Venous thromboembolism prophylaxis practice and its association with outcomes in Australia and New Zealand burns patients

Background:Patients with burn injuries are considered to have an increased risk of venous thromboembolism(VTE).While untreated VTEs can be fatal,no studies have examined chemoprophylaxis effectiveness.This study aimed to quantify the variation in prevalence of VTE prophylaxis use in patients in Australian and New Zealand burns units and whether prophylaxis use is associated with in-hospital outcomes following burn injury.Methods:Admission data for adult burns patients(aged≥16 years)admitted between 1 July 2016 and 31 December 2018 were extracted from the Burns Registry of Australia and New Zealand.Mixed effects logistic regression modelling investigated whether VTE prophylaxis usewas associated with the primary outcome of in-hospital mortality.Results:There were 5066 admissions over the study period.Of these patients,81%(n=3799)with a valid response to the VTE prophylaxis data field received some form of VTE prophylaxis.Use of VTE prophylaxis ranged from 48.6%to 94.8%of patients between units.In-hospital death was recorded in<1%of patients(n=33).After adjusting for confounders,receiving VTE prophylaxis was associated with a decrease in the adjusted odds of in-hospital mortality(adjusted odds ratio=0.21;95%CI,0.07–0.63;p=0.006).Conclusions:Variation in the use of VTE prophylaxis was observed between the units,and prophylaxis use was associated with a decrease in the odds of mortality.These findings provide an opportunity to engage with units to further explore differences in prophylaxis use and develop future best practice guidelines.

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.

Retrospective review of a tertiary adult burn centre's experience with modified Meek grafting

Background:Autologous split skin grafting is the gold standard in treating patients with massive burns.However,the limited availability of donor sites remains a problem.The aim of this study is to present our experience with the modified Meek technique of grafting,outcomes achieved and recommendations for optimized outcomes.Methods:We retrospectively reviewed patient records from our tertiary referral burn centre and the Bi-National Burns Registry to identify all patients who had modified Meek grafting between 2010 and 2013.Patient records were reviewed individually and information regarding patient demographics,mechanism of injury and surgical management was recorded.Outcome measures including graft take rate,requirement for further surgery and complications were also recorded.Results:Eleven patients had modified Meek grafting procedures.The average age of patients was 46 years old(range 23–64).The average total body surface area(TBSA)burnt was 56.75%(range 20–80%).On average,87%of the grafted areas healed well and did not require regrafting.In the regrafted areas,infection was the leading cause of graft failure.Conclusions:Modified Meek grafting is a useful method of skin expansion.Similar to any other grafting technique,infection needs to be sought and treated promptly.It is recommended for larger burns where donor sites are not adequate or where it is desirable to limit their extent.

A rare case of failed healing in previously burned skin after a secondary burns

Background:Patients presenting with large surface area burns are common in our practice;however, patients with a secondary large burn on pre-existing burn scars and grafts are rare and not reported. Case presentation:We report on an unusual case of a patient sustaining a secondary large burn to areas previously injured by a burn from a different mechanism. We discuss the potential implications when managing a case like this and suggest potential biological reasons why the skin may behave differently. Our patient was a 33-year-old man who presented with a 5%TBSA burn on skin scarred by a previous 40%total body surface area (TBSA) burn and skin grafts. Initially assessed as superficial partial thickness in depth, the wounds were treated conservatively with dressings;however, they failed to heal and became infected requiring surgical management. Conclusions:Burns sustained in areas of previous burn scars and grafts may behave differently to normal patterns of healing, requiring more aggressive management and surgical intervention at an early stage.

Efficacy and safety of a dual-scan protocol for carbon dioxide laser in the treatment of split-thickness skin graft contraction in a red Duroc pig model

Background:Fractional CO_(2) laser plays an important role in scar management post split-thickness skin graft by loosening the graft contracture and restoring the smoothness of the surface.However,the optimal treatment protocol remains unknown.This study applied a dual-scan protocol to achieve both releasing and ablation of contracted skin graft.We comprehensively describe this treatment method and compare the efficacy and safety between this dual-scan method and the conventional mono-scan mode.Methods:A hypercontracted scar model after split-thickness skin grafting in red Duroc pigs was established.All scars meeting the inclusion criteria were randomly divided into four groups:high fluence–low density(HF–LD),low fluence–high density(LF–HD),combined group and control group.The energy per unit areawas similar in the HF–LD and LF–HD groups.Two laser interventions were performed at a 6-week interval.The efficacy of the treatment was evaluated by objective measures of scar area,release rate,elasticity,thickness and flatness,while the safetywas evaluated based on adverse reactions and melanin index.Collagen structurewas observed histologically.The animals were followed up for a maximum of 126 days after modeling.Results:A total of 28 contracted scars were included,7 in each group.At 18 weeks postoperatively,the HF–LD and the combined groups showed significantly increased scar release rate(p=0.000)and elasticity(p=0.036)and decreased type I/III collagen ratio(p=0.002)compared with the control and LF–HD groups.In terms of flatness,the combined group was significantly better than the HF–LD group for elevations<1mm(p=0.019).No significant skin side effects,pigmentation or scar thickness changes were observed at 18 weeks.Conclusions:Dual-scan protocol could achieve superficial ablation and deep release of contracted split-thickness skin graft in a single treatment,with similar contraction release and texture improvement compared to a single deep scan.Its main advantage is to restore a smoother scar appearance.Adequate laser penetration was necessary for the release of contracted scars.