[Determining depth of burns using laser Doppler imaging]. / Brandwonddiepte bepalen met laser-Doppler-imaging.

Early accurate assessment of burn depth is important to determine the optimal treatment of burns (conservative versus surgery). Laser Doppler imaging (LDI) is a technique that allows accurate measurement of burn depth by measuring dermal perfusion. Although it has been demonstrated that LDI led to faster decisions as to whether or not to operate, this has not lead to shorter wound healing time or cost savings in Dutch burn care. LDI is used in all Dutch burn centres. In case of doubt about the depth of a burn in primary or secondary care, referral to a burn centre is advisable.

Return to work after specialised burn care: A two-year prospective follow-up study of the prevalence, predictors and related costs.

BACKGROUND: Burn injuries may cause long-term disability and work absence, and therefore result in high healthcare and productivity costs. Up to now, detailed information on return to work (RTW) and productivity costs after burns is lacking. AIMS: The aim of this study was to accurately assess RTW after burn injuries, to identify predictors of absenteeism and to calculate healthcare and productivity costs from a societal perspective. METHODS: A prospective cohort study was conducted in the burn centre of Rotterdam, the Netherlands, including all admitted working-age patients from 1 August 2011 to 31 July 2012. At 3, 12 and 24 months post-burn, patients were sent a questionnaire: including the Work and Medical Consumption questionnaire for the assessment of work absence and medical consumption and the EQ-5D-3L plus a cognitive dimension to assess post-burn and pre-burn quality of life (QOL). Cost analyses were from a societal perspective according the micro-costing method and the friction cost method was applied for the calculation of productivity loss. Univariate logistic regression was used to identify predictors of absenteeism at three months. RESULTS: A total of 104 patients were included in the study with a mean total body surface area (TBSA) burned of 8% (median 4%). 66 respondents were pre-employed, at 3 months 70% was back at work, at 12 months 92% and 8% had not returned to work at time of final follow-up at 24 months. Predictors of absenteeism at 3 months were: TBSA, length of stay, ICU-admission and surgery. Mean costs related to loss in productivity were €11.916 [95% CI 8.930-14.902] and accounted for 30% of total costs in pre-employed respondents in the first two years. CONCLUSION: This two-year follow-up study demonstrates that burn injuries cause substantial and prolonged productivity loss amongst burn survivors with mixed burn severity. This absenteeism contributes to already high societal costs of burn injuries. Predictors of absenteeism found in this study were primarily fixed patient and treatment related factors, future studies should focus on modifiable factors, in order to improve RTW outcomes. Also, more attention in the rehabilitation trajectory is needed to optimally support RTW in burn survivors.

Epidemiology and costs of patients with toxic epidermal necrolysis: a 27-year retrospective study.

BACKGROUND: Recently, the importance of reporting the results and principles of management in Toxic epidermal necrolysis (TEN) patients was underscored. Treatment of TEN focuses on supportive care, often provided in a burn centre setting. Mortality in TEN patients can be high; the SCORTEN score is a scoring system that predicts mortality in patients with TEN. The predictive value of the SCORTEN score in our setting is unclear, as are the treatment costs of TEN patients. OBJECTIVE: To describe patient characteristics, treatment, outcome and direct medical costs of patients with TEN treated in one Dutch burn centre in a 27-year period. In addition, determinants of mortality and the predictive value of the SCORTEN score were assessed. METHODS: A retrospective study was conducted in all patients with TEN (including Stevens-Johnson syndrome (SJS) and overlap SJS-TEN) admitted to the burn centre Rotterdam between January 1987 and December 2013. The discriminative value of the SCORTEN score was assessed by receiver-operator characteristics curve analysis. RESULTS: A total of 63 patients were admitted in 27-year period. Overall mortality was 39.7%, mortality in TEN patients (>30%TBSA) was 37.1%. A higher age (OR = 1.04, 95%CI: 1.02-1.07) and comorbidity (OR = 4.25, 95%CI: 1.2-14.7) were associated with mortality. The discriminative value of the SCORTEN prediction model in our population was limited (AUC=0.72, 95%CI: 0.57-0.86). The mean direct medical hospital-based costs was €41.361. CONCLUSION: Toxic epidermal necrolysis is a severe adverse drug reaction, with a high mortality. Elderly patients and patients with comorbidity, especially circulatory comorbidity, have a relatively high risk of decease. The SCORTEN score, a frequently used prediction model in patients with TEN, underestimated the mortality in our study, mainly due to limited availability in patients with a good prognosis. The treatment of patient with TEN is associated with high direct medical hospital-based costs, also compared to burn patients in general.

Reconstructive surgery after burns: a 10-year follow-up study.

BACKGROUND: There is minimal insight into the prevalence of reconstructive surgery after burns. The objective of this study was to analyse the prevalence, predictors, indications, techniques and medical costs of reconstructive surgery after burns. METHODS: A retrospective cohort study was conducted in the three Dutch burn centres. Patients with acute burns, admitted from January 1998 until December 2001, were included. Data on patient and injury characteristics and reconstructive surgery details were collected in a 10-year follow-up period. RESULTS: In 13.0% (n=229/1768) of the patients with burns, reconstructive surgery was performed during the 10-year follow-up period. Mean number of reconstructive procedure per patient were 3.6 (range 1-25). Frequently reconstructed locations were hands and head/neck. The most important indication was scar contracture and the most applied technique was release plus random flaps/skin grafting. Mean medical costs of reconstructive surgery per patient over 10-years were €8342. CONCLUSIONS: With this study we elucidated the reconstructive needs of patients after burns. The data presented can be used as reference in future studies that aim to improve scar quality of burns and decrease the need for reconstructive surgery.

Photographic assessment of burn size and depth: reliability and validity.

OBJECTIVE: The aim of this study was to examine the reliability and validity of using photographs of burns to assess both burn size and depth. METHOD: Fifty randomly selected photographs taken on day 0-1 post burn were assessed by seven burn experts and eight referring physicians. Inter-rater reliability in both groups (experts vs. referrers) was calculated. The validity of burn size assessment was calculated using live assessment as the gold standard, and of burn depth using clinical assessment in combination with laser Doppler imaging as the gold standard. The validity of the photographically-assessed indication for surgery was calculated using laser Doppler imaging and actual treatment as the gold standard. Finally, agreement in referral indication was calculated. RESULTS: Using photographs, burn size could be assessed reliably and validly by experts (ICCs of 0.83 and 0.87), but not by referrers (ICCs of 0.68 and 0.78). Photographic assessment of burn depth was neither reliable nor valid, with ICCs respectively of 0.38 and 0.28 for experts and 0.24 and 0.13 for referrers. The indication for surgery could also not be assessed validly. Agreement between assessors regarding referral indication was low. CONCLUSION: Burn size, but not burn depth, can be assessed reliably and validly by experts using photographs of the burn wound. We recommend exploring other forms of telemedicine, like live interactive video, to investigate whether this leads to an improved burn depth assessment where clinical assessment is not possible. DECLARATION OF INTEREST: There were no external sources of funding for this study. The authors have no conflicts of interest to declare with regard to the manuscript or its content.