The Role of Burn Centers in the Treatment of Necrotizing Soft-Tissue Infections: A Nationwide Dutch Study.

Patients with extensive and complex wounds due to Necrotizing Soft-Tissue Infections (NSTI) may be referred to a burn center. This study describes the characteristics, outcomes, as well as diagnostic challenges of these patients. Patients admitted to three hospitals with a burn center for the treatment of NSTI in a 5-year period were included. Eighty patients (median age 54 years, 60% male) were identified, of whom 30 (38%) were referred by other centers, usually after survival of the initial septic phase. Those referred from other centers, compared to those primarily admitted to the study hospitals, were more likely to have group A streptococcal involvement (62% vs 35%, p = .02), larger wounds (median 7% vs 2% total body surface area, p < .001), and a longer length of stay (median 49 vs 22 days, p < .001). Despite a high incidence of septic shock (50%), the mortality rate was low (12%) for those primarily admitted. Approximately half (53%) of the patients were initially misdiagnosed upon presentation, which was associated with delay to first surgery (16 hours vs 4 hours, p < .001). Those initially misdiagnosed had more (severe) comorbidities, and less frequently reported pain or blue livid discoloration of the skin. This study underlines the burn centers' function as referral centers for extensively affected patients with NSTI. Besides the unique wound and reconstructive expertise, the low mortality rate indicates these centers provide adequate acute care as well. A major remaining challenge remains recognition of the disease upon presentation. Future studies in which factors associated with misdiagnosis are explored are needed.

Hydrosurgical and conventional debridement of burns: randomized clinical trial.

BACKGROUND: Tangential excision of burned tissue followed by skin grafting is the cornerstone of burn surgery. Hydrosurgery has become popular for tangential excision, with the hypothesis that enhanced preservation of vital dermal tissue reduces scarring. The aim of this trial was to compare scar quality after hydrosurgical versus conventional debridement before split-skin grafting. METHODS: A double-blind randomized within-patient multicentre controlled trial was conducted in patients with burns that required split-skin grafting. One wound area was randomized to hydrosurgical debridement and the other to Weck knife debridement. The primary outcome was scar quality at 12 months, assessed with the observer part of the Patient and Observer Scar Assessment Scale (POSAS). Secondary outcomes included complications, scar quality, colour, pliability, and histological dermal preservation. RESULTS: Some 137 patients were randomized. At 12 months, scars of the hydrosurgical debrided wounds had a lower POSAS observer total item score (mean 2.42 (95 per cent c.i. 2.26 to 2.59) versus 2.54 (95 per cent c.i. 2.36 to 2.72; P = 0.023)) and overall opinion score (mean 3.08 (95 per cent c.i. 2.88 to 3.28) versus 3.30 (95 per cent c.i. 3.09-3.51); P = 0.006). Patient-reported scar quality and pliability measurements were significantly better for the hydrosurgically debrided wounds. Complication rates did not differ between both treatments. Histologically, significantly more dermis was preserved with hydrosurgery (P < 0.001). CONCLUSION: One year after surgery scar quality and pliability was better for hydrosurgically debrided burns, probably owing to enhanced histological preservation of dermis. REGISTRATION NUMBER: Trial NL6085 (NTR6232 (http://www.trialregister.nl)).

The impact of early information concerning the surgical operations on anxiety in patients with burns.

AIMS: Stress has been linked to poor coping with health-related issues, poor adaptation, a decrease of quality of life, poor recovery and poor wound healing. Therefore, it is important to address patients' uncertainty and feelings of anxiety. The aim of this study was to examine the effect of providing early treatment information based on an LDI-scan to patients with burns on their feelings of anxiety. DESIGN: An observational prospective pre-test post-test study. METHODS: Patients with intermediate burns (n = 59) admitted to our burn centre in 2016 were evaluated for anxiety using a visual analogue scale (VAS-A) before and after an LDI-scan was made. Two groups were compared: a group that heard whether surgery would or would not be recommended for wound closure (certain group) versus a group that heard to wait and see whether an operation was determined to be helpful (uncertain group). RESULTS: Before the LDI-scan was made, both groups showed clinically high levels of anxiety (median VAS scores above 5). After the information gathered with the LDI was discussed with the patient, anxiety dropped significantly (median VAS below 3; p = .001). No significant differences between the groups were observed (p > .05). CONCLUSION: In contrast to other studies, anxiety was significantly reduced in all our study groups after information was shared. Early communication of knowledge by health care professionals is important regardless whether it includes treatment uncertainty.

The Effectiveness of Burn Scar Contracture Release Surgery in Low- and Middle-income Countries.

Worldwide, many scar contracture release surgeries are performed to improve range of motion (ROM) after a burn injury. There is a particular need in low- and middle-income countries (LMICs) for such procedures. However, well-designed longitudinal studies on this topic are lacking globally. The present study therefore aimed to evaluate the long-term effectiveness of contracture release surgery performed in an LMIC. METHODS: This pre-/postintervention study was conducted in a rural regional referral hospital in Tanzania. All patients undergoing contracture release surgery during surgical missions were eligible. ROM data were indexed to normal values to compare various joints. Surgery was considered effective if the ROM of all planes of motion of a single joint increased at least 25% postoperatively or if the ROM reached 100% of normal ROM. Follow-ups were at discharge and at 1, 3, 6, and 12 months postoperatively. RESULTS: A total of 70 joints of 44 patients were included. Follow-up rate at 12 months was 86%. Contracture release surgery was effective in 79% of the joints (P < 0.001) and resulted in a mean ROM improvement from 32% to 90% of the normal value (P < 0.001). A predictive factor for a quicker rehabilitation was lower age (R 2 = 11%, P = 0.001). Complication rate was 52%, consisting of mostly minor complications. CONCLUSIONS: This is the first study to evaluate the long-term effectiveness of contracture release surgery in an LMIC. The follow-up rate was high and showed that contracture release surgery is safe, effective, and sustainable. We call for the implementation of outcome research in future surgical missions.

Topical treatment for facial burns.

BACKGROUND: Burn injuries are an important health problem. They occur frequently in the head and neck region. The face is the area central to a person's identity that provides our most expressive means of communication. Topical interventions are currently the cornerstone of treatment of burns to the face. OBJECTIVES: To assess the effects of topical interventions on wound healing in people with facial burns of any depth. SEARCH METHODS: In December 2019 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting. SELECTION CRITERIA: Randomised controlled trials (RCTs) that evaluated the effects of topical treatment for facial burns were eligible for inclusion in this review. DATA COLLECTION AND ANALYSIS: Two review authors independently performed study selection, data extraction, risk of bias assessment and GRADE assessment of the certainty of the evidence. MAIN RESULTS: In this first update, we included 12 RCTs, comprising 507 participants. Most trials included adults admitted to specialised burn centres after recent burn injuries. Topical agents included antimicrobial agents (silver sulphadiazine (SSD), Aquacel-Ag, cerium-sulphadiazine, gentamicin cream, mafenide acetate cream, bacitracin), non-antimicrobial agents (Moist Exposed Burn Ointment (MEBO), saline-soaked dressings, skin substitutes (including bioengineered skin substitute (TransCyte), allograft, and xenograft (porcine Xenoderm), and miscellaneous treatments (growth hormone therapy, recombinant human granulocyte-macrophage colony-stimulating factor hydrogel (rhGMCS)), enzymatic debridement, and cream with Helix Aspersa extract). Almost all the evidence included in this review was assessed as low or very low-certainty, often because of high risk of bias due to unclear randomisation procedures (i.e. sequence generation and allocation concealment); lack of blinding of participants, providers and sometimes outcome assessors; and imprecision resulting from few participants, low event rates or both, often in single studies. Topical antimicrobial agents versus topical non-antimicrobial agents There is moderate-certainty evidence that there is probably little or no difference between antimicrobial agents and non-antimicrobial agents (SSD and MEBO) in time to complete wound healing (hazard ratio (HR) 0.84 (95% confidence interval (CI) 0.78 to 1.85, 1 study, 39 participants). Topical antimicrobial agents may make little or no difference to the proportion of wounds completely healed compared with topical non-antimicrobial agents (comparison SSD and MEBO, risk ratio (RR) 0.94, 95% CI 0.68 to 1.29; 1 study, 39 participants; low-certainty evidence). We are uncertain whether there is a difference in wound infection (comparison topical antimicrobial agent (Aquacel-Ag) and MEBO; RR 0.38, 95% CI 0.12 to 1.21; 1 study, 40 participants; very low-certainty evidence). No trials reported change in wound surface area over time or partial wound healing. There is low-certainty evidence for the secondary outcomes scar quality and patient satisfaction. Two studies assessed pain but it was incompletely reported. Topical antimicrobial agents versus other topical antimicrobial agents It is uncertain whether topical antimicrobial agents make any difference in effects as the evidence is low to very low-certainty. For primary outcomes, there is low-certainty evidence for time to partial (i.e. greater than 90%) wound healing (comparison SSD versus cerium SSD: mean difference (MD) -7.10 days, 95% CI -16.43 to 2.23; 1 study, 142 participants). There is very low-certainty evidence regarding whether topical antimicrobial agents make a difference to wound infection (RR 0.73, 95% CI 0.46 to 1.17; 1 study, 15 participants). There is low to very low-certainty evidence for the proportion of facial burns requiring surgery, pain, scar quality, adverse effects and length of hospital stay. Skin substitutes versus topical antimicrobial agents There is low-certainty evidence that a skin substitute may slightly reduce time to partial (i.e. greater than 90%) wound healing, compared with a non-specified antibacterial agent (MD -6.00 days, 95% CI -8.69 to -3.31; 1 study, 34 participants). We are uncertain whether skin substitutes in general make any other difference in effects as the evidence is very low certainty. Outcomes included wound infection, pain, scar quality, adverse effects of treatment and length of hospital stay. Single studies showed contrasting low-certainty evidence. A bioengineered skin substitute may slightly reduce procedural pain (MD -4.00, 95% CI -5.05 to -2.95; 34 participants) and background pain (MD -2.00, 95% CI -3.05 to -0.95; 34 participants) compared with an unspecified antimicrobial agent. In contrast, a biological dressing (porcine Xenoderm) might slightly increase pain in superficial burns (MD 1.20, 95% CI 0.65 to 1.75; 15 participants (30 wounds)) as well as deep partial thickness burns (MD 3.00, 95% CI 2.34 to 3.66; 10 participants (20 wounds)), compared with antimicrobial agents (Physiotulle Ag (Coloplast)). Miscellaneous treatments versus miscellaneous treatments Single studies show low to very low-certainty effects of interventions. Low-certainty evidence shows that MEBO may slightly reduce time to complete wound healing compared with saline soaked dressing (MD -1.7 days, 95% CI -3.32 to -0.08; 40 participants). In addition, a cream containing Helix Aspersa may slightly increase the proportion of wounds completely healed at 14 days compared with MEBO (RR 4.77, 95% CI 1.87 to 12.15; 43 participants). We are uncertain whether any miscellaneous treatment in the included studies makes a difference in effects for the outcomes wound infection, scar quality, pain and patient satisfaction as the evidence is low to very low-certainty. AUTHORS' CONCLUSIONS: There is mainly low to very low-certainty evidence on the effects of any topical intervention on wound healing in people with facial burns. The number of RCTs in burn care is growing, but the body of evidence is still hampered due to an insufficient number of studies that follow appropriate evidence-based standards of conducting and reporting RCTs.

Long-term scar quality after hydrosurgical versus conventional debridement of deep dermal burns (HyCon trial): study protocol for a randomized controlled trial.

BACKGROUND: Deep dermal burns require tangential excision of non-viable tissue and skin grafting to improve wound healing and burn-scar quality. Tangential excision is conventionally performed with a knife, but during the last decade hydrosurgery has become popular as a new tool for tangential excision. Hydrosurgery is generally thought to be a more precise and controlled manner of burn debridement leading to preservation of viable tissue and, therefore, better scar quality. Although scar quality is considered to be one of the most important outcomes in burn surgery today, no randomized controlled study has compared the effect of these two common treatment modalities with scar quality as a primary outcome. The aim of this study is, therefore, to compare long-term scar quality after hydrosurgical versus conventional tangential excision in deep dermal burns. METHODS/DESIGN: A multicenter, randomized, intra-patient, controlled trial will be conducted in the Dutch burn centers of Rotterdam, Beverwijk, and Groningen. All patients with deep dermal burns that require excision and grafting are eligible. Exclusion criteria are: a burn wound < 50 cm2, total body surface area (TBSA) burned > 30%, full-thickness burns, chemical or electrical burns, infected wounds (clinical symptoms in combination with positive wound swabs), insufficient knowledge of the Dutch or English language, patients that are unlikely to comply with requirements of the study protocol and follow-up, and patients who are (temporarily) incompetent because of sedation and/or intubation. A total of 137 patients will be included. Comparable wound areas A and B will be appointed, randomized and either excised conventionally with a knife or with the hydrosurgery system. The primary outcome is scar quality measured by the observer score of the Patient and Observer Scar Assessment Scale (POSAS); a subjective scar-assessment instrument, consisting of two separate six-item scales (observer and patient) that are both scored on a 10-point rating scale. DISCUSSION: This study will contribute to the optimal surgical treatment of patients with deep dermal burn wounds. TRIAL REGISTRATION: Dutch Trial Register, NTR6232 . Registered on 23 January 2017.

Epidemiology and Outcome of Patients With Burns Treated With Cerium Nitrate Silversulfadiazine.

In this study, the outcome of treatment with Flammacerium in burn patients is studied. The retrospective study involved patients with acute burns admitted to the Burn Centre of Martini Hospital, Groningen, The Netherlands, between 2009 and 2014. The outcome parameters were mortality, complications (noninfectious and infectious), need of surgery, and length of stay. The group of patients consisted of 853 patients, of which 554 were male (64.9%). There were 23 patients with a total burn size of 40% TBSA or more (2.7%). In total, 13 of the 853 patients (1.5%) died, and none of them were children (<16 years). The overall mortality in the group of patient with burns >40% TBSA was 30.4%. In the elderly group (>70 years), the mortality rate was 6.3%. Treatment with Flammacerium is applicable in all thermal burn patients. Especially children, elderly patients, and patients with severe burns can benefit from a more conservative treatment with Flammacerium whereby the first operation can be postponed until the patient is stabilized and in which the wounds can be covered directly with skin transplants.

Long-term scar quality in burns with three distinct healing potentials: A multicenter prospective cohort study.

The laser Doppler imager is used in cases of indeterminate burn depth to accurately predict wound healing time at an early stage. The laser Doppler imager classifies burns into three estimated healing potentials as follows: high, <14 days; intermediate, 14-21 days; and low, >21 days. At this time, the relationship between these healing potentials and long-term scar quality is unknown. The objective of this study was to determine the long-term scar quality of burns with three distinct healing potentials. The secondary objectives were to compare treatment strategies in intermediate wounds, to study the effect of the timing of surgery on low healing potential wounds and to identify predictors of reduced scar quality. Hence, in a prospective cohort study, scar quality was determined in patients whose burns were assessed with laser Doppler imaging. Scar Quality was assessed with objective and subjective measurement tools, including overall scar quality (Patient and Observer Scar Assessment Scale) as a primary outcome and color and elasticity parameters. A total of 141 patients (>19 months postburn) with 216 scars were included. Wounds with high and intermediate healing potential did not significantly differ regarding scar quality. Wounds with a low healing potential had a significantly lower scar quality. Analysis of 76 surgically treated low healing potential wounds showed no significant differences in the primary outcome regarding the timing of surgery (≤14 days vs. >14). Predictors of reduced long-term scar quality were darker skin type and multiple surgeries. In conclusion, scar quality was strongly related to the healing potential category. Scar quality was very similar in high and intermediate healing potential wounds. No positive effects were found on scar quality or on healing time in surgically treated wounds with intermediate healing potential, advocating a conservative approach. Further studies should focus on the optimal timing of surgery in low healing potential wounds.

Cost-Effectiveness of Laser Doppler Imaging in Burn Care in The Netherlands: A Randomized Controlled Trial.

BACKGROUND: In patients with burns, an early accurate diagnosis of burn depth facilitates optimal treatment. Laser Doppler imaging combined with clinical assessment leads to an accurate estimate of burn depth. However, the actual effects of the introduction of laser Doppler imaging on therapeutic decisions, clinical outcomes, and costs are unknown. METHODS: A randomized controlled trial was conducted in the Dutch burn centers, including 202 patients with burns of indeterminate depth. In the standard care group, estimation of burn depth was based on clinical assessment only; in the laser Doppler imaging group, clinical assessment and laser Doppler imaging were combined. Primary outcome was time to wound healing. Furthermore, therapeutic decisions and cost-effectiveness were analyzed. RESULTS: Mean time to wound healing was 14.3 days (95 percent CI, 12.8 to 15.9 days) in the laser Doppler imaging group and 15.5 days (95 percent CI, 13.9 to 17.2 days) in the standard care group (p = 0.258). On the day of randomization, clinicians decided significantly more often on operative or nonoperative treatment in the laser Doppler imaging group (p < 0.001), instead of postponing their treatment choice. Analyses in a subgroup of admitted patients requiring surgery showed a significant earlier decision for surgery and a shorter wound healing time in the laser Doppler imaging group. Mean total costs per patient were comparable in both groups. CONCLUSIONS: Laser Doppler imaging improved therapeutic decisions. It resulted in a shorter wound healing time in the subgroup of admitted patients requiring surgery and has the potential for cost savings of €875 per scanned patient.

Burns to the head and neck: Epidemiology and predictors of surgery.

BACKGROUND: The face is a frequent site of burn, but prevalence rates vary and reports are often limited to one healthcare setting. We examined the incidence of facial burns in the Netherlands in Emergency Departments (ED), hospitals and burn centres. Additionally, we identified which patient, injury and burn-related characteristics were predictors of facial burns, facial surgery and facial reconstruction in burn centres. METHODS: A retrospective, observational study was conducted including data from the Dutch Injury Surveillance System, the National Hospital Discharge Register and burn centres in a 5-year period (2003-2007). RESULTS: Facial burn incidences per 100,000 were 15.1 for ED visits, 1.3 for hospital admissions and 1.4 for burn centre admissions. A total of 2691 patients were admitted to Dutch burn centres; 47.5% (n=1277) had facial burns of which 20.5% received primary facial surgery and 5.3% received facial reconstruction in follow-up. Predictors of facial burns and facial surgery were identified. Predictors of facial reconstructive surgery were burns to the neck (ventral), fire/flame burns and number of facial surgeries in the acute phase of the burn. CONCLUSIONS: One in five patients with facial burns admitted to a Dutch burn centre received primary facial surgery and 1 in 20 received facial reconstructive surgery within a follow-up of minimum 2 years.

Cost-effectiveness of laser Doppler imaging in burn care in the Netherlands.

BACKGROUND: Early accurate assessment of burn depth is important to determine the optimal treatment of burns. The method most used to determine burn depth is clinical assessment, which is the least expensive, but not the most accurate.Laser Doppler imaging (LDI) is a technique with which a more accurate (>95%) estimate of burn depth can be made by measuring the dermal perfusion. The actual effect on therapeutic decisions, clinical outcomes and the costs of the introduction of this device, however, are unknown. Before we decide to implement LDI in Dutch burn care, a study on the effectiveness and cost-effectiveness of LDI is necessary. METHODS/DESIGN: A multicenter randomised controlled trial will be conducted in the Dutch burn centres: Beverwijk, Groningen and Rotterdam. All patients treated as outpatient or admitted to a burn centre within 5 days post burn, with burns of indeterminate depth (burns not obviously superficial or full thickness) and a total body surface area burned of ≤ 20% are eligible. A total of 200 patients will be included. Burn depth will be diagnosed by both clinical assessment and laser Doppler imaging between 2-5 days post burn in all patients. Subsequently, patients are randomly divided in two groups: 'new diagnostic strategy' versus 'current diagnostic strategy'. The results of the LDI-scan will only be provided to the treating clinician in the 'new diagnostic strategy' group. The main endpoint is the effect of LDI on wound healing time.In addition we measure: a) the effect of LDI on other patient outcomes (quality of life, scar quality), b) the effect of LDI on diagnostic and therapeutic decisions, and c) the effect of LDI on total (medical and non-medical) costs and cost-effectiveness. DISCUSSION: This trial will contribute to our current knowledge on the use of LDI in burn care and will provide evidence on its cost-effectiveness. TRIAL REGISTRATION: NCT01489540.

Effectiveness of cerium nitrate-silver sulfadiazine in the treatment of facial burns: a multicenter, randomized, controlled trial.

BACKGROUND: The face is a very frequent site of burn injuries. This multicenter, randomized, controlled trial thus investigates the effectiveness of cerium nitrate-silver sulfadiazine in the treatment of facial burns compared with silver sulfadiazine. METHODS: Adult patients with acute facial burns admitted to Dutch burn centers were randomized to treatment with either cerium nitrate-silver sulfadiazine or silver sulfadiazine. Primary outcome was need for surgery and time to wound healing. Aesthetic and functional outcome was assessed at 3, 6, and 12 months after burn. RESULTS: From March of 2006 until January of 2009, 179 patients were randomized and 154 could be included. The two groups of patients (cerium nitrate-silver sulfadiazine group, n=78; silver sulfadiazine group, n=76), were comparable regarding sex, age, percentage total body surface area burned, and cause. During admission, four patients died, leaving 77 and 73 patients for primary analyses, respectively. Surgery was required in 13 (16.9 percent) compared with 15 patients (20.5 percent) (p=0.57; odds ratio, 0.8; 95 percent CI, 0.3 to 1.8), respectively. Median time to wound healing was 11.0 days in the cerium nitrate-silver sulfadiazine group (interquartile range, 7.0 to 15.0) and 9.0 days for silver sulfadiazine group (interquartile range, 5.0 to 15.75) (p=0.17). There were no significant differences in functional and aesthetic outcome. CONCLUSIONS: No differences were found in effectiveness of both treatments. The vast majority of facial burns do not require surgery, and treatment with cerium nitrate-silver sulfadiazine and silver sulfadiazine leads to satisfactory outcome, both aesthetically and functionally. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Efficacy of skin stretching for burn scar excision: a multicenter randomized controlled trial.

BACKGROUND: Burn survivors are frequently faced with disfiguring scars. Various techniques exist to improve scar appearance, such as laser treatment and dermabrasion. Next to that, surgical reconstruction, such as scar excision is an option. This randomized controlled trial investigates whether a larger burn scar can be excised using a skin-stretching device for wound closure, thereby optimizing use of adjacent healthy skin. This technique may allow scar excision in a one-step procedure instead of two or more steps, which is necessary for serial excision and tissue expansion. METHODS: Two arms were compared: scar excision and closure by skin stretch and scar excision without additional techniques. The primary outcome measure was scar surface area reduction. In addition, complications were registered. RESULTS: Fifteen patients were randomized for skin stretch and 15 patients were randomized for scar excision only. In the skin stretch group, 10 of 15 scars were completely excised compared with three of 15 in the scar excision-only group (p = 0.025). In the skin stretch group, a significantly larger reduction in scar area was achieved: 95 ± 11 percent of the scar was excised versus 78 ± 17 percent in the scar excision-only group (p = 0.003). One patient in the skin stretch group and three patients in the scar excision-only group experienced partial wound dehiscence (p = 0.598). CONCLUSIONS: In burn scar reconstructions, a significantly larger reduction in scar area can be achieved using a skin-stretching device compared with scar excision with no additional techniques, without an increased risk of complications. It was shown that skin stretching is of added value for scars that cannot be excised in a one-step procedure.