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

Introduction: Superficial burns that affect the epidermis and upper dermis only are characterised by redness of the skin that blanches on pressure, pain, and hypersensitivity. The skin blisters within hours and usually heals with minimal scarring within 2 to 3 weeks if no infection is present. Most minor burns occur in the home, with less than 5% requiring hospital treatment., Methods and Outcomes: We conducted a systematic review and aimed to answer the following clinical question: What are the effects of treatments for minor thermal burns? We searched: Medline, Embase, The Cochrane Library, and other important databases up to October 2008 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA)., Results: We found eight systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions., Conclusions: In this systematic review, we present information relating to the effectiveness and safety of the following interventions: alginate dressing; antibiotics; chlorhexidine-impregnated paraffin gauze dressing; foam dressing; hydrocolloid dressing; hydrogel dressing; paraffin gauze dressing; polyurethane film; silicone-coated nylon dressing; and silver sulfadiazine cream.

Objective: To examine the response of the Victorian State Trauma System to the February 2009 bushfires., Design and Setting: A retrospective review of the strategic response required to treat patients with bushfire-related injury in the first 72 hours of the Victorian bushfires that began on 7 February 2009. Emergency department (ED) presentations and initial management of patients presenting to the state's adult burns centre (The Alfred Hospital [The Alfred]) were analysed, as well as injuries and deaths associated with the fires., Results: There were 414 patients who presented to hospital EDs as a result of the bushfires. Patients were triaged at the emergency scene, at treatment centres and in hospital. National and statewide burns disaster plans were activated. Twenty-two patients with burns presented to the state's burns referral centres, of whom 18 were adults. Adult burns patients at The Alfred spent 48.7 hours in theatre in the first 72 hours. There were a further 390 bushfire-related ED presentations across the state in the first 72 hours. Most patients with serious burns were triaged to and managed at burns referral centres. Throughout the disaster, burns referral centres continued to have substantial surge capacity., Conclusions: Most bushfire victims either died, or survived with minor injuries. As a result of good prehospital triage and planning, the small number of patients with serious burns did not overload the acute health care system.

Background: An acute burn wound is a complex and evolving injury. Extensive burns produce, in addition to local tissue damage, systemic consequences. Treatment of partial thickness burn wounds is directed towards promoting healing, and a wide variety of dressings is currently available. Improvements in technology and advances in understanding of wound healing have driven the development of new dressings. Dressing selection should be based on their effects of healing, but ease of application and removal, dressing change requirements, cost and patient comfort should also be considered., Objectives: To assess the effects of burn wound dressings for superficial and partial thickness burns., Search Strategy: We searched the Cochrane Wounds Group Specialised Register (Searched 29/5/08); The Cochrane Central Register of Controlled Trials (CENTRAL) - The Cochrane Library Issue 2 2008; Ovid MEDLINE - 1950 to May Week 3 2008; Ovid EMBASE - 1980 to 2008 Week 21 and Ovid CINAHL - 1982 to May Week 4 2008., Selection Criteria: All randomised controlled trials (RCTs) that evaluated the effects of burn wound dressings for superficial and partial thickness burns., Data Collection and Analysis: Two authors using standardised forms extracted the data independently. Each trial was assessed for internal validity with differences resolved by discussion., Main Results: A total of 26 RCTs are included in this review and most were methodologically poor. A number of dressings appear to have some benefit over other products in the management of superficial and partial thickness burns. This benefit relates to time to wound healing, the number of dressing changes and the level of pain experienced. The use of biosynthetic dressings is associated with a decrease in time to healing and reduction in pain during dressing changes. The use of silver sulphadiazine (SSD) as a comparator on burn wounds for the full duration of treatment needs to be reconsidered, as a number of studies showed delays in time to wound healing and increased number of dressing applications in patients treated with SSD dressings., Authors' Conclusions: There is a paucity of high quality RCTs on dressings for superficial and partial thickness burn injury. The studies summarised in this review evaluated a variety of interventions, comparators and clinical endpoints. Despite some potentially positive findings, the evidence, which largely derives from trials with methodological shortcomings, is of limited usefulness in aiding clinicians in choosing suitable treatments.

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

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

Background: Decision-making in the management of combined major skeletal and soft tissue trauma to the lower limb is a complex process made more difficult by the uncertainty surrounding outcomes. The aim of this study was to review and present our experience with flap reconstruction of traumatic lower limb defects, with particular reference to in-hospital complications and outcomes related to timing, choice of flap and pre-existing complications., Methods: Retrospective review of all lower limb flap reconstructions carried out by the Plastic and Reconstructive Surgery Unit at the Alfred Hospital from 1 July 2001 to 20 October 2005 (51-month period) was carried out., Results: Sixty-four patients had 83 flap reconstructions (35 free and 48 local) of 70 separate lower limb injuries. Internal skeletal fixation was followed by earlier soft tissue coverage and lower deep metal infection rates. Twenty-seven flaps (32.5%) developed soft tissue infections, and 16 fixation devices (25.8%) were complicated by deep metal infection. There were six (12.5%) local flap partial necrosis and four (11.4%) free flap failures. Limbs in which flaps were carried out after day 5 were more likely to develop deep metal infection (P = 0.04) and suffer free flap failure or local flap partial necrosis (P = 0.02). Three patients underwent secondary amputation during their initial admission., Conclusions: The current study presented our experience with flap reconstruction of complex lower limb injuries at a major trauma centre. Thorough wound debridement, internal fixation and early soft tissue coverage (within 5 days of injury) were associated with lower infection rates and optimal outcomes.

Background: A burn wound is a complex and evolving injury, with both local and systemic consequences. Treatment includes using variety of dressings, but newer strategies such as topical negative pressure therapy have been developed to try and promote the wound healing process and minimize burn wound progression to involve deeper tissue in the acute phase. Topical negative pressure uses a suction force to drain excess fluids., Objectives: To assess the effectiveness of TNP for those people with partial thickness burns., Search Strategy: We searched the Cochrane Wounds Group Specialised Register (searched April 2007), the Cochrane Central Register of Controlled Trials (CENTRAL)(The Cochrane Library Issue 2, 2007), Ovid MEDLINE (1950 to April Week 4 2007), Ovid EMBASE (1980 to Week 18 2007) and Ovid CINAHL (1982 to April Week 4 2007)., Selection Criteria: All randomised controlled trials (RCTs) and controlled clinical trials (CCTs) that evaluated the safety and effectiveness of TNP for partial thickness burns., Data Collection and Analysis: Two authors using standardised forms extracted the data independently. Each trial was assessed for internal validity with differences resolved by discussion. A narrative synthesis of results was undertaken as the absence of missing data, poor reporting, or both precluded the authors to undertake any formal statistical analysis., Main Results: One RCT satisfied the inclusion criteria. The methodological quality of the trial was poor., Authors' Conclusions: There is a paucity of high quality RCTs on TNP for partial thickness burn injury with insufficient sample size and adequate power to detect differences, if there are any, between TNP and conventional burn wound therapy dressings.

Background: Pain is a major issue for patients suffering from many different types of wounds in particular those with burn injuries. Prompt, aggressive use of opioid analgesics such as morphine has been suggested as critical to avert the cycle of pain and anxiety, but side effects are encountered. It is proposed that newer agents such as lidocaine could be effective in reducing pain and alleviating the escalating opioid dosage requirements in patients with burn injury., Objectives: To assess the safety and effectiveness of intravenous lidocaine as a means of pain relief versus no therapy, placebo, other drugs or two or more of the above therapies in combination in patients exposed to burn injury., Search Strategy: We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2007), MEDLINE (1966 to March 2007), EMBASE (1980 to 2007), CINAHL (1982 to March 2007)., Selection Criteria: Those trials that were considered were: randomised controlled trials (RCTs) and controlled clinical trials (CCTs), both published and unpublished studies, which assessed the efficacy of intravenous lidocaine varying doses as a single-agent therapy with no therapy, placebo, other analgesics such as opioids, lidocaine plus another drug, or two or more of the above therapies as a means of pain relief in patients exposed to burn injury., Data Collection and Analysis: The two review authors applied the entry criteria to identified studies., Main Results: No clinically relevant RCTs or CCTs were identified through the above searches., Authors' Conclusions: No information is available from the published RCTs or CCTs on clinically relevant primary outcome measures which can influence current burns care practice and management. Therefore, since current clinical evidence is subject to the inherent weaknesses of case series or reports, intravenous lidocaine must be considered a pharmacological agent under investigation in burns care whose effectiveness is yet to be determined in well-designed and conducted clinical trials.

Background: A burn injury increases the body's metabolic demands, and therefore nutritional requirements. Provision of an adequate supply of nutrients is believed to lower the incidence of metabolic abnormalities, thus reducing septic morbidity, improving survival rates, and decreasing hospital length of stay. Enteral nutrition support is the best feeding method for patients who are unable to achieve an adequate oral intake to maintain gastrointestinal functioning, however, its timing (i.e. early versus late) needs to be established., Objectives: To assess the effectiveness and safety of early versus late enteral nutrition support in adults with burn injury., Search Strategy: We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library, issue 1, 2006), the Cochrane Injuries Group's Specialised Register, MEDLINE (1966 to May week 1, 2006), EMBASE (1980 to week 17, 2005) and CINAHL (1982 to May week 1, 2006)., Selection Criteria: We included all randomised controlled trials comparing early enteral nutrition support (within 24 hours of injury) versus delayed enteral support (greater than 24 hours)., Data Collection and Analysis: Two authors used standardised forms to independently extract the data. Each trial was assessed for internal validity with differences resolved by discussion., Main Results: A total of three randomised controlled trials were eligible for inclusion in this review. Results of the studies indicate that evidence about the benefit of early enteral nutritional support on standardised clinical outcomes such as length of hospital stay and mortality, remains inconclusive. Similarly, the question of whether early enteral feeding influenced or decreased metabolic rate as documented in part by our included studies, remains uncertain., Authors' Conclusions: This systematic review has not found sufficient evidence to support or refute the effectiveness of early versus late enteral nutrition support in adults with burn injury. The trials showed some promising results that would suggest early enteral nutrition support may blunt the hypermetabolic response to thermal injury, but this is insufficient to provide clear guidelines for practice. Further research incorporating larger sample sizes and rigorous methodology that utilises valid and reliable outcome measures, is essential.

Nine seedlots of the widely planted southern and central European native tree species Acer pseudoplatanus L. were collected along a north-south gradient spanning 21° of latitude in Europe. We investigated how the heat sum during seed development influences seed maturity as assessed by physical, physiological and biochemical traits. Using principal component analysis we found predictable and consistent patterns in all traits, which correlated with heat sum. For example, compared with fruits from their native range (Italy and France, heat sum >3000°C d), fruits from the coldest location (Scotland; heat sum of 1873°C d) were shorter (c. 30 v. 42 mm), germinated over a narrower temperature range (5-20 v. 5-35°C) and had smaller embryos (28 v. > 70 mg) with a higher water content (c. 63 v. 48%), less negative solute potentials (c. -2.4 v. -4.1 MPa) and were more desiccation sensitive (critical water potential of -20.2 v. -55.4 to -60.7 MPa). The observed level of desiccation-tolerance for the French and Italian seedlots is more consistent with the intermediate category than the previous classification of A. pseudoplatanus as recalcitrant. Our results demonstrate that a lower heat sum causes fruits from northern Europe to be dispersed before maximum potential seed quality is achieved.

Background: The Parkland formula is established as the "gold standard" for initial fluid resuscitation for major burns. The purpose of this study was to review our fluid resuscitation practice for major burns to determine whether anecdotal observations of significant variations from the Parkland formula were wide spread and whether any difference could be used as a basis for a revision of fluid resuscitation in major burns., Methods: A retrospective review of 127 presentations to The Alfred Burns Unit with total body surface area (TBSA) affected > or =15% was conducted. A retrospective review of the resuscitation data from these patients was compared with the Parkland formula as well as other studies., Results: A total of 49 patients with complete data on fluid administration and uncomplicated burns were included in the analysis. Significantly larger volumes of fluid (5.58 mL/kg per %TBSA) were given to these patients in the first 24 h than predicted by the Parkland formula. Mean arterial pressure, pulse rate and urine output were at satisfactory levels. Clinically evident complications from fluid administration were minimal. Mortality was similar to that in other centres., Conclusion: Fluid resuscitation volumes significantly higher than those predicted by the Parkland formula were given, without adverse consequences. This retrospective review supports a prospective, multicentre, randomized, controlled study comparing this study with the Parkland formula, resulting in a better guide to initial fluid resuscitation in major burns.

Background: Management of necrotizing fasciitis places significant demands upon hospital and medical resources. A successful management usually requires extensive surgical intervention and an adjunct hyperbaric oxygen treatment. The cost impact on the health care system has not been well characterized. We have, therefore, analysed the cost of treating this disease at an Australian tertiary referral hospital with extensive case experience and well-developed financial costing systems and have compared this with the current casemix-based government funding arrangements applying in Victoria, Australia., Methods: Data was extracted from the medical records of 92 sequential patients treated by the Alfred Hospital (Melbourne, Australia) during the four financial years 2000-04. Clinical costing data and government funding data was provided by the hospital's Finance Departments., Results: The total Alfred Hospital in-patient costs for treating the patients was $5,935,545 with a mean cost per patient of $64,517 (range, $1025 to $514,889). The total casemix-based funding allocation derived from treating these patients was calculated at $3,208,664 with the per patient mean $34,887 (range, $1331 to $387,168). This analysis does not include allowance for non-Alfred Hospital costs such as those incurred by the ambulance service, referring hospitals, for rehabilitation or as a result of the burden of residual disability., Conclusions: This study has confirmed that a significant economic burden is involved in treating necrotizing fasciitis. There is a substantial difference between the hospital costs and government funding for treating these patients in the Australian setting.

There has been an explosion in the use of the vacuum-assisted closure device since 1997. Selectively and judiciously used, it is a valuable tool. However, we are concerned by the expanding list of 'indications' for its use. Prolonged applications, frequently several weeks, at the expense of early surgical reconstruction, might compromise the outcome in selected cases. We report four cases that illustrate this problem and stress the importance of timely surgical reconstruction utilizing the range of reconstructive techniques available as well as vacuum-assisted closure dressing.

Over the past 12 months, the Victorian Trauma Centre at the Alfred Hospital, Melbourne, has dealt with serious head and neck injuries associated with angle grinder use. Three cases are presented, documenting the circumstances and severity of these injuries and subsequent management. Angle grinder injuries are a source of serious morbidity and mortality, much of which is preventable.

In densely scarred digits, tendon reconstruction fails because of paucity of blood supply. This inevitably leads to adhesion formation and failure of gliding. Staged tendon grafting with silicone spaces can improve results but does not ameliorate the essential problem of reduced vascularity and may indeed worsen it. Tendon grafts can be implanted with their own living sheaths as free or pedicled vascularised transfers from the foot or forearm to either extensor or flexor sites in the hand. These mesenteric tendons with their fascial or synovial sheaths intact and vascularised by adjacent vascular pedicles include the extensor hallucis brevis and longus or the extensor digitorum communis on the dorsalis pedis system, the palmaris longus on the radial arterial system, the sublimus tendons of the ring and little fingers on the ulnar arterial system as well as the extensor indicis on the second metacarpal arterial system. These tendon grafts can be inserted into the intact or reconstructed tunnel systems of the digit and repaired proximally and distally to the tendon remnants. Gliding is enhanced although limitations still potentially occur at the proximal tendon junctions.

Some of the most dramatic advances in reconstructive surgery have involved microvascular free-flap transfers. Although initial studies stressed the need for the procedures to be restricted to the healthy, with no evidence of vascular disease, it has become apparent that such restrictions need not apply if adequate patient care is available. Refinements of technique and development of new operations have made the free flap available to all. In particular, the procedure has been found to have unique benefits in the elderly and infirm population.

A case-control study was conducted in Melbourne, Australia. Forty-one men with histologically confirmed squamous cell oral or pharyngeal cancer were compared with 398 male community controls. A statistically significant increase in risk was found for alcohol (ethanol) consumption and for smoking, and there was a synergistic effect for these two exposures. Statistically significant protection was noted with increasing intake of dietary vitamin C, dietary beta-carotene, fruit, vegetables, and dietary fiber. The mean serum levels of beta-carotene and vitamin A were statistically significantly lower when the cases were compared with another set of 88 male controls of a similar age who were hospitalized for minor surgical operations. This study confirms a causal effect of smoking and alcohol and a protective role for a high dietary intake of fruit, vegetables, cereals, and, particularly, beta-carotene- and vitamin C-containing foods.

A case-control study was conducted in Melbourne, Australia of 88 consecutive males admitted for the surgical removal of a nonmelanocytic skin cancer (histologically confirmed basal cell carcinoma and squamous cell carcinoma) and of 88 male control patients admitted for small elective surgical procedures. In both cases and controls, previous diet, alcohol consumption, and smoking habit were investigated and serum beta-carotene and vitamin A levels were measured. A statistically significant inverse relationship was found between the risk of skin cancer and a high intake of fish (p = 0.05); vegetables in general (p < 0.001); beans, lentils, or peas (p < 0.001), carrots, silverbeet (Swiss chard), or pumpkin (p < 0.001); cruciferous vegetables (cabbage, brussel sprouts, or broccoli) (p < 0.001); and beta-carotene- and vitamin C-containing foods (p = 0.004). Cases had a lower mean serum level of beta-carotene (p < 0.001) and vitamin A (p = 0.02) than controls. The incidence of skin cancer in the study was inversely related to the level of serum beta-carotene (p < 0.0001). The correlation coefficient between dietary beta-carotene/vitamin C and serum beta-carotene was 0.22 (p = 0.04). Smoking and alcohol consumption showed no statistically significant association with the risk of nonmelanocytic skin cancer. The results were similar for both cell types. A high intake of vegetables including cruciferous vegetables, beta-carotene- and vitamin C-containing foods, and fish appears to be protective for nonmelanocytic skin cancer, and this deserves further study, as does the possible etiologic relevance of the low serum levels of beta-carotene and vitamin A.

Surgical correction of syndactyly of the Apert hand should begin by 6 months and be completed by 3 years of age. As much surgery as possible is carried out at each sitting. Digit separation should be in order of functional importance. The first web space is deepened with a four-flap Z-plasty or a dorsal skin flap from the web and index finger. Syndactyly release using a dorsal flap and zig-zag technique is used to create the second and fourth web spaces. The complex long-ring syndactyly often requires a pedicled groin flap for reconstruction and preservation of growth potential. A five-digit hand can be achieved with adequate grasp and stable, sensate, well-aligned digits. These children can attain some degree of independent finger motion and aesthetically acceptable hands with this approach.

Two cases of a pattern of Dupuytren's disease in the thumb not described before are presented. The more usual pattern of radial disease is discussed and compared with that in the fingers.

A simple, effective and rapid method of fixation of unstable zygomatic fractures is described, in which a K-wire is inserted percutaneously through the prominence of the fractured malar and stabilized by further passage through both maxillae. The results of 11 cases are discussed. The method is compared with other commonly used methods of fixation, and with other techniques for internal fixation with K-wire previously described.