The reliability of digital images when used to assess burn wounds

Photographic Evaluation of Burn Depth via Telemedicine: Insights from Iranian Surgeons

Background

The accurate assessment of burn depth is crucial for determining appropriate treatment. Telemedicine has emerged as a promising tool for supporting burn diagnosis and decision-making, as it allows for remote consultation with burn specialists and access to high-quality imaging. The aim of this study was to evaluate the diagnostic capabilities of telemedicine in diagnosing burn depth.

Methods

A total of 15 Iranian surgeons participated in this study; they were presented with 13 images of partial thickness burn ulcers located on the extremities and trunk of patients. The participating surgeons were required to provide their diagnoses of burn type and depth, as well as the necessity of surgical intervention, and their responses were recorded.

Results

Data from 11 participants and 143 responses were analyzed. The average diagnostic accuracy for superficial burns was 79.3%, while for deep burns, it was 13.72%. The mean total diagnostic accuracy was 75.2%.

Conclusion

The results of this study suggest that photographs can be a reliable diagnostic tool for evaluating superficial burns. However, photographs are neither valid nor reliable for assessing burn depth. These findings have important implications for the use of telemedicine in burn diagnosis and indicate that additional diagnostic tools may be necessary for accurate assessment of deep burns.

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.

Prevalence and severity of abscesses and cellulitis, and their associations with other health outcomes, in a community-based study of people who inject drugs in London, UK

BACKGROUND

Skin and soft tissue infections (SSTI) are a common but preventable cause of morbidity and mortality among people who inject drugs (PWID). They can be severe, and hospitalisations of PWID with SSTI are rising. The most common SSTI presentations are abscesses and cellulitis.

METHODS

We used data from Care & Prevent, a cross-sectional community survey of PWID in London. We reported the lifetime prevalence of SSTI, severity of infections, key risk factors, and associated sequelae. Pictorial questions were used to assess SSTI severity.

RESULTS

We recruited 455 PWID. SSTI lifetime prevalence was high: 64% reported an abscess and/or cellulitis. Over one-third (37%) reported a severe infection, 137 (47%) reported hospitalisation. SSTIrisk factors were: aged 35+ years, injecting once or more times a day, subcutaneous or intra-muscular injections, and making four or more attempts to achieve an injection. Those who reported having other health conditions were at higher odds of having an abscess or cellulitis, with risk tending to increase with number of reported conditions. Half (46%) employed self-care for their worst SSTI, and 43% waited for ten or more days before seeking medical care or not seeking medical care at all.

CONCLUSIONS

Abscess and cellulitis are very common among PWID in London. We corroborate findings indicating SSTIs are associated with risks, e.g. venous access problems, as well as other co-morbid conditions: septicaemia, endocarditis, DVT, and kidney disease. These co-morbidities may impact SSTIs severity and outcomes. Delayed healthcare seeking potentially exacerbates infection severity, which in turn increases poorer health outcomes and complications.

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.

Histological case-control study of peeling-induced skin changes by different peeling agents in surgically subcutaneous undermined skin flaps in facelift patients

A histological evaluation of peeling-induced skin changes in subcutaneous undermined preauricular facial skin flaps of nine patients was performed. There were three treatment groups: Trichloroacetic acid (TCA) 25%, TCA 40% and phenol/croton oil; one group served as control. Two independent evaluators determined the epidermal and dermal thickness and the depth of necrosis (micrometre). The percentual tissue damage due to the peeling was calculated, and a one-sample t-test for statistical significance was performed. On the basis of the histomorphological changes, peeling depth was classified as superficial, superficial-partial, deep-partial and full thickness chemical burn. The histological results revealed a progression of wound depth for different peeling agents without full thickness necrosis. TCA peels of up to 40% can be safely applied on subcutaneous undermined facial skin flaps without impairing the vascular patency, producing a predictable chemical burn, whereas deep peels such as phenol/croton oil peels should not be applied on subcutaneous undermined skin so as to not produce skin slough or necrosis by impairing vascular patency.

Measurements of the clinical competence of doctors and nurses to process telemedicine referrals for burns patients

Simulated telemedicine referrals were used to test the ability of groups of clinicians to manage telemedicine referrals of patients with burn injuries. Sixty-one participants recorded burn depth from digital images using a four-point scale. The definitive (‘gold standard’) diagnoses were based on a review by an experienced consultant burns surgeon. Sixty clinical cases that reflected the routine referrals to a specialist burns service were used for the study. The mean kappa scores for the participants ranged from 0.33 to 0.58, indicating poor to good agreement. The scores for the groups all had a similar pattern, with more experienced staff scoring higher than junior staff. The doctors and nurses specializing in burns had higher scores than the general surgical nurses.

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.

Utilization of laser Doppler flowmetry and tissue spectrophotometry for burn depth assessment using a miniature swine model

Currently, the diagnosis of burn depth is primarily based on a visual assessment and can be dependent on the surgeons' experience. The goal of this study was to determine the ability of laser Doppler flowmeter combined with a tissue spectrophotometer to discriminate burn depth in a miniature swine burn model. Burn injuries of varying depth, including superficial-partial, deep-partial, and full thickness, were created in seven Göttingen minipigs using an aluminium bar (100 °C), which was applied to the abdominal skin for periods of 1, 3, 6, 12, 30, and 60 seconds with gravity alone. The depth of injury was evaluated histologically using hematoxylin and eosin staining. All burns were assessed 3 hours after injury using a device that combines a laser light and a white light to determine blood flow, hemoglobin oxygenation, and relative amount of hemoglobin. The blood flow (41 vs. 124 arbitrary units [AU]) and relative amount of hemoglobin (32 vs. 52 AU) were significantly lower in full thickness compared with superficial-partial thickness burns. However, no significant differences in hemoglobin oxygenation were observed between these depths of burns (61 vs. 60%). These results show the ability of laser Doppler flowmeter and tissue spectrophotometer in combination to discriminate between various depths of injury in the minipig model, suggesting that this device may offer a valuable tool for burn depth assessment influencing burn management.

Assessment of signs of foot infection in diabetes patients using photographic foot imaging and infrared thermography

BACKGROUND

Patients with diabetic foot disease require frequent screening to prevent complications and may be helped through telemedical home monitoring. Within this context, the goal was to determine the validity and reliability of assessing diabetic foot infection using photographic foot imaging and infrared thermography.

SUBJECTS AND METHODS

For 38 patients with diabetes who presented with a foot infection or were admitted to the hospital with a foot-related complication, photographs of the plantar foot surface using a photographic imaging device and temperature data from six plantar regions using an infrared thermometer were obtained. A temperature difference between feet of >2.2 °C defined a "hotspot." Two independent observers assessed each foot for presence of foot infection, both live (using the Perfusion-Extent-Depth-Infection-Sensation classification) and from photographs 2 and 4 weeks later (for presence of erythema and ulcers). Agreement in diagnosis between live assessment and (the combination of ) photographic assessment and temperature recordings was calculated.

RESULTS

Diagnosis of infection from photographs was specific (>85%) but not very sensitive (<60%). Diagnosis based on hotspots present was sensitive (>90%) but not very specific (<25%). Diagnosis based on the combination of photographic and temperature assessments was both sensitive (>60%) and specific (>79%). Intra-observer agreement between photographic assessments was good (Cohen's κ=0.77 and 0.52 for both observers).

CONCLUSIONS

Diagnosis of foot infection in patients with diabetes seems valid and reliable using photographic imaging in combination with infrared thermography. This supports the intended use of these modalities for the home monitoring of high-risk patients with diabetes to facilitate early diagnosis of signs of foot infection.

Burn depth analysis using multidimensional scaling applied to psychophysical experiment data

In this paper a psychophysical experiment and a multidimensional scaling (MDS) analysis are undergone to determine the physical characteristics that physicians employ to diagnose a burn depth. Subsequently, these characteristics are translated into mathematical features, correlated with these physical characteristics analysis. Finally, a study to verify the ability of these mathematical features to classify burns is performed. In this study, a space with axes correlated with the MDS axes has been developed. 74 images have been represented in this space and a k-nearest neighbor classifier has been used to classify these 74 images. A success rate of 66.2% was obtained when classifying burns into three burn depths and a success rate of 83.8% was obtained when burns were classified as those which needed grafts and those which did not. Additional studies have been performed comparing our system with a principal component analysis and a support vector machine classifier. Results validate the ability of the mathematical features extracted from the psychophysical experiment to classify burns into their depths. In addition, the method has been compared with another state-of-the-art method and the same database.

Combined reflectance confocal microscopy/optical coherence tomography imaging for skin burn assessment

A combined high-resolution reflectance confocal microscopy (RCM)/optical coherence tomography (OCT) instrument for assessing skin burn gravity has been built and tested. This instruments allows for visualizing skin intracellular details with submicron resolution in the RCM mode and morphological and birefringence modifications to depths on the order of 1.2 mm in the OCT mode. Preliminary testing of the dual modality imaging approach has been performed on the skin of volunteers with some burn scars and on normal and thermally-injured Epiderm FTTM skin constructs. The initial results show that these two optical technologies have complementary capabilities that can offer the clinician a set of clinically comprehensive parameters: OCT helps to visualize deeper burn injuries and possibly quantify collagen destruction by measuring skin birefringence, while RCM provides submicron details of the integrity of the epidermal layer and identifies the presence of the superficial blood flow in the upper dermis. Therefore, the combination of these two technologies within the same instrument may provide a more comprehensive set of parameters that may help clinicians to more objectively and nonivasively assess burn injury gravity by determining tissue structural integrity and viability.

Reliability and validity of a mobile phone for radiographic assessment of ankle injuries: a randomized inter- and intraobserver agreement study

BACKGROUND

Current mobile phone technology may allow orthopaedic surgeons to make clinical decisions using radiographs viewed on a small mobile device screen. The purpose of this study was to examine the reliability and validity of interpreting ankle fracture images viewed on a mobile device and a computer monitor, with a hypothesis that the agreement in clinical decision making between the mobile device and computer monitor would be high.

METHODS

A randomized interobserver and intraobserver reliability study was conducted in which 16 mortise and lateral ankle images representing a severity spectrum of malleolar ankle, plafond, and extra-articular tibial fractures were shown to volunteer orthopaedic surgeons on both an Apple fourth-generation iPod Touch and a 23-inch liquid crystal display (LCD) computer monitor. Participants answered a multiple-choice questionnaire for each image regarding diagnosis, severity, need for higher level imaging, need for acute inpatient versus outpatient management, and plan of treatment. Inter- and intraobserver reliability was assessed by kappa (κ), multirater kappa statistics, and intraclass correlation coefficient (ICC).

RESULTS

Ninety-three orthopaedic surgeon volunteers completed the study. Excellent intraobserver agreement (κ ≥ 0.8) was found for all variables measured, including diagnosis (median κ = 0.84), need for computed tomography scan (κ = 0.86), need for reduction (κ = 0.82), treatment setting (κ = 0.82), and treatment type (κ = 0.87). Interobserver agreement was consistent between the mobile device and computer screen. Interobserver agreement for the severity assessment had a slightly higher ICC for the mobile device compared with the computer monitor (ICC = 0.83 vs 0.79). Sixty-seven percent (62/93) said at the completion of the study they were "completely" or "very" comfortable using a mobile device as a primary viewing device for new emergency room, inpatient, or transfer request consults.

CONCLUSIONS

Strong reliability for radiographic assessment of ankle injuries existed between a 23-inch computer monitor and a handheld mobile device. Further study is warranted to validate the technology to apply to other anatomic locations and imaging modalities.

LEVEL OF EVIDENCE

Level II, diagnostic study.

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.

Quantitative assessments of burn degree by high-frequency ultrasonic backscattering and statistical model

An accurate and quantitative modality to assess the burn degree is crucial for determining further treatments to be properly applied to burn injury patients. Ultrasounds with frequencies higher than 20 MHz have been applied to dermatological diagnosis due to its high resolution and noninvasive capability. Yet, it is still lacking a substantial means to sensitively correlate the burn degree and ultrasonic measurements quantitatively. Thus, a 50 MHz ultrasound system was developed and implemented to measure ultrasonic signals backscattered from the burned skin tissues. Various burn degrees were achieved by placing a 100 °C brass plate onto the dorsal skins of anesthetized rats for various durations ranged from 5 to 20 s. The burn degrees were correlated with ultrasonic parameters, including integrated backscatter (IB) and Nakagami parameter (m) calculated from ultrasonic signals acquired from the burned tissues of a 5 × 1.4 mm (width × depth) area. Results demonstrated that both IB and m decreased exponentially with the increase of burn degree. Specifically, an IB of -79.0 ± 2.4 (mean ± standard deviation) dB for normal skin tissues tended to decrease to -94.0 ± 1.3 dB for those burned for 20 s, while the corresponding Nakagami parameters tended to decrease from 0.76 ± 0.08 to 0.45 ± 0.04. The variation of both IB and m was partially associated with the change of properties of collagen fibers from the burned tissues verified by samples of tissue histological sections. Particularly, the m parameter may be more sensitive to differentiate burned skin due to the fact that it has a greater rate of change with respect to different burn durations. These ultrasonic parameters in conjunction with high-frequency B-mode and Nakagami images could have the potential to assess the burn degree quantitatively.

Assessment of burn depth and burn wound healing potential

The depth of a burn wound and/or its healing potential are the most important determinants of the therapeutic management and of the residual morbidity or scarring. Traditionally, burn surgeons divide burns into superficial which heal by rapid re-epithelialization with minimal scarring and deep burns requiring surgical therapy. Clinical assessment remains the most frequent technique to measure the depth of a burn wound although this has been shown to be accurate in only 60-75% of the cases, even when carried out by an experienced burn surgeon. In this article we review all current modalities useful to provide an objective assessment of the burn wound depth, from simple clinical evaluation to biopsy and histology and to various perfusion measurement techniques such as thermography, vital dyes, video angiography, video microscopy, and laser Doppler techniques. The different needs according to the different diagnostic situations are considered. It is concluded that for the initial emergency assessment, the use of telemetry and simple burn photographs are the best option, that for research purposes a wide range of different techniques can be used but that, most importantly, for the actual treatment decisions, laser Doppler imaging is the only technique that has been shown to accurately predict wound outcome with a large weight of evidence. Moreover this technique has been approved for burn depth assessment by regulatory bodies including the FDA.

Diagnosis, access and outcomes: Update of a systematic review of telemedicine services

Telemedicine services are being increasingly used. Although insurers and other payers are covering some services in the USA, the rationale for these coverage decisions is not always evidence-based. We reviewed the literature for telemedicine services that substitute for face-to-face medical diagnosis and treatment. We focused on three types of telemedicine services: store-and-forward, home-based and office/hospital-based services. Studies were included if they were relevant to at least one of the three study areas, addressed at least one key question and contained reported results. We excluded articles that did not study a service requiring face-to-face encounters (i.e. teleradiology was excluded). Our search initially identified 4083 citations. After review, 597 were judged to be potentially relevant at the title/abstract level. Following a full-text review, 106 studies were included. Store-and-forward services have been studied in many specialties, the most common being dermatology, wound care and ophthalmology. The evidence for their efficacy is mixed. Several limited studies showed the benefits of home-based telemedicine interventions in chronic diseases. Studies of office/hospital-based telemedicine suggest that telemedicine is most effective for verbal interactions, e.g. videoconferencing for diagnosis and treatment in specialties like neurology and psychiatry. There are still significant gaps in the evidence base between where telemedicine is used and where its use is supported by high-quality evidence. Further well-designed research is necessary to understand how best to deploy telemedicine services in health care.

State of the Art in Burn Treatment

Optimal treatment of burn victims requires deep understanding of the profound pathophysiological changes occurring locally and systemically after injury. Accurate estimation of burn size and depth, as well as early resuscitation, is essential. Good burn care includes also cleansing, debridement, and prevention of sepsis. Wound healing, is of major importance to the survival and clinical outcome of burn patients. An ideal therapy would not only promote rapid healing but would also act as an antiscarring therapy. The present article is a literature review of the most up-to-date modalities applied to burn treatment without overlooking the numerous controversies that still persist.