The development of the International Society for Burn Injuries and progress in burn care: The whole is greater than the sum of its parts

TY - JOUR

T1 - The development of the International Society for Burn Injuries and progress in burn care

T2 - The whole is greater than the sum of its parts

AU - Pruitt, Basil A.

N1 - Funding Information: Basil A Pruitt Jr. * US Army Institute of Surgical Research, Department of Surgery, University of Texas Health Science Center at San Antonio, 7330 San Pedro, Suite 536, San Antonio, TX 78216, USA * Tel.: +1-210-342-7903; fax: +1-210-342-2966. Reprint requests: Library Branch, US Army Institute of Surgical Research, 3400 Rawley E. Chambers Avenue, Fort Sam Houston, TX 78234-6315 The International Society for Burn Injuries (ISBI), even though it was not formally established for another six years, had its beginnings at the First International Congress on Research in Burns. That congress, which was sponsored by the US Army, US Navy, US Air Force and the US Public Health Service, under the auspices of the American Institute of Biological Sciences, convened at the National Naval Medical Center in Bethesda, MD in September 1960. At that first congress, 57 papers were presented by participants from 15 countries. On the final day of the congress, seven speakers, including Curtis P. Artz, Francis D. Moore, James D. Hardy, William A. Altemeier, William D. Holden, Ole J. Malm and Charles M. Pomerat presented summary papers focused on consensus identified problem areas as subjects for clinical and laboratory research [1–7] . The participants considered the meeting such a success that a Second Congress was scheduled. The proceedings were published as a book titled ‘Research in burns’ which was edited by Curtis Artz, who had been coordinator of both the Planning Committee and the Program Committee of the Congress ( Fig. 1 ) [8] . The papers that were presented at the First Congress and at subsequent congresses have generated vigorous formal and informal discussion. The resulting exchange of information has expanded research activity which has accelerated improvement in burn care and increased the survival of burn patients. The velocity of improvement in burn care has increased as the ISBI has matured, as indexed by the content of each Burn Congress since 1960 ( ). Similarly, as manifested by the accomplishments of its committees, the scope and velocity of ISBI activities have increased since the Society was formed shortly after the Second Congress. Table 1 At the initial 1960 Congress, Anne Phillips, from the Massachusetts General Hospital, indicated that almost one in ten fatal burn cases (9%), had ‘uremia’ (renal dysfunction) as a cause of death [9] . Tumbusch and colleagues from the United States Army Surgical Research Unit documented the changing epidemiology of infection in severely burned patients and reported the emergence of Pseudomonas septicemia as a frequent cause of death in such patients [10] . Douglas Jackson and Bruce Macmillan each presented papers describing extensive primary excision of deep burns and neither could identify a beneficial effect on survival [11,12] . However, Macmillan and Altemeier, who had treated patients with more extensive burns, noted an excision-related reduction in postburn morbidity, an improved nutritional status and more rapid rehabilitation. Allograft skin, either fresh, frozen, or lyophilized was the only biologic dressing given consideration at that meeting. Carl Moyer presented the results of studies confirming that burn injury increased both heat production and heat loss but he attributed those changes to vaporizational heat loss through the open wound [13] . The changes that have occurred in fluid resuscitation, wound care and metabolic and nutritional management during the 38 years since the First Congress will serve to illustrate the advantages of multidisciplinary research in which the whole is typically greater than the sum of its parts. Similarly, the totality of activity of the International Society for Burn Injuries has been greater than that of its members since the Society has existed. The ISBI, as an organization expressing the consensus of its membership, can continue to exert a proportionately greater influence on targeted aspects of burn prevention, burn unit planning and mass casualty care than individual members. In September 1965, the participants in the Second International Congress on Research in Burns, hosted by A.B. Wallace, then a reader in plastic surgery at the University of Edinburgh, were welcomed by His Royal Highness, Philip, the Duke of Edinburgh. As evident in the transactions volume that was published, the 13 scientific sessions of that congress covered topics which included fluid resuscitation and wound management, as well as metabolic and nutritional support ) [14] . This Second Congress generated as great, if not greater, enthusiasm among the participants for subsequent quinquennial International Congresses. Additionally, the participants decided to establish a permanent organization “…in the hope of reducing the incidence of this major scourge as well as improving care…” [15] A.B. Wallace orchestrated the birth of the ISBI and became the Secretary General, a position he held until his death in December 1974. The original members of the ISBI Executive Committee, who represented 13 countries, ensured that the young Society received truly global input ( Table 2 [16] . There were approximately 300 participants in the Edinburgh Congress during which 72 papers were presented by speakers representing 18 countries. Considerable interest was expressed in the use of synthetic colloid solutions for resuscitation and C.R. Ricketts of the Birmingham Accident Hospital placed the usefulness of dextran solutions of various molecular weights in clinical perspective [17] . R.J. Jones and E.J. Lowbury of the same institution reported that in a mouse model of invasive Pseudomonas burn wound sepsis, high dose systemic antibiotic therapy could lengthen survival without effect on mortality. They found that the effect of intraperitoneal Pseudomonas antiserum was strain-specific and time limited with no survival noted when the antiserum was given 72 or more hours after infection [18] . Harrison, Lindberg and Mason when reporting the disappointing results of their evaluation of eight skin substitutes in a murine model noted, in passing, the effectiveness of the newly rediscovered sulfonamide-containing burn cream Sulfamylon® [19] . Harry Soroff and colleagues from Tufts University reported that the administration of a fixed dose of human growth hormone to burn patients was associated with increased nitrogen storage but they found that effect to be strongly dependent on the nutritional status of the patient, the time postburn, the patient's age and possibly the patient's gender [20] . The final scientific session of the 1965 Congress consisted of a symposium on burn unit design in which emphasis was placed on limiting cross contamination and infection. Jim Laing described his new Wessex Regional Burns Unit in which his goal was to ensure physical isolation of the patient in a “sterile environment” [21] . B.W. Haynes advanced his concept of “total isolation” in a “life island” and Stanley Levenson and colleagues described their use of specially designed “plastic isolators” in the operating room and on the wards to contain infection and prevent spread of infection among patients [22,23] . All of those methodologies proved to be imperfect and incapable of reducing infections of endogenous origin. The Second Congress closed with a public meeting on the prevention of burn injury [24] . Prevention concerns centered on methods to reduce burns of children caused by hot liquids, electric cords and open flames. The Third Congress, which took place in Prague, Czechoslovakia in 1970, was hosted by R. Vrabec and Z. Konı́c̆ková. Following an opening address by Secretary General Wallace [25] , the participants, representing now 29 countries, delivered and heard 203 scientific papers which were published in a Transactions volume. Several investigators described the effectiveness of crystalloid fluid as the sole component of burn patient resuscitation [26] and numerous papers reported the effectiveness of topical chemotherapeutic agents such as sulfonamide-containing creams and silver nitrate soaks [27,28] . The papers on skin replacement ranged from that given by J.C. Tanner reporting on the use of his recently developed 12 to 1 expansion ratio mesh grafts to those describing the use of allograft skin, xenograft skin, amniotic membranes and a polypeptide laminate nylon velour skin substitute [29–33] . In studies of postburn hypermetabolism, Arturson noted a dissociation between evaporative water loss and metabolic rate as manifested by the failure of blockage of water loss from the wound surface to reduce the elevated oxygen consumption of burn patients [34] . At the business meeting during the Third Congress, many members advanced the proposal that the interval between congresses be reduced to four years rather than five in the light of the intensity of burn research and the velocity with which changes in burn care were occurring. The General Assembly voted to hold the next Congress in Buenos Aires, Argentina in 1974. The Fourth, now International Congress on Burn Injuries, was hosted by Fortunato Benaim in Buenos Aires in September 1974. The program consisted of 200 scientific papers, delivered by representatives of 34 countries, 11 films and seven plenary sessions which addressed the topics of The Acute Phase of Burn Care; The Metabolic Response; Infection and Sepsis; Burn Wound Healing; Prevention, First Aid and Education; Skin Replacement; and Reconstruction. During the Congress, Rayfield, Vaught, Curreri and Baxter reported that burn injury resulted in activation of the fibrinolytic system as manifested by an elevation of fibrin degradation products in the burn wound and in the plasma which exerted deleterious effects on the lung and influenced resuscitation fluid requirements [35] . In the field of wound care, the use of Sulfamylon soaks was described and the usefulness of wound biopsies in monitoring the microbial status of the burn wound was documented [36,37] . Muhlbauer of Germany, anticipating recent studies by others of the effect of direct current on burn wounds, reported that magnetic fields favorably influenced wound healing and reduced keloid formation [38] . Papers in the skin replacement session remained focused on the use of naturally occurring biologic dressings which still required frequent reapplication and ultimate replacement with autogenous skin. In the workshops on the metabolic response to burn injury, Wilmore presented the results of his studies indicating that burn patients are internally warm, not externally cold and that the catecholamines were of central importance in the hypermetabolic response [39] . The Fifth International Congress on Burn Injury was held in Stockholm, Sweden in June 1978 and was hosted by Arturson, Nylen and Sorensen. The congress participants were offered a menu of 355 scientific papers, 64 posters and 21 films and videos, presented by representatives of 36 countries. The congress included nine ‘main’ or plenary sessions on epidemiology and prevention; metabolism and nutrition; resuscitation and complications; immunology and infection; burn wound healing, early excision and surgery of hand burns; technical aids in surgery of head and neck burns; topical therapy, enzymatic debridement and biologic and synthetic dressings; psychology and psychiatry; and nursing. The papers on fluid resuscitation described the time course of increased postburn microvascular permeability [40] and dissected the cardiovascular effects of salt water and colloid content to evaluate hypertonic salt solutions and refine resuscitation regimens [41–43] . In the sessions on wound care, the successful application of early excision, pioneered by Janzekovic, was reported by many and she described her application of tangential excision to the treatment of burned hands [44] . As the specter of invasive burn wound sepsis receded, the impact of inhalation injury and pneumonia on burn patient outcome was emphasized by several authors. In the poster presentations, several biologic dressings were described, including a totally synthetic bilaminate dressing developed by Silverstein which demonstrated that an effective skin substitute should have both a dermal and epidermal analog [45] . In the sessions on metabolism and nutrition, papers were presented which further defined the neurohumoral changes that orchestrate postburn hypermetabolism as well as the distribution and utilization of nutrients [46,47] . The Sixth International Congress on Burns, hosted by John Boswick, convened in San Francisco, California in late August and early September 1982. The attendees heard 429 papers presented by delegates from 43 countries and participated in 40 breakfast and 40 lunch panels at which specific topics such as epidemiology and prevention were discussed in detail. In the scientific sessions on fluid resuscitation, the effects of Dextran on edema formation and fluid requirements were considered and an entire session was devoted to resuscitation with hypertonic salt solutions [48,49] . In the field of wound care, several papers described the effectiveness of topical antimicrobial agents that were variations of silver sulfadiazine and Sulfamylon® burn creams. Biobrane® caught the attention of the congress as a multipurpose, collagen-based, synthetic bilaminate skin substitute [50] . The advantages of burn wound excision were further extolled but C.F.T. Snelling and colleagues dampened that enthusiasm with their report of the prodigious blood loss associated with tangential excision [51] . In the area of metabolism, Cleon Goodwin identified a subcellular basis for postburn hypermetabolism, i.e. increased mitochondrial oxygen consumption and an increased mitochondrial phosphorylation rate, both independent of weight loss [52] . The Seventh International Congress on Burn Injuries, hosted by A. Murray Clarke, was held in Melbourne, Australia in February 1986. A program of 235 scientific papers, four plenary sessions and eight videos, presented by representatives of 24 countries, was offered to the participants. In the field of fluid resuscitation, a correlation between elevated renal blood flow and sodium excretion was identified and the limitations of urinary function as an index of resuscitation were recognized [53,54] . Collagen-based, synthetic skin substitutes were reported to be comparable to biologic dressings in providing temporary wound coverage [55] . David Herndon et al. reported that early massive excision improved the salvage of children whose burns were of such an extent that salvage was previously unprecedented [56] . The use of cultured epidermal grafts was proposed as a means of achieving definitive closure of the wounds of patients with extensive burns and limited donor sites [57] . The survival of extensively burned patients now highlighted the need for scar control and topical application of silicone gel was reported to reduce hypertrophic scar formation, the mechanism of which remains unidentified to this day [58] . The diagnosis and treatment of inhalation injury received considerable attention as the threat of burn wound infections had further receded [59] . In the area of metabolism, the identification of central hypogonadism further refined our understanding of postinjury neurohormonal alterations [60] . Several authors claimed specific advantage for enteral nutritional support as compared to parenteral support even in massively burned patients [61] . The Eighth International Congress on Burn Injuries, hosted by Manohar Keswani, convened in New Delhi, India in November 1990. The program consisted of 324 scientific papers, 10 panel discussions, 9 videos and 6 posters presented by representatives of 43 countries. There were five general or plenary sessions in which selected speakers presented invited lectures. Douglas Jackson reviewed changes in burn care that had occurred during the preceding 50 years, Gösta Arturson reviewed the effects of burn wound pathophysiology on fluid resuscitation, Janet Marvin spoke on ‘Successful burn care without expensive equipment’ and your current President described how burn research is enhanced by involvement of investigators representing many disciplines. John Boswick, who completed his tenure as Secretary General at this Congress, spoke on ‘Methods of improving burn care internationally’. At the Eighth Congress, little attention was given to fluid resuscitation in the scientific sections as a reflection of the general acceptance of formula-based resuscitation to prevent burn shock and organ failure. Instead, there was a shift of focus to papers on postresuscitation intensive care describing the management of inhalation injury and life-threatening complications of burn injury [62,63] . Many papers reported evaluations of a variety of synthetic skin substitutes and an entire scientific session was devoted to cultured epidermal autografts [64] . Several topical antimicrobial treatments of variable effectiveness were described and the emergence of nonbacterial opportunistic organisms as the cause of burn wound infections was noted [65,66] . In the metabolic sessions the deleterious effects of burn injury and supervening infection on thyroid function were described [67] . W.G. Cioffi and colleagues reported that current burn patient management techniques were associated with an amelioration of the magnitude of postburn hypermetabolism [68] . That change was shown to simplify nutritional support by reducing the caloric loads required to prevent loss of lean body mass. The Ninth Congress of the International Society for Burn Injuries, hosted by Serge Baux, was held in Paris, France in late June and early July of 1994. The program that was presented by representatives of 47 countries, included 403 scientific papers, 117 posters and 14 videos. Invited lectures were presented on healing and scar formation by Hugo Linares and burn sepsis by David Heimbach. Two plenary session debates were conducted: Robert Demling spoke for the use of human albumin in the first 24 h of resuscitation and Basil Pruitt, who won the vote of the audience at the conclusion of the debate, spoke against the use of colloid containing fluid for burn patient resuscitation. The optimum timing of excision and grafting of the burn wound was debated by W. Boeckx and D. Herndon. Four educational courses covering the topics of nutrition, pain management, secondary surgical treatment and smoke inhalation were well attended. In the correlative sessions of the Ninth Congress, the presentations on fluid resuscitation were focused on pharmacologic interventions to reduce burn wound edema and resuscitation fluid needs and on techniques to improve physiologic monitoring of organ function during the resuscitation period [69–71] . Papers on wound care reported on the use of new optical and other technologies to assess extent and even depth of the burn wound [72,73] . Additionally, several authors reported on their evaluations of new skin substitutes with special attention given to the development of dermal substitutes [74,75] . Several authors presented their techniques to enhance the engraftment and expand the usefulness of cultured epidermal autografts [76,77] . Rouabhia et al reported the apparent persistence of sheets of ‘chimeric keratinocytes’ (co-cultured autogenous and allogeneic cells) on an animal model [78] . Beneficial effects of low amperage direct current in accelerating the restoration of microvascular integrity and maintaining blood flow in the zone of stasis to salvage deep dermal burns were also reported at that congress [79] . Interest in inhalation injury as a significant comorbid factor in burn patients was evident in the papers reporting improved outcome in patients treated with high frequency ventilation or extracorporeal membrane oxygenation [80,81] . The correlative sessions on nutrition and metabolism were largely concerned with the enhancement of nitrogen retention by manipulation of the major dietary components and the effectiveness of nutritional supplements in altering immune function and improving resistance to infection [82–85] . The papers and posters that will be presented at the Tenth Congress of the ISBI, hosted by Eldad and Rosenberg, have been selected from among the 416 abstracts which were submitted by representatives of 37 countries. The content of those papers will reflect the continuing evolution in burn care and record further improvement in the outcome of burn patients. This brief review illustrates that improvements in the care of burn patients, developed during the lifetime of the ISBI, a mere 32 yr, have eliminated renal failure as a complication of burn injury, controlled burn wound infection, tamed inhalation injury and revolutionized metabolic and nutritional support. The aggregate effect of these advances has been a significant increase in survival of burn patients of all ages. Analysis of the advances reported at the first nine Congresses of the ISBI identifies those factors which favor productive biomedical research and the prompt incorporation of research results into patient care procedures. The vast majority of the scientific discoveries and the clinical developments responsible for these major advances have originated at burn centers with an identifiable research program. Burn centers, as their name implies, facilitate biomedical research by ensuring a dependable supply of patients of interest. The expertise and experience of the clinical staff enable them to identify significant problems requiring research for resolution. Burn centers also provide adequate space and facilities for clinical studies and provide access to necessary laboratory-based research support. A research oriented burn center typically ensures stability of senior staff who possess sufficient expertise to provide effective internal review of research effectiveness, assess the reliability of results and also evaluate quality of care. Burn center size alone confers specific advantages such as providing an intellectual critical mass of investigators and the flexibility of funding necessary to exploit unanticipated findings promptly. Size also facilitates maintaining state-of-the-art research technology by use of planned equipment upgrade and replacement programs. Burn center research productivity is greatest when an integrated clinical-laboratory collaborative research program can be developed as illustrated by the advances in burn care which I have described. Recognition of hypovolemic shock and renal failure as a frequent complication in the resuscitation period led to the development of animal models used by Harkins, Evans and Baxter to identify the magnitude of burn-induced hypovolemia and reduction in cardiac output ) [86–88] . That information returned to the bedside in the form of the formulae used to predict fluid needs [86–92] . Subsequent clinical studies have completed the research loop by identifying the refinements of resuscitation that have essentially eliminated early postburn renal failure ( Table 3 [93] . When more patients with extensive burns survived resuscitation, the importance of burn wound infections as a limiting factor in survival became apparent in the late 1950s and early 1960s , which reduced the incidence of invasive burn wound sepsis and by limiting intraeschar microbial proliferation permitted staged, relatively late excisions to be carried out in patients with massive burns with a lesser risk of hematogenous dissemination of bacteria ). [10] . That problem was also transported to the laboratory where animal models of invasive burn wound sepsis were developed. Studies using those models demonstrated that topical antimicrobial chemotherapeutic agents could convert universal mortality to uniform survival [94] . Those results were returned to the clinic in the form of Sulfamylon burn cream ( Fig. 2 ) [95,96] . Effective topical antimicrobial chemotherapy in combination with prompt burn wound excision have reduced invasive burn wound sepsis by a factor of ten ( Table 4 As invasive burn wound sepsis essentially disappeared, clinicians recognized the importance of the lung as the predominant site of life threatening infection in burn patients and noted an association of pneumonia with inhalation injury ( Fig. 3 ) [97] . That problem was also taken to the laboratory where studies using an animal model of inhalation injury revealed that the response of the airways to the constituents of smoke was characterized by mucosal necrosis, airway edema and bronchospasm resulting in an increase in low air flow/high blood flow compartments within the lung associated with atelectasis and the development of pneumonia [98] . To complete the clinic-laboratory-clinic cycle, this information led to the prophylactic use of high frequency ventilation which has reduced the incidence of pneumonia and increased survival of burn patients with inhalation injury [99] . In similar fashion, the debate about whether burn patients were externally cold or internally warm and whether one should try to reduce the elevated metabolic rate or provide nutrients to satisfy measured caloric needs was resolved only when patients could be studied in an environmentally controlled metabolic chamber ( . Studies in that chamber demonstrated that the burn patient was internally warm, not externally cold Fig. 4 ) [100] . Moreover, whole limb plethysmographic studies indicated that the hypermetabolism was wound directed [101] . Correlative laboratory studies identified the importance of the microbial burden of the burn wound, presumably as a result of persistent activation of endogenous pyrogens and other inflammatory cytokines [102] . Those studies appear to have defined the actual infection-free energy cost of burn wound healing. The clinical relevance of those studies is reflected in the change from the former curvilinear relationship between metabolic rate and burn size to the current linear relationship [103] . The linear relationship has reduced the level of nutritional support required by the vast majority of burn patients and decreased the incidence of complications related to high calorie and high volume feedings. Each of these advances in our understanding of pathophysiology and the resulting improvements in burn care illustrate the benefits of integrated clinical-laboratory research as well as the wide spectrum of expertise necessary for that research. The importance of each problem to be studied was initially validated by burn center surgeons. A critical scientific mass with the required expertise was readily generated by the formation of a research team including allied scientists and physicians representing other disciplines. Laboratory models were developed as necessary, the patient relevance of which was ensured by the continuing involvement of surgeons and other clinicians. State-of-the-art technology was utilized for laboratory assays and clinical monitoring throughout the reiterative research cycle from clinic to laboratory and back to clinic. The collaborative integration of clinic and laboratory staff permitted prompt clinical application of laboratory findings and expedited the identification of the limitations and side effects of the new treatments developed in the laboratory. Identified limitations and side effects, as well as the emergence of comorbidities and problems previously obscured by the successfully treated problem, quickly became topics for new research programs as did inhalation injury when burn wound infection was controlled. A program of integrated clinical and laboratory research by virtue of its collaborative multispecialty and multidisciplinary character prevents duplication of research efforts within an institution, minimizes costs by efficient utilization of resources and facilitates what has been recently termed “capture of the unexpected benefits of medical research” as exemplified by the beneficial metabolic effects of topical control of the burn wound flora [104] . In short, the whole of integrated clinical-laboratory research is clearly greater, in terms of research velocity, productivity and efficiency, than the sum of its clinical and laboratory parts working alone. During the period of rapid scientific advancement that has characterized the life of our society, the ISBI itself has undergone parallel development and maturation. The membership roster in 1969, the year in which I became a member of the ISBI, listed 571 members representing 72 countries ). That total membership includes five honorary members, 103 senior members, 1697 regular members and 122 individuals living in countries from which dues cannot be exported. Of those members, 1557 are physicians, 47 hold doctoral degrees and 149 are nurses. Among the membership there are also 22 physical therapists, 14 occupational therapists, 4 medical social workers and 134 industry representatives and other laity. [16] . Today there are 1927 ISBI members representing 96 countries ( Table 5 In addition to expanding in number and geographic distribution, the Society's committee structure has expanded and increased its productivity during the past four decades. In the original constitution provision was made for no committee other than the Executive Committee. That committee was assigned the task of deciding the scientific program of the Congress in cooperation with members of the host country [16] . In 1971, A.B. Wallace in collaboration with the World Health Organization, formed five action committees to address areas of special interest to the Society [105] . Those Committees on Burn Prevention, Teaching and Record Keeping, Organization of Burn Care, Nurses Training and Recruitment and Laboratory Services for a Burns Unit all met in June 1972. The initial reports of those committees were published in 1973 [106] . At the September 10, 1973 meeting of the ISBI Executive Committee, numerous changes in the constitution were proposed [107] . In 1974, at the Fourth Congress, the General Assembly approved the recommendation of the Executive Committee to establish a Programme Committee, a Finance Committee and a Journal Committee in addition to the five action committees. The Society's Committees have presented workshops, panels, scientific sessions and plenary sessions during each Congress beginning in 1974. In the early years of the Society, specific scientific sessions dealt with prevention in terms of nation-specific burn epidemiology with emphasis on the prevention of childhood burns [24] . On the morning of the first day of the Fourth Congress in Buenos Aires, the action committees on statistics and records and unit structure combined to present a plenary session on data collection and the organization of burn centers [108] . The Statistics and Records Committee worked diligently to develop a universal basic data set to serve as a reliable epidemiological and registry tool. The Unit Structure Committee provided a platform at each congress where those members who were organizing and building burn units could benefit from both the good design features and the mistakes of others who had recently built a burn unit [109] . The Recruitment and Training Committee focused its efforts on the nurse members of the ISBI and sponsored quadrennial International Burn Nurse Congresses. That program has been continued by the current ISBI Nursing Committee which most recently sponsored a Congress in the Dominican Republic in 1996. In 1978, a Disaster Planning Committee and a Rehabilitation Committee were established ). The basic field-care team which consists of a surgeon, a registered nurse, two licensed practical nurses and a respiratory therapist, all experienced in burn care, can be expanded or modified, in terms of staffing, to meet the specific needs of special situations. [110] . The Disaster Planning Committee very promptly defined levels of disaster response keyed to the number of casualties and identified a burn care team which, with appropriate equipment and supplies, could provide initial in-the-field resuscitation and care for 50 patients having the usual distribution of burn size in mass casualty and disaster situations ( Table 6 In 1990, a new constitution and bylaws were adopted at the Congress in New Delhi and eight standing committees were established: Burn Care, Disaster Planning, Laboratory Services, Nursing, Prevention, Program, Rehabilitation and Research [111] . Between the Eighth and Ninth Congresses, the Prevention Committee was particularly active and productive as Latarjet and his committee developed guidelines which were distributed to the membership in booklet form as ‘Simple guides’ to burn epidemiology, burn treatment, burn prevention and the burn registry [112–115] . The latter was supplemented by burn registry software designed by Saffle and his colleagues as a stand-alone program packaged, with the guidelines, in a ‘Burn guide briefcase’. Following the Ninth Congress, each committee was given a specific charge to address during the four years leading up to this congress. At the meeting of the General Assembly, you will hear the reports of those committees which will illustrate the effectiveness of the Society's Committee Chairs and the productivity of the members of the committees. I now claim Presidential privilege to highlight the following committee achievements over the past four years. Judkins has completed a questionnaire survey of his Burn Care Committee, the results of which he feels can be used to establish minimum standards for burn care “which are achievable worldwide and depend on scarce or sophisticated resources only for that small number of patients with a complex or major burn”. As part of that initiative, it may be possible to define a verifiable treatment facility (a level II burn center?) for burn patients who do not require burn center care and bring, perhaps by telemedicine technology, the advantages of expert care, formal quality assessment and outcome analysis to those facilities where the majority of burn patients receive care. Verification of such facilities could become a regional outreach activity of current burn centers. During the past four years, Yukioka and the Disaster Planning Committee have developed new guidelines for planning the medical care needed in mass casualty and disaster situations. Albert McManus and the Laboratory Committee have developed a list of laboratory capabilities and the related equipment, supplies and personnel needed for disaster care situations. The Nursing Committee organized and conducted the IV International Congress on Nursing, Social and Rehabilitative Care of the Burn Patient in the Dominican Republic in October 1996 and is well along with planning for the Fifth International Congress on Nursing, Psychosocial and Rehabilitation Care which will be held in the Netherlands in the year 2000. With the leadership of Janet Marvin, that committee has also established the criteria and process which will be used to select the recipient of the Wendy Swift Award which recognizes one of the early leaders of the ISBI. Patiño and the Rehabilitation Committee have developed a poster illustrating the principles of rehabilitation which will be available to the membership at this Congress [116] . Gamelli and the Research Committee completed a survey questionnaire of the ISBI membership to determine their assessment of research needs and the needed research qualifications of investigators. Three quarters of the respondents felt that current criteria for care at a burn center should be reevaluated and liberalized, 60% believed that research was most cost effective when conducted as an integrated clinical/laboratory research program and 85% felt that the ISBI should take an active role in setting international policy on burn care. 83% of the respondents were of the opinion that burn care fellowships should incorporate a standard curriculum and three-quarters felt that a fellowship should be required for all who care for a significant number of burn patients. The results of that survey support the concept of establishing standards for burn care wherever it is delivered and defining, as noted above, what could be termed a Level 2 burn treatment facility. The ad hoc Industrial Relations Committee, established at the Paris Congress, has been most successful under the leadership of Carlos Blanco whose efforts have generated $20,000.00 which is being used to support ISBI members from developing countries who are attending this congress. The last committee to be mentioned is the Program Committee which deserves special commendation for their quick response to, at times, prodigious demands. To obtain ISBI support of international faculty for national or regional meetings, the program of the meeting must be reviewed and approved by the Chair of the Program Committee and also approved by the Executive Committee. The Program Committee as a whole is also charged with reviewing the abstracts and selecting the papers for presentation at each ISBI Congress. During the past quadrennium, Herndon has provided reviews (at times, of necessity, expedited reviews) of the scientific programs of 10 national meetings and 4 regional meetings, all of which received ISBI endorsement. Additionally, he and the other Program Committee members reviewed 416 abstracts for this Congress with a turn-around time of only 22 days. In addition to this record of effective committee action, the organization as a whole has provided travel support for visiting lecturers at 10 of the 14 national burn meetings and 3 of the 4 regional burn meetings at which the ISBI has been officially represented. Travel grants have also been awarded to eight members from developing countries who are attending this Tenth Congress and funds were provided for additional travel grants administered by the Organizing Committee of the Congress. Since 1994, the ISBI has funded three Visiting Professorships and has awarded nine traveling fellowships to seven physicians and two nurses to enhance burn care capabilities in developing countries. The ISBI has also maintained its status as a participating society in the biennial World Congresses of Surgery. During International Surgical Week (ISW) 1995 in Lisbon and ISW 1997 in Acapulco, the Society presented six main scientific sessions, two luncheon panels and two free paper sessions involving 42 ISBI members [117,118] . Similar ISBI participation in International Surgical Week 1999 in Vienna has been planned. As we have seen to be the case with scientific progress, the progress of our committees and the ISBI as a whole has been greater than could have been achieved by individual members working alone. The successes that have been realized in burn care and in the activities of the ISBI have significantly increased the survival of burn patients of all ages ( ) and generated the momentum that will carry the Society and its members into the new millennium under the leadership of David Heimbach. I thank each member for giving me the privilege of serving as your President during the past four years. I anticipate, enjoying with you, even greater successes between now and the Congress in 2002 as we address the problems revealed by continued improvement in burn care and apply the collective expertise and wisdom of the ISBI to the organizational and societal problems of burn injury on a global scale. Table 7

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