Fibrinogen is an independent predictor of mortality in major trauma patients: A five-year statewide cohort study

IntroductionFibrinogen may be reduced following traumatic injury due to loss from haemorrhage, increased consumption and reduced synthesis. In the absence of clinical trials, guidelines for fibrinogen replacement are based on expert opinion and vary internationally. We aimed to determine prevalence and predictors of low fibrinogen on admission in major trauma patients and investigate association of fibrinogen levels with patient outcomes.Patients and methodsData on all major trauma patients (January 2007–July 2011) identified through a prospective statewide trauma registry in Victoria, Australia were linked with laboratory and transfusion data. Major trauma included any of the following: death after injury, injury severity score (ISS) >15, admission to intensive care unit requiring mechanical ventilation, or urgent surgery for intrathoracic, intracranial, intra-abdominal procedures or fixation of pelvic or spinal fractures. Associations between initial fibrinogen level and in-hospital mortality were analysed using multiple logistic regression.ResultsOf 4773 patients identified, 114 (2.4%) had fibrinogen less than 1 g/L, 283 (5.9%) 1.0–1.5 g/L, 617 (12.9%) 1.6–1.9 g/L, 3024 (63.4%) 2–4 g/L and 735 (15%) >4 g/L. Median fibrinogen was 2.6 g/L (interquartile range 2.1–3.4). After adjusting for age, gender, ISS, injury type, pH, temperature, Glasgow Coma Score (GCS), initial international normalised ratio and platelet count, the lowest fibrinogen categories, compared with normal range, were associated with increased in-hospital mortality (adjusted odds ratio [OR] for less than 1 g/L 3.28 [95% CI 1.71–6.28, p < 0.01], 1–1.5 g/L adjusted OR 2.08 [95% CI 1.36–3.16, p < 0.01] and 1.6–1.9 g/L adjusted OR 1.39 [95% CI 0.97–2.00, p = 0.08]). Predictors of initial fibrinogen <1.5 g/L were younger age, lower GCS, systolic blood pressure <90 mmHg, chest decompression, penetrating injury, ISS >25 and lower pH and temperature.ConclusionsInitial fibrinogen levels less than the normal range are independently associated with higher in-hospital mortality in major trauma patients. Future studies are warranted to investigate whether earlier and/or greater fibrinogen replacement improves clinical outcomes.     

Lethal triad in severe burns

IntroductionHypothermia, acidaemia and coagulopathy in trauma is associated with significant mortality. This study aimed to identify the incidence of the lethal triad in major burns, and describe demographics and outcomes.MethodsPatients admitted during a 71 month period with a total body surface area burn (TBSA) ≥ 30% were identified. A structured review of a prospective database was conducted. The lethal triad was defined as a combination of coagulopathy (International normalised ratio > 1.2), hypothermia (temperature ≤ 35.5 °C) and acidaemia (pH ≤ 7.25).ResultsFifteen of 117 patients fulfilled the criteria for the lethal triad on admission. Lethal triad patients had a higher median (IQR) abbreviated burn severity index (ABSI) (12 (9–13) vs. 8.5 (6–10), p = 0.001), mean (SD) TBSA burn (59.2% (18.7) vs. 47.9% (18.1), p = 0.027), mean (SD) age (46 (22.6) vs. 33 (28.3) years, p = 0.033), and had a higher incidence of inhalational injury (p < 0.0001) and full-thickness burns (p = 0.021). Both groups received similar volumes of fluid (p > 0.05).The lethal triad was associated with increased mortality (66.7% vs. 13.7%, p < 0.0001). With logistic regression analysis and adjustment for ABSI, the lethal triad was not shown to be a predictor of mortality (p > 0.05).ConclusionBurn patients with the lethal triad have a high mortality rate which reflects the severity of the injury sustained.     

Effects of differential-phase remote ischemic preconditioning intervention in laparoscopic partial nephrectomy: A single blinded,randomized controlled trial in a parallel group design

Study ObjectiveThere are two windows of protection for remote ischemic preconditioning (RIPC), an early (ERIPC) and a late-phase (LRIPC). While ERIPC has been well studied, works on LRIPC are relatively scarce, especially for the kidneys. We aimed to compare the effects of early-phase versus late-phase RIPC in patients with laparoscopic partial nephrectomy (LPN).DesignA randomized controlled studySettingThe Second Affiliated Hospital of Anhui Medical University, 1 May 2012 to 30 October 2013PatientsSixty-five ASA 1 to 2 patients scheduled for LPN were located randomly to ERIPC group, LRIPC group and CON group (control).InterventionsThree five-minute cycles of right upper limb ischaemia and reperfusion were performed after induction of anesthesia in ERIPC group. Patients in LRIPC group received similar treatment 24 h before surgery, while control patients were not subjected to preconditioning.MeasurementsSerum neutrophil gelatinase-associated lipocalin (NGAL) and serum cystatin C (CysC) were evaluated before the induction of anesthesia (0h), 2 h (2 h) and 6 h (6 h) after surgery. Unilateral glomerular filtration rates (GFR) were assessed before and after surgery to evaluate overall renal function.Main ResultsSerum NGAL and CysC were significantly lower in ERIPC and LRIPC groups at 2h post-operation (P < 0.001), 6h post-operation (P < 0.001). Additionally, The GFR were significantly lower in ERIPC and LRIPC groups than in CON group at the 3rd month after surgery (P = 0.019; P < 0.001). Moreover, compared to the ERIPC group, concentration of NGAL and CysC in LRIPC group decreased to a greater extent, while GFR and the percentage of decrement was significantly less in the LRIPC group (P = 0.016; P < 0.001).ConclusionsRegardless of early-phase or late-phase intervention, limb remote ischemic preconditioning confers protection on renal ischemia-reperfusion injury in patients with laparoscopic partial nephrectomy, and the late-phase protection is more prominent.     

Brown adipose tissue recruitment in a rodent model of severe burns

BackgroundSevere burns results in a prolonged hypermetabolic response. Brown adipose tissue (BAT), abundant in uncoupling protein 1 (UCP1), plays a key role in non-shivering thermogenesis. We set out to determine if BAT is recruited in response to severe burns.MethodsMale balb-c mice underwent scald burns on approximately 20–25% of their total body surface. BAT was harvested from the interscapular fat pad of sham and burned mice at 3 h, 24 h, 4 days, and 10 days after injury. High-resolution respirometry was used to determine mitochondrial respiratory function in BAT. BAT protein concentration, and mitochondrial enzyme activity were also determined.ResultsRespiration increased in BAT of burned mice, peaking at 24 h after injury (after injury, P < 0.001). While UCP1 independent respiration was not significantly altered by burn, UCP1 dependent respiration increased >2-fold at 24 h after injury when compared to the 3 h and sham group (P < 0.01). Normalized to citrate synthase activity, total uncoupled (P < 0.05) and UCP1 dependent (P < 0.01) respiration remained elevated at 24 h after injury.ConclusionsWe show a time-dependent recruitment of rodent BAT in response to severe burns. Given recent reports that humans, including patients with severe burns, have functional BAT, these data support a role for BAT in the hypermetabolic response to severe burns.     

Residual neuromuscular block as a risk factor for critical respiratory events in the post anesthesia care unit

ObjectiveResidual neuromuscular block is an important postoperative complication associated to the use of neuromuscular blocking drugs. The purpose of this study was to access the incidence of residual neuromuscular block in a post-anesthesia care unit and to evaluate its association with critical respiratory events.Material and methodsProspective cohort study was conducted in a Post Anesthetic Care Unit (PACU) for a period of 3 weeks. Two hundred two adult patients who submitted to scheduled non-cardiac and non-intracranial surgery were eligible to the study. The primary outcome variable was residual neuromuscular block after arrival to PACU that was defined as train-of-four ratio <0.9 and objectively quantified using acceleromyography. Demographic data, perioperative variables, lengths of hospital and recovery room stay and critical respiratory events were recorded. Inadequate emergence was classified in its different forms according to the Richmond agitation and sedation scale 10 min after admission to the recovery room.ResultsResidual neuromuscular block incidence in the post-anesthesia care unit was 29.7% (95% confidence interval: 23.4, 36.1). Patients with residual neuromuscular block had more frequently overall critical respiratory events (51% versus 16%, P < 0.001), airway obstruction (10% versus 2%, P = 0.029), mild-moderate hypoxemia (23% versus 4%, P < 0.001), severe hypoxemia (7% versus 1%, P = 0.033), respiratory failure (8% versus 1%, P = 0.031), inability to breathe deeply (38% versus 12%, P < 0.001) and muscular weakness (16% versus 1%, P < 0.001). Residual neuromuscular block was more common after high-risk surgery (53% versus 33%, P = 0.011) and was more often associated with post-operative hypoactive emergence as defined by the Richmond Agitation and Sedation Scale (21% versus 6%, P = 0.001).ConclusionsThis study suggests that residual neuromuscular block is common in the PACU and is associated with more frequent critical respiratory events.     

Parada cardiaca relacionada con la anestesia en pediatría. Registro en un hospital infantil terciario

ObjectivesThe aim of this study is to analyze the cardiac arrests related to anesthesia in a tertiary children's hospital, in order to identify risk factors that would lead to opportunities for improvement.MethodsA 5-year retrospective study was conducted on anesthesia related cardiac arrest occurring in pediatric patients. All urgent and elective anesthetic procedures performed by anesthesiologists were included. Data collected included patient characteristics, the procedure, the probable cause, and outcome of the cardiac arrest. Odds ratio was calculated by univariate analysis to determine the clinical factors associated with cardiac arrest and mortality.ResultsThere were a total of 15 cardiac arrests related to anesthesia in 43,391 anesthetic procedures (3.4 per 10,000), with an incidence in children with ASA I-II versus ASA ≥III of 0.28 and 19.27 per 10,000, respectively. The main risk factors were children ASA ≥ III (P < .001), less than one month old (P < .001), less than one year old (P < .001), emergency procedures (P < .01), cardiac procedures (P < .001) and procedures performed in the catheterization laboratory (P < .05). The main causes of cardiac arrest were cardiovascular (53.3%), mainly due to hypovolemia, and cardiovascular depression associated with induction of anesthesia, followed by respiratory causes (20%), and medication causes (20%). The incidence of mortality and neurological injury within the first 24 h after the cardiac arrest was 0.92 and 1.38 per 10,000, respectively. The mortality in the first 3 months was 1.6 per 10,000. The main causes of death were ASA ≥ III, age under one year, pulmonary arterial hypertension, cardiac arrest in areas remote from the surgery area, a duration of cardiopulmonary resuscitation over 20 min, and when hypothermia was not applied after cardiac arrest.ConclusionThe main risk factors for cardiac arrest were ASA ≥ III, age under one year, emergency procedures, cardiology procedures and procedures performed in the catheterization laboratory. The main cause of the cardiac arrest was due mainly to cardiovascular hypovolemia. All patients who died or had neurological injury were ASA ≥ III. Pulmonary arterial hypertension is a risk of anesthesia-related mortality.     

Female patients display poorer burn-specific quality of life 12 months after a burn injury

IntroductionAlthough gender differences in morbidity and mortality have been measured in patients with moderate to severe burn injury, little attention has been directed at gender effects on health-related quality of life (HRQoL) following burn injury. The current study was therefore conducted to prospectively measure changes in HRQoL for males and females in a sample of burn patients.MethodsA total of 114 adults who received treatment at a statewide burns service for a sustained burns injury participated in this study. Instruments measuring generic health status (Short Form 36 Medical Outcomes Survey version 2), burn-specific HRQoL (Burns Specific Health Scale-Brief), psychological distress (Kessler Psychological Distress Scale) and alcohol use (Alcohol Use Disorders Identification Tool) were prospectively measured at 3, 6 and 12 months post-burn.ResultsIn the 12 months post-injury, female patients showed overall poorer physical (p = 0.01) and mental health status (p < 0.001), greater psychological distress (p < 0.001), and greater difficulty with aspects of burn-specific HRQoL: body image (p < 0.001), affect (p < 0.001), interpersonal functioning (p = 0.005), heat sensitivity (p = 0.01) and treatment regime (p = 0.01). While significant interaction effects suggested that female patients had more improvement in difficulties with treatment regime (p = 0.007), female patients continued to report greater difficulty with multiple aspects of physical and psychosocial health status 12 months post-injury.ConclusionEven though demographic variables, injury characteristics and burn care interventions were similar across genders, following burn injury female patients reported greater impairments in generic and burn-specific HRQoL along with psychological morbidity, when compared to male patients. Urgent clinical and research attention utilising an evidence-based research framework, which incorporates the use of larger sample sizes, the use of validated instruments to measure appropriate outcomes, and a commitment to monitoring long-term care, can only improve burn-care.     

Comparison of prognostic models for burn patients: A retrospective nationwide registry study

BackgroundPrognostic burn index (PBI) is a unique model utilized to predict mortality of burn patients in Japan. In contrast, other prediction models are rarely used in Japan, and their accuracy and predictive value are unknown. The present study aimed to compare commonly used burn prediction models and determine the appropriate model for mortality prediction in Japanese burn patients.MethodsJapanese burn patients registered in the nationwide burn registry of Japanese Society for Burn Injury between April 1, 2011 and March 31, 2019 were reviewed retrospectively. The prognostic performance of PBI was compared with Baux score, revised Baux score, abbreviated burn severity index (ABSI), Ryan score and Belgian outcome in burn injury score (BOBI). The primary outcome was in-hospital mortality.ResultsThe study included 7911 acute burn patients. The overall mortality rate was 10.7%, the median age was 52 (interquartile range, 26–72) years, and the median % total body surface area was 7% (interquartile range, 3%–17%). The areas under the receiver operating characteristic curve for PBI, Baux score, ABSI, revised Baux score, Ryan score, and BOBI were 0.940 (95% confidence interval [CI]: 0.931–0.948), 0.943 (95% CI: 0.934–0.951; p = 0.002), 0.945 (95% CI: 0.937–0.953; p = 0.058), 0.946 (95% CI: 0.937–0.953; p = 0.002), 0.859 (95% CI: 0.846–0.870; p < 0.001), and 0.896 (95% CI: 0.885–0.905; p < 0.001), respectively.ConclusionAlthough the performance of PBI was good, it was not superior to the Baux score, revised Baux score, and ABSI. These three scores have a high prognostic accuracy. Hence, they are considered as alternative burn prognostic scores in Japan. The Baux score was an optimal prognostic model for patients with burns in Japan.     

A remarkable point for evaluating the severity of burns: Thiol–disulfide profile

AimThe objective of this study was to examine the thiol–disulfide profile tests in patients suffering from burn injuries.MethodsThis case–control study comprised 48 patients with thermal burn injuries and 61 healthy individuals. Thiol–disulfide tests were conducted in both groups, and also, the changes of thiol–disulfide parameters were analyzed at zero time and on days 3, 7, 15, and 30 of the admission in patients with burn injuries.ResultsThe patients had significantly decreased native and total thiol levels and native thiol/total thiol ratios, and significantly increased disulfide/native thiol and disulfide/total thiol ratios compared to control individuals (p < 0.001 for all). The variations of native thiol levels, total thiol levels, and disulfide/native thiol ratios were significantly different over time in patients with burn injuries (p < 0.001, p < 0.001, p < 0.05, respectively). There were strong associations with the clinical parameters and thiol–disulfide profile tests (p < 0.05 for all).ConclusionThere was a metabolic disturbance of the thiol–disulfide system among patients with burn injuries. The courses of thiol–disulfide variables in time overlapped with the burn mechanism. Strong associations provide that thiol–disulfide homeostasis might be a notable key for evaluating the severity of burns and predicting the survival.     

Process of Care Partly Explains the Variation in Mortality Between Hospitals After Peripheral Vascular Surgery

ObjectivesThe aim of this study is to investigate whether variation in mortality at hospital level reflects differences in quality of care of peripheral vascular surgery patients.DesignObservational study.MaterialsIn 11 hospitals in the Netherlands, 711 consecutive vascular surgery patients were enrolled.MethodsMultilevel logistic regression models were used to relate patient characteristics, structure and process of care to mortality at 1 year. The models were constructed by consecutively adding age, sex and Lee index, then remaining risk factors, followed by structural measures for quality of care and finally, selected process of care parameters.ResultsTotal 1-year mortality was 11%, ranging from 6% to 26% in different hospitals. Large differences in patient characteristics and quality indicators were observed between hospitals (e.g., age > 70 years: 28–58%; beta-blocker therapy: 39–87%). Adjusted analyses showed that a large part of variation in mortality was explained by age, sex and the Lee index (Akaike’s information criterion (AIC) = 59, p < 0.001). Another substantial part of the variation was explained by process of care (AIC = 5, p = 0.001).ConclusionsDifferences between hospitals exist in patient characteristics, structure of care, process of care and mortality. Even after adjusting for the patient population at risk, a substantial part of the variation in mortality can be explained by differences in process measures of quality of care.     

Repetitive extracorporeal shock wave applications are superior in inducing angiogenesis after full thickness burn compared to single application

ObjectiveBurn wounds remain a challenge due to subsequent wound infection and septicemia, which can be prevented by acceleration of wound healing. The aim of the study was to analyze microcirculation and leukocyte endothelium interaction with particular focus on angiogenesis after full-thickness burn using three different repetitions of low energy shock waves.MethodsFull-thickness burns were inflicted to the ears of hairless mice (n = 44; area: 1.6 ± 0.05 mm² (mean ± SEM)). Mice were randomized into four groups: the control group received a burn injury but no shock waves; group A received ESWA (0.03 mJ/mm²) on day one after burn injury; group B received shock waves on day one and day three after burn injury; group C ESWA on day one, three and seven after burn injury. Intravital fluorescent microscopy was used to assess microcirculatory parameters, angiogenesis and leukocyte interaction. Values were obtained before burn (baseline value) immediately after and on days 1, 3, 7 and 12 after burn.ResultsShock-wave treated groups showed significantly accelerated angiogenesis compared to the control group. The non-perfused area (NPA) is regarded as a parameter for angiogenesis and showed the following data on day 12 2.7 ± 0.4% (group A, p = 0.001), 1.4 ± 0.5% (group B, p < 0.001), 1.0 ± 0.3% (group C, p < 0.001), 6.1 ± 0.9% (control group). Edema formation is positively correlated with the number of shock wave applications: day 12: group A: 173.2 ± 9.8%, group B: 184.2 ± 6.6%, group C: 201.1 ± 6.9%, p = 0.009 vs. control: 162.3 ± 8.7% (all data: mean ± SEM).ConclusionAccording to our data shock waves positively impact the wound healing process following burn injury. Angiogenesis showed significantly improved activity after shock wave application. In all three treatment groups angiogenesis was higher compared to the control group. Within the ESWA groups, double applications showed better results than single application and three applications showed better results than single or double applications.     

Pharmacokinetics and pharmacodynamics of cisatracurium in patients undergoing surgery with two hemodilution methods

ObjectiveTo investigate the pharmacokinetics and pharmacodynamics of cisatracurium in patients undergoing surgery under acute normovolemic hemodilution (ANH) and acute hypervolemic hemodilution (AHH).MethodsNinety patients with orthopedic surgery were divided into ANH, AHH and control groups, which received hemodilution by hydroxyethyl starch 130/0.4 transfusion, Voluven transfusion and regular transfusion and infusion during surgery, respectively. Each group was divided into 3 sub-groups, administrated with cisatracurium at dosage of 0.1, 0.2 and 0.3 mg/kg respectively. The changes in plasma protein, pH and electrolytes from the hemodilution beginning to surgery finish were monitored. Before and after cisatracurium administration, the phamocodynamic indicators of muscle relaxant were observed, and the plasma drug concentration was measured.ResultsAfter hemodilution or regular transfusion, all three groups experienced a distinct drop in total plasma protein, albumin and pH. Compared with control group, the plasma concentrations of both K⁺ and Ca^2 + in ANH and AHH groups significantly dropped (P < 0.05), and those in each group after administration of cisatracurium also dropped, compared with before (P < 0.05). After administration with cisatracurium, the onset time of muscle relaxation in AHH group was extended notably, compared with AHH and control groups (P < 0.05), with no distinct difference of residual pharmacodynamics parameters (P > 0.05). In the same hemodilution or regular infusion, with increase of drug dosage, the onset time of muscle relaxation was shortened, and the period of no response to train-of-four stimulation, muscle relaxation blockade duration and action time of muscle relaxation blockade in body were extended (P < 0.05).ConclusionWhen using cisatracurium under AHH, the dosage should be increased appropriately, while it need not be adjusted under ANH.     

Comparison of hepatic epithelioid angiomyolipoma and non-hepatitis B,non-hepatitis C hepatocellular carcinoma on contrast-enhanced ultrasound

PurposeThe purpose of this study was to retrospectively compare the imaging features of hepatic epithelioid angiomyolipoma (HEAML) to those of hepatocellular carcinoma negative for hepatitis B surface antigen and hepatitis C antibody (NBNC-HCC) on contrast-enhanced ultrasound (CEUS) with sulphur hexafluoride microbubbles.Material and methodsTwenty-two patients (4 men, 18 women) with a mean age of 42.6 ± 10.2 (SD) years (range: 22–63 years) with histopathologically confirmed HEMAL were included in the study. Forty-four patients (30 men, 14 women) with a mean age of 57.3 ± 15.9 years (range: 19-85 years) with histopathologically confirmed NBNC-HCC were randomly selected from our institution's database as a control group. The CEUS characteristics of the two groups were compared.ResultsOn conventional ultrasound, significant differences in tumor diameter were found between HEAML (4.0 ± 2.0 [SD] cm; range: 1.3–8.9 cm) and NBNC-HCC (8.4 ± 4.4 [SD] cm; range: 1.6-18 cm) (P < 0.001) as well as in degrees of enhancement during the portal (P = 0.001) and late phases (P = 0.003), contrast distribution (P < 0.001) and absence of pseudocaspule (P < 0.001). On CEUS, hyperenhancement during the arterial phase was observed in 21/22 (95.5%) HEAMLs and in 43/44 (97.7%) NBNC-HCCs (P > 0.999). Homogeneous enhancement was more frequent in HEAMLs (20/22; 90.9%) than in NBNC-HCCs (13/44; 29.6%) (P < 0.001). Pseudocapsule was observed in 0/22 HEAMLs (0.0%) and in 36/44 NBNC-HCCs (81.8%) (P = 0.017). A prolonged enhancement was observed in 5/22 HEAMLs (22.7%) and in 0/44 NBNC-HCCs (0.0%) (P < 0.001) during the late phase.ConclusionCEUS with sulphur hexafluoride microbubbles is helpful in discriminating between HEAML and NBNC-HCC. Homogeneous enhancement and lack of pseudocapsule are suggestive features for the diagnosis of HEAML.     

Inhalation injury in burn patients: Establishing the link between diagnosis and prognosis

This study was to re-evaluate inhalation injury as a prognostic factor in burn patients and to determine the factors that should be considered when refining the definition of inhalation injury. A total of 192 burn patients (152 men, 40 women; mean age, 46.1 ± 13.8 years) who were suspected to have an inhalation injury and underwent bronchoscopy between January 2010 and June 2012 were included in this prospective observational study. All patients underwent bronchoscopy within 24 h of sustaining the burn. The bronchoscopic findings were classified as normal, mild, moderate, and severe. Mechanical ventilation was administered, when required. Age, percentage of TBSA burned, ABSI score, requirement of mechanical ventilation and PF ratio, but not inhalation injury, COHb level, and bronchoscopic grades, significantly differed between the survivors and non-survivors (p < 0.05). Mechanical ventilation (adjusted odds ratio [OR]: 9.787) and severe inhalation injury on bronchoscopy (adjusted OR: 45.357) were independent predictors of mortality on multivariate logistic regression analysis. Inhalation injury diagnosed through history does not predict mortality from burns. Other components such as severity of inhalation injury determined using bronchoscopy, and administration of mechanical ventilation might help predict the morbidity and mortality of burn patients with inhalation injury and all of the factors should be considered when the definition of inhalation injury is refined.     

Prevalence and Risk Factors for Hypertrophic Scarring of Split Thickness Autograft Donor Sites in a Pediatric Burn Population

TitlePrevalence and Risk Factors for Hypertrophic Scarring of Split Thickness Autograft Donor Sites in a Pediatric Burn Population.ObjectiveThe split-thickness autograft remains a fundamental treatment for burn injuries; however, donor sites may remain hypersensitive, hyperemic, less pliable, and develop hypertrophic scarring. This study sought to assess the long-term scarring of donor sites after pediatric burns.MethodsA retrospective review of pediatric burn patients treated at a single institution (2010–2016) was performed. Primary outcomes were prevalence of donor site hypertrophic scarring, scarring time course, and risk factor assessment.Results237 pediatric burn patients were identified. Mean age at burn was 7 yrs., mean %TBSA was 26% with 17% being Full Thickness. Mean follow-up was 2.4 yrs. Hypertrophic scarring was observed in 152 (64%) patients with 81 (34%) patients having persistent hypertrophic scarring through long-term follow-up. Patient-specific risk factors for hypertrophic scarring were Hispanic ethnicity (P = 0.03), increased %TBSA (P = 0.03), %Full Thickness burn (P = 0.02) and total autograft amount (P = 0.03). Donor site factors for hypertrophic scarring were longer time to epithelialization (P < 0.0001), increased donor site harvest depth (P < 0.0001), autografts harvested in the acute burn setting (P = 0.008), and thigh donor site location (vs. all other sites; P < 0.0001). The scalp, arm, foot, and lower leg donor sites (vs. all other sites) were less likely to develop HTS (P < 0.0001, 0.02, 0.005, 0.002, respectively), along with a history of previous donor site harvest (P = 0.04).ConclusionsHypertrophic scarring is a prominent burden in donor site wounds of pediatric burn patients. Knowledge of pertinent risk factors can assist with guiding management and expectations.     

There is still a care gap in osteoporosis management for patients with rheumatoid arthritis

ObjectivesTo assess compliance rates with the current Canadian osteoporosis guidelines and whether the Fracture Risk Assessment Tool score in patients with rheumatoid arthritis correlated with the likelihood of receiving osteoporosis treatment and having a bone mineral density test.MethodsCharts of serial outpatients with rheumatoid arthritis were reviewed to collect bone mineral density test data and patients’ use of calcium, vitamin D, and osteoporosis treatment. Odds ratios (OR) were calculated to determine if a higher Fracture Risk Assessment Tool score increased the likelihood of osteoporosis treatment or having a bone mineral density test.ResultsUsing the Fracture Risk Assessment Tool, the 10-year risk of major osteoporotic fracture was high in 92 (12.5%), moderate in 216 (29.3%), and low in 429 (58.2%) patients. Compared to those at low risk, patients identified as high risk were more likely to receive osteoporosis treatment (OR 16.31, 95% CI 9.45–28.13, P < 0.001); calcium (OR 3.89, 95% CI 2.43–6.25, P < 0.001); vitamin D (OR 3.46, 95% CI 2.12–5.64, P < 0.001); and to have had a bone mineral density test (OR 10.22, 95% CI 5.50–18.96, P < 0.001). Among 124 patients currently taking prednisone, half (46.8%) were prescribed a bisphosphonate.ConclusionsAlthough compliance with current osteoporosis guidelines remains low among all patients with rheumatoid arthritis, higher risk patients were more likely to have a bone mineral density test and receive treatment for osteoporosis, as indicated by the clear dose response seen along the 10-year fracture risk from low to high-risk groups.     

Colitis isquémica. ¿La localización en el colon derecho tiene peor pronóstico?

IntroductionMost patients with ischemic colitis have a favourable evolution; nevertheless, the location in the right colon has been associated with a worse prognosis. The purpose of this study is to compare the clinical presentation and results of right colon ischemic colitis (CICD) with ischemic colitis of other colonic segments (non-CIDC).MethodsRetrospective, observational study of patients admitted to our hospital with ischemic colitis between 1993 and 2014, identified through a computerized search of the ICD9 codes. They were divided into 2 groups: CICD and non-CICD. Comorbidities, clinical presentation, need for surgery, and mortality were compared. Multivariate analysis was performed using logistic regression adjusting for age and sex. Statistical significance was established at a value of P < 0.05.ResultsA total of 204 patients were identified, 61 (30%) with CICD; 61% of CICD patients required surgery compared to 22% of non-CICD patients (P < 0.001). Post-surgical mortality (32 vs. 55%) and overall mortality (20 vs. 15%) differences were not statistically significant. CICD patients had more commonly unfavourable outcomes than non-CICD patients (61 vs. 25%, P < 0.001). The odds ratio (OR) for surgery was 5.28 and 4.47 for unfavourable outcomes for patients with CICD.ConclusionsCICD patients have a worse prognosis than non-CICD patients, 5 times more likely to need surgery and 4 times more likely to have unfavourable outcomes.     

Impact of length of red blood cells transfusion on postoperative delirium in elderly patients undergoing hip fracture surgery: A cohort study

PurposeThe purpose of the present study was to test whether older red blood cells (RBCs) transfusion results in an increased risk of postoperative delirium (POD) and various in-hospital postoperative complications in elderly patients undergoing hip fracture surgery.Materials and methodsPatients (≥65 years) who underwent hip fracture surgery were enrolled, 179 patients were divided into two groups according to the storage time of the RBCs. The shorter storage time of RBCs transfusion group comprised patients who received RBCs ≤14 days old and the longer storage time of RBCs transfusion group comprised patients who received RBCs >14 days old. The blood samples were collected before anaesthesia induction, 4 and 24 h after RBCs transfusion for the determination of proinflammatory mediators, malondialdehyde, and superoxide dismutase activity.ResultsThere was no difference in the baseline characteristics, the incidence of POD, and the in-hospital postoperative complications between the shorter storage time of RBCs transfusion group and the longer storage time of RBCs transfusion groups (P > 0.05). Compared with the shorter storage time of RBCs transfusion group, the longer storage time of RBCs transfusion caused significantly longer duration of POD (P < 0.05). There were significantly increased plasma levels of IL-8 and malondialdehyde at 24 h and IL-1β at 4 h after RBCs transfusion in the POD group compared with the non-POD group (P < 0.05).ConclusionTransfusion of the longer storage RBCs is not associated with a higher incidence of POD or in-hospital postoperative complications, but with longer duration of POD in elderly patients undergoing hip fracture surgery.