Current understanding of the chronic stress response to burn injury from human studies

There is a marked inflammatory and hypermetabolic response following a burn injury.The inter-linked responses are more pronounced than for other forms of trauma and can persist for≥3 years post-injury in burned patients.After a burn,patients have an increased risk of diseases of ageing including cancer,diabetes and cardiovascular disease,highlighting the need for effective long-term strategies to ameliorate the stress response post-burn.Current therapeutic strategies for post-burn recovery include removal of damaged tissue with surgical excision and wound repair,nutritional supplementation and rehabilitative exercise.These strategies aim to minimize the hypermetabolic and inflammatory responses,as well as reducing the loss of lean body mass.This review briefly summarises the inflammatory and hypermetabolic responses and provides an update on the current therapeutic strategies for burned patients.The review examines the persistent nutritional challenge of ensuring sufficient energy intake of each macronutrient to fuel the hypermetabolic and counteract the catabolic response of burn injury,whilst reducing periods of hyperglycaemia and hypertriglyceridemia.Patients require individualized treatment options tailored to unique systemic responses following a burn,facilitated by a precision medicine approach to improve clinical and physiological outcomes in burned patients.Thus,this review discusses the utility of metabolic flexibility assessment to aid clinical decision making and prescription relating to nutritional supplementation and rehabilitative exercise in the burned patient.

Predictors of itch and pain in the 12 months following burn injury:results from the Burns Registry of Australia and New Zealand(BRANZ)Long-Term Outcomes Project

Background:Itch and pain are common complaints of patients with burn injuries.This study aimed to describe the prevalence and predictors of itch and moderate to severe pain in the first 12 months following a burn injury,and determine the association between itch,moderate to severe pain,workrelated outcomes,and health-related quality of life following a burn injury.Methods:Burn patients aged 18 years and older were recruited from five Australian specialist burn units.Patients completed the 36-item Short Form Health Survey Version 2(SF-36 V2),the Sickness Impact Profile(SIP)work scale,and a specially developed questionnaire relating to itch at 1,6,and 12 months post-injury.Moderate to severe pain was defined as a score less than 40 on the bodily pain domain of the SF-36 V2.Multivariate mixed-effects regression models were used to identify patient and burn injury predictors of itch and moderate to severe pain.Results:Three hundred and twenty-eight patients were included.The prevalence of itch decreased from 50%at 1 month to 27%at 12 months.Similarly,the prevalence of moderate to severe pain decreased from 23%at 1 month to 13%at 12 months.Compared to patients aged 18-34,the adjusted odds of experiencing any itch were 59%(95%CI:0.20,0.82)and 55%(95%CI:0.22,0.91)lower for patients aged between 35 and 49 and≥50 years,respectively.Compared to patients aged 18-34,the adjusted odds of experiencing moderate to severe pain were 3.12(95%CI:1.35,7.20)and 3.42(95%CI:1.47,7.93)times higher for patients aged 35-49 and≥50 years,respectively.Conclusions:Less than 15%of patients reported moderate or severe pain at 12 months,while approximately one-quarter of the patients reported itch at the same period.The presence of moderate to severe pain was associated with a greater negative impact on health-related quality of life and work outcomes compared to itch.Further research is needed to improve our ability to identify patients at higher risk of persistent itch and pain who would benefit from targeted review and intervention studies.

Demonstration of the test-retest reliability and sensitivity of the Lower Limb Functional Index-10 as a measure of functional recovery post burn injury:a cross-sectional repeated measures study design

Background:Lower limb burns can significantly delay recovery of function.Measuring lower limb functional outcomes is challenging in the unique burn patient population and necessitates the use of reliable and valid tools.The aims of this study were to examine the test-retest reliability,sensitivity,and internal consistency of Sections 1 and 3 of the Lower Limb Functional Index-10(LLFI-10)questionnaire for measuring functional ability in patients with lower limb burns over time.Methods:Twenty-nine adult patients who had sustained a lower limb burn injury in the previous 12 months completed the test-retest procedure of the study.In addition,the minimal detectable change(MDC)was calculated for Section 1 and 3 of the LLFI-10.Section 1 is focused on the activity limitations experienced by patients with a lower limb disorder whereas Section 3 involves patients indicating their current percentage of pre-injury duties.Results:Section 1 of the LLFI-10 demonstrated excellent test-retest reliability(intra-class correlation coefficient(ICC)0.98,95%CI 0.96–0.99)whilst Section 3 demonstrated high test-retest reliability(ICC 0.88,95%CI 0.79–0.94).MDC scores for Sections 1 and 3 were 1.27 points and 30.22%,respectively.Internal consistency was demonstrated with a significant negative association(rs=?0.83)between Sections 1 and 3 of the LLFI-10(p<0.001).Conclusions:This study demonstrates that Section 1 and 3 of the LLFI-10 are reliable for measuring functional ability in patients who have sustained lower limb burns in the previous 12 months,and furthermore,Section 1 is sensitive to changes in patient function over time.

An objective measure for the assessment and management of fluid shifts in acute major burns

Background: Major burns are life threatening. Fluid resuscitation is required for survival to maintain intravascular volumes and prevent hypovolemic shock. Bioimpedance spectroscopy (BIS) has been recognised as a potential method of monitoring fluid shifts after burn and in other disease states. The aims of this study were to examine the reliability of BIS across different dressing conditions and electrode positions, establish the influence of Acticoat?on BIS variable measures and determine the validity of whole-body BIS to assess net fluid shift in the presence of moderate to major burns. Methods: An observational longitudinal cohort study was conducted from December 2014 to February 2016. Patients with over 15% total body surface area (TBSA) burns and injury less than 48 h were enrolled in the study. BIS triplicate measures were collected in an open wound and with an ActicoatTMdressing (at 5 half hour intervals). Standard and alternate electrode placements were utilised for the reliability analysis and standard placement only for determining the validity of BIS in moderate to major burns. The ImpediMde SFB7 was used to collect whole-body and segmental BIS measures. Stata statistical software, release 14 was utilised to analyse all results. Descriptive analyses were performed and were reported using the means and standard deviations (SD). Results: BIS-repeated measures established BIS raw resistance (R), and predicted volume variables were reliable in any condition (intra-class correlation coefficient (ICC) 0.996-0.999, 95% confidence intervals (CI) 0.996-0.999) without a systematic difference. Acticoat?dressings significantly influenced all BIS-predicted volumes (p≤0.01) as determined by multilevel mixed effects (MLME) linear regression analysis. Validity of BIS was demonstrated by resistance variables significantly decreasing with increasing net ionic fluid shift and increased TBSA (severity of injury) and calculated fluid volumes increasing with increasing net fluid shift and TBSA. BIS resistance also decreased with time as oedema reduced. For clinical use, a calculator was developed to adjust BIS variables when an Acticoat?dressing is in situ, thus facilitating BIS variable change estimates in real time, with dressings intact. Conclusion: BIS may be used clinically to monitor fluid volume change in major acute burns.