[5] Garrel D, Patenaude J, Nedelec B, Samson L, Dorais J,Champoux J, et al. Decreased mortality and infectiousmorbidity in adult burn patients given enteral glutaminesupplements: a prospective, controlled, randomized clinicaltrial. Crit Care Med 2003;31:2444–9.

Hai-tao Ren*

Chun-mao Han

Department of Burns and Wound Center,

The Second Affiliated Hospital, School of Medicine,

Zhejiang University, Hangzhou 310009, ChinaYuan Li

b u r n s 3 9 ( 2 0 1 3 ) 1 4 9 2 – 1 4 9 91494

(shown in Fig. 2). It shows that the four studies were almost

symmetrically distributed in the two sides of the middle line,

and the bias was acceptable. We also noted that not all the

authors were affiliated to the Burns Department; maybe this

is a reason that the effect size was not transformed and

aggregated correctly.

Furthermore, we analysed the other effect sizes againsuch as

mortality and Gram-negative bacteraemia; the result is consis-

tent with Lin et al. [1]. However, there were only two studies

which had the same outcome as the size effect among the four;

so, the bias is inevitably increased sharply. Hence, more high-

Fig. 2 – Funnel plot of experimental (glutamine) vs control

groups as the LOS.

quality randomised controlled trials (RCTs) are needed.

To summarise, we conclude that glutamine supplementa-

tion significantly decreases LOS compared to controls in

critically ill patients with burns.

Conflict of interest

The authors have declared no conflicts of interest.

r e f e r e n c e s

[1] Lin J-J, Chung X-J, Yang C-Y, Lau H-L. A meta-analysis oftrials using the intention to treat principle for glutaminesupplementation in critically ill patients with burn. Burns2013.

[2] Peng X, Yan H, You Z, Wang P, Wang S. Effects of enteralsupplementation with glutamine granules on intestinalmucosal barrier function in severe burned patients. Burns2004;30:135–9.

[3] Wischmeyer PE, Lynch J, Liedel J, Wolfson R, Riehm J,Gottlieb L, et al. Glutamine administration reduces Gram-negative bacteremia in severely burned patients: aprospective, randomized, double-blind trial versusisonitrogenous control. Crit Care Med 2001;29:2075–80.

[4] Zhou Y-P, Jiang Z-M, Sun Y-H, Wang X-R, Ma E-L, Wilmore D.The effect of supplemental enteral glutamine on plasmalevels, gut function, and outcome in severe burns: arandomized, double-blind, controlled clinical trial. J ParenterEnteral Nutr 2003;27:241–5.

Department of Ultrasound, Zhejiang Women’s Hospital,

School of Medicine, Zhejiang University, Hangzhou 310006, China

*Corresponding author. Tel.: +86 13777822681

E-mail address: renht@126.com (H.-t. Ren)

Accepted 21 May 2013

0305-4179/$36.00.

# 2013 Elsevier Ltd and ISBI. All rights reserved.

http://dx.doi.org/10.1016/j.burns.2013.05.021

Letter to the Editor

Response to Letter to the Editor: Ameta-analysis of trials using the in-tention to treat principle for glutaminesupplementation in critically illpatients with burn

There are three questions in Ren et al.’s letter.

Question 1:

Ren et al. claimed that ‘‘the length of hospital stay (LOS) was described

as (mean W SD) days in the three included studies, while different as

(mean W SD) days/1%TBSA in only another included study [1]. Lin et al.

aggregated them together directly, so the result is misleading.’’

Our opinion:

We think Ren et al. held misconceptions. In Garrel’s study [1], length

of care was defined that the time from admission to the complete

healing of grafted and ungrafted wounds, including donor sites, as

determined by the surgical team. And, Garrel et al. claimed the

number of LOS day (mean W SD) was 29 W 17 and 33 W 17 for Control

and Glutamine in Table 3. These messages were self-explanatory.

Question 2:

Ren et al. claimed that the number of patients was 42 and 19 for

Control and Glutamine in Fig. 1.

Our opinion:

The clinical outcomes of the 41 patients who participated in the

study are shown in Garrel’s article.

Question 3:

Ren et al. claimed that they transformed the data to the same unit

(days) and did the analysis of this part again (the number of LOS day

was 41.16 W 37.38 and 36 W 14.18 for Control and Glutamine in Fig. 1).

Our opinion:

We don’t know how to transform those data. Would they mind giving

us any hints as to how they believe these data were transformed?

b u r n s 3 9 ( 2 0 1 3 ) 1 4 9 2 – 1 4 9 9 1495

r e f e r e n c e

[1] Garrel D, Patenaude J, Nedelec B, Samson L, Dorais J,Champoux J, et al. Decreased mortality and infectiousmorbidity in adult burn patients given enteral glutaminesupplements: a prospective, controlled, randomized clinicaltrial. Crit Care Med 2003;31:2444–9.

Jiun-Jie Lin*

Xiu-Juan Chung

Chung-Yih Yang

Hui-Ling Lau

Fong-Yuan Hospital Department of Health

Executive Yuan, Taiwan, ROC

*Corresponding author at: No. 100 An-Kan Rd.,

Fongyuan Dist., Taichung City 42055, Taiwan, ROC.

Tel.: +886 4 25271180 1153

E-mail address: baicalin1@gmail.com (J.-J. Lin)

0305-4179/$36.00.

# 2013 Elsevier Ltd and ISBI. All rights reserved.

http://dx.doi.org/10.1016/j.burns.2013.08.014

Letter to the Editor

Re: Burn Care Centres are lacking atmajor trauma centres in the UnitedKingdom

Dear Editor,

We read with interest the letter written by Mr Sammy Al-Benna

regarding burn care facilities at Major Trauma Centres in the

United Kingdom [1]. We suspect that he is rather tardy in his

comments as the burns services around the country are moving

forward significantly in ensuring the best possible burn care

provision within the Trauma Service within the NHS. We note

that in 2001 the National Burn Care Review described a structure

of Burn Care Networks ranging from burn care facilities which

provided burn services to small burn injuries provided by plastic

surgery departments to the provision of more complex burn

injuries provided by burn units and the most complex being

provided by burn centres. As every Major Trauma Centre needs

to have a Plastic Surgery Department to be compliant with its

terms of trauma provision it should be expected that every

Trauma Centre can provide appropriate burn care facilities and

treatment to the vast majority of burn injuries. A recent review

of burn cases in the South East Burns Network showed that up to

80% of burn injuries admitted to hospital could be catered for in

a burns facility rather than the more complex Burns Unit and

Burns Centre environments.

This has been taken further in the South East Burns

Network where burns facility designation has been formally

introduced to the plastic surgery services at the Major Trauma

Centres in the South East. We feel that such a process ensures

equity of access at both Major Trauma Centres and other

hospitals where plastic surgery services or burns services are

based. It also ensures that burns providers of all levels work

together and ensure that patients get treated in the right place

at the right time by the right people.

We are also keen to point out that the vast majority of burns

injuries only involve burn injury and rarely involve poly-

trauma. However, we do acknowledge the fact that appropri-

ate provision of burn care should be available and is indeed

being made available at all Major Trauma Centres.

Yours sincerely

Mr D Nikkhah

Mr B S Dheansa

Conflicts of interest

None.

r e f e r e n c e

[1] Al-Benna S. Burn care facilities are lacking at major traumacentres in England. Burns 2013;39(3):533. Epub 2012/09/19.

Dariush Nikkhah*

Baljit Dheansa

East Grinstead, United Kingdom

*Corresponding author. Tel.: +44 07747096896

E-mail addresses: nikkhahd@gmail.com

dariushnikkhah@hotmail.com (D. Nikkhah)

0305-4179/$36.00.

Crown Copyright # 2013 Published by Elsevier Ltd and ISBI.

All rights reserved.

http://dx.doi.org/10.1016/j.burns.2013.04.027

Letter to the Editor

Adequate specialised burn care ser-vices are essential at major traumacentres

Sir,

It is an honour that the article entitled ‘‘Burn care facilities are

lacking at major trauma centres in England’’ [1] has aroused

the interest of Nikkah and Dheansa. It is gratifying to see their

statement of unqualified agreement that adequate burn care

and surgery services must be a key feature of all major trauma

centres. It is the obligation of clinicians to make careful,

thoughtful appraisals, and to provide balanced advice to

patients regarding the most effective treatment [2–4]. The

development of trauma networks is to be welcomed as

providing a structure of emergency care delivery within

which to offer the best chance of an optimal outcome for

most people who have a burn injury [1].