Iterative refinement of a histologic algorithm for burn depth categorization based on 798 consecutive burn wound biopsies.

INTRODUCTION: Our group previously reported a burn biopsy algorithm (BBA-V1) for categorizing burn wound depth. Here, we sought to promulgate a newer, simpler version of the BBA (BBA-V2). METHODS: Burn wounds undergoing excision underwent 4 mm biopsies procured every 25 cm2. Serial still photos were obtained at enrollment and at excision intraoperatively. Burn wounds assessed as likely to heal by 21 days were imaged within 72 h of injury and at 21 days. A sample of 798 burn wound biopsies were classified by both BBAV1 and BBAV2 algorithms. For nonoperative burn wounds, the proportion of healing versus nonhealing pixels at 21 days after injury were compared. RESULTS: The 798 biopsies were classified by BBAV1 as 24% SPT, 47% DPT, 28% FT and by BBAV2 as 3% SPT, 67% DPT, and 30% FT (p < 0.0001). Overall, the proportion of biopsies whose wound reclassification changed from a nonoperative to operative pathway was 21% (95% CI: 18-24%). Nonoperative wounds judged at injury as being SPT contained 12.8 million pixels. Repeat 21-day imaging revealed 11.3 million healed pixels (accuracy = 89.6% (95% CI: 89.59-89.62)). CONCLUSIONS: BBA-V2 was associated with a significantly higher concordance with visual assessment for burn wounds clinically judged as deep partial and full thickness.

Evaluation of a Deep Learning Reconstruction for High-Quality T2-Weighted Breast Magnetic Resonance Imaging.

Deep learning (DL) reconstruction techniques to improve MR image quality are becoming commercially available with the hope that they will be applicable to multiple imaging application sites and acquisition protocols. However, before clinical implementation, these methods must be validated for specific use cases. In this work, the quality of standard-of-care (SOC) T2w and a high-spatial-resolution (HR) imaging of the breast were assessed both with and without prototype DL reconstruction. Studies were performed using data collected from phantoms, 20 retrospectively collected SOC patient exams, and 56 prospectively acquired SOC and HR patient exams. Image quality was quantitatively assessed via signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), and edge sharpness. Qualitatively, all in vivo images were scored by either two or four radiologist readers using 5-point Likert scales in the following categories: artifacts, perceived sharpness, perceived SNR, and overall quality. Differences in reader scores were tested for significance. Reader preference and perception of signal intensity changes were also assessed. Application of the DL resulted in higher average SNR (1.2-2.8 times), CNR (1.0-1.8 times), and image sharpness (1.2-1.7 times). Qualitatively, the SOC acquisition with DL resulted in significantly improved image quality scores in all categories compared to non-DL images. HR acquisition with DL significantly increased SNR, sharpness, and overall quality compared to both the non-DL SOC and the non-DL HR images. The acquisition time for the HR data only required a 20% increase compared to the SOC acquisition and readers typically preferred DL images over non-DL counterparts. Overall, the DL reconstruction demonstrated improved T2w image quality in clinical breast MRI.

American Burn Association Strategic Quality Summit 2022: Setting the Direction for the Future.

The American Burn Association (ABA) hosted a Burn Care Strategic Quality Summit (SQS) in an ongoing effort to advance the quality of burn care. The goals of the SQS were to discuss and describe characteristics of quality burn care, identify goals for advancing burn care, and develop a roadmap to guide future endeavors while integrating current ABA quality programs. Forty multidisciplinary members attended the two-day event. Prior to the event, they participated in a pre-meeting webinar, reviewed relevant literature, and contemplated statements regarding their vision for improving burn care. At the in-person, professionally facilitated Summit in Chicago, Illinois, in June 2022, participants discussed various elements of quality burn care and shared ideas on future initiatives to advance burn care through small and large group interactive activities. Key outcomes of the SQS included burn-related definitions of quality care, avenues for integration of current ABA quality programs, goals for advancing quality efforts in burn care, and work streams with tasks for a roadmap to guide future burn care quality-related endeavors. Work streams included roadmap development, data strategy, quality program integration, and partners and stakeholders. This paper summarizes the goals and outcomes of the SQS and describes the status of established ABA quality programs as a launching point for futurework.

American Burn Association (ABA) Burn Care Quality Platform (BCQP) and Large Data Set Analysis Considerations: A Practical Guide to Investigating Clinical Questions in Burns via Large Data Sets.

The Burn Care Quality Platform (BCQP) consolidates data previously collected from the National Burn Repository and the Burn Quality Improvement Program into a single registry. Its data elements and their associated definitions are tailored to create consistency across other national trauma registries, namely the National Trauma Data Bank implemented by the American College of Surgeons Trauma Quality Improvement Program (ACS TQIP). The BCQP now includes 103 participating burn centers and has captured data from 375,000 total patients as of 2021. With 12,000 patients entered under the current data dictionary, the BCQP represents the largest registry of its kind. On behalf of the American Burn Association Research Committee, the aim of this whitepaper is to provide a succinct overview of the BCQP, showcasing its unique features, strengths, limitations, and relevant statistical considerations. This whitepaper will highlight the resources available to the burn research community and offer insight on proper study design when preparing to conduct a large data set investigation for burn care. All recommendations herein were formulated through the consensus of a multidisciplinary committee and based on the available scientific evidence.

Acute Surgical Management of the Burn Patient.

Burn management has developed over time to encompass care that includes more than just survival but also quality of life and successful reintegration into society. Identification of burns that require timely operative intervention supports the goals of excellent functional and aesthetic outcomes in burn survivors. Appropriate patient optimization, detailed preoperative planning, and intraoperative communication are keys to success.

Automated Placement of Scan and Pre-Scan Volumes for Breast MRI Using a Convolutional Neural Network.

Graphically prescribed patient-specific imaging volumes and local pre-scan volumes are routinely placed by MRI technologists to optimize image quality. However, manual placement of these volumes by MR technologists is time-consuming, tedious, and subject to intra- and inter-operator variability. Resolving these bottlenecks is critical with the rise in abbreviated breast MRI exams for screening purposes. This work proposes an automated approach for the placement of scan and pre-scan volumes for breast MRI. Anatomic 3-plane scout image series and associated scan volumes were retrospectively collected from 333 clinical breast exams acquired on 10 individual MRI scanners. Bilateral pre-scan volumes were also generated and reviewed in consensus by three MR physicists. A deep convolutional neural network was trained to predict both the scan and pre-scan volumes from the 3-plane scout images. The agreement between the network-predicted volumes and the clinical scan volumes or physicist-placed pre-scan volumes was evaluated using the intersection over union, the absolute distance between volume centers, and the difference in volume sizes. The scan volume model achieved a median 3D intersection over union of 0.69. The median error in scan volume location was 2.7 cm and the median size error was 2%. The median 3D intersection over union for the pre-scan placement was 0.68 with no significant difference in mean value between the left and right pre-scan volumes. The median error in the pre-scan volume location was 1.3 cm and the median size error was -2%. The average estimated uncertainty in positioning or volume size for both models ranged from 0.2 to 3.4 cm. Overall, this work demonstrates the feasibility of an automated approach for the placement of scan and pre-scan volumes based on a neural network model.

Clinical Investigation of a Rapid Non-invasive Multispectral Imaging Device Utilizing an Artificial Intelligence Algorithm for Improved Burn Assessment.

Currently, the incorrect judgment of burn depth remains common even among experienced surgeons. Contributing to this problem are change in burn appearance throughout the first week requiring periodic evaluation until a confident diagnosis can be made. To overcome these issues, we investigated the feasibility of an artificial intelligence algorithm trained with multispectral images of burn injuries to predict burn depth rapidly and accurately, including burns of indeterminate depth. In a feasibility study, 406 multispectral images of burns were collected within 72 hours of injury and then serially for up to 7 days. Simultaneously, the subject's clinician indicated whether the burn was of indeterminate depth. The final depth of burned regions within images were agreed upon by a panel of burn practitioners using biopsies and 21-day healing assessments as reference standards. We compared three convolutional neural network architectures and an ensemble in their capability to automatically highlight areas of nonhealing burn regions within images. The top algorithm was the ensemble with 81% sensitivity, 100% specificity, and 97% positive predictive value (PPV). Its sensitivity and PPV were found to increase in a sigmoid shape during the first week postburn, with the inflection point at day 2.5. Additionally, when burns were labeled as indeterminate, the algorithm's sensitivity, specificity, PPV, and negative predictive value were: 70%, 100%, 97%, and 100%. These results suggest multispectral imaging combined with artificial intelligence is feasible for detecting nonhealing burn tissue and could play an important role in aiding the earlier diagnosis of indeterminate burns.

A Brief History of RECELL® and Its Current Indications.

A concise history of the development of the RECELL® device and the seminal work of Dr. Fiona Wood will be provided, as well as the current indications and potential future prospects for the use of RECELL® in the United States.

Burn Resuscitation Practices in North America: Results of the Acute Burn ResUscitation Multicenter Prospective Trial (ABRUPT).

OBJECTIVES: ABRUPT was a prospective, noninterventional, observational study of resuscitation practices at 21 burn centers. The primary goal was to examine burn resuscitation with albumin or crystalloids alone, to design a future prospective randomized trial. SUMMARY BACKGROUND DATA: No modern prospective study has determined whether to use colloids or crystalloids for acute burn resuscitation. METHODS: Patients ≥18 years with burns ≥ 20% total body surface area (TBSA) had hourly documentation of resuscitation parameters for 48 hours. Patients received either crystalloids alone or had albumin supplemented to crystalloid based on center protocols. RESULTS: Of 379 enrollees, two-thirds (253) were resuscitated with albumin and one-third (126) were resuscitated with crystalloid alone. Albumin patients received more total fluid than Crystalloid patients (5.2 ± 2.3 vs 3.7 ± 1.7 mL/kg/% TBSA burn/24 hours), but patients in the Albumin Group were older, had larger burns, higher admission Sequential Organ Failure Assessment (SOFA) scores, and more inhalation injury. Albumin lowered the in-to-out (I/O) ratio and was started ≤12 hours in patients with the highest initial fluid requirements, given >12 hours with intermediate requirements, and avoided in patients who responded to crystalloid alone. CONCLUSIONS: Albumin use is associated with older age, larger and deeper burns, and more severe organ dysfunction at presentation. Albumin supplementation is started when initial crystalloid rates are above expected targets and improves the I/O ratio. The fluid received in the first 24 hours was at or above the Parkland Formula estimate.

DEEP FACTOR MODEL: A NOVEL APPROACH FOR MOTION COMPENSATED MULTI-DIMENSIONAL MRI.

Recent quantitative parameter mapping methods including MR fingerprinting (MRF) collect a time series of images that capture the evolution of magnetization. The focus of this work is to introduce a novel approach termed as Deep Factor Model(DFM), which offers an efficient representation of the multi-contrast image time series. The higher efficiency of the representation enables the acquisition of the images in a highly undersampled fashion, which translates to reduced scan time in 3D high-resolution multi-contrast applications. The approach integrates motion estimation and compensation, making the approach robust to subject motion during the scan.

The Influence of Data-Driven Compressed Sensing Reconstruction on Quantitative Pharmacokinetic Analysis in Breast DCE MRI.

Radial acquisition with MOCCO reconstruction has been previously proposed for high spatial and temporal resolution breast DCE imaging. In this work, we characterize MOCCO across a wide range of temporal contrast enhancement in a digital reference object (DRO). Time-resolved radial data was simulated using a DRO with lesions in different PK parameters. The under sampled data were reconstructed at 5 s temporal resolution using the data-driven low-rank temporal model for MOCCO, compressed sensing with temporal total variation (CS-TV) and more conventional low-rank reconstruction (PCB). Our results demonstrated that MOCCO was able to recover curves with Ktrans values ranging from 0.01 to 0.8 min-1 and fixed Ve = 0.3, where the fitted results are within a 10% bias error range. MOCCO reconstruction showed less impact on the selection of different temporal models than conventional low-rank reconstruction and the greater error was observed with PCB. CS-TV showed overall underestimation in both Ktrans and Ve. For the Monte-Carlo simulations, MOCCO was found to provide the most accurate reconstruction results for curves with intermediate lesion kinetics in the presence of noise. Initial in vivo experiences are reported in one patient volunteer. Overall, MOCCO was able to provide reconstructed time-series data that resulted in a more accurate measurement of PK parameters than PCB and CS-TV.

Bismuth/petroleum gauze plus high density polyethylene vs. bismuth/petroleum gauze: A comparison of donor site healing and patient comfort.

INTRODUCTION: Skin grafting continues to be a fundamental component of burn treatment and inherently, a donor site must be created and treated. Burn surgeons agree that specific dressings may have a significant affect on donor site healing, but we have no consensus as to which dressing provides maximum benefit. METHODS: Retrospective analysis of prospectively collected data from an observational, within-patient controlled assessment of a practice pattern intervention. The project compared donor sites treated with high-density polyethylene plus an overlying layer of bismuth/petroleum gauze to donor sites treated with bismuth/petroleum gauze alone. The primary endpoint was patient reported pain using a standard visual analog scale from 0 (no pain) to 10 (worst possible pain). A 2-point reduction in pain was considered clinically significant. Healing was defined as complete detachment of the dressings and> 95% wound re-epitheliazation. RESULTS: A total of 30 patients were observed and analyzed. Both dressings were associated with a mean pain rating of 6 out of 10 (STD= ± 2) and a median pain rating of 6 out of 10 (range = 0-10). Additionally, both dressings were associated with a mean healing time of 20 days (SEM=1.1). The subjective dressing preference showed that a majority of patients had no preference between the two modalities (n = 20). However, when an actual preference was stated (n = 10), bismuth/petroleum gauze alone was preferred by 9 out of 10 patients. CONCLUSION: Clinically and subjectively, we found no discernible differences between the 2 dressing regimens. Thus, bismuth/petroleum gauze alone is the more cost effective dressing choice. Our burn center continues to use bismuth/petroleum gauze alone as its standard of care for donor site dressings and will continue to try to define the optimal donor site dressing.

Evaluating Real-World National and Regional Trends in Definitive Closure in U.S. Burn Care: A Survey of U.S. Burn Centers.

To better understand trends in burn treatment patterns related to definitive closure, this study sought to benchmark real-world survey data with national data contained within the National Burn Repository version 8.0 (NBR v8.0) across key burn center practice patterns, resource utilization, and clinical outcomes. A survey, administered to a representative sample of U.S. burn surgeons, collected information across several domains: burn center characteristics, patient characteristics including number of patients and burn size and depth, aggregate number of procedures, resource use such as autograft procedure time and dressing changes, and costs. Survey findings were aggregated by key outcomes (number of procedures, costs) nationally and regionally. Aggregated burn center data were also compared to the NBR to identify trends relative to current treatment patterns. Benchmarking survey results against the NBR v8.0 demonstrated shifts in burn center patient mix, with more severe cases being seen in the inpatient setting and less severe burns moving to the outpatient setting. An overall reduction in the number of autograft procedures was observed compared to NBR v8.0, and time efficiencies improved as the intervention time per TBSA decreases as TBSA increases. Both nationally and regionally, an increase in costs was observed. The results suggest resource use estimates from NBR v8.0 may be higher than current practices, thus highlighting the importance of improved and timely NBR reporting and further research on burn center standard of care practices. This study demonstrates significant variations in burn center characteristics, practice patterns, and resource utilization, thus increasing our understanding of burn center operations and behavior.

A phase 3, open-label, controlled, randomized, multicenter trial evaluating the efficacy and safety of StrataGraft® construct in patients with deep partial-thickness thermal burns.

OBJECTIVE: This phase 3 study evaluated StrataGraft construct as a donor-site sparing alternative to autograft in patients with deep partial-thickness (DPT) burns. METHODS: Patients aged ≥18 years with 3-49% total body surface area (TBSA) thermal burns were enrolled. In each patient, 2 DPT areas (≤2000cm2 total) of comparable depth after excision were randomized to either cryopreserved StrataGraft or autograft. Coprimary endpoints were: the difference in percent area of StrataGraft treatment site and autograft treatment site autografted at Month 3 (M3), and the proportion of patients achieving durable wound closure of the StrataGraft site without autograft at M3. Safety assessments were performed in all patients. Efficacy and safety follow-up continued to 1 year. RESULTS: Seventy-one patients were enrolled. By M3, there was a 96% reduction in mean percent area of StrataGraft treatment sites that required autografting, compared with autograft treatment sites (4.3% vs 102.1%, respectively; P<.0001). StrataGraft treatment resulted in durable wound closure at M3 without autografting in 92% (95% CI: 85.6, 98.8; n/n 59/64) of patients for whom data were available. The most common StrataGraft-related adverse event was pruritus (15%). CONCLUSIONS: Both coprimary endpoints were achieved. StrataGraft may offer a new treatment for DPT burns to reduce the need for autografting. CLINICAL TRIAL IDENTIFIER: NCT03005106.

Characteristics of Burn-Injured Children in 117 U.S. PICUs (2009-2017): A Retrospective Virtual Pediatric Systems Database Study.

OBJECTIVES: To describe characteristics and outcomes of children with burn injury treated in U.S. PICUs. DESIGN: Retrospective study of admissions in the Virtual Pediatric Systems, LLC, database from 2009 to 2017. SETTING: One hundred and seventeen PICUs in the United States. PATIENTS: Patients less than 18 years old admitted with an active diagnosis of burn at admission. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 2,056 patients were included. They were predominantly male (62.6%) and less than 6 years old (66.7%). Cutaneous burns were recorded in 92.1% of patients, mouth/pharynx burns in 5.8%, inhalation injury in 5.1%, and larynx/trachea/lung burns in 4.5%. Among those with an etiology recorded (n = 861), scald was most common (38.6%), particularly in children less than 2 years old (67.8%). Fire/flame burns were most common (46.6%) in children greater than or equal to 2 years. Multiple organ failure was present in 26.2% of patients. Most patients (89%) were at facilities without American Burn Association pediatric verification. PICU mortality occurred in 4.5% of patients. On multivariable analysis using Pediatric Index of Mortality 2, greater than or equal to 30% total body surface area burned was significantly associated with mortality (odds ratio, 5.40; 95% CI, 2.16-13.51; p = 0.0003). When Pediatric Risk of Mortality III was used, greater than or equal to 30% total body surface area burned (odds ratio, 5.45; 95% CI, 1.95-15.26; p = 0.001) and inhalation injury (odds ratio, 5.39; 95% CI, 1.58-18.42; p = 0.007) were significantly associated with mortality. Among 366 survivors (18.6%) with Pediatric Cerebral Performance Category or Pediatric Overall Performance Category data, 190 (51.9%) had a greater than or equal to 1 point increase in Pediatric Cerebral Performance Category or Pediatric Overall Performance Category disability category and 80 (21.9%) had a new designation of moderate or severe disability, or persistent vegetative state. CONCLUSIONS: Burn-injured patients in U.S. PICUs have a substantial burden of organ failure, morbidity, and mortality. Coordination among specialized facilities may be particularly important in this population, especially for those with higher % total body surface area burned or inhalation injury.

Spatial dependency and the role of local susceptibility for velocity selective arterial spin labeling (VS-ASL) relative tagging efficiency using accelerated 3D radial sampling with a BIR-8 preparation.

PURPOSE: Velocity selective arterial spin labeling (VS-ASL) is a promising approach for non-contrast perfusion imaging that provides robustness to vascular geometry and transit times; however, VS-ASL assumes spatially uniform tagging efficiency. This work presents a mapping approach to investigate VS-ASL relative tagging efficiency including the impact of local susceptibility effects on a BIR-8 preparation. METHODS: Numerical simulations of tagging efficiency were performed to evaluate sensitivity to regionally varying local susceptibility gradients and blood velocity. Tagging efficiency mapping was performed in susceptibility phantoms and healthy human subjects (N = 7) using a VS-ASL preparation module followed by a short, high spatial resolution 3D radial-based image acquisition. Tagging efficiency maps were compared to 4D-flow, B1 , and B0 maps acquired in the same imaging session for six of the seven subjects. RESULTS: Numerical simulations were found to predict reduced tagging efficiency with the combination of high blood velocity and local gradient fields. Phantom experiments corroborated numerical results. Relative efficiency mapping in normal volunteers showed unique efficiency patterns depending on individual subject anatomy and physiology. Uniform tagging efficiency was generally observed in vivo, but reduced efficiency was noted in regions of high blood velocity and local susceptibility gradients. CONCLUSION: We demonstrate an approach to map the relative tagging efficiency and show application of this methodology to a novel BIR-8 preparation recently proposed in the literature. We present results showing rapid flow in the presence of local susceptibility gradients can lead to complicated signal modulations in both tag and control images and reduced tagging efficiency.

Determining clinically meaningful thresholds for innovative burn care products to reduce autograft: A US burn surgeon Delphi panel.

Reducing the amount of donor skin needed for definitive wound closure can improve outcomes in patients with severe burns. This Delphi Consensus Panel (DCP) aimed to achieve expert consensus on the percentage reduction in donor skin for autograft that constitutes a clinically meaningful benefit. A two-round DCP of fifteen US burn surgeons was conducted via a web-based survey platform. Fourteen panelists (93.3%) completed both rounds. In Round 2, consensus, defined as ≥70% agreement, was achieved for five of the seven consensus statements. All panelists agreed that a clinically meaningful reduction in the amount of donor skin required would facilitate wound management and decrease donor site morbidity experienced by patients. Furthermore, based on three treatment scenarios, consensus was achieved for a clinically meaningful reduction in the amount of donor skin required for autograft for the adult population in deep partial-thickness and full-thickness burns. Findings from this DCP indicate that an innovative cellular and/or tissue product that would reduce the needed amount of donor skin, by the identified thresholds, has the potential to improve the outcomes for patients with severe burn injuries in a meaningful way.