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.

A population-based comparison study of the mental health of patients with intentional and unintentional burns

Background:A number of studies report high prevalence of mental health conditions among burn patients. However there is a need to understand differences in the temporal relationship between mental health conditions and intentional and unintentional burns to hasten psychological prevention and intervention. This study aims to compare the socio-demographic profile, burn characteristics and pre-and post-burn psychiatric morbidity of burn patients by intent-of-injury. Methods:De-identified linked hospital, death and mental health (MH) case registry data of burn patients hospitalised in Western Australia between 1 January 1980 and 30 June 2012 were analysed. Crude (observed) post-burn rates of mental health admissions were generated by burn intent-of-injury. Descriptive statistics were performed to compare the characteristics of the burn patients. Results:A total of 30,997 individuals were hospitalised for a first burn;360 (1.2%) had self-harm burns and 206 (0.7%) assault burns. Over the study period, admission rates for assault burns increased by 4.8%per year (95%confidence interval (CI) 3.1–6.5%) and self-harm burns increased 6.9%per year (95%CI 4.8–9.1%). Self-harm and assault burns occurred mainly among those aged 15 to 44 years (median age, interquartile range (IQR):self-harm 30 years, 22–40;assault 31 years, 23–38). Those with self-harm burns had a longer index hospital stay (median (IQR):self-harm 15 days (5–35) vs 4 days (1–11) assault vs 4 days (1–10) unintentional) and higher in-hospital mortality (7.2%self-harm vs 1.9%assault burns vs 0.8%unintentional). More than half (55.0%) of self-harm burns had a prior hospitalisation (5-year lookback) for a MH condition vs 10.7%of assault burns and 2.8%of unintentional burns. Crude post-burn rates of MH admissions per 100 person-years (PY) by intent-of-burn subgroups:self-harm 209 per 100 PY, assault burns 11 per 100 PY and unintentional burns 3 per 100 PY. Conclusions:Intentional burn patients experienced significantly higher pre-and post-burn mental health morbidity along with significant adverse outcome in comparison with unintentional burns. Early psychological assessment and intervention could help in improving the MH of these patients.

Non-severe burn injury increases cancer incidence in mice and has long-term impacts on the activation and function of T cells

Background:Recent evidence suggests that burn patients are at increased risk of hospital admission for infection,mental health conditions,cardiovascular disease and cancer for many years after discharge for the burn injury itself.Burn injury has also been shown to induce sustained immune system dysfunction.This change to immune function may contribute to the increased risk of chronic disease observed.However,the mechanisms that disrupt long-term immune function in response to burn trauma,and their link to long-term morbidity,remain unknown.In this study we investigated changes to immune function after burn injury using a murine model of non-severe injury.Methods:An established mouse model of non-severe burn injury(full thickness burn equivalent to 8%total body surface area)was used in combination with an orthotopic model of B16 melanoma to investigate the link between burns and cancer.Considering that CD8^(+)T cells are important drivers of effective tumour suppression in this model,we also investigated potential dysregulation of this immune population using mouse models of burn injury in combination with herpes simplex virus infection.Flow cytometry was used to detect and quantify cell populations of interest and changes in immune function.Results:We demonstrate that 4 weeks after a non-severe burn injury,mice were significantly more susceptible to tumour development than controls using an orthotopic model of B16 melanoma.In addition,our results reveal that CD8^(+)T cell expansion,differentiation and memory potential is significantly impaired at 1 month post-burn.Conclusions:Our data suggests that CD8^(+)T cell-mediated immunity may be dysfunctional for a sustained period after even non-severe burn injury.Further studies in patients to validate these findings may support clinical intervention to restore or protect immunity in patients after burn injury and reduce the increased risk of secondary morbidities observed.

Identification of factors predicting scar outcome after burn injury in children:a prospective case-control study

Background:There is a lack of rigorous research investigating the factors that influence scar outcome in children. Improved clinical decision-making to reduce the health burden due to post-burn scarring in children will be guided by evidence on risk factors and risk stratification. This study aimed to examine the association between selected patient, injury and clinical factors and the development of raised scar after burn injury. Novel patient factors were investigated including selected immunological co-morbidities (asthma, eczema and diabetes type 1 and type 2) and skin pigmentation (Fitzpatrick skin type). Methods:A prospective case-control study was conducted among 186 children who sustained a burn injury in Western Australia. Logistic regression was used to explore the relationship between explanatory variables and a defined outcome measure:scar height measured by a modified Vancouver Scar Scale (mVSS). Results:The overall correct prediction rate of the model was 80.6%;80.9%for children with raised scars (>1 mm) and 80.4%for children without raised scars (≤1 mm). After adjustment for other variables, each 1%increase in%total body surface area (%TBSA) of burn increased the odds of raised scar by 15.8%(95%CI=4.4-28.5%). Raised scar was also predicted by time to healing of longer than 14 days (OR=11.621;95%CI=3.727-36.234) and multiple surgical procedures (OR=11.521;1.994-66.566). Conclusions:Greater burn surface area, time to healing of longer than 14 days, and multiple operations are independently associated with raised scar in children after burn injury. Scar prevention strategies should be targeted to children with these risk factors.

Long-term mental health outcomes after unintentional burns sustained during childhood:a retrospective cohort study

Background:Burns are a devastating injury that can cause physical and psychological issues. Limited data exist on long-term mental health (MH) after unintentional burns sustained during childhood. This study assessed long-term MH admissions after paediatric burns. Methods:This retrospective cohort study included all children (<18 years) hospitalised for a first burn (n=11,967) in Western Australia, 1980–2012, and a frequency matched uninjured comparison cohort (n=46,548). Linked hospital, MH and death data were examined. Multivariable negative binomial regression modelling was used to generate incidence rate ratios (IRR) and 95%confidence intervals (CI). Results:The burn cohort had a significantly higher adjusted rate of post-burn MH admissions compared to the uninjured cohort (IRR, 95%CI:2.55, 2.07–3.15). Post-burn MH admission rates were twice as high for those younger than 5 years at index burn (IRR, 95%CI 2.06, 1.54–2.74), three times higher for those 5–9 years and 15–18 years (IRR, 95%CI:3.21, 1.92–5.37 and 3.37, 2.13–5.33, respectively) and almost five times higher for those aged 10–14 (IRR, 95%CI:4.90, 3.10–7.76), when compared with respective ages of uninjured children. The burn cohort had higher admission rates for mood and anxiety disorders (IRR, 95%CI:2.79, 2.20–3.53), psychotic disorders (IRR, 95%CI:2.82, 1.97–4.03) and mental and behavioural conditions relating to drug and alcohol abuse (IRR, 95%CI:4.25, 3.39–5.32). Conclusions:Ongoing MH support is indicated for paediatric burn patients for a prolonged period after discharge to potentially prevent psychiatric morbidity and associated academic, social and psychological issues.

Burn care: The challenges of research

Burn care is an area which has advanced relentlessly over the past decades with improved survival and quality of survival. However, there are many challenges which overshadow the successes. The translation of what we know into clinical practice remains a challenge due to issues on many levels from overcoming personal opinion to resource allocation. We live in a time of exponential increase in knowledge in diverse areas which could be harnessed to improve the lives of those suffering burn injuries. Breaking down silos in education training and research remain challenging and again the allocation of resource is key. Ultimately when the goal is "One World One Standard of Burn Care" the greatest challenge is in education with specific reference to burn injury prevention and first aid.

Plasma lipidomics reveal systemic changes persistent throughout early life following a childhood burn injury

Background:Non-severe paediatric burns can result in poor long-term health outcomes.This occurs even in cases with good acute burn-related outcomes,including minimal scarring.The mechanisms that underpin the transition from non-severe burn to sustained negative long-term health impacts are currently unknown.However,sustained metabolic and immune changes have been observed in paediatric burn studies,suggesting these changes may be important.The plasma lipidome consists of a rich pool of bioactive metabolites that play critical roles in systemic processes including molecular signalling and inflammation.We hypothesised that changes in the plasma lipidome may reflect underlying changes in health status and be linked to long-term health after burn trauma.Methods:This study analysed the lipidome in children who had previously experienced a non-severe burn,compared to non-injured controls.Thirty-three participants were recruited between the ages of 5 and 8 years who had experienced a non-severe burn between the ages of 1 and 3 years.Plasma samples were also collected from a non-injured,healthy,age and gender matched control group(n=21).Plasma lipids were measured using reversed-phase liquid chromatographymass spectrometery(LC-MS).Results:In total 838 reproducible lipid species from 19 sub-classes passed quality control procedures and progressed to statistical analysis.Analysis of individual lipid metabolites showed significantly higher concentrations of lysophosphatidylethanolamines and phosphatidylethanolamines,and significantly lower concentrations in myristic,palmitic and palmitoleic acids in the plasma of those who had experienced burn injury compared to controls.Conclusion:Long-term changes in the lipid profile may give insight into the mechanisms underlying poor long-term health subsequent to non-severe burn injury.Further work to investigate the relationship between long-term pathology and lipidomic changes may lead to a better understanding of the causes of secondary morbidity post-burn and to clinical intervention to reduce the long-term health burden of burn trauma.

Understanding acute burn injury as a chronic disease

While treatment for burn injury has improved significantly over the past few decades,reducing mortality and improving patient outcomes,recent evidence has revealed that burn injury is associated with a number of secondary pathologies,many of which arise long after the initial injury has healed.Population studies have linked burn injury with increased risk of cancer,cardiovascular disease,nervous system disorders,diabetes,musculoskeletal disorders,gastrointestinal disease,infections,anxiety and depression.The wide range of secondary pathologies indicates that burn can cause sustained disruption of homeostasis,presenting new challenges for post-burn care.Understanding burn injury as a chronic disease will improve patient care,providing evidence for better long-term support and monitoring of patients.Through focused research into the mechanisms underpinning long-term dysfunction,a better understanding of burn injury pathology may help with the development of preventative treatments to improve long-term health outcomes.The review will outline evidence of long-term health effects,possible mechanisms linking burn injury to long-term health and current research into burns as a chronic disease.

A retrospective cohort study to compare post-injury admissions for infectious diseases in burn patients, non-burn trauma patients and uninjured people

Background: Injury triggers a range of systemic effects including inflammation and immune responses. This study aimed to compare infectious disease admissions after burn and other types of injury using linked hospital admissions data. Methods: A retrospective longitudinal study using linked health data of all patients admitted with burns in Western Australia (n = 30,997), 1980–2012, and age and gender frequency matched cohorts of people with non-burn trauma (n = 28,647) and no injury admissions (n = 123,399). Analyses included direct standardisation, negative binomial regression and Cox proportional hazards regression. Results: Annual age-standardised infectious disease admission rates were highest for the burn cohort, followed by the non-burn trauma and uninjured cohorts. Age-standardised admission rates by decade showed different patterns across major categories of infectious diseases, with the lower respiratory and skin and soft tissue infections the most common for those with burns and other open trauma. Compared with the uninjured, those with burns had twice the admission rate for infectious disease after discharge (incident rate ratio (IRR), 95% confidence interval (CI): 2.04, 1.98–2.11) while non-burn trauma experienced 1.74 times higher rates (95%CI: 1.68–1.81). The burn cohort experienced 10% higher rates of first-time admissions after discharge when compared with the non-burn trauma (hazard ratio (HR), 95%CI: 1.10, 1.05–1.15). Compared with the uninjured cohort, incident admissions were highest during the first 30 days after discharge for burns (HR, 95%CI: 5.18, 4.15–6.48) and non-burn trauma (HR, 95%CI: 5.06, 4.03–6.34). While incident rates remained high over the study period, the magnitude decreased with increasing time from discharge: burn vs uninjured: HR, 95%CI: 30 days to 1 year: 1.69, 1.53–1.87;1 to 10 years: 1.40, 1.33–1.47;10 years to end of study period: 1.16, 1.08–1.24;non-burn trauma vs uninjured: HR, 95%CI: 30 days to 1 year: 1.71, 1.55–1.90;1 to 10 years: 1.30, 1.24–1.37;10 years to end of study period: 1.09, 1.03–1.17). Conclusions: Burns and non-burn trauma patients had higher admission rates for infectious diseases compared with age and gender matched uninjured people. The pattern of annual admission rates for major categories of infectious diseases varied across injury groups. Overal , the burn cohort experienced the highest rates for digestive, lower respiratory and skin and soft tissue infections. These results suggest long-term vulnerability to infectious disease after injury, possibly related to long-term immune dysfunction.

Sexuality following trauma injury: A literature review

Restoration of the quality of life(QoL)of trauma injury survivors is the aim of trauma rehabilitation.It is generally acknowledged that sexuality is an important component of QoL;however,rehabilitation services frequently fall short of including sexuality as a matter of routine.The literature was reviewed to examine the experiences of trauma survivors from three groups:spinal cord injury(SCI),traumatic brain injury(TBI)and burns.The focus was on the impact of trauma on the QoL to identify future research directions and to advocate for the inclusion of sexuality as an integral part of rehabilitation.Databases searched were Proquest,Ovid,Cinahl,Medline,PsycInfo and Cochrane Central Register of controlled trials.A total of 36 eligible studies were included:SCI(n=25),TBI(n=6),burns(n=5).Four themes were identified across the three trauma groups that were labeled as physiological impact of trauma on sexuality,cognitive-genital dissociation(CGD),sexual disenfranchisement(SD)and sexual rediscovery(SR).Trauma injury has a significant impact on sexuality,which is not routinely addressed within rehabilitation services.Further sexuality research is required among all trauma groups to improve rehabilitation services and in turn QoL outcomes for all trauma survivors.