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Introduction: The spleen is the second most frequently injured organ following blunt abdominal trauma. Trends in management have changed over the years. Traditionally, laparotomy and splenectomy was the standard management. Presently, nonoperative management (NOM) of splenic injury is the most common management strategy in hemodynamically stable patients. Splenic injuries can be managed via simple observation (OBS) or with angiography and embolization (AE). Angio-embolization has shown to be a valuable alternative to observational management and has increased the success rate of nonoperative management in many series.Diagnostics: Improved imaging techniques and advances in interventional radiology have led to a better selection of patients who are amenable to nonoperative management. Despite this, there is still a lot of debate about which patients are prone to NOM.Angiography and Embolization: The optimal patient selection is still a matter of debate and the role of CT and angio-embolization has not yet fully evolved. We discuss the role of sonography and CT features, such as contrast extravasation, pseudoaneurysms, arteriovenous fistulas, or hemoperitoneum, to determine the optimal patient selection for angiography and embolization. We also review the efficiency, technical considerations (proximal or selective embolization), logistics, and complication rates of AE for blunt traumatic splenic injuries. [ABSTRACT FROM AUTHOR]

Background: Value-based healthcare (VBHC) is increasingly implemented in healthcare worldwide. Transparent measurement of the outcomes most important and relevant to patients is essential in VBHC, which is supported by a core set of most important quality indicators and outcomes. Therefore, the aim of this study was to develop a VBHC-burns core set for adult burn patients., Methods: A three-round modified national Delphi study, including 44 outcomes and 24 quality indicators, was conducted to reach consensus among Dutch patients, burn care professionals and researchers. Items were rated on a nine-point Likert scale and selected if ≥ 70% in each group considered an item 'important'. Subsequently, instruments quantifying selected outcomes were identified based on a literature review and were chosen in a consensus meeting using recommendations from the Dutch consensus-based standard set and the Dutch Centre of Expertise on Health Disparities. Time assessment points were chosen to reflect the burn care and patient recovery process. Finally, the initial core set was evaluated in practice, leading to the adapted VBHC-burns core set., Results: Twenty-seven patients, 63 burn care professionals and 23 researchers participated. Ten outcomes and four quality indicators were selected in the Delphi study, including the outcomes pain, wound healing, physical activity, self-care, independence, return to work, depression, itching, scar flexibility and return to school. Quality indicators included shared decision-making (SDM), the number of patients receiving aftercare, determination of burn depth, and assessment of active range of motion. After evaluation of its use in clinical practice, the core set included all items except SDM, which are assessed by 9 patient-reported outcome instruments or measured in clinical care. Assessment time points included are at discharge, 2 weeks, 3 months, 12 months after discharge and annually afterwards., Conclusion: A VBHC-burns core set was developed, consisting of outcomes and quality indicators that are important to burn patients and burn care professionals. The VBHC-burns core set is now systemically monitored and analysed in Dutch burn care to improve care and patient relevant outcomes. As improving burn care and patient relevant outcomes is important worldwide, the developed VBHC-burns core set could be inspiring for other countries., Competing Interests: Declaration of Competing Interest Not applicable., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Despite an increase in knowledge, blood loss during burn excisional surgery remains a major challenge and is an independent predictor of mortality. During burn surgery, limited measures are available to control the bleeding. Increased fibrinolysis could be one of the contributing factors of blood loss during burn excisional surgery. Tranexamic acid inhibits the fibrinolytic response, and a small body of evidence shows positive effects of tranexamic acid on the volume of blood loss., Methods: The main objectives of this study are twofold, (1) to investigate whether tranexamic acid reduces blood loss and (2) to investigate the changes in coagulation after burn trauma and during burn excisional surgery. This study is a multicenter double-blind randomized clinical trial in patients scheduled for burn excisional surgery within the Dutch burn centers. All adult patients scheduled for burn surgery with an expected blood loss of ≥ 250 are eligible for inclusion in this study. The study is powered on a blood loss reduction of 25% in the intervention group. In total, 95 subjects will be included. The intervention group will receive 1500 mg tranexamic acid versus placebo in the other group. Primary endpoint is reduction of blood loss. Secondary endpoints include occurrence of fibrinolysis during surgery, graft take of the split skin graft, and differences in coagulation and blood clot formation., Discussion: This protocol of a randomized controlled trial aims to investigate the efficacy of tranexamic acid in reducing blood loss during burn excisional surgery. Furthermore, this study aims to clarify the coagulation status after burn trauma and during the surgical process., Trial Registration: EudraCT: 2020-005405-10; ClinicalTrial.gov: NCT05507983 (retrospectively registered in August 2022, inclusion started in December 2021)., (© 2024. The Author(s).)

Background: The Patient and Observer Scar Assessment Scale (POSAS) is frequently used to assess scar quality after burns. It is important to be aware of the minimal important change (MIC) and the minimal clinically important difference (MCID) to establish if a POSAS score represents a clinically relevant change or difference. The aim of this study is to explore the MIC and MCID of POSAS version 2.0., Methods: This prospective study included 127 patients with deep dermal burns that underwent split thickness skin grafting with a mean age of 44 years (range 0 - 87) and total body surface area burned of 10 % (range 0.5 - 55). POSAS data was obtained for one burn scar area at three, six, and 12 months after split skin grafting. At the second and third visits, patients rated the degree of clinical change in scar quality in comparison to the previous visit. At 12 months, they completed the POSAS for a second burn scar area and rated the degree of clinical difference between the two scar areas. Two anchor-based methods were used to determine the MIC and MCID., Results: MIC values of the patient POSAS ranged from - 0.59 to - 0.29 between three and six months and from - 0.75 to - 0.38 between six and 12 months follow-up. Both had a poor discriminatory value. MCID values ranged from - 0.39 and - 0.08, with a better discriminatory value., Conclusion: Results suggest that patients consider minor differences (less than 0.75 on the 1-10 scale) in POSAS scores as clinically important scar quality changes. MCID values can be used to evaluate the effects of burn treatment and perform sample-size calculations., Competing Interests: Declaration of Competing Interest Dr. van Zuijlen is the developer of the Patient and Observer Scar Assessment Scale. The authors have no financial interest to declare in relation to the content of this communication., (Copyright © 2024. Published by Elsevier Ltd.)

Background: Burn scar maturation can take several years but is generally studied shortly after injury. Therefore, we investigated patient-reported scar quality up to 5-7 years post-burn., Methods: Patients with ≤ 20 % total body surface area burned completed the Patient Scale of the Patient and Observer Scar Assessment Scale (POSAS 2.0) on the same scar at 3, > 18 months (median 28 months) and 5-7 years (median 63 months) post-burn., Results: Fifty-eight patients (21 children; 37 adults) with a median total body surface area burned (TBSA) of 6.3 % participated. Average patient-reported scar quality (POSAS score) was generally worst at 3 months (median score: 4.2), best at 28 months (median score: 2.2) and intermediate at 63 months post-burn (median score: 3.4) (p < 0.001). Many patients (66 %) reported a median 1.8 point higher (worse) POSAS score at 63 months compared to 28 months post-burn, whereas 14 % reported an identical, and 21 % a lower (better) score. At any assessment, largest differences with normal skin were reported for scar colour. Univariate predictive factors of long-term patient-reported scar quality were scar quality at 3 months (p = 0.002) and 28 months post-burn (p < 0.001), full-thickness burn size (p = 0.033), length of hospital stay (p = 0.003), and number of surgeries (p < 0.001)., Conclusion: Two-thirds of patients with burns up to 20 % TBSA scored the quality of their scars worse at 63 months compared to 28 months post-burn. Whether this corresponds to increased dissatisfaction with scars in the long term should be further investigated. These new insights add to the body of knowledge on scar maturation and underscores the importance of discussing patients' expectations., Competing Interests: Declaration of Competing Interest All authors whose names are listed immediately below have no financial and personal relationships with other people or organisations that could inappropriately influence (bias) their work. Examples of potential conflicts of interest include employment, consultancies, stock ownership, honoraria, paid expert testimony, patent applications/registrations, and grants or other funding., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Since insight into the motivation of behaviour in bioethanol related burn accidents is lacking, this study aimed to qualitatively examine influencing factors in bioethanol related burn accidents. In order to identify target points for effective burn prevention., Methods: Patients previously admitted with bioethanol related acute non-intentional burn injury to the three Dutch burn centres were eligible. One interviewer conducted fourteen semi-structured interviews. Interviews were transcribed and coded by two independent researchers. Conclusions were drawn based on generalised statements on the concerned topics., Results: Four overall themes in influencing factors were found, namely 1) motivation; including non-designated use and impaired judgement, 2) knowledge and education; including unknown product and properties and information overload, 3) risk perception; including poor recognisability of risks and preferred trial and error and 4) thresholds; including easy availability and unclear liability., Conclusion: Trust in consumers may be over-estimated, as proper use cannot be expected. To prevent future bioethanol related burn incidents, thresholds for obtaining and using bioethanol should be increased, safe alternatives to ignite open fires and wood stoves should be provided and knowledge and warnings should be improved., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd and International Society of Burns Injuries. All rights reserved.)

For deep partial-thickness burns no consensus on the optimal treatment has been reached due to conflicting study outcomes with low quality evidence. Treatment options in high- and middle-income countries include conservative treatment with delayed excision and grafting if needed; and early excision and grafting. The majority of timing of surgery studies focus on survival rather than on quality of life. This study protocol describes a study that aims to compare long-term scar quality, clinical outcomes, and patient-reported outcomes between the treatment options. A multicentre prospective study will be conducted in the three Dutch burn centres (Rotterdam, Beverwijk, and Groningen). All adult patients with acute deep-partial thickness burns, based on healing potential with Laser Doppler Imaging, are eligible for inclusion. During a nine-month baseline period, standard practice will be monitored. This includes conservative treatment with dressings and topical agents, and excision and grafting of residual defects if needed 14-21 days post-burn. The subsequent nine months, early surgery is advocated, involving excision and grafting in the first week to ten days post-burn. The primary outcome compared between the two groups is long-term scar quality assessed by the Patient and Observer Scar Assessment Scale 3.0 twelve months after discharge. Secondary outcomes include clinical outcomes and patient-reported outcomes like quality of life and return to work. The aim of the study is to assess long-term scar quality in deep partial-thickness burns after conservative treatment with delayed excision and grafting if needed, compared to early excision and grafting. Adding to the ongoing debate on the optimal treatment of these burns. The broad range of studied outcomes will be used for the development of a decision aid for deep partial-thickness burns, to fully inform patients at the point of consent to surgery and support optimal person-centred care., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Salemans et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Objective: To develop a color code and to investigate the validity of Laser Speckle Contrast Imaging (LSCI) for measuring burn wound healing potential (HP) in burn patients as compared to the reference standard Laser Doppler Imaging (LDI)., Method: A prospective, observational, cohort study was conducted in adult patients with acute burn wounds. The relationship between mean flux measured with LDI and mean perfusion units (PU) measured with LSCI was expressed in a regression formula. Measurements were performed between 2 and 5 days after the burn wound. The creation of a LSCI color code was done by mapping the clinically validated color code of the LDI to the corresponding values on the LSCI scale. To assess validity of the LSCI, the ability of the LSCI to discriminate between HP < 14 and ≥ 14 days and HP < 21 and original ≥ 21 days according to the LDI reference standard was evaluated, with calculation of receiver operating characteristics (ROC) curves., Results: A total of 50 patients were included with a median age of 40 years and total body surface area burned of 6%. LSCI values of 143 PU and 113 PU were derived as the cut-off values for the need of conservative treatment (HP < 14 and ≥ 14 days) resp. surgical closure (HP < 21 and ≥ 21 days). These LSCI cut off values showed a good discrimination between HP 14 days versus ≥ 14 days (Area Under Curve (AUC)= 0.89; sensitivity 85% and specificity = 82%) and a good discrimination between HP 21 days versus ≥ 21 days (AUC of 0.89, sensitivity 81% and specificity 88%)., Conclusion: This is the first study in which a color code for the LSCI in adult clinical burn patients has been developed. Our study reconfirms the good performance of the LSCI for prediction of burn wound healing potential. This provides additional evidence for the potential value of the LSCI in specialized burn care., Competing Interests: Declaration of Competing Interest The authors declare that they have no conflict of interest. Perimed AB provided the Laser Speckle Contrast Imager for free. Perimed AB did not have any involvement in the study design, data collection and data analysis, nor in the writing process and submission of this paper., (Copyright © 2023. Published by Elsevier Ltd.)

Patients with extensive and complex wounds due to Necrotizing Soft-Tissue Infections (NSTI) may be referred to a burn center. This study describes the characteristics, outcomes, as well as diagnostic challenges of these patients. Patients admitted to three hospitals with a burn center for the treatment of NSTI in a 5-year period were included. Eighty patients (median age 54 years, 60% male) were identified, of whom 30 (38%) were referred by other centers, usually after survival of the initial septic phase. Those referred from other centers, compared to those primarily admitted to the study hospitals, were more likely to have group A streptococcal involvement (62% vs 35%, p = .02), larger wounds (median 7% vs 2% total body surface area, p < .001), and a longer length of stay (median 49 vs 22 days, p < .001). Despite a high incidence of septic shock (50%), the mortality rate was low (12%) for those primarily admitted. Approximately half (53%) of the patients were initially misdiagnosed upon presentation, which was associated with delay to first surgery (16 hours vs 4 hours, p < .001). Those initially misdiagnosed had more (severe) comorbidities, and less frequently reported pain or blue livid discoloration of the skin. This study underlines the burn centers' function as referral centers for extensively affected patients with NSTI. Besides the unique wound and reconstructive expertise, the low mortality rate indicates these centers provide adequate acute care as well. A major remaining challenge remains recognition of the disease upon presentation. Future studies in which factors associated with misdiagnosis are explored are needed., (© The Author(s) 2023. Published by Oxford University Press on behalf of the American Burn Association.)

Purpose: Data on the epidemiology, treatment, and outcome of burn patients treated at non-burn centre hospitals are not available. The primary aim was to compare the burn characteristics of patients admitted to a hospital with or without a specialized burn centre., Methods: This multicentre, prospective, cohort study enrolled patients with burns admitted to a hospital without a burn centre and patients with < 10% total body surface area (TBSA) burned admitted to the burn centre. Primary outcome measure was the burn-related injury characteristics. Secondary outcome measures were adherence to the Emergency Management of Severe Burns (EMSB) referral criteria, treatment (costs), quality of life, and scar quality., Results: During the 2-year study period, 48 patients were admitted to a non-burn centre and 148 patients to the burn centre. In the non-burn centre group, age [44 (P 25 -P 75 26-61) versus 30 (P 25 -P 75 8-52) years; P = 0.007] and Injury Severity Score [2 (P 25 -P 75 1-4) versus 1 (P 25 -P 75 1-1); P < 0.001] were higher. In the burn centre group, the TBSA burned was significantly higher [4% (P 25 -P 75 2-6) versus 2% (P 25 -P 75 1-4); P = 0.001], and more surgical procedures were performed (in 54 versus 7 patients; P = 0.004). At 12 months, > 85% of the non-burn centre group and > 75% of the burn centre group reported no problems in quality of life. Scar quality score was < 1.5 in both groups, with significantly poorer scores in the burn centre group (P ≤ 0.007)., Conclusion: Both groups differed in patient, burn, and treatment characteristics. At 12 months, quality of life and scar quality were good in both groups. Significantly poorer scar quality scores were found in the burn centre group. This might be related to their larger burns and more frequent surgery. The organization of burn care in the Netherlands seems to work adequately. Patients are treated locally when possible and are transferred when necessary., (© 2023. The Author(s).)

Background: Blood loss during burn excisional surgery remains an important factor as it is associated with significant comorbidity, mortality and longer length of stay. Blood loss is, among others, influenced by length of surgery, burn size, excision size and age. Most literature available is aimed at large burns and little research is available for small burns. Therefore, the goal of this study is to investigate blood loss and develop a prediction model to identify patient at risk for blood loss during burn excisional surgery ≤ 10% body surface area., Study Design and Methods: This retrospective study included adult patients who underwent burn excisional surgery of ≤ 10% body surface area in the period 2013-2018. Duplicates, patients with missing data and delayed surgeries were excluded. Primary outcome was blood loss. A prediction model for per-operative blood loss (>250 ml) was built using a multivariable logistic regression analysis with stepwise backward elimination. Discriminative ability was assessed by the area under the ROC-curve in conjunction with optimism and calibration., Results: In total 269 patients were included for analysis. Median blood loss was 50 ml (0-150) / % body surface area (BSA) excised and 0.28 (0-0.81) ml / cm 2 . Median burn size was 4% BSA and median excision size was 2% BSA. Blood loss of> 250 ml was present in 39% of patients. The model can predict blood loss> 250 ml based on %BSA excised, length of surgery and ASA-score with an AUC of 0.922 (95% CI 0.883 - 0.949) and an AUC after optimism correction of 0.915. The calibration curve showed an intercept of 0.0 (95% CI -0.36 to 0.36) with a slope of 1.0 (95% CI 0.78-1.22)., Conclusion: Median blood loss during burn excisional surgery of ≤ 10% BSA is 50 ml / % BSA excised and 0.28 ml / cm 2 excised. However, a substantial part of patients is at risk for higher blood loss. The prediction model can predict P(blood loss>250 ml) with an AUC of 0.922, based on expected length of surgery, ASA-score and size of excision. The model can be used to identify patients at risk for significant blood loss (>250 ml)., (Copyright © 2023 Elsevier Ltd and ISBI. All rights reserved.)

Background: A European response plan to burn mass casualty incidents has been jointly developed by the European Commission and the European Burn Association. Upon request for assistance by an affected country, the plan outlines a mechanism for coordinated international assistance, aiming to alleviate the burden of care in the affected country and to offer adequate specialized care to all patients who can benefit from it. To that aim, Burn Assessment Teams are deployed to assess and triage patients. Their transportation priority recommendations are used to distribute outnumbering burn casualties to foreign burn centers. Following an appropriate medical evacuation, these casualties receive specialized care in those facilities., Methods: The European Burns Association's disaster committee developed medical-organizational guidelines to support this European plan. The experts identified fields of interest, defined questions to be addressed, performed relevant literature searches, and added their expertise in burn disaster preparedness and response. Due to the lack of high-level evidence in the available literature, recommendations and specially designed implementation tools were provided from expert opinion. The European Burns Association officially endorsed the draft recommendations in 2019, and the final full text was approved by the EBA executive committee in 2022., Recommendations: The resulting 46 recommendations address four fields. Field 1 underlines the need for national preparedness plans and the necessary core items within such plans, including coordination and integration with an international response. Field 2 describes Burn Assessment Teams' roles, composition, training requirements, and reporting goals. Field 3 addresses the goals of specialized in-hospital triage, appropriate severity criteria, and their effects on priorities and triage. Finally, field 4 covers medical evacuations, including their timing and organization, the composition of evacuation teams and their assets, preparation, and the principles of en route care., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests. Thomas Leclerc: no conflict of interest to declare. Folke Sjöberg: no conflict of interest to declare. Serge Jennes: no conflict of interest to declare. José Ramón Martinez-Mendez: no conflict of interest to declare. Cornelis H. van der Vlies: no conflict of interest to declare. Anna Battustitta: no conflict of interest to declare. J. Alfonso Lozano-Basanta: no conflict of interest to declare. Naiem Moiememen: no conflict of interest to declare. Stian K. Almeland: no conflict of interest to declare., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: The population of elderly patients with burn injuries is growing. Insight into long-term mortality rates of elderly after burn injury and predictors affecting outcome is limited. This study aimed to provide this information., Methods: A multicentre observational retrospective cohort study was conducted in all three Dutch burn centres. Patients aged ≥65 years, admitted with burn injuries between 2009 and 2018, were included. Data were retrieved from electronic patient records and the Dutch Burn Repository R3. Mortality rates and standardized mortality ratios (SMRs) were calculated. Multivariable logistic regression was used to assess predictors for in-hospital mortality and mortality after discharge at 1 year and five-year. Survival analysis was used to assess predictors of five-year mortality., Results: In total, 682/771 admitted patients were discharged. One-year and five-year mortality rates were 8.1 and 23.4%. The SMRs were 1.9(95%CI 1.5-2.5) and 1.4(95%CI 1.2-1.6), respectively. The SMRs were highest in patients aged 75-80 years at 1 year (SMRs 2.7, 95%CI 1.82-3.87) and five-year in patients aged 65-74 years (SMRs 10.1, 95%CI 7.7-13.0). Independent predictors for mortality at 1 year after discharge were higher age (OR 1.1, 95%CI 1.0-1.1), severe comorbidity, (ASA-score ≥ 3) (OR 4.8, 95%CI 2.3-9.7), and a non-home discharge location (OR 2.0, 95%CI 1.1-3.8). The relative risk of dying up to five-year was increased by age (HR 1.1, 95%CI 1.0-1.1), severe comorbidity (HR 2.3, 95%CI 1.6-3.5), and non-home discharge location (HR 2.1, 95%CI 1.4-3.2)., Conclusion: Long-term mortality until five-year after burn injury was higher than the age and sex-matched general Dutch population, and predicted by higher age, severe comorbidity, and a non-home discharge destination. Next to pre-injury characteristics, potential long-lasting systemic consequences on biological mechanisms following burn injuries probably play a role in increased mortality. Decreased health status makes patients more prone to burn injuries, leading to early death., (© 2023. The Author(s).)

Objective: Laser-based tissue perfusion monitoring techniques have been increasingly used in animal and human research to assess blood flow. However, these techniques use arbitrary units, and knowledge about their comparability is scarce. This study aimed to model the relationship between laser speckle contrast imaging (LSCI) and laser Doppler perfusion imaging (LDPI), for measuring tissue perfusion over a wide range of blood flux values., Methods: Fifteen healthy volunteers (53% female, median age 29 [IQR 22-40] years) were enrolled in this study. We performed iontophoresis with sodium nitroprusside on the forearm to induce regional vasodilation to increase skin blood flux. Besides, a stepwise vascular occlusion was applied on the contralateral upper arm to reduce blood flux. Both techniques were compared using a linear mixed model analysis., Results: Baseline blood flux values measured by LSCI were 33 ± 6.5 arbitrary unit (AU) (Coefficient of variation [CV] = 20%) and by LDPI 60 ± 11.5 AU (CV = 19%). At the end of the iontophoresis protocol, the regional blood flux increased to 724 ± 412% and 259 ± 87% of baseline measured by LDPI and LSCI, respectively. On the other hand, during the stepwise vascular occlusion test, the blood flux reduced to 212 ± 40% and 412 ± 177% of its baseline at LDPI and LSCI, respectively. A strong correlation was found between the LSCI and LDPI instruments at increased blood flux with respect to baseline skin blood flux; however, the correlation was weak at reduced blood flux with respect to baseline., Discussion: LSCI and LDPI instruments are highly linear for blood flux higher than baseline skin blood flux; however, the correlation decreased for blood flux lower than baseline. This study's findings could be a basis for using LSCI in specific patient populations, such as burn care., (© 2022 The Authors. Microcirculation published by John Wiley & Sons Ltd.)

Background: Burn care is centralized in highly specialized burn centers in Europe. These centers are of limited capacity and may be overwhelmed by a sudden surge in case of a burn mass casualty incident. Prior incidents in Europe and abroad have sustained high standards of care through well-orchestrated responses to share the burden of care in several burn centers. A burn mass casualty incident in Romania in 2015 sparked an initiative to strengthen the existing EU mechanisms. This paper aims to provide insight into developing a response plan for burn mass casualties within the EU Civil Protection Mechanism., Methods: The European Burns Association drafted medical guidelines for burn mass casualty incidents based on a literature review and an in-depth analysis of the Romanian incident. An online questionnaire surveyed European burn centers and EU States for burn mass casualty preparedness., Results: The Romanian burn mass casualty in 2015 highlighted the lack of a burn-specific mechanism, leading to the late onset of international transfers. In Europe, 71% of respondents had existing mass casualty response plans, though only 35% reported having a burn-specific plan. A burns response plan for burn mass casualties was developed and adopted as a Commission staff working document in preparation for further implementation. The plan builds on the existing Union Civil Protection Mechanism framework and the standards of the WHO Emergency Medical Teams initiative to provide 1) burn assessment teams for specialized in-hospital triage of patients, 2) specialized burn care across European burn centers, and 3) medevac capacities from participating states., Conclusion: The European burn mass casualty response plan could enable the delivery of high-level burn care in the face of an overwhelming incident in an affected European country. Further steps for integration and implementation of the plan within the Union Civil Protection Mechanism framework are needed., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Stian Kreken Almeland: No conflicts of interests to declare, Evelyn Depoortere: No conflicts of interests to declare, Serge Jennes: No conflicts of interests to declare, Folke Sjöberg: No conflicts of interests to declare, J. Alfonso Lozano Basanta: No conflicts of interests to declare, Sofia Zanatta: No conflicts of interests to declare, Calin Alexandru: No conflicts of interests to declare, José Ramón Martinez-Mendez: No conflicts of interests to declare, Cornelis H van der Vlies: No conflicts of interests to declare, Amy Hughes: No conflicts of interests to declare, Juan Pedro Barret: No conflicts of interests to declare, Naiem Moiemen: No conflicts of interests to declare, Thomas Leclerc: No conflicts of interests to declare., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Health care is undergoing a profound technological and digital transformation and has become increasingly complex. It is important for burns professionals and researchers to adapt to these developments which may require new ways of thinking and subsequent new strategies. As Einstein has put it: "We must learn to see the world anew." The relatively new scientific discipline "Complexity science" can give more direction to this and is the metaphorical open door that should not go unnoticed in view of the burn care of the future. Complexity science studies "why the whole is more than the sum of the parts." It studies how multiple separate components interact with each other and their environment and how these interactions lead to "behavior of the system." Biological systems are always part of smaller and larger systems and exhibit the behavior of adaptivity, hence the name complex adaptive systems. From the perspective of complexity science, a severe burn injury is an extreme disruption of the "human body system." But this disruption also applies to the systems at the organ and cellular levels. All these systems follow the principles of complex systems. Awareness of the scaling process at multilevel helps to understand and manage the complex situation when dealing with severe burn cases. This paper aims to create awareness of the concept of complexity and to demonstrate the value and possibilities of complexity science methods and tools for the future of burn care through examples from preclinical, clinical, and organizational perspectives in burn care., (© The Author(s) 2022. Published by Oxford University Press on behalf of the American Burn Association.)

Purpose: The aim of this study was to gain insight into the epidemiology of burn patients admitted to a hospital without a burn center or referred to a burn center., Methods: This retrospective, nationwide, cohort study included patients with burns or inhalation trauma, admitted between 2014 and 2018, from a national trauma registry. The primary outcome measure was admission to a hospital with or without a burn center. Secondary outcome measures were patient and injury characteristics, Intensive Care Unit (ICU) admission and length of stay, and hospital length of stay (HLOS)., Results: Of the 5524 included patients, 2787 (50.4%) were treated at a non-burn center, 1745 (31.6%) were subsequently transferred to a burn center, and 992 (18.0%) were primarily presented and treated at a burn center. The annual number of patients decreased from 1199 to 1055 (- 12.4%). At all admission locations, a clear incidence peak was observed in children ≤ 4 years and in patients of ≥ 80 years. The number of ICU admissions for the entire population increased from 201 to 233 (33.0%). The mean HLOS for the entire population was 8 (SD 14) days per patient. This number remained stable over the years in all groups., Conclusion: Half of all burn patients were admitted in a non-burn center and the other half in a burn center. The number and incidence rate of patients admitted with burns or inhalation trauma decreased over time. An increased incidence rate was found in children and elderly. The number of patients admitted to the ICU increased, whereas mean hospital length of stay remained stable., (© 2021. The Author(s).)

Background: Tangential excision of burned tissue followed by skin grafting is the cornerstone of burn surgery. Hydrosurgery has become popular for tangential excision, with the hypothesis that enhanced preservation of vital dermal tissue reduces scarring. The aim of this trial was to compare scar quality after hydrosurgical versus conventional debridement before split-skin grafting., Methods: A double-blind randomized within-patient multicentre controlled trial was conducted in patients with burns that required split-skin grafting. One wound area was randomized to hydrosurgical debridement and the other to Weck knife debridement. The primary outcome was scar quality at 12 months, assessed with the observer part of the Patient and Observer Scar Assessment Scale (POSAS). Secondary outcomes included complications, scar quality, colour, pliability, and histological dermal preservation., Results: Some 137 patients were randomized. At 12 months, scars of the hydrosurgical debrided wounds had a lower POSAS observer total item score (mean 2.42 (95 per cent c.i. 2.26 to 2.59) versus 2.54 (95 per cent c.i. 2.36 to 2.72; P = 0.023)) and overall opinion score (mean 3.08 (95 per cent c.i. 2.88 to 3.28) versus 3.30 (95 per cent c.i. 3.09-3.51); P = 0.006). Patient-reported scar quality and pliability measurements were significantly better for the hydrosurgically debrided wounds. Complication rates did not differ between both treatments. Histologically, significantly more dermis was preserved with hydrosurgery (P < 0.001)., Conclusion: One year after surgery scar quality and pliability was better for hydrosurgically debrided burns, probably owing to enhanced histological preservation of dermis., Registration Number: Trial NL6085 (NTR6232 (http://www.trialregister.nl))., (© The Author(s) 2022. Published by Oxford University Press on behalf of BJS Society Ltd. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Assessing frailty in patients with an acute trauma can be challenging. To provide trustworthy results, tools should be feasible and reliable. This systematic review evaluated existing evidence on the feasibility and reliability of frailty assessment tools applied in acute in-hospital trauma patients., Methods: A systematic search was conducted in relevant databases until February 2020. Studies evaluating the feasibility and/or reliability of a multidimensional frailty assessment tool used to identify frail trauma patients were identified. The feasibility and reliability results and the risk of bias of included studies were assessed. This study was conducted and reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and registered in Prospective Register of Systematic Reviews (ID: CRD42020175003)., Results: Nineteen studies evaluating 12 frailty assessment tools were included. The risk of bias of the included studies was fair to good. The most frequently evaluated tool was the Clinical Frailty Scale (CFS) (n = 5). All studies evaluated feasibility in terms of the percentage of patients for whom frailty could be assessed; feasibility was high (median, 97%; range, 49-100%). Other feasibility aspects, including time needed for completion, tool availability and costs, availability of instructions, and necessity of training for users, were hardly reported. Reliability was only assessed in three studies, all evaluating the CFS. The interrater reliability varied between 42% and >90% agreement, with a Krippendorff α of 0.27 to 0.41., Conclusion: Feasibility of most instruments was generally high. Other aspects were hardly reported. Reliability was only evaluated for the CFS with results varying from poor to good. The reliability of frailty assessment tools for acute trauma patients needs further critical evaluation to conclude whether assessment leads to trustworthy results that are useful in clinical practice., Level of Evidence: Systematic review, Level II., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

An important aspect of the rehabilitation of burn patients is social participation, including daily activities and work. Detailed information on long-term activity impairment and employment is scarce. Therefore, we investigated activity impairment, work status, and work productivity loss in adults 5-7 years following burn injuries, and investigated associations with burn-specific health-related quality of life (HRQL) domains. Adult participants completed the Work Productivity and Activity Impairment General Health questionnaire and the Burn Specific Health Scale-brief (BSHS-B) 5-7 years post-burn. Outcomes were compared between participants with mild/intermediate and severe burns (>20% total body surface area burned). Seventy-six (36%) of the 213 participants experienced some degree of activity impairment due to burn-related problems 5-7 years post-burn. Seventy percent of the population was employed; 12% of them experienced work productivity loss due to burn-related problems. Nineteen percent reported changes in their work situation (partly) because of the burn injury. A higher proportion of participants with severe burns had activity impairments (56% vs 29%; P = .001) and work productivity loss (26% vs 8%; P < .001) compared to participants with mild/intermediate burns. Activity impairment and work productivity loss were both associated with burn-related work problems and lower mood, measured with the BSHS-B. In conclusion, a substantial part of the study population experienced activity impairment and work productivity loss, was unemployed, and/or reported changes in their work situation due to their injury. Particularly patients with severe burns reported productivity loss and had lower employment rates. This subscribes the importance of addressing work-related functioning in the rehabilitation of burn patients., (© The Author(s) 2021. Published by Oxford University Press on behalf of the American Burn Association.)

Background: The primary aim was to determine to what extent referral and admission of burn patients to a hospital with or without a burn center was in line with the EMSB referral criteria., Methods: This was a retrospective, multicenter cohort study. Burn patients admitted from 2014 to 2018 to a hospital in the Southwest Netherland trauma region and Network Emergency Care Brabant were included in this study. Outcome measures were the adherence to the EMSB referral criteria., Results: A total of 1790 patients were included, of whom 951 patients were primarily presented to a non-burn center. Of these patients, 666 (70.0%) were managed according to the referral criteria; 263 (27.7%) were appropriately not referred, 403 (42.4%) were appropriately referred. Twenty (2.1%) were overtransferred, and 265 (27.9%) undertransferred. In 1213 patients treated at a burn center 1119 (92.3%) met the referral criteria. Adherence was lowest for electrical (N = 4; 14.3%) and chemical burns (N = 16; 42.1%), and was highest in 'children ≥5% total body surface area (TBSA) burned' (N = 109; 83.2%)., Conclusion: The overall adherence to the referral criteria of patients presented to a non-burn center was fairly high. However, approximately 25% was not transferred to a burn center while meeting the criteria. Most improvement for individual criteria can be achieved in patients with electrical and chemical burns., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Long-term scar formation is an important adverse consequence in children with burns, however, information regarding scar quality in the long-term is lacking. Therefore, we evaluated scar quality and its predictors in children with burns 5-7 years after injury. Parents of children with mild/intermediate burns (≤10% total body surface area burned), and of children with severe burns (>10% burned) completed the patient scale of the Patient and Observer Scar Assessment Scale (POSAS 2.0) for their children's-in their opinion-worst scar 5-7 years post-burn. Outcomes and predictive factors of scar quality were studied, and, for children with severe burns, POSAS parent scores were compared with observer scores. We included 103 children with mild/intermediate burns and 28 with severe burns (response rate: 51%). Most children (87%) had scars that differed from normal skin, with most differences reported for colour, and least for pain. Except for colour, children with severe burns had significantly higher scores (difference 0-2 points) on all scar characteristics (representing poorer scar quality) compared with children with mild/intermediate burns. Parent POSAS scores were on average 2.0-2.6 points higher compared to observer scores. Number of surgeries predicted both the mean POSAS and the mean overall opinion of a scar. In conclusion, 5-7 years post-burn, the scar of the majority of children differed from normal skin, especially on the characteristic colour. The uncovered insights are useful in counselling of children and their parents on expectations of the final outcome of their (children's) scar(s), and help in further targeting scar prevention strategies for the individual child., (© 2021 The Authors. Wound Repair and Regeneration published by Wiley Periodicals LLC on behalf of The Wound Healing Society.)

Background: Skin grafting is the current gold standard for treatment of deeper burns. How patients appraise the donor-site scar is poorly investigated. The aim of this study was to evaluate long-term patient-reported quality of donor-site scars after split skin grafting and identify possible predictors., Methods: A prospective cohort study was conducted. Patients were included in a Dutch burn centre during one year. Patient-reported quality of donor-site scars and their worst burn scar was assessed at 12 months using the Patient and Observer Scar Assessment Scale (POSAS). Mixed model analyses were used to identify predictors of scar quality., Results: This study included 115 donor-site scars of 72 patients with a mean TBSA burned of 11.2%. The vast majority of the donor-site scars (84.4%) were rated as having at least minor differences with normal skin (POSAS item score ≥2) on one or more scar characteristics and the overall opinion on 80.9% of the donor-site scars was that they deviated from normal skin 12 months after surgery. The overall opinion on the donor-site scar was 3.2 ± 2.1 vs. 5.1 ± 2.4 on the burn scar. A younger age, female gender, a darker skin type, and location on the lower leg were predictors of reduced donor-site scar quality. In addition, time to re-epithelization was associated with scar quality., Conclusion: This study provided new insights in long-term scar quality of donor-sites. Donor-site scars differed from normal skin in a large part of the population 12 months after surgery. Results of this study can be used to inform patients on the long-term outcomes of their scars and to tailor preventive or therapeutic treatment options., (Copyright © 2020 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Hemostasis during burn surgery is difficult to achieve, and high blood loss commonly occurs. Bleeding control measures are limited, and many patients require allogeneic blood transfusions. Cell salvage is a well-known method used to reduce transfusions. However, its evidence in burns is limited. Therefore, this study aimed to examine the feasibility of cell salvage during burn surgery., Study Design and Methods: A prospective, observational study was conducted with 16 patients (20 measurements) scheduled for major burn surgery. Blood was recovered by washing saturated gauze pads with heparinized saline, which was then processed using the Cell Saver. Erythrocyte concentrate quality was analyzed by measuring hemoglobin, hematocrit, potassium, and free hemoglobin concentration. Microbial contamination was assessed based on cultures at every step of the process. Differences in blood samples were tested using the Student's t-test., Results: The red blood cell mass recovered was 29 ± 11% of the mass lost. Patients' preoperative hemoglobin and hematocrit levels were 10.5 ± 1.8 g/dL and 0.33 ± 0.05 L/L, respectively. The erythrocyte concentrate showed hemoglobin and hematocrit levels of 13.2 ± 3.9 g/dL and 0.40 ± 0.11 L/L thus showing a concentration effect. The potassium level was lower in the erythrocyte concentrate (2.5 ± 1.5 vs. 4.1 ± 0.4 mmol/L, p < 0.05). The free hemoglobin level was low (0.16 ± 0.21 μmol/L). All cultures of the erythrocyte concentrate showed bacterial growth compared to 21% of wound cultures., Conclusion: Recovering erythrocytes during burn excisional surgery using cell salvage is possible. Despite strict sterile handling, erythrocyte concentrates of all patients showed bacterial contamination. The consequence of this contamination remains unclear and should be investigated in future studies., (Copyright © 2020. Published by Elsevier Ltd.)

Objectives: The primary aim of this study was to evaluate the number of patients reported to a hospital with injuries from consumer fireworks in the months December-January in the past 10 years, and to describe the association between the type of fireworks, injury pattern, treatment, and permanent impairment., Methods: A multicenter, retrospective, observational case series. Patients were selected from two hospitals in the Southwest Netherlands: a level 1 trauma center and a specialized burn center. All patients with any fireworks-related injuries treated between December 1 and January 31, during 2007 (December) to 2017 (January), were eligible for participation. The primary outcome was the number of patients with any type of injury caused by fireworks. The secondary outcome measures were patient and injury characteristics, treatment details, and whole person impairment (WPI). The percentage WPI expresses a patient's degree of permanent impairments as a result of fireworks-related injuries., Results: Of the 297 eligible patients, 272 patients were included. From 2007 to 2017, between 21 and 40 patients were treated, and no clear increase or decrease was observed in the number of patients and in the number of patients per type of fireworks. Explosive fireworks mainly caused upper extremity (N = 65; 68%) injuries, while rockets (N = 24; 41%) and aerials (N = 7; 41%) mainly affected the head/neck. Decorative fireworks predominantly resulted in burns (N = 82; 68%), and explosive fireworks in soft tissue lacerations (N = 24; 25%), fractures (N = 16; 17%), and amputations (N = 14; 15%). Patients injured by explosive and homemade fireworks were most often admitted to a hospital (respectively N = 24; 36% and N = 12; 80%), and resulted in the highest proportion undergoing surgical procedures (respectively N = 22; 33% and N = 7; 47%). WPI found in this study was between 0 to 95%, with a median of 0%. In 34 (14%) patients, the injuries resulted in a WPI of ≥1%, mostly as a result of explosive fireworks (N = 18; 53%)., Conclusion: This study found no increase or decrease in the number of patients treated in two specialized hospitals. Explosive and homemade fireworks could be considered as most dangerous, as they result into the most hospital admissions, surgical procedures, and into the most injuries with permanent impairment as a result.

There exists little to no data on the development of donor-site scars that remain after split skin graft harvesting. The objectives of this study were to (a) examine changes in characteristics of donor-site scar quality over time and (b) assess the agreement between patient-reported and observer-reported donor-site scar quality in a burn population. A prospective cohort study was conducted including patients who underwent split skin grafting for their burn injury. Patients and observers completed the Patient and Observer Scar Assessment Scale (POSAS) for the first harvested donor site at 3 and 12 months post-surgery. This study included 80 patients with a median age of 34 years. At 3 months post-surgery, the patients scored the POSAS items itch and color as most deviant from normal skin, both improved between 3 and 12 months (3.1 vs 1.5 and 5.0 vs 3.5, respectively [P < .001]). Other scar characteristics did not show significant change over time. The patients' overall opinion score improved from 3.9 to 3.2 (P < .001). Observers rated the items vascularization and pigmentation most severe, only vascularization improved significantly between both time points. Their overall opinion score decreased from 2.7 to 2.3 (P < .001). The inter-observer agreement between patients and observers was considered poor (ICC < 0.4) at both time points. Results of current study indicate that observers underestimate the impact of donor-site scars. This has to be kept in mind while guiding therapy and expectations. LEVEL OF EVIDENCE: II, prospective cohort study., (© 2020 by the Wound Healing Society.)

Hamate fractures can be treated nonoperatively, with the percutaneous Kirschner wire (K-wire) fixation, or with excision of a fractured hook of the hamate. Screw fixation is less popular owing to the risk of iatrogenic ulnar nerve injury. The aim of this study was to present the functional results of patients with hamate fractures treated with headless compression screws (HCS). The primary outcome was the Michigan Hand Outcome Questionnaire (MHOQ) after at least 4 months of follow-up. Nine patients were included in this retrospective cohort study. A median MHOQ total score of 67% was reported (interquartile range [IQR]: 44-76). No complications were found during follow-up. HCS fixation is a safe alternative to treat hamate fractures with good functional outcome. This is a Level IV study., Competing Interests: Conflict of Interest None declared., (© Thieme Medical Publishers.)

Background  Closed reduction and cast immobilization of displaced distal radius fractures carries the risk of secondary displacement, which could result in a symptomatic malunion. In patients with a symptomatic malunion, a corrective osteotomy can be performed to improve pain and functional impairment of the wrist joint. Objective  The aim of this study was to assess the functional outcomes of children who underwent a corrective osteotomy due to a symptomatic malunion of the distal radius. Methods  Between 2009 and 2016, all consecutive corrective osteotomies of the distal radius of patients younger than 18 years were reviewed. The primary outcome was functional outcome assessed with the ABILHAND-Kids score. Secondary outcomes were QuickDASH (Quick Disabilities of Arm, Shoulder, and Hand) score, range of motion, complications, and radiological outcomes. Results  A total of 13 patients with a median age of 13 years (interquartile range [IQR]: 12.5-16) were included. The median time to follow-up was 31 months (IQR: 26-51). The median ABILHAND-Kids score was 42 (range: 37-42), and the median QuickDASH was 0 (range: 0-39). Range of motion did not differ significantly between the injured and the uninjured sides for all parameters. One patient had a nonunion requiring additional operative treatment. The postoperative radiological parameters showed an improvement of radial inclination, radial height, ulnar variance, dorsal tilt, and dorsal tilt. Conclusion  Corrective osteotomy for children is an effective method for treating symptomatic malunions of the distal radius. Level of Evidence  This is a Level IV study., Competing Interests: Conflict of Interest None declared., (© Thieme Medical Publishers.)

Background: Health-related quality of life (HRQL) is a key outcome in the evaluation of burn treatment. Health-related quality of life instruments with robust measurement properties are required to provide high-quality evidence to improve patient care. The aim of this review was to critically appraise the measurement properties of HRQL instruments used in burns., Methods: A systematic search was conducted in Embase, MEDLINE, CINAHL, Cochrane, Web of Science, and Google scholar to reveal articles on the development and/or validation of HRQL instruments in burns. Measurement properties were assessed using the Consensus-based Standards for the selection of health Measurement Instruments methodology. A modified Grading of Recommendations, Assessment, Development, and Evaluation analysis was used to assess risk of bias (prospero ID, CRD42016048065)., Results: Forty-three articles covering 15 HRQL instruments (12 disease-specific and 3 generic instruments) were included. Methodological quality and evidence on measurement properties varied widely. None of the instruments provided enough evidence on their measurement properties to be highly recommended for routine use; however, two instruments had somewhat more favorable measurement properties. The Burn-Specific Health Scale-Brief (BSHS-B) is easy to use, widely accessible, and demonstrated sufficient evidence for most measurement properties. The Brisbane Burn Scar Impact Profiles were the only instruments with high-quality evidence for content validity., Conclusion: The Burn Specific Health Scale-Brief (burn-specific HRQL) and the Brisbane Burn Scar Impact Profile (burn scar HRQL) instruments have the best measurement properties. There is only weak evidence on the measurement properties of generic HRQL instruments in burn patients. Results of this study form important input to reach consensus on a universally used instrument to assess HRQL in burn patients., Level of Evidence: Systematic review, level III.

Objective: People in the Netherlands are legally allowed to celebrate New Year's Eve with consumer fireworks. The aim of this study was to provide detailed information about the patient and injury characteristics, medical and societal costs, and clinical and functional outcome in patients with injuries resulting from this tradition., Methods: A multicenter, prospective, observational case series performed in the Southwest Netherlands trauma region, which reflects 15% of the country and includes a level I trauma center, a specialized burn center, a specialized eye hospital, and 13 general hospitals. All patients with any injury caused by consumer fireworks, treated at a Dutch hospital between December 1, 2017 and January 31, 2018, were eligible for inclusion. Exclusion criteria were unknown contact information or insufficient understanding of Dutch or English language. The primary outcome measure was injury characteristics. Secondary outcome measures included treatment, direct medical and indirect societal costs, and clinical and functional outcome until one year after trauma., Results: 54 out of 63 eligible patients agreed to participate in this study. The majority were males (N = 50; 93%), 50% were children below 16 years of age, and 46% were bystanders. Injuries were mainly located to the upper extremity or eyes, and were mostly burns (N = 38; 48%) of partial thickness (N = 32; 84%). Fifteen (28%) patients were admitted and 11 (20%) patients needed surgical treatment. The mean total costs per patient were €6,320 (95% CI €3,400 to €9,245). The most important cost category was hospital admission. Only few patients reported complaints in patient-reported quality of life and functional outcome after 12 months follow-up., Conclusion: This study found that young males are most vulnerable for fireworks injuries and that most injuries consist of burns, located to the arm and hand, and eye injuries. On the long-term only few patients experienced reduced quality of life and functional limitations., Competing Interests: The authors have declared that no competing interests exist.

Little is known about delirium in elderly burn center patients. The aim of this study is to provide information on the prevalence of delirium and risk factors contributing to the onset of delirium. All patients aged 70 years or older admitted with burn injuries to the Burn Center, Maasstad Hospital, in 2011 to 2017 were eligible for inclusion. We retrospectively collected data regarding the presence of delirium, potential risk factors contributing to the onset of delirium and outcome after delirium. We included elderly 90 patients in this study. The prevalence of delirium in our population was 13% (N = 12). Risk factors for delirium were advanced age, increased American Society for Anesthesiologists score, physical impairment and the use of anticholinergic drugs during admission. Patients with delirium had a poorer outcome, with prolonged hospital stay and increased mortality 6 and 12 months after discharge. Delirium is diagnosed in 13% of the elderly patients admitted to our burn center. Risk factors for delirium found in this study are advanced age, poor physical health status, physical impairment, and the use of anticholinergic drugs. Delirium is related to poor outcomes, including prolonged hospital stay and mortality after discharge., (© The Author(s) 2019. Published by Oxford University Press on behalf of the American Burn Association.)

Split-thickness skin grafting remains a fundamental treatment for patients with deep burns and other traumatic injuries. Unfortunately, the donor site wound that remains after split skin graft (SSG) harvesting may also cause problems for the patient; they can lead to discomfort and scars with a poor cosmetic outcome. Regrafting of the donor site is one of the methods described to improve donor site healing and scarring. In this report, we describe a case of a 26-year-old woman with a self-inflicted chemical burn (0.5% TBSA) who underwent split skin grafting. During surgery, only part of the donor site was regrafted with split skin graft remnants. This part healed faster and had a better scar quality at 3 months postsurgery. Nevertheless, the appearance and patients' opinion on the regrafted part deteriorated after 12 months. With this case report, we aim to create awareness of the long-term consequences of regrafting, which may differ from short-time results. Patients expected to have poor reepithelialization potential may benefit from regrafting of the SSG on the donor site. But in healthy young individuals, timewise there would be no benefit since it can lead to an aesthetically displeasing result., (© American Burn Association 2019. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Burden of disease estimates are an important resource in public health. Currently, robust estimates are not available for the burn population. Our objectives are to adapt a refined methodology (INTEGRIS method) to burns and to apply this new INTEGRIS-burns method to estimate, and compare, the burden of disease of burn injuries in Australia, New Zealand and the Netherlands., Methods: Existing European and Western-Australian health-related quality of life (HRQL) datasets were combined to derive disability weights for three homogenous burn injury groups based on percentage total body surface area (%TBSA) burned. Subsequently, incidence data from Australia, New Zealand, and the Netherlands from 2010 to 2017 were used to compute annual non-fatal burden of disease estimates for each of these three countries. Non-fatal burden of disease was measured by years lived with disability (YLD)., Results: The combined dataset included 7159 HRQL (EQ-5D-3 L) outcomes from 3401 patients. Disability weights ranged from 0.046 (subgroup < 5% TBSA burned > 24 months post-burn) to 0.497 (subgroup > 20% TBSA burned 0-1 months post-burn). In 2017 the non-fatal burden of disease of burns for the three countries (YLDs/100,000 inhabitants) was 281 for Australia, 279 for New Zealand and 133 for the Netherlands., Conclusions: This project established a method for more precise estimates of the YLDs of burns, as it is the only method adapted to the nature of burn injuries and their recovery. Compared to previous used methods, the INTEGRIS-burns method includes improved disability weights based on severity categorization of burn patients; a better substantiated proportion of patients with lifelong disability based; and, the application of burn specific recovery timeframes. Information derived from the adapted method can be used as input for health decision making at both the national and international level. Future studies should investigate whether the application is valid in low- and middle- income countries.

Background: Intra-operative image acquisition can be obtained indirectly (via verbal request to a technician) or directly (executed at the tableside, by a surgeon stepping on a foot pedal). Direct image acquisition could reduce the exposure time and thus the risk of radiation damage. The aim of this randomized controlled trial was to compare direct surgeon-controlled fluoroscopy with indirect technician-operated fluoroscopy during internal fixation of a hip fracture., Methods: From March 5, 2014 to August 19, 2015, 100 patients who had sustained a hip fracture that required internal fixation were enrolled. Patients were randomized between direct surgeon-controlled image acquisition using a foot pedal (n = 52) and indirect image acquisition by a radiology technician (n = 48). The primary outcome measure was the radiation exposure time; secondary outcome measures were the associated effective radiation dose and the dose area product., (dap) Results: A total of 96 patients (with a median age of 84 years) were enrolled in this study. Eighty-nine (93%) patients had a pertrochanteric fracture. No statistically significant differences between direct image acquisition and indirect image acquisition were found for overall radiation time, total radiation dose or DAP for the total population. When adjusted for potential confounders, a difference in overall radiation time of 18.50 s (95% CI 2.19; 34.81, p = 0.027) was found in favour of indirect image acquisition., Conclusion: This study showed statistically significantly lower radiation duration using indirect fluoroscopy for the total population and the pertrochanteric fracture subgroup when adjusted for several confounders. No significant effect on radiation dose and DAP was found., (Copyright © 2019. Published by Elsevier Ltd.)

Objective: To provide a complete overview of all burn debridement techniques studied in recent literature and to find the best evidence with regard to efficiency and safety., Method: A systematic review was performed. Searches were conducted in electronic databases such as PubMed, Embase, Cochrane, CINAHL, Web of Science, and Academic Search Premier. All studies published from 1990 onwards, on the efficiency and/or safety of burn debridement techniques in patients with thermal burn injuries of any age, were included. Primary outcomes were time to complete wound healing and time to complete debridement. Randomized trials were critically appraised., Results: Twenty-seven studies, including four randomized clinical trials, were included. Time to wound healing in the conventional tangential excision (seven studies), hydrosurgery (eight studies), enzymatic debridement (eleven studies), and shock waves group (one study) ranged from 13-30, 11-13, 19-33, and 16 days, respectively. Time to complete debridement ranged from 5-10, 4-23, and 1-9 days, respectively. Furthermore, secondary outcomes (including grafting, mortality, and scar quality) were compared between the debridement categories., Conclusion: Convincing evidence in favor of any of these techniques is currently lacking. Future studies regarding (new) debridement techniques need to use standardized and validated outcome measurement tools to allow improved standardization and comparisons across studies., (Copyright © 2019 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Introduction: Burn injury can affect health-related quality of life (HRQL). Knowledge concerning long-term HRQL in burn patients is limited. Therefore our aim was to evaluate long-term HRQL and to study predictors of impaired long-term HRQL., Methods: All adults with a length of stay (LOS) of ≥1 day (2011-2012) were invited. Also, adults with severe burns, i.e., >20% total body surface area (TBSA) burned or TBSA full thickness>5% (2010-2013) were invited. Participants completed the EuroQol(EQ)-5 D-5L + C and visual analogue scale (EQ-VAS) 5-7 years after burns., Results: This study included 256 patients (mean %TBSA 10%); 187 patients with minor burns and 69 patients with severe burns. Mean EQ-5D summary was 0.90 and EQ-VAS 83.2 in the minor burn patients, and 0.79 and 78.1 in the severe burn patients. Some problems in at least one dimension were experienced by 81% of patients with severe burns and 45% of those with minor burns. However, a minority reported severe or extreme problems; 15% of those with severe burns and 6% of those with minor burns. Patients with severe burns reported significantly more problems, except for anxiety/depression. In both patient groups most problems were reported on pain/discomfort. Length of hospital stay, gender and age were associated with lower long-term HRQL (EQ-VAS) in multivariate analyses, whereas only length of stay was associated with a lower summary score., Conclusions: The majority of patients experienced some problems with HRQL 5-7 years post burn. This emphasizes that burns can have a negative impact on an individual's HRQL, particularly in more severely burned patients, that persists for years. The HRQL dimensions most frequently affected include pain/discomfort and anxiety/depression. Patients with a prolonged hospital stay, females and older patients are at higher risk of poor HRQL in the long-term., (Copyright © 2019 Elsevier Ltd and ISBI. All rights reserved.)

Purpose: Mortality in burn intensive care unit (ICU) has been decreasing and treatment appears to be changing. The aims of this study: (1) examine outcome in burn patients, (2) examine changes in ICU indication and (3) explore the influence of a changing case-mix., Methods: Retrospective study in patients admitted to ICU (1987-2016). Four groups were specified: major burns (≥15% TBSA), inhalation injury with small injury (<15% TBSA, inhalation injury), watchful waiting (<15% TBSA, without inhalation injury), tender loving care (patients withheld from treatment). Logistic regression was performed to evaluate the relation between case-mix and outcome., Results: Overall mortality decreased to 7%. Mortality of major burns decreased by 15%. The major burn group decreased by 36%. The inhalation injury and watchful waiting group increased by 9% and 21%. The percentage of ventilated patients increased by 14% in the major burn group. 40% of patients were ventilated in the watchful waiting group., Conclusions: After correction for case-mix, survival improved, mainly in the major burn group. Case-mix shifted towards inhalation injury and watchful waiting. Growth of the watchful waiting group is not necessarily harmful. However, the increase of mechanical ventilation could be. We suggest raising awareness for risks and consequences of mechanical ventilation., (Copyright © 2019 Elsevier Ltd and ISBI. All rights reserved.)

Scar formation is an important adverse consequence of burns. How patients appraise their scar quality is often studied shortly after sustaining the injury, but information in the long-term is scarce. Our aim was, therefore, to evaluate long-term patient-reported quality of burn scars. Adults with a burn center admission of ≥1 day between August 2011 and September 2012 were invited to complete a questionnaire on long-term consequences of burns. We enriched this sample with patients with severe burns (>20% total body surface area [TBSA] burned or TBSA full thickness >5%) treated between January 2010 and March 2013. Self-reported scar quality was assessed with the Patient Scale of the Patient and Observer Scar Assessment Scale (POSAS). Patients completed this scale for their-in their opinion-most severe scar ≥5 years after burns. This study included 251 patients with a mean %TBSA burned of 10%. The vast majority (91.4%) reported at least minor differences with normal skin (POSAS item score ≥2) on one or more scar characteristics and 78.9% of the patients' overall opinion was that their scar deviated from normal skin. Patients with severe burns had higher POSAS scores, representing worse scar quality, than patients with mild/intermediate burns, except for color, which was high in both groups. A longer hospital stay predicted reduced scar quality (both mean POSAS and mean overall opinion of the scar) in multivariate analyses. In addition, female gender was also associated with a poorer overall opinion of the scar. In conclusion, this study provides new insights in long-term scar quality. Scars differed from normal skin in a large part of the burn population more than 5 years after burns, especially in those with severe burns. Female gender is associated with a poorer patients' overall opinion of their scar, which may be an indication of gender differences in perception of scar quality after burns., (© 2019 The Authors. Wound Repair and Regeneration published by Wiley Periodicals, Inc. on behalf of by the Wound Healing Society.)