Sepsis has recently been defined as "life-threatening organ dysfunction caused by a dysregulated host response to infection". A great amount of effort has been made to develop early treatments for sepsis through the Surviving Sepsis Campaign. There are similar but slightly different recommendations for the treatment of sepsis in the pediatric population. These international efforts have led to earlier diagnosis and treatments for sepsis that have led to improvements in survival. Sepsis is also the leading cause of death in the burn patient but most clinical sepsis studies have excluded burns. The reason for the exclusion is that the sepsis found in burn patients is different than that of the general population. The early treatment strategies, such as those directed by the Surviving Sepsis Campaign, focus on patients presenting to hospitals with recent signs of infection. Burn patients lose their primary barrier to infection, the skin, and thus the risk of infection persists as long as that barrier is absent. Efforts have been made to define sepsis, septic shock and infection in the burn population but there is constant need for revisions. One focus of this review is to discuss the differences in burn sepsis versus sepsis of the general population. Children often have profound responses to sepsis but can also make remarkable recoveries. This review will also explore problems specific to pediatric burns. The treatment of burns requires a continuous vigilance to watch for the subtle early signs of sepsis and then expeditious initiation of aggressive therapy. Strategies covering optimal management of pediatric burn sepsis will also be summarized.

Burns to the face affect a part of the body that cannot be hidden and thus exposes potentially major changes in appearance to society. Therefore, it is incumbent upon the caregiver to optimize healing and minimize scarring. The goal for partial-thickness burns is to have them heal within 2-3 weeks to minimize healing time. For full-thickness burns there needs to be strategies to optimize the outcomes for skin grafting and minimize scarring. The goal of this review is to discuss the best way to improve the outcomes of these devastating injuries.

To apply the modified pediatric RIFLE criteria for severity of acute kidney injury (AKI) to pediatric burn ICU patients and to evaluate the overall incidence of AKI, risk factors for AKI and influence of AKI on outcome. Retrospective, descriptive cohort study. 10-bed burn PICU facility. All consecutive patients with a burn injury of 10% or more of total body surface area percentage (TBSA, %) admitted during a 2 year period. Data of 123 patients were studied. The incidence of AKI was 45.5%. Patients with AKI tended to have higher mortality than those without AKI (p = 0.057). All nonsurvivors attained pRIFLE AKI by combination of serum creatinine and urine output criteria. Patients with a more severe form of AKI (Failure and Injury) as well as patients with late AKI had more episodes of sepsis as compared to patients with early AKI and the Risk category of AKI. Logistic regression analysis indicated that PRISM score and TBSA were the independent risk factors for acute kidney injury in pediatric burn patients; the presence of sepsis and septic shock were the independent risk factors for the Failure class of AKI. We observed a high incidence of AKI in the burn PICU population. Sepsis seems to contribute to the development of the Failure class of AKI. Maximum Failure class of AKI is associated with high mortality.

Critical appraisal of outcomes after burn shock resuscitation with albumin has previously been restricted to small relatively old randomized trials, some with high risk of bias. Extensive recent data from nonrandomized studies assessing the use of albumin can potentially reduce bias and add precision. The objective of this meta-analysis was to determine the effect of burn shock resuscitation with albumin on mortality and morbidity in adult patients. Randomized and nonrandomized controlled clinical studies evaluating mortality and morbidity in adult patients receiving albumin for burn shock resuscitation were identified by multiple methods, including computer database searches and examination of journal contents and reference lists. Extracted data were quantitatively combined by random-effects meta-analysis. Four randomized and four nonrandomized studies with 688 total adult patients were included. Treatment effects did not differ significantly between the included randomized and nonrandomized studies. Albumin infusion during the first 24 hours showed no significant overall effect on mortality. However, significant statistical heterogeneity was present, which could be abolished by excluding two studies at high risk of bias. After those exclusions, albumin infusion was associated with reduced mortality. The pooled odds ratio was 0.34 with a 95% confidence interval of 0.19 to 0.58 (P < .001). Albumin administration was also accompanied by decreased occurrence of compartment syndrome (pooled odds ratio, 0.19; 95% confidence interval, 0.07-0.50; P < .001). This meta-analysis suggests that albumin can improve outcomes of burn shock resuscitation. However, the scope and quality of current evidence are limited, and additional trials are needed.

IN BRIEF Treatment of lower-extremity burn injuries in adults with diabetes can be complex, and some diabetes-related factors can lead to impaired healing of such wounds, putting patients at risk of amputation. In this retrospective review of adult patients with lower-extremity burns, patients with pre-injury neuropathy and higher A1C levels were more likely to require amputations after their burn injury. The authors conclude that lower-extremity burn injuries in patients with diabetes require close follow-up and possibly referral to a burn specialist for interventions and treatment strategies to offset more serious complications.

IN BRIEF Treatment of lower-extremity burn injuries in adults with diabetes can be complex, and some diabetes-related factors can lead to impaired healing of such wounds, putting patients at risk of amputation. In this retrospective review of adult patients with lower-extremity burns, patients with pre-injury neuropathy and higher A1C levels were more likely to require amputations after their burn injury. The authors conclude that lower-extremity burn injuries in patients with diabetes require close follow-up and possibly referral to a burn specialist for interventions and treatment strategies to offset more serious complications.

Envelope (env) proteins of certain endogenous retroviruses (ERVs) participate in various pathophysiological processes. In this study, we characterized pathophysiologic properties of two murine leukemia virus-type ERV (MuLV-ERV) env genes cloned from the ovary of C57BL/6J mice. The two env genes (named ENV(OV1) and ENV(OV2)), with 1,926 bp coding region, originated from two MuLV-ERV loci on chromosomes 8 and 18, respectively. ENV(OV1) and ENV(OV2) were ~75 kDa and predominantly expressed on the cell membrane. They were capable of producing pseudotype murine leukemia virus virions. Tropism trait and infectivity of ENV(OV2) were similar to the polytropic env; however, ENV(OV1) had very low level of infectivity. Overexpression of ENV(OV2), but not ENV(OV1), exerted cytotoxic effects and induced expression of COX-2, IL-1β, IL-6, and iNOS. These findings suggest that the ENV(OV1) and ENV(OV2) are capable of serving as an env protein for virion assembly, and they exert differential cytotoxicity and modulation of inflammatory mediators.

Transposable repetitive elements, named the "TREome," represent ~40% of the mouse genome. We postulate that the germ line genome undergoes temporal and spatial diversification into somatic genomes in conjunction with the TREome activity. C57BL/6J inbred mice were subjected to genomic landscape analyses using a TREome probe from murine leukemia virus-type endogenous retroviruses (MLV-ERVs). None shared the same MLV-ERV landscape within each comparison group: (1) sperm and 18 tissues from one mouse, (2) six brain compartments from two females, (3) spleen and thymus samples from four age groups, (4) three spatial tissue sets from two females, and (5) kidney and liver samples from three females and three males. Interestingly, males had more genomic MLV-ERV copies than females; moreover, only in the males, the kidneys had higher MLV-ERV copies than the livers. Perhaps, the mouse-, gender-, and tissue/cell-dependent MLV-ERV landscapes are linked to the individual-specific and dynamic phenotypes of the C57BL/6J inbred population.

The prescription of splints (orthoses) to help protect vulnerable structures and maintain range of motion after skin grafting surgery is an integral part of burn recovery. The degree to which a patient adheres to wearing a prescribed orthosis is believed to play a major role in outcome. Oftentimes however, an orthosis is uncomfortable or undesirable to wear thus affecting a patient’s adherence. At our burn center, while the patient is in ICU, orthosis application and wear is heavily dependent on staff. During care on the acute ward, the responsibility is shared by family and staff. In outpatient (OP), the patient and caregiver are primarily responsible for orthotic wear adherence. The purpose of our study was to use temperature sensors to objectively determine patient adherence with splints during the three different stages of burn recovery.

Objectives

Determine the relationship between the volume of burn admissions and outcomes for children with burns.

Design

Retrospective review of the National Burn Repository from 2000-2009 using mixed effect logistic regression modeling.

Setting

Tertiary burn centers in the United States.

Patients

All children <18 years of age admitted with burn injury to a burn center submitting data to the National Burn Repository.

Interventions

None.

Measurements and main results

Of the 210,683 records in the NBR from 2000-2009, 33,115 records for children ≤ 18 years of age met criteria for analysis; 26,280 had burn sizes smaller than 10%; only 32 of these children died. Volume of children treated varied greatly among facilities. Age, total body surface area burn, inhalation injury, and burn center volume influenced mortality (p < 0.05) An increase in the median yearly admissions of 100 decreased the odds of mortality by approximately 40%. High volume centers (admitting >200 pediatric patients/year) had the lowest mortality when adjusting for age and injury characteristics (p < 0.05).

Conclusions

Higher volume pediatric burn centers had lower mortality, particularly at larger burn sizes. The lower mortality of children a high volume centers could reflect greater experience, resource, and specialized expertise in treating pediatric patients.