Burn injury outcomes in patients with pre-existing diabetic mellitus: Risk of hospital-acquired infections and inpatient mortality

Evaluating the association between time to skin grafting for truncal burn patients and complications: a comparative cohort study using the National Trauma Data Bank

BACKGROUND

The split-thickness skin graft (STSG) procedure is frequently used in the reconstruction of burn-injured patients. This study assessed the impact of graft timing on associated skin complications in patients with torso burns using a comprehensive national database.

METHODS

Truncal burn (2nd-degree and 3rd-degree burns covering 20-89% TBSA) patients who underwent STSG in the National Trauma Data Bank from 2011 to 2015 were studied. The outcomes examined were graft-related complications (superficial surgical site infections, deep surgical site infections, and graft failure), overall mortality and hospital length of stay (LOS). Patients were compared based on the presence or absence of grafting complications. A linear regression model was used to assess the relationship between hospital LOS and graft timing, considering other variables.

RESULTS

Among the 853 studied patients, the cohort with graft complications exhibited a significantly prolonged time to STSG (413.0 h compared to 264.6 h, P<0.001) and a higher percentage of patients with pre-existing diabetes (18.5 vs. 8.0%, P=0.008). The multiple logistic regression analysis revealed that both the extended time to STSG (odds=1.001, P=0.003) and pre-existing diabetes (odds=2.790, P=0.010) significantly elevated the likelihood of complications associated with STSG. Notably, this delay did not elevate mortality risks. A positive relationship was found between grafting delay and LOS.

CONCLUSION

The findings underscore that a prolonged duration to skin grafting contributes to extended hospital stays and increased graft-related complications. However, the role of grafting delay in influencing the mortality of truncal burn patients appeared inconsequential, indicating that mortality may be influenced by various factors.

THE EFFECT OF MULTIDRUG-RESISTANT ORGANISM INFECTION ON MORTALITY OF BURN PATIENTS AT RSUPN DR. CIPTO MANGUNKUSUMO

Susceptibility to infection and increased antibiotic resistance place burn patients at risk of infection caused by multidrug-resistant organisms (MDRO). This condition can progress to sepsis, which can increase morbidity and mortality. A retrospective cohort study using medical record data of patients treated at RSUPN dr. Cipto Mangunkusumo in the period January 2020 to June 2022 was conducted. Of a total 160 subjects in the study period, 82.5% were aged <60 years, 16.88% had comorbidities, the most common cause of burns was fire (86.25%), the use of medical devices was 90.63%, with a median length of stay of 14 days. The most common Gram-negative MDRO pathogens were K. pneumoniae (29.91%), Enterobacter sp (22.32%) and Acinetobacter (20.54%): 45% of MDRO infected patients died. Bivariate analysis was conducted to find the effect of MDRO infection on burn patient mortality (RR 1,103; 95% CI 1,004-1,211, p=0.046). After adjusting for the role variables, namely: age, comorbidities, TBSA, use of medical devices, length of stay and multivariate analysis, it was found that the variables that had an effect on MDRO infection mortality were length of stay and age. MDRO infection has an effect on the mortality rate of burn patients. Mortality of burn patients due to MDRO infection is greater (45%) compared to non MDRO (21.43%). The most common Gram-negative MDRO pathogen is K. pneumoniae.

[Burns and Diabetes Mellitus: Epidemiology, Clinical Presentation and Prognosis]

Burns in diabetics are quite frequent and serious in relation to diabetic neuropathy, which is common in this population, delaying healing and predisposing to the risk of infection. The objective of this study was to describe the characteristics of burns in diabetics hospitalized at the CTB of Tunis over 18 months. During the study period, 891 patients were hospitalized, including 43 diabetics (5%). The average age of our patients was 57 years old with a male predominance (65%). Type 2 diabetes was present in 86% of cases and type 1 diabetes in 14% of cases. Degenerative complications were reported in 10 cases (23%), such as diabetic retinopathy (n=6), diabetic nephropathy (n=4) and diabetic neuropathy (n=6). The circumstances of burns were related to a domestic accident in 2/3 of the cases (76.7%). Thermal burns were involved in 83.7% of cases. 86% of the patients had decompensated their diabetes during their hospitalization. Sepsis marked the evolution of the patients in 55.8% of cases. In our study, poor prognostic factors were: a glycosylated haemoglobin > 13%, an extent of burns greater than 20%, and a delay in consultation greater than 6 hours. The mortality rate was 18.6%.

Psychiatric Illness and Substance Abuse: Unaddressed Factors in Burn Injury

Patients with psychiatric illness and substance use comorbidities have high rates of burn injuries and experience prolonged hospital admissions. This retrospective chart review characterizes this marginalized population's inpatient burn care and examines post-discharge outcomes compared to burn patients without psychiatric or substance use comorbidities treated at our center. Patients admitted to a single burn center from January 1, 2018 to June 1, 2022 were included. Patient demographics, history of psychiatric disorders, treatment course, and post-discharge outcomes were collected. A total of 1660 patients were included in this study, of which 91 (6%) patients were diagnosed for psychiatric comorbidity and/or substance use comorbidity on admission for burn care. In this cohort of 91 patients with psychiatric and/or substance use comorbidities, the majority of patients were undomiciled (66%) and male (67%). In this cohort, 66 (72%) patients reported recent history or had positive urine toxicology results for illicit substances on admission. In this cohort, a total of 25 (28%) patients had psychiatric comorbidity at the time of burn injury or admission and 69 (76%) patients received inpatient psychiatric care, with 31 (46%) patients requiring psychiatric holds. After discharge, the readmission rate within 1 year of patients with psychiatric and/or substance use comorbidity was over four times greater than that of patients without psychiatric and/or substance use comorbidity. The most common causes of readmission were subsequent mental health crisis (40%) and inability to perform burn care (32%). Our study presents strategies to improve burn care for this marginalized and high-risk population.

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.

Predicting and Estimating Burn Outcomes: An Institutional Analysis of 4622 cases

Advances in burn care have improved patient outcomes, and independently validated indices and predictors of burn outcomes warrant re-evaluation. The purpose of this study is to consolidate predictors of burn outcomes and determine the factors that significantly contribute to length-of-stay (LOS) and mortality. A retrospective review was conducted of all burn patients (n=5778) admitted to a quaternary provincial burn unit from 1973 to 2017. Our inclusion criteria yielded 4622 independent cases. Multivariate linear and logistic regression models were generated, and area-under-receiver-operator-curve (AUROC) analysis was performed. Burn predictors included %TBSA, Baux (classic and revised) index, Abbreviated Burn Severity Index (ABSI), and Ryan score. Primary outcomes were mortality and LOS. Multivariate logistic regression for mortality showed the Baux index to be the best predictor for mortality (OR=1.11, p<0.001). The AUROC for Baux index was 0.95. With regards to LOS, ABSI was the best predictor for LOS (p<0.001). ICU stay, ventilator use, alcoholism, age, significantly associated with increased LOS. Interestingly, hypertension had a protective effect for LOS (p<0.01) and trended towards a protective effect in mortality. Lethal score 50% (LS50) improved over the study period. The regressions show that burn mortality and LOS are best predicted with the Baux index and ABSI, respectively. Hypertension may have a protective effect on burn outcomes and may be attributed to increased perfusion to the periphery. These predictive scores are useful in determining institutional outcomes in burn surgery. Objective benchmarking of improvement in burn care outcomes can be established using LS50 trends.

Comparative Outcomes for Trauma Patients in Prison and the General Population

BACKGROUND

Prisoners are a vulnerable population, and there are few contemporary studies that consider trauma patient outcomes within the prisoner population. Therefore, we sought to provide a descriptive analysis of prisoners involved in trauma and evaluate whether a healthcare disparity exists. We hypothesized that prisoners and non-prisoners have a similar risk of mortality and in-hospital complications after trauma.

METHODS

The Trauma Quality Improvement Program (2015-2016) was queried for trauma patients based upon location inside or outside of prison at the time of injury. A multivariable logistic regression analysis was performed to compare these groups for risk of mortality-the primary outcome.

RESULTS

From 593,818 trauma patients, 1115 were located in prison. Compared to non-prisoners, prisoner trauma patients had no significant difference in mortality (5.1 vs 6.0%, P = .204). However, after adjusting for covariates, prisoners had a shorter length of stay (LOS) (mean days, 6.3 vs 7.8, P < .001), shorter intensive care unit (ICU) LOS (mean days, 5.44 vs 5.89, P = .004), and fewer complications, including lower rates of drug/alcohol withdrawal (.4% vs 1.1%, P = .030), pneumonia (.5 vs 1.6%, P = .004), and urinary tract infections (.0 vs 1.1%, P < .001). Upon performing a multivariable logistic regression model, prisoner trauma patients had a similar associated risk of mortality compared to non-prisoners (OR 1.61, CI .52-4.94, P = .409).

DISCUSSION

Our results suggest that prisoner trauma patients at least receive equivalent treatment in terms of mortality and may have better outcomes when considering some complications. Future prospective studies are needed to confirm these results and explore other factors, which impact prisoner patient outcomes.

Outcomes and complications of diabetic burn injuries: a single center experience

INTRODUCTION

Comorbid conditions may adversely affect burn outcomes. Burn injuries remain one of the most prevalent injuries presenting to emergency departments. The current study compares the outcomes of burn injuries in diabetic and non-diabetic patients.

METHODS

A retrospective review of 705 burn patients admitted to the burn unit was performed. All adult patients (18 years old and above) who were admitted to the burn unit were included. The study compared the complications and outcomes of the diabetic and non-diabetic burn patient.

RESULTS

Patient were divided into diabetic (14%) and non-diabetic groups (86%). Diabetic burn patients were more likely to be older with a mean age of 58.7 years compared to 33.6 years in non-diabetic group (P=0.000). Inhalation injury was found in 3% of diabetic group compared to 14% of non-diabetic group (P=0.009). Diabetic patients were more likely to have associated medical comorbidities especially hypertension. Overall mortality rate was 13% and overall length of stay (LOS) was 28.4 days with no significant differences between groups.

CONCLUSION

Older age, hypertension and contact burns are significantly associated with DM in burn patients. No increased risk of burn-related infections, mortality and LOS were observed in the DM group.

Environmental Contamination of Contact Precaution and Non-Contact Precaution Patient Rooms in Six Acute Care Facilities

BACKGROUND

Environmental contamination is an important source of hospital multidrug-resistant organism (MDRO) transmission. Factors such as patient MDRO contact precautions (CP) status, patient proximity to surfaces, and unit type likely influence MDRO contamination and bacterial bioburden levels on patient room surfaces. Identifying factors associated with environmental contamination in patient rooms and on shared unit surfaces could help identify important environmental MDRO transmission routes.

METHODS

Surfaces were sampled from MDRO CP and non-CP rooms, nursing stations, and mobile equipment in acute care, intensive care, and transplant units within 6 acute care hospitals using a convenience sampling approach blinded to cleaning events. Precaution rooms had patients with clinical or surveillance tests positive for methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, carbapenem-resistant Enterobacteriaceae or Acinetobacter within the previous 6 months, or Clostridioides difficile toxin within the past 30 days. Rooms not meeting this definition were considered non-CP rooms. Samples were cultured for the above MDROs and total bioburden.

RESULTS

Overall, an estimated 13% of rooms were contaminated with at least 1 MDRO. MDROs were detected more frequently in CP rooms (32% of 209 room-sample events) than non-CP rooms (12% of 234 room-sample events). Surface bioburden did not differ significantly between CP and non-CP rooms or MDRO-positive and MDRO-negative rooms.

CONCLUSIONS

CP room surfaces are contaminated more frequently than non-CP room surfaces; however, contamination of non-CP room surfaces is not uncommon and may be an important reservoir for ongoing MDRO transmission. MDRO contamination of non-CP rooms may indicate asymptomatic patient MDRO carriage, inadequate terminal cleaning, or cross-contamination of room surfaces via healthcare personnel hands.

Re-evaluation of the Effect of Age on In-hospital Burn Mortality in a Resource-Limited Setting

BACKGROUND

This global burden of burn injury is suffered disproportionately by people in low-income and middle-income countries, where 70% of all burns occur. Models based in high-income countries to prognosticate burn mortality treat age as a linearly increasing risk factor. It is unclear whether this relationship is similar in resource-limited settings.

METHODS

We analyzed patients from the Kamuzu Central Hospital Burn Registry in Lilongwe, Malawi, from 2011 to 2019. We examined the relationship between burn-associated mortality and age using adjusted survival analysis over 60 d, categorized into four groups: (1) younger children <5 y; (2) older children 5-17 y; (3) adults 18-40 y; and (4) older adults >40 y.

RESULTS

A total of 2499 patients were included. Most patients were <5 y old (n = 1444) with only 133 patients >40 y. Older adults had the highest crude mortality at 34.6% and older children with the lowest at 13%. Compared to younger children, the hazard ratio adjusted for sex, percent total body surface area, and operative intervention was 0.59 (95% confidence interval, 0.44, 0.79) for older children and 0.55 (95% confidence interval, 0.40, 0.76) for adults. Older adults were statistically similar to younger children.

CONCLUSIONS

We show in this cohort study of burn-injured patients in a resource-limited environment that the relationship between mortality and age is not linear and that the use of age-categorized mortality prediction models is more accurate in delineating mortality characteristics. Categorizing age based on local burn epidemiology will help describe burn mortality characteristics more accurately, leading to better-informed management strategies aimed at attenuating burn mortality for different populations.

Sex-Based Differences in Inpatient Burn Mortality

BACKGROUND

Among burn patients, research is conflicted, but may suggest that females are at increased risk of mortality, despite the opposite being true in non-burn trauma. Our objective was to determine whether sex-based differences in burn mortality exist, and assess whether patient demographics, comorbid conditions, and injury characteristics explain said differences.

METHODS

Adult patients admitted with burn injury-including inhalation injury only-between 2004 and 2013 were included. Inverse probability of treatment weights (IPTW) and inverse probability of censor weights (IPCW) were calculated using admit year, patient demographics, comorbid conditions, and injury characteristics to adjust for potential confounding and informative censoring. Standardized Kaplan-Meier survival curves, weighted by both IPTW and IPCW, were used to estimate the 30-day and 60-day risk of inpatient mortality across sex.

RESULTS

Females were older (median age 44 vs. 41 years old, p < 0.0001) and more likely to be Black (32% vs. 25%, p < 0.0001), have diabetes (14% vs. 10%, p < 0.0001), pulmonary disease (14% vs. 7%, p < 0.0001), heart failure (4% vs. 2%, p = 0.001), scald burns (45% vs. 26%, p < 0.0001), and inhalational injuries (10% vs. 8%, p = 0.04). Even after weighting, females were still over twice as likely to die after 60 days (RR 2.87, 95% CI 1.09, 7.51).

CONCLUSION

Female burn patients have a significantly higher risk of 60-day mortality, even after accounting for demographics, comorbid conditions, burn size, and inhalational injury. Future research efforts and treatments to attenuate mortality should account for these sex-based differences. The project was supported by the National Institutes of Health, Grant Number UL1TR001111.

Plasma glucagon-like peptide 1 was associated with hospital-acquired infections and long-term mortality in burn patients

BACKGROUND

Although glucagon-like peptide 1 levels have been closely associated with inflammation and mortality in septic patients, the clinical importance of glucagon-like peptide 1 on hospital-acquired infections and long-term mortality after burn injury remains unexplored.

METHODS

Plasma samples from 144 burn patients were collected on admission to determine total glucagon-like peptide 1, interleukin 6, and monocyte chemotactic protein-1 levels. Hospital-acquired infections were determined by positive microbial culture. One-year mortality was assessed by telephone interview. Factors associated with glucagon-like peptide 1 were determined by multivariable linear logistic regression. Predicting the clinical importance of glucagon-like peptide 1 on the development of hospital-acquired infections and mortality were determined by Cox proportional hazards models and further by receiver operating characteristic curve analysis. Kaplan-Meier analyses were performed to examine whether the mean glucagon-like peptide 1 level of the cohort could discriminate the hospital-acquired infections-free survival.

RESULTS

Median burn size was 41% (19%-70%) of total body surface area. Hospital-acquired infections developed in 36 (25%) patients after a mean of 10 ± 1 days after injury. Interleukin 6, monocyte chemotactic protein-1, and blood urea nitrogen levels and thrombin time were independently associated with increased glucagon-like peptide 1 levels. Levels of glucagon-like peptide 1 (median, interquartile range) were greater in patients who developed hospital-acquired infections than in those who did not (237 pmol/L, 76-524 vs 80 pmol/L, 51-158; P < .001) and in patients who died (536 pmol/L, interquartile range: 336-891 pmol vs 98 pmol/L, 47-189; P < .001). Although the glucagon-like peptide 1 level could not predict hospital-acquired infections-free survival in individual patients, it could predict 1-year mortality independently (P = .021). Moreover, a glucagon-like peptide 1 level of 200 pmol/L could discriminate hospital-acquired infections-free survival (P < .001).

CONCLUSION

Admission glucagon-like peptide 1 level can discriminate hospital-acquired infections-free survival and predict long-term mortality in a group of patients with burn injury. Our data suggests that glucagon-like peptide 1 may be a predictive biomarker for hospital-acquired infections and mortality in burn patients.