Moustafa Elmasry

Standardised mortality ratio based on the sum of age and percentage total body surface area burned is an adequate quality indicator in burn care: An exploratory review

Standardised Mortality Ratio (SMR) based on generic mortality predicting models is an established quality indicator in critical care. Burn-specific mortality models are preferred for the comparison among patients with burns as their predictive value is better. The aim was to assess whether the sum of age (years) and percentage total body surface area burned (which constitutes the Baux score) is acceptable in comparison to other more complex models, and to find out if data collected from a separate burn centre are sufficient for SMR based quality assessment. The predictive value of nine burn-specific models was tested by comparing values from the area under the receiver-operating characteristic curve (AUC) and a non-inferiority analysis using 1% as the limit (delta). SMR was analysed by comparing data from seven reference sources, including the North American National Burn Repository (NBR), with the observed mortality (years 1993-2012, n=1613, 80 deaths). The AUC values ranged between 0.934 and 0.976. The AUC 0.970 (95% CI 0.96-0.98) for the Baux score was non-inferior to the other models. SMR was 0.52 (95% CI 0.28-0.88) for the most recent five-year period compared with NBR based data. The analysis suggests that SMR based on the Baux score is eligible as an indicator of quality for setting standards of mortality in burn care. More advanced modelling only marginally improves the predictive value. The SMR can detect mortality differences in data from a single centre.

Improvement in mortality at a National Burn Centre since 2000: Was it the result of increased resources?

Abstract The aim of this study was to find out whether the charging costs (calculated using interventional burn score) increased as mortality decreased. During the last 2 decades, mortality has declined significantly in the Linköping Burn Centre. The burn score that we use has been validated as a measure of workload and is used to calculate the charging costs of each burned patient. We compared the charging costs and mortality in 2 time periods (2000–2007 and 2008–2015). A total of 1363 admissions were included. We investigated the change in the burn score, as a surrogate for total costs per patient. Multivariable regression was used to analyze risk-adjusted mortality and burn score. The median total body surface area % (TBSA%) was 6.5% (10–90 centile 1.0–31.0), age 33 years (1.3–72.2), duration of stay/ TBSA% was 1.4 days (0.3–5.3), and 960 (70%) were males. Crude mortality declined from 7.5% in 2000–2007 to 3.4% in 2008–2015, whereas the cumulative burn score was not increased (P  =  .08). Regression analysis showed that risk-adjusted mortality decreased (odds ratio 0.42, P  =  .02), whereas the adjusted burn score did not change (P  =  .14, model R2 0.86). Mortality decreased but there was no increase in the daily use of resources as measured by the interventional burn score. The data suggest that the improvements in quality obtained have been achieved within present routines for care of patients (multidisciplinary/orientated to patients’ safety).

Skin regeneration in three dimensions, current status, challenges and opportunities

Skin regeneration is a life-saving need for many patients, whom list is stretched from burn victims to motor-car accidents. Spraying cells, either keratinocytes or stem cells, were associated with variable results and, in many cases, unfavorable outcomes. As the spatial configuration of the skin is distinctive, many trials investigated the bio-printing or the construction of three dimensional skin models where different layers of the skin were preserved. Although some of these models showed the histological configuration of the skin, their acceptance by the wound was questionable as a consequence of delayed vascularization. In this mini-review, different models for three dimensional regeneration of the skin will be discussed with their main points of strength and challenges as well as their possible opportunities.

Changes in patterns of treatment of burned children at the Linkoping Burn Centre, Sweden, 2009–2014

INTRODUCTION Children are a relatively large group among patients with burns in Sweden. We changed the management of childrens burns to a flexible, outpatient-based plan. The aim was to follow up the outpatient management for childrens burns during the period 2009-2014, and track it, to find out to what extent the patients had been treated flexibly as outpatients, and to clarify the reasons behind those who did not fit in the plan. METHODS Descriptive retrospective analysis dividing the patients into three groups: inpatients only, flexible management, and outpatients. Other variables recorded included: age, sex, percentage total body surface area burned (TBSA%), percentage full thickness burn (FTB%), cause of burn, county of residence, operations required, number of visits to the outpatient department, costs, and duration of overnight stay in the hospital. RESULTS The study group included 620 children: nine were managed strictly as inpatients, 204 as flexible outpatients, and 407 strictly as outpatients. Among the total there were 269 children who came from remote areas (43%), and of these 260 were treated as outpatients and flexible outpatients. Median TBSA% in the whole group was 1 (10th-90th centile 0-9) with the biggest median TBSA% 12 (5-38) in the inpatient group. The most common cause of injury was scalds (332/620, 54%). Costs/patient (US

Treatment of Children With Scalds by Xenografts: Report From a Swedish Burn Centre

) was lower in the flexible outpatient group than in the inpatient group (median 10 557 (3213-35802) and 35343 (7344-66554), respectively). CONCLUSION Based on the results, we expect that the flexible outpatient treatment plan for children with minor to moderate burns can be expanded in the future. The results encourage us to continue the service and to further reduce duration of stay in hospital below the level already achieved (25% of the whole period of care).

N-Terminal Brain Natriuretic Peptide First Week After Burn Injury

Scalds are the most common type of burn in children, and one way to treat them is with xenografts with no topical antimicrobials in line with the recommendations of a recent review. However, this treatment has not been examined in detail. Our aim was to describe the treatment of such children when biological dressings (xenografts) were used without local antimicrobials. We reviewed the medical records of all children admitted to a Swedish National Burn Centre during the period 2010–2012 with scalds who were treated with xenografts. Percentage TBSA injured, age, length of hospital stay, number of operations, antibiotics given, duration of antibiotic treatment, and pain score during the first 3 days, application of xenografts, and clinical notes of wound infection were recorded. We studied 67 children, (43 of whom were boys), with a median (interquartile range [IQR]) age of 1 (1–2) year and median (IQR) TBSA% 6.2 (4–11). Twenty children (30%) required operation. Twelve (18%) developed a wound infection, 29 (43%) had other infections, and 26 (39%) were free from infection. The median (IQR) duration of systemic antibiotics was 10 (6–13) days. On the day that the xenografts were applied 10 of the children had a Face, Legs, Activity, Cry, and Consolability (FLACC) score between 3 and 7, and during the following 2 days, only four children scored in this range. The remaining 57 children had scores < 3 on the day that xenografts were applied and on the following 2 days. Median (IQR) length of stay/TBSA% was 0.7 (0.4–1.0). Treatment with xenografts was associated with median length of stay/TBSA% <1 and low pain scores. Despite a high rate of prescription of systemic antibiotics, most were for reasons other than wound infection.

Microbial cellulose dressing compared with silver sulphadiazine for the treatment of partial thickness burns: A prospective, randomised, clinical trial

B-type natriuretic peptide has shown promising results as a biomarker for acute kidney injury in general intensive care patients. It may also indirectly reflect fluid balance of the circulation. Among burn patients, it has been observed to indicate excessive fluid resuscitation and organ dysfunction, although its clinical use to indicate acute kidney injury or guide fluid resuscitation has not been validated. The aim of this study was to evaluate whether the N-terminal pro-brain natriuretic peptide values are related to the amount of fluids given after severe burn injury and whether it can act as a novel biomarker for acute kidney injury in these patients. Nineteen consecutive burn patients were included. Plasma N-terminal pro-brain natriuretic peptide was measured daily during 1 week from admission. Other variables such as laboratory values and intravenous infusions were also recorded. The association between acute kidney injury and N-terminal pro-brain natriuretic peptide values was analyzed with a multivariable panel regression model, adjusted for burned total body surface area, age, body mass index, and laboratory values. N-terminal pro-brain natriuretic peptide values varied between single patients, and even more between the patients who developed acute kidney injury. Older age, lower body mass index, and cumulative infusions were independently associated with higher N-terminal pro-brain natriuretic peptide values, whereas acute kidney injury was not. N-terminal pro-brain natriuretic peptide values correlated with cumulative infusions given during the first week. The authors could not validate the role of N-terminal pro-brain natriuretic peptide as a biomarker for acute kidney injury in burns.

C-reactive protein response patterns after antibiotic treatment among children with scalds

BACKGROUND The current treatment for partial thickness burns at the trial site is silver sulphadiazine, as it minimises bacterial colonisation of wounds. Its deleterious effect on wound healing, together with the need for repeated, often painful, procedures, has brought about the search for a better treatment. Microbial cellulose has shown promising results that avoid these disadvantages. The aim of this study was therefore to compare microbial cellulose with silver sulphadiazine as a dressing for partial thickness burns. METHOD All patients who presented with partial thickness (superficial and deep dermal) burns from October 2014 to October 2016 were screened for this randomised clinical trial. Twenty patients were included in each group: the cellulose group was treated with microbial cellulose sheets and the control group with silver sulphadiazine cream 10mg/g. The wound was evaluated every third day. Pain was assessed using the Face, Legs, Activity, Cry, Consolability (FLACC) scale during and after each procedure. Other variables recorded were age, sex, percentage total body surface area burned (TBSA%), clinical signs of infection, time for epithelialisation and hospital stay. Linear multivariable regression was used to analyse the significance of differences between the treatment groups by adjusting for the size and depth of the burn, and the patients age. RESULTS Median TBSA% was 9% (IQR 5.5-12.5). The median number of dressing changes was 1 (IQR 1-2) in the cellulose group, which was lower than that in the control group (median 9.5, IQR 6-16) (p<0.001). Multivariable regression analysis showed that the group treated with microbial cellulose spent 6.3 (95% CI 0.2-12.5) fewer days in hospital (p=0.04), had a mean score that was 3.4 (95% CI 2.5-4.3) points lower during wound care (p<0.001), and 2.2 (95% CI 1.6-2.7) afterwards (p<0.001). Epithelialisation was quicker, but not significantly so. CONCLUSION These results suggest that the microbial cellulose dressing is a better first choice for treatment of partial thickness burns than silver sulphadiazine cream. Fewer dressings of the wound were done and, combined with the low pain scores, this is good for both the patients and the health care system. The differences in randomisation of the area of burns is, however, a concern that needs to be included in the interpretation of the results.

Male Breast Glandular Liposculpturing, Response on Commentary

BACKGROUND Scalds are the most common cause of burns in children, yet there is little information available about the inflammatory response. The aim of the study was to investigate the response to treatment with antibiotics among scalded children by following the C-reactive protein (CRP) concentration, procalcitonin (PCT) concentration, and white blood cell count (WCC) during the first two weeks after injury. METHODS All children with scalds who presented to the Burn Centre during 2010-2016 were included in this retrospective study. All measurements of CRP, PCT, and WCC from the first 14days after injury were recorded, and each patients maximum values during days 0-2, 3-7, and 8-14 were used for calculations. Multivariable regression for panel data was used to study the inflammatory response after antibiotic treatment. RESULTS A total of 216 children were included. C-reactive protein was 45mg/L (p<0.001) higher in the group treated with antibiotics, and decreased with 8.8mg/L per day over the studied time in this group, which was more than twice as fast as among the children who were not given antibiotics. CONCLUSION The CRP response, among children with minor scalds treated with antibiotics, shows an appreciable rise during the first week of injury that subsided rapidly during the second week.

Male Breast Glandular Liposculpture Challenges

Dear Sir, We have followed with interest the recent comments [1] on our recent publication [2] in your prestigious journal and we would like to clarify some of the points raised. The patients who attend our clinic are young males \ 50 years old, coming for body contouring mainly for the anterior chest wall and abdomen. As mentioned in many text books of plastic surgery, exclusion of secondary gynecomastia is a must which is our clinical praxis. In addition, radiological examination of the male breast when there is diffuse enlargement with no related clinical findings is not indicated [3]. We think that ultrasound or MRI examination is beneficial, but it’s an extra economic burden on the patients and we can use them when indicated. We acknowledge that the proportion of two dissatisfied patients out of a total number of 18 (11%) is considered high. However, one of the two dissatisfied patients had minor irregularities and asked for the revision at the 6-month follow-up visit, but he changed his mind at the 9-month follow-up, which was after the publication of the article. Therefore, it is clear that the 6-month follow-up period was a disadvantage for us as we could have lowered the percentage of dissatisfied patients to 5.5% if we had chosen a longer follow-up. Regarding the issue of breast cancer finding, it has been suggested that patients with a hard, irregular or asymmetrical mass, nipple discharge, axillary adenopathy, or a mass fixed to the skin or the chest wall must have a biopsy, which none of the study patients had [4]. Such an issue could deserve a future study to determine the odds of incidence after liposuction treatment of gynecomastia. As scarring is an important concern for most of our patients, we place the skin access incisions in a relatively hidden area, the upper one is placed behind the anterior axillary line in the hairy axilla, while the second one is 10 cm inferior and more posterior. The usual skin incision is a blade 11 stab around 3–5 mm which we think is more aesthetically appealing for our patients who, most of them, have dark skin that could increase the risk of developing hypertrophic or keloid scars, which would not be acceptable if unfortunately, it happened in a circum-areolar incision. Liposuction combined with surgical excision of residual breast tissue through periareolar incisions has several other drawbacks. The periareolar incision is adjacent to the main mound of breast tissue and too close to the area that needs to be liposuctioned, therefore providing less control when performing liposuction [5]. It also combines the morbidity of two separate procedures, namely liposuction and open excision, which explains the relatively high rate of complications in some studies [6]. Furthermore, radical resection of the gland with a subcutaneous & Islam Abdelrahman islam.abdelrahman@liu.se; islammohamedy@yahoo.com