Functional and Psychosocial Outcomes of Older Adults After Burn Injury: Results From a Multicenter Database of Severe Burn Injury:

Recovery of functional independence following major burn: A systematic review

BACKGROUND

Major burn injury, despite advancements in care and prevention, can have a profound impact on long-term morbidity, affecting quality of life and socioeconomic standing. We aim to explore factors predicting recovery of independence, the expected rate and time in majorly burned patients, and the measures of progress used.

METHOD

A systematic search of four databases (MEDLINE, EMBASE, COCHRANE, CINAHL) was conducted for studies reporting outcomes pertaining to physical ability indicative of independent function in adult (>15 y) cohorts who had suffered a major burn (>20% TBSA) up to 30 years after treatment in a developed specialised burn service. Data extracted included factors affecting rate of and time to achievement of function in five independence domains, as well as the outcome measures used.

RESULTS

21 eligible studies were included comprising 1298 major burns survivors with a combined mean age of 39.6 y and a mean TBSA of 25.8%. The most significant recurring factors impacting recovery of independent function were older age, female gender, burn severity, prolonged ICU and hospital admission, preceding mental health conditions, and post-acute psychological issues. Exercise-based rehabilitation conferred benefits on major burn patients even over 2 years following injury. Discharge to independent living from hospital occurred in 27% to 97% of patients, while reported return to work rates varied from 52% to 80%. Burns Specific Health Scale-Brief, Functional Independence Measure, and Physical Composite Score (SF-36) were the most widely used outcome scoring systems.

CONCLUSION

Major burn survivors have protracted recovery with potential for persistent chronic impairments, remaining consistently below baseline levels of function. Non-modifiable factors such as age and gender, and disease characteristics such as burn size with associated physical, physiological and psychosocial sequelae are contributory. Further research is required to explore achievement of specific milestones of major burn and polytrauma critical care patients, while early targeted rehabilitation addressing physical, psychological, and vocational needs has promising potential benefit.

Minority pediatric burn survivors undergo more burn operations: A single center's five-year experience

Burn injuries remain a significant source of trauma in the United States and disproportionately affect racial and ethnic minorities. Although disparities are well documented in adults, less is known regarding those in pediatric populations. To address this gap in literature, we aim to better characterize burn injuries, inpatient treatments, and post-discharge outcomes in minority pediatric burn patients. We hypothesize minority patients undergo more surgery and re-admissions than non-minority patients for burn care. This is a single institution retrospective chart review of pediatric patient admissions with burn injuries from July 1st, 2016 to July 1st, 2021. Demographics, details of injury, inpatient surgical and non-surgical care, and post-discharge outcomes were collected. Patients identifying as Hispanic/Latino, Black, and Asian were coded as minority patients. Univariate analysis was utilized. A total of 332 patients with average age of 4.9 years (SD: 4.4) and average total burn surface area (TBSA) of 8.5% (SD: 10.0) were collected. Minority patients were significantly more likely to experience accidental burn injury (p < 0.01), inhalational injury (p < 0.01), surgical management (p < 0.01), and to undergo skin graft (p < 0.01) than White patients. Minority patients were significantly more likely to undergo laser treatment after discharge (p < 0.01) than White patients. Our study shows minority pediatric patients are at risk for non-intentional burn injuries that undergo surgical management such as skin grafting and longitudinal reconstructive procedures including laser therapy more often. Short-term goals should include facilitating improved physical and psychosocial outcomes in this often-underserved patient population.

Key Exercise Concepts in the Rehabilitation from Severe Burns

This article presents information on the benefits of exercise in counteracting the detrimental effects of bed rest, and/or severe burns. Exercise is key for maintaining physical function, lean body mass, metabolic recovery, and psychosocial health after major burn injuries. The details of an exercise training program conducted in severely burned persons are presented, as well as information on the importance of proper regulation of body temperature during exercise or physical activity. The sections on exercise and thermoregulation are followed by a section on the role of exercise in scarring and contractures. Finally, gaps in the current knowledge of exercise, thermoregulation, and contractures are presented.

Factors Associated with the Rehabilitation of the Older Adult Burn Patient

The number of older people is increasing and as a result so will the number of older adult patients who present with a burn injury. There are distinct differences between older and younger burn patients, particularly with respect to skin anatomy and physiology and frailty. These are 2 important factors that influence the rehabilitation efforts with respect to older adult burn patients. There has been minimal work done studying the specific rehabilitation of older adult burn patients. More work is needed to fully understand the rehabilitation needs of older adult burn patients.

The Impact of Facial Burns on Short- and Long-Term Quality of Life and Psychological Distress-A Prospective Matched Cohort Study

Burn injuries are a major healthcare challenge worldwide, with up to 50% of all minor burns located on the head and neck. With this study, we sought to describe the effect of facial burns (FB) on health-related quality of life through a prospective and matched cohort study design. Patients completed the 36 Item Short Form (SF-36) and the Hospital Anxiety and Depression Scale (HADS). Results were analyzed based on the distribution of datasets. In total, 55 patients with FB and 55 age-and sex-matched candidates were recruited. The most common mechanism of thermal injury was burns from flames. The FB group scored lower in physical and psychological dimensions than the control group, both acutely and one year after injury. An analysis of each domain showed that subjects in the FB group trended toward improvements in their score after one-year post-burn in physical functioning (acute: 71.0 ± 29.2; one-year: 83.7 ± 23.9; p = 0.02) and bodily pain (acute: 58.5 ± 30.3; one-year: 77.9 ± 30.5; p = 0.01) domains. Additionally, the FB group had significanlyt higher scores for anxiety (FB: 4.8 ± 3.2; control: 2.5 ± 2.8; p = <0.002) and depression (FB: 3.9 ± 3.5; control: 2.1 ± 2.7; p = 0.01) compared to the control. In conclusion, facial burns are associated with physical and psychosocial deficits, as well as elevated levels of psychological distress.

Critical Care Rehabilitation of the Burn Patient

Despite the fact that modern burn care has significantly reduced the mortality associated with severe burn injuries, the rehabilitation and community reintegration of survivors continues to be a challenge. An interprofessional team approach is essential for optimal outcomes. This includes early occupational and physical therapy, beginning in the intensive care unit (ICU). Burn-specific techniques (edema management, wound healing, and contracture prevention) are successfully integrated into the burn ICU. Research demonstrates that early intensive rehabilitation of critically ill burn patients is safe and effective. Further work on the physiologic, functional, and long-term impact of this care is needed.

Short-term and long-term increased mortality in elderly patients with burn injury: a national longitudinal cohort study

BACKGROUND

The population of elderly patients with burn injuries is growing. Insight into long-term mortality rates of elderly after burn injury and predictors affecting outcome is limited. This study aimed to provide this information.

METHODS

A multicentre observational retrospective cohort study was conducted in all three Dutch burn centres. Patients aged ≥65 years, admitted with burn injuries between 2009 and 2018, were included. Data were retrieved from electronic patient records and the Dutch Burn Repository R3. Mortality rates and standardized mortality ratios (SMRs) were calculated. Multivariable logistic regression was used to assess predictors for in-hospital mortality and mortality after discharge at 1 year and five-year. Survival analysis was used to assess predictors of five-year mortality.

RESULTS

In total, 682/771 admitted patients were discharged. One-year and five-year mortality rates were 8.1 and 23.4%. The SMRs were 1.9(95%CI 1.5-2.5) and 1.4(95%CI 1.2-1.6), respectively. The SMRs were highest in patients aged 75-80 years at 1 year (SMRs 2.7, 95%CI 1.82-3.87) and five-year in patients aged 65-74 years (SMRs 10.1, 95%CI 7.7-13.0). Independent predictors for mortality at 1 year after discharge were higher age (OR 1.1, 95%CI 1.0-1.1), severe comorbidity, (ASA-score ≥ 3) (OR 4.8, 95%CI 2.3-9.7), and a non-home discharge location (OR 2.0, 95%CI 1.1-3.8). The relative risk of dying up to five-year was increased by age (HR 1.1, 95%CI 1.0-1.1), severe comorbidity (HR 2.3, 95%CI 1.6-3.5), and non-home discharge location (HR 2.1, 95%CI 1.4-3.2).

CONCLUSION

Long-term mortality until five-year after burn injury was higher than the age and sex-matched general Dutch population, and predicted by higher age, severe comorbidity, and a non-home discharge destination. Next to pre-injury characteristics, potential long-lasting systemic consequences on biological mechanisms following burn injuries probably play a role in increased mortality. Decreased health status makes patients more prone to burn injuries, leading to early death.

Burn Patient Perspectives on Disability Weights and the Philosophy of Disability: A Gap in the Literature

Background

Disability-adjusted life years (DALY) have a ubiquitous presence in academic global health, including attempts to understand the global burden of burn injuries.

Objective

The present scoping review aimed to examine whether disability weights (DWs) were informed by burn patient perspectives and secondarily to determine whether literature indicates which of the three most common philosophical models of disability best aligns with burn patient experiences.

Methods

A review of six databases was conducted and The Critical Appraisal Skills Program (CASP) checklist was utilized.

Results

Out of a total of 764 articles, zero studies solicited patient perspectives of DWs. Four articles contained data that could be extrapolated to patient perspectives on disability. All articles utilized semi-structured interviews of burn survivors and reported thematic elements including return to work, self-image, and social integration. Patients reported similar themes that burn injuries were disabling injuries and instrumentally detrimental, with modulation based on the patient's social circumstances.

Conclusions

This scoping review highlights a significant gap in literature. First, no studies were found directly investigating burn patient perspectives on burn DWs. Current DWs have been derived from expert opinions with limited input from patients. Second, the limited primary patient data gleaned from this review suggest patients consider their injuries as instrumentally detrimental, which aligns most closely with the welfarist view of disability. More explicit investigations into the philosophical model of disability best aligning with burn patient experiences are needed to ground the health economics of burns in sound theory.

Proceedings of the 2021 American Burn Association State and Future of Burn Science Meeting

Periodically, the American Burn Association (ABA) has convened a State of the Science meeting on various topics representing multiple disciplines within burn care and research. In 2021 at the request of the ABA President, meeting development was guided by the ABA's Burn Science Advisory Panel (BSAP) and a subgroup of meeting chairs. The goal of the meeting was to produce both an evaluation of the current literature and ongoing studies, and to produce a research agenda and/or define subject matter-relevant next steps to advance the field(s). Members of the BSAP defined the topics to be addressed and subsequently solicited for nominations of expert speakers and topic leaders from the ABA's Research Committee. Current background literature for each topic was compiled by the meeting chairs and the library then enhanced by the invited topic and breakout discussion leaders. The meeting was held in New Orleans, LA on November 2nd and 3rd and was formatted to allow for 12 different topics, each with two subtopics, to be addressed. Topic leaders provided a brief overview of each topic to approximately 100 attendees, followed by expert-lead breakout sessions for each topic that allowed for focused discussion among subject matter experts and interested participants. The breakout and topic group leaders worked with the participants to determine research needs and associated next steps including white papers, reviews and in some cases collaborative grant proposals. Here, summaries from each topic area will be presented to highlight the main foci of discussion and associated conclusions.

A National Analysis of Discharge Disposition in Older Adults with Burns—Estimating the Likelihood of Independence at Discharge

Whereas older age predicts higher burn mortality, the impact of age on discharge disposition is less well defined in older adults with burns. This investigation assesses the relationship between older age and discharge disposition after burns in a nationally representative sample. We queried the 2007-2015 National Trauma Data Bank for non-fatal burn hospitalizations in older adults. Pre-defined age categories were 55-64 years (working-age comparison group), 65-74 years (young-old), 75-84 years (middle-old), and 85+ years (old-old). Covariables included inhalation injury, comorbidities, burn total body surface area, injury mechanism, and race/ethnicity. Discharge to non-independent living (nursing home, rehabilitation, and other facilities) was the primary outcome. Logistic regression assessed the association between older age and discharge to non-independent living. There were 25,840 non-fatal burn hospitalizations in older adults during the study period. Working-age encounters comprised 53% of admissions, young-old accounted for 28%, middle-old comprised 15% and old-old comprised 4%. Discharge to non-independent living increased with burn TBSA and older age in survivors. Starting in young-old, the majority (65 %) of patients with burns ≥20% TBSA were discharged to non-independent living. Adjusted odd ratios for discharge to non-independent living were 2.0 for young-old, 3.3 for middle-old and 5.6 for old-old patients, when compared to working-age patients (all p&lt;0.001). Older age strongly predicts non-independent discharge after acute burn hospitalization. Matrix analysis of discharge disposition indicates a stepwise rise in discharge to non-independent living with higher age and TBSA, providing a realistic discharge framework for treatment decisions and expectations about achieving independent living after burn hospitalization.

Self-reported health measures in burn survivors undergoing burn surgery following acute hospitalization: A burn model system national database investigation

INTRODUCTION

Health Related Quality of Life (HRQoL) surveys such as PROMIS-29 may facilitate shared decision-making regarding surgery after burn injury. We aimed to examine whether scar revision and contracture release surgery after index hospitalization was associated with differences in HRQoL.

METHODS

Patient and PROMIS-29 Profile v2.0 data were extracted from the Burn Model System (BMS) at 6-, 12-, and 24-months after burn. PROMIS-29 measures 7 health-related domains. Linear regression was performed to identify associations between independent burn patient variables (e.g. scar-related surgery) and PROMIS-29 scores. Socio-demographic and injury variables were analyzed using logistic regression to determine the likelihood of undergoing burn-related surgery.

RESULTS

Of 727 participants, 201 (27.6%) underwent ≥ 1 scar/contracture operation within 24 months of injury. Number of operations at index hospital admission and range of motion (ROM) deficit at discharge were correlated with an increased likelihood of undergoing subsequent scar/contracture surgery (p < 0.05). Participants undergoing scar/contracture surgery and those that were Medicaid insured reported significantly worse HRQoL for PROMIS domains: anxiety, depression, and fatigue (p < 0.05).

CONCLUSIONS

After adjusting for burn severity and available confounders, participants who underwent scar-related burn reconstructive surgery after index hospitalization reported overall worse Health-Related Quality of Life (HRQoL) in multiple domains.

Wound Healing in Older Adults With Severe Burns: Clinical Treatment Considerations and Challenges

Background:

The older adult population continues to rapidly expand in number, with a projection by the United States (US) Census Bureau that there will be more individuals older than > 65 years (77.0 million) than those younger than < 18 years (76.5 million) by 2034. This review provides an overview of aging as it relates to wound healing and burn injuries in older adult patients, summarizes current treatment practices, and addresses the key challenges and considerations for treating severe burn injuries in this specific patient population.

Materials and methods:

A narrative literature search was conducted, focusing on recent primary literature on burns and wound healing in elderly patients.

Results:

Studies showed that the aging process results in both physiologic (eg, nutritional and metabolic status) and anatomic changes (eg, thinning dermis) that contribute to a reduced capacity to recover from burn-injury trauma compared with younger patients. Owing to impaired vision, decreased coordination, comorbidities, and medication-induced side effects, older adults (ie, > 65 years) are susceptible to severe burn injury (deep-partial thickness and full-thickness), which is associated with significant morbidity and mortality.

Conclusion:

A better understanding of the effects of age-related changes regarding wound healing in older adult patients who incur severe burn injuries may provide insight into clinical strategies to improve outcomes among this population.

Edward F. Adolph Distinguished Lecture. It's more than skin deep: thermoregulatory and cardiovascular consequences of severe burn injuries in humans

Each year, within the United States, tens of thousands of individuals are hospitalized for burn-related injuries. The treatment of deep burns often involves skin grafts to accelerate healing and reduce the risk of infection. The grafting procedure results in a physical disruption between the injured and subsequently debrided host site and the skin graft placed on top of that site. Both neural and vascular connections must occur between the host site and the graft for neural modulation of skin blood flow to take place. Furthermore, evaporative cooling from such burn injured areas is effectively absent, leading to greatly impaired thermoregulatory responses in individuals with large portions of their body surface area burned. Hospitalization following a burn injury can last weeks to months, with cardiovascular and metabolic consequences of such injuries having the potential to adversely affect the burn survivor for years postdischarge. With that background, the objectives of this article are to discuss 1) our current understanding of the physiology and associated consequences of skin grafting, 2) the effects of skin grafts on efferent thermoregulatory responses and the associated consequences pertaining to whole body thermoregulation, 3) approaches that may reduce the risk of excessive hyperthermia in burn survivors, 4) the long-term cardiovascular consequences of burn injuries, and 5) the extent to which burn survivors can "normalize" otherwise compromised cardiovascular responses. Our primary objective is to guide the reader toward an understanding that severe burn injuries result in significant physiological consequences that can persist for years after the injury.

Usage of intermingled skin allografts and autografts in a senior patient with major burn injury

Mortality rate in older adults following extensive burn injury is extremely high, and management of these patients is challenging. One of the main problems is that autologous split-thickness skin grafts are scarce and the wounds cannot be covered quickly and effectively. Intermingled skin grafting is a low-tech and economic method, which not only maximizes the use of precious autologous skin but also prevents the wounds from infection and consumption. Herein we present a case of extensive burn injury in a 68-year-old female successfully treated with intermingled skin grafting. The patient was accidentally burned by gas flame, resulting in a major burn injury covering 80% of her total body surface area. Early burn wound excision was performed and the wound was temporarily covered with irradiated porcine skin in the first week after injury. Autologous stamp-like skin grafts were applied to the wound bed 4 weeks after injury. In this operation, the results were not satisfactory. The take rate of the skin grafts is only about 50%. We covered the wounds with intermingled skin allografts and autografts 8 weeks after injury: autografts (0.5 cm × 0.5 cm) + fresh close relative’s allografts (1 cm × 1 cm) + cryopreserved allografts (2 cm × 2 cm).

Patient experience of scar assessment and the use of scar assessment tools during burns rehabilitation: a qualitative study

Background

Scar assessment plays a key role during burns aftercare, to monitor scar remodelling and patients’ psychosocial well-being. To aid assessment, subjective scar assessment scales are available that use health-care professionals’ and patients’ opinions to score scar characteristics. The subjective scales are more widely used in clinical practice over objective scar measures. To date, there is no research that considers patients’ views on scar assessment and the role of subjective and objective assessment tools. Therefore, the aim of this qualitative study was to explore patients’ perspectives on scar assessment and the utility of scar assessment tools during burns rehabilitation.

Methods

Semi-structured interviews were conducted with 10 adult burn patients who were being reviewed in clinic for scarring. Participants were recruited via their clinical care team and research nurses at the Queen Elizabeth Hospital, Birmingham, UK. Topics covered during interview included patient experience of scar assessment, the use of scar assessment tools and discussion surrounding important factors to be addressed when assessing scars. A thematic analysis using the Framework Method was conducted.

Results

Participants identified key subthemes that contribute towards the overarching theme of patient-centred scar assessment. These are: patient-led care; continuity in care; learning how to self-manage scarring; and psychological assessment. Links were demonstrated between these subthemes and the remaining themes that describe scar assessment strategies, indicating their potential patient-centred contributions. The subjective opinions of clinicians were found to be valued above the use of subjective or objective scar assessment tools. Scar assessment scales were perceived to be a beneficial method for self-reflection in relation to psychosocial functioning. However, minimal feedback and review of completed assessment scales led to uncertainty regarding their purpose. Patients perceived objective tools to be of primary use for health-care professionals, though the measures may aid patients’ understanding of scar properties.

Conclusions

Scar assessment tools should be used to support, rather than replace, health-care professionals’ subjective judgements of scarring. Adapting the way in which clinicians introduce and use scar assessment tools, according to patient needs, can support a patient-centred approach to scar assessment.

The efficacy of resistance training in addition to usual care for adults with acute burn injury: A randomised controlled trial

Resistance training immediately after a burn injury has not been investigated previously. This randomised, controlled trial assessed the impact of resistance training on quality of life plus a number of physical, functional and safety outcomes in adults with a burn injury. Patients were randomly assigned to receive, in addition to standard physiotherapy, four weeks of high intensity resistance training (RTG) or sham resistance training (CG) three days per week, commenced within 72h of the burn injury. Outcome data was collected at six weeks, three and six months after burn injury. Quality of life at 6 months was the primary endpoint. Data analysis was an available cases analysis with no data imputed. Regression analyses were used for all longitudinal outcome data and between-group comparisons were used for descriptive analyses. Forty-eight patients were randomised resistance training (RTG) (n=23) or control group (CG) (n=25). The RTG demonstrated improved outcomes for the functional domain of the Burn Specific Health Scale-Brief (p=0.017) and the Quick Disability of Arm Shoulder and Hand (p<0.001). Between group differences were seen for C-reactive protein and retinol binding protein (p=0.001). Total quality of life scores, lower limb disability, muscle strength and volume were not seen to be different between groups (p>0.05). Resistance training in addition to usual rehabilitation therapy showed evidence of improving functional outcomes, particularly in upper limb burn injuries. Additionally, resistance training commenced acutely after a burn injury was not seen to be harmful to patients.

Exercise Training Improves Microvascular Function in Burn Injury Survivors

INTRODUCTION

Vasodilator function is impaired in individuals with well-healed burn injuries; however, therapeutic interventions that lessen or reverse this maladaptation are lacking. The purpose of this study was to test the hypothesis that a 6-month community-based exercise training program would increase microvascular dilator function in individuals with well-healed burn injuries, irrespective of the magnitude of the injured body surface area. Further, we hypothesize that macrovascular dilator function would remain unchanged posttraining.

METHODS

Microvascular function (forearm reactive hyperemia), macrovascular function (brachial artery flow-mediated dilation), and the maximal vasodilatory response after ischemic handgrip exercise (an estimate of microvascular remodeling) were assessed before and after exercise training in nonburned control subjects (n = 11) and individuals with burn injuries covering a moderate body surface area (26% ± 7%; n = 13) and a high body surface area (59% ± 15%; n = 19).

RESULTS

Peak vascular conductance and area under the curve during postocclusive reactive hyperemia increased from pretraining to posttraining in control and burn injury groups (both P < 0.05), the magnitude of which did not differ between groups (both P = 0.6). Likewise, the maximal vasodilatory response after ischemic handgrip exercise increased in all groups after exercise training (P < 0.05). Macrovascular dilator function did not differ across time or between groups (P = 0.8).

CONCLUSIONS

These data suggest that a community-based exercise training program improves microvascular function in individuals with well-healed burn injuries, which may be due in part to vascular remodeling.

Amputation Following Burn Injury

Amputation following burn injury is rare. Previous studies describe the risk of amputation after electrical burn injuries. Therefore, we describe the distribution of amputations and evaluate risk factors for amputation following burn injury at a large regional burn center. We conducted a retrospective analysis of patients ≥17 years admitted from January 2002 to December 2015. Patients who did and did not undergo an amputation procedure were compared. A multivariate logistic regression model was used to determine the risk factors for amputation. Amputations were further categorized by extremity location and type (major, minor) for comparison. Of the 8313 patients included for analysis, 1.4% had at least one amputation (n = 119). Amputees were older (46.7 ± 17.4 years) than nonamputees (42.6 ± 16.8 years; P = .009). The majority of amputees were white (47.9%) followed by black (39.5%) when compared with nonamputees (white: 57.1%, black: 27.3%; P = .012). The most common burn etiology for amputees was flame (41.2%) followed by electrical (23.5%) and other (21.9%). Black race (odds ratio [OR]: 2.29; 95% confidence interval [CI]: 1.22-4.30; P = .010), electric (OR: 13.54; 95% CI: 6.23-29.45; P < .001) and increased %TBSA (OR: 1.03; 95% CI: 1.02-1.05; P < .001) were associated with amputation. Burn etiology, the presence of preexisting comorbidities, black race, and increased %TBSA increase the odds of post burn injury. The role of race on the risk of amputation requires further study.

Early Enteral Nutrition in Geriatric Burn Patients: Is There a Benefit?

Nutrition is a critical component of acute burn care and wound healing. There is no consensus over the appropriate timing of initiating enteral nutrition in geriatric burn patients. This study aimed to assess the impact of early enteral nutrition on outcomes in this patient population. We performed a 1-year (2017) analysis of the American College of Surgeons Trauma Quality Improvement Program and included all older adult (age ≥65 years) isolated thermal burn patients who were admitted for more than 24 hr and received enteral nutrition. Patients were stratified into two groups based on the timing of initiation of feeding: early (≤24 hr) vs late (>24 hr). Multivariate logistic regression was performed to control for potential confounding factors. Outcome measures were hospital and intensive care unit lengths of stay, in-hospital complications, and mortality. A total of 1,004,440 trauma patients were analyzed, of which 324 patients were included (early: 90 vs late: 234). The mean age was 73.9 years and mean TBSA burnt was 31%. Patients in the early enteral nutrition group had significantly lower rates of in-hospital complications and mortality (15.6% vs 26.1%; P = 0.044), and a shorter hospital length of stay (17 [11,23] days vs 20 [14,24] days; P = 0.042) and intensive care unit length of stay (13 [8,15] days vs 17 [9,21] days; P = 0.042). In our regression model of geriatric burn patients, early enteral nutrition was associated with improved outcomes. The cumulative benefits observed may warrant incorporating early enteral nutrition as part of intensive care protocols.

A Scoping Review on the Long-Term Outcomes in Persons with Adult-Acquired Burn Injuries

Adult-acquired burn injuries are a life-altering event that can lead to debilitating functional or psychological impairments. With advancements in health care resulting in decreased mortality rates, survivors of burn injuries can expect to live longer. This warrants a shift in focus to better understand what happens to adults once they are discharged from the hospital into the community. Therefore, the purpose of this scoping review was to map the literature regarding the long-term outcomes of community-dwelling adult-acquired burn survivors. A computer-assisted literature search was conducted on literature from January 1, 2000 to August 31, 2018 utilizing four large databases (MEDLINE, EMBASE, CINHAL, and PsycINFO). Articles were included if they had a minimum of five individuals with a burn injury as a result of an accidental injury who were at least 18 years of age at the time of injury. Fifty-four articles were found suitable for inclusion in this review. The majority of studies were conducted in the United States and were longitudinal in design. Four themes were apparent from the articles: postburn complications, psychosocial outcomes, quality of life, and community participation. Data are lacking with respect to outcomes more than 5 years postburn as well as qualitative research. Furthermore, more literature is needed to understand the impact of postburn complications, coping strategies, and posttraumatic growth as well as barriers to community participation. Overall, there is an emerging body of literature that describes the long-term outcomes of adult-acquired burn survivors up to 5 years postburn.

Progressive exercise training improves maximal aerobic capacity in individuals with well-healed burn injuries

Long-term rehabilitative strategies are important for individuals with well-healed burn injuries. Such information is particularly critical because patients are routinely surviving severe burn injuries given medical advances in the acute care setting. The purpose of this study was to test the hypothesis that a 6-mo community-based exercise training program will increase maximal aerobic capacity (V̇o_2max) in subjects with prior burn injuries, with the extent of that increase influenced by the severity of the burn injury (i.e., percent body surface area burned). Maximal aerobic capacity (indirect calorimetry) and skeletal muscle oxidative enzyme activity (biopsy of the vastus lateralis muscle) were measured pre- and postexercise training in noninjured control subjects (n = 11) and in individuals with well-healed burn injuries (n = 13, moderate body surface area burned; n = 20, high body surface area burned). Exercise training increased V̇o_2max in all groups (control: 15 ± 5%; moderate body surface area: 11 ± 3%; high body surface area: 11 ± 2%; P < 0.05), though the magnitude of this improvement did not differ between groups (P = 0.7). Exercise training also increased the activity of the skeletal muscle oxidative enzymes citrate synthase (P < 0.05) and cytochrome c oxidase (P < 0.05), an effect that did not differ between groups (P = 0.2). These data suggest that 6 mo of progressive exercise training improves V̇o_2max in individuals with burn injuries and that the magnitude of body surface area burned does not lessen this adaptive response.

Psychosocial and quality of life impact of scars in the surgical, traumatic and burn populations: a scoping review protocol

INTRODUCTION

Despite the fact that millions of scars affect individuals annually, little is known about their psychosocial impact and overall quality of life (QOL) on individuals. Scars from multiple aetiologies may cause psychiatric and emotional disturbances, can limit physical functioning and increase costs to the healthcare system. The purpose of this protocol is to describe the methodological considerations that will guide the completion of a scoping review that will summarise the extent, range and nature of psychosocial health outcomes and QOL of scars of all aetiologies.

METHODS AND ANALYSIS

A modified Arksey and O'Malley (2005) framework will be completed, namely having ongoing consultation between experts from the beginning of the process, then (1) identifying the research question/s, (2) identifying the relevant studies from electronic databases and grey literature, with (3) study selection and (4) charting of data by two independent coders, and (5) collating, summarising and reporting data. Experts will include a health information specialist (TAW), scar expert (JSF), scoping review consultant (SCK), as well as at least two independent coders (NZ, AM).

ETHICS AND DISSEMINATION

Ethics approval will not be sought for this scoping review. We plan to disseminate this research through publications, presentations and meetings with relevant stakeholders.

The prevalence of comorbidities among acute burn patients

Introduction

The elderly population in Iran is growing, and more medical comorbidities can be identified, so hospital admissions of burn patients with associated medical comorbidities are expected to rise as well. As these medical comorbidities may affect the prognosis of burn patients, additional health care services are likely to be required. Therefore, the aim of this study was to determine the prevalence of comorbidities among patients with burn injury.

Methods

A retrospective study of all burn patients admitted to the Motahari Burn Hospital, Iran over a 14-month period was conducted. Variables gathered from patients’ medical record files were demographic characteristics, clinical burn features, hospital course, and preexisting comorbidities. The comorbidity score of patients was calculated by using the updated Charlson comorbidity index.

Results

A total of 732 patients were hospitalized, 136 (18.5%) patients had comorbidities, and more than 57% of elderly people (≥61 years) had one or more comorbid conditions. The most common cause of burn injury among the comorbid patients was scald (38.2%) injury. The two most frequent comorbid conditions among all cases were congestive heart failure (25.8%) and diabetes (23.5%), respectively. As patients got older, the Charlson score also increased. There were no significant differences between comorbid and noncomorbid patients in terms of hospitalization period and mortality rate. Those comorbid patients who died had significantly higher Charlson score and larger mean burn sizes compared to surviving comorbid patients; they were also significantly older.

Conclusion

The prevalence of comorbidities in burn patients was 18.5% and among older burn patients rose to 57%. Diabetes and congestive heart failure were the two most common comorbid conditions.

Racial and Ethnic Disparities in Discharge to Rehabilitation Following Burn Injury

Racial and ethnic disparities in access to inpatient rehabilitation have been previously described for various injury groups; however, no studies have evaluated whether such disparities exist among burn patients. Their aim was to determine if racial disparities in discharge destination (inpatient rehabilitation, skilled nursing facility, home with home health, or home) following burn injury existed in this single-institution study. A retrospective analysis of all adult burn patients admitted to UNC Jaycee Burn Center from 2002 to 2012 was conducted. Patient characteristics included age, gender, burn mechanism, insurance status, percentage total body surface area (%TBSA) burned, presence of inhalation injury, and hospital length of stay. Patients were categorized into one of three mutually exclusive racial or ethnic groups: White, Hispanic, or Black. Propensity score weighting followed by ordered logistic regression was performed in the analytical sample and in a subgroup analysis of patients with severe burns (TBSA > 20%). For analysis, 4198 patients were included: 2661 White, 340 Hispanic, and 1197 Black. Propensity weighting resulted in covariate balance among racial groups. Black patients (OR: 1.58, 95% CI: 1.23-2.03; P < .001) were more likely than Whites to be discharged to a higher level of rehabilitation, whereas Hispanics were less likely (OR: 0.78, 95% CI: 0.38-1.58; P = .448). In their subgroup analysis, Black (OR: 1.88, 95% CI: 1.07-3.28; P = .026) and Hispanic (OR: 1.53, 95% CI: 0.31-7.51; P = .603) patients were more likely to discharge to a higher level of rehabilitation than White patients. Racial and ethnic disparities in discharge destination to a higher level of rehabilitative services among burn-injured patients exist particularly for Hispanic patients but not for Black or White burn patient groups. Further studies are needed to elucidate the potential sources of these disparities specifically for Hispanic patients.

Vasodilator function is impaired in burn injury survivors

The effect of severe burn injury on vascular health is unknown. We tested the hypothesis that, compared with nonburn control subjects, vasodilator function would be reduced and that pulse-wave velocity (a measure of arterial stiffness) would be increased in individuals with prior burn injuries, the extent of which would be associated with the magnitude of body surface area having sustained a severe burn. Pulse-wave velocity and macrovascular (flow-mediated dilation) and microvascular (reactive hyperemia) dilator functions were assessed in 14 nonburned control subjects and 32 age-matched subjects with well-healed burn injuries. Fifteen subjects with burn injuries covering 17-40% of body surface area were assigned to a moderate burn injury group, and 17 subjects with burn injuries covering >40% of body surface area were assigned to a high burn injury group. Pulse-wave velocity [ P = 0.3 (central) and P = 0.3 (peripheral)] did not differ between the three groups. Macrovascular dilator function was reduced in the moderate ( P = 0.07) and high ( P < 0.05) burn injury groups compared with the control group. Likewise, peak vascular conductance during postocclusive reactive hyperemia differed from the moderate burn injury group ( P = 0.08 vs. control) and the high burn injury group ( P < 0.05 vs. control). These data suggest that vasodilator function is impaired in well-healed burn injury survivors, with the extent of impairment not dependent on the magnitude of body surface area having sustained a severe burn injury.

Health related quality of life in adults after burn injuries: A systematic review

OBJECTIVES

Measurement of health-related quality of life (HRQL) is essential to qualify the subjective burden of burns in survivors. We performed a systematic review of HRQL studies in adult burn patients to evaluate study design, instruments used, methodological quality, and recovery patterns.

METHODS

A systematic review was performed. Relevant databases were searched from the earliest record until October 2016. Studies examining HRQL in adults after burn injuries were included. Risk of bias was scored using the Quality in Prognostic Studies tool.

RESULTS

Twenty different HRQL instruments were used among the 94 included studies. The Burn Specific Health Scale-Brief (BSHS-B) (46%), the Short Form-36 (SF-36) (42%) and the EuroQol questionnaire (EQ-5D) (9%) were most often applied. Most domains, both mentally and physically orientated, were affected shortly after burns but improved over time. The lowest scores were reported for the domains 'work' and 'heat sensitivity' (BSHS-B), 'bodily pain', 'physical role limitations' (SF-36), and 'pain/discomfort' (EQ-5D) in the short-term and for 'work' and 'heat sensitivity', 'emotional functioning' (SF-36), 'physical functioning' and 'pain/discomfort' in the long-term. Risk of bias was generally low in outcome measurement and high in study attrition.

CONCLUSION

Consensus on preferred validated methodologies of HRQL measurement in burn patients would facilitate comparability across studies, resulting in improved insights in recovery patterns and better estimates of HRQL after burns. We recommend to develop a guideline on the measurement of HRQL in burns. Five domains representing a variety of topics had low scores in the long-term and require special attention in the aftermath of burns.

Assessment of Somatization and Medically Unexplained Symptoms in Later Life

The assessment of medically unexplained symptoms and "somatic symptom disorders" in older adults is challenging due to somatic multimorbidity, which threatens the validity of somatization questionnaires. In a systematic review study, the Patient Health Questionnaire-15 (PHQ-15) and the somatization subscale of the Symptom Checklist 90-item version (SCL-90 SOM) are recommended out of 40 questionnaires for usage in large-scale studies. While both scales measure physical symptoms which in younger persons often refer to unexplained symptoms, in older persons, these symptoms may originate from somatic diseases. Using empirical data, we show that PHQ-15 and SCL-90 SOM among older patients correlate with proxies of somatization as with somatic disease burden. Updating the previous systematic review, revealed six additional questionnaires. Cross-validation studies are needed as none of 46 identified scales met the criteria of suitability for an older population. Nonetheless, specific recommendations can be made for studying older persons, namely the SCL-90 SOM and PHQ-15 for population-based studies, the Freiburg Complaint List and somatization subscale of the Brief Symptom Inventory 53-item version for studies in primary care, and finally the Schedule for Evaluating Persistent Symptoms and Somatic Symptom Experiences Questionnaire for monitoring treatment studies.

The National Institute on Disability, Independent Living, and Rehabilitation Research Burn Model System: Twenty Years of Contributions to Clinical Service and Research

The National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) established the Burn Model System (BMS) in 1993 to improve the lives of burn survivors. The BMS program includes 1) a multicenter longitudinal database describing the functional and psychosocial recovery of burn survivors; 2) site-specific burn-related research; and 3) a knowledge dissemination component directed toward patients and providers. Output from each BMS component was analyzed. Database structure, content, and access procedures are described. Publications using the database were identified and categorized to illustrate the content area of the work. Unused areas of the database were identified for future study. Publications related to site-specific projects were cataloged. The most frequently cited articles are summarized to illustrate the scope of these projects. The effectiveness of dissemination activities was measured by quantifying website hits and information downloads. There were 25 NIDILRR-supported publications that utilized the database. These articles covered topics related to psychological outcomes, functional outcomes, community reintegration, and burn demographics. There were 172 site-specific publications; highly cited articles demonstrate a wide scope of study. For information dissemination, visits to the BMS website quadrupled between 2013 and 2014, with 124,063 downloads of educational material in 2014. The NIDILRR BMS program has played a major role in defining the course of burn recovery, and making that information accessible to the general public. The accumulating information in the database serves as a rich resource to the burn community for future study. The BMS is a model for collaborative research that is multidisciplinary and outcome focused.

Resistance training for rehabilitation after burn injury: A systematic literature review & meta-analysis

BACKGROUND/AIM

Resistance training is beneficial for rehabilitation in many clinical conditions, though this has not been systematically reviewed in burns. The objective was to determine the effectiveness of resistance training on muscle strength, lean mass, function, quality of life and pain, in children and adults after burn injury.

METHODS

Medline & EMBASE, PubMed, CINAHL and CENTRAL were searched from inception to October 2016. Studies were identified that implemented resistance training in rehabilitation. Data were combined and included in meta-analyses for muscle strength and lean mass. Otherwise, narrative analysis was completed. The quality of evidence for each outcome was summarised and rated using the GRADE framework.

RESULTS

Eleven studies matched our inclusion criteria. Primary analysis did not demonstrate significant improvements for increasing muscle strength (SMD 0.74, 95% CI -0.02 to 1.50, p=0.06). Sensitivity analysis to correct an apparent anomaly in published data suggested a positive effect (SMD 0.37, 95% CI 0.08-0.65, p=0.01). Psychological quality of life demonstrated benefit from training (MD=25.3, 95% CI 3.94-49.7). All studies were rated as having high risk of bias. The quality of the evidence was rated as low or very low.

CONCLUSION

Further research with robust methodology is recommended to assess the potential benefit suggested in this review.

National Institute on Disability, Independent Living, and Rehabilitation Research Burn Model System: Review of Program and Database

The Burn Model System (BMS) centers program was created in 1994 to evaluate the long-term outcomes of burn injuries. As part of this multicenter program, a comprehensive longitudinal database was developed to facilitate the study of a number of functional and psychosocial outcomes after burn injury. In this article, we provide an overview of the data collection procedures, measures selection process, and an overview of the participant data collected between 1994 and 2016. Surveys were administered during hospitalization and at 6, 12, and 24 months after discharge, and in the most recent funding cycle, data collection at every 5 years postinjury was added. More than 7200 people with burn injury were eligible to participate in the BMS National Longitudinal Database. Of these, >5900 (82%) were alive at discharge and consented to follow-up data collection. The BMS National Longitudinal Database represents a large sample of people with burn injury, including information on demographic characteristics, injury characteristics, and health outcomes. The database is publicly available and can be used to examine the effect of burn injury on long-term outcomes.

Predicting Heterotopic Ossification Early After Burn Injuries: A Risk Scoring System

OBJECTIVE

The purpose of this study is to develop a scoring system that stratifies burn patients at the time of hospital admission according to risk of developing heterotopic ossification (HO).

SUMMARY OF BACKGROUND DATA

HO in burns is an uncommon but severely debilitating problem with a poorly understood mechanism and no fully effective prophylactic measures.

METHODS

Data were obtained from the Burn Model System National Database from 1994 to 2010 (n = 3693). The primary outcome is diagnosis of HO at hospital discharge. Logistic regression analysis was used to determine significant demographic and medical predictors of HO. A risk scoring system was created in which point values were assigned to predictive factors and final risk score is correlated with the percent risk of developing HO. The model was internally and externally validated.

RESULTS

The mean age of the subjects is 42.5 ± 16.0 years, the mean total body surface area (TBSA) burned is 18.5 ± 16.4%, and the population is 74.9% male. TBSA and the need for grafting of the arm, head/neck, and trunk were significant predictors of HO development (P < 0.01). A 13-point risk scoring system was developed using these significant predictors. The model c-statistic is 0.92. The risk scoring system demonstrated evidence of internal and external validity. An online calculator was developed to facilitate translation of knowledge to practice and research.

CONCLUSIONS

This HO risk scoring system identifies high-risk burn patients suitable for diagnostic testing and interventional HO prophylaxis trials.

Creation of a decision aid for goal setting after geriatric burns: a study from the prognostic assessment of life and limitations after trauma in the elderly [PALLIATE] consortium

OBJECTIVES

We hypothesized that a decision-support aid to predict index admission mortality and discharge disposition for geriatric burns could be constructed using the well-accepted Baux score (age +total body surface area burned) in a geriatric-specific cohort.

METHODS

National Burn Repository version 8.0 (2002-2011) was queried for all subjects aged 65 years or older. Baux scores were calculated and patients grouped into deciles. Three discharge outcomes (death,home, discharge to nonhome setting) were measured per decile. A receiver operating characteristic analysis was used to determine optimal Baux score cutpoints based on the Youden Index. The odds of mortality at various Baux score cutoffs were estimated using logistic regression.

RESULTS

The sample was composed of 8,001 subjects. Withdrawal of care was documented in 264 deaths; median time to withdrawal was three days. As Baux score increased, three peaks in disposition were seen. Less than 50% of patients with a Baux score of 80 or greater were discharged home. Patients with a moderate Baux score (80-130) had an increased likelihood of discharge to a nonhome setting. Baux scores of 130 or greater were nearly uniformly fatal (mortality, 94-100%). Baux score of 86.15 or less was predictive of discharge home (area under the curve, 0.698; sensitivity, 75.28%; specificity, 54.64%), and a score greater than 93.3 was predictive of mortality (area under the curve, 0.779; sensitivity, 57.46%; specificity, 87.08%).

CONCLUSION

For geriatric patients whose Baux scores exceed 86, return-to-home rates drop drastically; mortality increases at a score greater than 93, and mortality is nearly universal at a score ≥130 or greater. We are piloting a display of these findings as a decision-making aid when setting goals of care with stakeholders after geriatric burns.

LEVEL OF EVIDENCE

Epidemiologic/prognostic study, level III; therapeutic/care management, level IV.

Predictors of moderate to severe fatigue 12 months following admission to hospital for burn: Results from the Burns Registry of Australia and New Zealand (BRANZ) Long Term Outcomes project

INTRODUCTION

Fatigue has been identified as an outcome of concern following burn but is rarely captured in outcomes studies. We aimed to: (i) describe the prevalence, and predictors, of moderate to severe fatigue in the first 12 months following burn, and (ii) establish the association between fatigue and health-related quality of life and work outcomes.

METHODS

Adult burns patients, admitted >24h, were recruited from five BRANZ sites. Participants were followed-up at 1-, 6-, and 12-months after injury using the Brief Fatigue Inventory (BFI), 36-item Short Form Health Survey (SF-36) and the Sickness Impact Profile (SIP)-work scale. Moderate to severe fatigue was defined as a global BFI score of 4-10. Multivariable mixed effects regression modelling was used to identify demographic, socioeconomic, burn size and severity predictors of moderate/severe fatigue at follow-up.

RESULTS

The mean±SD age of the 328 participants was 42.1±16.7years, 70% were male, 47% were flame burns, and the mean±SD %TBSA was 8.7±11.2. The prevalence of moderate/severe fatigue decreased from 37% at 1-month, to 32% at 6-months and 26% at 12-months. The adjusted odds of moderate/severe fatigue were 2.62 (95% CI: 1.27, 5.42) times higher for women compared to men, and 2.64 (95% CI: 1.03, 6.79) times higher in patients with a %TBSA≥20. Compared to patients in major cities, the adjusted odds of reporting moderate/severe fatigue were 2.48 fold higher (95% CI: 1.17, 5.24) for patients residing in inner regional areas, and 3.60 fold (95% CI: 1.43, 9.05) higher for patients living in remote/very remote areas. At each time point, the physical and mental health summary scores, and each sub-scale score, of the SF-36 were significantly lower in patients reporting moderate/severe fatigue. Patients experiencing moderate to severe fatigue reported higher work-related disability on the SIP work scale at each time point after injury.

DISCUSSION AND CONCLUSION

More than a quarter of participants reported moderate to severe fatigue on the BFI at 12-months and fatigue was strongly associated with poorer health-related quality of life and greater work-related disability.

Risk factors for the development of heterotopic ossification in seriously burned adults: A National Institute on Disability, Independent Living and Rehabilitation Research burn model system database analysis

BACKGROUND

Heterotopic ossification (HO) is a debilitating complication of burn injury; however, incidence and risk factors are poorly understood. In this study, we use a multicenter database of adults with burn injuries to identify and analyze clinical factors that predict HO formation.

METHODS

Data from six high-volume burn centers, in the Burn Injury Model System Database, were analyzed. Univariate logistic regression models were used for model selection. Cluster-adjusted multivariate logistic regression was then used to evaluate the relationship between clinical and demographic data and the development of HO.

RESULTS

Of 2,979 patients in the database with information on HO that addressed risk factors for development of HO, 98 (3.5%) developed HO. Of these 98 patients, 97 had arm burns, and 96 had arm grafts. When controlling for age and sex in a multivariate model, patients with greater than 30% total body surface area burn had 11.5 times higher odds of developing HO (p < 0.001), and those with arm burns that required skin grafting had 96.4 times higher odds of developing HO (p = 0.04). For each additional time a patient went to the operating room, odds of HO increased by 30% (odds ratio, 1.32; p < 0.001), and each additional ventilator day increased odds by 3.5% (odds ratio, 1.035; p < 0.001). Joint contracture, inhalation injury, and bone exposure did not significantly increase odds of HO.

CONCLUSION

Risk factors for HO development include greater than 30% total body surface area burn, arm burns, arm grafts, ventilator days, and number of trips to the operating room. Future studies can use these results to identify highest-risk patients to guide deployment of prophylactic and experimental treatments.

LEVEL OF EVIDENCE

Prognostic study, level III.

Frailty score on admission predicts outcomes in elderly burn injury

With longer life expectancy, the number of burn injuries in the elderly continues to increase. Prediction of outcomes for the elderly is complicated by preinjury physical fitness and comorbid illness. The authors hypothesize that admission frailty assessment would be predictive of outcomes in the elderly burn population. Our primary aim was to determine if higher frailty scores were associated with higher risk of mortality for elderly burn patients. The secondary aims were to assess if higher frailty scores were associated with increased length of stay, increased needs for mechanical ventilation and poor discharge disposition. A 2-year retrospective chart review was performed of all admitted acute burn patients 65 years or older. Data collected included: age, gender, %TBSA of burn injury, presence of inhalation injury, in hospital mortality, hospital length of stay, ventilator days, ICU length of stay, surgical procedures, insurance status, and discharge disposition. Frailty scores were assessed from admission data and calculated using the Canadian Study of Health and Aging clinical frailty scale. A total of 89 patients met entry criteria. Mean age was 75.3 ± 8.1 years and consisted of 62 men and 27 women. Mean %TBSA was 9.6 ± 9.1% and mean frailty score (FS) was 4.5 ± 1.2. Eighty patients survived to discharge and nine died. Nonsurvivors had significantly higher FS compared to survivors (5.2 ± 1.2 vs 4.4 ± 1.2). FS were also significantly higher in patients discharged to skilled nursing facilities (SNF) (5.34 ± 0.9) compared to those who were discharged home (4.1 ± 1.2) or to physical rehabilitation facilities (4 ± 1.5). Multivariate linear regression analysis revealed that age (B = 0.04) and discharge to SNF (B = 1.2) are independently associated with higher FS. However, survivors were independently associated with a significantly lower FS (B = -1.3). Multivariate logistic regression analysis revealed high admission FS independently increased the risk of discharge to SNF (odds ratio of 2.5 [1.3-4.8, 95% confidence interval]) and increased the risk of mortality (odds ratio of 1.67 [1.01-2.7, 95% confidence interval]). Frailty scores on admission allow for a more complete assessment of elderly patients and can be used to establish benchmark models for burn injury outcomes. In addition FS can be used as a research tool to improve outcomes for elderly burn injured patients.

Long term outcomes data for the Burns Registry of Australia and New Zealand: Is it feasible?

BACKGROUND

Incorporating routine and standardised collection of long term outcomes following burn into burn registries would improve the capacity to quantify burn burden and evaluate care.

AIMS

To evaluate methods for collecting the long term functional and quality of life outcomes of burns patients and establish the feasibility of implementing these outcomes into a multi-centre burns registry.

METHODS

Five Burns Registry of Australia and New Zealand (BRANZ) centres participated in this prospective, longitudinal study. Patients admitted to the centres between November 2009 and November 2010 were followed-up at 1, 6, 12 and 24-months after injury using measures of burn specific health, health status, fatigue, itch and return to work. Participants in the study were compared to BRANZ registered patients at the centres over the study timeframe to identify participation bias, predictors of successful follow-up were established using a Generalised Estimating Equation model, and the completion rates by mode of administration were assessed.

RESULTS

463 patients participated in the study, representing 24% of all BRANZ admissions in the same timeframe. Compared to all BRANZ patients in the same timeframe, the median %TBSA and hospital length of stay was greater in the study participants. The follow-up rates were 63% at 1-month, 47% at 6-months; 40% at 12-months, and 21% at 24-months after injury, and there was marked variation in follow-up rates between the centres. Increasing age, greater %TBSA and opt-in centres were associated with greater follow-up. Centres which predominantly used one mode of administration experienced better follow-up rates.

CONCLUSIONS

The low participation rates, high loss to follow-up and responder bias observed indicate that greater consideration needs to be given to alternative models for follow-up, including tailoring the follow-up protocol to burn severity or type.

Aerobic Fitness Is Disproportionately Low in Adult Burn Survivors Years After Injury

A maximal aerobic capacity below the 20th percentile is associated with an increased risk of all-cause mortality (Blair 1995). Adult Adult burn survivors have a lower aerobic capacity compared with nonburned adults when evaluated 38 ± 23 days postinjury (deLateur 2007). However, it is unknown whether burn survivors with well-healed skin grafts (ie, multiple years postinjury) also have low aerobic capacity. This project tested the hypothesis that aerobic fitness, as measured by maximal aerobic capacity (VO2max), is reduced in well-healed adult burn survivors when compared with normative values from nonburned individuals. Twenty-five burn survivors (36 ± 12 years old; 13 females) with well-healed split-thickness grafts (median, 16 years postinjury; range, 1-51 years) covering at least 17% of their BSA (mean, 40 ± 16%; range, 17-75%) performed a graded cycle ergometry exercise to test volitional fatigue. Expired gases and minute ventilation were measured via a metabolic cart for the determination of VO2max. Each subject's VO2max was compared with sex- and age-matched normative values from population data published by the American College of Sports Medicine, the American Heart Association, and recent epidemiological data (Aspenes 2011). Subjects had a VO2max of 29.4 ± 10.1 ml O2/kg body mass/min (median, 27.5; range, 15.9-53.3). The use of American College of Sports Medicine normative values showed that mean VO2max of the subjects was in the lower 24th percentile (median, 10th percentile). A total of 88% of the subjects had a VO2max below American Heart Association age-adjusted normative values. Similarly, 20 of the 25 subjects had a VO2max in the lower 25% percentile of recent epidemiological data. Relative to nongrafted subjects, 80 to 88% of the evaluated skin-graft subjects had a very low aerobic capacity. On the basis of these findings, adult burn survivors are disproportionally unfit relative to the general U.S. population, and this puts them at an increased risk of all-cause mortality (Blair 1995).

Long-term mortality among older adults with burn injury: a population-based study in Australia

OBJECTIVE

To assess if burn injury in older adults is associated with changes in long-term all-cause mortality and to estimate the increased risk of death attributable to burn injury.

METHODS

We conducted a population-based matched longitudinal study - based on administrative data from Western Australia's hospital morbidity data system and death register. A cohort of 6014 individuals who were aged at least 45 years when hospitalized for a first burn injury in 1980-2012 was identified. A non-injury comparison cohort, randomly selected from Western Australia's electoral roll (n = 25 759), was matched to the patients. We used Kaplan-Meier plots and Cox proportional hazards regression to analyse the data and generated mortality rate ratios and attributable risk percentages.

FINDINGS

For those hospitalized with burns, 180 (3%) died in hospital and 2498 (42%) died after discharge. Individuals with burn injury had a 1.4-fold greater mortality rate than those with no injury (95% confidence interval, CI: 1.3-1.5). In this cohort, the long-term mortality attributable to burn injury was 29%. Mortality risk was increased by both severe and minor burns, with adjusted mortality rate ratios of 1.3 (95% CI: 1.1-1.9) and 2.1 (95% CI: 1.9-2.3), respectively.

CONCLUSION

Burn injury is associated with increased long-term mortality. In our study population, sole reliance on data on in-hospital deaths would lead to an underestimate of the true mortality burden associated with burn injury.

Patterns of recovery over 12 months following a burn injury in Australia

OBJECTIVE

To describe patients' generic health status and health-related quality of life (HRQoL) 12-months following admission to a state-wide burns service.

METHODS

A total of 114 injured adults with >10% total body surface area burned (TBSA) or burns less than 10% TBSA to smaller anatomical areas such as the hands and feet participated in this study. Retrospective assessment of pre-burn injury status and prospective assessment of generic health and HRQoL were followed up at 3, 6 and 12-months after injury using the 36-item Short Form Health Survey (SF-36 v.2) and Burns Specific Health Scale-Brief (BSHS-B). The SF-36 v.2 was administered retrospectively during the initial hospital stay to assess pre-injury HRQoL. Changes in instruments scores were assessed using multilevel mixed effects regression models. Mean scores were compared over time and between severity groups as defined by <10%, 10-30% and >30% TBSA.

RESULTS

For the overall sample, the SF-36 v.2 physical component scale (PCS) score between 3 and 12-months post-burn injury were significantly lower than pre-injury scores (p<0.01), with no significant change over time for the mental component scale (MCS) (p=0.36). Significant %TBSA-burden by time interactions highlighted changes from pre-burn injury in overall PCS (p=0.02), physical functioning (p<0.001) and role-physical (p=0.03), with subscales worse for the TBSA >30% group. With respect to the BSHS-B, significant improvement from 3 to 12-months post-burn injury was seen for the entire sample in simple abilities (p<0.001), hand function (p=0.001), work (p=0.01), and treatment regime (p=0.004) subscales. The TBSA >30% group showed a greater rate of improvement in simple abilities (p=0.01) and hand function (p=0.005) between 3 and 12 months post-burn injury.

CONCLUSIONS

Whilst certain HRQoL measures improve over the 12-months, in most cases they do not reach pre-morbid levels. Patients face ongoing challenges regarding their physical and psychosocial recovery 12-months post-burn injury with respect to generic health and burn-specific health. These challenges vary at different time periods over the 12-month post-burn period, and may provide windows of opportunity in which to address ongoing issues.

The Burns Evaluation and Mortality Study (BEAMS): predicting deaths in Australian and New Zealand burn patients admitted to intensive care with burns

BACKGROUND

An understanding of prognosis following burns is important. It alleviates patient and familial stress, provides a framework for better resource use, and facilitates benchmarking of performance between specialist centers.

METHODS

Data were collected from eight tertiary referral burns centers in Australia and New Zealand. Our aim was to identify factors independently associated with mortality to develop a mortality prediction model, which accurately quantifies the risk of death among adults with burns who require intensive care.

RESULTS

Between January 2005 and December 2011, 1,715 patients were admitted to intensive care unit with acute thermal burns. The mean (SD) age was 41.1 (18.0) years, and 20.3% (n = 348) were female. Median percentage of total body surface area was 17% (6-35%) and percent full-thickness surface area was 4% (0-20%). Inhalational injury was documented as present in 36.2%. Accidental injury was the most common etiology of burn (70.4%) and most frequently via a flame (68.3%). Overall hospital mortality was 10.9% (n = 187). Independent risk factors for death were age (odds ratio [OR], 1.08; 95% confidence interval [CI], 1.06-1.10; p < 0.001), percentage of full-thickness surface area (OR, 1.07; 95% CI 1.06-1.08; p < 0.001), and Acute Physiology and Chronic Health Evaluation II score excluding age (OR, 1.11; 95% CI, 1.07-1.15; p < 0.001) and female sex (OR, 3.35; 95% CI, 1.84-6.11; p = 0.001). There was no association between inhalational injury or deliberate self-harm and death, as well as etiology or type of burn.

CONCLUSION

A highly discriminatory mortality prediction model was developed using logistic regression. Risk of death following major burns can be predicted from a combination of physiologic and burns specific parameters. Female sex is a highly significant risk factor.

The impact of caregiver support on mortality following burn injury in the elderly

Advances in burn care have decreased mortality in the past 20 years, but affecting elderly mortality rates (>65 years) remain challenging. This study evaluates the impact of home caregiver support on elderly burn patients' mortality. The authors retrospectively reviewed patients aged 65 and older admitted to their burn center from July 1995 to October 2004. Patient demographics, Injury Severity Score, TBSA, and patients' primary caregiver were collected. The outcomes were mortality, disposition, and length of stay and these were evaluated using univariate and subsequently multivariate regression. Significance was calculated at P ≤ .05. A total of 112 patients were included in the analysis. The mean age was 76±8. Male patients constituted 47%, whereas 53% were female patients, and mean TBSA was 21±16%. Thirty patients' primary caregiver was a spouse, for 38 it was a child, and 44 had no caregiver. Fifty-eight patients survived (51.7%), and 54 patients died (48.3%). Only 21% of the survivors had a child as their primary caregiver; however, 48% of the nonsurvivors had a child as the primary caregiver (P ≤ 0.05). On multivariate analysis, age, TBSA, and child as primary caregiver were all independent predictors of mortality. Having a child as a caregiver provided the largest impact, with an odds ratio of 4.4 (95% confidence interval, 1.2-15.62; P = .02).

Review of burn research for the year 2011

The year 2011 was another robust year for burn research. Over 1100 articles were published on a wide range of burn injury and treatment topics. In this review, we highlight some of the interesting and potentially influential research in the following areas: critical care, infection, inhalation injury, epidemiology, wound characterization and treatment, nutrition and metabolism, pain management, burn reconstruction, psychology, and rehabilitation. As in years past, burn injury research reflects the multidisciplinary and holistic care that is needed to treat this challenging injury condition.