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Aim: The aim was to compare two dressing treatments for partial-thickness burns: biosynthetic cellulose dressing (BsC) (Epiprotect (R) S2Medical AB, Linkoping, Sweden) and porcine xenograft (EZ Derm (R), Molnlycke Health Care, Gothenburg, Sweden). Methods: Twenty-four adults with partial-thickness burns were included in this randomized clinical trial conducted at The Burn Centers in Linkoping and Uppsala, Sweden between June 2016 and November 2018. Time to healing was the primary outcome. Secondary outcomes were wound infection, pain, impact on everyday life, length of hospital stay, cost, and burn scar outcome (evaluated with POSAS). Results: We found no significant differences between the two dressing groups regarding time to healing, wound infection, pain, impact on everyday life, duration of hospital stay, cost, or burn scar outcome at the first follow up. Burn scar outcome at the 12-month follow up showed that the porcine xenograft group patients scored their scars higher on the POSAS items thickness (p = 0.048) and relief (p = 0.050). This difference was, however, not confirmed by the observer. Conclusions: The results showed the dressings performed similarly when used in adults with burns evaluated as partial thickness. (C) 2021 The Authors. Published by Elsevier Ltd.

This article represents the response to the inquiries adopted by Dr. Raghuraman M Sethuraman, M.D., regarding our recently published study which compared the erector spinae plane block (ESPB) versus paravertebral block (PVB) regarding postoperative analgesic consumption following breast surgeries (Elewa et al, BMC Anesthesiol 22: 1-9, 2022). We would like to introduce our appreciation and gratitude to the author for his interest in our work, despite being inaccurate in some of his comments.

Introduction As compared to younger adults, older people have a greater risk of domestic accidents, such as burns, and their prognosis is worsened by a diminished physiological ability to face a thermal trauma. The in-hospital mortality is adversely affected by old age and burn size, whereas less is known about the long-term-survival in elderly patients who survive a burn injury. The aim of this study was to investigate if elderly burn patients after discharge from a Swedish National Burn Centre have a shorter remaining life compared to the national population, by using calculated remaining Life Expectancy (rLE). Methods In this retrospective study we included all patients who were admitted for burns to the Linkoping Burn Centre during 1993–2016 and who were 60 years or older and alive, at the time of discharge. The control group was extracted from Statistics Sweden, the national statistics database, and consisted of all individuals from the Swedish population matched for each patient in the study group, by sex and age at the year of discharge. The proportion who died before reaching the rLE was compared between the study population and the control group by calculating risk ratio. Results The study group consisted of 111 former patients and 77 of them (69%) died before reaching the rLE, with mean 4.7 years of life lost (YLL), which was 33% more than that (52%) of the control group (RR 1.33, 95% CI 1.18–1.51). Burn related factors, such as TBSA % or FTB % were not found to account for this effect. Conclusion We found that the long-time survival of elderly patients after burns is shorter than that of a national control, the magnitude of which is quantitatively important. The current study does not support that burn related factors account for this effect and the reason should therefore be sought in other factors, such as e.g., co-morbidity or psychosocial issues.

Introduction: SN132D is a manganese (Mn) -containing, polymeric nanomaterial developed as an intravenous contrast agent for tumor selective MRI. It was designed for optimal physiological targeting and preferential accumulation in malignant lesions by means of the Enhanced Permeability and Retention (EPR) effect. Combined non-clinical data have demonstrated proof of concept (PoC) in various in vivo cancer models and a safety profile in line with FIH administration of SN132D in the SPAGOPIX-01 clinical study. Methods: SPAGOPIX-01 is a Phase I, FIH, open-label, non-randomized and non-placebo-controlled study in participants with diagnosed breast cancer. MRI was performed prior to and at 2 h and 4 h after the end of the SN132D infusion. SN132D safety and tolerability were the primary objectives. MRI enhancing properties of SN132D in primary tumor, liver, and pancreas as well as pharmacokinetics of SN132D were secondary objectives. Results: So far, 12 female breast cancer patients of planned up to 20 have been enrolled between September 2019 and December 2021. Of these, six patients received SN132D at 10 μmol Mn/kg (cohort 1) and six patients at 20 μmol Mn/kg (cohort 2). In cohort 1 (10 μmol Mn/kg), SN132D was well-tolerated. No clinically significant findings were observed for clinical laboratory tests, vital signs, 12-lead electrocardiogram (ECG), or physical examination. No serious adverse events (SAEs) were registered; nine mild AEs were reported for four subjects. The most reported AEs in patients administered 10 μmol Mn/kg SN132D were injection site reactions (2 AEs) and flushing (2 AEs). In cohort 2, SN132D was also well-tolerated. No clinically significant findings were observed for vital signs, ECG, or physical examination. No SAEs were registered; 12 AEs were reported for six patients. The most common AE was transiently elevated transaminase levels, with single reports from four patients. The second and third most common AEs were moderate vomiting (reported twice from a single patient) and mild flushing. Remaining AEs were single events reported by single patients. None of the AEs required treatment and all resolved without any intervention. Pharmacokinetics of SN132D was assessed at up to 24 h post dose. In cohort 1, SN132D, based on Mn plasma concentrations, had a mean Cmax of 0.915±0.187 μg/mL, a mean initial half-life of 7.17± 1.02 min, a mean AUCinf of 0.890±0.20 h*μg/mL and a mean plasma clearance of 0.646±0.157 L/h/kg. In cohort 2, SN132D had a mean Cmax of 2.0±0.341μg/mL, a mean initial half-life of 7.0±1.60 min, a mean AUCinf of 2.04±0.28 h*μg/mL and a mean plasma clearance of 0.548±0.068 L/h/kg. MR image analysis in cohort 1 revealed that although contrast was insufficient for the generation of clinically relevant tumor images at the 10 μmol Mn/kg dose level, there was still a measurable enhancement. In cohort 2, MR images were analyzed for five subjects and clinically relevant contrast increase in the primary tumor without signal increase in the background was observed in all patients. In addition, all MRI images, including both dose cohorts, showed contrast increase in both liver and pancreas at post-dose imaging timepoints. Conclusions: Initial clinical data generated to date demonstrate an acceptable safety profile and PoC for SN132D in the breast cancer patients. Physiological targeting with functional nanoparticles appears suitable for tumor MRI imaging. Our data are in agreement with preclinical data in rodent tumor models. The data are supporting the continuation of the SPAGOPIX-01 clinical trial and we will further explore SN132D in a cohort of pancreatic cancer patients with liver involvement. Citation Format: Fredrik Wärnberg, Andreas Karakatsanis, Liliya Shcherbina, Folke Sjöberg, Paul Hargreaves, Ioan-Dan Curiac, Edvin Johansson, Oskar Axelsson, Mats Hansen. Safety, tolerability, and efficacy of the novel intravenous manganese-based contrast agent SN132D in patients with breast cancer: initial results of a Phase I, First-In-Human clinical trial SPAGOPIX-01 [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P3-04-03.

Pirepemat (IRL752) is a cortical enhancer being developed for the prevention of falls in patients with Parkinson disease. This first-in-human, randomized, double-blind, placebo-controlled phase 1 study evaluated safety, tolerability, and pharmacokinetics (PK) of pirepemat administered as oral single ascending doses (10, 35, 75, 175, 350 mg) and multiple ascending doses (100 and 250 mg 3 times daily) for 7 days to healthy male volunteers. Twenty and 24 subjects were randomly assigned in the single ascending dose and multiple ascending doses parts of the study, respectively. Pirepemat was generally well tolerated, although an increased frequency of adverse events of mild intensity within nervous system disorders (headache and dizziness) was seen after administration of 350 mg as a single dose and after multiple doses of 100 and 250 mg. PK of pirepemat showed a linear relationship over the dose range studied and exhibited dose proportionality after multiple-dose administration. Accumulation after 7 days of multiple dosing was minor. Absorption was rapid, with a median time to maximum concentration of 2.0 hours on day 1 and day 7 (100 and 250 mg) and a mean terminal half-life between 3.7 and 5.2 hours. Food intake had no (obvious) impact on PK. The results support 3-times-daily dosing and further clinical development. Funding Agencies|Integrative Research Laboratories Sweden AB, Gothenburg, Sweden

Previous studies have shown that burn patients were satisfied with the received care. Satisfaction was not strongly associated to burns or to psycho-social characteristics, suggesting that other factors, related to burn care specific aspects, may be important. The aim of this study was to analyze the independent effect of provided workload on the general satisfaction in adult patients at a Swedish national Burn Centre. The study population (n = 122) included patients ≥18 years, treated at the Linköping Burn Centre between 2016 and 2017. Experienced burn care was evaluated with the PS-RESKA survey (score range: 0-4), and provided workload was scored with the Burn Scoring System (BSC). Groups were compared with χ 2 test, MW test, or Fisher´s exact test. Multivariable logistic regression analyzed the independent effect of BSC on the outcome High Satisfaction (= score ≥3 to the survey-question: "How would you score your global experience at the Burn Centre?"). In-patients (n = 60) had more often larger burns and required more workload than out-patients (median[IQR]: TBSA% = 6.3 [3-12.3] % vs. 0.7 [0.3-2] %, p < .001; BSC = 65 [25.5-135.5] vs. 6 [4-9], p < .001). Both groups were highly satisfied with the experienced care (mean score [SD] = 3.68 [0.57] vs. 3.41 [0.77], p = .03). Neither characteristics of the patients (age, sex), nor TBSA% nor provided workload (BSC) were independently associated with High Satisfaction. Regardless of burn severity, demographics and provided workload, adult patients with burns were highly satisfied with the experienced burn care. This finding suggested that the reason of the satisfaction was multifactorial. Funding agencies: Department of Hand Surgery, Plastic Surgery and Burns; Linkoping University, Linkoping, Sweden

The relationship between infrastructure, technology, model of care, and human resources influences patient outcomes and safety, staff productivity and satisfaction, retention of personnel, and treatment and social costs. This concept underpins the need for evidence-based design and has been widely adopted to inform hospital infrastructure planning. The aim of this review is to establish evidence-based, universally applicable key features of a burn unit that support function in a comprehensive patient-centered model of care. A literature search in medical, architectural, and engineering databases was conducted. Burn associations’ guidelines and relevant articles published in English, between 1990 and 2020, were included, and the available evidence is summarized in the review. Few studies have been published on burn unit design in the past 30 years. Most of them focus on the role of design in infection control and prevention and consist primarily of descriptive or observational reports, opportunistic historical cohort studies, and reviews. The evidence available in the literature is not sufficient to create a definitive infrastructure guideline to inform burn unit design, and there are considerable difficulties in creating evidence that will be widely applicable. In the absence of a strong evidence base, consensus guidelines on burn unit infrastructure should be developed, to help healthcare providers, architects, and engineers make informed decisions, when designing new or renovated facilities.

To investigate if donor and recipient site morbidity (healing time and cosmesis) could be reduced by a novel, modified split-thickness skin grafting (STSG) technique using a dermal component in the STSG procedure (DG). The STSG technique has been used for 150 years in surgery with limited improvements. Its drawbacks are well known and relate to donor site morbidity and recipient site cosmetic shortcomings (especially mesh patterns, wound contracture, and scarring). The Dermal graft technique (DG) has emerged as an interesting alternative, which reduces donor site morbidity, increases graft yield, and has the potential to avoid the mesh procedure in the STSG procedure due to its elastic properties. A prospective, dual-centre, intra-individual controlled comparison study. Twenty-one patients received both an unmeshed dermis graft and a regular 1:1.5 meshed STSG. Aesthetic and scar assessments were done using The Patient and Observer Scar Assessment Scale (POSAS) and a Cutometer Dual MPA 580 on both donor and recipient sites. These were also examined histologically for remodelling and scar formation. Dermal graft donor sites and the STSG donor sites healed in 8 and 14 days, respectively (p p Trial registration: ClinicalTrials.gov Identifier (NCT05189743) 12/01/2022.

Background This study was performed to develop and validate a cardiac surgical intensive care risk adjustment model for mixed cardiac surgery based on a few preoperative laboratory tests, extracorporeal circulation time, and measurements at arrival to the intensive care unit. Methods This was a retrospective study of admissions to 5 cardiac surgical intensive care units in Sweden that submitted data to the Swedish Intensive Care Registry. Admissions from 2008 to 2014 (n = 21,450) were used for model development, whereas admissions from 2015 to 2016 (n = 6463) were used for validation. Models were built using logistic regression with transformation of raw values or categorization into groups. Results The final model showed good performance, with an area under the receiver operating characteristics curve of 0.86 (95% confidence interval, 0.83-0.89), a Cox calibration intercept of –0.16 (95% confidence interval, –0.47 to 0.19), and a slope of 1.01 (95% confidence interval, 0.89-1.13) in the validation cohort. Conclusions Eleven variables available on admission to the intensive care unit can be used to predict 30-day mortality after cardiac surgery. The model performance was better than those of general intensive care risk adjustment models used in cardiac surgical intensive care and also avoided the subjective assessment of the cause of admission. The standardized mortality ratio improves over time in Swedish cardiac surgical intensive care.

Delirium is defined as a disturbance of attention and awareness that develops over a short period of time, is a change from the baseline, and typically fluctuates over time. Burn care involves a high prevalence of known risk factors for delirium such as sedation, inflammation, and prolonged stay in hospital. Our aim was to explore the extent of delirium and the impact of factors associated with it for adult patients who have been admitted to hospital with burns.In this retrospective study, all adult patients who had been admitted with burns during a four-year period were studied, including both those who were treated with intensive care and intermediate care only (no intensive care). Daily records of the assessment of delirium using the Nursing Delirium Screening Scale (Nu-DESC) were analysed together with age, sex, the percentage of total body surface area burned, operations, and numbers of wound care procedures under anaesthesia, concentrations of plasma C-reactive protein, and other clinical variables. Logistic regression was used to analyse factors that were associated with delirium and its effect on mortality, and linear regression was used to analyse its effect on the duration of hospital stay.Fifty-one patients (19%) of the total 262 showed signs of delirium (Nu-DESC score of 2 or more) at least once during their stay in hospital. Signs of delirium were recorded in 42/89 patients (47%) who received intensive care, and in 9/173 (5%) who had intermediate care. Independent factors for delirium in the multivariable regression were: age over 74 years; number of operations and wound care procedures under anaesthesia; and the provision of intensive care (area under the curve 0.940, 95% CI 0.899-0.981). Duration of hospital stay, adjusted for age and burn size, was 13.2 (95% CI 7.4-18.9, p0.001) days longer in the group who had delirium. We found no independent effects of delirium on mortality.We found a strong association between delirium and older age, provision ofr intensive care, and number of interventions under anaesthesia. A further 5% of patients who did not receive intensive care also showed signs of delirium, which is a finding that deserves to be thoroughly investigated in the future.

Background The pain of a burn mainly results from the inflammatory cascade that is induced by the injured tissue, and is classified as background, breakthrough, procedural and postoperative pain. High doses of opioids are usually needed to treat background pain, so its management includes a combination of types of analgesia to reduce the side effects. Lidocaine given intravenously has been shown in two small, uncontrolled studies to have an appreciable effect on pain after burns. Objectives In this prospective double-blind controlled trial we aimed to examine and quantify the opioid-sparing effect of a continuous infusion of lidocaine for the treatment of background pain during the early period after a burn. Methods Adult patients injured with burns of >10 total body surface area burned (TBSA%) and treated with a morphine based patient-controlled analgesia device (PCA) were randomised to have either lidocaine infusion starting with a bolus dose (1 mg lidocaine/kg) followed by continuous infusion (180 mg lidocaine/hour) or a placebo infusion, for seven consecutive days. Total daily consumption of opioids (mg) and amount of pain (visual analogue score, VAS) were recorded. Results We included 19 patients, 10 of whom were given a lidocaine infusion. There were no differences between groups in VAS, TBSA%, time of enrolment to the study since the initial burn, or duration of hospital stay. The opioid consumption in the lidocaine group declined by roughly 25% during the period of the study. Conclusion An intravenous infusion of lidocaine was safe and had an opioid-sparing effect when treating background pain in burns.

Background Pain control following breast surgery is of utmost importance in order to reduce the chance of chronic pain development, and facilitate early rehabilitation. The erector spinae plane block (ESPB) is a recently developed regional anaesthesia procedure successfully used for different types of surgical procedures including thoracic and abdominal surgeries. Methods A double-blind, randomized, controlled trial was conducted on 90 patients who were scheduled for modified radical mastectomy (MRM). Patients were randomly categorized into groups I (women who underwent ESPB), II (women who underwent paravertebral block (PVB), and III (women who underwent general anaesthesia). Results The ESPB (4.9 ± 1.2 mg) and PVB (5.8 ± 1.3 mg) groups had significantly lower total morphine consumption than the control group had (16.4 ± 3.1 mg; p p = 0.076). Moreover, patients in the ESPB and PVB groups had a significantly longer time to first required anaesthesia than those in the control group (7.9 ± 1.2 versus 7.5 ± 0.9 versus 2 ± 1.2 h, respectively; p p Conclusion ESPB and PVB provide effective postoperative analgesia for women undergoing MRM. The ESPB appears to be as effective as the PVB. Trial registration The study was registered before the enrolment of the first patient at the Pan African Clinical Trial Registry (www.pactr.org) database. Identification number for the registry is (PACTR202008836682092).

Blood group has been found to be important in the development of many diseases and the outcome of several disease processes, especially cardiovascular morbidity and mortality, such as caused by trauma and sepsis. The main reason is claimed to be related to glycobiology and effects mediated through the endothelium. This study investigated the possible effect of blood group (ABO) on burn care outcome. Burn outcome prediction models are extremely accurate and as such can be used to identify outcome effects even in single centre settings. In this retrospective risk adjusted observational study, we investigated the effect of ABO blood group on ventilatory time, length of hospital stay (LOS), and 90 day mortality among patients with burns. RESULTS: A total of 225 patients were included (2008-2019) with median TBSA of 26%; interquartile range (IQR) of 20-37%; median age 45 years (IQR 22-65 years); median Baux score (age + TBSA%); 76 (IQR 53- 97); 168 (75%) were male; median duration of hospital stay was 31 days (IQR 19-56); a total of 138 (61%) received treatment with mechanical ventilation; and 29 (13%) died. In a multivariable regression model, we were unable to isolate any significant effect of any blood group (O, A, B, AB) on the outcome measures studied (ventilatory time, LOS, and mortality). IN SUMMARY: contrary to many other major areas of disease in which ABO blood groups affect outcome, we were unable to find any such effect on patients with burns. Given the precision of the outcome models presented (AUC 0.93) any such an effect, if missed due to the limited study cohort, may be considered limited and to have only a minor clinical impact. Funding agencies: Carnegie foundation (Stockholm, Sweden); Queen Victoria Foundation (Stockholm, Sweden); Department of Hand Surgery, Plastic Surgery and Burns, Linkoping University Hospital; Linkoping University Linkoping, Sweden

Background Patient-controlled sedation (PCS) with propofol accompanied by a bedside nurse anaesthetist is an alternative sedation method for endoscopic procedures compared with midazolam administered by a nurse or endoscopist. Increasing costs in health care demands an economic perspective when introducing alternative methods. We applied a hospital perspective on a cost analysis comparing different methods of sedation and the resource use that were expected to affect cost differences related to the sedation. Methods Based on two randomised previous studies, the direct costs were determined for different sedation methods during two advanced endoscopic procedures: endoscopic retrograde cholangiopancreatography (ERCP) and flexible bronchoscopy including endobronchial ultrasound. ERCP comparisons were made between midazolam sedation by the endoscopic team, PCS with a bedside nurse anaesthetist and propofol sedation administered by a nurse anaesthetist. Bronchoscopy comparisons were made between midazolam sedation by the endoscopic team and PCS with a bedside nurse anaesthetist, categorised by premedication morphine-scopolamine or glycopyrronium. Results Propofol PCS with a bedside nurse anaesthetist resulted in lower costs per patient for sedation for both ERCP (233 USD) and bronchoscopy (premedication morphine-scopolamine 267 USD, premedication glycopyrronium 269 USD) compared with midazolam (ERCP 425 USD, bronchoscopy 337 USD). Aborted procedures that needed to be repeated and prolonged hospital stays significantly increased the cost for the midazolam groups. Conclusion Propofol PCS with a bedside nurse anaesthetist reduces the direct sedation costs for ERCP and bronchoscopy procedures compared with midazolam sedation.

Objective A history of psychiatric disorders is more common among patients who have had burns than in the general population. To try and find out the scale of the problem we have assessed self-reported symptoms of anxiety and depression after a burn. Methods Consecutive patients with burns measuring more than 10% total body surface area or duration of stay in hospital of seven days or more were included. Personal and clinical details about the patients were extracted from the database at each center. Data were collected from the Hospital Anxiety and Depression Scale, as well as Health-Related Quality of Life (HRQoL; Short Form-36, SF-36) and questionnaires about socioeconomic factors. All results were obtained 12 and 24 months after the burn, and compared with those from a reference group. Results A total of 156 patients responded to the questionnaires. Mean (SD) age and TBSA (%) were 46 (16.4) years and 23.6 (19.2) %, respectively. There were no differences in incidence between the burn and reference groups in anxiety or depression either 12 or 24 months after the burn. Those who reported higher anxiety and depression scores also had consistently poorer HRQoL as assessed by the SF-36. Conclusion Seen as a group, people who have had burns report anxiety and depression the same range as a reference group. Some patients, however, express more anxiety and depression, and concomitantly poorer HRQoL. These patients should be identified, and offered additional support.

AIM This study described the basic characteristics of children aged 0-16 years who were treated in intensive care units (ICUs) and paediatric ICUs (PICUs), compared their outcomes and examined any causes of death. METHODS This was a retrospective cohort study of admissions to 74 ICUs and three PICUs in Sweden that were recorded in the Swedish Intensive Care Registry from January 1, 2008 to December 31, 2012. RESULTS We retrieved data on 12 756 children who were admitted 17 003 times. The case mix differed between the ICUs, which were mainly admissions for injuries, accidents and observation, and PICUs, which were mainly admissions for malformations, genetic abnormalities and respiratory problems (p

Cell regenerative therapy is a modern solution for difficult-to-heal wounds. Keratinocytes, the most common cell type in the skin, are difficult to obtain without the creation of another wound. Stem cell differentiation towards keratinocytes is a challenging process, and it is difficult to reproduce in chemically defined media. Nevertheless, a co-culture of keratinocytes with stem cells usually achieves efficient differentiation. This systematic review aims to identify the secretions of normal human keratinocytes reported in the literature and correlate them with the differentiation process. An online search revealed 338 references, of which 100 met the selection criteria. A total of 80 different keratinocyte secretions were reported, which can be grouped mainly into cytokines, growth factors, and antimicrobial peptides. The growth-factor group mostly affects stem cell differentiation into keratinocytes, especially epidermal growth factor and members of the transforming growth factor family. Nevertheless, the reported secretions reflected the nature of the involved studies, as most of them focused on keratinocyte interaction with inflammation. This review highlights the secretory function of keratinocytes, as well as the need for intense investigation to characterize these secretions and evaluate their regenerative capacities. Funding Agencies|Centre for Advanced Medical Products, Sweden; Hand and Plastic Surgery Department, Linkoping University Hospital, Region Ostergotland, Sweden

The rules governing Medicinal Products in the European Union necessitates the production of cell-based therapy in good manufacturing practice facilities. The produced cells may need several hours in transportation to reach the application sites. In this study, we investigated four candidate solutions for transporting human keratinocytes. The solutions are (1) normal saline, (2) saline with 2.5% human serum albumin (Saline + HSA), (3) chemically defined, xeno-free keratinocyte media and (4) keratinocyte media with pituitary bovine extract (PBE-media). One million keratinocytes from three donors were suspended in each solution and kept at 4 °C for up to 24 h. Cells kept in Saline + HSA showed higher viability after 1, 3 and 24 h. Then, equal number of viable cells were seeded on collagenous matrix and cultured for 48 h. The adhesion and colonization were higher in the cells kept in PBE-media, while the keratinocyte surface marker, cytokeratin 14, was present in all studied groups. These results confirmed the suitability of Saline + HSA as a cell transportation solution for clinical use, which will be the choice for the planned clinical trial. Keratinocyte PBE-media can be an alternative for cells transported for research purpose, if the same media type is going to be used in the following experiments. Funding: Open Access funding provided by Linköping University Library

Introduction: Previous investigations have shown that fluid resuscitation of burns using the Parkland formula results in controlled hypovolaemia and that kidney injury is a common complication. Enhancing monitoring of tissue perfusion might reduce complications. Plasma renin has recently been suggested to be a promising marker for tissue hypoperfusion in intensive care patients. The aim of this study was to explore plasma renin levels during the first 48 hours after major burns in patients resuscitated using the Parkland formula. Materials and methods: Patients 18 years or older of age with 10% or more total body surface area (TBSA) burned, admitted to Linköping Burn Intensive Care Unit, and resuscitated using the Parkland formula were included. Samples for plasma renin were drawn at admission and eight-hourly thereafter for 48 hours. Results: Fifteen patients were included. Median TBSA burned was 36% and age 53 years. The fluid volumes provided were in accordance with the Parkland formula. Mean arterial pressure, urinary output, and lactate remained within reference ranges during the first 48 hours. At eight hours after burn median plasma renin was elevated to more than 25 times the upper reference value, decreasing to about four times the upper reference at 48 hours. Renin concentration was associated with lactate levels and TBSA burned. Conclusion: During Parkland fluid resuscitation of severe burns, plasma renin levels were extremely elevated. The fact that the traditionally used endpoints for Parkland fluid resuscitation remained within the reference range raises concerns about whether the increased renin concentrations may signal a relative renal hypoperfusion.

n/a Funding Agencies|Linkoping University; Ostergotland County Council

BackgroundBurn injury is associated with a long-standing inflammatory reaction. The use of albumin solutions for plasma volume support is controversial because of concerns of increased capillary leakage, which could aggravate the commonly seen interstitial oedema.MethodsIn the present open controlled clinical trial, an intravenous infusion of 20% albumin at 3 mL/kg was given over 30 min to 15 burn patients and 15 healthy volunteers. Blood samples and urine were collected for 5 h. Plasma dilution, plasma albumin and colloid osmotic pressure were compared. Mass balance calculations were used to estimate plasma volume expansion and capillary leakage of fluid and albumin.ResultsThe patients were studied between 4 and 14 (median, 7) days after the burn injury, which spread over 7–48% (median, 15%) of the total body surface area. The albumin solution expanded the plasma volume by almost 15%, equivalent to twice the infused volume, in both groups. The urinary excretion exceeded the infused volume by a factor of 2.5. Capillary leakage of albumin occurred at a rate of 3.4 ± 1.5 g/h in burn patients and 3.7 ± 1.6 g/h in the volunteers (P = 0.61), which corresponded to 2.4 ± 1.0% and 2.5 ± 1.2% per hour of the intravascular pool (P = 0.85). The median half-life of the plasma volume expansion was 5.9 (25th–75th percentiles 2.7–11.7) h in the burn patients and 6.9 (3.4–8.5) h in the volunteers (P = 0.56).ConclusionsAlbumin 20% was an effective volume expander in patients at 1 week post-burn. No relevant differences were found between burn patients and healthy volunteers.Trial registrationEudraCT 2016-000996-26on May 31, 2016.

This paper illustrates the efficacy of an artificial intelligence (AI) (a convolutional neural network, based on the U-Net), for the burn-depth assessment using semantic segmentation of polarized high-performance light camera images of burn wounds. The proposed method is evaluated for paediatric scald injuries to differentiate four burn wound depths: superficial partial-thickness (healing in 0–7 days), superficial to intermediate partial-thickness (healing in 8–13 days), intermediate to deep partial-thickness (healing in 14–20 days), deep partial-thickness (healing after 21 days) and full-thickness burns, based on observed healing time. In total 100 burn images were acquired. Seventeen images contained all 4 burn depths and were used to train the network. Leave-one-out cross-validation reports were generated and an accuracy and dice coefficient average of almost 97% was then obtained. After that, the remaining 83 burn-wound images were evaluated using the different network during the cross-validation, achieving an accuracy and dice coefficient, both on average 92%. This technique offers an interesting new automated alternative for clinical decision support to assess and localize burn-depths in 2D digital images. Further training and improvement of the underlying algorithm by e.g., more images, seems feasible and thus promising for the future.

The Baux score - the sum of age and total body surface area burned (TBSA %) - is a good predictor of mortality has a high specificity but low sensitivity. Our aim was to examine the causes of death in patients who die with Baux scores of100, which may explain the lower sensitivity and possibly affect the prediction of mortality.All patients admitted to our centre for burn care from 1993 to 2015 (n=1946) were included in this retrospective, descriptive, exploratory study. The study group comprised those patients who died with Baux scores of100 (n=23), and their medical charts were examined for the cause of death and for coexisting diseases.Crude mortality was 5% (93/1946) for the overall cohort, and a quarter of the patients who died (23/93) had Baux scores of less than 100 (range 64-99). In this latter group, flame burns were the most common (18/23), the median (10th-90th centile) age was 70 (46-86) years and for TBSA 21 (5.0-40.5) %, of which 7 (0-27.0) % of the area was full thickness. The main causes of death in 17 of the 23 were classified as "other than burn", being cerebral disease (n=9), cardiovascular disease (n=6), and respiratory failure (n=2). Among the remaining six (burn-related) deaths, multiple organ failure (predominantly renal failure) was responsible. When we excluded the cases in which the cause of death was not related to the burn, the Baux mortality prediction value improved (receiver operating characteristics area under the curve, AUC) from 0.9733 (95% CI 0.9633-0.9834) to 0.9888 (95% CI 0.9839-0.9936) and the sensitivity estimate increased from 45.2% to 53.9%.Patients with burns who died with a Baux score100 were a quarter of all the patients who died. An important finding is that most of these deaths were caused by reasons other than the burn, usually cerebrovascular disease. This may be the explanation why the sensitivity of the Baux score is low, as factors other than age and TBSA % explain the fatal outcome.

Forearm skin hyperemia during release after brachial occlusion has been proposed for evaluating peripheral arterial disease and endothelial dysfunction. We used a novel fiberoptic system integrating Laser Doppler Flowmetry and Diffuse Reflectance Spectroscopy for a comprehensive pointwise model based microcirculation characterization. The aim was to evaluate and compare the temporal and the spatiotemporal variabilities in forearm skin microcirculation parameters (speed resolved perfusion; low speed SR, ; mid-speed 1–10 mm/s, high speed > 10 mm/s, and total perfusion (Perf SR, tot ); the concentration and oxygenation of red blood cells, C RBC and S O2 ). Ten healthy subjects underwent arterial and venous forearm occlusions (AO, VO), repeated within one week. The repeatability was calculated as the coefficient of variation (CV) and the agreement as the intra-class correlation coefficient (ICC). The temporal CVs for conventional perfusion, Perf conv , Perf SR, tot , C RBC and S O2 were 14%, 12%, 9% and 9%, respectively, while the ICC were > 0.75 (excellent). The perfusion measures generally had a higher spatiotemporal than temporal variability, which was not the case for S O2 and C RBC . The corresponding spatiotemporal CVs were 33%, 32%, 18% and 15%, respectively. During VO, C RBC had a CV 0.40 (fair-good), and after release this was the case for C RBC (AO and VO), S O2 (VO) and Perf SR, (VO). In conclusion, the skin microcirculation parameters showed excellent temporal repeatability, while the spatiotemporal repeatability especially for perfusion was poorer. The parameters with acceptable repeatability and fair-good agreement were: C RBC during and after release of VO, the Perf SR, after release of VO, the S O2 and the C RBC after release of AO. However, the value of these parameters in discriminating endothelial function remains to be studied.

As widely reported, the progress in burn care during recent decades has reduced the hospital mortality. The effect of the burns on long-term outcome has not received so much attention, and more study is indicated. The aim of this retrospective study was to investigate the long-time survival among patients who had been treated for burns.We studied 1487 patients who were discharged alive from the Linköping University Hospital Burn Centre during the period 1993 until the end of December 2012. We used Cox's regression analysis to study the effect of burns on long-term survival after adjustment for different factors.Age and a full-thickness burn were significantly associated with mortality after discharge (p0.001), whereas percentage of total body surface area burned (TBSA %), need for mechanical ventilation, and gender were not. Less than 1% of the patients with burns (13/1487) died within 30 days of discharge and a total of 176/1487 (12%) died during follow-up.Age and full-thickness burns reduce the long-time survival after discharge from the Burn Centre, whereas the effect of TBSA% and need for artificial ventilation ends with discharge.

Background Patients with sepsis may have an increased risk of late mortality, but the causes of late death are unclear. This retrospective matched cohort study aimed to determine the causes of late death (>= 1 year) among patients with sepsis compared to patients without sepsis. Methods 8760 patients with severe sepsis or septic shock (2001 consensus criteria) registered in the Swedish Intensive Care Registry (2008-2013) were compared with a 1:1 matched (gender, age, SAPS3 probability for death, ICU length of stay) control group consisting of non-septic ICU patients. Causes of death (International Classification of Diseases codes) were obtained from the Swedish Cause of Death Register (2008-2014). Results During 2008-2014, 903 patients with sepsis died at >= 365 days after their initial septic event, compared to 884 patients in the control group. Median time of follow-up was 313 days (sepsis group, interquartile range 11-838 days) vs 288 days (control group, 9-836 days). The most common causes of death were heart diseases (sepsis: 50.2%, non-septic: 48.6%) and cancer (sepsis: 33.7%, non-septic: 31.7%). Infectious diseases were significantly more common cause of death in the sepsis group (24.3% vs 19.6%, respectively; P < .05). Pneumonia was a common infectious cause of death in both groups, whereas sepsis was more common in the sepsis group. Conclusions The most common causes of late death after ICU admission among patients with and without sepsis were heart diseases and cancer. However, patients with sepsis more frequently had infectious diseases as a cause of late death, compared to non-septic patients. Funding Agencies|Region Ostergotland

In the last 20 years, large changes in burn care and in the background and logistics around the care for the burn injured have occurred which has implications for how burn care now should be administered and practically performed. Firstly, the incidence of burn injuries has decreased in the Western world and a decrease of about 30% is evident from e.g., since the eighties [1, 2]. In parallel, length of stay in the burn care facilities for the injured has been reduced to about 40% of what it was at that time [3, 4]. Thirdly, the outcome of burns has been significantly improved over the same time period. This may be exemplified by the 50% survival chance that was present for a 45% total burn surface area (TBSA%) burn in a 21-year-old in the late 1970s, which is to be compared to the corresponding 50% survival chance for 80–90% TBSA% burn in the same age patient today [5, 6]. Fourth, patients, with smaller burns, today are to a significant extent treated as outpatients and smaller injuries may have their surgery done as outpatients as well [7–9]. At the same time, an increasing proportion of the patients are in the elderly age groups where the injury poses a larger treat as compared to in younger patients [10, 11]. In this age group, care is to a large extent influenced also by co-morbidities and the possibility to obtain good end results seen especially from the patient perspective [12].

This chapter addresses the treatment algorithms and bundles to be undertaken at the second or last treatment level, the burn center [1, 2]. The burn center provides the last treatment level where also burn surgery is undertaken to cover full-thickness burn wounds. This chapter focuses on the early period of admission at the burn center usually encompassing the first 24–48 h after the burn, whereas the treatment strategies presented in the previous chapter focuses mainly on the triage and patient examination necessary for the acute care and proper prioritization for the next care level. One central aim has then been to do a proper trauma evaluation in line with a trauma triage guideline such as the ATLS and possibly also by a specific burn-based triage algorithm such as the ABLS [3–5] or the EMSB courses [6–8]. It is then important to strictly follow the algorithm so that no specific detail in the patient background or injury profile is over seen—this strategy is then also continued at the receiving site as will be described below. Prior to referral contact is taken between the refereeing physician and the corresponding person at the receiving unit. As was stressed in the previous chapter, there are concerns that there may be details overlooked or the information may be hampered by at times the lack of experience at the referral site. This especially has been a topic of interest as burn care is constantly being further centralized as incidence numbers decline in most high-income western countries and the chance for different physician categories to be exposed to burns decline [9]. To facilitate the communication between referral and receiving units increasing focus has been directed at telemedicine tools that further enhances and facilitates communications [10–12]. Especially photos of injured tissues have been found valuable. Challenges that need special attentions in the early evaluation of the burn injured is related to the need for intubation, estimation of the burn size and depth and correspondingly the magnitude and titration of fluid treatment, and need of escharotomies. A significant portion of the early assessment that will also ensue at the burn center has already been described in detail in the previous chapter and therefore is only shortly mentioned now, and focus is instead directed to important issues to be examined and dealt with at the burn center.

The incidence and prevalence of burn injuries is decreasing worldwide and in parallel there is an increase in outpatient type of care and a shortening in length of stay [1] that has been significant during the last 20 years [2, 3]. This is particularly so for the high income countries [4]. For the low income countries, data is still lacking [4]. This has led to a decreasing demand on health care volume for the care of burns. This has during the last 10 years been a contributing factor for a decrease in the availability of burn care facilities and has boasted the process for centralized care [5–7].

Introduction In line with other researchers in the field of burns’ care, we think that research investigating the long-term outcome of scars is largely lacking. As scarring is of the utmost importance to the patient, clinicians who treat burns must aim to find treatments that lead to a good end result. The aim of this study was to study scar outcomes at six and 12 months after injury. It is an extension of a previous randomised controlled trial (RCT) in which two dressings (porcine xenograft and silver foam dressing) were examined with respect to their ability to help heal partial thickness scalds. Method Children aged six months – six years with acute partial thickness scalds, on the trunk, or extremities, or both, were included. In the previous study, the silver foam was found to have significantly shorter healing times than the xenograft. Children were assessed at six and 12 months after injury for this study, and photographs were taken of the burn site, and both the patient and observer scar assessment scale (POSAS) and the Vancouver scar scale (VSS) were completed and evaluated by blinded observers. Results Of the 58 children from the original RCT, 39 returned to the clinic for evaluation of their scars at six months, and 34 at 12 months after injury. There were no differences in POSAS, VSS total scores, or incidence of hypertrophic scarring between the different dressings. Fifteen children were assessed as having hypertrophic scarring, all of whom had healing times that had extended beyond 14 days. Conclusions This study compared burn scarring after two different treatments for burns in children with partial-thickness scalds and the data suggested that neither dressing had a more favourable impact on scar outcome. The conclusion is, however, tempered by the non-return of all the patients to the follow up. However, as anticipated, regardless of the dressing used, longer healing times were associated with higher scar scores (more scarring) and hypertrophic scarring.

We present in this paper the application of deep convolutional neural networks, which are a state-of-the-art artificial intelligence (AI) approach in machine learning, for automated time-independent prediction of burn depth. Colour images of four types of burn depth injured in first few days, including normal skin and background, acquired by a TiVi camera were trained and tested with four pre-trained deep convolutional neural networks: VGG-16, GoogleNet, ResNet-50, and ResNet-101. In the end, the best 10-fold cross-validation results obtained from ResNet- 101 with an average, minimum, and maximum accuracy are 81.66%, 72.06% and 88.06%, respectively; and the average accuracy, sensitivity and specificity for the four different types of burn depth are 90.54%, 74.35% and 94.25%, respectively. The accuracy was compared to the clinical diagnosis obtained after the wound had healed. Hence, application of AI is very promising for prediction of burn depth and therefore can be a useful tool to help in guiding clinical decision and initial treatment of burn wounds. Funding agencies: Analytic Imaging Diagnostic Arena (AIDA)

Aim Our aim was to compare two different regimens for the treatment of children with partial-thickness scalds. These were treated with either a porcine xenograft (EZderm ® , Molnlycke Health Care, Gothenburg, Sweden) or a silver-foam dressing (Mepilex ® Ag, Molnlycke Health Care, Gothenburg, Sweden). Methods We organised a prospective randomised clinical trial that included 58 children admitted between May 2015 and May 2018 with partial-thickness scalds to The Burn Centre in Linkoping, Sweden. The primary outcome was time to healing. Secondary outcomes were pain, need for operation, wound infection, duration of hospital stay, changes of dressings, and time taken. Results The patients treated with silver-foam dressing had a significantly shorter healing time. The median time to 97% healing for this group was 9 (7–23) days compared to 15 (9–29) days in the porcine xenograft group (p = 0.004). The median time to complete healing for the silver-foam group was 15 (9–29) days and for the porcine xenograft group 20.5 (11–42) days (p = 0.010). Pain, wound infection, duration of hospital stay, and the proportion of operations were similar between the groups. Number of dressing changes and time for dressing changes were lower in the silver-foam dressing group (p = 0.03 for both variables). Conclusions We compared two different treatments for children with partial-thickness scalds, and the data indicate that wound healing was faster, fewer dressing changes were needed, and dressing times were shorter in the silver-foam group.

Background: Chronic pain after burn can have severe physical and psychological effects on former patients years after the initial injury. Although the issue of pain after burn has gained increased attention over the past years, prospective, longitudinal studies are scarce. Our aim was to prospectively investigate consecutive burn patients for pain severity over time and to evaluate the prevalence and characteristics of post-burn pain to 2-7 years after the burn. As an additional aim, the effects of burn and individual-related factors, especially health related Quality of Life (HRQoL), were investigated. Method: Sixty-seven consecutive burn patients were assessed during acute care at 3, 6, 12 and 24 months, as well as at 2-7 years post-burn. HRQoL, symptoms of post-traumatic stress disorder (PTSD) and other psychiatric disorders were investigated. During the interviews that took place 2-7 years after the injury (mean 4.6 1.9 years), current chronic post-burn pain was assessed using the Brief Pain Inventory-Short Form (BPI-SF). Results: One-third of the patients still reported pain 2-7 years after the injury. Pain severity and interference with daily life were mainly mild to moderate though they were found to be associated with significantly lower HRQoL. Chronic pain after bum was associated with both burn- and individual-related factors. In logistic regression analysis HRQoL at 3 and 12 months and symptoms of PTSD at 12 months were independent factors in predicting chronic pain after burn. Conclusion: Pain after burn becomes a chronic burden for many former burn patients and decreases HRQoL. A novel finding in this study was that HRQoL assessed early after burn was a predictor for the development of chronic pain. This finding may help to predict future pain problems and serve as an indicator for pain preventive measures. (C) 2016 The Authors. Published by Elsevier Ltd. Funding Agencies|Swedish Research Council; Swedish Council for Working Life and Social Research

Distal half leg complex wounds are usually a formidable problem that necessitates either local or free flap coverage. The aim of this study was to compare cost billing charges in free Gracilis flap (fGF) and local fasciocutaneous perforator flap (lFPF) in reconstructing complex soft tissue leg and foot defects.Thirty consecutive adult (15-year-old) patients with soft tissue defects in the leg and/or foot requiring tissue coverage with a flap in the period between 2012 and 2015 were randomly assigned (block randomization) to either an fGF or lFPF procedure. The outcome measures addressed were total billed charges costs, perioperative billed charges cost, partial or complete flap loss, length of hospital stay, inpatient postsurgical care duration, complications, operating time and number of operative scrub staff.One patient suffered from complete flap loss in each group. Reconstruction with lFPF showed total lower billed charges costs by 62% (2509 USD) (p 0.001) and perioperative billed charges cost by 54% (779 USD) (p 0.001), and shorter total hospital stay (36.5 days; p 0.001), inpatient postsurgical care duration (6.4 days; p 0.001), operating time (4.3 h; p 0.001) and fewer scrub staff (2.2 persons; p 0.001).These results suggest that neither flap is totally superior to the other; the choice should instead be based on the outcome sought and logistics. lFPF requires lower billed charges cost and resource use and saves operative time and personnel and reduces length of hospital stay. Our approach changed towards using perforator flaps in medium-sized defects, keeping the free flap option for larger defects.

Sweden has one of the world’s lowest child injury mortality rates, but injuries are still the leading cause of death among children. Child injury mortality in the country has been declining, but this decline seems to decrease recently. Our objective was therefore to further examine changes in the mortality of children’s death from injury over time and to assess the contribution of various effects on mortality. The underlying hypothesis for this investigation is that the incidence of lethal injuries in children, still is decreasing and that this may be sex specific. We studied all deaths from injury in Sweden under-18-year-olds during the 14 years 1999–2012. We identified those aged under 18 whose underlying cause of death was recorded as International Classification of Diseases, 10th Revision (ICD-10) diagnosis from V01 to X39 in the Swedish cause of death, where all dead citizens are registered. From the 1 January 1999 to 31 December 2012, 1213 children under the age of 18 died of injuries in Sweden. The incidence declined during this period (r = −0.606, p = 0.02) to 3.3 deaths/100,000 children-years (95 % CI 2.6–4.2). Death from unintentional injury was more common than that after intentional injury (p

Standardised Mortality Ratio (SMR) based on generic mortality predicting models is an established quality indicator in critical care. Burn-specific mortality models are preferred for the comparison among patients with burns as their predictive value is better. The aim was to assess whether the sum of age (years) and percentage total body surface area burned (which constitutes the Baux score) is acceptable in comparison to other more complex models, and to find out if data collected from a separate burn centre are sufficient for SMR based quality assessment. The predictive value of nine burn-specific models was tested by comparing values from the area under the receiver-operating characteristic curve (AUC) and a non-inferiority analysis using 1% as the limit (delta). SMR was analysed by comparing data from seven reference sources, including the North American National Burn Repository (NBR), with the observed mortality (years 1993-2012, n=1613, 80 deaths). The AUC values ranged between 0.934 and 0.976. The AUC 0.970 (95% CI 0.96-0.98) for the Baux score was non-inferior to the other models. SMR was 0.52 (95% CI 0.28-0.88) for the most recent five-year period compared with NBR based data. The analysis suggests that SMR based on the Baux score is eligible as an indicator of quality for setting standards of mortality in burn care. More advanced modelling only marginally improves the predictive value. The SMR can detect mortality differences in data from a single centre.

Scalds are the most common type of burn in children, and one way to treat them is with xenografts with no topical antimicrobials in line with the recommendations of a recent review. However, this treatment has not been examined in detail. Our aim was to describe the treatment of such children when biological dressings (xenografts) were used without local antimicrobials. We reviewed the medical records of all children admitted to a Swedish National Burn Centre during the period 2010-2012 with scalds who were treated with xenografts. Percentage TBSA injured, age, length of hospital stay, number of operations, antibiotics given, duration of antibiotic treatment, and pain score during the first 3 days, application of xenografts, and clinical notes of wound infection were recorded. We studied 67 children, (43 of whom were boys), with a median (interquartile range [IQR]) age of 1 (1-2) year and median (IQR) TBSA% 6.2 (4-11). Twenty children (30%) required operation. Twelve (18%) developed a wound infection, 29 (43%) had other infections, and 26 (39%) were free from infection. The median (IQR) duration of systemic antibiotics was 10 (6-13) days. On the day that the xenografts were applied 10 of the children had a Face, Legs, Activity, Cry, and Consolability (FLACC) score between 3 and 7, and during the following 2 days, only four children scored in this range. The remaining 57 children had scores amp;lt;3 on the day that xenografts were applied and on the following 2 days. Median (IQR) length of stay/TBSA% was 0.7 (0.4-1.0). Treatment with xenografts was associated with median length of stay/TBSA% amp;lt; 1 and low pain scores. Despite a high rate of prescription of systemic antibiotics, most were for reasons other than wound infection. Funding Agencies|Department of Hand Surgery, Plastic Surgery and Burns, Linkoping University Hospital, Sweden

Worldwide, ketamine is used during paediatric procedures, but no recommendations are available regarding a suitable dose for rectal administration during procedures involving high levels of pain and/or anxiety such as burn wound dressing change.We evaluated three different single doses of rectally administered racemic ketamine mixed with a fixed dose of 0.5mg/kg of midazolam. In total, 90 children - aged 6 months to 4 years - were randomised 1:1:1 to receive 4mg/kg (K-4 group), 6mg/kg (K-6 group) or 8mg/kg (K-8 group) of racemic ketamine for a maximum of three consecutive procedures. Primary outcome measure was procedural pain evaluated by Face, Legs, Activity, Cry, Consolability (FLACC) behavioural scale. Secondary outcome included feasibility and recovery time. Patient safety was evaluated using surrogate outcomes.In total, 201 procedures in 90 children aged 19±8months were completed. The median maximum pain was FLACC 0 in all groups (p=0.141). The feasibility was better for groups K-6 (p=0.049) and K-8 (p=0.027) compared with K-4, and the mean recovery time was the longest for group K-8 (36±22min) compared with groups K-4 (25±15min; p=0.003) and K-6 (27±20min; p=0.025). Median maximum sedation measured by the University of Michigan Sedation Scale (UMSS) was higher in group K-8 compared with group K-4 (p0.0001) and K-6 (p=0.023). One child in group K-8 had a study drug-related serious adverse event - laryngospasm/airway obstruction. No rescue analgosedative medication was administered for group K-6.A rectally administered mixture of racemic ketamine (6mg/kg) and midazolam (0.5mg/kg) during paediatric burn dressing procedures with a duration of approximately 30min provides optimal conditions regarding pain relief, feasibility, recovery time and patient safety, with no need for rescue analgosedative medication.

Background To our knowledge this is the first published estimate of the charges of the care of burns in Sweden. The Linkoping Burn Interventional Score has been used to calculate the charges for each burned patient since 1993. The treatment of burns is versatile, and depends on the depth and extension of the burn. This requires a flexible system to detect the actual differences in the care provided. We aimed to describe the model of burn care that we used to calculate the charges incurred during the acute phase until discharge, so it could be reproduced and applied in other burn centres, which would facilitate a future objective comparison of the expenses in burn care. Methods All patients admitted with burns during the period 2010–15 were included. We analysed clinical and economic data from the daily burn scores during the acute phase of the burn until discharge from the burn centre. Results Total median charge/patient was US$ 28 199 (10th–90th centiles 4668-197 781) for 696 patients admitted. Burns caused by hot objects and electricity resulted in the highest charges/TBSA%, while charges/day were similar for the different causes of injury. Flame burns resulted in the highest mean charges/admission, probably because they had the longest duration of stay. Mean charges/patient increased in a linear fashion among the different age groups. Conclusion Our intervention-based estimate of charges has proved to be a valid tool that is sensitive to the procedures that drive the costs of the care of burns such as large TBSA%, intensive care, and operations. The burn score system could be reproduced easily in other burn centres worldwide and facilitate the comparison regardless of the differences in the currency and the economic circumstances.

Objectives: Laser speckle contrast imaging (LSCI) is an emerging technique for the assessment of burns in humans and interobserver differences have not been studied. The aim of this study was to compare assessments of perfusion images by different professional groups regarding (i) perfusion values and (ii) burn depth assessment. Methods: Twelve observers without LSCI experience were included. The observers were evenly recruited from three professional groups: plastic surgeons with experience in assessing burns, nurses with experience in treating burns, and junior doctors with limited experience of burns. Ten cases were included. Each case consisted of one digital photo of the burn with a pre-marked region of interest (ROI) and two unmarked perfusion images of the same area. The first and the second perfusion image was from 24h and 72-96h after injury, respectively. The perfusion values from both perfusion images were used to generate a LSCI recommendation based on the perfusion trend (the derivative between the two perfusion values). As a last step, each observer was asked to estimate the burn depth using their clinical experience and all available information. Intraclass correlation (ICC) was calculated between the different professional groups and among all observers. Results: Perfusion values and perfusion trends between all observers had an ICC of 0.96 (95% CI 0.91-0.99). Burn depth assessment by all observers yielded an ICC of 0.53 (95% CI: 0.31-0.80) and an accuracy of 0.53 (weighted kappa). LSCI recommendations generated by all observers had an ICC of 0.95 (95% CI: 0.90-0.99). Conclusion: Observers can reliably identify the same ROI, which results in observer-independent perfusion measurements, irrespective of burn experience. Extensive burn experience did not further improve burn depth assessment. The LSCI recommendation was more accurate in all professional groups. Introducing LSCI measurements would be likely improve early assessment of burns. (C) 2019 Elsevier Ltd and ISBI. All rights reserved.

Objective: After iontophoresis of vasoactive drugs into the skin, a decrease in perfusion is commonly observed. We delivered vasoactive drugs by iontophoresis using different delivery protocols to study how these affect this decrease in perfusion as measured using LDF. Methods: We measured skin perfusion during iontophoresis of (ACh), MCh, andNAusing a single pulse or separate pulses at different skin sites, and during repeated delivery of ACh at the same site. Results: Perfusion half-life was 6.1 (5.6-6.6) minutes for ACh and 41 (29-69) minutes for MCh (p less than 0.001). The maximum response with multiple pulses of ACh iontophoresis was lower than with a single pulse, 30 (22-37) PU vs. 43 (36-50) PU, p less than 0.001. Vasoconstriction to NA was more rapid with a single pulse than with multiple pulses. The perfusion half-life of ACh decreased with repeated delivery of ACh at the same site-first 16 (14-18), second 5.9 (5.1-6-9) and third 3.2 (2.9-3.5) minutes, p less than 0.001. Conclusions: The drug delivery protocol affects microvascular responses to iontophoresis, possibly as a result of differences in the dynamics of local drug concentrations. Perfusion half-life may be used as a measure to quantify the rate of perfusion recovery after iontophoresis of vasoactive drugs.

The Simplified Acute Physiology 3 outcome prediction model has a narrow time window for recording physiologic measurements. Our objective was to examine the prevalence and impact of missing physiologic data on the Simplified Acute Physiology 3 model's performance.Retrospective analysis of prospectively collected data.Sixty-three ICUs in the Swedish Intensive Care Registry.Patients admitted during 2011-2014 (n = 107,310).None.Model performance was analyzed using the area under the receiver operating curve, scaled Brier's score, and standardized mortality rate. We used a recalibrated Simplified Acute Physiology 3 model and examined model performance in the original dataset and in a dataset of complete records where missing data were generated (simulated dataset). One or more data were missing in 40.9% of the admissions, more common in survivors and low-risk admissions than in nonsurvivors and high-risk admissions. Discrimination did not decrease with one to two missing variables, but accuracy was highest with no missing data. Calibration was best in the original dataset with a mix of full records and records with some missing values (area under the receiver operating curve was 0.85, scaled Brier 27%, and standardized mortality rate 0.99). With zero, one, and two data missing, the scaled Brier was 31%, 26%, and 21%; area under the receiver operating curve was 0.84, 0.87, and 0.89; and standardized mortality rate was 0.92, 1.05 and 1.10, respectively. Datasets where the missing data were simulated for oxygenation or oxygenation and hydrogen ion concentration together performed worse than datasets with these data originally missing.There is a coupling between missing physiologic data, admission type, low risk, and survival. Increased loss of physiologic data reduced model performance and will deflate mortality risk, resulting in falsely high standardized mortality rates.