Burns - Articles in Press

Response to Letter to the Editor: ‘Photography and the mobile phone camera: A good method for burn depth analysis with implications for remote assessment’ - Corrected Proof

David Boccara, Marc Chaouat, Cindy Uzan, Anne Lacheré, Maurice Mimoun — 2012-02-22

The use of numeric photography is a very interesting tool to diagnose burn depth and will probably be more and more used in the future . In our study, we showed that while photographic evaluation has certain limits, it nevertheless remains relatively reliable. It is of interest because of the possibilities for sharing and distribution.

Complex chemical burns following a mass casualty chemical plant incident: How optimal planning and organisation can make a difference - Corrected Proof

Tomás B. O’Neill, Jeremy Rawlins, Suzanne Rea, Fiona Wood — 2012-02-22

Abstract: Introduction: Four employees at a chemical plant sustained extensive chemical burns following the explosion of a pipeline containing 100% sulphuric acid. We describe the management of these patients from the initial ED triage through to discharge from hospital in life and limb threatening chemical burns.Methods: Four patients who sustained chemical burns to the torso and extremities are reviewed. Data was retrieved from patient case notes and operating theatre logbooks.Results: Four patients sustained chemical burns during the blast and were immediately transferred to a local ED where a prompt referral was made to the burns service. All patients were male aged 25–59 years (mean 46.5). Burn size was 2–50% BSA (mean 22.5). Following RFDS transfer to the state burns service two patients required immediate excisional surgery. In these patients the chemical burn involved full thickness skin loss with extensive underlying muscle and neurovascular damage. One patient required immediate above knee amputation of one leg and fascial burn excision of the other. The other patient required fascial burn excision of both legs followed by Integra placement 24h later. Both patients had prolonged hospital stays due to the complex nature of their injuries requiring multiple trips to theatre and lengthy rehabilitation. The two patients with smaller burns had straightforward surgery and an unremarkable recovery.Conclusion: Early communication following this mass casualty incident allowed for organisation of tertiary services and early radical surgery which was life saving. Management lessons were learnt following this mass casualty chemical burn incident.

The epidemiology of pediatric burns undergoing intensive care in Burn Centre Brno, Czech Republic, 1997–2009 - Corrected Proof

2012-02-22

Abstract: The aim of this study was to determine the basic epidemiological characteristics of severely burned children who were admitted to the intensive care unit (ICU), Department of Burns and Reconstructive Surgery Faculty Hospital Brno, Czech Republic in the years 1997–2009.Methods: We collected and evaluated epidemiological data such as age, sex, burn etiology, length of hospitalization, duration of the ICU stay, surgical or conservative therapeutic strategies, the use of mechanical ventilation and its duration, day and month of injury and the extent of burned area.Results: In total 383 children (253 boys, 130 girls) aged 0–14 years, underwent intensive care for at least 48h. Male to female ratio was 1.95:1. The average range of burn area in the group was 16.43±12.86% TBSA (total body surface area). During the reporting period, 16 children were admitted with burns over 50% TBSA. 328 children suffered burns indoors, with 55 children being burned outdoors. Indoor/outdoor ratio was set at 5.96:1. The most frequent etiological agent was scalding (hot water, soup, coffee, oil, tea). The total number of scalded children in this group was 312 (81.46%). Mechanical ventilation was used in 96 cases (25.07% of all the admitted patients). The duration of mechanical ventilation in these patients was 8.03±5.67 days in average. The average length of stay in ICU was 10.71±10.92 days and total length of hospital stay was an average of 21.55±14.55 days. A total of 184 patients (48.04%) were treated surgically and therefore required necrectomy and skin grafting. The other 199 (51.96%) patients were treated conservatively. During the reporting period 3 children died (0.78%).Conclusion: In our report we identify basic epidemiological data defined in the aim of this study for burned children requiring intensive care.

Lycopene inhibits caspase-3 activity and reduces oxidative organ damage in a rat model of thermal injury - Corrected Proof

2012-02-22

Abstract: Oxidative stress has been implicated in various pathological processes including burn induced multiple organ damage. This study investigated the effects of lycopene treatment against oxidative injury in rats with thermal trauma. Under ether anesthesia, shaved dorsum of the rats was exposed to 90°C bath for 10s to induce burn and treated either vehicle (olive oil) or lycopene (50mg/kg orally). Rats were decapitated 48h after injury and the tissue samples from lung and kidney were taken for histological analysis and the determination of malondialdehyde (MDA) and glutathione (GSH) levels, myeloperoxidase (MPO), superoxide dismutase (SOD), catalase (CAT) and caspase-3 activities. Proinflammatory cytokines, TNF-α and IL-1β, were assayed in blood samples. Severe skin scald injury caused a significant decrease in GSH levels, SOD and CAT activities, and significant increases in MDA levels, MPO and caspase-3 activities of tissues. Similarly, plasma TNF-α and IL-1β were elevated in the burn group as compared to the control group. Lycopene treatment reversed all these biochemical indices. According to the findings of the present study, lycopene possesses antiinflammatory, antiapoptotic and antioxidant effects that prevents burn-induced oxidative damage in remote organs.

Distribution of Ambler class A, B and D β-lactamases among Pseudomonas aeruginosa isolates - Corrected Proof

2012-02-21

Abstract: Objectives: We determined the prevalence rate of classes A, B and D β-lactamases among extended-spectrum cephalosporin (ESC)-non-susceptible Pseudomonas aeruginosa clinical isolates from burned patients.Methods: Disc susceptibility testing was performed on 156 P. aeruginosa isolates collected during 2010 at Prince Salman Hospital in Riyadh, Saudi Arabia. Phenotypic screening of ESBLs and MBLs in the isolates resistant to ceftazidime (MIC>8mg/L) was carried out. Genes encoding ESBLs and MBL were sought by PCR in ESBL- and MBL-producing isolates.Results: The resistance rate to ceftazidime was 22.43%. The resistance rates for ESC-non-susceptible P. aeruginosa isolates to piperacillin, piperacillin/tazobactam, cefepime, aztreonam, imipenem, amikacin, gentamicin and ciprofloxacin were 100%, 71.14%, 88.57%, 48.57%, 70.0%, 82.5%, 87.5%, and 90.0% respectively. No resistance was detected to polymyxine B. The prevalence of ESBL and MBL in ESC-non-susceptible P. aeruginosa was 69.44% and 42.85%, respectively. The prevalence of structural genes for VEB-1, OXA-10 and GES ESBLs in P. aeruginosa was 68%, 56% and 20%, respectively. VIM gene was detected in 15 (100%) of MBL-producing isolates. OXA-10 like gene was concomitant with VEB, GES and/or VIM. Eight isolates harbored OXA-10 with VEB (imipenem MIC 6–8mg/L), while five isolates harbored OXA-10 with VIM (imipenem MIC≥32mg/L) and one isolate contained OXA-10, VEB and GES (imipenem MIC 8mg/L). PER was not detected in this study.Conclusion: VEB-1 and OXA-10 are the predominant ESBL genes and blaVIM is the dominate MBL gene in ESC-non-sensitive P. aeruginosa isolates in Saudi Arabia. VEB, OXA-10 and GES ESBLs have not been reported previously in Saudi Arabia and GES has not been reported previously in Middle East and North Africa.

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

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.

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

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.

Characteristics of fatal and hospital admissions for burns in Fiji: A population-based study (TRIP Project-2) - Corrected Proof

2012-02-20

Abstract: Background: Over 95% of burn deaths are estimated to occur in low-and-middle-income countries. However, the epidemiology of burn-related injuries in Pacific Island Countries is unclear. This study investigated the incidence and demographic characteristics associated with fatal and hospitalised burns in Fiji.Methods: This cross-sectional study utilised the Fiji Injury Surveillance in Hospital database to estimate the population-based incidence and contextual characteristics associated with burns resulting in death or hospital admission (≥12h) during a 12-month period commencing 1st October 2005.Results: 116 people were admitted to hospital or died as a result of burns during the study period accounting for an overall annual incidence of 17.8/100,000 population, and mortality rate of 3.4/100,000. Most (92.2%) burns occurred at home, and 85.3% were recorded as unintentional. Burns were disproportionately higher among Fijian children compared with Fijian–Indian children with the converse occurring in adulthood. In adults, Indian women were at particularly high risk of death from self-inflicted burns as a consequence of ‘conflict situations’.Conclusion: Burns are a significant public health burden in Fiji requiring prevention and management strategies informed by important differences in the context of these injuries among the major ethic groups of the country.

Risk factors of burns among children in Mongolia - Corrected Proof

Tseren-Ochir Khandarmaa, Md. Harun-Or-Rashid, Junichi Sakamoto — 2012-02-20

Abstract: Burn is one of the leading causes of under-5 childhood injuries. Identification of risk factors and awareness level of caregivers could help reduction of burn-related morbidity. The objectives of this study were to identify general perceptions of risk factors of childhood burns, prevalence of burns among under-five Mongolian children, and to assess knowledge and practice of burn care and care seeking behaviors for care givers of those children. A household-based cross-sectional survey was conducted from September to October 2010 including 865 households with 1154 under-5 children. Data were collected by face-to-face interview using semi-structured questionnaire. Of total 1154 children, 291 (25.2%) had burn injury in their life-time. Above half of them had suffered a scald. Majority of burns occurred at home and urban children were at higher risk. The age up to 36 months, boys, and fewer children (<3) in the household were found as significant risk factors for childhood burns. Caregivers’ knowledge and practices on childhood burns were generally insufficient; most of them indicated the importance of physical environment at home. We concluded that burns were common among under-5 children, and caregivers’ knowledge and practices on burns was inadequate. Specific interventions like “Caregivers education program” encouraging safe domestic environmental conditions should be undertaken to increase their awareness on burn-related issues to reduce childhood burns in Mongolia.

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

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.

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

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.

Virtual reality for acute pain reduction in adolescents undergoing burn wound care: A prospective randomized controlled trial - Corrected Proof

Belinda Kipping, Sylvia Rodger, Kate Miller, Roy M. Kimble — 2012-02-20

Abstract: Background: Effective pain management remains a challenge for adolescents during conscious burn wound care procedures. Virtual reality (VR) shows promise as a non-pharmacological adjunct in reducing pain.Aims: This study assessed off-the-shelf VR for (1) its effect on reducing acute pain intensity during adolescent burn wound care, and (2) its clinical utility in a busy hospital setting.Methods: Forty-one adolescents (11–17 years) participated in this prospective randomized controlled trial. Acute pain outcomes including adolescent self-report, nursing staff behavioral observation, caregiver observation and physiological measures were collected. Length of procedure times and adolescent reactions were also recorded to inform clinical utility.Results: Nursing staff reported a statistically significant reduction in pain scores during dressing removal, and significantly less rescue doses of Entonox given to those receiving VR, compared to those receiving standard distraction. For all other pain outcomes and length of treatment, there was a trend for lower pain scores and treatment times for those receiving VR, but these differences were not statistically significant.Conclusion: Despite only minimal pain reduction achieved using off-the-shelf VR, other results from this trial and previous research on younger children with burns suggest a customized, adolescent and hospital friendly device may be more effective in pain reduction.

Late-onset rabdomyolysis in burn patients in the intensive care unit - Corrected Proof

Silviu Constantin Badoiu, Carmen Caramitru — 2012-02-20

Dear editor, we read the article of our colleagues from Scotland, concerning the late onset of rabdomyolysis in burn patients, admitted in the intensive care unit . We consider this work to be very interesting as it refines the issue of rabdomyolysis in non-electrically injured severely burned patients .

Lymphatic regeneration in meshed skin grafts - Corrected Proof

C. Hadamitzky, H.O. Rennekampff, R. Pabst, C. Radtke, P.M. Vogt — 2012-02-20

We read with great interest the article written by Meier et al. entitled “Microvascular regeneration in meshed skin transplants after severe burns”. This pioneer study thoroughly analyses the extent of blood capillary and lymphatic regeneration in successfully transplanted meshed skin grafts in eight patients after burn wounds of the deep second and third grades during a period of 18 months follow up. The major question of the study was to understand to which extent the lymphatic and blood capillary microvascular environment play a role in skin graft transplantation and how they evolve with time.

Characteristics of bloodstream infections in burn patients: An 11-year retrospective study - Corrected Proof

2012-02-20

Abstract: Aims: The principal aim of this study was to describe infection related characteristics of blood stream infections (BSI) in patients with burns. We sought to determine the organisms that caused BSI and factors that could predict the outcome of BSI.Methods: Data was collected on admitted patients with burns from January 1998 to December 2008. Selected information from databases was analysed using SPSS version 17 (SPSS Inc., Chicago). Descriptive, univariate and multivariate analysis was undertaken to determine factors predictive of clinical outcome. The factors analysed by univariate analysis were selected on clinical plausibility. Multivariate analysis used a crosstabs procedure initially to estimate maximum likelihood. Factors that were associated with a p value <0.15 were entered into a binary logistic regression to detect which factors were independent predictors of mortality in BSI and outcome according to specific organisms.Results: Ninety-nine out of 2364 (4%) patients developed 212-documented BSI. The median time from burn to BSI was 7 (interquartile range 3–16) days. Gram-positive organisms, in particular Methicillin resistant Staphylococcus aureus and Coagulase negative Staphylococci, were the most common bacteria associated with BSI in the first week of hospital admission. The mortality rate for all admissions over the data collection period was 3%. Of the 99 patients with BSI, 13 died giving a mortality rate, in the presence of BSI, of 13%. Univariate analysis found that the factors predictive of P. aeruginosa mortality were inhalational injury, higher total body surface area burns, total days of antibiotic treatment and elevated Acute Physiological and Chronic Health Evaluation (APACHE) II scores. Multivariate analysis identified inhalational injury to be the only factor associated with BSI-related mortality.Conclusion: Whilst the overall mortality in our cohort was low, the presence of BSI increased this four-fold. Whilst infections caused by Gram-positive pathogens occurred earlier in the patient stay than Gram-negative organisms, the highest mortality was associated with P. aeruginosa infections. This study highlights the negative effects of BSI on clinical outcomes in burn patients.

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

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.

Protective effect of glucose–insulin–potassium (GIK) on intestinal tissues after severe burn in experimental rats - Corrected Proof

2012-02-16

Abstract: Intestinal barrier damage after scald and burns, other trauma or major operations result in severe intestinal infections that cause serious consequences. Therefore, it is important to develop methods to protect intestinal barrier after severe burns. This study used rats that had full-thickness burn of approximately 30% of the total body surface area to investigate the effect and mechanism of glucose–insulin–potassium (GIK) and provide experimental evidence for application of GIK in protecting the intestine after burns or other trauma and major surgeries. The results show that the degree of intestinal damage and plasma diamine oxidase (DAO) levels in GIK (the concentrations of glucose, insulin, sodium chloride and potassium chloride were 100gl−1, 70Ul−1, 9gl−1 and 5gl−1, respectively) and insulin (30IUl−1) treatment groups were significantly lower than that in control group; the status of anti-inflammatory and pro-inflammatory cytokines and the ratio between them in GIK and insulin groups also significantly improved compared to those in control group; intestinal tumour necrosis factor-alpha (TNFα), nuclear factor-kappaB (NF-κB) and interleukin-10 (IL-10) messenger RNA (mRNA) expression and IL10/TNFα in GIK and insulin groups 2 days after the injury were also improved significantly compared to those in control group. All the indices including body weight detected in GIK group were improved to those in insulin group. Taken together, these results show that GIK and insulin show protective effect on intestine after severe burn, which may relate to controlling hyperglycaemia and regulating intestinal expression of NFκB and pro-inflammatory and anti-inflammatory cytokine genes by GIK and insulin; the protective effect of GIK on intestinal tissue after severe burn is superior to that of using insulin alone, which may attribute to improving the nutritional status by glucose supplement and the relatively higher dose of insulin in the GIK group.

The effects of splinting on shoulder function in adult burns - Corrected Proof

Alison M. Kolmus, Anne E. Holland, Martin J. Byrne, Heather J. Cleland — 2012-02-15

Abstract: Introduction: Exercises are commonly prescribed to improve shoulder range following axillary burns, but the effect of additional splinting is unclear.Aim: To compare splinting and exercise to exercise alone in adults with axillary burns.Method: Prospective randomised study allocating participants to a splinting (n=27) or no splinting group (n=25). Outcomes measured at six and twelve weeks were shoulder abduction and flexion range, quality of life using the Burn Specific Health Scale-Brief (BSHS-B) questionnaire and upper limb function using the Upper Extremity Functional Index (UEFI) and the Grocery Shelving Task (GST).Results: At week twelve, there was no difference between groups for shoulder abduction (mean difference 0°, 95% CI −22 to 22°), flexion (mean difference 2°, 95% CI −18 to 23°), BSHS-B (mean difference −2 points, 95% CI −23 to 18 points), UEFI (mean difference −3 points, 95% CI −19 to 14 points) and GST (mean difference −9s, 95% CI −20 to 3s). Adherence to splinting decreased from 77% of participants at week one to 16% at week twelve.Conclusion: Shoulder splints did not improve clinical outcomes in this study population and low adherence rates suggest splinting may be unacceptable to patients and makes drawing firm conclusions difficult.

Simultaneous lightning injury in a group of people: Case report - Corrected Proof

Darius Kubilius, Rytis Rimdeika — 2012-02-15

Previously, no analysis of lightning injuries in Lithuania exists . It is worth mentioning that the frequency of lightning in Lithuania is not high. There are two to six lightning flashes detected per square kilometre during a year in Lithuania . However, mortality from lightning is 0.5 deaths per million population per year in Lithuania . It is possible to presume that considering the frequency of lightning in Lithuania and the density of population, it is comparable with countries having a higher mortality rate from lightning, such as South Africa, for example . The mortality from lightning is an important epidemiological indicator of lightning injuries in Lithuania. However, our aim is to describe a group injury case of lightning, where 16 people were hit by lightning at the same time. Although the majority of lightning injuries pertain to individuals (70%) and group injuries are rare , the latter may serve as a general model of lightning strike injuries.

Burn mortality in Iraq - Corrected Proof

Ari Raheem Qader — 2012-02-13

Abstract: Mortality rates are important outcome parameters after burn, and can serve as objective end points for quality control. Causes of death after severe burn have changed over time. In a prospective study, eight hundred and eighty-four burn patients were admitted to the Burns and Plastic surgery Hospital in Sulaimani–Kurdistan region of Iraq in 2009. Age, gender, nationality, cause of burn, extent of injury, cause of death and mortality rate were tabulated and analyzed, 338 (38.2%) were male and 546 (61.8%) were female. The highest number of cases occurred in January, with the highest short period incidence occurring in April. Out of 884 cases, 260 persons died. Burn injuries were more frequent and larger with higher mortality in females than in males. Flame was the major cause of burns. Self-inflicted burns were noted mainly in young women. A large number of burns which affect children and females, occur in the domestic setting and could have been prevented. Therefore, it is necessary to implement programs for health education relating to prevention of burn injuries focusing on the domestic setting.

A prospective randomised clinical pilot study to compare the effectiveness of Biobrane® synthetic wound dressing, with or without autologous cell suspension, to the local standard treatment regimen in paediatric scald injuries - Corrected Proof

F. Wood, L. Martin, D. Lewis, J. Rawlins, T. McWilliams, S. Burrows, S. Rea — 2012-02-10

Abstract: Background: Scald is the most common cause of burn in children in Australia. The time taken by the burn wound to heal impacts on scar outcome. Commonly scald injuries are treated conservatively; in our unit the practice is that if healing does not occur within 10 days, surgery is used to aid healing with the aim of improving scar outcome. This randomised controlled pilot study compares early treatment regimens to facilitate tissue salvage and reduce the incidence of definitive surgery at 10 days following scald injury.Methods: All paediatric patients with partial thickness scald injury were clinically assessed between July 1, 2009 and June 30, 2010. A burn of 2% TBSAB or more and deemed not to heal within 10 days, were considered for the trial. These patients were randomised to one of three treatment arms: the local standard treatment (Intrasite™, Acticoat™ and Duoderm® dressings every 2–3 days) with surgery at 10 days, Biobrane® only or Biobrane® and autologous cell suspension using the ReCell® kit. The primary outcome was surgery performed after 10 days; secondary outcomes were rates of healing, pain experienced, and scar outcomes.Results: 15% of scald presentations in the 12 month period met the eligibility criteria. 13 patients were recruited into the pilot study; early intervention was associated with a decreased time to healing with fewer dressing changes, less pain and better scar outcomes.Conclusion: Investment of surgical resources in the acute stages within 4 days of injury saved on nursing time, dressing, analgesic and scar management costs.

Epidemiology of burns throughout the World. Part II: Intentional burns in adults - Corrected Proof

Michael D. Peck — 2012-02-10

Abstract: A significant number of burns and deaths from fire are intentionally wrought. Rates of intentional burns are unevenly distributed throughout the world; India has a particularly high rate in young women whereas in Europe rates are higher in men in mid-life. Data from hospitalized burn patients worldwide reveal incidence rates for assault by fire and scalds ranging from 3% to 10%. The average proportion of the body surface area burned in an assault by fire or scalds is approximately 20%. In different parts of the world, attempted burning of others or oneself can be attributed to different motives. Circumstances under which assaults occur fall largely into the categories of interpersonal conflict, including spousal abuse, elder abuse, or interactions over contentious business transactions. Contributing social factors to assaults by burning include drug and alcohol abuse, non-constructive use of leisure time, non-participation in religious and community activities, unstable relationships, and extramarital affairs. Although the incidence of self-mutilation and suicide attempts by burning are relatively low, deliberate self-harm carries a significant risk of death, with an overall mortality rate of 65% worldwide. In those who resort to self-immolation, circumstantial themes reflect domestic discord, family dysfunction, and the social ramifications of unemployment. Preventing injurious burn-related violence requires a multifaceted approach, including legislation and enforcement, education, and advocacy. Better standardized assessment tools are needed to screen for risks of abuse and for psychiatric disorders in perpetrators.

Ankle dorsiflexion postburn scar contractures: Anatomy and reconstructive techniques - Corrected Proof

Viktor M. Grishkevich — 2012-02-10

Abstract: Background: Postburn ankle scar contractures cause functional limitations of all lower extremities and create a serious cosmetic defect, not allowing patients to use normal foot wear, and, therefore, needing surgical reconstruction. The anatomic features of ankle dorsiflexion contractures and their treatment have been covered in the literature far less than other joint contractures, and their treatment is still a challenge for many surgeons. A common treatment method is incisional release of the contracture and defect resurfacing with skin graft. Rarely, distally based sural or free flaps and Ilizarov fixator are used.Methods: Anatomy of postburn ankle scar contractures in 55 patients was studied and contractures were surgically treated using a specific approach and technique. Follow-up results were observed from 6months to 16years.Results: According to the anatomic features, dorsiflexion scar contractures were divided into three types: edge, medial, and total. Edge contractures were caused by burns and scars located on the lateral or medial ankle surface and were characterized by the presence of the fold along the anterior edge ankle; the skin of the anterior ankle surface was not injured. Medial contractures were caused by scars located on the anterior ankle surface and were characterized by the presence of the fold along the medial ankle line. Total contractures were caused by scars tightly surrounding the ankle. In fold's sheets of edge and medial contractures there is a trapeze-shaped surface deficit in length (cause of contracture) and a surface surplus in width which allows contracture release with local trapezoid flaps. For total contractures, wide scar excision and skin grafting were indicated.Conclusion: Three anatomic types of ankle dorsiflexion scar contractures were identified: edge, medial, and total. An anatomically justified technique for edge and medial contractures is trapeze-flap plasty; total contractures are effectively eliminated with scar excision and skin grafting.

Aromatherapy massage seems to enhance relaxation in children with burns: An observational pilot study - Corrected Proof

2012-02-06

Abstract: Objective: This observational pilot study investigated effects of aromatherapy massage in paediatric burn patients.Methods: The setting was a 17 beds level I burn unit in Cape Town, South Africa. Between January and October 2009 heart rates and respiratory rates of patients who underwent aromatherapy massage sessions were read before and after the sessions. Primary outcomes were decline in heart rates and respiratory rates, a sign of relaxation. Behavioural responses (sleep/awake state, facial expression, body posture) were documented as secondary outcomes.Results: A convenience sample of 71 paediatric burn patients (median age 3 years) underwent a total of 126 massage sessions. Mean heart rate decreased significantly from 118 (SD 20) to 109 (SD 21), t=9.8, p<0.001. Mean respiratory rate decreased significantly from 34 (SD 8) to 30 (SD 8), t=10.2, p<0.001. Most massage sessions (92.8%) elicited positive behaviour to the massage, e.g. the child fell asleep, calmed or asked to continue. Nine patients (7.2%) with a median age of 15 months who underwent a single massage session did not show positive behaviour but cried, wriggled or were distressed.Conclusions: Aromatherapy massage seems to be a helpful nonpharmacological approach to reduce hospitalized paediatric burn patients’ distress. Future studies with better research designs and validated outcome measures should confirm our findings.

Early depth assessment of local burns by videomicroscopy: A novel proposed classification - Corrected Proof

2012-01-27

Abstract: Purpose: Videomicroscopy is very useful for burn depth assessment in an early phase; however, there is no practical classification that includes complicated anatomic, pathologic, and morphologic findings of burn wounds.The aim of this study was to propose a novel classification to assess burn depth in its early phase easily and reliably by videomicroscopy.Methods: Forty-four patients with 56 intermediate-depth burn wounds were included. Burn depth was divided into each grade according to our proposed classification, which is composed of five categories based on dermal capillary integrity patterns. The intrarater and interrater reliabilities of the assessment by the second and third authors were evaluated by Cohen's unweighted κ-value.Results: The results of the measurements according to the proposed classification showed an accuracy of 92.9%, sensitivity of 81.8%, and specificity of 100.0%.The intrarater reliability of the second and third authors showed substantial agreement (κ=0.719 and 0.729, respectively). The interrater reliability of the sum of each observer's variable also showed substantial agreement (κ=0.636).Conclusion: This pattern analysis system is easy to use even for inexperienced personnel, and is reliable with high accuracy and specificity. Intrarater and interrater statistics also support its reliability and reproducibility.

Post burn pruritus—A review of current treatment options - Corrected Proof

2012-01-16

Abstract: Post burn pruritus is a well recognised symptom in almost all burn patients. Yet, there is insufficient awareness about the etiopathogenesis and a lack of a systematic approach in the assessment and treatment of this distressing symptom. The current standard therapies include antihistamines, which are effective as sole therapy in only 20% patients, and emollients. There is a lacunae of clear consensus on the care of patients not responding to antihistamines. We review the literature on the etiology and pathogenesis of post burn pruritus, which has both central and peripheral pathways. The published studies on the currently available therapeutic options to treat itch in burns are discussed. On the basis of current evidence in literature, gabapentin used in the treatment of neuropathic pain, has demonstrated great promise, and is suggested as the next option for this subset of patients, not relieved with antihistamines.

Issues to address in burn care for ethnic minority children: A qualitative study of the experiences of health care staff - Corrected Proof

J. Suurmond, J. Dokter, N. Van Loey, M.L. Essink-Bot — 2012-01-13

Abstract: Introduction: Numerous studies have shown that ethnic minority children in the developed world are at greater risk of sustaining burns compared to children from non-ethnic minority backgrounds. However, little is known about the experiences of hospital health care staff with ethnic minority children and parents. A qualitative interview study was conducted to gain more insight into burn care for ethnic minority children and the potential challenges this presents.Methods: Semi-structured interviews on burn care for ethnic minority children were conducted in 2009 with health care staff (N=17) working in two burn centers in the Netherlands. Interviews were transcribed and analyzed using a framework method.Results: Health care staff identified the following issues in burn care for ethnic minority children and their parents: (1) linguistic barriers to communication with parents about pressure garments, dressing changes, skin grafting procedures, and psychosocial support; (2) biological/genetic features of differing pigmentation of skin and skin healing; (3) cultural differences between parents and health care staff; (4) insecurity or irritation about linguistic and cultural barriers.Conclusions: Burn health care staff should have knowledge of biological/genetic features of dark skin, awareness of cultural differences, and transcultural communication skills to deliver culturally competent care tailored to the needs of ethnic minority children and their parents.

Evaluation of wound healing activities of kefir products - Corrected Proof

2012-01-12

Abstract: Kefirs are natural probiotic compounds with antibacterial and anti-inflammatory properties which were tested in experimental burn injury. Kefir gels were prepared from an extract of continuously cultured kefir grains in MRS Broth medium for 24, 48 and 96h. Similar burn injuries were made on dorsal skin surface of 56 rats. After 24h the wounds were infected with Pseudomonas aeruginosa. The infected rats were divided in to 7 groups of 8 rats each. The base gel, silver sulfadiazine ointment, kefir 24h gel, kefir 48h gel, kefir 96h gel and kefir grains 96h gel were applied twice a day. Burn wound area was measured at baseline, one and two weeks. After two weeks the animals in all groups were sacrificed and whole skin wound areas were removed and percentage of epithelization, scar formation, inflammation and angiogenesis were evaluated. Results indicated that at the end of the 2nd week the percentage of wound size were lowest in order of kefir 96h gel

Skin burns after laser exposure: Histological analysis and predictive simulation - Corrected Proof

Nathanaëlle Museux, Laetitia Perez, Laurent Autrique, Diane Agay — 2012-01-12

Abstract: Thermal effects of laser irradiation on skin are investigated in this paper. The main purpose is to determine the damage level induced by a laser exposure. Potential burns induced by two lasers (wavelength 808nm and 1940nm) are studied and animal experimentations are performed. Several exposure durations and laser powers are tested. Based on previous works, a mathematical model dedicated to temperature prediction is proposed and finite-element method is implemented. This numerical predictive tool based on the bioheat equation takes into account heat losses due to the convection on skin surface, blood circulatory and also evaporation. Thermal behavior of each skin layer is also described considering distinct thermal and optical properties. Since the mathematical model is able to estimate damage levels, histological analyses were also carried through. It is confirmed that the mathematical model is an efficient predictive tool for estimation of damage caused by lasers and that thermal effects sharply depend on laser wavelength.

Response to Letter to the Editor: ‘Lymphatic regeneration in meshed skin grafts’ - Corrected Proof

T.O. Meier, M. Guggenheim, B.R. Amann-Vesti — 2012-01-11

We would like to thank Hadamitzky et al. for their very interesting comments. They point out that the successful regeneration of skin lymphatics and blood microvessels of meshed transplants after deep burns and in venous ulcer is depending on different factors including the bacterial environment and the lymphatic drainage. We fully agree with them and have mentioned it also in the discussion of your paper . We emphasized that the microvascular regeneration is a result of a viable wound bed created by debridement. One of the aims of the excision of the eschar is to eliminate the bacterial colonization or wound infection. In our study burn patients did not have signs of an infection of the wound area. In the previous study of our group regarding microangiopathy of split skin grafts in venous ulcers, no prior wound infection was reported . We conclude that the bacterial environment does not explain a potential difference in microvascular regeneration in the two studies. However, we agree that the chronic interstitial edema in the wound area might influence microvascular regeneration substantially as well as wound infection. In patients with venous ulcers microcirculation is severely damaged by the increased venous pressure leading to pathological changes also of the subcutaneous tissue. We hypothesize that this mechanism is responsible for the insufficient regeneration of microvessels in venous ulcers and might explain the differences, at least in part, in the two study populations.

Compliance with nutrition support guidelines in acutely burned patients - Corrected Proof

Brennen Holt, Caran Graves, Iris Faraklas, Amalia Cochran — 2012-01-09

Abstract: Background: Adequate and timely provision of nutritional support is a crucial component of care of the critically ill burn patient. The goal of this study was to assess a single center's consistency with Society of Critical Care Medicine/American Society for Parenteral and Enteral Nutrition (SCCM/ASPEN) guidelines for nutritional support in critically ill patients.Methods: Acutely burned patients >45kg in weight admitted to a regional burn center during a two-year period and who required 5 or more days of full enteral nutritional support were eligible for inclusion in this retrospective review. Specific outcomes evaluated include time from admission to feeding tube placement and enteral feeding initiation and percent of nutritional goal received within the first week of hospital stay. Descriptive statistics were used for all analyses. IRB approval was obtained.Results: Thirty-seven patients were included in this retrospective review. Median age of patients was 44.9 years (IQR: 24.2–55.1), and median burn injury size was 30% (IQR: 19–47). Median time to feeding tube placement was 31.1h post admission (IQR: 23.6–50.2h), while median time to initiation of EN was 47.9h post admission (IQR: 32.4–59.9h). The median time required for patients to reach 60% of caloric goal was 3 days post-admission (IQR: 3–4.5).Conclusion: The median time for initiation of enteral nutrition was within the SCCM/ASPEN guidelines for initial nutrition in the critically ill patient. This project identified a 16h time lag between placement of enteral access and initiation of enteral nutrition. Development of a protocol for feeding tube placement and enteral nutrition management may optimize early nutritional support in the acutely injured burn patient.

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

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.

Paediatric injuries associated with the use of disposable barbecues: Are we finding ourselves in hot sand? - Corrected Proof

Pieter Vermaak, Mahammed Haj Basheer, Hussein Taki, Timothy Burge — 2012-01-09

Abstract: Aim: To document, describe and raise awareness of a preventable injury associated with the use of disposable barbecues.Methods: We conducted a retrospective study of incidents involving barbecue burns. Cases were identified through the burn injury database of a tertiary paediatric burns referral centre and case notes reviewed. Experiments were performed to evaluate the dissipation of heat from sand.Results: Over a 3-month period, 9 children were identified out of a series of 296. The median age was 5 years and burns were sustained through contact with hot sand where disposable barbecues had been used. 87% (n=13) of the burns were partial thickness and most affected critical areas such as the hands and feet. The majority (93%) responded well to debridement and simple dressings and all patients made a complete recovery. Experiments show that, even after a prolonged period of time, sand can retain sufficient heat to cause a contact burn.Discussion and conclusion: We have noted an increased incidence of burns with this mechanism of injury. The burns are usually superficial, they tend to occur predominantly in children and involve critical areas. We suggest that areas where disposable barbecues have stood should be cooled and children kept away from the area for at least 5min. The results of the study have been forwarded to the Prevention Committee of the British Burn Association with the aim of raising awareness of this mechanism of burn.

Response to Letter to the Editor: Comments on “Late-onset rhabdomyolysis in burn patients in the intensive care unit” - Corrected Proof

Sarah E. Bache, Ian Taggart, Charlotte Gilhooly — 2012-01-09

We read with interest the two further case reports from Badoiu and Caramitru of late-onset rhabdomyolysis (RML) in burns patients. We note several similarities to our documented experience . Following mildly raised initial CPK levels, there was a return to normal before a secondary increase in CPK levels on days 11 and 14. The patients suffered from inhalation injury, in common with six of our seven patients. They also received several of the drugs we highlighted as possible causative factors for late-onset RML, although no single cause was found. We would add to this that it is our feeling that sepsis may be the most significant factor, and although this is not directly mentioned in their reports, both patients were on dual therapy antibiotics.

Post-burn hypertrophic scars are characterized by high levels of IL-1β mRNA and protein and TNF-α type I receptors - Corrected Proof

2012-01-09

Abstract: Post-burn hypertrophic scars are characterized by increased collagen synthesis and hyperplasia, and may be associated with erythema, pain, dysesthesia, pruritus, and skin border elevation. Although the etiopathogenesis of hypertrophic scarring remains unclear, proinflammatory and profibrogenic cytokines are known to play an important role in general skin dysfunction. This study assessed mRNA expression, proteins, and type I receptors of tumor necrosis factor-alpha (TNF-α) and interleukin 1-beta (IL-1β) in normal skin, normotrophic and post-burn hypertrophic scars. Skin biopsies were obtained from 10 hypertrophic and 9 normotrophic scars, and 4 normal skin sites. Only post-burn scars covering more than 10% of the body were included. Ex vivo histopathological analysis evaluated scar maturity, in situ hybridization assessed mRNA expression, and cytokine protein and cytokine/cell colocalization were performed using single- and double-label immunohistochemistry, respectively. IL-1β is overexpressed in hypertrophic scars at the post-transcriptional level, associated primarily with keratinocytes and CD1a+ cells. Type I receptors for TNF-α are overexpressed in blood vessels of hypertrophic scars. The coordinated overexpression of IL-1β and TNF-α type I receptor may maintain the fibrogenic phenotypes of hypertrophic scars, even those in “remission”.

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

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.

Burn and cancer risk: A state-wide longitudinal analysis - Corrected Proof

Janine Duke, Suzanne Rea, James Semmens, Dale W. Edgar, Fiona Wood — 2011-12-05

Abstract: Background: Major burn can lead to impairment of the immune system and individuals who experience chronic immunosuppression are at a greater risk of developing a malignancy. Examination of prospective long term follow-up data to clarify the risk of cancer in this patient group is important.Methods: Linked hospital morbidity records of 23,450 persons admitted with an index burn in Western Australia from 1983 to 2008 were merged with cancer and death data. The cancer incidence of those hospitalised for burn was compared to the general population of Western Australia. Poisson regression was used to assess the impact of burn severity and skin graft on cancer risk.Results: From 1983 to 2008, there were 759 notifications of cancer (standardised incidence ratio (SIR), 95% confidence interval (CI): 0.97, 0.90–1.04). For the cohort admitted 1983–2008, a significant decrease in cancer risk for males (SIR, 95%CI: 0.90, 0.83–0.99), and a non-significant increase in cancer risk for females (SIR, 95%CI: 1.12, 1.00–1.28) were estimated. For the sub-cohort admitted 1983–1987 with optimum follow-up, incidence of cancer was significantly less for males (SIR, 95%CI: 0.86, 0.75–0.99), while a significant increase in risk of cancer for females (SIR, 95%CI: 1.39, 1.15–1.69) was estimated.Conclusions: There appears to be a gender effect in relation to incidence of cancer after burn. The risk of cancer for females hospitalised for burn during 1983–1987, with optimum follow-up time, was significant and increased in magnitude to 39% greater incidence of all-cause cancer than that for females in the general population of Western Australia.Burn and cancer risk: A state-wide longitudinal analysis.

Burns represent a significant proportion of the total serious trauma workload in England and Wales - Corrected Proof

Nicholas S. Kalson, Tom Jenks, Maralyn Woodford, Fiona E. Lecky, Ken W. Dunn — 2011-12-02

Abstract: Traumatic injury is the leading cause of death in the first four decades of life. However, current estimates for traumatic injury rates fail to take into account burns. The aim of this work was to estimate the contribution of burns to serious traumatic injury in England and Wales. We have determined population-based burns rates using the International Burn Injury Database (iBID, www.ibidb.org) which collects data from regional burn centres, and non-burns rate using data from the Trauma Audit and Research Network (TARN) which collects data from emergency departments (ED, www.TARN.ac.uk). Due to incomplete national coverage of TARN, non-burns rates were estimated using data from 94 EDs that contributed data to TARN. Both non-burn and burns rates were calculated nationally and for each regional burn service catchment area (n=17). Only serious injuries (≥72h admission or death) were included. Burns rate was 4.7 and non-burns rate 82.7 per 100,000 per year nationally. Burns therefore contributed 5.4% of all serious traumatic injuries. Contribution of burns in different regional burn service catchment areas was between 1.5% and 12%. This data suggests that burns contribute significantly to the overall trauma workload, and should be carefully considered in healthcare planning and policy.

Epidemiology of burns in Iran during the last decade (2000–2010): review of literature and methodological considerations - Corrected Proof

Homayoun Sadeghi-Bazargani, Reza Mohammadi — 2011-11-28

Abstract: The approach to burn prevention, to be effective in a particular area, should be based on sound knowledge of etiological patterns of burns injuries and must take into account the geographical variations and socioeconomic differences in burn epidemiology. Although many articles are published on burns epidemiology in Iran, a holistic view of burn epidemiology in Iran is not well presented in literature. In this study, a wide literature review was made on articles published regarding burns injuries in Iran. Pubmed, Embase, Scopus, and Iranian scientific information (SID) databases were searched for information on epidemiology of burns in Iran during the years 2000–2010. During the investigation we found that few Farsi journals were not indexed in SID during the earlier years of the decade, so to increase the chance of capturing necessary information these were checked by hand. As the second source, available data from the Iranian National Home Injury Registry Database (INHIRD) during two Iranian calendar years in the period 2001–2003 were used to extract necessary information. The results of this review helped in defining the magnitude of the burns problem, exploring the role of gender and age in burns, defining the agents causing burns, burn extent, burn mortality and place of injury occurrence. Some areas with paucity of information as well as methodological pitfalls in published research were identified and discussed.

Deep sole burns in several participants in a traditional festival of the firewalking ceremony in Kee-lung, Taiwan—Clinical experiences and prevention strategies - Corrected Proof

2011-11-24

Abstract: Purpose: Firewalking is a common Taoist cleansing ceremony in Taiwan, but burns associated with the practice have rarely been reported. We analyzed the patients with plantar burns from one firewalking ceremony.Materials and methods: In one firewalking ceremony, 12 Taoist disciples suffered from contact burns to the soles of their feet while walking over burning coals. Eight of them had at least second-degree burns over areas larger than 1% of their total body surface areas (TBSAs). The age, sex, medical history, date of injury, time taken to traverse the fire pit, depth and TBSA of the burns, treatment, length of stay, and outcome were recorded and analyzed.Results: Deep, disseminated second- to third-degree burns were noted and healing took as long as three weeks in some patients. Because disseminated hypertrophic scars form after burns, the soles involved regain much of their tensile strength while walking. The patients experienced only a few difficulties in their daily lives three months after injury.Conclusion: From our experience treating patients with deep disseminated second- to third-degree plantar burns caused by firewalking, we conclude that they should be treated conservatively, with secondary healing rather than a skin graft.

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

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.

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

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.

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

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.

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

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.

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

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.

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

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.

Urban compared with rural and remote burn hospitalisations in Western Australia - Corrected Proof

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.

Moist occlusive dressing (Aquacel® Ag) versus moist open dressing (MEBO®) in the management of partial-thickness facial burns: A comparative study in Ain Shams University - Corrected Proof

Amr Mabrouk, Nahed Samir Boughdadi, Hesham A. Helal, Basim M. Zaki, Ashraf Maher — 2011-11-18

Abstract: Introduction: The face is the central point of the physical features; it transmits expressions and emotions, communicates feelings and allows for individual identity. Facial burns are very common and are devastating to the affected patient and results into numerous physical, emotional and psychosocial sequels. Partial thickness facial burns are very common especially among children. This study compares the effect of standard moist open technique management and a moist closed technique for partial thickness burns of the face.Patients and methods: Patients with partial-thickness facial burns admitted in the burn unit, Ain Shams University, Cairo, Egypt in the period from April 2009 to December 2009 were included in this study. They were divided into two groups to receive either open treatment with MEBO® (n=20) or coverage with Aquacel® Ag (n=20). Demographics (age, gender, ethnicity, TBSA, burn areas), length of hospital stay (LOS), rate of infections, time to total healing, frequency of dressing changes, pain, cost benefit and patient discomfort were compared between the two groups. The long-term outcome (incidence of hypertrophic scarring) was assessed for up to 6 months follow-up period.Results: There were no significant differences in demographics between the two groups. In the group treated with the Aquacel® Ag, the mean time for re-epithelialization was 10.5 days, while it was 12.4 days in the MEBO® group (p<0.05). Frequency of changes, pain and patient discomfort were less with Aquacel® Ag. Cost was of no significant difference between the two groups. Scar quality improved in the Aquacel® Ag treatment group. Three and 6 months follow-up was done and long-term outcomes were recorded in both groups.Conclusion: Moist occlusive dressing (Aquacel® Ag) significantly improves the management and healing rate of partial thickness facial burns with better long-term outcome compared to moist open dressing (MEBO®).

The use of Suprathel® in deep dermal burns: First results of a prospective study - Corrected Proof

M. Keck, H.F. Selig, D.B. Lumenta, L.P. Kamolz, M. Mittlböck, M. Frey — 2011-11-14

Abstract: Introduction: While autologous skin grafting has been the standard for coverage of full-thickness areas, several options for deep-partial-thickness defects exist. With regard to economising donor sites, we compared a copolymer based on dl-lactid acid (Suprathel®) as temporary wound dressing with autologous skin, and analysed time to healing and scar quality in matched areas of deep-partial-thickness burn.Methods: We recruited 18 patients with a median age of 45 years (range: 25–83 years), for this prospective, non-blinded controlled non-inferiority study, suffering from deep-partial-thickness burns from November 2009 to July 2010. After early tangential excision, matched deep-partial-thickness areas were covered with 1:1.5 meshed autologous skin grafts and the copolymer for direct intra-individual comparison. Scars were evaluated by means of the Vancouver Scar Scale (VSS), the Patient and Observer Scar Assessment Scale (POSAS) and suction cutometry (MPA 580, Courage and Khazaka Electronic GmbH, Cologne, Germany) on days 30 and 90, postoperatively.Results: Fifteen days after surgery, complete wound closure was present in 44.4% (8/18) of all areas covered with copolymer and 88.9% (16/18) in the split-thickness skin graft (STSG) area (p=0.008). Evaluation of the total VSS, POSAS and cutometry satisfied the criterion of non-inferiority for Suprathel® on day 30. Ninety days after surgery, only the Observer Scar Scale showed that Suprathel is non-inferior to STSG, albeit the mean total VSS and Patient Scar Scale were better in Suprathel® areas.Conclusion: Suprathel® represents a solid, reliable epidermal skin substitute with longer healing times in comparison to skin grafts but comparable results concerning early scar formation. Suprathel® can serve as a tool in treatment portfolio for adult patients suffering from deep dermal burns. Especially in patients with extensive burns, Suprathel® can be used to cover the deep dermal burn wounds to save STSGs and its donor sites for the coverage of full-thickness burned areas.

Ethnic differences in burn mechanism and severity in a UK paediatric population - Corrected Proof

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.