How to evaluate scar colour after burn injuries - A clinical comparison of the Mexameter® and the subjective scar assessment (POSAS/VSS).

INTRODUCTION: Scarring after burn injuries remains one of the major challenges in burn medicine and is the subject of current research. Accurate and high-quality assessment of scars is needed to enable exact outcome evaluation of different treatments. Our aim was to evaluate the most common subjective scar evaluation scores-the POSAS (Patient and Observer Scar Assessment Scale) and VSS (Vancouver Scar Scale)-in comparison with the objective device Mexameter® for colour evaluation. METHODS: A prospective monocentre study was performed, which included 120 examined scar areas of 60 patients with third degree burns who had received skin grafts between 1975 and 2018 with a total burned surface area (TBSA) > 2%. Two different scar areas in comparison with one healthy skin area concerning 'colour', 'pigmentation', and 'vascularization' were evaluated by the Mexameter® MX 18, the OSAS, and the VSS by the same examiner, as well as the PSAS by the patient. RESULTS: The mean TBSA of the 60 patients was 24.3%. In the OSAS, 61% of the scars were evaluated as 'hyper-', 19% as 'hypo-', and 19% as 'mix-pigmented'. Furthermore, 65% of the scars were estimated as highly vascularized. In the Mexameter®, the melanin index values of the scar areas compared to the healthy skin areas showed a small difference of 12 (p < 0.05). The mean difference of erythema between the scar and the healthy skin areas was 84 (p < 0.001). For the Mexameter®, moderate correlations were found when comparing 'erythema' with the OSAS category 'vascularization' (r = 0.33, p < 0.05) and 'melanin' with the OSAS parameter 'pigmentation' (r = 0.28, p < 0.05). When comparing the Mexameter® measurements to the OSAS questionnaire, 27% of the scars were wrongly evaluated as 'hyperpigmented' by the observer and 21% as 'hypervascularized', while showing low measurements in the device. Additionally, a novel Mexameter® ordinal scare scale was calculated. CONCLUSION: In this study, we were able to show on a relatively large patient population that with the Mexameter®, the subjectivity of the scar colour assessment by examiner/patient can be overcome, but precise differentiation can still be ensured with subjective evaluation tools. We further introduced a novel Mexameter® Scar Scale. It is necessary to further investigate the vast range of objective devices and develop scar panels for with an incorporation of objective and subjective devices to further improve reliability with reduced bias in terms of scar assessment.

The BUrn Mortality Prediction (BUMP) Score - An improved mortality prediction score based on data of the German burn registry.

BACKGROUND: Burn injuries constitute the fourth most common injuries globally. Patient outcomes must be currently assessed to provide appropriate patient care with high quality standards. However, existing mortality prediction scoring methods have been shown to lack accuracy in current burn patient populations. Therefore, this study aimed to validate existing scores using current patient data and assess whether new prediction parameters can provide better accuracy. METHODS: A retrospective analysis of the patient data from the German Burn Registry between 2016 and 2019 was performed to evaluate all Abbreviated Burn Severity Index (ABSI) score parameters. All patients over 16 years of age who received intensive care were included. Descriptive statistics and logistic regression analysis were used to identify novel prediction parameters based on the parameters documented at admission and establish a new prediction score, the BUrn Mortality Prediction (BUMP) score. The quality of the new score was subsequently compared to that of the original ABSI, modified ABSI, Galeiras, Revised Baux score and TIMM. The new prediction score was then validated using patient data collected in the German Burn Registry in 2020. RESULTS: In total, 7276 patients were included. Age; the presence of at least two comorbidities; burn injuries caused by work-related accidents, traffic accidents and suicide attempts; total burn surface area; inhalation trauma and full-thickness burns were identified as independent significant predictors of mortality (p < 0.001). Additionally, we evaluated new age groups to improve prediction accuracy. The number of comorbidities (p < 0.001) and the aetiology (burns occurring at work [p = 0.028], burns caused by traffic accidents [p < 0.001] or burns due to attempted suicide [p < 0.001]) had a significant influence on mortality. The BUMP score, which was developed based on these parameters, showed the best fitness and showed more accurate mortality prediction than all the above-mentioned scores (area under the receiver operating characteristic curve: 0.947 [0.939-0.954] compared to 0.926 [0.915-0.936], 0.928 [0.918-0.939], 0.937 [0.928-0.947], 0.939 [0.930-0.948], 0.940 [0.932-0.949] respectively). CONCLUSIONS: A novel score (BUMP score) was developed for the purpose of external quality assessment of burn centres participating in the German burn registry, where observed and expected outcomes are compared on a hospital level, and for scientifically applications. The clinical impact of this score and its generalisability to other patient populations needs to be evaluated.

Does patient load affect clinical outcome of burn patients in specialized centers? An analysis of the German Burn Registry.

Hospital volume has been identified as an independent outcome parameter for a number of medical fields and surgical procedures, and there is a tendency to increase required patient numbers for center verification. However, the existing literature does not support a clear correlation between patient load and clinical outcome in adult burn care and recent data from Germany does not exist. We therefore evaluated the effect of patient volume in German burn centers on clinical outcome. Patient data was extracted from the German Burn Registry from 2015 to 2018. For better inter-center comparability, solely burn patients with a TBSA ≥ 10% were included. Mortality, number of surgeries and length of stay (LOS) were evaluated with respect to burn center patient volume. Burn center volume was divided into two and three groups. A total of 2718 patients with a TBSA ≥ 10% were admitted to the participating 17 burn centers. Independent from the division of patient data into either 2 or 3 groups, the TBSA and ABSI score-related severity of burn injuries were comparable between groups. There was no significant difference in mortality due to center size. Nevertheless, patients treated in large volume burn centers showed a significantly increased LOS (+4.5 days, [1.9-7.2] CI, p = 0.001) and required significantly more surgeries (+0.5 surgeries [0.2-0.8] CI, p = 0.002) when compared to the small volume centers. A similar phenomenon regarding mortality and LOS (p 0.001) was observed after dividing the centers into two groups. Interestingly a division into three groups showed significant differences with the best outcome for patients in medium-volume centers. Nevertheless, mortality did not differ significantly. Therefore, our data demonstrates that in contrast to many other medical fields, outcome and mortality are not automatically improved in burn care by simply increasing the patient load, at least in centers treating 20-100 BICU patients/year.

Influence Of Pre-Existing Neurological Illnesses On The Outcome Of Severe Burn Injuries.

It is known that patients suffering from neurological illnesses have an increased risk of burn injuries. These burns are often very severe and lead to poor outcomes. To date, only a few studies have evaluated the impact of pre-existing neurological illnesses on the outcome of burn injuries. None of them performed a regression analysis regarding specific influence on mortality. Between 1996 and 2016, 1475 patients were admitted to the BICU of a specialized German burn center: 26 had less than 1% TBSA burned and were excluded; 177 had pre-existing neurological disorders (group N). 87 patients with psychological disorders were excluded. 1185 patients without neurological or psychological disorders formed the control group. Length of hospital stay, TBSA and number of operations were analyzed using the chi-squared test and Mann-Whitney U-test. Additionally, mortality was evaluated using the logistic regression analysis adjusted for known outcome predictors. Mean age of the patients in the control group was 41.53 years with a BICU stay of 18 days, TBSA of 18.25% and mortality rate of 12.4%; 23.7% had inhalation injuries. Patients in group N had a mean age of 54.63 years, a BICU stay of 27 days, mean TBSA of 20.97%; 31.1% had inhalation injuries and mortality was 20.3%. Patients with neurological disorders were older and showed higher affected TBSA, higher rates of inhalation injury, mortality and affected TBSA, and a longer stay in the BICU compared to the control group. Nevertheless, pre-existing neurological disorders alone had no significant influence on mortality.

Il est avéré que les patients souffrant de pathologie neurologique ont un risque plus élevé de brûlure. Elles sont souvent particulièrement graves et d'évolution défavorable mais la littérature à ce sujet reste pauvre et aucune étude n'a utilisé de régression logistique pour évaluer la corrélation pathologie neurologique- évolution d'une brûlure. Entre 1996 et 2016, 1 475 patients ont été hospitalisés en réanimation spécifique dans un CTB allemand. Vingt- six d'entre eux, brûlés sur moins de 1% SCT, n'ont pas été inclus dans l'étude, pas plus 87 patients psychiatriques si bien que 177 patients souffrant de pathologie neurologique (N) ont été comparés à 1 185 n'en souffrant pas (C). Les durées d'hospitalisation, la surface brûlée et le nombre d'interventions chirurgicales ont été analysée en utilisant C² ou Mann-Whitney. En outre, nous avons effectué une régression logistique étudiant la mortalité, en utilisant les facteurs connus de mortalité. Le groupe C avait 41,53 ans, souffrait de brûlures sur 18,25% SCT, avait inhalé des fumées dans 23,7% des cas, avait un taux de mortalité de 12,4% et restait 18 j en réanimation. Dans le groupe N, ces chiffres étaient respectivement de 54,63 ans, 20,97% SCT, 31,1% de fumées, 20,3% de mortalité et 27 jours en réa. Tous les chiffres étudiés étaient plus élevés dans N que dans C. Toutefois, l'existence de comorbidité neurologique n'apparaissait pas un critère indépendant de mortalité.

Does Platelet-Rich Fibrin Enhance Healing Of Burn Wounds? Our First Experiences And Main Pitfalls.

Recent research found that enzymatic debridement clearly improves long-term scarring in burns. By reducing the spontaneous wound-healing period, scarring might be optimized. The latest publications show that wound healing can be accelerated by the application of platelet-rich fibrin (PRF). However to date no study that evaluates PRF treatment in burn wounds following enzymatic debridement has been published. We conducted a single-center prospective observational trial treating ten patients with partial thickness to deep dermal burns after enzymatic debridement with PRF. After wound treatment, the dressing remained untouched for five days. For wound healing, we compared different dressings and treatment options. Minimum pain and no signs of infection were observed during any of the treatments. Physicians were able to learn the manufacture of PRF quickly. For two early treatments, skin grafting was required. In one case, the dressing was removed too early. In a second case, the wait for spontaneous wound healing was not long enough. After a standardized treatment procedure was set, we found that results were clearly improving. Mean healing time of seven wounds treated with Suprathel® dressing was 18 days (min 9 days, max 21 days). PRF application might be useful to reduce healing time in partial thickness to deep dermal burn wounds that heal spontaneously after enzymatic debridement. Thus, scarring can be improved.

Les données récentes indiquent clairement que le débridement enzymatique (DE) diminue nettement les séquelles de brûlure, en accélérant leur cicatrisation (et l'on sait que la France est le seul pays d'Europe où cette technique est inutilisable, NDRLF). Les dernières publications montrent que cette cicatrisation peut être accélérée par l'utilisation locale de Fibrine Riche en Plaquettes (FRP). Cette technique n'a pas encore été évaluée couplée au DE. Nous avons évalué ce couplage auprès de 10 patients victimes de brûlures des 2èmes degrés intermédiaire et profond, le pansement étant laissé en place 5 jours après DE+PRP, plusieurs options ayant été essayées. La douleur restait minimale et aucune infection n'a été observée. Les praticiens ont facilement appris la préparation de FRP. Deux échecs ont été observés en début de série (nécessité de greffe). Dans un cas, le pansement a été enlevé trop précocement. Dans l'autre, la greffe a été décidée trop rapidement. La standardisation subséquente du protocole en a nettement amélioré les résultats. Le délai moyen de cicatrisation de 7 patients sous Suprathel® était de 18 j (9- 21). La FRP pourrait être utile à réduire le délai de cicatrisation des brûlures intermédiaires à profondes après débridement enzymatique et ainsi en limiter les séquelles.

Our Initial Experience In The Customized Treatment Of Donor Site And Burn Wounds With A New Nanofibrous Temporary Epidermal Layer.

Recently, electrospinning technology has gained increasing attention for wound care. SpinCare™ electrospun polymer nanofibrous temporary epidermal layer is one of the latest developments in the market. Our objective was to explore the potential use of the new SpinCare™ system for treating burns and wounds. We conducted a single-center prospective observational trial, treating 10 patients with superficial to partial thickness wounds including burn wounds with a nanofibrous dressing. Treatment was evaluated, including procedures, place of injury, treatment times, ease of use etc. Ten superficial to deep dermal wounds were treated successfully. Inexperienced users learned the handling of the device quickly. Covering difficult-to-access wound surfaces was challenging. One leading problem is that the product is nearly opaque once applied on the moist wound. We introduced a standardized 3-day treatment protocol. After application, wounds were covered with a silicon layer for 2 days. The nanofibrous dressing appeared to be suitable following enzymatic debridement in burn wounds. Because there is a risk of wounds drying out under the dressing, the application should probably be limited to superficial and partial thickness wounds if not combined with other treatment options. The electrospun polymer nanofibrous temporary epidermal layer shows promising results in the treatment of superficial to partial thickness wounds including burns. However, minor improvements might help to optimize its usage and thus take full advantage of all existing treatment options.

Récemment, la technologie d'électro filage, plus couramment appelée électro spinning, a trouvé des applications dans le domaine du traitement des plaies. SpinCare™, épiderme temporaire en polymères nano fibreux obtenu par électro spinning, est l'un des derniers développements sur le marché. Notre objectif était d'étudier les utilisations potentielles du nouveau dispositif SpinCare™ dans le traitement des brûlures et des plaies. Nous avons conduit une étude prospective, observationnelle, mono centrique. Nous avons traité 10 patients présentant des plaies de profondeur superficielle à intermédiaire, incluant les brûlures, avec le polymère nano fibreux. Nous avons évalué ce traitement, en tenant compte à la fois du protocole, de la localisation de la plaie, de la durée du traitement, de la facilité d'utilisation, etc. Nous avons obtenu la cicatrisation de 10 plaies atteignant le derme plus ou moins profondément. La courbe d'apprentissage était rapide. L'application sur des plaies de localisation difficile a pu être réalisée. L'un des problèmes majeurs est que le produit devient pratiquement opaque après application sur la plaie humide. Nous avons élaboré un protocole de traitement sur 3 jours. Après l'application du polymère nano fibreux, celui-ci a été recouvert d'une feuille de silicone pour 2 jours. Ce pansement semble pouvoir être appliqué sur une plaie ayant subi un débridement enzymatique dans le cadre des brûlures. En raison du risque d'assèchement de la plaie sous le pansement, son utilisation est probablement réservée aux plaies de profondeur superficielle à intermédiaire s'il n'est pas associé à d'autres options thérapeutiques. Cet épiderme temporaire en polymères nano fibreux obtenu par électro spinning semble être prometteur dans le traitement des plaies de profondeur superficielle à intermédiaire, y compris les brûlures. Cependant, quelques améliorations permettraient d'optimiser son utilisation et de supplanter avantageusement d'autres traitements.

Patients' satisfaction with anesthesia in enzymatic debridement from a surgical perspective.

INTRODUCTION: Various clinical studies found that enzymatic debridement (EDNX) is superior to tangential excision after severe burns. The current study evaluates patients' satisfaction with pain management in EDNX with special respect to different anesthesia techniques. METHODS: Between 2015 and 2016, all patients at a department of plastic surgery were asked to complete a German-wide validated pain questionnaire. In a retrospective study design, satisfaction with pain management was compared between the control group (diagnosis from the whole field of plastic surgery except burns) and the EDNX group (burns treated with EDNX only). Analgosedation, general, regional and local anesthesia were chosen for pain management. RESULTS: In the control group 403 patients (153 females, 250 males, medium age 53 years) could be included The EDNX group included 88 patients (20 females, 68 males, medium age 38 years). The mean burn size was 5.3% TBSA. Between 0.5%-10.5% of the surface was treated with EDNX. EDNX patients could be treated under analgosedation and regional anesthesia, by topical anesthesia creme and without any anesthesia. They reported less pain during stress (p = 0.04) and were less frequently affected by motion (p = 0.024) and nausea (<0.001). However, they felt that they need more information about alternative anesthetic treatments (<0.001). CONCLUSION: EDNX can be performed sufficiently either under analgosedation, regional or local anesthesia. Thus, side effects of general anesthesia can be reduced and treatment costs can be decreased. However, it was found that neither after topical anesthetic creme nor after hand block pain treatment was sufficient.

Pre-Hospital Care Of Patients With Severe Burns In Germany: A Review Of 29 Years Of Experience.

Despite the high number of burn injuries worldwide, pre-hospital care differs across regions. Data documenting pre-hospital care of severe burn injuries in Germany are scarce. Nevertheless, efficient prehospital care of burn patients is crucial for later outcomes. Therefore, we retrospectively analyzed pre-hospital care in patients admitted to the burn intensive care unit of a specialized burn center in Germany from 1989 to 2018. Approximately one-third of all admitted patients arrived intubated to the burn intensive care unit. Mean total burned surface area was higher in intubated patients than in non-intubated patients. Hypothermia prevention measures were undertaken in most patients. Although cooling was performed in only 36 primarily admitted patients, it did not have an effect on temperature at admission. Instead, in the regression analysis a positive influence on mortality could be found (p=0.03). Inhalation injury was a reason for intubation and corticosteroid therapy. Corticosteroid use declined over the years and had no significant influence on mortality (p=0.38). Inhalation injury could be diagnosed in only 50.68% of patients receiving corticosteroids. Furthermore, especially in recent years, most patients with inhalation injuries did not receive corticosteroids. Although efficient prehospital care is crucial for later outcomes, standard pre-hospital care through first aiders and emergency personnel has not been applied. Therefore, strategies for information exchange, leading to standardized pre-hospital treatment guidelines, should be given high priority with special attention on pre-hospital cooling. In the future, data from registries and surveys can help expand information regarding pre-hospital burn treatment.

Malgré une incidence mondiale élevée, la prise en charge pré- hospitalière des brûlés est éminemment variable. Les données à ce sujet sont rares en Allemagne, alors qu'une prise en charge pré- hospitalière est fondamentale pour le devenir à terme de ces patients. Nous avons donc analysé rétrospectivement les dossiers pré- hospitaliers des patients admis dans l'USI d'un CTB allemand. Environ 1/3 des patients y arrivent intubés et leur surface atteinte est plus élevée. L'hypothermie est la plupart du temps prévenue. Bien qu'utilisé chez seulement 36 patients, le refroidissement local n'a pas entraîné d'hypothermie, alors qu'il permet de réduire la mortalité (p = 0,003). L'inhalation de fumées était une indication à l'intubation et la corticothérapie, celle- ci, de moins en moins utilisée (quasiment pas dans les dernières années), n'ayant pas d'effet sur la mortalité (p = 0 ,38). Une inhalation de fumées n'a par ailleurs été objectivée que chez 50,68% des patients ayant reçu des corticoïdes. On constante que les recommandations sur la prise en charge pré- hospitalière des brûlés n'est pas appliquée, tant par les secouristes que par les urgentistes. Ainsi, le développement d'une campagne de communication à ce sujet, insistant sur le refroidissement local, est nécessaire et pourra être amendée selon de futures études rétro- et prospectives.

Time from accident to admission to a burn intensive care unit: how long does it actually take? A 25-year retrospective data analysis from a german burn center.

Severe burn injuries often require specialized treatment at a burn center. It is known that prompt admission to an intensive care unit is essential for achieving good outcome. Nevertheless, very little is known about the duration of time before a patient is admitted to a specialized center after a burn injury in Germany, and whether the situation has improved over time. We retrospectively analyzed time from burn injury to admission to the burn intensive care unit in the Cologne-Merheim Medical Center - one of Germany's specialized burn centers - over the last 25 years. Moreover, we analyzed the data based on differences according to time of injury and day of the week, as well as severity of the burn injury. There was no weekend effect with regard to transfer time; instead transfer time was particularly short on a Monday or on Sundays. Furthermore, patients with severe burn injuries of 40-89% total body surface area (TBSA) showed the least differences in transfer time. Interestingly, the youngest and the oldest patients arrived at the burn intensive care unit (BICU) the fastest. This study should help elucidate published knowledge regarding transfer time from the scene of the accident to admission to a BICU in Germany.

Les brûlés graves ont fréquemment besoin d'une prise en charge spécialisée dans un centre de brûlés (CTB). Il est avéré qu'une admission rapide dans un service de réanimation pour brûlés (SRB) est un paramètre d'évolution favorable. Cependant, on ne sait que peu de chose sur le temps écoulé, en Allemagne, entre la brûlure et l'admission en CTB, et si ce délai s'est raccourci au fil du temps. Nous avons analysé le délai entre brûlure et arrivée dans le SRB de Cologne-Merheim sur une durée de 25 ans. Nous avons aussi étudié l'impact de la gravité de la brûlure, du jour et de l'heure de sa survenue sur ce délai. Il n'y a pas « d'effet week-end ¼, et le délai est plus court les lundis et dimanches. Le délai est relativement homogène pour des surfaces brûlées de 40 à 89%. Les patients les plus jeunes et les plus âgés sont ceux qui arrivent le plus vite en SRB. Cette étude devrait aider à clarifier les données déjà publiées concernant le temps de transfert du lieu de l'accident au SRB en Allemagne.

Contamination of burn wounds by Achromobacter Xylosoxidans followed by severe infection: 10-year analysis of a burn unit population.

Gram-negative infections predominate in burn surgery. Until recently, Achromobacter species were described as sepsis-causing bacteria in immunocompromised patients only. Severe infections associated with Achromobacter species in burn patients have been rarely reported. We retrospectively analyzed all burn patients in our database, who were treated at the Intensive Care Burn Unit (ICBU) of the Cologne Merheim Burn Centre from January 2006 to December 2015, focusing on contamination and infection by Achromobacter species.We identified 20 patients with burns contaminated by Achromobacter species within the 10-year study period. Four of these patients showed signs of infection concomitant with detection of Achromobacter species. Despite receiving complex antibiotic therapy based on antibiogram and resistogram typing, 3 of these patients, who had extensive burns, developed severe sepsis. Two patients ultimately died of multiple organ failure. In 1 case, Achromobacter xylosoxidans was the only isolate detected from the swabs and blood samples taken during the last stage of sepsis. Achromobacter xylosoxidans contamination of wounds of severely burned immunocompromised patients can lead to systemic lethal infection. Close monitoring of burn wounds for contamination by Achromobacter xylosoxidans is essential, and appropriate therapy must be administered as soon as possible.

Les infections à Gram négatif prédominent chez les brûlés. Jusqu'à une période récente, Achromobacter xylosoxidans (Ax) n'était décrit comme pathogène que chez les patients immunodéprimés. Les infections sévères à Achromobacter n'ont été que rarement décrites chez les brûlés. Nous avons rétrospectivement revu tous les patients hospitalisés dans l'unité de réanimation du centre de traitement des brûlés Merheim de Cologne entre janvier 2006 et décembre 2015, à la recherche d'une infection ou d'une contamination à Achromobacter et avons trouvé 20 patients. Quatre d'entre eux présentaient des signes de sepsis dont trois, sévèrement brûlés, un sepsis sévère malgré une antibiothérapie adaptée à l'antibiogramme, deux en étant décédés dans un tableau de défaillance multiviscérale. Dans un cas, Ax était la seule bactérie isolée de prélèvements cutané et sanguins, prélevés en phase tardive du sepsis. La contamination cutanée par Ax, chez des patients immuodéprimés car sévèrement brûlés, peut conduire à un sepsis létal. La surveillance rapprochée de l'écologie de la brûlure et une antibiothérapie adaptée précoce sont donc essentielles.

A European comparison of reimbursement in breast reconstruction.

AIMS: Case payment mechanisms have become the principal means of remunerating hospitals in most developed countries. The purpose of this study was to make an international comparison of reimbursement for breast reconstructive surgery. METHODS: We analysed remuneration for unilateral and bilateral female breast reconstruction (pedicled flaps, free flaps, alloplastic procedures) across five different European countries. National grouper software was used to identify Diagnosis Related Groups from which the proceeds were derived. RESULTS: The mean reimbursement was € 5593 for pedicled flaps, € 9149 for free flaps and € 4037 for implant-based reconstructions. The highest payments were in Sweden and the lowest in Italy. When adjusting payments by purchasing power parities, the relation among the countries did not change. The Austrian system makes a clear distinction between one-stage and two-stage delayed reconstructive interventions whereas reimbursement in other countries favoured a two-stage approach. Only one of five national reimbursement systems distinguishes between unilateral and bilateral reconstructions. CONCLUSIONS: Across a spectrum of European countries, reimbursement for breast reconstruction was based on similar procedure-specific systems, although there was a wide variation in tariffs and consideration of other factors such as underlying diagnosis. As delivery of healthcare becomes more rationalised, there is a need for individualised reimbursement which correlates directly with activity. Drawing on the experience of different healthcare systems may lead to development of a more robust and fair system of reimbursement.