Who crashes their car following wrist fracture?

BACKGROUND: Wrist fractures are common injuries associated with high disability in the early recovery period. The impact of wrist fractures on safe return to drive is not understood. PURPOSE: (1) To compare the proportion of adults who were drivers in car crashes before and after wrist fracture; (2) To examine potential factors (demographic and/or clinical) associated with increased odds of being a driver in a car crash following wrist fracture. STUDY DESIGN: Retrospective cohort study. METHODS: Three state-wide government datasets (MainRoads Western Australia [WA], Hospital Morbidity Data Collection and the Emergency Department Data Collection) were used to obtain and link demographic, clinical and car crash information relating to adults with a wrist fracture sustained between 2008 and 2017. McNemar's tests were used to compare the proportion of drivers in a car crash within the 2 years prior to and following the fracture date. Multivariable logistic regressions were used to identify if any variables were associated with increased odds of crashing in the post-fracture period. RESULTS: Data relating to 37,107 adults revealed a 3.3% (95% CI 3.0%-3.6%, p < 0.05) decrease in the proportion of drivers in a car crash following wrist fracture, persisting for the entire 2 years post-fracture, when compared to the proportion who crashed before their fracture. Those with more severe wrist fracture injury patterns had 79%(95% CI 1.07-3.0, p = 0.03) higher odds of having a crash in the first 3 months following their injury, compared to those with isolated wrist fracture injuries. CONCLUSIONS: These results inform and update return to drive recommendations. The reduced proportion of drivers involved in crashes following wrist fracture persisted for 2 years; longer than the expected physical recovery timeframe. It is important that hand therapists actively educate the sub-group of adults with more severe wrist fracture injury patterns of the increased likelihood of car crash for the 3 months following their fracture.

Incomplete Systemic Recovery and Metabolic Phenoreversion in Post-Acute-Phase Nonhospitalized COVID-19 Patients: Implications for Assessment of Post-Acute COVID-19 Syndrome.

We present a multivariate metabotyping approach to assess the functional recovery of nonhospitalized COVID-19 patients and the possible biochemical sequelae of "Post-Acute COVID-19 Syndrome", colloquially known as long-COVID. Blood samples were taken from patients ca. 3 months after acute COVID-19 infection with further assessment of symptoms at 6 months. Some 57% of the patients had one or more persistent symptoms including respiratory-related symptoms like cough, dyspnea, and rhinorrhea or other nonrespiratory symptoms including chronic fatigue, anosmia, myalgia, or joint pain. Plasma samples were quantitatively analyzed for lipoproteins, glycoproteins, amino acids, biogenic amines, and tryptophan pathway intermediates using Nuclear Magnetic Resonance (NMR) spectroscopy and mass spectrometry. Metabolic data for the follow-up patients (n = 27) were compared with controls (n = 41) and hospitalized severe acute respiratory syndrome SARS-CoV-2 positive patients (n = 18, with multiple time-points). Univariate and multivariate statistics revealed variable patterns of functional recovery with many patients exhibiting residual COVID-19 biomarker signatures. Several parameters were persistently perturbed, e.g., elevated taurine (p = 3.6 × 10-3 versus controls) and reduced glutamine/glutamate ratio (p = 6.95 × 10-8 versus controls), indicative of possible liver and muscle damage and a high energy demand linked to more generalized tissue repair or immune function. Some parameters showed near-complete normalization, e.g., the plasma apolipoprotein B100/A1 ratio was similar to that of healthy controls but significantly lower (p = 4.2 × 10-3) than post-acute COVID-19 patients, reflecting partial reversion of the metabolic phenotype (phenoreversion) toward the healthy metabolic state. Plasma neopterin was normalized in all follow-up patients, indicative of a reduction in the adaptive immune activity that has been previously detected in active SARS-CoV-2 infection. Other systemic inflammatory biomarkers such as GlycA and the kynurenine/tryptophan ratio remained elevated in some, but not all, patients. Correlation analysis, principal component analysis (PCA), and orthogonal-partial least-squares discriminant analysis (O-PLS-DA) showed that the follow-up patients were, as a group, metabolically distinct from controls and partially comapped with the acute-phase patients. Significant systematic metabolic differences between asymptomatic and symptomatic follow-up patients were also observed for multiple metabolites. The overall metabolic variance of the symptomatic patients was significantly greater than that of nonsymptomatic patients for multiple parameters (χ2p = 0.014). Thus, asymptomatic follow-up patients including those with post-acute COVID-19 Syndrome displayed a spectrum of multiple persistent biochemical pathophysiology, suggesting that the metabolic phenotyping approach may be deployed for multisystem functional assessment of individual post-acute COVID-19 patients.

Poorer first aid after burn is associated with remoteness in Australia: Where to from here?

OBJECTIVE: Early intervention with appropriate first aid following burn injury improves clinical outcomes. Previous evidence suggests geographic remoteness may be a barrier to receiving appropriate burns first aid. This study investigated the prevalence of gold standard first aid in patients managed in Australian burn services and whether geographic remoteness was associated with receiving gold standard first aid. DESIGN: Registry-based cohort study. SETTING: Binational clinical quality registry. PARTICIPANTS: Burn-injured patients admitted to a specialist Australian burn service. MAIN OUTCOME MEASURES: Receiving gold standard first aid following a burn injury. RESULTS: Approximately two-thirds of patients received gold standard first aid. Patients whose burns were sustained in very remote regions had a greater risk of receiving no first aid, compared to gold standard first aid, relative to patients who sustained their burn injuries in major cities. CONCLUSIONS: Nearly two-thirds of patients received gold standard burns first aid following injury. However, patients who were injured in the most remote regions of Australia were at an increased risk of not receiving gold standard first aid treatment within 3 hours of injury. Further examination of factors contributing to poorer first aid standards in remote areas is required.

Improved and standardized method for assessing years lived with disability after burns and its application to estimate the non-fatal burden of disease of burn injuries in Australia, New Zealand and the Netherlands.

BACKGROUND: Burden of disease estimates are an important resource in public health. Currently, robust estimates are not available for the burn population. Our objectives are to adapt a refined methodology (INTEGRIS method) to burns and to apply this new INTEGRIS-burns method to estimate, and compare, the burden of disease of burn injuries in Australia, New Zealand and the Netherlands. METHODS: Existing European and Western-Australian health-related quality of life (HRQL) datasets were combined to derive disability weights for three homogenous burn injury groups based on percentage total body surface area (%TBSA) burned. Subsequently, incidence data from Australia, New Zealand, and the Netherlands from 2010 to 2017 were used to compute annual non-fatal burden of disease estimates for each of these three countries. Non-fatal burden of disease was measured by years lived with disability (YLD). RESULTS: The combined dataset included 7159 HRQL (EQ-5D-3 L) outcomes from 3401 patients. Disability weights ranged from 0.046 (subgroup < 5% TBSA burned > 24 months post-burn) to 0.497 (subgroup > 20% TBSA burned 0-1 months post-burn). In 2017 the non-fatal burden of disease of burns for the three countries (YLDs/100,000 inhabitants) was 281 for Australia, 279 for New Zealand and 133 for the Netherlands. CONCLUSIONS: This project established a method for more precise estimates of the YLDs of burns, as it is the only method adapted to the nature of burn injuries and their recovery. Compared to previous used methods, the INTEGRIS-burns method includes improved disability weights based on severity categorization of burn patients; a better substantiated proportion of patients with lifelong disability based; and, the application of burn specific recovery timeframes. Information derived from the adapted method can be used as input for health decision making at both the national and international level. Future studies should investigate whether the application is valid in low- and middle- income countries.

A randomised investigation of film-forming silicone gel in superficial partial thickness face and neck burn patients: Indication of improved early scar pigmentation outcomes.

INTRODUCTION: Burns to the face and neck are a source of considerable distress and a challenge to manage with dressings. Further, these often superficial injuries pose a risk of scarring and altered pigmentation. Silicone gels have emerged as a potential solution to the challenges of conservative management for face and neck burn injuries. The aims of this study were to explore the effect of topical silicone compared to routine treatment of conservatively managed burns to the face and neck. METHODS: This single-blind, randomised, controlled trial compared topical silicone film-forming dressing to standard of care for superficial partial thickness burns to the face and neck. Time to healing was the primary outcome and secondary outcomes included: 1) scar assessments (modified Vancouver Scar Scale, Dermalab Combo and Patient and Observer Scar Assessment Scale) at six weeks and three months; and 2) pain intensity scale at wound review appointments. RESULTS: Of the 55 participants in the face/neck study, 34 were male and 21 were female. Median age was 36 years (range from 25 to 47 years). The median time to healing for the silicone group was 9 days (CI 7.6 -10.4) and the control group was 7 days (CI 5.3- 8.7), p = 0.056. Analysis demonstrated significantly reduced pigmentation at six weeks in mVSS scores for the silicone group (Md = 0, IQR = 0) compared to the control group (Md = 0, IQR = 0 - 3), p = 0.043. We found no evidence of differences in reported pain between the groups (Silicone - Md = 1.15, IQR 0.3 - 4.5 vs control group - Md = 1.5, IQR 0.6 - 3.8, z = -0.63, p = 0.53). No other differences were observed, and no adverse events were associated with the topical silicone in the study whereas an infection and a reaction were experienced in the control group. CONCLUSION: Film-forming silicone gel had comparable effects to standard of care emollient on wound healing of superficial partial thickness burns of the face and neck. Silicone treated wounds were associated with a significant improvement in scar pigmentation outcome at six weeks post-burn.

Postoperative hypothermia is associated with reduced length of stay in adult acute burn survivors.

BACKGROUND: The hypermetabolic response after a burn predisposes patients to hypothermia due to dysfunction of thermoregulation. Traditionally, hypothermia is avoided actively in burn care due to reported complications associated with low body temperature. The likelihood of hypothermia with acute burn surgery is compounded by general anesthesia, exposure of wound areas and prolonged operation times. However, we find limited studies exploring the effects of perioperative hypothermia on length of stay in the adult burn population. OBJECTIVE: To determine associations between postoperative hypothermia and hospital length of stay in adult burns patients. METHOD: This retrospective cohort study involved patients admitted to the State Adult Burn Unit in Western Australia between 1st January 2015 to 28th February 2021. All adults who underwent surgery for acute burn, and had postoperative recovery room body temperature recorded, were included in the study. In this study, we defined normothermia as >36.5C and hypothermia as < 36.0 °C with mild, moderate, and severe hypothermia being 35.0-35.9 °C, 34.0-34.9 °C and < 34.0 °C, respectively. Patients with hyperthermia were excluded. Multivariable general linear models explored if hypothermia was independently associated with length of stay. RESULTS: Among 1486 adult patients, 1338 (90%) were normothermic postoperatively, with temperatures >36.0C. We included 148 (10%) patients with hypothermia (temperature <36.0 °C) postoperatively. Most burns in the study population were minor: 96% had burns < 15% TBSA. Data modelling demonstrated that hypothermia was associated with a shorter length of hospital stay (coefficient = -0.129, p = 0.041). CONCLUSION: In adult acute burn patients, postoperative hypothermia was associated with reduced length of stay after surgery. The positive results of this study indicate that a review of the core temperature targets with acute burn surgery, and timing of burn patient cooling practices in general is warranted.

The Short- and Long-Term Outcome Priorities of a Western Australian Adult Burn Population.

To optimize patient recovery, understanding which outcomes are most important to burn patients is key. However, research to determine what outcomes are patient priorities is limited. Therefore, we assessed what outcomes are most important to Western Australian burn patients, separately in the short-term (<6 months) and long-term (6-24 months) after injury. Adult patients who had a burn injury 3-36 months ago completed a survey, rating the importance of 36 short- and long-term outcomes. The survey items were ranked according to the number of patients reporting the outcome as "very important." Results were compared between subgroups based on age, gender, burn size, and number of surgeries. Ninety-three patients were included. In the short-term, "not having a wound infection" (87.1%), "good wound healing" (83.9%), and "walking or moving around" (74.7%) were the most important outcomes. "Lifting or moving something" (67.6%), "walking or moving around" (66.2%), and "being independent" (66.2%) were reported as most important in the long-term. Scar-related outcomes were more important to females and to patients with multiple surgeries; mental health outcomes were priorities for females and patients with major burns; walking and moving around to males and older patients; and social and financial outcomes were rated highly by patients with major burns and multiple surgeries. In conclusion, the most important outcomes were consistent across time periods, indicating the importance of core outcomes in longitudinal follow-up. The wide range of priority outcomes and differences between subgroups underlines the need for multidisciplinary care and a patient-centered approach to support patients.

Trauma patient heterotopic ossification diagnosis is associated with increased hospital length of stay.

BACKGROUND: Traumatic heterotopic ossification (tHO) refers to the development of extra-skeletal bone in muscle and soft tissues following tissue insult secondary to surgery or trauma. This presents a persistent clinical concern associated with significant patient morbidity and expense to diagnose and treat. Traumatic HO is a substantial barrier to rehabilitation for trauma-injured patients. As such, the development of tHO after burn and other trauma is hypothesised to prolong inpatient length of stay (LOS) and thus increase health care costs. OBJECTIVE: To investigate the association between an inpatient tHO diagnosis and hospital LOS in trauma patients. METHODS: A retrospective audit of trauma patients over a 14-year period was completed using data from four WA hospitals. Burn and neurological trauma patients diagnosed with tHO as an inpatient (tHO+) and control subjects (tHO-), matched (1:3) by age, gender, and injury severity factors, were identified using medical diagnostic codes. Data relating to patient and injury-related determinants of LOS from tHO+ and tHO- subjects were analysed to model the association of tHO on total hospital length of stay. RESULTS: 188 identified patients were hospitalised due to traumatic injury; 47 patients with tHO following burn injury (n = 17), spinal cord injury (n = 13) and traumatic brain injury (n = 17), and 141 control patients. Those who developed tHO during hospitalisation had a significantly higher median LOS than matched trauma patients who did not develop tHO (142 days vs. 61 days). Multivariate regression analyses identified the following independent predictive factors of a prolonged hospital LOS: tHO diagnosis, mechanical ventilation hours, injury to the hip region and thigh area, other ossification disorder, pressure injury, admission to intensive care unit and deep vein thrombosis. Trauma patients diagnosed with tHO during their hospital admission stayed 1.6 times longer than trauma patients matched for injury severity without a tHO diagnosis (IRR 1.56, 95% CI 1.35-1.79, p<0.001). CONCLUSION: Traumatic heterotopic ossification is an independent explanatory factor for increased hospital LOS in patients following burns, spinal cord, and traumatic brain injury. Early diagnosis may assist in reducing the impact of tHO on acute hospital stay after trauma.

Evaluation of the accuracy of diagnostic coding and clinical documentation for traumatic heterotopic ossification diagnoses in Western Australian hospitals.

BACKGROUND: Traumatic heterotopic ossification (tHO) refers to the pathological formation of ectopic bone in soft tissues that can occur following burn, neurological ororthopaedic trauma. As completeness and accuracy of medical diagnostic coding can vary based on coding practices and depend on the institutional culture of clinical documentation, it is important to assess diagnostic coding in that local context. To the authors' knowledge, there is no prior study evaluating the accuracy of medical diagnostic coding or specificity of clinical documentation for tHO diagnoses across Western Australia (WA) trauma centres or across the full range of inciting injury and surgical events. OBJECTIVE: To evaluate and compare the clinical documentation and the diagnostic accuracy of ICD-10-AM coding for tHO in trauma populations across 4 WA hospitals. METHODS: A retrospective data search of the WA trauma database was conducted to identify patients with tHO admitted to WA hospitals following burn, neurological or orthopaedic trauma. Patient demographic and tHO diagnostic characteristics were assessed for all inpatient and outpatient tHO diagnoses. The frequency and distribution of M61 (HO-specific) and broader, musculoskeletal (non-specific) ICD-10-AM codes were evaluated for tHO cases in each trauma population. RESULTS: HO-specific M61 ICD-10-AM codes failed to identify more than a third of true tHO cases, with a high prevalence of non-specific HO codes (19.4 %) and cases identified via manual chart review (25.4 %). The sensitivity of M61 codes for correctly diagnosing tHO after burn injury was 50 %. ROC analysis showed that M61 ICD-10-AM codes as a predictor of a true positive tHO diagnosis were a less than favourable method (AUC=0.731, 95 % CI=0.561-0.902, p = 0.012). Marked variability in clinical documentation for tHO was identified across the hospital network. CONCLUSION: Coding inaccuracies may, in part, be influenced by insufficiencies in clinical documentation for tHO diagnoses, which may have implications for future research and patient care. Clinicians should consistently employ standardised clinical terminology from the point of care to increase the likelihood of accurate medical diagnostic coding for tHO diagnoses.

Functional Brain Changes Following Burn Injury: A Narrative Review.

BACKGROUND: Burn injuries cause significant motor and sensory dysfunctions that can negatively impact burn survivors' quality of life. The underlying mechanisms of these burn-induced dysfunctions have primarily been associated with damage to the peripheral neural architecture, however, evidence points to a systemic influence of burn injury. Central nervous system (CNS) reorganizations due to inflammation, afferent dysfunction, and pain could contribute to persistent motor and sensory dysfunction in burn survivors. Recent evidence shows that the capacity for neuroplasticity is associated with self-reported functional recovery in burn survivors. OBJECTIVE: This review first outlines motor and sensory dysfunctions following burn injury and critically examines recent literature investigating the mechanisms mediating CNS reorganization following burn injury. The review then provides recommendations for future research and interventions targeting the CNS such as non-invasive brain stimulation to improve functional recovery. CONCLUSIONS: Directing focus to the CNS following burn injury, alongside the development of non-invasive methods to induce functionally beneficial neuroplasticity in the CNS, could advance treatments and transform clinical practice to improve quality of life in burn survivors.

Is clinician reported practice in Western Australian emergency departments aligned with direct discharge pathway protocols for minor self-limiting fractures? A multi-centre professional survey.

OBJECTIVE: To determine ED clinician's current management for five common minor self-limiting fractures (MSLF) and evaluate practice against evidence-informed direct discharge pathway (DD) protocols. METHODS: A survey was provided to doctors, nurse practitioners and advanced scope physiotherapists working in seven metropolitan, public health EDs in Perth, Australia. The relative odds of ED location (e.g. which facility) and clinician level factors (e.g. country of initial training, years of ED experience, profession) on recommending care completely consistent with evidence informed direct discharge pathway protocols were estimated. RESULTS: Two hundred sixty-two clinicians completed the survey. There was variability in practice across all sites, with most reported care assessed at 60%-76% consistency with individual elements of DD care provision. Highest consistency was seen in lower limb immobilisation and DVT prophylaxis. Lowest consistency was seen in weight bearing advice, pain management and (boxer's) fracture reduction and immobilisation. There were very low levels of complete consistency, ranging from 9% (boxer's fracture) to 25% (radial head fracture). Two factors were associated with increased odds of completely consistent care: (i) clinician experience working in ED, with greater duration of practice associated with increased odds ratios (OR range, 1.6-3.3); and (ii) profession, where advanced scope physiotherapy was associated with increased odds ratios (OR range, 3.2-25.0). CONCLUSIONS: Survey results suggested system wide variation in ED fracture management practice and target areas for service improvement. Avenues for service improvement could include hospital wide agreed management plans for specific fractures and support for less experienced clinicians.

Working Towards Holistic Scar Assessment and Improved Shared Decision Making in Global Burn Care.

Cutaneous burn scars impact various aspects of life. Scar treatment is mainly evaluated on scar characteristics. Consensus is needed on which other outcomes to capture, ensuring they are relevant to patients, clinicians, and researchers. The aim of this study was to identify, discuss and analyze outcomes related to cutaneous burn scarring, incorporating the voice of patients and views of healthcare professionals. For this, a Delphi process consisting of two survey rounds and a consensus meeting was initiated. Burn scar-related outcomes were identified from an existing comprehensive list of 100 outcomes by an international panel of patients, healthcare professionals and researchers. Fifty-nine outcomes were identified from the Delphi process as related to scarring (≥60% votes). Outcomes less impactful in relation to scar outcomes included psychosocial issues, sense of normality, understanding of treatment, costs and systemic issues. To represent a holistic assessment of outcomes related to cutaneous burn scarring, this Delphi process established a battery of outcomes currently included in scar quality assessment tools, and an expanded set of less frequently considered outcomes. Future work in this area must include the patient voice from developing countries. This is essential to identify globally applicable outcomes related to scarring.

Early ambulation impacts on quality-of-life outcomes positively after lower limb burn injury: A group trajectory analysis.

INTRODUCTION: Despite the challenges of providing burn care throughout the 2.5MKm2 jurisdiction of Western Australia, early intervention after injury remains a key premise of the multidisciplinary model of care applied by the State Adult Burn Unit (SABU) team. In particular, contemporary guidelines support the facilitation of early ambulation after lower limb burn and skin grafting. Thus, this study aimed to evaluate the association between the timing of ambulation after burn and surgery on quality of life (QoL) outcomes. METHODS: Data from 1707 lower limb burn patients aged ≥ 18, admitted to the SABU between February 2011- December 2019, were included. Self-reported QoL longitudinal outcomes were assessed using the Short Form 36 and Burn Specific Health Scale Brief. Three recovery trajectories were defined according to their QoL outcome responses, mapped out to one year. Early ambulation was defined as occurring within 48 h of acute burn or surgery, as per SABU routine practice. RESULTS: Early ambulation was shown to have a positive association to the higher QoL trajectory group (>75% of cohort), though not statistically significant for the Physical Component (PCS) and Mental health Component (MCS) summary scores of the SF36; however, ambulation pathway was associated with adjusted long-term BSHS-B QoL outcomes. The least favorable trajectory of long-term recovery of the physical aspects of QoL was seen in those with higher TBSA and complications and increasing age and comorbidities. In contrast, the mental health components of QoL were robust to all those factors, apart from pre-existing comorbidities. CONCLUSION: Early ambulation after lower limb burn, and surgery, was positively associated with early and long-term QoL outcomes. Recovery trajectory is strongly indicated by where the patient journey begins after early acute care. The optimal physical QoL recovery trajectory was shared by those who were younger with reduced TBSA; complications; and, comorbidities whereas the mental health QoL trajectories were only impacted by comorbidities.

Timing of surgery in acute deep partial-thickness burns: A study protocol.

For deep partial-thickness burns no consensus on the optimal treatment has been reached due to conflicting study outcomes with low quality evidence. Treatment options in high- and middle-income countries include conservative treatment with delayed excision and grafting if needed; and early excision and grafting. The majority of timing of surgery studies focus on survival rather than on quality of life. This study protocol describes a study that aims to compare long-term scar quality, clinical outcomes, and patient-reported outcomes between the treatment options. A multicentre prospective study will be conducted in the three Dutch burn centres (Rotterdam, Beverwijk, and Groningen). All adult patients with acute deep-partial thickness burns, based on healing potential with Laser Doppler Imaging, are eligible for inclusion. During a nine-month baseline period, standard practice will be monitored. This includes conservative treatment with dressings and topical agents, and excision and grafting of residual defects if needed 14-21 days post-burn. The subsequent nine months, early surgery is advocated, involving excision and grafting in the first week to ten days post-burn. The primary outcome compared between the two groups is long-term scar quality assessed by the Patient and Observer Scar Assessment Scale 3.0 twelve months after discharge. Secondary outcomes include clinical outcomes and patient-reported outcomes like quality of life and return to work. The aim of the study is to assess long-term scar quality in deep partial-thickness burns after conservative treatment with delayed excision and grafting if needed, compared to early excision and grafting. Adding to the ongoing debate on the optimal treatment of these burns. The broad range of studied outcomes will be used for the development of a decision aid for deep partial-thickness burns, to fully inform patients at the point of consent to surgery and support optimal person-centred care.

Adherence With Early Allied Health Assessments in Specialist Burn Services.

Appropriate multidisciplinary allied health assessment during the early stages of admission following burn injury positively influences recovery and quality of life. Variation in allied health care may affect patient outcomes. We aimed to explore adherence in providing early allied health assessments in accordance with local parameters. Associations between the number of assessments and hospital length of stay (LOS) were also explored. The Burns Registry of Australia and New Zealand was queried for adult (≥ 16 years) burn injured patients admitted to a specialist burn service for > 48 hours between July 2016 and June 2020. Quality indicator data relating to allied health assessment processes were examined; patients were grouped according to the number of assessments they received within 48 hours of admission. Of the 5789 patients included in the study, 5598 (97%) received at least one allied health assessment within 48 hours of admission and 3976 (69%) received all three assessments. A greater proportion of patients who received no assessments were admitted on a Saturday. Patients receiving three assessments had more severe injuries compared to their counterparts who received fewer assessments. Hospital LOS was not associated with the number of allied health assessments during an acute admission following burn injury after accounting for confounding factors, particularly TBSA. Multidisciplinary allied health teams provide routine burn care to Australian and New Zealand burns patients at a consistent level. Further, this study provides evidence that allied health input is prioritized towards patients with increasing severity of burn injury, playing an integral role in early rehabilitation.

Current understanding of the chronic stress response to burn injury from human studies.

There is a marked inflammatory and hypermetabolic response following a burn injury. The interlinked responses are more pronounced than for other forms of trauma and can persist for ≥3 years post-injury in burned patients. After a burn, patients have an increased risk of diseases of ageing including cancer, diabetes and cardiovascular disease, highlighting the need for effective long-term strategies to ameliorate the stress response post-burn. Current therapeutic strategies for post-burn recovery include removal of damaged tissue with surgical excision and wound repair, nutritional supplementation and rehabilitative exercise. These strategies aim to minimize the hypermetabolic and inflammatory responses, as well as reducing the loss of lean body mass. This review briefly summarises the inflammatory and hypermetabolic responses and provides an update on the current therapeutic strategies for burned patients. The review examines the persistent nutritional challenge of ensuring sufficient energy intake of each macronutrient to fuel the hypermetabolic and counteract the catabolic response of burn injury, whilst reducing periods of hyperglycaemia and hypertriglyceridemia. Patients require individualized treatment options tailored to unique systemic responses following a burn, facilitated by a precision medicine approach to improve clinical and physiological outcomes in burned patients. Thus, this review discusses the utility of metabolic flexibility assessment to aid clinical decision making and prescription relating to nutritional supplementation and rehabilitative exercise in the burned patient.

Case study: Pilot testing of a local acupuncture intervention protocol for burn scars.

BACKGROUND: Following burn injury and a prolonged duration of healing, scars may become hypertrophic, causing movement restriction, increased scar thickness, colour and pliability, and symptoms such as pain and itch. Acupuncture has emerged as a potentially beneficial treatment for neuroinflammation, which perpetuates the negative features of hypertrophic scars. The aim of this study was to pilot test an evidence-based methodology for applying and measuring the clinical effects of localised acupuncture for symptomatic scars, in a patient with a healed burn injury. METHODS: A 71-year-old caucasian male presented with a hypertrophic scar that was painful and itchy after burn injury and subsequent skin grafting. He received acupuncture and massage treatment local to his scar as per the local (verum) group of the author's clinical trial under recruitment. Needles were inserted around the circumference of the skin grafted area and adjacent to areas of raised scar tissue within the grafted area and stimulated via bi-directional rotation. Outcome measures included a Numerical Rating Scale (NRS) for pain and itch, Patient and Observer Scar Assessment Scale (POSAS) self-assessment component and SF36 quality-of-life measure to capture any non-specific acupuncture effects. CONCLUSION: Acupuncture applied locally around the scar was associated with short-term relief of symptoms and significantly reduced his subjective outcome measure scores relating to scar thickness, redness and pliability out to six months after injury. Some short-term increase in symptoms occurred on several occasions following treatment; however, treatment was well tolerated supporting the use of this protocol for a larger future clinical trial. LAY SUMMARY: Following injury to the skin, scars can become raised, red and reduce movement. Other common symptoms may include pain and itch. Previous studies suggest acupuncture may help symptomatic scars, but more research is needed to confirm this with larger samples of patients.This case study tested the active treatment protocol for a clinical trial using acupuncture on symptomatic scars. A 71-year-old white man had a burn scar on his torso after a workplace accident. His treatment involved scar massage and local acupuncture. The acupuncture needles were inserted around the skin graft borders and thickened bands of scar tissue.Outcomes were measured using surveys recording symptoms, scar characteristics and quality of life. These were used to assess treatment effect and how well the protocol was tolerated. Over the course of treatment both pain and itch improvedThis case report showed that the treatment protocol was well tolerated, and that local acupuncture was associated with improved scar symptoms and physical characteristics up to six months after injury.

Does exercise influence burn-induced inflammation: A cross-over randomised controlled feasibility trial.

BACKGROUND: Burn injuries trigger a greater and more persistent inflammatory response than other trauma cases. Exercise has been shown to positively influence inflammation in healthy and diseased populations, however little is known about the latent effect of exercise on chronic inflammation in burn injured patients. The aims of the pilot study were to assess the feasibility of implementing a long duration exercise training program, in burn injured individuals including learnings associated with conducting a clinical trial in COVID-19 pandemic. METHODS: Fifteen participants with a burn injury between 5-20% total body surface area acquired greater than a year ago were randomised in a within-subject designed study, into one of two conditions, exercise-control or control-exercise. The exercise condition consisted of six weeks of resistance and cardiovascular exercises, completed remotely or supervised in a hospital gym. A comprehensive outcome measurement was completed at the initial, mid and end point of each exercise and control condition. To determine the success of implementation, the feasibility indicator for the data completeness across the comprehensive outcome battery was set at 80%. RESULTS: Half (49%) of eligible participants in the timeframe, were recruited and commenced the study. Six participants withdrew prior to completion and a total of 15 participants completed the study. Eight participants were randomised to the exercise-control and seven to the control exercise group. Five participants trained remotely and seven did supervised training. Three participants completed a mix of both supervised and remote training initiated due to COVID restrictions. Outcome measures were completed on 97% of protocolised occasions and 100% of participants completed the exercise training. CONCLUSIONS: Conducting a long duration exercise training study on burn injured individuals is feasible using the described methods. The knowledge gained helps improve the methodology in larger-scale projects. Insights into the impact of COVID-19 on this clinical trial and success enhancing adaptations for the researcher, research practice and the participant, are presented.

Greater In-Hospital Care and Early Rehabilitation Needs in People with COVID-19 Compared with Those without COVID-19.

↔This study aims to compare the characteristics, in-hospital data and rehabilitation needs between those who tested positive versus negative for COVID-19 during hospitalisation with suspected COVID-19. In this cross-sectional study, a convenience sample of adults admitted to Western Australian tertiary hospitals with suspected COVID-19 was recruited. Participants were grouped according to their polymerase chain reaction (PCR) test result into COVID-19 positive (COVID+) and COVID-19 negative (COVID−) groups. Between-group comparisons of characteristics of the participants and hospital admission data were performed. Sixty-five participants were included (38 COVID+ and 27 COVID−; 36 females [55%]). Participants in the COVID+ group had greater acute hospital length of stay (LOS) (median [25−75th percentile] 10 [5−21] vs. 3 [2−5] days; p < 0.05] and only those with COVID+ required mechanical ventilation (8 [21%] participants). Twenty-one percent of the COVID+ participants were discharged to inpatient rehabilitation (7% of the COVID− participants). Of note, pre-existing pulmonary disease was more prevalent in the COVID− group (59% vs. 13%; p < 0.05). Within the COVID+ group, when compared to participants discharged home, those who required inpatient rehabilitation had worse peripheral oxygen saturation (SpO2) on admission (86 ± 5.7% vs. 93 ± 3.8%; p < 0.05) and longer median LOS (30 [23−37] vs. 7 [4−13] days; p < 0.05). Despite having less people with pre-existing pulmonary disease, the COVID+ group required more care and rehabilitation than the COVID− group. In the COVID+ group, SpO2 on hospital presentation was associated with LOS, critical care needs, mechanical ventilation duration and the need for inpatient rehabilitation.

An investigation of early enteral nutrition provision in major burn patients in Australia and New Zealand.

AIMS: Early enteral nutrition (provided within 24 h of admission) is the optimal form of nutritional support for major burn injuries. The aim of this study was to (i) audit early enteral nutrition practices, (ii) identify characteristics of patients who received early enteral nutrition, and (iii) investigate whether early enteral nutrition was associated with in-hospital outcomes. METHODS: An analysis of prospectively collected data from the Burns Registry of Australia and New Zealand was conducted. Specifically, this study focused on major burns patients (defined as burns affecting more than 20% and 15% total body surface area for adult paediatric patients, respectively) admitted to a specialist burn service between 1 July 2016 and 30 June 2019. RESULTS: Data from 474 major burns patients (88 paediatric patients) revealed 69% received early enteral nutrition. Paediatric patients who received early enteral nutrition were younger than their counterparts who did not receive the same support (p = 0.04). Adult patients who received early enteral nutrition sustained larger burns (p < 0.001). Early enteral nutrition was not associated with in-hospital mortality following major burn injury in adult patients in either unadjusted (p = 0.77) or confounder-adjusted (p = 0.69) analyses. CONCLUSIONS: Approximately two-thirds of patients with major burn injuries received early enteral nutrition. Early enteral nutrition was not associated with in-hospital mortality following major burn injury. Further research should focus on modifiable reasons why major burns patients do not receive enteral nutrition within 24 h of admission.