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Zavala S, Pape KO, Walroth TA, Reger M, Hoyte B, Thomas W, Adams B, Hill DM. Vitamin D Deficiency Is Associated With Increased Length of Stay After Acute Burn Injury: A Multicenter Analysis. J Burn Care Res 2024; 45:728-732. [PMID: 38141248 DOI: 10.1093/jbcr/irad201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Indexed: 12/25/2023]
Abstract
In burn patients, vitamin D deficiency has been associated with increased incidence of sepsis and infectious complications. The objective of this study was to assess the impact of vitamin D deficiency in adult burn patients on hospital length of stay (LOS). This was a multicenter retrospective study of adult patients at 7 burn centers admitted over a 3.5-year period, who had a 25-hydroxyvitamin D concentration drawn within the first 7 days of injury. Of 1147 patients screened, 412 were included. Fifty-seven percent were vitamin D deficient. Patients with vitamin D deficiency had longer LOS (18.0 vs 12.0 days, P < .001), acute kidney injury (AKI) requiring renal replacement therapy (7.3 vs 1.7%, P = .009), more days requiring vasopressors (mean 1.24 vs 0.58 days, P = .008), and fewer ventilator-free days of the first 28 days (mean 22.9 vs 25.1, P < .001). Univariable analysis identified burn center, AKI, TBSA, inhalation injury, admission concentration, days until concentration drawn, days until initiating supplementation, and dose as significantly associated with LOS. After controlling for center, TBSA, age, and inhalation injury, vitamin D deficiency was associated with longer LOS. In conclusion, patients with thermal injuries and vitamin D deficiency on admission have increased LOS and worsened clinical outcomes when compared with patients with nondeficient vitamin D concentrations.
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Affiliation(s)
- Sarah Zavala
- Department of Pharmacy, Jesse Brown VA Medical Center, Chicago, IL 60612, USA
| | - Kate O Pape
- Department of Pharmacy, University of Iowa Health Care, Iowa City, IA 52245, USA
| | - Todd A Walroth
- Department of Pharmacy, Eskenazi Health, Indianapolis, IN 46202, USA
| | - Melissa Reger
- Department of Pharmacy, Community Regional Medical Center, Fresno, CA 93721, USA
| | - Brittany Hoyte
- Department of Pharmacy, Corewell Health, Grand Rapids, MI 49503, USA
| | - Wendy Thomas
- Department of Pharmacy, Corewell Health, Grand Rapids, MI 49503, USA
| | - Beatrice Adams
- Department of Pharmacy, Tampa General Hospital, Tampa, FL 33606, USA
| | - David M Hill
- Department of Pharmacy, Regional One Health, Memphis, TN 38103, USA
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Rohaiem SN, Khan BF, Al-Julaih GH, Mohammedin AS. Atraumatic Fractures in Multi-Morbid Older Adults: A Series of Five Cases and Review of Literature. Cureus 2023; 15:e51333. [PMID: 38288221 PMCID: PMC10824280 DOI: 10.7759/cureus.51333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/29/2023] [Indexed: 01/31/2024] Open
Abstract
Atraumatic fractures (ATFs) are a fragility fracture subtype with occasional medicolegal issues. ATFs are defined as fractures because of a "low-energy mechanism that is usually considered incapable of producing a fracture." They are an underreported disorder, with epidemiological variations. ATF phenomena were previously reported not only in older adults, but also in children, young adults, older adults, and animals. This study is a short retrospective case series exploring atraumatic fractures in a tertiary care university hospital. Over a period of two years, a total of seven ATF cases were identified. However, only five fulfilled the inclusion criteria. Local causes of pathologic fractures (e.g., metastasis) and elder abuse or neglect were excluded. Comparison of the cases' clinical profile, fracture profile, and management was done. All five cases were frail females with significant osteotoxic burdens from medications and multi-morbidities. ATF presentations included typical (as pain) and atypical (as painless, loud crack, and sudden giveaway) symptomatology. One ATF had a coincident unexplained aseptic fever. Three cases had more than one fracture (fracture cascade), confirmed and followed up by x-rays. All the cases were managed conservatively except for one case that underwent hip hemiarthroplasty. Plans of care included managing the osteotoxic multi-morbidities burden, focusing on the whole body, not only on the fracture or bone. The study provided insights about challenges in presentations of ATF (as the bone fracture acute phase reaction: osteogenic aseptic fever). Risk factors are classically assumed to be osteoporosis, but it is usually systemic and multifactorial. A high risk of fracture warning sign could help decrease ATF occurrence or fracture cascades. Four ATF categories were detected to help healthcare systems identify high-risk patients and raise awareness among medical staff, families, and caregivers. Future studies of the at-risk groups are needed to understand ATF knowledge gaps, challenges, and the best treatments.
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Affiliation(s)
| | - Basim F Khan
- Pediatrics and Child Health, King Fahd Hospital of the University, Al-Khobar, SAU
| | | | - Ahmed S Mohammedin
- Geriatrics and Gerontology, Ain Shams University, Cairo, EGY
- Internal Medicine/Geriatrics, King Fahd Hospital of the University, Imam Abdulrahman bin Faisal University, Al-Khobar, SAU
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Mohammadi AA, Shafaeipour A. Evaluation of Vitamin D3 and Calcium Deficiency after Recovery from Extensive Burn. World J Plast Surg 2021; 10:60-65. [PMID: 33833955 PMCID: PMC8016369 DOI: 10.29252/wjps.10.1.60] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Previous studies in pediatric populations have demonstrated that vitamin D deficiency is common in patients with large burns. The aim of the current comparative study was to investigate the serum level of vitamin D in patients with large burns [>20% total body surface area (TBSA)] after 6 months of therapy. METHODS This case control study was conducted during 6-month period from 2017 to 2018 in Amiralmomenin Hospital, Shiraz, Iran. Forty two patients with large burns (>20% TBSA) and at least 6 months’ post-burn period were enrolled. Also, 42 healthy and age and sex matched controls from those referring for routine check-ups were included for comparison. None of the patients and controls received vitamin D supplements. The serum level of calcium (Ca), parathormone (PTH) and vitamin D were compared between the groups. RESULTS There was no significant difference between the two study groups regarding the baseline characteristics including the age (p=0.085), gender (p=0.275) and duration of sun exposure (p=0.894). We found that those with major burns had significantly higher serum levels of PTH (50.48±26.49 vs. 33.64±15.80; p=0.001). In addition, the serum levels of vitamin D were significantly lower in burn patients compared to healthy controls (18.15±9.18 vs. 31.43±16.27; p<0.001). CONCLUSION Major burns (≥20% TBSA) are associated with increased serum levels of PTH and decreased serum levels of vitamin D. However, serum levels of calcium are not affected by major burns.
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Affiliation(s)
| | - Asma Shafaeipour
- Department of Surgery, Shiraz University of Medical Sciences, Shiraz, Iran
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Abstract
Recently, many studies have demonstrated pleotropic effects of vitamin D, including immune modulation and cardiovascular system activity. Sufficient vitamin D concentrations and supplementation of vitamin D may be of benefit in burn-injured patients. Low 25(OH)D has been observed in nearly all pediatric and most adult burn patients. Vitamin D has primarily been studied in pediatric burn patients, focusing on bone marker measurements and the incidence of fractures. The preferred vitamin D dose, formulation, and route of administration remain unknown, and there is limited data on the impact of vitamin D status on clinical outcomes. Further research should focus on determining optimal monitoring strategies, supplementation regimens and clinical outcomes like mortality, length of stay and incidence of sepsis.
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Vitamin D status and its influence on outcomes following major burn injury and critical illness. BURNS & TRAUMA 2018; 6:11. [PMID: 29721511 PMCID: PMC5910591 DOI: 10.1186/s41038-018-0113-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 03/23/2018] [Indexed: 12/11/2022]
Abstract
Vitamin D deficiency is common among the general population. It is also observed in up to 76% of critically ill patients. Despite the high prevalence of hypovitaminosis D in critical illness, vitamin D is often overlooked by medical staff as the clinical implications and consequences of vitamin D deficiency in acute contexts remain to be fully understood. Vitamin D has a broad range of pleotropic effects on various processes and systems including the immune-inflammatory response. 1α,25-dihydroxyvitamin D (1,25(OH)2D), has been shown to promote a tolerogenic immune response limiting deleterious inflammatory effects, modulation of the innate immune system, and enhancement of anti-microbial peptides. Vitamin D deficiency is frequently observed in critically ill patients and has been related to extrinsic causes (i.e., limited sunlight exposure), magnitude of injury/illness, or the treatment started by medical doctors including fluid resuscitation. Low levels of vitamin D in critically ill patients have been associated with sepsis, organ failure, and mortality. Despite this, there are subpopulations of critical illness, such as burn patients, where the literature regarding vitamin D status and its influence on outcomes remain insufficient. Thermal injury results in damage to both burned and non-burned tissues, as well as induces an exaggerated and persistent immune-inflammatory and hypermetabolic response. In this review, we propose potential mechanisms in which burn injury affects the vitamin D status and summarizes current literature investigating the influence of vitamin D status on outcomes. In addition, we reviewed the literature and trials investigating vitamin D supplementation in critically ill patients and discuss the therapeutic potential of vitamin D supplementation in burn and critically ill patients. We also highlight current limitations of studies that have investigated vitamin D status and supplementation in critical illness. Thermal injury influences vitamin D status. More studies investigating vitamin D depletion in burn patients and its influence on prognosis, via standardized methodology, are required to reach definitive conclusions and influence clinical practice.
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Kaewboonchoo O, Sung FC, Lin CL, Hsu HC, Kuo CT. Hip fracture risk in patients with burn injury: a retrospective cohort study in Taiwan. Osteoporos Int 2017; 28:3415-3420. [PMID: 28875313 DOI: 10.1007/s00198-017-4209-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Accepted: 08/22/2017] [Indexed: 11/25/2022]
Abstract
UNLABELLED This work aimed to evaluate the hip fracture risk for patients with burn injury. A total of 16,430 patients with burn injury had an adjusted hazard ratio of 1.54 to encounter a hip fracture, compared with controls without the injury. These results encourage future studies focusing on mechanisms leading to fracture associated with burn injury. INTRODUCTION The relationship between burn injury and hip fracture risk is unclear. We conducted a retrospective cohort study to investigate this relationship. METHODS From insurance data of Taiwan, we identified a cohort with 16,430 burn patients in 2000-2010 and a comparison cohort of 65,716 persons without the history of burn, frequency matched by sex, age, and diagnosis date. Both cohorts were followed up to the end of 2011 to evaluate the risk of hip fracture. RESULTS Patients with burn injury were 1.62-fold more likely than comparisons to encounter a hip fracture (6.95 vs. 4.28 per 1000 person-years), with an adjusted hazard ratio (aHR) of 1.54 (95% confidence interval (CI) = 1.40-1.68). The fracture incidence increased with age and is slightly greater for women than for men in both cohorts. The fracture risk was greater for patients with burn in the eyes, face, and head with an incidence of 7.14 per 1000 person-years, or an aHR of 2.09 (95% CI = 1.53, 2.86). Diabetes and osteoporosis were also associated with an increased hip fracture risk. CONCLUSION Burn injury is associated with an increased risk of hip fracture. Diabetes and osteoporosis are associated with an enhanced risk.
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Affiliation(s)
- O Kaewboonchoo
- Department of Public Health Nursing, Mahidol University Faculty of Public Health, Khet Ratchathewi, Thailand
| | - F C Sung
- Department of Public Health Nursing, Mahidol University Faculty of Public Health, Khet Ratchathewi, Thailand
- Department of Health Services Administration, China Medical University College of Public Health, Taichung, Taiwan
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
| | - C L Lin
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
| | - H C Hsu
- Department of Orthopedic Surgery, China Medical University Hospital, Taichung, Taiwan
| | - C T Kuo
- Department of Public Health Nursing, Mahidol University Faculty of Public Health, Khet Ratchathewi, Thailand.
- Department of Public Health, China Medical University College of Public Health, 91 Hseuh Shih Road, Taichung, 404, Taiwan.
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Duke JM, Randall SM, Fear MW, Boyd JH, Wood FM. Fracture admissions after burns: A retrospective longitudinal study. Burns 2017; 43:1175-1182. [PMID: 28318751 DOI: 10.1016/j.burns.2017.02.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 02/22/2017] [Accepted: 02/23/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Severe burn triggers systemic responses that result in reduced muscle mass and changes in bone formation, with recent evidence also suggesting systemic effects on bone after minor burns. The aim of this study was to assess if people hospitalised with a burn have increased admissions for fractures after discharge. METHODS A population-based longitudinal study using linked hospital morbidity and death data from Western Australia was undertaken of all persons hospitalised for a first burn (n=30,997) during the period 1980-2012. Australian population-based annual rates for fracture admissions for the period 1993-2012 were obtained from the Australian Institute of Health and Welfare. Rates of hospital admissions for fractures in the burn cohort and the Australian population were standardised, using the direct method, to the age and gender structure of the Western Australian population at the 2006. Annual standardised fracture admission rates for the period 1993-2012 were graphed with estimated 95% confidence intervals. Age and gender specific fracture rates were also examined. RESULTS A total of 4004 members of the burn cohort had at least one fracture admission for a total of 6096. The median (IQR) time to the first fracture admission after burn was 6.9 years (2.8-13.6) and the median age (IQR) at first fracture admission was 31 years (20-49). The burn cohort experienced admissions for fractures at a rate approximately twice that of the Australian population. While rates were generally higher for males in the burn cohort when compared with males in the Australian population, female burn patients had significantly higher rates over the entire study period when compared with the female Australian population. Elevated rates were observed for those younger than 20 years at the time of the burn admission; however, rates were significantly and consistently elevated during the study period for those 20 years and older at the time of the burn. CONCLUSIONS Burn patients experienced significantly higher age and gender standardised rates of admissions for fractures after discharge from hospital for their index burn. Further prospective research is indicated to clarify any underlyling pathogenic processes linked to the burn that may increase a patient's risk of having a fracture serious enough to undergo admission.
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Affiliation(s)
- Janine M Duke
- Burn Injury Research Unit, School of Surgery, University of Western Australia, Perth, Western Australia, Australia.
| | - Sean M Randall
- Centre for Data Linkage, Curtin University, Perth, Western Australia, Australia.
| | - Mark W Fear
- Burn Injury Research Unit, School of Surgery, University of Western Australia, Perth, Western Australia, Australia.
| | - James H Boyd
- Centre for Data Linkage, Curtin University, Perth, Western Australia, Australia.
| | - Fiona M Wood
- Burn Injury Research Unit, School of Surgery, University of Western Australia, Perth, Western Australia, Australia; Burns Service of Western Australia, Fiona Stanley Hospital and Princess Margaret Hospital, Perth, Western Australia, Australia.
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Gottschlich MM, Mayes T, Khoury J, Kagan RJ. Clinical Trial of Vitamin D 2 vs D 3 Supplementation in Critically Ill Pediatric Burn Patients. JPEN J Parenter Enteral Nutr 2016; 41:412-421. [PMID: 26059899 DOI: 10.1177/0148607115587948] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Hypovitaminosis D exists postburn. However, evidence-based guidelines for vitamin D repletion are unknown. This investigation examined differences between D2 and D3 supplementation on outcome in children with burn injuries. METHODS Fifty patients with total body surface area burn of 55.7% ± 2.6% and full-thickness injury of 40.8% ± 3.8% were enrolled, ranging in age from 0.7-18.4 years. All participants received multivitamin supplementation per standardized clinical protocol. In addition, 100 IU/kg D2, D3, or placebo was administered daily during hospitalization using a randomized, double-blinded study design. Assay of total 25-hydroxyvitamin D (D25), 1,25-dihydroxyvitamin D (D1,25), 25-hydroxyvitamin D2 (25-OH-D2), 25-hydroxyvitamin D3 (25-OH-D3), and parathyroid hormone (PTH) was performed at 4 preplanned time intervals (baseline, midpoint, discharge, and 1 year postburn). Differences in vitamin D status were compared over time and at each specific study interval. RESULTS There were no significant differences in serum vitamin D levels between groups, but >10% of patients had low D25 at discharge, and percent deficiency worsened by the 1-year follow up for the placebo (75%), D2 (56%), and D3 (25%) groups. There were no statistical differences in PTH or clinical outcomes between treatment groups, although vitamin D supplementation demonstrated nonsignificant but clinically relevant decreases in exogenous insulin requirements, sepsis, and scar formation. CONCLUSIONS The high incidence of low serum D25 levels 1 year following serious thermal injury indicates prolonged compromise. Continued treatment with vitamin D3 beyond the acute phase postburn is recommended to counteract the trajectory of abnormal serum levels and associated morbidity.
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Affiliation(s)
- Michele M Gottschlich
- 1 Department of Research, Shriners Hospitals for Children, Cincinnati, Ohio, USA.,2 Department of Nutrition, Shriners Hospitals for Children, Cincinnati, Ohio, USA.,3 Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Theresa Mayes
- 2 Department of Nutrition, Shriners Hospitals for Children, Cincinnati, Ohio, USA.,4 Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Jane Khoury
- 4 Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Richard J Kagan
- 3 Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,5 Department of Surgery, Shriners Hospitals for Children, Cincinnati, Ohio, USA
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Increased admissions for musculoskeletal diseases after burns sustained during childhood and adolescence. Burns 2015; 41:1674-1682. [DOI: 10.1016/j.burns.2015.08.028] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 08/19/2015] [Accepted: 08/23/2015] [Indexed: 11/19/2022]
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Randall SM, Fear MW, Wood FM, Rea S, Boyd JH, Duke JM. Long-term musculoskeletal morbidity after adult burn injury: a population-based cohort study. BMJ Open 2015; 5:e009395. [PMID: 26362668 PMCID: PMC4567662 DOI: 10.1136/bmjopen-2015-009395] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To investigate if adults who are hospitalised for a burn injury have increased long-term hospital use for musculoskeletal diseases. DESIGN A population-based retrospective cohort study using linked administrative health data from the Western Australian Data Linkage System. SUBJECTS Records of 17,753 persons aged at least 20 years when hospitalised for a first burn injury in Western Australia during the period 1980-2012, and 70,758 persons who were age and gender-frequency matched with no injury admissions randomly selected from Western Australia's electoral roll. MAIN OUTCOME MEASURES Admission rates and cumulative length of stay for musculoskeletal diseases. Negative binomial and Cox proportional hazards regression modelling were used to generate incidence rate ratios (IRR) and HRs with 95% CIs, respectively. RESULTS After adjustment for pre-existing health status and demographic characteristics, the burn cohort had almost twice the hospitalisation rate for a musculoskeletal condition (IRR, 95% CI 1.98, 1.86 to 2.10), and spent 3.70 times as long in hospital with a musculoskeletal diagnosis (95% CI 3.10 to 4.42) over the 33-year period, than the uninjured comparison cohort. Adjusted survival analyses of incident post-burn musculoskeletal disease admissions found significant increases for the 15-year post burn discharge period (0-6 months: HR, 95% CI 2.51, 2.04 to 3.11; 6 months-2 years: HR, 95% CI 1.77, 1.53 to 2.05; 2-15 years: HR, 95% CI 1.32, 1.23 to 1.42). Incident admission rates were significantly elevated for 20 years post-burn for minor and severe burn injury for a range of musculoskeletal diseases that included arthropathies, dorsopathies, osteopathies and soft tissue disorders. CONCLUSIONS Minor and severe burn injuries were associated with significantly increased post-burn incident admission rates, long-term hospital use and prolonged length of stay for a range of musculoskeletal diseases. Further research is required that facilitates identification of at-risk patients and appropriate treatment pathways, to reduce the long-term morbidity associated with burns.
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Affiliation(s)
- Sean M Randall
- Centre for Data Linkage, Curtin University, Perth, Western Australia, Australia
| | - Mark W Fear
- Burn Injury Research Unit, School of Surgery, University of Western Australia, Perth, Western Australia, Australia
| | - Fiona M Wood
- Burn Injury Research Unit, School of Surgery, University of Western Australia, Perth, Western Australia, Australia
- Burns Service of Western Australia, Royal Perth Hospital and Princess Margaret Hospital, Perth, Western Australia, Australia
| | - Suzanne Rea
- Burn Injury Research Unit, School of Surgery, University of Western Australia, Perth, Western Australia, Australia
- Burns Service of Western Australia, Royal Perth Hospital and Princess Margaret Hospital, Perth, Western Australia, Australia
| | - James H Boyd
- Centre for Data Linkage, Curtin University, Perth, Western Australia, Australia
| | - Janine M Duke
- Burn Injury Research Unit, School of Surgery, University of Western Australia, Perth, Western Australia, Australia
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Mayes T, Gottschlich MM, Khoury J, Kagan RJ. Investigation of Bone Health Subsequent to Vitamin D Supplementation in Children Following Burn Injury. Nutr Clin Pract 2015; 30:830-7. [PMID: 26024678 DOI: 10.1177/0884533615587720] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The effect of supplemental vitamin D on fracture occurrence following burn injuries is unclear. The objective of this study was to evaluate postintervention incidence of fractures in children during the rehabilitative phase postburn (PB) following participation in a randomized clinical trial of vitamin D supplementation. MATERIALS AND METHODS Follow-up for fracture evaluation was obtained in 39 of 50 patients randomized to daily enteral vitamin D2, D3, or placebo throughout the acute burn course. Serum 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D, D2, D3, calcitonin, and bone alkaline phosphatase (BAP) measurements were obtained PB day 7, midpoint, discharge, and 1-year PB. Urinary calcium was obtained PB day 7 and midpoint. Dual-energy x-ray absorptiometry (DXA) was performed at discharge and 1-year PB. RESULTS Fractures were reported in 6 of 39 respondents. Four fractures occurred in the placebo group, 2 in the D2 group, and none in the D3 group. Serum vitamin D, calcitonin, BAP, and urinary calcium were similar between fracture groups. The group with fracture morbidity had larger burn size (83.8% ± 4.9% vs 53.0% ± 2.9%, P < .0001), greater full-thickness burn (69.7% ± 9.4% vs 39.4% ± 4.1%, P = .02), and increased incidence of inhalation injury (33% vs 6%, P = .04). Decreased bone mineral density z score was noted at discharge in the placebo fracture compared with no-fracture group (P < .05). CONCLUSION This preliminary report suggests there may be benefit of vitamin D3 in reducing postdischarge fracture risk. Results reaffirm the importance of monitoring bone health in pediatric patients postburn.
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Affiliation(s)
- Theresa Mayes
- Department of Nutrition, Shriners Hospitals for Children, Cincinnati, Ohio Division of Nutrition Therapy, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Michele M Gottschlich
- Department of Nutrition, Shriners Hospitals for Children, Cincinnati, Ohio Department of Research, Shriners Hospitals for Children, Cincinnati, Ohio Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Jane Khoury
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Richard J Kagan
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio Department of Surgery, Shriners Hospitals for Children, Cincinnati, Ohio
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12
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Prelack K, Yu YM, Sheridan RL. Nutrition and metabolism in the rehabilitative phase of recovery in burn children: a review of clinical and research findings in a speciality pediatric burn hospital. BURNS & TRAUMA 2015; 3:7. [PMID: 27574653 PMCID: PMC4964101 DOI: 10.1186/s41038-015-0004-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Accepted: 04/06/2015] [Indexed: 11/10/2022]
Abstract
During the rehabilitation phase of burn injury, patient care transitions from critical care medicine to restorative treatment strategies that encompass physical and occupational therapies, nutrition repletion, and psychosocial support for community reintegration. As pediatric burn patients undergo rehabilitation, nutrition assessment remains ongoing to define nutritional status and any alterations in metabolism that may take place. For some, a persistent hypermetabolic state appears evident, and weight loss may continue. The severity and duration however varies among patients. Many patients enter their rehabilitative phase with visible lean body mass depletion, and the focus of nutritional therapy for them shifts to replenishing nutritional status, while supporting rehabilitative efforts. Over the past decade, we have conducted studies on energy and protein metabolism, body composition, including bone mineralization, and general wellness in over 130 patients to better understand changes in metabolism and nutritional status during the rehabilitative phase of recovery. This abstract summarizes our findings.
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Affiliation(s)
- Kathy Prelack
- Shriners Hospitals For Children, Boston, Massachusetts USA
| | - Yong Ming Yu
- Shriners Hospitals For Children, Boston, Massachusetts USA
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Abstract
Burn injuries pose complex biopsychosocial challenges to recovery and improved comprehensive care. The physical and emotional sequelae of burns differ, depending on burn severity, individual resilience, and stage of development when they occur. Most burn survivors are resilient and recover, whereas some are more vulnerable and have complicated outcomes. Physical rehabilitation is affected by orthopedic, neurologic, and metabolic complications and disabilities. Psychiatric recovery is affected by pain, mental disorders, substance abuse, and burn stigmatization. Individual resilience, social supports, and educational or occupational achievements affect outcomes.
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Affiliation(s)
- Frederick J Stoddard
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Colleen M Ryan
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jeffrey C Schneider
- Spaulding Rehabilitation Hospital, Harvard Medical School, 300 1st Avenue, Boston, MA 02129, USA.
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Abstract
Supplementation of micronutrients after burn injury is common practice in order to fight oxidative stress, support the immune system, and optimize wound healing. Assessing micronutrient status after burn injury is difficult because of hemodilution in the resuscitation phase, redistribution of nutrients from the serum to other organs, and decreases in carrier proteins such as albumin. Although there are many preclinical data, there are limited studies in burn patients. Promising research is being conducted on combinations of micronutrients, especially via the intravenous route.
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O'Halloran E, Kular J, Xu J, Wood F, Fear M. Non-severe burn injury leads to depletion of bone volume that can be ameliorated by inhibiting TNF-α. Burns 2014; 41:558-64. [PMID: 25305071 DOI: 10.1016/j.burns.2014.09.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Revised: 09/01/2014] [Accepted: 09/02/2014] [Indexed: 11/29/2022]
Abstract
Bone loss after severe burn injury is well established, and is thought to be a consequence of the severe hyper-metabolic response as well as changes in cytokine and glucocorticoid levels that decrease bone synthesis and increase rate of loss. However, 90% of presentations are for non-severe burns which do not elicit this response. Little is known about whether these non-severe injuries may also affect bone tissue, and whether other mechanisms may be involved. To investigate whether bone loss occurs after a non-severe burn injury we used a mouse model of an approximately 8% total body surface area (TBSA) full-thickness burn and micro-CT. We also assessed whether blocking TNF-α after a burn injury by administration of an antibody could modulate the impacts of the burn on bone tissue. There was a significant loss of trabecular bone volume of (3.27% compared to 5.27%, p=0.0051) after non-severe burn injury. Trabecular number was significantly decreased (0.57/mm after injury compared to 1.02/mm controls, p=0.0051) and spacing increased after burn injury (0.40 compared to 0.28, p=0.0083). Anti-TNF-α antibodies significantly improved trabecular bone volume (8.53%, p=0.0034) and number after burn injury (1.28/mm, p=0.0034). There was no significant change observed in cortical bone after burn injury or administration of anti-TNF-α antibodies. These findings show that non-severe burn injury can lead to changes in bone metabolism. Monitoring bone density in patients with non-severe injuries and interventions to limit the impacts of the inflammatory storm may benefit patient recovery and outcomes.
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Affiliation(s)
- Emily O'Halloran
- Burn Injury Research Unit, School of Surgery, University of Western Australia, Perth, Australia
| | - Jasreen Kular
- School of Pathology and Laboratory Medicine, University of Western Australia, Perth, Australia
| | - Jiake Xu
- School of Pathology and Laboratory Medicine, University of Western Australia, Perth, Australia
| | - Fiona Wood
- Burn Injury Research Unit, School of Surgery, University of Western Australia, Perth, Australia; The Fiona Wood Foundation, Royal Perth Hospital, Perth, Australia; Burns Service of Western Australia, Department of Health, Perth, Australia
| | - Mark Fear
- Burn Injury Research Unit, School of Surgery, University of Western Australia, Perth, Australia; The Fiona Wood Foundation, Royal Perth Hospital, Perth, Australia; School of Medicine, University of Notre Dame Australia, Fremantle, Australia.
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Abstract
Burn injuries pose complex biopsychosocial challenges to recovery and improved comprehensive care. The physical and emotional sequelae of burns differ, depending on burn severity, individual resilience, and stage of development when they occur. Most burn survivors are resilient and recover, whereas some are more vulnerable and have complicated outcomes. Physical rehabilitation is affected by orthopedic, neurologic, and metabolic complications and disabilities. Psychiatric recovery is affected by pain, mental disorders, substance abuse, and burn stigmatization. Individual resilience, social supports, and educational or occupational achievements affect outcomes.
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Affiliation(s)
- Frederick J Stoddard
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Colleen M Ryan
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jeffrey C Schneider
- Trauma, Burn and Orthopedic Program, Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, 125 Nashua Street, Boston, MA 02114, USA.
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Affiliation(s)
- Yong Suk Cho
- Department of Surgery, Burn Center, Hangang Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
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18
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Mehta S, Booth S, Dheansa B. Should we give vitamin D to severe burns patients? Burns 2013; 39:830-1. [DOI: 10.1016/j.burns.2012.11.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Accepted: 11/07/2012] [Indexed: 11/29/2022]
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19
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Micronutrient Requirements of Pediatric Patients With Burns. TOP CLIN NUTR 2013. [DOI: 10.1097/tin.0b013e31828d7bd0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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21
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Cox S, Rode H, Darani A, Fitzpatrick-Swallow V. Thermal injury within the first 4 months of life. Burns 2011; 37:828-34. [DOI: 10.1016/j.burns.2011.02.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2010] [Revised: 12/17/2010] [Accepted: 02/03/2011] [Indexed: 10/18/2022]
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22
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Schneider JC, Qu HD. Neurologic and Musculoskeletal Complications of Burn Injuries. Phys Med Rehabil Clin N Am 2011; 22:261-75, vi. [DOI: 10.1016/j.pmr.2011.01.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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23
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Gore SM, Dziewulski P. Avulsion fracture of the olecranon following thermal injury: a case report. Burns 2009; 36:e53-5. [PMID: 19765904 DOI: 10.1016/j.burns.2009.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2009] [Accepted: 07/01/2009] [Indexed: 11/19/2022]
Affiliation(s)
- Sinclair M Gore
- St. Andrew's Centre for Plastic Surgery and Burns, Broomfield Hospital, Chelmsford, Essex, United Kingdom.
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24
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Effects of a 12-week rehabilitation program with music & exercise groups on range of motion in young children with severe burns. J Burn Care Res 2009; 29:939-48. [PMID: 18849852 DOI: 10.1097/bcr.0b013e31818b9e0e] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Previous studies indicate that rehabilitation programs supplemented with a strength and endurance-based exercise program improve lean body mass, pulmonary function, endurance, strength, and functional outcomes in severely burned children over the age of 7-years when compared with standard of care (SOC). To date, supplemental exercise programming for severely burned children under the age of 7-years has not yet been explored. The purpose of this study was to determine if a 12-week rehabilitation program supplemented with music & exercise, was more effective in improving functional outcomes than the SOC alone. This is a descriptive study that measured elbow and knee range of motion (ROM) in 24 severely burned children between ages 2 and 6 years. Groups were compared for demographics as well as active and passive ROM to bilateral elbows and knees. A total of 15 patients completed the rehabilitation with supplemental music and exercise, and data was compared with 9 patients who received SOC. Patients receiving the 12-week program significantly improved ROM in all joints assessed except for one. Patients receiving SOC showed a significant improvement in only one of the joints assessed. Providing a structured supplemental music and exercise program in conjunction with occupational and physical therapy seems to improve both passive and active ROM to a greater extent than the SOC alone.
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Chan MM, Chan GM. Nutritional therapy for burns in children and adults. Nutrition 2008; 25:261-9. [PMID: 19097858 DOI: 10.1016/j.nut.2008.10.011] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2008] [Revised: 10/09/2008] [Accepted: 10/15/2008] [Indexed: 10/21/2022]
Abstract
Burns are a serious injury that requires optimal nutritional support. This review discusses the nutritional care for adults and children with major burns. A burned patient's metabolism is greatly accelerated with increased requirements for energy, carbohydrates, proteins, fats, vitamins, minerals, and antioxidants. Early nutrition by parenteral and enteral feedings is vital. Careful assessment of the nutritional state of the burn patient is also important to reduce infection, recovery time, and long-term sequelae.
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Affiliation(s)
- Melissa M Chan
- Department of Surgery, University Health Care's Burn Center, Department of Pediatrics, University of Utah Health Science Center, Salt Lake City, Utah, USA
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Xin W, Yin Z, Qin Z, Jian L, Tanuseputro P, Gomez M, Beveridge M, Zhenjiang L. Characteristics of 1494 pediatric burn patients in Shanghai. Burns 2006; 32:613-8. [PMID: 16713685 DOI: 10.1016/j.burns.2005.12.012] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2005] [Accepted: 12/15/2005] [Indexed: 11/20/2022]
Abstract
To analyze the epidemiological characteristics of pediatric burn patients in Shanghai and to determine the targets for a pediatric burn prevention program, a retrospective review of all medical records of acute pediatric burn patients (age</=14 years old) admitted to the Burn Center of the Ruijin Hospital between January 1980 and December 2002 was performed. Patient demographics, etiology of burn, mechanism of injury, extent and anatomical areas burned, number of operations, and length of hospital stay were recorded. A total of 1494 pediatric burn patients were admitted. Six hundred eighty-seven (46%) patients were from the migrant population (non-registered population of temporary workers from rural areas outside of Shanghai). Scalding was the main cause of pediatric burns in the age groups. Children 0-3-year-old were the most common victims of scalding, chemical burns, and contact burns. Domestic burns resulted in 1293 (86.5%) injuries followed by burns occurring while playing in public. The incidence of domestic burns has increased since the beginning of the study period, while the incidence of burns while playing in public has decreased. The median total body surface area was 4% for mild burns, 10% for moderate burns, and 18% for extensive burns. Predominant areas involved were the head, neck, anterior trunk, and right lower limb. Most children received conservative treatment, and their mean hospital stay was 16.1+/-12.2 days. There were 17 (1.1%) deaths, mostly due to sepsis (82.4%). Migrant children are the majority of burn victims since 1996. The education of burn prevention should focus on the migrant population in an industrializing city.
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Affiliation(s)
- Wang Xin
- Burn Center, Ruijin Hospital, Shanghai Second Medical University, 200025 Shanghai, PR China
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Abstract
Nutrition Support Pharmacist features issues pertinent to the practice of clinical pharmacy in the area of nutritional support. The column is edited by Dr. Roland Dickerson, Professor of Pharmacy, University of Tennessee Health Science Center; Memphis, TN. Address correspondence to Dr. Roland N. Dickerson, University of Tennessee Health Science Center, 26 South Dunlap St., Memphis, TN 38163. This article provides a summary of our approach to the nutritional management of the thermally injured patient. However, it must be pointed out that there are other alternative effective evidence-based approaches to managing this problematic patient population. There are numerous exceptions to the above outlined guidelines that the astute clinician must be able to identify. However, for the beginning reader, this approach will provide a sound foundation upon which to build their practice in the management of these difficult patients.
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Affiliation(s)
- Roland N. Dickerson
- University of Tennessee Health Science Center, 26 South Dunlap St., Rm 210, Memphis, TN 38163
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Gottschlich MM, Mayes T, Khoury J, Warden GD. Hypovitaminosis D in acutely injured pediatric burn patients. ACTA ACUST UNITED AC 2004; 104:931-41, quiz 1031. [PMID: 15175591 DOI: 10.1016/j.jada.2004.03.020] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
PROBLEM The prevalence of vitamin D insufficiency, its etiology, and associated sequelae among acutely injured burn patients is unknown. OBJECTIVE This study assessed vitamin D and endocrine status, as well as the effect of anabolic agents, in pediatric patients who had sustained burns in excess of 25% total body surface area (TBSA). SUBJECTS Sixty-nine patients with a mean TBSA burn of 50.6+/-2.2% (range 27% to 94%) and full thickness injury of 41.3+/-3.0% (range 0% to 94%) were studied. Subjects ranged in age from 0.6 to 18 years (mean, 5.8+/-0.6 years). Main outcome measures Blood samples were obtained for serum 25-hydroxyvitamin D (D25), 1,25-dihydroxyvitamin D (D1,25), albumin, cortisol, triiodothyronine (T3), tetraiodothyronine (T(4)), thyroid stimulating hormone (TSH), and parathormone (PTH). RESULTS Two hundred eighty morning blood samples of D25 and D1,25 demonstrated that 45% and 26.2% were low and 8.9% and 11% were very low, respectively. At least one low D25 or D1,25 level occurred in 62.3% of all subjects. Very low levels were noted in 23.2% of all patients. There was an increased incidence of hyperparathyroidism in patients with very low serum D25. Vitamin D25 and D1,25 levels were lower in subjects with larger burns or inhalation injury, as well as those treated with thyroxine or oxandrolone. Serum albumin, cortisol, T(4), and TSH were not correlated with concentration of vitamin D. CONCLUSIONS Demonstration of a high incidence of low serum vitamin D indicates vitamin D status may be significantly compromised in burned children. It is unclear why vitamin D deficiency exists in this population. The most effective way to improve vitamin D status remains elusive at this time.
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