Investigating the intra- and inter-rater reliability of a panel of subjective and objective burn scar measurement tools

•

Subjective scar measures have poor reliability unless repeated by more than one assessor.

•

Objective scar measures have been demonstrated to have good to excellent reliability.

•

Physical symptoms of scars such as pain and itch were found to be more important to patients compared to surface, area and colour although this finding was not sustained when corrected for multiple comparisons.

Background

Research into the treatment of hypertrophic burn scar is hampered by the variability and subjectivity of existing outcome measures. This study aims to measure the inter- and intra-rater reliability of a panel of subjective and objective burn scar measurement tools.

Methods

Three independent assessors evaluated 55 scar and normal skin sites using subjective (modified Vancouver Scar Scale [mVSS] & Patient and Observer Scar Assessment Scale [POSAS]) and objective tools. The intra-class correlation coefficient was utilised to measure reliability (acceptable when >0.70). Patient satisfaction with the different tools and scar parameter importance were assessed via questionnaires.

Results

The inter-rater reliabilities of the mVSS and POSAS were below the acceptable limit. For erythema and pigmentation, all of the Scanoskin and DSM II measures (except the b* value) had acceptable to excellent intra and inter-rater reliability. The Dermascan ultrasound (dermal thickness, intensity) had excellent intra- and inter-rater reliability (>0.90). The Cutometer R0 (firmness) had acceptable reliability but not R2 (gross elasticity). All objective measurement tools had good overall satisfaction scores. Patients rated scar related pain and itch as more important compared to appearance although this finding was not sustained when corrected for multiple comparisons.

Conclusion

The objective scar measures demonstrated acceptable to excellent intra- and inter-rater reliability and performed better than the subjective scar scales.

A gellan-based fluid gel carrier to enhance topical spray delivery

Autologous cell transplantation was introduced to clinical practice nearly four decades ago to enhance burn wound re-epithelialisation. Autologous cultured or uncultured cells are often delivered to the surface in saline-like suspensions. This delivery method is limited because droplets of the sprayed suspension form upon deposition and run across the wound bed, leading to uneven coverage and cell loss. One way to circumvent this problem would be to use a gel-based material to enhance surface retention. Fibrin systems have been explored as co-delivery system with keratinocytes or as adjunct to 'seal' the cells following spray delivery, but the high costs and need for autologous blood has impeded its widespread use. Aside from fibrin gel, which can exhibit variable properties, it has not been possible to develop a gel-based carrier that solidifies on the skin surface. This is because it is challenging to develop a material that is sprayable but gels on contact with the skin surface. The manuscript reports the use of an engineered carrier device to deliver cells via spraying, to enhance retention upon a wound. The device involves shear-structuring of a gelling biopolymer, gellan, during the gelation process; forming a yield-stress fluid with shear-sensitive behaviours, known as a fluid gel. In this study, a formulation of gellan gum fluid gels are reported, formed with from 0.75 or 0.9% (w/v) polymer and varying the salt concentrations. The rheological properties and the propensity of the material to wet a surface were determined for polymer modified and non-polymer modified cell suspensions. The gellan fluid gels had a significantly higher viscosity and contact angle when compared to the non-polymer carrier. Viability of cells was not impeded by encapsulation in the gellan fluid gel or spraying. The shear thinning property of the material enabled it to be applied using an airbrush and spray angle, distance and air pressure were optimised for coverage and viability. STATEMENT OF SIGNIFICANCE: Spray delivery of skin cells has successfully translated to clinical practice. However, it has not yet been widely accepted due to limited retention and disputable cell viability in the wound. Here, we report a method for delivering cells onto wound surfaces using a gellan-based shear-thinning gel system. The viscoelastic properties allow the material to liquefy upon spraying and restructure rapidly on the surface. Our results demonstrate reduced run-off from the surface compared to currently used low-viscosity cell carriers. Moreover, encapsulated cells remain viable throughout the process. Although this paper studies the encapsulation of one cell type, a similar approach could potentially be adopted for other cell types. Our data supports further studies to confirm these results in in vivo models.

Microalbuminuria: A marker of systemic endothelial dysfunction during burn excision

INTRODUCTION

Systemic endothelial dysfunction characterises both burn injury and surgery and can be monitored by serial immunoassay of urine albumin (microalbuminuria). The aim of this study was to assess microalbuminuria before and during burn excision and identify factors that may influence it.

METHODS

Serial half-hourly urine albumin/creatinine ratio (ACR, normal <2.3mg/mmol) was measured in 25 adult patients during 44 burn-excision procedures, at a median of 5 days post-injury. Median total body surface area (TBSA) excised was 12%.

RESULTS

Pre-operative median ACR was normal rising to 3.25mg/mmol at 1.5h of surgery (p<0.05). Per-operative ACR at 0.5, 1, 2 and 2.5h were all associated with % TBSA burn excised (p<0.04). Median intraoperative ACR at 1h was 2.3mg/mmol for surgery within 48h post-injury, 1.6 for surgery at 2-7 days and 25.5 during excisions later than 1 month after injury (p<0.05). ACR at 1h was associated with CRP at 48h post-surgery (p=0.04). Per-operative ACR was also significantly correlated with post-operative complications.

CONCLUSION

Systemic endothelial dysfunction of acute thermal injury assessed by microalbuminuria recurs with surgery, is minimal at 2-7 days post-burn and affected by % TBSA burn excised and post-operative complications.

Microalbuminuria: A marker of endothelial dysfunction in thermal injury

INTRODUCTION

Systemic endothelial dysfunction (SED) and capillary leak occur following severe burn. SED can be assessed as low-level albuminuria (microalbuminuria) detectable only by sensitive immunoassay. This study compared the magnitude and duration of microalbuminuria with burn surface area and associated aggravating factors.

METHODS

Serial urine specimens were collected from 2 to 36 h after injury from 43 adult burn patients with a mean total body surface area (TBSA) of 32% (range 15-68%) and during 44 episodes of wound manipulation within the same period. Urinary albumin was expressed as the albumin/creatinine ratio (ACR, normal <2.3 mg/mmol).

RESULTS

Median ACR was highest 2h after injury (12.3 range 1.8-118 mg/mmol) returning to normal within 6 h. Full thickness burns (mean 17%) showed a significant association with ACR between 3 and 7h after burn. ACR was higher for up to 8 h in the presence of inhalation injury, alcohol intoxication or accelerant (p<0.05). ACR rose within 30 min of escharotomy or wound scrubbing (p<0.01).

CONCLUSION

Severe burn produces variable SED which recurs with wound manipulation. Inhalation injury, alcohol intoxication and accelerant all showed a stronger association with SED than TBSA. Microalbuminuria provides a means of monitoring microvascular integrity during the early after injury period.

Aetiology and outcome of burns in the elderly

INTRODUCTION

This retrospective study, analyses aetiology and factors affecting the outcome of burns in patients over 65 years of age.

METHODS

Sixty-three consecutive patients, over 65 years of age, were admitted to a Burns Unit over a period of 3 years. Retrospective data was analyzed, taking into account aetiology, burn thickness and area, co-morbid factors. Also, surgery as a factor-affecting outcome was examined.

RESULTS

There was a significant difference of total body surface area burn (TBSA), Abbreviated Burn Severity Index (ABSI), Baux score and the number of pre-existing co-morbid factors between survivors and non-survivors. Age and surgery were not significant to the outcome. Patients undergoing surgery had increased hospital stay without any difference in mortality. The timing of surgery did not have any impact on hospital stay or survival.

CONCLUSION

This study shows a positive correlation between the number of co-morbid conditions and mortality. Early surgery after careful patient selection does not have any negative impact on patient survival.

Reconstructive surgery with a dermal regeneration template: clinical and histologic study

Integra artificial skin was introduced in 1981 and its use in acute surgical management of burns is well established, but Integra has also been used in patients undergoing reconstructive surgery. Over a period of 25 months, the authors used Integra to cover 30 anatomic sites in 20 consecutive patients requiring reconstructive surgery and then analyzed the clinical and histologic outcomes. The most common reason for surgery was release of contracture followed by resurfacing of tight or painful scars. The authors assessed patients' satisfaction using a visual analog scale and scar appearance using a modified Vancouver Burn Index Scale. They evaluated the progress of wound healing by examining weekly punch-biopsy specimens with standard and immunohistochemical stains. Patients reported a 72 percent increase in range of movement, a 62 percent improvement in softness, and a 59 percent improvement in appearance compared with their preoperative states. Pruritus and dryness were the main complaints, and neither was improved much. Four distinct phases of dermal regeneration could be demonstrated histologically: imbibition, fibroblast migration, neovascularization, and remodeling and maturation. Full vascularization of the neodermis occurred at 4 weeks. The color of the wound reflected the state of neodermal vascularization. No adnexa, nerve endings, or elastic fibers were seen in any of the specimens. The new collagen was histologically indistinguishable from normal dermal collagen. The authors conclude that Integra is a useful tool in reconstructive surgery. The additional cost of its use can be justified by its distinct benefits compared with current methodology.

Turret exostosis of the thumb

Eighteen cases of turret exostoses of the hand have been reported, all associated with dorsal injuries. We present a case of turret exostosis involving the volar aspect of the thumb.

Primary flexor tendon repair in zone 1

This paper presents an analysis of the results of repair of 102 complete flexor tendon disruptions in zone 1 which were rehabilitated by an early active mobilization technique during a 7 year period from 1992 to 1998. These injuries were subdivided into: distal tendon divisions requiring reinsertion; more proximal tendon divisions but still distal to the A4 pulley; tendon divisions under or just proximal to the A4 pulley; and closed avulsions of the flexor digitorum profundus tendon from the distal phalanx. Assessment by Strickland's original criteria showed good and excellent results of 64%, 60%, 55% and 67% respectively in the four groups. However, examination of the results measuring the range of movement of the distal interphalangeal (DIP) joint alone provided a more realistic assessment of the affect of this injury on DIP joint function, with good and excellent results of only 50%, 46%, 50% and 22% respectively in the four groups.

Composite graft replacement of digital tips. 2. A study in children

This study investigated the outcome of composite graft replacement of 50 amputated digital tips in 50 children over a period of 3 years and 6 months. Eleven of 18 tips (61%) which were replaced within 5 hours survived completely while none of 32 digital tips replaced after 5 hours survived completely. This difference was highly significant. The mean delay time between amputation and replacement in the successful group was 3.9 hours and in the others was 7.2 hours. This difference was also statistically significant. The implications of the findings of this series to the use of this treatment are discussed.

Composite graft replacement of digital tips. 1. Before 1850 and after 1950

The successes of composite grafting of fingertips in the early years of plastic surgery have been repeated in the few studies of this treatment which have been reported during the last 50 years. The early and recent history of this subject are reviewed in the light of the increasingly pessimistic view of composite graft replacement of fingertips taken by recent reviewers.

The neurovascular Tranquilli-Leali flap

A modification of the flap first described in 1935 by Tranquilli-Leali and described again by Atasoy et al (1970) is presented. The relative indications for use of the original and the modified flap are examined in the light of our experience of 116 flaps over a period of 4 years.

The rupture rate of acute flexor tendon repairs mobilized by the controlled active motion regimen

A series of 233 patients with complete divisions of flexor tendons in zones 1 and 2 underwent operation following emergency admission over a period of 3.5 years. These included 203 patients with 317 divided tendons in 224 fingers injuries in zones 1 and 2 and 30 patients with 30 complete divisions of the flexor pollicis longus tendon in zones 1 and 2. All of these patients were mobilized post-operatively in a controlled active motion regimen. 13 (5.8%) fingers and five (16.6%) thumbs suffered tendon rupture during the post-operative period. Patients treated during the last year of the study were followed prospectively for a minimum period of 3 months; ten of the 16 (62.5%) fingers with zone 1 repairs, 50 of the 63 (79.4%) fingers with zone 2 repairs, all three (100%) FPL divisions in zone 1 and three of four (75%) FPL divisions in zone 2 had good and excellent results on assessment by the original Strickland criteria (Strickland and Glogovac, 1980). These results confirm the safety of this regimen as an alternative to other regimens of post-operative flexor tendon repair mobilization in zone 1 and 2 finger injuries. However, in the unmodified form used in this series, this regimen has too high a rupture rate for FPL mobilization.

A modification of the Zancolli reverse digital artery flap

Indications for the use of the reverse digital artery flap described by Zancolli are considered, with a modification to the technique which leaves a more acceptable donor defect in the palm of the hand.