemic prophylaxis tend to lead to more resistant organisms. After the initial resuscitation, the most common cause of death is from sepsis and multiple organ dysfunction syndrome. The diagnosis is difficult in the burn population because the constant exposure from the open wound leads to an inflammatory response that leads to persistent hypermetabolism. This paper reviews the current understanding and treatment of infection and sepsis in burns.

Predictors of Sepsis and Sepsis-related Mortality in Critically Ill Burn Patients: A Single Tertiary Care Center Experience

Background

Clinical diagnosis of sepsis is challenging, emphasizing the importance of regular bacterial surveillance, and tailored antimicrobial therapy. This study aims to elucidate the predictors of sepsis in critically ill burn patients.

Methods

A retrospective analysis was conducted on patients admitted to the burn intensive care unit between 2016 and 2022. Demographics, type of burn, total body surface area (TBSA), presence of inhalation injury, mortality, sepsis, deep vein thrombosis, pulmonary embolism, pneumonia, cultures, and laboratory findings were collected. Descriptive statistics and survival analysis were used to analyze trends during the 7-year period.

Results

The study encompassed 196 participants. Among patient factors, men constituted 73.4% (n = 102) of those without sepsis and 86.0% (n = 49) with sepsis, with an association between sepsis and lower age (34 versus 41 years) as well as larger TBSA (41.1% versus 17.3%). Inhalation injury was a significant predictor of sepsis [35.1% (n = 20) versus 11.6% (n = 16)]. Mortality was higher in sepsis cases [17.5% (n = 10) versus 2.9% (n = 4)], as well as positive blood cultures [47.4% (n = 27) versus 2.2% (n = 3)], positive wound cultures [71.9% (n = 41) versus 12.2% (n = 17)], and positive fungal cultures [12.3% (n = 7) versus 0% (n = 0)]. Multivariable analysis identified age and TBSA as significant predictors of sepsis (P = 0.025, P < 0.001).

Conclusions

Age, TBSA affected emerge as a strong risk factor for sepsis among critically ill burn patients. It underscores the need for vigilant monitoring to improve outcomes and reduce sepsis-related mortality.

Usefulness of mid-regional proadrenomedullin levels in the resuscitation phase of severely burned patients and its utility in early sepsis detection

INTRODUCTION

Mid-regional proadrenomedullin (MR-proADM) reflects the adrenomedullin level, which has vasodilatory activity, decreases endothelial permeability, and downregulates proinflammatory cytokines. Sepsis diagnosis in these patients is difficult, and MR-proADM is a widely studied sepsis biomarker. This study evaluates MR-proADM levels during the resuscitation phase, considering the potential influence of haemodynamic changes and its usefulness for the early sepsis detection in burn patients.

METHODS

A prospective observational study performed in the Critical Burn Unit. Demographic data, burn characteristics, comorbidities, prognostic/severity scales, and haemodynamic parameters were collected. The resuscitation protocol guided by diuresis, transpulmonary thermodilution, and lactate levels was followed. Blood samples were collected at various time points for biomarker measurement. Biomarker levels, including MR-proADM, C-reactive protein, and procalcitonin were measured during the resuscitation phase and septic episodes.

RESULTS

Twenty-seven patients were included, with a mean age of 51 years, a mean total body surface area burn of 41.8%, a mean Abbreviated Burn Severity Index of 9.7, and a mean Baux score of 92. MR-proADM levels were elevated on admission (0.9 ± 0.5 nmol/l) and continued to increase slightly during the resuscitation phase (2.4 ± 2.2 nmol/l). Haemodynamic changes during resuscitation did not significantly affect MR-proADM levels. Twelve of the 27 patients developed sepsis, whose MR-proADM levels were significantly elevated on the day of clinical diagnosis (3.91 ± 2.99 nmol/l) and even the day before (2.57 ± 3.37). Higher MR-proADM levels were associated with greater severity as measured by the Sequential Organ Failure Assessment score. The mean MR-proadrenomedullin values during resuscitation in the patients who died was 3.51 ± 2.30 nmol/l, whereas in the survivors it was 1.28 ± 1.10 nmol/l (p = 0.0001).

CONCLUSION

MR-proadrenomedullin values are elevated after thermal injury but are not affected by haemodynamic changes. During septic episodes in burn patients, MR-proADM rises early (the day before sepsis diagnosis). Higher levels of MR-proADM are associated with greater organ dysfunction and mortality.

Serum procalcitonin and C-reactive protein as indices of early sepsis and mortality in North Indian pediatric burn injuries: a prospective evaluation and literature review

BACKGROUND

Delays in diagnosing sepsis in children afflicted with thermal injuries can result in high morbidity and mortality. Our study evaluated the role of the biomarkers Procalcitonin (PCT) and C-reactive protein (CRP) as predictors of early sepsis and mortality, respectively, in this group of patients.

METHODS

This was a prospective evaluation of 90 pediatric burn cases treated at a tertiary care burn center in Northern India. Patients, aged 1-16 years, presenting within 24 hours of being burned, with >10% body surface area of burn injury were included in the study. Levels of PCT and CRP were measured on days 1, 3, 5, and 7. Patients were followed until discharge, 30th post-burn day, or death, whichever occurred first.

RESULTS

Sepsis was clinically present in 49 of 90 (54.4%) cases with a median 30% total body surface area (TBSA) of burns. Mortality was seen in 31 of 90 (34.4%) cases with a median of 35% TBSA burns. High PCT and CRP were seen in the sepsis group, particularly on days 3, 5, and 7. PCT was also significantly higher in the mortality group (days 1 and 3).

CONCLUSIONS

While PCT was a good early predictor of sepsis and mortality in children with burns, CRP was reliable as a predictor of sepsis only. Both markers, however, can serve as adjuncts to culture sensitivity reports for diagnosing early onset sepsis and initiation of antibiotic therapy in appropriate patients.

A Pilot Analysis for a Multicentric, Retrospective Study on Biodiversity and Difficult-to-Treat Pathogens in Burn Centers across the United States (MICROBE)

Following burn injury, patients are at increased risk of infection and are often cited as having a high incidence of difficult-to-treat pathogens (DTp). The purpose of this study is to determine the incidence of DTp after burn injury, which factors are associated with their development, and subsequent outcomes. This single-center, retrospective study assessed patients with thermal or inhalation injury who had a positive culture resulting in initiation of treatment (i.e., excision, topical, or systemic antimicrobials). Demographic data, pathogen and resistance profiles, and prior exposure to topical and systemic antimicrobials were collected. Pathogens were considered DTp if they were multi-drug-resistant (MDR), extensively drug-resistant (XDR), methicillin-resistant Staphylococcus aureus (MRSA), extended-spectrum beta-lactamase (ESBL)-producing, AmpC-producing, carbapenem-resistant, difficult-to-treat resistance (DTR) Pseudomonas sp., carbapenem-resistant Acinetobacter baumannii (CRAB), or Stenotrophomonas spp. Sixty-five patients who grew 376 pathogens were included in the final analysis. Two-hundred thirteen (56.7%) pathogens were considered DTp. Prior exposure to 7 of the 11 collected topical antimicrobials and 9 of 11 systemic antimicrobial classes were significantly associated with future development of a DTp. This remained true for six and eight, respectively, after controlling for significant covariates via logistic regression. As there were only four deaths, a Cox-proportional hazard analysis was not feasible. The Kaplan-Meier plot according to DTp revealed a clear divergence in mortality (Log rank p = 0.0583). In this analysis, exposure to topical and systemic antibiotics was associated with the development of DTp. The results from this pilot study will inform the next iteration of multicenter study.

PROGNOSTIC VALUES OF NEUTROPHIL/LYMPHOCYTE RATIO IN SEVERE BURN PATIENTS

The aim of this study was to evaluate the characteristics and prognostic value of the neutrophil/lymphocyte ratio (NLR) in patients with severe burns. A retrospective study was conducted on 245 burn patients over 18 years old without comorbidity or combined injury, burn extent ≥20% TBSA, hospitalized within 24 hours after burn. The collected criteria included patient characteristics, NLR on admission, 3rd and 7th day after burn, and outcome. The results showed that NLR was higher than the normal value at all collected times. In addition, compared to the survivor group, NLR on admission, 3rd and 7th day after burn was significantly higher in the mortality group (p <.01). Multivariate analysis found that the NLR on the 7th day postburn was an independent factor associated with mortality (p <.05), along with the increase in age, burn extent, and presence of inhalation injury (AUC = .85; cut off: 14.13; sensitivity: 75% and specificity: 83.43%). In conclusion, NLR on the 7th day post burn may be used as a predictive factor for mortality amongst severe burn patients.

Nonsteroidal Anti-Inflammatory Drugs Decrease Coagulopathy Incidence in Severe Burn Patients

The study investigated the impact of nonsteroidal anti-inflammatory drugs (NSAIDs) on burn-induced coagulopathy in severely burned patients. Patients with a greater than 20% TBSA were identified in the TriNetX research network and categorized into receiving or not receiving NSAIDs in the first week after the burn. The statistical significance of the rate of burn-induced coagulopathy, mortality and sepsis in the week following injury was analysed. We observed 837 severely burned patients taking NSAIDS during the week following the burn and 1036 patients without. After matching for age, gender and race, the risk of burn-induced coagulopathy significantly decreased (p < 0.0001) in patients taking NSAIDs (17.7%) compared to those without (32.3%). Patients taking NSAIDs were also less likely to develop sepsis (p < 0.01) and thrombocytopenia (p < 0.001) or die the week following injury (p < 0.0001). In conclusion, the early protective effects of NSAIDs at reducing the risk of coagulopathy as well as sepsis and mortality occur during the acute phase of burns.

Sepsis in surgical patients: Burn sepsis

Patients with large burn injuries remain a challenge. The loss of skin barrier integrity and induced immunosuppression after injury increases their vulnerability to infection. Sepsis remains the primary cause of death for burn-injured patients who survive their acute injury and resuscitation. The objective of this work is to describe the current understanding and management of sepsis in the burn-injured patient and newer strategies to approach its management. Current understanding of the systemic inflammatory response to burn injury and sepsis, preventative strategies, and novel research will be discussed. Understanding the origin of burn sepsis from wounds themselves is key to understanding current paradigms. Infection control and management begins from the time of injury and continues throughout the patient's hospital course. The use of personal protective equipment, burn unit design considerations, and optimization of prevention protocols and catheter care all play a role in burn sepsis prevention and management. The emergence of drug-resistant pathogens poses a particular challenge for burn patients due to the chronicity with which their wounds are sometimes open. The difficulty of systemic antibiotics to reach wounds has underscored the need to anticipate resistant organisms moving forward. Antibiotic strategies and newer approaches, such as phage therapy, will be discussed. Multi-omics approaches to understanding burn sepsis have developed in hopes of identifying patients more susceptible or at risk of developing burn sepsis. As with many aspects of burn care, a multidisciplinary, proactive approach to the management of burn sepsis is key to minimizing the morbidity and mortality associated with this complication.

Prevention and Management of Wound Infections in Burn Patients

The leading cause of morbidity in burn patients is infection with pneumonia, urinary tract infection, cellulitis, and wound infection being the most common cause. High mortality is due to the immunocompromised status of patients and abundance of multidrug-resistant organisms in burn units. Despite the criteria set forth by American Association of Burn, the diagnosis and treatment of burn infections are not always straightforward. Topical antimicrobials, isolation, hygiene, and personal protective equipment are common preventive measures. Additionally medical and nutritional optimization of the patients is crucial to reverse the immunocompromised status triggered by burn injury.

Differentiated expressed miRNAs in splenic monocyte induced by burn injury in mice

To find potential biomarkers based on miRNA and their potential targets in splenic monocytes in burn-injured mice. Male Balb/c mice were subjected to sham or scalding injury of 15% total body surface area. Spenic CD11b+ monocytes were purified with magnetic beads. The monocytes were cultured in the presence of lipopolysaccharide. The proliferation of monocytes was detected by MTT assay, and the cytokines in the supernatant were examined by enzyme linked immunosorbent assay. The purified monocytes were also under total RNA extraction. The differential monocytic miRNAs expression between the sham and burn-injured mice was analysed by miRNA microarray. The activity of monocytes was comparable between the two groups (p > 0.05). However, monocytes from burn-injured mice secreted higher levels of tumour necrosis factor (TNF)-α and transforming growth factor-β, but lower level of monocyte chemoattratctant protein-1. A total of 54 miRNAs were differentially expressed in monocytes from burn relative to sham-injured mice (fold >3). Further quantitative reverse transcription polymerase chain reaction confirmed that the expression of miR-146a was significantly down-regulated, while miR-3091-6p was up-regulated after burn injury. Using the combination of Miranda and TargetScan softwares, we found that mir-146a may regulate 180 potential target genes including TNF receptor related factor 6 (TRAF6), interleukin-1 receptor related kinase 1 (IRAK1) and CD28. Mir-3091-6p may regulate 39 potential targets, including SOCS7 (cytokine signal transduction inhibitor 7) and ARRB2 (arrestin, β 2). The miRNAs expressed by monocytes after burn injury may be involved in the regulation of innate immune response in burn injury.

An Overview of Recent Developments in the Management of Burn Injuries

According to the World Health Organization (WHO), around 11 million people suffer from burns every year, and 180,000 die from them. A burn is a condition in which heat, chemical substances, an electrical current or other factors cause tissue damage. Burns mainly affect the skin, but can also affect deeper tissues such as bones or muscles. When burned, the skin loses its main functions, such as protection from the external environment, pathogens, evaporation and heat loss. Depending on the stage of the burn, the patient's condition and the cause of the burn, we need to choose the most appropriate treatment. Personalization and multidisciplinary collaboration are key to the successful management of burn patients. In this comprehensive review, we have collected and discussed the available treatment options, focusing on recent advances in topical treatments, wound cleansing, dressings, skin grafting, nutrition, pain and scar tissue management.

Surviving Sepsis After Burn Campaign

INTRODUCTION

The Surviving Sepsis Campaign was developed to improve outcomes for all patients with sepsis. Despite sepsis being the primary cause of death after thermal injury, burns have always been excluded from the Surviving Sepsis efforts. To improve sepsis outcomes in burn patients, an international group of burn experts developed the Surviving Sepsis After Burn Campaign (SSABC) as a testable guideline to improve burn sepsis outcomes.

METHODS

The International Society for Burn Injuries (ISBI) reached out to regional or national burn organizations to recommend members to participate in the program. Two members of the ISBI developed specific "patient/population, intervention, comparison and outcome" (PICO) questions that paralleled the 2021 Surviving Sepsis Campaign [1]. SSABC participants were asked to search the current literature and rate its quality for each topic. At the Congress of the ISBI, in Guadalajara, Mexico, August 28, 2022, a majority of the participants met to create "statements" based on the literature. The "summary statements" were then sent to all members for comment with the hope of developing an 80% consensus. After four reviews, a consensus statement for each topic was created or "no consensus" was reported.

RESULTS

The committee developed sixty statements within fourteen topics that provide guidance for the early treatment of sepsis in burn patients. These statements should be used to improve the care of sepsis in burn patients. The statements should not be considered as "static" comments but should rather be used as guidelines for future testing of the best treatments for sepsis in burn patients. They should be updated on a regular basis.

CONCLUSION

Members of the burn community from the around the world have developed the Surviving Sepsis After Burn Campaign guidelines with the goal of improving the outcome of sepsis in burn patients.

Temperature Derangement on Admission is Associated With Mortality in Burn Patients-A Nationwide Analysis and Opportunity for Improvement

Although single-institution studies have described the relationship between hypothermia, burn severity, and complications, there are no national estimates on how temperature on admission impacts hospital mortality. This study aims to evaluate the relationship between admission temperature and complications on a national scale to expose opportunities for improved outcomes. The US National Trauma Data Bank (NTDB) was analyzed between 2007 and 2018. Mortality was modeled using multivariable logistic regression including burn severity variables (% total burn surface area (TBSA), inhalation injury, emergency department (ED) temperature), demographics, and facility variables. Temperature was parsed into three categories: hypothermia (<36.0°C), euthermia (36.0-37.9°C), and hyperthermia (≥38.0°C). A total of 116,796 burn encounters were included of which 77.9% were euthermic, 20.6% were hypothermic and 1.45% were hyperthermic on admission. For every 1.0C drop in body temperature from 36.0°C, mortality increased by 5%. Both hypothermia and hyperthermia were independently associated with increased odds of mortality when controlling for age, gender, inhalation injury, number of comorbidities, and %TBSA burned (p < .001). All temperatures below 36.0°C were significantly associated with increased odds of mortality. Patients with ED temperatures between 32.5 and 33.5°C had the highest odds of mortality (22.0, 95% CI 15.6-31.0, p < .001). ED hypothermia and hyperthermia are independently associated with mortality even when controlling for known covariates associated with inpatient death. These findings underscore the importance of early warming interventions both at the prehospital stage and upon ED arrival. ED temperature could become a quality metric in benchmarking burn centers to improve mortality.

Critical Care of the Burn Patient

Care of the critically ill burned patient must integrate a multidisciplinary care team composed of burn care specialists. As resuscitative mortality decreases more patients are surviving to experience multisystem organ failure relating to complications of their injuries. Clinicians must be aware of physiologic changes following burn injury and the implicated impacts on management strategy. Promoting wound closure and rehabilitation should be the backdrop for which management decisions are made.

The First 24 Hours: Burn Shock Resuscitation and Early Complications

Resuscitation is required for the management of patients with severe thermal injury. Some of the initial pathophysiologic events following burn injury include an exaggerated inflammatory state, injury to the endothelium, and increased capillary permeability, which all culminate in shock. Understanding these processes is critical to the effective management of patients with burn injuries. Formulas predicting fluid requirements during burn resuscitation have evolved over the past century in response to clinical experience and research efforts. Modern resuscitation features individualized fluid titration and monitoring along with colloid-based adjuncts. Despite these developments, complications from over-resuscitation still occur.

Infections in Burn Patients

Infections are the leading cause of mortality in burn patients who survive their initial resuscitation. Burn injury leads to immunosuppression and a dysregulated inflammatory response which can have a prolonged impact. Early surgical excision along with support of the multidisciplinary burn team has improved mortality in burn patients. The authors review diagnostic and therapeutic challenges as well as strategies for management of burn related infections.

LncRNA GAS5 suppresses inflammatory responses by inhibiting HMGB1 release via miR-155-5p/SIRT1 axis in sepsis

Sepsis comprises a lethal immunologic response due to infection. Increasingly, evidence has demonstrated the important role of long non-coding RNA growth arrest-specific transcript 5 (GAS5) in the regulation of sepsis. Nevertheless, the mechanisms by which GAS5 participates in the progression of sepsis remain unclear. Our study demonstrated the role and underlying mechanism of GAS5 in regulating lipopolysaccharide (LPS)-induced inflammation. In this study, GAS5 expression was found to be markedly decreased in serum samples of sepsis patients and a sepsis mouse model, and was negatively related with HMGB1 expression. GAS5 overexpression inhibited cell inflammatory responses by decreasing HMGB1 release. Furthermore, GAS5 inhibited LPS-mediated hyperacetylation and the release of HMGB1 by increasing the expression of sirtuin1 (SIRT1). Additionally, upregulated GAS5 attenuated inflammatory responses in vitro and vivo, and the knockdown of a miR-155-5p mimic and SIRT1 rescued the effects of GAS5 upregulation. Mechanistically, GAS5 sponged miR-155-5p to upregulate SIRT1, thereby inhibiting HMGB1 acetylation and release. In conclusion, our findings indicate that GAS5 suppresses inflammatory responses by modulating the miR-155-5p/SIRT1/HMGB1 axis in sepsis, providing a novel therapeutic target for inflammation in sepsis.

Use of procalcitonin as a biomarker for sepsis in pediatric burns

Infection and sepsis continue to be the leading cause of morbidity and death in burn injuries. Diagnosing sepsis in burns is challenging as signs and symptoms of sepsis are not specific and overlap with those related to the burn injury. While the use of procalcitonin (PCT) as a biomarker is recommended for diagnosing sepsis in burns, evidence for children with burns is scarce. In this study, we aimed to investigate the role of PCT in distinguishing sepsis in pediatric burns. A prospective observational study was conducted in a single pediatric burn unit. Children hospitalized with burns ≤ 30% of total body surface area were included while patients with chemical burn, inhalation injury, or concomitant chronic diseases were excluded. Patients were classified into three groups for sepsis, systemic inflammatory response syndrome (SIRS), or controls using the American Burn Association (ABA) criteria. The predictive role of C-reactive protein (CRP) and PCT was investigated for distinguishing sepsis. Seventy-two patients were included in the study. The median total body surface area (TBSA) size was 12% (2.0-28.5%), and the median abbreviated burn severity index (ABSI) score was 3 (2-7). The median length of burn unit stay was 9.5 days (1-59 days). Sepsis was diagnosed in 11 patients (15.2%), and SIRS was present in 23 patients (40.0%), whereas 38 patients (52.8%) had neither SIRS nor sepsis (control group). Receiver operating characteristic analysis revealed that CRP and PCT levels distinguished sepsis patients from non-sepsis patients while PCT had a higher positive predictive value (50.0% vs. 45.0%). Optimal cutoff values of CRP and PCT for distinguishing sepsis were 66.75 mg/L and 0.95 ng/mL.

CONCLUSIONS

PCT levels could distinguish sepsis in children with burn injuries, performing better than CRP levels. Confirmatory studies are needed to evaluate the development of sepsis and the role of PCT in diagnosing sepsis in pediatric burn patients.

WHAT IS KNOWN

• Even though there are excellent criteria for the diagnosis of infection and sepsis in children and several clinical parameters and biomarkers are being studied, it's difficult to diagnose burn wound sepsis in children.

WHAT IS NEW

• Data from this study showed that procalcitonin levels performed better than CRP levels as a biomarker for distinguishing sepsis from systemic inflammatory response syndrome (SIRS) in children with burn injuries.

Prospective study and validation of early warning marker discovery based on integrating multi-omics analysis in severe burn patients with sepsis

Background

Early detection, timely diagnosis and rapid response are essential for case management and precautions of burn-associated sepsis. However, studies on indicators for early warning and intervention have rarely been conducted. This study was performed to better understand the pathophysiological changes and targets for prevention of severe burn injuries.

Methods

We conducted a multi-center, prospective multi-omics study, including genomics, microRNAomics, proteomics and single-cell transcriptomics, in 60 patients with severe burn injuries. A mouse model of severe burn injuries was also constructed to verify the early warning ability and therapeutic effects of potential markers.

Results

Through genomic analysis, we identified seven important susceptibility genes (DNAH11, LAMA2, ABCA2, ZFAND4, CEP290, MUC20 and ENTPD1) in patients with severe burn injuries complicated with sepsis. Through plasma miRNAomics studies, we identified four miRNAs (hsa-miR-16-5p, hsa-miR-185-5p, hsa-miR-451a and hsa-miR-423-5p) that may serve as early warning markers of burn-associated sepsis. A proteomic study indicated the changes in abundance of major proteins at different time points after severe burn injury and revealed the candidate early warning markers S100A8 and SERPINA10. In addition, the proteomic analysis indicated that neutrophils play an important role in the pathogenesis of severe burn injuries, as also supported by findings from single-cell transcriptome sequencing of neutrophils. Through further studies on severely burned mice, we determined that S100A8 is also a potential early therapeutic target for severe burn injuries, beyond being an early warning indicator.

Conclusions

Our multi-omics study identified seven susceptibility genes, four miRNAs and two proteins as early warning markers for severe burn-associated sepsis. In severe burn-associated sepsis, the protein S100A8 has both warning and therapeutic effects.

Analysis of Potential Risk Factors for Multidrug-Resistance at a Burn Unit

BACKGROUND

Infections by multidrug-resistant (MDR) microorganisms are associated with increased morbidity and mortality in burn patients. This study aimed to analyze the evolution of MDR bacteria over a five-year period at Coimbra Burns Unit (CBU) in Portugal, seeking to assess the possible associations of specific bacteria with presumed risk factors.

METHODS

The data obtained consisted of identified bacteria present in any microbiological sample from each patient (including blood, central venous catheter, urine, tracheal aspirate and/or wound exudate). Univariate models and a multivariate model were constructed for each of the MDR bacteria species that infected at least 50 patients or that had five or more MDR strains. Statistical hypothesis tests with a p-value less than 0.05 were considered significant.

RESULTS

Of a total of 341 samples obtained, 107 were MDR, corresponding to 10 species. Globally, there was no significant variation in MDR bacteria frequency over the period under analysis. Some risk factors and/or trends were identified for some species, but none was linked to all of them.

CONCLUSIONS

The risks for the development of MDR in bacteria in burn patients are multifactorial, mainly linked to longer hospital stays, the use of invasive devices and inadequate antimicrobial treatment. However, the influence of these risks regarding specific bacterial species is not straightforward and may rely on individual characteristics, type of treatment and/or local prevalent flora. Due to the severity of multidrug-resistant infections, continued microbiological surveillance with the aid of rapid diagnostic tests and prompt institution of appropriate antimicrobial therapy are crucial to improving outcomes for burn patients.

Glutamine promotes O-GlcNAcylation of G6PD and inhibits AGR2 S-glutathionylation to maintain the intestinal mucus barrier in burned septic mice

Mucus forms the first line of defence of the intestinal mucosa barrier, and mucin is its core component. Glutamine is a vital energy substance for goblet cells; it can promote mucus synthesis and alleviate damage to the intestinal mucus barrier after burn injury, but its mechanism is not fully understood. This study focused on the molecular mechanisms underlying the effects of glutamine on the synthesis and modification of mucin 2 (MUC2) by using animal and cellular models of burn sepsis. We found that anterior gradient-2 (AGR2) plays a key role in the posttranslational modification of MUC2. Oxidative stress induced by burn sepsis enhanced the S-glutathionylation of AGR2, interfered with the processing and modification of MUC2 precursors by AGR2 and blocked the synthesis of mature MUC2. Further studies revealed that NADPH, catalysed by glucose-6-phosphate dehydrogenase (G6PD), is a key molecule in inhibiting oxidative stress and regulating AGR2 activity. Glutamine promotes O-linked N-acetylglucosamine (O-GlcNAc) modification of G6PD via the hexosamine pathway, which facilitates G6PD homodimer formation and increases NADPH synthesis, thereby inhibiting AGR2 S-glutathionylation and promoting MUC2 maturation, ultimately reducing damage to the intestinal mucus barrier after burn sepsis. Overall, we have demonstrated that the central mechanisms of glutamine in promoting MUC2 maturation and maintaining the intestinal mucus barrier are the enhancement of G6PD glycosylation and inhibition of AGR2 S-glutathionylation.

Effects of enteral nutrition with different energy supplies on metabolic changes and organ damage in burned rats

BACKGROUND

Enteral nutrition (EN) is an important treatment for burn patients. However, severe gastrointestinal damage caused by major burns often leads to EN intolerance. Trophic EN solves this problem basically, but how to transition from trophic EN to standard EN smoothly is still a challenge in burn clinical nutrition. The aim of this study is to investigate the effects of EN with different energy supplies on metabolic changes, organ damage and prognosis in burned rats.

METHODS

Different feeding regimens were designed based on the continuous monitoring of resting energy expenditure in rats. Thirty-two Sprague-Dawley rats were randomly divided into a normal control group, burn +50% REE group, burn +75% REE group and burn +100% REE group. At the end of a nutritional treatment cycle (14th day), nuclear magnetic resonance spectroscopy, blood biochemistry analysis and quantification of subscab bacteria were performed to explore the differences in metabolic changes, degrees of organ damage and prognoses between the groups.

RESULTS

Sixteen metabolites involving seven metabolic pathways were identified from the different energy supply groups. After burn injury, resting energy consumption and body weight loss increased obviously. Meanwhile, weight loss was inversely related to energy supply. The greatest changes in the degree of organ damage, the level of plasma proteins, lipids and endotoxins, as well as the quantification of subscab bacteria were observed in the 50% REE group, followed by the 75 and 100% groups.

CONCLUSIONS

Achieving an early balance between energy supply and expenditure is conducive to mitigating metabolic disorders and improving prognosis after burn injury.

Interferon gamma as an immune modulating adjunct therapy for invasive mucormycosis after severe burn – A case report

Background

Mucormycosis is a deadly fungal infection that mainly affects severely immunocompromised patients. We report herein the case of a previously immunocompetent adult woman who developed invasive cutaneous mucormycosis after severe burn injuries. Interferon-gamma (IFN-γ) treatment was added after failure of conventional treatment and confirmation of a sustained profound immunodepression. The diagnosis was based on a reduced expression of HLA-DR on monocytes (mHLA-DR), NK lymphopenia and a high proportion of immature neutrophils. The immune-related alterations were longitudinally monitored using panels of immune-related biomarkers.

Results

Initiation of IFN-γ was associated with a rapid clinical improvement and a subsequent healing of mucormycosis infection, with no residual fungi at the surgical wound repair. The serial immunological assessment showed sharp improvements of immune parameters: a rapid recovery of mHLA-DR and of transcriptomic markers for T-cell proliferation. The patient survived and was later discharged from the ICU.

Conclusion

The treatment with recombinant IFN-γ participated to the resolution of a progressively invasive mucormycosis infection, with rapid improvement in immune parameters. In the era of precision medicine in the ICU, availability of comprehensive immune monitoring tools could help guiding management of refractory infections and provide rationale for immune stimulation strategies in these high risk patients.

Human skin processing affects clinical outcome in allograft recipients

Skin allografts represent a milestone in burn patient treatment. However, skin procurement is still burdened by high rates of contamination, and validation procedures have not yet been standardized. In addition, it is not clear if tissue viability affects allograft skin outcomes. In 2120 skin samples from 610 donors, a retrospective analysis was performed to identify donor and procurement variables associated with bacterial contamination and tissue viability. Post-processing contamination was associated significantly with the donor type, cause of death, length of hospitalization, procurement site, surgeon, interval between procurement and banking, and decontamination method. Tissue viability appeared to be negatively associated with freezing. In two series of skin allograft recipients (155 and 195 patients), we evaluated the role of skin characteristics and procurement variables on clinical outcomes. We found that the length of hospitalization was associated significantly with donor age. Procalcitonin and PCR values in allograft recipients were correlated with the decontamination method. No significant associations were observed between tissue viability and clinical outcomes (length of hospitalization, cause of donor death, or inflammatory parameters) after allograft transplantation. In these large case series, we identified donor and procurement variables that may affect allograft skin recipients. The decontamination method appeared to be a critical step for skin allograft requiring better standardization.

Emergence of a Carbapenem-Resistant Klebsiella pneumoniae Isolate Co-harbouring Dual bla NDM- 6 -Carrying Plasmids in China

The widespread emergence of carbapenem-resistant Klebsiella pneumoniae (CRKP) with limited therapeutic options has become a global concern. In this study, a K. pneumoniae strain called KP2e was recovered from a human case of fatal septic shock in a Chinese hospital. Polymerase chain reaction and sequencing, antimicrobial susceptibility testing, conjugation experiments, S1 nuclease-pulsed field gel electrophoresis/southern blot, whole genome sequencing and comparative genomics were performed to investigate the phenotypic and molecular characteristics of this isolate. KP2e possessed the NDM-6-encoding gene and exhibited resistance to almost all β-lactams except for monobactam. This strain belonged to sequence type 4024, the complete genome of which was composed of one chromosome and three plasmids. Furthermore, bla_NDM–6 coexisted on two self-transmissible plasmids, which were assigned to types IncFIB and IncN. A structure of IS26-composite transposon capturing an identical Tn125 remnant (ΔISAba125-bla_NDM–6-ble_MBL-trpF-dsbC-cutA-groES-ΔgroEL) was identified in the two plasmids, and this conserved bla_NDM-surrounding genetic context was similar to that of few IncN plasmids found in other regions of China. Our research appears to be the first description of a clinical strain that emerged co-harbouring dual bla_NDM-carrying plasmids, and the first report of NDM-6-positive CRKP in China. These findings demonstrated that IncN is a key medium in the evolution and expanding dissemination of bla_NDM genes among various species, which indicates that close monitoring and rapid detection of bla_NDM-harbouring plasmids is necessary.

Modern Aspects of Burn Injury Immunopathogenesis and Prognostic Immunobiochemical Markers (Mini-Review)

Burn injuries are among the most common peacetime injuries, with mortality ranging from 2.3% to 3.6%. At the same time, 85–90% of patients with burns are people of working age and children. Burn injury leads to metabolic disorders and systemic inflammatory response, inefficient energy consumption, and other physiological changes that can lead to dysfunction of organs and systems. The most formidable complication of burn injuries is sepsis mediated by multiple organ failure, the most common cause of poor prognosis in patients and has specific differences in these injuries. The purpose of this article was to dwell in detail on the most promising immunobiochemical markers of sepsis in the format of a mini-review, based on the main aspects of the immunopathogenesis of this complication. The pathogenesis of a burn injury and any general pathological process is based on an inflammatory reaction and large-scale changes in the skin and mucous membranes. This review is devoted to the progress in understanding the main aspects of the immunopathogenesis of burn lesions and the features of post-burn immune dysfunction, manifested by disorders in the innate and adaptive immunity systems. Attention is focused on the role in the immunopathogenesis of the development of systemic and local disorders in burn injury. Characterization of primary immunobiochemical markers of burn injury (cytokines, growth factors, C-reactive protein, procalcitonin, presepsin, matrix metalloproteinases, reactive oxygen species, nitric oxide, hemostasis parameters) is presented. The problem of treating burn lesions is associated with constant monitoring of the condition of patients and regular monitoring of specific immunobiochemical markers predicting sepsis for the timely initiation of a specific therapy.

Amputations secondary to burn injuries in a resource-limited setting

INTRODUCTION

Amputations are a devastating consequence of severe burns. Amputations in a resource-limited setting are challenging as rehabilitation services available to these patients are inconsistent and often fragmented. Epileptic patients are a particularly vulnerable group when it comes to burn-injuries and often sustain deeper burns. The aim of this study is to analyse amputations secondary to burn injuries. We seek to identify vulnerable groups as a means for advocacy efforts to reduce the devastation of an amputation secondary to a burn injury. This paper highlights the burden of these injuries on the healthcare system and emphasizes the need for additional trained therapists for the rehabilitation of these patients.

METHODS

A retrospective database review was conducted. All burns admissions who underwent an amputation between 1 February 2016 and 31 January 2019 were considered.

RESULTS

A total of 1575 patients were admitted during the study period. Fifty-four percent of the admissions were paediatric patients. The amputation rate in the paediatric population was 1.5% (13/850) while in the adult population it was 4.8% (35/724) . Most paediatric amputations were as a result of electrical injuries. Flame burns were most likely to result in amputations in the adult group and convulsions were the leading circumstance leading to the injury. There was no significant difference in sepsis or length of stay between the groups. There were no mortalities in the paediatric group but there was an 11% mortality rate in the adult group.

CONCLUSION

The incidence of amputations in burns is low, however, it remains a devastating morbidity. Epileptics are a vulnerable group and these patients account for the most amputations among adult burns patients. Education interventions are needed regarding their diagnosis, administration of their medication and the importance of compliance. Advocacy efforts to ensure constant supply of anti-epileptic drugs at the clinics and other district level health facilities is also essential. Electrical injuries in children are not as common as hot water scalds, however, they are more likely to result in amputation. Communities need to be informed of the risk associated with illegal electrical connections and initiatives need to drive the safe provision of affordable electricity to these under-privileged, vulnerable communities.

The Role of the Immune System in Pediatric Burns: A Systematic Review

Burns are one of the most common causes of home injuries, characterized by serious damage to the skin and causing the death of affected tissues. In this review, we intended to collect information on the pathophysiological effects of burns in pediatric patients, with particular emphasis on local and systemic responses. A total of 92 articles were included in the review, and the time range of the searched articles was from 2000 to 2021. The occurrence of thermal injuries is a problem that requires special attention in pediatric patients who are still developing. Their exposure to various burns may cause disturbances in the immune response, not only in the area of tissue damage itself but also by disrupting the systemic immune response. The aspect of immunological mechanisms in burns requires further research, and in particular, it is important to focus on younger patients as the existence of subtle differences in wound healing between adults and children may significantly influence the treatment of pediatric patients.

The effect of NPWT in wound healing and bacterial count on deep dermal burn injury model: An experimental study

Background

Sepsis is one of the main causes in burn victim's mortality. The use of negative pressure wound therapy (NPWT) provides an ideal environment to accelerate wound healing. We compare the use of normal saline (NS), intermittent NPWT, continuous NPWT and silver sulfadiazine in wound healing process.

Method

This study involved 6 Yorkshire pigs; each pig was induced with 20 burns on the flank area. Burns were divided into 4 treatment groups: NS gauze, intermittent NPWT, continuous NPWT, and silver sulfadiazine dressing. Burns were evaluated on day 1,3,7,14, and 21 for its morphology and bacterial colonization and on day 14 and 21 for the remaining burn surface area.

Result

Wound that received NPWT therapy appeared better in both granulation and crust formation. Remaining burn surface area (mm²) on day 14 in NS group, intermittent NPWT, continuous NPWT, and silver sulfadiazine were 107.43 ± 83.43, 178.07 ± 74.83, 146.10 ± 69.1, 126.03 ± 83.22, respectively(p = 0.457); on day 21 in NS group, intermittent NPWT, continuous NPWT, and silver sulfadiazine were 13.16 ± 16.86, 59.49 ± 20.72, 54.79 ± 46.59, 48.95 ± 39.84, respectively(p=0.169). There were no significant differences in each treatment group bacterial colonization(p>0.05). There were no significant correlation between bacterial colonization and remaining burn surface area (p>0.05).

Conclusion

While morphologically, the wound in NPWT treatment groups appeared better in granulation and crust formation, the remaining wound surface area and the number of bacterial colonization were not significantly difference compared to standard therapy (silver sulfadiazine and NS gauze). There were no significant correlation between the amount of bacterial colonization and remaining wound surface area on every treatment group.

•

Sepsis is one of cause burn injury mortality.

•

NPWT is promising burn injury treatment.

•

There was no significant difference of wound healing in various treatments.

The prognostic value of N-terminal pro-brain natriuretic peptide (NT-proBNP) in major burn patients with sepsis

The aim is to examine the prognostic value of N-terminal pro-brain natriuretic peptide (NT-proBNP) in patients with major burns and sepsis. We collected the data of major burn patients who were admitted to our department. We compared the age, sex, burn area, burn depth, length of hospitalization, and mortality rate between the sepsis group and non-sepsis group and compared NT-proBNP, procalcitonin (PCT), platelet count, Sequential Organ Failure Assessment (SOFA) score, and quick SOFA (qSOFA) score between the survivors and nonsurvivors in the sepsis group. Receiver operating characteristic (ROC) curves were used in sepsis patients to evaluate the prognostic value of NT-proBNP, PCT, SOFA score, qSOFA score, et al.. Kaplan-Meier survival curves were used to compare the 90-day survival curves of patients. Logistic regression analysis was used to analyse the risk factors that affect the prognosis of sepsis patients. There were 90 major burn patients with sepsis and 114 major burn patients without sepsis. The mortality rate for the major burn sepsis group was significantly higher than that for the non-sepsis group. The NT-proBNP level in sepsis patients in the nonsurvivor group was 2900 pg/mL, which was significantly higher than that in patients in the survivor group. Survival analysis showed that the mean survival time for the NT-proBNP >2000 pg/mL group was 15.08 days. Multivariate regression analysis indicated that NT-proBNP was an independent risk factor for mortality in burn patients with sepsis. NT-proBNP can be used as a prognostic marker in patients with major burns and sepsis.

Türkiye Güneydoğu Anadolu bölgesinde pediatrik yanık vakalarının analizi:10 yıllık retrospektif çalışma

Background: Burns continue to be a serious global public health problem all over the world, especially in developing countries. Materials and Methods: The age, gender, cause of injury, and total body surface area (TBSA) of the burn, complications, and mortality rate of 1,038 patients who were hospitalized in our burn center between January 1, 2010, and January 1, 2020, were analyzed. Results: The burned surface area was greater in boys than in girls. The mean burned body surface area for all patients was 9.2 ± 6.35, and the mortality rate was 1.45%. Hot liquids, such as tea, hot milk, hot water, and oily food, were the causes of burns in 84.7% of the patients. Hot objects, hot melted nylon, hot tandoor and embers, and hot asphalt accounted for 7.7% of the burns. Moreover, flame burns, electrical burns and frostbite, and other burn causes accounted for 5.6%, 1.2 %, and 0.8% of burn injuries, respectively. Conclusions: In our region, pediatric burns occurred mostly in boys under the age of three and in children whose parents had low educational levels living in rural areas. We believe that the burn prevention program should be adjusted according to these results.

Comparative Transcriptome Analysis of Superficial and Deep Partial-Thickness Burn Wounds in Yorkshire vs Red Duroc Pigs

Hypertrophic scars are a common negative outcome of deep partial-thickness burn wounds resulting in increased dermal thickness, wound area contracture, and inflammation of the affected area. The red Duroc and Yorkshire porcine breeds are common large animal models for studying dermal wounds due to their structural similarities to human skin; however, the porcine transcriptomic profiles of dermal burn wounds and healing process are not well known. In response, a longitudinal transcriptomic comparative study was conducted comparing red Duroc and Yorkshire superficial and DPT burn wounds to their respective control uninjured tissue. Using next-generation RNA-sequencing, total RNAs were isolated from burn wound tissue harvested at 0, 3, 7, 15, 30, and 60 days post-burn and mRNA-seq and gene expression read counts were generated. Significant differentially expressed genes relative to uninjured tissue were defined and active biological processes were determined using gene set enrichment analyses. Additionally, collagen deposition, α-SMA protein concentration, epidermal and dermal thickness measurements, and wound area changes in response to burn injury were characterized. Overall, the red Duroc pigs, in response to both burn wound types, elicited a more robust and prolonged inflammatory immune response, fibroblast migration and proliferation as well as heightened levels of extracellular matrix modulation relative to respective burn types in the Yorkshire pigs. Collectively, the red Duroc deep partial-thickness burn wounds produce a greater degree of hypertrohic scar like response compared to Yorkshire DPT burn wounds. These findings will facilitate future porcine burn studies down-selecting treatment targets and determining effects of novel therapeutic strategies.

Inhibition of Bruton's Tyrosine Kinase Protects Against Burn Sepsis-Induced Intestinal Injury

This study aimed to investigate the role and molecular mechanisms of Bruton's tyrosine kinase (BTK), a member of the Tec family in burn sepsis-induced intestinal injury. Eighty C57BL/6 mice were randomly divided into four groups: the sham group, the burn group, the burn + sepsis group, and the burn + sepsis + LFM-A13 (a selective BTK inhibitor) group. The dynamic expression profiles of BTK and p-BTK in the intestine were measured by Western blot analysis. Intestinal histopathological changes and cellular apoptosis were determined. Inflammatory cytokines in serum and intestinal tissue were examined through enzyme-linked immunosorbent assay. Myeloperoxidase (MPO) activity was determined via a colorimetric assay. Intestinal p-BTK expression in the burn+sepsis group was significantly increased compared with that in the sham and burn groups. In the burn + sepsis group, the p-BTK expression level increased over time, peaked at 12, and then decreased at 24 h. LFM-A13 administration significantly inhibited p-BTK expression in the intestine. In contrast to the sham and burn groups, the burn + sepsis group exhibited obvious histopathological changes, which gradually aggravated over time. LFM-A13 also reduced the histopathological changes and cellular apoptosis in intestinal tissues, inhibited the inflammatory cytokines IL-4, IL-6, and TNF-α in serum and intestinal tissues, and significantly inhibited the increase in intestinal MPO activity induced by burn sepsis. BTK activation is one important aspect of the signaling event that may mediate the release of the anti-inflammatory cytokine IL-4 and the pro-inflammatory cytokines IL-6 and TNF-α; oxidative stress; and intestinal cell apoptosis. Thus, it contributes to burn sepsis-induced intestinal injury.

Specific patterns of vital sign fluctuations predict infection and enable sepsis diagnosis in pediatric burn patients

Early recognition of the clinical signs of bloodstream infection in pediatric burn patients is key to improving survival rates in the burn unit. The objective of this study was to propose a simple scoring criteria that used readily available temperature, heart rate (HR) and mean arterial pressure (MAP) data to accurately predict bloodstream infection in pediatric burn patients. A retrospective chart review included 100 patients admitted to the pediatric burn unit for >20% total body surface area (TBSA) burn injuries. Each patient had multiple blood culture tests, and each test was treated as a separate and independent “infection event” for analysis. The time at each blood culture draw was time 0 for that event, and temperature, HR and MAP data was collected for 24 hours after the blood culture was drawn. “Infection events” included in this study had at least six complete sets of temperature, HR and MAP data entries. Median temperature, HR and MAP, as well as mean fever spikes, HR spikes and MAP dips, were compared between infection group (positive blood cultures) and control group (negative blood cultures). These vital sign fluctuations were evaluated individually and as a combination of all three as timely predictors of bloodstream infection. In addition, we tested the prediction of Gram-negative bacteria versus Gram-positive or fungi present in blood cultures. Patients in the infection group had significantly higher median temperatures (p<0.001), mean fever spikes (p<0.001) and mean HR spikes (p<0.001), compared to the control group. Using the combination scoring criteria to predict bloodstream infection, the strongest predictive values in the 24-hour timeframe had high sensitivity (93%) and specificity (81%). The predictive test metric based on vital sign spikes predicted Gram-negative bacteria, but with limited sensitivity (57%) and specificity (44%). A simple scoring criteria using a combination of fever spikes, HR spikes and MAP dips predicted bloodstream infection in pediatric burn patients, and can be feasibly implemented in routine clinical care. There is also potential to use the predictive metric to detect a few select organisms based on vital signs, however further work is necessary to enhance accuracy to levels that would allow consideration for clinical use.

Optimizing large-scale autologous human keratinocyte sheets for major burns-Toward an animal-free production and a more accessible clinical application

Background and Aims

Autologous keratinocyte sheets constitute an important component of the burn wound treatment toolbox available to a surgeon and can be considered a life‐saving procedure for patients with severe burns over 50% of their total body surface area. Large‐scale keratinocyte sheet cultivation still fundamentally relies on the use of animal components such as inactivated murine 3T3 fibroblasts as feeders, animal‐derived enzymes such as trypsin, as well as media components such as fetal bovine serum (FBS). This study was therefore aimed to optimize autologous keratinocyte sheets by comparing various alternatives to critical components in their production.

Methods

Human skin samples were retrieved from remnant operative tissues. Cell isolation efficiency and viability were investigated by comparing the efficacy of porcine‐derived trypsin and animal‐free enzymes (Accutase and TrypLESelect). The subsequent expansion of the cells and the keratinocyte sheet formation was analyzed, comparing various cell culture substrates (inactivated murine 3T3 fibroblasts, inactivated human fibroblasts, Collagen I or plain tissue culture plastic), as well as media containing serum or chemically defined animal‐free media.

Results

The cell isolation step showed clear cell yield advantages when using porcine‐derived trypsin, compared to animal‐free alternatives. The keratinocyte sheets produced using animal‐free serum were similar to those produced using 3T3 feeder layer and FBS‐containing medium, particularly in mechanical integrity as all grafts were liftable. In addition, sheets grown on collagen in an animal‐free medium showed indications of advantages in homogeneity, speed, reduced variability, and differentiation status compared to the other growth conditions investigated. Most importantly, the procedure was compatible with the up‐scaling requirements of major burn wound treatments.

Conclusion

This study demonstrated that animal‐free components could be used successfully to reduce the risk profile of large‐scale autologous keratinocyte sheet production, and thereby increase clinical accessibility.