Grading of severity of the condition in burn patients by serum protein and albumin/globulin studies. Ann Plast Surg. 2010;65:74-79. [PMID: 20548219 DOI: 10.1097/sap.0b013e3181c47d71]

Clinical Significance of Serum Albumin/Globulin Ratio in Patients With Pyogenic Liver Abscess

Pyogenic liver abscess (PLA) remains a significant challenge for modern clinicians. Serum albumin/globulin ratio (AGR) can reflect the progress of many diseases. However, the clinical significance of AGR in PLA has not been evaluated. The aim of this study was to explore the effect of AGR on the clinical characteristic and prognosis in PLA patients. This retrospective study included 392 PLA patients who admitted to the First Affiliated Hospital of Xi'an Jiaotong University from January, 2007 to December, 2016. The medical records on admission were collected. Compared with the healthy controls and the patients with extraperitoneal infection or non-infectious liver disease, PLA patients had lower levels of AGR. The mean level of AGR in PLA patients was 1.02 ± 0.25. There were 179 (45.4%) patients with AGR > 1.02 and 213 (54.6%) patients with AGR ≤ 1.02. The baseline data and treatment plans of PLA patients with high or low AGR were comparative. However, PLA patients with a low AGR had higher body temperature, leukocytes and neutrophils, lower hemoglobin, poorer liver and coagulation function, larger abscess diameter, higher positive rate of pus culture and proportion of Escherichia coli, and were more susceptible to multiple bacteria. Moreover, PLA patients with a low AGR had more complications, including systemic inflammatory response syndrome (SIRS), peritoneal effusion and pleural effusion. And it also needs longer time for temperature normalization and hospital stay. In conclusion, PLA patients have lower AGR and lower AGR is associated with worse clinical manifestations, more complications and poorer prognosis. Thus, monitoring of AGR is of great clinical significance for evaluating the progress of PLA patients.

Predicting Burn Mortality Using a Simple Novel Prediction Model

Background  Prediction of outcome for burn patients allows appropriate allocation of resources and prognostication. There is a paucity of simple to use burn-specific mortality prediction models which consider both endogenous and exogenous factors. Our objective was to create such a model.

Methods  A prospective observational study was performed on consecutive eligible consenting burns patients. Demographic data, total burn surface area (TBSA), results of complete blood count, kidney function test, and arterial blood gas analysis were collected. The quantitative variables were compared using the unpaired student t -test/nonparametric Mann Whitney U-test. Qualitative variables were compared using the ⊠2-test/Fischer exact test. Binary logistic regression analysis was done and a logit score was derived and simplified. The discrimination of these models was tested using the receiver operating characteristic curve; calibration was checked using the Hosmer—Lemeshow goodness of fit statistic, and the probability of death calculated. Validation was done using the bootstrapping technique in 5,000 samples. A p -value of <0.05 was considered significant.

Results  On univariate analysis TBSA ( p <0.001) and Acute Physiology and Chronic Health Evaluation II (APACHE II) score ( p = 0.004) were found to be independent predictors of mortality. TBSA (odds ratio [OR] 1.094, 95% confidence interval [CI] 1.037–1.155, p = 0.001) and APACHE II (OR 1.166, 95% CI 1.034–1.313, p = 0.012) retained significance on binary logistic regression analysis. The prediction model devised performed well (area under the receiver operating characteristic 0.778, 95% CI 0.681–0.875).

Conclusion  The prediction of mortality can be done accurately at the bedside using TBSA and APACHE II score.

Low-soluble TREM-like transcript-1 levels early after severe burn reflect increased coagulation disorders and predict 30-day mortality

BACKGROUND

Patients with severe burns often show systemic coagulation changes in the early stage and even develop extensive coagulopathy. Previous studies have confirmed that soluble TREM-like transcript-1 (sTLT-1) mediates a novel mechanism of haemostasis and thrombosis in inflammatory vascular injury. At present, the role of sTLT-1 in patients with severe burns is not well known.

OBJECTIVE

To investigate the early association between sTLT-1 levels and markers of burn severity, coagulation disorders, endothelial permeability, shock and prognosis in patients with severe burns.

METHODS

A prospective, observational study was conducted with 60 severe burn patients (divided into a death group and a survival group according to 30-day prognosis) admitted to our hospital. Twenty-eight healthy volunteers were recruited as the control group. Blood components at 48 h after burn were analysed for sTLT-1 and biomarkers reflecting platelet activation, shock, endothelial glycocalyx damage, capillary leakage, haemostasis, fibrinolytic activity, natural anticoagulation and blood cells. We compared the three groups, analysed the correlation between sTLT-1 and biomarkers, and investigated the predictive value of sTLT-1 for 30-day prognosis.

RESULT

Compared with the surviving patients, the patients who died had a lower degree of platelet activation [lower sTLT-1, platelet factor 4 (PF-4) and platelet counts] and a higher degree of burn [higher abbreviated burn severity index score (ABSI score)], shock (higher lactate), endothelial glycocalyx damage [higher syndecan-1 and soluble thrombomodulin (sTM)] and capillary leakage [higher resuscitation fluid (0-48 h), lower albumin] as well as decreased haemostasis [higher activated partial prothrombin time (APTT), lower fibrinogen and thrombin-antithrombin III complex (TAT)], increased fibrinolytic activity [higher D-dimer and tissue-type plasminogen activator (tPA)] and decreased natural anticoagulation [lower protein C (PC) and protein S (PS)]. Higher D-dimer (P = 0.013) and lower PF-4 (P = 0.001) were significantly independently associated with lower sTLT-1. Low circulating sTLT-1 (a unit is 50 pg/mL) (odds ratio [OR] 2.08 [95% CI 1.11-3.92], P = 0.022) was an independent predictor of increased 30-day mortality.

CONCLUSION

Low sTLT-1 levels at 48 h after burn in patients with severe burns is associated with increased coagulation disorders. Low circulating sTLT-1 levels were an independent predictor of increased 30-day mortality.

Lower Serum Albumin Shortly After Admission Predicts Prolonged Hospital Stay in Younger Burn Patients

The purpose of this study was to assess whether albumin levels could be used to aid in the prediction of hospital stay in adult burn patients. A retrospective review of burn patients from 2009 to 2014 was used. Demographic, injury details, albumin levels within 72 hours of admission, and clinical outcomes were recorded. The abbreviated burn severity index (ABSI) was calculated for each patient. Hospital stay >3 weeks was defined as "prolonged stay." Since albumin showed a significant interaction with age, patients were divided into two groups based on a median age of 40 years. Albumin, total BSA, and ABSI were each used as predictors, and the area under the curve (AUC) of a receiver operating characteristic curve was calculated. A composite score was created for the ≤ 40 years age group using ABSI and albumin levels to predict an increased length of stay. Thirty-eight of 198 (19.2%) patients had a stay >3 weeks. The AUCs for albumin level, total BSA, and ABSI alone in younger patients were 0.97, 0.97, and 0.96, respectively. Among patients older than 40, the AUC values were substantially lower indicating lower predictive value. The probability of prolonged stay for patients with albumin level ≥ 2.4 g/dl was low (.8%) compared with those with albumin level <2.4 g/dl (96.5%). Adding ABSI to this model increased predictive accuracy. Albumin level obtained within 72 hours of admission was an effective predictor of prolonged hospital stay in adult burn patients ≤ 40 years.

The Gamma Gap and All-Cause Mortality

Background

The difference between total serum protein and albumin, i.e. the gamma gap, is a frequently used clinical screening measure for both latent infection and malignancy. However, there are no studies defining a positive gamma gap. Further, whether it is an independent risk factor of mortality is unknown.

Methods and Findings

This study examined the association between gamma gap, all-cause mortality, and specific causes of death (cardiovascular, cancer, pulmonary, or other) in 12,260 participants of the National Health and Nutrition Examination Survey (NHANES) from 1999–2004. Participants had a comprehensive metabolic panel measured, which was linked with vital status data from the National Death Index. Cause of death was based on ICD10 codes from death certificates. Analyses were performed with Cox proportional hazards models adjusted for mortality risk factors. The mean (SE) age was 46 (0.3) years and the mean gamma gap was 3.0 (0.01) g/dl. The population was 52% women and 10% black. During a median follow-up period of 4.8 years (IQR: 3.3 to 6.2 years), there were 723 deaths. The unadjusted 5-year cumulative incidences across quartiles of the gamma gap (1.7–2.7, 2.8–3.0, 3.1–3.2, and 3.3–7.9 g/dl) were 5.7%, 4.2%, 5.5%, and 7.8%. After adjustment for risk factors, participants with a gamma gap of ≥3.1 g/dl had a 30% higher risk of death compared to participants with a gamma gap <3.1 g/dl (HR: 1.30; 95%CI: 1.08, 1.55; P = 0.006). Gamma gap (per 1.0 g/dl) was most strongly associated with death from pulmonary causes (HR 2.22; 95%CI: 1.19, 4.17; P = 0.01).

Conclusions

The gamma gap is an independent risk factor for all-cause mortality at values as low as 3.1 g/dl (in contrast to the traditional definition of 4.0 g/dl), and is strongly associated with death from pulmonary causes. Future studies should examine the biologic pathways underlying these associations.

Rhabdomyolysis, compartment syndrome and thermal injury

Rhabdomyolysis (RML) after electrical burns and crush injuries is a well-known clinical entity, but its occurrence following thermal injury has not gained so much attention. Capillary leak syndrome and following polycompartmental syndrome are devastating end results of major thermal injuries. In the current review, polycompartment syndrome within the clinical picture of systemic oedema and its relationship to RML is discussed along with its management and prevention.

Serum albumin level as a risk factor for mortality in burn patients

OBJECTIVE

Hypoalbuminemia is a common clinical deficiency in burn patients and is associated with complications related to increased extravascular fluid, including edema, abnormal healing, and susceptibility to sepsis. Some prognostic scales do not include biochemical parameters, whereas others consider them together with comorbidities. The purpose of this study was to determine whether serum albumin can predict mortality in burn patients.

METHODS

We studied burn patients ≥16 years of age who had complete clinical documentation, including the Abbreviated Burn Severity Index, serum albumin, globulin, and lipids. Sensitivity and specificity analyses were performed to determine the cut-off level of albumin that predicts mortality.

RESULTS

In our analysis of 486 patients, we found that mortality was higher for burns caused by flame (p=0.000), full-thickness burns (p=0.004), inhalation injuries (p=0.000), burns affecting >30% of the body surface area (p=0.001), and burns associated with infection (p=0.008). Protein and lipid levels were lower in the patients who died (p<0.05). Albumin levels showed the highest sensitivity and specificity (84% and 83%, respectively), and the area under the receiver-operating characteristic curve (0.869) had a cut-off of 1.95 g/dL for mortality.

CONCLUSION

Patients with albumin levels <2 g/dL had a mortality risk of >80%, with 84% sensitivity and 83% specificity. At admission, the albumin level could be used as a sensitive and specific marker of burn severity and an indicator of mortality.