Temporal trends in burn size estimation and the impact of the NSW Trauma App on estimation accuracy.

BACKGROUND: Several studies demonstrated that burn size calculations by referring clinicians are poor. The purpose of this study was to determine if inaccuracies in burn size estimation have improved with time within the same population, and whether widespread roll-out of a smartphone-based TBSA calculator (in the form of the NSW Trauma App) had an impact on accuracy. METHODS: A review of all burn-injured adult patients transferred to Burn Units from August 2015, following the roll out of the NSW Trauma App, to January 2021 was performed. The TBSA determined by the referring centre was compared with the TBSA calculated by the Burn Unit. This was compared to historical data from the same population between January 2009 and August 2013. RESULTS: There were 767 adult burn-injured patients transferred to a Burn Unit between 2015 and 2021. The median overall TBSA was 7%. There were 290 patients (37.9%) who had equivalent TBSA calculations by the referring hospital and the Burn Unit. This was a significant improvement compared to the preceding time period (P < 0.005). Overestimation by the referring hospital occurred in 364 cases (47.5%), which was significantly reduced compared to 2009 - 2013 (P < 0.001). Unlike the earlier time period where changes in estimation accuracy were seen in relation to increasing time after the burn injury, burn size estimation accuracy remained relatively consistent in the contemporary time period with no significant change observed (P = 0.86). CONCLUSIONS: This cumulative, longitudinal study of nearly 1500 adult burn-injured patients over 13 years demonstrates improvements in burn size estimation by referring clinicians over time. It is the largest cohort of patients analysed with respect to burn size estimation and is the first to demonstrate improvements in accuracy of TBSA in association with a smartphone-based app. Adopting this simple strategy into burn retrieval systems will augment early assessment of these injuries and improve outcomes.

The burn injury transfer feedback form: A 16 year Australian statewide review of burn inter-hospital transfer.

INTRODUCTION: Modern burn care is centralised, and studies show that early, prompt referral to dedicated burn services improve clinical outcomes. We describe the use of a novel clinical instrument, the burn injury Transfer Feedback Form, to support and educate referring clinicians about the early assessment and management of burn injuries. Since 2005, Transfer Feedback Forms have been completed for all burn-injured patients with inter-hospital transfer to a specialised burn unit in the state of New South Wales (NSW), Australia. The aim of this study was to review physiological, procedural, and system or process issues in the care of both adult and paediatric burn-injured patients needing retrieval and transfer in NSW as identified by the Transfer Feedback Form. Secondary objectives were to determine any significant differences in these parameters between metropolitan and regional or remote referring institutions, and if any improvements occurred in these parameters over time. METHODS: This was a retrospective analysis of all patients who were transferred to a burn unit in NSW between July 2005 and July 2021 using their prospectively completed Transfer Feedback Forms. Patients were divided into metropolitan and non-metropolitan referral sources based on geographic location. Clinical issues or deficiencies identified during each patient transfer were then classified into various groups. To determine if transfer-related clinical concerns had changed with time, two distinct periods before and after 2015, when the NSW Trauma App was introduced, were analysed. We compared trends in frequency of transfer-related concerns before and after App introduction by using interrupted time series analysis. RESULTS: A total of 3233 patients had Feedback Forms submitted during the 16-year period. We included 929 children (28.7%) and 2304 adults (71.3%). Transfer-related clinical issues were identified in 904 adults (39.0%) and 484 children (52.0%). In both adult and paediatric patients, the most common transfer-related clinical deficiency was in relation to burn size estimation with 525 patients (43.7%) and 207 patients (30.6%), respectively. Between the time periods analysed, the number of issues arising during inter-hospital transfer fell significantly for both adults (from 46.1% to 26.1%; p < 0.05) and children (from 55.3% to 40.7%; p < 0.05). Segmented regression analysis demonstrated a significant break in the rate of transfer-related clinical issues in 2014 (p < 0.05) and 2015 (p < 0.01) for adults. Accurate body surface area estimations also increased significantly by 53% and 50% for adults and children (p < 0.05 for both), respectively, after 2015. CONCLUSION: Our analysis indicates that the early care of burn-injured patients undergoing inter-hospital transfer is associated with clinical, technical, and logistical challenges. However, introduction of the burn injury Transfer Feedback Form has been associated with improvements in early burn care by referring centres both temporally and geographically. Smartphone-based applications such as the NSW Trauma App have also probably contributed to these findings. Adopting these simple, inexpensive strategies into burn care systems will augment inter-hospital transfer of burn-injured patients, and improve clinical outcomes.

Wound healing and dermal regeneration in severe burn patients treated with NovoSorb® Biodegradable Temporising Matrix: A prospective clinical study.

INTRODUCTION: For extensive burns, autologous donor skin may be insufficient for early debridement and grafting in a single stage. A novel, synthetic polyurethane dermal template (NovoSorb® Biodegradable Temporising Matrix, BTM) was developed to address this need. The aim of this study was to evaluate use of BTM for primary dermal repair after deep burn injury. METHODS: A multicentre, prospective, clinical study was conducted from September 2015 to May 2018. The primary endpoint was % split skin graft take over applied BTM at 7-10 days after grafting. Secondary endpoints included % BTM take, incidence of infection and adverse events, and scar quality to 12 months after BTM application. RESULTS: Thirty patients were treated with BTM and delayed split skin grafting. The % graft take had a mean of 81.9% and % BTM take had a mean of 88.6%, demonstrating effective integration of BTM. When managed appropriately, it was possible for BTM to integrate successfully despite findings suggestive of infection. Scar quality improved over time. DISCUSSION: These results provide additional clinical evidence on the safety and performance of BTM as an effective dermal substitute in the treatment of patients with deep burn injuries.

Early protein C activation is reflective of burn injury severity and plays a critical role in inflammatory burden and patient outcomes.

BACKGROUND: Navigating the complexities of a severe burn injury is a challenging endeavour where the natural course of some patients can be difficult to predict. Straddling both the coagulation and inflammatory cascades that feature strongly in the burns systemic pathophysiology, we propose the pleiotropic protein C (PC) system may produce a viable biomarker to assist traditional evaluation methods for diagnostic and prognostic purposes. METHODS: We enrolled 86 patients in a prospective observational cohort study. Over three weeks, serial blood samples were taken and measured for PC, activated (A)PC, their receptor endothelial protein C receptor (EPCR), and a panel of inflammatory cytokines including C-reactive protein (CRP), tumour necrosis factor-α, interleukin (IL)-1ß, IL-6, IL-8, and IL-17. Their temporal trends were analysed alongside clinical factors including burn size, burn depth, presence of inhalational injury, and a composite outcome of requiring increased support. RESULTS: (i) APC increased from a nadir on Day 3 (2.3±2.1ng/mL vs 4.1±2.5ng/mL by Day 18, p<0.0005), only becoming appropriately correlated to PC from Day 6 onwards (r=0.412-0.721, p<0.05 for all Days 6-21). (ii) This early disturbance in the PC system was amplified in the more severe burns (≥30% total body surface area, predominantly full thickness, or with inhalational injury), which were characterised by a marked fall in PC activation (approximated by APC/PC ratio) and APC levels during Days 0-3 with low unchanged PC levels. Critically low levels of this cytoprotective agent was associated with greater inflammatory burden, as reflected by significantly elevated CRP, IL-6, and IL-8 levels in the more severe compared to less severe burns, and by negative correlations between both PC and APC with most inflammatory cytokines. (iii) Alongside clinical markers of severity at admission (burn size, burn depth, and presence of inhalational injury), only Day 0 APC/PC ratio (OR 1.048 (1.014-1.083), p=0.006), APC (OR 1.364 (1.032-1.803), p=0.029), PC (OR 0.899 (0.849-0.953), p<0.0005), and not any inflammatory cytokines were predictive markers of requiring increased support. Uniquely, decreased Day 0 PC was further individually associated with each increased total length of stay, ICU length of stay, intravenous fluid resuscitation, and total surgeries, as well as possibly mortality. CONCLUSION: An early functional depletion of the cytoprotective PC system provides a physiological link between severe burns and the cytokine storm, likely contributing to worse outcomes. Our findings on the changes in APC, PC and PC activation during this pathological state support APC and PC as early diagnostic and prognostic biomarkers, and provides a basis for their therapeutic potential in severe burn injuries.

Treating the burnt auricle using Biobrane.

Auricle burns remain a challenge for surgeons who must navigate the common and morbid complication of chondritis through often complex and painful dressing regimes. Our technique involving the application of Biobrane promotes healing, is individualized, single application and conducive to topical antimicrobial application. We find it is a simple and effective approach to treating the burnt auricle.

A Critical Update of the Assessment and Acute Management of Patients with Severe Burns.

Significance: Burns are debilitating, life threatening, and difficult to assess and manage. Recent advances in assessment and management have occurred since a comprehensive review of the care of patients with severe burns was last published, which may influence research and clinical practice. Recent Advances: Recent advances have occurred in the understanding of burn pathophysiology, which has led to the identification of potential biomarkers of burn severity, such as protein C. There is new evidence about the potential superiority of natural colloids over crystalloids during fluid resuscitation, and new evidence about components of initial and perioperative management, including an improved understanding of pain following burns. Critical Issues: The limitations of the clinical examination highlight the need for imaging and biomarkers to assist in estimations of burn severity. Fluid resuscitation reduces mortality, although there is conjecture over the ideal method. The subsequent perioperative period is associated with significant morbidity and the evidence for preventing and treating pain, infection, and fluid overload while maximizing wound healing potential is described. Future Directions: Promising developments are ongoing in imaging technology, histopathology, biomarkers, and wound healing adjuncts such as hyperbaric oxygen therapy, topical negative pressure therapy, stem cell treatments, and skin substitutes. The greatest benefit from further research on management of patients with burns would most likely be derived from the elucidation of optimal fluid resuscitation protocols, pain management protocols, and surgical techniques from randomized controlled trials.

Plasma protein C levels are directly associated with better outcomes in patients with severe burns.

Protein C circulates in human plasma to regulate inflammation and coagulation. It has shown a crucial role in wound healing in animals, and low plasma levels predict the presence of a wound in diabetic patients. However, no detailed study has measured protein C levels in patients with severe burns over the course of a hospital admission. A severe burn is associated with dysfunction of inflammation and coagulation as well as a significant risk of morbidity and mortality. The current methods of burn assessment have shortcomings in reliability and have limited prognostic value. The discovery of a biomarker that estimates burn severity and predicts clinical events with greater accuracy than current methods may improve management, resource allocation and patient counseling. This is the first study to assess the potential role of protein C as a biomarker of burn severity. We measured the plasma protein C levels of 86 patients immediately following a severe burn, then every three days over the first three weeks of a hospital admission. We also analysed the relationships between burn characteristics, blood test results including plasma protein C levels and clinical events. We used a primary composite outcome of increased support utilisation defined as: a mean intravenous fluid administration volume of five litres or more per day over the first 72 h of admission, a length of stay in the intensive care unit of more than four days, or greater than four surgical procedures during admission. The hypothesis was that low protein C levels would be negatively associated with increased support utilisation. At presentation to hospital after a severe burn, the mean plasma protein C level was 76 ± 20% with a range of 34-130% compared to the normal range of 70-180%. The initial low can be plausibly explained by impaired synthesis, increased degradation and excessive consumption of protein C following a burn. Levels increased gradually over six days then remained at a steady-state until the end of the inpatient study period, day 21. A multivariable regression model (Nagelkerke's R2 = 0.83) showed that the plasma protein C level on admission contributed the most to the ability of the model to predict increased support utilisation (OR = 0.825 (95% CI = 0.698-0.977), P = 0.025), followed by burn size (OR = 1.252 (95% CI = 1.025-1.530), P = 0.027), burn depth (partial thickness was used as the reference, full thickness OR = 80.499 (1.569-4129.248), P = 0.029), and neutrophil count on admission (OR = 1.532 (95% CI = 0.950-2.473), P = 0.08). Together, these four variables predicted increased support utilisation with 93.2% accuracy, 83.3% sensitivity and 97.6% specificity. However if protein C values were disregarded, only 49.5% of the variance was explained, with 82% accuracy, 63% sensitivity and 91.5% specificity. Thus, protein C may be a useful biomarker of burn severity and study replication will enable validation of these novel findings.

Insecure adult attachment style is associated with elevated psychological symptoms in early adjustment to severe burn: A cross-sectional study.

Research into recovery and adjustment after burn injury has indicated a link between psychopathological symptoms including traumatic stress, distress, depression and anxiety, and worse psychosocial and physical outcomes. The severity of psychological symptoms does not always correlate with that of the burn injury, and symptoms can be ongoing in certain patients for extensive periods, leading to a need for early screening in burns patients for psychological vulnerabilities. One potential factor influencing recovery from the psychological impact of burn injury is adult attachment style, specifically secure and insecure attachment, as this describes how an individual organizes their stress regulation. This cross-sectional study measured: (a) attachment style (via the Relationship Questionnaire [RQ]): (b) negative psychological symptoms (via the Depression Anxiety and Stress Scale [DASS]); and, (c) post-traumatic symptoms (via the Davidson Trauma Scale [DTS]) in a cohort of burns patients (n = 104, 51 analysed) in a severe burns unit in Australia during the acute phase of their recovery. Secure attachment style was inversely related to psychopathological symptoms. Secure participants scored significantly lower scores on the DASS (M = 17.63, SD = 17.07) compared to self-rated insecure participants [(M = 42.38, SD = 34.69), p < .01] and on the DTS (M = 14.22, SD = 15.42) compared to insecure participants [(M = 40.54, SD = 35.72), p < .01]. Similar results were found in analyses controlling for covariates of gender, age and burn severity as potential confounders. This research suggests attachment style may play an important role in psychosocial recovery from severe burn injury.

Auricular reconstruction.

External ear abnormalities are common. These may affect ear shape, size, prominence and degree of development. They may also be associated with hearing loss. The early identification and management of hearing loss is essential. There are several options for reconstruction of the external ear using both autologous and non-autologous techniques. The aim of this article is to outline the different reconstructive options.

Type-D Personality and Elevated Psychological Symptoms In Early Adjustment of Severe Burn Injury Patients.

Severe burn injuries are highly traumatic requiring lengthy recovery. High levels of distress in the early stages of treatment have been associated with poor physical and psychosocial recovery outcomes. Identifying traits relating to distress and personal coping styles may aid screening. Type-D, or 'distressed', personality may be such a trait. Type-D personality refers to an ongoing personality organization defined by a tendency to experience greater negative emotions and thoughts while simultaneously socially inhibiting their expression (Denollet et al., 1996 . Type-D has been linked to poor health outcomes in those with cardiovascular disease as well as other populations and has been found to be associated with elevated psychological symptoms. Currently, there are no investigations in the literature looking at Type-D in the severe burns injury population. This study aimed to investigate Type-D in severe burn injury patients, specifically regarding the presence of psychological symptoms in early treatment, using data gathered during a pilot study conducted at a severe burn injury unit. The DS-16, Davidson Trauma scale and Depression Anxiety and Stress Scale scores were analysed along with demographic and clinical data in 54 participants (40 males, 14 females). Participants who were found to have Type-D displayed significantly higher levels of psychopathology. Additionally, Type-D was found to be a significant predictor of psychological symptoms.

The Role of Th-17 Cells and γδ T-Cells in Modulating the Systemic Inflammatory Response to Severe Burn Injury.

Burns are a global public health problem, accounting for an estimated 265,000 deaths annually. Inflammation is essential in supplying the growth factors, cytokines and chemokines needed to recruit T-cells and myeloid cells to the site of a burn injury for wound healing. However, major burns generate a marked pathophysiological inflammatory response through a widespread release of abundant pro-inflammatory mediators that predispose patients to a systemic inflammatory response syndrome, sepsis and multi-organ failure. Recently, there has been promising investigation into the role of γδ T-cells and Th-17 cells in the regulation and propagation of this inflammatory response. This study reviews the current literature on the post-burn immune response.

A clinical update on posttraumatic stress disorder in burn injury survivors.

OBJECTIVES: Burn injuries are complex traumatic events carrying high risks of acute physical and psychosocial morbidity. With greater survival, clinical and research attention has turned to psychosocial recovery outcomes and risk factors. It is timely to summarise current issues in posttraumatic disorders after burn injury for mental health and integrative care clinicians. Posttraumatic stress disorder (PTSD) is a common outcome of severe burn injury. There are difficulties in delivering current best practice treatments to many survivors especially those in rural and remote areas and those with comorbidities. Vicarious traumatization of clinicians, families and carers requires attention and internationally there are moves to psychosocial screening and outcome tracking. CONCLUSIONS: The role of the multidisciplinary treatment, integrated and trauma-informed care is essential. While level 1 evidence for PTSD treatments theoretically applies, adaptations that consider comorbidities and treatment contexts are often essential with further research required.

The Burns Registry of Australia and New Zealand: progressing the evidence base for burn care.

OBJECTIVE: Analysis of data from the Burns Registry of Australia and New Zealand (BRANZ) to determine the extent of variation between participating units in treatment and in specific outcomes during the first 4 years of its operation. DESIGN: BRANZ, an initiative of the Australian and New Zealand Burn Association, is a clinical quality registry developed in accordance with the Australian Commission on Safety and Quality in Healthcare national operating principles. SETTING: Patients with burn injury who fulfil pre-defined criteria are transferred to and managed in designated burn units. There are 17 adult and paediatric units in Australia and New Zealand that manage almost all patients with significant burn injury. Twelve of these units treat adult patients. PARTICIPANTS: Data on 7184 adult cases were contributed by ten acute adult burn units to the registry between July 2010 and June 2014.Major outcomes: In-hospital mortality, hospital length of stay, skin grafting rates, and rates of admission to intensive care units. RESULTS: Considerable variations in unit profiles (including numbers of patients treated), in treatment and in outcomes were identified. CONCLUSIONS: Despite the highly centralised delivery of care to patients with severe or complex burn injury, and the relatively small number of specialist burn units, we found significant variation between units in clinical management and in outcomes. BRANZ data from its first 4 years of operation support its feasibility and the value of further development of the registry. Based on these results, the focus of ongoing research is to improve understanding of the reasons for variations in practice and of their effect on outcomes for patients, and to develop evidence-informed clinical guidelines for burn management in Australia and New Zealand.

Activated protein C to heal pressure ulcers.

Pressure ulcers present a major clinical challenge, are physically debilitating and place the patient at risk of serious comorbidities such as septic shock. Recombinant human activated protein C (APC) is an anticoagulant with anti-inflammatory, cytoprotective and angiogenic effects that promote rapid wound healing. Topical negative pressure wound therapy (TNP) has become widely used as a treatment modality in wounds although its efficacy has not been proven through randomised controlled trials. The aim of this study was to determine the preliminary efficacy and safety of treatment with APC for severe chronic pressure sores with and without TNP. This case presentation describes the history, management and outcome of two patients each with a severe chronic non-healing pressure ulcer that had failed to respond to conventional therapy. TNP was added to conservative management of both ulcers with no improvement seen. Then local application of small doses of APC was added to TNP and with conservative management, resulted in significant clinical improvement and rapid healing of both ulcers, displaying rapid growth of vascular granulation tissue with subsequent epithelialisation. Patients tolerated the treatment well and improvements suggested by long-term follow-up were provided. Randomised placebo-controlled double blind trials are needed to quantify the efficacy, safety, cost-effectiveness, optimal dose and quality of life changes seen from treatment with APC.

Acute management of skin tears: a change in practice pilot study.

Skin tears are an increasingly common injury occurring in the elderly population and have significant associated morbidity secondary to poor wound healing, prolonged hospital stays and reduced mobility. There has been a shift in practice for the acute management of skin tears within our institution, which has resulted in improved outcomes and reduced morbidity for this common and debilitating injury. Review of past and current practices including cost analyses has led to the establishment of a management protocol for the hospital and wider area health service with the aim to reduce the burden of disease amongst our ever-expanding elderly population.

The patient-body relationship and the "lived experience" of a facial burn injury: a phenomenological inquiry of early psychosocial adjustment.

BACKGROUND: Throughout development and into adulthood, a person's face is the central focus for interpersonal communication, providing an important insight into one's identity, age, sociocultural background, and emotional state. The face facilitates important social, including nonverbal, communication. Therefore, sustaining a severe burn, and in particular a facial burn, is a devastating and traumatizing injury. Burn survivors may encounter unique psychosocial problems and experience higher rates of psychosocial maladjustment, although there may be a number of potentially mediating factors. OBJECTIVES: The purpose of this phenomenological study was to examine the early recovery experience of patients with a facial burn. In particular, this study focused on how the injury impacted on the participants' relationship with their own body and the challenges of early psychosocial adjustment within the first 4 months of sustaining the injury. METHODS: In 2011, six adult participants encompassing two females and four males ranging from 29 to 55 years of age with superficial to deep dermal facial burns (with background burns of 0.8%-55% total body surface area) were recruited from a severe burn injury unit in Australia for participation in a Burns Modified Adult Attachment Interview. Narrative data were analyzed thematically and informed by Colaizzi's method of data analysis. RESULTS: Three overarching themes emerged: relationship to self/other, coping, and meaning-making. Themes identified related to how the experience affected the participants' sense of relationship with their own bodies and with others, as well as other challenges of early psychosocial adjustment. All participants indicated that they had experienced some early changes in their relationship with their body following their burn injury. CONCLUSION: These findings highlight the struggle burn survivors experienced with postburn adjustment, but expressed altruism and optimism around their recovery. Past trauma was observed to be a significant finding in this sample. Understanding the "lived experience" supports the way clinical and family systems can foster positive adjustment and coping. Consequently, multidisciplinary burn teams and health care professionals need to understand the principles of trauma-informed care and translate these into practice in the treatment of this group of patients.

Mandibular phosphaturic mesenchymal tumor-mixed connective tissue variant in a young girl.

Phosphaturic mesenchymal tumor-mixed connective tissue variant (PMTMCT) is an extremely rare tumor associated with tumor-induced osteomalacia. The majority occur in middle age and arise from the extremities. This report describes a young girl with PMTMCT arising in the mandible and with no evidence of paraneoplastic syndrome.