The Use of Laser Doppler Imaging in Nitric Acid Burns: A Case Report and Literature Review.

Laser Doppler imaging (LDI) technology has been validated to assess thermal burn depth by predicting wound healing potential. However, there is no clear evidence for its use in chemical burns. We present a case of an 8% total burn surface area (TBSA) nitric acid burn following an industrial accident, in an otherwise healthy 36-year-old man. LDI assessment was suggestive of poor healing potential of >21 days, warranting surgical management. However, conservative management was opted for based on clinical assessment as the wound eschar appeared thin and more consistent with epithelial staining. Patient follow-up confirmed a total burn healing time of two months, suggesting that the LDI assessment was accurate. A comprehensive literature review was performed using the MEDLINE (PubMed) database to identify animal or clinical studies evaluating the efficacy of LDI in chemical burns. A qualitative synthesis of our findings is presented. We identified two experimental studies in porcine models with sulfur mustard burns, each confirming the accuracy of LDI assessment when compared to the histopathology findings. Limited experimental animal studies on the use of LDI suggest similar validity in chemical burns, and this correlates with the clinical outcome in this case. However, this alone is insufficient to prove its validity and define its role in the assessment of chemical burns. Clinical trials are required to further assess and define the parameters of LDI use and efficacy in this context.

Management of minor burns during the COVID-19 pandemic: A patient-centred approach.

INTRODUCTION: The UK government introduced lockdown measures on 23 March 2020 due to the first wave of the COVID-19 pandemic. A restructuring of clinical services was necessary to accommodate mandatory changes while also maintaining the best possible standards for patient care. The present study explored the initial management, follow-up and patient-reported outcomes of burn injuries <15% total body surface area (TBSA) during the height of the COVID-19 lockdown at a tertiary burns centre. METHODS: A retrospective review of all adult patients with burns <15% TBSA during the national lockdown (23 March 2020 to 10 May 2020) was undertaken at The Queen Elizabeth Hospital Birmingham (QEHB), UK. All referrals from non-QEHB telemedicine (external) or QEHB emergency (internal) departments were reviewed for management, length of hospital stay and pattern of follow-up (ward attender, self-care, community or outreach nurses). A telephone survey based on a structured questionnaire was conducted to establish patients' satisfaction. RESULTS: A total of 84 burn patients were included in the study. The mean age was 39 years (age range = 19-91 years) and the male:female ratio was 4:1. Patients were managed non-operatively (n = 69, 82%) or operatively (n = 15, 18%). Patients attended the ward attender acute burns clinic only once (n = 36, 61%). The telephone survey captured 70% (n = 59) of the study population and 57 patients (97% of respondents) were pleased with the ongoing care and burn healing. CONCLUSION: The integration of patient led self-care, reduction in admissions, minimal clinics attendance and a telemedicine follow-up is an effective model for small burns management during the COVID-19 pandemic. A high degree of patient satisfaction was achieved with continuous and approachable communication channels with the burn multidisciplinary team. We continue to implement this effective model of burns management throughout the COVID-19 pandemic and the subsequent period. LAY SUMMARY: The lockdown measures due to the first wave of COVID-19 pandemic affected the way we manage all medical emergencies including burns. The initial management, follow-up and patient satisfaction for small burn injuries during lockdown has not been reported previously. The aim of this study is to examine the outcome in terms of small burn management, hospital stay, number of clinic reviews, healing and patient satisfaction during the lockdown period in a burn centre in the UK. This would look at the need for operations and whether patients stayed longer if they required an intervention. We reviewed adult patients with small burns during the national lockdown (23 March 2020 to 10 May 2020) at The Queen Elizabeth Hospital Birmingham (QEHB). All referrals from telemedicine, referral system (external) or QEHB (internal) were reviewed for management, length of hospital stay and pattern of follow-up. Patients were reviewed in the acute burns clinic and given advice for burn management and dressing for self-care. Follow-up was mostly via email (telemedicine) A telephone survey based on a structured questionnaire was conducted to find out patients' satisfaction. Four times more men than women had small burns during the lockdown period. The average age was 39 years. The majority were managed conservatively with dressings (82%) and a small proportion required an operation (18%). Most patients attended the acute burns clinic only once (61%) for initial assessment and management. The telephone survey captured 70% of patient and 97% of respondents were pleased with the care and burn healing. The integration of patient-led self-care, reduction in admissions, minimal clinics attendance and a telemedicine follow-up is an effective model for burns management during the COVID-19 pandemic. A high degree of patient satisfaction was achieved with continuous and approachable communication channels with burn multidisciplinary team. We continue to implement this effective model of burns management throughout the COVID-19 pandemic and the subsequent period.

Burns and socioeconomic deprivation: the experience of an adult burns centre.

INTRODUCTION: Burns incidence, mortality and complication rates have been shown to be directly correlated by race, gender and socioeconomic status. As such, socioeconomic status (SES) has been previously highlighted as a target for burn prevention in the UK and abroad. The Queen Elizabeth Hospital, Birmingham (QEHB) is the regional Burns Centre for the Midlands Burn Network, supporting a population of 13.7 million METHODS: 16-year retrospective review was performed of all acute adult burns assessed by the Burns and Plastics Department, QEHB. The data included patient demographics (age, gender, ethnic origin and postcode), mechanism of injury, total body surface area (TBSA) affected and whether first aid was given. IMD Rank, IMD Scores were obtained from individual postcodes, as well as incidence data per electoral ward. RESULTS: In our analyses there were 3369 total acute admissions and acute assessments. 812 patients (24.1%) were in the most deprived decile. 1715 patients (50.9%) live within the 3 most deprived deciles. The deciles with the lowest completion of first aid were the first (524, 70.72%), third (257, 72.39%) and second (351, 72.82%). CONCLUSIONS: This study shows patients from the most deprived areas are over-represented in burns incidence and are less likely to perform first aid. We feel this should be highlighted in burns prevention and education strategies.

A five year review of paediatric burns and social deprivation: Is there a link?

AIM: To establish if there is a correlation between burn incidence and social deprivation in order to formulate a more effective burns prevention strategy. METHODS: A quantitative retrospective review of International Burn Injury Database (IBID) was carried out over a period from 2006 to 2011 to obtain data for children referred to our burns centre in West Midlands. Social deprivation scores for geographical areas were obtained from Office of National Statistics (ONS). Statistical analysis was carried out using Graphpad Prism. RESULTS: 1688 children were reviewed at our burns centre. Statistical analysis using Pearson correlation coefficient showed a slight association between social deprivation and increasing burn incidence r2=0.1268, 95% confidence interval 0.018-0.219, p value<0.0001. There was a slight male preponderance (58%). The most common mechanism of injury was scalding (61%). The most commonly affected age group were 1-2 year olds (38%). There were statistically significant differences in the ethnicity of children with significantly more children from Asian and African backgrounds being referred compared to Caucasian children. We found that appropriate first aid was administered in 67% of cases overall. We did not find a statistically significant link between first aid provision and social deprivation score. DISCUSSION: There was only a slight positive correlation between social deprivation and burn incidence. However, there did not seem to be any change in mechanism of burn in the most deprived groups compared to overall pattern, nor was there a significant difference in appropriate first aid provision. CONCLUSION: It would seem that dissemination of burn prevention strategies and first aid advice need to be improved across all geographical areas as this was uniformly lacking and the increased burn incidence in more socially deprived groups, although present, was not statistically significant.

Successful application of keratinocyte suspension using autologous fibrin spray.

OBJECTIVE: The back is a challenging anatomical area to resurface in acute burns due to its large surface area, its dependent position with the patient lying down and the shearing forces applied to any method of resurfacing employed. This case study presents the use of Vivostat® (Vivostat A/S, Lillerød, Denmark) in resurfacing the back in conjunction with Recell® regenerative epithelial suspension. Vivostat® (Vivostat A/S, Lillerød, Denmark) is a "novel patented biotechnological process that enables reproducible preparation of autologous fibrin sealant or platelet rich fibrin without cryoprecipitation or a separate thrombin component" [1]. METHODS: A 29-year-old female sustained 27% total body surface area (TBSA) flame burns, including the whole back. This area was initially grafted with the sandwich autograft/allograft technique on day four after injury, with approximately 80% graft take on day eight. Unfortunately, there was subsequent significant graft loss on the back proving to be a stubborn area to treat despite further grafting sessions. This challenge led to the decision to use Vivostat® (Vivostat A/S, Lillerød, Denmark) and Recell® to resurface the back. RESULTS: The patient underwent one session of resurfacing with Vivostat® (Vivostat A/S, Lillerød, Denmark) and Recell® and went on to have full healing on the back. CONCLUSIONS: NICE (The National Institute for Health and Care Excellence) states that Recell® shows potential to improve healing in acute burns and we believe that its co-delivery with fibrin via Vivostat® (Vivostat A/S, Lillerød, Denmark) allows for precise delivery of the fibrin suspended cells while minimising loss in the "run off" encountered when Recell® is just simply sprayed on, assisting the anchoring of keratinocytes to the wound surface and thus aiding in the treatment of challenging areas.

Spray-on-skin cells in burns: a common practice with no agreed protocol.

OBJECTIVES: Cultured epithelial autograft (CEA) has been used for skin coverage after burn wound excision since 1981. It is used in burn units and centres throughout the U.K.; however, there appears to be no agreed standards of practice. We aimed to investigate the experience and current practice with its usage in the management of acute burn injury. METHODS: An online survey was sent to twenty-five burns consultants in the U.K., who are members of the British Burn Association. RESULTS: We received 14 responses. Rarely have the responders agreed to the same practice in most of the questions. Different choices were given by responders with regards the indications for cell culture, techniques used, primary and secondary dressings used, first wound review timing, and measures used to evaluate outcomes. CONCLUSION: In the current economic environment, the NHS needs to rationalize services on the basis of cost effectiveness. CEA is an expensive procedure that requires an adequately sterile laboratory, special equipments and highly experienced dedicated staff. When dealing with expensive management options, it is important to have an agreed protocol that can form the standard that can be referred to when auditing practices and results to improve burn management and patients' care.

Frontal affinity chromatography-mass spectrometry.

Frontal affinity chromatography (FAC) is a biophysical method for the discovery and characterization of molecular interactions in a flow-based system. Several different modes of analysis are possible by interfacing to the mass spectrometer, including robust single-compound characterizations as well as high-throughput screening of over 1,000 compounds per run. The method supports thermodynamic and kinetic characterization of interactions for a wide range of molecular species and possesses similarities to flow-based biosensors such as surface plasmon resonance. It offers sensitive detection of ligands present well below their respective dissociation constants, and can be assembled from readily available laboratory components. Direct coupling of the FAC cartridge to the mass spectrometer is useful for the interrogation of single compounds or mixtures of limited complexity. An offline fractionation schema is more appropriate for discovery-mode applications. A high-performance FAC system enabling both modes can be assembled in 2-3 h. Measurements of dissociation constants can be made with such a system in 0.5-3 h, and the system supports higher-throughput screening modes at a rate of 10,000 compounds d(-1).

Detection and identification of sub-nanogram levels of protein in a nanoLC-trypsin-MS system.

Proteomic workflows involving liquid-based protein separations are an alternative to gel-based protein analysis, however the trypsin digestion procedure is usually difficult to implement, particularly when processing low abundance proteins from capillary column effluent. To convert the protein to peptides for the purpose of identification, current protocols require several sample handling steps, and sample losses become an issue. In this study, we present an improved system that conducts reversed-phase protein chromatography and rapid on-line tryptic digestion requiring sub-nanogram quantities of protein. This system employs a novel mirror-gradient concept that allows for dynamic titration of the column effluent to create optimal conditions for real-time tryptic digestion. The purpose behind this development was to improve the limits of detection of the online concept, to support flow-based alternatives to gel-based proteomics and to simplify the characterization of low abundance proteins. Using test mixtures of proteins, we show that peptide mass fingerprinting with high sequence representation can be easily achieved at the 20 fmol level, with detection limits down to 5 fmol (85 pg myoglobin). Limits of identification using standard data-dependent MS/MS experiments are as low as 10 fmol. These results suggest that the nanoLC-trypsin-MS/MS system could represent an alternative to the conventional "1D-gel to MS" proteomic strategy.

Capsular flap for correction of contour deformities of the breast.

We describe a technique in which the breast implant capsule is used to fill localized depressions in the breast, including those under the nipple-areola complex. Capsules have been reported to persist long-term and their high vascularity renders them suitable for use as flaps.

Referral patterns in paediatric orbital cellulitis.

OBJECTIVES: Orbital cellulitis in children may result in severe visual morbidity and even mortality if not managed appropriately. The definitive management of orbital cellulitis is in the realms of the otolaryngologist, as the underlying pathology is associated with sinus disease in more than 90% of cases. Our observations suggest that there is a tendency for patients with suspected orbital cellulitis not to be referred promptly for otolaryngological opinion and management, which may result in adverse outcomes. The aim of this study was to determine the initial management by establishing general practitioners' attitudes to the referral and management of suspected orbital cellulitis. METHODS: Anonymous questionnaires were sent to general practitioners to ascertain details on their initial treatment modalities and preferred specialist referral. General practitioners in Worcestershire and North Staffordshire, two major regions in the West Midlands, UK, were targeted. RESULTS: The majority of general practitioners initially commenced patients on oral antibiotics, and referred patients primarily to ophthalmologists for further assessment, although significant variations in referral patterns were found. CONCLUSION: Better education for primary care physicians is needed regarding the initial management and referral of paediatric patients with suspected orbital cellulitis. They should be referred promptly for hospital admission. A good multidisciplinary approach with quick involvement of the three specialities (ear, nose and throat, ophthalmology and paediatrics) would avoid delays in the definitive management and ensure optimal outcomes.

Frontal affinity chromatography-mass spectrometry assay technology for multiple stages of drug discovery: applications of a chromatographic biosensor.

This article presents new concepts in affinity chromatography/mass spectrometry for the study of molecular interactions. Chromatographic assays involving estrogen receptor-beta, sorbitol dehydrogenase, human alpha-thrombin, cholera toxin B subunit, beta-galactosidase, and Griffonia simplicifolia isolectin B(4) were established in microaffinity columns and operated in frontal analysis mode. Methods and formalism are presented for the measurement of dissociation constants, using direct methods in which the mass spectrometric signature of the ligand is used to measure breakthrough time and, hence, binding strength. The direct approach is capable of measuring sub-micromolar K(d) and higher, on sub-pmol amounts of immobilized protein, as shown in the cholera toxin assay. Indirect assays that demonstrate the advantage of routine, rugged performance were developed. By tracking the effect of a test ligand on a selected probe, or indicator ligand, dissociation constants in the low nanomolar range could be reliably determined for ligands to estrogen receptor-beta. Mass spectrometry supports the resolution of complex ligand mixtures, and it is demonstrated in the sorbitol dehydrogenase assay that ligands can be rank ordered across approximately three orders of magnitude in K(d), in a single run. A new concept for rapid mixture prescreening is presented, in which an indicator ligand can be used to discriminate between mixtures that contain high levels of weak ligands and those that contain single strong ligands.