Attwells S, Faour S, Kim CY
… +3 more, Correia A, Joachim K, Gus E
J Burn Care Res
· 2026 May · PMID 42102169
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Burn registries are critical in understanding, managing, and addressing the complexities of burn injuries and care by providing comprehensive data on injury patterns, treatment modalities, and outcomes. Current registrie...Burn registries are critical in understanding, managing, and addressing the complexities of burn injuries and care by providing comprehensive data on injury patterns, treatment modalities, and outcomes. Current registries focus on the acute phase of inpatient burn care and lack data on outpatient and long-term treatment outcomes. This study aimed to validate the Burn Injury Surveillance Tool (BIST); a pilot electronic data collection tool designed to standardize burn data collection that includes both inpatient and outpatient data. Developed based on data dictionaries from established international registries, the tool includes six key sections capturing patient information, injury etiology, injury severity, acute treatment, quality-of-care indicators, and long-term outcomes. Validation involved two non-burn specialized participants and one burn specialized participant using the tool to extract data from 45 retrospective burn cases at the Hospital for Sick Children, Toronto, Canada. Inter-rater reliability was assessed through percent agreement and Kappa statistics. Our results indicate high percent agreement and strong inter-rater reliability for most variables, particularly patient demographics and burn characteristics. Challenges included discrepancies in subjective measures such as injury circumstances and specific total burn surface area values, which highlighted areas for tool refinement. The creation and validation of the Burn Injury Surveillance Tool provided valuable insights as of how to incorporate outpatient data into new and existing burn registries. Beyond its immediate findings, this study offers a methodological framework for validating integrated in- and outpatient datasets that can be adapted for other clinical registries, supporting more complete and interoperable burn registry designs.
Al Hayek S, Bullis J, Davis-Walz TA
… +1 more, Galet C
J Burn Care Res
· 2026 May · PMID 42102149
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Children represent 20% of all burn admissions annually; 20-30% are related to abuse or neglect. Our institution Child Protective Services (CPS) recently decided to stop following and interpreting hair toxicology results...Children represent 20% of all burn admissions annually; 20-30% are related to abuse or neglect. Our institution Child Protective Services (CPS) recently decided to stop following and interpreting hair toxicology results for pediatric burn patients. Drug use/exposure is an important risk factor for child abuse/neglect. The goal of this study was to evaluate the value of hair toxicology testing to identify child abuse or neglect. Medical records of pediatric patients ≤14 years admitted between 1/1/2019 and 2/29/2024 were reviewed. Demographics, burn injury information, suspicion of child abuse/neglect on admission, routine urine drug screening tests, hair toxicology results, and reporting to the State Health and Human Services (HHS) were collected. Descriptive statistics were obtained. Univariate analyses were performed to assess the utility of hair toxicology with p < 0.05 considered significant. Two hundred ninety-eight patients were included; child abuse was suspected in 31.5%; hair toxicology performed for 75.2% and positive for 35.7%. Hair toxicology was more likely to be performed when child abuse was suspected on admission (81.9% vs. 72.1%, p = 0.044), and to be positive (40.4% vs. 20.6%, p < 0.001). Suspicion on admission was associated with higher HHS involvement (95.7% vs. 24%, p < 0.001). HHS was more likely to be involved when hair toxicology was performed (54% vs. 24.3%, p < 0.004) and positive (96.3% vs. 28.4%, p < 0.001). Hair toxicology screening for pediatric burn patients is still a valuable tool to help clinicians report suspected abuse/neglect not otherwise detected on admission using other tools.
Har-Shai L, Gershov S, Lagziel T
… +7 more, Manasseh N, Keller A, Tzarfati GG, Hilewitz D, Ad-El D, Kalish E, Olshinka A
J Burn Care Res
· 2026 May · PMID 42102144
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Systemic inflammation after pediatric burn injury frequently causes fever, complicating early recognition of infectious complications. Improved risk-stratification may help identify patients at risk for adverse clinical...Systemic inflammation after pediatric burn injury frequently causes fever, complicating early recognition of infectious complications. Improved risk-stratification may help identify patients at risk for adverse clinical events during hospitalization. This study aimed to develop and validate a machine learning (ML)-based model using a Random Forest (RF) algorithm to predict fever and related adverse outcomes in hospitalized pediatric burn patients. We conducted a retrospective analysis of 595 pediatric burn patients admitted to a tertiary center between 2012 and 2022. Extracted data included demographics, burn characteristics, clinical interventions, laboratory values, and outcomes. RF models were trained to predict three key endpoints: fever (>38.5°C), transfer to pediatric intensive care unit (PICU), and need for surgical intervention. To address missing data and class imbalance, we employed multiple imputation techniques and generated synthetic data through bootstrap sampling to improve model robustness. The patient cohort had a mean age of 4.27 (range: 0.2-18.1) years and an average total body surface area (TBSA) of 5.49 (range: 0.3-45.0). The RF models demonstrated high predictive accuracy, with F1-scores of 0.81±0.037 (fever), 0.88±0.091 (PICU transfer), and 0.81±0.027 (surgery). Area Under the Curve (AUC) values were 0.96, 0.97, and 0.95, respectively. Feature importance analysis identified younger age, lower body weight, female sex, and head and neck burn location as key predictors. These ML-based RF models demonstrate strong potential for early risk-stratification of fever and high-risk trajectories in hospitalized pediatric burn patients, guiding monitoring intensity, diagnostic vigilance, and resource planning. Prospective evaluation is needed to determine whether model-informed workflows improve outcomes.
Reddy D, Jimenez L, Al-Tariq K
… +7 more, Ziedins E, D'Orio C, Pierson B, Moffatt LT, Shupp JW, Travis TE, Carney BC
J Burn Care Res
· 2026 Apr · PMID 42059653
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Burn injuries often lead to hypertrophic scars (HTS), which negatively affect quality of life and skin function. HTS results from abnormal wound healing characterized by excess, disorganized collagen confined to the orig...Burn injuries often lead to hypertrophic scars (HTS), which negatively affect quality of life and skin function. HTS results 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 four HTS and two NS sites. Punch biopsies were collected at postoperative days 49 and 70, corresponding to pre- and post-FLSR timepoints. FLSR 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 ANOVA. 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.
Sinha S, Mandujano-Tinoco EA, Kutluberk E
… +11 more, Mulder PPG, Collao N, Chockalingam K, Pun A, Dardari R, Verly M, Fraulin FOG, Harrop AR, Rosin NL, Gabriel V, Biernaskie J
J Burn Care Res
· 2026 Apr · PMID 42053371
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UNLABELLED: Severe burns provoke a systemic "genomic storm," yet cell states associated with divergent outcomes remain unclear. We profiled blood cells by single-cell RNA-Sequencing (73,014 cells) from adult burn patient...UNLABELLED: Severe burns provoke a systemic "genomic storm," yet cell states associated with divergent outcomes remain unclear. We profiled blood cells by single-cell RNA-Sequencing (73,014 cells) from adult burn patients within post-burn day 17 (n=4) and healthy donors (n=5), integrated data with bulk signatures of burn size, inhalation injury, and mortality, and evaluated clinical associations in the ABA National Burn Repository. Burn was associated with emergency hematopoiesis marked by expansion of hematopoietic stem/progenitor-like cells, immature neutrophils, and plasmablast/plasma cell states, alongside depletion of naïve CD4+/CD8+ T cells and dendritic cells. Larger burns (>20% TBSA) showed enrichment of humoral transcriptional programs, including plasmablast/plasma cell activation and suppression of cytotoxic CD8+ T-cell states. In multivariable models, inhalation injury was a stronger predictor of death (adjusted OR 1.9) than burn size (adjusted OR 1.1) and shared greater overlap with the most perturbed single cells in non-survivors; 55% of co-perturbed cells were neutrophils, implicating granulocyte dysregulation as a common lethal axis. We identified a neutrophil-specific 5-gene panel (OLFM4, RETN, LCN2, ARG1, BTNL3) that discriminated survivors vs non-survivors after burns (AUC >0.9) and generalized to trauma (n=158; AUC 0.81) and ICU COVID-19 (n=103; AUC 0.75), providing information orthogonal to conventional biomarkers and severity scores. Cytomorphology corroborated transcriptomic immaturity, with ~2-fold higher band neutrophils and larger neutrophil size in a fatal case. Computational drug-reversal analysis highlighted galectin-1 inhibition as a candidate modulator of mortality-associated neutrophil programs. Together, our findings suggest that immature neutrophils represent a shared immune feature across severe burns and other forms of critical illness. Structured Abstract Objective: To define cell-specific immune programs associated with burn size, severity, inhalation injury, and fatal trajectories. BACKGROUND: Large burns provoke a "genomic storm" yet cellular drivers of divergent clinical outcomes remain unknown. METHODS: We profiled 73,014 immune cells (scRNA-seq) from 4 adult burn patients and 5 healthy donors, mapping TBSA, inhalation injury, and mortality signatures from bulk datasets onto single-cell atlas. Clinical patterns were validated using ABA NBR. 5-gene neutrophil panel was developed to predict burn mortality and tested in trauma (n=158) and ICU COVID-19 (n=103) cohorts. RESULTS: Burns were associated with emergency hematopoiesis, expanding HSPCs, immature neutrophils, and plasmablasts while depleting naïve CD4+/CD8+ T cells. Large burns (>20% TBSA) showed enrichment of humoral responses by activating plasmablasts and plasma cells at the expense of CD8+ T-mediated immunity. While >20% TBSA increased mortality (OR 1.1), inhalation injury was a stronger independent predictor (OR 1.9) and shared 55% of its most perturbed cells with non-survivors, converging on neutrophils as the dominant transcriptional state. 5-gene immature neutrophil signature predicted burn mortality with AUC >0.9, generalized to trauma (AUC 0.81) and COVID-19 (AUC 0.75), and was orthogonal to conventional biomarkers and severity scores. Non-survivor had ~2-fold greater band neutrophils, supporting neutrophil nuclear segmentation and size as potential indicators of burn severity. In silico screening identified galectin-1 inhibition as a potential suppressor of death-associated neutrophil programs. CONCLUSION: Immature neutrophil surges associate with mortality in burns, trauma, and COVID-19. 5-gene panel may identify this risk and therapeutic modulation of these cells will reveal whether they are modifiable features of critical illness.
J Burn Care Res
· 2026 Apr · PMID 42041122
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BACKGROUND: The Burn Specific Health Scale Brief (BSHS-B) is the only specific, standardized, multidimensional tool designed precisely to measure health-related quality of life(HRQoL) after burns. It is translated into m...BACKGROUND: The Burn Specific Health Scale Brief (BSHS-B) is the only specific, standardized, multidimensional tool designed precisely to measure health-related quality of life(HRQoL) after burns. It is translated into many different languages and is used worldwide. Till now, the Arabic version is not offered. The current study aimed to translate, culturally adapt, and validate the BSHS-B into Arabic (BSHS-B-AR). METHODS: 188 burn patients completed the final Arabic version of BSHS-B to assess the psychometric properties of BSHS-B-AR. Reliability was tested by internal consistency (Cronbach's alpha) and test-retest reliability (interclass correlation coefficients [ICCs]). Validity was investigated through floor and ceiling effect and confirmatory factor analysis(CFA). Also, convergent validity was assessed using the World Health Organization Quality of Life scale abbreviated version (WHOQOL-BREF) questionnaire and a construct validity was verified through known group technique. RESULTS: The scale showed excellent reliability. Cronbach's alpha was > 0.90 (total scale and for each sub-domain) and ICC was > 0.80 for the total scale and for the nine domains. Validity of the scale was satisfactory through CFA (82.7% of the total variance) and it showed a good fit with the original scale (CFI = 0.933). Also, a significant positive correlation was found between the BSHS-B-AR and the WHOQOL-BREF (P <0.001). The scale was able to discriminate between patient groups according to site of burns and length of hospitalization (p <0.05). CONCLUSION: The Arabic version of the BSHS-B is a reliable and a valid scale that can be used both in Arabic and international communities.
J Burn Care Res
· 2026 Apr · PMID 42033303
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BACKGROUND: Major burn injury triggers systemic inflammation and metabolic responses beyond the skin. Early intestinal barrier failure can amplify post-burn inflammation and organ dysfunction, yet the dynamic epithelial...BACKGROUND: Major burn injury triggers systemic inflammation and metabolic responses beyond the skin. Early intestinal barrier failure can amplify post-burn inflammation and organ dysfunction, yet the dynamic epithelial lesions that generate focal leakage in vivo remain unclear. We characterized villus-tip epithelial shedding, epithelial gap formation, and tracer leak sites early after burn using intravital multiphoton fluorescence microscopy. METHODS: Male C57BL/6 mice were assigned to Control or Burn groups (30-35% total body surface area full-thickness burn; n=6/group). Intestinal permeability was assessed at 2, 4, and 6 hours post-injury using luminal fluorescein isothiocyanate-dextran (4 kilodaltons) with portal venous sampling. Distal-ileum intravital imaging was performed 330-420 minutes post-injury (1-minute intervals). Ten villi per mouse were quantified for shedding duration and prevalence, condensation-first versus extrusion-first sequence, epithelial gap density, goblet-cell proportion, and focal luminal tracer leak sites. RESULTS: Major burn shortened shedding duration and increased shedding prevalence during the 90-minute observation (p<0.05), with a shift toward a condensation-first pattern and fewer extrusion-first events (p<0.05). Burn increased epithelial gap density and goblet-cell proportion (p<0.05). Portal serum fluorescein isothiocyanate-dextran concentrations were elevated at 6 hours (p<0.05), and imaging localized tracer penetration to discrete post-shedding epithelial defects, consistent with incomplete sealing. CONCLUSIONS: Major burn rapidly disrupts intestinal barrier integrity through accelerated stress-associated shedding, increased gap formation, and focal leak sites. These time-resolved structural lesions provide an in vivo substrate for early hyperpermeability and suggest a time-critical window for gut-directed interventions to mitigate downstream post-burn complications.
Kieffer H, Santarelli MD, Wagner AL
… +2 more, Jeffery AD, Stark RJ
J Burn Care Res
· 2026 Apr · PMID 42028952
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Alterations in both the innate and adaptive immune systems can induce a significant immunocompromised state among those hospitalized after burn-injury. These changes can devolve into the clinical entity known as persiste...Alterations in both the innate and adaptive immune systems can induce a significant immunocompromised state among those hospitalized after burn-injury. These changes can devolve into the clinical entity known as persistent inflammation, immunosuppression, and catabolism syndrome (PIICS) characterized by profound and chronic immune dysregulation. PIICS is defined by the presence of lymphopenia, elevated CRP levels, and evidence of catabolism through weight loss or hypoalbuminemia in the context of a prolonged hospitalization. Though PIICS has previously been described in burn-injured patients, this immunophenotype in the setting of serious bacterial and fungal infections is poorly characterized. We performed a detailed retrospective analysis of burn-injured adults (aged 19 to 64 years old) in a de-identified institutional database of patient medical records from 1997 to 2023. Of the 960 patients admitted for a primary burn injury, the overall prevalence of serious infections and PIICS was 38% and 25%, respectively. Both the presence of an inhalation injury and the total body surface area (TBSA) burn size correlated with the development of serious infections and PIICS. Patients with PIICS had more pathogens isolated and a higher prevalence of Acinetobacter and Stenotrophomonas infections. The immunophenotype of PIICS was strongly associated with recurrent infections during hospitalization. Detailed assessments of PIICS criteria, including trends in lymphocyte count, may help identify the development of serious bacterial and fungal infections in burn-injured adults.
Cumaran M, Cancio L, Schoen J
… +6 more, Nosanov L, Ainsworth C, Fan E, Lonergan T, Lorusso R, Sousse LE
J Burn Care Res
· 2026 Apr · PMID 42011937
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Extracorporeal membrane oxygenation (ECMO) has been used to successfully minimize, replace, or avoid the use of mechanical ventilation in burned and non-burned populations. Further research on ECMO in the burned populati...Extracorporeal membrane oxygenation (ECMO) has been used to successfully minimize, replace, or avoid the use of mechanical ventilation in burned and non-burned populations. Further research on ECMO in the burned population is warranted, particularly with the insufficient patient numbers reported in the literature. A panel composed of national leaders in ECMO and/or burn injury discussed the use of ECMO in burned patients as part of the MedStar Washington Hospital Center Burn Center Multidisciplinary Lecture Series. Panelists examined current methods, institutional practices, and clinical controversies around the use of ECMO in burns. While institutional capacity and protocols vary widely, the discussion highlighted that need for both retrospective and prospective data demonstrating guidelines to maximize the clinical benefits of ECMO in burned patients. Further multicenter investigation is needed to define patient selection criteria, timing, and perioperative management strategies such as anticoagulation in this patient population.
J Burn Care Res
· 2026 Apr · PMID 42011936
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BACKGROUND: Over 357 500 structure fires occur in the United States annually, resulting in 2710 civilian deaths. Combustion of plastic, vinyl, wood, silk, and petroleum can release toxic hydrogen cyanide gas. Empiric tre...BACKGROUND: Over 357 500 structure fires occur in the United States annually, resulting in 2710 civilian deaths. Combustion of plastic, vinyl, wood, silk, and petroleum can release toxic hydrogen cyanide gas. Empiric treatment with hydroxocobalamin has been advocated for cyanide toxicity without clear guidelines, and overuse can occur. Our study objective was to evaluate protocol compliance for the use of hydroxocobalamin for inhaled cyanide toxicity pre- and post-implementation of criteria and a smart order set. METHODS: We performed a retrospective review of compliance for the use of hydroxocobalamin, pre- (2022) versus post-implementation (2023-2024) of protocol criteria in patients with inhalation injury. Patients would receive hydroxocobalamin if they were exposed to smoke in an enclosed space, had the injury within 2 hours, experienced a cardiac arrest at the scene or prior to hospital arrival, had a Glasgow Coma Score < 10 at the scene or admission, or had lactate >10 and carboxyhemoglobin >10. Patients without an inhalation injury were excluded. Baseline demographics, laboratory values, and medication administration data were collected. RESULTS: Overall, 127 patients met inclusion criteria, 62 in the pre-protocol group and 65 in the post-protocol group. Appropriate utilization of the antidote based on the protocol criteria was 29% in the pre-group vs. 48% in the post-group. Administration of the antidote 2 hours after exposure was the most common reason for protocol deviation in both groups. There were no differences in mortality rates, hospital or ICU length of stay, or duration of mechanical ventilation between groups. CONCLUSION: Identification of patients with risk factors for inhalation injury with cyanide toxicity is key. Development of criteria for use ensures judicious stewardship of this antidote.
J Burn Care Res
· 2026 Apr · PMID 42007563
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Bleeding is commonly used to determine the adequacy of tangential burn wound excision. However, bleeding is an imprecise surrogate of tissue viability, as it is influenced by local and systemic physiology as well as oper...Bleeding is commonly used to determine the adequacy of tangential burn wound excision. However, bleeding is an imprecise surrogate of tissue viability, as it is influenced by local and systemic physiology as well as operative conditions. This correspondence revisits the Three "P's" framework described by Cartotto and Fish, namely identification of Pearly white dermis, Pale yellow fat, and Patent vessels, as a more reliable and biologically grounded set of intraoperative endpoints for wound bed viability. Each component conveys critical information regarding tissue structure, perfusion, and suitability for graft take that bleeding alone cannot provide. As burn surgery increasingly emphasizes precision, tissue preservation, and reproducible outcomes, explicit teaching and consistent adoption of the Three "P's" as primary debridement endpoints is timely and necessary.
Doshi S, Wong C, Rogers A
… +2 more, Mason S, Wallace D
J Burn Care Res
· 2026 Apr · PMID 42007562
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Tracheoesophageal fistula (TEF) is a rare but devastating complication of mechanical ventilation and tracheostomy, classically described as a late sequela of prolonged airway instrumentation. Patients with severe burn in...Tracheoesophageal fistula (TEF) is a rare but devastating complication of mechanical ventilation and tracheostomy, classically described as a late sequela of prolonged airway instrumentation. Patients with severe burn injury and inhalation injury represent a uniquely vulnerable population due to airway mucosal ischemia, thermal injury, and impaired tissue healing. We report a case of fulminant posterior tracheal wall failure with early TEF formation occurring within days of tracheostomy in a 75-year-old patient with extensive full-thickness facial burns following thermal inhalation injury from hot liquid exposure. The clinical course was marked by early ventilatory warning signs including intermittent ventilator dyssynchrony, transient reductions in tidal volumes, and progressive cuff leak prior to catastrophic airway failure. Bronchoscopy demonstrated a large posterior tracheal defect with migration of the tracheostomy tube into the esophagus. Given the extent of injury and limited reconstructive options, care was transitioned to a comfort-focused approach. This case highlights an early airway failure phenotype that differs from the traditional delayed presentation of TEF and underscores the importance of heightened clinical vigilance. Persistent cuff leaks or unexplained ventilatory instability in patients with inhalation injury should prompt urgent airway reassessment to allow early intervention before irreversible airway disruption occurs.
Gerstner G, Smiley K, Lidwell D
… +1 more, Bryant L
J Burn Care Res
· 2026 Apr · PMID 41968356
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Patients with burn injuries are at higher risk of vascular injury, volume loss, endothelial dysfunction and hypercoagulability-mechanisms also associated with strokes. Few studies identify the risk of cerebral vascular a...Patients with burn injuries are at higher risk of vascular injury, volume loss, endothelial dysfunction and hypercoagulability-mechanisms also associated with strokes. Few studies identify the risk of cerebral vascular accidents in patients with cutaneous burns. This scoping review sought to synthesize the available literature reporting cerebrovascular accidents after cutaneous burns. We searched PubMed Medline, Ovid Medline, and Cochrane databases from their inception until 27 February 2025 to identify papers reporting stroke after burn injuries in their titles and abstracts. We then screened publications individually for reports of stroke after burns. A preliminary search generated 1137 studies to review, with 12 meeting final inclusion criteria. Six were cohort or observational studies and six were case reports/series. Most studies demonstrated an increased incidence or hazard ratio of stroke following burn, although their heterogeneity limited comparative analysis. None of the included studies originated from the United States, underscoring a major gap in applicability. Further research is warranted to determine the risk of stroke after burn injury and clinical management.
Hunter MA, Chowanic A, Biziorek J
… +4 more, Fan Z, Sangji NF, Suwanabol PA, Hemmila MR
J Burn Care Res
· 2026 Apr · PMID 41968349
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Burn injuries in older adults present unique clinical challenges due to age-related health changes, including impaired wound healing and diminished immune responses. Frailty, characterized by decreased physiologic reserv...Burn injuries in older adults present unique clinical challenges due to age-related health changes, including impaired wound healing and diminished immune responses. Frailty, characterized by decreased physiologic reserve, has emerged as a powerful predictor of outcomes after burn injury, yet its impact on emergency department disposition remains understudied. This retrospective, cross-sectional study analyzed adult emergency department visits for thermal burn injuries using data from the Nationwide Emergency Department Sample from 2019 to 2022. Adult patients with thermal burns were classified by age, gender, race, household income, and frailty score. Multivariable logistic regression was used to assess factors associated with discharge disposition, focusing on home discharge as a marker of functional independence. Of over one million identified encounters, older age and higher frailty scores were significant, independent predictors of reduced likelihood of discharge home. Patients with intermediate and high frailty scores were disproportionately represented among those admitted or transferred, regardless of chronological age. Additional factors associated with disposition included burn mechanism, injury region, and patient demographics. These findings suggest that routine frailty assessment at the point of emergency department care may improve risk stratification and guide resource allocation, helping identify older adults at risk for loss of independence. Integration of frailty screening into emergency burn care pathways, alongside development of age-specific guidelines, may optimize outcomes for this vulnerable population.