Fiona M. Wood

Core outcomes for adult burn survivors: A clinical overview

Burn trauma ranges from the minor burn to the devastating injury, which can impact on all aspects of a persons life including aesthetic appearance, relationships with others and psychological, social and physical functioning. Measurement of outcome in burns patients is therefore complex and multi-faceted. The increasing numbers of major burn survivors implies that understanding health outcomes in these patients has assumed high priority. This paper sets out a conceptual framework for unifying outcome measurement, which may be useful to all members of the multidisciplinary team who are contemplating outcome assessment in their burn patients. It outlines seven core domains of assessment which are (i) skin; (ii) neuromuscular function; (iii) sensory and pain; (iv) psychological function; (v) physical role function; (vi) community participation; and (vii) perceived quality of life. Within each domain, we present a brief clinical review of the most commonly administered measurement tools that have been, or potentially could be, used to assess aspects of these core domains. Where possible, the psychometric properties and clinical utility of these tools are presented. A concise discussion of key methodological issues which should be addressed in this assessment process is then provided, together with suggestions for future research.

Direct measurement of cutaneous pressures generated by pressure garments

Pressure garments are the mainstay of burn scar management despite limited scientific evidence. This study demonstrates a simple method of directly measuring the cutaneous pressures generated by a pressure garment. The results show pressure garments generate an increase in subdermal pressures in the range 9-90 mmHg depending on the anatomical site. Garments over soft sites generate pressures ranging from 9 to 33 mmHg. Over bony prominences the pressures range from 47 to 90 mmHg. This method is believed to be more representative of the pressures generated than the interpositional techniques that measure garment-skin interface pressure, as it avoids garment distortion, the interference effect of the measurement device (size, conformation, area) and directly measures subdermal pressures. The method should be useful for larger research projects on pressure therapy and also for clinical management of pressure garments in the treatment of hypertrophic scar.

Demonstration of the validity of the SF-36 for measurement of the temporal recovery of quality of life outcomes in burns survivors

OBJECTIVE Outcome assessment after burn is complex. Determination of quality of life is often measured using the Burns Specific Health Scale (BSHS), a validated tool in the burn population. The SF-36 is a generic quality of life questionnaire that is validated for numerous populations, but not in burns. The aim of the study was to examine the validity of SF-36, using the BSHS as a reference. METHODS 280 burn patients were recruited at Royal Perth Hospital. Each completed SF-36 and BSHS-B at regular intervals to 2 years after burn. Regression modelling was used to assess the temporal validity and the relative sensitivity of the measures. RESULTS SF-36 domains and BSHS-B demonstrated significant associations at all time points (r=0.37-0.76, p<0.002). In the months after burn, SF-36 domains: role physical; bodily pain; social function and role emotional outperformed BSHS-B total score and domain scores. Greater measurement sensitivity was demonstrated in all SF-36 summary and subscales measures (except General Health) when compared to BSHS-B and sub-domains. CONCLUSION This study demonstrated SF-36 as a valid measure of recovery of quality of life in the burn patient population. The data suggests that SF-36 components were more sensitive to change than the BSHS-B from ∼1 month after injury.

Characterisation of the cell suspension harvested from the dermal epidermal junction using a ReCell® kit

BACKGROUND The use of non-cultured autologous cells to promote wound healing and in reconstructive procedures is increasing. One common method for preparing these cells is the use of the ReCell(®) device. However, despite its current clinical use, no characterisation of the cell suspension produced using a ReCell(®) device has been published. OBJECTIVE To characterise the ReCell suspension that is applied to wounds for cell type, viability, yield, stability and proliferative potential. METHODS The ReCell(®) device was used to harvest cells from a 2 cm(2) piece of split-thickness skin isolated using a dermatome. The resulting cell suspension was analysed for cell yield, cell type, viability over time, proliferative potential and reproducibility. RESULTS Average viable cell yield was 1.7×10(6)/cm(2) of tissue, with 75.5% of the total cell isolate viable. Total viable cell number was not significantly reduced after 4 h storage at 22°C or 4°C, and was stable for 24 h at 4°C. Proliferative potential was assessed using a colony forming assay, with 0.3% of viable cells isolated forming keratinocyte colonies. Predominantly the suspension contained keratinocytes (64.3±28.8%) and fibroblasts (30.3±14.0%), with a small population of melanocytes also identified (3.5±0.5%). Finally, the supernatant contained low total protein (0.92 mg/ml) and the supernatant had no significant effects on cell viability or growth when applied ex vivo. CONCLUSIONS These results suggest the ReCell(®) device provides a method for the preparation of a cell suspension with high viability and proliferative potential, containing viable melanocytes and no apparent toxic cell debris. Further work on the sustained viability of these cells in vivo, and in particular after application to the wound, will be important to better understand the potential of the ReCell(®) device in the clinic.

A 26-Year Population-Based Study of Burn Injury Hospital Admissions in Western Australia

The aim of the study was to use state-wide health administrative data to assess the incidence, temporal trends, and external cause of burn injury-related hospital admissions and mortality in Western Australia from 1983 to 2008. Linked hospital morbidity and death data for all persons hospitalized with an index burn injury in Western Australia for the period 1983–2008 were identified. Annual age-specific incidence and age standardized rates were estimated. Poisson regression analyses were used to estimate temporal trends in hospital admissions and mortality. Zero-truncated negative binomial regression analysis was used to identify factors associated with hospital length of stay. From 1983 to 2008, there were 23,450 hospitalizations for an index burn injury. Hospital admission rates declined by an average annual rate of 2% (incidence rate ratio [IRR], 95% confidence interval [CI] = 0.983, 0.981–0.984), and burn-related mortality declined by an average annual rate of 2% (IRR, 95% CI = 0.98, 0.96–1.01). Aboriginal people while having significantly higher hospitalization rates than non-Aboriginal people experienced a greater 26-year decline in hospitalizations of 58% (IRR, 95% CI = 0.42, 0.37–0.48) compared with 32% (IRR, 95% CI = 0.68, 0.65–0.71) for non-Aboriginal people. Children younger than 5 years, 20- to 24-year-old men, and adults older than 65 years remain at high risk for burn injury, and males continue to be hospitalized twice as frequently as females. The results demonstrate declines in burn injury hospitalizations and mortality in both Aboriginal and non-Aboriginal populations. Continued research is required of the impacts of medical interventions and the burn pathway of identified high-risk populations.

In vivo assessment of human burn scars through automated quantification of vascularity using optical coherence tomography.

Abstract. In scars arising from burns, objective assessment of vascularity is important in the early identification of pathological scarring, and in the assessment of progression and treatment response. We demonstrate the first clinical assessment and automated quantification of vascularity in cutaneous burn scars of human patients in vivo that uses optical coherence tomography (OCT). Scar microvasculature was delineated in three-dimensional OCT images using speckle decorrelation. The diameter and area density of blood vessels were automatically quantified. A substantial increase was observed in the measured density of vasculature in hypertrophic scar tissues (38%) when compared against normal, unscarred skin (22%). A proliferation of larger vessels (diameter≥100  μm) was revealed in hypertrophic scarring, which was absent from normal scars and normal skin over the investigated physical depth range of 600 μm. This study establishes the feasibility of this methodology as a means of clinical monitoring of scar progression.

Bone marrow-derived cells in the healing burn wound—More than just inflammation

Scarring after severe burn is a result of changes in collagen deposition and fibroblast activity that result in repaired but not regenerated tissue. Re-epithelialisation of wounds and dermal cell repopulation has been thought to be driven by cells in the periphery of the wound. However, recent research demonstrated that cells originating from the bone marrow contribute to healing wounds in other tissues and also after incisional injury. We investigated the contribution of bone marrow-derived cells to long-term cell populations in scar tissue (primarily fibroblasts and keratinocytes) after severe burn. Wild-type mice were lethally irradiated and then the bone marrow reconstituted by injection of chimeric bone marrow cells expressing EGFP marker protein. Mice with chimeric bone marrow were then given a burn, either an 1-cm diameter injury (to mimic minor injury) or 2-cm diameter (to mimic moderate injury). Wounds were analysed at days 1, 3, 7, 14, 21, 28, 56 and 120 using FACS and immunohistochemistry to identify the percentage and cell type within the wound originating from the bone marrow. The inflammatory cell infiltrate at the early time-points was bone marrow in origin. At later time-points, we noted that over half of the fibroblast population was bone marrow-derived; we also observed that a small percentage of keratinocytes appeared to be bone marrow in origin. These findings support the theory that the bone marrow plays an important role in providing cells not only for inflammation but also dermal and epidermal cells during burn wound healing. This increases our understanding of cell origins in the healing wound, and has the potential to impact on clinical practice providing a potential mechanism for intervention away from conventional topical treatments and directed instead to systemic treatments affecting the bone marrow response.

Persistent pain outcomes and patient satisfaction with pain management after burn injury.

ObjectivesAcute burn pain management has advanced significantly, yet little is known about long-term pain outcomes after severe burn injury. Even less is known about patient satisfaction with pain management after burn injury. This study examined the long-term pain and psychological outcomes of burn survivors who were treated at the Burns Service of Western Australia between 1994 and 2005. MethodsOf 2114 burn survivors who were mailed standardized self-report measures of pain, depressive, and posttraumatic stress symptoms, 492 returned completed questionnaires. Of these, 18% reported persistent burn-related pain, and 27% and 14% reported clinically significant depressive and posttraumatic stress symptoms, respectively. Those with persistent pain reported significantly more severe depressive and posttraumatic stress symptoms compared with those with no pain. Interestingly, respondents with persistent burn-related pain recalled significantly higher levels of procedural and dressing change acute pain than those without pain symptoms. Linear multiple regression analyses revealed that the extent to which pain treatment expectations were met predicted overall satisfaction with pain treatment, beyond the effects of perceived pain improvement, current burn pain intensity, depression and posttraumatic stress symptoms, age, sex, and total burn surface area. DiscussionCollectively, these findings suggest a significant proportion of severely injured burn survivors continue to experience persistent pain and point to the need to identify and treat persistent pain more effectively. Moreover, assessing and managing pain treatment expectations during the early phase of recovery postburn may yield improved levels of patient satisfaction with treatment received.

Candidemia and invasive candidiasis: A review of the literature for the burns surgeon

Advances in critical care, operative techniques, early fluid resuscitation, antimicrobials to control bacterial infections, nutritional support to manage the hypermetabolic response and early wound excision and coverage has improved survival rates in major burns patients. These advances in management have been associated with increased recognition of invasive infections caused by Candida species in critically ill burns patients. Candida albicans is the most common species to cause invasive Candida infections, however, non-albicans Candida species appear to becoming more frequent. These later species may be less fluconazole susceptible than Candida albicans. High crude and attributable mortality rates from invasive Candida sepsis are multi-factorial. Diagnosis of invasive candidiasis and candidemia remains difficult. Prophylactic and pre-emptive therapies appear promising strategies, but there is no specific approach which is well-studied and clearly efficacious in high-risk burns patients. Treatment options for invasive candidiasis include several amphotericin B formulations and newer less toxic antifungal agents, such as azoles and echinocandins. We review the currently available data on diagnostic and management strategies for invasive candidiasis and candidemia; whenever possible providing reference to the high-risk burn patients. We also present an algorithm for the management of candidemia and invasive candidiasis in burn patients.

A study of burn hospitalizations for children younger than 5 years of age: 1983-2008

OBJECTIVE: Burn injury is a leading cause of emergency department visits and hospitalizations for young children. We aimed to use statewide linked health administrative data to evaluate the incidence, temporal trends, and cause of burn injuries for children younger than 5 years hospitalized for burn injuries in Western Australia for the period 1983–2008. METHODS: Epidemiologic analysis of linked hospital morbidity and death data of children younger than 5 years hospitalized with an index burn injury in Western Australia for the period 1983–2008. Poisson regression analyses were used to estimate temporal trends in hospital admissions and the external cause of the burn injury. RESULTS: From 1983 to 2008, there were 5398 hospitalizations for an index burn injury and 3 burn-related deaths. Hospital admission rates declined by an average annual rate of 2.3% (incidence rate ratio: 0.977 [95% confidence interval: 0.974–0.981]). More than half of the admissions were for scald burns. Hospitalizations declined for injury caused by scald, flame, contact, and electrical burns; however, the number of hospital admissions increased for chemical burns during the study period. CONCLUSIONS: The burn-injury hospitalizations reported in this study were preventable. Most burns occurred in the home and resulted from exposure to a household hazard. Further effort needs to be devoted to burn prevention and safety strategies, particularly in relation to scalds, to further reduce the incidence of burn injury in young children.