John Vandervord

Combination of activated protein C and topical negative pressure rapidly regenerates granulation tissue over exposed bone to heal recalcitrant orthopedic wounds.

Chronic wounds arising from orthopedic surgery present a major clinical challenge. Osteomyelitis may develop from polymicrobial infection, which can be unresponsive to treatment and lead to amputation. Topical negative pressure (TNP) is an effective treatment in wound management and is now used worldwide. Activated protein C (APC) is an anticoagulant with cytoprotective and healing properties. The aim of this study was to determine whether combined treatment of TNP and APC was tolerated and was efficacious for treatment of difficult-to-treat wounds. Four patients who presented to Royal North Shore Hospital with wounds that were not responsive to conventional therapy were studied. All cases showed a marked reduction in wound size and depth within 1 week of starting treatment and progressively improved over time. There was a remarkable increase in the volume of granulation tissue. After treatment, wounds either completely closed or provided sufficient granulation tissue to allow split-thickness skin grafting. The treatment was well tolerated, and the patients were able to be managed on out-patient basis. Long-term follow-up suggested that this treatment prevented osteomyelitis. This innovative treatment is very promising and may significantly increase quality of care for patients with recalcitrant orthopedic wounds. A randomized, placebo-controlled double blind trial is required to further determine the efficacy of APC plus TNP.

The patient-body relationship and the "lived experience" of a facial burn injury: a phenomenological inquiry of early psychosocial adjustment

Background Throughout development and into adulthood, a person’s face is the central focus for interpersonal communication, providing an important insight into one’s identity, age, sociocultural background, and emotional state. The face facilitates important social, including nonverbal, communication. Therefore, sustaining a severe burn, and in particular a facial burn, is a devastating and traumatizing injury. Burn survivors may encounter unique psychosocial problems and experience higher rates of psychosocial maladjustment, although there may be a number of potentially mediating factors. Objectives The purpose of this phenomenological study was to examine the early recovery experience of patients with a facial burn. In particular, this study focused on how the injury impacted on the participants’ relationship with their own body and the challenges of early psychosocial adjustment within the first 4 months of sustaining the injury. Methods In 2011, six adult participants encompassing two females and four males ranging from 29 to 55 years of age with superficial to deep dermal facial burns (with background burns of 0.8%–55% total body surface area) were recruited from a severe burn injury unit in Australia for participation in a Burns Modified Adult Attachment Interview. Narrative data were analyzed thematically and informed by Colaizzi’s method of data analysis. Results Three overarching themes emerged: relationship to self/other, coping, and meaning-making. Themes identified related to how the experience affected the participants’ sense of relationship with their own bodies and with others, as well as other challenges of early psychosocial adjustment. All participants indicated that they had experienced some early changes in their relationship with their body following their burn injury. Conclusion These findings highlight the struggle burn survivors experienced with postburn adjustment, but expressed altruism and optimism around their recovery. Past trauma was observed to be a significant finding in this sample. Understanding the “lived experience” supports the way clinical and family systems can foster positive adjustment and coping. Consequently, multidisciplinary burn teams and health care professionals need to understand the principles of trauma-informed care and translate these into practice in the treatment of this group of patients.

Initial experience with cultured epithelial autografts in massively burnt patients

Background:  Prognosis in patients with severe burns is improved by early debridement and coverage with skin. The limiting factor in these patients is the lack of unburnt skin for harvesting. Cultured epithelial autograft (CEA) sheets provide an alternative means of covering debrided skin. This is a report on an initial experience with using CEA sheets.

Self-inflicted burns: a case series.

Self-inflicted burns are regularly admitted to burns units worldwide. Most of these patients are referred to psychiatric services and are successfully treated however some return to hospital with recurrent self-inflicted burns. The aim of this study is to explore the characteristics of the recurrent self-inflicted burn patients admitted to the Royal North Shore Hospital during 2004-2011. Burn patients were drawn from a computerized database and recurrent self-inflicted burn patients were identified. Of the total of 1442 burn patients, 40 (2.8%) were identified as self-inflicted burns. Of these patients, 5 (0.4%) were identified to have sustained previous self-inflicted burns and were interviewed by a psychiatrist. Each patient had been diagnosed with a borderline personality disorder and had suffered other forms of deliberate self-harm. Self-inflicted burns were utilized to relieve or help regulate psychological distress, rather than to commit suicide. Most patients had a history of emotional neglect, physical and/or sexual abuse during their early life experience. Following discharge from hospital, the patients described varying levels of psychiatric follow-up, from a post-discharge review at a local community mental health centre to twice-weekly psychotherapy. The patients who engaged in regular psychotherapy described feeling more in control of their emotions and reported having a longer period of abstinence from self-inflicted burn. Although these patients represent a small proportion of all burns, the repeat nature of their injuries led to a significant use of clinical resources. A coordinated and consistent treatment pathway involving surgical and psychiatric services for recurrent self-inflicted burns may assist in the management of these challenging patients.

Acute management of skin tears: a change in practice pilot study.

Skin tears are an increasingly common injury occurring in the elderly population and have significant associated morbidity secondary to poor wound healing, prolonged hospital stays and reduced mobility. There has been a shift in practice for the acute management of skin tears within our institution, which has resulted in improved outcomes and reduced morbidity for this common and debilitating injury. Review of past and current practices including cost analyses has led to the establishment of a management protocol for the hospital and wider area health service with the aim to reduce the burden of disease amongst our ever‐expanding elderly population.

Activated protein C to heal pressure ulcers

Pressure ulcers present a major clinical challenge, are physically debilitating and place the patient at risk of serious comorbidities such as septic shock. Recombinant human activated protein C (APC) is an anticoagulant with anti‐inflammatory, cytoprotective and angiogenic effects that promote rapid wound healing. Topical negative pressure wound therapy (TNP) has become widely used as a treatment modality in wounds although its efficacy has not been proven through randomised controlled trials. The aim of this study was to determine the preliminary efficacy and safety of treatment with APC for severe chronic pressure sores with and without TNP. This case presentation describes the history, management and outcome of two patients each with a severe chronic non‐healing pressure ulcer that had failed to respond to conventional therapy. TNP was added to conservative management of both ulcers with no improvement seen. Then local application of small doses of APC was added to TNP and with conservative management, resulted in significant clinical improvement and rapid healing of both ulcers, displaying rapid growth of vascular granulation tissue with subsequent epithelialisation. Patients tolerated the treatment well and improvements suggested by long‐term follow‐up were provided. Randomised placebo‐controlled double blind trials are needed to quantify the efficacy, safety, cost‐effectiveness, optimal dose and quality of life changes seen from treatment with APC.

A clinical update on posttraumatic stress disorder in burn injury survivors

Objectives: Burn injuries are complex traumatic events carrying high risks of acute physical and psychosocial morbidity. With greater survival, clinical and research attention has turned to psychosocial recovery outcomes and risk factors. It is timely to summarise current issues in posttraumatic disorders after burn injury for mental health and integrative care clinicians. Posttraumatic stress disorder (PTSD) is a common outcome of severe burn injury. There are difficulties in delivering current best practice treatments to many survivors especially those in rural and remote areas and those with comorbidities. Vicarious traumatization of clinicians, families and carers requires attention and internationally there are moves to psychosocial screening and outcome tracking. Conclusions: The role of the multidisciplinary treatment, integrated and trauma-informed care is essential. While level 1 evidence for PTSD treatments theoretically applies, adaptations that consider comorbidities and treatment contexts are often essential with further research required.

The role of resilience in the recovery of the burn-injured patient: an integrative review

Severe burn injuries are catastrophic life events resulting in significant physical and psychological effects. With long periods of hospitalization and rehabilitation, burn survivors encounter many issues, including an altered body image and loss of function and independence that subsequently influence quality of life and the family unit. Consequently, resilience has been identified as a fundamental concept that facilitates the adaptability required to navigate the lengthy and complex recovery process. However, over time, the notion of resilience has shifted from a static, innate trait to a fluid and multidimensional concept. Here, we review the evidence surrounding the role of resilience in the recovery of burn injury. This integrative review was based on a systematic search of five electronic databases. Of the 89 articles identified, ten primary research papers met the inclusion criteria. Three key themes were identified encompassing relational strengths, positive coping, and the resistance to trauma symptoms that are fundamental constructs associated with developing and sustaining resilience that resonate with the broader literature on burn recovery. However, limited evidence is currently available within the burns context. While resilience appears to be a vital component influencing the recovery from burns trauma, it still remains a broad construct within the burns framework. Regular assessment of resilience in burn-injured patients is recommended in clinical practice in addition to longitudinal and intervention studies to best inform patient care.

The Role of Th-17 Cells and γδ T-Cells in Modulating the Systemic Inflammatory Response to Severe Burn Injury

Burns are a global public health problem, accounting for an estimated 265,000 deaths annually. Inflammation is essential in supplying the growth factors, cytokines and chemokines needed to recruit T-cells and myeloid cells to the site of a burn injury for wound healing. However, major burns generate a marked pathophysiological inflammatory response through a widespread release of abundant pro-inflammatory mediators that predispose patients to a systemic inflammatory response syndrome, sepsis and multi-organ failure. Recently, there has been promising investigation into the role of γδ T-cells and Th-17 cells in the regulation and propagation of this inflammatory response. This study reviews the current literature on the post-burn immune response.

The Burns Registry of Australia and New Zealand: progressing the evidence base for burn care

Objective: Analysis of data from the Burns Registry of Australia and New Zealand (BRANZ) to determine the extent of variation between participating units in treatment and in specific outcomes during the first 4 years of its operation.