A systematic review of objective burn scar measurements

Background:Problematic 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.Methods:A 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.Results:After 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.Conclusions:Objective 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 I colorimeter for colour,Dermascan high-frequency ultrasound for scar thickness and Cutometer for skin elasticity and pliability.

Patient experience of scar assessment and the use of scar assessment tools during burns rehabilitation:a qualitative study

Background:Scar assessment plays a key role during burns aftercare,to monitor scar remodelling and patients’psychosocial well-being.To aid assessment,subjective scar assessment scales are available that use health-care professionals’and patients’opinions to score scar characteristics.The subjective scales are more widely used in clinical practice over objective scar measures.To date,there is no research that considers patients’views on scar assessment and the role of subjective and objective assessment tools.Therefore,the aim of this qualitative study was to explore patients’perspectives on scar assessment and the utility of scar assessment tools during burns rehabilitation.Methods:Semi-structured interviews were conducted with 10 adult burn patients who were being reviewed in clinic for scarring.Participants were recruited via their clinical care team and research nurses at the Queen Elizabeth Hospital,Birmingham,UK.Topics covered during interview included patient experience of scar assessment,the use of scar assessment tools and discussion surrounding important factors to be addressed when assessing scars.A thematic analysis using the Framework Method was conducted.Results:Participants identified key subthemes that contribute towards the overarching theme of patient-centred scar assessment.These are:patient-led care;continuity in care;learning how to self-manage scarring;and psychological assessment.Links were demonstrated between these subthemes and the remaining themes that describe scar assessment strategies,indicating their potential patient-centred contributions.The subjective opinions of clinicians were found to be valued above the use of subjective or objective scar assessment tools.Scar assessment scales were perceived to be a beneficial method for self-reflection in relation to psychosocial function-ing.However,minimal feedback and review of completed assessment scales led to uncertainty regarding their purpose.Patients perceived objective tools to be of primary use for health-care professionals,though the measures may aid patients’understanding of scar properties.Conclusions:Scar assessment tools should be used to support,rather than replace,health-care professionals’subjective judgements of scarring.Adapting the way in which clinicians introduce and use scar assessment tools,according to patient needs,can support a patient-centred approach to scar assessment.

Burn injury prevention in low-and middleincome countries:scoping systematic review

Background:Burn injuries are a leading cause of morbidity and disability,with the burden of disease being disproportionately higher in low-and middle-income countries(LMIC).Burn prevention programmes have led to significant reductions in the incidence of burns in high-income countries.However,a previous systematic review published in 2015 highlighted that implementation and evaluation of similar programmes has been limited in LMIC.The objective of this scoping review and narrative synthesis was to summarise and understand the initiatives that have been carried out to reduce burn injuries in LMIC and their effectiveness.Methods:We aimed to identify publications that described studies of effectiveness of burn prevention interventions applied to any population within a LMIC and measured burn incidence or burns-related outcomes.Suitable publications were identified from three sources.Firstly,data was extracted from manuscripts identified in the systematic review published by Rybarczyk et al.We then performed a search for manuscripts on burn prevention interventions published between January 2015 and September 2020.Finally,we extracted data from two systematic reviews where burn evidence was not the primary outcome,which were identified by senior authors.A quality assessment and narrative synthesis of included manuscripts were performed.Results:In total,24 manuscripts were identified and categorized according to intervention type.The majority of manuscripts(n=16)described education-based interventions.Four manuscripts focused on environmental modification interventions and four adopted a mixedmethods approach.All of the education-based initiatives demonstrated improvements in knowledge relating to burn safety or first aid,however few measured the impact of their intervention on burn incidence.Four manuscripts described population-based educational interventions and noted reductions in burn incidence.Only one of the four manuscripts describing environmental modification interventions reported burns as a primary outcome measure,noting a reduction in burn incidence.All mixed-method interventions demonstrated some positive improvements in either burn incidence or burns-related safety practices.Conclusion:There is a lack of published literature describing large-scale burn prevention programmes in LMIC that can demonstrate sustained reductions in burn incidence.Populationlevel,collaborative projects are necessary to drive forward burn prevention through specific environmental or legislative changes and supplementary educational programmes.

Heparin resistance in severe thermal injury:a prospective cohort study

Background:Low molecular-weight heparin(LMWH)is routinely administered to burn patients for thromboprophylaxis.Some studies have reported heparin resistance,yet the mechanism(s)and prevalence have not been systematically studied.We hypothesized that nucleosomes,composed of histone structures with associated DNA released from injured tissue and activated immune cells in the form of neutrophil extracellular traps(NETs or NETosis),neutralize LMWH resulting in suboptimal anticoagulation,assessed by reduction in anti-factor Xa activity.Methods:Blood was sampled from>15%total body surface area(TBSA)burn patients receiving LMWH on days 5,10 and 14.Peak anti-factor Xa(AFXa)activity,anti-thrombin(ATIII)activity,cellfree DNA(cfDNA)levels and nucleosome levels were measured.Mixed effects regression was adjusted for multiple confounders,including injury severity and ATIII activity,and was used to test the association between nucleosomes and AFXa.Results:A total of 30 patients with severe burns were included.Mean TBSA 43%(SD 17).Twentythree(77%)patients were affected by heparin resistance(defined by AFXa activity<0.2 IU/mL).Mean peak AFXa activity across samples was 0.18 IU/mL(SD 0.11).Mean ATIII was 81.9%activity(SD 20.4).Samples taken at higher LWMH doses were found to have significantly increased AFXa activity,though the effect was not observed at all doses,at 8000 IU no samples were heparin resistant.Nucleosome levels were negatively correlated with AFXa(r=−0.29,p=0.050)consistent with the hypothesis.The final model,with peak AFXa as the response variable,was adjusted for nucleosome levels(p=0.0453),ATIII activity(p=0.0053),LMWH dose pre-sample(p=0.0049),drug given(enoxaparin or tinzaparin)(p=0.03),and other confounders including severity of injury,age,gender,time point of sample.Conclusions:Heparin resistance is a prevalent issue in severe burns.Nucleosome levels were increased post-burn,and showed an inverse association with AFXa consistent with the hypothesis that they may interfere with the anticoagulant effect of heparin in vivo and contribute to heparin resistance.Accurate monitoring of AFXa activity with appropriate therapy escalation plans are recommended with dose adjustment following severe burn injury.

Ensuring that the outcome domains proposed for use in burns research are relevant to adult burn patients:a systematic review of qualitative research evidence

Background:There have been several attempts to define core outcome domains for use in research focused on adult burns.Some have been based in expert opinion,whilst others have used primary qualitative research to understand patients’perspectives on outcomes.To date there has not been a systematic review of qualitative research in burns to identify a comprehensive list of patientcentred outcome domains.We therefore conducted a systematic review of qualitative research studies in adult burns.Methods:We searched multiple databases for English-language,peer-reviewed,qualitative research papers.We used search strategies devised using the SPIDER tool for qualitative synthesis.Our review utilized an iterative three-step approach:(1)outcome-focused coding;(2)development of descriptive accounts of outcome-relevant issues;and(3)revisiting studies and the broader theoretical literature in order to frame the review findings.Results:Forty-one articles were included.We categorized papers according to their primary focus.The category with the most papers was adaptation to life following burn injury(n=13).We defined 19 outcome domains across the 41 articles:(1)sense of self;(2)emotional and psychological morbidity;(3)sensory;(4)scarring and scar characteristics;(5)impact on relationships;(6)mobility and range of joint motion;(7)work;(8)activities of daily living and self-care;(9)treatment burden;(10)engagement in activities;(11)wound healing and infection;(12)other physical manifestations;(13)financial impact;(14)impact on spouses and family members;(15)analgesia and side effects;(16)cognitive skills;(17)length of hospital stay;(18)access to healthcare;and(19)speech and communication.We suggest that sense of self is a core concern for patients that,to date,has not been clearly conceptualized in the burns outcome domain literature.Conclusions:This outcome domain framework identifies domains that are not covered in previous attempts to outline core outcome domains for adult burn research.It does so with reference to existing theoretical perspectives from the sociology and psychology of medicine.We propose that this framework can be used as a basis to ensure that outcome assessment is patient-centred.Sense of self requires further consideration as a core outcome domain.

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

Background: It is commonly accepted that burns taking longer than 3 weeks 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. Methods: We performed a prospective study of 383 paediatric burns treated non-operatively at a regional burns centre over a 2-year period from May 2011 to April 2013. Scar assessment was performed by a senior burns therapist using the Vancouver Scar Scale. Results: Overall 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 8 days. 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. Conclusions: The 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 3 weeks is overly simplistic and should be abandoned: in paediatric burns, every day counts.

Vitamin D status and its influence on outcomes following major burn injury and critical illness

Vitamin D deficiency is common among the general population. It is also observed in up to 76% of critically ill patients.Despite the high prevalence of hypovitaminosis D in critical illness, vitamin D is often overlooked by medical staff as the clinical implications and consequences of vitamin D deficiency in acute contexts remain to be fully understood.Vitamin D has a broad range of pleotropic effects on various processes and systems including the immuneinflammatory response. 1α,25-dihydroxyvitamin D (1,25(OH)2D), has been shown to promote a tolerogenic immune response limiting deleterious inflammatory effects, modulation of the innate immune system, and enhancement of anti-microbial peptides. Vitamin D deficiency is frequently observed in critically ill patients and has been related to extrinsic causes (i.e., limited sunlight exposure), magnitude of injury/illness, or the treatment started by medical doctors including fluid resuscitation. Low levels of vitamin D in critically ill patients have been associated with sepsis, organ failure, and mortality. Despite this, there are subpopulations of critical illness, such as burn patients, where the literature regarding vitamin D status and its influence on outcomes remain insufficient. Thermal injury results in damage to both burned and non-burned tissues, as well as induces an exaggerated and persistent immune-inflammatory and hypermetabolic response. In this review, we propose potential mechanisms in which burn injury affects the vitamin D status and summarizes current literature investigating the influence of vitamin D status on outcomes. In addition, wereviewed the literature and trials investigating vitamin D supplementation in critically ill patients and discuss the therapeutic potential of vitamin D supplementation in burn and critically ill patients. We also highlight current limitations of studies that have investigated vitamin D status and supplementation in critical illness. Thermal injury influences vitamin D status. More studies investigating vitamin D depletion in burn patients and its influence on prognosis, via standardized methodology, are required to reach definitive conclusions and influence clinical practice.