Measurement of itching: validation of the Leuven Itch Scale

Objective

To develop the Leuven Itch Scale (LIS), which measures itching through evaluation of the dimensions of the itch experience; and to provide evidence of the validity, reliability, and responsiveness of the LIS.

Materials and methods

A clinimetric study using a longitudinal design. Patients with burns (n = 46), atopic dermatitis (n = 63), or chronic urticaria (n = 41) were included. Evidence for validity (based on test content, relations with other variables and internal structure), reliability and responsiveness of the LIS was evaluated.

Results

Validity evidence based on test content was demonstrated by very low percentages of invalid scores for most items. Validity evidence based on relations with other variables was found, because all hypotheses that were put forward could be accepted. With respect to validity evidence on internal structure, a significant moderate positive correlation was found between itch frequency and itch distress, and between itch frequency and severity. As hypothesized, itch severity and distress were strongly correlated. Test-retest reliability showed a moderate to almost perfect agreement for about half of the items. However, the remaining items could be subject to changes in the itch, rather than reflecting instability of the Leuven Itch Scale. In terms of responsiveness, the Leuven Itch Scale did not suffer from floor or ceiling effects and could detect changes in itch frequency in patients with burns.

Conclusion

The Leuven Itch Scale is a useful and clinimetrically sound instrument to measure pruritus in different patient populations affected by itching.     

Controversies in fluid resuscitation for burn management: literature review and our experience

The purpose of this review is to summarise the commonly used formulae for fluid resuscitation in major burns and to discuss the controversy surrounding the use of protein-based colloids as a component of these types of formulae. Fluid resuscitation in major burns is one of the most critical steps in managing this type of injury. In practice, a wide variety of formulae for fluid resuscitation has been suggested. Some propose only the use of crystalloids, while others combine the colloids together with crystalloids. A review was performed of the literature addressing fluid resuscitation formulae and our experience using our formula is presented. At the authors' burn centre a unique formula is in use, which combines plasma and crystalloids. Our experience using this specific formula extends over a period of 15 years and 356 patients with major burns have been resuscitated using this protocol. At our centre, 27 deaths were recorded, 19 of which had third degree burns of more than 80% total body surface area (TBSA). The protein-based colloids are included in most of the formulae and the beneficial effect is considered to be higher than the potential side effects. We are in favour of administering colloids during the resuscitation period for major burns, starting in the early period after injury.     

Determining transfusion use in major burn patients: A retrospective review and analysis from 2009 to 2019

Blood transfusion is an important treatment for patients with major burns. Understanding the predictive factors of blood product usage in major burns can improve effective transfusion therapy. We retrospectively reviewed the medical records of the Burn Center, First Affiliated Hospital of the Chinese Naval Military Medical University, from August 2009 to July 2019 and enrolled all patients with major burns treated in that decade. Basic information, condition, and blood-transfusion details of the patients were analyzed to identify predictive factors for blood use and prognosis. Despite a yearly decreasing trend, the frequency of use of blood-product usage in major burns was high at 57.72%, with 5.39 times and 28.76 units of blood usage per person. Burn area was the most important predictive factor for blood transfusion at different stages. Burn depth, combined with injury, age, and other factors, affected blood use. Blood use or volume correlated with prognosis; especially, platelet and cryoprecipitate use was significantly associated with increased mortality. Blood product usage in major burns patients is related not only to the clinical condition, but also to doctors' experience, which can predict prognosis. Blood use is associated with increased mortality, although we found no evidence of a causal association.     

Biosynthetic compound dressings--management of hand burns

To achieve optimal hand function, wound closure becomes the most important ingredient in hand burns. This study documents the use of a biosynthetic compound dressing (Biobrane) which has been fabricated as a glove for management of hand burns. The glove allowed rapid active motion and minimized the pain of open wounds. Forty-two Biobrane glove applications were evaluated with 50 per cent applied over superficial hand burns and 50 per cent over deep partial thickness or full thickness injuries. In the superficial hand burns, the patients were discharged home after a mean time of 2.8 days. With the deep burns the dressing provided a closed wound after early excision of eschar without the use of an autograft or biological dressing. Based on these studies, we conclude that the biosynthetic compound dressing glove is a useful adjunct to be added to the armamentarium for treatment of the burned hand.     

Ten-year Brisbane experience in petrol burns: a preventable health burden

Petrol is one of the most widely used and freely available fuels in use in developed countries today. This study examines the clinical details and demographics of adults with petrol burns over a 10-year period with a view to identifying any trends. The majority of petrol burns were due to human error and thus theoretically preventable. This study determined that the young male (aged 16-25) is most at risk, mainly through the misuse of petrol. The best method of prevention of these burns might be education targeting this group of population. This study provides a basis upon which effective intervention programmes can be designed.     

Chemical burns: A review

Chemical burns form a significant percentage of mortality from burns and total burns cases reported. There are over 65,000 chemicals available on the market, a large number of which can cause tissue damage. Despite this, they are often mismanaged. The severity of the chemical burn is dictated by the substance responsible, the percentage burn, the concentration, time since exposure, subsequent management and regional skin properties. Burns can be caused by both acids and alkalis. Acid burns cause eschars which limit the extent of the burn. Alkali burns therefore tend to be deeper. Like all burns, the patient should be resuscitated according to the Adult Trauma Life Support guidelines. Copious irrigation forms the mainstay of treatment. Neutralising agents are present for certain chemicals but their use should not delay the irrigation process which may take several hours. We look at the most common chemicals encountered in daily life and explore special considerations when dealing with resulting burns. Chemical burns are often associated with other injuries such as inhalation injury, so it is essential that the patient is considered holistically and all other injuries considered before concentrating all efforts on the chemical burn alone.     

The indications for Versajet<Superscript>®</Superscript> hydrosurgical debridement in burns

Versajet® (Smith and Nephew) is a hydrosurgical debridement tool that has been used in the debridement of burns. Versajet® debridement is expensive and time consuming; therefore, clear indications for its use in burns surgery are needed. A review of the literature followed by a prospective trial of ten consecutive burns patients was carried out to ascertain the indications for the use of Versajet® debridement in our department. Versajet® made an excellent tool at lower settings for cleaning late presentation paediatric scalds, the debridement of mixed-depth burns to allow dermal preservation and the debridement and/or excision of all thickness burns in anatomically difficult areas. Three indications for the use of Versajet® in our unit were developed: cleaning of late-presentation paediatric scalds to allow the application of Biobrane®, dermal preservation in mid-dermal paediatric burns and debridement of anatomically difficult burns. Each of these three indications is illustrated photographically with case reports.     

Epidemiology of domestic chemical burns in Saudi Arabia

The authors reviewed the domestic chemical injury experience in two major government hospitals in Saudi Arabia to determine the most common causative agents and the circumstances of the injury in order to give recommendations for their prevention and reduction of their morbidity. A total of 59 cases were included. The mean age was 25 years and the male to female ratio was 3:1. Alkali drain cleaners were the major cause of chemical burns in the series and this was seen in 75% of the total study population. The remaining 25% of cases resulted from concentrated sulfuric acid, car battery acid and topical application of medical herbs by non-professionals. Unfortunately, immediate water lavage was not done in the majority of alkali and acid burns and hence skin grafting was required in most patients. It was concluded that efforts for prevention of chemical burns in Saudi Arabia should be directed towards education of the population regarding the proper use of alkali cleaners for clogged drains. These cleaners and battery acid containers should also be kept in a safe place away from the reach of children. Furthermore, a warning to the public regarding the non-professional use of medical herbs should be given. Finally, increased awareness among the Saudi population as to the need for prompt water irrigation of chemical burns should help reduce the morbidity from these injuries.     

Prognostic scoring systems in burns: a review

Survival after burn has steadily improved over the last few decades. Patient mortality is, however, still the primary outcome measure for burn care. Scoring systems aim to use the most predictive premorbid and injury factors to yield an expected likelihood of death for a given patient. Age, burn surface area and inhalational injury remain the mainstays of burn prognostication, but their relative weighting varies between scoring systems. Biochemical markers may hold the key to predicting outcomes in burns. Alternatively, the incorporation of global scales such as those used in the general intensive care unit may have relevance in burn patients. Outcomes other than mortality are increasingly relevant, especially as mortality after burns continues to improve.The evolution of prognostic scoring in burns is reviewed with specific reference to the more widely regarded measures. Alternative approaches to burn prognostication are reviewed along with evidence for the use of outcomes other than mortality. The purpose and utility of prognostic scoring in general is discussed with relevance to its potential uses in audit, research and at the bedside.     

The Meek micrograft technique for burns; review on its outcomes: Searching for the superior skin grafting technique

IntroductionAutologous split thickness skin grafting is the standard-of-care for the majority of deep dermal and full thickness burns: Meshed grafting is most commonly used. Patients with extensive burn injuries have limited donor site availability. Meek micrografting is a well-known technique to enable larger expansions. A review was conducted on the outcomes of the Meek micrograft technique.MethodA database search in PubMed, Web of Science, Google Scholar and the Cochrane Library was conducted from the first Meek micrografting report in 1958 until 2021, including terms ‘burns’, ‘micrografting’ and/or ‘Meek’. Original papers reporting outcomes of Meek micrografting were included.Results1529 papers were identified and eventually 15 articles were included, the majority classified as poor quality according to Chambers criteria. 310 patients with 56% mean TBSA were described. Weighted averages were calculated for ‘graft take’ 82 ± 7%, ‘time to wound closure’ 53 ± 20 days and ‘length of hospital stay’ 61 ± 31 days. Scar quality was minimally described and often poorly assessed. Limited data were available on outcomes ‘donor site size’, ‘number of operations’, ‘cost effectiveness’ and ‘bacterial load/wound infection rate’.ConclusionOverall poor study quality and the specific lack of data on scar quality, made it impossible to draw conclusions on the outcomes of Meek micrografting. A randomized controlled trial is required to further investigate the performance of the Meek micrograft technique.     

Characteristics and aetiology of low-temperature burns in Beijing of China

This study was designed to analyse the characteristics and aetiology of low-temperature burns and explore the prevention and treatment strategies. In total, 206 patients hospitalised with low-temperature burns in a major burn center in Beijing from 2017 to 2021 were included. There were 35–49 cases per year, with an average of 41 ± 4.5 cases. The prevalence of low-temperature burns was higher in female than in male and are mainly resulted from two kinds of incidents: unintended burns from heat treatment (50.97%, 105/206) and improper use of heating devices to keep warm (43.69%, 90/206). Most cases occurred in autumn (33.01%, 68/206) and the least in spring (17.96%, 37/206); cases in summer (24.27%, 50/206) and winter (24.76%, 51/206) accounted for nearly a quadrant respectively. Low-temperature burns in summer were mainly unintended burns from heat treatment (80%, 40/50), whereas in autumn were mainly resulted from improper use of heating devices to keep warm (55.88%, 38/68), the difference was statistically significant (χ² = 42.801, P < .001). Of all the cases, the burn size ranged from 0.2% to 5% TBSA, mostly less than 1% (85.92%, 177/206); third-degree burns accounted for 98.54% (203/206). Patients admitted after 3 weeks post-injury accounted for 42.23% (87/206). All patients were cured, and most of them were by surgeries (70.87%, 146/206). The results of the study show that low-temperature burn injury features a predictable morbidity among different seasons, a higher prevalence in adult women and a frequent occurrence at home. The wounds of low-temperature burns are often small in size but deep in depth, and can be easily misdiagnosed as superficial burns. However, most low-temperature burn wounds require surgical treatment. The study also suggests that based on the characteristics and aetiology of low-temperature burns, targeted prevention and treatment measures should be mapped out.     

Management of facial burns with a collagen/glycosaminoglycan skin substitute-prospective experience with 12 consecutive patients with large, deep facial burns

Management of deep facial burns remains one of the greatest challenges in burn care. We have developed a protocol over the past 20 years for management of facial burns that includes excision and coverage with thick autograft. However, the results were not perfect. Deformities of the eyelids, nose and mouth as well as the prominence of skin graft junctures demonstrated the need to explore novel approaches. Integra has been used with success in the management of burns of the trunk and extremities. The purpose of this study was to prospectively evaluate the aesthetic outcome of the use of Integra for deep facial burns. Twelve consecutive patients underwent excision of large, deep facial burns and placement of Integra. Integra provides excellent color and minimally visible skin graft junctures. The texture is good but not as supple as thick autograft. Integra is not well suited for use in the coverage of eyelid burns due to the need to wait 2 weeks for adequate vascularization. In summary, thick autograft remains the gold standard for deep facial burns. However, for patients with extensive burns and limited donor sites, Integra provides an acceptable alternative.     

Classification of biomaterials and their related complications in abdominal wall hernia surgery

Summary The value of the use of biomaterials for the repair of abdominal wall hernias is gaining increasing recognition. The use of synthetic mesh to achieve a tension-free repair has resulted in a significant reduction in postoperative pain, in length of the recovery period, and in the number of recurrences. However, certain physical properties of biomaterials can lead to undesirable consequences. These include increased risk of infection, seroma formation, biomaterial-related intestinal obstruction, and fistula formation and failure of repair due to shrinkage of the mesh. The purpose of this paper is to discuss the mechanism of these problems with special emphasis on pore size, molecular permeation and shrinkage of biomaterials and their effects on infection, seroma formation, and recurrence of mesh repair of abdominal wall hernias.     

特重度腕部高压电烧伤治疗的改进

目的减少特重度腕部电烧伤截肢率。方法将１９８０年１月至１９９８年３月的１８０例２１６个上肢腕部高压电烧伤分为两个时期进行比较分析,病例按其伤情分为Ⅰ、Ⅱ、Ⅲ、Ⅳ四型,由于认识上的提高和全身治疗及创面修复方法上的改进,如早期综合用药预防血管栓塞,积极的血管重建和使用大网膜和皮瓣早期修复创面等。将两组各型腕部电烧伤治疗措施和最终的截肢率进行比较。结果１９８０～１９８９年及１９８９～１９９８年两个时期轻、中度腕部电烧伤（Ⅰ、Ⅱ型）截肢率保持为零,特重度腕部电烧伤截肢率由前一时期的８０％降至后一时期的３８９％。结论重建腕部血管通道、手术修复创面及综合治疗是减少特重度腕部电烧伤截肢率的有效方法。     

Structural alterations of prosthetic meshes in humans

The use of prosthetic mesh in abdominal wall hernia surgery is a well-accepted practice. What is not settled, however, is the type of prosthesis that best suits the purpose. The narrow choice today means a prosthesis of polyester or polypropylene. These are available in many designs, configuration of weave, thickness of weave and strand, and size of pore. There has been a pervasive feeling that these materials "shrink". To what extent they do has not been accurately defined. This study was designed to measure such "shrinkage". Interestingly, our measurements revealed that prosthetic meshes could "expand" as well as "shrink". The extent to which they do varies between –40% and 58.5%. Whereas it was felt that fibrocyte activity and its eventual scar formation accounted for the "shrinkage" of the mesh, we have discovered that structural alterations in the size of the mesh pores can be affected by distilled water, saline, blood, formalin, bleach, as well as in vivo implantation. Prosthetic meshes are, therefore, not the inert materials they are claimed to be and can expand as well as shrink. We have, unfortunately, not been able to correlate the degree or direction of change to any known parameter. Electronic Publication     

Management of burns of the perineum and buttocks

Twenty patients are reported who suffered acute thermal bums of the perineum and buttocks and were treated at the Shriners Burns Institute, Cincinnati Unit. Seventeen of the 20 patients had burns which resulted from ignition of clothing. The most common source of ignition was refuse fires. Ages ranged from 11 months to 12 years; 17 of the patients were males and 3 were females.Topical agents used to treat the perineal burns consisted of mafenide (Sulfamylon), gentamicin and silver sulphadiazine. All perineal burns were treated by the open technique. The whirlpool was used two times a day for cleansing and débriding the superficial eschar. Initial wound care, in addition to hydrotherapy, consisted of cleaning the perineum twice a day with a mixture of saline, peroxide and ‘Dreft’, after which the topical agent was applied. Once the eschar was removed, the wounds were prepared for grafting by the use of porcine xenografts or cadaver allografts. Meshed skin grafts were used for final coverage.Pseudomonas aeruginosa was the most common organism recovered; Escherichia coli was a close second. Follow-up on these patients revealed that late complications of the buttocks and perineum were minimal. A colostomy was performed in 1 of the 20 patients. This experience indicated that colostomy is not necessary for the handling of perineal burns and that involvement of the perineum in acute burns can be handled by relatively simple means.     

Prevention oriented epidemiologic study of accidental burns in rural areas of Ardabil, Iran

PURPOSE OF STUDY: Burns are one of the leading causes of injury-related deaths in Iran. We conducted a study to investigate features of burns in rural areas of Ardabil Province from October 2004 through March 2005, with an aim to providing content for effective prevention programs. BASIC PROCEDURES: This study employed longitudinal prospective methodology. The study population included all patients presenting with burns to local health care facilities during the study period. MAIN FINDINGS: A total of 1179 cases were studied. Most of the cases (59.4%) were females. Mean of age of victims was 22.3+/-19 years in females and 13.6+/-17 years in males. The vast majority (91.2%) of burns occurred at home. More than two-thirds of burns were because of hot liquids or steam. The majority of scald burns resulted during use of heating devices such as samovars, gas stoves, valors and picnic gas stoves. Overturning and spilling of hot liquids were the most common injury mechanisms. PRINCIPLE CONCLUSIONS: Prevention programs should focus on children and adult women. Prevention efforts should target home environments and focus on prevention of scalding burns.     

The true cost of burn

It is difficult to define the true cost of a burns injury, however there has always been a consensus that the costs associated with burns care are high. This study aims to achieve an accurate calculation of the cost of acute burns care in an Australian context. A retrospective review of 20 adult burn patients treated at our Centre was performed. An itemized price list was prepared based on items, services and equipment actually utilized in the care of burns patients. Case records were reviewed for a count of quantities to calculate costs for each item. Regression analysis was performed to produce a cost vs %TBSA curve for cost prediction. A cost breakdown was also performed for analysis of the most significant areas of expenditure and their trends with %TBSA. The cost calculated for an average adult burns patient was AU$71,056 (US$73,532). The total cost of all 20 patients was AU$2,449,112 (US$2,534,464). %TBSA injured was confirmed as the primary determinant of cost. Hospital length of stay, operative costs, dressings and staffing were found to be the most significant components of cost and increased most prominently with %TBSA. Compared to our findings, expenditure for prevention and education programs is minimal. There is limited conclusive evidence that changes in management protocols have had successful impact on the cost of burns treatment. Future progress in burns management may effect factors such as hospital length of stay, however until such changes, resource allocation should recognize the importance of prevention and its success at reduction of injury severity for real reductions in cost of burns care.     

Perineal hernia,another incisional hernia?

A secondary perineal hernia is a type of incisional hernia of the pelvic floor, occurring after pelvic surgery such as abdominoperineal excision of the rectum and pelvic exenteration. Our aim is to review the available literature on the subject. This report reviews a recently repaired case, followed by a review of the available literature on the presenting condition, concentrating on approaches and methods of repair. Perineal hernias are uncommon, and not many surgeons face them. It is not known if and how these hernias could be prevented. The method and approach of repair should probably be individualized, but we believe that the use of a mesh is important in the repair of such hernias because of the significant tissue defect prevailing in most of the cases, in addition to the unhealthy tissues related to the use of radiotherapy. The laparoscopic approach has been recently utilized and its use is expected to increase.