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Holloway A, Williams F, Akinkuotu A, Charles A, Gallaher JR. Race, area deprivation index, and access to surgical burn care in a pediatric population in North Carolina. Burns 2023; 49:1298-1304. [PMID: 36682975 PMCID: PMC10349900 DOI: 10.1016/j.burns.2023.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 12/20/2022] [Accepted: 01/11/2023] [Indexed: 01/18/2023]
Abstract
BACKGROUND Burns represent a leading cause of morbidity and mortality for children. This study explores the intersecting effects of social deprivation and race in pediatric burn patients. METHODS We performed a retrospective review of all pediatric patients (<18 years old) admitted to a tertiary burn center in North Carolina from 2009 to 2019. We used bivariate analysis to compare patients based on reported race, comparing African Americans (AA) to all others. Modified Poisson regression was used to model the probability of undergoing autologous skin grafting based on AA race. RESULTS Of 4227 children admitted, AA children were disproportionally represented, comprising 33.7% of patients versus a state population of 22.3%. AA patients had larger %TBSA with a median of 3% (IQR 1-6) compared to 2% (IQR 1-5, p < 0.001) and longer median length of stay at 5.8 days (SD 13.6) versus 4.9 days (SD 13.8). AA patients were more likely to have autologous skin grafting compared to other races, with an adjusted RR of 1.49 (95% CI 1.22-1.83) when controlling for Area Deprivation Index (ADI) national rank, age, %TBSA, and burn type. CONCLUSIONS AA children were disproportionately represented and had larger burns, even when controlling for ADI. They had longer hospital stays and were more likely to have autologous skin grafting, even accounting for burn size and type. The intersection between social deprivation and race creates a unique risk for AA patients. Further investigation into this phenomenon and factors underlying surgical intervention selection are indicated to inform best treatment practices and future preventative strategies.
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Affiliation(s)
- Alexa Holloway
- Department of Surgery, University of North Carolina at Chapel Hill, United States
| | - Felicia Williams
- Department of Surgery, University of North Carolina at Chapel Hill, United States
| | - Adesola Akinkuotu
- Department of Surgery, University of North Carolina at Chapel Hill, United States
| | - Anthony Charles
- Department of Surgery, University of North Carolina at Chapel Hill, United States
| | - Jared R Gallaher
- Department of Surgery, University of North Carolina at Chapel Hill, United States.
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2
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Patterson K, Onwuka A, Schwartz DM, Fabia RB, Thakkar R. Length of Stay per Total Body Surface Area Burn: A Validation Study Using the National Burn Registry. J Burn Care Res 2022; 43:1227-1232. [DOI: 10.1093/jbcr/irac105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
A length of stay (LOS) of one day per percent total body surface area (TBSA) burn has been generally accepted but not validated in current pediatric burn studies. The primary objective of this study is to validate previous Pediatric Injury Quality Improvement Collaboration (PIQIC) findings by using a national burn registry to evaluate LOS per TBSA burn relative to burn mechanism, sociodemographic characteristics, and clinical factors which influence this ratio. We evaluated patients 0-18 years old who sustained a burn injury and whose demographics were submitted to the National Burn Registry (NBR) dataset from July 2008 through June 2018. Mixed effects generalized additive regression models were performed to identify characteristics associated with the LOS per TBSA burn ratio. Among 51,561 pediatric burn patients, 45% were Non-Hispanic White, 58% were male, and median age was 3.0 years old (IQR: 1.0, 9.0). The most common burn mechanism was scald (55.9%). The median LOS per TBSA burn ratio across all cases was 0.9 (IQR: 0.4, 1.75). In adjusted models, scald burns had a mean predicted LOS per TBSA burn value of 1.2 while chemical burns had the highest ratio (4.8). Non-Hispanic White patients had lower LOS per TBSA burn ratios than all other races and ethnicities (p<0.05). These data substantiate evidence on variance in LOS per TBSA burn relative to burn mechanism and race/ethnicity. Knowing these variations can guide expectations in hospital LOS for patients and families and help burn centers benchmark their clinical performance.
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Affiliation(s)
- Kelli Patterson
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children’s Hospital, 700 Children’s Drive , Columbus, OH
| | - Amanda Onwuka
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children’s Hospital, 700 Children’s Drive , Columbus, OH
| | - Dana M Schwartz
- Center for Pediatric Trauma Research, The Research Institute at Nationwide Children’s Hospital, 700 Children’s Drive , Columbus, OH
- Department of Pediatric Surgery, Nationwide Children’s Hospital, 700 Children’s Drive , Columbus, OH
| | - Renata B Fabia
- Center for Pediatric Trauma Research, The Research Institute at Nationwide Children’s Hospital, 700 Children’s Drive , Columbus, OH
- Department of Pediatric Surgery, Nationwide Children’s Hospital, 700 Children’s Drive , Columbus, OH
| | - Rajan Thakkar
- Center for Pediatric Trauma Research, The Research Institute at Nationwide Children’s Hospital, 700 Children’s Drive , Columbus, OH
- Department of Pediatric Surgery, Nationwide Children’s Hospital, 700 Children’s Drive , Columbus, OH
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3
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Gibran NS, Shipper E, Phuong J, Braverman M, Bixby P, Price MA, Bulger EM. Developing a national trauma research action plan: Results from the Burn Research Gap Delphi Survey. J Trauma Acute Care Surg 2022; 92:201-212. [PMID: 34554139 DOI: 10.1097/ta.0000000000003409] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The 2016 National Academies of Science, Engineering and Medicine call for a national integrated, military-civilian trauma action plan to achieve zero preventable deaths and disability after injury included a proposal to establish a National Trauma Research Action Plan to "strengthen trauma research and ensure that the resources available for this research are commensurate with the importance of injury and the potential for improvement in patient outcomes." The Department of Defense funded the Coalition for National Trauma Research to generate a comprehensive research agenda spanning the continuum of trauma/burn care from prehospital to rehabilitation. The Burn/Reconstructive Surgery group represents one focus area for this research agenda development. METHODS Experts in burn and reconstructive surgery research identified gaps in knowledge, generated research questions and prioritized questions using a consensus driven Delphi survey approach. Participants were identified using established Delphi recruitment guidelines to ensure heterogeneity and generalizability with military and civilian representatives. Literature reviews informed the panel. Panelists were encouraged to use a PICO format to generate research questions: Patient/Population; Intervention; Compare/Control; Outcome. Participants ranked the priority of each question on a nine-point Likert scale, which was categorized to represent low, medium, and high priority items. Consensus was defined based on ≥60% panelist agreement. RESULTS Subject matter experts generated 949 research questions in 29 Burn & 26 Reconstruction topics. Five hundred ninety-seven questions reached consensus. Of these, 338 (57%) were high-priority, 180 (30%), medium-priority, and 78 (13%) low-priority questions. CONCLUSION Many high-priority questions translate to complex wound management and outcomes. Panel recognition that significant gaps in knowledge exist in understanding functional outcomes after injury underscores the importance of long-term recovery metrics even when studying acute injury or interventions such as resuscitation or inhalation injury. Funding agencies and burn/reconstructive surgery researchers should consider these gaps when they prioritize future research. LEVEL OF EVIDENCE Expert consensus, Level IV.
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Affiliation(s)
- Nicole S Gibran
- From the Harborview Medical Center UW Department of Surgery (N.S.G., E.B.), Seattle WA; UW Department of Biomedical Informatics and Medical Education (J.P.), Seattle WA; Coalition for National Trauma Research (E.S., M.B., P.B., M.P.), San Antonio, Texas
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4
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Darnell D, Areán PA, Dorsey S, Atkins DC, Tanana MJ, Hirsch T, Mooney SD, Boudreaux ED, Comtois KA. Harnessing Innovative Technologies to Train Nurses in Suicide Safety Planning With Hospitalized Patients: Protocol for Formative and Pilot Feasibility Research. JMIR Res Protoc 2021; 10:e33695. [PMID: 34914618 PMCID: PMC8717131 DOI: 10.2196/33695] [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] [Received: 09/20/2021] [Revised: 10/15/2021] [Accepted: 10/21/2021] [Indexed: 11/29/2022] Open
Abstract
Background Suicide is the 10th leading cause of death in the United States, with >47,000 deaths in 2019. Most people who died by suicide had contact with the health care system in the year before their death. Health care provider training is a top research priority identified by the National Action Alliance for Suicide Prevention; however, evidence-based approaches that target skill-building are resource intensive and difficult to implement. Advances in artificial intelligence technology hold promise for improving the scalability and sustainability of training methods, as it is now possible for computers to assess the intervention delivery skills of trainees and provide feedback to guide skill improvements. Much remains to be known about how best to integrate these novel technologies into continuing education for health care providers. Objective In Project WISE (Workplace Integrated Support and Education), we aim to develop e-learning training in suicide safety planning, enhanced with novel skill-building technologies that can be integrated into the routine workflow of nurses serving patients hospitalized for medical or surgical reasons or traumatic injury. The research aims include identifying strategies for the implementation and workflow integration of both the training and safety planning with patients, adapting 2 existing technologies to enhance general counseling skills for use in suicide safety planning (a conversational agent and an artificial intelligence–based feedback system), observing training acceptability and nurse engagement with the training components, and assessing the feasibility of recruitment, retention, and collection of longitudinal self-report and electronic health record data for patients identified as at risk of suicide. Methods Our developmental research includes qualitative and observational methods to explore the implementation context and technology usability, formative evaluation of the training paradigm, and pilot research to assess the feasibility of conducting a future cluster randomized pragmatic trial. The trial will examine whether patients hospitalized for medical or surgical reasons or traumatic injury who are at risk of suicide have better suicide-related postdischarge outcomes when admitted to a unit with nurses trained using the skill-building technology than those admitted to a unit with untrained nurses. The research takes place at a level 1 trauma center, which is also a safety-net hospital and academic medical center. Results Project WISE was funded in July 2019. As of September 2021, we have completed focus groups and usability testing with 27 acute care and 3 acute and intensive care nurses. We began data collection for research aims 3 and 4 in November 2021. All research has been approved by the University of Washington institutional review board. Conclusions Project WISE aims to further the national agenda to improve suicide prevention in health care settings by training nurses in suicide prevention with medically hospitalized patients using novel e-learning technologies. International Registered Report Identifier (IRRID) DERR1-10.2196/33695
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Affiliation(s)
- Doyanne Darnell
- Department of Psychiatry & Behavioral Sciences, University of Washington, Seattle, WA, United States
| | - Patricia A Areán
- Department of Psychiatry & Behavioral Sciences, University of Washington, Seattle, WA, United States
| | - Shannon Dorsey
- Department of Psychology, University of Washington, Seattle, WA, United States
| | - David C Atkins
- Department of Psychiatry & Behavioral Sciences, University of Washington, Seattle, WA, United States
| | - Michael J Tanana
- Social Research Institute, University of Utah, Salt Lake City, UT, United States
| | - Tad Hirsch
- College of Arts, Media, and Design, Northeastern University, Boston, MA, United States
| | - Sean D Mooney
- Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, WA, United States
| | - Edwin D Boudreaux
- University of Massachusetts Medical School, Worcester, MA, United States
| | - Katherine Anne Comtois
- Department of Psychiatry & Behavioral Sciences, University of Washington, Seattle, WA, United States
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Dukes K, Baldwin S, Assimacopoulos E, Grieve B, Hagedorn J, Wibbenmeyer L. Influential Factors in the Recovery Process of Burn Survivors in a Predominately Rural State: A Qualitative Study. J Burn Care Res 2021; 43:374-380. [PMID: 34891162 DOI: 10.1093/jbcr/irab232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Navigating the recovery journey following a burn injury can be challenging. Survivor stories can help define recovery constructs that can be incorporated into support programs. We undertook this study to determine themes of recovery in a predominately rural state. Eleven purposefully selected burn survivors were interviewed using a semi-structured format. Consensus coding of verbatim transcriptions was used to determine themes of successful recovery. Four support-specific themes were identified. These included: using active coping strategies, expressing altruism through helping others, finding meaning and acceptance, and the active seeking and use of support. These themes could be incorporated into support programming and would help guide future survivors through the recovery period.
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Affiliation(s)
- Kimberly Dukes
- University of Iowa Carver College of Medicine, 200 Hawkins Dr, Iowa City, IA 52242, USA.,Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, Iowa 52246, USA
| | - Stephanie Baldwin
- Department of Obstetrics and Gynecology, University of Florida/Ascension Sacred Heart 5153 North 9 th Ave. #403 Pensacola, FL 32504, USA
| | - Evangelia Assimacopoulos
- University of Iowa Carver College of Medicine, 200 Hawkins Dr, Iowa City, IA 52242, USA.,Department of Emergency Medicine, University of Iowa Hospitals and Clinics, 200 Hawkins Dr, Iowa City, IA 52242, USA
| | - Brian Grieve
- University of Iowa Carver College of Medicine, 200 Hawkins Dr, Iowa City, IA 52242, USA
| | - Joshua Hagedorn
- University of Iowa Carver College of Medicine, 200 Hawkins Dr, Iowa City, IA 52242, USA
| | - Lucy Wibbenmeyer
- University of Iowa Carver College of Medicine, 200 Hawkins Dr, Iowa City, IA 52242, USA.,Department of Surgery, University of Iowa Hospitals and Clinics, 200 Hawkins Dr, Iowa City, IA 52242, USA
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6
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Pompermaier L, Drake Af Hagelsrum E, Ydenius V, Sjöberg F, Steinvall I, Elmasry M. Patient Reported Experiences at a Swedish National Burn Centre. J Burn Care Res 2021; 43:249-255. [PMID: 34131732 PMCID: PMC8737083 DOI: 10.1093/jbcr/irab091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Previous studies have shown that burn patients were satisfied with the received care. Satisfaction was not strongly associated to burns or to psycho-social characteristics, suggesting that other factors, related to burn care specific aspects, may be important. The aim of this study was to analyze the independent effect of provided workload on the general satisfaction in adult patients at a Swedish national Burn Centre. The study population (n = 122) included patients ≥18 years, treated at the Linköping Burn Centre between 2016 and 2017. Experienced burn care was evaluated with the PS-RESKA survey (score range: 0–4), and provided workload was scored with the Burn Scoring System (BSC). Groups were compared with χ 2 test, MW test, or Fisher´s exact test. Multivariable logistic regression analyzed the independent effect of BSC on the outcome High Satisfaction (= score ≥3 to the survey-question: “How would you score your global experience at the Burn Centre?”). In-patients (n = 60) had more often larger burns and required more workload than out-patients (median[IQR]: TBSA% = 6.3 [3–12.3] % vs. 0.7 [0.3–2] %, p < .001; BSC = 65 [25.5–135.5] vs. 6 [4–9], p < .001). Both groups were highly satisfied with the experienced care (mean score [SD] = 3.68 [0.57] vs. 3.41 [0.77], p = .03). Neither characteristics of the patients (age, sex), nor TBSA% nor provided workload (BSC) were independently associated with High Satisfaction. Regardless of burn severity, demographics and provided workload, adult patients with burns were highly satisfied with the experienced burn care. This finding suggested that the reason of the satisfaction was multifactorial.
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Affiliation(s)
- Laura Pompermaier
- Department of Hand Surgery, Plastic Surgery and Burns, Department of Biomedical and Clinical Sciences, Linköping University, Sweden
| | - Emma Drake Af Hagelsrum
- Department of Hand Surgery, Plastic Surgery and Burns, Department of Biomedical and Clinical Sciences, Linköping University, Sweden
| | - Viktor Ydenius
- Department of Hand Surgery, Plastic Surgery and Burns, Department of Biomedical and Clinical Sciences, Linköping University, Sweden
| | - Folke Sjöberg
- Department of Hand Surgery, Plastic Surgery and Burns, Department of Biomedical and Clinical Sciences, Linköping University, Sweden.,Department of Anaesthesiology and Intensive Care, Linköping University, Sweden
| | - Ingrid Steinvall
- Department of Hand Surgery, Plastic Surgery and Burns, Department of Biomedical and Clinical Sciences, Linköping University, Sweden
| | - Moustafa Elmasry
- Department of Hand Surgery, Plastic Surgery and Burns, Department of Biomedical and Clinical Sciences, Linköping University, Sweden
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7
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Giretzlehner M, Ganitzer I, Haller H. Technical and Medical Aspects of Burn Size Assessment and Documentation. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:242. [PMID: 33807630 PMCID: PMC7999209 DOI: 10.3390/medicina57030242] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 02/18/2021] [Accepted: 03/02/2021] [Indexed: 11/16/2022]
Abstract
In burn medicine, the percentage of the burned body surface area (TBSA-B) to the total body surface area (TBSA) is a crucial parameter to ensure adequate treatment and therapy. Inaccurate estimations of the burn extent can lead to wrong medical decisions resulting in considerable consequences for patients. These include, for instance, over-resuscitation, complications due to fluid aggregation from burn edema, or non-optimal distribution of patients. Due to the frequent inaccurate TBSA-B estimation in practice, objective methods allowing for precise assessments are required. Over time, various methods have been established whose development has been influenced by contemporary technical standards. This article provides an overview of the history of burn size estimation and describes existing methods with a critical view of their benefits and limitations. Traditional methods that are still of great practical relevance were developed from the middle of the 20th century. These include the "Lund Browder Chart", the "Rule of Nines", and the "Rule of Palms". These methods have in common that they assume specific values for different body parts' surface as a proportion of the TBSA. Due to the missing consideration of differences regarding sex, age, weight, height, and body shape, these methods have practical limitations. Due to intensive medical research, it has been possible to develop three-dimensional computer-based systems that consider patients' body characteristics and allow a very realistic burn size assessment. To ensure high-quality burn treatment, comprehensive documentation of the treatment process, and wound healing is essential. Although traditional paper-based documentation is still used in practice, it no longer meets modern requirements. Instead, adequate documentation is ensured by electronic documentation systems. An illustrative software already being used worldwide is "BurnCase 3D". It allows for an accurate burn size assessment and a complete medical documentation.
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Affiliation(s)
- Michael Giretzlehner
- Research Unit for Medical Informatics, RISC Software GmbH, Johannes Kepler University Linz, Upper Austrian Research GmbH, A-4232 Hagenberg, Austria;
| | - Isabell Ganitzer
- Research Unit for Medical Informatics, RISC Software GmbH, Johannes Kepler University Linz, Upper Austrian Research GmbH, A-4232 Hagenberg, Austria;
| | - Herbert Haller
- Trauma Hospital Berlin, Trauma Hospital Linz (ret), HLMedConsult, A-4020 Leonding, Austria;
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Witt CE, Stewart BT, Rivara FP, Mandell SP, Gibran NS, Pham TN, Arbabi S. Inpatient and post-discharge outcomes following inhalation injury among critically injured burn patients. J Burn Care Res 2021; 42:1168-1175. [PMID: 33560337 DOI: 10.1093/jbcr/irab029] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Inhalation injury is associated with high inpatient mortality, but the impact of inhalation injury after discharge and on non-mortality outcomes are poorly characterized. To address this gap, we evaluated the effect of inhalation injury on post-discharge morbidity, mortality and hospital readmissions among patients who sustained burn injury, as well as on in-hospital outcomes for context.This was a retrospective cohort study of patients with cutaneous fire/flame burns admitted to a burn center intensive care unit from 1/1/2009-12/31/2015, with or without inhalation injury. Records were linked to statewide hospital admission and vital statistics databases to assess post-discharge outcomes. Mixed-effects Poisson regression was used to assess mortality, complications, and readmissions. The overall cohort included 830 patients with cutaneous burns; of these, 201 patients had inhalation injury. In-hospital mortality was 31% among inhalation injury patients versus 6% in patients without inhalation injury (adjusted OR 2.35; 95% CI 1.66-3.31). Inhalation injury was also associated with an increased risk of in-hospital pneumonia and tracheostomy (p<0.05 for all). Inhalation injury was not associated with greater post-discharge mortality, all-cause readmission, readmission for pulmonary diagnosis, or readmission requiring intubation. Among the subset of patients with bronchoscopy-confirmed inhalation injury (n=124; 62% of inhalation injuries), higher injury grade was not associated with greater inpatient or post-discharge mortality. Inhalation injury was associated with increased early morbidity and mortality, but did not contribute to post-discharge mortality or readmission. These findings have implications for shared decision-making with patients and families, and for estimating healthcare utilization after initial hospitalization.
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Affiliation(s)
- Cordelie E Witt
- Department of Surgery, University of Colorado, Denver, CO.,Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA
| | - Barclay T Stewart
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA.,Department of Surgery, University of Washington, Seattle, WA
| | - Frederick P Rivara
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA.,Department of Pediatrics, University of Washington, Seattle, WA
| | - Samuel P Mandell
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA.,Department of Surgery, University of Washington, Seattle, WA
| | - Nicole S Gibran
- Department of Surgery, University of Washington, Seattle, WA
| | - Tam N Pham
- Department of Surgery, University of Washington, Seattle, WA
| | - Saman Arbabi
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA.,Department of Surgery, University of Washington, Seattle, WA
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9
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Stoppe C, Hill A, Day AG, Kristof AS, Hundeshagen G, Kneser U, Beier J, Lumenta D, Kim BS, Plock J, Collins DP, Gille J, Jiang X, Heyland DK. The initial validation of a novel outcome measure in severe burns- the Persistent Organ Dysfunction +Death: Results from a multicenter evaluation. Burns 2020; 47:765-775. [PMID: 33288334 DOI: 10.1016/j.burns.2020.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 08/25/2020] [Accepted: 09/24/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION A need exists to improve the efficiency of clinical trials in burn care. The objective of this study was to validate "Persistent Organ Dysfunction" plus death as endpoint in burn patients and to demonstrate its statistical efficiency. METHODS This secondary outcome analysis of a dataset from a prospective international multicenter RCT (RE-ENERGIZE) included patients with burned total body surface area >20% and a 6-month follow-up. Persistent organ dysfunction was defined as persistence of organ dysfunction with life-supportiing technologies and ICU care. RESULTS In the 539 included patients, the prevalence of 0p p+ pdeath was 40% at day 14 and of 27% at day 28. At both timepoints, survivors with POD (vs. survivors without POD) had a higher mortality rate, longer ICU- and hospital-stays, and a reduced quality of life. POD + death as an endpoint could result in reduced sample size requirements for clinical trials. Detecting a 25% relative risk reduction in 28-day mortality would require a sample size of 4492 patients, whereas 1236 patients would be required were 28-day POD + death used. CONCLUSIONS POD + death represents a promising composite outcome measure that may reduce the sample size requirements of clinical trials in severe burns patients. Further validation in larger clinical trials is warranted. STUDY TYPE Prospective cohort study, level of evidence: II.
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Affiliation(s)
- Christian Stoppe
- Department of Intensive Care Medicine, University Hospital RWTH, Aachen, Germany; CARE-Cardiovascular Critical Care & Anesthesia Evaluation and Research, Aachen, Germany
| | - Aileen Hill
- Department of Intensive Care Medicine, University Hospital RWTH, Aachen, Germany; CARE-Cardiovascular Critical Care & Anesthesia Evaluation and Research, Aachen, Germany
| | - Andrew G Day
- KGH Research Institute, Kingston Health Sciences Centre, Kingston, Ontario
| | - Arnold S Kristof
- Meakins-Christie Laboratories and Translational Research in Respiratory Diseases Program, Research Institute of the McGill University Health Centre, Faculty of Medicine, Departments of Medicine and Critical Care, Montreal, Canada
| | - Gabriel Hundeshagen
- Department of Hand, Plastic and Reconstructive Surgery, Burn Trauma Center. BG Trauma Center Ludwigshafen; University of Heidelberg, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Burn Trauma Center. BG Trauma Center Ludwigshafen; University of Heidelberg, Germany
| | - Justus Beier
- Department of Plastic, Hand and Burn Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - David Lumenta
- Research Unit for Tissue Regeneration, Repair and Reconstruction, Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Bong-Sung Kim
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Jan Plock
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Declan P Collins
- Department of Burns and Plastic Surgery, Chelsea and Westminster Hospital, London, United Kingdom
| | - Jochen Gille
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy. Burn Unit. St. Georg Hospital GmbH Leipzig, 04129 Leipzig, Germany
| | - Xuran Jiang
- Department of Critical Care Medicine, Queen´s University, K7L 2V7 Kingston, Canada
| | - Daren K Heyland
- Department of Critical Care Medicine, Queen´s University, K7L 2V7 Kingston, Canada.
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10
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Demographics and clinical outcomes of adult burn patients admitted to a single provincial burn centre: A 40-year review. Burns 2020; 46:1958-1967. [PMID: 32660831 DOI: 10.1016/j.burns.2020.06.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 06/23/2020] [Indexed: 11/18/2022]
Abstract
INTRODUCTION This study evaluated trends in demographics and outcomes of cutaneous burns over a forty-year period at a Canadian burn centre. METHODS Retrospective review was performed of all consecutive adult burn admissions to the Vancouver General Hospital (VGH) between 1976 and 2015. Comparison was made to the 2016 American Burn Association - National Burn Repository. RESULTS There were 4105 admissions during study period. Both overall admissions and admissions per 100,000 BC residents declined (p < 0.0001). Males represented three quarters of admissions. There was a decrease in large burns (p < 0.05). Flame burns were most commonly associated with larger TBSA, ICU stays, and mortality. Mortality decreased from 11.3% to 2.8% (p < 0.05). Factors found to affect mortality included: increased length of stay, age and burn size, male gender, and number of complications. Baux50 and rBaux50 increased, from 102.8 to 116.7 and 112.2 to 125.3 respectively (p < 0.05, respectively). CONCLUSIONS This study represents the largest report on burn epidemiology in Canada. The incidence of burns has decreased significantly over the last forty years. Mortality has improved over this time frame, as evident by increases in Baux50 and rBaux50 scores. Further data is largely in concurrence with that of the National Burn Repository's amalgamation of US centres.
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11
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Armstrong M, Wheeler KK, Shi J, Thakkar RK, Fabia RB, Groner JI, Noffsinger D, Giles SA, Xiang H. Epidemiology and trend of US pediatric burn hospitalizations, 2003-2016. Burns 2020; 47:551-559. [PMID: 33781634 DOI: 10.1016/j.burns.2020.05.021] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 05/15/2020] [Accepted: 05/21/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Thermal injury is a leading cause of unintentional pediatric trauma morbidity and mortality. METHODS This retrospective analysis of the 2003-2016 Kids' Inpatient Database (KID) included children <18 years old with a burn principal diagnosis. The objectives were to describe the trend of US pediatric burn hospital admissions and the patient and hospital characteristics of admitted children in 2016. The trends (2003-2012) and (2012-2016) were evaluated separately due to the 2015 implementation of International Classification of Diseases, Tenth Revision (ICD-10). RESULTS The population rate of pediatric burn admissions decreased by 4.6% from 2003 to 2012, but the proportion of admissions to hospitals with burn pediatric patient volumes≥100 increased by 63.9%. The overall mortality rate of hospitalized burn patients decreased by 48.1%. Median length of stay increased slightly for patients with a burn ≥20% total body surface area (TBSA) but decreased for patients with TBSA burn <20%. From 2012 to 2016, the population rate decreased by 13.4%. In 2016, an estimated 8160 children were admitted with a burn principal diagnosis, and 41.4% transferred in from other facilities. Children age 1-4 years were the most commonly admitted age group (49.7%). Patients with ≥20% TBSA burns accounted for 7.8% of admissions (95% confidence interval [CI]: 5.1-10.4%). Burn-related complications were documented in 5.9% of admissions (95% CI: 4.6-7.1%). CONCLUSION Pediatric burn hospitalizations and burn-related mortality have decreased over time. The increases in transfers and admissions to hospitals with high pediatric burn volumes suggest increasing regionalization of care.
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Affiliation(s)
- Megan Armstrong
- Center for Pediatric Trauma Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA; Center for Injury Research and Policy, The Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA.
| | - Krista K Wheeler
- Center for Pediatric Trauma Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA; Center for Injury Research and Policy, The Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA; Department of Pediatric Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA.
| | - Junxin Shi
- Biostatistics Resource, The Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA.
| | - Rajan K Thakkar
- Center for Pediatric Trauma Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA; Department of Pediatric Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA; Department of Pediatrics, The Ohio State University, 370 West 9th Avenue, Columbus, OH 43210, USA.
| | - Renata B Fabia
- Center for Pediatric Trauma Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA; Department of Pediatric Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA; Department of Pediatrics, The Ohio State University, 370 West 9th Avenue, Columbus, OH 43210, USA.
| | - Jonathan I Groner
- Center for Pediatric Trauma Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA; Center for Injury Research and Policy, The Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA; Department of Pediatric Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA; Department of Pediatrics, The Ohio State University, 370 West 9th Avenue, Columbus, OH 43210, USA.
| | - Dana Noffsinger
- Center for Pediatric Trauma Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA; Department of Pediatric Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA.
| | - Sheila A Giles
- Center for Pediatric Trauma Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA; Department of Pediatric Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA.
| | - Henry Xiang
- Center for Pediatric Trauma Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA; Center for Injury Research and Policy, The Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA; Department of Pediatrics, The Ohio State University, 370 West 9th Avenue, Columbus, OH 43210, USA.
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12
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Krasnoff CC, Grigorian A, Chin T, Joe V, Kong A, Barrios C, Kuza CM, Nahmias J. Pediatric burn-trauma patients have increased length of stay compared to trauma-only patients: A propensity matched analysis. Burns 2020; 47:78-83. [PMID: 33293153 DOI: 10.1016/j.burns.2020.04.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 04/17/2020] [Accepted: 04/24/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Trauma is the leading cause of mortality in children. Burn injury involves intensive resources, especially in pediatric patients. We hypothesized that among pediatric trauma patients, combined burn-trauma (BT) patients have increased length of stay (LOS) and mortality compared to trauma-only (T) patients. METHODS The Pediatric Trauma Quality Improvement Program (2014-2016) was queried and BT patients were 1:2 propensity-score-matched to T patients based on age, gender, hypotension on admission, injury type and severity. RESULTS 93 BT patients were matched to 186 T patients. There were no differences in matched characteristics. BT patients had a longer median LOS (4 vs 2 days, p<0.001) with no difference in mortality (1.1% vs 1.1%, p=1.00), intensive care unit (ICU) LOS (3 vs 3 days, p=0.55), or complications including decubitus ulcer (0% vs 1.1%, p=0.32), deep vein thrombosis (0% vs 0.5%, p=0.48), extremity compartment syndrome (1.1% vs 0%, p=0.16), and urinary tract infection (1.1% vs 1.1%, p=1.00). CONCLUSION Pediatric BT patients had twice the LOS compared to a matched group of pediatric T patients. There was no difference between the cohorts in ICU LOS, complications or mortality rate. When evaluating risk-stratified quality metrics such as LOS, concomitant burn injury should be incorporated.
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Affiliation(s)
- Chloe C Krasnoff
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA, USA.
| | - Areg Grigorian
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA, USA
| | - Theresa Chin
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA, USA
| | - Victor Joe
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA, USA
| | - Allen Kong
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA, USA
| | - Cristobal Barrios
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA, USA
| | - Catherine M Kuza
- University of Southern California, Department of Anesthesiology, Los Angeles, CA, USA
| | - Jeffry Nahmias
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA, USA
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13
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Curtis EE, Yenikomshian HA, Carrougher GJ, Gibran NS, Mandell SP. Early patient deaths after transfer to a regional burn center. Burns 2019; 46:97-103. [PMID: 31859086 DOI: 10.1016/j.burns.2019.02.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 02/04/2019] [Accepted: 02/27/2019] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Patients who sustain burn injuries are frequently transferred to regional burn centers. Severely injured patients, unlikely to survive, may be transported far from home and family to die shortly after arrival. An examination of early deaths, those that happen within a week of transfer, may offer an opportunity to revise the way we think about critical burns and consider the best way to provide regional care. METHODS This is a focused review of burn patients who survived ≤1 week after transfer to a regional center from 2013-2017. Originating location data such as city, state, population at origin were obtained. Transfer data, including mode of transport and distance traveled, as well as patient characteristics, Total Body Surface Area (TBSA) burned, inhalation injury, medical history with calculation of revised-Baux (r-Baux) score were analyzed. RESULTS 25 patients (1.2%) met inclusion criteria. Patients were transferred from a wide geographic area with population ranges of 1000 to 279,000. 21 patients met criteria for burn resuscitation by TBSA; 4 (19%) were placed on comfort care upon arrival, 7 (33%) were placed on comfort care after discussion with the patient's family, and 10 (48%) received full resuscitation efforts. Of these 10 patients, 2 died as "full code", 8 were transitioned to comfort care after failed resuscitation or other events. Code status was not always addressed prior to the decision to transfer. Two patients were transferred after cardiac arrest in the field both of which had significant medical comorbidities in addition to their burn. CONCLUSIONS Regional burn centers support a variety of populations. Transferring patients for which care is futile may have a profound impact on resource utilization from a variety of perspectives including transferring centers, receiving centers, regional Emergency Medical Services and families. Referring providers need to be supported in identifying these severely injured, potentially expectant patients. Transfer of patients may negatively impact families as a loved one may die far from home, before family can arrive. With our increasing ability to utilize telemedicine, transfer may not always provide the best support we can offer for providers, patients, and families. APPLICABILITY OF RESEARCH TO PRACTICE Early deaths after transfer to a regional burn center, especially those that do not undergo a full resuscitation, should be critically examined to determine the appropriateness of transfer in a palliative, patient and family centered approach.
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Affiliation(s)
- Eleanor E Curtis
- Department of Surgery, UW Medicine Regional Burn Center, University of Washington, Seattle, WA, United States.
| | - Haig A Yenikomshian
- Department of Plastic Surgery, University of Southern California, Los Angeles, CA, United States
| | - Gretchen J Carrougher
- Department of Surgery, UW Medicine Regional Burn Center, University of Washington, Seattle, WA, United States
| | - Nicole S Gibran
- Department of Surgery, UW Medicine Regional Burn Center, University of Washington, Seattle, WA, United States
| | - Samuel P Mandell
- Department of Surgery, UW Medicine Regional Burn Center, University of Washington, Seattle, WA, United States
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14
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Abstract
Burn injury is the most devastating of survivable injuries and is a worldwide public health crisis. Burn injury is among the most severe metabolic stresses a patient can sustain. A major burn leads to an inflammatory response and catabolism that, when compounded by burn wound nutrient losses, can lead to severe nutrition losses and deficiencies. These losses can impair immune function and wound healing and place burn patients at high risk for organ injury and mortality. Experimental data indicate glutamine (GLN) is well positioned mechanistically, perhaps above and beyond in any other intensive care unit setting, to improve outcome in burn-injured patients. Initial clinical trial data have also shown a consistent signal of reduced mortality and reduced hospital length of stay in burn-injured subjects, without signals of clinical risk. A number of GLN clinical trials demonstrate significant reductions of gram-negative bacteremia in burn injury, perhaps via maintenance of the gut barrier or gut immune function. Current societal recommendations continue to suggest the use of GLN in burn injury. The promising clinical data in burn-injured patients, with no signals of harm, have warranted study of GLN in the definitive RE-ENERGIZE trial, which is now ongoing.
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Affiliation(s)
- Paul E Wischmeyer
- Department of Anesthesiology and Duke Clinical Research Institute, Duke University Hospital, Durham, North Carolina, USA
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15
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Anderson KT, Bartz-Kurycki MA, Garwood GM, Martin R, Gutierrez R, Supak DN, Wythe SN, Kawaguchi AL, Austin MT, Huzar TF, Tsao K. Let the right one in: High admission rate for low-acuity pediatric burns. Surgery 2019; 165:360-364. [DOI: 10.1016/j.surg.2018.06.046] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 05/11/2018] [Accepted: 06/25/2018] [Indexed: 10/28/2022]
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16
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Abdelrahman I, Steinvall I, Fredrikson M, Sjoberg F, Elmasry M. Use of the burn intervention score to calculate the charges of the care of burns. Burns 2019; 45:303-309. [PMID: 30612888 DOI: 10.1016/j.burns.2018.12.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 11/16/2018] [Accepted: 12/10/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND To our knowledge this is the first published estimate of the charges of the care of burns in Sweden. The Linköping Burn Interventional Score has been used to calculate the charges for each burned patient since 1993. The treatment of burns is versatile, and depends on the depth and extension of the burn. This requires a flexible system to detect the actual differences in the care provided. We aimed to describe the model of burn care that we used to calculate the charges incurred during the acute phase until discharge, so it could be reproduced and applied in other burn centres, which would facilitate a future objective comparison of the expenses in burn care. METHODS All patients admitted with burns during the period 2010-15 were included. We analysed clinical and economic data from the daily burn scores during the acute phase of the burn until discharge from the burn centre. RESULTS Total median charge/patient was US$ 28 199 (10th-90th centiles 4668-197 781) for 696 patients admitted. Burns caused by hot objects and electricity resulted in the highest charges/TBSA%, while charges/day were similar for the different causes of injury. Flame burns resulted in the highest mean charges/admission, probably because they had the longest duration of stay. Mean charges/patient increased in a linear fashion among the different age groups. CONCLUSION Our intervention-based estimate of charges has proved to be a valid tool that is sensitive to the procedures that drive the costs of the care of burns such as large TBSA%, intensive care, and operations. The burn score system could be reproduced easily in other burn centres worldwide and facilitate the comparison regardless of the differences in the currency and the economic circumstances.
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Affiliation(s)
- Islam Abdelrahman
- The Plastic Surgery Unit, Surgery Department, Suez Canal University, Ismailia, Egypt; Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden.
| | - Ingrid Steinvall
- Department of Hand Surgery, Plastic Surgery and Burns, Department of Clinical and Experimental Medicine, 8 Linköping University, Linköping, Sweden.
| | - Mats Fredrikson
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden.
| | - Folke Sjoberg
- Department of Hand Surgery, Plastic Surgery and Burns, Department of Clinical and Experimental Medicine, 8 Linköping University, Linköping, Sweden; Department of Anaesthesiology and Intensive Care, Linköping University, Linköping, Sweden.
| | - Moustafa Elmasry
- The Plastic Surgery Unit, Surgery Department, Suez Canal University, Ismailia, Egypt; Department of Hand Surgery, Plastic Surgery and Burns, Department of Clinical and Experimental Medicine, 8 Linköping University, Linköping, Sweden.
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17
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Carrougher GJ, McMullen K, Mandell SP, Amtmann D, Kowalske KJ, Schneider JC, Herndon DN, Gibran NS. Impact of Burn-Related Amputations on Return to Work: Findings From the Burn Injury Model System National Database. J Burn Care Res 2018; 40:21-28. [DOI: 10.1093/jbcr/iry057] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
| | - Kara McMullen
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington
| | - Samuel P Mandell
- Department of Surgery, University of Washington, Seattle, Washington
| | - Dagmar Amtmann
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington
| | | | - Jeffrey C Schneider
- Spaulding Rehabilitation Hospital/Harvard Medical School, Boston, Massachusetts
| | | | - Nicole S Gibran
- Department of Surgery, University of Washington, Seattle, Washington
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18
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Baldwin S, Yuan H, Liao J, Grieve B, Heard J, Wibbenmeyer LA. Burn Survivor Quality of Life and Barriers to Support Program Participation. J Burn Care Res 2018; 39:823-830. [DOI: 10.1093/jbcr/irx058] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
| | - Haimao Yuan
- Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City
| | - Junlin Liao
- Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City
| | - Brian Grieve
- University of Iowa Carver College of Medicine, Iowa City
| | - Jason Heard
- Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City
| | - Lucy A Wibbenmeyer
- Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City
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Video-Enhanced Telemedicine Improves the Care of Acutely Injured Burn Patients in a Rural State. J Burn Care Res 2018; 37:e531-e538. [PMID: 26132049 DOI: 10.1097/bcr.0000000000000268] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The acute care of burn patients is critical and can be a daunting experience for emergency personnel because of the scarcity of burn injuries. Telemedicine that incorporates a visual component can provide immediate expertise in the treatment and management of these injuries. The authors sought to evaluate the addition of video telemedicine to our current telephone burn transfer program. During a 2-year period, 282 patients, 59.4% of all burn patients transferred from outside hospitals, were enrolled in the study. In addition to the scripted call with the charge nurse (ChargeRN) and the accepting physician, nine hospitals also transmitted video images of the wounds before transfer as part of a store and forward telemedicine transfer program (77, 27.6%). The accuracy of burn size estimations (BSA burned) and management changes (fluid requirements, transfer mode, and final disposition) were analyzed between the telephones-only sites (T only) and the video-enhanced sites. Referringstaff participating in video-enhanced telemedicine were sent a Google survey assessing their experience the following day. The referring staff (Referringstaff) was correct in their burn assessment 20% of the time. Video assessment improved the ChargeRN BSA burned and resulted in more accurate fluid resuscitation (P = .030), changes in both transportation mode (P = .042), and disposition decisions (P = .20). The majority of the Referringstaff found that video-enhanced telemedicine helped them communicate with the burn staff more effectively (3.4 ± 0.37, scale 1-4). This study reports the successful implementation of video-enhanced telemedicine pilot project in a rural state. Video-enhanced telemedicine using a store and forward process improved burn size estimation and facilitated management changes. Although not quantitatively assessed, the low cost of the system coupled with the changes in transportation and disposition strongly suggests a decrease in healthcare costs associated with the addition of video to a telephone-only transfer program.
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20
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Validation of the burn intervention score in a National Burn Centre. Burns 2018; 44:1159-1166. [PMID: 29475745 DOI: 10.1016/j.burns.2018.02.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2017] [Revised: 01/11/2018] [Accepted: 02/02/2018] [Indexed: 11/20/2022]
Abstract
The Linköping burn score has been used for two decades to calculate the cost to the hospital of each burned patient. Our aim was to validate the Burn Score in a dedicated Burn Centre by analysing the associations with burn-specific factors: percentage of total body surface area burned (TBSA%), cause of injury, patients referred from other (non-specialist) centres, and survival, to find out which of these factors resulted in higher scores. Our second aim was to analyse the variation in scores of each category of care (surveillance, respiration, circulation, wound care, mobilisation, laboratory tests, infusions, and operation). We made a retrospective analysis of all burned patients admitted during the period 2000-15. Multivariable regression models were used to analyse predictive factors for an increased daily burn score, the cumulative burn score (the sum of the daily burn scores for each patient) and the total burn score (total sum of burn scores for the whole group throughout the study period) in addition to sub-analysis of the different categories of care that make up the burn score. We retrieved 22301 daily recordings for inpatients. Mobilisation and care of the wound accounted for more than half of the total burn score during the study. Increased TBSA% and age over 45 years were associated with increased cumulative (model R2 0.43, p<0.001) and daily (model R2 0.61, p<0.001) burn scores. Patients who died had higher daily burn scores, while the cumulative burn score decreased with shorter duration of hospital stay (p<0.001). To our knowledge this is the first long term analysis and validation of a system for scoring burn interventions in patients with burns that explores its association with the factors important for outcome. Calculations of costs are based on the score, and it provides an indicator of the nurses' workload. It also gives important information about the different dimensions of the care provided from thorough investigation of the scores for each category.
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21
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Heyland DK, Wischmeyer P, Jeschke MG, Wibbenmeyer L, Turgeon AF, Stelfox HT, Day AG, Garrel D. A RandomizEd trial of ENtERal Glutamine to minimIZE thermal injury (The RE-ENERGIZE Trial): a clinical trial protocol. Scars Burn Heal 2017; 3:2059513117745241. [PMID: 29799545 PMCID: PMC5965329 DOI: 10.1177/2059513117745241] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Burn injury represents a significant public health problem worldwide. More
than in any other injury, the inflammation and catabolism associated with
severe burns can exacerbate nutrient deficiencies resulting in impaired
immune function and increased risk of developing infection, organ
dysfunction and death. Consequently, over the last few decades numerous
trials have evaluated the impact of different nutritional strategies in
severe burn injury. Glutamine is of particular interest, as it appears vital
for a number of key stress-response pathways in serious illness. The purpose
of the current manuscript is to provide the rationale and protocol for a
large clinical trial of supplemental enteral glutamine in 2700 severe
burn-injured patients. Methods: We propose a multicentre, double-blind, pragmatic, randomized, clinical trial
involving 80 tertiary intensive care unit (ICU) burn centres worldwide. We
aim to enrol patients with deep second- and/or third-degree burns at
moderate or high risk for death. We will exclude patients admitted > 72 h
before screening and patients with advanced liver and kidney disease. The
study intervention consists of enteral glutamine 0.5 g/kg/day vs. isocaloric
maltodextran control delivered enterally. Primary outcome will be six-month
mortality. Key secondary outcomes include time to discharge alive from
hospital, ICU and hospital mortality, length of stay and health-related
quality of life at six months. Significance: This study will be the first large international multicentre trial examining
the effects of glutamine in burn patients. Negative or positive, the results
of this trial will inform the clinical practice of burns care worldwide. Clinicaltrials.gov ID #NCT00985205 Patients with severe burns need to recover in a hospital burn unit for a long
time and are at high risk of developing infections and dying. Proper nutrition
and certain nutrients may improve survival in these patients and shorten their
stay in the burn unit. Glutamine is a building block of protein that is normally
made in the body and is found in different foods we eat. It is of great interest
because it has several beneficial effects on the body during serious illness,
such as with burn injury. In this study, we will look at the effect of glutamine
supplementation on survival and time spent in hospital. A total of 80 burn units
around the world will enrol 2700 patients with 2nd or 3rd degree burns over 4
years. Patients will receive either glutamine powder or a placebo through a
feeding tube or mixed with food, from admission to the burn unit, until a week
after the burn wound has healed. The main outcome for this study is survival at
6 months. Other outcomes include the time taken to be discharged from hospital
alive and duration of stay in the burn unit. This study will be the first large
international multicentre trial examining the effects of glutamine in burn
patients. Glutamine may lead to better survival and less complications in burn
patients, who have a devastating and disabling burn injury. If the trial is
positive, the results will be used to inform how nutrition should be given to
such patients worldwide.
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Affiliation(s)
- Daren K Heyland
- Department of Critical Care Medicine, Kingston General Hospital, Kingston, ON, Canada.,Department of Public Health Sciences, Queen's University, Kingston, ON, Canada.,Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, ON, Canada
| | - Paul Wischmeyer
- Department of Anesthesiology and Surgery, Duke Clinical Research Institute. Duke University School of Medicine, Durham, NC, USA
| | - Marc G Jeschke
- Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute Department of Surgery, Division of Plastic Surgery, Department of Immunology University of Toronto, Toronto, ON, Canada
| | | | - Alexis F Turgeon
- CHU de Québec - Université Laval Research Centre, Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Université Laval, Québec City, QC, Canada.,Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec City, QC, Canada
| | - Henry T Stelfox
- Department of Critical Care Medicine and O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
| | - Andrew G Day
- Department of Public Health Sciences, Queen's University, Kingston, ON, Canada
| | - Dominique Garrel
- Department of Nutrition, Faculty of Medicine, University of Montreal, Montreal, QC, Canada
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Elmasry M, Steinvall I, Abdelrahman I, Olofsson P, Sjoberg F. Changes in patterns of treatment of burned children at the Linkoping Burn Centre, Sweden, 2009–2014. Burns 2017; 43:1111-1119. [DOI: 10.1016/j.burns.2017.02.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 02/16/2017] [Accepted: 02/20/2017] [Indexed: 11/26/2022]
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23
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Tang CQ, Li JQ, Shou BM, Pan BH, Chen TS, Xiao YQ, Zheng XP, Xiao SC, Tan Q, Xia ZF. Epidemiology and outcomes of bloodstream infections in 177 severe burn patients from an industrial disaster: a multicentre retrospective study. Clin Microbiol Infect 2017. [PMID: 28642142 DOI: 10.1016/j.cmi.2017.06.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVES To determine the characteristics of bloodstream infections (BSIs) and to evaluate the impact of BSIs on mortality in severe burn patients. METHODS A retrospective observational study was conducted in 20 tertiary hospitals. A total of 185 patients who experienced a massive dust explosion in eastern China were included. RESULTS After exclusion, 177 patients were analysed. The median total body surface area (TBSA) burned was 95% (interquartile range 85%-98%). Inhalation injuries occurred in 97.2%. The overall 90-day mortality was 35% (62/177). During the study period, 120 (67.8%) patients developed 253 episodes of BSI with 323 unique causative pathogens. Sixty-six episodes were polymicrobial infections. Catheter-related BSIs (CRBSIs) accounted for 41.5% of the episodes. Acinetobacter baumannii (19.5%), Klebsiella pneumoniae (13.9%) and Candida (12.7%) were the most common organisms. Antimicrobial resistance was found in 63.5% of the isolates, particularly in Gram-negative bacteria. Patients who developed BSIs had a greater illness severity at admission to the intensive care unit, and worse outcomes. After adjusting for demographics, severity of illness and treatment characteristics in a multivariate logistic model, there was a trend toward BSI increasing the risk of 90-day mortality (adjusted OR 3.4; 95% CI 0.9-12.9; p=0.069). In subgroup analyses, CRBSIs (adjusted OR 5.7; 95% CI 1.3-24.9; p=0.021 versus no BSI) and polymicrobial BSIs (adjusted OR 6.1; 95% CI 1.3-28.1; p=0.020 versus no BSI) had greater risk of 90-day mortality. CONCLUSIONS A strikingly high rate of BSIs was observed in severe burn patients. Gram-negative organisms and fungi were the leading causes. CRBSIs and polymicrobial BSIs were associated with high mortality.
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Affiliation(s)
- C Q Tang
- Department of Burn Surgery, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - J Q Li
- Department of Burn Surgery, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - B M Shou
- Department of Burns and Plastic Surgery, The Drum Tower Clinical Medical College, Nanjing Medical University, Nanjing, Jiangsu, China
| | - B H Pan
- Department of Burn Surgery, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - T S Chen
- Department of Burn Surgery, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Y Q Xiao
- Department of Burn Surgery, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - X P Zheng
- Department of Burn Surgery, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - S C Xiao
- Department of Burn Surgery, Changhai Hospital, The Second Military Medical University, Shanghai, China.
| | - Q Tan
- Department of Burns and Plastic Surgery, Affiliated Drum Tower Hospital, Nanjing University Medical School, Nanjing, Jiangsu, China.
| | - Z F Xia
- Department of Burn Surgery, Changhai Hospital, The Second Military Medical University, Shanghai, China.
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Hold the Pendulum: Rates of Acute Kidney Injury are Increased in Patients Who Receive Resuscitation Volumes Less than Predicted by the Parkland Equation. Ann Surg 2017; 264:1142-1147. [PMID: 27828823 DOI: 10.1097/sla.0000000000001615] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To determine whether restrictive fluid resuscitation results in increased rates of acute kidney injury (AKI) or infectious complications. BACKGROUND Studies demonstrate that patients often receive volumes in excess of those predicted by the Parkland equation, with potentially detrimental sequelae. However, the consequences of under-resuscitation are not well-studied. METHODS Data were collected from a multicenter prospective cohort study. Adults with greater than 20% total burned surface area injury were divided into 3 groups on the basis of the pattern of resuscitation in the first 24 hours: volumes less than (restrictive), equal to, or greater than (excessive) standard resuscitation (4 to 6 cc/kg/% total burned surface area). Multivariable regression analysis was employed to determine the effect of fluid group on AKI, burn wound infections (BWIs), and pneumonia. RESULTS Among 330 patients, 33% received restrictive volumes, 39% received standard resuscitation volumes, and 28% received excessive volumes. The standard and excessive groups had higher mean baseline APACHE scores (24.2 vs 16, P < 0.05 and 22.3 vs 16, P < 0.05) than the restrictive group, but were similar in other characteristics. After adjustment for confounders, restrictive resuscitation was associated with greater probability of AKI [odds ratio (OR) 3.25, 95% confidence interval (95% CI) 1.18-8.94]. No difference in the probability of BWI or pneumonia among groups was found (BWI: restrictive vs standard OR 0.74, 95% CI 0.39-1.40, excessive vs standard OR 1.40, 95% CI 0.75-2.60, pneumonia: restrictive vs standard, OR 0.52, 95% CI 0.26-1.05; excessive vs standard, OR 1.12, 95% CI 0.58-2.14). CONCLUSIONS Restrictive resuscitation is associated with increased AKI, without changes in infectious complications.
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Abdelrahman I, Elmasry M, Olofsson P, Steinvall I, Fredrikson M, Sjoberg F. Division of overall duration of stay into operative stay and postoperative stay improves the overall estimate as a measure of quality of outcome in burn care. PLoS One 2017; 12:e0174579. [PMID: 28362844 PMCID: PMC5376076 DOI: 10.1371/journal.pone.0174579] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 03/06/2017] [Indexed: 11/19/2022] Open
Abstract
Total duration of stay adjusted for percentage of the total body surface area burned (TBSA%) is a commonly used outcome measure in burn care. However, it has been criticised as it is affected by many factors, some of which are not strictly part of burn care. A division into operative stay and postoperative stay may improve this measure. The aim was to evaluate if operative stay can serve as a more standardised measure by: comparing the variation in operative stay/TBSA% with the variation in total stay/TBSA%, and to study different factors associated with operative stay and postoperative stay.
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Affiliation(s)
- Islam Abdelrahman
- Plastic Surgery Unit, Surgery Department, Suez Canal University, Ismailia, Egypt
- Department of Plastic Surgery, Hand Surgery, and Burns, Linköping University, Linköping, Sweden
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Moustafa Elmasry
- Plastic Surgery Unit, Surgery Department, Suez Canal University, Ismailia, Egypt
- Department of Plastic Surgery, Hand Surgery, and Burns, Linköping University, Linköping, Sweden
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Pia Olofsson
- Department of Plastic Surgery, Hand Surgery, and Burns, Linköping University, Linköping, Sweden
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Ingrid Steinvall
- Department of Plastic Surgery, Hand Surgery, and Burns, Linköping University, Linköping, Sweden
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
- * E-mail:
| | - Mats Fredrikson
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Folke Sjoberg
- Department of Plastic Surgery, Hand Surgery, and Burns, Linköping University, Linköping, Sweden
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
- Department of Anaesthesiology and Intensive Care, Linköping University, Linköping, Sweden
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Elmasry M, Steinvall I, Thorfinn J, Abdelrahman I, Olofsson P, Sjoberg F. Staged excisions of moderate-sized burns compared with total excision with immediate autograft: an evaluation of two strategies. INTERNATIONAL JOURNAL OF BURNS AND TRAUMA 2017; 7:6-11. [PMID: 28123862 PMCID: PMC5259592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 01/07/2017] [Indexed: 06/06/2023]
Abstract
BACKGROUND Different surgical techniques have evolved since excision and autografting became the treatment of choice for deep burns in the 1970s. The treatment plan at the Burn Center, Linköping University Hospital, Sweden, has shifted from single-stage excision and immediate autografting to staged excisions and temporary cover with xenografts before autografting. The aim of this study was to find out if the change in policy resulted in extended duration of hospital stay/total body surface area burned (LOS/TBSA%). METHODS Retrospective clinical cohort including surgically-managed patients with burns of 15%-60% TBSA% within each treatment group. The first had early full excisions of deep dermal and full thickness burns and immediate autografts (1997-98), excision and immediate autograft group) and the second had staged excisions before final autografts using xenografts for temporary cover (2010-11, staged excision group). RESULTS The study included 57 patients with deep dermal and full-thickness burns, 28 of whom had excision and immediate autografting, and 29 of whom had staged excisions with xenografting before final autografting. Adjusted (LOS/TBSA%) was close to 1, and did not differ between groups. Mean operating time for the staged excision group was shorter and the excised area/operation was smaller. The total operating time/TBSA% did not differ between groups. CONCLUSION Staged excisions with temporary cover did not affect adjusted LOS/TBSA% or total operating time. Staged excisions may be thought to be more expensive because of the cost of covering the wound between stages, but this needs to be further investigated as do the factors that predict long term outcome.
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Affiliation(s)
- Moustafa Elmasry
- The Burn Center, Department of Hand Surgery, Plastic Surgery, and Burns, Department of Clinical and Experimental Medicine, Linköping UniversityLinköping, Sweden
- Plastic Surgery Unit, Department of Surgery, Suez Canal UniversityIsmailia, Egypt
| | - Ingrid Steinvall
- The Burn Center, Department of Hand Surgery, Plastic Surgery, and Burns, Department of Clinical and Experimental Medicine, Linköping UniversityLinköping, Sweden
| | - Johan Thorfinn
- The Burn Center, Department of Hand Surgery, Plastic Surgery, and Burns, Department of Clinical and Experimental Medicine, Linköping UniversityLinköping, Sweden
| | - Islam Abdelrahman
- The Burn Center, Department of Hand Surgery, Plastic Surgery, and Burns, Department of Clinical and Experimental Medicine, Linköping UniversityLinköping, Sweden
- Plastic Surgery Unit, Department of Surgery, Suez Canal UniversityIsmailia, Egypt
| | - Pia Olofsson
- The Burn Center, Department of Hand Surgery, Plastic Surgery, and Burns, Department of Clinical and Experimental Medicine, Linköping UniversityLinköping, Sweden
| | - Folke Sjoberg
- The Burn Center, Department of Hand Surgery, Plastic Surgery, and Burns, Department of Clinical and Experimental Medicine, Linköping UniversityLinköping, Sweden
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Elmasry M, Steinvall I, Thorfinn J, Olofsson P, Abbas A, Abdelrahman I, Adly O, Sjoberg F. Temporary coverage of burns with a xenograft and sequential excision, compared with total early excision and autograft. ANNALS OF BURNS AND FIRE DISASTERS 2016; 29:196-201. [PMID: 28149249 PMCID: PMC5266237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 04/11/2016] [Indexed: 06/06/2023]
Abstract
During the 80s and 90s, early and total excision of full thickness burns followed by immediate autograft was the most common treatment, with repeated excision and grafting, mostly for failed grafts. It was hypothesized, therefore, that delayed coverage with an autograft preceded by a temporary xenograft after early and sequential smaller excisions would lead to a better wound bed with fewer failed grafts, a smaller donor site, and possibly also a shorter duration of stay in hospital. We carried out a case control study with retrospective analysis from our National Burn Centre registry for the period 1997-2011. Patients who had been managed with early total excision and autograft were compared with those who had had sequential smaller excisions covered with temporary xenografts until the burn was ready for the final autograft. The sequential excision and xenograft group (n=42) required one-third fewer autografts than patients in the total excision and autograft group (n=45), who needed more than one operation (p<0.001). We could not detect any differences in duration of stay in hospital / total body surface area burned% (duration of stay/TBSA%) (2.0 and 1.8) (p=0.83). The two groups showed no major differences in terms of adjusted duration of stay, but our findings suggest that doing early, smaller, sequential excisions using a xenograft for temporary cover can result in shorter operating times, saving us the trouble of making big excisions. However, costs tended to be higher when the burns were > 25% TBSA.
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Affiliation(s)
- M. Elmasry
- Department of Plastic Surgery and Hand Surgery, Burn Centre, Linköping University, Sweden
- Plastic Surgery Unit, Department of Surgery, Suez Canal University, Egypt
| | - I. Steinvall
- Department of Plastic Surgery and Hand Surgery, Burn Centre, Linköping University, Sweden
| | - J. Thorfinn
- Department of Plastic Surgery and Hand Surgery, Burn Centre, Linköping University, Sweden
| | - P. Olofsson
- Department of Plastic Surgery and Hand Surgery, Burn Centre, Linköping University, Sweden
| | - A.H. Abbas
- Plastic Surgery Unit, Department of Surgery, Suez Canal University, Egypt
| | - I. Abdelrahman
- Department of Plastic Surgery and Hand Surgery, Burn Centre, Linköping University, Sweden
- Plastic Surgery Unit, Department of Surgery, Suez Canal University, Egypt
| | - O.A. Adly
- Plastic Surgery Unit, Department of Surgery, Suez Canal University, Egypt
| | - F. Sjoberg
- Department of Plastic Surgery and Hand Surgery, Burn Centre, Linköping University, Sweden
- Department of Anaesthesiology and Intensive Care, Linköping University, Sweden
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Variation in Inpatient Rehabilitation Utilization After Hospitalization for Burn Injury in the United States. J Burn Care Res 2016; 36:613-8. [PMID: 25423440 DOI: 10.1097/bcr.0000000000000200] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Approximately 45,000 individuals are hospitalized annually for burn treatment. Rehabilitation after hospitalization can offer a significant improvement in functional outcomes. Very little is known nationally about rehabilitation for burns, and practices may vary substantially depending on the region based on observed Medicare post-hospitalization spending amounts. This study was designed to measure variation in rehabilitation utilization by state of hospitalization for patients hospitalized with burn injury. This retrospective cohort study used nationally collected data over a 10-year period (2001 to 2010), from the Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SIDs). Patients hospitalized for burn injury (n = 57,968) were identified by ICD-9-CM codes and were examined to see specifically if they were discharged immediately to inpatient rehabilitation after hospitalization (primary endpoint). Both unadjusted and adjusted likelihoods were calculated for each state taking into account the effects of age, insurance status, hospitalization at a burn center, and extent of burn injury by TBSA. The relative risk of discharge to inpatient rehabilitation varied by as much as 6-fold among different states. Higher TBSA, having health insurance, higher age, and burn center hospitalization all increased the likelihood of discharge to inpatient rehabilitation following acute care hospitalization. There was significant variation between states in inpatient rehabilitation utilization after adjusting for variables known to affect each outcome. Future efforts should be focused on identifying the cause of this state-to-state variation, its relationship to patient outcome, and standardizing treatment across the United States.
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Long-term survival after burns in a Swedish population. Burns 2016; 43:157-161. [PMID: 27613474 DOI: 10.1016/j.burns.2016.07.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Revised: 07/14/2016] [Accepted: 07/19/2016] [Indexed: 11/23/2022]
Abstract
INTRODUCTION As widely reported, the progress in burn care during recent decades has reduced the hospital mortality. The effect of the burns on long-term outcome has not received so much attention, and more study is indicated. The aim of this retrospective study was to investigate the long-time survival among patients who had been treated for burns. METHODS We studied 1487 patients who were discharged alive from the Linköping University Hospital Burn Centre during the period 1993 until the end of December 2012. We used Cox's regression analysis to study the effect of burns on long-term survival after adjustment for different factors. RESULTS Age and a full-thickness burn were significantly associated with mortality after discharge (p<0.001), whereas percentage of total body surface area burned (TBSA %), need for mechanical ventilation, and gender were not. Less than 1% of the patients with burns (13/1487) died within 30 days of discharge and a total of 176/1487 (12%) died during follow-up. CONCLUSION Age and full-thickness burns reduce the long-time survival after discharge from the Burn Centre, whereas the effect of TBSA% and need for artificial ventilation ends with discharge.
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Epidemiology and outcomes of pediatric burns over 35 years at Parkland Hospital. Burns 2016; 42:202-208. [DOI: 10.1016/j.burns.2015.10.011] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 08/27/2015] [Accepted: 10/07/2015] [Indexed: 11/21/2022]
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Steinvall I, Elmasry M, Fredrikson M, Sjoberg F. Standardised mortality ratio based on the sum of age and percentage total body surface area burned is an adequate quality indicator in burn care: An exploratory review. Burns 2015; 42:28-40. [PMID: 26700877 DOI: 10.1016/j.burns.2015.10.032] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Revised: 10/28/2015] [Accepted: 10/29/2015] [Indexed: 11/27/2022]
Abstract
Standardised Mortality Ratio (SMR) based on generic mortality predicting models is an established quality indicator in critical care. Burn-specific mortality models are preferred for the comparison among patients with burns as their predictive value is better. The aim was to assess whether the sum of age (years) and percentage total body surface area burned (which constitutes the Baux score) is acceptable in comparison to other more complex models, and to find out if data collected from a separate burn centre are sufficient for SMR based quality assessment. The predictive value of nine burn-specific models was tested by comparing values from the area under the receiver-operating characteristic curve (AUC) and a non-inferiority analysis using 1% as the limit (delta). SMR was analysed by comparing data from seven reference sources, including the North American National Burn Repository (NBR), with the observed mortality (years 1993-2012, n=1613, 80 deaths). The AUC values ranged between 0.934 and 0.976. The AUC 0.970 (95% CI 0.96-0.98) for the Baux score was non-inferior to the other models. SMR was 0.52 (95% CI 0.28-0.88) for the most recent five-year period compared with NBR based data. The analysis suggests that SMR based on the Baux score is eligible as an indicator of quality for setting standards of mortality in burn care. More advanced modelling only marginally improves the predictive value. The SMR can detect mortality differences in data from a single centre.
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Affiliation(s)
- Ingrid Steinvall
- The Burn Centre, Department of Plastic Surgery, Hand Surgery, and Burns, Linköping University, Linköping, Sweden; Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden.
| | - Moustafa Elmasry
- The Burn Centre, Department of Plastic Surgery, Hand Surgery, and Burns, Linköping University, Linköping, Sweden; Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden; The Plastic Surgery Unit, Surgery Department, Suez Canal University, Ismailia, Egypt
| | - Mats Fredrikson
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Folke Sjoberg
- The Burn Centre, Department of Plastic Surgery, Hand Surgery, and Burns, Linköping University, Linköping, Sweden; Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden; Department of Anaesthesiology and Intensive Care, Linköping University, Linköping, Sweden
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Inclusion of coexisting morbidity in a TBSA% and age based model for the prediction of mortality after burns does not increase its predictive power. Burns 2015; 41:1868-1876. [PMID: 26507519 DOI: 10.1016/j.burns.2015.09.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Revised: 09/09/2015] [Accepted: 09/23/2015] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Several models for predicting mortality have been developed for patients with burns, and the most commonly used are based on age and total body surface area (TBSA%). They often show good predictive precision as depicted by high values for area under the receiver operating characteristic curves (AUC). However the effect of coexisting morbidity on such prediction models has not to our knowledge been thoroughly examined. We hypothesised that adding it to a previously published model (based on age, TBSA%, full thickness burns, gender, and need for mechanical ventilation) would further improve its predictive power. METHODS We studied 772 patients admitted during the period 1997-2008 to the Linköping University Hospital, National Burn Centre with any type of burns. We defined coexisting morbidity as any of the medical conditions listed in the Charlson list, as well as psychiatric disorders or drug or alcohol misuse. We added coexisting medical conditions to the model for predicting mortality (age, TBSA%, and need for mechanical ventilation) to determine whether it improved the model as assessed by changes in deviances between the models. RESULTS Mean (SD) age and TBSA% was 35 (26) years and 13 (17) %, respectively. Among 725 patients who survived, 105 (14%) had one or more coexisting condition, compared with 28 (60%) among those 47 who died. The presence of coexisting conditions increased with age (p<0.001) among patients with burns. The AUC of the mortality prediction model in this study, based on the variables age, TBSA%, and need for mechanical ventilation was 0.980 (n=772); after inclusion of coexisting morbidity in the model, the AUC improved only marginally, to 0.986. The model was not significantly better either. CONCLUSION Adding coexisting morbidity to a model for prediction of mortality after a burn based on age, TBSA%, and the need for mechanical ventilation did not significantly improve its predictive value. This is probably because coexisting morbidity is automatically adjusted for by age in the original model.
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Stewart BT, Gyedu A, Agbenorku P, Amankwa R, Kushner AL, Gibran N. Routine systemic antibiotic prophylaxis for burn injuries in developing countries: A best evidence topic (BET). Int J Surg 2015; 21:168-72. [PMID: 26260622 DOI: 10.1016/j.ijsu.2015.08.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Revised: 07/15/2015] [Accepted: 08/05/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Burns are common in low- and middle-income countries (LMICs) and complicated by unhygienic conditions, malnutrition, use of high-risk homemade dressings and delayed presentation. Resultantly, use of routine systemic antibiotic prophylaxis (SAP) to prevent wound infection is common practice despite this intervention being abandoned in high-income countries due to increased antimicrobial resistance and non-bacterial suprainfection. METHODS A best evidence topic (BET) was constructed using a structured protocol. The question addressed was: In LMICs, does routine use of SAP reduce burn wound infection, morbidity or mortality? RESULTS From 704 retrieved records, 48 reports met criteria to be examined. Of those, 3 studies represented the best available evidence. Together, two randomized clinical trials (RCTs) and a retrospective cohort study reported no difference in the proportion of wound infection, any infection or length of hospital stay between SAP groups and controls. One RCT described a greater proportion of wounds infected with P. aeruginosa among SAP arms compared to controls. The studies had few participants and significant methodological weaknesses. CONCLUSION On the basis of limited, currently available evidence, the use of SAP cannot be recommended for patients in LMICs that present soon after burn injury.
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Affiliation(s)
- Barclay T Stewart
- Department of Surgery, University of Washington, Seattle, USA; Department of Surgery, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.
| | - Adam Gyedu
- Department of Surgery, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana; Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Pius Agbenorku
- Department of Surgery, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana; Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Richcane Amankwa
- Department of Microbiology, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Adam L Kushner
- Surgeons OverSeas (SOS), New York, NY, USA; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Department of Surgery, Columbia University, New York, NY, USA
| | - Nicole Gibran
- UW Medicine Regional Burn Center, USA; Department of Surgery, Harborview Medical Center, Seattle, WA, USA
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Auxenfans C, Menet V, Catherine Z, Shipkov H, Lacroix P, Bertin-Maghit M, Damour O, Braye F. Cultured autologous keratinocytes in the treatment of large and deep burns: a retrospective study over 15 years. Burns 2014; 41:71-9. [PMID: 24996248 DOI: 10.1016/j.burns.2014.05.019] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Revised: 04/07/2014] [Accepted: 05/28/2014] [Indexed: 11/29/2022]
Abstract
AIM The aim was to review the use and indications of cultured autologous epidermis (CAE) in extensive burns and to evaluate the efficiency of our strategy of burn treatment. MATERIALS AND METHODS This retrospective study comprised 15 years (1997-2012). INCLUSION CRITERIA all patients who received CAE. EXCLUSION CRITERIA patients who died before complete healing and patients who received exclusively cultured allogeneic keratinocytes. Evaluation criteria were clinical. Time and success of wound healing after CAE graft were evaluated. RESULTS A total of 63 patients were included with severity Baux score of 107 (from 70 to 140) and mean percentage of TBSA of 71% (from 40% to 97%). The CAE were used as Cuono method, in STSG donor sites and deep 2nd degree burns and in combination with large-meshed STSG (1:6-1:12) in extensively burned patients. Cuono method was used in 6 patients. The final take was 16% (0-30) because of the great fragility of the obtained epidermis. Nine patients with deep 2nd degree burns (mean TBSA 81%, from 60 to 97%) were successfully treated with only CAE without skin grafting. Combined technique (STSG meshed at 1:6-1:12 covered with CAE) was used in 27 patients (mean TBSA 69%, from 49% to 96%) with 85% success rate. Finally, donor sites treated with CAE in 49 patients could be harvested several times thanks to rapid epithelialization (time of wound healing was 7 days (from 5 to 10 days)). CONCLUSION The CAE allow rapid healing of STSG donor sites and deep 2nd second degree burns in extensively burned patients.
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Affiliation(s)
| | - Veronique Menet
- Tissues and Cells Bank, Edouard Herriot Hospital, Lyon, France
| | | | | | | | | | - Odile Damour
- Tissues and Cells Bank, Edouard Herriot Hospital, Lyon, France
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Response to Dr Elmasry et al.'s letter to editor. Burns 2014; 40:773-4. [PMID: 24556074 DOI: 10.1016/j.burns.2013.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Accepted: 12/12/2013] [Indexed: 11/21/2022]
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Elmasry M, Steinvall I, Sjöberg F. "Is the length of time in acute burn surgery associated with poorer outcomes?". Burns 2014; 40:772-3. [PMID: 24438741 DOI: 10.1016/j.burns.2013.11.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2013] [Accepted: 11/13/2013] [Indexed: 10/25/2022]
Affiliation(s)
- Moustafa Elmasry
- Burn Center Departments of Hand, Plastic Surgery and Intensive Care, Östergötland County Council, Linköping University Hospital, Linköping University, Linköping, Sweden; Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden; Department of Surgery, Plastic Surgery Unit, Suez Canal University, Ismailia, Egypt.
| | - Ingrid Steinvall
- Burn Center Departments of Hand, Plastic Surgery and Intensive Care, Östergötland County Council, Linköping University Hospital, Linköping University, Linköping, Sweden; Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Folke Sjöberg
- Burn Center Departments of Hand, Plastic Surgery and Intensive Care, Östergötland County Council, Linköping University Hospital, Linköping University, Linköping, Sweden; Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
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