Comparison of clinical outcomes in diabetic and non-diabetic burns patients in a national burns referral centre in southeast Asia: A 3-year retrospective review

Foot Burns and Diabetes: A Systematic Review of Current Clinical Studies and Proposal of a New Treatment Algorithm

This study aims to systematically identify studies that evaluate lower extremity burn injury in the diabetic population, evaluate their clinical course and patient outcomes, and present a treatment algorithm tailored to diabetic burn patients. Our systematic review of the PubMed and Web of Science databases yielded 429 unique articles. After exclusion and inclusion criteria were applied, 59 articles were selected for evaluation. In diabetic patients, the thermal injury was largely a result of decreased awareness and education regarding heat therapies in the context of peripheral neuropathy. All noncase studies found that metrics such as hospital length of stay, ICU admission rates, rates of comorbidity, complication rates, scald injuries, infection rates, and cost of treatment were significantly increased in the diabetic burn population as compared to their nondiabetic counterparts. Where infection was present, microorganisms colonizing diabetic burn wounds were different than those found in the burn wounds of immunocompetent individuals. Operative intervention including split-skin graft, amputation, and debridement were more often utilized in diabetic burn patients. Foot burns in diabetic patients pose unique clinical risks to patients, and as such need to be an alternate treatment protocol to reflect their pathology. Education and training programs are crucial in the prevention of diabetic foot burns to avoid complications, protracted healing, and adverse outcomes. A unique algorithm can guide the unique treatment of this clinical entity.

Epidemiology and mortality in patients hospitalized for burns in Catalonia, Spain

Burn injuries are one of the leading causes of morbidity worldwide. Although the overall incidence of burns and burn-related mortality is declining, these factors have not been analysed in our population for 25 years. The aim of this study has been to determine whether the epidemiological profile of patients hospitalized for burns has changed over the past 25 years. We performed a retrospective cohort study of patients hospitalised between 1 January 2011 and 31 December 2018 with a primary diagnosis of burns. The incidence of burns in our setting was 3.68/105 population. Most patients admitted for burns were men (61%), aged between 35 and 45 years (16.8%), followed by children aged between 0 and 4 years (12.4%). Scalding was the most prevalent mechanism of injury, and the region most frequently affected was the hands. The mean burned total body surface (TBSA) area was 8.3%, and the proportion of severely burned patients was 9.7%. Obesity was the most prevalent comorbidity (39.5%). The median length of stay was 1.8 days. The most frequent in-hospital complications were sepsis (16.6%), acute kidney injury (7.9%), and cardiovascular complications (5.9%). Risk factors for mortality were advanced age, high abbreviated burn severity index score, smoke inhalation, existing cardiovascular disease full-thickness burn, and high percentage of burned TBSA. Overall mortality was 4.3%. Multi-organ failure was the most frequent cause of death, with an incidence of 49.5%. The population has aged over the 25 years since the previous study, and the number of comorbidities has increased. The incidence and severity of burns, and the percentage of burned TBSA have all decreased, with scalding being the most prevalent mechanism of injury. The clinical presentation and evolution of burns differs between children and adults. Risk factors for mortality were advanced age, smoke inhalation, existing cardiovascular disease, full-thickness burn, and high percentage of burned TBSA.

Impact of diabetes on clinical outcome in severely burned patients

INTRODUCTION

According to the International Diabetes Federation, approximately 425 million people worldwide suffer from diabetes mellitus, a figure that will double in the next 20 years. Data on the ratio of treated diabetics in burn intensive care units remain scarce and the effects on the mortality rate are poorly defined.

METHODS

Our retrospective, single-centre study aimed to evaluate differences in the risk factors due to diabetes mellitus, the clinical outcome and the patient population of diabetic patients after severe burn injuries over a time period of 21 years.

RESULTS

Despite increasing numbers of diabetic patients, the ratio of burn patients suffering from diabetes remained stable during the study period. The risk factors for mortality were higher age (OR 1.03, 95% confidence interval (CI), 1.02-1.04, p < 0.0001), female sex (OR 1.56, 95% CI, 1.06-2.29, p = 0.025), higher % total body surface area (TBSA) (OR 3.88, 95% CI, 2.81-5.46, p < 0.0001), full thickness burns (OR 8.58, 95% CI, 3.84 - 23.60, p < 0.0001) and the presence of inhalation injuries (OR 4.68, 95% CI, 3.15-7.02, p < 0.0001) Patients with diabetes had a smaller extent of burned areas with a median TBSA of 30% (quartiles: 22-50%, p = 0.036) compared to non-diabetic patients (35% (25-55%)) but had a similar length of stay with a median of 29 (quartiles: 13-44) days vs. 23 (10-48) days. Outcome analysis showed an overall mortality of 35.6%. Diabetes was not associated with higher mortality rate after burn injury in a univariate model (OR 1.80, 95% CI 0.92-3.51). After correction for %TBSA, the effect of diabetes on mortality was significant (OR 2.80, 95% CI, 1.33-5.90).

CONCLUSION

Our data indicate higher mortality rates (50-100%) of diabetic patients with TBSA greater than 40% in severely burned patients compared to non-diabetic patients without a significant outcome due to the low number of cases in the subgroup analyses.

Effects of Drug-Free Pectin Hydrogel Films on Thermal Burn Wounds in Streptozotocin-Induced Diabetic Rats

This study aims to examine the influence of drug-free pectin hydrogel films on partial-thickness burn wounds using streptozotocin-induced diabetic rats as the animal model. Thirty male Sprague Dawley rats were included in the wound healing study, and scalding water was used to produce wounds in the dorsum region of the rats. Two different formulations of pectin hydrogel films, PH 2.5% and PH 5%, were prepared using a solvent evaporation method. MEBO^® (moist exposed burn ointment), a commercial herbal formulation was used as a positive control. The progress of the wound healing was observed and compared between untreated normal rats, untreated diabetic rats, diabetic rats treated with MEBO^®, diabetic rats treated with PH 2.5%, and diabetic rats treated with PH 5%. The results showed that diabetic rats treated with PH 5% healed faster than the untreated diabetic rats and diabetic rats treated with PH 2.5%. Interestingly, the diabetic rats treated with PH 5% healed as well as diabetic rats treated with MEBO^®, where wounds were healed entirely on day 20. Nevertheless, both PH 2.5% and PH 5% showed a greater zone of inhibition than MEBO^® when tested against Staphylococcus aureus.

Clinical outcomes in 'diabese' burn patients: A systematic review and meta-analysis

OBJECTIVE

The objective of this study was to update the current status of clinical outcomes in diabetic (type II) and obese (BMI: 30-39.9 kg/m²) burn patients.

METHODS

We adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. We searched MEDLINE (PubMed), Google Scholar, Scopus, and Embase for studies related to a number of comorbidities and burn outcomes. Search terms for each of these databases are listed in the Appendix. From this search, we screened 6923 articles. Through our selection criteria, 12 articles focusing on either diabetes or obesity were selected for systematic review and meta-analysis. Data was analyzed using the "meta" package in R software to produce pooled odds ratios from the random effect model.

RESULTS

Diabetic patients had 2.38 times higher odds of mortality [OR: 2.38, 95% CI:1.66, 3.41], however no statistically significant difference was found in mortality in obese patients [OR: 2.49, 95% CI: 0.36, 17.19]. Obese patients had 2.18 times higher odds of inhalation injury [95%CI: 1.23, 3.88], whereas diabetic patients did not show a difference in odds of inhalation injury [OR:1.02, 95% CI: 0.57, 1.81]. Diabetic patients had higher odds of complications resulting from infection: 5.47 times higher odds of wound, skin, or soft tissue infections [95% CI:1.97, 15.18]; 2.28 times higher odds of UTI or CAUTI [95% CI:1.50, 3.46]; and 1.78 times higher odds of pneumonia or respiratory tract infections [95% CI:1.15, 2.77]. Obese patients also had similar complications related to infection: 2.15 times higher odds of wound infection [95% CI: 1.04, 4.42] and 1.96 times higher odds of pneumonia [95% CI: 1.08, 3.56]. Other notable complications in diabetic patients were higher odds of amputation [OR: 37, 95% CI: 1.76, 779.34], respiratory failure [OR: 4.39, 95% CI: 1.85, 10.42], heart failure [OR: 6.22, 95% CI: 1.93, 20.06], and renal failure [OR: 2.95, 95% CI: 1.1, 7.86].

CONCLUSIONS

Diabetic patients have higher odds of mortality, whereas no statistically significant difference of mortality was found in obese patients. Obese patients had higher odds of inhalation injury, whereas odds of inhalation injury was unchanged in diabetic patients. Diabetic patients had higher odds of failure in multiple organs, whereas such failure in obese patients was not reported. Both diabetic and obese patients had multiple complications related to infection.

In Patients with Lower Extremity Burns and Osteomyelitis, Diabetes Mellitus Increases Amputation Rate

In this retrospective analysis, we investigated the rate of radiologically confirmed osteomyelitis, extremity amputation and healthcare utilization in both the diabetic and non-diabetic lower extremity burn populations to determine the impact of diabetes mellitus on these outcomes. The burn registry was used to identify all patients admitted to our tertiary burn center from 2014 to 2018. Only patients with lower extremity burns (foot and/or ankle) were included. Statistical analysis was performed using Student's t test, chi-squared test, and Fischer's exact test. Of the 315 patients identified, 103 had a known diagnosis of diabetes mellitus and 212 did not. Seventeen patients were found to have osteomyelitis within three months of the burn injury. Fifteen of these patients had a history of diabetes. Notably, when non-diabetics were diagnosed with osteomyelitis, significant differences were observed in both length of stay and cost in comparison to their counterparts without osteomyelitis (36 vs 9 days; p=0.0003; $226,289 vs $48,818, p=0.0001). Eleven patients required an amputation and 10 (90.9%) of these patients had comorbid diabetes and documented diabetic neuropathy. Compared to non-diabetics, the diabetic cohort demonstrated both a higher average length of stay (13.7 vs 9.2 days, p-value=0.0016) and hospitalization cost ($72,883 vs $50,500, p-value=0.0058). Our findings highlight that diabetic patients with lower extremity burns are more likely to develop osteomyelitis than their non-diabetic counterparts and when osteomyelitis is present, diabetic patients have an increased amputation rate. Further study is required to develop protocols to treat this population, with the specific goal of minimizing patient morbidity and optimizing healthcare utilization.

High Glucose Variability Increases 30-Day Readmission Rates in Patients with Type 2 Diabetes Hospitalized in Department of Surgery

Glucose variability is common among hospitalized patients with type 2 diabetes mellitus (DM). I investigated to assess the variability of glucose in patients with type 2 DM accounts for in-hospital readmission rates in department of Surgery. I retrospectively analyzed 206 patients with type 2 DM, who was admitted to our hospital for surgical interventions and re-admitted within 30 days after discharge. I also enrolled 610 age, sex and diabetic duration matched patients with type 2 DM, as control. Outcomes measure included average and standard deviation (SD) of blood glucose during admission, glycated hemoglobin (HbA1c), lipid profile, renal function, length of stay (LOS). Patients who had re-admission within 30 days after discharge had higher SD of blood glucose levels than control (84.7 ± 53.5 mg/dL vs. 46.2 ± 42.8 mg/dL, p < 0.001) but not average of blood glucose levels. Comparing to control group, the study group also had higher HbA1c (8.4 ± 1.3% vs. 7.7 ± 1.1%, p = 0.015) and LOS (8.5 ± 2.5 days vs 7.0 ± 1.5 days, p = 0.020). The independent predictors of 30-day readmission rates were SD of blood glucose during admission and HbA1c (hazard ratio: 1.680, 1.493; p value < 0.001, 0.008, respectively). Decreasing glucose variability during admission for surgery is important for patients with type 2 DM to decreasing re-admission rates and LOS. HBA1c may also identify patients at higher risk of postoperative complications and possibility of re-admission.

Effects of Diabetes Mellitus on the Mortality, Length of Hospital Stay and Number of Operations in Burn Patients

Background

The effects of diabetes mellitus (DM) on mortality and morbidities in burn patients have not been sufficiently elucidated.

Objective

The present study aimed to investigate the effects of DM on the mortality, length of hospital stay, and number of operations in burn patients.

Methods

A retrospective cohort study was performed using medical records of 3,220 burn patients. Multiple logistic regression, linear regression, and Poisson regression models were used to determine whether DM increases mortality in patients with burn injury, whether DM prolongs length of hospital stay in burn survivors, and whether DM increases the number of operations in burn survivors, respectively.

Results

After adjusting for potential confounding factors, DM significantly increased odds of death in burn patients (adjusted odds ratio 3.225 [95% confidence interval 1.405~7.400], p=0.006). DM also increased the mean length of hospital stay in burn survivors (adjusted mean ratio 1.312 [95% confidence interval 1.198~1.437], p<0.001). Furthermore, DM significantly increased the mean number of operations in burn survivors (adjusted mean ratio 1.576 [95% confidence interval 1.391~1.785], p<0.001).

Conclusion

DM increases mortality, elongates hospital stay and makes more operations required in patients with burn injury.

Does diabetes mellitus comorbidity affect in-hospital mortality and length of stay? Analysis of administrative data in an Italian Academic Hospital

AIMS

Hospitalized patients with comorbid diabetes mellitus may have worse outcomes than the others. We conducted a study to assess whether comorbid diabetes affects in-hospital mortality and length of stay.

METHODS

For this population-based study, we analyzed the administrative databases of the Regional Health Information System of the Region Friuli Venezia Giulia, where the Hospital of Udine is located. Hospital discharge data were linked at the individual patient level with the regional Diabetes Mellitus Registry to identify diabetic patients. For each 3-digit ICD-9-CM discharge diagnosis code, we assessed the difference in length of stay and in-hospital mortality between diabetic and non-diabetic patients. We conducted both univariate and multivariate analyses, adjusted for age, sex, Charlson's comorbidity score, and urgency of hospitalization, through linear and logistic regression models.

RESULTS

After adjusting for potential confounders, diabetes significantly increased the risk of in-hospital death among patients hospitalized for bacterial pneumonia (OR = 1.94) and intestinal obstruction (OR = 4.23) and length of stay among those admitted for several diagnoses, including acute myocardial infarction and acute renal failure. Admission glucose blood level was associated with in-hospital death in patients with pneumonia and intestinal obstruction, and increased length of stay for several conditions.

CONCLUSIONS

Patients with diabetes mellitus who are hospitalized for other health problems may have increased risk of in-hospital death and longer hospital stay. For this reason, diabetes should be promptly recognized upon admission and properly managed.