Use of 816 consecutive burn wound biopsies to inform a histologic algorithm for burn depth categorization

2021 ◽  
Author(s):  
Herb A Phelan ◽  
James H Holmes IV ◽  
William L Hickerson ◽  
Clay J Cockerell ◽  
Jeffrey W Shupp ◽  
...  
Keyword(s):  
New Technologies ◽  
A Priori ◽  
Machine Learning Algorithms ◽  
Burn Wound ◽  
Prospective Multicenter Study ◽  
Reticular Dermis ◽  
Burn Wounds ◽  
Misclassification Rates ◽  
Burn Depth ◽  
Burn Depth Assessment

Abstract Introduction Burn experts are only 77% accurate when subjectively assessing burn depth, leaving almost a quarter of patients to undergo unnecessary surgery or conversely suffer a delay in treatment. To aid clinicians in burn depth assessment (BDA), new technologies are being studied with machine learning algorithms calibrated to histologic standards. Our group has iteratively created a theoretical burn biopsy algorithm (BBA) based on histologic analysis, and subsequently informed it with the largest burn wound biopsy repository in the literature. Here, we sought to report that process. Methods The was an IRB-approved, prospective, multicenter study. A BBA was created a priori and refined in an iterative manner. Patients with burn wounds assessed by burn experts as requiring excision and autograft underwent 4mm biopsies procured every 25cm 2. Serial still photos were obtained at enrollment and at excision intraoperatively. Burn biopsies were histologically assessed for presence/absence of epidermis, papillary dermis, reticular dermis, and proportion of necrotic adnexal structures by a dermatopathologist using H&E with whole slide scanning. First degree and superficial 2 nd degree were considered to be burn wounds likely to have healed without surgery, while deep 2 nd and 3 rd degree burns were considered unlikely to heal by 21 days. Biopsy pathology results were correlated with still photos by five burn experts for consensus of final burn depth diagnosis. Results Sixty-six subjects were enrolled with 117 wounds and 816 biopsies. The BBA was used to categorize subjects’ wounds into 4 categories: 7% of burns were categorized as 1 st degree, 13% as superficial 2 nd degree, 43% as deep 2 nd degree, and 37% as 3 rd degree. Therefore 20% of burn wounds were incorrectly judged as needing excision and grafting by the clinical team as per the BBA. As H&E is unable to assess the viability of papillary and reticular dermis, with time our team came to appreciate the greater importance of adnexal structure necrosis over dermal appearance in assessing healing potential. Conclusions Our study demonstrates that a BBA with objective histologic criteria can be used to categorize BDA with clinical misclassification rates consistent with past literature. This study serves as the largest analysis of burn biopsies by modern day burn experts and the first to define histologic parameters for BDA.

136 Use of 816 Consecutive Burn Wound Biopsies to Inform a Histologic Algorithm for Burn Depth Diagnosis

2021 ◽  
Vol 42 (Supplement_1) ◽  
pp. S90-S91
Author(s):  
Herb A Phelan ◽  
James H Holmes ◽  
Clay J COCKERELL ◽  
William L Hickerson ◽  
Jeffrey W Shupp ◽  
...  
Keyword(s):  
New Technologies ◽  
A Priori ◽  
Machine Learning Algorithms ◽  
Burn Wound ◽  
Prospective Multicenter Study ◽  
Reticular Dermis ◽  
Burn Wounds ◽  
Current State ◽  
Misclassification Rates ◽  
Burn Depth

Abstract Introduction Burn experts are only 77% accurate when subjectively assessing burn depth, leaving almost a quarter of patients to undergo unnecessary surgery or conversely suffer a delay in treatment. To aid clinicians in burn depth assessment (BDA), new technologies are being studied with machine learning algorithms calibrated to histologic standards. Our group has iteratively created a theoretical burn biopsy algorithm (BBA) based on histologic analysis, and subsequently informed it with the largest burn wound biopsy repository in the literature. Here, we sought to report that process. Methods This was an IRB-approved, prospective, multicenter study. A BBA was created a priori and refined in an iterative manner, resulting in the current state of the algorithm seen in Figure 1. Patients with burn wounds assessed by burn experts as requiring excision and autograft underwent 4mm biopsies procured every 25cm2. Serial still photos were obtained at enrollment and at excision intraoperatively. Burn biopsies were histologically assessed for presence/absence of epidermis, papillary dermis, reticular dermis, and proportion of necrotic adnexal structures by a dermatopathologist using H&E with whole slide scanning. First degree and superficial 2nd degree were considered to be burn wounds likely to have healed without surgery, while deep 2nd and 3rd degree burns were considered unlikely to heal by 21 days. Biopsy histopathology results were correlated with still photos by 3 burn experts for consensus of final burn depth diagnosis. Results Sixty-six subjects were enrolled with 117 wounds and 816 biopsies. The BBA was used to categorize 100% of subjects into 4 categories: 7% of burns were categorized as 1st degree, 13% as superficial 2nd degree, 43% as deep 2nd degree, and 37% as 3rd degree. Therefore 20% of burn wounds were incorrectly judged as needing excision and grafting by the clinical team. As H&E is unable to assess the viability of papillary and reticular dermis, with time our team came to appreciate the greater importance of adnexal structure necrosis over dermal appearance in assessing healing potential. Conclusions Our study demonstrates that a BBA with objective histologic criteria can be used to categorize BDA with clinical misclassification rates consistent with past literature. This study serves as the largest analysis of burn biopsies by modern day burn experts and the first to define histologic parameters for BDA.

Management of the Burn Wound

2019 ◽  
Author(s):  
Nicole S. Gibran ◽  
Jose P. Sterling ◽  
David M. Heimbach
Keyword(s):  
Wound Care ◽  
Donor Site ◽  
Skin Grafting ◽  
Wound Management ◽  
Skin Substitutes ◽  
Burn Wound ◽  
Burn Wounds ◽  
Initial Care ◽  
Wound Excision ◽  
Burn Depth

Current approaches to burn management are based on an understanding of the biology and physiology of human skin and the pathophysiology of the burn wound. The clinical evaluation and initial care of a burn wound is described and includes an assessment of burn depth, determining the need for escharatomy and daily burn wound care. Burns can be topical or surgical. Topical burn wounds require choice in the use of antibiotics. Considerations and techniques for surgical burn wound management are described and include early excision and grafting, wound excision, skin grafting, graft and donor-site dressings, postoperative wound care, biologic dressings and skin substitutes, allograft and xenograft skin, cultured epidermal autografts, and skin substitutes. Figures show the two distinct layers of the skin, various types of burns, and both fascial and tangential excision of burn wounds.  This review contains 12 figures, 11 tables, and 61 references. Keywords: Burn wound, graft, partial-thickness, full-thickness, dermis, epidermis,  sloughing, dressing

Management of the Burn Wound

2019 ◽  
Author(s):  
Nicole S. Gibran ◽  
Jose P. Sterling ◽  
David M. Heimbach
Keyword(s):  
Wound Care ◽  
Donor Site ◽  
Skin Grafting ◽  
Wound Management ◽  
Skin Substitutes ◽  
Burn Wound ◽  
Burn Wounds ◽  
Initial Care ◽  
Wound Excision ◽  
Burn Depth

Current approaches to burn management are based on an understanding of the biology and physiology of human skin and the pathophysiology of the burn wound. The clinical evaluation and initial care of a burn wound is described and includes an assessment of burn depth, determining the need for escharatomy and daily burn wound care. Burns can be topical or surgical. Topical burn wounds require choice in the use of antibiotics. Considerations and techniques for surgical burn wound management are described and include early excision and grafting, wound excision, skin grafting, graft and donor-site dressings, postoperative wound care, biologic dressings and skin substitutes, allograft and xenograft skin, cultured epidermal autografts, and skin substitutes. Figures show the two distinct layers of the skin, various types of burns, and both fascial and tangential excision of burn wounds.  This review contains 12 figures, 11 tables, and 61 references. Keywords: Burn wound, graft, partial-thickness, full-thickness, dermis, epidermis,  sloughing, dressing

Burn depth assessment

2019 ◽  
pp. 77-88
Author(s):  
Peter George Dziewulski ◽  
Quentin Frew
Keyword(s):  
Hypertrophic Scar ◽  
Surgical Planning ◽  
Surgical Intervention ◽  
Wound Care ◽  
Scar Formation ◽  
Wound Management ◽  
Burn Wound ◽  
Increased Risk ◽  
Burn Depth ◽  
Burn Depth Assessment

Burn depth assessment is key assessing healing potential and risk of scarring. It informs wound management and surgical planning. The dynamic and evolving nature of a burn wound can make this difficult. Burns which are likely to take longer than 3 weeks to heal have a significantly increased risk of hypertrophic scar formation leading to functional and aesthetic morbidity. Assessing healing potential allows the treating clinician to optimize wound care and the need for surgical intervention.

First preliminary Clinical Experiences using Hyperspectral Imaging for Burn Depth Assessment of Hand Burns

2021 ◽  
Author(s):  
Dominik Promny ◽  
Juliane Aich ◽  
Moritz Billner ◽  
Bert Reichert
Keyword(s):  
Hyperspectral Imaging ◽  
Correct Diagnosis ◽  
Control Group ◽  
Clinical Experiences ◽  
Healthy Skin ◽  
Burn Wounds ◽  
Dorsal Hand ◽  
Hand Burns ◽  
Burn Depth ◽  
Burn Depth Assessment

Abstract The accurate assessment of burn wounds is challenging but crucial for correct diagnosis and following therapy. The most frequent technique to evaluate burn wounds remains the clinical assessment often subjective depending on the experience of the physician. Hyperspectral Imaging is intended to counteract this subjective diagnosis by an accurate and objective analysis of perfusion parameters. The purpose of this study was to analyse the ability of technical burn depth assessment and to investigate a possible link between a certain value to burn depth versus value of healthy skin references. Methods A total of 118 subjects were included in this study between July 2017 and July 2019. 74 images with dorsal hand burns and 44 images of healthy skin on the dorsal hand as control group were analysed. In Hyperspectral Imaging recordings burn wounds were analysed with special interest to wound centre, intermediate zone, and wound margin. Results Significant results were determined for the differentiation between superficial partial burns and healthy skin. Furthermore, the distinction of full thickness burns was significantly possible. Conclusion Currently, it cannot be shown that the use of Hyperspectral Imaging technology significantly assesses the actual burn depth of thermal wounds of the dorsal hand reliably. However, the results show tendencies to improved analysis for differentiations supporting physicians in early objective optimal treatment selection.

642 The Use of Laser Speckle Contrast Imaging in Assessing Depth and Progression of Burn Wounds

2020 ◽  
Vol 41 (Supplement_1) ◽  
pp. S166-S167
Author(s):  
Laura Cooper ◽  
Rodney K Chan ◽  
Phillip Kemp Bohan ◽  
Anders H Carlsson ◽  
Tyler Everett
Keyword(s):  
Ccd Camera ◽  
Laser Speckle ◽  
Measurement Tool ◽  
Contrast Imaging ◽  
Burn Wound ◽  
Laser Speckle Contrast Imaging ◽  
Burn Wounds ◽  
Speckle Contrast ◽  
Partial Thickness ◽  
Burn Depth

Abstract Introduction The ability of laser speckle contrast imaging (LSCI) to provide real-time images of blood flow makes this modality appealing in the assessment of burn wounds, particularly for clinicians making treatment decisions based on burn wound depth and presumed progression. Here we present 2 preclinical studies that used LSCI to assess wound progress, both immediately and months after injury. Methods LSCI images were taken 10-40cm away from the wound and captured with a 1388x1038-pixel CCD camera. In the first study, LSCI images were captured prior to and immediately following creation of superficial partial-thickness (SPTB, 10s), deep partial-thickness (DPTB, 15s), and full-thickness burns (FTB, 20s), and on post-burn day (PBD) 1, 2, and 3. In the second study, LSCI images were obtained before and after DPTB creation and on PBD 7, 14, 21, 28, 60, 90, and 120. Results 92 wounds from 9 swine were included. Speckle data was normalized to control sites and converted to percentages ([speckle wound/speckle control] x 100), producing speckle percentage of control (SPOC) which quantifies the relative decrease or increase in speckle output (vascularity). SPOC was significantly decreased for all burn times on PBD 0, 1, and 2. By PBD 3, only DPTB and FTB remained diminished (p=0.028 and p=0.005, respectively), and FTB SPOC was significantly less than the SPTB (p=0.015). In the second study, SPOC showed an increase post-debridement on PBD 7, noted as post-debridement day (PDD) 0. SPOC continued to increase significantly to a peak at PDD 7 (p< 0.0001) and remained elevated until PDD 28. By PDD 60, SPOC was no longer significantly increased. Conclusions LSCI is a reliable method for analyzing burn depth and wound progression in the preclinical setting. LSCI data shows an immediate decrease in vascularity at all burn depths immediately following burn creation, followed by a peak in vascularity on PDD 7, with a trend back to normal by PDD 60. Applicability of Research to Practice The correlation of wound bed vascularity based on LSCI to known data on burn depth and progression suggests that LSCI could be a useful measurement tool in the clinical setting for the provider determining wound viability.

scholarly journals Is It Possible to Forecast the Price of Bitcoin?

Forecasting ◽  
2021 ◽  
Vol 3 (2) ◽  
pp. 377-420
Author(s):  
Julien Chevallier ◽  
Dominique Guégan ◽  
Stéphane Goutte
Keyword(s):  
Data Analytics ◽  
Daily Variation ◽  
A Priori ◽  
Machine Learning Algorithms ◽  
Support Vector ◽  
Market Growth ◽  
Network Support ◽  
Market Participants ◽  
Nearest Neighbours ◽  
Stationary Behavior

This paper focuses on forecasting the price of Bitcoin, motivated by its market growth and the recent interest of market participants and academics. We deploy six machine learning algorithms (e.g., Artificial Neural Network, Support Vector Machine, Random Forest, k-Nearest Neighbours, AdaBoost, Ridge regression), without deciding a priori which one is the ‘best’ model. The main contribution is to use these data analytics techniques with great caution in the parameterization, instead of classical parametric modelings (AR), to disentangle the non-stationary behavior of the data. As soon as Bitcoin is also used for diversification in portfolios, we need to investigate its interactions with stocks, bonds, foreign exchange, and commodities. We identify that other cryptocurrencies convey enough information to explain the daily variation of Bitcoin’s spot and futures prices. Forecasting results point to the segmentation of Bitcoin concerning alternative assets. Finally, trading strategies are implemented.

577 The Collaboration of Burn Outreach and Wound Care Nurses

2021 ◽  
Vol 42 (Supplement_1) ◽  
pp. S140-S140
Author(s):  
Ekta Vohra
Keyword(s):  
Wound Care ◽  
Medical Center ◽  
Academic Medical Center ◽  
Hospital Setting ◽  
Basic Knowledge ◽  
Definitive Treatment ◽  
Knowledge Gap ◽  
Burn Wound ◽  
Improvement Project ◽  
Burn Wounds

Abstract Introduction Certified wound care nurses perform a vital role in skin health and management in the hospital setting. During the certification process, minimal time is spent on burn wound education, despite the fact that wound care nurses are consulted for various wound etiologies; one of those being burns. This construct created a need for collaboration between the burn team and wound care nurses. Although all burns are essentially wounds, the reality is that all wounds are not burns. The management of the burn wound is often different from the management of pressure injuries or surgical wounds. In speaking with the wound care nurses at this large urban academic medical center, a knowledge gap was identified in burn wound care education as well as appropriate and timely consultation of the burn team. Methods This knowledge improvement project focused on educating the wound care nurses in assessment and treatment of burns, and the process for burn service consultation. Burn education was provided through in-person didactic presentations. The lecture included burn wound photos with opportunities to classify the potential depth of burn wounds as well as typical complications. Additionally, it discussed when a burn consult is needed. A basic knowledge retrospective pre-posttest method was utilized. Results An educational plan was tailored to meet the learning needs of the wound care nurses to address the knowledge gap. Post test data results were tracked. Post scores were increased, indicating a successful educational intervention. Also, while providing the education, the burn outreach coordinator identified an opportunity to expand the burn center’s presence among colleagues through collaboration with the wound care nurses. The wound nurses made excellent ambassadors for the mission of the burn service. Conclusions Provision of burn education across disciplines may improve recognition of burn wounds and facilitate definitive treatment.

674 Machine Learning and Automation in Burn Care: A Systematic Review

2021 ◽  
Vol 42 (Supplement_1) ◽  
pp. S193-S193
Author(s):  
Samantha Huang ◽  
Justin Dang ◽  
Clifford C Sheckter ◽  
Haig A Yenikomshian ◽  
Justin Gillenwater
Keyword(s):  
Machine Learning ◽  
Systematic Review ◽  
Total Body Surface Area ◽  
Burn Wound ◽  
Burn Care ◽  
Surgeon Experience ◽  
Automated Software ◽  
Burn Depth ◽  
Automated Methods ◽  
Equal Weighting

Abstract Introduction Current methods of burn evaluation and treatment are subjective and dependent on surgeon experience, with high rates of inter-rater variability leading to inaccurate diagnoses and treatment. Machine learning (ML) and automated methods are being used to develop more objective and accurate methods for burn diagnosis and triage. Defined as a subfield of artificial intelligence that applies algorithms capable of knowledge acquisition, machine learning draws patterns from data, which it can then apply to clinically relevant tasks. This technology has the potential to improve burn management by quantitating diagnoses, improving diagnostic accuracy, and increasing access to burn care. The aim of this systematic review is to summarize the literature regarding machine learning and automated methods for burn wound evaluation and treatment. Methods A systematic review of articles available on PubMed and MEDLINE (OVID) was performed. Keywords used in the search process included burns, machine learning, deep learning, burn classification technology, and mobile applications. Reviews, case reports, and opinion papers were excluded. Data were extracted on study design, study objectives, study models, devices used to capture data, machine learning, or automated software used, expertise level and number of evaluators, and ML accuracy of burn wound evaluation. Results The search identified 592 unique titles. After screening, 35 relevant articles were identified for systematic review. Nine studies used machine learning and automated software to estimate percent total body surface area (%TBSA) burned, 4 calculated fluid requirements, 18 estimated burn depth, 5 estimated need for surgery, 6 predicted mortality, and 2 evaluated scarring in burn patients. Devices used to estimate %TBSA burned showed an accuracy comparable to or better than traditional methods. Burn depth estimation sensitivities resulted in unweighted means >81%, which increased to >83% with equal weighting applied. Mortality prediction sensitivity had an unweighted mean of 96.75%, which increased to 99.35% with equal weighting. Conclusions Machine learning and automated technology are promising tools that provide objective and accurate measures of evaluating burn wounds. Existing methods address the key steps in burn care management; however, existing data reporting on their robustness remain in the early stages. Further resources should be dedicated to leveraging this technology to improve outcomes in burn care.

556 The Use of a Concentrated Surfactant Based Gel to Promote Burn Wound Healing

2021 ◽  
Vol 42 (Supplement_1) ◽  
pp. S126-S127
Author(s):  
Rebecca Coffey ◽  
Rachel Penny
Keyword(s):  
Wound Healing ◽  
New Product ◽  
Ease Of Use ◽  
Burn Injuries ◽  
Full Thickness ◽  
Burn Wound ◽  
Burn Wounds ◽  
Burn Care ◽  
Product Trial ◽  
Burn Wound Healing

Abstract Introduction Strategies to remove necrotic tissue from burn wounds include excisional and non-excisional debridement. Alternative treatments could promote burn wound healing while minimizing patient discomfort and the need for surgery. We evaluated the usage of a concentrated surfactant gel (CSG) to promote burn wound healing in those with indeterminate depth and full thickness burn injuries. Methods An IRB approved retrospective study was conducted during a 10-patient new product trial period with enrollment between September and October 2019. Patients included in this study had indeterminate or full thickness burn wounds and were treated with a concentrated surfactant-based gel. Patients with non-burn diagnoses were excluded. Data collected included demographic information, injury descriptors, and additional burn wound characteristics. Results A total of 10 patients were included in this study as part of a new product trial. The subjects were 80% male with an average TBSA of 7.5%. 40% had indeterminate and 60% had full thickness burn wounds. Prior to initiation of the CSG, the burn wounds had been open for an average of 41 days. There were no infections or complications with usage of the CSG. 90% of patients reported less pain than the standard of care topical agents for burns. Average duration of treatment with the CSG until healing was 28 days. After usage of the CSG, no patients required surgery. Conclusions Our findings support the usage of a concentrated surfactant-based gel in patients with burn wounds. Patients reported decreased pain during dressing changes and ease of use compared to the standard topical agent in burn care. It also prevented surgical debridement in those with indeterminate and full thickness burn injuries.

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