Burns

Editorial Board

2012-06-01

A systematic review of the evidence for telemedicine in burn care: With a UK perspective

D.L. Wallace, A. Hussain, N. Khan, Y.T. Wilson — 2011-11-11

Abstract: A comprehensive systematic review of telemedicine in burn care was carried out. Studies published between 1993 and 2010 were included. The main outcome measures were the level of evidence, technical feasibility, clinical feasibility, clinical management and cost effectiveness. The search strategy yielded 24 studies, none of which were randomised. There were only five studies with a control group, and in three of these the patients act as their own controls. Four studies performed quantitative cost analysis, and five more provide qualitative cost analysis. All studies demonstrate technical and clinical feasibility. If the significant potentials of telemedicine to assist in the acute triage, management guidance and outpatient care are to be realised, then research needs to be undertaken to provide evidence for such investment.

Role of the PPAR-α agonist fenofibrate in severe pediatric burn

2012-01-09

Abstract: Fenofibrate is a peroxisome proliferator activated receptor alpha agonist that contains both pro and anti-inflammatory properties, and has been used in the treatment of dyslipidemia and diabetes for decades. Its receptors are expressed in the liver, skeletal muscle, cardiac, enteric, and renal cells, which allow it to provide systemic regulation of lipoprotein metabolism, fatty acid oxidation, and fatty acid transport. Hyperglycemia is a common complication found in the burn population because hepatic glucose production and catecholamine-mediated hepatic glycogenolysis are augmented. Insulin resistance occurs often in these patients and is associated with poor outcomes. In the pediatric burn population, fenofibrate has been found to ameliorate or decrease the number of hypoglycemic episodes when compared to management with insulin alone. Its mechanism of action is thought to involve an improvement in insulin signaling in skeletal muscle, as well as improvements in mitochondrial function, glucose oxidation, and insulin sensitivity. The long term use of fenofibrate in severely burned patients may improve hyperglycemia and insulin resistance, as well as improve wound healing, and reduce apoptosis, and oxidative stress.

Burn patients, parents and doctors; are we in agreement?

2012-02-20

Abstract: Background: Burns in children present a serious challenge for patients, parents and doctors. This study aimed to investigate differences in desire for burn reconstruction in paediatric patient, parent and surgeon groups.Methods: This study is a case series (n=21). Questionnaires were administered to patients, their parents and surgeons. Medical records were also reviewed. Data were analysed to ascertain how different factors affected desire for reconstruction between parents, patients and surgeons.Results: Surgeons and parents were more likely to desire surgery than paediatric patients (76.2 vs 61.9 vs 52.4% respectively). Surgeons were more likely to recommend surgery for pre-pubescent patients (81.8 vs 70%). All groups were more likely to desire surgery for female patients. Patients and parents desired surgery more for hidden scars. Higher VSS scores were associated with a higher desire for surgery in all groups. Agreement between patients and parents was highest (Kappa=0.81) with poor-moderate agreement between surgeons, patients and parents (Kappa=0.12–0.24).Conclusions: This study suggests that paediatric patients are less likely to want burn reconstruction compared to parents and surgeons. Gender and age may impact on desire for surgery. Opportunities for improving patient, parent and surgeon agreement may exist. Further research is warranted to validate these results.

Commercially available interactive video games in burn rehabilitation: therapeutic potential

2012-03-05

Abstract: Commercially available interactive video games (IVG) like the Nintendo Wii™ (NW) and PlayStation™II Eye Toy (PE) are increasingly used in the rehabilitation of patients with burn. Such games have gained popularity in burn rehabilitation because they encourage range of motion (ROM) while distracting from pain. However, IVGs were not originally designed for rehabilitation purposes but rather for entertainment and may lack specificity for achieving rehabilitative goals. Objectively evaluating the specific demands of IVGs in relation to common burn therapy goals will determine their true therapeutic benefit and guide their use in burn rehabilitation. Upper extremity (UE) motion of 24 normal children was measured using 3D motion analysis during play with the two types of IVGs most commonly described for use after burn: NW and PE. Data was analyzed using t-tests and One-way Analysis of Variance. Active range of motion for shoulder flexion and abduction during play with both PE and NW was within functional range, thus supporting the idea that IVGs offer activities with therapeutic potential to improve ROM. PE resulted in higher demands and longer duration of UE motion than NW, and therefore may be the preferred tool when UE ROM or muscular endurance are the goals of rehabilitation. When choosing a suitable IVG for application in rehabilitation, the user's impairment together with the therapeutic attributes of the IVG should be considered to optimize outcome.

Digital image analysis versus clinical assessment of wound epithelialization: A validation study

M.C.T. Bloemen, B.K.H.L. Boekema, M. Vlig, P.P.M. van Zuijlen, E. Middelkoop — 2012-03-02

Abstract: To evaluate the progress in wound healing, wound assessment is mandatory. Epithelialization is traditionally assessed subjectively by the clinician. In a previous study, subjective assessment of epithelialization was shown to be reliable. In this study, reliability of epithelialization measured by digital image analysis was investigated and then, we validated the subjective evaluation by comparing this assessment to measurements with digital image analysis. Clinicians assessed epithelialization in 50 burn wounds that were treated with a split skin graft. Epithelialization of these wounds was also measured by three observers using digital image analysis. Reliability of digital image analysis was tested using the intraclass correlation (IC). To test validity, subjective clinical assessment was correlated with digital image analysis (IC). The results showed that interobserver reliability of epithelialization measured by digital image analysis was good (IC coefficient 0.74). Subjective clinical assessment of epithelialization showed a strong correlation with digital image analysis (IC coefficient 0.80). In conclusion, subjective clinical evaluation of wound epithelialization is as good as an objective measure, in this study digital image analysis. Since digital image analysis is more time-consuming, we recommend the use of the subjective evaluation for daily practice.

Association between depression, patient scar assessment and burn-specific health in hospitalized burn patients

Young Sook Roh, Hyun Soo Chung, Boeun Kwon, GiYon Kim — 2012-02-23

Abstract: Background: Depression is one of the most common psychological problems arising after a burn, but its relationship with patient scar assessment and burn-specific health are poorly understood. The aim of this study was to identify the incidence of in-hospital symptoms of depression, compare level of patient scar assessment, and burn-specific health by depression cutoff point, and identify the relationship between depression and these variables.Methods: In a cross-sectional descriptive study, 113 burn patients from two inpatient burn centers were divided into two groups based on the cutoff point of the Korean Center for Epidemiologic Studies Depression Scale (Korean CES-D): ≥25 or <25. Patient Scar Assessment Scale and Korean Burn-Specific Health Scale-Brief (BSHS-B-K) were used to identify associations with depression.Results: Incidence of severe, definite depression as assessed by a score of 25 or above on the Korean CES-D was approximately 50% on an average at 60.9 days after injury. Burn patients with the Korean CES-D≥25 had significantly higher total mean patient scar assessment scores (43.34±11.49 vs. 36.84±9.56, t=3.265, p=.001), and lower burn-specific health subscale scores compared to patients with Korean CES-D<25. Depression was positively correlated with all subscales of the Patient Scar Assessment, ranging from r=.196 to .335 except scar color. Depression was significantly correlated with all subscales of the BSHS-B-K, range from r=−.320 to −.725.Conclusion: Results indicate that incidence of symptoms of depression is relatively high, and depressed burn patients report worse burn scar or sensation and lower levels of burn-specific health. Early, timely recognition and management of depression in these patients are warranted.

Standardizing the diagnosis of inhalation injury using a descriptive score based on mucosal injury criteria

Christos Ikonomidis, Florian Lang, Alexandre Radu, Mette M. Berger — 2012-02-20

Abstract: Introduction: Inhalation injury is an important determinant of outcome in patients with major burns. However the diagnostic criteria remain imprecise, preventing objective comparisons of published data. The aims were to evaluate the utility of an inhalation score based on mucosal injury, while assessing separately the oro-pharyngeal sphere (ENT) and tracheobronchial tree (TB) in patients admitted to the ICU with a suspicion of inhalation injury.Methods: Prospective observational study in 100 patients admitted with suspicion of inhalation injury among 168 consecutive burn admissions to the ICU of a university hospital. Inclusion criteria, endoscopic airway assessment during the first hours. ENT/TB lesion grading was 1: oedema, hyperemia, hypersecretion, 2: bullous mucosal detachment, erosion, exudates, 3: profound ulcers, necrosis.Results: Of the 100 patients (age 42±17years, burns 23±19%BSA), 79 presented an ENT inhalation injury ≥ENT1 (soot present in 24%): 36 had a tracheobronchial extension, 33 having a grade ≥TB1. Burned vibrissae: 10 patients “without” suffered ENT injury, while 6 patients “with” had no further lesions. Length of mechanical ventilation was strongly associated with the first 24hrs’ fluid resuscitation volume (p<0.0001) and the presence of inhalation injury (p=0.03), while the ICU length of stay was correlated with the %BSA. Soot was associated with prolonged mechanical ventilation (p=0.0115). There was no extubation failure.Conclusions: The developed inhalation score was simple to use, providing a unified language, and drawing attention to upper airway involvement. Burned vibrissae and suspected history proved to be insufficient diagnostic criteria. Further studies are required to validate the score in a larger population.

Changing pattern of fungal infection in burn patients

Sujata Sarabahi, V.K. Tiwari, Savita Arora, Malini R. Capoor, Anurag Pandey — 2011-10-31

Abstract: Invasive fungal burn wound infection is an important emerging cause of late onset morbidity and high mortality in patients with major burns. Following a pilot study done in our unit in 1 year, i.e. January 2008–March 2009 in 71 patients where 28% (20 patients) of the burn wound biopsies from suspected cases showed fungal wound invasion (FWI), a detailed study was planned in order to study the epidemiology of fungal infection in burns in our unit wherein routine wound biopsies in 100 patients were sent on 7th, 14th and 21st postburn day over a one year period (July 2009–June 2010). 12 patients (12%) were diagnosed with FWI on culture. This was then followed by another study in a 9 month period (July 2010–March 2011) when wound samples for only 36 patients in whom there was clinical suspicion of fungal infection were sent. 16 of these patients were diagnosed with fungal wound invasion (FWI) thus establishing an incidence of 44% from suspected cases. These studies showing the increase in fungal infection in our unit have therefore made us wiser, increased our awareness and our accuracy in diagnosing this uncommon infection in extensive burns where patient is not only severely immunocompromised but also has many other risk factors making them more vulnerable to fungal invasion. Another glaring fact which emerged from these studies was the rising incidence of nonalbicans Candida infection compared to Candida albicans, especially C. tropicalis and C. krusei which are more severe in nature and associated with a higher mortality. This signifies that there is a shift of FWI in burns from commensal organism, i.e. C. albicans to pathogenic nosocomial organisms, i.e. C. nonalbicans.

The use of topical, un-buffered sodium hypochlorite in the management of burn wound infection

E. Coetzee, A. Whitelaw, D. Kahn, H. Rode — 2011-11-21

Abstract: Background: Burn wound infections are a major cause of morbidity and mortality. The bactericidal action of sodium hypochlorite has been known for centuries and it has been in clinical practice for over 70 years. Whereas a buffered sodium hypochlorite solution is not universally available, an un-buffered solution is cheap and easy to prepare.Aim: The aim of this study was to determine the optimum concentration with regard to safety and efficacy, as well as shelf life of an un-buffered sodium hypochlorite solution for the topical management of burn wound infections.Methods: Human fibroblasts were exposed to serial dilutions of un-buffered sodium hypochlorite solutions for 30min and assessed for viability. Isolates of Pseudomonas aeruginosa, Staphylococcus aureus and Streptococcus pyogenes were exposed to the same dilutions of un-buffered sodium hypochlorite to establish the minimum bactericidal concentration. The pH, osmolality and electrolyte concentrations were measured. These experiments were repeated with solution stored at room temperature for 6 consecutive days.Results: 24% of fibroblasts were viable after exposure to a 0.025% solution and 98.9% with a 0.003% solution. The MBC for the P. aeruginosa isolates was 0.003%, for S. aureus was 0.006% and for S. pyogenes was 0.0015%. This remained constant for 6 consecutive days. The un-buffered 0.0025% solution has a pH of 10, an osmolality of 168 sodium concentration of 89mmol/dl and chloride of 84mmol/dl. This remained stable for 14 days.Conclusions: An un-buffered solution of sodium hypochlorite with a concentration of 0.006% would be suitable for the topical management of burn wound infections caused by common pathogens. It has a shelf life of at least 6 days.

MicroRNA profiling in denatured dermis of deep burn patients

2012-02-23

Abstract: Background: Denatured dermis is a part of the dermis in deep burn wound and has the ability to restore normal morphology and function. Skin grafting with the preservation of denatured dermis is a new kind of surgical procedure and has reported satisfactory clinical effects, such as lessened scar contracture and a better restoration of the appearance and function. However, the underlying mechanism of the recovery of denatured dermal function remains unclear. MicroRNAs (miRNAs) are a new class of regulatory noncoding single-stranded RNAs, which play a key role in normal development and physiology, as well as in disease development. This study analysed the profile of miRNAs in denatured dermis from patients and further investigated the possible roles of miRNAs played in the functional recovery of denatured dermis by prediction of the potential target genes of differentially expressed miRNAs.Methods: The denatured dermis and paired normal skin were collected and analysed by miRNA array. The miRNA profiling results were validated by real-time reverse transcriptase polymerase chain reaction (RT-PCR), and bioinformatics’ analysis was employed to further predict the miRNA targets.Results: A total of 66 miRNAs were differentially expressed in denatured dermis compared with those in normal skin, among which 34 were down-regulated while 32 are up-regulated. The most significantly up-regulated miRNA was miR-663, and the most significantly down-regulated one was miR-203. Differentially expressed miRNAs were predicted to be related with several signalling pathways in wound healing.Conclusion: The differential miRNA expression identified in this study supplies experimental basis for further understanding the mechanisms of functional recovery of the denatured dermis.

Improved skin wound epithelialization by topical delivery of soluble factors from fibroblast aggregates

2011-11-23

Abstract: Introduction: Timely coverage of an excised burn wound with a split-thickness skin graft, and efficient epithelialization at the donor site wound are key components in the treatment of burn patients. Prompt healing is dependent on paracrine support from underlying dermal connective tissue fibroblasts.Study aim: Using the skin graft donor site in pig as a model for epithelialization, our aim was to evaluate if dermal signals, derived from cultured dermal fibroblast aggregates (Finectra), can promote epidermal regeneration.Materials and methods: Partial-thickness skin wounds were made with a dermatome on the backs of three domestic pigs. After randomization, topical treatment was initiated by application of Finectra (n=6) or factors from standard fibroblast monolayer cultures (n=6) trapped in a slow-clotting fibrin matrix. Saline was applied to contralateral wounds to serve as corresponding untreated controls (n=12). After 3 days, full-thickness skin samples representing the whole wound area were obtained. Histological sections of these samples were analyzed for epithelialization, cell migration from lateral wound edges and hair follicles, as well as for formation of granulation tissue.Results: In response to topical delivery of Finectra, a significant acceleration of epithelialization (p<0.001) across the wound surface as well as from the wound edges was evident. Marked increase in thickness of granulation tissue (p<0.001) was noted in wounds treated with Finectra. Epihelialization originated from adnexal structures in which epithelial islets showed positive staining for cytokeratin-14 and PCNA.Conclusion: These data show that the fibroblast aggregate-derived paracrine mediators, Finectra, stimulate epidermal regeneration in vivo.

Ethnic differences in burn mechanism and severity in a UK paediatric population

Kian Tjon Tan, Phoebe M. Prowse, Sian Falder — 2011-11-14

Abstract: Background: Burns in children are a major public health problem with long-lasting physical and psychological sequelae. Previous studies have identified that children from ethnic minorities have higher rates of burns.Objective: The purpose of this study was to analyse the differences in paediatric burn mechanism and severity within different ethnic groups.Methods: Demographic and burn data from all paediatric patients presenting with burn at the Burns Service, Alder Hey Children's NHS Foundation Trust, Liverpool, UK were collected over a 5 year period.Results: 766 paediatric patients (age range: 7 days to 16 years old, mean: 4.5 years) were included in the study. Ethnic minority children had higher total body surface area of burn (p<0.001) and length of stay (p<0.001) compared with non-ethnic minority children. Chinese children had most burns from hot food (60%), whereas non-ethnic minority children had most burns from hot beverages (35.8%). Ethnic minority children were more deprived compared with non-ethnic minority children (Index of Multiple Deprivation 48.7 vs. 40.9; p=0.02).Conclusion: These results show that there are significant differences in the patterns of burns in ethnic minority groups. This data should guide targeted public health prevention and educational strategies.

Family function and social support in Iranian self-immolated women

2011-11-11

Abstract: Aim: The significance of family function and social support in Iranian self-immolated women was investigated in this study.Methods: In a prospective design, we selected 53 cases (31 self-immolated women and 22 women with unintentional burn) from Tehran and Shiraz burn centre (Motahari and Ghotbeddin Shirazi, respectively). The average age of the experimental group was 26.19 (S=7.11) with a burn percentage of 46.11 (S=25.52), and the average age of the control group was 29.15 (S=5.12) and their burn percentage was 43 (S=25.98). Along with Demographic Information Questionnaire, participants were administered Family Assessment Device (FAD) and Social Support Scale (SSS). To analyse data, we used chi-square test (χ2), t-test, multivariate analysis of variance (MANOVA) and also logistic regression analysis.Results: Data showed that the difference of Family Function sub-scales between the experimental and control groups was not significant (Wilk's lambda=0.75, F=1.67, df=(8, 51), P<0.05). On the other hand, two independent sample t-tests showed a significant difference of Social Support between the two groups (t=–3.31, df=51, P<0.002).Conclusions: Consistent with previous studies, this research showed that the less Social Support one perceives the more one at risk for self-immolation. Although the mean scores of FAD sub-scales in control group were more than experimental group, there was no significant difference between the two groups.

Secondary abdominal compartment syndrome in patients with toxic epidermal necrolysis

2011-11-10

Abstract: Introduction: Secondary abdominal compartment syndrome (ACS) is a severe complication in patients admitted to burn intensive care units (BICUs). Unlike patients with thermal burns, patients with toxic epidermal necrolysis (TEN) present with a different pathophysiology and usually require less fluid.Patients and methods: We reviewed our registry of adult patients presenting with TEN in our 8-bed BICU over the course of 11 years and identified and analyzed patients treated for ACS and decompressive laparotomy (DL).Results: From a total of 29 patients with bioptic confirmed TEN, 5 underwent DL due to ACS with a mean age of 57 years, mean percentage of total body surface area (TBSA) affected of 54±25%, complete epidermolysis of 28±24% TBSA, a mean severity of illness score (SCORTEN) of 3.8±0.8, and a mean intra-abdominal pressure before DL of 33±7mmHg. Mortality was 100% in patients with ACS versus 33% without ACS.Conclusion: An ACS that requires DL worsens the already critical condition of a TEN patient considerably. TEN-related impaired intestinal functionality and increasing intestinal edema due to systemic capillary leakage warrant early initiation of intra-abdominal pressure monitoring to identify patients at high risk of ACS.

Epidemiological studies of electrical injuries in Shaanxi Province of China: A retrospective report of 383 cases

2011-11-21

Abstract: A statistical survey was conducted at the Burn Unit of the Tangdu Hospital, Shaanxi, China, during the 10-year period from January 2000 to December 2009. In this retrospective study, 383 patients who admitted to our burn unit because of electrical trauma were included. Data including the patient's general condition, clinical presentation, complications and operation times was collected retrospectively and analyzed with epidemiological methods. Subjects in our collective were predominantly male (90.3%, n=346/383) and were composed by those who injured in work-related incidents (78.3%, n=300/383), rural individuals (58.2%, n=223/383) and students (9.4%, n=36/383). High voltage was directly correlated to severity clinical complications, and amputation. The percentage of myocardial impairment was 79.3% (n=92/116) among patients who suffered with electrical current through heart tissue. Along with the more developed east area of China, electrical injuries are becoming a growing concern of the developing West part in China as well. Electrical injuries induce serious tissue damage, need long hospital stay, and result in high rate of permanent disability and economic hardship for the afflicted families. A competent prevention program needs to be developed to address this problem.

A novel option in negative pressure wound therapy (NPWT) for chronic and acute wound care

2011-11-21

Abstract: Introduction: Negative pressure wound therapy (NPWT) has become a widely accepted technique in treatment of all kinds of wounds. After a long period of clinical application of the V.A.C.™ system (KCI Inc., San Antonio, Texas, USA) a number of options for delivery of NPWT are now commercially available. An urgent need exists for evidence demonstrating clinical efficacy of these new devices to support clinicians regarding their choice of NPWT.Methods: 42 patients with an acute or chronic wound were randomly assigned to either treatment by V.A.C.™ (group A) or therapy with an alternative newly available polyurethane foam-based NPWT system (RENASYS GO™ – F/P, Smith & Nephew GmbH) (group B). In both groups NPWT was applied after surgical debridement to prepare the wound bed for skin grafting. After skin grafting NPWT was applied additionally to secure skin grafts and improve grafts survival. Primary outcome measures were the time to complete healing (days) and duration of the NPWT application (days). Secondary outcome measures were the number of dressing changes and reported complications. In addition, we evaluated the cost-benefit in the clinical implementation.Results: There were no significant differences comparing the investigated parameters between both groups. Especially average time to complete healing and average time NPWT was applied did not differ (p>0.05). No complications occurred in either group. By an almost identical supply agreement of both providers for our hospital RENASYS™ system appeared to be more cost-effective.Conclusion: After a long period of preserving a monopoly market position of the V.A.C.™ system, a new comparable option was successfully tested in this preliminary study. The polyurethane foam-based NPWT system (RENASYS GO™ – F/P, Smith & Nephew GmbH) is an efficient and cost-effective alternative NPWT system, which we effectively implemented in therapeutic management of different kinds of wounds.

30 years of burn disasters within the UK: Guidance for UK emergency preparedness

C.W.M. Horner, E. Crighton, P. Dziewulski — 2011-12-06

Abstract: Aim: To review casualty profiles of major UK burn disasters over the last 30 years in order to provide guidance to aid burn and emergency service planning and provision so as to improve emergency preparedness for future national disasters.Methods: A review of published literature was undertaken for disasters within the UK that had occurred between 1980 and 2009. Those producing 10 or more casualties with at least one sustaining cutaneous burns injuries were included. Frequency and extent of burns were recorded and analysed.Results: In total 37 disasters were included in this study, their frequency of occurrence falling over the 30 years reviewed. Burns tended to make up a small proportion of all casualties and were often relatively small in size with only 3 disasters having more than 5 patients with >10% burns.Discussion: This paper can help guide appropriate staffing and bed capacity planning for regional burns units and provide realistic figures to guide scenarios for national emergency training exercises. Due to the infrequent nature of major disasters, Critical Care, Trauma Care and Burn Care Networks will all need to be closely integrated and their implementation rehearsed so as to ensure optimal response to a major national disaster.

Perceptions of tap water temperatures, scald risk and prevention among parents and older people in social housing: A qualitative study

Mary Alison Durand, Judith Green, Phil Edwards, Sarah Milton, Suzanne Lutchmun — 2011-11-21

Abstract: Background: Young children and older people are particularly vulnerable to tap water scalding. For children, there are also socio-economic inequalities in risk. Evidence suggests that reducing tap water temperatures in social (public) housing through ‘passive’ means is effective in reducing risk. However, little is known about parents’ or older people's perceptions of scald risk and prevention.Objectives: This study aimed to document the views of parents and older residents in social housing in an inner-London borough about their tap water temperature, perceived scalding risk and scald prevention strategies.Methods: Analysis of twenty in-depth interviews with 11 parents and 10 people aged 65 years or older.Results: Tap water was described as very hot, but participants did not consider themselves at risk, viewing scald prevention as a personal responsibility achieved with a range of everyday, routine strategies. Very hot water was preferred for health- and convenience-related reasons. However, it was felt that others, particularly children, could be scalded, and some concern was expressed about the environmental and financial impacts of excessively hot water.Conclusions: Those seeking to introduce engineering-based scald prevention interventions in social housing should emphasise the potential environmental and financial impacts of water temperature reduction, in addition to promoting safety benefits for vulnerable others.

Urban compared with rural and remote burn hospitalisations in Western Australia

Janine Duke, Suzanne Rea, James Semmens, Fiona Wood — 2011-11-21

Abstract: Aim: To compare the incidence, temporal trends and cause of burn hospitalisations between urban, rural and remote regions in Western Australia, 1983–2008.Methods: De-identified linked hospital morbidity and mortality records for all persons hospitalised for an index burn in Western Australia were analysed 1983–2008. Annual age-specific incidence and age standardised rates were estimated. Poisson regression analyses were used to estimate temporal trends in hospital admissions by urban, rural and remote region.Results: Of 23,450 burn-related hospital admissions 1983–2008, 14,007 (59.7%) were in urban, 5442 (23.1%) rural and 4021 (17.2%) remote hospital regions. Hospitalisation rates were higher in rural (Incidence rate ratio (IRR), 95% CI: 1.5, 1.4–1.6) and remote (IRR, 95%C: 2.1, 2.0–2.2) regions compared to urban. Age-standardised rates of burn hospital admissions declined from 1983 to 2008 for each region with 26-year declines of 56% (95% CI: 51–60) for remote, 71% (95% CI: 68–73) for rural, and 9% (95% CI: 4–14) for admissions in urban regions. Scald was the most common cause for urban admissions while flame the most common cause for rural and remote burn admissions.Conclusions: Significant differences in the incidence, and cause of burn were identified between urban, rural and remote regions in Western Australia.

Differential expression of the immunoinflammatory response in trauma patients: Burn vs. non-burn

2011-11-21

Abstract: Rationale: Cytokines are central mediators of the immune-inflammatory response to injury and subsequent multiple organ dysfunction syndrome (MODS). Although previous studies evaluated cytokine levels after trauma, differences between patients with burn and non-burn trauma have not been assessed systematically.Methods: A prospective database of trauma patients admitted between May 2004 and September 2007 to the burn or surgical intensive care units within 24h of injury with an anticipated stay of at least 72h was analyzed. Sequential clinical and laboratory parameters were collected in the first week, including multiplex analysis data for plasma levels of inflammatory cytokines (IL-6, and IL-8). Patients with known pre-injury coagulopathy were excluded. A Marshall score of 10 or greater was defined as MODS.Results: A total of 179 patients were enrolled (67 burn and 112 non-burn). Plasma IL-6 and IL-8 levels were markedly elevated in both burn and non-burn patients compared to healthy volunteers. Burn subjects had higher levels of IL-6 and IL-8 than the non-burn on days 1 through 7 after injury. Subjects with burns and at least 30% total body surface area were older and had a lower injury severity score, a higher prevalence of MODS, and correspondingly higher mortality. Multivariate analysis of injury type, MODS, and time did not demonstrate an influence of MODS.Conclusions: Burns were associated with a greater and more sustained immune-inflammatory response than non-burn trauma as evidenced by elevated plasma IL-6 and IL-8 levels during the first week. There was no association between MODS and plasma cytokine levels.

The effect of exercise training on pulmonary function and aerobic capacity in adults with burn

T.L. Grisbrook, K.E. Wallman, C.M. Elliott, F.M. Wood, D.W. Edgar, S.L. Reid — 2012-02-20

Abstract: Purpose: Pulmonary function (PF) is compromised in some individuals following burn, which may result in impaired aerobic capacity. Exercise training improves PF and exercise capacity in children recovering from burns, yet it is unknown if adults will demonstrate the same response.Procedures: 9 burn injured participants (%TBSA 42 ±18.38, 6.56 years ±3.68 post injury) and 9 matched controls participated in a 12-week goal directed interval training and resistance exercise programme. PF was measured using spirometry, and a graded exercise test quantified peak oxygen consumption , both prior to and following the exercise training. The Canadian Occupational Performance Measure assessed the participant's goal attainment.Results: Burn injured participants had significantly lower PF (FEV1/FVC ratio) than the healthy controls both prior to and following the exercise intervention (F(1,16)=8.93, p=0.009). Exercise training did not improve PF in either group, however both groups had a significant improvement in their , maximal minute ventilation, and work achieved on a graded exercise test (F(1,16)=19.325, p<0.001), (F(1,16)=51.417, p<0.001) and (F(1,16)=36.938, p<0.001), respectively, following the exercise training. All participants achieved their occupational performance goals.Conclusion: Although the exercise training did not alter PF, both aerobic capacity and occupational performance were improved.

Unusual coverage of postburn sequela of the scalp using a combined free forearm and tubed abdominal flap

Nicolae Antohi, Vitalie Stan — 2012-02-20

Reconstruction of the extensive defect of the scalp associated with bone defect constitutes a primary indication for free flap transfer. However, the main difficulties in considering this type of reconstruction could be unavailability of appropriate donor sites and absence of suitable vessels for microvascular anastomoses in the recipient area. In such a situation, the surgeon is faced with diminished number of options for reconstruction, and the solution to solve the particular case could come even from the “surgical archives”. In this case report we describe a combination of the two oblique abdominal tube flaps with a free radial forearm flap, transferring them as a single complex of tissues to the scalp.

Chemistry experiments with elemental metals – Fuel for the minds, formula for disaster?

Isabel Teo, Krishna Rao, Wee Leon Lam, Robert H. Caulfield — 2012-02-20

We would like to highlight the need for safety provision and training regarding burns first aid in schools where experiments are conducted with elements like sodium and potassium. This was felt necessary after a 15 year old male student presented to Sheffield Children's Hospital with burns following exposure to elemental potassium.

Post-burn non-emergent hair in the male moustache area

Sue Royston, Eunan Tiernan, Philip Wright — 2012-02-23

A possible outcome of a burn to the beard or moustache area in men is a reduction in hair growth. Where this is caused by the destruction of entire hair follicles it is primarily an aesthetic concern. If the damage is more superficial, then any hairs continuing to be produced may not emerge through the scarred skin and can be a cause of considerable discomfort. As far as we are aware this latter outcome has not previously been discussed in the literature.

Cryopreserved human skin allografts: Viability and delay of rejection in severely burned patients

Sonia Gaucher, Mohamed Jarraya — 2012-02-23

In case of extensive burns, human skin allograft rejection is delayed as a consequence of the immunodepression induced by burn injury. Nevertheless, rejection delay is not only linked to the recipient, but also related to skin preservation modalities. Thus, allografts could be cryopreserved, stored at +4°C or glycerol-preserved with high density of glycerol. Depending on the modalities, it is possible to divide allografts into two categories: viable (i.e. allografts cryopreserved or stored at +4°C) and non-viable (i.e. glycerol-preserved allografts). Skin viability can be tested by various methods, including the MTT (3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyltetrazolium bromide) assay, a metabolic assay for which reproducibility and reliability have been successfully reported .

A call for evidence: Timing of surgery in burns

M.J. Hop, C.J. Hoogewerf, M.E. van Baar, C.H. van der Vlies, E. Middelkoop — 2012-03-14

Despite the progress in burn care, there is still no worldwide consensus on the best timing of surgery in burns. In some countries, for example the United Kingdom (UK), early excision and grafting is well accepted, while in other countries, like the Netherlands, delayed excision and grafting is the usual approach. This difference was the topic of a “battle” between two burn surgeons: A. Kay, Royal Centre for Defence Medicine (UK) and G.I.J.M. Beerthuizen, Martini Hospital Groningen (The Netherlands), organised at the European Burn Association Congress in The Hague on September 24th, 2011.

Jose Pablo Sterling — 2012-03-19

Burns is a great book for surgeons, burn team members, and novices of burn care. It provides clear and practical fundamentals of clinical burn care. Whereas, most burn care text are written by multiple contributing authors, sometimes providing conflicting information. Dr. Sheridan, ensuring a clear message and guidance, solely wrote Burns.