Examining Disparities in Alcohol Use Testing on Burn Patient Admissions: A Call for Association Guidance.

Burn injuries are associated with as well as complicated by alcohol misuse. To date, there are no stated guidelines for alcohol testing upon burn patient admissions. This study investigated if there were associations between race and testing for alcohol upon burn admissions, controlling for demographics, burn severity (degree), and other circumstances associated with burn injuries. This study was a secondary analysis of 32 258 cases from the National Burn Data Repository. The dependent variable was whether a burn case was screened for alcohol use, and independent variables were age, gender, whether physical abuse was reported, mental health comorbidities, marital status, the severity of burns, whether the injury was work-related, injury circumstances, and etiology of injury. Controlling for independent variables, race was associated with an increased probability of having been screened for alcohol use on admission to a burn center. Data reflecting alcohol screening/testing results reported in the NBR were not included in the analysis. Study results were consistent with the possibility of bias and may have influenced decisions to screen/test for alcohol misuse/abuse in reported burn cases. It is argued these findings support the recommendation that guidelines for alcohol testing of burn patients are warranted and would benefit from specific guidance from the American Burn Association.

Assessment and Management of Acute Burn Injuries.

Burn injuries can affect patients from all walks of life and represent a significant healthcare problem globally. The skin is the largest organ of the body and consequences of injury range of minor pain to severe end-organ dysfunction and even death. The acute assessment and management of burn-injured patients is a critical part of their short-term and long-term outcomes and often benefit from specialty, multidisciplinary care. Local wound care and appropriate excision and grafting are important parts of managing the functional, cosmetic, and physiologic derangements caused by burn injuries. Large burns also require judicious fluid resuscitation. Electrical, chemical, and inhalational injuries are less common than thermal burns but require additional care and are often associated with increased morbidity.

Development and evaluation of deep learning algorithms for assessment of acute burns and the need for surgery.

Assessment of burn extent and depth are critical and require very specialized diagnosis. Automated image-based algorithms could assist in performing wound detection and classification. We aimed to develop two deep-learning algorithms that respectively identify burns, and classify whether they require surgery. An additional aim assessed the performances in different Fitzpatrick skin types. Annotated burn (n = 1105) and background (n = 536) images were collected. Using a commercially available platform for deep learning algorithms, two models were trained and validated on 70% of the images and tested on the remaining 30%. Accuracy was measured for each image using the percentage of wound area correctly identified and F1 scores for the wound identifier; and area under the receiver operating characteristic (AUC) curve, sensitivity, and specificity for the wound classifier. The wound identifier algorithm detected an average of 87.2% of the wound areas accurately in the test set. For the wound classifier algorithm, the AUC was 0.885. The wound identifier algorithm was more accurate in patients with darker skin types; the wound classifier was more accurate in patients with lighter skin types. To conclude, image-based algorithms can support the assessment of acute burns with relatively good accuracy although larger and different datasets are needed.

Initial Pain Assessment and Management in Pediatric Burn Patients Presenting to a Major Trauma Center in Saudi Arabia.

BACKGROUND: Pediatric burn injury is a traumatic experience for affected children and their families. Burn pain is frequently undertreated and may adversely affect patient experience and outcomes. The aim of this study was to investigate the current practice of initial pediatric burn pain assessment and management at a major trauma center in Riyadh, Kingdom of Saudi Arabia. METHODS: We conducted a retrospective cohort study that included children 14 years and younger who visited King Saud Medical City in the Kingdom of Saudi Arabia with a presenting complaint of burn injury from January 01, 2017 to August 30, 2018. Variables were reported using descriptive statistics as appropriate. RESULTS: The 309 patients who were analyzed were classified into 3 age groups ranging from 0 to younger than 3 years (61%), 3 to 7 years (24%), and older than 7 years (15%). They included 145 (47%) female and 164 (53%) male patients. Pain levels of 182 patients (59%) were documented using an age-appropriate tool. In 75 children (24%), pain levels were documented using an alternate tool, and the tool used was not defined for 44 children (14%). Pain assessment was not documented for 8 children. Of those with an age-appropriate tool, the median initial pain score was 4 (interquartile range [IQR], 2-4). Analgesia was recorded to have been administered to 139 patients (45%), within a median time of 50 minutes (IQR, 17-154 minutes) to first analgesia. Among patients who had appropriate assessment of pain, 92 (50.3%) received analgesia compared with 52 (41.3%) who did not have appropriate assessment (P = 0.12). Among patients who had appropriate pain assessment, time to analgesia was 42 minutes (IQR, 15-132 minutes) compared with 53 minutes (IQR, 17-189 minutes) among patients who did not have appropriate assessment (P = 0.48). DISCUSSION: Most pediatric patients presenting with burns had pain assessment, but a substantial proportion of children were not managed using recommended age-specific tools. The use of age-specific tools was not necessarily associated with delivery of analgesia. For pediatric burns, prompt delivery of analgesia should be prioritized with pain assessment using age-appropriate tools being recommended, but optional.

Application of multiple deep learning models for automatic burn wound assessment.

PURPOSE: Accurate assessment of the percentage of total body surface area (%TBSA) burned is crucial in managing burn injuries. It is difficult to estimate the size of an irregular shape by inspection. Many articles reported the discrepancy of estimating %TBSA burned by different doctors. We set up a system with multiple deep learning (DL) models for %TBSA estimation, as well as the segmentation of possibly poor-perfused deep burn regions from the entire wound. METHODS: We proposed boundary-based labeling for datasets of total burn wound and palm, whereas region-based labeling for the dataset of deep burn wound. Several powerful DL models (U-Net, PSPNet, DeeplabV3+, Mask R-CNN) with encoders ResNet101 had been trained and tested from the above datasets. With the subject distances, the %TBSA burned could be calculated by the segmentation of total burn wound area with respect to the palm size. The percentage of deep burn area could be obtained from the segmentation of deep burn area from the entire wound. RESULTS: A total of 4991 images of early burn wounds and 1050 images of palms were boundary-based labeled. 1565 out of 4994 images with deep burn were preprocessed with superpixel segmentation into small regions before labeling. DeeplabV3+ had slightly better performance in three tasks with precision: 0.90767, recall: 0.90065 for total burn wound segmentation; precision: 0.98987, recall: 0.99036 for palm segmentation; and precision: 0.90152, recall: 0.90219 for deep burn segmentation. CONCLUSION: Combining the segmentation results and clinical data, %TBSA burned, the volume of fluid for resuscitation, and the percentage of deep burn area can be automatically diagnosed by DL models with a pixel-to-pixel method. Artificial intelligence provides consistent, accurate and rapid assessments of burn wounds.

Enhanced skin burn assessment through transfer learning: a novel framework for human tissue analysis.

Visual inspection is the typical way for evaluating burns, due to the rising occurrence of burns globally, visual inspection may not be sufficient to detect skin burns because the severity of burns can vary and some burns may not be immediately apparent to the naked eye. Burns can have catastrophic and incapacitating effects and if they are not treated on time can cause scarring, organ failure, and even death. Burns are a prominent cause of considerable morbidity, but for a variety of reasons, traditional clinical approaches may struggle to effectively predict the severity of burn wounds at an early stage. Since computer-aided diagnosis is growing in popularity, our proposed study tackles the gap in artificial intelligence research, where machine learning has received a lot of attention but transfer learning has received less attention. In this paper, we describe a method that makes use of transfer learning to improve the performance of ML models, showcasing its usefulness in diverse applications. The transfer learning approach estimates the severity of skin burn damage using the image data of skin burns and uses the results to improve future methods. The DL technique consists of a basic CNN and seven distinct transfer learning model types. The photos are separated into those displaying first, second, and third-degree burns as well as those showing healthy skin using a fully connected feed-forward neural network. The results demonstrate that the accuracy of 93.87% for the basic CNN model which is significantly lower, with the VGG-16 model achieving the greatest accuracy at 97.43% and being followed by the DenseNet121 model at 96.66%. The proposed approach based on CNN and transfer learning techniques are tested on datasets from Kaggle 2022 and Maharashtra Institute of Technology open-school medical repository datasets that are clubbed together. The suggested CNN-based approach can assist healthcare professionals in promptly and precisely assessing burn damage, resulting in appropriate therapies and greatly minimising the detrimental effects of burn injuries.

Gender-based disparities in burn injuries, care and outcomes: A World Health Organization (WHO) Global Burn Registry cohort study.

BACKGROUND: We aimed to describe the gender-based disparities in burn injury patterns, care received, and mortality across national income levels. METHODS: In the WHO Global Burn Registry (GBR), we compared patient demographics, injury characteristics, care and outcomes by sex using Chi-square statistics. Logistic regression was used to identify the associations of patient sex with surgical treatment and in-hospital mortality. RESULTS: Among 6431 burn patients (38 % female; 62 % male), females less frequently received surgical treatment during index hospitalization (49 % vs 56 %, p < 0.001), and more frequently died in-hospital (26 % vs 16 %, p < 0.001) than males. Odds of in in-hospital death was 2.16 (95 % CI: 1.73-2.71) times higher among females compared to males in middle-income countries. CONCLUSIONS: Across national income levels, there appears to be important gender-based disparities among burn injury epidemiology, treatment received and outcomes that require redress. Multinational registries can be utilized to track and to evaluate initiatives to reduce gender disparities at national, regional and global levels.

The Impact of Plastic Surgery Volume on Inpatient Burn Outcomes.

BACKGROUND: Acute burn care involves multiple types of physicians. Plastic surgery offers the full spectrum of acute burn care and reconstructive surgery. The authors hypothesize that access to plastic surgery will be associated with improved inpatient outcomes in the treatment of acute burns. METHODS: Acute burn encounters with known percentage total body surface area were extracted from the National Inpatient Sample from 2012 to 2014 based on International Classification of Diseases, Ninth Edition, codes. Plastic surgery volume per facility was determined based on procedure codes for flaps, breast reconstruction, and complex hand reconstruction. Outcomes included odds of receiving a flap, patient safety indicators, and mortality. Regression models included the following variables: age, percentage total body surface area, gender, inhalation injury, comorbidities, hospital size, and urban/teaching status of hospital. RESULTS: The weighted sample included 99,510 burn admissions with a mean percentage total body surface area of 15.5 percent. The weighted median plastic surgery volume by facility was 245 cases per year. Compared with the lowest quartile, the upper three quartiles of plastic surgery volume were associated with increased likelihood of undergoing flap procedures (p < 0.03). The top quartile of plastic surgery volume was also associated with decreased odds of patient safety indicator events (p < 0.001). Plastic surgery facility volume was not significantly associated with a difference in the likelihood of inpatient death. CONCLUSIONS: Burn encounters treated at high-volume plastic surgery facilities were more likely to undergo flap operations. High-volume plastic surgery centers were also associated with a lower likelihood of inpatient complications. Therefore, where feasible, acute burn patients should be triaged to high-volume centers. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The predictive validity of the Functional Assessment for Burns - Critical Care (FAB-CC) score for discharge outcomes in major burns.

INTRODUCTION: Physical function scoring of burn ICU patients is recommended but currently validated scores are lacking. OBJECTIVE: To evaluate the predictive validity of the FAB -CC for burn ICU patients' discharge outcome. METHODS: All patients underwent daily exercise and FAB -CC screen if they were stable. Two FAB-CC scores were performed; FAB-CC1 on the first day the patient passed the FAB-CC screen, FAB-CC2 within 48 h before ICU discharge. Hospital discharge outcome was defined as transfer for further inpatient rehabilitation or home with social care versus home with no social care. 76 patients' data were entered into the analyses. We used multiple logistic regression analysis to identify variables that predict discharge outcome. RESULTS: Increasing patient age (p = 0.001), duration of ventilation (p = 0.0003), ICU Length of stay (LOS) (p = 0.0001), total hospital LOS (p < 0.0001), presence of cardiopulmonary disease (p = 0.008), neurological disorder (p = 0.0003) and psychiatric illness (p = 0.003) are positively associated with transfer for inpatient rehabilitation or home with social care. Increasing FAB-CC1 (p < 0.0001) and FAB -CC2 (p = 0.0001) are negatively associated with transfer for inpatient rehabilitation or home with social care. The most predictive model for discharge outcome combined the variables patient age, FAB-CC1, FAB-CC2 and psychiatric illness. Patient age (p = 0.01), FAB-CC1 (p = 0.02) and psychiatric illness (p = 0.009) independently predict discharge outcome. CONCLUSIONS: FAB-CC2 is associated with, and FAB-CC1 has predictive validity for, patient hospital discharge outcome. These findings, in conjunction with our earlier work, confirm clinical utility of the FAB-CC for burns ICU patients.

Epidemiology and Management of Pediatric Head and Neck Burns: An Institutional Review.

BACKGROUND: Pediatric head and neck burns (HNBs) require special attention due to the potential for long-term disfigurement, functional impairment, and psychosocial stigma. METHODS: We performed a retrospective review of patients <18 years old admitted to Grady Memorial Hospital with a diagnosis of HNB from 2009-2017. Demographic data, burn characteristics, management, and hospital course were analyzed. RESULTS: Of the 272 patients included, 65.4% were male with a mean age of 63.2 months. Burn mechanism was primarily secondary to scalding liquids (70.2%) or flames (23.9%). The average total body surface area involved was 10.3%, and 3.0% for the head/neck. Average length of stay was 5.2 days and overall mortality was 1.1%. Twenty-five patients (9.2%) required surgery in the acute setting, and 5 (1.8%) required secondary surgery for hypertrophic scarring or contracture. DISCUSSION: Pediatric HNBs occur most commonly in males <6 years old secondary to scalding liquids or open flames. Most patients can be managed nonoperatively without long-term sequelae.

Optimizing emergency management to reduce morbidity and mortality in pediatric burn patients.

Burns are a significant cause of injury-induced morbidity and mortality in pediatric patients. The spectrum of management for pediatric burn victims is vast and relies heavily on both the classification of the burn and the body systems involved. The immediate focus of management includes resuscitation and stabilization, fluid management, and pain control. Additional focus includes decreasing the risk of infection as well as improving healing and cosmetic outcomes. Discharge care and appropriate follow-up instructions need to be communicated carefully in order to avoid long-standing complications. This supplement reviews methods for accurate classification and management of the full range of burns seen in pediatric patients.

The Effect of Surgical Intervention on Pediatric Burn Injury Survival in a Resource-Poor Setting.

INTRODUCTION: Burns are one of the most common injuries sustained globally. Low- and middle-income countries (LMICs) are disproportionately affected by burn injury morbidity and mortality; African children have the highest burn mortality globally. In high-income countries, early surgical intervention has shown to improve survival. However, when applied to burn victims in LMICs, improved survival in the early excision cohort (≤5 d) was not seen. Therefore, we aimed to determine the magnitude of the effect of surgical intervention on burn injury survival. METHODS: A retrospective analysis of a prospectively collected data, utilizing the Kamuzu Central Hospital Burn Database from May 2011 to July 2019, was performed. Pediatric patients (≤12 y) were included. Patients were excluded if they underwent surgical intervention for nonacute burn care management. Bivariate analyses stratifying by type of surgical intervention was performed, comparing demographics, burn characteristics, surgical intervention, and patient mortality. Standardized estimates were adjusted using the inverse-probability of treatment weights to account for confounding. Weighted logistic regression modeling was performed to determine the odds of mortality based on if a patient underwent surgical intervention. RESULTS: During the study, 2364 patients were seen at the Kamuzu Central Hospital, 1785 (75.5%) were children ≤12 y who met inclusion criteria. In the overall cohort, 342 (19.2%) underwent operations, including split-thickness skin graft (n = 196, 57.3%), debridement (n = 116, 33.9%), escharotomy (n = 19, 5.6%), and amputation (n = 1, 0.3%). The surgery cohort was older (4.2 ± 3.1 versus 3.1 ± 2.6 y, P < 0.001) with larger percent total body surface area burns (16%, interquartile range: 10-24 versus 13%, interquartile range: 8-20, P < 0.001) than those who did not have surgery. In the propensity score-weighted logistic regression predicting survival, patients undergoing surgery after burn injury had an increased odds of survival (odds ratio: 5.24, 95% confidence interval: 2.40-11.44, P = 0.003) when compared with patients not undergoing surgery. CONCLUSIONS: In this propensity-weighted analysis, surgical intervention following burn injury increases the odds of survival by a factor of 5.24 when compared with patients not undergoing surgical intervention. Efforts to enhance burn infrastructure to deliver surgical care is imperative to attenuate burn mortality in resource-poor settings.

Cohort study evaluating management of burns in the community in clinical practice in the UK: costs and outcomes.

OBJECTIVE: To evaluate health outcomes, resource use and corresponding costs attributable to managing burns in clinical practice, from initial presentation, among a cohort of adults in the UK. DESIGN: Retrospective cohort analysis of the records of a randomly selected cohort of 260 patients from The Health Improvement Network (THIN) database who had 294 evaluable burns. SETTING: Primary and secondary care sectors in the UK. PRIMARY AND SECONDARY OUTCOME MEASURES: Patients' characteristics, wound-related health outcomes, healthcare resource use and total National Health Service (NHS) cost of patient management. RESULTS: Diagnosis was incomplete in 63% of patients' records as the location, depth and size of the burns were missing. Overall, 70% of all the burns healed within 24 months and the time to healing was a mean of 7.8 months per burn. Sixty-six per cent of burns were initially managed in the community and the other 34% were managed at accident and emergency departments. Patients' wounds were subsequently managed predominantly by practice nurses and hospital outpatient clinics. Forty-five per cent of burns had no documented dressings in the patients' records. The mean NHS cost of wound care in clinical practice over 24 months from initial presentation was an estimated £16 924 per burn, ranging from £12 002 to £40 577 for a healed and unhealed wound, respectively. CONCLUSIONS: Due to incomplete documentation in the patients' records, it is difficult to say whether the time to healing was excessive or what other confounding factors may have contributed to the delayed healing. This study indicates the need for education of general practice clinicians on the management and care of burn wounds. Furthermore, it is beholden on the burns community to determine how the poor healing rates can be improved. Strategies are required to improve documentation in patients' records, integration of care between different providers, wound healing rates and reducing infection.

Assessment of a quality improvement intervention to improve the consistency of total body surface area burn estimates between referring facilities and a pediatric burn center.

BACKGROUND: Burns are a significant source of pediatric morbidity and frequently result in transfer of care to a pediatric burn center. Data suggest that referring facilities often overestimate the total body surface area (%TBSA) of burns in comparison to the subsequent assessment at the pediatric burn center. Such discrepancies may trigger inappropriately aggressive interventions with potential for patient harm. Our baseline assessment of data from 106 patients transferred to our pediatric burn center over a one-year period showed that 59/106 (56%) patients had a %TBSA recorded at the time of transfer and 18/59 (31%) had clinically significant differences (>5% difference) in estimates between the referring facility and the pediatric burn center. METHODS: Informed by this clinical audit and a root cause analysis, we implemented practices to enhance consistency of clinical assessments between referring facilities and our pediatric burn center. These practices included the use of a common clinical assessment instrument (a standardized Lund and Browder form) that was integrated into the interfacility transfer process as well as educational outreach at referring facilities for providers who treat children with burns, prioritizing facilities with the highest number of discrepancies. RESULTS: Follow up data was reviewed 16-23 months after initiating the intervention. Cumulatively, we found significant improvement in the proportion of patients with %TBSA recorded (94% vs 56%, p < 0.001) that achieved our goal to exceed 90% and a reduction in clinically significant discrepancies that exceeded our goal of 15% (10% vs 31%, p = 0.002). CONCLUSIONS: Referring facilities often overestimate the %TBSA in comparison to the subsequent assessment at the pediatric burn center. The consistency of the %TBSA estimates can be improved by interventions that utilize the sharing of a common clinical assessment instrument and standardization of the transfer intake process.

The medico-legal assessment of asylum seeker victims in Italy.

INTRODUCTION: Changing patterns of migration has required states and governments to respond to the specific medical and legal needs of asylum seekers. Based on medical assessments undertaken at the University Institute of Legal Medicine, the present study aims to describe the cases of asylum applicants who have suffered from physical violence, including torture, and the variables involved. METHODS: Over a 10-year period, 225 survivors were examined by clinical forensic professionals from the University Institute of Legal Medicine. RESULTS: 85% of asylum applicants came from Africa, 87% were male, and the most common age group was 26-40 years old. 46% of applicants fled their country for political reasons. Blunt force injuries were reported in 45% of cases, the trunk was the most affected area of the body (40%), and applicants presented with an average of two different mechanisms of lesions and an average of four lesions each. DISCUSSION/CONCLUSION: Assessment of physical violence on asylum seekers requires the cooperation of professionals with different skillsets and training.