Validation of alternate electrodes positions for the measurement of hand volume using Bioimpedance Spectroscopy in a non-injured population

Mr Dale Edwick1,2,3, Mr  Jeremy Rawlins2,5, Professor Fiona Wood1,3,4, A/Professor Dale Edgar1,2,3,4

1Fiona Wood Foundation, Murdoch, Australia, 2Burns Service Of Western Australia – Fiona Stanley Hospital, Murdoch, Australia, 3Burn Injury Research Node – The University of Notre Dame Australia, Fremantle, Australia, 4Burn Injury Research Unit – The University of Western Australia, Crawley, Australia, 5Department of Plastic and Maxillofacial Surgery – Royal Perth Hospital, Perth, Australia

Abstract:

Background: Bioimpedance spectroscopy (BIS) is a measure of body composition, which has been shown to detect non-clinical lymphedema, and has the sensitivity to measure the reduction in hand volume elicited by elevation for a period of three minutes. Alternate electrodes positions have been shown to be suitable for measuring fluid shifts using BIS in moderate to large burns, where wounds preclude standardized electrode placement.

Aim: The aim of this study was to determine if measurement of hand volume by BIS was comparable in four electrode configurations in non-injured subjects.

Methods: Electrode positions on the dorsum of the hand and forearm has previously been described for measuring hand volumes by BIS. Three alternate electrode configurations were assessed using a combination of volar and dorsal hand and forearm electrode placements. BIS measures were performed on 30 subjects (60 hands), and recorded in triplicate for each configuration.

Results:  Hand volume impedance depended on the inter-electrode distance and electrode configurations. Compared to the standard configuration, as the inter-electrode distance increased from 5 to 9 cm, the volar/volar placement showed a percentage impedance difference decrease of 5.04 to -0.014% (4.88Ω to -0.02Ω). The dorsal hand/volar forearm configuration also showed a decrease in difference of 12.64 to -2.07% (12.23Ω to -2.52Ω) with increasing inter-electrode distance. The volar hand/dorsal forearm configuration demonstrated an increasing difference as distance increased (-2.23Ω to -13.14Ω).

Conclusion: Preliminary results indicate that alternate electrodes positions are comparable to the standard for hand volume measurement by BIS. Validation is required in a burns population.

Biography:
Dale is a Senior Physiotherapist in the State Adult Burns Unit at Fiona Stanley Hospital in Western Australia. He is also a PhD candidate at The University of Notre Dame Australia, investigating proactive management of oedema following hand burn injury.

Treatment of partial thickness burns: a prospective, randomised controlled trial comparing Biobrane®, Acticoat®, Mepilex® Ag and Aquacel® Ag

Shivani Aggarwala1, 2, Sarah Robert1, Megan Brady1, Mario D’Souza2, James Doherty1,2, Varun Harish1, Sepher Lajevardi1, Peter Haertsch1, 2, Peter Maitz1, 2, Andrea C Issler-Fisher1

1Burns Unit, Concord Repatriation General Hospital, Hospital Rd, Concord NSW 2139, Australia

2University of Sydney, Camperdown, NSW 2006

Improvements in technology and marked progression in our understanding of wound healing has promoted an enormous expansion in the range of dressing options available to treat partial thickness burns.  The aim of the study was to compare the efficacy of four routinely used dressings – Biobrane®, Acticoat®, Mepilex® Ag and Aquacel® Ag – for the management of partial thickness burn injuries.

A randomized controlled trial was initiated in June 2013 at the burns outpatient clinic of Concord Repatriation General Hospital.  Patients aged 18 to 65 years who presented within 72 hours post injury, and with clinically diagnosed partial thickness burn that could be managed in the outpatient setting were included in this study.  Patients were excluded if they were diabetic, presented with full thickness burn, signs of infection, or if they had burns resulting from an electrical or chemical injury. Patients were also excluded if the burns involved specific anatomical locations such as the eyelids, ears, lips or genitalia.

The primary objective was to determine the days until wound closure (≥90% re-epithelialization). Additionally, the number of dressing changes required, pain, the incidence of infection and scarring was assessed. Patients were followed up at 3 and 6 months to further evaluate scarring.

At the time of presentation, the data collection will be completed and results hereof will be presented.

Biography:

Dr Shivani Aggarwala is medical graduate from the University of Sydney. She is currently working as a surgical SRMO at Concord Burns Unit. She has a keen interest in burns and reconstructive surgery.

 

Burn Scar Maturation with or without Pressure Garment Therapy (PGT)

Dr Zhe Li1,2, Frank Li1, Brooke Farrugia3, Young  Li4, Professor Peter Maitz1,2

1Burns Unit, Concord Hospital, Concord, Australia, 2University of Sydney Medical School, Sydney, Australia, 3Graduate School of Biomedical Engineering, UNSW, Sydney, Australia, 4Pathology, Concord Hospiotal, Concord, Australia

Abstract:
Delayed wound healing in severe burns leads to aberrant ECM deposition in dermal tissue and the development of hypertrophic scar (HS).

PGT is commonly used for HS management in the believe that the compression could restrict the blood flow to scar area, inhibit HS tissue growth by controlling collagen synthesis, causing apoptosis, limiting nutrient supplies.1,2,3 Mechanically PGT significantly hindered scar contraction, reduced skin hardness and increased skin strength.4 However, as HS has a natural trend to mature by itself given enough time, studies raised questions about the effect of PGT on scar maturation 5 suggesting the evidence of PGT effectiveness was anecdotal6 . A meta-analysis of randomized controlled trials indicated that PGT does not appear to alter global scar scores. 7

This study aims to define the progression characteristics of HS at histological, cellular and molecular levels. Biopsies were collected from HS areas with or without PGT compression through a time course post burns.  In addition to monitor the clinical features and the changes of ECM proteins in HS tissue, we also examined the changes of proteoglycans (PGs) and glycosaminoglycans (GAGs), the key skin molecules in normal skin, compressed and non-compressed HS samples. PGs and GAGs are critical for wound healing, skin remodelling and skin function. Data from this study would facilitate better understanding the development and maturation of HS in severe burns. More importantly, it could help define the clinical effectiveness of PGT in HS prevention and treatment, and understand how PGT regulates HS remodelling and maturation post burns.

Biography:
Through years of medical and scientific trainings, Dr Zhe Li has developed expertise knowledge and skills in cell biology, skin tissue engineering and regenerative medicine; and cell/tissue therapy for severe burn wound healing.  Since 2003 he has been leading the clinical laboratory service to provide cultured skin autografts for severe burn care in all Burn Centrers under NSW Statewide Severe Burns Services.

INTEGRA® Dermal Regeneration Template in major paediatric burns – A review of 17 years experience at the Women’s and Children’s Hospital Adelaide

Dr Lachlan Farmer1, Ms Linda Quinn1, Dr Rebecca Cooksey1, Mr Darren Molony1, Dr Amy Jeeves1, Mr Bernard Carney1, Dr Michelle Lodge1

1Women’s And Children’s Hospital Adelaide, North Adelaide, Australia

Abstract:
A major burn presents numerous short and long-term challenges to the burn and reconstructive surgeon. INTEGRA® Dermal Regeneration Template is a standard intervention for acute and reconstructive management of burns in our unit, beginning in 2000. We have previously presented our experience in 2004 and 2011 both at ANZBA and internationally. Since 2011 we have built upon our unit experience of INTEGRA® use especially in major paediatric burns. Over this period we have continued to improve our management techniques.

We present an update of our caseload and outcomes as well as experiences and lessons learnt from the use of INTEGRA® Dermal Regeneration Template. Associated complications and suggested management, as well as a treatment algorithm for the use of INTEGRA in the acute management of a major paediatric burn is discussed.

Biography:
Dr. Lachlan Farmer is an unaccredited registrar in the Department of Plastic and Reconstructive Surgery at the Women’s and Children’s Hospital here in Adelaide. He hopes to undertake advanced training in Plastic, Reconstructive and Burns Surgery.

Systemically administration of androgens in burn injury wound healing

Mr Huaikai Shi1, Mrs Ulla Simanainen2, Miss Roxanne Parungao3, Mr  Brian Lesmana4, Mr  Brenton  Condor5, Mr David Handelsman6, Mr Mark  Cooper7, Mr Peter  Maitz8, Mrs Yiwei Wang9

1ANZAC Research Institute, Concord, Australia, 2ANZAC Research Institute, Concord, Australia, 3ANZAC Research Institute, Concord, Australia, 4ANZAC Research Institute, Concord, Australia, 5ANZAC Research Institute, Concord, Australia, 6ANZAC Research Institute, Concord, Australia, 7ANZAC Research Institute, Concord, Australia , 8Burns Unit, Concord Repatriation General Hospital , Concord, Australia, 9ANZAC Research Institute, Concord, Australia

Abstract:
Rational: Androgens have been known to inhibit cutaneous (non-burn) wound repair in men and male mice by exacerbating wound inflammation and modifying re-epithelialization. However, recent studies have reported that in severe burn injury (over 20% TBSA), androgen treated patients better maintain lean body mass, have improved hypermetabolic response and shorter healing time. This highlights a contradictory and context-dependent role of androgens in the wound healing of burn injury and simple incisional skin wound healing.

Objective:The aim of this study was to identify the role of androgens in severe burn injury wound healing, in particular whether androgens target local healing processes or systemic burn induced hypermetabolic state.

Methods: Mice were subjected to a thermal injury from a hot brass rod (4cm²) constituting a severe large burn. After 48 hrs following thermal injury, the wound site was debrided to remove damaged skin and to avoid infection prior to wound dressing. Mice were weighed and harvested at different time points post injury. Energy expenditure and metabolic changes were measured using metabolic cages. Wound healing rate, epidermal migration, matrix deposition were also analysed.

Results: In the present study, all mice induced hypermetabolism response with continued weight lost and muscle wasting over 7 days post burn injury. Androgen (DHT) treated mice had significantly improved burn injury wound healing with respect to body weight, muscle wasting and better maintained adipose tissue. However, no differences were shown on local wound healing parameters, suggesting systemic administration of DHT has no negative effects on local healing process.

Biography:
Mr Shi, a first year PHD student works at Burns Unit, Anzac Research Institute, The university of Sydney. His PHD focus on identifing the role of androgens in severe burn injury wound healing, in particularly whether androgen targets local healing process or systemic burn induced hypermetabolic state.

 

Macronutrients, metabolism and burn injury wound healing

Dr Yiwei  Wang1, Dr Jonathan  Hew1, Dr Craig Mooney1, Dr Julian  Smyth1, Miss Roxanne Parungo1, Professor David Le Couteur1, Dr Zhe Li1, Professor Peter  Maitz1

1Anzac Research Institute, Concord West, Australia

Abstract:
Background: Diets high in both protein and energy content have been clinically proven to effectively enhance the wound healing process post severe burn injury. However, the optimum macronutrient composition for small and severe burn injury and the mechanisms by which nutrition influences the healing process remains unclear.

Methods:  Male C57BL6 mice (n = 180) were fed control chow ad libitum for 8 weeks. At 8 weeks, two individual 1x1cm burn injury wounds was surgically created. During the healing process, mice were fed one of 12 experimental diets for 4 weeks. These diets were selected to cover a wide spectrum of macronutrient balance. Wound healing rate was measured and skin/organ biopsy collected on day 3,5,7,10,14, 21 and 28. The metabolic changes were measured using a state of the art “Promethion” metabolic cage system.

Results: We surprisingly found that the optimum diet for small burn injury wound healing is a low protein with an optimal ratio of protein: carbohydrate: fat at P5: C48: F48. Approximate 50% of wounds healed by 4 days compared to the standard chow and the poorest diet (high fat, high protein). In additional to local wound healing, we also found this low protein diet generated better metabolic outcomes over wound repair.

Biography:
Dr Yiwei Wang is a Senior Research Fellow within the Burns Research Group at the ANZAC Research Institute. Dr Yiwei Wang was awarded her PhD from Kingston University, United Kingdom for development of a new biomaterial-based drug delivery device. She further gained post-doctoral and commercial experience in tissue engineering, drug delivery and wound healing at NPL Management, Ltd, U.K. and the University of Queensland, Australia. She joined the Burns Research Group at the ANZAC Research Institute in 2010 as an expert specializing in wound healing and skin regeneration. She is currently managing the Burns Laboratory and leading several research projects which include investigation of androgens in several burn injuries; development of a living 3D skin substitute and study of the optimal nutritional support in burns wound healing.

Incidence of Acute Kidney Injury in patients with ≥10% TBSA burns admitted to an Australian Burns Centre

Dr Lara Kimmel1,2, Dr Scott WIlson3,4,5, Professor Rowan Walker3,4, Ms Yvonne Singer6, Miss Heather Cleland6,7

1Physiotherapy Department, The Alfred, Melbourne, Australia, 2Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia, 3Department of Renal Medicine, The Alfred, Melbourne, Australia, 4Department of Medicine, Monash University, Melbourne, Australia, 5Baker IDI, Melbourne, Australia, 6Victorian Adult Burns Service, The Alfred, Melbourne, Australia, 7Department of Surgery, Monash University, Melbourne, Australia

Abstract:
Background: Acute Kidney Injury (AKI) complicates the management of approximately 25% of patients with severe burns and is associated with long term complications. The aims of this study were to examine the incidence of, and factors associated with, the development of AKI in patients with %TBSA ≥10, as well as the relationship with length of stay (LOS).

Methods: Retrospective medical record review of consecutive burns patients admitted to The Alfred.  Demographic and injury details were recorded. Factors associated with AKI were determined using multiple logistic regression.

Results: Between 2010 and June 2014, 300 patients were admitted with burn injury and data on 267 patients was available for analysis.  Median age was 54.5 years with 78% being male.  Median %TBSA was 15 (IQR 12, 20).  The AKI incidence was 22.5%, including 15% (27/184) in patients with %TBSA 10-19. Factors associated with AKI included increasing age and %TBSA (OR 1.05 p<0.001) as well as increased surgeries (p<0.041) and a cardiac comorbidity (p<0.01). All patients with renal comorbidity developed AKI. In the %TBSA 10-19 cohort, only increasing age (OR 1.05 p < 0.001) was associated with AKI. After accounting for confounding factors, the probability of discharge in non-AKI group was greater than for the AKI patients at all time points (p<0.001).

Conclusion: This is the first study to show an association between patients with %TBSA 10-19 and AKI.  Given the association between AKI and complications, prospective research is needed to further understand AKI in burns with the aim of risk reduction.

Biography:
Lara has worked as a physiotherapist at The Alfred for over 20 years, mainly in the area of trauma and orthopaedics.  She completed her PhD through Monash University in 2016 and has a wide variety of research interests.

How do skin thickness measurements obtained via ultrasound compare to histologically determined values?

Ms Christine Andrews1, Ms Margit Kempf1, Prof Roy Kimble2, Dr Leila Cuttle3

1Centre for Children’s Burns and Trauma Research, The University of Queensland, Child Health Research Centre, Brisbane, Australia, 2Centre for Children’s Burns and Trauma Research, Child Health Research Centre, The University of Queensland, Queensland University of Technology, Children’s Health Queensland, Lady Cilento Children’s Hospital, Brisbane, Australia, 3Centre for Children’s Burns and Trauma Research, Queensland University of Technology, Institute of Health and Biomedical Innovation at Centre for Children’s Health Research, Brisbane, Australia

Abstract:
Introduction

Ultrasonographic measurement of skin and burn scar thickness for clinical and research purposes is gaining popularity. However, the relationship between in vivo ultrasound measurements and histologically determined (biopsy) values for skin thickness is poorly understood. This study investigates the influence of excision and biopsy processing procedures on skin thickness measurements.

Methods

Skin thickness was measured in six large white pigs (35kgs) from cranial and caudal locations on both flanks. Using ultrasound (22MHz hockey stick probe), skin was scanned in vivo, excised and rescanned ex vivo. Excised skin was processed for histological analysis using three techniques; (1) 10% formalin for 24-36 hours, (2) skin stretched to in vivo dimensions and pinned, 10% formalin for 24-36 hours, (3) snap frozen.

Results

Mean shrinkage after excision was 12% for length and 19% for width. Ex vivo ultrasound measurements were 5% thicker than in vivo. The dermis and total skin were significantly thicker (p < 0.0001) after histological analysis of routinely processed formalin and frozen sections than in vivo. Mean relative thickening was: 54% (dermis) and 41% (total skin) for formalin-fixed; 66% (dermis) and 51% (total skin) for frozen-fixed sections. Pinning the sample to approximate in vivo size/tension during processing resulted in values most comparable to those in vivo.

Discussion/Conclusions

The substantial disparity between in vivo and ex vivo thickness measurements highlights caution when absolute and to a lesser extent relative values for depth are compared. Overestimation of depth as a result of processing artefact must be considered by researchers examining skin samples.

Biography:
Christine is a PhD student from the University of Queensland working with the Children’s Burns and Trauma Research group at the Lady Cilento Children’s Hospital. She commenced her studies in May 2014, prior to this she worked as a veterinarian in private practice for over 15 years. Her field of interest is the pathophysiology of burns. Her research examines the relationship between temperature, duration of contact and tissue injury severity for scald burns.

Evidence-based injury prediction data for the temperature of water to cause a severe deep spill/splash scald injury

Ms Christine Andrews1, Ms Margit Kempf1, Prof Roy Kimble2, Dr Leila Cuttle3

1Centre for Children’s Burns and Trauma Research, Child Health Research Centre, The University of Queensland, Brisbane, Australia, 2Centre for Children’s Burns and Trauma Research, Child Health Research Centre, The University of Queensland, Queensland University of Technology, Children’s Health Queensland, Lady Cilento Children’s Hospital, Brisbane, Australia, 3Centre for Children’s Burns and Trauma Research, Queensland University of Technology, Institute of Health and Biomedical Innovation at Centre for Children’s Health Research, Brisbane, Australia

Abstract:
Introduction

To reduce the risk of a severe burn, understanding the relationship between water temperature and tissue injury severity is essential. Evidence-based injury prediction data is lacking for the temperature of water likely to result in a deep scald injury from a spill/splash event.

Methods

Using a porcine scald model, water from 60 to 100⁰C for 5 seconds was tested and the severity of tissue injury investigated. Wound examination, biopsies and Laser Doppler Imaging were performed at 1, 24 hours and at 3 and 7 days post-burn. Burn conditions demonstrating mid-to-deep dermal damage (histologically) were followed for 21 days to assess time to re-epithelialise. Results were compared to burn conditions reported for children with severe scalds requiring split-thickness skin grafts (SSG) by retrospectively reviewing the Queensland Paediatric Burns Registry.

Results

By day 7, water at ≤ 75⁰C showed less dermal damage than 80⁰C or higher, this was statistically significant for scalds ≥ 90⁰C (p <0.05). Damage to ≥ 75% of the depth of dermis was associated with a burn taking longer than 3 weeks to re-epithelialise. A 5 second exposure to water ≥ 85⁰C resulted in burns which remained un-repepithelisied by day 21. Clinically, water was estimated to be ≥ 85⁰C in 74% of cases where a SSG was performed.

Discussion/ Conclusions

Novel evidence-based injury prediction data for accidental spill/splash scalds is presented. Quantitative histological data is translated to the clinically relevant outcome of time to healing and experimental evidence is compared to clinical data describing scald injuries in children.

Biography:
Christine is a PhD student from the University of Queensland working with the Children’s Burns and Trauma Research group at the Lady Cilento Children’s Hospital. She commenced her studies in May 2014, prior to this she worked as a veterinarian in private practice for over 15 years. Her field of interest is the pathophysiology of burns. Her research examines the relationship between temperature, duration of contact and tissue injury severity for scald burns.

Circulating protein C levels in severe burns

Dr Thomas Lang1,2,3,4, Dr Albert Kim4, Dr Aruna Wijewardena4, Mr Ruilong Zhao1,2, Ms Rachel McGrath2,4, Dr Siobhan Fitzpatrick4, Dr Nancy Huang4, Dr John Vandervord2,4, Professor Gregory Fulcher2,4, Professor Christopher Jackson1,2

1The Kolling Institute, St. Leonards, Australia, 2The University of Sydney, Camperdown, Australia, 3St. George Hospital, Kogarah, Australia, 4Royal North Shore Hospital, St. Leonards, Australia

Abstract:
Background

Activated protein C (APC) is a naturally occurring anticoagulant with potent cytoprotective and anti-inflammatory effects. Recent evidence indicates that APC heals recalcitrant wounds through stimulation of angiogenesis and re-epithelialisation. Low levels of protein C (PC) are associated with, and may predispose to, foot ulcers in diabetic patients, irrespective of glucose control. Whether there is a relationship between PC and burn injury, and subsequent healing is unknown.

Aims

This is a longitudinal study to measure plasma PC levels in patients with acute severe partial thickness burns throughout their hospital admission.

Method

Ethics approval was gained for the enrolment of 90 patients admitted to the Royal North Shore Hospital Severe Burns Unit with partial thickness burns affecting 10-80% of the total body surface area. Plasma levels of PC were measured every three days for three weeks.

Results

The level of plasma PC in burn patients on day of admission (Day 0) was 75.8±3.0% (n=47, mean±SEM), with a range of 34–125%, compared to the normal range of 80–180%. The proportion of patients with serum PC level <80% at baseline was 57.4% (n=27). PC levels increased over time (n=38 in each group, p<0.0001, Friedman analysis): day 0 (76.4±3.4%) vs day 3 (91.2±4.4%) vs day 6 (106.1±5.4%). Of the patients completed to date, further significant increases have occurred until day 18.

Discussion

Burns patients have wide-ranging but overall low plasma PC on admission, which increases over time. Whether the PC level on admission is predictive of outcome is currently under investigation.

Biography:
Thomas is a Resident Medical Officer from Sydney completing a Master of Philosophy (Research) at the University of Sydney in conjunction with The Kolling Institute and Royal North Shore Hospital Severe Burns Unit. This is his second visit to The Adelaide Oval, after attending Australia’s first day-night test match against New Zealand.

 

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About ANZBA

ANZBA is a not for profit organisation and the peak body for health professionals responsible for the care of the burn injured in Australia and New Zealand. ANZBA encourages higher standards of care through education, performance monitoring and research.

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