Necrotising soft tissue infections. / Nekrotiserende bløtdelsinfeksjoner.

Necrotising soft tissue infections can affect the skin, subcutaneous tissue, superficial fascia, deep fascia and musculature. The infections are severe, they spread quickly and can result in extensive tissue loss. Although rare, morbidity and mortality rates are high. Early clinical identification is crucial for the outcome, and rapid infection control through surgery and targeted antibiotic treatment is needed to save lives. Few prospective clinical trials have been conducted for the treatment of this type of infection. Specific challenges include rapid identification of the condition and the uncertain efficacy of the various treatment options. In this clinical review article, we describe clinical characteristics, diagnostics and treatment.

Medisinsk pedagogikk som forskningsfelt i Norge ­ en bibliometrisk studie.

BACKGROUND: Medical education is a growing international field of research. However, no overview exists of Norwegian researchers' contribution to the field. This study aimed to identify and describe medical education research originating from Norwegian research institutions. MATERIAL AND METHOD: We performed targeted searches in Web of Science, PubMed, ProQuest Education and Cristin, and identified published research within the field from Norwegian institutions. Using bibliometric analyses, we mapped patterns in research output over time, research communities that have published their work, and which publication channels were used. We also categorized the research articles according to methodology, empirical origin, educational level and topic. RESULTS: We found 423 published research articles linked to Norwegian research institutions and an increase in the number of publications in the last decade. The studies were published in 141 different scientific journals. Of these, the Journal of the Norwegian Medical Association had 94 articles (22 %). A total of 122 (29 %) articles were published in key medical education journals. Altogether 249 (59 %) of the studies were quantitative and 262 (62 %) were based on empirical data from Norway. A little more than half, 237 (56 %), focused on undergraduate medical education. Researchers affiliated to the University of Oslo were involved in 173 (43 %) articles. The most frequently researched topics were curricula, teaching and learning technology, retention and career choices. INTERPRETATION: Research activity within the field of medical education is increasing in Norway, but few Norwegian researchers publish in the specialised medical education journals.

Patients over 75 years admitted to the National Burn Centre, Haukeland University Hospital, 2000-19. / Pasienter over 75 år innlagt ved Brannskadeavdelinga, Haukeland universitetssjukehus 2000­19.

BACKGROUND: The number of burn patients over the age of 75 receiving advanced treatment, including extensive surgery and intensive care, is increasing. We aimed to describe the treatment and outcomes for burn patients over the age of 75 admitted to the National Burn Centre at Haukeland University Hospital. We also wanted to investigate whether frailty scores can be a predictor of the treatment outcome. MATERIAL AND METHOD: All patients ≥ 75 years admitted to the National Burn Centre at Haukeland University Hospital in the period 2000-19 were included in the study. Frailty scores were calculated retrospectively based on patients' medical records. RESULTS: Our study included 101 patients (50 women and 51 men). The number of admissions of older burn patients increased from an average of 3.3 per year in 2000-14 to 10.2 in the period 2015-19. The median total body surface area with burns was 11 % (range 0.9-80 %). Seventeen patients received palliative care, and 12 patients receiving active treatment died in hospital. In 68 of 84 (81 %) actively treated patients, tangential excision and split-thickness skin grafting were performed. The remainder received conservative treatment (non-surgical) with wound care and application of a silver dressing. Patients who died in hospital had a significantly higher total body surface area with burns (p < 0.0001) and higher frailty scores (p = 0.003) than patients who survived. INTERPRETATION: The yearly number of patients over the age of 75 treated at the National Burn Centre tripled during the period. More than two-thirds of the patients were discharged alive. Extent of burn injury and frailty score are associated with mortality and may be useful for adjusting therapy.

European Burns Association guidelines for the management of burn mass casualty incidents within a European response plan.

BACKGROUND: A European response plan to burn mass casualty incidents has been jointly developed by the European Commission and the European Burn Association. Upon request for assistance by an affected country, the plan outlines a mechanism for coordinated international assistance, aiming to alleviate the burden of care in the affected country and to offer adequate specialized care to all patients who can benefit from it. To that aim, Burn Assessment Teams are deployed to assess and triage patients. Their transportation priority recommendations are used to distribute outnumbering burn casualties to foreign burn centers. Following an appropriate medical evacuation, these casualties receive specialized care in those facilities. METHODS: The European Burns Association's disaster committee developed medical-organizational guidelines to support this European plan. The experts identified fields of interest, defined questions to be addressed, performed relevant literature searches, and added their expertise in burn disaster preparedness and response. Due to the lack of high-level evidence in the available literature, recommendations and specially designed implementation tools were provided from expert opinion. The European Burns Association officially endorsed the draft recommendations in 2019, and the final full text was approved by the EBA executive committee in 2022. RECOMMENDATIONS: The resulting 46 recommendations address four fields. Field 1 underlines the need for national preparedness plans and the necessary core items within such plans, including coordination and integration with an international response. Field 2 describes Burn Assessment Teams' roles, composition, training requirements, and reporting goals. Field 3 addresses the goals of specialized in-hospital triage, appropriate severity criteria, and their effects on priorities and triage. Finally, field 4 covers medical evacuations, including their timing and organization, the composition of evacuation teams and their assets, preparation, and the principles of en route care.

Agreement of clinical assessment of burn size and burn depth between referring hospitals and burn centres: A systematic review.

BACKGROUND: The quality of burn care is highly dependent on the initial assessment and care. The aim of this systematic review was to investigate the agreement of clinical assessment of burn depth and %TBSA between the referring units and the receiving burn centres. METHODS: Included articles had to meet criteria defined in a PICO (patients, interventions, comparisons, outcomes). Relevant databases were searched using a predetermined search string (November 6th 2021). Data were extracted in a standardised fashion. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach for test accuracy was used to assess the certainty of evidence. The QUADAS-2 tool was used to assess the risk of bias of individual studies as 'high', 'low' or 'unclear'. RESULTS: A total of 412 abstracts were retrieved and of these 28 studies with a total of 6461 patients were included, all reporting %TBSA and one burn depth. All studies were cross-sectional and most of them comprising retrospectively enrolled consecutive cohort. All studies showed a low agreement between %TBSA calculations made at referring units and at burn centres. Most studies directly comparing estimations of %TBSA at referring institutions and burn centers showed a proportion of overestimations of 50% or higher. The study of burn depth showed that 55% were equal to the estimates from the burn centre. Most studies had severe study limitations and the risk of imprecision was high. The overall certainty of evidence for accuracy of clinical estimations in referring centres is low (GRADE ⊕⊕ОО) for %TBSA and very low (GRADE ⊕ООО) for burn depth and resuscitation. CONCLUSION: Overestimation of %TBSA at referring hospitals occurs very frequently. The overall certainty of evidence for accuracy of clinical estimations in referring centres is low for burn size and very low for burn depth. The findings suggest that the burn community has a significant challenge in educating and communicating better with our colleagues at referring institutions and that high-quality studies are needed.

Clinical Characteristics and Histopathology in Suspected Necrotizing Soft Tissue Infections.

Background: Necrotizing soft tissue infections (NSTIs) are severe diseases with high morbidity and mortality. The diagnosis is challenging. Several guidelines recommend tissue biopsies as an adjunct diagnostic in routine management, but neither biopsy sampling nor classification is standardized or validated. We studied the quality of tissue biopsy examination as part of routine diagnostics in NSTIs. Methods: This was a retrospective cohort study of adult patients undergoing surgery due to suspected NSTIs in which tissue biopsy was taken as part of routine management. Clinical data were reviewed. The biopsies were evaluated according to a proposed histopathologic classification system and independently assessed by 2 pathologists. Interrater reliability and diagnostic accuracy were determined. Results: Tissue biopsies from 75 patients were examined, 55 NSTIs and 20 non-NSTIs cases. The cohorts were similar in clinical characteristics. Interrater reliability for histopathologic staging was moderate (0.53) and fair (0.37) for diagnosis. The sensitivity of histologic diagnosis was 75% and the specificity 80%. The positive predictive value was 91% and the negative predictive value 53%. Necrotizing Infection Clinical Composite Endpoint (NICCE) success was associated with a more severe histological stage, achieved by 42% and 71% of the cases in stage 1 and 2, respectively (P = .046). Conclusions: Our findings suggest that tissue biopsies have low clinical accuracy. The interrater reliability among experienced pathologists is only fair to moderate. A histopathologically more severe stage was associated with favorable outcome. These findings discourage the use of histopathologic evaluation as part of contemporary management of patients with suspected NSTI.

Burn mass casualty incidents in Europe: A European response plan within the European Union Civil Protection Mechanism.

BACKGROUND: Burn care is centralized in highly specialized burn centers in Europe. These centers are of limited capacity and may be overwhelmed by a sudden surge in case of a burn mass casualty incident. Prior incidents in Europe and abroad have sustained high standards of care through well-orchestrated responses to share the burden of care in several burn centers. A burn mass casualty incident in Romania in 2015 sparked an initiative to strengthen the existing EU mechanisms. This paper aims to provide insight into developing a response plan for burn mass casualties within the EU Civil Protection Mechanism. METHODS: The European Burns Association drafted medical guidelines for burn mass casualty incidents based on a literature review and an in-depth analysis of the Romanian incident. An online questionnaire surveyed European burn centers and EU States for burn mass casualty preparedness. RESULTS: The Romanian burn mass casualty in 2015 highlighted the lack of a burn-specific mechanism, leading to the late onset of international transfers. In Europe, 71% of respondents had existing mass casualty response plans, though only 35% reported having a burn-specific plan. A burns response plan for burn mass casualties was developed and adopted as a Commission staff working document in preparation for further implementation. The plan builds on the existing Union Civil Protection Mechanism framework and the standards of the WHO Emergency Medical Teams initiative to provide 1) burn assessment teams for specialized in-hospital triage of patients, 2) specialized burn care across European burn centers, and 3) medevac capacities from participating states. CONCLUSION: The European burn mass casualty response plan could enable the delivery of high-level burn care in the face of an overwhelming incident in an affected European country. Further steps for integration and implementation of the plan within the Union Civil Protection Mechanism framework are needed.

Vasoactive and/or inotropic drugs in initial resuscitation of burn injuries: A systematic review.

BACKGROUND: According to current guidelines, initial burn resuscitation should be performed with fluids alone. The aims of the study were to review the frequency of use of vasoactive and/or inotropic drugs in initial burn resuscitation, and assess the benefits and harms of adding such drugs to fluids. METHODS: A systematic literature search was conducted in PubMed, Embase, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, UpToDate, and SveMed+ through 3 December 2021. The search included studies on critically ill burn patients receiving vasoactive and/or inotropic drugs in addition to fluids within 48 h after burn injury. RESULTS: The literature search identified 1058 unique publications that were screened for inclusion. After assessing 115 publications in full text, only two retrospective cohort studies were included. One study found that 16 out of 52 (31%) patients received vasopressor(s). Factors associated with vasopressor use were increasing age, burn depth, and % total body surface area (TBSA) burnt. Another study observed that 20 out of 111 (18%) patients received vasopressor(s). Vasopressor use was associated with increasing age, Baux score, and %TBSA burnt in addition to more frequent dialysis treatment and increased mortality. Study quality assessed by the Newcastle-Ottawa quality assessment scale was considered good in one study, but uncertain due to limited description of methods in the other. CONCLUSION: This systematic review revealed that there is a lack of evidence regarding the benefits and harms of using vasoactive and/or inotropic drugs in addition to fluids during early resuscitation of patients with major burns.

A simplified fluid resuscitation formula for burns in mass casualty scenarios: Analysis of the consensus recommendation from the WHO Emergency Medical Teams Technical Working Group on Burns.

BACKGROUND: Burn fluid resuscitation guidelines have not specifically addressed mass casualty with resource limited situations, except for oral rehydration for burns below 40% total body surface area (TBSA). The World Health Organization Technical Working Group on Burns (TWGB) recommends an initial fluid rate of 100 mL/kg/24 h, either orally or intravenously, beyond 20% TBSA burned. We aimed to compare this formula with current guidelines. METHODS: The TWGB formula was numerically compared with 2-4 mL/kg/%TBSA for adults and the Galveston formula for children. RESULTS: In adults, the TWGB formula estimated fluid volumes within the range of current guidelines for burns between 25 and 50% TBSA, and a maximal 20 mL/kg/24 h difference in the 20-25% and the 50-60% TBSA ranges. In children, estimated resuscitation volumes between 20 and 60% TBSA approximated estimations by the Galveston formula, but only partially compensated for maintenance fluids. Beyond 60% TBSA, the TWGB formula underestimated fluid to be given in all age groups. CONCLUSION: The TWGB formula for mass burn casualties may enable appropriate fluid resuscitation for most salvageable burned patients in disasters. This simple formula is easy to implement. It should simplify patient management including transfers, reduce the risk of early complications, and thereby optimize disaster response, provided that tailored resuscitation is given whenever specialized care becomes available.

Burn Unit Design-The Missing Link for Quality and Safety.

The relationship between infrastructure, technology, model of care, and human resources influences patient outcomes and safety, staff productivity and satisfaction, retention of personnel, and treatment and social costs. This concept underpins the need for evidence-based design and has been widely adopted to inform hospital infrastructure planning. The aim of this review is to establish evidence-based, universally applicable key features of a burn unit that support function in a comprehensive patient-centered model of care. A literature search in medical, architectural, and engineering databases was conducted. Burn associations' guidelines and relevant articles published in English, between 1990 and 2020, were included, and the available evidence is summarized in the review. Few studies have been published on burn unit design in the past 30 years. Most of them focus on the role of design in infection control and prevention and consist primarily of descriptive or observational reports, opportunistic historical cohort studies, and reviews. The evidence available in the literature is not sufficient to create a definitive infrastructure guideline to inform burn unit design, and there are considerable difficulties in creating evidence that will be widely applicable. In the absence of a strong evidence base, consensus guidelines on burn unit infrastructure should be developed, to help healthcare providers, architects, and engineers make informed decisions, when designing new or renovated facilities.

Recommendations for burns care in mass casualty incidents: WHO Emergency Medical Teams Technical Working Group on Burns (WHO TWGB) 2017-2020.

Health and logistical needs in emergencies have been well recognised. The last 7 years has witnessed improved professionalisation and standardisation of care for disaster affected communities - led in part by the World Health Organisation Emergency Medical Team (EMT) initiative. Mass casualty incidents (MCIs) resulting in burn injuries present unique challenges. Burn management benefits from specialist skills, expert knowledge, and timely availability of specialist resources. With burn MCIs occurring globally, and wide variance in existing burn care capacity, the need to strengthen burn care capability is evident. Although some high-income countries have well-established disaster management plans, including burn specific plans, many do not - the majority of countries where burn mass casualty events occur are without such established plans. Developing globally relevant recommendations is a first step in addressing this deficit and increasing preparedness to deal with such disasters. Global burn experts were invited to a succession of Technical Working Group on burns (TWGB) meetings to: 1) review literature on burn care in MCIs; and 2) define and agree on recommendations for burn care in MCIs. The resulting 22 recommendations provide a framework to guide national and international specialist burn teams and health facilities to support delivery of safe care and improved outcomes to burn patients in MCIs.

Causal Analysis of World Health Organization's Surgical Safety Checklist Implementation Quality and Impact on Care Processes and Patient Outcomes: Secondary Analysis From a Large Stepped Wedge Cluster Randomized Controlled Trial in Norway.

OBJECTIVE: We hypothesize that high-quality implementation of the World Health Organization's Surgical Safety Checklist (SSC) will lead to improved care processes and subsequently reduction of peri- and postoperative complications. BACKGROUND: Implementation of the SSC was associated with robust reduction in morbidity and length of in-hospital stay in a stepped wedge cluster randomized controlled trial conducted in 2 Norwegian hospitals. Further investigation of precisely how the SSC improves care processes and subsequently patient outcomes is needed to understand the causal mechanisms of improvement. METHODS: Care process metrics are reported from one of our earlier trial hospitals. Primary outcomes were in-hospital complications and care process metrics, e.g., patient warming and antibiotics. Secondary outcome was quality of SSC implementation. Analyses include Pearson's exact χ test and binary logistic regression. RESULTS: A total of 3702 procedures (1398 control vs. 2304 intervention procedures) were analyzed. High-quality SSC implementation (all 3 checklist parts) improved processes and outcomes of care. Use of forced air warming blankets increased from 35.3% to 42.4% (P < 0.001). Antibiotic administration postincision decreased from 12.5% to 9.8%, antibiotic administration preincision increased from 54.5% to 63.1%, and nonadministration of antibiotics decreased from 33.0% to 27.1%. Surgical infections decreased from 7.4% (104/1398) to 3.6% (P < 0.001). Adjusted SSC effect on surgical infections resulted in an odds ratio (OR) of 0.52 (95% confidence interval (CI): 0.38-0.72) for intervention procedures, 0.54 (95% CI: 0.37-0.79) for antibiotics provided before incision, and 0.24 (95% CI: 0.11-0.52) when using forced air warming blankets. Blood transfusion costs were reduced by 40% with the use of the SSC. CONCLUSIONS: When implemented well, the SSC improved operating room care processes; subsequently, high-quality SSC implementation and improved care processes led to better patient outcomes.

Development and validation of a new assessment tool for suturing skills in medical students.

BACKGROUND: In recent years, emphasis has been put on that medical student should demonstrate pre-practice/pre-registration core procedural skills to ensure patient safety. Nonetheless, the formal teaching and training of basic suturing skills to medical students have received relatively little attention and there is no standard for what should be tested and how. The aim of this study was to develop and validate, using scientific methods, a tool for assessment of medical students' suturing skills, measuring both micro- and macrosurgical qualities. METHODS: A tool was constructed and content, construct, concurrent validity, and inter-rater, inter-item, inter-test reliability were tested. Three groups were included: students with no training in suturing skills, students who have had training, plastic surgery. RESULTS: The results show promising reliability and validity when assessing novice medical students' suturing skills. CONCLUSIONS: Further studies are needed on implementation of the instrument. Moreover, how the instrument can be used to give formative feedback, evaluate if a required standard is met and for curriculum development needs further investigation.Level of Evidence: Not ratable.