Babchi oil-induced phytophotodermatitis mimicking burn injury.

Babchi (Psorylea corylifolia) is occasionally used by patients as a herbal treatment in conditions such as psoriasis and vitiligo, due to its anti-inflammatory, anti-oxidant and immune-modulatory properties (Shrestha et al., 2018; Chopra et al., 2013). Due to its psoralen containing furocoumarins, it has the potential to induce photosensitive reactions. We present the first reported case of Babchi-induced phytophotodermatitis in the UK, presenting as sunburn.

Pediatric Toxic Shock Syndrome After a 7% Burn: A Case Study and Systematic Literature Review.

INTRODUCTION: Toxic shock syndrome (TSS) is a life-threatening condition, which occurs in children after sustaining a burn. Often diagnosed retrospectively, many patients may not receive optimal treatment.The primary objective of this study was to evaluate a severe and complex case of TSS at our unit and subsequently conduct a Preferred Reporting for Systematic Reviews and Meta-Analyses-compliant systematic literature review, to identify cases of postthermal injury TSS and evaluate their presentation and management. CASE REPORT: A 9-year-old boy with Down syndrome presented with a 7% total body surface area scald to his back and posterior head. Four days after discharge, he developed a fever. The following day, he deteriorated, becoming stridulous and unresponsive. A working diagnosis of TSS was made. The patient's intensive care stay was arduous with multiple complications, including 2 cardiac arrests. METHODS: A Preferred Reporting for Systematic Reviews and Meta-Analyses-compliant systematic literature review was conducted. MEDLINE, PubMed, and Web of Science were searched using key terms "burns, thermal injury, scalds, paediatric, child, infant, neonate, toxic shock syndrome" to identify cases. Two authors independently checked each study against inclusion criteria. RESULTS: The systematic literature search yielded 9 articles, identifying 40 cases. Ages ranged between 9 months and 8 years. The mean number of days' postburn patients presented with symptoms of TSS was 2.5 days (1-7 days). The most common presenting symptoms were fever (75%), rash (70%), and diarrhea, and/or vomiting (52.5%). Intravenous immunoglobulins were administered in 11 (27.5%) cases. DISCUSSION: We have highlighted a case where a possible delayed diagnosis along with the immunodeficiency seen in Down syndrome may have impacted the severity of TSS. The literature review highlighted that a significant proportion of patients do not meet diagnostic criteria. CONCLUSIONS: It is fundamental that appropriate diagnostic and management guidelines are developed. Furthermore, this case highlights the importance of educating patient's carers and health professionals of key symptoms to be wary of postburn.

In hot water: The impact of burn injuries from hot water bottles - Experience of a UK burns unit and review of the literature.

INTRODUCTION: Hot water bottles (HWBs) are a common domestic item in the UK. Their use is associated with burns injuries, either by contact for prolonged periods with the skin, or through the HWB leaking or bursting. METHODS: We used electronic health records to retrospectively review HWB related burns treated by the Burns Service at Chelsea and Westminster Hospital between January 2017-March 2018. We analysed the mechanism of injury, size and depth of burn, method of treatment and costs associated with HWB burns in our centre. RESULTS: 80 patients sustained HWB burns during this period, with a similar incidence of contact burns (41/80, 51.3%) and scalds (38/80, 47.5%), with one steam burn. The commonest area burnt was the lower limb (40/80, 50%). Most burns had a TBSA of 1% or smaller (50/80, 62.5%). 30 patients had full thickness burns, with 37 in total received operative management. We estimate that the total cost for managing this cohort of patients was over £68,634. CONCLUSIONS: There are a significant proportion of patients presenting with HWB burns that could be prevented, with significant impact on patient morbidity and resource burden on the NHS. Targeted public awareness campaigns are needed to ameliorate these injuries.

Implementation of a checklist to enhance operation note quality at a UK burns centre.

INTRODUCTION: Operation notes are fundamental for clinical, academic and medico-legal purposes. Good Surgical Practice (2014) provides guidelines to assist note completion but the literature suggests poor adherence to these. The aim of this study was to evaluate and improve operation note quality at a UK burns centre through implementation of a burns surgery-specific checklist. METHODS: A 22-component burns surgery-specific checklist, modified from Good Surgical Practice (2014), was designed and implemented. The quality of 80 operation notes (40 pre and 40 post-implementation) was assessed against this checklist. Fisher's exact and Mann-Whitney U statistical tests were used to evaluate pre and post-intervention note quality. RESULTS: Before checklist implementation, only 6/22 components (27.3%) were recorded on every note. 4/22 components (18.2%) were not recorded on any, including microbiology specimen and clinical photography, which are particularly important in burns. After implementation, 16/22 (72.7%) were recorded on every note, with a statistically significant improvement in all other components (p≤0.01), except venous thromboembolism prophylaxis (p=0.10). The median percentage score of components recorded improved from 78.2 to 100% (p<0.01). CONCLUSION: To our knowledge, this is the first study in available literature to show that a burns surgery-specific checklist can significantly improve burns operation note quality. This presents a simple and cheap method to improve note quality and may enhance post-operative intra/inter-team communication and patient care. At our unit, we have now developed an electronic checklist format with mandatory field completion to facilitate total compliance.

Revised Baux Score and updated Charlson comorbidity index are independently associated with mortality in burns intensive care patients.

PURPOSE: The purpose of the current study was to utilise established scoring systems to analyse the association of (i) burn injury severity, (ii) comorbid status and (iii) associated systemic physiological disturbance with inpatient mortality in patients with severe burn injuries admitted to intensive care. METHODS: Case notes of all patients with acute thermal injuries affecting ≥15% total body surface area (TBSA) admitted to the Burns Intensive Care Unit (BICU) at Chelsea and Westminster Hospital during a 10-year period were retrospectively reviewed. Revised Baux Score, Belgian Outcome in Burn Injury (BOBI) Score, Abbreviated Burn Severity Index (ABSI), APACHE II Score, Sequential Organ Failure Assessment (SOFA) Score and Updated Charlson Comorbidity Index (CCI) were computed for each patient and analysed for association with inpatient mortality. RESULTS: Ninety mechanically ventilated patients (median age 45.7 years, median % TBSA burned 36.5%) were included. 72 patients had full thickness burns and 35 patients had inhalational injuries. Forty-four patients died in hospital while 46 survived to discharge. In a multivariate logistic regression model, only the Revised Baux Score (p<0.001) and updated CCI (p=0.014) were independently associated with mortality. This gave a ROC curve with area under the curve of 0.920. On multivariate cox regression survival analysis, only the Revised Baux Score (p<0.001) and the updated CCI (p=0.004) were independently associated with shorter time to death. CONCLUSION: Our data suggest that the Revised Baux Score and the updated CCI are independently associated with inpatient mortality in patients admitted to intensive care with burn injuries affecting ≥15% TBSA. This emphasises the importance of comorbidities in the prognosis of patients with severe burn injuries.

Geographical analysis of socioeconomic factors in risk of domestic burn injury in London 2007-2013.

PURPOSE: This study aims to explore the geographical distribution of burn injuries in Greater London and the association of socioeconomic factors in areas at risk. METHODS: Data on burn injury cases classified as occurring in patients' own homes in Greater London and admitted to a specialised burns service for ≥1 day during a 7-year period were obtained from the International Burn Injury Database (iBID). Age- and gender-adjusted standardised incidence ratios (SIRs) were calculated for each Lower Layer Super Output Area (LSOA) in Greater London. Bayesian methods were used to calculate relative risks as best estimates of spatially-smoothed SIRs. RESULTS: Of a total of 2911 admissions to specialised burns services in Greater London in the study period, 2100 (72.1%) cases occurred in patients' own homes. Percentage of ethnic minorities (p=0.005), Income Deprivation Affecting Children Index (p<0.001), Health Deprivation and Disability Score (p=0.031), percentage of families with 3 or more children (p=0.004) and Barriers to Housing and Services Score (p=0.001) remained independently associated with the relative risk of paediatric domestic burn injury in a multivariate linear regression model. Percentage of ethnic minorities (p<0.001), Health Deprivation and Disability Score (p<0.001) and Barriers to Housing and Services Score (p=0.036) remained independently associated with the relative risk of adult domestic burn injury in a multivariate linear regression model. CONCLUSIONS: Socioeconomic factors are associated with an increased risk of burn injury in Greater London, but may be more important in children than adults. The specific factors identified are ethnicity, poor general health, household structure, housing issues and income deprivation affecting children.

Safety and efficacy of excision and direct closure in acute burns surgery: outcome analysis in a prospective series of 100 patients and a survey of UK burns surgeons' attitudes.

Many burns surgeons avoid excision and direct closure of acute burns owing to concerns over wound dehiscence, scarring and infection. There is no evidence in the literature to support this practice. We present outcomes of a prospective series of 100 patients who underwent excision and direct closure of 138 burns over a 2-year period, along with results from a survey sent to 33 senior burns surgeons to gauge attitudes towards direct closure in burns surgery. 47% of survey respondents never perform direct closure. Dehiscence was cited as the most common concern, followed by hypertrophic scarring (HTS). In our cohort, the superficial dehiscence rate was 12% and the HTS rate was 16%, with no scarring contractures. Patients with healing time greater than 14 days were more likely to develop HTS (p=0.008), as were those with wound dehiscence (p=0.014). Patients undergoing part-grafting in addition to direct closure took significantly longer to heal than those undergoing direct closure alone (p=0.0002), with the donor site or graft delaying healing in the majority. Excision and direct closure of acute burn wounds avoids donor site morbidity and has an acceptable complication rate. It is a safe and effective treatment for full thickness burns in selected cases.

Training in microsurgical skills: Does course-based learning deliver?

Practical skill training courses are an increasingly popular method of teaching surgical skills. Few data are available from instructional courses indicating how successful they are at imparting practical skills to those individuals who attend them. We aimed to identify the skill benefits gained by trainee surgeons attending a 5-day microsurgical skills course. A global scoring system was devised to objectively assess the level of skill employed by trainees to complete an arterial microvascular anastamosis. Vessel patency, anastamotic construct, and care of tissue in the surrounding operative field were taken into account. Postoperative tissue viability and physiological vessel function following anastamosis were also investigated. The majority of surgeons (60%) exhibited an increase in their level of microsurgical skill during the course. The remaining candidates remained static or deteriorated. Attendance at this microsurgical training workshop resulted in an improvement in microsurgical skills in most trainees. In-course assessment by training courses would allow identification of individuals requiring further training or skill refinement.

How do we assess microsurgical skill?

How does one demonstrate competence in microsurgery? This will become an increasingly more important question as further reforms in surgical training and revalidation are implemented. Any assessment of competence should include an assessment of technical skill, but there is presently no validated objective assessment technique to do this. We examine the ideal characteristics of an assessment technique and review the methods currently being validated and which could be applicable to microsurgical skills.

Hyperhidrosis: a review of current management.

Primary hyperhidrosis is a troublesome disorder of excessive perspiration that affects as much as 1 percent of the population. Sufferers are usually young and are often affected by related social, professional, and psychological problems. Many methods for treating hyperhidrosis exist; however, no single treatment is without its weakness or complications. This article aims to clarify the issues related to the use of each treatment modality, including the most recently proposed method using botulinum toxin.