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The protein C (PC) system has proven to be a crucial cascade in systemic inflammatory and coagulopathic disorders such as severe sepsis and, more recently, in severe burns. We aimed to conflate our recent systemic findings with further investigations in the local tissue effects of a severe burn injury on the expression of PC and its main receptor endothelial protein C receptor (EPCR). Of the 86 patients enrolled in our recent study, 34 consented to biopsies of both normal and burn edge tissue. These were examined histologically and immunostained for PC, EPCR, and CD68. The burn samples expressed lower PC (p = 0.0027) and higher EPCR (p = 0.0253) than the normal samples in a histological severity-dependent manner. There was also a negative association between PC expression and CD68 positive macrophage infiltration (τb = −0.214, p = 0.020), which was expectedly higher in burn edge samples (p &lt, 0.0005). Interestingly, while there were no correlations between tissue and plasma PC or EPCR, local PC expression was also prognostic of our previously established outcome of a patient requiring increased medical support (OR 0.217 (95%CI 0.052 to 0.901), p = 0.035). The results suggest that local PC cascade changes from a burn injury may be a separate process to the systemic effects and that the local levels may provide useful information in addition to the diagnostic and prognostic abilities we previously found in the circulating PC system.

Barbecue devices can be classified into several categories, including electrical, gas-fuelled and charcoal-based devices. Recreational outdoor burns are a preventable cause of morbidity and disability. This study aims to describe and analyse contact-related barbecue coal burns in the paediatric age group across New South Wales and the Australian Capital Territory. A retrospective review from January 2010 to January 2019 at The Children’s Hospital at Westmead. All barbecue coal burn injuries in children less than 16 years that attended or were referred to the Burns Unit were included. There were 48 patients whom presented with a contact burn barbecue coal-related injury. The male to female ratio was 5:3 with an average age of 2.5 years. Most injuries occurred in the home setting. The most common site of injury were the hands. The most frequent type of injury was a mid-dermal burn, followed by deep and superficial, respectively. Charcoal barbeque burns in children were uncommon, usually occurred at home and most commonly involved critical burn areas such as the hands, with the potential for long-term functional impairment. This case series highlights the importance of understanding prevention campaigns around barbecues Level of evidence: Level IV, risk/prognostic study.

Modern burn care is centralised, and studies show that early, prompt referral to dedicated burn services improve clinical outcomes. We describe the use of a novel clinical instrument, the burn injury Transfer Feedback Form, to support and educate referring clinicians about the early assessment and management of burn injuries. Since 2005, Transfer Feedback Forms have been completed for all burn-injured patients with inter-hospital transfer to a specialised burn unit in the state of New South Wales (NSW), Australia. The aim of this study was to review physiological, procedural, and system or process issues in the care of both adult and paediatric burn-injured patients needing retrieval and transfer in NSW as identified by the Transfer Feedback Form. Secondary objectives were to determine any significant differences in these parameters between metropolitan and regional or remote referring institutions, and if any improvements occurred in these parameters over time.This was a retrospective analysis of all patients who were transferred to a burn unit in NSW between July 2005 and July 2021 using their prospectively completed Transfer Feedback Forms. Patients were divided into metropolitan and non-metropolitan referral sources based on geographic location. Clinical issues or deficiencies identified during each patient transfer were then classified into various groups. To determine if transfer-related clinical concerns had changed with time, two distinct periods before and after 2015, when the NSW Trauma App was introduced, were analysed. We compared trends in frequency of transfer-related concerns before and after App introduction by using interrupted time series analysis.A total of 3233 patients had Feedback Forms submitted during the 16-year period. We included 929 children (28.7%) and 2304 adults (71.3%). Transfer-related clinical issues were identified in 904 adults (39.0%) and 484 children (52.0%). In both adult and paediatric patients, the most common transfer-related clinical deficiency was in relation to burn size estimation with 525 patients (43.7%) and 207 patients (30.6%), respectively. Between the time periods analysed, the number of issues arising during inter-hospital transfer fell significantly for both adults (from 46.1% to 26.1%; p 0.05) and children (from 55.3% to 40.7%; p 0.05). Segmented regression analysis demonstrated a significant break in the rate of transfer-related clinical issues in 2014 (p 0.05) and 2015 (p 0.01) for adults. Accurate body surface area estimations also increased significantly by 53% and 50% for adults and children (p 0.05 for both), respectively, after 2015.Our analysis indicates that the early care of burn-injured patients undergoing inter-hospital transfer is associated with clinical, technical, and logistical challenges. However, introduction of the burn injury Transfer Feedback Form has been associated with improvements in early burn care by referring centres both temporally and geographically. Smartphone-based applications such as the NSW Trauma App have also probably contributed to these findings. Adopting these simple, inexpensive strategies into burn care systems will augment inter-hospital transfer of burn-injured patients, and improve clinical outcomes.

Background: Factor V Leiden is the most common form of inherited thrombophilic syndrome, affecting five per cent of caucasians. While increased rates of venous thromboembolic complications have been regularly reported in factor V Leiden patients, little is known about their risk of microvascular complications or flap failure rates in free-flap surgery. The aim of this review is to qualitatively review the published literature on outcomes of free-flap surgery in patients with factor V Leiden. Methods: MEDLINE®, PubMed, EMBASE and Cochrane were searched from their dates of inception to March 2017. Nine studies of level IV evidence were included in this qualitative review. In total, these studies included 22 patients who underwent 24 free-flap operations. Results: Nine flap failures were reported due to thrombotic complications. Even heterozygous factor V Leiden patients had a relatively high risk of free-flap failure (3/15 free flaps), and patients who were heterozygous for factor V Leiden and had other coexistent thrombophilias had an even higher failure rate (5/6 free flaps). However, the small sample size across the nine studies, as well as the inevitable publication bias, means that definitive conclusions cannot be drawn. Conclusion: Despite factor V Leiden being a relatively common condition in Australia, current evidence for outcomes of free-flap reconstruction in this patient population is lacking.

Research into recovery and adjustment after burn injury has indicated a link between psychopathological symptoms including traumatic stress, distress, depression and anxiety, and worse psychosocial and physical outcomes. The severity of psychological symptoms does not always correlate with that of the burn injury, and symptoms can be ongoing in certain patients for extensive periods, leading to a need for early screening in burns patients for psychological vulnerabilities. One potential factor influencing recovery from the psychological impact of burn injury is adult attachment style, specifically secure and insecure attachment, as this describes how an individual organizes their stress regulation. This cross-sectional study measured: (a) attachment style (via the Relationship Questionnaire [RQ]): (b) negative psychological symptoms (via the Depression Anxiety and Stress Scale [DASS]); and, (c) post-traumatic symptoms (via the Davidson Trauma Scale [DTS]) in a cohort of burns patients (n = 104, 51 analysed) in a severe burns unit in Australia during the acute phase of their recovery. Secure attachment style was inversely related to psychopathological symptoms. Secure participants scored significantly lower scores on the DASS (M = 17.63, SD = 17.07) compared to self-rated insecure participants [(M = 42.38, SD = 34.69), p

Although general principles of pressure wound management begin with optimisation of patient and wound factors to promote healing, refractory cases may require surgical intervention. Compared with other areas, ischial tuberosity (IT) wounds tend to occur in wheelchair-bound patients and may respond well to surgical debridement and flap reconstruction where added tissue bulk is preventative for further pressure ulcer formation. IT ulcers may occur in patients with some degree of ambulatory potential or those who have a temporary impairment. While the most commonly used flap for typical IT ulcers is the musculocutaneous hamstring flap, for these patients, this is not suitable due to the sacrifice of muscle function. We designed a combined posterior thigh flap with pedicled gracilis to provide robust coverage and vascularised muscle bulk, while preserving hamstring function and potential for re-advancement in ulcer recurrence. Patients were selected for their grade of ulcer, compliance with physiotherapy, and their need to preserve muscle function. Each underwent surgical debridement and reconstruction using the combination flap. End-points included wound coverage, post-operative mobility, and complications. Follow-up was 3 months post-surgery. All patients achieved complete coverage of their wound. In the follow-up period, there were no wound complications or ulcer recurrence. We describe a novel reconstruction method for IT pressure ulcers that maintains patient mobility. This combination perforator-based fasciocutaneous and gracilis flap is a superior reconstructive option that has reduced donor site morbidity and relatively simple operative technique and can be reutilised in ulcer recurrence. Level of Evidence: Level V, therapeutic study.

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.

Auricle burns remain a challenge for surgeons who must navigate the common and morbid complication of chondritis through often complex and painful dressing regimes. Our technique involving the application of Biobrane promotes healing, is individualized, single application and conducive to topical antimicrobial application. We find it is a simple and effective approach to treating the burnt auricle.

Auricle burns remain a challenge for surgeons who must navigate the common and morbid complication of chondritis through often complex and painful dressing regimes. Our technique involving the application of Biobrane promotes healing, is individualized, single application and conducive to topical antimicrobial application. We find it is a simple and effective approach to treating the burnt auricle.

Navigating the complexities of a severe burn injury is a challenging endeavour where the natural course of some patients can be difficult to predict. Straddling both the coagulation and inflammatory cascades that feature strongly in the burns systemic pathophysiology, we propose the pleiotropic protein C (PC) system may produce a viable biomarker to assist traditional evaluation methods for diagnostic and prognostic purposes.We enrolled 86 patients in a prospective observational cohort study. Over three weeks, serial blood samples were taken and measured for PC, activated (A)PC, their receptor endothelial protein C receptor (EPCR), and a panel of inflammatory cytokines including C-reactive protein (CRP), tumour necrosis factor-α, interleukin (IL)-1β, IL-6, IL-8, and IL-17. Their temporal trends were analysed alongside clinical factors including burn size, burn depth, presence of inhalational injury, and a composite outcome of requiring increased support.(i) APC increased from a nadir on Day 3 (2.3±2.1ng/mL vs 4.1±2.5ng/mL by Day 18, p0.0005), only becoming appropriately correlated to PC from Day 6 onwards (r=0.412-0.721, p0.05 for all Days 6-21). (ii) This early disturbance in the PC system was amplified in the more severe burns (≥30% total body surface area, predominantly full thickness, or with inhalational injury), which were characterised by a marked fall in PC activation (approximated by APC/PC ratio) and APC levels during Days 0-3 with low unchanged PC levels. Critically low levels of this cytoprotective agent was associated with greater inflammatory burden, as reflected by significantly elevated CRP, IL-6, and IL-8 levels in the more severe compared to less severe burns, and by negative correlations between both PC and APC with most inflammatory cytokines. (iii) Alongside clinical markers of severity at admission (burn size, burn depth, and presence of inhalational injury), only Day 0 APC/PC ratio (OR 1.048 (1.014-1.083), p=0.006), APC (OR 1.364 (1.032-1.803), p=0.029), PC (OR 0.899 (0.849-0.953), p0.0005), and not any inflammatory cytokines were predictive markers of requiring increased support. Uniquely, decreased Day 0 PC was further individually associated with each increased total length of stay, ICU length of stay, intravenous fluid resuscitation, and total surgeries, as well as possibly mortality.An early functional depletion of the cytoprotective PC system provides a physiological link between severe burns and the cytokine storm, likely contributing to worse outcomes. Our findings on the changes in APC, PC and PC activation during this pathological state support APC and PC as early diagnostic and prognostic biomarkers, and provides a basis for their therapeutic potential in severe burn injuries.

Severe burn injuries are highly traumatic requiring lengthy recovery. High levels of distress in the early stages of treatment have been associated with poor physical and psychosocial recovery outcomes. Identifying traits relating to distress and personal coping styles may aid screening. Type-D, or 'distressed', personality may be such a trait. Type-D personality refers to an ongoing personality organization defined by a tendency to experience greater negative emotions and thoughts while simultaneously socially inhibiting their expression (Denollet et al., 1996 . Type-D has been linked to poor health outcomes in those with cardiovascular disease as well as other populations and has been found to be associated with elevated psychological symptoms. Currently, there are no investigations in the literature looking at Type-D in the severe burns injury population. This study aimed to investigate Type-D in severe burn injury patients, specifically regarding the presence of psychological symptoms in early treatment, using data gathered during a pilot study conducted at a severe burn injury unit. The DS-16, Davidson Trauma scale and Depression Anxiety and Stress Scale scores were analysed along with demographic and clinical data in 54 participants (40 males, 14 females). Participants who were found to have Type-D displayed significantly higher levels of psychopathology. Additionally, Type-D was found to be a significant predictor of psychological symptoms.

External ear abnormalities are common. These may affect ear shape, size, prominence and degree of development. They may also be associated with hearing loss. The early identification and management of hearing loss is essential. There are several options for reconstruction of the external ear using both autologous and non-autologous techniques. The aim of this article is to outline the different reconstructive options.

Protein C circulates in human plasma to regulate inflammation and coagulation. It has shown a crucial role in wound healing in animals, and low plasma levels predict the presence of a wound in diabetic patients. However, no detailed study has measured protein C levels in patients with severe burns over the course of a hospital admission. A severe burn is associated with dysfunction of inflammation and coagulation as well as a significant risk of morbidity and mortality. The current methods of burn assessment have shortcomings in reliability and have limited prognostic value. The discovery of a biomarker that estimates burn severity and predicts clinical events with greater accuracy than current methods may improve management, resource allocation and patient counseling. This is the first study to assess the potential role of protein C as a biomarker of burn severity. We measured the plasma protein C levels of 86 patients immediately following a severe burn, then every three days over the first three weeks of a hospital admission. We also analysed the relationships between burn characteristics, blood test results including plasma protein C levels and clinical events. We used a primary composite outcome of increased support utilisation defined as: a mean intravenous fluid administration volume of five litres or more per day over the first 72 h of admission, a length of stay in the intensive care unit of more than four days, or greater than four surgical procedures during admission. The hypothesis was that low protein C levels would be negatively associated with increased support utilisation. At presentation to hospital after a severe burn, the mean plasma protein C level was 76 ± 20% with a range of 34–130% compared to the normal range of 70–180%. The initial low can be plausibly explained by impaired synthesis, increased degradation and excessive consumption of protein C following a burn. Levels increased gradually over six days then remained at a steady-state until the end of the inpatient study period, day 21. A multivariable regression model (Nagelkerke’s R2 = 0.83) showed that the plasma protein C level on admission contributed the most to the ability of the model to predict increased support utilisation (OR = 0.825 (95% CI = 0.698-0.977), P = 0.025), followed by burn size (OR = 1.252 (95% CI = 1.025–1.530), P = 0.027), burn depth (partial thickness was used as the reference, full thickness OR = 80.499 (1.569–4129.248), P = 0.029), and neutrophil count on admission (OR = 1.532 (95% CI = 0.950–2.473), P = 0.08). Together, these four variables predicted increased support utilisation with 93.2% accuracy, 83.3% sensitivity and 97.6% specificity. However if protein C values were disregarded, only 49.5% of the variance was explained, with 82% accuracy, 63% sensitivity and 91.5% specificity. Thus, protein C may be a useful biomarker of burn severity and study replication will enable validation of these novel findings.

Peer support has long been recognised as an essential component of a supportive network for people facing adversity. In particular, burn survivor peer support is a valuable and credible resource available to those rehabilitating from a severe burn. The aim of this study was to explore burn survivors' experiences of providing and receiving inpatient peer support to develop an in-depth understanding of the influence during the rehabilitation journey. In 2011, twenty-one burn survivors were recruited from four severe burn units across Australia. A qualitative phenomenological methodology was used to construct themes depicting survivors' experiences. Participants were selected through purposeful sampling, and data collected through in-depth individual semi-structured interviews. Data were analysed using Colaizzi's phenomenological method of data analysis. Central to burn rehabilitation was the notion of peer support having a significant impact on burn survivors' psychosocial rehabilitation. The emergent theme 'Burn Survivor Peer Support' identified five cluster themes: (1) Encouragement, inspiration and hope (2) Reassurance (3) The Importance of Timing (4) The Same Skin (5) Appropriate Matching. These findings demonstrate that peer support assists with fostering reassurance, hope and motivation in burn rehabilitation. A national network based on a clinician led inpatient burn survivor peer support programme could provide burn survivors across Australia, and in particular remote access locations, with the benefits of peer support necessary to endure the rehabilitation journey.

Objectives: Burn injuries are complex traumatic events carrying high risks of acute physical and psychosocial morbidity. With greater survival, clinical and research attention has turned to psychosocial recovery outcomes and risk factors. It is timely to summarise current issues in posttraumatic disorders after burn injury for mental health and integrative care clinicians. Posttraumatic stress disorder (PTSD) is a common outcome of severe burn injury. There are difficulties in delivering current best practice treatments to many survivors especially those in rural and remote areas and those with comorbidities. Vicarious traumatization of clinicians, families and carers requires attention and internationally there are moves to psychosocial screening and outcome tracking. Conclusions: The role of the multidisciplinary treatment, integrated and trauma-informed care is essential. While level 1 evidence for PTSD treatments theoretically applies, adaptations that consider comorbidities and treatment contexts are often essential with further research required.

Pressure ulcers present a major clinical challenge, are physically debilitating and place the patient at risk of serious comorbidities such as septic shock. Recombinant human activated protein C (APC) is an anticoagulant with anti-inflammatory, cytoprotective and angiogenic effects that promote rapid wound healing. Topical negative pressure wound therapy (TNP) has become widely used as a treatment modality in wounds although its efficacy has not been proven through randomised controlled trials. The aim of this study was to determine the preliminary efficacy and safety of treatment with APC for severe chronic pressure sores with and without TNP. This case presentation describes the history, management and outcome of two patients each with a severe chronic non-healing pressure ulcer that had failed to respond to conventional therapy. TNP was added to conservative management of both ulcers with no improvement seen. Then local application of small doses of APC was added to TNP and with conservative management, resulted in significant clinical improvement and rapid healing of both ulcers, displaying rapid growth of vascular granulation tissue with subsequent epithelialisation. Patients tolerated the treatment well and improvements suggested by long-term follow-up were provided. Randomised placebo-controlled double blind trials are needed to quantify the efficacy, safety, cost-effectiveness, optimal dose and quality of life changes seen from treatment with APC.

Burns are a global public health problem, accounting for an estimated 265,000 deaths annually. Inflammation is essential in supplying the growth factors, cytokines and chemokines needed to recruit T-cells and myeloid cells to the site of a burn injury for wound healing. However, major burns generate a marked pathophysiological inflammatory response through a widespread release of abundant pro-inflammatory mediators that predispose patients to a systemic inflammatory response syndrome, sepsis and multi-organ failure. Recently, there has been promising investigation into the role of γδ T-cells and Th-17 cells in the regulation and propagation of this inflammatory response. This study reviews the current literature on the post-burn immune response.

Phosphaturic mesenchymal tumor–mixed connective tissue variant (PMTMCT) is an extremely rare tumor associated with tumor-induced osteomalacia. The majority occur in middle age and arise from the extremities. This report describes a young girl with PMTMCT arising in the mandible and with no evidence of paraneoplastic syndrome.

Severe burn injuries are catastrophic life events resulting in significant physical and psychological effects. With long periods of hospitalization and rehabilitation, burn survivors encounter many issues, including an altered body image and loss of function and independence that subsequently influence quality of life and the family unit. Consequently, resilience has been identified as a fundamental concept that facilitates the adaptability required to navigate the lengthy and complex recovery process. However, over time, the notion of resilience has shifted from a static, innate trait to a fluid and multidimensional concept. Here, we review the evidence surrounding the role of resilience in the recovery of burn injury. This integrative review was based on a systematic search of five electronic databases. Of the 89 articles identified, ten primary research papers met the inclusion criteria. Three key themes were identified encompassing relational strengths, positive coping, and the resistance to trauma symptoms that are fundamental constructs associated with developing and sustaining resilience that resonate with the broader literature on burn recovery. However, limited evidence is currently available within the burns context. While resilience appears to be a vital component influencing the recovery from burns trauma, it still remains a broad construct within the burns framework. Regular assessment of resilience in burn-injured patients is recommended in clinical practice in addition to longitudinal and intervention studies to best inform patient care.

Self-inflicted burns are regularly admitted to burns units worldwide. Most of these patients are referred to psychiatric services and are successfully treated however some return to hospital with recurrent self-inflicted burns. The aim of this study is to explore the characteristics of the recurrent self-inflicted burn patients admitted to the Royal North Shore Hospital during 2004-2011. Burn patients were drawn from a computerized database and recurrent self-inflicted burn patients were identified. Of the total of 1442 burn patients, 40 (2.8%) were identified as self-inflicted burns. Of these patients, 5 (0.4%) were identified to have sustained previous self-inflicted burns and were interviewed by a psychiatrist. Each patient had been diagnosed with a borderline personality disorder and had suffered other forms of deliberate self-harm. Self-inflicted burns were utilized to relieve or help regulate psychological distress, rather than to commit suicide. Most patients had a history of emotional neglect, physical and/or sexual abuse during their early life experience. Following discharge from hospital, the patients described varying levels of psychiatric follow-up, from a post-discharge review at a local community mental health centre to twice-weekly psychotherapy. The patients who engaged in regular psychotherapy described feeling more in control of their emotions and reported having a longer period of abstinence from self-inflicted burn. Although these patients represent a small proportion of all burns, the repeat nature of their injuries led to a significant use of clinical resources. A coordinated and consistent treatment pathway involving surgical and psychiatric services for recurrent self-inflicted burns may assist in the management of these challenging patients.

Objective: The aim of this surgical procedure was to definitively correct severe recurrent upper and lower bilateral eyelid ectropion after 2 attempts with full-thickness skin grafts. It was necessary to repair all 4 eyelids with forehead skin. Middle lamella support was required. Methods: Bilateral median forehead flaps, which were well vascularized by the supratrochlear vessels, were chosen for this procedure to utilize the readily available forehead tissue. The median forehead flap can be easily positioned to cover the entire eyelid. Furthermore, the flap could be split in half, without the risk of vascular compromise. Middle lamella support was provided with a cartilage graft from the nasal septum. Results: At 4 months, the patient no longer suffered from exposure keratopathy and both forehead flaps had healed well. At 12 months, the functional and cosmetic outcomes of this procedure were acceptable. Conclusions: This method of surgery can be effective in the young, in whom the Mustarde cheek advancement fails, or when there is little available unburnt tissue. It can be used as an alternative to a forehead flap when both upper and lower eyelids are damaged bilaterally. The split forehead flap definitively corrected the ectropion in this case.

Background: Prognosis in patients with severe burns is improved by early debridement and coverage with skin. The limiting factor in these patients is the lack of unburnt skin for harvesting. Cultured epithelial autograft (CEA) sheets provide an alternative means of covering debrided skin. This is a report on an initial experience with using CEA sheets. Methods: The two patients in this study had their medical records examined retrospectively. Results: The effective take of the CEA sheets was zero in both patients. One of the patients died approximately 6 weeks after admission. Conclusions: Because of the poor graft take seen in the patients in the present study, the use of CEA sheets only as a form of temporary biological dressing is recommended.

Chronic wounds arising from orthopedic surgery present a major clinical challenge. Osteomyelitis may develop from polymicrobial infection, which can be unresponsive to treatment and lead to amputation. Topical negative pressure (TNP) is an effective treatment in wound management and is now used worldwide. Activated protein C (APC) is an anticoagulant with cytoprotective and healing properties. The aim of this study was to determine whether combined treatment of TNP and APC was tolerated and was efficacious for treatment of difficult-to-treat wounds. Four patients who presented to Royal North Shore Hospital with wounds that were not responsive to conventional therapy were studied. All cases showed a marked reduction in wound size and depth within 1 week of starting treatment and progressively improved over time. There was a remarkable increase in the volume of granulation tissue. After treatment, wounds either completely closed or provided sufficient granulation tissue to allow split-thickness skin grafting. The treatment was well tolerated, and the patients were able to be managed on out-patient basis. Long-term follow-up suggested that this treatment prevented osteomyelitis. This innovative treatment is very promising and may significantly increase quality of care for patients with recalcitrant orthopedic wounds. A randomized, placebo-controlled double blind trial is required to further determine the efficacy of APC plus TNP.

Objective: Critical illness polyneuropathy in burn patients is an underreported condition. It is associated with high mortality rates and prolonged hospital stay and rehabilitation. This study aims to further define the cause and outcome of critical illness polyneuropathy following major burn injuries. Methods: A retrospective review of all burn patients with neuropathy that presented to Royal North Shore Hospital, Sydney, between the period of 2004 and 2009 was performed. The neurological findings, diagnostic processes, and outcomes were examined. End points such as duration on the ventilator, length of intensive care, and hospital stay were recorded. Results: There were 7 patients in total that exhibited abnormal neurological findings. Ages ranged from 17 to 43 years with all injuries sustained in flame burns. Mean total burnt surface area is 46%. There was no mortality in this series but all 7 had evidence of sepsis and multiorgan failure with an average 42 days spent on the ventilator. Clinical findings varied greatly. Five had involvement of nerves away from the site of burns. Upper-limb weakness tended to have a slower recovery. Examination and neurophysiologic studies were often hampered by pain and bandaging over burnt skin. Conclusions: Neurological manifestations of critical illness polyneuropathy are varied and cannot always be explained by direct thermal or compression injury. This study confirms a strong link to sepsis, multiple organ failure, and slow ventilatory wean. The requirement for a precise neurophysiological diagnosis of critical illness polyneuropathy needs to be balanced with technical considerations and the likelihood of alternative diagnoses.

To date there is no published literature on the dangers of hair removal wax burns. This case review illustrates the steady influx of patients presenting to Royal North Shore Hospital (RNSH) with hair removal wax burns. Between January and December 2006, 10 patients out of 395 with burns (2.5%) presented to our dressing clinic with hair removal wax burns. All sustained burns under 5% total body surface area (TBSA) and two required debriding and split skin grafting (SSG). The mechanism of the burns was re-heating the hair removal wax in the microwave for too long.

Loyola M McLean,1–3 Vanessa Rogers,3–4 Rachel Kornhaber,5–7 Marie-Therese Proctor,8 Julia Kwiet,3–4 Jeffrey Streimer,3–4 John Vandervord6 1Brain and Mind Centre and Discipline of Psychiatry, Sydney Medical School, University of Sydney, Sydney, NSW, Australia; 2Westmead Psychotherapy Program, Discipline of Psychiatry, Sydney Medical School, University of Sydney and Western Sydney Local Health District, Parramatta, NSW, Australia; 3Consultation-Liaison Psychiatry, Royal North Shore Hospital, Sydney, NSW, Australia; 4Discipline of Psychiatry, Sydney Medical School, University of Sydney, Sydney, NSW, Australia; 5School of Health Sciences, Faculty of Health, University of Tasmania, Alexandria, NSW, Australia; 6Severe Burns Injury Unit, Royal North Shore Hospital, St Leonards, Sydney, NSW, Australia; 7School of Nursing, University of Adelaide, SA, Australia; 8Graduate School of Counselling, Excelsia College, Sydney, NSW, Australia Background: Throughout development and into adulthood, a person's face is the central focus for interpersonal communication, providing an important insight into one's identity, age, sociocultural background, and emotional state. The face facilitates important social, including nonverbal, communication. Therefore, sustaining a severe burn, and in particular a facial burn, is a devastating and traumatizing injury. Burn survivors may encounter unique psychosocial problems and experience higher rates of psychosocial maladjustment, although there may be a number of potentially mediating factors. Objectives: The purpose of this phenomenological study was to examine the early recovery experience of patients with a facial burn. In particular, this study focused on how the injury impacted on the participants’ relationship with their own body and the challenges of early psychosocial adjustment within the first 4 months of sustaining the injury. Methods: In 2011, six adult participants encompassing two females and four males ranging from 29 to 55 years of age with superficial to deep dermal facial burns (with background burns of 0.8%–55% total body surface area) were recruited from a severe burn injury unit in Australia for participation in a Burns Modified Adult Attachment Interview. Narrative data were analyzed thematically and informed by Colaizzi's method of data analysis. Results: Three overarching themes emerged: relationship to self/other, coping, and meaning-making. Themes identified related to how the experience affected the participants’ sense of relationship with their own bodies and with others, as well as other challenges of early psychosocial adjustment. All participants indicated that they had experienced some early changes in their relationship with their body following their burn injury. Conclusion: These findings highlight the struggle burn survivors experienced with postburn adjustment, but expressed altruism and optimism around their recovery. Past trauma was observed to be a significant finding in this sample. Understanding the “lived experience” supports the way clinical and family systems can foster positive adjustment and coping. Consequently, multidisciplinary burn teams and health care professionals need to understand the principles of trauma-informed care and translate these into practice in the treatment of this group of patients. Keywords: facial burn, body image, psychosocial adjustment, complex trauma, posttraumatic growth, phenomenology

Prognosis in patients with severe burns is improved by early debridement and coverage with skin. The limiting factor in these patients is the lack of unburnt skin for harvesting. Cultured epithelial autograft (CEA) sheets provide an alternative means of covering debrided skin. This is a report on an initial experience with using CEA sheets.The two patients in this study had their medical records examined retrospectively.The effective take of the CEA sheets was zero in both patients. One of the patients died approximately 6 weeks after admission.Because of the poor graft take seen in the patients in the present study, the use of CEA sheets only as a form of temporary biological dressing is recommended.

Purpose: To review the incidence of Venous Thromboembolism (VTE) complications at Royal North Shore Hospital comparing medical and surgical specialties. To assess compliance to VTE prophylaxis and review the incidence of VTE complications when guidelines are adhered to. To identify strategies which would improve surgical and medical compliance to VTE guidelines. Methodology: A review of the medical records of all patients diagnosed with PE or DVT over a 12 month period was undertaken. A ward survey of current in patients was conducted to determine compliance to guidelines in both surgical and medical patients. Results: Both surgical specialties and medical specialties were reviewed. Surgical specialties complied with the guidelines more often than medical specialties. Surgical patients were broken down into specialties and reviewed as elective admissions and emergency admissions. DVT complications occurred more often than PEs. The ward survey confirmed surgical specialties complied more often with VTE prophylaxis than medical specialties. Conclusion: VTE is a costly complication to both the patient and the hospital during hospital admission, which is potentially preventable when adequate assessment and prophylaxis is undertaken. RNSH has recently reviewed and implemented guidelines for VTE prophylaxis in accordance with current research. This paper indicates that surgical specialties are complying with guidelines more often than medical specialties but there is still room for improvement.

The perceptions of three groups of women regarding their body image, self-concept, total self-image, and self-esteem were compared. The groups included 64 women who had mastectomies and wore external breast prostheses, 31 women who had mastectomies and underwent breast reconstruction, and a control group of 78 women who had not experienced mastectomy. The body image, total self-image, and self-esteem mean scores indicated that the prosthesis and reconstruction groups had more positive feelings regarding their bodies than did the control group. There were no significant differences in self-concept among the three groups. These findings challenge a common assumption that mastectomy automatically results in psychiatric morbidity caused by an altered body image and suggest that health professionals should not make assumptions about how a woman will psychologically respond to mastectomy.

Purpose: Orbital floor blow out fractures can produce diplopia and enophthalmos that require correction by reconstituting the orbital floor defect with implants. The type of implant used has evolved from bone to various synthetic materials. The choice of implant depends upon surgeon, the institution and experience. The aim of this paper is to evaluate the evidence for the implants available for orbital floor reconstitution. Methodology: This study is a literature review of the available evidence for use of implants in orbital floor reconstruction. An evidence based medicine, Cochrane database and Medline search was performed specifically at articles dealing with orbital floor fractures and the type of implant used. The outcomes included diplopia, enophthalmos, re-operation, infection and imaging. Results: There were a total of 19 articles specifically looking at orbital floor fractures and type of implant. Only two of which were comparative trials comparing bone with biodegradable mesh and titanium (Al-Sukhun and Lindqvist 2006 and Ellis and Tan 2003, respectively). These studies suggested not using bone due to operative duration and bone resorption seen on scanning. The remaining articles were case series on outcomes of specifically used implants such as titanium, bone, silicone, and polyethylene. These articles demonstrated that either of the implants is safe and effective to use in orbital floor fractures with the exception of silicone where Laxenaire et al., (1997) demonstrated a 20% extrusion rate. Conclusions: It is safe to use either bone autograft or the various available synthetic materials such as titanium or polyethylene in orbital floor reconstitution.

Purpose: To highlight the danger of reverse thermal burns secondary to exposure to LPG when refuelling vehicles. Methodology: Review of patient medical records and the burns data base Results: Over a 12 month period 4 people have presented to RNSH Severe Burns Unit after sustaining a reverse thermal burn injury while refuelling their vehicle with LPG. The burn was primarily to the first web space of the dominant hand. Other areas were also involved. TBSA was