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Diab J, Pye M, Diab V, Hopkins Z, Cha J, Maitz PK, Issler-Fisher AC. The impact of COVID-19 on adult burns: A statewide review of epidemiology and clinical outcomes. Burns 2024; 50:381-387. [PMID: 37996282 DOI: 10.1016/j.burns.2023.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 08/27/2023] [Accepted: 10/18/2023] [Indexed: 11/25/2023]
Abstract
INTRODUCTION The COVID-19 pandemic has significantly impacted the clinical presentations of burns and the provision of services. This study aims to describe and analyse patterns and trends in adult burns across New South Wales (NSW) and the Australian Capital Territory. METHODS A NSW statewide retrospective review was conducted from 2017 to 2022 for adult patients with burns. A comparative analysis was performed for the COVID-19 group (2020-2022) and control group between 2017 and 2019. RESULTS We found a total of 11,433 patients (7102 non-COVID vs 4331 COVID-19). The average age in the COVID-19 group was 1.4 years older than counterparts (40.6 vs 42.0, p < 0.001). The 18 - 25 and 36 - 45 age groups experienced significantly lower proportions of presentations, whereas, the 76-85 years experienced significantly higher proportions. There was a significantly higher proportion of pressure injuries (0.1% vs 0.4%, p < 0.001) and contact burns (17.2% vs 18.7%), but lower explosions (1.3% vs 0.2%) for the COVID-19 group compared to their counterparts. The mean TBSA% was 0.4% greater in the COVID-19 group compared to their counterparts (2.4 vs 2.8, p < 0.001). There were significantly more operating sessions (0.2 vs 0.3, p < 0.001). The mean length of stay was significantly greater by 0.8 days for the COVID-19 group compared to their counterparts (1.5 vs 2.3, p < 0.001). CONCLUSIONS Epidemiological changes were not greatly different to previous years from the impact of COVID-19. The shift in elderly presentations and operative interventions reflects the holistic care of burns units working in a new landscape with an invigorated focus on telehealth and outpatient care.
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Affiliation(s)
- Jason Diab
- Concord Repatriation General Hospital, Burns Unit, Australia; ANZAC Research Institute, Concord Repatriation General Hospital, Sydney, Australia; Concord Clinical School, University of Sydney, Sydney, Australia; School of Medicine, University of Notre Dame, Sydney, Australia; School of Medicine, University of New South Wales, Sydney, Australia.
| | - Miranda Pye
- Concord Repatriation General Hospital, Burns Unit, Australia; Concord Clinical School, University of Sydney, Sydney, Australia
| | - Vanessa Diab
- School of Medicine, University of Notre Dame, Sydney, Australia
| | | | - Jeon Cha
- Royal North Shore Hospital, Burns Unit, Australia
| | - Peter Km Maitz
- Concord Repatriation General Hospital, Burns Unit, Australia; ANZAC Research Institute, Concord Repatriation General Hospital, Sydney, Australia; Concord Clinical School, University of Sydney, Sydney, Australia
| | - Andrea C Issler-Fisher
- Concord Repatriation General Hospital, Burns Unit, Australia; ANZAC Research Institute, Concord Repatriation General Hospital, Sydney, Australia; Concord Clinical School, University of Sydney, Sydney, Australia
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Gunawardena DA, Stanley E, Issler-Fisher AC. Understanding Neural Factors in Burn-related Pruritus and Neuropathic Pain. J Burn Care Res 2023; 44:1182-1188. [PMID: 36794899 DOI: 10.1093/jbcr/irad021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Indexed: 02/17/2023]
Abstract
Post-burn pruritus and neuropathic pain significantly affect the quality of life of affected individuals in several domains including psychosocial well-being, sleep and general impairment in activities of daily living. Whilst neural mediators involved in itch in the non-burns setting have been well investigated, there remains a lacuna of literature examining the pathophysiological and histological changes unique to burn-related pruritus and neuropathic pain. The aim of our study was to conduct a scoping review into the neural factors that contribute to burn-related pruritus and neuropathic pain. A scoping review was conducted to provide an overview of the available evidence. The PubMed, EMBASE and Medline databases were searched for publications. Data regarding neural mediators implicated, population demographics, total body surface area (TBSA) affected and sex was extracted. In total, 11 studies were included in this review with a total of 881 patients. The most frequently investigated neurotransmitter was the Substance P (SP) neuropeptide which appeared in 36% of studies (n = 4), followed by calcitonin gene-related peptide (CGRP) in 27% of studies (n = 3). Post-burn pruritus and neuropathic pain are symptomatic experiences that are predicated upon a heterogeneous group of underlying mechanisms. What is clear from the literature, however, is that itch and pain may occur secondary to the influence of both neuropeptides, such as SP, and other neural mediators including Transient receptor protein channels. Of the articles included for review, they were characterized by small sample sizes and large differences in statistical methodology and reporting.
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Affiliation(s)
- Dulan A Gunawardena
- Concord Clinical School, University of Sydney, New South Wales, Australia
- Concord Repatriation General Hospital, Sydney, New South Wales, Australia
| | - Edward Stanley
- Concord Repatriation General Hospital, Sydney, New South Wales, Australia
| | - Andrea C Issler-Fisher
- Concord Clinical School, University of Sydney, New South Wales, Australia
- Concord Repatriation General Hospital, Sydney, New South Wales, Australia
- ANZAC Research Institute, Concord, New South Wales, Australia
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Tsai KHY, Shi H, Parungao RJ, Naficy S, Ding X, Ding X, Hew JJ, Wang X, Chrzanowski W, Lavery GG, Li Z, Issler-Fisher AC, Chen J, Tan Q, Maitz PK, Cooper MS, Wang Y. Skin 11β-hydroxysteroid dehydrogenase type 1 enzyme expression regulates burn wound healing and can be targeted to modify scar characteristics. Burns Trauma 2023; 11:tkac052. [PMID: 36694861 PMCID: PMC9862341 DOI: 10.1093/burnst/tkac052] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 09/29/2022] [Accepted: 11/16/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND Excessive scarring and fibrosis are the most severe and common complications of burn injury. Prolonged exposure to high levels of glucocorticoids detrimentally impacts on skin, leading to skin thinning and impaired wound healing. Skin can generate active glucocorticoids locally through expression and activity of the 11β-hydroxysteroid dehydrogenase type 1 enzyme (11β-HSD1). We hypothesised that burn injury would induce 11β-HSD1 expression and local glucocorticoid metabolism, which would have important impacts on wound healing, fibrosis and scarring. We additionally proposed that pharmacological manipulation of this system could improve aspects of post-burn scarring. METHODS Skin 11β-HSD1 expression in burns patients and mice was examined. The impacts of 11β-HSD1 mediating glucocorticoid metabolism on burn wound healing, scar formation and scar elasticity and quality were additionally examined using a murine 11β-HSD1 genetic knockout model. Slow-release scaffolds containing therapeutic agents, including active and inactive glucocorticoids, were developed and pre-clinically tested in mice with burn injury. RESULTS We demonstrate that 11β-HSD1 expression levels increased substantially in both human and mouse skin after burn injury. 11β-HSD1 knockout mice experienced faster wound healing than wild type mice but the healed wounds manifested significantly more collagen deposition, tensile strength and stiffness, features characteristic of excessive scarring. Application of slow-release prednisone, an inactive glucocorticoid, slowed the initial rate of wound closure but significantly reduced post-burn scarring via reductions in inflammation, myofibroblast generation, collagen production and scar stiffness. CONCLUSIONS Skin 11β-HSD1 expression is a key regulator of wound healing and scarring after burn injury. Application of an inactive glucocorticoid capable of activation by local 11β-HSD1 in skin slows the initial rate of wound closure but significantlyimproves scar characteristics post burn injury.
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Affiliation(s)
- Kevin H-Y Tsai
- Adrenal Steroid Group, ANZAC Research Institute, Concord Hospital, The University of Sydney, Sydney, NSW 2137, Australia
- Burns and Reconstructive Surgery Research Group, ANZAC Research Institute, Concord Hospital, The University of Sydney, Sydney, NSW 2137, Australia
| | - Huaikai Shi
- Burns and Reconstructive Surgery Research Group, ANZAC Research Institute, Concord Hospital, The University of Sydney, Sydney, NSW 2137, Australia
| | - Roxanne J Parungao
- Burns and Reconstructive Surgery Research Group, ANZAC Research Institute, Concord Hospital, The University of Sydney, Sydney, NSW 2137, Australia
| | - Sina Naficy
- School of Chemical and Biomolecular Engineering, The University of Sydney, Sydney, NSW 2006, Australia
| | - Xiaotong Ding
- Jiangsu Provincial Engineering Research Centre of TCM External Medication Development and Application, Nanjing University of Chinese Medicine, Nanjing, Jiangsu, 210023, China
| | - Xiaofeng Ding
- Department of Burns and Plastic Surgery, Nanjing Drum Tower Hospital Clinical College, Nanjing University of Chinese Medicine, Nanjing, Jiangsu, 210008, China
| | - Jonathan J Hew
- Burns and Reconstructive Surgery Research Group, ANZAC Research Institute, Concord Hospital, The University of Sydney, Sydney, NSW 2137, Australia
| | - Xiaosuo Wang
- Heart Research Institute, The University of Sydney, Sydney, NSW 2006 , Australia
| | - Wojciech Chrzanowski
- Sydney Nano Institute, Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2006, Australia
| | - Gareth G Lavery
- Department of Biosciences, Centre for Healthy Ageing and Understanding Disease, Nottingham Trent University, NG1 4BU, UK
| | - Zhe Li
- Burns and Reconstructive Surgery Unit, Concord Repatriation General Hospital, Sydney, NSW 2137, Australia
| | - Andrea C Issler-Fisher
- Burns and Reconstructive Surgery Unit, Concord Repatriation General Hospital, Sydney, NSW 2137, Australia
| | - Jun Chen
- Jiangsu Provincial Engineering Research Centre of TCM External Medication Development and Application, Nanjing University of Chinese Medicine, Nanjing, Jiangsu, 210023, China
| | - Qian Tan
- Department of Burns and Plastic Surgery, Nanjing Drum Tower Hospital Clinical College, Nanjing University of Chinese Medicine, Nanjing, Jiangsu, 210008, China
| | - Peter K Maitz
- Burns and Reconstructive Surgery Research Group, ANZAC Research Institute, Concord Hospital, The University of Sydney, Sydney, NSW 2137, Australia
- Burns and Reconstructive Surgery Unit, Concord Repatriation General Hospital, Sydney, NSW 2137, Australia
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Ross SW, Malcolm J, Maitz J, Li Z, Wang Y, Issler-Fisher AC. Fractional ablative laser therapy for the treatment of severe burn scars: A pilot study of the underlying mechanisms. Burns 2023; 49:573-582. [PMID: 36642662 DOI: 10.1016/j.burns.2022.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 12/12/2022] [Accepted: 12/28/2022] [Indexed: 01/03/2023]
Abstract
Ablative fractional resurfacing is clinically an efficient treatment for burn scar management. The aim of this pilot study was to investigate the poorly understood mechanisms underlying ablative fractional CO2 laser (AFL-CO2) therapy in relation to biomarkers S100 and 11β-hydroxysteroid dehydrogenase type 1 (11β-HSD1). S100 stains for Langerhans cells and neuronal cells, potentially representing the pruritus experienced. 11β-HSD1 catalyses the interconversion of cortisol and cortisone in cells, promoting tissue remodelling. Immunohistochemical analysis of S100 and 11β-HSD1 protein expression in the dermis and epidermis of the skin was performed on normal skin, before and after AFL-CO2 therapy. Data assessing outcome parameters was collected concurrently with the skin biopsies. 13 patients were treated with AFL-CO2 therapy. Langerhans cells decreased by 39% after 2nd treatment. Neuronal cells were overexpressed before treatment in the scar tissue by 91% but levels returned to that resembling normal skin. 11β-HSD1 expression in keratinocytes was significantly higher after laser treatment compared to before in scar tissue (p <0.01). No clear correlation was found in dermal fibroblast numbers throughout the treatment course. Whilst the role of the explored mechanisms and their association with clinical outcomes cannot conclusively be stated, this pilot study demonstrates promising trends that encourages investigation into this relationship.
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Affiliation(s)
- Stewart W Ross
- Faculty of Engineering, University of Sydney, Sydney, Australia; ANZAC Research Institute, Concord Repatriation General Hospital, Sydney, Australia.
| | - Josephine Malcolm
- Burns Unit, Concord Repatriation General Hospital, Sydney, Australia; ANZAC Research Institute, Concord Repatriation General Hospital, Sydney, Australia
| | - Joanneke Maitz
- Burns Unit, Concord Repatriation General Hospital, Sydney, Australia; ANZAC Research Institute, Concord Repatriation General Hospital, Sydney, Australia
| | - Zhe Li
- Burns Unit, Concord Repatriation General Hospital, Sydney, Australia; ANZAC Research Institute, Concord Repatriation General Hospital, Sydney, Australia; Concord Clinical School, University of Sydney, Sydney, Australia
| | - Yiwei Wang
- Faculty of Engineering, University of Sydney, Sydney, Australia; Burns Unit, Concord Repatriation General Hospital, Sydney, Australia; ANZAC Research Institute, Concord Repatriation General Hospital, Sydney, Australia
| | - Andrea C Issler-Fisher
- Burns Unit, Concord Repatriation General Hospital, Sydney, Australia; ANZAC Research Institute, Concord Repatriation General Hospital, Sydney, Australia; Concord Clinical School, University of Sydney, Sydney, Australia
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Stynes G, Haertsch P, O'Hara J, Knight R, Issler-Fisher AC, Maitz PKM. Alginate dressings continuously for fourteen days on uncontaminated, superficial, partial thickness burns. J Burn Care Res 2022:6743261. [PMID: 36181757 DOI: 10.1093/jbcr/irac143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Indexed: 01/27/2023]
Abstract
Calcium alginate dressings are commonly used on split-thickness skin donor sites, where they are typically removed after 14 days. Alginates have been used previously on superficial, partial thickness burns, but changed every 3-4 days. In this study, alginates were applied to superficial, partial thickness burns on adults within 36 hours of injury, then left intact for up to 14 days. Wound healing (≥95% wound epithelialisation) and pain were measured. Twenty-one burns were reviewed on ten patients. Per the initial protocol, six patients were reviewed every 3-5 days, with removal of only secondary dressings, until day 13-14, when the alginate dressings were removed. One patient was reviewed every 3-5 days until day 10, when a clinic nurse removed the alginate dressing. Restrictions on movement during the COVID pandemic necessitated a protocol change, with only one review at approximately day 14 for removal of alginate and secondary dressings; three patients were reviewed in this manner. Burns on all patients were 100% epithelialised at the time of final review and there were no complications, such as scarring, infection, or need for grafting. Following initial debridement and dressings, patients reported minimal pain. Dressing costs appeared to be significantly decreased. This protocol may be particularly useful for patients managed in rural and remote locations, with telemedicine support if required.
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Affiliation(s)
- Gil Stynes
- Burns Unit, Concord Repatriation General Hospital, Hospital Rd, Concord NSW 2139, Australia.,University of Sydney, Camperdown, NSW.,ANZAC Research Institute, Concord Repatriation General Hospital, Sydney, Australia.,Department of Surgery, Wollongong Hospital, 252 Loftus St, Wollongong 2500, NSW, Australia
| | - Peter Haertsch
- Burns Unit, Concord Repatriation General Hospital, Hospital Rd, Concord NSW 2139, Australia.,University of Sydney, Camperdown, NSW.,Department of Surgery, Wollongong Hospital, 252 Loftus St, Wollongong 2500, NSW, Australia
| | - Justine O'Hara
- Burns Unit, Concord Repatriation General Hospital, Hospital Rd, Concord NSW 2139, Australia.,University of Sydney, Camperdown, NSW
| | - Robert Knight
- Department of Surgery, Wollongong Hospital, 252 Loftus St, Wollongong 2500, NSW, Australia
| | - Andrea C Issler-Fisher
- Burns Unit, Concord Repatriation General Hospital, Hospital Rd, Concord NSW 2139, Australia.,University of Sydney, Camperdown, NSW.,ANZAC Research Institute, Concord Repatriation General Hospital, Sydney, Australia
| | - Peter K M Maitz
- Burns Unit, Concord Repatriation General Hospital, Hospital Rd, Concord NSW 2139, Australia.,University of Sydney, Camperdown, NSW.,ANZAC Research Institute, Concord Repatriation General Hospital, Sydney, Australia
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Aggarwala S, Harish V, Roberts S, Brady M, Lajevardi S, Doherty J, D'Souza M, Haertsch PA, Maitz PKM, Issler-Fisher AC. Treatment of Partial Thickness Burns: A Prospective, Randomized Controlled Trial Comparing Four Routinely Used Burns Dressings in an Ambulatory Care Setting. J Burn Care Res 2021; 42:934-943. [PMID: 32930784 DOI: 10.1093/jbcr/iraa158] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
This prospective, randomized controlled trial study compared the effects of four dressings for adult partial thickness burns, focusing on re-epithelialization time and cost effectiveness. Adults with partial thickness burns meeting inclusion criteria were randomized to either Biobrane™, Acticoat™, Mepilex® Ag, or Aquacel® Ag. Primary endpoint for analysis was >95% re-epithelialization. Incremental cost-effectiveness ratios were calculated based on dressing costs. Dominance probabilities between treatment arms were calculated from bootstrap resampling trial data. One hunderd thirty-one partial thickness burn wounds in 119 patients were randomized. Adjusting for sex, age, smoking status, burn mechanism, TBSA, and first aid adequacy, Mepilex® Ag had a reduced time to re-epithelialization compared to Biobrane™ (IRR: 1.26; 95% CI: 1.07-1.48, P < .01). Economic analysis showed that there was a 99%, 71%, and 53% probability that Mepilex® Ag dominated (cheaper and more effective) Biobrane™, Acticoat™, and Aquacel® Ag, respectively. Mepilex® Ag achieved faster re-epithelialization and better cost effectiveness. Patient satisfaction and comfort seems better with Biobrane™ although not reflected within the end outcome of the healed wound. It is the patients' (after extensive education) and clinicians' choice, level of experience, and availability of products in praxis that will guide the decision as to which the product is used individually on which patient.
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Affiliation(s)
- Shivani Aggarwala
- Burns Unit, Concord Repatriation General Hospital, Concord, New South Wales, Australia.,University of Sydney, Camperdown, New South Wales, Australia
| | - Varun Harish
- Burns Unit, Concord Repatriation General Hospital, Concord, New South Wales, Australia.,University of Sydney, Camperdown, New South Wales, Australia
| | - Sarah Roberts
- Burns Unit, Concord Repatriation General Hospital, Concord, New South Wales, Australia
| | - Megan Brady
- Burns Unit, Concord Repatriation General Hospital, Concord, New South Wales, Australia
| | - Sepehr Lajevardi
- Burns Unit, Concord Repatriation General Hospital, Concord, New South Wales, Australia.,University of Sydney, Camperdown, New South Wales, Australia
| | - James Doherty
- Burns Unit, Concord Repatriation General Hospital, Concord, New South Wales, Australia
| | - Mario D'Souza
- Burns Unit, Concord Repatriation General Hospital, Concord, New South Wales, Australia
| | - Peter A Haertsch
- Burns Unit, Concord Repatriation General Hospital, Concord, New South Wales, Australia.,University of Sydney, Camperdown, New South Wales, Australia
| | - Peter K M Maitz
- Burns Unit, Concord Repatriation General Hospital, Concord, New South Wales, Australia.,University of Sydney, Camperdown, New South Wales, Australia.,ANZAC Research Institute, Concord Repatriation General Hospital, Sydney, Australia
| | - Andrea C Issler-Fisher
- Burns Unit, Concord Repatriation General Hospital, Concord, New South Wales, Australia.,University of Sydney, Camperdown, New South Wales, Australia.,ANZAC Research Institute, Concord Repatriation General Hospital, Sydney, Australia
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Abstract
BACKGROUND Burns injuries are dynamic and evolve over time. Burn injuries to the feet present with seasonal variation, affecting clinical outcomes for certain high-risk groups. Although they affect a very small percentage of the body, burn injuries to the feet can affect mobility, morbidity and rehabilitation, particularly in patients with diabetes. OBJECTIVE The aim of this article is to provide an understanding of seasonal variation in foot burns for high-risk groups and how to manage them appropriately. This article provides a comprehensive analysis on epidemiology, pathology and management, with the aim of providing guidance for general practitioners (GPs). DISCUSSION The management of foot burns is multidisciplinary, involving GPs, allied health specialists, nurses, medical and surgical specialties. The epidemiological variations of these injuries have shown differences in clinical outcomes among high-risk groups such as the elderly and people with diabetes. Education and prevention are crucial in reducing the rate of injury in the rising number of patients in high-risk groups.
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Affiliation(s)
- Jason Diab
- MBBS, BMedSci, MIPH, MS, Surgical registrar, Burns Unit, Concord Repatriation General Hospital, NSW; Clinical Associate Lecturer, Concord Clinical School, University of Sydney, NSW; Clinical Associate Lecturer, School of Medicine, University of Notre Dame, Sydney, NSW
| | - Miranda Pye
- BN, Grad Dip (Nursing Science @ Burns Nursing), MN (NP), Clinical Nurse Specialist, Burns Unit, Concord Repatriation General Hospital, NSW
| | - Christine Parker
- BN, Nurse Unit Manager, Burns Unit, Concord Repatriation General Hospital, NSW
| | - Justine O'Hara
- BSc, MBBS (Hons), FRACS, Burns and Plastic Surgeon, Burns Unit, Concord Repatriation General Hospital, NSW
| | - Peter KM Maitz
- AM, MD, FRACS, Director, Burns Unit, Concord Repatriation General Hospital, NSW; Professor of Burns, ANZAC Research Institute, Concord Repatriation General Hospital, NSW; Professor of Burns, Concord Clinical School, University of Sydney, NSW
| | - Andrea C Issler-Fisher
- MD, PhD, EBOPRAS, Burns Fellow, Burns Unit, Concord Repatriation General Hospital, NSW; Clinical Lecturer, ANZAC Research Institute, Concord Repatriation General Hospital, NSW; Clinical Lecturer, Concord Clinical School, University of Sydney, NSW
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Issler-Fisher AC, Fisher OM, Haertsch PA, Li Z, Maitz PKM. Effectiveness and safety of ablative fractional CO 2 laser for the treatment of burn scars: A case-control study. Burns 2021; 47:785-795. [PMID: 33121852 DOI: 10.1016/j.burns.2020.10.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 09/14/2020] [Accepted: 10/02/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Burn scars are a major clinical challenge. The aim of this study was to determine the effectiveness and safety of one treatment with the ablative fractional CO2 laser (AFL-CO2) compared to standard burn scar treatment. METHOD From December 2014 to October 2018 patients were prospectively recruited and treatment effects analyzed by assessing various outcome parameters from the date of first consultation and after treatment. A case control study was conducted looking at the impact of one AFL-CO2 treatment compared to a cohort subjected to conventional conservative treatment. Adverse effects were noted at follow up. RESULTS 187 patients were included, with 167 in the AFL-CO2, and 20 in the control cohort. Baseline demographics and scar characteristics showed no significant differences. Ultrasound measured scar thickness as well as the Vancouver Scar Scale (VSS) revealed a significant reduction in the treatment cohort, but no significant improvement in the control group. The POSAS-O was significantly improved in both cohorts. Subjective parameters (POSAS-P, DN4-Pain, and modified D4Pruritus scores) decreased significantly in the AFL-CO2 cohort but remained unchanged in the control group. The BSHS-B quality of life score increased significantly in the AFL-CO2 group, but worsened at the follow up of the untreated patients. Sub-domain analyses found the biggest differences in Affect, Body Image, Heat Sensitivity, Treatment and Work. Complications occurred in 5 patients (2.9%). CONCLUSIONS This study demonstrates that AFL-CO2 is an effective and safe treatment modality for burn scars improving thickness, symptoms and quality of life of burn survivors when compared to conventional scar treatment.
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Affiliation(s)
- Andrea C Issler-Fisher
- Burns Unit, Concord Repatriation General Hospital, Sydney, Australia; ANZAC Research Institute, Concord Repatriation General Hospital, Sydney, Australia; Concord Clinical School, University of Sydney, Sydney, Australia.
| | - Oliver M Fisher
- School of Medicine, University of Notre Dame, Sydney, NSW 2010, Australia; University of New South Wales Department of Surgery, St George Hospital, Kogarah, Australia
| | - Peter A Haertsch
- Burns Unit, Concord Repatriation General Hospital, Sydney, Australia; Concord Clinical School, University of Sydney, Sydney, Australia
| | - Zhe Li
- Burns Unit, Concord Repatriation General Hospital, Sydney, Australia; ANZAC Research Institute, Concord Repatriation General Hospital, Sydney, Australia; Concord Clinical School, University of Sydney, Sydney, Australia
| | - Peter K M Maitz
- Burns Unit, Concord Repatriation General Hospital, Sydney, Australia; ANZAC Research Institute, Concord Repatriation General Hospital, Sydney, Australia; Concord Clinical School, University of Sydney, Sydney, Australia
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Clayton NA, Haertsch PA, Maitz PK, Issler-Fisher AC. Ablative Fractional Resurfacing in Acute Care Management of Facial Burns: A New Approach to Minimize the Need for Acute Surgical Reconstruction. J Burn Care Res 2019; 40:368-372. [DOI: 10.1093/jbcr/irz030] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Nicola A Clayton
- Speech Pathology Department, Concord Repatriation General Hospital, Sydney, Australia
- Burns Unit, Concord Repatriation General Hospital, Sydney, Australia
- School of Health & Rehabilitation Sciences, University of Queensland, Brisbane, Australia
| | - Peter A Haertsch
- Speech Pathology Department, Concord Repatriation General Hospital, Sydney, Australia
| | - Peter K Maitz
- Speech Pathology Department, Concord Repatriation General Hospital, Sydney, Australia
- Faculty of Medicine, University of Sydney, Australia
| | - Andrea C Issler-Fisher
- Speech Pathology Department, Concord Repatriation General Hospital, Sydney, Australia
- Faculty of Medicine, University of Sydney, Australia
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Clayton NA, Nicholls CM, Blazquez K, Brownlow C, Maitz PK, Fisher OM, Issler-Fisher AC. Dysphagia in older persons following severe burns: Burn location is irrelevant to risk of dysphagia and its complications in patients over 75 years. Burns 2018; 44:1997-2005. [PMID: 30107942 DOI: 10.1016/j.burns.2018.07.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 06/14/2018] [Accepted: 07/19/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND Management of burns in older persons is complex with evidence indicating advanced age is associated with elevated risk for morbidity and mortality. Dysphagia and its sequelae may further increase this risk. AIMS (1) Determine the prevalence, and (2) identify risk factors for dysphagia in patients admitted with severe burn injury over 75 years. METHODS All patients >75 years admitted to Concord Repatriation General Hospital with severe burn injury over a 4-year period (2013-2017) were assessed for dysphagia on presentation and continually monitored throughout their admission. Burn injury, demographic and nutritional data were captured and analysed for association with and predictive value for dysphagia. RESULTS Sixty-six patients (35 male; 31 female) aged 75-96 years (median 82 years) were recruited. Dysphagia was identified in 46.97% during their hospital admission. Dysphagia was significantly associated with burn size, pre-existing cognitive impairment, mechanical ventilation, duration of enteral feeding, hospital length of stay, in-hospital complications and mortality. No association was identified between burn location, burn mechanism, surgery and dysphagia. Burn size and Malnutrition Screening Tool score were found to be independent predictors for dysphagia. CONCLUSIONS Dysphagia prevalence is high in older persons with burns and is associated with increased morbidity and mortality, regardless of burn location.
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Affiliation(s)
- Nicola A Clayton
- Speech Pathology Department, Concord Repatriation General Hospital, NSW, Australia; Burns Unit, Concord Repatriation General Hospital, NSW 2139, Australia; School of Health & Rehabilitation Sciences, University of Queensland, QLD, Australia.
| | - Caroline M Nicholls
- Burns Unit, Concord Repatriation General Hospital, NSW 2139, Australia; Nutrition & Dietetics Department, Concord Repatriation General Hospital, NSW, Australia
| | - Karen Blazquez
- Speech Pathology Department, Concord Repatriation General Hospital, NSW, Australia
| | - Cheryl Brownlow
- Burns Unit, Concord Repatriation General Hospital, NSW 2139, Australia; Nutrition & Dietetics Department, Concord Repatriation General Hospital, NSW, Australia
| | - Peter K Maitz
- Burns Unit, Concord Repatriation General Hospital, NSW 2139, Australia; Faculty of Medicine, University of Sydney, Sydney, NSW, Australia
| | - Oliver M Fisher
- UNSW Department of Surgery, St George Hospital, Sydney, NSW, Australia
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Issler-Fisher AC, Fisher OM, Smialkowski AO, Li F, van Schalkwyk CP, Haertsch P, Maitz PKM. Ablative fractional CO 2 laser for burn scar reconstruction: An extensive subjective and objective short-term outcome analysis of a prospective treatment cohort. Burns 2016; 43:573-582. [PMID: 27707636 DOI: 10.1016/j.burns.2016.09.014] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Revised: 09/13/2016] [Accepted: 09/13/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND The introduction of ablative fractional CO2 lasers (CO2-AFL) for burn scar management shows promising results. Whilst recent studies have focused on objective scar outcomes following CO2-AFL treatment, to date no data on patient subjective factors such as quality of life are available. METHODS A prospective study was initiated to analyze the safety and efficacy of the CO2-AFL. Various objective and subjective outcome parameters were prospectively collected from the date of first consultation and follow-up following treatment. Objective factors include the Vancouver Scar Scale (VSS), the Patient and Observer Scar Assessment Scale (POSAS), and ultrasound measurements of the thickness of the scar. Subjective parameters included the assessment of neuropathic pain and pruritus, as well as the evaluation of improvement of quality of life following CO2-AFL with the Burns Specific Health Scale (BSHS-B). For treatment effect analysis, patients were stratified according to scar maturation status (> or <2 years after injury). RESULTS 47 patients with 118 burn scars completed at least one treatment cycle. At a median of 55 days (IQR 32-74) after CO2-AFL treatment all analyzed objective parameters decreased significantly: intra-patient normalized scar thickness decreased from a median of 2.4mm to 1.9mm (p<0.001) with a concomitant VSS-drop from a median of 7 to 6 (p<0.001). The overall POSAS patient scale decreased from a median of 9 to 5 (p<0.001) with similar effects documented in POSAS observer scales. Both pain and pruritus showed significant reduction. Quality of life increased significantly by 15 points (median 120 to 135; p<0.001). All of the identified changes following CO2-AFL were equally significant irrespective of scar maturation status. CONCLUSION Our preliminary results confirm significant improvement in thickness, texture, colour, and symptoms following treatment with CO2-AFL. Foremost, quality of life of patients with both immature and mature scars (up to 23 years after injury) improved significantly after just one treatment session. To our knowledge, this is the first study to document such holistic treatment effects in burn patients treated by CO2-AFL.
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Affiliation(s)
| | - Oliver M Fisher
- St. Vincent's Centre for Applied Medical Research, Sydney, Australia
| | | | - Frank Li
- Burns Unit, Concord Repatriation General Hospital, Sydney, Australia
| | | | - Peter Haertsch
- Burns Unit, Concord Repatriation General Hospital, Sydney, Australia
| | - Peter K M Maitz
- Burns Unit, Concord Repatriation General Hospital, Sydney, Australia; ANZAC Research Institute, Concord Repatriation General Hospital, Sydney, Australia; University of Sydney, Sydney, Australia
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Issler-Fisher AC, Fakin RM, Fisher OM, McKew G, Gazzola R, Rauch AK, Gottlieb T, Haertsch P, Guggenheim M, Giovanoli P, Maitz PKM. Microbiological findings in burn patients treated in a general versus a designated intensive care unit: Effect on length of stay. Burns 2016; 42:1805-1818. [PMID: 27372144 DOI: 10.1016/j.burns.2016.06.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 05/12/2016] [Accepted: 06/10/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Infection is one of the most common causes of mortality and morbidity in burn patients. The incidence and frequency of microbiological micro-organisms are known to vary across different models of intensive care units. To date, no study has attempted to describe the different findings in burn patients treated in an open, general intensive care unit (GICU) versus a dedicated burns intensive care unit (BICU). Only limited data is available on the effect of these microbiological micro-organisms on patients' length of stay. AIM To characterize and compare the microbiological flora and antibiotic resistance patterns encountered in two different models of burn intensive care and to determine the effect of specific microbiological types on length of intensive care unit (ICU) and overall stay. METHODS A retrospective case-control study of 209 burn patients treated in two highly specialized, Western burn referral centres between September 2009 and March 2014. RESULTS 9710 culture results were analysed, of which 2590 (26.7%) yielded positive results (1537 in the GICU and 1050 in the BICU). Gram-positive cultures were more frequently found in the GICU, whereas Gram-negative and yeast cultures were more prevalent in the BICU. The most frequently encountered micro-organisms in both units were similar and included Staphylococcus aureus, Pseudomonas aeruginosa, coagulase-negative staphylococci (CoNS) and Candida albicans. Significantly more resistant bacteria were detected in the BICU. Testing positive across all types of microbiological isolates, as well as for both Gram-positive and -negative bacteria significantly prolonged patient length of stay. This effect was even more pronounced if the micro-organisms were resistant to antimicrobial therapy. CONCLUSION There are notable differences in the microbiological isolate and antibiotic resistance patterns between burn patients treated in a GICU compared to a designated BICU. In both units, testing positive for resistant microbiological micro-organisms is significantly associated with longer hospital stay.
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Affiliation(s)
| | - Richard M Fakin
- Division of Plastic and Hand Surgery, University Hospital Zurich, Switzerland
| | - Oliver M Fisher
- St Vincent's Centre for Applied Medical Research, Sydney, Australia
| | - Genevieve McKew
- Department of Microbiology and Infectious Diseases, Concord Repatriation General Hospital, Sydney, Australia; University of Sydney, Sydney, Australia
| | - Riccardo Gazzola
- Division of Plastic and Hand Surgery, University Hospital Zurich, Switzerland
| | - Ann-Kathrin Rauch
- Division of Plastic and Hand Surgery, University Hospital Zurich, Switzerland
| | - Thomas Gottlieb
- Department of Microbiology and Infectious Diseases, Concord Repatriation General Hospital, Sydney, Australia; University of Sydney, Sydney, Australia
| | - Peter Haertsch
- Burns Unit, Concord Repatriation General Hospital, Sydney, Australia
| | - Merlin Guggenheim
- Division of Plastic and Hand Surgery, University Hospital Zurich, Switzerland
| | - Pietro Giovanoli
- Division of Plastic and Hand Surgery, University Hospital Zurich, Switzerland
| | - Peter K M Maitz
- Burns Unit, Concord Repatriation General Hospital, Sydney, Australia; University of Sydney, Sydney, Australia; ANZAC Research Institute, Concord Repatriation General Hospital, Sydney, Australia
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Issler-Fisher AC, McKew G, Fisher OM, Harish V, Gottlieb T, Maitz PKM. Risk factors for, and the effect of MRSA colonization on the clinical outcomes of severely burnt patients. Burns 2015; 41:1212-20. [PMID: 26150350 DOI: 10.1016/j.burns.2015.03.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2014] [Revised: 12/09/2014] [Accepted: 03/03/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND MRSA is an on-going problem for burn patients. AIM To analyze risk factors for, and the effect of MRSA colonization on burn patients' outcome. METHODS During 21 months burn patients' details and MRSA isolates were analyzed, and a case-control study performed. RESULTS Of 357 burn patients, 57 (16%) tested positive for MRSA. Compared to the MRSA negative group, MRSA positive patients had a higher median total burn surface area (15%[IQR 5-17%] vs. 5%[IQR 2-8%]; p<0.001), more admissions to ICU (54% vs. 26%; p<0.001), longer ICU length of stay (4.3 vs. 1.0 days; p<0.001), required more operations (1.6 vs. 0.8; p<0.001), and had longer total hospital length of stay (25.5 vs. 8.0 days; p<0.001). MRSA positivity was a significant independent predictor of increased length of stay (6.0 days, 95%CI 2.39-9.6 days; p=0.001) in a multivariable regression model correcting for patients TBSA and co-morbidities. Cardiac comorbidities (OR 5.14, 95%CI 1.76-15.62; p<0.001) and a longer exposure to the hospital environment (OR 1.05, 95%CI 1.02-1.09, p=0.005) increased the likelihood for MRSA positivity. CONCLUSION The negative impact of MRSA positivity on burn patients outcome indicates the need for improved screening procedures for early identification and further efforts toward MRSA infection control to prevent cross-infection as this may significantly impair patients' outcome.
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Affiliation(s)
| | - Genevieve McKew
- Department of Microbiology and Infectious Diseases, Concord Repatriation General Hospital, Sydney, Australia; University of Sydney, Sydney, Australia
| | - Oliver M Fisher
- St. Vincent's Centre for Applied Medical Research, Sydney, Australia
| | - Varun Harish
- Burns Unit, Concord Repatriation General Hospital, Sydney, Australia; ANZAC Research Institute, Concord Repatriation General Hospital, Sydney, Australia; University of Sydney, Sydney, Australia
| | - Thomas Gottlieb
- Department of Microbiology and Infectious Diseases, Concord Repatriation General Hospital, Sydney, Australia; University of Sydney, Sydney, Australia
| | - Peter K M Maitz
- Burns Unit, Concord Repatriation General Hospital, Sydney, Australia; ANZAC Research Institute, Concord Repatriation General Hospital, Sydney, Australia; University of Sydney, Sydney, Australia
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