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Volume XXIX |
Number 2 |
June 2016 |
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Summaries
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BURNS IN SWEDEN: TEMPORAL TRENDS FROM 1987 TO 2010
(Svee A., Jonsson A., Sjöberg F., Huss F. - Sweden)
Our aim was to investigate the epidemiology of burned patients admitted to hospitals in Sweden, and to examine temporal trends during the last three decades. Our hypothesis was that there has been an appreciable decline in the number of patients admitted. Retrospective data about burned patients treated at Swedish hospitals 1987 - 2010 were obtained from the Swedish National Board of Health and Welfare. Patients with primary or secondary ICD diagnoses of burns were included, reviewed and statistically interpreted in terms of sex, age, incidence, mortality in hospital and duration of stay. A total of 30,478 patients were admitted to hospitals with burns. The absolute number of admissions declined by 42% (95% CI 39 to 44). There was a highly significant reduction of 45% (95% CI: 38 to 51) in the ageadjusted incidence (admissions/million population) over the years, and the reduction was significant for both sexes. Children aged 0-4 years (n=8308) were most likely to be admitted to hospital (27%). The median duration of stay shortened over time (p < 0.0001). There was an overall significant reduction in deaths at hospital/100 admissions over time (p < 0.0001). We think that the improvements are the result of a combination of preventive measures, improved treatments and greater use of outpatient facilities. If we understand these trends and the relations between age-adjusted incidence and actual number of admissions, we can gain insight into what is needed for future provision of emergency health care.
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| 90 |
EPIDEMIOLOGY OF NOSOCOMIAL FUNGAL INFECTIONS IN THE NATIONAL CENTER FOR BURNS IN CASABLANCA, MOROCCO
(Rafik A., Diouri M., Bahechar N., Chlihi A. - Morocco)
Fungal infection is a leading cause of death in burns patients and incurs significant costs for burn units. Our aim was to determine epidemiology of these infections, and analyze risk factors in the burns intensive care unit of the National Center for Burns and Plastic Surgery at Ibn-Rochd University Hospital, Casablanca. It is a retrospective review of all patients admitted from 2011-2014 who developed cultures positive for fungal organisms. Criteria for nosocomial fungal infections were those of the Center for Disease Control in Atlanta (1988, revised 1992, 2004). Microbiological surveillance was carried out daily. Patient demographic data, % TBSA, type of infection, site(s), species and number of cultures, and risk factors for fungal infections were collected. Mean age of patients was 24.5 +/- 27.3 years; 63% were female. Mean % TBSA was 30.7 +/- 23.4%, and % FTSA was 21.7 +/- 20.1%. Injury due to flame was most common (82%), followed by scald (10%), contact (4%), electrical (3%) and chemical (1%). Incidence of nosocomial fungal infection was 10%. The fungal pathogen most frequently isolated was Candida albicans (65.7%), followed by other Candida species (18.6%). Aspergillus spp was present in 3.9% and was statistically associated with mortality (3.2%) and morbidity. In our study, risk factors for these infections were mostly degree of burn (mean TBSA = 30.7%) and prolonged broad-spectrum antibiotic therapy. These two factors were associated with a higher incidence of multiple positive cultures, and significantly increased mortality (21.6%). Amphotericin B and fluconazole were the most frequently used antifungal agents. Fungi are emerging as important nosocomial pathogens. The main clinical implications are thinking faster about fungi infections and being more careful with antibiotic prescriptions.
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| 94 |
EXHAUST SYSTEM-RELATED BURNS AFFECTING CHILDREN: A UK PERSPECTIVE AND LITERATURE REVIEW
(Vermaak P.V., Deall C.E., McArdle C., Burge T. - UK)
Burns caused by exhaust systems in children may be associated with considerable morbidity. Current epidemiological data varies, but no data are available for the UK population. We aim to identify the pattern of exhaust-related burns affecting children who presented to a regional centre for paediatric burn care in the UK. Patients who sustained burns related to exhaust mechanisms between May 2005 and August 2012 were identified via the departmental database. Data collected included patient demographics, burn injury information, management and outcomes. Thirty-nine patients sustained 43 burns from contact with exhaust mechanisms, and the majority were less than 5 years of age. 77% of the patients were male. Burns affected critical areas such as the hands and feet in 26% of cases. Most burns involved a total body surface area of =1% and were partial thickness in depth. Thirty-three percent of patients required operative intervention. Time to heal was less than 3 weeks in 69% of cases and 3 patients healed with hypertrophic scarring. The majority of burns were small in size and partial thickness in depth. Most were treated conservatively and healed with low complication rates. More than 1 in 5 injuries involved critical burn areas, highlighting the potential for considerable morbidity. The age profile in our study contrasted with other results worldwide. Our study highlights the need for vigilant supervision of children around motorcycles. We recommend the wearing of protective long trousers when riding motorcycles and the fitting of external shields to motorcycle exhaust pipes.
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| 97 |
FACE AND/OR NECK BURNS: A RISK FACTOR FOR RESPIRATORY INFECTION?
(Costa Santos D., Barros F., Gomes N., Guedes T., Maia M. - Portugal)
Infections are a common cause of morbidity and mortality in burn patients, and almost 50% of infection-related deaths in burn patients are caused by pneumonia. The proportion of facial and/or neck burns (FNB) in burn centre admissions is high, and these patients have a well known respiratory risk. However, it is not well established in the literature if the occurrence of a FNB is a risk factor for respiratory infection during hospitalization. A retrospective, single-centre trial at the burn unit of the Prelada Hospital was conducted, including patients admitted between January 2011 and December 2014. The primary objective was to investigate the existence of a relation between face and/or neck burns and occurrence of respiratory infection. A total of 229 patients were included in the study, 126 with FNB and 103 without FNB. Higher total body surface area (TBSA) burned, inhalation injury and early endotracheal intubation were statistically more frequent in the FNB group. These variables were also more prevalent in the group that developed respiratory infection during the burn unit stay. Concerning FNB patients, the most frequent microbiological strains isolated in respiratory secretion cultures were Staphylococcus aureus, Pseudomonas aeruginosa and Streptococcus pneumonia, while in nFNB patients it was Klebsiella pneumoniae. In our population, only early ETI, inhalation injury and higher TBSA appear to be independent risk factors for respiratory infection in FNB patients, although age, male sex and co-morbidities are also known risk factors for respiratory infection in burn patients.
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| 103 |
FACTORS AT SCENE AND IN TRANSFER RELATED TO THE DEVELOPMENT OF HYPOTHERMIA IN MAJOR BURNS
(Steele J.E., Atkins J.L., Vizcaychipi M.P. - UK)
There is a paucity of evidence regarding incidence and causes of hypothermia in patients with major burns and its impact on outcomes. This paper identifies contributing factors to hypothermia and its relationship with the severity of physiological scoring systems on admission to a tertiary centre. Patients with burns >20% TBSA admitted between March 2010 and July 2013 comprised this retrospective survey. Data relating to causative factors at time of burn, during transfer, physiological outcome scores (BOBI, SOFA, RTS and APACHE II), length of hospital stay and mortality were collected. SPSS statistical software was used for analysis. The study included 31 patients (medians: age 32 years, burn size 30% TBSA). 13% (n=4) of patients died during hospital admission. 42% (n=13) of patients had a temperature <36.0C on arrival. Temperature on arrival at the burns centre was related to the severity of all physiological scores (p≤0.001). There was no difference between groups in terms of mortality in hospital (p=0.151) or length of hospital stay (p=0.547). Our results show that hypothermia is related to burn severity and patient physiological status. They do not show a relationship between hypothermia and external factors at the time of the burn. This paper prompts further investigation into the prevention of hypothermia in patients with major burns.
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| 108 |
MÉCANISMES ET TRAITEMENT DE L'ANÉMIE AIGUË CHEZ LE BRÛLÉ GRAVE
(Siah S., El Khatib K., Messaoudi N. - Maroc)
Les brûlés graves présentent souvent, au cours de la phase aiguë, des anémies plus au moins profondes pouvant nécessiter des transfusions. L'anémie du brûlé a deux origines principales: le saignement péri-opératoire (des stratégies doivent être mises en place pour le réduire) et l'anémie de réanimation (que l'on peut en partie réduire en évitant les bilans inutiles) chez un patient ayant des troubles de l'hématopoïèse. Le traitement, chez ces patients à l'hématopoïèse altérée, repose sur la transfusion. Celle-ci n'est pas dénuée d'effets secondaires et une stratégie transfusionnelle restrictive doit être appliquée.
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| 111 |
BURN PATIENT CARE LOST IN GOOD MANUFACTURING PRACTICES?
(Dimitropoulos G., Jafari P., de Buys Roessingh A., Hirt-Burri N., Raffoul W., Applegate L.A. - Switzerland)
Application of cell therapies in burn care started in the early 80s in specialized hospital centers world-wide. Since 2007, cell therapies have been considered as "Advanced Therapy Medicinal Products" (ATMP), so classified by European Directives along with associated Regulations by the European Parliament. Consequently, regulatory changes have transformed the standard linear clinical care pathway into a more complex one. It is important to ensure the safety of cellular therapies used for burn patients and to standardize as much as possible the cell sources and products developed using cell culture procedures. However, we can definitely affirm that concentrating the bulk of energy and resources on the implementation of Good Manufacturing Practice (GMP) alone will have a major negative impact on the care of severely burned patients world-wide. Developing fully accredited infrastructures and training personnel (required by the new directives), along with obtaining approval for clinical trials to go ahead, can be a lengthy process.We discuss whether or not these patients could benefit from cell therapies provided by standard in-hospital laboratories, thus avoiding having to meet rigid regulations concerning the use of industrial pharmaceutical products. "Hospital Exemption" could be a preferred means to offer burn patients a customized and safe product, as many adaptations may be required throughout their treatment pathway. Patients who are in need of rapid treatment will be the ones to suffer the most from regulations intended to help them.
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| 116 |
COMBINATION OF MEDICAL NEEDLING AND NON-CULTURED AUTOLOGOUS SKIN CELL TRANSPLANTATION (RENOVACELL) FOR REPIGMENTATION OF HYPOPIGMENTED BURN SCARS IN CHILDREN AND YOUNG PEOPLE
(Busch K.H., Bender R., Walezko N., Aziz H., Altintas M.A., Aust M.C. - Germany)
Burn scars remain a serious physical and psychological problem for the affected. Clinical studies as well as basic scientific research have shown that Medical Needling can significantly increase the quality of burn scars with comparatively low risk and stress for the patient with regards to skin elasticity, moisture, erythema and transepidermal water loss. However, Medical Needling has no influence on repigmentation of large hypopigmented scars. The goal is to evaluate whether both established methods - Needling (improvement of scar quality) and ReNovaCell (repigmentation) - can be combined. So far, eight patients with mean age of 20 years (6-28 years) with deep second and third degree burn scars have been treated. The average treated tissue surface was 76cm² (15-250cm²) and was focused on areas like face, neck, chest and arm. Medical Needling is performed using a roller covered with 3mm long needles. The roller is vertically, horizontally and diagonally rolled over the scar, inducing microtrauma. Then, non-cultured autologous skin cell suspension (ReNovaCell) is applied, according to the known protocol. The patients were followed 12 months postoperatively. Pigmentation changes were measured objectively, and with patient and observer ratings. Patient satisfaction/preference was also obtained. We present the final study results. Taken together, pigmentation ratings and objective measures indicate improvement in six of the study participants. Melanin increase seen 12 months after ReNovaCell treatment in the study group as a whole is notable. Medical Needling in combination with ReNovaCell shows promise for repigmentation of burn scars.
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| 123 |
COMPARISON OF MORTALITY PREDICTION MODELS AND VALIDATION OF SAPS II IN CRITICALLY ILL BURNS PATIENTS
(Pantet O., Faouzi M., Brusselaers N., Vernay A., Berger M.M. - Switzerland)
Specific burn outcome prediction scores such as the Abbreviated Burn Severity Index (ABSI), Ryan, Belgian Outcome of Burn Injury (BOBI) and revised Baux scores have been extensively studied. Validation studies of the critical care score SAPS II (Simplified Acute Physiology Score) have included burns patients but not addressed them as a cohort. The study aimed at comparing their performance in a Swiss burns intensive care unit (ICU) and to observe whether they were affected by a standardized definition of inhalation injury. We conducted a retrospective cohort study, including all consecutive ICU burn admissions (n=492) between 1996 and 2013: 5 epochs were defined by protocol changes. As required for SAPS II calculation, stays <24h were excluded. Data were collected on age, gender, total body surface area burned (TBSA) and inhalation injury (systematic standardized diagnosis since 2006). Study epochs were compared (?2 test, ANOVA). Score performance was assessed by receiver operating characteristic curve analysis. SAPS II performed well (AUC 0.89), particularly in burns <40% TBSA (AUC 0.93). Revised Baux and ABSI scores were not affected by the standardized diagnosis of inhalation injury and showed the best performance (AUC 0.92 and 0.91 respectively). In contrast, the accuracy of the BOBI and Ryan scores was lower (AUC 0.84 and 0.81) and reduced after 2006. The excellent predictive performance of the classic scores (revised Baux score and ABSI) was confirmed. SAPS II was nearly as accurate, particularly in burns <40% TBSA. Ryan and BOBI scores were least accurate, as they heavily weight inhalation injury.
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| 130 |
EFFET PARADOXAL DU TYPE D'EXCISION SUR LA PRISE ET LE DÉLAI DE CICATRISATION DES GREFFES EXPANSÉES POUR LE TRAITEMENT DES BRÛLURES AIGUËS: A PROPOS DE 1129 CAS
(Guibert M., Chaouat M., Boccara D., Marco O., Lavocat R., Alameri O., Deslandes E., Montlahuc C., Mimoun M. - France)
La greffe de peau mince expansée est très employée dans le traitement des brûlures aiguës. Nous avons étudié l'influence de la préparation du sous-sol sur le taux de prise et le délai de cicatrisation des greffes expansées. Nous avons analysé rétrospectivement les 1 129 greffes expansées réalisées dans notre service entre 1995 et 2005 pour le traitement des brûlures aiguës. Leur taux de prise a été significativement meilleur après une préparation du sous-sol par avulsion (82%) par rapport à une préparation du sous-sol par excision tangentielle (75%). Ce taux était meilleur lorsque l'avulsion était pratiquée dans les 7 jours suivant la brûlure (83% vs 73%). Pour une prise en charge entre 7 et 21 jours, ce taux a semblé être meilleur après excision tangentielle, mais de façon non significative. La durée d'évolution jusqu'à cicatrisation était significativement raccourcie pour une préparation du sous-sol par excision tangentielle par rapport à une préparation du sous-sol par avulsion. Ces résultats montrent, paradoxalement, qu'une préparation du sous-sol par avulsion favorise la prise des greffes expansées mais rallonge leur délai de cicatrisation au contraire de l'excision tangentielle.
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| 135 |
BRACHIAL ARTERY PROTECTED BY WRAPPED LATISSIMUS DORSI MUSCLE FLAP IN HIGH VOLTAGE ELECTRICAL INJURY
(Gencel E., Eser C., Kokacya O., Kesiktas E., Yavuz M. - Turkey)
High voltage electrical injury can disrupt the vascular system and lead to extremity amputations. It is important to protect main vessels from progressive burn necrosis in order to salvage a limb. The brachial artery should be totally isolated from the burned area by a muscle flap to prevent vessel disruption. In this study, we report the use of a wrap-around latissimus dorsi muscle flap to protect a skeletonized brachial artery in a high voltage electrical injury in order to salvage the upper extremity and restore function. The flap wrapped around the exposed brachial artery segment and luminal status of the artery was assessed using magnetic resonance angiography. No vascular intervention was required. The flap survived completely with good elbow function. Extremity amputation was not encountered. This method using a latissimus dorsi flap allows the surgeon to protect the main upper extremity artery and reconstruct arm defects, which contributes to restoring arm function in high voltage electrical injury.
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| 139 |
SCALD MANAGEMENT PROTOCOLS - OUTCOME DIFFERENCES IN TWO DIFFERENT TIME PERIODS USING DIFFERENT TREATMENT STRATEGIES
(Elmasry M., Steinvall I., Thorfinn J., Abbas A.H., Adly O.A., Abdelrahman I., Nagi M.A., Sjoberg F. - Sweden)
Over the years the treatment of scalds in our centre has changed, moving more towards the use of biological dressings (xenografts). Management of scalds with mid dermal or deep dermal injuries differs among centers using different types of dressings, and recently biological membrane dressings were recommended for this type of injury. Here we describe differences in treatment outcome in different periods of time. All patients with scalds who presented to the Linkoping Burn Centre during two periods, early (1997-98) and later (2010-12) were included. Data were collected in the unit database and analyzed retrospectively. A lower proportion of autograft operations was found in the later period, falling from 32% to 19%. Hospital stay was shorter in the later period (3.5 days shorter, p=0.01) and adjusted duration of hospital stay/TBSA% was shorter (1.2 to 0.7, p=0.07). The two study groups were similar in most of the studied variables: we could not report any significant differences regarding outcome except for unadjusted duration of hospital stay. Further studies are required to investigate functional and aesthetic outcome differences between the treatment modalities.
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| 144 |
BEWARE FLAMMABLE FINGERNAILS. CASE REPORT: SYNTHETIC FINGERNAILS RESULT IN FULL THICKNESS BURN AND TERMINALISATION
(Arnaout A., Cubitt J., Nguyen D. - Wales)
Having long artificial (acrylic) nails is a current fashion trend, and they are becoming an increasingly popular cosmetic enhancement. We believe that they can be a potential burn hazard to their unknowing users. We present the first reported case in medical literature of a woman whose acrylic nail ignited from a cigarette butt a short distance from the nail while she was taking the final puffs. She sustained a full thickness burn to her dominant left thumb, resulting in terminalisation. Acrylic nails are very flammable and, once ignited, they burn to completion, with the source of flame removed. The temperature at the end of a cigarette can reach 900oC when the smoker takes a puff, which would explain how the artificial nail in our case study ignited. The flammability hazard of artificial fingernails is apparently well known in the beautician community. There are multiple beauty websites and blogs raising awareness of the danger of synthetic nails catching fire. We feel this potential risk should be further highlighted to the public.
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| 146 |
THE INSTRUCTIONAL VALUE OF INTERNATIONAL SURGICAL VOLUNTEERISM FROM A RESIDENT'S PERSPECTIVE
(Tocco-Tussardi I., Boccella S., Bassetto F. - Italy)
The aim of this article is to document the experience of the author who volunteered as a resident for 6 months at a districtlevel hospital in central Kenya. Peculiarities emerging from the report are: specificity of the experience to plastic reconstructive surgery; highly complex reconstructive procedures performed under direct supervision of a qualified mentor; exposure to diverse approaches through collaboration with different volunteer plastic surgeons; enhancement of long-term surveillance; and opportunity to expand surgical knowledge outside one's field of specialty. The humanitarian setting allows maximal exposure and learning and can play a significant role in the resident's education.
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| 151 |
VULNÉROLOGIE: UN NÉOLOGISME POUR MAGNIFIER LE CONCEPT «PLAIES ET CICATRISATION»
(Costagliola M., Atiyeh B. - France)
Bien que la cicatrisation des plaies soit un thème médico-chirurgical essentiel depuis l'Antiquité, il a été longtemps négligé. L'essor dans ce domaine, ces 20 dernières années, de la recherche fondamentale et le développement de nouvelles techniques ont fait que la cicatrisation est devenue une entité à part entière, transversale, intéressant plusieurs spécialités. Il a semblé souhaitable, en nous appuyant sur des arguments étymologiques, sémantiques et botaniques, de proposer un néologisme pour regrouper sous une même appellation tous les professionnels de santé oeuvrant dans ce secteur de soins et magnifier ainsi le concept « Plaies et Cicatrisation ».
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| 155 |
COMPTE RENDU DE LA TABLE RONDE DU 35ÈME CONGRÈS DE LA SFETB À METZ (10-12 JUIN 2015) CONCERNANT LES BRÛLURES PÉRIBUCCALES
(Perrot P. - France)
La table ronde de chirurgie portant sur les brûlures péribuccales était divisée en deux parties: «prise en charge en aigu des brûlures péribuccales» et «séquelles de brûlures péribuccales / session de cas cliniques adulte et enfant». Ceci en est le résumé, construit en revoyant les prises vidéo en direct de la session, à laquelle assistait l'auteur.
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