Revised estimates of mortality from the Birmingham Burn Centre, 2001-2010: a continuing analysis over 65 years.

OBJECTIVE: The Birmingham Burn Centre has continued to publish mortality data over the last 65 years. It is one of the longest running cross-sectional cohort studies in the world. We present the latest data from the study, with a comparison to previous results. BACKGROUND: Results from the previous decade failed to show any improvement in mortality despite perceived advances in burn care. The aim of this update was to establish current mortality statistics and ascertain whether improvement had now been made. METHODS: Data were collected for a 10-year period on all burn-injured patients admitted to the Birmingham Burn Centre (Birmingham Children's Hospital, Selly Oak Hospital, and Queen Elizabeth Hospital Birmingham). Patients' age, percentage of burn, date of injury, and outcome were recorded and analyzed with both probit and logistic regression analyses. RESULTS: A total of 4577 patients were included in the analysis, with a mean total body surface area (TBSA) burn of 7.2% and a mean age of 22 years. Comparison of probit model results with previous results demonstrates improvement in predicted mortality and lethal area (LA50) of burns. Logistic regression produces similar results to the probit analysis. Trend analysis proved a statistically significant improvement in mortality. CONCLUSIONS: The last decade of burn care at Birmingham Burn Centre demonstrates an improvement in predicted mortality and LA50. This reflects our structured, multidisciplinary approach to burn-injured patients, early surgical excision and wound closure, and general advances in the intensive care of patients.

Spray-on-skin cells in burns: a common practice with no agreed protocol.

OBJECTIVES: Cultured epithelial autograft (CEA) has been used for skin coverage after burn wound excision since 1981. It is used in burn units and centres throughout the U.K.; however, there appears to be no agreed standards of practice. We aimed to investigate the experience and current practice with its usage in the management of acute burn injury. METHODS: An online survey was sent to twenty-five burns consultants in the U.K., who are members of the British Burn Association. RESULTS: We received 14 responses. Rarely have the responders agreed to the same practice in most of the questions. Different choices were given by responders with regards the indications for cell culture, techniques used, primary and secondary dressings used, first wound review timing, and measures used to evaluate outcomes. CONCLUSION: In the current economic environment, the NHS needs to rationalize services on the basis of cost effectiveness. CEA is an expensive procedure that requires an adequately sterile laboratory, special equipments and highly experienced dedicated staff. When dealing with expensive management options, it is important to have an agreed protocol that can form the standard that can be referred to when auditing practices and results to improve burn management and patients' care.

Acticoat dressings and major burns: systemic silver absorption.

Despite widespread use of wound dressings containing silver, few studies have investigated patients' serum silver levels. An earlier study of Acticoat use in small burns showed transient elevations of serum silver. The aim of this study was to examine the serum silver profile when Acticoat is used in major burns. A prospective study of 6 patients with burns greater than 20% total body surface area (TBSA). All burn wounds, including grafted and non-grafted areas and skin graft donor sites, were dressed with Acticoat or Acticoat Absorbent. Patients' serum silver levels, biochemistry and haematology were examined before, during and after the application of the silver dressings. The median total wound size (including donor sites) was 46.1% TBSA. The median maximum serum silver level recorded, 200.3 µg/L, reached at a median of 9.5 days following initial silver dressing application. This decreased to a median of 164.8 µg/L at the end of the treatment period and to a median of 8.2 µg/L at the end of follow-up. One adverse event, partial skin graft loss was thought to be dressing related. In this small study, serum silver levels were elevated but remained similar to that reported following the use of silver sulfadiazine. This study confirmed our view that Acticoat is safe to use on patients with burns, even when they are extensive.

Hair straighteners: a significant burn risk.

BACKGROUND AND AIM: Hair straighteners have become increasingly common household appliances. The purpose of this study was to investigate the temperatures reached by the exposed plates of hair straighteners when switched on, and the length of time taken to cool to a safe temperature after switching off. We also present the case of a child with deep dermal burns caused by a hair straightener, highlighting its potential danger when left unattended. METHODS: Eight different hair straighteners were tested using a calibrated thermometer. Maximum temperature reached and length of time taken to cool to 40 degrees C were recorded three times for each straightener. RESULTS: Among the eight straighteners tested, the size of the plates varied between 22.5 and 53.9cm(2). Plate material was ceramic in all but one case. Average maximum temperature was 163 degrees C (122-210 degrees C). Mean time taken to cool to 40 degrees C from switch-off was 26min (18-44min). None of the devices tested could be locked closed. DISCUSSION AND CONCLUSION: Hair straighteners present a significant risk of burn when left unattended, both while switched on and for up to 44min after turning off. We offer some recommendations to improve safety.

The safety of nanocrystalline silver dressings on burns: a study of systemic silver absorption.

INTRODUCTION: Wound dressings containing silver have been in widespread use for many years. However, there are few quantitative data on the systemic absorption of silver or whether there is associated clinical risk. OBJECTIVES: To assess systemic silver levels when Acticoat dressings containing nanocrystalline silver were used, and to determine whether increases in such levels were associated with haematological or biochemical indicators of toxicity. METHOD: A prospective, single-centre, open-label study of 30 patients with relatively small burns that required skin grafting. Serum silver levels were measured before, during and at discontinuation of the use of the Acticoat dressings, and again at 3 and 6 months following completion of treatment. RESULTS: The median total postoperative wound size was 12% of the total body surface area. The median time to maximum silver levels was 9 days. The median maximum serum silver level was 56.8 microg/l. The median serum level at 6 months was 0.8 microg/l. There were no haematological or biochemical indicators of toxicity associated with the silver absorption observed in this study. CONCLUSION: This study has confirmed our view that Acticoat products are safe for use on burns and they remain a standard part of treatment at our centre.

Cultured autologous keratinocytes in suspension accelerate epithelial maturation in an in vivo wound model as measured by surface electrical capacitance.

BACKGROUND: Human epidermis serves as a protective covering against loss of endogenous fluids and exogenous microbial invasion. Cultured epithelial autograft suspensions have been used to enhance epithelialization to improve mortality, morbidity, and the overall quality of the scar. The measurement of surface electrical capacitance as an indicator of transepidermal water loss has been used in neonatology and dermatology to determine epidermal maturation. This tool has been used in a double-blind, randomized, controlled trial to compare the effects of cultured epithelial autograft in suspension on epidermal healing and maturation compared with a control in an in vivo partial thickness wound model. METHODS: In this double-blind, randomized, controlled trial (n = 8), the authors assessed the effect of cultured epithelial autograft on epidermal healing and maturation in standardized partial thickness wounds. Surface electrical capacitance was compared on 16 split-thickness skin graft donor sites treated with cultured epithelial autograft (n = 8) against controls treated with Dulbecco's Modified Eagle's Medium (n = 8) using a NOVA Dermaphase Meter at 4, 5, 6, and 7 days postoperatively. RESULTS: A statistically significant difference on continuous readings at days 5 (p = 0.012) and 7 (p = 0.036) and instantaneously on days 5 (p = 0.025) and 6 (p = 0.036) in surface electrical capacitance was observed in the cultured epithelial autograft over the Dulbecco's Modified Eagle's Medium-treated wounds. CONCLUSIONS: Measuring surface electrical capacitance provides an objective and repeatable method of assessing epidermal maturation. This study indicates that the rate of epithelialization and epidermal maturation is more rapid in partial thickness epidermal skin wounds treated with cultured epithelial autograft.

Negative-pressure wound therapy: a snapshot of the evidence.

Topical negative pressure (TNP) is a mode of therapy used to encourage wound healing. It can be used as a primary treatment for chronic/complex wounds or as an adjunct to surgery. Based on the evidence to date, the clinical effectiveness of negative-pressure therapy is still unclear. Although case reports and retrospective studies have demonstrated enhanced wound healing in acute/traumatic wounds, chronic wounds, infected wounds, wounds secondary to diabetes mellitus, sternal wounds and lower limb wounds, there are very few randomised controlled trials, with unclear results. The evidence is lacking for the use of TNP therapy for other indications to enhance wound healing such as patients with decubitus ulcers, diabetes and peripheral vascular disease and to improve skin graft take. There have been, as yet, no quality-of-life studies available for negative-pressure therapy. Despite this, the usage of TNP has increased. This review provides an overview of clinical studies using TNP and proposes avenues for further research to elucidate the exact mechanism of TNP, in addition to large randomised controlled clinical trials of patients undergoing this therapy.

In vitro transfer of keratinocytes: comparison of transfer from fibrin membrane and delivery by aerosol spray.

There are a variety of approaches for the delivery of autologous keratinocytes to restore epithelial coverage of burns wounds that include utilizing cultured keratinocyte sheets, transfer of cultured keratinocytes using a membrane and more recently aerosol spraying of a keratinocyte suspension. The purpose of this study was to compare the effectiveness of direct aerosol delivery of a keratinocyte suspension with a fibrin transfer system to an in vitro wound model consisting of organotypical deepidermalized dermis (DED). A comparison was made between the number of keratinocytes delivered to DED with time, either by transfer from a fibrin membrane or using an aerosol. Additionally, the effect of application time of fibrin membranes to DED, on the number of keratinocytes delivered was investigated and compared with keratinocytes delivered by aerosol at the same time points. After 2 days culture little transfer of keratinocytes had occurred from the fibrin membrane to the DED, whereas 20% more cells were present on the DED than were initially delivered by aerosol spraying. After 7 days, aerosol-delivered cells were found to express cytokeratin K6, indicating a proliferative phenotype. The results from this study show that preconfluent keratinocytes can be delivered by aerosol, and thus may well find application clinically.