J. Dokter

The use of cultured autologous epidermis in the treatment of extensive burn wounds

Seventeen patients with deep second- and third-degree burn wounds have been grafted with cultured autologous epidermis. These epidermal cell sheets were cultivated according to the feeder layer technique as described by Rheinwald and Green. After dispase treatment and detachment from the culture vessel, the cell sheets, mounted on a polyamide mesh, were ready for grafting. Patients with wounds excised at an early stage, prepared with human cadaver allografts or synthetic dressings, showed a significantly better graft take than nonexcised, chronic granulating wounds which were grafted at a later stage (47% versus 15%; p less than 0.002). Sandwich treatment of expanded mesh autografts and cultured autograft overlay did not improve the graft take, although in some cases wound healing was accelerated. The graft take was inversely correlated with the age of the patient (p = 0.01), and showed a weak inverse correlation with the day of first (and subsequent) culture grafting (p = 0.07). Wound infection was the main cause of graft failure. Up to 4 years after grafting, the grafted areas showed continued stability and the regenerated skin became supple, smooth, and pliable. Hypertrophic scar formation was less than observed in comparable areas treated with meshed grafts. Wound contraction occurred approximately to the same extent as in split-thickness skin grafts. We emphasize that by a better control of wound infection the graft take, also in secondary-stage procedures, can significantly improve.

Mortality and causes of death in a burn centre

Mortality rates are important outcome parameters after burn, and can serve as objective end points for quality control. Causes of death after severe burn have changed over time; in the international literature, multisystem organ failure is seen as the most important cause, but the exact distribution of causes of death remains unknown. Insight into underlying agents of mortality can be directive in research and prevention programmes. This comparison between results from the Rotterdam Burn Centre (RBC) and the American National Burn Repository (NBR) examines the most important predictive parameters for fatal outcome, i.e. age, total body surface area involved and presence of inhalation injury. Causes of death were attributed for all fatal outcomes treated in the RBC from 1996 to 2006. The mortality rate at the RBC was 6.9% and at the NBR was 5.6%, with almost no differences in age or total body surface area involved. The discrepancy in mortality rate might have been due to the high incidence of inhalation injury among the RBC population. However, the mortality rate at the RBC after admission with intention to treat decreased to 4.9%. The most frequent cause of death appeared to be multisystem organ failure, in 64.9% of cases; 93% of these had systemic inflammatory response syndrome at time of death and, in 45.9%, infection was deemed responsible for the fatal clinical deterioration (in 21.3% sepsis was proved and in 24.6% was highly suspected). To compare mortality rates between different burn centres and periods of time, uniform classifications are needed, particularly for presence of inhalation injury and for causes of death. Prevention of multisystem organ failure, by better management of infection and systemic inflammatory response syndrome, might do most to decrease mortality after burn.

Accuracy of burn size assessment prior to arrival in Dutch Burn centres and its consequences in children: A nationwide evaluation §

BACKGROUND Total body surface area (TBSA) burned, expressed as percentage is one of the most important aspects of the initial care of a burn victim. It determines whether transfer to a burn centre is necessary as well as the need for, and amount of, intravenous fluid resuscitation. Numerous studies, however, have highlighted inaccuracies in TBSA assessment. Therefore, the differences in burn size estimates between referrers and burn centres in children and its consequences in terms of transfer and intravenous fluid resuscitation were investigated. METHODS This study involved two time periods from January 2002 until March 2004 and January 2007 until August 2008. All referred children admitted to a Dutch Burn centre within 24h post burn were eligible. Data were obtained from patient records retrospectively and in part prospectively. RESULTS A total of 323 and 299 children were included in periods 1 and 2, respectively. Referring physicians overestimated burn size with a factor two (mean difference: 6% TBSA ± 5.5). About one in five children was referred to a burn centre without fulfilling the criteria for referral with regard to burn size (assessed by burn specialists) special localisation or inhalation trauma. Proportions of children receiving intravenous fluid resuscitation regardless of indication increased from 33% to 49% (p<0.01). The received volumes tended to be higher than necessary. CONCLUSIONS Referring physicians overestimate burn size in children admitted to Dutch burn centres. This has little negative consequences, however, in terms of unindicated transfers to a burn centre or unnecessary fluid resuscitation.

Reliability and Validity of the Dutch Version of the American Burn Association/Shriners Hospital for Children Burn Outcomes Questionnaire (5–18 Years of Age)

The American Burn Association/Shriners Hospital for Children Burn Outcomes Questionnaire (BOQ) is a self-administered questionnaire to monitor functional outcome after burns in children and adolescents. This study aimed to assess feasibility, reliability, and validity of the Dutch BOQ. The BOQ was adapted into Dutch and tested in a population of children and adolescents aged 5 to 15 years who were primary admissions to a Dutch or Belgian burn center (n = 6) during the period of March 2001 through February 2004. To assess validity, the Child Health Questionnaire (CHQ) and the EuroQol-5D (EQ-5D) were included. Response rate was 53% among parents (n = 145) and 48% among adolescents (n = 52). Internal consistency of the BOQ scales was good (Cronbach’s &agr; >0.7 in all but one scale). Test and retest results were similar; there were no significant differences between parents and adolescents in this respect. Expected high correlations between BOQ scales and conceptually equivalent CHQ and EQ-5D scales were found in eight of 12 comparisons. Eleven scales showed significant differences in the expected direction between children with a long length of stay versus those with a short length of stay. The Dutch BOQ can be used to evaluate functional outcome after burns in children aged 5 years and older. Our study showed that the Dutch BOQ is a feasible instrument with good reliability and validity.

Epidemiology and trends in severe burns in the Netherlands

INTRODUCTION The aim of this study was to characterize the epidemiology of severe burns in the Netherlands, including trends in burn centre admissions, non burn centre admissions and differences by age. METHODS Patients with burn-related primary admission in a Dutch centre from 1995 to 2011 were included. Nationwide prospectively collected data were used from three separate historical databases and the uniform Dutch Burn Repository R3 (2009 onwards). General hospital data were derived from the National Hospital Discharge Register. Age and gender-adjusted rates were calculated by direct standardization, using the 2005 population as the reference standard. RESULTS The annual number of admitted patients increased from 430 in 1995 to 747 in 2011, incidence rates increased from 2.72 to 4.66 per 100,000. Incidence rates were high in young children, aged 0-4 years and doubled from 10.26 to 22.96 per 100,000. Incidence rates in persons from 5 up to 59 increased as well, in older adults (60 years and older) admission rates were stable. Overall burn centre mortality rate was 4.1%, and significantly decreased over time. There was a trend towards admissions of less extensive burns, median total burned surface area (TBSA) decreased from 8% to 4%. Length of stay and length of stay per percent TBSA decreased over time as well. CONCLUSIONS Data on 9031 patients admitted in a 17-year period showed an increasing incidence rate of burn-related burn centre admissions, with a decreasing TBSA and decreasing in-burn centre mortality. These data are important for prevention and establishment of required burn care capacity.

Epidemiology of children admitted to the Dutch burn centres. Changes in referral influence admittance rates in burn centres

BACKGROUND In the Beverwijk Burn Centre a remarkable rise has been noted in the number of paediatric admissions since 2000. To investigate if this is a national trend and, if so, what may have caused it, a retrospective epidemiological study has been undertaken. MATERIALS AND METHODS The databases of the three Dutch burn centres were combined. Data on the population at risk for admission in a burn centre and data on burns related hospital admissions were added. Two age groups, 0-4 years and 5-17 years and two time periods, 1995-1999 and 2000-2007, were compared. RESULTS The mean number of paediatric admissions in the Dutch burn centres per year increased by 44.0% and 44.3% for the younger children (0-4 years) and the older children (5-17 years), respectively, whereas the number of paediatric burn admissions in other hospitals in the Netherlands decreased. The percentage of children that was referred from other hospitals increased in both age groups, and for the younger children this was significant. CONCLUSION There has been a shift in paediatric burn care towards a greater volume of admissions in specialized burn care of especially young children with less severe burns. A possible explanation for the increased number of referred children may be the introduction of the EMSB course in 1998, since EMSB guidelines dictate stricter and generally accepted referral criteria.

External validation of the revised Baux score for the prediction of mortality in patients with acute burn injury.

BACKGROUND Since the original Baux score was outdated and inhalation injury was recognized as an important contributor to mortality, Osler et al. developed a revised Baux score for the prediction of mortality of burn patients in an American population. The aim of this study was to validate the revised Baux score with data of patients admitted to the Rotterdam Burn Center (RBC) in the Netherlands. METHODS Prospectively collected data were analyzed for all patients with acute burn injury admitted to the RBC from 1987 to 2009 (n = 4,389), including sex, age, total body surface area involved, inhalation injury, mortality, and premorbid conditions. Logistic regression analysis was used to determine the relationship between mortality and possible contributing variables. The discriminative power of the revised Baux score was assessed by receiver operating characteristics curve analysis. RESULTS Overall mortality in our center was 6.5%; mortality in patients with intention to treat was 4.4%. Age, total body surface area, inhalation injury, as well as premorbid circulatory and central nervous system conditions were significant independent predictors of in-hospital mortality. Revised Baux score in the RBC population (area under the curve, 0.96; 95% confidence interval, 0.95–0.97) performed less specific and sensitive in a selected group of patients with high Baux scores (area under the curve, 0.81; 95% confidence interval, 0.76–0.84). CONCLUSION The revised Baux score is a simple and accurate model for predicting mortality in patients with acute burn injuries in a burn center setting. LEVEL OF EVIDENCE Prognostic study, level III.

Pain insensitivity syndrome misinterpreted as inflicted burns

We present a case study of a 10-year-old child with severe burns that were misinterpreted as inflicted burns. Because of multiple injuries since early life, the family was under suspicion of child abuse and therefore under supervision of the Child Care Board for 2 years before the boy was burned. Because the boy incurred the burns without feeling pain, we conducted a thorough medical examination and laboratory testing, evaluated detection and pain thresholds, and used MRI to study brain morphology and brain activation patterns during pain between this patient and 3 healthy age- and gender-matched controls. We found elevated detection and pain thresholds and lower brain activation during pain in the patient compared with the healthy controls and reference values. The patient received the diagnosis of hereditary sensory and autonomic neuropathy type IV on the basis of clinical findings and the laboratory testing, complemented with the altered pain and detection thresholds and MRI findings. Hereditary sensory and autonomic neuropathy IV is a very rare congenital pain insensitivity syndrome characterized by the absence of pain and temperature sensation combined with oral mutilation due to unawareness, fractures, and anhidrosis caused by abnormalities in the peripheral nerves. Health care workers should be aware of the potential presence of this disease to prevent false accusations of child abuse.

Reduction in skin grafting after the introduction of hydrofiber dressings in partial thickness burns: A comparison between a hydrofiber and silver sulphadiazine

AIM/PURPOSE The aim of this study was to compare clinical outcome of children with scald burns treated with a hydrofiber dressing (Aquacel(®), Convatec Inc.) with the former standard of care with silver sulfadiazine (Flammazine(®); Solvay Pharmaceuticals), considering surgical intervention and length of stay (LOS). METHODS A retrospective study of all consecutive children from zero to four years with primary scald burns up to 10% admitted to the Burn Centre of the Maasstad Hospital Rotterdam between January 1987 and January 2010 were reviewed. For data collection a prospective computerized database was used. For comparison the study period was divided into two periods representing the period before and after the introduction of the hydrofiber dressing (HFD), respectively 1987-1999 (period 1) and 1999-2010 (period 2). RESULTS Over the whole study period 27.3% of 502 patients treated with silver sulfadiazine (Ag-SD) underwent surgery, while before the introduction of HFD 30.5% of 338 Ag-SD treated patients were operated upon. After the introduction of the HFD 20.7% of 164 patients treated with Ag-SD eventually underwent skin grafting, a significant difference with the 11.6% of 302 patients whose wounds were dressed with HFD (p<0.01). CONCLUSIONS Compared to silver sulfadiazine treatment a reduced number of surgical interventions was observed in mixed partial thickness scald burns up to 10% TBSA burned in children aged 0-4 years after the introduction of hydrofiber dressings. The mode of treatment with this wound dressing also limited hospital length of stay.

The implementation and evaluation of therapeutic touch in burn patients: an instructive experience of conducting a scientific study within a non-academic nursing setting.

OBJECTIVE Evaluation of therapeutic touch (TT) in the nursing of burn patients; post hoc evaluation of the research process in a non-academic nursing setting. METHODS 38 burn patients received either TT or nursing presence. On admission, days 2, 5 and 10 of hospitalization, data were collected on anxiety for pain, salivary cortisol, and pain medication. Interviews with nurses were held concerning research in a non-academic setting. RESULTS Anxiety for pain was more reduced on day 10 in the TT-group. The TT-group was prescribed less morphine on day 1 and 2. On day 2 cortisol level before dressing changes was higher in the TT-group. The situational challenges of this study led to inconsistencies in data collection and a high patient attrition rate, weakening its statistical power. CONCLUSION Conducting an effect study within daily nursing practice should not be done with a nursing staff inexperienced in research. Analysis of the remaining data justifies further research on TT for burn patients with pain, anxiety for pain, and cortisol levels as outcomes. PRACTICE IMPLICATIONS Administering and evaluating TT during daily care requires nurses experienced both in TT and research, thus leading to less attrition and missing data, increasing the power of future studies.