Jason Wasiak

A systematic review of the quality of burn scar rating scales for clinical and research use

INTRODUCTION Scar rating scales have the potential to contribute to better evaluation of scar properties in both research and clinical settings. Despite a large number of scars assessment scales being available, there is limited information regarding the clinimetric properties of many of these scales. The purpose of the review was to inform clinical and research practice by determining the quality and appropriateness of existing scales. This review summarises the available evidence for the clinimetric properties of reliability, validity (including responsiveness), interpretability and feasibility of existing scales. METHODS Electronic searches of MEDLINE, CINAHL, EMBASE and The Cochrane Library databases from 1990 onwards were used to identify English articles related to burn scar assessment scales. Scales were critically reviewed for clinimetric properties that were reported in, but not necessarily the focus of studies. RESULTS A total of 29 studies provided data for 18 different scar rating scales. Most scar rating scales assessed vascularity, pliability, height and thickness. Some scales contained additional items such as itch. Only the Patient and Observer Scar Assessment Scale (POSAS) received a high quality rating but only in the area of reliability for total scores and the subscale vascularity. The Vancouver Scar Scale (VSS) received indeterminate ratings for construct validity, reliability and responsiveness. Where evidence was available, all other criteria for the POSAS, VSS and the remaining 17 scales received an indeterminate rating due to methodological issues, or a low quality rating. Poorly defined hypotheses limited the ability to give a high quality rating to data pertaining to construct validity, responsiveness and interpretability. No scale had empirical testing of content validity and no scale was of sufficient quality to consider criterion validity. CONCLUSIONS The POSAS, with high quality reliability but indeterminate validity, was considered to be superior in performance based on existing evidence. The VSS had the most thorough review of clnimetrics although available data received indeterminate quality ratings. On the basis of the evidence, the use of total scores has not been supported, nor has the measurement of pigmentation using a categorical scale.

The epidemiology of burn injuries in an Australian setting, 2000-2006.

OBJECTIVES To describe presentation characteristics of burn leading to death or hospital treatment (i.e. inpatient admissions and emergency department [ED] presentations) across the state of Victoria, Australia, for the years 2000-2006 inclusive. METHODS Data were provided by the Victorian Injury Surveillance Unit (VISU) from three different datasets pertaining to burn deaths, hospital inpatient admissions and non-admitted ED presentations. Population estimates were derived from census data provided by Australian Bureau of Statistics. RESULTS During the 7-year period, 178 people died and 36,430 were treated for non-fatal burn injury, comprising 7543 hospital admissions and 28,887 non-admitted ED presentations. Males, children aged less than 5 years of age, and the elderly (> or =65 years of age) were at the highest risk of injury. Contact with heat and hot substances represented the major aetiological factor contributing to thermal injuries accounting for 64% of all hospital admissions and 90% of ED presentations. Temporal trends indicate no change in the population rate of burn deaths or hospital admissions during the study period. CONCLUSIONS ED presentations and hospital admissions and deaths have remained the same over this study period, but rates of burn remain high in males, children and the elderly. This could be due to variations in the implementation of government prevention and control programs and the divergence in efficient treatments and clinical practices amongst hospital care providers. Therefore, educational efforts for prevention should be the keystone to minimise the incidence of burns.

Ten-Year Epidemiological Study of Pediatric Burns in Canada

The aim of this study was to report on the temporal trends, incidence rates, demographic, and external-cause data for all burn injury related deaths and hospital admissions among children Canadian aged 0 to 19 years for the years 1994 to 2003. Statistics Canada and Canadian Institute of Health Information data were used to describe burn injury related deaths and hospital admission trends in children aged 0 to 19 years who were residents of Canada (1994–2003). Population estimates were derived from census data provided by Statistics Canada. During the 10-year period, 494 children died and 10,229 were admitted to a Canadian hospital because of a burn-related injury. Males and children aged less than 5 years of age were at the highest risk of injury, with children aged 1 to 5 years at the highest risk of death. Scalds represented the major etiological factor contributing to thermal injuries accounting for 50% of all hospital admissions. Temporal trends indicate a significant a significant decline in burn injuries across all age groups during the period 1994 to 2003. There has been a clear reduction in the number of patients with burn injury requiring hospital admission. This trend indicates success in safety initiative to prevent burn injuries as well as in improvements in the treatments of burn and hospital admission procedures. Nonetheless, burn injury remains a serious threat to the well-being of the Canadian pediatric population.

Synthetic Devices for Reconstructive Surgery of the Cruciate Ligaments: A Systematic Review

PURPOSE The role of synthetic devices in the management of the cruciate ligament-injured knee remains controversial. The aim of this systematic review was to assess the safety and efficacy of synthetic devices in cruciate ligament surgery. METHODS A systematic review of the electronic databases Medline, Embase, and The Cochrane Library (issue 1, 2014) on January 13, 2014, was performed to identify controlled and uncontrolled trials. Trials that assessed the safety and efficacy of synthetic devices for cruciate ligament surgery were included. The main variables assessed included rates of failure, revision, and noninfective effusion and synovitis. Patient-reported outcome assessments and complications were also assessed where reported. RESULTS From 511 records screened, we included 85 articles published between 1985 and 2013 reporting on 6 synthetic devices (ligament augmentation and reconstruction system [Ligament Augmentation and Reconstruction System (LARS; Surgical Implants and Devices, Arc-sur-Tille, France)]; Leeds-Keio [Xiros (formerly Neoligaments), Leeds, England]; Kennedy ligament augmentation device [3M, St Paul, MN]; Dacron [Stryker, Kalamazoo, MI]; Gore-Tex [W.L. Gore and Associates, Flagstaff, AZ]; and Trevira [Telos (limited liability company), Marburg, Germany]). The heterogeneity of the included studies precluded meta-analysis. The results were analyzed by device and then type of reconstruction (anterior cruciate ligament [ACL]/posterior cruciate ligament [PCL]/combined ACL and PCL). The lowest cumulative rates of failure were seen with the LARS device (2.6% for ACL and 1% for PCL surgery). The highest failure rate was seen in the Dacron ACL group (cumulative rate, 33.6%). Rates of noninfective synovitis and effusion ranged from 0.2% in the LARS ACL group to 27.6% in the Gore-Tex ACL group. Revision rates ranged from 2.6% (LARS) to 11.8% (Trevira-Hochfest; Telos). Recent designs, specifically the LARS, showed good improvement in the outcome scores. The mean preoperative and postoperative Lysholm knee scores were 54 and 88, respectively; the mean preoperative and postoperative Tegner activity scale scores were 3.3 and 6, respectively. CONCLUSIONS Preliminary results for newer-generation devices, specifically the LARS, show lower reported rates of failure, revision, and sterile effusion/synovitis when compared with older devices. LEVEL OF EVIDENCE Level IV, systematic review of Level II through IV studies.

Candida in Burns: Risk Factors and Outcomes

Sepsis due to Candida is an uncommon but a significant cause of death in burns patients. Colonization is common, but consensus guidelines for prophylaxis and empirical therapy do not specifically include this cohort. Our aim was to define predictive factors for candidaemia in a burns unit, to guide protocols for prevention and early treatment. We conducted a 10-year review (July 1998–December 2007) of patients admitted to the Victorian Adult Burns Service, Melbourne, Australia. Of 1929 patients admitted with acute burn injury, 143 had Candida isolated at any site, most commonly Candida albicans. There were 12 episodes of candidaemia. Prior colonization was an important risk factor for candidaemia, and the risk increased substantially with the number of colonized sites; indeed 43% of patients colonized at more than three sites (and not on antifungals) developed candidaemia. Other risk factors were higher total burn surface area, higher full-thickness surface area, prolonged admission, number and duration of intensive care unit admissions, number of visits to the operating theatre, alcohol as a contributing factor to burn, prior treatment with total parenteral nutrition, or certain antibiotics (ceftriaxone, vancomycin, amikacin, co-trimoxazole). The attributable mortality of candidaemia was 15% (n = 2). Initiation of antifungal therapy was often delayed. Our results support early empirical antifungal therapy in septic burns patients who are colonized, before the results of cultures become known. The role of prophylactic antifungals is less clear, but should be strongly considered for patients colonized at multiple sites.

Three decades of disasters: a review of disaster-specific literature from 1977-2009.

INTRODUCTION The potential for disasters exists in all communities. To mitigate the potential catastrophes that confront humanity in the new millennium, an evidence-based approach to disaster management is required urgently. This study moves toward such an evidence-based approach by identifying peer-reviewed publications following a range of disasters and events over the past three decades. METHODS Peer-reviewed, event-specific literature was identified using a comprehensive search of the electronically indexed database, MEDLINE (1956-January 2009). An extended comprehensive search was conducted for one event to compare the event-specific literature indexed in MEDLINE to other electronic databases (EMBASE, CINAHL, AMED, CENTRAL, Psych Info, Maternity and Infant Care, EBM Reviews). RESULTS Following 25 individual disasters or overwhelming crises, a total of 2,098 peer-reviewed, event-specific publications were published in 789 journals (652 publications following disasters/events caused by natural hazards, 966 following human-made/technological disasters/events, and 480 following conflict/complex humanitarian events).The event with the greatest number of peer-reviewed, event-specific publications was the 11 September 2001 terrorist attacks (686 publications). Prehospital and Disaster Medicine published the greatest number of peer-reviewed, event-specific publications (54), followed by Journal of Traumatic Stress (42), Military Medicine (40), and Psychiatric Services (40). The primary topics of event-specific publications were mental health, medical health, and response. When an extended, comprehensive search was conducted for one event, 75% of all peer-reviewed, event-specific publications were indexed in MEDLINE. CONCLUSIONS A broad range of multi-disciplinary journals publish peer reviewed, event-specific publications. While the majority of peer-reviewed, event-specific literature is indexed in MEDLINE, comprehensive search strategies should include EMBASE to increase yield.

A systematic review of the management and outcome of toxic epidermal necrolysis treated in burns centres

INTRODUCTION Toxic epidermal necrolysis (TEN) is a rare condition characterised by mucocutaneous exfoliation of greater than 30% total body surface area (%TBSA), increasingly being treated in burns centres. The rate of mortality varies significantly in the literature, with recent prospective studies in non-burns centres reporting percentage mortality of approximately 45%. We undertook a systematic review of published studies that included TEN patients treated specifically in burns centres to determine a cumulative mortality rate. METHODS Electronic searches of MEDLINE, EMBASE and The Cochrane Library (Issue 4, 2010) databases from 1966 onwards were used to identify English articles related to the treatment of TEN in burns centres. RESULTS The systematic literature search identified 20 studies which specifically described patients with TEN grater than 30% %TBSA. Treatment regimens varied amongst studies, as did mortality. The overall percentage mortality of the combined populations was 30%. Risk factors commonly described as associated with mortality included age, %TBSA and delay to definitive treatment. CONCLUSION The review highlights the variation between principles of treatment and mortality amongst burns centres. It offers a standard that burns centre can use to internationally compare their mortality rates. The review supports the ongoing reporting of outcomes in TEN patients with epidermal detachment greater than 30%.

An examination of factors that affect return to work following burns: A systematic review of the literature

AIMS To review the literature on return to work (RTW) in patients with burns. METHODS Using a predetermined search strategy, we searched Ovid MEDLINE (1950 to January 2008) database to identify all English studies related to burn and work, rehabilitation, employment, return to work, occupation or vocational training. RESULTS Twenty-one studies were identified with 3134 patients. An average of 66% of patients returned to work following their burn; with rates even higher in patients with lower total body surface are burns. Time taken to RTW ranged from 4.7 weeks to 24 months. Common barriers to RTW were extent and severity of the burn, longer length of stay in hospital and number of operative procedures. CONCLUSIONS This review found that the severity of burn was the most significant barrier to RTW. Further research is required to explore physical and psychosocial interventions aimed at helping people with burns return to and sustain employment.

Clinical factors affecting mortality in elderly burn patients admitted to a burns service

INTRODUCTION The purpose of this retrospective study was to provide basic probabilistic predictors of mortality to assist in determining appropriate therapeutic aggression in elderly burns population. METHOD Eighty patients over the age of 70 years were admitted to the Victorian Adult Burns Service in Melbourne, Australia, over a period of 4 years. Retrospective data was analysed, taking into account patient demographics, type, site, depth and area of burn, presence of inhalation injury, number of co-morbidities, survival time and the number of operations performed, withdrawal of care and implementation of comfort measures only. RESULTS Comparing survivors and non-survivors, significant differences were found between age, percentage total burn surface area (TBSA%), percentage full thickness surface area (FTSA%), presence of inhalation injury, site of burn and number of operations. The number of co-morbidities and gender were not significant to outcome. FTSA%, presence of inhalation injury, site of burn, age and number of operations were all significantly related to survival time. When patients who obtained comfort care were excluded from analysis, age and the number of operations were not considered to be significantly related to mortality. CONCLUSION This study indicates that TBSA%, FTSA%, inhalation injury and age are significant predictors of death in the elderly burns population, although only the first three remain significant when patients who receive comfort care measures only are excluded.

The cardiac dose-sparing benefits of deep inspiration breath-hold in left breast irradiation: a systematic review

Despite technical advancements in breast radiation therapy, cardiac structures are still subject to significant levels of irradiation. As the use of adjuvant radiation therapy after breast‐conserving surgery continues to improve survival for early breast cancer patients, the associated radiation‐induced cardiac toxicities become increasingly relevant. Our primary aim was to evaluate the cardiac‐sparing benefits of the deep inspiration breath‐hold (DIBH) technique.