Eur. Burn J., Volume 2, Issue 4 (December 2021) – 9 articles

Respiratory compromise is a recognised sequelae of major burn injuries, and in rare instances requires extracorporeal membrane oxygenation (ECMO). Over a ten-year period, our hospital trust, an ECMO centre and burns facility, had five major burn patients requiring ECMO, whose burn injuries would normally be managed at trusts with higher levels of burn care. Three patients (60%) survived to hospital discharge, one (20%) died at our trust, and one patient died after repatriation. All patients required regular, time-intensive dressing changes from our specialist nursing team, beyond their regular duties. This review presents these patients, as well as a review of the literature on the use of ECMO in burn injury patients. A formal review of the overlap between the networks that cater to ECMO and burn patients is recommended. Full article

Although they are a common type of injury worldwide, burns are challenging to diagnose, not least by untrained point-of-care clinicians. Given their visual nature, developments in artificial intelligence (AI) have sparked growing interest in the automated diagnosis of burns. This review aims to appraise the state of evidence thus far, with a focus on the identification and severity classification of acute burns. Three publicly available electronic databases were searched to identify peer-reviewed studies on the automated diagnosis of acute burns, published in English since 2005. From the 20 identified, three were excluded on the grounds that they concerned animals, older burns or lacked peer review. The remaining 17 studies, from nine different countries, were classified into three AI generations, considering the type of algorithms developed and the images used. Whereas the algorithms for burn identification have not gained much in accuracy across generations, those for severity classification improved substantially (from 66.2% to 96.4%), not least in the latest generation (n = 8). Those eight studies were further assessed for methodological bias and results applicability, using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. This highlighted the feasibility nature of the studies and their detrimental dependence on online databases of poorly documented images, at the expense of a substantial risk for patient selection and limited applicability in the clinical setting. In moving past the pilot stage, future development work would benefit from greater input from clinicians, who could contribute essential point-of-care knowledge and perspectives. Full article

The CARe Burn Scales are a portfolio of burn-specific PROMs for people affected by burns, including a Child Form (for children < 8 years (parent-proxy)), a Young Person Form (for young people aged 8–17 years), an Adult Form, and a Parent Form (for parents/carers of children aged 0–17 years). This study aimed to determine the responsiveness and minimal important difference (MID) values of the three scales developed for use in paediatric burn services and research. Participants were recruited by 15 UK Burn Services. Participants completed the appropriate CARe Burn Scale and a set of appropriate comparison validated measures, at three time points: 4 weeks (T1), 3 months (T2) and 6 months (T3) post-burn injury. Spearman’s correlation analysis and effect sizes based on Cohen’s d thresholds were reported and MID values were calculated. At baseline, 250 participants completed the Child Form, 69 completed the Young Person Form, and 320 completed the Parent Form. A total of 85–92% of participants were retained at follow up. The tested CARe Burn Scales were all responsive to change over time. MID values were created for all subscales and ranged from 2 to 11 for the Child Form, 3 to 14 for the Young Person Form and 3 to 10 for the Parent Form. The CARe Burn Scales for children, young people and parents are responsive to change over time. The scales are freely available for clinical and research use. Full article

It is well-understood that wound care poses a significant burden on the healthcare system and patient well-being. As such, it is imperative to develop efficient methods that facilitate tissue repair. Our group previously developed a nutritional gel scaffold, proven to accelerate wound repair. Due to its gel-like properties, this scaffold requires a time-consuming reconstitution, and is optimized for cavernous wounds. This pilot study examined the feasibility of a powdered form of this scaffold to accelerate healing of full-thickness wounds, thus broadening the range of applications, while providing a practical product. Splinted full-thickness wounds were generated on the backs of 6 mice, and treated with either powder, the original gel scaffold, or no treatment. Feasibility and efficacy of the powder was assessed through comparison of clinical wound measurements and histological assessments. There was a significant effect of treatment on rate of epithelialization [H(3) = 8.346, p = 0.0024] and on days to epithelial closure [H(3) = 8.482, p = 0.0061]. Post hoc analysis revealed that while requiring no reconstitution and simple to apply, the powder was sufficient to accelerate epithelialization compared to untreated wounds (p < 0.05). Furthermore, our results suggest that application of this powder did not alter certain processes associated with healing progress, such as epidermal thickness and collagen deposition. As such, this powder may provide a novel alternative to our previously developed gel scaffold by accelerating epithelialization, while providing a practical product. Future studies necessitate further evaluation of healing measures with a larger sample size. Full article

The protein C (PC) system has proven to be a crucial cascade in systemic inflammatory and coagulopathic disorders such as severe sepsis and, more recently, in severe burns. We aimed to conflate our recent systemic findings with further investigations in the local tissue effects of a severe burn injury on the expression of PC and its main receptor endothelial protein C receptor (EPCR). Of the 86 patients enrolled in our recent study, 34 consented to biopsies of both normal and burn edge tissue. These were examined histologically and immunostained for PC, EPCR, and CD68. The burn samples expressed lower PC (p = 0.0027) and higher EPCR (p = 0.0253) than the normal samples in a histological severity-dependent manner. There was also a negative association between PC expression and CD68 positive macrophage infiltration (τ_b = −0.214, p = 0.020), which was expectedly higher in burn edge samples (p < 0.0005). Interestingly, while there were no correlations between tissue and plasma PC or EPCR, local PC expression was also prognostic of our previously established outcome of a patient requiring increased medical support (OR 0.217 (95%CI 0.052 to 0.901), p = 0.035). The results suggest that local PC cascade changes from a burn injury may be a separate process to the systemic effects and that the local levels may provide useful information in addition to the diagnostic and prognostic abilities we previously found in the circulating PC system. Full article

Stress disorders are common after burn injuries and universal screening is recommended. This study describes current screening practices and provider beliefs regarding screening for stress disorders in patients with burns in the US. This was a 31-question survey distributed to the American Burn Association. Sixty-two percent of 121 respondents indicated their institution formally screened for ASD and/or PTSD. The most common reason for not screening was a lack of mental healthcare providers (46%), lack of funding (26%) and lack of time (20%). The timing of screening, the person administering the screening, and the method of screening varied for both pediatric and adult patients. Most respondents (87%) believed screening should be a standard of care, but only 32% were comfortable screening pediatric patients and 62% were comfortable screening adults. While screening for ASD and PTSD is recommended for patients with burns, our study indicates that screening is not a current standard of care. Lack of mental healthcare providers, funding, and time are contributing factors. Among those institutions that screen, a uniform screening practice does not exist. Full article

Background: chronic wounds are complex to manage and require an objective assessment for diagnosis and prognosis purposes. Therefore, this article aims to provide an overview of available noninvasive imaging techniques for chronic wound healing described in the literature. Methods: a systematic literature review using electronic databases was performed with appropriate “Mesh” terms. The primary outcome was the validity and reliability of the instrument, whilst the secondary outcome was its feasibility, such as speed of assessment, ease of use and cost of the tool. All studies underwent quality assessment of diagnostic accuracy studies (QUADAS) to ensure the quality of the data. Results: 44 articles were identified evaluating six wound assessment modalities. Most studies (n = 9) reported on a two-dimensional device with a mean error ranging from 1.9–5.1% and an inter/intra rater correlation over 0.9 with a high ICC (>95%). The average QUADAS score was 13, with the lowest being 9 and the highest being 14. Conclusion: this review collectively evaluates objective, reliable, quantitative, and innovative tools to assess wound healing objectively. The most superior wound measuring device was two dimensional. However, hyperspectral imaging had strong potential but required further development in its technology and future clinic validation studies. Full article

The effect of poorly treated pain is well documented in the literature. To offer support for the development of geriatric-specific pain management protocols, this review sought to scope the literature to identify what has been accomplished in geriatric burn pain management and offer suggestions. Arksey and O’Malley’s scoping review methodology was employed with extensive database and grey literature searches. A narrative synthesis was employed to analyse the evidence. The PRISMA extension guidelines for scoping reviews were followed in reporting this review. Sixteen evidence types comprising eleven reviews, two retrospective studies, two book chapters, and one practice guideline were retained in the review. The two retrospective studies emerged from the United States. The review findings suggest that though a plethora of generic pain assessment tools exist, they are yet to be validated in the older adult burn population. Pain management strategies involved the use of pharmacological agents (mainly opioids), but no outcome regarding pain relief was reported. Key issues identified include cautious use of opioids, oversedation concerns, and varied complexities associated with pain management. Though the literature remains largely unexplored, the complexities associated with geriatric burn pain management suggest a need for a multidisciplinary approach. More prospective studies are also needed to evaluate both pharmacological and non-pharmacological interventions in the geriatric burn population. Full article

Invasive fungal wound infection (FWI) after burn injury, while uncommon, is associated with significant morbidity and mortality. There are numerous risk factors for FWI, including large burn size and incomplete excision of burn wounds. FWI can be challenging to diagnose. Close attention to changes in the physical examination and, in particular, to the appearance of burn wounds leads the burn team to be suspicious of FWI. Once FWI is suspected, histopathological evaluation of an incisional biopsy provides definitive diagnosis, while tissue culture enables identification of the causative organism to the species level and facilitates targeted antifungal therapy. Management of FWI focuses largely on aggressive surgical intervention, in addition to adjunctive systemic and topical antifungals and nonpharmacologic therapies. Treatment of FWI involves a multifaceted approach, which requires expertise from the entire multidisciplinary burn team. Full article