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Introduction: The aim of this study was to investigate the efficacy of limiting increases in theatre ambient temperature to 27°C to prevent intraoperative patient hypothermia., Methods: This single-centre, comparative cohort clinical study investigated the management of theatre ambient temperatures involving patients with ≥ 20 % TBSA burn injuries at Victorian Adult Burns Service (Melbourne, Australia). Data from the intervention group (August 2021 - February 2023, theatre ambient temperature increase limited to 27°C) was compared with a historical cohort (August 2019 - August 2021). Patient hypothermia was defined as core temperature below 36°C., Results: In total, 29 patients underwent 107 surgical procedures in the operating theatre. Patient hypothermia was recorded on 45 occasions (42.1 %) and of these, between 35.1 and 36.0°C on 28 occasions (62.2 %). There was no statistically significant difference in the incidence of hypothermia, hospital LOS, ICU LOS, total operations, or mortality between the study cohort and historical cohort. Patients who suffered hypothermia had lower BMI, lower preoperative temperature, and shorter ICU LOS., Conclusion: Increasing theatre ambient temperature to 27°C is adequate in most cases. A more nuanced approach with selective increase of theatre ambient temperature beyond 27°C, only where clinically indicated, is a refinement that will benefit both patients and staff., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Crown Copyright © 2024. Published by Elsevier Ltd. All rights reserved.)

Introduction: This study interrogates infection related data in the Burns Registry of Australia and New Zealand (BRANZ), to examine associations of multi-drug resistant organisms (MDROs) and blood stream infection (BSI)., Methods: Data between July 2016 and June 2021 were analysed to determine prevalence, risk factors and outcomes associated with BSIs and MDROs: Methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), carbapenem-resistant Pseudomonas spp. (CRP), and carbapenem-resistant Enterobacter (CRE). Data completeness and value for quality improvement activity were assessed., Results: We found a low incidence (3.4%) of the resistant organisms of interest, and no change over the study period. Fequency varied between services and increased with age and size of burn. MRSA was the commonest organism in all age groups. A positive BSI result occurred in 1.6% of patients (12.1% of cultures taken) at a median time of 10.2 days post injury. Free text identification of organisms was inconsistently documented., Conclusions: The low rate and patterns of acquisition of MDROs of interest and BSIs is comparable with reports from countries with low incidence of massive burns. Wider adoption of a standardized laboratory reporting framework would help realise the potential of clinical quality registries to provide data which supports evidence based infection prevention initiatives., Competing Interests: COI statement – Burns none., (Crown Copyright © 2024. Published by Elsevier Ltd. All rights reserved.)

Introduction: The Surviving Sepsis Campaign was developed to improve outcomes for all patients with sepsis. Despite sepsis being the primary cause of death after thermal injury, burns have always been excluded from the Surviving Sepsis efforts. To improve sepsis outcomes in burn patients, an international group of burn experts developed the Surviving Sepsis After Burn Campaign (SSABC) as a testable guideline to improve burn sepsis outcomes., Methods: The International Society for Burn Injuries (ISBI) reached out to regional or national burn organizations to recommend members to participate in the program. Two members of the ISBI developed specific "patient/population, intervention, comparison and outcome" (PICO) questions that paralleled the 2021 Surviving Sepsis Campaign [1]. SSABC participants were asked to search the current literature and rate its quality for each topic. At the Congress of the ISBI, in Guadalajara, Mexico, August 28, 2022, a majority of the participants met to create "statements" based on the literature. The "summary statements" were then sent to all members for comment with the hope of developing an 80% consensus. After four reviews, a consensus statement for each topic was created or "no consensus" was reported., Results: The committee developed sixty statements within fourteen topics that provide guidance for the early treatment of sepsis in burn patients. These statements should be used to improve the care of sepsis in burn patients. The statements should not be considered as "static" comments but should rather be used as guidelines for future testing of the best treatments for sepsis in burn patients. They should be updated on a regular basis., Conclusion: Members of the burn community from the around the world have developed the Surviving Sepsis After Burn Campaign guidelines with the goal of improving the outcome of sepsis in burn patients., Competing Interests: Declaration of Competing Interest Kevin Chung is Chief Medical Officer for SeaStar Medical, Denver, Colorado. No other author has declared a conflict of interest related to the publication., (Copyright © 2023 Elsevier Ltd and International Society of Burns Injuries. All rights reserved.)

Introduction: Patients with severe burns (≥20 % total body surface area [TBSA]) have specific and time sensitive needs on arrival to the burn centre. Burn care systems in Australia and New Zealand are organised differently during weekday business hours compared to overnight and weekends. The aims of this study were to compare the profile of adult patients with severe burns admitted during business hours with patients admitted out of hours and to quantify the association between time of admission and in-hospital outcomes in the Australian and New Zealand context., Methods: Data were extracted from the Burns Registry of Australia and New Zealand for adults (≥18 years) with severe burns admitted to Australian or New Zealand burn centres between July 2016 and June 2020. Differences in patient profiles, clinical management, and in-hospital outcomes were investigated. Univariable and multivariable logistic and linear regression models were used to quantify associations between time of admission and in-hospital outcomes of interest., Results: We found 623 patients eligible for inclusion. Most patients were admitted out of hours (69.2 %), their median age was 42 years, and most were male (78 %). The median size burn was 30 % TBSA and 32 % of patients had an inhalation injury. A greater proportion of patients admitted out of hours had alcohol and/or drugs involved with injury compared to patients admitted during business hours. No other differences between groups were observed. Patients in both groups had similar odds of dying in hospital (Odds Ratio [OR], 95 % Confidence Interval [95 %CI] 1.49 [0.64, 3.48]), developing acute kidney injury within 72 h (OR, 95 %CI 0.58 [0.32, 1.07]), or sepsis (OR, 95 %CI 1.04 [0.46, 2.35]). No association was found between time of admission and hospital (%, 95 %CI 1.00 [0.82, 1.23]) nor intensive care length of stay (%, 95 %CI 0.97 [0.73, 1.27])., Discussion: In this first Australian and/or New Zealand study to explore the association between time of admission and burn patient in-hospital outcomes, out of hours admission was not associated with patient outcomes of interest., Conclusion: These findings support current models of care in Australian and New Zealand burn centres, however further investigation is required. Nonetheless, given most severe burns patients arrive out of hours to burn the centre, it is plausible that out of hours availability of senior burn clinicians will improve patient care and safety resilience within burn care systems., Competing Interests: Conflict of interest statement The authors declare they have no competing interests., (Copyright © 2022 International Society of Burns Injuries. All rights reserved.)

Introduction: Scalds from hot tap water can have devastating consequences and lifelong impact on survivors. The aims of this study were to (i) describe the frequency, demographic profile, injury event characteristics, and in-hospital outcomes for people with tap water scalds admitted to Australian and New Zealand burn centres; and (ii) determine whether variation was present in the frequency and epidemiological characteristics of tap water scalds between jurisdictions., Methods: Data were extracted from the Burns Registry of Australia and New Zealand for people with tap water scalds admitted to Australian or New Zealand burn centres between January 1, 2010 and December 31, 2018. Demographic, injury severity and event characteristics, surgical intervention, and in-hospital outcomes were investigated., Results: We included 650 people with tap water scalds admitted to Australian and New Zealand burn centres during the study period. Australians with tap water scalds (median [IQR] 29 [1-69] years) were older than New Zealanders (2 [1-36] years). Most tap water scalds occurred in the home, and 92% of these occurred in the bathroom. More than 55% of injuries occurred due to the accidental alteration of water temperature at the tap fixture. Two thirds of patients underwent a surgical wound procedure. The overall mortality rate was 3.7%, and the median hospital length of stay was 8.8 days., Conclusion: Tap water scalds remain a public health problem in Australia and New Zealand. Our research highlights where gaps in current heated water regulations in residential homes perpetuate risks of tap water scalds, particularly in high-risk groups at the extremes of age. Extending current heated water regulations to include all Australia and New Zealand homes is urgently needed in conjunction with design safety improvements, and ongoing education of key stakeholders., (Crown Copyright © 2021. Published by Elsevier Ltd. All rights reserved.)

Introduction: For extensive burns, autologous donor skin may be insufficient for early debridement and grafting in a single stage. A novel, synthetic polyurethane dermal template (NovoSorb® Biodegradable Temporising Matrix, BTM) was developed to address this need. The aim of this study was to evaluate use of BTM for primary dermal repair after deep burn injury., Methods: A multicentre, prospective, clinical study was conducted from September 2015 to May 2018. The primary endpoint was % split skin graft take over applied BTM at 7-10 days after grafting. Secondary endpoints included % BTM take, incidence of infection and adverse events, and scar quality to 12 months after BTM application., Results: Thirty patients were treated with BTM and delayed split skin grafting. The % graft take had a mean of 81.9% and % BTM take had a mean of 88.6%, demonstrating effective integration of BTM. When managed appropriately, it was possible for BTM to integrate successfully despite findings suggestive of infection. Scar quality improved over time., Discussion: These results provide additional clinical evidence on the safety and performance of BTM as an effective dermal substitute in the treatment of patients with deep burn injuries., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objectives: To describe incidence and characteristics of hospital presentations and deaths due to burn injury in the Australian state of Victoria from 2008 to 2017 and identify trends in incidence and patterns., Methods: Three population-based datasets were used to ascertain burn-related hospital admissions, emergency department presentations, and deaths. These were the Victorian Admitted Episodes Dataset (VAED), Victorian Emergency Minimum Dataset (VEMD), and the Cause of Death-Unit Record File (COD-URF), respectively. Descriptive statistics on demographics (age and gender), burn injury characteristics (intent, cause, burn size and body region) and hospital burden (length of stay (LOS) and costs) were used to present the profile of patients. Incidence rates by age, gender and intent were calculated. Trend analysis on incidence was carried out using forced Poisson Regression models with the natural logarithm of the annual populations as an offset. Incident rate ratios were used to interpret the models. Risk ratios were used to compare the risk differences between population sub-groups. A negative binomial model was used to test the association between LOS and age and the total body surface area (TBSA) of the burn., Results: Overall males had higher rates of death, admission and ED presentation. For adults, the elderly had the highest rates of deaths and admissions while for children, the very young had highest rates for admissions and presentations. Exposure to smoke, fire and flames was the most common cause of deaths, and contact with heat and hot substances was most common among ED presentations. The elderly and those with Total Body Surface Area (TBSA) burn ≥20% had a higher risk of longer hospital stay. Rates of severe burns and deaths from burns remained stable during the study period in the setting of an annual 2% increase in population. Paediatric hospital admission rates decreased over time., Conclusion: The risk of sustaining burn injury, the types of burn and outcomes, varied by age and gender. We found evidence of a limited decrease in burn injury rates in some sub-groups: appropriate and effective targeted prevention strategies for burns are needed to avoid the significant short and long-term suffering experienced., (Copyright © 2021 Elsevier Ltd and ISBI. All rights reserved.)

Introduction: An emerging amount of literature emphasises the ever-growing shortage of burn surgeons worldwide. Despite burn surgery being a fundamental competency in the Australia and New Zealand plastic and reconstructive surgery training curriculum, a perceived lack of interest amongst trainees exists. The aim of this study was to investigate Australasian plastic surgery trainees' interest in burn surgery as a career and compare with the Brown and Mills survey in 2004., Methods: An electronic survey was distributed to all Australian and New Zealand plastic and reconstructive surgery trainees during the March 2021 registrar trainee conference. This anonymous survey was adapted from the original survey conducted by Brown and Mills in 2004, with additional questions to determine the perceived importance of burns surgery as a subspecialty of plastic and reconstructive surgery, and to elicit possible solutions to the issue of workforce shortage. A reminder email was sent one month following the conference to improve the response rate. The survey was hosted by Survey Monkey (San Mateo, California, USA)., Results: The survey was distributed to all 121 trainees and 71 (58.7%) responded. An increase in interest amongst trainees in pursuing a career in burn surgery was found, with 34 trainees (48.6% of respondents) interested, mostly on a half time or sessional basis. The three most common barriers to practising burn surgery remain unchanged, and were nature of burn operations, nature of burn care and on-call commitments; inadequacy of exposure or training ranked fourth. We found a strong overall response that burn surgery and burn care remained an important component of plastic and reconstructive surgery., Discussion: Inadequate exposure or training has evolved to present a bigger barrier in this study compared to a similar study conducted 17 years ago. Burn units and training bodies may offer additional job placements to address these feelings of insufficient exposure. Facilitating employment of burn surgeons on a half-time or sessional capacity is a sustainable model, and will arguably improve clinical service provision. Strong and early mentorship and allocation of commensurate resources and funding will help to address the high workload., Conclusions: Interest in burn surgery has improved over the last 17 years and the most common deterrents persist, namely nature of burn operations, nature of burn care and on-call commitments. However, many of these issues are modifiable or amenable to change. The opportunity exists for relevant stakeholders to address some of these concerns raised, and thereby addressing the issue of burn surgeon shortage., (Copyright © 2021 Elsevier Ltd and ISBI. All rights reserved.)

Background: Severe burns are accompanied by an acute and prolonged hypermetabolic response typified by elevated levels of proinflammatory cytokines and acute phase proteins. When persistent, this inflammatory response can result in multi-organ dysfunction and death. Regarded as the standard of care, early removal of devitalised tissue and eschar mitigates this hypermetabolic response. Ascertaining the optimal time point for early excision, which remains controversial, has several clinical implications., Methods: This retrospective observational study included 836 adult thermal burns patients with total burned surface area ≥20% from all Burns Registry of Australia and New Zealand (BRANZ) Hospital sites, including the Victorian Adult Burns Service (VABS), from July 1 2009 to June 30 2018. Patients were divided into two groups, "early" and "delayed", based on a 24-hour excision cut-off from when the injury occurred. Outcome measurements included mortality, hospital length of stay, intensive care unit length of stay, ventilation requirements and the incidence of positive blood cultures., Results: Among all patients at BRANZ sites, excision within 24 h was associated with reduced mean length of ICU stay (6.6 ± 8.1 vs. 9.2 ± 10.6 days; p = 0.008) and lower mean mechanical ventilator hourly use (94.9 ± 160.8 vs. 159.2 ± 219.1 h; p = 0.001) in the 20-29% TBSA sub-group. Beyond this, no significant differences were observed in outcome measurements., Conclusions: While it is physiologically important to perform early burn wound excision to mitigate the inflammatory response, delaying excision beyond 24 h for surgical planning, possibly up to 72 h after injury, may be a reasonable approach for certain patient groups., (Copyright © 2020 Elsevier Ltd and ISBI. All rights reserved.)

Background: In 2009, the Burns Registry of Australia and New Zealand (BRANZ) published a set of clinical quality indicators (QIs) to monitor performance, improve quality of care, and inform and change policy. With several years of data collected since the initial development of the indicators for burns, the BRANZ QI Working Party reviewed the clinical QIs for relevance and meaning, and considered new QIs that had not been collected previously., Method: Using published literature and expert opinion, the QI Working Party, consisting of multidisciplinary burn clinicians, reviewed the QIs for burn care to be included as routine data items in the BRANZ., Results: In July 2016, the list of clinical QIs in the BRANZ was updated to 23 QIs/data items, covering structure, process, and outcome measures. Four QIs were removed as they were not found to be useful, nine QIs/data items were revised, and eight new QIs/data items were added as they were considered to be clinically useful., Conclusion: This review outlines the changes made to the QIs collected by the BRANZ four years since their development and implementation. Ongoing refinement of the BRANZ QIs will ensure that high quality data is collected to drive improvements in clinical and patient outcomes., (Copyright © 2020. Published by Elsevier Ltd.)

Background: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare life-threatening hypersensitivity conditions associated with epidermal detachment and mucositis. The indication for flexible nasoendoscopy (FNE) and overall predictive factors for early intubation are unclear., Objectives: To describe the incidence of airway involvement and the key indicators for intubation in our SJS or TEN patient cohort. To determine the association between FNE findings and early intubation., Methods: A retrospective review of 45 patients with biopsy proven SJS or TEN admitted to an Australian tertiary burns centre from 2010 to 2017., Results: Thirty-five patients were diagnosed with TEN (77.8%), followed by overlap syndrome (SJS-TEN) (n = 6, 13.3%) and SJS (n = 4, 8.9%). Twenty (44.4%) patients were intubated; and all 20 had a diagnosis of TEN (100.0%) (p < 0.05). Intubated patients had a higher increase in total body surface area percentage(%) from day 1-3 [10.0% (IQR 0.0-23.8%)] and a longer length of stay [26.0 days (IQR 12.5-34.0)], compared to non-intubated patients [0.0% (IQR 0.0-4.0%)], [10.0 days (IQR 6.0-14.0)] (p < 0.05) respectively. The main indications for intubation were to facilitate operative and dressing management (47.4%) followed by airway involvement (26.3%). FNE was performed on 32 patients (71.1%), however FNE findings did not significantly influence intubation rates., Conclusion: More than half (n = 20, 57.1%) of the 35 patients diagnosed with TEN underwent intubation, mainly to facilitate operative and dressing management. FNE was performed on most patients, however there was no clear association between FNE findings and early intubation., (Crown Copyright © 2019. Published by Elsevier Ltd. All rights reserved.)

Introduction: Psychosocial risk and protective factors specific to acute burn patients have been shown to impact on longer-term health outcomes. Yet the nature and impact of such factors throughout the acute hospital admission phase have not been extensively examined to date. This study analysed the psychosocial pre-admission, hospitalisation and discharge factors for a sample of burn patients at an Australian specialist acute burns unit (The Alfred) and the relationship with their admission length., Methods: A retrospective audit was undertaken of psychosocial factors documented in patient medical records, Victorian Adult Burns Service registry data, and social work files (January-December 2014)., Results: Two hundred and forty-nine patients were identified, with a mean age of 42.83 years and a preponderance of men (73.9%). The majority (71%) had a low burn severity (<10%), and an average of eight psychosocial factors. Independent of the severity of the burn, two psychosocial domains were strongly predictive of length of stay - coping with treatment and discharge planning - along with pre-existing psychosocial factors and family support., Conclusion: A diversity of psychosocial factors was identified, highlighting the clinical complexity of this patient group. Given three domains of admission-related psychosocial factors were predictive of the length of patient stay, more targeted psychosocial interventions in these areas may ensure patients and their families are supported more effectively throughout an admission, and length of stay costs may also be reduced., (Copyright © 2019 Elsevier Ltd and ISBI. All rights reserved.)

Introduction: Studies describing the epidemiology of severe burns (>20% total body surface area) in adults are limited despite the extensive associated morbidity and mortality. This study aimed to describe the epidemiology of severe burn injuries admitted to burn centres in Australia and New Zealand., Materials and Methods: Data from the Burns Registry of Australia and New Zealand (BRANZ) were used in this study. Patients were eligible for inclusion if they were admitted between August 2009 and June 2013, were adults (18-years or older), and had burns of 20% total body surface area (TBSA) or greater. Demographics, burn characteristics and in-hospital mortality risk factors were investigated using multivariable Cox proportional hazards analysis., Results: There were 496 BRANZ registered patients who met the inclusion criteria. Over half of the patients were aged 18-40 years and most were male. The median (IQR) TBSA was 31 (25-47). Most (75%) patients had burns involving <50% TBSA, 58% sustained their burn injury at home, and 86% had sustained flame burns. Leisure activities, working for income and preparing food together accounted for over 48% of the activities undertaken at the time of injury. The in-hospital mortality rate was 17% and the median (IQR) length of stay was 24 (12-44) days. Seventy-two percent were admitted to an intensive care unit (ICU) and 40% of patients had an associated inhalation injury. Alcohol and/or drug involvement was suspected in 25% of cases., Conclusion: This study describes the demographics, burn injury characteristics and in-hospital outcomes of severe burn injuries in adults whilst also identifying key predictors of inpatient mortality. Key findings included the over-representation of young males, intentional self-harm injuries and flame as a cause of burns and highlights high risk groups to help aid in the development of targeted prevention strategies., (Copyright © 2019. Published by Elsevier Ltd.)

Background: A high prevalence of self-inflicted burn injury is noted in severe burn injury. It remains unclear as to whether gender and past psychiatric history impact upon whether injury is self-inflicted and the outcomes., Aims: Review the psychiatric history of patients treated in a statewide burn service following severe burn injury and determine whether psychiatric history, extent of burn and mortality are impacted by gender and whether the injury was self-inflicted., Method: A data linkage study was performed with psychiatric history and mental health service contact data matched to patients' data collected via a previous retrospective file audit. Unadjusted and adjusted logistic regression modelling measured interactions between gender and self-inflicted burn status, and other study outcomes., Results: In total, 298 patients (47 with a self-inflicted burn) were admitted following a severe burn. Patients with self-inflicted burns were significantly more likely to have total body surface area burn of at least 50% (OR=9.3; 95%CI: 4.7-18.5) and die within 24h of admission (OR=10.5; 95%CI:4.7-23.2). They were significantly more likely to have a past psychiatric diagnosis and public mental health service contact in the month pre-injury (OR=18.9; 95%CI: 7.5-47.2). Male patients had significantly lower rates of a psychiatric diagnosis and recent mental health service contact. Males with self-inflicted injury are far more likely to die than males with a non-self-inflicted injury., Conclusions: Psychiatric clinicians should assertively screen the psychiatric history of patients with severe burn injury, and participate in the acute and longer-term management of persons admitted with a self-inflicted burn., (Copyright © 2018 Elsevier Ltd and ISBI. All rights reserved.)

Background: Burn injuries to workers can have a devastating impact, however knowledge of the epidemiology of work-related burn injuries in Australia and New Zealand is limited., Purpose: To describe epidemiological characteristics of work-related burn injuries in Australia and New Zealand, and to compare these with non-work-related burns., Methods: Adult burn injury data, 2009-2016, were extracted from the Burns Registry of Australia and New Zealand. Descriptive statistics were used to describe demographic, injury, management and outcome characteristics. Differences between work-related and non-work-related injuries were assessed using Chi-square and Wilcoxon rank-sum tests., Results: Of 10,574 adult patients treated in burn centres in Australia and New Zealand, 2009-2016, 17% had work-related burns. Most work-related cases were male (85%), less than 35 years old (53%), and had sustained flame (33%), scald (30%) or chemicals (17%) burns. Proportions of chemical, scald and electrical burns were greater for work-related than for non-work-related burns, with this being most marked for chemical and electrical burns (17% vs. 3% and 7% vs. 1%, respectively)., Conclusions: Almost one in five cases of working-aged people admitted to Australian and New Zealand burns centres was work-related. Through identification of vulnerable groups, this study informs policy and strategies to minimise occupational burn risk., (Copyright © 2018 Elsevier Ltd and ISBI. All rights reserved.)

Objective: Diphoterine is a hypertonic, amphoteric, polyvalent and chelating decontamination solution used in the treatment of cutaneous and ocular chemical burns. Due to infrequent use by emergency physicians along with the small number of available studies, its debate in the literature as to its efficacy and safety remains inconclusive., Methods: A structured literature search was performed in MEDLINE, EMBASE BIOLOGICAL ABSTRACTS and TOXNET to June 2016 for original English-language studies reporting on the safety and effectiveness of Diphoterine. Methodological and reporting quality of pre-clinical animal studies was assessed using the Systematic Review Centre for Laboratory Animal Experimentation (SYRCLE) risk of bias tool and Animal Research: Reporting of In Vivo Experiments (ARRIVE) guidelines. Clinical studies were assessed using Chambers' criteria., Results: 13 studies (seven in the pre-clinical, five in the clinical setting and one mixed) met the study inclusion criteria. Pre-clinical studies showed a faster resolution of pH and reduced tissue necrosis with Diphoterine. Clinical studies showed reduced tissue necrosis/severity of symptoms, faster pH resolution and a reduction in pain when using Diphoterine. No adverse events were attributable to Diphoterine. Reporting and methodology of the studies was poor or showed a high risk of bias., Conclusions: Diphoterine appears to be safe to use and is probably superior to other rinsing solutions. However, immediate decontamination is imperative and if Diphoterine is not available a different rinsing solution should be used. The methodology of the published literature for Diphoterine is generally poor and future publications should use the frameworks given as templates., (Crown Copyright © 2017. Published by Elsevier Ltd. All rights reserved.)

Background: Early excision of burns reduces the incidence of local and systemic infections caused by colonising microorganisms, and reduces mortality and length of hospital stay. Appropriate antibiotic prophylaxis can reduce the risk of postoperative wound infections and skin graft loss. Antibiotic selection should be based on likely pathogens. However, there are few studies that have investigated the early pathogenic colonisers of acute burn wounds., Aim: To describe pathogenic microorganisms found in acute burns and to make further recommendations on the use of early perioperative prophylactic antibiotics., Methods: All burns patients admitted at the tertiary adult burns centre in Victoria over a 2-year period, who had surface swabs or tissue samples obtained from wounds within 24h of injury were included in this retrospective cohort study. Pathogenic organisms were examined with respect to patient characteristics, burn characteristics, treatment provided and immediate exposure to environmental contaminants., Results: Nearly one third of burns patients had wounds colonised with pathogenic microorganisms. Gram-negative bacteria were isolated from 52% of these. Staphylococcus aureus was the most common isolate. Pseudomonas and Enterobacter species were the most common gram-negatives. The only independent risk factor associated with early colonisation with gram-negative bacteria was per cent TBSA burn., Conclusion: Increased colonisation of acute burn wounds with pathogenic gram-negative bacteria was associated with increased size of burn., (Copyright © 2017 Elsevier Ltd and ISBI. All rights reserved.)

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., (Copyright © 2016 Elsevier Ltd and ISBI. All rights reserved.)

Background: Artificial dermal templates play an important role in physiologic wound closure after injury. In addition to contributing to stable, durable and flexible wound closure, they provide a scaffold for tissue repair. Several dermal templates are commercially available, with animal-derived Integra(®) dermal regeneration template perhaps the most widely used. NovoSorb™ Biodegradable Temporising Matrix (BTM) is a fully synthetic alternative that eliminates any risk of cross-species residual antigenicity. In this study, we aimed to compare early response after application of NovoSorb™ BTM with Integra(®) in terms of temporary wound closure, host cell infiltration, neovascularisation and collagen deposition in a mouse model., Methods: Twenty athymic nude mice received full-thickness skin excision followed by grafting of the dermal template (n=10 NovoSorb™ BTM, n=10 Integra(®)), with the grafts excised and assessed after two weeks., Results: All twenty mice achieved temporary wound closure with no evidence of wound contracture. Microscopically, all twenty grafts became infiltrated with host cells along the entire length of the template, with NovoSorb™ BTM demonstrating a particular abundance of host inflammatory cells. Evidence of new collagen deposition and neovascularisation was observed in both templates, with NovoSorb™ BTM demonstrating a more extensive vascular network at this time point. However, a greater inflammatory response was also observed in the NovoSorb™ BTM grafts at this time point., Conclusions: In this study, NovoSorb™ BTM demonstrates favourable properties as a dermal template, but further investigation is required to assess the significance of the differing inflammatory and vascular response to its implantation compared with Integra(®)., (Copyright © 2016 Elsevier Ltd and ISBI. All rights reserved.)

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., (Copyright © 2015 Elsevier Ltd and ISBI. All rights reserved.)

Aims: To report on the use of Biobrane, a synthetic skin substitute, as a temporary wound cover in patients with severe burn. In particular we wished to examine the role of Biobrane in maintaining a healthy wound bed following surgical excision and identify factors associated with regrafting., Methods: A retrospective case series review was performed on patients with severe burns (≥ 20% TBSA), admitted to the Victorian Adult Burns Service, in Melbourne, from January 2009 to June 2012. Logistic regression analysis was performed to identify factors associated with regrafting., Results: Out of 58 patients with median %TBSA burn of 30%, 22 patients (37.9%) required regrafting of at least one area previously treated with Biobrane and split-skin graft. On univariate analysis, need for regrafting was significantly associated with increasing %TBSA (OR 1.04, 95% CI: 1.01-1.08; p=0.02); and after multivariate analysis to adjust for this effect, hospital LOS (OR 1.04, 95% CI: 1.02-1.07; p=0.001); total operative time (OR 1.16, 95% CI; 1.06-1.28; p=0.002) and total number of surgeries (OR 1.69, 95% CI: 1.27-2.26, p<0.001) remained significantly associated with regrafting. Age, gender, time to surgical debridement and Biobrane application, and anatomical region were not found to be associated with regraft., Conclusion: At our institution, Biobrane has emerged as an alternative option to maintain a healthy wound bed after burn excision and prior to grafting. Our small number of extensive graft failures, small areas of regrafting and low infection rate following Biobrane application reflects our current experience with Biobrane. Precise indications and most appropriate methods for Biobrane use are yet to be established., (Copyright © 2014. Published by Elsevier Ltd.)

Background: In Australia and New Zealand (ANZ), health care is provided for ∼26 million people dispersed across the eight million square kilometres of the two countries. Providing optimal care prior to and during transfer across such vast distances is challenging. Lengthening the time taken to definitive burn care has a negative impact on burn outcome. The aims of this study were to determine if transfer time and admission pathway influenced burn mortality and to identify the factors predicting burn mortality in ANZ., Method: The study included all adult burn patient admission data from 15 of 17 burn services submitted to the Australian and New Zealand Burn Association bi-national registry (2010-2012). Multivariate logistic regression analyses were conducted to address the study aims., Results: Of the 2892 patients, 69 (2.4%) died following burn. Time to admission and direct admission to a burn centre did not independently influence burn mortality except when patients with inhalation injury took >16 h to transfer to definitive care. The risk of death was increased 5.7 times in the presence of inhalation injury. Burn size and age amplified the risk of death while gender did not., Conclusion: In ANZ, pre-hospital transport systems and peripheral hospital stabilisation were not associated with an increased risk of death due to burn except when inhalation injury was present. The results of this study indicate that burn patients with inhalation injury should be stabilised and transferred to a burn service within 16 h of burn., (Copyright © 2015 Elsevier Ltd and ISBI. All rights reserved.)

Introduction: Our aim was to provide descriptive information to burn clinicians, who have extensive experience treating major burns and determining prognosis, as to whether significant differences in mortality exist between major burns injuries and the comparatively less common toxic epidermal necrolysis for a given age and total body surface area percentage., Methods: Retrospective data was analyzed of all deceased patients admitted to the Victorian Adult Burns Service in Melbourne, Australia over a period of 10 years with greater than 30% total body surface area burned or greater than 30% total body surface area epidermal detachment in the case of toxic epidermal necrolysis. Retrospective data was also collected on all patients, survivors and deceased, with toxic epidermal necrolysis and these patients were matched with burns patients by age and % total body surface area burned. Comparisons in outcomes were performed with mortality being the primary variable of interest., Results: Toxic epidermal necrolysis patients that died were older (median: 68.5 vs 57 yrs; P=0.04), had a longer length of hospital stay (36.5 vs 0.8 days; P=0.001) and significantly longer periods of mechanical ventilation (1404 vs 14.5h; P=0.011) than major burns patients that died. When toxic epidermal necrolysis patients were matched to major burns patients by age and total body surface area burned, there were no significant differences between the two groups with respect to mortality., Conclusion: Palliative care approaches are more frequently administered at the time of presentation for major burns patients in comparison to toxic epidermal necrolysis patients. This may be due to a perception that if toxic epidermal necrolysis patients can survive their initial systemic injury, they are likely to survive, as opposed to major burns patients who often undergo extensive surgery and for whom other factors should be taken into account in the context of end-of-life decision making., (Copyright © 2014 Elsevier Ltd and ISBI. All rights reserved.)

Introduction: Toxic epidermal necrolysis (TEN) is a rare condition characterised by mucocutaneous exfoliation of greater than 30% total body surface area (%TBSA), increasingly being treated in burns centres. The rate of mortality varies significantly in the literature, with recent prospective studies in non-burns centres reporting percentage mortality of approximately 45%. We undertook a systematic review of published studies that included TEN patients treated specifically in burns centres to determine a cumulative mortality rate., Methods: Electronic searches of MEDLINE, EMBASE and The Cochrane Library (Issue 4, 2010) databases from 1966 onwards were used to identify English articles related to the treatment of TEN in burns centres., Results: The systematic literature search identified 20 studies which specifically described patients with TEN grater than 30% %TBSA. Treatment regimens varied amongst studies, as did mortality. The overall percentage mortality of the combined populations was 30%. Risk factors commonly described as associated with mortality included age, %TBSA and delay to definitive treatment., Conclusion: The review highlights the variation between principles of treatment and mortality amongst burns centres. It offers a standard that burns centre can use to internationally compare their mortality rates. The review supports the ongoing reporting of outcomes in TEN patients with epidermal detachment greater than 30%., (Copyright © 2014 Elsevier Ltd and ISBI. All rights reserved.)

Background: Toxic Epidermal Necrolysis (TEN) is characterized by an exfoliative rash resembling widespread burns. It is often considered on the same spectrum of disease as Stevens Johnson Syndrome but is distinguished by epidermal detachment of >30% of total body surface area (TBSA). Ocular involvement of TEN may result in complications requiring intensive topical, systemic or operative treatment. This study aimed to identify the current hospital management of, and factors associated with, ophthalmic involvement in adult TEN patients., Methods: All adult TEN patients admitted to the Victorian Adult Burns Service over an 12-year period were included. Retrospective data analyzed included patient demographics, site of TEN involvement, % TBSA, complications, duration of ocular follow up and visual outcomes., Results: TEN patients with and without ocular involvement were compared. Cutaneous involvement of the head and neck was found to be significantly associated with ocular involvement of TEN. Age, TBSA involvement, presence of a prodrome, and presence of comorbidities were not found to be significantly associated with ocular involvement. Management of ophthalmic involvement of TEN varied between patients., Conclusions: Clinicians should have a high index of suspicion for ocular involvement when exfoliation of the head and neck is present and should seek ophthalmological advice early in the course of disease., (Copyright © 2013 Elsevier Ltd and ISBI. All rights reserved.)

Introduction: Infection remains the primary cause of morbidity and mortality in the burns patient population. While candidal infection in burns patients is well described, there is dearth of information regarding non-candidal fungal infections in this setting., Method: All adult burns patients who developed non-candidal fungal infections over a period of 10 years (between January 2001 and June 2011) were included. Retrospective data analyzed included patient demographics, organisms cultured, antibiotic susceptibility patterns, treatment, length of stay and overall mortality., Results: The incidence of non-candidal fungal infections at our centre over the time period studied was 0.04%. A total of 12 patients had a fungus other than Candida isolated. Of these 12 patients, seven were thought to have clinically significant fungal infections and were treated with targeted anti-fungal therapy. Between them, seven species of fungus were isolated: Aspergillus fumigatus (n=7), Scedosporium prolificans (n=2), Fusarium solani (n=2), Mucor spp. (n=2), Absydia corymbifera (n=1), Penicillium (n=1) and Alternaria spp. (n=1). Of those definitively treated, two died, although fungal infection was not believed to be a contributing factor to these deaths., Conclusion: We demonstrate a low incidence and attributable mortality of non-candidal fungal infections in the setting of early antifungal therapy and extensive surgical debridement at our state-wide Burns Service., (Copyright © 2013 Elsevier Ltd and ISBI. All rights reserved.)

Introduction: Sustaining a moderate to severe burn injury is associated with the potential for substantial impairments to long-term physical and psychosocial health, including health related quality of life (HRQoL). The objective of this study was to identify clinical and patient characteristics which predict HRQoL 12-months after injury., Methods: A total of 125 patients were recruited over the study period, although only 99 were included in the final analysis representing all those who completed both the pre-burn and 12-months after burn injury Short Form 36 Medical Outcomes Survey (SF-36v2). These patients also completed the Burn Specific Health Scale-Brief (BSHS-B). Patient demographics and burn injury characteristics and treatment factors were collected to identify which factors predict 12-month health status outcomes. Multiple linear regression analyses were conducted to identify important predictors of outcomes. The SF36v2 models were adjusted for pre-injury measurements., Results: Older age (regression coefficient -0.26, 95% confidence interval (95% CI) -0.38, -0.13), female gender (-8.08, 95% CI -12.8, -3.34) and increased percentage of full-thickness burns per body surface area (-0.51; 95% CI -0.88, -0.13) were important predictors of poorer physical health status at 12 months. Older age (-0.15, 95% CI -0.26, -0.04) and increased percentage of full-thickness burns per body surface area (-0.36, 95% CI -0.69, -0.03) were important predictors of poorer mental health status at 12 months. Older age (-0.38; 95%CI -0.66, -0.11) and female gender (-12.17; 95% CI -22.76, -1.57) were important predictors of poorer BSHS-B total score at 12 months after injury., Conclusions: Given the complexity of burn care rehabilitation, physical and psychosocial screening and assessment within the first weeks after a burn injury along with adequate monitoring after discharge should be undertaken in burn injured patients. In this context, patients of specific demographics, such as female patients and older patients, and patients with a higher percentage of full thickness surface area burns are of greater risk for poorer physical and psychological outcomes and may benefit from additional monitoring and rehabilitation., (Copyright © 2014 Elsevier Ltd and ISBI. All rights reserved.)

Introduction: Cadaveric cutaneous allografts are used in burns surgery both as a temporary bio-dressing and occasionally as definitive management of partial thickness burns. Nonetheless, limitations in the understanding of the biology of these grafts have meant that their role in burns surgery continues to be controversial., Methods: A review of all patients suffering 20% or greater total body surface area (TBSA) burns over an eight year period that received cadaveric allografts were identified. To investigate whether tissue viability plays a role in engraftment success, five samples of cryopreserved cadaveric cutaneous allograft processed at the Donor Tissue Bank of Victoria (DTBV) were submitted to our laboratory for viability analysis using two methods of Trypan Blue Exclusion and tetrazolium salt (MTT) assays., Results: During the study period, 36 patients received cadaveric allograft at our institution. The average total burn surface area (TBSA) for this group of patients was 40% and all patients received cadaveric skin as a temporizing measure prior to definitive grafting. Cadaveric allograft was used in complicated cases such as wound contamination, where synthetic dressings had failed. Viability tests showed fewer than 30% viability in processed allografts when compared to fresh skin following the thawing process. However, the skin structure in the frozen allografts was histologically well preserved., Conclusion: Cryopreserved cutaneous cadaveric allograft has a positive and definite role as an adjunct to conventional dressing and grafting where available, particularly in patients with large TBSA burns. The low viability of cryopreserved specimens processed at DTBV suggests that cell viability in cadaveric allograft may not be essential for its clinical function as a wound dressing or even as permanent dermal substitute., (Copyright © 2013 Elsevier Ltd and ISBI. All rights reserved.)

The catastrophic wildfires of February 2009 in Victoria, Australia killed 173 people and hospitalised 18 adults with burns. We conducted a case-control study of wildfire victims (WFVs) compared to routine burns patients to assess early differences in bacteriology. Demographic, outcome and bacteriology data (for the first 72 h) were prospectively collected on all 18 WFVs, and compared to those of 36 RBPs matched 2:1 for age, gender, burns severity (total body surface area ≥20%) and ICU admission. We found that WFVs had more positive cultures overall (10/18 [56%] vs 7/36 [19%], p=0.04), and we cultured more Gram negative bacteria from wounds (11/13 [85%] vs 3/12 [25%], p=0.005). Although WFVs were more likely to culture Enterobacteriaceae (5/18 vs 2/36) and Aeromonas spp. (3/18 vs 1/36), and less likely to culture Staphylococcus aureus (2/18 vs 6/36), these differences were not statistically significant. Given the predominance of Gram negative organisms cultured from WFVs, our routine burn wound prophylaxis (intravenous cephazolin) would have been inadequate in the WFV group. We suggest that an alternative regimen of oxacillin/nafcillin/flucloxacillin plus gentamicin (or a fluoroquinolone if renal impairment present) may be more appropriate for burn wound prophylaxis in this complex group of patients., (Crown Copyright © 2012. Published by Elsevier Ltd. All rights reserved.)

Background: Prior to 2004, Australia and New Zealand lacked a systematic method to measure burn incidence, aetiology and quality of care or outcomes for burn patients. The Australian and New Zealand Burn Association (ANZBA) commenced the Bi-National Burns Registry (Bi-NBR) at that time. As a result of the limitations identified with the registry, ANZBA collaborated with Monash University to develop the registry as a clinical quality registry [1]., Method: A Steering Committee was formed to oversee the conduct and development of the registry. A Reference Committee revised the minimum dataset and working parties developed clinical quality indicators, and an outcome pilot project., Results: Institutional ethics approval has been obtained for 16 out of 17 sites and a formalised governance process developed. The minimum dataset was improved and includes clinical quality indicators. The Bi-NBR clinical quality registry was launched on July 1st 2009. A long-term outcome pilot project has been developed with five burn units participating (recruitment commenced October 2009)., Conclusion: Through a rigorous development process, a clinical quality registry for burns has been established which allows benchmarking of processes and outcomes between units. The intention is that all burns units across Australia and New Zealand will contribute to the registry., (Copyright © 2011 Elsevier Ltd and ISBI. All rights reserved.)

Background: Clinical quality indicators are routinely used to benchmark and drive improvements in healthcare. There is a dearth of standardised clinical quality indicators established for management of burns that allow quality of care to be monitored and benchmarked across Australia and New Zealand., Method: Using published quality indicator development processes and clinician experience, the Bi-National Burn Registry (Bi-NBR) working party developed quality indicators for burn care to be included as routine data items in the Bi-NBR., Results: Twenty indicators covering structure, process and outcome measures were identified. Preliminary testing resulted in further revision to the quality indicators to increase validity, reliability and improve data quality. The quality indicators are routinely collected in the Bi-NBR and reported quarterly., Conclusion: This is the first published account of the development and testing of standardised Bi-National clinical quality indicators for burns. The Bi-NBR quality indicators project remains a work in progress and it is hoped that further refinement of the indicators, in conjunction with international collaborators will assist in driving improvements in burn care., (Copyright © 2011 Elsevier Ltd and ISBI. All rights reserved.)

Background: The Alfred pre-hospital fluid isotonic crystalloid resuscitation formula for major burns (body weight (kg)×%TBSA burnt=mls in the first 2 h) was adopted by Ambulance Victoria in 2007 for the early and consistent correction of fluid deficit in major burns patients. The aim of this study was to evaluate the associated change in pre-hospital fluid administration., Methods: A retrospective explicit chart review of patient records was conducted of all patients with major burns presenting to The Alfred Emergency & Trauma Centre over a 10 year period. Patient demographics, fluid resuscitation and outcomes in the period before the introduction of the new formula were compared to those in the post-introduction period., Results: There were 126 patients with major burns (≥20% total body surface area burnt) included in the study. The median fluid volume administration pre-hospital after introduction of The Alfred formula was 0.35 (0.22-0.44) mL/kg/%TBSA burnt, which was significantly higher than 0.14 (0.04-0.26) mL/kg/%TBSA administered in the prior period (p=0.013). There was no significant change in physiological endpoints associated with the increased volume. At 24 h, the volume of fluid administered in patients when The Alfred formula was used was 4.9±1.6 mL/kg/%TBSA, which was not significantly higher than the volume administered before 2007 of 4.8±2.2 mL/%TBSA/kg (p=0.802)., Discussion: The Alfred pre-hospital fluid formula has resulted in patients receiving significantly more fluids early, although still below volumes suggested by the Parkland formula. There were no adverse effects of this increased volume detected over the study period. The Alfred pre-hospital fluid formula appears to be safe and more effective in delivering fluid volumes predicted by the current 'gold standard'., (Copyright © 2011 Elsevier Ltd and ISBI. All rights reserved.)

Purpose: To identify and quantify the health related concepts contained in the most common outcome instruments used in adult burn care, and to compare the content of these instruments based on their linkage to the International Classification of Functioning, Disability and Health (ICF). The ICF has been validated as a reference tool by the World Health Organization and is a framework that incorporates physical, emotional, environmental and social aspects of daily functioning., Methods: Electronic searches of MEDLINE, EMBASE CINAHL, PsychINFO and the Cochrane Library from 2003 onwards were carried out using a predetermined search strategy. Specific characteristics of the included studies and data pertaining to the outcome instruments were extracted. Two reviewers independently categorised the underlying concepts contained in the most commonly used outcome measures and linked them to ICF categories using standardised linkage rules., Results: Out of a total 132 included studies, 151 outcome instruments were identified. Of these, 14 frequently used generic and burn-specific instruments were selected for linkage to the ICF. From the 381 items contained in the 14 instruments, 356 concepts were extracted and subsequently linked to 99 ICF categories. Nearly 46% of the concepts were linked to body function and 20% to activities and participation, whereas only a few concepts were formally linked to health condition, body structures and personal or environmental factors., Conclusion: The ICF proved highly useful for the content comparison of frequently used generic and burn-specific instruments. The results may provide clinicians and researchers with new insights when selecting health-status measures for clinical studies in those with burn injury., (Copyright © 2011 Elsevier Ltd and ISBI. All rights reserved.)

Background: Pain is a major issue for patients with severe burn. High dose intravenous opioids form the mainstay of procedural burns pain management; however it was suggested that intravenous lidocaine assists with minimising the pain experience. This study aimed to evaluate whether intravenous lidocaine improved analgesic efficacy and decreased opioid consumption during a burn wound care procedure., Methods: A prospective double-blind randomized crossover study compared intravenous lidocaine versus placebo alongside patient controlled analgesia (PCA) in 45 patients with severe burn undergoing wound care procedures (i.e. dressing change±debridement) on two consecutive days. Subjects were randomised to either the intervention or control condition on the first dressing day, and received the alternate condition on the second dressing day. During the intervention condition, subjects received lidocaine of 1.5 mg/kg/body weight followed by two boluses of 0.5 mg/kg at 5-min intervals followed by a continuous infusion. During the control condition, 0.9% sodium chloride was administered at an equivalent volume, dose and rate to that of lidocaine. Primary end points included pain intensity as measured by verbal rating scale (VRS), time to rescue analgesia, opioid requests and consumption and overall anxiety and level of satisfaction., Results: Changes in the VRS score was significantly lower for lidocaine [difference (95% CI)=0.36 (0.17-0.55)] as compared to placebo. However, there were no significant clinical or statistical differences regarding the effects of lidocaine and placebo on opioid requests and consumption, anxiety or level of satisfaction during the first and second dressing procedures., Conclusions: In this study, the clinical benefit of intravenous lidocaine for pain relief during burn wound dressing changes in terms of overall pain scores and opioid consumption was unremarkable. Further investigations using different lidocaine regimes for the management of procedural burn pain are warranted., (Copyright © 2011 Elsevier Ltd and ISBI. All rights reserved.)

Introduction: This study is a retrospective analysis of 168 adult burns patients who received definitive treatment for partial thickness burns with Biobrane at a specialist burns centre. Our aim was to establish whether Biobrane served as a reliable, definitive treatment option or whether further treatment and allocation of surgical and nursing resources was required after application., Methods: We conducted a retrospective two year chart review (January 1 2007 and December 31 2008) of patients admitted to the Victorian Adult Burns Service, in Melbourne, Australia., Results: Use of Biobrane was associated with the need for further treatment interventions in a total of 74 patients (44%). Of these, Biobrane failure was found to be associated with infection in 28 cases (37.8%) and 48 (65%) patients underwent further surgery. A total of 87 patients (52%) had burns that took greater than three weeks from the time of injury to full re-epithelisation. Factors found to be associated with Biobrane failure were female gender, increasing percentage surface area of Biobrane application and when Biobrane was used in conjunction with split skin grafting to another area., Conclusion: The application of Biobrane to burns of mid-dermal or 'indeterminate' depth in our institution has resulted in high rates of return to theatre, positive wound cultures and delayed healing, and the recognition of the need to re-conceptualise the principles of use of this product. The use of Biobrane in smaller mid dermal or mixed depth burns may lead to increased operations and use of other hospital resources, without clear evidence of improved outcomes., (Copyright © 2011 Elsevier Ltd and ISBI. All rights reserved.)

Introduction: We aimed to identify the risk factors for, and outcomes of Pseudomonas aeruginosa bacteraemia in adult burns patients., Method: All adult burns patients who developed a Gram-negative bacteraemia over a period of 7 years were included. Retrospective data analysed included patient demographics, organisms cultured, antibiotic susceptibility patterns, isolation of P. aeruginosa in non-blood isolates, treatment, length of stay and mortality., Results: Forty-three patients developed a Gram-negative bacteraemia over the study period, 12 of whom had Pseudomonas bacteraemia during the course of their admission. In eight patients (18.6%) P. aeruginosa was the first Gram-negative isolated. The only factor predicting P. aeruginosa bacteraemia as a first episode (compared to another Gram-negative) was prior isolation of Pseudomonas at other sites (wound sites, urine or sputum). Overall length of stay was less in patients who developed P. aeruginosa as a first episode, mainly because of increased mortality in this group. Prior non-blood isolates of P. aeruginosa could have correctly predicted the sensitivity pattern of the strain of P. aeruginosa organism in 75% of patients who did not receive appropriate initial antibiotics., Conclusion: Prior colonisation with P. aeruginosa predicts P. aeruginosa in blood cultures, as opposed to other Gram-negative bacteria. Clinicians should have a high index of suspicion for P. aeruginosa bacteraemia where a septic burns patient has a prior history of non-blood P. aeruginosa cultures. Empirical antibiotic regimes based on the antibiotic-sensitivity patterns of previous non-blood P. aeruginosa isolates in each patient should be given at the time blood cultures are taken., (Copyright © 2010 Elsevier Ltd and ISBI. All rights reserved.)

Prediction of outcome for patients with major thermal injury is important to inform clinical decision making, alleviate individual suffering and improve hospital resource allocation. Age and burn size are widely accepted as the two largest contributors of mortality amongst burns patients. The APACHE (Acute Physiology and Chronic Health Evaluation) III-j score, which incorporates patient age, is also useful for mortality prediction, of intensive care populations. Validation for the burns specific cohort is unclear. A retrospective cohort study was performed on patients admitted to the Intensive Care Unit (ICU) via the Victorian Adult Burns Service (VABS), to compare observed mortality with burns specific markers of illness severity and APACHE III-j score. Our primary aim was to develop a mortality prediction tool for the burns population. Between January 1, 2002 and December 31, 2008, 228 patients were admitted to the ICU at The Alfred with acute burns. The mean age was 45.6 years and 81% (n=184) were male. Patients had severe injuries: the average percent TBSA (total body surface area) was 28% (IQR 10-40) and percent FTSA (full thickness surface area) was 18% (IQR 10-25). 86% (n=197) had airway involvement. Overall mortality in the 7-year period was 12% (n=27). Non-survivors were older, had larger and deeper burns, a higher incidence of deliberate self-harm, higher APACHE III-j scores and spent less time in hospital (but similar time in ICU), compared with survivors. Independent risk factors for death were percent FTSA (OR 1.03, 95% CI 1.01-1.05, p=0.01) and APACHE III-j score (OR 1.04, 95% CI 1.02-1.07, p<0.001). Mortality prediction based on both of these variables in combination was more specific than either individual variable alone (AUROC 0.85, 95% CI 0.79-0.92). Likelihood of death for patients with severe thermal injury can be predicted with accuracy from APACHE III-j score and percent FTSA. Prospective validation of our model on different burn populations is necessary., (Copyright © 2010 Elsevier Ltd and ISBI. All rights reserved.)

Aims: To review the literature on return to work (RTW) in patients with burns., Methods: Using a predetermined search strategy, we searched Ovid MEDLINE (1950 to January 2008) database to identify all English studies related to burn and work, rehabilitation, employment, return to work, occupation or vocational training., Results: Twenty-one studies were identified with 3134 patients. An average of 66% of patients returned to work following their burn; with rates even higher in patients with lower total body surface are burns. Time taken to RTW ranged from 4.7 weeks to 24 months. Common barriers to RTW were extent and severity of the burn, longer length of stay in hospital and number of operative procedures., Conclusions: This review found that the severity of burn was the most significant barrier to RTW. Further research is required to explore physical and psychosocial interventions aimed at helping people with burns return to and sustain employment., (Copyright © 2009 Elsevier Ltd and ISBI. All rights reserved.)

Objectives: To describe presentation characteristics of burn leading to death or hospital treatment (i.e. inpatient admissions and emergency department [ED] presentations) across the state of Victoria, Australia, for the years 2000-2006 inclusive., Methods: Data were provided by the Victorian Injury Surveillance Unit (VISU) from three different datasets pertaining to burn deaths, hospital inpatient admissions and non-admitted ED presentations. Population estimates were derived from census data provided by Australian Bureau of Statistics., Results: During the 7-year period, 178 people died and 36,430 were treated for non-fatal burn injury, comprising 7543 hospital admissions and 28,887 non-admitted ED presentations. Males, children aged less than 5 years of age, and the elderly (> or =65 years of age) were at the highest risk of injury. Contact with heat and hot substances represented the major aetiological factor contributing to thermal injuries accounting for 64% of all hospital admissions and 90% of ED presentations. Temporal trends indicate no change in the population rate of burn deaths or hospital admissions during the study period., Conclusions: ED presentations and hospital admissions and deaths have remained the same over this study period, but rates of burn remain high in males, children and the elderly. This could be due to variations in the implementation of government prevention and control programs and the divergence in efficient treatments and clinical practices amongst hospital care providers. Therefore, educational efforts for prevention should be the keystone to minimise the incidence of burns.

Objective: To evaluate the methodological quality of published randomised controlled trials (RCTs) in burn care treatment and management., Methods: Using a predetermined search strategy we searched Ovid MEDLINE (1950 to January 2008) database to identify all English RCTs related to burn care. Full text studies identified were reviewed for key demographic and methodological characteristics. Methodological trial quality was assessed using the Jadad scale., Results: A total of 257 studies involving 14,535 patients met the inclusion criteria. The median Jadad score was 2 (out of a best possible score of 5). Information was given in the introduction and discussion sections of most RCTs, although insufficient detail was provided on randomisation, allocation concealment, and blinding. The number of RCTs increased between 1950 and 2008 (Spearman's rho=0.6129, P<0.001), although the reporting quality did not improve over the same time period (P=0.1896) and was better in RCTs with larger sample sizes (median Jadad score, 4 vs. 2 points, P<0.0001). Methodological quality did not correlate with journal impact factor (P=0.2371)., Conclusions: The reporting standards of RCTs are highly variable and less than optimal in most cases. The advent of evidence-based medicine heralds a new approach to burns care and systematic steps are needed to improve the quality of RCTs in this field. Identifying and reviewing the existing number of RCTs not only highlights the need for burn clinicians to conduct more trials, but may also encourage burn health clinicians to consider the importance of conducting trials that follow appropriate, evidence-based standards.

Background: Pain arising in burns sufferers is often severe and protracted. The prospect of a dressing change can heighten existing pain by impacting both physically and psychologically. In this trial we examined whether pre-procedural virtual reality guided relaxation added to patient controlled analgesia with morphine reduced pain severity during awake dressings changes in burns patients., Methods: We conducted a prospective randomized clinical trial in all patients with burns necessitating admission to a tertiary burns referral centre. Eligible patients requiring awake dressings changes were randomly allocated to single use virtual reality relaxation plus intravenous morphine patient controlled analgesia (PCA) infusion or to intravenous morphine patient controlled analgesia infusion alone. Patients rated their worst pain intensity during the dressing change using a visual analogue scale. The primary outcome measure was presence of 30% or greater difference in pain intensity ratings between the groups in estimation of worst pain during the dressing change., Findings: Of 88 eligible and consenting patients having awake dressings changes, 43 were assigned to virtual reality relaxation plus intravenous morphine PCA infusion and 43 to morphine PCA infusion alone. The group receiving virtual reality relaxation plus morphine PCA infusion reported significantly higher pain intensities during the dressing change (mean=7.3) compared with patients receiving morphine PCA alone (mean=5.3) (p=0.003) (95% CI 0.6-2.8)., Interpretation: The addition of virtual reality guided relaxation to morphine PCA infusion in burns patients resulted in a significant increase in pain experienced during awake dressings changes. In the absence of a validated predictor for responsiveness to virtual reality relaxation such a therapy cannot be recommended for general use in burns patients having awake dressings changes.

Introduction: The purpose of this retrospective study was to provide basic probabilistic predictors of mortality to assist in determining appropriate therapeutic aggression in elderly burns population., Method: Eighty patients over the age of 70 years were admitted to the Victorian Adult Burns Service in Melbourne, Australia, over a period of 4 years. Retrospective data was analysed, taking into account patient demographics, type, site, depth and area of burn, presence of inhalation injury, number of co-morbidities, survival time and the number of operations performed, withdrawal of care and implementation of comfort measures only., Results: Comparing survivors and non-survivors, significant differences were found between age, percentage total burn surface area (TBSA%), percentage full thickness surface area (FTSA%), presence of inhalation injury, site of burn and number of operations. The number of co-morbidities and gender were not significant to outcome. FTSA%, presence of inhalation injury, site of burn, age and number of operations were all significantly related to survival time. When patients who obtained comfort care were excluded from analysis, age and the number of operations were not considered to be significantly related to mortality., Conclusion: This study indicates that TBSA%, FTSA%, inhalation injury and age are significant predictors of death in the elderly burns population, although only the first three remain significant when patients who receive comfort care measures only are excluded.

Activin A is a member of the transforming growth factor-beta (TGF-beta) family of cytokines and growth factors and upregulation of this protein has been linked with a number of disease processes associated with chronic inflammation and fibrosis. Its potential involvement in burns has not yet been investigated. We therefore studied the localization of activin in tissue sections from excised mid- and deep dermal and full thickness cutaneous burn by immunohistochemistry. There was cell-specific temporal expression in tissues with prominent expression from day 4 onwards in lymphocytes and histiocytes and expression from day 8 onwards in reactive fibroblasts and endothelial cells. Immunopositivity over the first 18 days persisted in reactive fibroblasts and lymphocytes although the latter were in most circumstances decreasing in number. These data are consistent with activin A being central to the inflammatory and repair phases occurring in burnt skin and early scar formation. Modulation of activin expression and actions may, therefore, be a target for the management of burns.

Objective: To assess the safety and efficacy of bioengineered skin substitutes in comparison with biological skin replacements and/or standard dressing methods in the management of burns, through a systematic review of the literature., Methods: Literature databases were searched up to April 2006, identifying randomised controlled trials., Results: Twenty randomised controlled trials were included in this review. The numerous sub-group analyses and the diversity of skin substitutes limited the ability to draw any conclusions from it. However, the evidence suggested that bioengineered skin substitutes, namely Biobrane, TransCyte, Dermagraft, Apligraf, autologous cultured skin, and allogeneic cultured skin, were at least as safe as biological skin replacements or topical agents/wound dressings. The safety of Integra could not be determined. For the management of partial thickness burns, the evidence suggested that bioengineered skin substitutes, namely Biobrane, TransCyte, Dermagraft, and allogeneic cultured skin, were at least as efficacious as topical agents/wound dressings or allograft. Apligraf combined with autograft was at least as efficacious as autograft alone. For the management of full thickness burns, the efficacy of autologous cultured skin could not be determined based on the available evidence. The efficacy of Integra could not be determined based on the available evidence., Conclusions: Additional methodologically rigorous randomised controlled trials with long-term follow-up would strengthen the evidence base for the use of bioengineered skin substitutes.