Abstract Introduction Interpatient heterogeneity was identified in an ongoing human subjects study investigating the use of indocyanine green (ICG) fluorescence imaging to evaluate burn depth and healing potential. A parallel swine model was initiated to investigate Second Window Indocyanine Green (SWIG), a novel method of delayed fluorescence imaging, in burn depth diagnosis and intraoperative visualization of excision endpoint. Methods Adult pigs with burns of various depths received a 7 mg injection of ICG for angiography (ICGA) followed by a 5 mg/kg intravenous infusion of ICG on post-burn day (PBD) 1 or 2. SWIG imaging was performed the following day on a region of interest (ROI). ICG microscopy and histologic staining was performed for tissue architecture and viability on a full thickness biopsy of the ROI. Fluorescence signal was captured before and after tangential excision. GraphPad Prism 8.0 was used for statistical analyses with Spearman correlation coefficient (ρ) due to the non-normal distribution of the data. Results There was a strong inverse correlation between perfusion as measured by ICGA peak fluorescence intensity and histologic burn depth (ρ = -0.89). SWIG signal-to-background ratio (SBR) was inversely correlated to histologic burn depth such that deeper burns exhibited less SWIG fluorescence signal than more superficial burns (ρ = -0.56). SWIG SBR was positively correlated with ICGA parameters including ICGA peak fluorescence intensity (ρ = 0.73) and ICGA egress slope (ρ = 0.67). In partial-thickness burns, SWIG fluorescence intensity progressively decreased with sequential excisions and was absent once a healthy, well-perfused wound bed was exposed. Deeper burns initially demonstrated low SWIG; however, the fluorescence increased with each excision until signal was again absent at the level of viable tissue (Fig. 1). Conclusions Variability in perfusion and inflammation contributes to heterogeneity in the ICGA and SWIG parameters in patients. The swine model data suggests that permeability and vascular destruction effects ICG delivery to the wound and ultimately, the SWIG signal. Furthermore, the eschar in deeper burns in pig skin interferes with top-down visualization of the deeper fluorescence signal and contributes to variable results. However, visualization of SWIG fluorescence during tangential excision to determine endpoints of excision may represent a novel use of this technique. Parallel studies of human and swine models more rapidly uncover the challenges with introducing new technologies and may facilitate translation through iterative experimental design approaches. Applicability of Research to Practice Our revised experimental approach has revealed that vascular destruction and eschar formation impair ICG delivery and fluorescence signal detection, highlighting key opportunities to address prior to translation for clinical use. Funding for the study NIGMS R01GM145723.

Frostbite injuries can have lasting sequelae including amputations, intolerance to cold, chronic pain, paresthesia, and inability to return to work. Despite this morbidity, the treatment of frostbite remains understudied. The FRostbite ObServational Trial (FROST) aims to address this gap through a multicenter evaluation of treatment practices and outcomes. As part of FROST, we reviewed institutional frostbite care protocols from 16 participating sites across North America. Practices were categorized as demonstrating uniform agreement (≥90% mentioned the practice), consensus ($\ge$75%), or majority if ($\ge$50%). Uniform agreement was limited to use of rapid rewarming and thrombolytics, the latter being influenced by site selection criteria for FROST participation. Consensus was achieved in multiple areas (such as urgency of treatment, perfusion assessment, the therapeutic windows for pharmaceutical interventions, and the therapeutic dosing of IV thrombolytics). Protocols varied on grades for thrombolytic treatment initiation, prostacyclin analog use, postthrombolytic anticoagulation treatment and duration, the role of physical or occupational therapy, splinting, and appropriate wound care. This manuscript provides a synthesis of protocols and expert opinions for the acute management of frostbite injury. This synthesized protocol may serve as a tool for centers to develop their own standard protocol to facilitate care for frostbite patients. Additionally, current opportunities for frostbite research and improving care are detailed in the manuscript. Education regarding prevention of injury and the need for emergent treatment is needed for both the public and the medical community.

The primary method to evaluate healing capacity of a burn wound is visual assessment; a subjective interpretation that risks over-excision. This ongoing study investigates the use of indocyanine green (ICG) fluorescence imaging to evaluate burn depth and healing potential. Early enrollment challenges encountered with the heterogeneity of human burn wounds, difficulty of patient recruitment early after a trauma, and variable timing of assessment post-injury led to the addition of a parallel translational pre-clinical swine model. Human subjects (n = 13) and adult pigs (n = 2) with burns of various depths received a 7 mg injection of ICG for angiography (ICGA) followed by a 5mg/kg intravenous (IV) infusion of ICG on post-burn day (PBD) 2 or 3. Second window indocyanine green (SWIG), a novel method of delayed fluorescence imaging, was performed the day after ICG injection on a region of interest (ROI) during wound care. A full thickness skin biopsy was taken from the center of the ROI and ICG microscopy and histologic staining was performed for tissue architecture and viability. MATLAB R2023b was used for data processing and GraphPad Prism 8.0 was used for statistical analyses. In patient samples, there was high interpatient variability between histologic cellular viability and perfusion as measured by ICGA peak fluorescence intensity when looking at the ROI (R2 = 0.04). Microscopically, the tissue exhibited intense inflammatory cell infiltrate at the interface of viable and nonviable tissue in some tissues without correlation to need for skin grafting. Patients had a wide range of SWIG fluorescence intensities and patterns. Qualitatively within patients, ICGA and SWIG signals exhibit inverse fluorescence intensities. In our pig model, there was a strong linear correlation between increasing burn depth and decreasing ICGA peak fluorescence intensity (R2 = 0.84). Additionally, samples with a burn depth < 50% demonstrated significantly higher SWIG fluorescence intensity compared to those > 50% (p = 0.003). Variability in perfusion and inflammation contributes to heterogeneity in the ICGA and SWIG parameters in patients. The swine model supports our hypothesis that ICG signal is dependent on inflammation, permeability and destruction of the vessels affecting ICG delivery to the wound. However, the animal model simplifies the true complexity of the burn microenvironment and may contribute to clinical failure during translation to human subjects. The experimental approach we have pivoted to given the known challenges with human subjects research, exacerbated in trauma and burn injury, represents a paradigm shift. This iterative, bidirectional approach using human subjects and animal models in parallel, allows more nimble experimental design modifications and data interpretation to ensure translational success. NIGMS 5R01GM145723

Abstract Introduction Early determination of burn depth is essential for guiding proper treatment of burn injuries. The primary technique used to evaluate burn depth is visual assessment, relying heavily on subjective interpretation while risking over-excision. Second window indocyanine green (SWIG) is a novel method of delayed fluorescence imaging with possible utility in burn surgery, as indocyanine green (ICG) persists in burn wounds 24 hours after intravenous injection. The objective of this study is to correlate intraoperative SWIG florescence with burn depth as evaluated by lactate dehydrogenase (LDH) staining. Additionally, given inflammation is thought to impact the progression of a burn, we investigated the relationship between SWIG florescence signal and reactive inflammation. Methods Consented patients with indeterminate depth burns received a 5 mg/kg ICG infusion during their third daily burn care after admission or 24-hours prior to surgery. SWIG was performed 24 hours after ICG injection on a region of interest (ROI) during wound care or during burn excision. A full thickness skin biopsy was taken from the center of the ROI and processed for ICG microscopy and staining. Burn depths were scored using LDH-stained sections. To investigate the relationship between SWIG and inflammation, nude mice underwent a full thickness contact burn or received endotoxin to induce inflammation. Mice were injected with ICG at 5mg/kg and SWIG signal was captured at the non-burned control, burned, and inflamed ROIs 24 hours after injection. Signal-background ratio (SBR) was calculated using the ratio between the averaged ICG intensity in the burned or inflamed ROI and the control ROI. GraphPad Prism 8.0 was used for statistical analyses. Results There was no correlation between the raw SWIG fluorescence value of the ROI in vivo and burn depth as determined by LDH staining. Furthermore, when the fluorescence value of the ROI was normalized to the SWIG intensity of the overall image and the SWIG intensity of non-burn control skin, there was no correlation to burn depth. In mice, SWIG SBR was significantly higher in the burned region (3.2±0.5) compared to the endotoxin induced inflamed regions (1.6±0.1). Conclusions There is heterogeneity in the intraoperative fluorescence signal when compared to burn depth. This variability in fluorescence signal could be attributed to the effects of local inflammation on the burn wound microenvironment as animal studies have shown that ICG signal is present in non-burn inflamed tissue. Further studies are warranted to discern the role of inflammation on burn wound progression and fluorescence signal in humans. Applicability of Research to Practice This data supports the potential utility of perioperative ICG fluorescence imaging for guidance of surgical excision in patients with indeterminate depth burns.

Abstract Introduction Accurate estimation of total body surface area (TBSA) with documentation on a Lund Browder (LB) chart is critical in guiding burn treatment and determining proper level of care. Recent quality improvement (QI) review of a series of patients admitted to our regional burn center has raised concerns about inaccurate admission TBSA estimations. The purpose of this study is to evaluate initial LB charts and subsequent iterations throughout the hospitalization in order to identify opportunities to improve TBSA fidelity and subsequent delivered care. Methods The Burn Center institutional registry was queried for all patients admitted over a three-month period. After exclusion of those with non-burn etiologies, retrospective chart review was performed for remaining patients to gather data on demographics, injury characteristics, and clinical outcomes. TBSA estimations assessed included outside hospital, Emergency Department, burn center admission, and all other completed LB diagrams from the index hospitalization. Patients were subcategorized by time of admission and whether admitting attending staff was primarily specialized in Burns. Percentage difference between admission and final LB was computed to analyze under- and over-estimation tendencies. Results After exclusions, 100 patients – 53 adult and 47 pediatric cases – admitted 5/2023-8/2023 were included for analysis. The patient cohort was young (median 19 years) and predominantly male (65.0%). Most common burn etiologies were flame (33.0%), scald (28.0%), and contact (24.0%). Night/weekend admissions by the covering Acute Care surgeons comprised 54.0%. Admission total TBSA was equivalent to final TBSA for 75.0%, while 14.0% initially underestimated and 11.0% overestimated. Among patients with TBSA ≧ 20.0%, 44.4% had consistent initial to final TBSA while 55.6% underestimated, all of whom were admitted by a non-Burn physician at night or on the weekend. In this large burn cohort, the percent difference of underestimation ranged from 4.1-21.9%. Conclusions Lack of experience and familiarity with burn size estimation may make LB completion challenging, with associated clinical consequences. In our patient population this was particularly a problem in larger burns admitted by covering Acute Care Surgery staff. While over-estimation by referring facility and Emergency Medicine providers is common, admission initial LBs tended to underestimate in these cases. Further QI work is planned to improve the accuracy of initial TBSA calculations through use of a physician-nursing huddle protocol. Applicability of Research to Practice Inaccurate estimations of TBSA, especially upon admission, can lead to life-threatening consequences from inappropriate resuscitation and mis-triage. Our goal is to target initial LB completion processes to improve care while also fostering interprofessional teamwork.

Abstract Introduction Sepsis is a major cause of mortality in critically ill burn patients, in whom lab findings and signs can be non-specific for infection, and definitive microbial identification can take 2-4 days, potentially leading to treatment delays and poor antimicrobial stewardship. Adjunct tests could expedite sepsis detection and aid in treatment decisions. Existing literature suggests a role for serum procalcitonin (PCT) as a useful biomarker for early diagnosis of sepsis in burn patients. However, no consensus exists on the frequency of testing or clinically relevant thresholds and how they should guide medical decisions. This QI project set out to assess Burn Center provider perceptions on the utility of PCT screening through protocol development and implementation. Methods The institutional registry was queried for all patients admitted to the Burn service (inclusive of non-burn etiologies) 5/2023-8/2023 following introduction of a twice weekly PCT screening protocol. Screening was to start at admission or when clinically indicated and cease at time of discharge or total wound closure. The triggers for screening include: adults with > 20% total body surface area (TBSA) or > 10% TBSA with immunocompromise (including significant alcohol abuse and uncontrolled diabetes), hospitalization > 30 days, inhalation injury, and adults or children with any TBSA at attending discretion. Retrospective chart review gathered data on demographics, injury characteristics, infectious workups, and clinical outcomes. Providers were queried as to the utility they felt PCT had played in their patient management during this timeframe. Results A total of 112 patients (62 adult, 50 pediatric) were identified in the three-month study period, with 19.4% of adults meeting one or more triggers. PCT levels were drawn in all who met triggers except for one moribund patient who rapidly transitioned to comfort measures. Antibiotics outside of the perioperative period were given in 11.3%, and 8.1% had fever workups performed. In the pediatric population PCT was not checked during the index hospitalization -- 8.0% received antibiotics, but none required work-up for fever of unknown source. At the time of study conclusion Burn team members were equivocal regarding PCT screening and opted to continue assessing the protocol for an additional three months. Conclusions Our chosen triggers seemed appropriate to prompt patient screening. However, critically ill patients co-managed with the SICU were not reliably captured as it required another team with less protocol familiarity to order labs. Future work will entail refining the PCT screening protocol to help determine testing frequency, useful cut-offs, and algorithms for decision making. Applicability of Research to Practice Determining the utility of PCT screening in aiding the detection of sepsis could help reduce mortality-increasing treatment delays in severe burn patients.

Objective: This analysis includes pooled safety data from 2 clinical trials (NCT01437852; NCT03005106) that evaluated the safety and efficacy of StrataGraft in patients with deep partial-thickness (DPT) burns. Methods: The study enrolled 101 adult patients with thermal burns covering 3-49% of total body surface area. Patients were followed for up to 1 year. The pooled safety events included: adverse events (AEs), adverse reactions (ARs), serious AEs (SAEs), discontinuation, and deaths; immunological responses (reactivity to panel reactive antibodies [PRA] and human leukocyte antigen [HLA] class 1 alleles); and persistence of allogeneic DNA from StrataGraft. Results: Eighty-seven (86.1%) patients experienced 397 AEs. Thirty patients (29.7%) experienced ARs; 16 patients (15.8%) experienced SAEs. The most frequent AEs were pruritus (n = 31; 30.7%), and blister, hypertension, and hypertrophic scar (n = 11 each; 10.9%); the most common AR was pruritus (n = 13; 12.9%). One patient discontinued the study; 2 patients experienced SAEs (unrelated to StrataGraft) leading to death. PRA and HLA allele reactivity was = 25% at Month 3, with no persistent allogeneic DNA from StrataGraft. Conclusions: StrataGraft was well tolerated by patients, with a safety profile similar to autograft. StrataGraft may offer a safe alternative to autograft for DPT burns. (c) 2022 The Authors. Published by Elsevier Ltd. This is an open access article under the CC

Abstract Introduction Autograft (AG) is the standard of care treatment for deep burns but requires creation of a donor site wound prone to pain and scarring. Treatment with a bioengineered allogeneic cellularized construct (BACC) is an alternative approach that can reduce or eliminate the need for autografting. The BACC is a bilayer construct that was recently approved in the US for the treatment of adult deep partial-thickness (DPT) burns. Here, we report the analysis of pooled safety data from two open-label, randomized, controlled trials (STRATA2011 [NCT01437852] and STRATA2016 [NCT03005106]) that evaluated efficacy and safety of BACC versus autografting in patients with DPT burns. Methods The trials enrolled 101 patients aged ≥18 years with 3–49% total body surface area (TBSA) thermal burns. In each patient, two DPT areas on the torso or extremities were randomized to receive BACC or AG, where the mean total BACC dosage was 234.8 cm2 (range: 12.0–960.0 cm2). The safety endpoints assessed at each visit included: 1) treatment-emergent adverse events (TEAEs), treatment-related AEs (TRAEs), and serious AEs (SAEs); 2) changes in immunologic responses (panel reactive antibodies [PRA], anti-bovine serum albumin [BSA] antibody response [STRATA2016 only]); 3) persistence of allogeneic DNA; and 4) laboratory exam and vital signs. Results Eighty-seven patients (86.1%) experienced TEAEs, 30 patients (29.7%) experienced TRAEs, and 16 patients (15.8%) experienced SAEs. The most frequent TEAEs reported by ≥10% of patients in the pooled analysis were pruritus (n=31, 30.7%) and blister, hypertension, and hypertrophic scar (n=11, 10.9% each). The most frequent TRAEs (≥5% of patients) were pruritus (n=13, 12.9%) and blister (n=5, 5%). The most common SAEs were transplant (BACC or AG) failure, pneumonia, and deep vein thrombosis (n=2, 2% each), where only one SAE (impaired healing of moderate severity) was possibly related to BACC. One patient (1%) discontinued the trial due to a TEAE (traumatic brain injury). Two patients (2%) experienced SAEs that led to death, neither related to BACC. The number of patients with positive PRA values that were negative at baseline were 36 (38.7%) at Day 28 and 20 (22%) at Month 3. The number of patients with reactivity to HLA I class alleles found in the BACC increased from 4 (4%) at baseline to 39 (40.9%) at Day 28, then decreased to 22 (24.2%) at Month 3. No persistence of allogeneic DNA from the BACC was detected. Conclusions BACC is well tolerated and is not associated with any unexpected SAEs or TEAEs. The safety profile at BACC treatment sites is similar to that at AG treatment sites. Thus, BACC may offer a safe alternative to autografting for the treatment of DPT burns.

BACKGROUND: No objective technique exists to distinguish necrotic from viable tissue, risking over-excision in burns and loss of wound healing potential. Second window indocyanine green (SWIG) is a novel fluorescence-imaging modality being studied to identify residual solid tumors during oncological surgery. SWIG has also been shown to have avidity for necrosis in animal models, but translation of these findings to humans is lacking. The objective of this study was to evaluate SWIG in the identification of burn wound necrosis and compare it with previously published indocyanine green angiography (ICGA) techniques. STUDY DESIGN: This study used mouse, human skin xenograft and human patient burn models. Brightfield and SWIG near-infrared imaging were performed on macroscopic tissue samples, which were then cryopreserved, sectioned, and analyzed for microscopic fluorescence. SWIG fluorescence findings were correlated to visual assessment of the burn wound as well as histological markers of necrosis using hematoxylin and eosin and lactate dehydrogenase stains. RESULTS: We found that SWIG identified burn necrosis in a manner dependent on the dose and timing of indocyanine green (ICG) administration and had an inverse fluorescence signal compared with ICGA. Furthermore, SWIG fluorescence identified the interface of viable and nonviable tissue. CONCLUSION: Our study confirmed that ICGA is an inconsistent and nonstandardized modality to evaluate burn injuries. In contrast, SWIG imaging is a potential imaging modality to objectively prognosticate burn wound healing potential and guide intraoperative burn excision. Further studies are needed to define ratios of fluorescence intensity values to guide surgical decision-making in burn excision and to better define how ICG is retained in necrotic tissue to enhance utility of SWIG in other disease processes.

Hundreds of patients are treated for burn injuries each year at University of Wisconsin School of Medicine and Public Health. Pain management is particularly challenging during dressing changes and following skin grafting procedures. We performed a retrospective chart review from January 2011 through June 2018 to evaluate the effect of nonopioid analgesic medications on opioid use in nonintubated patients. Our primary outcome was the change in opioid use following the procedure. We found that most patients (69%) report severe pain (Numeric Rating Scale ≥7) immediately after autologous skin grafting. On average, patients required an additional 52 mg of oral morphine equivalents (ME) in the 24 h after the procedure compared with the 24 h before. The use of perioperative nonopioid analgesia varied between patients (acetaminophen 29%, gabapentin 29%, ketamine 35%, and all three 8%). Patients who received either gabapentin or a combination of acetaminophen, gabapentin, and ketamine had a smaller increase in their opioid use than patients who did not receive the medications (-25 ME, 95% confidence interval [-46, -4]; P = .018 and -47 ME, [-81, -11]; P = .010, respectively). These results support using a combination of acetaminophen, gabapentin, and ketamine for perioperative analgesia in burn patients undergoing autologous skin grafting.

Objective: This open-label, controlled, randomized study assessed the safety, tolerability, and efficacy of StrataGraft tissue compared to autograft in the treatment of deep partialthickness (DPT) burns. Methods: Thirty subjects with DPT thermal burns (3%-43% total body surface area) were treated with StrataGraft tissue as follows: cohort 1, <= 220 cm(2) refrigerated tissue; cohort 2, <= 440 cm(2) refrigerated tissue; and cohort 3, <= 440 cm(2) cryopreserved tissue. On each subject, two comparable areas of DPT burn were randomized to receive StrataGraft tissue or autograft. Coprimary end points were the percent area of the StrataGraft tissue treatment site undergoing salvage autografting by Day 28 and wound closure of treatment sites by 3 months. Results: By Day 28, no StrataGraft tissue treatment sites underwent autografting. By 3 months, 93% and 100% of the StrataGraft tissue and autograft treatment sites achieved complete wound closure, respectively. No significant differences in observer total and overall opinion POSAS scores between StrataGraft tissue and autograft treatment sites were observed at any timepoint. The most common adverse event was pruritus (17%). Conclusions: StrataGraft tissue treatment of DPT thermal burns reduced the need for autograft, resulted in wound closure and treatment-site cosmesis comparable to that of autograft, and was well tolerated. (C) 2019 The Authors. Published by Elsevier Ltd.

Wounds are a major source of complications in surgery, but many can be avoided by using a sound, evidence-based approach to wound care. Preoperative considerations are discussed and include smoking cessation, glycemic control, weight loss, and adequate nutritional intake. Intraoperative considerations are presented and include proper classification of surgical wounds, hyperoxia and warming, and fascia closure techniques. Postoperative considerations that are presented include recognizing both early and late fascia complications, understanding skin closure techniques, and using adjuncts to postoperative wound management. This review contains 7 figures, 24 tables, and 67 references. Keywords: Surgical site infection, infection, closure, suture, negative pressure wound therapy, open abdomen, mesh, surgery, granulation tissue

Acute wounds are the result of local trauma and may be associated with severe life-threatening injuries. All patients with acute wounds should be assessed for comorbidities such as malnutrition, diabetes, peripheral vascular disease, neuropathy, obesity, immune deficiency, autoimmune disorders, connective tissue diseases, coagulopathy, hepatic dysfunction, malignancy, smoking practices, medication use that could interfere with healing, and allergies. The authors address the key considerations in management of the acute wound, including anesthesia, location of wound repair (e.g. operating room or emergency department), hemostasis, irrigation, débridement, closure materials, timing and methods of closure, adjunctive treatment (e.g. tetanus and rabies prophylaxis, antibiotics, and nutritional supplementation), appropriate closure methods for specific wound types, dressings, postoperative wound care, and potential disturbances of wound healing. This review contains 11 figures, 31 tables, and 92 references. Keywords: wound, wound infection, burns, suture, staple, wound closure, wound healing, dehiscence, skin grafting

Traditionally, small pediatric burns are managed with inpatient admission and daily dressing changes. In 2011, our burn center implemented an outpatient short stay (OSS) program in which small pediatric burns were managed as an outpatient utilizing Mepilex Ag (TM) dressings changed under moderate sedation every 5 to 7 days. Pediatric burn cases were queried for 2 time periods: before the OSS program (2009-2010) and after the OSS program (2013-2014). Burns > 15% total body surface area (TBSA), children with polytrauma, and children > 10 years old were excluded. Independent t tests and chi-square tests were conducted to analyze differences in patient demographics, burn management, and burn outcomes between these groups. Two hundred nineteen cases were included in the analysis (77 pre-OSS and 142 post-OSS). There was no difference in patient age (P = 0.872) or TBSA (P = 0.786) between the groups. The post-OSS group had shorter inpatient length of stay (2.93 days vs 5.21 days; P < 0.001) and fewer dressing changes (2.32 vs 4.71; P < 0.001). There were no changes in readmission rates (P = 0.375) or burns requiring grafting (P = 0.155). Although not reaching statistical significance, less children in the post-OSS group had infectious complications (P = 0.054) or required reoperation in a 2-year follow-up period (P = 0.081). Patient and family satisfaction with the program was high. Children treated after the implementation of an OSS burn program at the University of Wisconsin had decreased inpatient length of stay and fewer painful burn dressing changes. These patients exhibited equivalent, if not superior burn outcomes.

Burn injury introduces unique clinical challenges that make it difficult to extrapolate mechanical ventilator (MV) practices designed for the management of general critical care patients to the burn population. We hypothesize that no consensus exists among North American burn centers with regard to optimal ventilator practices. The purpose of this study is to examine various MV practice patterns in the burn population and to identify potential opportunities for future research. A researcher designed, 24-item survey was sent electronically to 129 burn centers. The (2), Fisher's exact, and Cochran-Mantel-Haenszel tests were used to determine if there were significant differences in practice patterns. We analyzed 46 questionnaires for a 36% response rate. More than 95% of the burn centers reported greater than 100 annual admissions. Pressure support and volume assist control were the most common initial MV modes used with or without inhalation injury. In the setting of Berlin defined mild acute respiratory distress syndrome (ARDS), ARDSNet protocol and optimal positive end-expiratory pressure were the top ventilator choices, along with fluid restriction/diuresis as a nonventilator adjunct. For severe ARDS, airway pressure release ventilation and neuromuscular blockade were the most popular. The most frequently reported time frame for mechanical ventilation before tracheostomy was 2 weeks (25 of 45, 55%); however, all respondents reported in the affirmative that there are certain clinical situations where early tracheostomy is warranted. Wide variations in clinical practice exist among North American burn centers. No single ventilator mode or adjunct prevails in the management of burn patients regardless of pulmonary insult. Movement toward American Burn Association-supported, multicenter studies to determine best practices and guidelines for ventilator management in burn patients is prudent in light of these findings.

The Committee for the Organization and Delivery of Burn Care (ODBC) was charged by President Palmieri and the American Burn Association (ABA) Board of Directors with presenting a plenary session at the 45th Meeting of the ABA in Palm Springs, CA, in 2013. The objective of the plenary session was to inform the membership about the wide range of the activities performed by the ODBC committee. The hope was that this session would encourage active involvement within the ABA as a means to improve the delivery of future burn care. Selected current activities were summarized by key leaders of each project and highlighted in the plenary session. The history of the committee, current projects in disaster management, regionalization, best practice guidelines, federal partnerships, product development, new technologies, electronic medical records, and manpower issues in the burn workforce were summarized. The ODBC committee is a keystone committee of the ABA. It is tasked by the ABA leadership with addressing and leading progress in many areas that constitute current challenges in the delivery of burn care.

Wound healing remains a major challenge in modern medicine. Bone marrow- (BM) and adipose tissue- (AT) derived mesenchymal stromal/stem cells (MSCs) are of great interest for tissue reconstruction due to their unique immunological properties and regenerative potential. The purpose of this study was to characterize BM and AT-MSCs and evaluate their effect when administered in a porcine wound model. MSCs were derived from male Gottingen Minipigs and characterized according to established criteria. Allogeneic BM- or AT-MSCs were administered intradermally (1 x 10(6) cells) into partial-thickness wounds created on female animals, and covered with Vaseline (R) gauze or fibrin in a randomized pattern. Animals were euthanized at 7, 10, 14 and 21days. Tissues were analyzed visually for healing and by microscopic examination for epidermal development and remodelling. Polymerase chain reaction (PCR) was used to detect the presence of male DNA in the specimens. All wounds were healed by 14days. MSC-injected wounds were associated with improved appearance and faster re-epithelialization compared to saline controls. Evaluation of rete ridge depth and architecture showed that MSC treatment promoted a faster rate of epidermal maturation. Male DNA was detected in all samples at days 7 and 10, suggesting the presence of MSCs. We showed the safety, feasibility and potential efficacy of local injection of allogeneic BM- and AT-MSCs for treatment of wounds in a preclinical model. Our data in this large animal model support the potential use of BM- and AT-MSC for treatment of cutaneous wounds through modulation of healing and epithelialization. Copyright (c) 2013 John Wiley & Sons, Ltd.