Suzanne Rea

Core outcomes for adult burn survivors: A clinical overview

Burn trauma ranges from the minor burn to the devastating injury, which can impact on all aspects of a persons life including aesthetic appearance, relationships with others and psychological, social and physical functioning. Measurement of outcome in burns patients is therefore complex and multi-faceted. The increasing numbers of major burn survivors implies that understanding health outcomes in these patients has assumed high priority. This paper sets out a conceptual framework for unifying outcome measurement, which may be useful to all members of the multidisciplinary team who are contemplating outcome assessment in their burn patients. It outlines seven core domains of assessment which are (i) skin; (ii) neuromuscular function; (iii) sensory and pain; (iv) psychological function; (v) physical role function; (vi) community participation; and (vii) perceived quality of life. Within each domain, we present a brief clinical review of the most commonly administered measurement tools that have been, or potentially could be, used to assess aspects of these core domains. Where possible, the psychometric properties and clinical utility of these tools are presented. A concise discussion of key methodological issues which should be addressed in this assessment process is then provided, together with suggestions for future research.

Characterisation of the cell suspension harvested from the dermal epidermal junction using a ReCell® kit

BACKGROUND The use of non-cultured autologous cells to promote wound healing and in reconstructive procedures is increasing. One common method for preparing these cells is the use of the ReCell(®) device. However, despite its current clinical use, no characterisation of the cell suspension produced using a ReCell(®) device has been published. OBJECTIVE To characterise the ReCell suspension that is applied to wounds for cell type, viability, yield, stability and proliferative potential. METHODS The ReCell(®) device was used to harvest cells from a 2 cm(2) piece of split-thickness skin isolated using a dermatome. The resulting cell suspension was analysed for cell yield, cell type, viability over time, proliferative potential and reproducibility. RESULTS Average viable cell yield was 1.7×10(6)/cm(2) of tissue, with 75.5% of the total cell isolate viable. Total viable cell number was not significantly reduced after 4 h storage at 22°C or 4°C, and was stable for 24 h at 4°C. Proliferative potential was assessed using a colony forming assay, with 0.3% of viable cells isolated forming keratinocyte colonies. Predominantly the suspension contained keratinocytes (64.3±28.8%) and fibroblasts (30.3±14.0%), with a small population of melanocytes also identified (3.5±0.5%). Finally, the supernatant contained low total protein (0.92 mg/ml) and the supernatant had no significant effects on cell viability or growth when applied ex vivo. CONCLUSIONS These results suggest the ReCell(®) device provides a method for the preparation of a cell suspension with high viability and proliferative potential, containing viable melanocytes and no apparent toxic cell debris. Further work on the sustained viability of these cells in vivo, and in particular after application to the wound, will be important to better understand the potential of the ReCell(®) device in the clinic.

A 26-Year Population-Based Study of Burn Injury Hospital Admissions in Western Australia

The aim of the study was to use state-wide health administrative data to assess the incidence, temporal trends, and external cause of burn injury-related hospital admissions and mortality in Western Australia from 1983 to 2008. Linked hospital morbidity and death data for all persons hospitalized with an index burn injury in Western Australia for the period 1983–2008 were identified. Annual age-specific incidence and age standardized rates were estimated. Poisson regression analyses were used to estimate temporal trends in hospital admissions and mortality. Zero-truncated negative binomial regression analysis was used to identify factors associated with hospital length of stay. From 1983 to 2008, there were 23,450 hospitalizations for an index burn injury. Hospital admission rates declined by an average annual rate of 2% (incidence rate ratio [IRR], 95% confidence interval [CI] = 0.983, 0.981–0.984), and burn-related mortality declined by an average annual rate of 2% (IRR, 95% CI = 0.98, 0.96–1.01). Aboriginal people while having significantly higher hospitalization rates than non-Aboriginal people experienced a greater 26-year decline in hospitalizations of 58% (IRR, 95% CI = 0.42, 0.37–0.48) compared with 32% (IRR, 95% CI = 0.68, 0.65–0.71) for non-Aboriginal people. Children younger than 5 years, 20- to 24-year-old men, and adults older than 65 years remain at high risk for burn injury, and males continue to be hospitalized twice as frequently as females. The results demonstrate declines in burn injury hospitalizations and mortality in both Aboriginal and non-Aboriginal populations. Continued research is required of the impacts of medical interventions and the burn pathway of identified high-risk populations.

Bone marrow-derived cells in the healing burn wound—More than just inflammation

Scarring after severe burn is a result of changes in collagen deposition and fibroblast activity that result in repaired but not regenerated tissue. Re-epithelialisation of wounds and dermal cell repopulation has been thought to be driven by cells in the periphery of the wound. However, recent research demonstrated that cells originating from the bone marrow contribute to healing wounds in other tissues and also after incisional injury. We investigated the contribution of bone marrow-derived cells to long-term cell populations in scar tissue (primarily fibroblasts and keratinocytes) after severe burn. Wild-type mice were lethally irradiated and then the bone marrow reconstituted by injection of chimeric bone marrow cells expressing EGFP marker protein. Mice with chimeric bone marrow were then given a burn, either an 1-cm diameter injury (to mimic minor injury) or 2-cm diameter (to mimic moderate injury). Wounds were analysed at days 1, 3, 7, 14, 21, 28, 56 and 120 using FACS and immunohistochemistry to identify the percentage and cell type within the wound originating from the bone marrow. The inflammatory cell infiltrate at the early time-points was bone marrow in origin. At later time-points, we noted that over half of the fibroblast population was bone marrow-derived; we also observed that a small percentage of keratinocytes appeared to be bone marrow in origin. These findings support the theory that the bone marrow plays an important role in providing cells not only for inflammation but also dermal and epidermal cells during burn wound healing. This increases our understanding of cell origins in the healing wound, and has the potential to impact on clinical practice providing a potential mechanism for intervention away from conventional topical treatments and directed instead to systemic treatments affecting the bone marrow response.

Candidemia and invasive candidiasis: A review of the literature for the burns surgeon

Advances in critical care, operative techniques, early fluid resuscitation, antimicrobials to control bacterial infections, nutritional support to manage the hypermetabolic response and early wound excision and coverage has improved survival rates in major burns patients. These advances in management have been associated with increased recognition of invasive infections caused by Candida species in critically ill burns patients. Candida albicans is the most common species to cause invasive Candida infections, however, non-albicans Candida species appear to becoming more frequent. These later species may be less fluconazole susceptible than Candida albicans. High crude and attributable mortality rates from invasive Candida sepsis are multi-factorial. Diagnosis of invasive candidiasis and candidemia remains difficult. Prophylactic and pre-emptive therapies appear promising strategies, but there is no specific approach which is well-studied and clearly efficacious in high-risk burns patients. Treatment options for invasive candidiasis include several amphotericin B formulations and newer less toxic antifungal agents, such as azoles and echinocandins. We review the currently available data on diagnostic and management strategies for invasive candidiasis and candidemia; whenever possible providing reference to the high-risk burn patients. We also present an algorithm for the management of candidemia and invasive candidiasis in burn patients.

A study of burn hospitalizations for children younger than 5 years of age: 1983-2008

OBJECTIVE: Burn injury is a leading cause of emergency department visits and hospitalizations for young children. We aimed to use statewide linked health administrative data to evaluate the incidence, temporal trends, and cause of burn injuries for children younger than 5 years hospitalized for burn injuries in Western Australia for the period 1983–2008. METHODS: Epidemiologic analysis of linked hospital morbidity and death data of children younger than 5 years hospitalized with an index burn injury in Western Australia for the period 1983–2008. Poisson regression analyses were used to estimate temporal trends in hospital admissions and the external cause of the burn injury. RESULTS: From 1983 to 2008, there were 5398 hospitalizations for an index burn injury and 3 burn-related deaths. Hospital admission rates declined by an average annual rate of 2.3% (incidence rate ratio: 0.977 [95% confidence interval: 0.974–0.981]). More than half of the admissions were for scald burns. Hospitalizations declined for injury caused by scald, flame, contact, and electrical burns; however, the number of hospital admissions increased for chemical burns during the study period. CONCLUSIONS: The burn-injury hospitalizations reported in this study were preventable. Most burns occurred in the home and resulted from exposure to a household hazard. Further effort needs to be devoted to burn prevention and safety strategies, particularly in relation to scalds, to further reduce the incidence of burn injury in young children.

A prospective randomised clinical pilot study to compare the effectiveness of Biobrane ® synthetic wound dressing, with or without autologous cell suspension, to the local standard treatment regimen in paediatric scald injuries

BACKGROUND Scald is the most common cause of burn in children in Australia. The time taken by the burn wound to heal impacts on scar outcome. Commonly scald injuries are treated conservatively; in our unit the practice is that if healing does not occur within 10 days, surgery is used to aid healing with the aim of improving scar outcome. This randomised controlled pilot study compares early treatment regimens to facilitate tissue salvage and reduce the incidence of definitive surgery at 10 days following scald injury. METHODS All paediatric patients with partial thickness scald injury were clinically assessed between July 1, 2009 and June 30, 2010. A burn of 2% TBSAB or more and deemed not to heal within 10 days, were considered for the trial. These patients were randomised to one of three treatment arms: the local standard treatment (Intrasite™, Acticoat™ and Duoderm(®) dressings every 2-3 days) with surgery at 10 days, Biobrane(®) only or Biobrane(®) and autologous cell suspension using the ReCell(®) kit. The primary outcome was surgery performed after 10 days; secondary outcomes were rates of healing, pain experienced, and scar outcomes. RESULTS 15% of scald presentations in the 12 month period met the eligibility criteria. 13 patients were recruited into the pilot study; early intervention was associated with a decreased time to healing with fewer dressing changes, less pain and better scar outcomes. CONCLUSION Investment of surgical resources in the acute stages within 4 days of injury saved on nursing time, dressing, analgesic and scar management costs.

Systemic Decreases in Cutaneous Innervation after Burn Injury

Innervation of the skin is important in order to maintain functional sensation and enable appropriate response to environmental stimuli. Injury to the skin may involve peripheral nerve damage. Previous studies have shown an initial loss of nerve fibers followed by an increase above normal fiber density, which is followed by apoptosis and ultimately reduced innervation and sensory function in scar tissue (Hermanson et al., 1987; Stella et al., Supp.(767) 1994; Altun et al., 2001; Ward et al., 2004; Nedelec et al., 2005). Although some studies have found an association between reduced nerve density and sensation (Stella et al., 1994; Ward et al., 2004), other studies have not (Griffin et al., 2001; Nedelec et al., 2005). The contradictory nature of these findings is at least in part due to small sample numbers, incomplete functional and anatomical assessment, and the variable timeframes between injury and analysis. Herein, to better understand the changes in cutaneous innervation and sensory function, we have analyzed neuroanatomy in a rat model of burn injury, and assessed neuroanatomy in patients with unilateral burn injuries at least 18 months post-injury, which is commonly defined as the end point for scar maturity (Nedelec et al., 2005). All animal experiments were approved by the institutional animal ethics committee and were performed in accordance with the NHMRC Australian code of practice for the care and use of animals for scientific purposes. The human study was carried out in accordance with the regulations outlined in the national statement on ethical conduct in research involving humans issued by the NHMRC and was approved by the Royal Perth Hospital ethics committee.

Burn wounds infected by contaminated water: Case reports, review of the literature and recommendations for treatment

First-aid education for the management of burns advocates cool running water over burnt skin to limit soft tissue damage. However, the water used may itself constitute a risk. We report three cases of severe invasive and necrotizing infection in patients who used or immersed themselves in contaminated water in an attempt to extinguish the fire following acute major burns. Wound cultures from all patients yielded Aeromonas hydrophila and two yielded Bacillus cereus. One patient had a complex polymicrobial infection, including zygomycosis with Rhizomucor variabilis. All patients were treated aggressively with wound débridement, including one patient who required bilateral lower limb amputations to control progressive infection. All infections were successfully treated and all patients survived their burn injuries. We review the management of burns complicated by exposure to contaminated water leading to burn wound infections. We describe commonly reported organisms from various water sources, the appropriate initial empirical antimicrobial chemotherapy and present the clinician with a proposed algorithm for managing these serious infections.

Mortality After Burn Injury in Children: A 33-year Population-Based Study

OBJECTIVE: To assess the impact of burn injury sustained during childhood on long-term mortality and to quantify any increased risk of death attributable to burn injury. METHODS: A population-based cohort study of children younger than 15 years hospitalized for burn injury in Western Australia (1980–2012) and a matched noninjured comparison group. Deidentified extraction of linked hospital morbidity and death records for the period 1980–2012 were provided by the Western Australian Data Linkage System. An inception cohort (1980–2012) of burn cases younger than 15 years of age when hospitalized for a first burn injury (n = 10 426) and a frequency matched noninjured comparison cohort (n = 40 818) were identified. Survival analysis was conducted by using the Kaplan-Meier method and Cox proportional hazards regression. Mortality rate ratios and attributable risk percent adjusted for sociodemographic and preexisting heath factors were generated. RESULTS: The median follow-up time for the pediatric burn cohort was 18.1 years after discharge. The adjusted all-cause mortality rate ratios for burn injury was 1.6 (95% confidence interval: 1.3–2.0); children with burn injury had a 1.6 times greater rate of mortality than those with no injury. The index burn injury was estimated to account for 38% (attributable risk percent) of all recorded deaths in the burn injury cohort during the study period. CONCLUSIONS: Burn injury sustained by children is associated with an increased risk of long-term all-cause mortality. Estimates of the total mortality burden based on in-hospital deaths alone underestimates the true burden from burn injury.