Michael Giretzlehner

The potential impact of wrong TBSA estimations on fluid resuscitation in patients suffering from burns: Things to keep in mind

INTRODUCTION Accurate estimation of burn size is of critical importance, as it is incorporated in every resuscitation formula. The aim of this study was to investigate total burn surface area (TBSA) accuracy among burn specialists, evaluate the potential impact of incorrect evaluation on variations of resultant fluid resuscitation volumes and to discuss future possibilities to estimate or measure TBSA more precisely. METHODS In a poll during two international burn meetings in 2010 and 2011 demonstrating three pictures of patients with different burn wound patterns and sizes we asked participants to estimate the total surface area burned in percentages. We then calculated resultant fluid volume differences based on established resuscitation formulas. RESULTS In the polled 80 participants, the estimations for three patients demonstrated the following differences (DIF=MAX-MIN): for patient 1, 2 and 3 they were 22.5 (25-2.5), 16.5 (20-3.5) and 31.5 (40-8.5) %TBSA, respectively. Based on these differences we calculated the volume differences for patients 1,2 and 3, which were 1080ml (Cincinnati Formula), 5280ml (Parkland Formula) and 2016ml (Cincinnati Formula), respectively. CONCLUSIONS The analysis showed high deviations of total body surface area among participants, also resulting in large variations of initial fluid resuscitation volumes. One option to address estimation variances is to perform more accurate assessments; also incorporating new technologies aiding to improve the quality of body surface estimations and related decisions.

Intuitive presentation of clinical forensic data using anonymous and person-specific 3D reference manikins

The increasing use of CT/MR devices in forensic analysis motivates the need to present forensic findings from different sources in an intuitive reference visualization, with the aim of combining 3D volumetric images along with digital photographs of external findings into a 3D computer graphics model. This model allows a comprehensive presentation of forensic findings in court and enables comparative evaluation studies correlating data sources. The goal of this work was to investigate different methods to generate anonymous and patient-specific 3D models which may be used as reference visualizations. The issue of registering 3D volumetric as well as 2D photographic data to such 3D models is addressed to provide an intuitive context for injury documentation from arbitrary modalities. We present an image processing and visualization work-flow, discuss the major parts of this work-flow, compare the different investigated reference models, and show a number of cases studies that underline the suitability of the proposed work-flow for presenting forensically relevant information in 3D visualizations.

BurnCase 3D software validation study: Burn size measurement accuracy and inter-rater reliability

OBJECTIVE The aim of this study was to compare the accuracy of burn size estimation using the computer-assisted software BurnCase 3D (RISC Software GmbH, Hagenberg, Austria) with that using a 2D scan, considered to be the actual burn size. METHODS Thirty artificial burn areas were pre planned and prepared on three mannequins (one child, one female, and one male). Five trained physicians (raters) were asked to assess the size of all wound areas using BurnCase 3D software. The results were then compared with the real wound areas, as determined by 2D planimetry imaging. To examine inter-rater reliability, we performed an intraclass correlation analysis with a 95% confidence interval. RESULTS The mean wound area estimations of the five raters using BurnCase 3D were in total 20.7±0.9% for the child, 27.2±1.5% for the female and 16.5±0.1% for the male mannequin. Our analysis showed relative overestimations of 0.4%, 2.8% and 1.5% for the child, female and male mannequins respectively, compared to the 2D scan. The intraclass correlation between the single raters for mean percentage of the artificial burn areas was 98.6%. There was also a high intraclass correlation between the single raters and the 2D Scan visible. CONCLUSION BurnCase 3D is a valid and reliable tool for the determination of total body surface area burned in standard models. Further clinical studies including different pediatric and overweight adult mannequins are warranted.

Medical documentation of burn injuries

For successful treatment of burns one of the most important pillars is an adequate documentation. Otherwise, nobody in science, economics or quality control can comprehend this issue’s complexity [22]. Research, science and costing in burns are based on accurate assessment and documentation of burn injuries. Documentation required, is time consuming and labor intensive. For any scientific comparability of burns the exact and correct extent and depth of burns are essential.

BurnCase 3D – Realistic Adaptation of 3-Dimensional Human Body Models

This paper presents the results of the research project BurnCase in the field of realistic and anatomically correct deformations of 3D models of the human body. The project goal is to develop a software system named BurnCase 3D, which supports and enhances the documentation and diagnosis of human burn injuries.

A Meta-model Guided Expression Engine

Data acquisition and handling is known to be one of the most severe technical barriers in bio-medical research. In order to counter this problem, we created a generic data acquisition and managing system which can be set up for the given domain of application without the need for programming- or database-skills. The user definitions of the domain data structures are stored into an abstract meta data-model and allow the automatic creation of data-input and -managing interfaces. In order to enable the user to define complex search queries on the data or derive new data out of already existing, a meta-model-guided expression engine was developed. Grammatical and structural meta-data are interwoven in order to provide support in expression generation to the domain expert.

Using Generic Meta-Data-Models for Clustering Medical Data

We present a generic, meta-model based data storage system for research, clinical studies or disease registers, which is enabled to store data of almost arbitrary structure. The system is highly costumizeable and allows the user to set up a professional web-based data acquisition system including administration area, data input forms, overview tables and statistics within hours. Furthermore, we evaluated a number of clustering algorithms regarding their ability to cluster the stored datasets for similarity search and further statistical analysis.

An ontology-based clinical data warehouse for scientific research

Medical research but also quality management is based upon medical data. The integration, validation, processing, and exploration of this data is known to be a technical obstacle for researching medical domain experts and a major pitfall to (bio‐)medical research projects. To overcome this pitfall and actively support the medical domain expert in these tasks, we present an ontology‐based clinical data warehouse for scientific research. It is completely generic and adapts itself at run‐time to the current domain‐ontology, which can be freely defined by the domain expert and describes the actual field of research. The whole system adapts is appearance and behavior to this central ontology and appears to the user like a custom made solution. Furthermore, the elaborate structural meta‐information from the ontology is used to actively support the user in tasks that usually require profound IT knowledge, such as defining complex search queries or data quality constraints, or applying advanced data visualization algorithms to the data. The proposed warehouse supports the domain expert trough the whole process of knowledge discovery from data integration to exploration.

Burn surface area calculation instead of burn size estimation: our opinion

With great interest we have read the paper published by Harish et al. [1]. The authors have discussed the factor burn surface area estimation and the potential impact of inaccuracies in burn size assessment on burn care and on referral to specialised burn units. Furthermore, they stated that there is tendency for significant overestimation throughout the entire TBSA spectrum in referring centres. We partly agree with this paper and its statements, because we think that there is the general tendency to overestimate burn size [2–7] and that a correct evaluation of these factors is of utmost importance for initiating the appropriate treatment [7], but in contrast to them we think that inaccurate burn size estimation is not only a question of experience and teaching and thereby of referral centres or burn centres, but of using the right techniques. We think that in future there is need for objective burn size calculation instead of subjective estimation. Therefore, we think there is a need for new techniques like computer-aided systems [4–6], because nowadays, there are different techniques available in order to improve burn size assessment and thereby to improve burn care. We can use so-called three-dimensional technologies for assessing TBSA in different ways: First, wounds can be marked manually on a virtual patient model, which is the fastest, but depends on the accuracy of the person performing it. Second, the superimposition of digital images can support the user, who ideally just traces the wounds on the picture and by doing so marks the areas on the virtual model. Last but not least, it is also possible to use false colour pictures, generated by burn depth determination devices (e.g. Laser-Doppler-Imaging), which are superimposed automatically onto 3D models [4–6]. Which of these techniques will become standard of care is still under discussion, but in conclusion, we think that improving burn surface area calculations by using more objective methods instead of subjective assessments, will be the important step in order to improve future burn care.

Meta-model based knowledge discovery

Data acquisition and data mining are often seen as two independent processes in research. We introduce a meta-information based, highly generic data acquisition system which is able to store data of almost arbitrary structure. Based on the meta-information we plan to apply data mining algorithms for knowledge retrieval. Furthermore, the results from the data mining algorithms will be used to apply plausibility checks for the subsequent data acquisition, in order to maintain the quality of the collected data. So, the gap between data acquisition and data mining shall be decreased.