Burn scar contracture release surgery effectively improves functional range of motion, disability and quality of life: A pre/post cohort study with long-term follow-up in a Low- and Middle-Income Country.

OBJECTIVE: Burn scar contractures limit range of motion (ROM) of joints and have substantial impact on disability and the quality of life (QoL) of patients, particularly in a Low- and Middle-Income Country (LMIC) setting. Studies on the long-term outcome are lacking globally; this study describes the long-term impact of contracture release surgery performed in an LMIC. METHODS: This is a pre-post cohort study, conducted in a referral hospital in Tanzania. Patients who underwent burn scar contracture release surgery in 2017-2018 were eligible. ROM (goniometry), disability (WHODAS 2.0) and QoL (EQ-5D) were assessed. The ROM data were compared to the ROM that is required to perform activities of daily living without compensation, i.e. functional ROM. Assessments were performed preoperatively and at 1, 3, 6 and 12 months postoperatively. RESULTS: In total, 44 patients underwent surgery on 115 affected joints. At 12 months, the follow-up rate was 86%. The mean preoperative ROM was 37.3% of functional ROM (SD 31.2). This improved up to 108.7% at 12 months postoperatively (SD 42.0, p < 0.001). Disability-free survival improved from 55% preoperatively to 97% at 12 months (p < 0.001) postoperatively. QoL improved from 0.69 preoperatively, to 0.93 (max 1.0) at 12 months postoperatively (p < 0.001). Patients who regained functional ROM in all affected joints reported significantly less disability (p < 0.001) and higher QoL (p < 0.001) compared to patients without functional ROM. CONCLUSIONS: Contracture release surgery performed in an LMIC significantly improved functional ROM, disability and QoL. Results showed that regaining a functional joint is associated with less disability and higher QoL.

The FLIR ONE thermal imager for the assessment of burn wounds: Reliability and validity study.

BACKGROUND: Objective measurement tools may be of great value to provide early and reliable burn wound assessment. Thermal imaging is an easy, accessible and objective technique, which measures skin temperature as an indicator of tissue perfusion. These thermal images might be helpful in the assessment of burn wounds. However, before implementation of a novel measurement tool into clinical practice is considered, it is appropriate to test its clinimetric properties (i.e. reliability and validity). The objective of this study was to assess the reliability and validity of the recently introduced FLIR ONE thermal imager. MATERIAL AND METHODS: Two observers obtained thermal images of burn wounds in adult patients at day 1-3, 4-7 and 8-10 after burn. Subsequently, temperature differences between the burn wound and healthy skin (ΔT) were calculated on an iPad mini containing the FLIR Tools app. To assess reliability, ΔT values of both observers were compared by calculating the intraclass correlation coefficient (ICC) and measurement error parameters. To assess validity, the ΔT values of the first observer were compared to the registered healing time of the burn wounds, which was specified into three categories: (I) ≤14 days, (II) 15-21 days and (III) >21 days. The ability of the FLIR ONE to discriminate between healing ≤21 days and >21 days was evaluated by means of a receiver operating characteristic curve and an optimal ΔT cut-off value. RESULTS: Reliability: ICCs were 0.99 for each time point, indicating excellent reliability up to 10 days after burn. The standard error of measurement varied between 0.17-0.22°C. VALIDITY: the area under the curve was calculated at 0.69 (95% CI 0.54-0.84). A cut-off value of -1.15°C shows a moderate discrimination between burn wound healing ≤21 days and >21 days (46% sensitivity; 82% specificity). CONCLUSION: Our results show that the FLIR ONE thermal imager is highly reliable, but the moderate validity calls for additional research. However, the FLIR ONE is pre-eminently feasible, allowing easy and fast measurements in clinical burn practice.

Assessing blood flow, microvasculature, erythema and redness in hypertrophic scars: A cross sectional study showing different features that require precise definitions.

BACKGROUND: In hypertrophic scar assessment, laser Doppler imaging (LDI), colorimetry and subjective assessment (POSAS) can be used to evaluate blood flow, erythema and redness, respectively. In addition, the microvasculature (i.e. presence of microvessels) can be determined by immunohistochemistry. These measurement techniques are frequently used in clinical practice and/or in research to evaluate treatment response and monitor scar development. However, until now it has not been tested to what extent the outcomes of these techniques are associated, whilst the outcome terms are frequently used interchangeably or replaced by the umbrella term 'vascularization'. This is confusing, as every technique seems to measure a specific feature. Therefore, we evaluated the correlations of the four measurement techniques. METHODS: We included 32 consecutive patients, aged ≥18 years, who underwent elective resection of a hypertrophic scar. Pre-operatively, we performed LDI (measuring blood flow), colorimetry (measuring erythema) and the POSAS (subjective redness) within the predefined scar area of interest (∼1.5cm). Subsequently, the scar was excised and the area of interest was sent for immunohistochemistry, to determine the presence of microvessels. RESULTS: Only a statistically significant correlation was found between erythema values (colorimetry) and subjective redness assessment (POSAS) (r=0.403, p=0.030). We found no correlations between the outcomes of LDI, immunohistochemistry and colorimetry. CONCLUSIONS: Blood flow, the presence of microvessels and erythema appear to be different hypertrophic scar features because they show an absence of correlation. Therefore, in the field of scar assessment, these outcome terms cannot be used interchangeably. In addition, we conclude that the term 'vascularization' does not seem appropriate to serve as an umbrella term. The use of precise definitions in research as well as in clinical practice is recommended.

The evaluation of nasal mupirocin to prevent Staphylococcus aureus burn wound colonization in routine clinical practice.

BACKGROUND: Staphylococcus aureus wound colonization frequently occurs in patients with burns and can cause impaired wound healing. Nasal mupirocin application may contribute to the reduction of burn wound colonization of endogenous origin, whereas colonization by the exogenous route can be reduced by blocking cross-infection from other sources. In this study we evaluated whether the implementation of routine treatment of patients and burn center personnel using nasal mupirocin ointment reduces S. aureus burn wound colonization. METHODS: We composed three study groups, consisting of a control period (Control), a mupirocin period (MUP), in which patients with burns were all receiving nasal mupirocin at admission, and a mupirocin+personnel period (MUP+P), in which we also screened the burn center personnel and decolonized S. aureus carriers by nasal mupirocin. RESULTS: The patients who carried S. aureus in their nose and did not have S. aureus burn wound colonization at admission were considered as patients susceptible for the use of nasal mupirocin. In these patients, the S. aureus burn wound colonization rate was the same in all study groups. S. aureus nasal carriage was a significant independent risk factor for burn wound colonization (OR: 3.3; 95% CI: 1.4-7.6) when analyzed within the three study groups. CONCLUSION: Although S. aureus carriage is a significant risk factor for developing burn wound colonization, the routine use of nasal mupirocin did not contribute to a reduction of burn wound colonization.