Publications by authors named "Loren H Engrav"

49 Publications

An expanded delivery model for outpatient burn rehabilitation.

J Burn Care Res 2015 Jan-Feb;36(1):14-22

From the Departments of *Rehabilitation Medicine and †Surgery, Harborview Medical Center, University of Washington School of Medicine, Seattle; and ‡Department of Biostatistics and Informatics, University of Colorado Health Sciences Center, Denver.

Despite the numerous multidisciplinary services burn centers provide, a number of challenges to obtaining optimal outcomes exist. The goal of this study was to overcome the barriers to effective burn rehabilitation by utilizing an expanded care coordinator (ECC) to supplement the existing outpatient services. In this between-group, single-blind, randomized, controlled trial, the control group (n = 41) received standard outpatient care and the experimental group (n = 40) received additional services provided by the ECC, including telephone calls at set intervals (24 hours postdischarge, 2, 4, 8, 12 weeks postdischarge and 5, 7, 9 months postdischarge). The ECC was trained in motivational interviewing, crisis intervention, and solution-focused counseling. He assisted patients before and after each clinic visit, coordinated outpatient services in their geographic area (physical and occupational therapy, counseling, primary care provider referrals, etc.), and helped develop problem-solving approaches to accomplish individualized goals. Outcome measures included patient identified goals utilizing the goal attainment scale, the urn-specific health scale-brief, the Short Form 12, a patient satisfaction survey, and a return to work survey. The average subject age was 43 years (SD = 16.9) with a mean TBSA of 19% (SD = 18.8). The average length of hospitalization was 36 days (SD = 42.9). The patient and injury characteristics were similar between the study groups. For the experimental group, 33% completed seven calls, with 23% completing all the eight calls. All were assessed using general linear models and were adjusted for sex, age, length of hospitalization, urban vs rural area of residence, %TBSA burn, and ethnicity. There was no difference between the control and experimental groups for any of the outcome measures at either 6 or 12 months postburn. No differences in outcomes between the groups were found. All participants appreciated the individualized goal setting process that was used as an outcome measure and this may have accounted for the similar outcomes in both the groups. (The measure may have been more of an intervention, thus contributing to the strength of the control group.) Although most patients with burn injuries may not need an intervention that is this intensive, a subset of patients at higher risk or with more severe injuries may benefit from more intensive and personalized services. Future research should examine the benefits of individual goal setting processes for all the patients and also attempt to identify those patients most at risk for poorer outcomes and therefore, likely to benefit of more intensive personalized services.
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http://dx.doi.org/10.1097/BCR.0000000000000153DOI Listing
October 2015

Pruritus in adult burn survivors: postburn prevalence and risk factors associated with increased intensity.

J Burn Care Res 2013 Jan-Feb;34(1):94-101

Department of Surgery, University of Washington, Seattle, WA, USA.

Pruritus (itching) is a common and distressing complaint after injury. The purpose of this study was to investigate self-reported postburn pruritus in a large, multisite cohort study of adult burn survivors. Descriptive statistics, general linear regression, and mixed model repeated measures analyses were employed to test statistical significance. Two cohorts of adult burn survivors were studied. Group 1 participants (n = 637) were injured from 2006 to 2010 and were followed up prospectively for 2 years from the time of injury. Prevalence and severity of pruritus were compared across multiple subgroups. Prevalence of pruritus at discharge, 6, 12, and 24 months following injury were 93, 86, 83, and 73%, respectively. Regression results established that %TBSA-burn and %TBSA-grafted were correlated to itch intensity values. Group 2 participants (n = 336) were injured 4 to 10 years before an assessment using the validated 5-D Itch Scale. Many patients (44.4%) reported itching in the area of the burn, graft, or donor site. Within this group, 76% reported itching for <6 hours/day, and 52 and 29% considered itch intensity to be mild or moderate, respectively. This study confirms that the prevalence of burn pruritus is high, initially affecting >90% and persisting for >40% of long-term burn survivors. New predictors for postburn itch were identified to include younger age, dry skin, and raised/thick scars. Characterization of the impact of postburn pruritus on leisure, vocation, and sleep are quantified for those long-term survivors suffering from postburn pruritus.
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http://dx.doi.org/10.1097/BCR.0b013e3182644c25DOI Listing
June 2013

Harborview burns--1974 to 2009.

PLoS One 2012 5;7(7):e40086. Epub 2012 Jul 5.

Division of Plastic Surgery, Department of Surgery, University of Washington, Seattle, Washington, United States of America.

Background: Burn demographics, prevention and care have changed considerably since the 1970s. The objectives were to 1) identify new and confirm previously described changes, 2) make comparisons to the American Burn Association National Burn Repository, 3) determine when the administration of fluids in excess of the Baxter formula began and to identify potential causes, and 4) model mortality over time, during a 36-year period (1974-2009) at the Harborview Burn Center in Seattle, WA, USA.

Methods And Findings: 14,266 consecutive admissions were analyzed in five-year periods and many parameters compared to the National Burn Repository. Fluid resuscitation was compared in five-year periods from 1974 to 2009. Mortality was modeled with the rBaux model. Many changes are highlighted at the end of the manuscript including 1) the large increase in numbers of total and short-stay admissions, 2) the decline in numbers of large burn injuries, 3) that unadjusted case fatality declined to the mid-1980s but has changed little during the past two decades, 4) that race/ethnicity and payer status disparity exists, and 5) that the trajectory to death changed with fewer deaths occurring after seven days post-injury. Administration of fluids in excess of the Baxter formula during resuscitation of uncomplicated injuries was evident at least by the early 1990s and has continued to the present; the cause is likely multifactorial but pre-hospital fluids, prophylactic tracheal intubation and opioids may be involved.

Conclusions: 1) The dramatic changes include the rise in short-stay admissions; as a result, the model of burn care practiced since the 1970s is still required but is no longer sufficient. 2) Fluid administration in excess of the Baxter formula with uncomplicated injuries began at least two decades ago. 3) Unadjusted case fatality declined to ∼6% in the mid-1980s and changed little since then. The rBaux mortality model is quite accurate.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0040086PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3390332PMC
March 2013

Functional genomics unique to week 20 post wounding in the deep cone/fat dome of the Duroc/Yorkshire porcine model of fibroproliferative scarring.

PLoS One 2011 Apr 20;6(4):e19024. Epub 2011 Apr 20.

Department of Surgery, Division of Plastic Surgery, University of Washington, Seattle, Washington, United States of America.

Background: Hypertrophic scar was first described over 100 years ago; PubMed has more than 1,000 references on the topic. Nevertheless prevention and treatment remains poor, because 1) there has been no validated animal model; 2) human scar tissue, which is impossible to obtain in a controlled manner, has been the only source for study; 3) tissues typically have been homogenized, mixing cell populations; and 4) gene-by-gene studies are incomplete.

Methodology/principal Findings: We have assembled a system that overcomes these barriers and permits the study of genome-wide gene expression in microanatomical locations, in shallow and deep partial-thickness wounds, and pigmented and non-pigmented skin, using the Duroc(pigmented fibroproliferative)/Yorkshire(non-pigmented non-fibroproliferative) porcine model. We used this system to obtain the differential transcriptome at 1, 2, 3, 12 and 20 weeks post wounding. It is not clear when fibroproliferation begins, but it is fully developed in humans and the Duroc breed at 20 weeks. Therefore we obtained the derivative functional genomics unique to 20 weeks post wounding. We also obtained long-term, forty-six week follow-up with the model.

Conclusions/significance: 1) The scars are still thick at forty-six weeks post wounding further validating the model. 2) The differential transcriptome provides new insights into the fibroproliferative process as several genes thought fundamental to fibroproliferation are absent and others differentially expressed are newly implicated. 3) The findings in the derivative functional genomics support old concepts, which further validates the model, and suggests new avenues for reductionist exploration. In the future, these findings will be searched for directed networks likely involved in cutaneous fibroproliferation. These clues may lead to a better understanding of the systems biology of cutaneous fibroproliferation, and ultimately prevention and treatment of hypertrophic scarring.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0019024PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3080398PMC
April 2011

Spatial and temporal localization of the melanocortin 1 receptor and its ligand α-melanocyte-stimulating hormone during cutaneous wound repair.

J Histochem Cytochem 2011 Mar 12;59(3):278-88. Epub 2011 Jan 12.

Department of Surgery, University of Washington, Seattle, Washington 98104, USA.

Growing evidence indicates that the melanocortin 1 receptor (MC1R) and its ligand α-melanocyte-stimulating hormone (α-MSH) have other functions in the skin in addition to pigment production. Activation of the MC1R/α-MSH signaling pathway has been implicated in the regulation of both inflammation and extracellular matrix homeostasis. However, little is known about the role of MC1R/α-MSH signaling in the regulation of inflammatory and fibroproliferative responses to cutaneous injury. Although MC1R and α-MSH localization has been described in uninjured skin, their spatial and temporal expression during cutaneous wound repair has not been investigated. In this study, the authors report the localization of MC1R and α-MSH in murine cutaneous wounds, human acute burns, and hypertrophic scars. During murine wound repair, MC1R and α-MSH were detected in inflammatory cells and suprabasal keratinocytes at the leading edge of the migrating epithelial tongue. MC1R and α-MSH protein levels were upregulated in human burn wounds and hypertrophic scars compared to uninjured human skin, where receptor and ligand were absent. In burn wounds and hypertrophic scars, MC1R and α-MSH localized to epidermal keratinocytes and dermal fibroblasts. This spatiotemporal localization of MC1R and α-MSH in cutaneous wounds warrants future investigation into the role of MC1R/α-MSH signaling in the inflammatory and fibroproliferative responses to cutaneous injury. This article contains online supplemental material at http://www.jhc.org. Please visit this article online to view these materials.
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http://dx.doi.org/10.1369/0022155410397999DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3201153PMC
March 2011

The effect of virtual reality on pain and range of motion in adults with burn injuries.

J Burn Care Res 2009 Sep-Oct;30(5):785-91

Department of Surgery, University of Washington, Seattle, Washington, USA.

Few studies have empirically investigated the effects of immersive virtual reality (VR) on postburn physical therapy pain control and range of motion (ROM). We performed a prospective, randomized controlled study of the effects of adding VR to standard therapy in adults receiving active-assisted ROM physical therapy, by assessing pain scores and maximal joint ROM immediately before and after therapy on two consecutive days. Thirty-nine inpatients, aged 21 to 57 years (mean 35 years), with a mean TBSA burn of 18% (range, 3-60%) were studied using a within-subject, crossover design. All patients received their regular pretherapy pharmacologic analgesia regimen. During physical therapy sessions on two consecutive days (VR one day and no VR the other day; order randomized), each patient participated in active-assisted ROM exercises with an occupational or physical therapist. At the conclusion of each session, patients provided 0 to 100 Graphic Rating Scale measurements of pain after each 10-minute treatment condition. On the day with VR, patients wore a head-position-tracked, medical care environment-excluding VR helmet with stereophonic sound and interacted in a virtual environment conducive to burn care. ROM measurements for each joint exercised were recorded before and after each therapy session. Because of nonsignificant carryover and order effects, the data were analyzed using simple paired t-tests. VR reduced all Graphic Rating Scale pain scores (worst pain, time spent thinking about the pain, and pain unpleasantness by 27, 37, and 31% respectively), relative to the no VR condition. Average ROM improvement was slightly greater with the VR condition; however, this difference failed to reach clinical or statistical significance (P = .243). Ninety-seven percent of patients reported zero to mild nausea after the VR session. Immersive VR effectively reduced pain and did not impair ROM during postburn physical therapy. VR is easily used in the hospital setting and offers a safe, nonpharmacologic adjunctive analgesic treatment.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2880576PMC
http://dx.doi.org/10.1097/BCR.0b013e3181b485d3DOI Listing
January 2010

Panniculus morbidus follow-up.

Authors:
Loren H Engrav

Plast Reconstr Surg 2009 Jul;124(1):181e

Division of Plastic Surgery; Department of Surgery; University of Washington.

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http://dx.doi.org/10.1097/PRS.0b013e3181a83bbcDOI Listing
July 2009

Using QMethodology to identify reasons for distress in burn survivors postdischarge.

J Burn Care Res 2009 Jan-Feb;30(1):83-91

Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle, USA.

Reasons for distress after burn injuries have not been codified based on any type of acceptable empirical or statistical technique. The unique design methodology proposed in this study can identify the most common reasons cited for causing distress in burn survivors after discharge. A Q-sort task was developed with the assistance of our burn advisory group. After identifying 50 possible reasons for distress after discharge, each reason was placed on a laminated game card. In compliance with Qmethodology, a game board was developed that allowed patients to rank order each reason from "not causing distress" to "causing significant distress." A total of 69 burn survivors were enrolled in the study at four different time points: 1 month, 6 months, 1 year and 2 years postdischarge. After factor analysis, four factors accounted for all of the participants across time points. This indicates that at least four distinct groups of people can be categorized according to themes raised in rating reasons for distress. This Q-sort technique allowed us to capture the complexity of conceptualizing human distress by categorizing clusters of reported problems into similar groups. This methodology shows great promise for developing interventions that target unique needs of burn survivors.
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http://dx.doi.org/10.1097/BCR.0b013e3181921f42DOI Listing
March 2009

Expression of collagen genes in the cones of skin in the Duroc/Yorkshire porcine model of fibroproliferative scarring.

J Burn Care Res 2008 Sep-Oct;29(5):815-27

Division of Plastic Surgery, Department of Surgery, University of Washington, Seattle, WA 98104, USA.

During the past decades there has been minimal improvement in prevention and treatment of hypertrophic scarring. Reasons include the lack of a validated animal model, imprecise techniques to dissect scar into the histologic components, and limited methodology for measurement of gene expression. These problems have been addressed with the Duroc/Yorkshire model of healing, laser capture microdissection, and the Affymetrix Porcine GeneChip. Here we compared collagen gene expression in fibroproliferative healing in the Duroc breed to nonfibroproliferative healing in the Yorkshires. We made shallow and deep dorsal wounds, biopsied at 1, 2, 3, 12, and 20 weeks. We sampled the dermal cones by laser capture microdissection, extracted and amplified the RNA, and hybridized Affymetrix Porcine GeneChips. We also obtained samples of human hypertrophic scar approximately 20 weeks postinjury. Data were normalized and statistical analysis performed with mixed linear regression using the Bioconductor R/maanova package. Genes for further analysis were also restricted with four biologic criteria, including that the 20-week deep Duroc expression match the human samples. Eleven collagen genes and seven collagen types were differentially over expressed in deep Duroc wounds including 1a1, 1a2, 3a1, 4a1, 4a2, 5a1, 5a2, 5a3, 6a3 (transcript variant 5), 14a1 and 15a1. COL7a1 gene was differentially under expressed in deep Duroc wounds. The results suggest that collagens I, III, IV, V, VI, VII, XIV, and XV [corrected] are involved in the process of fibroproliferative scarring. With these clues, we will attempt to construct the regulatory pathway(s) of fibroproliferative healing.
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http://dx.doi.org/10.1097/BCR.0b013e3181848141DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2853751PMC
January 2009

Creeping fluid, technology and opioids.

Authors:
Loren H Engrav

J Burn Care Res 2008 Sep-Oct;29(5):857-8

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http://dx.doi.org/10.1097/BCR.0b013e3181848c5fDOI Listing
January 2009

Pediatric palm contact burns: a ten-year review.

J Burn Care Res 2008 Jul-Aug;29(4):614-8

Department of Surgery, University of Washington Burn Center, Seattle, Washinton 98104-2499, USA.

Management and proper approach to pediatric palm burns remains unclear. Our burn center's approach includes early, aggressive range of motion therapy, combined with a period of watchful waiting, reserving grafting only for those palms that do not heal in a timely manner. We reviewed our experience using this approach over a 10-year period. We performed a retrospective review of all pediatric patients with palm burns admitted to our burn center from 1994 to 2004. A total of 168 patients (194 palms) were included in the study. The average patient was 1.3 years old. A total of 168 of the injured palms (87%) healed without need for surgery. The average time to healing was 13 days (range 5-34). The 19 patients (26 palms, 13.4%) who underwent excision and grafting were managed with thick split thickness skin grafts. Of these, four patients (five palms, 19.2%) underwent secondary reconstruction, at an average of 166 days after the initial surgery. Of the 168 (87%) palms managed without surgery, only three patients (four palms) required late reconstruction (2.4%). Reconstructive procedures consisted of full-thickness skin grafts (n = 7) and z-plasty (n = 2). We have found that the majority of patients in this study healed without need for acute or reconstructive surgery. We therefore recommend aggressive hand therapy and conservative surgical management of palm burns in children.
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http://dx.doi.org/10.1097/BCR.0b013e31817db8f2DOI Listing
November 2008

Reversible marginal tarsorrhaphy: a salvage procedure for periocular burns.

Plast Reconstr Surg 2008 May;121(5):1627-1630

Seattle, Wash. From the Burn Center and Division of Plastic Surgery, Department of Surgery, and the Department of Ophthalmology, Harborview Medical Center, University of Washington.

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http://dx.doi.org/10.1097/PRS.0b013e31816c3b2fDOI Listing
May 2008

Resection of panniculus morbidus: a salvage procedure with a steep learning curve.

Plast Reconstr Surg 2008 Jan;121(1):108-114

Seattle, Wash. From the Department of Surgery, Division of Plastic Surgery, and Department of Rehabilitation Medicine, University of Washington, and Department of Hospitality and Nutrition, Harborview Medical Center.

Background: A subset of obese people develop a pannus hanging to the floor. This panniculus morbidus prevents weight loss, as the patient cannot exercise. It prevents hygiene, leading to a profound odor and ultimately results in intertrigo, cellulitis, and/or abdominal ulceration. The only two options are to live/die with it or resect it. Some of these people are otherwise ready for a weight loss program. For this group, resection of the panniculus morbidus may be indicated. The authors reviewed the literature and found the condition has not been addressed in this Journal since 1994 and was not considered in the recent supplement on body contouring. In 1998, the authors began resecting panniculus morbidus for this small group. The authors found the learning curve to be profoundly steep, with many wound complications, a finding that is quite in conflict with the literature on the subject, and decided to present their experience.

Methods: The authors conducted a retrospective chart review of 23 patients and collected data on demographics, ambulation, hygiene, technique, complications, and outcome.

Results: The technique of closure evolved as the authors struggled with complications. The current method of closure is three suture layers over four suction drains with a small wound vacuum-assisted closure device at each end of the incision. All patients ultimately healed and found it easier to ambulate and perform hygiene.

Conclusion: Resection of panniculus morbidus is a beneficial salvage procedure for some morbidly obese people, but the learning curve is steep and the current literature is misleading.
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http://dx.doi.org/10.1097/01.prs.0000293760.41152.29DOI Listing
January 2008

Assets and liabilities of the Burn Model System data model: a comparison with the National Burn Registry.

Arch Phys Med Rehabil 2007 Dec;88(12 Suppl 2):S7-17

Department of Preventive Medicine and Biometrics, University of Colorado and Health Sciences Center, Denver, CO 80262, USA.

Objectives: To determine whether the Burn Model System (BMS) population is representative of the larger burn population and to investigate threats to internal and external validity in a multicenter longitudinal database of severe burns.

Design: Cohort data for the BMS project have been collected since 1994. Follow-up data have been collected at 6, 12, and 24 months postburn. The demographic and burn characteristics of the BMS population were compared with those of patients in the National Burn Registry (NBR).

Setting: The BMS, which collected data for these analyses from 5 regional burn centers in the United States, and the NBR dataset, which is a registry of information collected through the Trauma Registry of the American College of Surgeons and includes data from 70 hospitals in the United States and Canada.

Participants: BMS study participants were severely burned patients treated at 1 of the 5 participating burn centers. We compared the BMS population with that of the NBR both in total and filtered to include only patients with comparable injuries.

Interventions: Not applicable.

Main Outcome Measures: Comparable demographic and burn characteristics contained in both the NBR and the 5-center BMS longitudinal database and baseline and follow-up distributions of demographic variables and burn characteristics in the BMS database.

Results: Although minor deviations in demographic distributions were found between the BMS and NBR and between discharge and follow-up populations, our results show that the BMS population sample is internally and externally valid and is adequate for answering research questions.

Conclusions: Cohort studies examining long-term outcomes have the potential flaw of using a nonrepresentative study population. The BMS population was found to be sufficiently representative, but future analyses will require cautious and purposeful application of statistical adjustment strategies.
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http://dx.doi.org/10.1016/j.apmr.2007.09.011DOI Listing
December 2007

Barriers to return to work after burn injuries.

Arch Phys Med Rehabil 2007 Dec;88(12 Suppl 2):S50-6

Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA.

Objective: To identify barriers to return to work after burn injury as identified by the patient.

Design: A cohort study with telephone interview up to 1 year.

Setting: Hospital-based burn centers at 3 national sites.

Participants: Hospitalized patients (N=154) meeting the American Burn Association criteria for major burn injury, employed at least 20 hours a week at the time of injury, and with access to a telephone after discharge.

Intervention: Patients were contacted via telephone every 2 weeks up to 4 months, then monthly up to 1 year after discharge.

Main Outcome Measures: A return to work survey was used to identify barriers that prevented patients from returning to work. A graphic rating scale determined the impact of each barrier.

Results: By 1 year, 79.7% of patients returned to work. Physical and wound issues were barriers early after discharge. Although physical abilities continued to be a significant barrier up to 1 year, working conditions (temperature, humidity, safety) and psychosocial factors (nightmares, flashbacks, appearance concerns) became important issues in those with long-term disability.

Conclusions: The majority of patients return to work after a burn injury. Although physical and work conditions are important barriers, psychosocial issues need to be evaluated and treated to optimize return to work.
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http://dx.doi.org/10.1016/j.apmr.2007.09.009DOI Listing
December 2007

Review of the female Duroc/Yorkshire pig model of human fibroproliferative scarring.

Wound Repair Regen 2007 Sep-Oct;15 Suppl 1:S32-9

Department of Surgery, Division of Plastic Surgery, University of Washington, Seattle, Washington 98104, USA.

Hypertrophic scarring after burns is an unsolved problem and remains as devastating today as it was in the 40s and it may be that the main reason for this is the lack of an accepted, useful animal model. The female, red Duroc pig was described as a model of hypertrophic scarring nearly 30 years ago but then vanished from the literature. This seemed strange since the authors reported that 12 of 12 pigs developed thick scar. In the mid 90s we explored the model and found that, indeed, the red Duroc pig does make thick scar. Other authors have established that the Yorkshire pig does not heal in this fashion so there is the possibility of a same species control. We have continued to explore the Duroc/Yorkshire model and herein describe our experiences. Is it a perfect model of hypertrophic scarring? No. Is it a useful model of hypertrophic scarring? Time will tell. We have now obtained gene expression data from the Duroc/Yorkshire model and analysis is underway.
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http://dx.doi.org/10.1111/j.1524-475X.2007.00223.xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2886711PMC
January 2008

Hypertrophic scar, wound contraction and hyper-hypopigmentation.

J Burn Care Res 2007 Jul-Aug;28(4):593-7

Division of Plastic Surgery, Department of Surgery, University of Washington, Harborview Medical Center, 325 Ninth Avenue, Seattle, WA 98104, USA.

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http://dx.doi.org/10.1097/BCR.0B013E318093E482DOI Listing
October 2007

Time to school re-entry after burn injury is quite short.

J Burn Care Res 2007 May-Jun;28(3):478-81; discussion 482-3

Burn Center, Division of Plastic Surgery and Department of Physical Medicine and Rehabilitation, University of Washington, Seattle, Washington 98104, USA.

Returning to school is an important indicator of functional aptitude and emotional adjustment in school-aged patients after burn injury. Only two reports in the burn literature provide objective data on time to school re-entry. However, these analyses did not address the impact of patient and burn injury characteristics on time to return to school. The purpose of this study was to determine the time for school re-entry and to identify the factors associated with re-entry time in a cohort of burned children treated at our burn center. We performed a retrospective review of all school age children treated at our burn center from 1997 to 2003 who were entered into a federally funded longitudinal research database for patients with severe burn injury. Time to school re-entry after discharge was calculated for each patient, and multivariate regression was used to identify the factors associated with longer time to return to school. A total of 64 patients were included in this study. The average time to school re-entry was 10.5 days (range, 0-40) and the median time was 7.5 days. Gender (male), age, and length of hospital stay were significantly associated (P < .05) with longer time to return to school. The average time to school return is quite short. Further studies are needed to increase understanding of the factors influencing longer time to re-entry and also to examine children's experiences upon re-entry.
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http://dx.doi.org/10.1097/BCR.0B013E318053d2EADOI Listing
October 2007

Extended time to wound closure is associated with increased risk of heterotopic ossification of the elbow.

J Burn Care Res 2007 May-Jun;28(3):447-50

University of Washington Burn Center, Harborview Medical Center, Department of Surgery, Box 359796, 325 Ninth Avenue, Seattle, Washington 98104, USA.

Heterotopic ossification (HO) is a well-recognized complication of burn injury that can result in significantly compromised limb function. The etiology and optimal treatment strategy for HO remain elusive. The purpose of this study was to examine the relationship between delay in elbow wound closure and the development of HO. We performed a case-control study to examine the relationship between delay in wound closure and development of HO. Cases (HO patients) were identified using our patient registry and matched with patients of similar age, burn size, and sex who did not develop HO. Time to wound closure was compared using bivariate statistics and the odds for developing HO based on time to wound closure was modeled using multivariate logistic regression. During the study period, a total of 45 patients developed elbow HO. When compared with controls matched for age, burn size, and sex, elbow wounds were open significantly longer in the cases than in the controls (48.7 days vs 24.2 days, P < .01). On multivariate logistic regression, the adjusted odds ratio was 1.08 (95% CI 1.04-1.12, P < .01). Time to elbow wound closure significantly impacts the risk of development of heterotopic ossification. Therefore, to minimize risk of HO formation, increased attention is warranted to optimize time to wound closure over joints. In addition, consideration of other soft tissue coverage options such as local flaps, including fascia or muscle flaps, may be warranted in cases of very deep elbow buns with high risk of skin graft failure.
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http://dx.doi.org/10.1097/BCR.0B013E318053D378DOI Listing
October 2007

The microvasculature in cutaneous wound healing in the female red Duroc pig is similar to that in human hypertrophic scars and different from that in the female Yorkshire pig.

J Burn Care Res 2007 May-Jun;28(3):500-6

Department of Burns and Plastic Surgery, Guangzhou Red Cross Hospital, The Fourth-affiliated Hospital, Jinan University, Guangzhou, PR China.

The female red Duroc pig has been found to be a promising model of hypertrophic scarring. The female Yorkshire pig has been demonstrated to heal in a very different manner, more resembling human normotrophic scarring. Given these observations, we studied microvessel density, an important aspect of wound healing, in human hypertrophic scars and the scars of the female Duroc and Yorkshire pigs. We studied microvessel density in uninjured skin; hypertrophic scars at 6 months or less, 7 to 12, and longer than 12 months; female Duroc tissues at 3 weeks and 3 and 5 months; and similar Yorkshire tissue, including uninjured skin and shallow and deep wounds. Antifactor VIII-related antigen was used to mark the endothelial cells. Computed assessment of microvessel density was used to quantify the microvasculature. In human hypertrophic scars, the microvessels were increased dramatically, and microvessel density and area were significantly elevated. We found similar results in the Duroc tissues at 5 months after deep wounding. In contrast, we found far less microvasculature and, at 5 months, the values had returned to normal in the Yorkshire tissues. This quantitative study of microvessel density further validates the female Duroc pig as an animal model of hypertrophic scarring and the female Yorkshire pig as a control.
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http://dx.doi.org/10.1097/BCR.0B013E318053DAFEDOI Listing
October 2007

Bilateral anterior abdominal bipedicle flap with permanent prosthesis for the massive abdominal skin-grafted hernia.

Am J Surg 2007 May;193(5):651-5

Division of Plastic and Reconstructive Surgery, University of Washington, Harborville Medical Center, 325 9th Avenue, Box 359796, Seattle, WA 98104-9796, USA.

Background: Fascial closure after damage control or decompression laparotomy is not always possible. The result is a ventral hernia covered with skin grafts. Massive hernias impair bowel, bladder, and respiratory function and are displeasing aesthetically. Most repair methods provide inadequate closure of large full-thickness abdominal wall defects. We describe our method of repair using bilateral anterior abdominal bipedicle flaps over permanent mesh.

Methods: We reviewed 6 patients who underwent this repair method. This staged repair first involves flap elevation followed by delay. In the next stage, the hernia skin graft is excised, mesh is placed, and flaps are advanced to midline to cover the mesh.

Results: The average hernia size was 885 +/- 274 cm2 (28-cm wide x 31-cm vertical), with a range of up to 37-cm wide. An average of 3 surgeries were required for closure, with a mean hospital stay of 22 days. No patients developed hernia recurrence with a mean follow-up period of 23 months.

Conclusions: This method provides successful and durable closure of massive skin-grafted hernias.
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http://dx.doi.org/10.1016/j.amjsurg.2006.12.029DOI Listing
May 2007

Brief report: sentinel lymph node dissection and burn scar carcinoma sentinel node and burn scar carcinoma.

Burns 2008 Mar 19;34(2):271-4. Epub 2007 Mar 19.

Department of Anesthesiology, Perioperative and Pain Medicine, Harvard University, 75 Francis Street, Boston, MA 02115, United States.

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http://dx.doi.org/10.1016/j.burns.2006.09.006DOI Listing
March 2008

The National Institute on Disability and Rehabilitation Research burn model system database: a tool for the multicenter study of the outcome of burn injury.

J Burn Care Res 2007 Jan-Feb;28(1):84-96

Division of Plastic Surgery and the Burn Center, Department of Surgery, Harborview Medical Center, University of Washington, Seattle, Washington 98104, USA.

Advances in critical care and surgical management have significantly improved survival after burn injury over the past several decades. However, today, survival alone is an insufficient outcome. In 1994, the National Institute on Disability and Rehabilitation Research (NIDRR) created a burn model system program to evaluate the long-term sequelae of burn injuries. As part of this multicenter program, a comprehensive demographic and outcome database was developed to facilitate the study of a number of functional and psychosocial outcomes after burns. The purpose of this study is to review the database design and structure as well as the data obtained during the last 10 years. This is a descriptive study of the NIDRR database structure as well as the patient data obtained from the four participating burn centers from 1994 to 2004. Data obtained during hospitalization and at 6, 12, and 24 months after discharge were reviewed and descriptive statistics were calculated for select database fields. The database is divided into several subsections, including demographics, injury complications, patient disposition, and functional and psychological surveys. A total of 4600 patients have been entered into the NIDRR database. To date, 3449 (75%) patients were alive at discharged and consented to follow-up data collection. The NIDRR database provides an expansive repository of patient, injury, and outcome data that can be used to analyze the impact of burn injury on physical and psychosocial function and for the design of interventions to enhance the quality of life of burn survivors.
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http://dx.doi.org/10.1097/BCR.0b013E31802C888EDOI Listing
March 2007

Burns as a result of assault: associated risk factors, injury characteristics, and outcomes.

J Burn Care Res 2007 Jan-Feb;28(1):21-8; discussion 29

Department of Rehabilitation Medicine, University of Washington Medical Center, Seattle, Washington 98104, USA.

The purpose of this study was to identify specific premorbid factors and injury characteristics associated with intentional burn injuries and to compare outcomes for individuals injured by assault and those with unintentional injuries. Participants sustaining major burns from May 1994 to August 2005 and consenting to a multisite, prospective, longitudinal outcome study were included. Etiology of the injury was classified as intentional (i.e., assault) or unintentional. Subjects <18 years old or with self-inflicted burns were excluded. Statistical analysis was performed with t-tests, chi2 tests, and analysis of variance. Eighty patients sustained intentional burn injuries and 1982 subjects sustained nonintentional burn injuries. Compared to patients with nonintentional burns, those with burns related to assault were more likely to be female, black, and unemployed and to have higher rates of premorbid substance use. Between the groups, there were no significant differences in preinjury living situation, education level, history of psychiatric treatment, or hospital length of stay. The intentional-burn group had larger burns and a greater in-hospital mortality rate, and these patients were less likely to be discharged to home. They also demonstrated significantly greater levels of psychological distress during the acute hospitalization but not at follow-up. Understanding the unique characteristics and needs of patients with intentional burn injuries is important because these individuals are less likely to have a steady income and more likely to rely on community social services. Affordable and accessible community-based health services are necessary in order to improve their outcomes.
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http://dx.doi.org/10.1097/BCR.0B013E31802C896FDOI Listing
March 2007

Correlation of clinical outcome of integra application with microbiologic and pathological biopsies.

J Trauma 2006 Nov;61(5):1212-7

University of Washington Burn Center, Department of Surgery, University of Washington, Seattle, Washington 98104, USA.

Background: Integra, a dermal replacement template consisting of bovine collagen, chondroitin-6-sulfate, and a silastic sheet is a postexcisional treatment for deep partial to full thickness burns where autograft is limited. This study correlates Integra histology and quantitative microbiology cultures with clinical outcomes after autografting.

Methods: Charts of 29 burn patients who underwent Integra treatment and neodermis biopsy at the time of ultra thin autografting were reviewed. We analyzed microbial contamination, inflammatory reaction, and autograft take.

Results: The mean burn size and age were 43% total body surface area and 39 years old, respectively. In quantitative neodermis cultures, 90% of samples had bacterial growth; nine samples (31%) had > 10(5) colony forming units per gram. The most common organism was Staphylococcus aureus (31%). Patients with quantitative bacterial counts >10(5) CFU/g received targeted systemic antibiotics. Integra take (83%) and autograft take (92%) were acceptable even in patients with high bacterial counts (78% Integra take; 86% autograft take). More than 50% of biopsies had dermal regeneration similar to normal dermis; foreign body reactions were unusual. Histologic evidence of inflammation, especially polymorphonuclear cells, was increased in biopsies with high bacterial counts.

Conclusion: Integra and autograft take can be acceptable even with high bacterial counts if wounds are treated with appropriate targeted topical and systemic antibiotics in the presence of microbial contamination. Neodermis biopsies showed fibrous in-growth congruent with existing Integra fibers with minimal foreign body reaction. These data support Integra use as a safe and effective treatment modality in patients with major burns.
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http://dx.doi.org/10.1097/01.ta.0000195982.71400.84DOI Listing
November 2006

Profile of patients lost to follow-up in the Burn Injury Rehabilitation Model Systems' longitudinal database.

J Burn Care Res 2006 Sep-Oct;27(5):703-12

University of Texas Southwestern Medical Center at Dallas, Texas 75390-9136, USA.

We sought to identify whether patterns exist in the Burn Injury Rehabilitation Model Systems' database among participants lost to follow-up at 6, 12, or 24 months after injury and to define characteristics that reliably discriminate between persons who are lost to follow-up and those who are not. All participants met the American Burn Association criteria for major burn injury, were 18 years of age or older, received care from one of four burn model systems, and consented to participate in a 2-year prospective data-collection process. Step-wise logistic regression was used to develop three prediction models for the probability of loss to follow-up. The percent of individuals successfully contacted for follow-up were 64% at 6 months, 54% at 12 months, and 42% at 24 months after injury. Individuals who were younger, not employed at time of burn, with less than a high school level education, a history of drug abuse, circumstances of injury involving suspected assault, and having no insurance for care were lost to follow-up. Longer stay in the hospital, on the other hand, increased the likelihood of follow-up. The same risk factors remained significant with or without adjusting for site indicating that these factors are independent and significant in spite of any potential site differences. Successful follow-up at 6- and 12-month intervals increased the likelihood of achieving a follow-up at 24 months after injury. The sociodemographic risk factors for attrition identified in this study represent significant enduring vulnerabilities. The findings necessitate a close examination of several factors and the use of strategies to reduce the risk of attrition.
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http://dx.doi.org/10.1097/01.BCR.0000238085.87863.81DOI Listing
January 2007

Histology of the thick scar on the female, red Duroc pig: final similarities to human hypertrophic scar.

Burns 2006 Sep 14;32(6):669-77. Epub 2006 Aug 14.

Division of Plastic Surgery, Department of Surgery, Harborview Medical Center, University of Washington, Seattle, WA, USA.

The etiology and treatment of hypertrophic scar remain puzzles even after decades of research. A significant reason is the lack of an accepted animal model of the process. The female, red Duroc pig model was described long ago. Since the skin of the pig is similar to that of humans, we are attempting to validate this model and found it to be encouraging. In this project we quantified myofibroblasts, mast cells and collagen nodules in the thick scar of the Duroc pig and compared these to the values for human hypertrophic scar. We found the results to be quite similar and so further validated the model. In addition, we observed that soon after wounding an inflammatory cell layer forms. The thickness of the inflammatory layer approaches the thickness of the skin removed as if the remaining dermis "knows" how much dermis is gone. In deep wounds this inflammatory layer thickens and this thickness is predictive of the thickness of the ultimate scar.
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http://dx.doi.org/10.1016/j.burns.2006.03.015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2878281PMC
September 2006

Complex wound management utilizing an artificial dermal matrix.

Ann Plast Surg 2006 Aug;57(2):199-202

Burn Center, Department of Surgery, University of Washington, Harborview Medical Center, Seattle, WA 98104, USA.

The benefits of the Integra Dermal Regeneration Template in the management of extensive burn injuries have been well documented. Integra can reduce donor- and graft-site scarring and has been reported to be capable of vascularizing over small areas of exposed bone and tendon. Given these potential advantages, we have used Integra for a variety of other reconstruction applications. We performed a retrospective review of patients with complex wounds treated with Integra at our burn center. Integra was used in the management of a variety of wounds, including necrotizing fasciitis, extremity degloving injury, meningococcemia, Marjolin ulcer, postburn lip reconstruction, and fourth-degree burns with exposed bone or tendon. Engraftment rates of Integra and autograft were 98% +/- 4% and 97% +/- 4%, respectively. All areas of graft loss healed without need for regrafting. The benefits of Integra in the management of acute burn wounds can be extended to other traumatic and complex wounds.
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http://dx.doi.org/10.1097/01.sap.0000218636.61803.d6DOI Listing
August 2006

Incidence and characteristics of hospitalized patients with pressure ulcers: State of Washington, 1987 to 2000.

Plast Reconstr Surg 2006 Feb;117(2):630-4

Department of Surgery, University of Washington, Harborview Injury Prevention and Research Center, Seattle, Washington, USA.

Background: Pressure ulcers complicate the hospital course of critically injured or ill patients. Guidelines have been promulgated to prevent pressure ulcers in hospitalized patients. The purpose of this study was to determine whether these guidelines have, in fact, reduced the incidence of pressure sores.

Methods: The authors examined census data from the National Center for Health Statistics and the Washington State Department of Health for the 14-year period 1987 through 2000 and identified patients with a pressure ulcer listed as the primary diagnosis (International Classification of Diseases, Ninth Revision, Clinical Modification code 707.0) and patients admitted for other diagnoses with pressure ulcer as a secondary diagnosis. The authors reasoned that patients who were admitted for treatment of pressure ulcers would have the diagnosis listed as primary, whereas those who were admitted for other reasons and developed pressure ulcers during the admission would have pressure ulcer listed as a secondary diagnosis. Other available data included patient age, sex, procedures for pressure ulcers (International Classification of Diseases, Ninth Revision, Clinical Modification codes 15920 through 15999), length of stay, and hospital charges for care.

Results: The incidence of pressure ulcers as a primary diagnosis varied from 7.0 to 8.3 per 100,000 population but did not change over the 14-year study period. The rate of operation for these ulcers also did not change. The incidence of pressure ulcers as either a primary or secondary diagnosis doubled from 34.5 to 71.6 per 100,000 (p < 0.001), whereas the incidence of operative procedures for these ulcers did not change.

Conclusion: The authors found no evidence that the guidelines for the prevention of pressure ulcers have been effective in decreasing pressure ulcer formation, but it may be that pressure ulcers are now being reported in a more thorough manner.
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http://dx.doi.org/10.1097/01.prs.0000197210.94131.39DOI Listing
February 2006

Elevated orbital pressure: another untoward effect of massive resuscitation after burn injury.

J Trauma 2006 Jan;60(1):72-6

Division of Plastic and Reconstructive Surgery, Harborview Medical Center, University of Washington, 325 Ninth Avenue, Seattle, WA 98104, USA.

Background: Fluid resuscitation remains a fundamental component of early burn care management. However, recent studies suggest that excessive volumes of resuscitation are being administered. Overresuscitation results in negative sequelae including abdominal and extremity compartment syndromes. Elevated intraocular pressure (IOP) has been described as another potentially devastating effect of massive fluid resuscitation in trauma patients. The orbit, similar to the abdomen and extremity, is a compartment, limited to expansion from edema anteriorly by the eyelids and orbital septum, and posteriorly by the bony orbital walls. The purpose of this study was to review the incidence of elevated IOP in a series of patients with major burn injury.

Methods: We retrospectively reviewed the charts of 13 consecutive patients admitted to our burn center with burn sizes >25% total body surface area (TBSA). All patients underwent serial IOP measurements for the first 72 hours following admission. Medical records were reviewed for fluid resuscitation volume, IOP measurements, need for canthotomy, and results of canthotomy procedures.

Results: Five of 13 patients had IOP >30 mm Hg and required lateral canthotomy. Canthotomy immediately reduced IOP (p = 0.009). Patients who developed elevated IOP received a significantly larger fluid resuscitation (9.0 cc/kg/%TBSA versus 6.0 cc/kg/%TBSA, p = 0.02). Elevated IOP was significantly associated with delivery of larger fluid resuscitation volume (p = 0.027).

Conclusions: Massive fluid resuscitation following burn injury can result in orbital compartment syndrome requiring lateral canthotomy. Early diagnosis and treatment of orbital compartment syndrome should be incorporated into the management of patients with major burn injury receiving large fluid resuscitation volume.
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http://dx.doi.org/10.1097/01.ta.0000197657.25382.b2DOI Listing
January 2006
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