Introduction Reliable characterization of a hypertrophic scar (HTS) is integral to epidemiologic studies designed to identify clinical and genetic risk factors for HTS. The Vancouver Scar Scale (VSS) has been widely used for this purpose; however, no publication has defined what score on this scale corresponds to a clinical diagnosis of HTS. Methods In a survey of 1000 burn care providers, we asked respondents what VSS score indicates a HTS and asked them to score scar photos using the VSS. We used receiver-operating-characteristic (ROC) curves to evaluate VSS subscores and their combinations in diagnosis of HTS. Results Of 130 responses (13.5%), most were physicians (43.9%) who had worked in burn care for over 10 years (63.1%) and did not use the VSS in clinical practice (58.5%). There was no consensus as to what VSS score indicates a diagnosis of HTS. VSS height score (0–3) performed best for diagnosis of HTS; using a cut-off of ≥1, height score was 99.5% sensitive and 85.9% specific for HTS. Conclusions Burn clinicians do not routinely use the VSS and perceptions vary widely regarding what constitutes a HTS. When a dichotomous variable is needed, the VSS height score with a cut-off of ≥1 may be optimal. Our findings underscore the need for an objective tool to reproducibly characterize HTS across burn centers.

Objective Hypertrophic scars (HTS) occur in 30–72% patients following thermal injury. Risk factors include skin color, female gender, young age, burn site, & burn severity. Recent correlations between genetic variations and clinical conditions suggest that single nucleotide polymorphisms (SNPs) may be associated with HTS formation. We hypothesized that a SNP in the p27kip1 gene (rs36228499) previously associated with decreased restenosis after coronary stenting would be associated with lower Vancouver scar scale (VSS) measurements and decreased itching. Methods Patient & injury characteristics were collected from adults with thermal burns. VSS scores were calculated at 4–9 months following injury. Genotyping was performed using real time PCR. Logistic regression was used to determine risk factors for hypertrophic scar as measured by a VSS score >7. Results 300 subjects had a median age of 39 years (range 18–91); 69% were male & median burn size was 7% TBSA (range 0.25–80). Consistent with literature, the p27kip1 variant SNP had an allele frequency of 40%, but was not associated with reduced HTS formation or lower itch scores in any genetic model. HTS formation was associated with American Indian/Alaskan Native race (OR, 12.2; P=0.02), facial burns (OR, 9.4; P=0.04), and burn size ≥20% TBSA (OR, 1.99; P=0.03). Conclusions Whereas the p27kip1 SNP may protect against vascular fibroproliferation, the effect cannot be generalized to cutaneous scars. Our study suggests that American Indian/Alaskan Native race, facial burns, and higher %TBSA are independent risk factors for HTS. The American Indian/Alaskan Native association suggests that there are potentially yet-to-be-identified genetic variants.

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STRUCTURED ABSTRACT Background Major pancreaticoduodenal injury can be devastating even if identified and controlled early. To date, both morbidity and mortality have resisted the improvements achieved with many other life-threatening injuries, with reported mortalities of 31–50%. We sought to elucidate the impact of the initial operation in the management of severe pancreaticoduodenal injury. Methods A retrospective review of all patients presenting to a single level-one trauma center who required pancreaticoduodenectomy for trauma from 1996–2010. We collected demographic and in-hospital data and compared subjects based on their initial operation. Results Fifteen patients (median age 29 yrs, 93% male, median ISS=35) underwent pancreaticoduodenectomy following blunt (n =5) or penetrating trauma (n=10). Twelve (80%) underwent damage control surgery (DCS) +/− the initial stage of Whipple resection as their first operation. Three (20%) underwent a complete Whipple procedure, including reconstruction, as their first operation. Overall, 87% of patients (13 of 15) were acidotic, hypothermic and coagulopathic during their first operation. Average operative time was longer for the completion pancreaticoduodenectomy vs. DCS (460±98 mins vs. 243±112 mins). There were no overall differences in complication rates, although the two patients that did not suffer a complication had DCS. In-hospital mortality was 13% (n=2). Conclusions We present both the largest series of patients to date who underwent a DCS or staged-Whipple procedure for complex pancreaticoduodenal trauma and the largest series due to blunt trauma. Using a staged approach, we report the lowest mortality rate for such injuries in the literature; less than half of that reported in the most recent series (33%). Given the frequent occurrence and recognized detrimental impact of acidosis, hypothermia and coagulopathy in patients with severe pancreaticoduodenal trauma, and proven benefits of DCS, we propose that these patients should undergo initial damage control surgery and staged reconstruction.