Mobile phones for the assessment of burns: we have the technology

Optimizing an Outpatient mHealth Intervention for Children with Burns: A Convergent Mixed-Methods Study

Burn injury is one of the most common traumatic injuries in childhood. Fortunately, 90% of pediatric burns may be treated in the outpatient setting after appropriate burn triage. Patients with burns face significant geographic disparities in accessing expert burn care due to regionalized care. To aid patients and their families during acute outpatient burn recovery, we developed a smartphone app, Telemedicine Optimized Burn Intervention (TOBI). With this app, we aimed to increase access to care by allowing secure, streamlined communication between patients and burn providers, including messaging and wound image transfer. The purpose of this study was to systematically evaluate user feedback to optimize the patient and provider experience. TOBI was evaluated using a convergent mixed-methods approach consisting of qualitative semi-structured interviews and quantitative measurements of app usability via the mHealth App Usability Questionnaire. Participants included 15 caregivers of pediatric patients with burns who used TOBI during treatment and ten burn providers. Users found TOBI to be a highly usable application in terms of usefulness, ease of use, satisfaction, and functionality. Qualitative data provided insight into user experience, satisfaction and preferences, difficulty navigating, usability and acceptability, and potential improvements. Although most users were highly satisfied, improvements were needed to optimize the burn app. We systematically made these improvements before we released TOBI for routine patient use. This study uncovered helpful recommendations for app improvements that can be generalized to other mobile health apps to increase their appeal and adoption.

Utility of Telehealth Platforms Applied to Burns Management: A Systematic Review

The financial burden of burn injuries has a considerable impact on patients and healthcare systems. Information and Communication Technologies (ICTs) have demonstrated their utility in the improvement of clinical practice and healthcare systems. Because referral centres for burn injuries cover large geographic areas, many specialists must find new strategies, including telehealth tools for patient evaluation, teleconsultation, and remote monitoring. This systematic review was performed according to PRISMA guidelines. PubMed, Cochrane, Medline, IBECS, and LILACS were the search engines used. Systematic reviews, meta-analyses, clinical trials, and observational studies were included in the study search. The protocol was registered in PROSPERO with the number CRD42022361137. In total, 37 of 185 studies queried for this study were eligible for the systematic review. Thirty studies were comparative observational studies, six were systematic reviews, and one was a randomised clinical trial. Studies suggest that telehealth allows better perception of triage, more accurate estimation of the TBSA, and resuscitation measures in the management of acute burns. In addition, some studies assess that TH tools are equivalent to face-to-face outpatient visits and cost-efficient because of transport savings and unnecessary referrals. However, more studies are required to provide significant evidence. However, the implementation of telehealth should be specifically adapted to each territory.

Clinical decision-support for acute burn referral and triage at specialized centres - Contribution from routine and digital health tools

BACKGROUND

Specialized care is crucial for severe burn injuries whereas minor burns should be handled at point-of-care. Misdiagnosis is common which leads to overburdening the system and to a lack of treatment for others due to resources shortage.

OBJECTIVES

The overarching aim was to evaluate four decision-support tools for diagnosis, referral, and triage of acute burns injuries in South Africa and Sweden: referral criteria, mortality prediction scores, image-based remote consultation and automated diagnosis.

METHODS

Study I retrospectively assessed adherence to referral criteria of 1165 patients admitted to the paediatric burns centre of the Western Cape of South Africa. Study II assessed mortality prediction of 372 patients admitted to the adults burns centre by evaluating an existing score (ABSI), and by using logistic regression. In study III, an online survey was used to assess the diagnostic accuracy of burn experts' image-based estimations using their smartphone or tablet. In study IV, two deep-learning algorithms were developed using 1105 acute burn images in order to identify the burn, and to classify burn depth.

RESULTS

Adherence to referral criteria was of 93.4%, and the age and severity criteria were associated with patient care. In adults, the ABSI score was a good predictor of mortality which affected a fifth of the patients and which was associated with gender, burn size and referral status. Experts were able to diagnose burn size, and burn depth using handheld devices. Finally, both a wound identifier and a depth classifier algorithm could be developed with relatively high accuracy.

CONCLUSIONS

Altogether the findings inform on the use of four tools along the care trajectory of patients with acute burns by assisting with the diagnosis, referral and triage from point-of-care to burns centres. This will assist with reducing inequities by improving access to the most appropriate care for patients.

Potential for Machine Learning in Burn Care

INTRODUCTION

Burn-related injuries are a leading cause of morbidity across the globe. Accurate assessment and treatment have been demonstrated to reduce the morbidity and mortality. This essay explores the forms of artificial intelligence to be implemented the field of burns management to optimise the care we deliver in the National Health Service (NHS) in the UK.

METHODS

Machine Learning methods which predict or classify are explored. This includes linear and logistic regression, artificial neural networks, deep learning, and decision tree analysis.

DISCUSSION

Utilizing Machine Learning in burns care holds potential from prevention, burns assessment, predicting mortality and critical care monitoring to healing time. Establishing a regional or national Machine Learning group would be the first step towards the development of these essential technologies.

CONCLUSION

The implementation of machine learning technologies will require buy-in from the NHS health boards, with significant implications with cost of investment, implementation, employment of machine learning teams and provision of training to medical professionals.

Telediagnosis of oral lesions using smartphone photography

OBJECTIVE

The objective of this observational study was to evaluate telediagnosis of oral lesions using smartphone photography.

MATERIALS AND METHODS

Individuals with visible oral lesions composed a convenience sample. The lesions were photographed using a smartphone camera and emailed along with clinical information to three evaluators, who formulated up to two diagnostic hypotheses for each case. A total of 235 photographs from 113 clinical cases were obtained. The evaluators answered questions regarding referral decisions, requests for additional tests, diagnostic difficulties, and image quality. The diagnostic hypotheses were compared to the gold standard by means of percent agreement and kappa coefficient. Consensual face-to-face diagnoses of three specialists-when only a clinical diagnosis was necessary-or histopathological results-when a biopsy was necessary-were considered the gold standard.

RESULTS

The telediagnosis was similar to the gold standard in 76% of the cases, and kappa coefficients showed almost perfect agreement (k = 0.817-0.903). The evaluators considered that referrals could have been avoided on an average of 35,4% of the cases.

CONCLUSION

Diagnosis of oral lesions using images taken with a smartphone showed almost perfect agreement and diagnostic accuracy comparable to face-to-face diagnosis.

Evaluating Discrepancies in Percent Total Body Surface Area Burn Assessments Between Prehospital Providers and Burn Center Physicians

Burns are routinely assessed at the scene of the incident by prehospital or emergency medical services providers. The initial management of burns is based on the calculation of the extent of the injury, reported as percent total body surface area. This study evaluates discrepancies in estimation of total body surface area (TBSA) between prehospital providers and burn team physicians over a 3-year period at an academic, university medical center serving as the regional burn center. A total of 120 adult and 27 pediatric patients (less than age 16 years) were included, with 95 (65%) male, 67 (45.6%) Caucasian, 62, median age 35 years (Interquartile Range 27). The most common etiology of burns was hot liquid, 39 (26.5%). Median [IQR] and mean (SD) estimated TBSA (%) were 4[1, 10] and 8.6 (12.8) for prehospital providers, and 2 [1, 6] and 5.9 (9.9) for burn team physicians. Bland-Altman plots evaluating 2nd and 3rd degree burns separately and combined demonstrated that, as burns involved more surface area, agreement decreased between emergency medical service providers and burn physicians. Agreement between pre-hospital providers and burn physicians decreased as total body surface areas of burns increased. This finding reaffirms the need for more standardized education and training for all medical personnel.

Usefulness of smartphone use among surgeons in clinical practice during the pandemic of COVID-19: a cross-sectional study

Background

With the magnitude and severity of the COVID-19 pandemic, the usual face-to-face consultation within a clinical setting is no longer feasible. Thus, this led to the need for alternate means to provide adequate patient care for surgical patients. This is where the role of smartphones comes into play, in which it is thus of paramount importance. This research study aimed to assess the usefulness of smartphones in surgical practice during COVID-19 pandemic.

Methods

This cross-sectional study is based on a questionnaire distributed among surgeons in different levels of practice working at Kuwait governmental hospitals during the COVID-19 pandemic. The questionnaire was developed via Google Docs to collect data for the current study.

Results

Out of 600 surgeons, 180 have responded to the questionnaire, giving a response rate of 30%. Of these, 42.8%, 85.5%, and 58.9% were aged between 35 and 44 years, were male, and Kuwaiti nationals, respectively. Almost all of the respondents (99.5%) were using smartphones for hospital-related work. The most common uses of the smartphones involved texting (70%), and viewing or taking images and videos using built-in cameras (60%) either in the emergency department, outpatient clinics, wards, or operating rooms. The majority of the respondents (88%) rated the use of smartphones in practice as important.

Conclusion

This study revealed that using smartphones in surgical practice was prevalent among the respondent surgeons in Kuwait during the pandemic. The majority of them considered using smartphones in practice to be important, due to its benefits in facilitating doctor–doctor and patient–doctor communication, reviewing the literature, and making clinical decisions. Guidelines are required for proper and legal use of smartphone devices in medical practice. Accordingly, recommendations are suggested.

mHealth for image-based diagnostics of acute burns in resource-poor settings: studies on the role of experts and the accuracy of their assessments

Diagnostic assistance using mobile technology is instrumental to timely and adequate care in resource-scarce settings, particularly for acute burns. Little is known, however, as regards to how remote diagnostic consultation in burns affects the work process. This article reviews a doctoral thesis on this topic based on four studies conducted in the Western Cape, South Africa prior to and in a very early phase of the implementation of an app for burn remote diagnostic assistance. The aim was to increase knowledge on how remote diagnostic assistance for burn injuries can influence the role and work of medical experts in a resource-poor setting. The congruence model was used as a reference framework to study the ‘input’ (study 1), ‘tasks’ (studies 2 and 3) and ‘people’ (study 4) involved. The results show higher burn incidence in young children (75.4 per 10 000) and gender differences primarily among adults. The quality of images was considered by experts as better when viewed on smartphones and tablets than on computers. The accuracy of burn size assessments was high overall but low for burn depth (ICC = 0.82 and 0.53 respectively). Experts described four positions pertaining to remote consultations: clinical specialist, gatekeeper, mentor and educator. They perceived images as improving accuracy of consultation and stressed the need for verbal communication among clinicians during critical situations. In conclusion, experts are satisfied with the quality of images seen on handheld devices and can accurately assess burn size using these, yet burn depth assessment is more challenging without additional clinical information. mHealth for diagnostic assistance can benefit current image-based consultation by systematising information quality, introducing enhanced security and improved access to experts. Remaining challenges include the necessity of verbal communication in some instances and replacing existing informal organisational practices.

Enzymatic debridement for burn wound care: Interrater-reliability and impact of experience in post-intervention therapy decision

INTRODUCTION

Enzymatic debridement (ED) has become a reliable tool for eschar removal. Although ED application is simple, wound bed evaluation and therapy decision post-intervention are prone to subjectivity and failure. Experience in ED might be the key, but this has not been proven yet. Aim of this study was to assess interrater reliability (IR) in post-intervention wound bed evaluation and therapy decision as well as the impact of experience. In addition, the authors introduce video assessment as a valuable tool for post-ED decision making and education.

MATERIAL AND METHODS

A video-based survey was conducted among physicians with various experience in ED. The survey involved multiple choice and 5-point Likert scale questions about professional status, experience in ED, confidence in post-ED wound bed evaluation and therapy decision. Subsequently, videos of 15 mixed pattern to full thickness burns immediately after removal of the enzyme complex were demonstrated. Participants were asked for evaluation of each burn wound, including bleeding pattern and consequent therapy decision. IR ≥80% was considered as a consensus. Responses were stratified according to participants' experience in applying ED (<10; 10-19; 20-49; ≥50 applications). IR was assessed by Chi^2-test (raw agreement (RA); ≥80% was considered as a consensus) and by Krippendorff's Alpha-test. In addition, expert consensus for therapy decision was compared to the actual clinical course of each shown patient. Last, participants were asked for their opinion on video as an assessment tool for post-ED wound bed evaluation, decision making and training.

RESULTS

31 physicians from 11 burn centers participated in the survey. Overall consensus (RA≥80%) in post-ED wound bed evaluation and therapy decision was achieved in 20 and 40%, respectively. Krippendorff's Alpha are given by 0.32 (95% CI: 0.15,0.49) and 0.31 (95% CI: 0.16,0.47), respectively. Subgroup analysis revealed that physicians with high experience in ED achieved significantly more consensus in post-intervention wound bed evaluation and therapy decision compared to physicians with moderate experience (60% vs. 13.3%; p=0.02 and 86.7 vs. 33.3%; p=0.04, respectively). Video analysis was considered a feasible (90.3%) and beneficial (93.5%) tool for post-intervention wound bed evaluation and therapy decision as well as useful for training purposes (100%).

CONCLUSION

Reliability of wound bed evaluation and therapy decision after ED depends on the experience of the rating physician. Video analysis is deemed to be a valuable tool for ED evaluation, decision making and user training.

Evaluation of a Managed Surgical Consultation Network in Malawi

BACKGROUND

Access to surgery is a challenge for low-income countries like Malawi due to shortages of specialists, especially in rural areas. District hospitals (DH) cater for the immediate surgical needs of rural patients, sending difficult cases to central hospitals (CH), usually with no prior communication.

METHODS

In 2018, a secure surgical managed consultation network (MCN) was established to improve communication between specialist surgeons and anaesthetists at Queen Elizabeth and Zomba Central Hospitals, and surgical providers from nine DHs referring to these facilities.

RESULTS

From May to December 2018, DHs requested specialist advice on 249 surgical cases through the MCN, including anonymised images (52% of cases). Ninety six percent of cases received advice, with a median of two specialists answering. For 74% of cases, a first response was received within an hour, and in 68% of the cases, a decision was taken within an hour from posting the case on MCN. In 60% of the cases, the advice was to refer immediately, in 26% not to refer and 11% to possibly refer at a later stage.

CONCLUSION

The MCN facilitated quick access to consultations with specialists on how to manage surgical patients in remote rural areas. It also helped to prevent unnecessary referrals, saving costs for patients, their guardians, referring hospitals and the health system as a whole. With time, the network has had spillover benefits, allowing the Ministry of Health closer monitoring of surgical activities in the districts and to respond faster to shortages of essential surgical resources.

Early clinical management of severe burn patients using telemedicine: a pilot study protocol

Background

Emergency physicians are responsible for assessing the severity of a patient's burns, which determines whether the patient needs to be transferred to a burn center. Such a proper assessment represents a daunting task because severe burn injuries are rare. Inaccurate estimates often result in unjustified and costly transfers and unneeded fluid resuscitation and assisted ventilation procedures. Telemedicine offers a solution to these challenges. The present pilot study aims to investigate the feasibility, acceptability, and potential value of a large telemedicine initiative at the University of Montreal Health Center's burn center and its network of referring hospitals.

Methods

A three-stage study protocol is proposed to achieve this objective. First, a proof of concept phase will assess the technical feasibility of telemedicine at one referring hospital with a high volume of patient transfers. Second, the organizational and human feasibility of the project will be evaluated in four referring medical centers. All teleconsultation sessions will be analyzed using the WHO's telemedicine implementation model. The third phase will consist of evaluating the potential impacts of telemedicine in a subset of 10 referring hospitals. The quality of communications between referring physicians and specialists will be assessed using semi-structured interviews. A pre-test/post-test with a comparison group design will be used to assess the effects of telemedicine on patient transfers, ventilation procedures, patient complications, mortality, length of ICU stay, and additional surgical procedures. The economic viability of telemedicine will be assessed using a cost-minimization approach.

Discussion

The telemedicine initiative is expected to yield positive and significant outcomes that are relevant to a wide range of medical centers that already use or are considering using a similar technology. The contribution of this pilot study lies in its ability to reveal technological, organizational, and human barriers and provide a preliminary assessment of the clinical and economic value of a large-scale telemedicine initiative in the context of burn medicine.

Expert Outpatient Burn Care in the Home Through Mobile Health Technology

Access to care for pediatric burns remsains a major public health problem in the United States. Telemedicine has an opportunity to improve access to care, but current models are expensive and inefficient. They have developed and pilot-tested the TeleBurn App, a novel smartphone application, to treat partial thickness burns while outpatient. The app allows the provision of expert clinical burn care directly in the patient's home through text and image messaging, video conferencing, and instructional videos. They retrospectively reviewed clinical outcomes and usability in pediatric partial thickness burn patients treated using the TeleBurn App compared with standard therapy alone. Standard therapy is considered to be face-to-face delivery of care. Burn wound care was provided to 32 patients via the app and 35 patients with standard therapy. Most (74%) patients offered the app, used it as their primary source of follow-up care. This group had no wound infections or unexpected returns to clinic or hospital. Both TeleBurn App and standard therapy groups had similar burn severity, age, and burn mechanism. Mean healing time was shorter in the app group (mean ± standard deviation: 11.6 ± 4.7 days versus standard therapy: 14.3 ± 5.4 [P = .03]) with fewer clinical encounters (0.93 ± 0.6 vs standard therapy: 3.3 ± 1.0 [P = .001]). Adherence with completion of therapy in patients using the app was 80 vs 64 per cent with standard therapy. They describe a functional, scalable mobile health application in clinical use in a pediatric burn program. Further prospective, randomized studies may validate this mobile health platform, improving access to expert burn care for a vulnerable population.

A smartphone-based consultation system for acute burns - methodological challenges related to follow-up of the system

BACKGROUND

A smartphone-based consultation system for acute burns is currently being implemented in the Western Cape, South Africa. Even though studies indicate that similar systems for burns tend to support valid diagnosis and influence patient management, the evidence is still sparse. There is a need for more in-depth evaluations, not least in resource-constrained settings where mHealth projects are increasing.

OBJECTIVE

This article describes the consultation system and assessments in relation to its implementation with a special focus on methodological challenges.

METHODS

A number of evaluations and assessments have been conducted, are ongoing or planned for in relation to the implementation of the teleconsultation system. Initial assessments showed that size and depth of burns could be assessed at least as well using photographs as at bedside and that the image quality of handheld devices can be used as well as computers. Studies on system usability are currently being done with a mixed-methods approach. A historical cohort design will be applied to assess the potential health impact of the system. Patients with burn injuries where the doctor at point of care has used the app to receive diagnostic support from a burns expert will be considered as exposed and patients with burn injuries where the app has not been used will be considered as non-exposed.

CONCLUSIONS

Smartphone-based consultation systems have the potential to strengthen the assessment of burn injury in many settings. However, ethically and methodologically sound evaluations are needed to find the best systems and solutions. This article identifies challenges and suggests potential assessments in relation to the implementation of such a system.

Video-Enhanced Telemedicine Improves the Care of Acutely Injured Burn Patients in a Rural State

The acute care of burn patients is critical and can be a daunting experience for emergency personnel because of the scarcity of burn injuries. Telemedicine that incorporates a visual component can provide immediate expertise in the treatment and management of these injuries. The authors sought to evaluate the addition of video telemedicine to our current telephone burn transfer program. During a 2-year period, 282 patients, 59.4% of all burn patients transferred from outside hospitals, were enrolled in the study. In addition to the scripted call with the charge nurse (ChargeRN) and the accepting physician, nine hospitals also transmitted video images of the wounds before transfer as part of a store and forward telemedicine transfer program (77, 27.6%). The accuracy of burn size estimations (BSA burned) and management changes (fluid requirements, transfer mode, and final disposition) were analyzed between the telephones-only sites (T only) and the video-enhanced sites. Referringstaff participating in video-enhanced telemedicine were sent a Google survey assessing their experience the following day. The referring staff (Referringstaff) was correct in their burn assessment 20% of the time. Video assessment improved the ChargeRN BSA burned and resulted in more accurate fluid resuscitation (P = .030), changes in both transportation mode (P = .042), and disposition decisions (P = .20). The majority of the Referringstaff found that video-enhanced telemedicine helped them communicate with the burn staff more effectively (3.4 ± 0.37, scale 1-4). This study reports the successful implementation of video-enhanced telemedicine pilot project in a rural state. Video-enhanced telemedicine using a store and forward process improved burn size estimation and facilitated management changes. Although not quantitatively assessed, the low cost of the system coupled with the changes in transportation and disposition strongly suggests a decrease in healthcare costs associated with the addition of video to a telephone-only transfer program.

The value of WhatsApp communication in paediatric burn care

BACKGROUND

Telemedicine is increasingly applied in developed settings to facilitate transfer of information to and from burn surgeons across vast geographic areas. WhatsApp is a widely available and extremely user-friendly encrypted smartphone application that does not require the expensive physical and personnel infrastructure that characterizes many of these telemedicine systems. The aim of this study was to review the use of WhatsApp to facilitate paediatric burn injury consultations to a regional burn centre in a developing country, where burn care continues to be thwarted by administrative apathy, poor resource allocation and lack of attention to medical and nursing education at all levels.

METHODS

A retrospective review was undertaken of all consultations using WhatsApp over an 18-month period, received by the burn centre's two senior medical practitioners. The specific origin and nature of the telemedicine requests for advice, transfer or follow-up were collected, as were data relating to the demographics of the patients, the aetiology, mechanism and extent of the burn injury. The impact of the system of communication in terms of reductions in admissions and clinic visits was assessed, and a cost analysis was undertaken. Feedback was also obtained from those health practitioners regularly using the service.

RESULTS

838 communications occurred during the study period, which included 1562 distinct clinical queries. 486 interactions (58%) originated from within the hospital, the majority of which were initiated by surgeons in training or burn nurse practitioners. 352 (42%) consultations were from outside the hospital. Queries related to the full spectrum of burn care, including emergency management and stabilization, triage and transfer, the need for escharotomy, fluid resuscitation, wound care, the timing and nature of surgical intervention, as well as follow-up and rehabilitation. While no significant changes in the number of surgical interventions or admissions were observed when compared to the five years prior to the intervention, outpatient visits reduced significantly during the study period. It was estimated that over 150 unnecessary admissions were also avoided as a result of the triage made possible by WhatsApp, which translated into considerable cost saving for the institution.

DISCUSSION

Incorporating WhatsApp technology into the daily processes of burn care has significantly improved the quality of paediatric burn care referrals to specialist burn services. Specifically, WhatsApp has contributed to reductions in unnecessary referrals and outpatient visits, facilitated opportunities for continuing medical education, improved the care of major burn injuries through more effective prehospital communication, and enabled greater allocation of scarce specialist resources at the burn centre. This study motivates for the wider application of WhatsApp for burn care referrals, especially in developing countries.

Accuracy of acute burns diagnosis made using smartphones and tablets: a questionnaire-based study among medical experts

BACKGROUND

Remote assistance for burns by medical experts can support nurses and general physicians in emergency care with diagnostic and management advice. Previous studies indicate a high diagnostic accuracy based on images viewed on a computer screen, but whether image-based analysis by experts using handheld devices is accurate remains to be determined.

METHOD

A review of patient data from eight emergency centres in the Western Cape, South Africa, revealed 10 typical cases of burns commonly seen in children and adults. A web-based questionnaire was created with 51 images of burns representing those cases. Burns specialists from two countries (South Africa and Sweden (n = 8 and 7 respectively)) and emergency medicine specialists from South Africa (n = 11) were contacted by email and asked to assess each burn's total body surface area (TBSA) and depth using a smartphone or tablet. The accuracy and inter-rater reliability of the assessments were measured using intraclass correlation coefficients (ICC), both for all cases aggregated and for paediatric and adult burn cases separately. Eight participants repeated the questionnaire on a computer and intra-rater reliability was calculated.

RESULTS

The assessments of TBSA are of high accuracy all specialists aggregated (ICC = 0.82 overall and 0.81 for both child and adult cases separately) and remain high for all three participant groups separately. The burn depth assessments have low accuracy all specialists aggregated, with ICCs of 0.53 overall, 0.61 for child and 0.46 for adult cases. The most accurate assessments of depth are among South African burns specialists (reaching acceptable for child cases); the other two groups' ICCs are low in all instances. Computer-based assessments were similar to those made on handheld devices.

CONCLUSION

As was the case for computer-based studies, burns images viewed on handheld devices may be a suitable means of seeking expert advice even with limited additional information when it comes to burn size but less so in the case of burn depth. Familiarity with the type of cases presented could facilitate image-based diagnosis of depth.

Smartphone-Based Thermal Imaging: A New Modality for Tissue Temperature Measurement in Hand and Upper Extremity Surgeries

BACKGROUND

Smartphone-based thermal imaging (SBTI) allows noninvasive temperature measurements. Its validity compared with a conventional infrared probe temperature scanner (IPTS) has not been studied. This study compares temperature measurements between the 2 technologies on human participants.

METHODS

Bilateral index finger temperature measurements were obtained on 30 healthy participants using IPTS and SBTI devices. Dominant versus nondominant sides (side-to-side difference) and individual side measurements between the 2 methods were compared for repeatability (precision) and agreement.

RESULTS

A total of 23 female and 7 male participants were tested. Based on nonoverlapping confidence intervals (CIs), intraclass correlation coefficient of repeatability was higher for SBTI than for IPTS measurements in side-to-side differences: 0.97 (95% CI, 0.96-0.99) versus 0.89 (95% CI, 0.82-0.95). The SBTI method recorded higher side-to-side difference and individual side measurements: 0.56°C (limits of agreement [LOA], -1.09°C to 2.20°C) and 2.64°C (LOA, 0.96°C-4.32°C), respectively.

CONCLUSIONS

In addition to higher precision, SBTI offers added benefits of instantaneous acquisition of the temperature map of the entire hand, allowing quick comparisons of the uninjured and injured fingers. SBTI measurements consistently yielded higher temperature readings in the side-to-side difference as well as individual measurements. This suggested that both devices are not interchangeable for absolute temperature comparisons but are interchangeable in monitoring the changes in temperatures. This study suggests the potential for SBTI devices to be used in the clinical settings and may be of special benefit in telemedicine.

systematized review of telemedicine applications in treating burn patients

Background: Telemedicine has been used in different fields of medicine in the past 20 years. The main advantages of this technology include saving costs, improving quality of care, and increasing access to specialists. This study aimed to review telemedicine applications in treating burn patients. Methods: In this systematized review study, related papers were searched using various databases, including PubMed, Scopus, and Science Direct. The time frame was between January 2000 and March 2016; finally, 32 papers were included in the study. Results: The findings revealed that telemedicine was used in burn care in three different ways: Remote patient follow-up, teleconsultation, and patient assessment. Conclusion: It seems that telemedicine can be easily applied in treating burn patients even when there is a limited financial resource. The use of this technology can help reduce possible errors in categorizing burn patients and decrease patients' transportation and treatment costs.

Use of digital images to aid in the decision-making for acute upper extremity trauma referral

This study evaluated the use of digital smartphone images in the decision-making for acute upper extremity trauma referrals. Surgeons (n = 15) were presented with ten upper limb trauma scenarios for consideration of immediate transfer. Based on verbal history and with additional images, participants were asked questions regarding diagnosis, injured tissues, recommended management and diagnostic and treatment confidence. Statistical analyses evaluated confidence level changes and relationships between confidence levels and independent variables. Confidence levels for diagnosis and treatment were increased with the provision of smartphone images, and this was statistically significant. The decision to transfer was changed in 22%. The photographs were more useful for amputation versus non-amputation injuries (diagnosis and treatment) and hand versus forearm injuries (diagnosis), and these differences reached statistical significance. Smartphone digital images were shown to be useful for decision-making in acute upper extremity trauma referrals. This improved communication may have implications for health cost savings and patient burden by minimizing unnecessary acute transfers.

LEVEL OF EVIDENCE

Diagnostic Level III.

Imaging Techniques for Clinical Burn Assessment with a Focus on Multispectral Imaging

Significance: Burn assessments, including extent and severity, are some of the most critical diagnoses in burn care, and many recently developed imaging techniques may have the potential to improve the accuracy of these evaluations. Recent Advances: Optical devices, telemedicine, and high-frequency ultrasound are among the highlights in recent burn imaging advancements. We present another promising technology, multispectral imaging (MSI), which also has the potential to impact current medical practice in burn care, among a variety of other specialties. Critical Issues: At this time, it is still a matter of debate as to why there is no consensus on the use of technology to assist burn assessments in the United States. Fortunately, the availability of techniques does not appear to be a limitation. However, the selection of appropriate imaging technology to augment the provision of burn care can be difficult for clinicians to navigate. There are many technologies available, but a comprehensive review summarizing the tissue characteristics measured by each technology in light of aiding clinicians in selecting the proper device is missing. This would be especially valuable for the nonburn specialists who encounter burn injuries. Future Directions: The questions of when burn assessment devices are useful to the burn team, how the various imaging devices work, and where the various burn imaging technologies fit into the spectrum of burn care will continue to be addressed. Technologies that can image a large surface area quickly, such as thermography or laser speckle imaging, may be suitable for initial burn assessment and triage. In the setting of presurgical planning, ultrasound or optical microscopy techniques, including optical coherence tomography, may prove useful. MSI, which actually has origins in burn care, may ultimately meet a high number of requirements for burn assessment in routine clinical use.

A Smartphone App and Cloud-Based Consultation System for Burn Injury Emergency Care

Background

Each year more than 10 million people worldwide are burned severely enough to require medical attention, with clinical outcomes noticeably worse in resource poor settings. Expert clinical advice on acute injuries can play a determinant role and there is a need for novel approaches that allow for timely access to advice. We developed an interactive mobile phone application that enables transfer of both patient data and pictures of a wound from the point-of-care to a remote burns expert who, in turn, provides advice back.

Methods and Results

The application is an integrated clinical decision support system that includes a mobile phone application and server software running in a cloud environment. The client application is installed on a smartphone and structured patient data and photographs can be captured in a protocol driven manner. The user can indicate the specific injured body surface(s) through a touchscreen interface and an integrated calculator estimates the total body surface area that the burn injury affects. Predefined standardised care advice including total fluid requirement is provided immediately by the software and the case data are relayed to a cloud server. A text message is automatically sent to a burn expert on call who then can access the cloud server with the smartphone app or a web browser, review the case and pictures, and respond with both structured and personalized advice to the health care professional at the point-of-care.

Conclusions

In this article, we present the design of the smartphone and the server application alongside the type of structured patient data collected together with the pictures taken at point-of-care. We report on how the application will be introduced at point-of-care and how its clinical impact will be evaluated prior to roll out. Challenges, strengths and limitations of the system are identified that may help materialising or hinder the expected outcome to provide a solution for remote consultation on burns that can be integrated into routine acute clinical care and thereby promote equity in injury emergency care, a growing public health burden.

Have Smartphones Contributed in the Clinical Progress of Oral and Maxillofacial Surgery?

BACKGROUND

Dental surgeons who encounter complex situations, such as those in unscheduled care, often have limited resources to provide a structured and specialty care. Therefore, there is always a need for cost-effective, easy to handle, easy to carry "Smartphones".

OBJECTIVE

The purpose of this paper was to undertake a review of literature on "Smartphone in Oral and Maxillofacial Surgery" online data-base and discuss the case series with emphasis on the role of attending dental surgeon and the maxillofacial surgeon.

MATERIALS AND METHODS

The available literature relevant to oral and maxillofacial surgery in online data-base of the United States National Library of Medicine: PubMed (http://www.ncbi.nlm.nih.gov/pubmed/) was searched. The inclusion criterion was to review the published clinical papers, abstracts and evidence based reviews on 'Uses of Smartphone in Oral and Maxillofacial Surgery'.

RESULTS

Six articles were found with the search term "Smartphone in Oral and Maxillofacial Surgery" in the literature searched. Five articles met the inclusion criteria for the study. The relevant data was extracted, tabulated, and reviewed to draw evidence-based conclusions for uses of smartphone in oral and maxillofacial surgery.

CONCLUSION

Utilization of smartphones in oral and maxillofacial surgery facilitate in differential diagnosis, treatment, follow up, prevention of the disease further and thereby improve the quality of patient care without requiring the presence of the maxillofacial surgeon in remote areas.

Can We Trust the Use of Smartphone Cameras in Clinical Practice? Laypeople Assessment of Their Image Quality

BACKGROUND

Smartphone cameras are rapidly being introduced in medical practice, among other devices for image-based teleconsultation. Little is known, however, about the actual quality of the images taken, which is the object of this study.

MATERIALS AND METHODS

A series of nonclinical objects (from three broad categories) were photographed by a professional photographer using three smartphones (iPhone(®) 4 [Apple, Cupertino, CA], Samsung [Suwon, Korea] Galaxy S2, and BlackBerry(®) 9800 [BlackBerry Ltd., Waterloo, ON, Canada]) and a digital camera (Canon [Tokyo, Japan] Mark II). In a Web survey a convenience sample of 60 laypeople "blind" to the types of camera assessed the quality of the photographs, individually and best overall. We then measured how each camera scored by object category and as a whole and whether a camera ranked best using a Mann-Whitney U test for 2×2 comparisons.

RESULTS

There were wide variations between and within categories in the quality assessments for all four cameras. The iPhone had the highest proportion of images individually evaluated as good, and it also ranked best for more objects compared with other cameras, including the digital one. The ratings of the Samsung or the BlackBerry smartphone did not significantly differ from those of the digital camera.

CONCLUSIONS

Whereas one smartphone camera ranked best more often, all three smartphones obtained results at least as good as those of the digital camera. Smartphone cameras can be a substitute for digital cameras for the purposes of medical teleconsulation.

Feasibility and accuracy of using mobile phone images of electrocardiograms to initiate the cardiac catheterization process

We assessed the feasibility of interpreting the presence of ST-segment elevation myocardial infarction (STEMI) using ECGs captured and transmitted by mobile phones. Transmitted ECGs were interpreted by four independent and blinded physicians, who classified them as STEMI, non-STEMI or indeterminate. After 2–4 weeks the same physicians were given the original paper ECGs for interpretation. In total, 87 ECGs were randomly selected for review. The overall agreement between the digital image readings and the printed copy readings was 94%. Of the 87 patients, 65 (75%) had cardiac catheterization following a STEMI ECG and 22 (25%) did not receive cardiac catheterization. The accuracy of digital ECGs and printed ECGs when compared to the findings from cardiac catheterization was similar. Agreement in ECG interpretations between printed images and mobile phone images was excellent, and both had similar accuracy in activating the cardiac catheterization laboratory. Mobile phone transmission is an inexpensive method of evaluating ECG images sent from pre-hospital settings to the emergency department.

The evaluation and management of thermal injuries: 2014 update

Burns are among the most common injuries presenting to the emergency department. While burns, especially large ones, may be associated with significant morbidity and mortality, most are minor and can be managed by emergency practitioners and discharged home with close follow-up. In contrast, patients with large burns require aggressive management of their airway, breathing and circulation in order to reduce mortality and morbidity. While early endotracheal intubation of patients with actual or impending airway compromise and aggressive fluid resuscitation have been emphasized, it appears that the pendulum may have swung a bit too far towards the extreme. The current review will briefly cover the epidemiology, pathogenesis and diagnosis of burn injuries with greater emphasis on airway and fluid management. We will also discuss the local management of the burn wound, which is all that is required for most burn patients in the emergency department.

The use of telemedicine in burn care: development of a mobile system for TBSA documentation and remote assessment

The requirements for accurate documentation within the process of burn assessment have increased dramatically over the years. TBSA (total body surface area) and burn depth are commonly determined by visual inspection, especially in the emergency or acute care setting. However, inexperience often results in incorrect estimation of these factors. In 2001, BurnCase 3D was initiated in order to develop a tool for objective burn assessment and documentation on mobile devices (Apple iPhoneTM). The centerpiece is a 3D model representing the actual patient. At two international burn meetings, a survey containing three pictures of patients was conducted and this data was collected. A patient-specific 3D model adapted to the height and weight of the real patient was created and the digital picture was superimposed in the computer system. The burns were transferred to the model and the TBSA in % was calculated by the software BurnCase 3D. The preferred methods of the 80 respondents for burn extent estimation were: the Rule of Nines (38%), the Rule of Palm (37%) and the Lund-Browder chart (18%). Analysis showed very high deviations of TBSA within the participants, even among the group of experts. In comparison to a computer-aided method we found massive overestimation of up to 230%. The use of BurnCase 3D could have a true impact on the quality of treatment in burns. In the acute care setting for burn injuries, telemedicine has great potential to help guide decisions regarding triage and transfer based on TBSA, burn depth, patient age and injury mechanism.

Telemedicine and burns: an overview

Access to specialized burn care is becoming more difficult and is being restricted by the decreasing number of specialized burn centers. It is also limited by distance and resources for many patients, particularly those living in poverty or in rural medically underserved communities. Telemedicine is a rapidly evolving technology related to the practice of medicine at a distance through rapid access to remote medical expertise by telecommunication and information technologies. Feasibility of telemedicine in burn care has been demonstrated by various centers. Its use facilitates the delivery of care to patients with burn injuries of all sizes. It allows delivery of acute care and can be appropriately used for a substantial portion of the long-term management of patients after a burn by guiding less-experienced surgeons to treat and follow-up patients more appropriately. Most importantly, it allows better effective triage which reduces unnecessary time and resource demanding referrals that might overwhelm system capacities. However, there are still numerous barriers to the implementation of telemedicine, including technical difficulties, legal uncertainties, limited financial support, reimbursement issues, and an inadequate evidence base of its value and efficiency.

Fast resuscitation and care of the burn patients by telemedicine: A review

BACKGROUND

In Iran, burns are the second most common cause of death, after traffic accidents in individuals under the age of 15 years. Many burned patients die or suffer injury due to lack of immediate care, so we need to use an alternative resuscitations to cure them immediately. Telemedicine describes the use of medical information exchanged from one site to another via electronic communications to improve patients' health status and care. The aim of this study was to express the advantages of Telemedicine to resuscitate and care burn patients.

MATERIALS AND METHODS

This study was a narrative review. The literature was searched on fast resuscitation and care of the patients' burn by telemedicine with the help of libraries, databases, and also searches engines available at Google, Google scholar, books and conference proceedings. In our searches, we employed the following keywords and their combinations: Telemedicine, Telecare, Burn, Burn patient, Air transport, Triage and Health Information Management in the searching areas of titles, keywords, abstracts and full texts.

RESULTS

In this study, more than 78 articles and reports were collected and 30 of them were selected based on their relevancy.

CONCLUSION

Acute evaluation of burn patients can be performed by the telemedicine and it plays an important role in improving access to the required expertise, and raises physician confidence in treating burn patients. This can reduce under-triage or over-triage for air transport and finally lead to saving time and cost.

Photographic assessment of burn wounds: a simple strategy in a resource-poor setting

OBJECTIVE

To validate the use of photographic burn wound assessment in evaluation of burn size and wound characteristics.

METHODS

Feasibility study of agreement between methods of measurement of burn size and characteristics, in patients admitted to the burn unit at Kamuzu Central Hospital (KCH), Malawi, over two months in 2011. Burn wounds were photographed and assessed clinically, concurrently, by an experienced clinician. Photographs reviewed by two blinded burn clinicians after 4-6 weeks. Correlation between clinical assessment and photographic evaluation was calculated using kappa score and Pearson's correlation coefficient.

RESULTS

Thirty-nine patients were included in evaluation of TBSA, and fifty wounds assessed for their characteristics. Pearson's correlation coefficient for agreement of TBSA between clinical exam and photograph review by expert#1, and #2, was 0.96, 0.93 (p<0.001), respectively. Pearson's correlation coefficients comparing expert#1 and #2 to the gold standard were: proportion of full-thickness burn (0.88 and 0.81, p<0.001), and epithelialized superficial burn (0.89 and 0.55, p<0.001). Kappa scores were significant for wound evolution (expert#1 0.57, expert#2 0.64, p<0.001), and prognosis (expert#1 0.80, expert#2 0.80, p<0.001).

CONCLUSIONS

Burn assessment with digital photography is a valid and affordable alternative to direct clinical exam, alleviating access issues to burn care in developing countries.

Increasing clinical presence of mobile communication technology: avoiding the pitfalls

Mobile communication technologies are employed in many diverse areas of healthcare delivery to provide improved quality and efficiency of communication and facilitate increased rapidity of data or information transfer. Mobile phones enable healthcare professionals to possess a portable platform from which to provide many healthcare-related applications and are a popular means to directly communicate with colleagues and patients. As involvement of mobile communication technology in healthcare delivery continues to rapidly expand, there are also important considerations of relevance to patient safety and security as a result. Here, we review the previous evidence of reported clinical risks associated with mobile communication technology, such as electromagnetic interference, confidentiality and data security, distraction/noise, infection control, and cross contamination. In conclusion, although mobile phones provide much putative potential improvement to healthcare delivery, further evaluation and research are required to both inform and protect health professionals and users of such technology in the healthcare environment and provide the evidence base to support the provision of clear and comprehensive guidelines.

Telemedicine using smartphones for oral and maxillofacial surgery consultation, communication, and treatment planning

Telemedicine is the specialty of medicine that uses the evolving telecommunications industry combined with medical information technology to provide remote medical services. The use of smartphone telemedicine is an efficient and effective way for remote specialist consultation and should be considered by the oral and maxillofacial surgeon. Smartphones provide fast and clear access to electronically mailed digital images and allows the oral/maxillofacial surgeon free mobility, not restricted by the constraints of a desktop personal computer. This in turn allows for improved efficiency of the specialty consultation and improved triaging, ultimately providing improved care to the maxillofacial patient.