Abstract Introduction The COVID-19 pandemic had a significant impact on mental health. With the increased incidence of mental health concerns, there has been an increase in the trends of suicide attempts and deaths globally. A small percentage of suicide cases included the rare method of self-harm and self-immolation. Previous research examining the incidence rates of self-immolation as a form of suicide during and after the COVID-19 pandemic is limited in the U.S. The objective of this study was to compare pre-, during, and post-COVID-19 pandemic rates of suicide through self-immolation by reviewing information entered and collected into a single institution’s burn registry data. Methods A retrospective review of burn registry data at a single ABA-verified burn center focused on data identified for patient admissions with self-immolation over ten years, which included the period of the pandemic (2014-2024). Three groups were created: pre-, during, and post-pandemic. ANOVA was used to compare the means between demographics, mortality, etiology, and increases of incidence in self-immolation. Results Of the total of 87 cases, significantly higher rates of mortality by self-immolation found after the pandemic. As well, the use of gasoline etiology subcategory was significantly higher during and after the pandemic. There was no statistically significant difference in self-immolation rates between all three periods. Conclusions The retrospective review at a single ABA-verified burn center did not see a significant increase in incidence rates for suicide by self-immolation. Changes in mechanism were seen during and after the pandemic, with the use of gasoline and higher mortality in self-immolation. Applicability of Research to Practice Understanding incidence rates, especially during an event as significant as the pandemic, would allow burn centers and other mental health organizations to develop programming addressing self-immolation as a mechanism of self-harm or suicide. Funding for the study N/A.

Burn injuries often lead to hypertrophic scars (HTS), which negatively affect quality of life and skin function. Hypertrophic scars result from abnormal wound healing characterized by excess, disorganized collagen confined to the original wound. Fractional ablative CO₂ laser revision (FLSR) has shown promise in improving burn scar symptoms by inducing micro-wound healing, but its specific mechanism remains unclear. Progress is limited by a lack of standardized, objective metrics to evaluate treatment response. We hypothesized that FLSR would shift HTS collagen structure toward that of normal skin (NS) and reduce galectin-1, a wound-healing molecule elevated in HTS, and that these changes could be quantified. Red Duroc pigs, whose wounds heal similarly to humans, were used to create HTS and NS sites. Each pig had 4 HTS and 2 NS sites. Punch biopsies were collected at postoperative days 49 and 70, corresponding to pre- and post-FLSR timepoints. Fractional ablative CO₂ laser revision was administered on days 49, 56, and 63. Biopsies were paraffin-embedded, sectioned, stained with Picrosirius Red, imaged at 40× (n = 3/tissue), and analyzed using CT-FIRE and CurveAlign software. Metrics included collagen fiber width, length, straightness, angle, number, and overall alignment. Data were compared using 2-way analysis of variance. Before treatment, NS and HTS differed significantly in collagen alignment and width. After treatment, HTS collagen alignment shifted toward NS values, while width differences persisted. Galectin-1 levels decreased in HTS after FLSR. Other parameters showed no significant changes. These findings indicate that FLSR alters collagen alignment and length in HTS and that quantitative collagen metrics provide a valuable, objective method for assessing HTS treatment effectiveness.

Abstract Introduction Accurate and consistent diagnosis of burn severity is necessary to ensure appropriate triage and transfer of burn-injured patients. We aimed to identify and describe triage patterns of burn-injured patients stratified by ABA guideline-based eligibility for transfer to burn centers (BC) and evaluate areas of potential cost savings. Methods This retrospective, observational study evaluated IQVIA’s Hospital Charge Data Master to identify burn-injured patients who were evaluated in an emergency room (ER) or inpatient (IP) setting from 1/1/2017 to 8/31/2023. Patients were categorized by burn depth (superficial, superficial partial thickness (SPT), deep partial thickness (DPT), or full thickness (FT)) and TBSA (< 10%, 10- < 20%, 20- < 30%, 30- < 40%, 40- < 50% or > =50%). Triage patterns were evaluated based on inpatient transfer/admission to BC, admission to a non-BC, or discharge from the ER and graded against ABA guidelines for transfer to BC for admission. Triage patterns were incorporated into the Burn Efficacy And Cost Outcomes Nexus (BEACON) model to evaluate how improvement of referral patterns based on improved diagnoses achieved with multispectral imaging with artificial intelligence (AI) wound healing predictions could impact resource use and outcomes. Results Among 28 952 adult burn-injured patients (superficial (13.5%), SPT (66.1%), DPT (1.9%), or FT (18.5%)), 21 591 (74.6%) met ABA criteria for BC transfer. Notably, among patients with either DPT and TBSA >10% or any FT burn (19.0%), 70.5% were discharged from ER (22.8%) or admitted to a non-BC (47.7%) despite meeting criteria for BC transfer. The BEACON model indicated potential reduction in LOS by 4.5 days due to faster time to decision among patients admitted to BCs and evaluated with multispectral imaging with AI. Additionally, when combined with 40% increase in appropriate BC transfers, cost savings between $6619 (2.7%) to $15 705 (6.2%) per burn-injury were estimated. Conclusions This “real-world” data indicates that a large proportion of patients with burn-injuries presenting to an ER for initial evaluation and triage and who meet ABA transfer criteria are either discharged or transferred to a non-BC. Applicability of Research to Practice With improved diagnosis of wound size and depth and faster time to make healing predictions, potential cost savings might be readily achievable. Funding for the study This project is being supported in whole or in part with federal funds from the Department of Health and Human Services (DHHS); Administration for Strategic Preparedness and Response; BARDA, under contract number 75A50123C00049. The findings and conclusions have not been formally disseminated by the DHHS and should not be construed to represent any agency determination or policy.

Abstract Introduction Prolonged immobilization as much as fourteen days after split thickness skin grafting (STSG) in burn patients has been described to minimize post-operative complications such as graft loss. Earlier mobilization after STSG is suggested to decrease deconditioning and decrease length of stay. However, there remains a paucity of literature exploring the timing of mobilization following STSG and discharge disposition in burn patients. In this work, it was hypothesized that early mobilization after STSG would be associated with increased incidence of discharge home. Methods Adult burn injured patients who presented to an ABA-verified burn center, underwent STSG, and survived to discharge over a three-year period from 2021 to 2024 were retrospectively reviewed. Patients were cohorted by timing of mobilization after their initial incidence of STSG, either early (POD0-1) or late (POD2 or later). Patient electronic medical records were reviewed for demographic information, injury characteristics, and operative timing. Prior level of function, prior living situation, highest level of mobility achieved during the initial therapy session after STSG, and final discharge disposition were collected. Discharge disposition was stratified into two categories: home (home without services, home health, outpatient, or previous living situation) or facility (acute rehab, subacute rehab, and long-term acute care). Results During the study period, there were 240 patients who met inclusion criteria. There was no significant difference in demographics, baseline function, prior living situation, or highest level of mobility achieved between mobility groups. Discharge disposition was not significantly different between early and late mobilization groups (p=.12). Overall, discharge home was not associated with early vs late mobilization (86.2% vs 81.8%, p=.40). A further sub-analysis by age and total body surface area (TBSA) was also performed. When stratified by age, no differences between mobility groups were observed in discharge to home in older patients aged ≥65 years (67.6% vs 46.2%, p=.20) or those aged <65 years (91.2% vs 90.6%, p>.99). There were also no differences between mobility groups in discharge to home in TBSA burns ≥20% (60.0% vs 50.0%, p>.99) or those <20% (89.6% vs 83.9%, p=.24). There was no difference in mortality among mobility groups (2.3% vs 1.5%, p>.99). Conclusions Mobilization timing after STSG had no significant differences in discharge disposition, even when considering age or burn size. Further study should examine functional markers beyond discharge disposition to better understand the impact of rehabilitation timing on outcomes in burn patients. Applicability of Research to Practice Burn therapists should utilize a variety of functional outcomes to measure patient response to rehabilitation after STSG. Funding for the study N/A.

Evaluate the influence of patient age on laser therapy outcomes for burn hypertrophic scars (HTS), with a specific focus on assessing differences in scar quality, pain, and itch across stratified age groups. A single-institution, retrospective cohort study analyzing outcomes of fractional ablative CO2 laser treatments among patients grouped into younger, middle-aged, and older cohorts using k-means clustering. Patients (n = 119) receiving 3 or more fractional ablative CO2 laser treatments were included. Scar metrics were evaluated pretreatment and after each laser session using the Patient and Observer Scar Assessment Scale (POSAS), Vancouver Scar Scale, and durometer measurements. Statistical analyses were performed to compare within- and between-group outcomes using analysis of variance with corrections for multiple comparisons. The study cohort included 119 patients, with 49.58% female participants and an average age of 44.86 years (±16.4). The patients were predominantly African American (38.7%), followed by White (28.6%), Hispanic (10.9%), Asian (5.9%), Native American (1.7%), and 14.3% unspecified. Fitzpatrick skin type classifications were most common in types V (32.8%) and II (20.2%), with lower representation in types VI (4.2%) and I (1.7%). Laser treatment led to significant improvements across all age groups in POSAS metrics, though the timing and extent varied. The older cohort showed significant improvement in the POSAS observer pliability scale after just 1 session (P < .05), while the younger and middle-aged groups required 2 or more sessions (P < .001). Middle-aged patients reported the highest baseline pain and itch levels, with mean scores of 6.17/10 and 6.64/10, respectively, compared to younger (4.26 and 4.97) and older (4.26 and 4.74) groups (P < .05). Pain and itch significantly decreased across all groups, with the middle-aged cohort showing the most consistent improvements (P < .05). Vancouver Scar Scale scores improved significantly for all groups, while durometer measurements showed significant changes only in the middle-aged cohort (P < .05). Age significantly influences laser therapy outcomes for burn HTS, with older patients experiencing earlier and more pronounced improvements in POSAS observer scales. Different age groups also reported varying levels of pain and itch throughout their laser treatment sessions. Importantly, considerable improvements were noted postlaser treatment across all age groups. These findings emphasize the importance of personalizing laser therapy to address age-specific physiological changes to optimize treatment timelines and outcomes for patients with burn HTS.

Skin fibrosis, especially hypertrophic scars (HTSs), remains understudied with few effective treatments. Studying HTS is challenging due to its natural tendency to improve over time, making it hard to separate intervention effects. This study evaluated fractional ablative laser treatment for symptomatic HTSs, focusing on variability in patient response. It was hypothesized that pain and itch would decrease posttreatment, and that demographic or injury characteristics might predict responders. A retrospective chart review analyzed pretreatment and 6 postlaser sessions using the Patient Scar Assessment Scale for pain and itch (1 = low, 10 = high). Patients showing a ≥ 3 point improvement were classified as "responders" (n = 48 for pain, n = 62 for itch); those with ≤ 2 point improvement or worsening were "nonresponders" (n = 62 for pain, n = 76 for itch). In total, 110 patients were analyzed for pain and 137 for itch. Most patients were nonresponders for both pain (56.4%) and itch (55.1%). Responders experienced significant reductions in pain and itch after the first session, with stable scores thereafter (P < .0001). Nonresponders showed no significant improvement in pain and, for itch, even a significant worsening after the first session. No significant differences were found between groups based on sex, skin type, race, scar age, scar size, or patient age. Responders had higher baseline pain and itch scores than nonresponders. The greatest symptom relief occurred after the first treatment. Demographic and injury characteristics did not predict treatment response.

Abstract Introduction Commonly accepted methods of subjective scar evaluation include the Vancouver Scar Scale (VSS) and the Patient and Observer Scar Assessment Scale (POSAS). POSAS is often considered superior to the VSS because of its incorporation of a patient’s own assessment of their scar in addition to clinician assessment. POSAS 2.0 was launched in 2005 and based on patient and clinician feedback, an updated POSAS 3.0 was published in 2023. Additional symptom details were added and the numeric scale was changed to verbal descriptive responses to improve clarity. Our center has used POSAS 2.0 to evaluate burn scar for over 10 years, but recognize the potential benefit of a transition to the 3.0 scale. This study sought to compare 2.0 and 3.0 scales to understand if they correlate with one another. It was hypothesized that 2.0 scores would correlate with 3.0 scores. Methods Patients with burn scars (n = 15) were enrolled in a prospective study. Before treatment, they completed POSAS 2.0 and 3.0. Each patient and observer evaluated 2 scars (n = 30 scars). 2.0 is scaled using a numerical rating from 1-10. 3.0 is scaled using words/categories. For the 3.0 scale, the words were coded into numbers (e.g., not = 2, minimally = 4, etc.). The different symptom-specific questions were tested for correlation using Pearson’s R test between the two scale versions (e.g., color, overall, vascularity, etc.). Results The majority of patients were male (n = 10, 67%), 7 patients identified as Black, and Fitzpatrick Skin Type (FST) spanned Type 2-5. The average age of patients was 46.7 years. Average age of the scar at time of evaluation was 11.5 months. POSAS 2.0 and 3.0 were strongly correlated (observer r = 0.92, patient r = 0.86, p<.0001) for the average scores. For the color-specific question, there was also strong correlation (observer r = 0.88, patient r = 0.80). Patients with FST 5 were even more strongly correlated for color (observer r = 0.91, patient r = 0.82). For both patient and observer symptom-specific questions, there was strong correlation (>r = 0.8) between the scale versions. Conclusions POSAS 3.0 is a comparable measurement to 2.0 for subjective assessment of burn scar. In future work, results from 2.0 can be used as comparisons for future studies that may only utilize 3.0. Applicability of Research to Practice POSAS has been used in the clinical setting as documentation of scar improvement after treatment. As providers move to 3.0, it is important to ensure the ability to make longitudinal comparisons of treatment effectiveness. This study shows that 3.0 can be compared to 2.0 without difficulty. Funding for the study This work was funded in part by the Charles and Mary Latham Fund. This work was funded in part by an award from the National Center for Advancing Translational Science (NCATS/NIH).

Abstract Introduction Split thickness skin grafting (STSG) remains standard of care for wound closure of deep and partial thickness wounds. Immobilization after STSG was historically utilized for graft loss prevention, with a majority of recently surveyed burn surgeons reporting immobilization practices until post-operative day (POD) 3 or later. Previous literature has explored feasibility of mobility earlier than POD3 following STSG without increased rates of graft loss. However, these studies are limited to small graft sizes, weightbearing limitations, lower extremity STSG, and non-critically ill patients. The aim of this study was to evaluate the association between time to mobilization after STSG and graft loss. It was hypothesized that early mobilization (POD1 and earlier) would not be associated with increased risk of graft loss. Methods Patients who underwent STSG for treatment of thermal burn injuries at an adult ABA-verified burn center between August 2021 to August 2024 were retrospectively reviewed. Each incidence of STSG was individually categorized by day of mobilization as early (POD0-1) or late (POD2 or later). STSG mobilization cohorts were then compared to identify rates of major graft loss using an institutional grading scale, defined as graft loss >50% of area grafted, graft loss requiring prolonged wound care (>5 days), or graft loss requiring re-operation. Results A total of 240 patients met inclusion criteria, with a total of 431 incidences of STSG. Of these, 392 were assigned to the early mobilization group and 39 to the late mobilization group. There was no difference between groups in terms of demographics, injury characteristics or surgical interventions, except for time to autograft. Median time to burn excision was 3 days in both groups. Nearly half of the grafts (48.7%) crossed a joint. Negative pressure wound therapy was used as a post-op dressing in most patients (92.3%). Among STSG incidences, 193 occurred in critically ill patients (44.7%). Rates of graft loss were similar between groups (9% vs 9.2%, p=.93). Early mobilization did not increase the odds of graft loss (OR 0.97; 95% CI, 0.47-2.01; p=.93). Ambulation, compared to in-bed exercises, was not associated with increased odds of graft loss (OR 1.63; 95% CI, 0.48-5.58; p=.44). The highest level of mobility achieved was not significantly different between groups. Graft location (lower vs. upper extremity) was not associated with increased odds of graft loss (OR 1.17; 95% CI, 0.53-2.60; p=.69). Conclusions The findings suggest that early mobilization within 24 hours after STSG does not increase the risk of graft loss in burn patients and out of bed ambulation does not increase the risk of graft loss compared to in-bed therapy alone. Further prospective studies are needed to better elucidate the relationship. Applicability of Research to Practice Understanding graft loss risk in tandem with patient rehabilitation needs can assist burn teams with rehabilitation planning and timing following STSG. Funding for the study N/A.

Timing of mobilization following split-thickness skin grafting (STSG) in burn patients varies amongst burn centers, due to concerns for graft loss with earlier postoperative mobilization. Existing literature supports the feasibility of earlier mobilization after STSG but is limited in scope. This study aimed to explore the association between time to mobilization after STSG and graft loss, hypothesizing that ultra-early mobilization within 24 h of STSG does not increase the risk of graft loss. Adult patients who underwent STSG for treatment of thermal burn injuries at an American Burn Association (ABA)-verified burn center from 2021 to 2024 were included. Each incident of STSG was categorized as ultra-early (£24 h) or late (>24 h) mobilization. Mobilization cohorts were then compared by graft loss using an institutional grading scale, defined as graft loss >50% of the area grafted, requiring prolonged wound care, or requiring re-operation. Mobilization was defined as either passive or active movement. Of the 240 patients included, there were a total of 431 STSG. Of these, 69 patients were critically ill with a total of 193 STSG. Rates of graft loss were similar between groups (9% vs 9.2%; P = .93). Neither ultra-early mobilization (OR, 0.59; 95% CI, 0.20-1.73; P = .33) or ambulation compared to in-bed exercises (OR, 1.41; 95% CI, 0.36-5.50; P = .62) increased the odds of graft loss. The findings suggest that ultra-early mobilization within 24 h after STSG does not increase the risk of graft loss in burn patients, and out-of-bed ambulation does not increase the risk of graft loss compared to in-bed therapy.

Abstract Introduction Burn injuries trigger long-lasting alterations in cutaneous innervation that contribute to chronic pain, itch, and sensory dysfunction. Epidermal nerve fiber density (ENFD) is a key biomarker of neural integrity, while vasoactive intestinal peptide (VIP) is a neuropeptide with potent effects on vasodilation, immune modulation, and wound healing. VIP upregulation in damaged skin may actively shape the wound environment by acting as a key ligand for paracrine signaling, influencing both nerve repair and inflammatory response cellular transduction pathways. Despite its potential importance, the coordinated analysis of ENFD and VIP expression in post-burn tissue has been limited by inconsistent methodology for their quantification. Methods Deep partial thickness burn wounds were created in porcine skin (n = 6). On day 13, healed wound and adjacent normal skin biopsies were taken. Biopsies were fixed, cryosectioned at 60 μm, and immunostained for pan-neuronal marker protein gene product 9.5 (PGP9.5), VIP, and DAPI. The thick, 60 μm sections allowed for 3D evaluation of nerves that would not otherwise be captured by thin (6 μm) sections. Laser confocal microscopy was used to acquire 40 μm z-stacks at 2 μm intervals with a 10× objective. ENFs were traced using NeuronJ software, applying standardized rules for counting fibers crossing the dermal-epidermal junction. This approach included using the 3D data captured from z-stacking. Statistical testing was completed with Welch’s adjusted T. Results Mean ENFD in normal skin was 10.36 ± 4.145 fibers/mm epidermis, compared with 2.489 ± 1.638 in the wound group, representing a 75.98% reduction (p=.0041). Representative confocal images confirmed consistent labeling of ENFs and clear delineation of the basement membrane. Inter-rater reproducibility of tracing was 0.920. VIP mean intensity values in normal skin were 11.16 ± 3.002 fluorescent intensity units (FIUs), compared with 26.61 ± 14.44 FIUs in the wounds, a 138.44% increase (p=.0465). Conclusions This study demonstrates that healed burn wound is characterized by ENF loss and VIP upregulation. The findings suggest that VIP is not merely a byproduct of injury but may play a mechanistic role in modulating neural regeneration and inflammatory states after burn injury. By combining structural and molecular analyses, this methodology provides a new approach to investigate the relation between innervation and neuropeptide signaling in healing skin. Applicability of Research to Practice Reduced ENFD provides an objective marker of small fiber loss, while VIP upregulation identifies a candidate therapeutic target for restoring balance between neural injury and repair. These measures could also be used to determine patients at risk for chronic pain and itch, guide neuro-regenerative treatment strategies, and monitor therapeutic efficacy over time. Funding for the study This work was funded in part by award number KL2TR001432 from the National Center for Advancing Translational Science (NCATS/NIH).

BACKGROUND/OBJECTIVE:Fractional ablative CO2 laser is an effective treatment for hypertrophic scars (HTS) and can enhance topical drug penetration through laser-assisted drug delivery. Although intralesional triamcinolone is a standard treatment for HTS, it is associated with more adverse effects than topical steroids and has limited applicability for large scars. PATIENTS AND METHODS:This single-institution, prospectively collected, retrospective chart review included 55 patients who underwent laser-assisted drug delivery treatment of either triamcinolone alone or a combination of triamcinolone and 5-fluorouracil. Scars were assessed using 4 subjective scales and objective firmness measurements. RESULTS:Both groups demonstrated significant reductions in scar assessment scores after 3 treatments, but there were no significant differences between the 2 treatment modalities. However, comparisons of baseline with posttreatment scores showed greater improvement in the combination group, suggesting a potential but not statistically significant advantage of combination therapy. CONCLUSION:Although both groups exhibited improvements in scar outcomes, neither showed significant improvement between groups, suggesting clinical effectiveness without clear superiority. In addition, there were equivocal differences in variables representing adverse effects. Given the comparable efficacy and adverse effects, this study suggests that adding 5-fluorouracil to triamcinolone may not be warranted in laser-assisted drug delivery treatment of hypertrophic scar.

Burn injury results in hypercoagulability and an increased venous thromboembolism risk. However, the most effective chemoprophylaxis for burn-injured patients has yet to be elucidated. Therefore, this study aims to identify the safety and efficacy of a burn center's venous thromboembolism protocol modification, which increased the dose of enoxaparin from 40 mg daily to 40mg twice daily with peak anti-Xa level adjustments. It was hypothesized that this change would not increase bleeding complications and would decrease venous thromboembolism rates. All adult, burn-injured patients admitted to a regional burn center were retrospectively reviewed 1 year before and after the implementation of this protocol modification. There were no differences in demographics, injury characteristics, or hospital length of stay between the pre- (n = 432) and postprotocol modification (n = 407) groups. Bleeding complications did not increase in the postprotocol group, including intraoperative blood loss (50 vs 25cc), the total number of transfusions (9.0 vs 6.0 units), and GI bleeding events (0.7 vs 0.2%) (all P > .05). Most patients receiving enoxaparin 40 mg twice daily achieved an initial therapeutic level based on peak anti-Xa measurements (46.5%), yet the rate of venous thromboembolisms between pre- and postprotocol groups was not statistically different (1.4 vs 0.7%, P = .5072). Factors associated with an initial sub- or supratherapeutic peak anti-Xa level were percent total body surface area, weight, body mass index, and creatinine clearance. Overall, this study demonstrated that a higher dose of enoxaparin (40 mg twice daily) with peak anti-Xa level adjustments was safe in burn-injured patients and necessary to obtain therapeutic levels of chemoprophylaxis.

Autologous skin grafts serve as the definitive coverage for lost or damaged skin and can be used on a variety of different wounds, including burns and complex dermatologic injuries unable to be repaired by primary closure. The universal objective in performing autologous skin grafting is for complete graft adherence without areas of significant graft failure, especially post-discharge. The purpose of this study is to identify what factors may contribute to post-discharge graft loss. It was hypothesized that there is more occurrence of graft loss in grafted burns with joint involvement, and also more graft loss in those patients who get discharged to a facility. The study was a retrospective chart review of patients who were admitted to a regional burn center and underwent autologous split thickness skin grafting (STSG) from January 2023 through August 2024 who had documented graft loss after their hospital discharge. Demographics, co-morbidities, grafting size and location, discharge disposition, type of dressing, and management strategies were evaluated. Overall, 148 patients with post-discharge graft loss were included in this study. The average age was 47.61 years old (SD +/- 17.34). The average length of stay after the last graft application was 7.64 days (SD +/- 6.43). A majority (64.86%) of these patients received allograft or synthetic skin substitute prior to autologous skin. Over half (55.41%) of the patients had no joint involvement in the areas with graft loss. There was 47.30% of the population were discharged home independently without need of services. A majority of patients (60.14%) were discharged home in dressings that remained in place until follow up in clinic. Contrary to our hypotheses, a majority of patients with graft loss did not have joint involvement, and most patients included in the analysis were discharged home independently with dressings to remain in place and not be changed until the clinic visit. Further research will compare patients with and without graft loss to better clarify contributing factors that may be present in one group versus the other. If factors contributing to outpatient graft-loss can be identified, an intervention may be applied which can ameliorate graft loss in future patients. N/A

Burn injuries often result in hypertrophic scars (HTS) associated with pain and itch (P&I). Laser scar revision (FLSR) has become a popular adjunct to existing treatments for HTS, yet some patients continue to experience P&I, severely impairing quality of life. Mental health disorders can greatly impact patient perception of P&I. This study assessed the influence of mental health on P&I perceptions in post-burn FLSR patients, hypothesizing that patients with no mental health diagnosis would improve more rapidly than those with a diagnosis during laser therapy. Demographics (age, sex, Fitzpatrick skin type, race) and scar characteristics (scar age, burn etiology, location, size) were obtained. Patients (n=110) were split into two cohorts, those with no mental health diagnosis, (NoMH, n=53) and those with (MHD, n=57). Inclusion in MHD required a preexisting diagnosis or one from inpatient burn psychology. All patients received a preoperative evaluation (pre-FLSR), at least 3 treatments (FLSR 1, 2, 3) and evaluation via patient and observer scar assessment scale (POSAS) -observer(-O), and -patient(-P). All P&I scores were obtained from the POSAS-P evaluations. Intergroup comparisons between P&I scores and FLSR sessions were not significant. However, intragroup analysis of MHD revealed significant decreases in pain between pre-FLSR and post-FLSR session 1 (p< 0.001), FLSR 2 (p< 0.05) and FLSR 3 (p< 0.01). In NoMH the only decrease was from pre-FLSR and FLSR 3 (p< 0.01). Itch scores decreased in MHD post-FLSR 2 (p <.05) and FLSR 3 (p <.001) compared to pre-FLSR. NoMH had no differences between pre- and post-laser itch. There were no differences between group POSAS-O average scores. For NoMH, there were decreased scores at post-FLSR 2 (p< 0.01) and FLSR 3 (p< 0.001) and in MHD at post-FLSR 2 (p< 0.001) and FLSR 3 (p< 0.0001). There were no significant differences in concomitant medications between the MHD and NoMH groups except related to SSRIs. Contrary to the hypothesis, MHD patients reported a more significant decrease in P&I throughout FLSR treatment compared to NoMH. This is despite POSAS-O scores demonstrating no differences between groups in observer-reported scar healing and suggests a factor outside of scar healing impacts P&I perception. Interventions implemented by the burn psychology team are a likely cause of the improved scar perception in MHD patients. The data further shows the importance of a dedicated burn psychology team and warrants further studies on the influence of psychological support on post-burn patient outcomes in the setting of laser. This work was funded in part by the National Center for Advancing Translational Science (NCATS/NIH)

Burn injuries are often associated with physical scarring in addition to severe psychosocial consequences, including heightened pain and pruritus (itch). These symptoms can persist long after the injury and often become recalcitrant to standard treatments, such as gabapentin and antihistamines. Fractional ablative CO2 laser scar revision (FLSR) has gained popularity as an adjunctive therapy to address the limitations of existing treatments. However, despite this treatment, some patients continue to experience both symptoms, which negatively impacting their quality of life and daily functioning. A retrospective review of 110 patients receiving laser scar revision between 2018 and 2024 was conducted at a single institution, with patients divided into two cohorts: those with a diagnosed mental health condition and those without. Patients with a mental health diagnosis (MHD) reported a more significant reduction in pain and pruritus over the course of three laser sessions compared to those without an MHD. Despite these differences in perception, no variation was observed in the objective measures of scar healing between the cohorts. Gabapentin dosage was associated with reductions in pain perception, particularly in the MHD group. This finding suggests that mental health interventions may enhance the subjective experience of recovery, potentially through neuroplastic changes influenced by psychotherapy as compared to medications. This study underscores the need to integrate mental health care into the physical recovery of burn patients. Future research should investigate the long-term outcomes of combined mental health and scar therapy interventions to improve patient quality of life postinjury.

Burn injuries induce a hypermetabolic and systemic inflammatory response that is difficult to mitigate. The post-burn inflammatory response is mediated by cytokines such as tumor necrosis factor alpha (TNF-α), (interleukin-6) IL-6, and interleukin-8 (IL-8). Advances in modern burn resuscitation have dramatically decreased the mortality associated with burn shock. However, prolonged inflammatory response following severe burns can be detrimental, leading to increased susceptibility to infections, multi-organ failure and death. Recently, there has been a shift towards the earlier use of colloids, such as albumin and fresh frozen plasma (FFP), to reduce the volume of crystalloids required to maintain end-organ perfusion during resuscitation. Previous literature has suggested that FFP use may increase the risk of exacerbating the host systemic immune response. The effect of FFP transfusion on cytokine host response in burn patients is currently unknown. In this study, we investigated the effects of FFP administration on the biomarkers of inflammation during resuscitation. A prospective study was performed on burn patients with >20% TBSA burns who underwent plasma inclusive burn resuscitation. Blood samples were collected within 4 hours of admission, immediately prior to and after administration of the first unit of FFP and after resuscitation was complete. Serum concentrations of IL-6, soluble IL-6 receptor (sIL-6R), TNF-α, TNF-α receptor (TNF-αR) were quantified using enzyme-linked immunosorbent assay (ELISA). Statistical analysis was performed using Friedman’s multiple comparison test to compare the serum concentrations prior to and after FFP administration. Twenty-nine patients were included in the analysis. The patients were predominantly male (75.9%) with a median age of 46 years and a median TBSA burn of 34%. The overall mortality was 27.6%. At baseline, IL-6 and TNF-α were elevated compared to normal reference ranges. IL-6 levels were higher after resuscitation [708 (374-1736)], than baseline [133 (66-270); p< 0.0001], pre-plasma [175 (90-340); p< 0.0001] and after one unit [152 (93-405); p=0.0008]. Similarly, TNF-α levels were higher post-resuscitation [14 (12-17)], compared to baseline [10 (9-13); p< 0.0001], pre-plasma [12 (9-14); p< 0.0001] and post-unit [12 (9-14); p=0.0001]. Levels of IL-6, TNF-α and their receptors did not differ pre-plasma and post-unit. The administration of FFP did not worsen the systemic inflammatory response seen in severe burn injuries. Concerns regarding exacerbating the systemic inflammatory response should not preclude the use of FFP as an adjunct for resuscitation based on this data. Additional research should be directed towards comparing the immune response of other colloids that can be used as resuscitation adjuncts. N/A

Frailty refers to an age-related syndrome of functional and physiological decline that is characterized by heightened vulnerability to adverse health events. Previous literature has demonstrated the efficacy of frailty assessment among burn injured patients. There is a U-shaped association between body mass index (BMI) and frailty with both ends of the BMI spectrum representing higher risk for elevated frailty scores. BMI has previously been shown to have a significant impact on inpatient length of stay, adverse events, and mortality. Despite this, there is a paucity of literature evaluating the complex relationship between frailty and BMI in burn patients. In this study, we investigated the relationship between BMI and frailty scores and their effects on burn outcomes in a multicenter population of older adult burn patients. Burn injured patients admitted to 12 burn centers from January 2017 to December 2019 who were 60 years and older were retrospectively reviewed. Demographics, injury characteristics, and clinical metrics were obtained. Frailty was assigned to patients using the Canadian Study of Health and Aging Clinical Frailty Scale (CSHA-CFS). BMI was used to stratify patients as underweight (UW; BMI< 18.5), non-obese (NO; BMI 18.5-24.9), overweight (OW; BMI 25-29.9), obese I (OI; BMI 30-34.9), obese II (OII; BMI 35-39.9), or obese III (OIII; BMI≥40). Outcomes evaluated included the number of operations per admission, length of stay (LOS), and in-hospital mortality. Data is presented as mean ± SD. Frailty score by BMI, LOS and mortality were examined by Kruskal-Wallis test. Of 1,632 older adult burn patients, 1,415 patients had BMI data and were included for study. Of these, 49 were UW, 413 NO, 475 OW, 278 OI, 105 OII, and 95 OIII. Mean age was 70±8.5 years, mean TBSA burn was 8.4±12.1%, and the mortality rate was 8.8%. Frailty score was higher in UW (4.7±1.1) compared to NW (4.1±1.4; p=0.03), OW (3.8±1.3; p< 0.0001), and OI (3.8±1.2; p=0.0001). Frailty in NW (4.1±1.4) was also higher compared to OW (3.8±1.3; p=0.01) and OI (3.8±1.2; p=0.04). Total operations, LOS, and mortality were not significantly affected by BMI classification. Frailty scores were significantly higher in underweight patients compared to normal weight, overweight or obese burn patients. Differences in BMI did not affect the LOS, total operations or mortality. Although the relationship of BMI and frailty remain complex, understanding the effect of BMI extremes like being underweight may help with determining frailty status. N/A

Burn followed by excision has long been the primary method used to create burn injury in model organism systems. Forgoing the burn and creating an excisional injury to replicate the burn wound is an alternative model to study full thickness injury to the skin; however, it has yet to be investigated whether this method adequately mimics the clinical trajectory of a healing burn injury. We aimed to investigate this excisional model and compare it to the traditional burn followed by excision model to understand the impact of the initial burn injury and determine whether the excisional model is an adequate method for porcine burn injury research.For this study, porcine subjects received either a full-thickness burn followed by excision or a full thickness excision wound only. Both models then underwent 4:1 meshed split-thickness autografting. Skin biopsies and digital photographs were taken over the next 14 days to evaluate healing, and non-invasive probes were used to evaluate scar characteristics four and seven weeks after initial injury.There was a significant difference between the burn + excision and excision only groups in the early time points when measuring re-epithelialization, dermal thickness, rete ridge ratio, cellularity, and erythema. Considerably fewer differences were noted in these parameters at the later time points, indicating more similarity in later tissue remodeling and scar formation between these two groups.This study demonstrates that the rate of wound healing after excision and grafting differs between wounds with a preceding burn injury and those without. However, that difference fades as wound healing progresses through the scar remodeling phase. These findings suggest that the type of porcine model used to study burn wound healing after excision and grafting impacts initial healing processes which should be considered when selecting a model and comparing results among different studies.

Aim: Severely burn injured patients present in an immunocompromised state with loss of skin integrity. Systemic antibiotics are necessary to treat infection in this population, but even small doses may select resistant organisms and alter the host microbiome. Despite this, preoperative antibiotics in burn injury remain debated and their impact on the host microbiome has not been fully elucidated. This work examined the effect of a single preoperative antibiotic dose on the microbiome and clinical outcomes in burn patients. Methods: Patients with burns < 10% total body surface area (TBSA) requiring a single excision and grafting operation were enrolled and randomized to receive a single preoperative dose of cefazolin (ABX) or no antibiotics (no-ABX). Blood samples, wound swabs, and buccal swabs were obtained serially during and after hospitalization to determine bacterial taxonomy characteristics. Graft loss was determined at clinic follow-up. Results: In ABX patients, there were 29 enriched bacterial taxa within wound beds at dressing takedown [log(LDA) ≥ 2, P ≤ 0.05] and greater than 10 bacterial taxa in buccal swabs at follow-up [log(LDA) ≥ 2, P ≤ 0.05]. There was increasing alpha diversity in ABX patients intraoperatively and at dressing takedown. There were no significant differences in graft loss between groups. Extremophile infiltration was noted in oral and wound microbiomes in ABX patients. Conclusion: Though not affected clinically, these data suggest that a single preoperative antibiotic dose significantly impacts the wound and oral microbiome. Innovative approaches to examining the antibiotic impact on the host microbiome of burn patients may help better tailor antibiotic stewardship.