Naiem S. Moiemen

A pilot evaluation study of high resolution digital thermal imaging in the assessment of burn depth

Thermal imaging is a tool that can be used to determine burn depth. We have revisited the use of this technology in the assessment of burns and aim to establish if high resolution, real-time technology can be practically used in conjunction with clinical examination to determine burn depth. 11 patients with burns affecting upper and lower limbs and the anterior and posterior trunk were included in this study. Digital and thermal images were recorded at between 42 h and 5 days post burn. When compared to skin temperature, full thickness burns were significantly cooler (p<0.001), as were deep partial thickness burns (p<0.05). Superficial partial thickness burns were not significantly different in temperature than non-burnt skin (p>0.05). Typically, full thickness burns were 2.3°C cooler than non-burnt skin; deep partial thickness burns were 1.2°C cooler than non-burnt skin; whilst superficial burns were only 0.1°C cooler. Thermal imaging can correctly determine difference in burn depth. The thermal camera produces images of high resolution and is quick and easy to use.

Chemical burns – An historical comparison and review of the literature

Chemical burns represent a small proportion of cutaneous burn with an incidence of up to 10.7%, but have been reported to account for up to 30% of all burn deaths. A review of the literature shows incidences ranging from 2.4% to 10.7%, with a substantial predominance in males. Adult patients with a burn referred to our Regional Burns Centre, over an eight-year period, were identified. 185 chemical burns were recorded (7.9%). The mean age of patient was 40 years (range 16-81 years) and male to female ratio was 6.4:1. Over three-quarters of chemical injuries occurred in the domestic or industrial setting. Acids caused 26% of all chemical burns and alkalis caused 55%. A previous study from the same centre highlights a change in the demographics of chemical burn over the last 25 years. The proportion of chemical burns has risen from 2.7% to 7.9%. Chemical burns occurring in an industrial setting, have dropped, whilst the number of domestic chemical burns has increased by over three times. This change reflects the improved industrial health and safety policy in recent years. The move from the industrial setting to the domestic has implications for future regulations.

Antimicrobial dressings: Comparison of the ability of a panel of dressings to prevent biofilm formation by key burn wound pathogens §

UNLABELLEDnAntimicrobial medicated dressings (AMD) are often used to reduce bacterial infection of burns and other wounds. However, there is limited literature regarding comparative efficacies to inform effective clinical decision making.nnnOBJECTIVESnFollowing on from a previous study where we demonstrated good antibiofilm properties of acetic acid (AA), we assessed and compared the in vitro anti-biofilm activity of a range of AMDs and non-AMDs to AA.nnnMETHODSnLaboratory experiments determined the ability of a range of eleven commercial AMD, two nAMD, and AA, to prevent the formation of biofilms of a panel of four isolates of Pseudomonas aeruginosa and Acinetobacter baumannii.nnnRESULTSnThere is a large variation in ability of different dressings to inhibit biofilm formation, seen between dressings that contain the same, and those that contain other antimicrobial agents. The best performing AMD were Mepilex(®) Ag and Acticoat. AA consistently prevented biofilm formation.nnnCONCLUSIONSnLarge variation exists in the ability of AMD to prevent biofilm formation and colonisation of wounds. A standardised in vitro methodology should be developed for external parties to examine and compare the efficacies of commercially available AMDs, along with robust clinical randomised controlled trials. This is essential for informed clinical decision-making and optimal patient management.

A systematic review of objective burn scar measurements

BackgroundProblematic scarring remains a challenging aspect to address in the treatment of burns and can significantly affect the quality of life of the burn survivor. At present, there are few treatments available in the clinic to control adverse scarring, but experimental pharmacological anti-scarring strategies are now beginning to emerge. Their comparative success must be based on objective measurements of scarring, yet currently the clinical assessment of scars is not carried out systematically and is mostly based on subjective review of patients. However, several techniques and devices are being introduced that allow objective analysis of the burn scar. The aim of this article is to evaluate various objective measurement tools currently available and recommend a useful panel that is suitable for use in clinical trials of anti-scarring therapies.MethodsA systematic literature search was done using the Web of Science, PubMed and Cochrane databases. The identified devices were then classified and grouped according to the parameters they measured.The tools were then compared and assessed in terms of inter- and intra-rater reproducibility, ease of use and cost.ResultsAfter duplicates were removed, 5062 articles were obtained in the search. After further screening, 157 articles which utilised objective burn scar measurement systems or tools were obtained. The scar measurement devices can be broadly classified into those measuring colour, metric variables, texture, biomechanical properties and pathophysiological disturbances.ConclusionsObjective scar measurement tools allow the accurate and reproducible evaluation of scars, which is important for both clinical and scientific use. However, studies to evaluate their relative performance and merits of these tools are scarce, and there remain factors, such as itch and pain, which cannot be measured objectively. On reviewing the available evidence, a panel of devices for objective scar measurement is recommended consisting of the 3D cameras (Eykona/Lifeviz/Vectra H1) for surface area and volume, DSM II colorimeter for colour, Dermascan high-frequency ultrasound for scar thickness and Cutometer for skin elasticity and pliability.

The Antibacterial Activity of Acetic Acid against Biofilm-Producing Pathogens of Relevance to Burns Patients

Introduction Localised infections, and burn wound sepsis are key concerns in the treatment of burns patients, and prevention of colonisation largely relies on biocides. Acetic acid has been shown to have good antibacterial activity against various planktonic organisms, however data is limited on efficacy, and few studies have been performed on biofilms. Objectives We sought to investigate the antibacterial activity of acetic acid against important burn wound colonising organisms growing planktonically and as biofilms. Methods Laboratory experiments were performed to test the ability of acetic acid to inhibit growth of pathogens, inhibit the formation of biofilms, and eradicate pre-formed biofilms. Results Twenty-nine isolates of common wound-infecting pathogens were tested. Acetic acid was antibacterial against planktonic growth, with an minimum inhibitory concentration of 0.16–0.31% for all isolates, and was also able to prevent formation of biofilms (at 0.31%). Eradication of mature biofilms was observed for all isolates after three hours of exposure. Conclusions This study provides evidence that acetic acid can inhibit growth of key burn wound pathogens when used at very dilute concentrations. Owing to current concerns of the reducing efficacy of systemic antibiotics, this novel biocide application offers great promise as a cheap and effective measure to treat infections in burns patients.

History of burns: The past, present and the future

Burn injuries are one of the most common and devastating afflictions on the human body. In this article we look back at how the treatment of burns has evolved over the centuries from a primarily topical therapy consisting of weird and wonderful topical concoctions in ancient times to one that spans multiple scientific fields of topical therapy, antibiotics, fluid resuscitation, skin excision and grafting, respiratory and metabolic care and nutrition. Most major advances in burn care occurred in the last 50 years, spurred on by wars and great fires. The use of systemic antibiotics and topical silver therapy greatly reduced sepsis related mortality. This along with the advent of antiseptic surgical techniques, burn depth classification and skin grafting allowed the excision and coverage of full-thickness burns which resulted in greatly improved survival rates. Advancements in the methods of assessing the surface area of burns paved way for more accurate fluid resuscitation, minimising the effects of shock and avoiding fluid over-loading. The introduction of metabolic care, nutritional support and care of inhalational injuries further improved the outcome of burn patients. We also briefly discuss some future directions in burn care such as the use of cell and pharmalogical therapies.

Hydrotherapy in burn care : a survey of hydrotherapy practices in the UK and Ireland and literature review

INTRODUCTIONnHydrotherapy is widely used in burns management however there are risks associated with its use, in particular cross-infection. Data regarding indications and techniques in common use is deficient. This study aimed to investigate hydrotherapy practices in the UK and Ireland.nnnMETHODSnA survey of the hydrotherapy practice of major burn care providers was performed by e mail and where necessary, follow up telephone contact.nnnRESULTSnThe survey included 28 burn care providers. 27 reported using hydrotherapy. Only 11 (41%) had defined indication criteria with 4 (15%) implementing a specific protocol. Variations in hydrotherapy practice were seen.nnnCONCLUSIONnHydrotherapy is used nationwide, however considerable variation in practice exists. One area worthy of further consideration is the need for appropriate standards of infection control.

A prospective study of time to healing and hypertrophic scarring in paediatric burns: every day counts

BackgroundIt is commonly accepted that burns taking longer than 3xa0weeks to heal have a much higher rate of hypertrophic scarring than those which heal more quickly. However, some of our patients develop hypertrophic scars despite healing within this 3-week period.MethodsWe performed a prospective study of 383 paediatric burns treated non-operatively at a regional burns centre over a 2-year periodxa0from May 2011 to April 2013. Scar assessment was performed by a senior burns therapist using the Vancouver Scar Scale.ResultsOverall rates of hypertrophic scarring were 17.2%. Time to healing was the strongest predictor of developing hypertrophic scarring, and the earliest hypertrophic scar developed in a patient who was healed after 8xa0days. The risk of hypertrophic scarring was multiplied by 1.138 for every additional day taken for the burn wound to heal. There was a trend towards higher rates of hypertrophic scarring in non-white skin types but this did not reach statistical significance.ConclusionsThe risk of hypertrophic scarring increases with every day and, therefore, every effort should be made to get the wound healed as quickly as possible, even within the traditional 3-week period usually allowed for healing. We believe that the traditional dogma of aiming for healing within 3xa0weeks is overly simplistic and should be abandoned: in paediatric burns, every day counts.Trial registrationNot applicable.

Advances in keratinocyte delivery in burn wound care

This review gives an updated overview on keratinocyte transplantation in burn wounds concentrating on application methods and future therapeutic cell delivery options with a special interest in hydrogels and spray devices for cell delivery. To achieve faster re-epithelialisation of burn wounds, the original autologous keratinocyte culture and transplantation technique was introduced over 3 decades ago. Application types of keratinocytes transplantation have improved from cell sheets to single-cell solutions delivered with a spray system. However, further enhancement of cell culture, cell viability and function in vivo, cell carrier and cell delivery systems remain themes of interest. Hydrogels such as chitosan, alginate, fibrin and collagen are frequently used in burn wound care and have advantageous characteristics as cell carriers. Future approaches of keratinocyte transplantation involve spray devices, but optimisation of application technique and carrier type is necessary.

Protocol for a systematic review of quantitative burn wound microbiology in the management of burns patients.

BackgroundSepsis from burn injuries can result from colonisation of burn wounds, especially in large surface area burns. Reducing bacterial infection will reduce morbidity and mortality, and mortality for severe burns can be as high as 15xa0%.There are various quantitative and semi-quantitative techniques to monitor bacterial load on wounds.In the UK, burn wounds are typically monitored for the presence or absence of bacteria through the collection and culture of swabs, but no absolute count is obtained. Quantitative burn wound culture provides a measure of bacterial count and is gaining increased popularity in some countries. It is however more resource intensive, and evidence for its utility appears to be inconsistent.This systematic review therefore aims to assess the evidence on the utility and reliability of different quantitative microbiology techniques in terms of diagnosing or predicting clinical outcomes.Methods/designStandard systematic review methods aimed at minimising bias will be employed for study identification, selection and data extraction. Bibliographic databases and ongoing trial registers will be searched and conference abstracts screened. Studies will be eligible if they are prospective studies or systematic reviews of burn patients (any age) for whom quantitative microbiology has been performed, whether it is compared to another method. Quality assessment will be based on quality assessment tools for diagnostic and prognostic studies and tailored to the review as necessary. Synthesis is likely to be primarily narrative, but meta-analysis may be considered where clinical and methodological homogeneity exists.DiscussionGiven the increasing use of quantitative methods, this is a timely systematic review, which will attempt to clarify the evidence base. As far as the authors are aware, it will be the first to address this topic.Trial registrationPROSPERO, CRD42015023903