Soman Sen

Keeping up with video game technology: Objective analysis of Xbox Kinect™ and PlayStation 3 Move™ for use in burn rehabilitation

Commercially available interactive video games are commonly used in rehabilitation to aide in physical recovery from a variety of conditions and injuries, including burns. Most video games were not originally designed for rehabilitation purposes and although some games have shown therapeutic potential in burn rehabilitation, the physical demands of more recently released video games, such as Microsoft Xbox Kinect™ (Kinect) and Sony PlayStation 3 Move™ (PS Move), have not been objectively evaluated. Video game technology is constantly evolving and demonstrating different immersive qualities and interactive demands that may or may not have therapeutic potential for patients recovering from burns. This study analyzed the upper extremity motion demands of Kinect and PS Move using three-dimensional motion analysis to determine their applicability in burn rehabilitation. Thirty normal children played each video game while real-time movement of their upper extremities was measured to determine maximal excursion and amount of elevation time. Maximal shoulder flexion, shoulder abduction and elbow flexion range of motion were significantly greater while playing Kinect than the PS Move (p≤0.01). Elevation time of the arms above 120° was also significantly longer with Kinect (p<0.05). The physical demands for shoulder and elbow range of motion while playing the Kinect, and to a lesser extent PS Move, are comparable to functional motion needed for daily tasks such as eating with a utensil and hair combing. Therefore, these more recently released commercially available video games show therapeutic potential in burn rehabilitation. Objectively quantifying the physical demands of video games commonly used in rehabilitation aides clinicians in the integration of them into practice and lays the framework for further research on their efficacy.

Commercially available interactive video games in burn rehabilitation: Therapeutic potential

Commercially available interactive video games (IVG) like the Nintendo Wii™ (NW) and PlayStation™II Eye Toy (PE) are increasingly used in the rehabilitation of patients with burn. Such games have gained popularity in burn rehabilitation because they encourage range of motion (ROM) while distracting from pain. However, IVGs were not originally designed for rehabilitation purposes but rather for entertainment and may lack specificity for achieving rehabilitative goals. Objectively evaluating the specific demands of IVGs in relation to common burn therapy goals will determine their true therapeutic benefit and guide their use in burn rehabilitation. Upper extremity (UE) motion of 24 normal children was measured using 3D motion analysis during play with the two types of IVGs most commonly described for use after burn: NW and PE. Data was analyzed using t-tests and One-way Analysis of Variance. Active range of motion for shoulder flexion and abduction during play with both PE and NW was within functional range, thus supporting the idea that IVGs offer activities with therapeutic potential to improve ROM. PE resulted in higher demands and longer duration of UE motion than NW, and therefore may be the preferred tool when UE ROM or muscular endurance are the goals of rehabilitation. When choosing a suitable IVG for application in rehabilitation, the users impairment together with the therapeutic attributes of the IVG should be considered to optimize outcome.

A ten-year review of lower extremity burns in diabetics: small burns that lead to major problems.

Diabetes mellitus with its resulting neurovascular changes may lead to an increased risk of burns and impaired wound healing. The purpose of this article is to review 10 years of experience with foot and lower leg burns in patients with diabetes at a single adult burn center. Patients with lower extremity burns and diabetes mellitus, between May 1999 and December 2009, were identified in the Trauma Registry of the American College of Surgeons database, and their charts were reviewed for data related to their outcomes. Sixty-eight diabetic patients, 87% male, with a mean age of 54 years, sustained foot or lower extremity burns with 37 having burns resulting from insensate feet. The pathogenesis included walking on a hot or very cold surface (8), soaking feet in hot water (22), warming feet on or near something hot such as a heater (13), or spilling hot water (7). The majority of patients were taking insulin (59.6%) or oral hyperglycemic medications (34.6%). Blood sugar levels were not well controlled (mean glucose, 215.8 mg/dl; mean hemoglobin A1c, 9.08%). Renal disease was common with admission serum blood urea nitrogen (27.5 mg/dl) and creatinine (2.21 mg/dl), and 13 were on dialysis preinjury. Cardiovascular problems were common with 39 (57%) having hypertension or cardiac disease, 3 having peripheral vascular disease, and 9, previous amputations. The mean burn size was 4.2% TBSA (range, 0.5–15%) with 57% being full thickness. Despite the small burn, the mean length of stay was 15.2 days (range, 1–95), with 5.65 days per 1% TBSA. Inability to heal these wounds was evident in 19 patients requiring readmission (one required 10 operative procedures). At least one patient sustained more than one burn. There were 62 complications with 30 episodes of infection (cellulitis, 28; osteomyelitis, 4; deep plantar infections, 2; ruptured Achilles tendon, 1) and 3 deaths. Eleven patients needed amputations (7 below-knee amputations, 4 transmetatarsal amputations, and 20 toe amputations) with several needing revisions or higher amputations. Patients with diabetes have an increased risk for lower extremity complications, but the risk of burns is not well known. The majority of lower extremity burns result from intentional exposure to sources of heat without recognition for the risk of burns. Once a burn occurs, morbidity and cost to the patient and society are severe. Prevention programs should be initiated to make diabetic patients and their doctors aware of the significant risk for burns.

Frailty score on admission predicts outcomes in elderly burn injury

With longer life expectancy, the number of burn injuries in the elderly continues to increase. Prediction of outcomes for the elderly is complicated by preinjury physical fitness and comorbid illness. The authors hypothesize that admission frailty assessment would be predictive of outcomes in the elderly burn population. Our primary aim was to determine if higher frailty scores were associated with higher risk of mortality for elderly burn patients. The secondary aims were to assess if higher frailty scores were associated with increased length of stay, increased needs for mechanical ventilation and poor discharge disposition. A 2-year retrospective chart review was performed of all admitted acute burn patients 65 years or older. Data collected included: age, gender, %TBSA of burn injury, presence of inhalation injury, in hospital mortality, hospital length of stay, ventilator days, ICU length of stay, surgical procedures, insurance status, and discharge disposition. Frailty scores were assessed from admission data and calculated using the Canadian Study of Health and Aging clinical frailty scale. A total of 89 patients met entry criteria. Mean age was 75.3 ± 8.1 years and consisted of 62 men and 27 women. Mean %TBSA was 9.6 ± 9.1% and mean frailty score (FS) was 4.5 ± 1.2. Eighty patients survived to discharge and nine died. Nonsurvivors had significantly higher FS compared to survivors (5.2 ± 1.2 vs 4.4 ± 1.2). FS were also significantly higher in patients discharged to skilled nursing facilities (SNF) (5.34 ± 0.9) compared to those who were discharged home (4.1 ± 1.2) or to physical rehabilitation facilities (4 ± 1.5). Multivariate linear regression analysis revealed that age (B = 0.04) and discharge to SNF (B = 1.2) are independently associated with higher FS. However, survivors were independently associated with a significantly lower FS (B = −1.3). Multivariate logistic regression analysis revealed high admission FS independently increased the risk of discharge to SNF (odds ratio of 2.5 [1.3–4.8, 95% confidence interval]) and increased the risk of mortality (odds ratio of 1.67 [1.01–2.7, 95% confidence interval]). Frailty scores on admission allow for a more complete assessment of elderly patients and can be used to establish benchmark models for burn injury outcomes. In addition FS can be used as a research tool to improve outcomes for elderly burn injured patients.

Long-term functional outcomes in the elderly after burn injury

Although the elderly represent a substantial proportion of the population, limited information exists on postdischarge long-term outcomes of elderly burn survivors. The purpose of this study was to assess elderly burn patient outcomes 2 to 10 years after discharge. This study was a prospective cross-sectional survey assessment of quality of life and retrospective trauma registry for the American College of Surgeons review of patients ≥ 60 years of age discharged alive after acute burn from 1997 to 2007. In-hospital treatment and burn demographic information were obtained from database and chart review. Surviving patients or their families were contacted, and the Short-Form-12 and Functional Independence Measure (FIM) administered. Of the 344 patients discharged, 232 participated. Mean age was 72.3 (60–85.8) years, TBSA burn was 7.8% (1–79), and length of stay was 11.2 ± 0.9 days (1–51). Most patients were discharged home (71%) or to a skilled nursing facility (SNF; 20%). Mean interval between discharge and survey administration was 46.1 months. In all, 24% of patients sent home died after discharge and prior to interview compared with 58% of patients sent to an SNF. On multivariate analysis, mortality increased with age (confidence interval [CI] 1.04–1.09), and government insurance (CI 0.34–0.94), but decreased with discharge to home (CI 1.68–4.47). There were no differences in FIM or Short-Form-12 scores between groups. Long-term mortality after discharge in elderly burn survivors is substantial. Patients sent to an SNF or with government insurance had increased mortality postdischarge. These data suggest that issues that may influence disposition status of elderly burn patients should be optimized prior to discharge to mitigate adverse outcomes associated with SNF placement.

Review of Burn Injury Research for the Year 2009

Research in burn care for the calendar year 2009 was robust and diverse with >1400 research articles published on a wide range of topics. In this review, the authors highlight some innovative and potentially impactful research related to the overall care of burn- injured patients. The authors grouped articles according to the following categories: critical care, infection, inhalation injury, epidemiology, psychology, wound characterization and treatment, nutrition and metabolism, pain and itch management, burn reconstruction, and rehabilitation. They found that the holistic nature of burn care is reflected in the diverse research performed in 2009 throughout the world and that this research has provided important evidence that has improved or will improve burn care overall.

Redefining the outcomes to resources ratio for burn patient triage in a mass casualty.

Recent disasters highlight the need for predisaster planning, including the need for accurate triage. Data-driven triage tables, such as that generated from the 2002 National Burn Repository, are vital to optimize resource use during a disaster. The study purpose was to generate a burn resource disaster triage table based on current burn-treatment outcomes. Data from the NBR after the year 2000 were audited. Records that missed age, burn size, or survival status were excluded from analysis. Duplicate records, readmissions, transfers, and nonburn injuries were eliminated. Resource use was divided into expectant (predicted mortality >90%), low (mortality 50–90%), medium (mortality 10–50%), high (mortality <10%, admission 14–21 days), very high (mortality <10%, admission <14 days), and outpatient. Tables were created for all patient admissions and with/without inhalation injury. Of the 286,293 records, 210,683 were from the year 2000 or later. Expectant status for those aged >70 years began at 50% burn; a 20- to 29-year-old never reached expectant status. Inhalation injury lowered the expectant category to a burn size of 40% in >70-year-olds, and at >90% in 20- to 29-year-olds. The 0- to 1.9-year old group without inhalation injury never reached expectant status; with inhalation injury, expectant status was reached at >80% burn. Changes in the triage tables suggest that burn care has changed in the past 10 years. Inhalation injury significantly alters triage in a burn disaster. Use of these updated tables for triage in a disaster may improve our ability to allocate resources.

Prospective comparison of packed red blood cell-to-fresh frozen plasma transfusion ratio of 4: 1 versus 1: 1 during acute massive burn excision.

BACKGROUND Acute burn excision results in at least 2% blood volume loss per percent excised; hence, massive blood loss (>50% total blood volume) occurs during major burn excisions. The purpose of this pilot study was to assess safety and prospectively compare the impact of a 4:1 versus a 1:1 packed red blood cell–fresh frozen plasma (PRBC/FFP) transfusion strategy on outcomes in children with burns greater than 20% total body surface area (TBSA). METHODS Children with greater than 20% TBSA burn were randomized to a 1:1 or 4:1 PRBC/FFP ratio during burn excision. Parameters measured on admission included demographics, burn size, and Pediatric Risk of Mortality scores. Laboratory values that were measured preoperatively, 1 hour, 12 hours, 24 hours, and 1 week included prothrombin time (PT), partial thromboplastin time (PTT), international normalized ratio (INR), fibrinogen, protein C, and antithrombin C (AIII). Total number of blood products transfused during operative interventions and during hospitalization were recorded. RESULTS Groups were similar in age, weight, TBSA, and Pediatric Risk of Mortality scores at admission. Preoperative fibrinogen, antithrombins III (AIII), protein C, hemoglobin, PT/PTT, INR, and platelets were similar between groups. The 1:1 group received more FFP (43.8 ± 0.03 U in 1:1 group vs. 15.7 ± 0.07 in the 4:1 group) and less PRBC (40.7 ± 0.02 U in 1:1 group vs. 73.1 ± 0.02 U in 4:1 group) than the 4:1 group. Approximately 50% blood volume was replaced with PRBC intraopaeratively. There was no difference in PT/PTT, INR, hemoglobin, or platelets between groups. Protein C and AIII were higher in the 1:1 group. Cost of FFP and PRBC were lower in the 1:1 group. CONCLUSION A 1:1 PRBC/FFP transfusion strategy increased FFP use, decreased overall PRBC use, and resulted in higher AIII and protein C postoperatively without a difference in INR or PT/PTT. This may represent compensatory changes in the 4:1 group in response to intraoperative blood loss. LEVEL OF EVIDENCE Therapeutic, level II.

A comparison of dexmedetomidine and midazolam for sedation in severe pediatric burn injury.

Dexmedetomidine (DEX) is an &agr;-adrenergic agonist that has been used for sedation during invasive procedures and endotracheal intubation. In pediatric burn injury, DEX has been shown to be safe as a long-term sedative in the intensive care unit (ICU). However, comparison of DEX with traditional sedatives, such as midazolam, for sedation in pediatric burn injury has not been performed. The purpose of this study was to compare DEX with midazolam in terms of sedation, efficacy, and side effects in children with burn injury. A retrospective review of all children with a TBSA burn injury ≥20% admitted from December 2008 to September 2010 was performed. Children who received a continuous DEX infusion were compared with children receiving a continuous midazolam infusion. Data collected included: age, TBSA burn, ventilator days, ICU days, hypotensive episodes, bradycardic episodes, and Richmond Agitation Score (RAS). A total of 21 patients who received DEX infusions were compared with 21 age-matched and burn size–matched patients who received midazolam infusions. Of the 21 DEX patients, nine also received midazolam infusions, eight prior to DEX and one after. These patients did not receive DEX and midazolam simultaneously. There was no difference in age (6.9 vs 6.4 years), TBSA (45.5 vs 49.2%), ICU days (45.3 vs 55.4), and ventilator days (38.5 vs 45.5) between the DEX and midazolam patients, respectively. The mean duration of infusion was 22.5 ± 24.9 days for DEX and 20.1 ± 24.8 days for midazolam. DEX patients had a mean RAS of −0.91 ± 0.8. Midazolam patients were more sedated with a mean RAS of −1.33 ± 0.7. Only one episode of bradycardia was noted in the DEX group. The DEX group had fewer hypotensive episodes (mean arterial pressure <60 mm Hg) while on infusion compared with the midazolam group (15.8 vs 29.7 episodes). Thus, it can be surmised that DEX is a safe and effective sedative for pediatric burn patients. Compared to midazolam, DEX may provide more effective sedation and less sedation-related hypotension.

A competing risk analysis for hospital length of stay in patients with burns

IMPORTANCE Current outcome predictors for illness and injury are measured at a single time point-admission. However, patient prognosis often changes during hospitalization, limiting the usefulness of those predictions. Accurate depiction of the dynamic interaction between competing events during hospitalization may enable real-time outcome assessment. OBJECTIVE To determine how the effects of burn outcome predictors (ie, age, total body surface area burn, and inhalation injury) and the outcomes of interest (ie, mortality and length of stay) vary as a function of time throughout hospitalization. DESIGN, SETTING, AND PARTICIPANTS In this retrospective study, we used the American Burn Associations National Burn Repository, containing outcomes and patient and injury characteristics, to identify 95 579 patients admitted with an acute burn injury to 80 tertiary American Burn Association burn centers from 2000 through 2009. We applied competing risk statistical methods to analyze patient outcomes. MAIN OUTCOMES AND MEASURES We estimated the cause-specific hazard rates for death and discharge to assess how the instantaneous risk of these events changed across time. We further evaluated the varying effects of patient age, total body surface area burn, and inhalation injury on the probability of discharge and death across time. RESULTS Maximum length of stay among patients who died was 270 days and 731 days among those discharged. Total body surface area, age, and inhalation injury had significant effects on the subdistribution hazard for discharge (P < .001); these effects varied across time (P < .002). Burn size (coefficient -0.046) determined early outcomes, while age (coefficient -0.034) determined outcomes later in the hospitalization. Inhalation injury (coefficient -0.622) played a variable role in survival and hospital length of stay. CONCLUSIONS AND RELEVANCE Real-time measurement of dynamic interrelationships among burn outcome predictors using competing risk analysis demonstrated that the key factors influencing outcomes differed throughout hospitalization. Further application of this analytic technique to other injury or illness types may improve assessment of outcomes.