Artificial intelligence in the management and treatment of burns: A systematic review and meta-analyses.

INTRODUCTION AND AIM: Artificial Intelligence (AI) is already being successfully employed to aid the interpretation of multiple facets of burns care. In the light of the growing influence of AI, this systematic review and diagnostic test accuracy meta-analyses aim to appraise and summarise the current direction of research in this field. METHOD: A systematic literature review was conducted of relevant studies published between 1990 and 2021, yielding 35 studies. Twelve studies were suitable for a Diagnostic Test Meta-Analyses. RESULTS: The studies generally focussed on burn depth (Accuracy 68.9%-95.4%, Sensitivity 90.8% and Specificity 84.4%), burn segmentation (Accuracy 76.0%-99.4%, Sensitivity 97.9% and specificity 97.6%) and burn related mortality (Accuracy >90%-97.5% Sensitivity 92.9% and specificity 93.4%). Neural networks were the most common machine learning (ML) algorithm utilised in 69% of the studies. The QUADAS-2 tool identified significant heterogeneity between studies. DISCUSSION: The potential application of AI in the management of burns patients is promising, especially given its propitious results across a spectrum of dimensions, including burn depth, size, mortality, related sepsis and acute kidney injuries. The accuracy of the results analysed within this study is comparable to current practices in burns care. CONCLUSION: The application of AI in the treatment and management of burns patients, as a series of point of care diagnostic adjuncts, is promising. Whilst AI is a potentially valuable tool, a full evaluation of its current utility and potential is limited by significant variations in research methodology and reporting.

Burns objective scar scale (BOSS): Validation of an objective measurement devices based burn scar scale panel.

AIMS: Hypertrophic scars in burn survivors are a major cause of morbidity but the development of evidence based treatments is hampered by the lack of objective measurements of these scars. The objective of our study is to investigate the most accurate parameters for objective scar assessment and to create a combination score to facilitate the use of a panel of objective scar measurement tools. METHODS: Three independent assessors evaluated fifty five scar sites on fifty five burn patients with both the subjective modified Vancouver Scar Scale (mVSS) and a panel of objective measurement tools including the DSM II Colormeter, Cutometer, Dermascan high frequency ultrasound. The sensitivity and specificity of the objective scar parameters in predicting a mVSS score of 6 or more using the Receiving Operator Characteristic Area under the curve (ROC AUC) was then calculated and the most accurate parameters were combined to create an objective global scar score. RESULTS: The ROC AUC values were found to be highest for the Dermascan scar thickness (0.897), dermal intensity and intensity ratio (0.914 and 0.919), Cutometer R0 value (0.942), and R0 ratio (0.944). For colour measurements, ratios of scar to normal skin performed better than the single parameters for both erythema and pigmentation measurements: DSM II Erythema ratio vs Erythema (0.885 vs 0.818), DSM II a* ratio vs a* (0.848 vs 0.741); DSM II Melanin ratio vs Melanin (0.854 vs 0.761), DSM II L* ratio vs L* (0.862 vs 0.767). Analysis of the ROC AUC with chi-square test values showed that the highest AUC (0.786) was obtained with the combination of the Cutometer R0, Dermascan scar thickness, intensity and their respective scar to normal skin ratios. A total score of 5 and above (out of 6 parameters) had the highest combined sensitivity (69.0%) and specificity (83.3%). CONCLUSION: The objective parameters for the DSM II Colormeter, Cutometer and Dermascan high frequency ultrasound were all found to have moderate to strong ROC AUC values and combination of the Cutometer R0 and Dermascan scar thickness and intensity values can be used to create an objective global scar scale that can accurately differentiate patients with hypertrophic burn scarring from non-hypertrophic scars or normal skin.

Dysregulation of the actin scavenging system and inhibition of DNase activity following severe thermal injury.

BACKGROUND: Circulating cell-free DNA (cfDNA) is not found in healthy subjects, but is readily detected after thermal injury and may contribute to the risk of multiple organ failure. The hypothesis was that a postburn reduction in DNase protein/enzyme activity could contribute to the increase in cfDNA following thermal injury. METHODS: Patients with severe burns covering at least 15 per cent of total body surface area were recruited to a prospective cohort study within 24 h of injury. Blood samples were collected from the day of injury for 12 months. RESULTS: Analysis of blood samples from 64 patients revealed a significant reduction in DNase activity on days 1-28 after injury, compared with healthy controls. DNase protein levels were not affected, suggesting the presence of an enzyme inhibitor. Further analysis revealed that actin (an inhibitor of DNase) was present in serum samples from patients but not those from controls, and concentrations of the actin scavenging proteins gelsolin and vitamin D-binding protein were significantly reduced after burn injury. In a pilot study of ten military patients with polytrauma, administration of blood products resulted in an increase in DNase activity and gelsolin levels. CONCLUSION: The results of this study suggest a novel biological mechanism for the accumulation of cfDNA following thermal injury by which high levels of actin released by damaged tissue cause a reduction in DNase activity. Restoration of the actin scavenging system could therefore restore DNase activity, and reduce the risk of cfDNA-induced host tissue damage and thrombosis.

ANTECEDENTES: El ADN libre de las células circulantes (circulating cell-free DNA, cfDNA) no se encuentra en sujetos sanos, pero se detecta fácilmente después de una lesión térmica y puede contribuir al riesgo de fallo multiorgánico. La hipótesis fue que una disminución en la actividad de la proteína/enzima ADNasa tras la lesión térmica podría contribuir a la elevación del cfDNA que ocurre tras la misma. MÉTODOS: Los pacientes con quemaduras graves con una extensión ≥ 15% del área de superficie corporal total (total body surface area, TBSA) se incluyeron en un estudio prospectivo de cohortes durante las primeras 24 horas posteriores a la lesión. Se recogieron muestras de sangre desde el día de la lesión hasta los 12 meses posteriores a la misma. RESULTADOS: El análisis de muestras de sangre de 64 pacientes reveló una reducción significativa de la actividad de la ADNasa en los días 1 a 28 después de la lesión, en comparación con los controles sanos. Los niveles de proteína ADNasa no se vieron afectados, lo que sugiere la presencia de un inhibidor enzimático. Un análisis adicional reveló que la actina (un inhibidor de la ADNasa) estaba presente en las muestras de suero de los pacientes, pero no en los controles, y las concentraciones de la gelsolina, proteína que causa la disociación de la actina, y la proteína de unión a la vitamina D se redujeron significativamente después de la lesión térmica. En un estudio piloto de 10 pacientes con politrauma por lesiones militares, la administración de hemoderivados produjo un aumento en la actividad de la ADNasa y de los niveles de gelsolina. CONCLUSIÓN: Este estudio sugiere un nuevo mecanismo biológico para la acumulación de cfDNA después de una lesión térmica, por el cual los altos niveles de actina liberada por el tejido dañado causarían una reducción en la actividad de la ADNasa. La restauración del sistema eliminador de actina podría, por lo tanto, restaurar la actividad de la ADNasa y reducir el riesgo de daño tisular y trombosis en el huésped inducido por el cfDNA.

Investigating the intra- and inter-rater reliability of a panel of subjective and objective burn scar measurement tools.

BACKGROUND: Research into the treatment of hypertrophic burn scar is hampered by the variability and subjectivity of existing outcome measures. This study aims to measure the inter- and intra-rater reliability of a panel of subjective and objective burn scar measurement tools. METHODS: Three independent assessors evaluated 55 scar and normal skin sites using subjective (modified Vancouver Scar Scale [mVSS] & Patient and Observer Scar Assessment Scale [POSAS]) and objective tools. The intra-class correlation coefficient was utilised to measure reliability (acceptable when >0.70). Patient satisfaction with the different tools and scar parameter importance were assessed via questionnaires. RESULTS: The inter-rater reliabilities of the mVSS and POSAS were below the acceptable limit. For erythema and pigmentation, all of the Scanoskin and DSM II measures (except the b* value) had acceptable to excellent intra and inter-rater reliability. The Dermascan ultrasound (dermal thickness, intensity) had excellent intra- and inter-rater reliability (>0.90). The Cutometer R0 (firmness) had acceptable reliability but not R2 (gross elasticity). All objective measurement tools had good overall satisfaction scores. Patients rated scar related pain and itch as more important compared to appearance although this finding was not sustained when corrected for multiple comparisons. CONCLUSION: The objective scar measures demonstrated acceptable to excellent intra- and inter-rater reliability and performed better than the subjective scar scales.

A gellan-based fluid gel carrier to enhance topical spray delivery.

Autologous cell transplantation was introduced to clinical practice nearly four decades ago to enhance burn wound re-epithelialisation. Autologous cultured or uncultured cells are often delivered to the surface in saline-like suspensions. This delivery method is limited because droplets of the sprayed suspension form upon deposition and run across the wound bed, leading to uneven coverage and cell loss. One way to circumvent this problem would be to use a gel-based material to enhance surface retention. Fibrin systems have been explored as co-delivery system with keratinocytes or as adjunct to 'seal' the cells following spray delivery, but the high costs and need for autologous blood has impeded its widespread use. Aside from fibrin gel, which can exhibit variable properties, it has not been possible to develop a gel-based carrier that solidifies on the skin surface. This is because it is challenging to develop a material that is sprayable but gels on contact with the skin surface. The manuscript reports the use of an engineered carrier device to deliver cells via spraying, to enhance retention upon a wound. The device involves shear-structuring of a gelling biopolymer, gellan, during the gelation process; forming a yield-stress fluid with shear-sensitive behaviours, known as a fluid gel. In this study, a formulation of gellan gum fluid gels are reported, formed with from 0.75 or 0.9% (w/v) polymer and varying the salt concentrations. The rheological properties and the propensity of the material to wet a surface were determined for polymer modified and non-polymer modified cell suspensions. The gellan fluid gels had a significantly higher viscosity and contact angle when compared to the non-polymer carrier. Viability of cells was not impeded by encapsulation in the gellan fluid gel or spraying. The shear thinning property of the material enabled it to be applied using an airbrush and spray angle, distance and air pressure were optimised for coverage and viability. STATEMENT OF SIGNIFICANCE: Spray delivery of skin cells has successfully translated to clinical practice. However, it has not yet been widely accepted due to limited retention and disputable cell viability in the wound. Here, we report a method for delivering cells onto wound surfaces using a gellan-based shear-thinning gel system. The viscoelastic properties allow the material to liquefy upon spraying and restructure rapidly on the surface. Our results demonstrate reduced run-off from the surface compared to currently used low-viscosity cell carriers. Moreover, encapsulated cells remain viable throughout the process. Although this paper studies the encapsulation of one cell type, a similar approach could potentially be adopted for other cell types. Our data supports further studies to confirm these results in in vivo models.

The influence of sex steroid hormones on the response to trauma and burn injury.

Trauma and related sequelae result in disturbance of homeostatic mechanisms frequently leading to cellular dysfunction and ultimately organ and system failure. Regardless of the type and severity of injury, gender dimorphism in outcomes following trauma have been reported, with females having lower mortality than males, suggesting that sex steroid hormones (SSH) play an important role in the response of body systems to trauma. In addition, several clinical and experimental studies have demonstrated the effects of SSH on the clinical course and outcomes following injury. Animal studies have reported the ability of SSH to modulate immune, inflammatory, metabolic and organ responses following traumatic injury. This indicates that homeostatic mechanisms, via direct and indirect pathways, can be maintained by SSH at local and systemic levels and hence result in more favourable prognosis. Here, we discuss the role and mechanisms by which SSH modulates the response of the body to injury by maintaining various processes and organ functions. Such properties of sex hormones represent potential novel therapeutic strategies and further our understanding of current therapies used following injury such as oxandrolone in burn-injured patients.

Changes in novel haematological parameters following thermal injury: A prospective observational cohort study.

The mortality caused by sepsis is high following thermal injury. Diagnosis is difficult due to the ongoing systemic inflammatory response. Previous studies suggest that cellular parameters may show promise as diagnostic markers of sepsis. The aim of this study was to evaluate the effect of thermal injury on novel haematological parameters and to study their association with clinical outcomes. Haematological analysis was performed using a Sysmex XN-1000 analyser on blood samples acquired on the day of the thermal injury to 12 months post-injury in 39 patients (15-95% TBSA). Platelet counts had a nadir at day 3 followed by a rebound thrombocytosis at day 21, with nadir values significantly lower in septic patients. Measurements of extended neutrophil parameters (NEUT-Y and NEUT-RI) demonstrated that septic patients had significantly higher levels of neutrophil nucleic acid content. A combination of platelet impedance count (PLT-I) and NEUT-Y at day 3 post-injury exhibited good discriminatory power for the identifying septic patients (AUROC = 0.915, 95% CI [0.827, 1.000]). Importantly, the model had improved performance when adjusted for mortality with an AUROC of 0.974 (0.931, 1.000). A combination of PLT-I and NEUT-Y show potential for the early diagnosis of sepsis post-burn injury. Importantly, these tests can be performed rapidly and require a small volume of whole blood highlighting their potential utility in clinical practice.

The clinical efficacy of Diphoterine® in the management of cutaneous chemical burns: a 2-year evaluation study.

Diphoterine(®) is an amphoteric irrigating agent for the treatment of chemical burns and rapidly neutralises both acids and alkalis faster than water alone. Diphoterine(®) is widely used as a first aid agent in a wide range of industries globally. This is a retrospective review of the clinical use of Diphoterine(®) on chemical burns in an adult tertiary referral burn centre, often with a delay of several hours after the injury. patients admitted with chemical burns within 24 hours of the incident with an abnormal wound pH or in pain, were treated with Diphoterine(®) spray. Over a 32-month period, 1,875 burn referrals were admitted of which 131 (7%) were chemical burns. Diphoterine(®) was used in 47 patients (36%). The male to female ratio for the 131 patients was 4:1. Alkaline burns were the commonest (55%). patients who received Diphoterine(®) were significantly younger (38 vs 43 years; p=0.05) and presented earlier (0.5 vs 2.55 days; p=0.004). There was a significant change in the wound pH pre- and post-application of Diphoterine(®), compared to patients who were treated with water irrigation only, with a pH change of 1.076 vs 0.4 (p <0.05). There was no significant difference in the time to healing, the length of hospital stay, or need for surgery. in conclusion, based on our retrospective cohort, Diphoterine(®) could be a valuable tool for use in hospital settings to neutralise both alkaline and acid burns.

La solution Diphotérine® est un agent d'irrigation amphotère pour le traitement des brûlures chimiques qui neutralise les acides et alcalis plus rapidement que l'eau seule. La Diphotérine® est largement utilisé comme un premier agent de l'aide dans un large éventail d'industries au monde. Nous présentons une revue rétrospective de l'utilisation clinique de la Diphotérine® sur les brûlures chimiques. Cette revue se base sur les données d'un centre de référence tertiaire pour les brûlés adultes où souvent les patients se sont présentés avec un retard de plusieurs heures après la blessure. Tous les patients atteints de brûlures chimiques, admis entre les 24 heures suivant l'incident dans la douleur ou avec le pH anormale de la plaie, ont été traités avec la Diphotérine® appliquée par pulvérisation. Sur une période de 32 mois, 1 875 références de brûlures ont été admis dont 131 (7%) étaient des brûlures chimiques. La Diphotérine® a été utilisée chez 47 patients (36%). Le rapport hommes-femmes pour les 131 patients était de 4: 1. Les brûlures alcalines étaient les plus fréquentes (55%). Les patients qui ont reçu la Diphotérine® étaient significativement plus jeunes (38 v 43; p = 0,05) et si sont présentés plus tôt par rapport aux patients plus âgés (0,5 v 2,55 jours; p = 0,004). Il y avait un changement significatif dans le pH avant et aprés l'application de la Diphotérine®, par rapport aux patients qui ont été traités avec l'irrigation de l'eau seulement, avec un changement de pH de 1,076 v 0,4 (p <0,05). Il n'y avait pas de différence significative dans le temps de la guérison, la durée de séjour à l'hôpital, ou le besoin de chirurgie. En conclusion, sur la base de notre cohorte rétrospective, la Diphotérine® pourrait être un outil précieux en milieu hospitalier pour neutraliser des brûlures alcalines et à l'acide.

Is a self-inflicted burn part of a repeated self-harm pattern?

Self-inflicted burns (SIB) consistently account for a small proportion of burn injuries. There is a wide spectrum of SIB, from minor burns through to major life threatening burn injuries in suicidal patients who have committed self-immolation. Non-fatal deliberate self-harm (DSH) is a common reason for presenting to hospital. This occurs in many forms including wounding, burning and poisoning to name a few. Such behaviours are commonly repeated, sometimes with increasing severity. DSH is a major risk factor for subsequent suicide. We had observed patterns of repeated self harm behaviours in patients presenting to our centre with SIB. Patterns of repeated DSH in those presenting with self-inflicted burns have not previously been described in the literature. In a five-year period (2008 to 2012) 84 patients presented to our burns centre with SIB. Within this population, 39 patients (46%) were identified on a national database as having been admitted to an acute National Health Service (NHS) trust somewhere in the UK with sequelae of deliberate self-harm. There had been a total of 128 additional hospital admissions. In the majority of cases (85%) another admission preceded the presentation to our service with SIB. Only four out of the 17 SIB patients (24%) who died of their injuries had previous hospital admissions with DSH. This lends weight to the need for thorough holistic assessment of any patient admitted to hospital with sequelae of deliberate self-harm in order to try and provide appropriate support and interventions for these vulnerable individuals to prevent recurrent self-harm or suicide.

Les brûlures auto-infligées ne représentent qu'une faible proportion de ce traumatisme. Il existe un large éventail de ce type de lésions depuis les blessures mineures jusqu'aux brûlures graves chez les patients suicidaires. L'automutilation survient sous de nombreuses formes. Ces comportements sont souvent récidivants, parfois avec sévérité croissante, et représentent un facteur de risque majeur de suicide ultérieur. Nous avons observé des cas de comportements répétés d'automutilation chez nos patients. Dans une période de cinq ans (2008-2012) 84 patients ont été admis dans notre centre avec des brûlures auto-infligées. Dans cette population, 39 patients (46%) ont été identifiés sur une base de données nationale comme ayant été admis dans une Association du Service National de Santé britannique quelque part dans le Royaume-Uni avec des séquelles d'automutilation. Il y avait eu un total de 128 hospitalisations supplémentaires. Dans la majorité des cas (85%) une autre admission précédait l'arrivée dans notre service. Seulement 4 des 17 patients (24%) morts de leurs blessures avaient eu des hospitalisations précédentes pour automutilation. Cela montre la nécessité d'une évaluation globale approfondie de tout patient admis à l'hôpital avec des séquelles d'automutilation, afin d'intervenir par une prise en charge appropriée de ces personnes vulnérables et prévenir l'automutilation ou la récidive de la tentative de suicide.

Parental authority to refuse acute burn treatment versus the protection our children deserve.

Our society has empowered parents to care for their children and take legally binding decisions on their behalf. One of the areas where such decision making is required is in medical care when a child's health is at stake. Three cases of child abuse and neglect were identified and reported. Literature searches were done to identify cases of child abuse in Kuwait using Medline and PubMed. News of child abuse was searched for using search engines (bbc.co.uk, cnn.com, and foxnews.com). The British Child Protection Act and the Kuwaiti Criminal Prosecution Code were studied. Child abuse and neglect exist in Kuwait and are probably underreported. The laws in Kuwait are designed to punish child abuse once it has occurred rather than aiming at preventing it. It is reported that 75% of those responsible for child abuse are the parents. They retain full authority to restrict medical access. Medical staff are offered very limited support and are restricted as to what they can achieve due to the Kuwaiti legal infrastructure, which should be amended so as to protect children rather than prosecute offenders. A local authority has to be established and empowered to investigate, report, and act when suspicions of child abuse arise.

Notre société a habilité les parents à s'occuper de leurs enfants et de prendre des décisions juridiquement contraignantes en leur nom. L'un des domaines où une telle prise de décision est nécessaire, c'est dans les soins médicaux lorsque la santé de l'enfant est en cause. Trois cas d'abus et de négligence envers des enfants ont été identifiés et signalés. Des recherches documentaires ont été effectuées pour identifier les cas de maltraitance d'enfants au Koweït en utilisant Medline et PubMed. Les informations sur les abus en âge pédiatrique ont été recherchées en utilisant les moteurs de recherche bbc.co.uk, cnn.com et foxnews.com. La loi sur la protection des enfants dans le Royaume Uni et le Code de procédure criminelle koweïtienne ont été étudiés. La maltraitance des enfants et la négligence existent au Koweït et sont probablement sous-estimées. Les lois du Koweït visent à punir la maltraitance des enfants une fois vérifiée plutôt que de viser à la prévenir. Il est rapporté que 75% des responsables de la maltraitance des enfants sont les parents, qui conservent tous les pouvoirs pour limiter l'accès médical. Le personnel médical possède un soutien très limité et sont limités quant à ce qu'ils peuvent réaliser grâce à l'infrastructure juridique du Koweït. L'infrastructure juridique du pays Koweït doit être modifiée pour protéger les enfants plutôt que de poursuivre les contrevenants. Une autorité locale doit être établie et habilitée à enquêter, rapporter et agir lorsque les soupçons de maltraitance surviennent.

The antibacterial activity and stability of acetic acid.

Acetic acid has been shown to have good antibacterial activity against micro-organisms such as Pseudomonas aeruginosa. This study examined the activity against a range of bacterial pathogens and also assessed any reduction in antibacterial activity due to evaporation or inactivation by organic material in dressings. Acetic acid was active at dilutions as low as 0.166% and the activity was not reduced by evaporation nor by inactivation by cotton swabs. Burn injuries are a major problem in countries with limited resources. Acetic acid is an ideal candidate for use in patients who are treated in those parts of the world.

The use of Osmed(TM) tissue expanders in paediatric burns reconstruction.

Background. Tissue expansion has been a major advance in reconstructive burn surgery. The conventional tissue expander requires serial filling with the possibility of painful procedures, which can be a major challenge and source of anxiety in children. The osmotic self-inflating tissue expander, on the other hand, is a device that does not require external filling, offering apparent benefits particularly in the paediatric population. We used Osmed(TM) tissue expanders for secondary burn reconstruction in children and teenagers who had sustained burns during childhood. Methods. Patients who were treated with Osmed(TM) expanders for secondary burns reconstruction were recorded. Patient demographics (i.e. burn injury data, indications for surgery), Osmed(TM) tissue expander data (i.e. operative data, complications, problems encountered during and after treatment, explantation time, final expander volume) and overall success were recorded. Results. Twelve Osmed(TM) self-inflating tissue expanders were used in patients for secondary burns reconstruction between October 2007 and January 2009. All our patients sustained their burns during childhood. There were three females and one male; the age range was 14-19 yr (mean age, 16 yr). Tissue expanders were removed on average at 6-7 weeks except in two patients. We noted four complications in our cohort. Overall the mean expansion was 65% of the proposed final volume. Discussion. We found the Osmed(TM) tissue expander simple to implant and well tolerated by our patients. However, none of the devices achieved full expansion and overexpansion was not possible. We believe conventional tissue expanders are still the gold standard, although osmotic expanders may have a role in burn reconstruction in younger children.

Epidemiology and outcome of burns at the Saud Al Babtain Burns, Plastic Surgery and Reconstructive Center, Kuwait: our experience over five years (from 2006 to 2010).

Aim To determine the epidemiology and clinical presentation, and any contributing factors responsible for burns and outcome of care in Kuwait over the 5-yr period January 2006 to December 2010. Patients and methods. The study reviewed 1702 burn patients admitted over the study period to the Saud Al Babtain Burns, Plastic and Reconstructive Surgery Center, Kuwait. Patient characteristics, including age, sex, type of burn, nationality, total body surface area (TBSA) burn, hospital stay in days, and mortality were recorded. Results. Seventy-one per cent of the 1702 burn patients admitted were males; 540 were children. The majority of patients (64%) had less than 15% TBSA burns and only 14% had more than 50% TBSA burns. Flame burns were the most common cause of burn injuries (60%), followed by scalds (29%). Scalds were most common in children. The mortality rate was 5.75%. Flame burn was the leading cause of mortality. Lethal dose 50 (% TBSA at which a certain group has a 50% chance of survival) for adults (16-40 yr) and for the elderly (>65 yr) was 76.5% and 41.8% TBSA respectively. Conclusion. Burn injury is an important public health concern and is associated with high morbidity and mortality. Flame and scald burns are commonly a result of domestic and occupational accidents and they are preventable. Effective initial resuscitation, infection control, and adequate surgical treatment improve outcomes.

Objectif. Déterminer l'épidémiologie et décrire la présentation clinique et les éventuels facteurs responsables des brûlures et des résultats des soins au Koweït au cours des dernières cinq années. Patients et méthodes. Un nombre total de 1702 patients brûlés hospitalisés dans le Centre de Chirurgie Plastique et Reconstructive Saud Al Babtain au Koweït Center entre janvier 2006 et décembre 2010 ont été pris en considération. Les caractéristiques des patients (âge, sexe, type de brûlure, nationalité, surface corporelle totale (SCT) brûlée, journées de séjour à l'hôpital, mortalité) ont été enregistrées. Résultats. Soixante-et-un pour cent des 1702 patients brûlés hospitalisés étaient des hommes; 540 patients étaient des enfants. La majorité des patients (64%) avaient des brûlures en moins de 15% de la SCT et seulement 14% avaient plus de 50%. Les flammes étaient la cause la plus commune des brûlures (60%), suivies par les brûlures (29%). Les ébouillantements étaient plus fréquents chez les enfants. Le taux de mortalité était de 5,75%. Les brûlures dues aux flammes étaient la principale cause de la mortalité. La dose létale 50 pour les adultes (16-40 ans) et pour les personnes âgées (> 65 ans) était respectivement de 76,5 et de 41,8% SCT. Conclusion. La brûlures constitue un important problème de santé publique et est associée à une morbidité et une mortalité élevée. Les brûlures dues aux flammes et aux ébouillantements sont souvent provoquées par des accidents domestiques. Pour améliorer les résultats il faut avoir une réanimation initiale efficace, un bon contrôle de l'infection et un traitement chirurgical adéquat.

End of life decisions and care of the adult burn patient.

INTRODUCTION: Despite advancements in the provision of burn care, there is still a significant cohort of patients who fail to respond to therapy or for whom treatment is deemed futile. The decision to withdraw support from, or to implement a Do-Not-Resuscitate (DNAR) order in, such patients can be challenging. Our aims were to review the withdrawal of life-sustaining treatment, issuing of DNAR orders and end of life care in burn patient deaths. METHODS: A retrospective case notes review was undertaken, for all burn in-patient deaths from 1st April 2001 to 31st December 2007. RESULTS: Following exclusions, 63 patients were included in our study, with a median age of 56 years (21-94). End of life decisions in younger patients (under 65 years) were more often due to burn severity. In those over 65 years, reasons were due to co-morbidities, and these decisions were made late in the patient's admission. In 34% of patients, end of life care was not comprehensively documented. CONCLUSION: A coherent, decisive approach should be adopted and adhered to by all members of the multi-disciplinary team, with clear, standardised documentation in place.

Hydroxyethylstarch supplementation in burn resuscitation--a prospective randomised controlled trial.

INTRODUCTION: Hydroxyethylstarches (HES) are thought to be beneficial in trauma and major surgery management, due to their volume expansion and anti-inflammatory properties. This study examined the use of 6% (HES) in burn resuscitation. METHODS: 26 adult patients with burns exceeding 15% total body surface area (TBSA) were randomised to either crystalloid (Hartmann's solution) or a colloid-supplemented resuscitation regime, where 1/3 of the crystalloid-predicted requirement was replaced by 6% HES. RESULTS: There was no difference in age, gender or TBSA between the two groups. The median (95% CI) fluid volume/%TBSA received in the first 24 h was 307 ml and 263 ml for the crystalloid only and HES-supplemented group respectively (p=0.0234, Mann-Whitney). Body weight gain within the first 24 h after injury was significantly lower in the HES-supplemented group 2.5 kg versus 1.4 kg respectively (p=0.0039). The median (95% CI) serum C-reactive protein at 48 h after injury was 210 (167-257) and 128 (74-145) mg/L for the crystalloid only and HES-supplemented group respectively (p=0.0001). Albumin-creatinine ratio per % burn (ACR, a marker of capillary leak) was lower in the HES-supplemented group at 12h after burn (p=0.0310). CONCLUSIONS: Patients treated with HES-supplemented resuscitation required less fluid, showed less interstitial oedema and a dampened inflammatory response compared to patients receiving isotonic crystalloid alone.

Toxic epidermal necrolysis: retrospective analysis of 21 consecutive cases managed at a tertiary centre.

BACKGROUND: Toxic epidermal necrolysis (TEN) is a rare, severe blistering disease. Outcome data in British patients is limited to case reports or small series. AIMS: To characterize the aetiology, clinical features, complications and outcome in TEN, and to evaluate the effect of treatments including intravenous immunoglobulin (IVIg). METHODS: This was a retrospective study of 21 consecutive patients with histologically confirmed TEN presenting between 1995 and 2007 to a tertiary referral unit for TEN in a university hospital in the UK. RESULTS: The mean age of the patients was 53.5 years. The mean surface area of denuded skin was 44% (range 30-90%). An adverse drug reaction was implicated in all patients, with mean time of TEN onset being 17 days (range 2-41 days) after initial drug exposure. The SCORTEN index was calculated in 19 patients (median SCORTEN 3, range 2-5). The SCORTEN predicted 7.3 deaths in this cohort, and 7 deaths were seen in the group of patients for whom SCORTEN was calculated. The overall mortality was 8/21 (38%). Ten patients received corticosteroids before transfer to our centre. In the steroid-treated group 4/10 patients (40%) died, and 4/11 patients (36%) who were not treated with steroids also died. Between 1995 and 2000, patients were treated with cyclophosphamide 1.5 mg/kg/day (n=2; both died) and subsequently with ciclosporin 2.5-4 mg/kg/day (n=3; 2 deaths). From 2000, patients were treated with IVIg 0.4-1 g/kg/day (n=14; 3 deaths); the SCORTEN-predicted mortality in this group was 5 deaths. Complications included sepsis (n=18), and organisms included Enterococcus, Acinetobacter, Staphylococcus aureus and methicillin-resistant S. aureus strains). Other complications included anaemia (n=17), lymphopenia (n=11) and neutrophilia (n=9). The presence of neutropenia (n=6; 4 deaths), renal impairment (n=5; 4 deaths) and disseminated intravascular coagulation (n=4; all died) were strong risk factors for mortality. Of 12 patients with ocular involvement, 6 (50%) developed symblepharon and/or visual impairment. CONCLUSIONS: This study confirmed the validity of SCORTEN in our series. In the subgroup treated with IVIg, there were three deaths, compared with the SCORTEN predicted mortality of five deaths. Corticosteroids did not seem to be beneficial.

An atypical cause of alkali chemical burn: a case report.

It has already been reported that wet ash turns into a strong alkali agent, which can cause full-thickness skin burns. A case is presented which has the particularity of sustained, self-inflicted contact with wet ash. The coal used was the self-igniting type normally used for burning scented weed or for smoking the hubbly bubbly or shisha pipe.

Microalbuminuria: a marker of systemic endothelial dysfunction during burn excision.

INTRODUCTION: Systemic endothelial dysfunction characterises both burn injury and surgery and can be monitored by serial immunoassay of urine albumin (microalbuminuria). The aim of this study was to assess microalbuminuria before and during burn excision and identify factors that may influence it. METHODS: Serial half-hourly urine albumin/creatinine ratio (ACR, normal <2.3mg/mmol) was measured in 25 adult patients during 44 burn-excision procedures, at a median of 5 days post-injury. Median total body surface area (TBSA) excised was 12%. RESULTS: Pre-operative median ACR was normal rising to 3.25mg/mmol at 1.5h of surgery (p<0.05). Per-operative ACR at 0.5, 1, 2 and 2.5h were all associated with % TBSA burn excised (p<0.04). Median intraoperative ACR at 1h was 2.3mg/mmol for surgery within 48h post-injury, 1.6 for surgery at 2-7 days and 25.5 during excisions later than 1 month after injury (p<0.05). ACR at 1h was associated with CRP at 48h post-surgery (p=0.04). Per-operative ACR was also significantly correlated with post-operative complications. CONCLUSION: Systemic endothelial dysfunction of acute thermal injury assessed by microalbuminuria recurs with surgery, is minimal at 2-7 days post-burn and affected by % TBSA burn excised and post-operative complications.

Aetiology and outcome of burns in the elderly.

INTRODUCTION: This retrospective study, analyses aetiology and factors affecting the outcome of burns in patients over 65 years of age. METHODS: Sixty-three consecutive patients, over 65 years of age, were admitted to a Burns Unit over a period of 3 years. Retrospective data was analyzed, taking into account aetiology, burn thickness and area, co-morbid factors. Also, surgery as a factor-affecting outcome was examined. RESULTS: There was a significant difference of total body surface area burn (TBSA), Abbreviated Burn Severity Index (ABSI), Baux score and the number of pre-existing co-morbid factors between survivors and non-survivors. Age and surgery were not significant to the outcome. Patients undergoing surgery had increased hospital stay without any difference in mortality. The timing of surgery did not have any impact on hospital stay or survival. CONCLUSION: This study shows a positive correlation between the number of co-morbid conditions and mortality. Early surgery after careful patient selection does not have any negative impact on patient survival.