PubMed Health⌕ Search

Biomedical subjects

Shari Honari

Publications and source records attributed to Shari Honari.

17 recordsLinked to original sources
PubMed2006

Complex wound management utilizing an artificial dermal matrix.

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.

Adolescent↗
PubMed2006

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

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.

Administration, Topical↗
PubMed2006

The optimal time for early excision in major burn injury.

INTRODUCTION: Early excision and grafting (E&G) drastically changed burn care in America by reducing morbidity, mortality and hospital length of stay (LOS). The present study was intended to determine whether an optimal time window exists between resuscitation and wound sepsis for the first E&G in a patient with a large burn. MATERIAL AND METHOD: The authors conducted a retrospective study of patients admitted between January 1994 and December 2000 with > or = 40% TBSA burns and at least 1 E&G procedure. Patients were grouped according to the day of their first operation. Patients allowed to heal indeterminate burns prior to excision and grafting of deep partial or full thickness burns were grouped as > or = d7 and were excluded from the present study. The authors correlated the time of first excision with infection, mortality and LOS. RESULTS: Seventy-five patients were identified and 12 patients allowed to heal indeterminate burn prior to excision and grafting of deep partial or full thickness burns were excluded. Sixty-three remaining patients included 51 males and 12 females. Mean burn size was 49% of total body surface area (TBSA) (44% deep partial or full thickness) and the mean age was 36 years. There were 61 flame (2 combined with electrical injuries), 1 scald and 1 chemical burn. Twelve died (19%) and 52 patients developed 121 infections. Whereas there was no statistical difference in mortality for patients operated on different days (p > 0.2), 60% of patients operated within the first 48 hours after injury died; this was not significant due to a small patient number CONCLUSIONS: The present data suggest that patients who undergo early excision and grafting within seven days following a major burn > or = 40% TBSA have equivalent infection or mortality rates regardless of when the first operation occurs between post burn day(PBD) 2 and PBD 7 (p > 0.2).

Adult↗
PubMed2005

Management of facial burns with a collagen/glycosaminoglycan skin substitute-prospective experience with 12 consecutive patients with large, deep facial burns.

Management of deep facial burns remains one of the greatest challenges in burn care. We have developed a protocol over the past 20 years for management of facial burns that includes excision and coverage with thick autograft. However, the results were not perfect. Deformities of the eyelids, nose and mouth as well as the prominence of skin graft junctures demonstrated the need to explore novel approaches. Integra has been used with success in the management of burns of the trunk and extremities. The purpose of this study was to prospectively evaluate the aesthetic outcome of the use of Integra for deep facial burns. Twelve consecutive patients underwent excision of large, deep facial burns and placement of Integra. Integra provides excellent color and minimally visible skin graft junctures. The texture is good but not as supple as thick autograft. Integra is not well suited for use in the coverage of eyelid burns due to the need to wait 2 weeks for adequate vascularization. In summary, thick autograft remains the gold standard for deep facial burns. However, for patients with extensive burns and limited donor sites, Integra provides an acceptable alternative.

Adult↗
PubMed2005

Patterns of grease burn injury: development of a classification system.

Grease burns occur commonly in the home during food preparation. It has been our observation that grease burns follow a particular pattern of injury. The purpose of this study was to review our institutional experience in the management of these burns to develop a classification scheme. We performed a retrospective review of patients admitted to our burn center with grease burns. Subjects were identified through our database and their charts were reviewed with particular attention to burn distribution, TBSA and need for grafting. We excluded workplace burns and children under the age of six. A total of 249 patients who fit the above criteria were admitted with grease burns to our burn center from 1993 to 2003. The sequence of events leading to burn and its distribution followed a consistent pattern. The majority of patients (86%) had an isolated upper extremity burn or upper extremity burn in combination with a face, trunk or lower extremity burn. Forty percent of patients required at least one excision and grafting procedure. Grease burns associated with cooking at home follow predictable patterns of injury. Based on these patterns we proposed a classification system for domestic grease burns.

Accidental Falls↗
PubMed2004

Is supra-Baxter resuscitation in burn patients a new phenomenon?

Baxter described the use of 4 cm3/kg/%TBSA as a guideline for fluid resuscitation after burns. However, recent studies have shown that, at the present time, patients generally receive greater than the "Baxter" formula. Pruitt has called this phenomenon "fluid creep," and it has the potential for significant consequences including abdominal and extremity compartment syndromes and severe pulmonary insults. The purpose of this paper is to determine if this supra-Baxter resuscitation is a new phenomenon. We performed a retrospective chart review with two cohorts of patients. Group 1 consisted of 11 patients admitted between 1975 and 1978 to our burn center. Group 2 consisted of 11 patients admitted to our burn center in 2000 who were matched for age, sex, and percent total body surface area burned. Group 1 received 3.6 +/- 1.1 cm3/kg/% TBSA of fluid in the first 24 h. Group 2 received 8.0 +/- 2.5 cm3/kg/% TBSA, which is 100% more than the Baxter formula. There was no difference in the median age, weight, or 24-h urine output between the two groups. Our data demonstrate that the "fluid creep" phenomenon is relatively new.

Adolescent↗
PubMed2004

"Opioid creep" is real and may be the cause of "fluid creep".

Recent studies have shown that burn patients receive larger volumes of fluids than predicted by the Baxter formula and the reason for this is unclear. One potential reason is that increased analgesics are used which could blunt the response to fluid resuscitation. The purpose of this study was to compare the administration of opioid agonists in patients treated at a single burn center in the 1970s and in the year 2000. We performed a retrospective chart review comparing two matched cohorts. Group I consisted of 11 patients admitted between 1975 and 1978. Group II consisted of 11 patients admitted in 2000 matched for age, sex and %TBSA. Patients in Group II received a significantly higher mean opioid equivalent than those in Group I (26.5 +/- 12.3 versus 3.9 +/- 2.2 in the first 24h, P < 0.001). In addition, in Group II, a larger variety and combination of opioid agonists were used. This review demonstrates a significant increase from the 1970s to 2000 in the type, dose prescribed and dose delivered of opioid agonists. Along with "fluid creep", we have also increased our use of opioid agonists or "opioid creep". Higher doses of opioid agonists may have hemodynamic consequences, which may contribute to the increased fluid volumes.

Adolescent↗
PubMed2003

What is the prevalence of hypertrophic scarring following burns?

Hypertrophic scarring after burns remains a major problem and is considered to be "common". Pressure garments are commonly used as treatment even though there is little sound data that they reduce the prevalence or magnitude of the scarring. In 1999 we began a study of the efficacy of pressure garments on forearm burns. After studying 30 patients, mainly white adults, we found no hypertrophic scar in either those treated with pressure or without. This prompted us to review the literature on the prevalence of hypertrophic scarring after burns and found only four articles with a relatively small number of patients and only three geographical locations. It became clear that the prevalence of hypertrophic scarring is really unknown. We then did a retrospective study of 110 burn survivors and counted all hypertrophic scars of all sizes and locations in all races and found the prevalence hypertrophic scarring to be 67% which conflicts with the published reports and our prospective study and suggests that further research is necessary. We concluded that a worldwide, prospective survey is necessary to establish the prevalence of hypertrophic scarring after burns. In this article we are calling for and offering to organize this survey.

Adolescent↗
PubMedDate not supplied

Comparison of patient satisfaction and self-reports of pain in adult burn-injured patients.

Procedural and background pain scores were assessed prospectively and compared with treatment goals and satisfaction scores in 84 adult (67 men and 17 women) burn-injured patients treated at a single, tertiary care medical center. We hypothesized that patient satisfaction with pain management plans would be highest among those patients who were experiencing the least pain and also among patients whose experiences most closely matched their treatment analgesic goals. Twice-weekly patient self-reports of worst and average procedural pain, background pain, treatment goals (the level of procedural pain and background pain patients reported that they would be satisfied as experiencing), and overall satisfaction with pain management plans were assessed using 10-point Graphic Rating Scales. Data concerning adjunctive treatments were also obtained. Opioid equivalents, representing pain medications administered, were compared. The majority of patients perceived that "no pain" during burn wound care was an unrealistic goal, a perception that was consistent throughout hospitalization. As hypothesized, average procedural pain levels demonstrated a negative association with patient satisfaction, indicating that patients with the highest levels of procedural pain also reported the lowest level of satisfaction. Opioid analgesic dosing was not significantly associated with ratings of procedural pain or treatment goals. Our findings support the hypothesis that patient satisfaction with pain management is highest in those who experience the least amount of burn care pain and do not support the hypothesis that satisfaction is highest in those whose pain experiences most closely match treatment analgesic goals.

Adolescent↗
PubMedDate not supplied

Pediatric pain control practices of North American Burn Centers.

This study investigated pediatric pain control practices in North American Burn Centers using a mail-in survey. Questions were asked regarding pain control practices, pain assessment methods, and perceived treatment efficacy for inpatients and outpatients in four age groups. Eighty-two centers responded with 111 surveys. Intravenous morphine was the most frequently used analgesic for wound care pain. The most common background pain medications were intravenous morphine, acetaminophen with codeine, and acetaminophen alone. The use of long-acting medications increased with increasing age. Additional areas reported in the text include nonpharmacologic and pharmacologic adjuvants, treatment of itching, pain assessment, outpatient pain management, and efficacy of pain control and assessment practices. There have been great advances in pediatric burn pain control and assessment in recent years, but room for improvement remains. This study provides a basis for evaluation and comparison among burn centers. It further highlights areas that may warrant additional study and intervention.

Adolescent↗
PubMedDate not supplied

Social support correlates with survival in patients with massive burn injury.

Large burn size, inhalation injury, age, and associated trauma increase the rate of mortality after burns. However, not all patients with large burns and significant risk factors die. In this study, we wanted to determine other presenting factors that might indicate a survival benefit for burn patients with large burns. We reviewed charts of 36 patients with burns > or =60% TBSA that were aggressively resuscitated at the University of Washington Burn Center from 1990 to 2000 to determine whether survivors of large burns exhibit presenting variables that predict survival. Patients who had comfort care measures initiated at admission were excluded from this analysis. Survivors (n = 16) and nonsurvivors (n = 20) had no significant differences in age, total burn size, inhalation injury, or need for escharotomy. Full-thickness burn size was significantly smaller for survivors (58%) than for nonsurvivors (73%; P = .02). Survivors (81%) were more likely than nonsurvivors to have social support (35%; P = .007). A full-thickness burn > or =80 % TBSA was the only variable uniformly associated with mortality, suggesting that patients who survive large burns have a partial-thickness component that heals without surgery. The difference in degree of social support was one unique distinction that may impact patient survival and is worth further investigation.

Adolescent↗
PubMedDate not supplied

Adult campfire burns: two avenues for prevention.

Campfires are a common component of outdoor festivities. Pediatric campfire burns have been well described. Adult campfire injuries also are common and have several important distinguishing characteristics. We performed a retrospective review of adult patients admitted with campfire burns to our burn center from July 1998 to July 2003. Medical records were reviewed with attention to mechanism of injury, intoxication level, burn size, and surgeries performed. A total of 27 patients with this injury were treated as inpatients over the course of the study period. Two distinct mechanisms of injury emerged: 1) contact with the campfire and 2) flash/flame injuries from igniting the fire. Eighty-one percent (13/16) of patients who sustained contact burns were intoxicated, as compared with 11% (1/11) of those who sustained flash/flame injuries. Nearly half of the patients with contact burns and more than half the patients with flash/flame burns required excision and grafting.

Adolescent↗
PubMedDate not supplied

The Versajet water dissector: a new tool for tangential excision.

Goulian and Watson knives work well for tangential burn excision on large flat areas. They do not work well in small areas and in areas with a three-dimensional structure. The Versajet Hydrosurgery System (Smith and Nephew, Key Largo, FL) is a new waterjet-powered surgical tool designed for wound excision. The small size of the cutting nozzle and the ability to easily maneuver the water dissector into small spaces makes it a potentially useful tool for excision of burns of the eyelids, digits and web spaces. The Versajet Hydrosurgery System contains a power console that propels saline through a handheld cutting device. This stream of pressurized saline functions as a knife. We have used the Versajet for burn excision in 44 patients. Although there is a learning curve for both surgeons using and operating room staff setting up the device, the Versajet provides a relatively facile method for excision of challenging aesthetic and functional areas.

Burns↗
PubMedDate not supplied

SCORTEN overestimates mortality in the setting of a standardized treatment protocol.

Toxic epidermal necrolysis (TEN) is a rare, severe, exfoliative disorder with a high mortality rate. SCORTEN is a recently developed scoring system that estimates severity and predicts mortality in patients with TEN based on seven independent clinical risk factors recorded within the first 24 hours of admission. An increasing SCORTEN level predicts a higher mortality rate. For more than 20 years, the treatment of TEN at our institution has involved the use of a standardized clinical pathway that includes removal of sloughed epidermis, dermal protection with porcine xenograft, early enteral nutrition, and critical care monitoring. We hypothesize that this standardized clinical approach will result in a lower mortality rate than predicted by SCORTEN. A retrospective review was performed on all patients treated for TEN using the standardized pathway from February 1987 to March 2004. SCORTEN was calculated in each patient. One hundred nine patients were treated for TEN during the study period. Overall observed mortality was 20% compared with a SCORTEN predicted mortality of 30%, resulting in a relative reduction in mortality of 33% (P = .011). In addition, observed probability of death was lower than predicted at all levels, except at SCORTEN score of 6 or greater. In conclusion, TEN remains a life-threatening disease with a high mortality rate. Our standardized treatment protocol results in significantly improved outcomes compared to those predicted by SCORTEN.

Adult↗
PubMedDate not supplied

Self-reports of anxiety in burn-injured hospitalized adults during routine wound care.

The purpose of this investigation was to examine the amount of anxiety patients believed tolerable and the amount of anxiety experienced during routine burn wound care. Participants included 47 hospitalized adults who provided data for four consecutive assessment periods. Patients (mean TBSA, 16%; range, 2-70%) were primarily Caucasian (87%) and had an average hospital stays of 23 days (range, 11-130). Reports of what level of anxiety they would be able to tolerate and what level of anxiety had been experienced were assessed using 10-point Graphic Rating Scales. The use of anxiolytic was recorded, and patient suggestions for reducing anxiety were obtained. The single most commonly endorsed anxiety treatment goal was 0, although 53% consistently chose a treatment goal other than 0 (range, 1-6). Two repeated-measure analyses of variance indicated that the amount of anxiety patients could tolerate and the amount they reported experiencing did not change over the course of time. Paired t-tests revealed that patients routinely reported more anxiety than they considered tolerable. Analyses of anxiety reports of patients treated with anxiolytics (n = 6) vs patients receiving no anxiolytics (n = 41) revealed inconsistent differences in actual anxiety and treatment goals across time. In general, patient suggestions for lessening anxiety included requests for education, communication, additional medications, and manipulation of the hospital environment. Anxiety for burn-injured, hospitalized adults remains a concern. Our findings are consistent with the literature indicating that adult patients hospitalized for burn wound care report appreciable anxiety, over and above what they consider "tolerable." Continued research is needed and should include investigations into the relationship between pain and anxiety during routine wound care.

Adolescent↗
PubMedDate not supplied

Arterial and venous complications of heparin-induced thrombocytopenia in burn patients.

Heparin-induced thrombocytopenia (HIT) is an antibody-mediated complication of heparin treatment that can result in a number of devastating thrombotic complications. Given the common use of heparin for deep venous thrombosis prophylaxis in patients with burns, we reviewed the incidence and complications of HIT in our burn center. We performed a retrospective review of all patients treated with heparin at our burn center who underwent testing for HIT from 2001 to 2005. Screening for HIT was performed by platelet factor 4 enzyme-linked immunoassay. Records were reviewed with particular attention to indications for HIT testing, duration of heparin therapy, type of heparin used (fractionated vs unfractionated), indication for heparin use (prophylactic vs therapeutic), treatment of HIT, and complications of HIT. During the 4-year study period, 625 patients received heparin therapy at some point during their hospital course. Of these patients, 43 (6.9%) underwent testing for HIT and 10 of the 43 screened patients (23%) were positive; the incidence among all heparinized burn patients was 1.6%. Thrombotic complications of HIT included arterial thrombosis requiring limb amputation (two patients), deep venous thrombosis (three patients), and pulmonary embolism (two patients). One patient died, presumably secondary to a pulmonary embolism. All patients were anticoagulated after HIT diagnosis, and four patients developed bleeding complications. HIT is a potentially devastating complication of heparin administration. Whereas our overall incidence of HIT was low, HIT+ patients developed significant complications, including arterial and venous thrombosis, pulmonary embolus, limb loss, and death. Treatment for such HIT-related thromboses usually resulted in bleeding complications requiring transfusions. The routine use of heparin for deep venous thrombosis prophylaxis needs to be carefully considered in light of these potential complications.

Amputation, Surgical↗