WikiJournal of Medicine/Comparison between the Lund-Browder chart and the BurnCase 3D® for consistency in estimating total body surface area burned

Introduction
Total body surface area burned (%) is the primary factor used in predicting burn patient mortality and it is the primary parameter for calculating total volume of fluid resuscitation. A variety of fluid resuscitation techniques are practiced for burn patients and they all rely on the patient’s body weight and %. This approach has the disadvantage that the calculation result depends on the clinical practitioner’s subjective measurement. Harish reported that estimation for % significantly varies among referring hospitals and burn units when identical patients were taken in. Giretzlehner et al. observed that in extreme cases estimation for % for the same patient could deviate up to 16.5% in relation to the mean value among burn specialists. which in turn either increase or decrease the volume of resuscitation fluid in the same proportion, or up to 5,280mL. Excessive or insufficient infusion amount has negative effects on treatment. Therefore, efforts have been made to address such subjective deviations. Among many tools we noted that the BurnCase 3D® is easy to adopt for most environments because it costs less than other alternatives and requires only commodity hardware to use, just a regular PC and any smartphone with a camera.

In this paper, we compare the difference of the estimation for % produced with the BurnCase 3D and the conventional, as a preliminary study, this paper investigates pros and cons of adoption.

Material and methods
For this study, 3 burn specialists with 7, 9, and 9 years, respectively, of experience in burn treatment made a review on a total of 262 pictures for 26 burn patients, who had been admitted to the Hanil General Hospital of South Korea between 2013 and 2017. In the data provided to the reviewers, we included age, sex, body weight, height, type of burn, and initial burn pictures. Those who suffered or  without any external wound were ruled out. Additionally, cases with photos of poor quality were discarded. After consulting a statistician, the number of observers was determined to 3 in order to reduce inter-observer variation. Each of the 3 participating burn specialists produced an estimated % based on the as well as the BurnCase 3D in sequence. Time spent on each estimation was recorded.

Statistical analysis was performed using the ® version 9.4 for Windows. To compare the results based on and the BurnCase 3D, we performed a. In consideration of, we used , in which we opted for the default setting. To verify differences among the three groups, we used, in which we chose average and nested-effects for unit and effect, respectively.

Results
We collected 262 pictures for 26 subjects (Table 1) consisting of 18 males and 7 females. The number of pictures for patients varied from 1 to 30. The patients were 54.2±15.8 years in age, and their was 24.6±3.4kg/m2. World Health Organization(WHO) defines 25kg/m2 and 30kg/m2 in BMI as overweight and obesity each in general. However, Korean Society for the Study of Obesity(KOSSO) and Asia-Pacific section of WHO have agreed to use lower indices of 23kg/m2 and 25kg/m2 for overweight and obesity because the prevalence of diabetes and cardiovascular diseases doubles above the 25kg/m2. With the regular WHO standard, 13 patients, or 50% of the 26, were overweight and none were in the category of obesity. With the WHO standard for Asians, then, 6 patients (23.1%) were overweight and 13 patients (50%) obese. Among them, 8 cases were caused by, 7 by flame, 2 by , 1 by contact, and 8 by. Out of the 26 subjects, the wounds appeared on different body parts as following: 8 cases in the head; 8 cases in the neck; 16 cases in the trunk (Ant. & Post.); 2 cases in the right buttock; 3 cases in left buttock; 4 cases in the genitalia; 10 cases in the right arm (except hand); 11 cases in the left arm (except hand); 2 cases in the right hand; 3 cases in the left hand; 8 cases in the right leg; 7 cases in the left leg; 4 cases in the right foot; 3 cases in the left foot. Only 3 cases had wounds near the anus or the perineum (Table 2). The average estimation for burn size against size of burned based on the  by each observer was: 10.5±11.2% (Observer 1), 11.5±12% (Observer 2), and 9.9±10.9%(Observer 3) (Table 3). The average of all of the observers with the was 10.6±11.3%. On the other hand, the average %TBSA based on BurnCase 3D was: 8.2±8.3%(Observer 1), 9.1±10.9%(Observer 2), and 8.9±12%(Observer 3). The average of all of the observers with the BurnCase 3D was 8.7±10.4%. The % difference between the two methods was calculated with a. The BurnCase 3D produced significantly smaller estimates, t (77) = 4.74, p<.0005, 95% CI: 1.11 to 3.58. Agreement ranking the size of the burns was high across methods, r = .95, p<.0005. In subgroup analysis for each rater separately, Observers 1 and 2 showed statistical significance (p < 0.05) whereas Observer 3 did not (p= 0.11) (Table 4).

The intraclass correlation for raters on the Lund-Browder chart was .97 using an absolute agreement, random effects model, ICC(A,1) in McGraw & Wong’s parlance. For BurnCase 3D, the ICC(A,1) was .92. Both are considered “excellent” reliability according to multiple rubrics. (Table 3).

A Bland-Altman plot examined the reproducibility of burn size estimates across methods, looking at the size of the discrepancy between the Lund-Browder minus BurnCase 3D estimates as a function of the average of the two estimates. The plot showed that the Lund-Browder tended to produce larger estimates of burn size, and that the difference increased with the size of the burns. There was a potentially influential outlier based on regression analyses, and dropping this outlier made the tendency of the Lund-Browder method to yield larger burn sizes even more pronounced.

a

aTBSA results using the

bTBSA results using the BurnCase 3D

c among observers in the

d among observers in the BurnCase 3D

The means of elapsed time with the were 172±174 seconds (Observer 1), 97±93 sec.(Observer 2), and 188±153 sec. (Observer 3) (Table 5), with the net mean of 152±148 sec. The means of elapsed time with the BurnCase 3D were 461±334 sec. (Observer 1), 500±563 sec. (Observer 2), and and 757±989 sec. (Observer 3), with the net average of 573±688 sec. The elapsed time difference between the two methods was also tested, and all of the Observers showed statistical difference (p < 0.05) (Table 6). This signifies that no difference exists between the observers (p = 0.20). Inter-individual variation had statistical significance for each method (p < 0.05) (Table 6).

aElapsed time using the

bElapsed time using the BurnCase 3D

c among observers in the

d among observers in the BurnCase 3D

Discussion
Accurate estimation for % is essential in burn treatment. This value is used for patient mortality estimation as well as calculating the required amount of resuscitating fluid. Three methods have been established and widely used for % estimation,  yet all of them have relied on practitioner’s subjective estimation. It has even been suggested that estimated % could vary depending on the physician’s burn-related experience grows. Collis et al. have reported that smaller burns tend to be overestimated while larger burns underestimated. A recent study suggested that estimation discrepancy worsens as time progresses. Such a gap is found among burn professionals and the discrepancy of burn size estimation could be as large as 16.5%, which could vary fluid used during resuscitation by as much as 5,000mL. Inadequate infusion in burn treatment may be a cause for both over-resuscitation and under-resuscitation. Over-estimation leads to excessive infusion, which may promote pulmonary complications,, and increase in likelihood of. On the other hand, under-estimation may cause and/or circulatory collapse. Such negative results, however, may be caused by diverse factors including pre-morbidities, burn type, preceded. Even so, inaccuracy in % estimation due to subjective observation only hinders treatment and research for burn.

We chose the BurnCase 3D to test if burn area estimation can be made less prone to subjective discrepancy. The basis for our choice is ease of adoption for most clinical environments: it does not require purchasing special hardware for data capturing or processing. It only requires a commodity smartphone with a camera and a PC to run the software. For comparison, we used the, which produces improved accuracy over the rule of palm and the rule of nines, but it has been reported that the result may be inaccurate for obese patients. Despite this shortcoming, the offers more practical benefits in photographic assessment.

In our study, 3clinicians with 7 to 9 years of burn treatment experience participated for burn area estimation with the and the BurnCase 3D. We identified in the BurnCase 3D-based estimations. In % assessment, we found meaningful statistical differences with the two methods between two observers while difference was insignificant for one observer. This implies variance in burn expertise among the observers. All 3 of the observers had substantial experience of 7 to 9 years as burn surgeons. Before starting with burn estimation, all 3 were given detailed instruction on how to use the software and went through a tutorial with 5 burn images, which were excluded from burn estimation for this study. Observer 3 is an author of this study and had some experience of using the software, which may explain the insignificant statistical difference. There is a possibility that in the case of Observer 3, such previous experiences could have improve the burn size estimation. In other words, the experience of using BurnCase 3D and checking the output may have enabled Observer 3 to 'calibrate' the result for when not using BurnCase 3D. This suggests that results obtained using BurnCase 3D are more positive and closer to being objective when compared with classical methods as part of the training and calibration process. This implies that the discrepancy of burn-size estimation could be reduced among burn specialist, medical students, and research associates if BurnCase 3D is widely used. However, we believe research on this calibration effect and the learning curve for BurnCase 3D merits additional research.

Repeated measures ANOVA and the Bland-Altman plot both indicate a small but significant tendency for the Lund-Browder method to produce larger estimates of burn size than the BurnCase 3D. This was true for 2 of 3 clinicians in subgroup analysis, and significant overall with an average difference of ~2% for burn size. The Bland-Altman plot indicates that the discrepancies tend to increase as the burn size increases. These results differ from findings in Giretzlehner et al. BurnCase3D produces lower levels of % in comparison with the Lund-Browder Chart and one possible explanation is that BurnCase3D estimates burn area more accurately, free from clinicians' subjective bias. In our experiment, however, in large burn areas, % estimation unexpectedly tended to be larger and the differences with the Lund-Browder Chart results were larger. To identify the cause of the seemingly anomalous differences, we investigated our data if pictures with large burn areas were taken in such a way that burn area estimation would be difficult but only in vain. We also looked in the literature to see if such differences are a characteristic of burn estimation that is based solely on the Lund-Browder Chart but did not find any work on the topic. Therefore, research investigating the % estimation differences with different methods, e.g., Rule of 9’s, Palm method, the Lund-Browder Chart, looks necessary in the future.

All three observers work in the same hospital. Burn estimation based on BurnCase 3D showed no difference between the observers, which agrees with the study by Parvizi et al., which reported of 0.98 with BurnCase 3D, similar to the ICC of .92 observed in the present study. These results imply that % estimation is consistent when the BurnCase 3D is used by different raters. With the few studies around the software, it merits further research to see if burn estimation variance can be reliably reduced with the BurnCase 3D.

BurnCase 3D has two methods of estimating % based on patient's photos: one that involves superimposing the photo on the 3D model; and the other that does not. In the non-superimposition method, the wound and the 3D model are merely displayed separately. Superimposing photos on the 3D model creates a more accurate wound representation at the cost of more estimation time by users. On the other hand, without superimposition, % estimation can be performed faster and the time difference is even more marked when the burn area is large. Observers spent around 2.5 minutes for burn estimation with the and more than 9 minutes with the BurnCase 3D, and more than 10 minutes for cases when % was considered to be greater than 10%. The greater the number of burn images, the more time our observers took for estimation. For our experiment, all of the photos were superimposed, and this may have contributed to the increased estimation time for each observer. Had we provided only the non-superimposition method, their estimation time may have been reduced, however, this factor was not anticipated in the experiment designing phase. In future work, we will adopt both methods for % estimation.

One known shortcoming of BurnCase 3D is that estimation result can be inaccurate when the wound is located where different body parts overlap, e.g., perineum or medial side in the buttock. Only 3 out of the 26 patients had wounds near the buttock or the perineum in our sample, limiting the potential for evaluating whether the  BurnCase 3D has a weakness in estimating burn areas in these regions.

Despite sufficiently wide spread of EMR (electronic medical record) systems in South Korea, little work has been published on computer-aided burn size estimation. In writing this paper as a preliminary study, we hoped to trigger future research activities.

Conclusion
This preliminary study found that both the and BurnCase 3D showed excellent inter-rater reliability in % estimation. The BurnCase 3D scores were very highly correlated with the Lund-Browder scores, but showed a small yet significant tendency to make smaller estimates of burn size (by almost 2%). The BurnCase 3D also took significantly longer to complete and score. These considerations need to be balanced against the lower costs associated with hardware and use of the BurnCase 3D.

Study limitations include that were very few subjects with 20% or above and few with burns on perineum; the small number of relevant observations did not let us evaluate some factors that might affect accuracy of BurnCase 3D. The meaningful discrepancy in user proficiency for using BurnCase 3D among observers and weak diversity of burn areas were additional factors that could be improved in future work.

Future studies should include a larger number of observers with varied proficiency, more in-depth evaluation methods for BurnCase 3D, diverse burn areas, as well as perhaps oversampling specific body parts that might be more challenging for some imaging techniques. Because accuracy of %TBSA estimation is related to prognosis, correlation of %TBSA estimation versus mortality would meaningfully contribute to future work.

Acknowledgements
We appreciate Dr. Michael Giretzlehner and the RISC Software, GmBH for offering the BurnCase 3D without any condition.

Disclosure
We were granted license for BurnCase 3D by Dr. Michael Giretzlehner of RISC Software GmbH, Austria, for academic research, and we did not request or receive any other form of financial or research assistance from him.

Conflict of interest
All authors declare that there is no conflict of interest.

Authors' contribution
KT Yoo has written most of the manuscript. GW Woo and TY Jang has contributed assessing data and data collection. JS Song performed the statistical analysis and its interpretation. All authors participated in the design of the study and approved the final version of the manuscript.

Ethics statement
This study was approved by the institutional review board in the Hanil General Hospital (HIRB-2017-009).