Epidemiology of burns in the United Arab Emirates: Lessons for prevention

Purpose

To study mechanism, risk factors and outcome of hospitalized burns so as to give recommendations for prevention.

Methods

Burn patients admitted to Al Ain hospital for more than 24 h or who died after arrival were studied over 4 years. Demographics, burn type, location and time of injury, total body burned surface area (TBSA), body region, hospital and ICU stay and outcome were analyzed.

Results

203 patients were studied, 69% were males and 25% were children under 5 years old. The most common location for burn was home. Women were burned more at home (p < 0.0001). 28% of patients were injured at work with more men (p < 0.0001) and non-UAE nationals (p < 0.01). Scalds from water, tea were the major hazard at home, while majority of burns at work were from gas and flame. Burns caused by gas and flame had larger TBSA and longer ICU stay. Six (3%) patients died and nine (4%) were transferred to the specialized burn center.

Conclusions

Safety education for caregivers and close supervision of young children is important to reduce pediatric burns. Occupational safety education of young men could prevent burns caused by gas and flame.     

Developing a burn injury severity score (BISS): Adding age and total body surface area burned to the injury severity score (ISS) improves mortality concordance

Background

There is limited research validating the injury severity score (ISS) in burns. We examined the concordance of ISS with burn mortality. We hypothesized that combining age and total body surface area (TBSA) burned to the ISS gives a more accurate mortality risk estimate.

Methods

Data from the Royal Perth Hospital Trauma Registry and the Royal Perth Hospital Burns Minimum Data Set were linked. Area under the receiver operating characteristic curve (AUC) measured concordance of ISS with mortality. Using logistic regression models with death as the dependent variable we developed a burn-specific injury severity score (BISS).

Results

There were 1344 burns with 24 (1.8%) deaths, median TBSA 5% (IQR 2–10), and median age 36 years (IQR 23–50). The results show ISS is a good predictor of death for burns when ISS ≤ 15 (OR 1.29, p = 0.02), but not for ISS > 15 (ISS 16–24: OR 1.09, p = 0.81; ISS 25–49: OR 0.81, p = 0.19). Comparing the AUCs adjusted for age, gender and cause, ISS of 84% (95% CI 82–85%) and BISS of 95% (95% CI 92–98%), demonstrated superior performance of BISS as a mortality predictor for burns.

Conclusion

ISS is a poor predictor of death in severe burns. The BISS combines ISS with age and TBSA and performs significantly better than the ISS.     

Enhancing the clinical utility of the Burn Specific Health Scale-Brief: Not just for major burns

Introduction

Like many other Western burn services, the proportion of major to minor burns managed at Royal Perth Hospital (RPH) is in the order of 1:10. The Burn Specific Health Scale-Brief (BSHS-B) is an established measure of recovery after major burn, however its performance and validity in a population with a high volume of minor burns is uncertain. Utilizing the tool across burns of all sizes would be useful in service wide clinical practice.

Aim

This study was designed to examine the reliability and validity of the BSHS-B across a sample of mostly minor burn patients.

Method

BSHS-B scores of patients, obtained between January 2006 and February 2013 and stored on a secure hospital database were collated and analyzedCronbach's alpha, factor analysis, logistic regression and longitudinal regression were used to examine reliability and validity of the BSHS-B.

Results

Data from 927 burn patients (2031 surveys) with a mean % total burn surface area (TBSA) of 6.7 (SD 10.0) were available for analysis. The BSHS-B demonstrated excellent reliability with a Cronbach's alpha of 0.95. First and second order factor analyses reduced the 40 item scale to four domains: Work; Affect and Relations; Physical Function; Skin Involvement, as per the established construct. TBSA, length of stay and burn surgery all predicted burn specific health in the first three months of injury (p < 0.001, p < 0.001, p = 0.03). BSHS-B whole scale and domain scores showed significant improvement over 24 months from burn (p < 0.001).

Discussion

The results from this study show that the structure and performance of the BSHS-B in a burn population consisting of 90% minor burns is consistent with that demonstrated in major burns.

Conclusion

The BSHS-B can be employed to track and predict recovery after burns of all sizes to assist the provision of targeted burn care.     

Predictors of re-epithelialization in pediatric burn

Introduction

An important treatment goal for burn wounds is to promote early wound closure. This study identifies factors associated with delayed re-epithelialization following pediatric burn.

Methods

Data were collected from August 2011 to August 2012, at a pediatric tertiary burn center. A total of 106 burn wounds were analyzed from 77 participants aged 4–12 years. Percentage of wound re-epithelialization at each dressing change was calculated using Visitrak™. Mixed effect regression analysis was performed to identify the demographic factors, wound and clinical characteristics associated with delayed re-epithelialization.

Results

Burn depth determined by laser Doppler imaging, ethnicity, pain scores, total body surface area (TBSA), mechanism of injury and days taken to present to the burn center were significant predictors of delayed re-epithelialization, accounting for 69% of variance. Flame burns delayed re-epithelialization by 39% compared to all other mechanisms (p = 0.003). When initial presentation to the burn center was on day 5, burns took an average of 42% longer to re-epithelialize, compared to those who presented on day 2 post burn (p < 0.000). Re-epithelialization was delayed by 14% when pain scores were reported as 10 (on the FPS-R), compared to 4 on the first dressing change (p = 0.015) for children who did not receive specialized preparation/distraction intervention. A larger TBSA was also a predictor of delayed re-epithelialization (p = 0.030). Darker skin complexion re-epithelialized 25% faster than lighter skin complexion (p = 0.001).

Conclusions

Burn depth, mechanism of injury and TBSA are always considered when developing the treatment and surgical management plan for patients with burns. This study identifies other factors influencing re-epithelialization, which can be controlled by the treating team, such as effective pain management and rapid referral to a specialized burn center, to achieve optimal outcomes.     

Clinical utility of fungal screening assays in adults with severe burns

Background

Fungal wound infection is a leading cause of burn wound infections, and diagnosis is often delayed as it conventionally requires culture and histopathology. Fungal screening assays have sped diagnosis of invasive fungal infections in other populations. Few studies have evaluated the performance of fungal screening assays outside of the hematologic malignancy and hematopoietic stem cell transplant populations.

Methods

We performed a three year retrospective analysis of all fungal screening assays in burn patients in the ICU between 2008 and 2011. The primary goal was to evaluate the correlation between the two available fungal screening assays, (1 → 3)-β-d-glucan (BG) and galactomannan (GM) assay, and fungal wound colonization (FWC) and infection (FWI). We also evaluated previously hypothesized causes of false positives and their associations with false positives in the burn population.

Results

We identified 53 patients [median 29% total body surface area burned (TBSA), IQR 17–51] with BG or GM serological tests available, of which 15 had a FWI or FWC. FWC/FWI was associated with higher TBSA (p = 0.02). BG and GM correlated with TBSA (BG 0.57, p < 0.01; GM 0.35, p = 0.02), but neither assay was associated with FWI/FWC or species of fungus involved when FWI/FWC was diagnosed.

Conclusions

Positive BG and GM fungal screening assays are not associated with FWI/FWC, or with species of fungus when FWC/FWI is present. BG false positives are common and associated with higher TBSA burns.     

Burns are more aggressive in the elderly: proportion of deep burn area/total burn area might have a role in mortality

Introduction

The objective is to identify whether epidemiologic differences in burns in the elderly lead to worse outcomes.

Methods

Case control study. Patients admitted between October 2006 and September 2009, comparing over 65 years old (n = 66) with under 65 (n = 235). Studied variables: agent, inhalation injury, total burn surface area (%TBSA), deep TBSA, proportion deep TBSA/TBSA, number of surgeries, ICU length of stay and mortality. These were compared using multivariate analysis, Mann-Whitney, proportion test and logistic regression.

Results

Over 65 had less TBSA, 13% (1-76) versus 22.5% (1-98) (p < 0.001) in under 65s. Deep TBSA (DTBSA) at admission had no difference, but the proportion of deep TBSA/TBSA was higher for the elderly (41% versus 23.3%) (p = 0.004). Elderly patients had significantly higher mortality than patients under 65, 48% versus 24%, and had 1.9 times more probability of death (OR 2.9, CI 95% 1.6-5.2). This increased to 12 times when adjusted for TBSA and DTBSA/TBSA proportion (OR = 12.02).

Discussion

Elderly people suffer from more severe burns at admission. The proportion of deep burns is higher. This, in association with their diminished functional reserve and social support, might explain in part their greater probability of mortality.     

In the media: Burns as a method of assault

Aim

The aims of this study were to determine whether a change occurred in the pattern of assault burn injury cases hospitalised to the adult state burns unit, Western Australia, from 2004 to mid-year of 2012, and to compare patient and burn characteristics of adult assault burns with those admitted for unintentional burns.

Methods

Study data were obtained from the Royal Perth Hospital (RPH) Burns Minimum Dataset (BMDS). Aggregated data of unintentional burn admissions during the same period were provided by the BMDS data manager to enable comparisons with assault burn patients.

Results

Assault burn admissions during 2004–2012 accounted for approximately 1% of all adult burn hospitalisations. All assault victims were burned by either thermal or scald agents. A high rate of intubation (24%) and ICU admission (1 in 3 cases) was observed in the fire assault group. The six assault cases undergoing intubation were severe burns, median TBSA 50%, most commonly affecting the face, head and torso, half of these cases had inhalational injuries and also required escharotomies.Comparison of admissions by calendar period showed no statistically significant differences in demographic, burn cause or TBSA%. However, statistically significant differences were found for pre-morbid psychiatric history (15% vs. 58%, p = 0.025) and concomitant fractures or dislocations (46% vs. 2%), p = 0.011).

Conclusions

While the proportion of assault burn admissions per total burn admissions steadily increased from 0.4% in 2009 to 1.5% in mid-2012, this proportion did not exceed that peak level observed of 2.1% for 2004.     

Serum phosphate level in burn patients

Introduction

Despite plasma phosphate imbalance being rare, it is a relatively common finding in certain subsets of burn patients. It may occur due to the burn itself or as a result of the treatment. Severe hypophosphataemia (<1.0 mg dl⁻¹) is associated with a significant morbidity and a fourfold increase in mortality. In this study, the relation between serum phosphate level and the total body surface area (TBSA) of the burn was compared.

Methods

According to the percentage of TBSA of the burn, the patients (n = 155) were divided into three groups: group A with 20–29% TBSA burns, group B with 30–39% and group C with more than 40% TBSA burns (62, 48 and 45 patients, respectively).Analysis of variance (ANOVA)-repeated measure was used to detect any statistically significant difference in the three post-burn time-points of 3rd, 6th and 9th days and the mean score of the serum phosphate level between the three groups.

Results

The incidence of hypophosphataemia at 9th post-burn day in the three groups was 6.1%, 32.4% and 73.5%, respectively. There were significant differences (p < 0.05) between mean serum phosphate levels of groups A and C, B and C and A and B as well. We found significant differences between the three post-burn follow-up time stages.

Discussion

We have shown that hypophosphataemia, defined as mean serum phosphate levels below 3.0 mg dl⁻¹, was very common following burn, based on 75.6% of patients with more than 40% burn at the 3rd post-burn day. As the percentage of TBSA of burn increases, the incidence of hypophosphataemia significantly increases. We suggest that phosphate level be routinely measured after a major burn, especially in patients with a complicated course, so that appropriate replacement therapy may be started in a timely manner.     

Management of patients in a dedicated burns intensive care unit (BICU) in a developing country

Background

In Pakistan the practice of managing extensive burns in dedicated intensive care units is not well established. This audit aims to define the characteristics of the victims of major burns and factors that increase mortality and outcome of the protocol-based management in a dedicated burns intensive care unit (BICU).

Patients and methods

This prospective audit included all patients admitted to the BICU of Suleiman Dawood Burns Unit in Karachi from 1st September 2002 to 31st August 2011. Demographic information, type and place of burn, total body surface area burn (TBSA), type of organ support provided, length of ICU stay, any associated medical diseases, and out outcome were documented.

Results

A total of 1597 patients were admitted to the BICU in 9 years. Median age of the patients was 22 (IQR = 32–7). 32% victims were children <14 years and only 7% were >50 years old. Male to female ratio was 1.4:1. Fire was the leading cause of burns in adults (64%) and scald burns were most common in (64%) in children. 72.4% of the accidents happened at home, where kitchen was the commonest location (597 cases). Mean TBSA burnt was 32.5% (SD ± 22.95%, 95%CI: 31.36–33.61). 27% patients needed ventilatory support, 4% were dialyzed and split skin graftings were performed in 20% patients. Average length of ICU stay was 10.42 days. Epilepsy, psychiatric illness and drug addiction were not common associations with burns. Overall mortality was 41.30% but it decreased over the years from 75% to 27%.

Conclusions

Groups of people most vulnerable to sustain burn are young females getting burnt in the kitchen, young males getting burnt at work, and small children falling in pots of hot water stored for drinking or bathing. TBSA >40%, age >50 years, fire burn and female gender were associated with a higher risk of death.Carefully planned, protocol based management of burn patients by burn teams of dedicated healthcare professionals, even with limited resources reduced mortality.

Recommendations

Burn hazard awareness, prevention and educational programmes targeted at the vulnerable population, i.e. women and young children at home and men at their work place is the single most cost-effective way of reducing the incidence of burns in developing countries.     

Stroke after burn: Population data analysis

Purpose of the study

We aimed to describe a population cohort study of burns with the prevalence of stroke, and discuss possible etiologies.

Analytical methods

This study uses data obtained from the Longitudinal Health Insurance Database 2005 (LHID2005). The study cohort consisted of all patients who had diagnoses of burn recorded in the database (ICD-9-CM codes 948) between January 1 2004 and December 31 2008 (N = 1549).

Main findings

The patients with burn and the comparison cohort are 7410 patients, 146 experienced stroke during the follow-up period of up to 5 years. In average, the burn patients suffered from stroke by 1.48 years after burn. The hazard ratio of stroke was 1.74 (95% CI, 1.15–2.63) for patients with TBSA burn <20%, 3.78 (95% CI, 1.39–10.26) for patients with TBSA burn ≥20%. The adjusted hazard ratio of ischemic stroke was 1.63 for patients with TBSA burn <20%, 2.96 for patients with TBSA burn ≥20%, whereas the hazard ratio of hemorrhagic stroke were not significant (p = 0.231).

Conclusions

In our study, severe burned patients, more than 60 years of age, had higher risk of stroke in their recovery life. We suggest close follow up for the burn patients in high risk of stroke.     

Estimating severity of burn in children: Pediatric Risk of Mortality (PRISM) score versus Abbreviated Burn Severity Index (ABSI)

Objective

The purpose of our study is to validate the Pediatric Risk of Mortality (PRISM) score and compare the accuracy of PRISM predicted outcomes to the Abbreviated Burn Severity Index (ABSI). We hypothesized that the PRISM score is more accurate in predicting mortality and hospital length of stay than the ABSI in children with severe burns.

Methods

All children <18 years of age admitted to a regional pediatric burn center between January 1, 2008 and July 1, 2010 were reviewed. Those with a Total Body Surface Area (TBSA) burn ≥20% who were admitted within 7 days of injury were selected for our study. Measured parameters included: demographics, burn characteristics, PRISM and ABSI scores at admission, and outcomes (mortality, hospital length of stay (LOS), ventilator days and cause of death).

Results

A total of 83 patients met criteria and had complete data sets. The mean age (±SEM) was 8.0 ± 0.6 years, mean % TBSA burn 49.9 ± 2.1%, 62.7% were male, and 45.8% had inhalation injury. Hospital LOS was 74.4 ± 7.9 days, with 31.5 ± 4.9 ventilator days. Mean PRISM score ranged from 14.2 to 16.0, with ABSI scores 7.9 to 8.5. Actual overall mortality was 18.1% compared to a PRISM predicted mortality of 19.8 ± 2.5% (p < 0.001, r = 0.570). ABSI predicted mortality varied from 10 to 20% for a score of 7.9 to 30–50% for a score of 8.5. Logistic regression showed that both PRISM (p < 0.001) and ABSI (p < 0.001) mortality predictions accurately estimated actual mortality, which remained true in a combined model. ABSI was predictive of hospital LOS (p < 0.001) and ventilator days (p < 0.001) while PRISM was not (p = 0.326 and p = 0.863).

Conclusions

Both PRISM and ABSI scores are predictive of mortality in severely burned children. Only ABSI correlates with hospital length of stay and ventilator days, and thus may also be more useful in predicting ICU resource utilization.     

Mental disorders among acute burn patients

Objective

To investigate mental disorders among acute hospitalized burn patients.

Method

Consecutive acute adult burn patients (n = 107) admitted to Helsinki Burn Centre were interviewed by an experienced psychiatrist with the Structured Clinical Interview for DSM-IV-TR for Axis I and II mental disorders assessed in three time frames (lifetime, the month prior to burn, and in acute care). Information on clinical features, psychiatric symptoms, personality traits, and burn severity (total body surface area, TBSA) was gathered.

Results

The mean TBSA was 9%. Most (61%) acute burn patients had at least one lifetime Axis I or II mental disorder. Prevalences of lifetime substance-related disorders (47%), psychotic disorders (10%), and Axis II personality disorders (23%) were high. The overall prevalence of Axis I mental disorders increased significantly (Q = 6.40, df = 1, p = 0.011) from the month prior to burn (40%) to acute care (48%). The prevalence of delirium for this period was significantly higher (0.9% vs. 13%; Q = 13.00, df = 1, p < 0.001) in acute care.

Conclusions

Mental disorders, particularly substance use disorders, psychotic disorders, and personality disorders are common among acute burn patients before injury. These disorders may predispose to burns. Burn itself may also predispose to mental disorders, particularly delirium.     

Utility of screening for diabetes in a burn center: Hemoglobin A1c,Diabetes Risk Test,or simple history?

Objective

Rates of diabetes mellitus (DM) are increasing. Early identification and treatment of hyperglycemia in the critical care setting can decrease morbidity and mortality. Many burn centers measure hemoglobin A1c (A1c). This study evaluates the prevalence of pre-existing DM and the utility of using A1c for identifying DM compared with a non-invasive risk assessment.

Methods

Adult patients admitted to our regional ABA-verified burn center from July 2008 to July 2009 had A1c levels evaluated and were asked to complete the American Diabetes Association Diabetes Risk Test (DRT).

Results

Forty-one patients consented to participate: 24 patients with burn (19 male) and 17 patients with non-burns (10 male). Non-burn patients had greater BMIs (BMI 32 vs. 28, p = 0.093) and had a higher rate of DM prior to admission (35% vs. 17%, p = 0.159) than the burn patients. These differences were not statistically significant. Most patients (23/41) were at high risk for developing DM based on the DRT. Patients with pre-existing DM were significantly more likely to have elevated A1c levels (>6.5%) compared with those without pre-existing DM (60% vs. 0%, p < 0.001). Compared with history of DM, DRT had a poor positive predictive value of 36% and 50% (burn and non-burn respectively) but a 100% negative predictive value for DM for both groups.

Conclusion

DM and obesity were more common in non-burn patients than in burn patients. A history of DM provides a simple, accurate method for identifying patients with DM. Use of A1c in the ICU provides little additional data for diagnosis of DM and does not impact patient management.     

Modernized standards in burns management: A comparative study in Komfo Anokye Teaching Hospital,Kumasi, Ghana

Background

Management of burns patients before May 2009 was very difficult at the Komfo Anokye Teaching Hospital (KATH).

Aim

To compile burns patients’ information in the new Burns Intensive Care Unit (BICU), analyze it and draw comparisons to information from the old BICU at KATH.

Methods

This retrospective study involves data from May 2007 to April 2009 (Group 1 – old BICU) and May 2009 to April 2011 (Group 2 – new BICU). The parameters of burn patients recorded included: record of admission, gender, age, aetiology of injury, Total Burns Surface Area (TBSA), the patients’ treatment regime and record of discharge/death. This information was analyzed with SPSS version 18.0.

Results

The total number of patients in the study was 511; Group 1 constituted 47.36% (n = 242) patients; males (n = 307, 61%) outnumbering females (n = 204, 39%). The overall mean, median and interquartile range (IQR) ages of the patients were 12.4 ± 2; 9.5 and 18.0 years respectively. The main aetiology of burns in Group 1 was flame burns (n = 115, 47.5%) and for Group 2 was scald (n = 151, 56.1%). The median TBSA recorded for Groups 1 and 2 were 32% and 41% respectively. A mortality rate of 19.1% (n = 46) and 12.7% (n = 34) were recorded for Groups 1 and 2 respectively which was statistically significant (p < 0.05). We found no differences for age and TBSA (P = 0.7168 and P = 0.8020 respectively). A Chi Square analysis for gender and aetiology of burn revealed no significant difference between Groups 1 and 2. A risk factor analysis for mortality within the Groups (using multiple regression analysis) identified only aetiology of burn in Group 1 to be a factor (P = 0.044).

Conclusion

This comparative study reveals that a significant difference in mortality was recorded for both groups. The mortality difference does not appear to be due to socio-demographic features. This study may demonstrate that modernized and advanced equipment with the adequate personnel play an essential role in burn management in low income countries such as Ghana.     

Clinical outcomes of isolated lower extremity or foot burns in diabetic versus non-diabetic patients: A 10-year retrospective analysis

Introduction

The incidence of diabetes mellitus (DM) in the United States is expected to increase from 8 per 1000 in 2008 to 15 per 1000 by 2050 [20]. As a result, DM patients will constitute a large proportion of Burn Center admissions, with burns typically due to contact burn or scalding. Peripheral vascular disease (PVD) and peripheral neuropathy (PN) are far more common in DM patients, particularly in those with poorly controlled disease, and are often associated with worse outcomes than non-diabetic (nDM) burn patients. This study sought to analyze whether the outcome of isolated leg and foot burns among DM and nDM individuals differed significantly.

Materials and methods

Retrospective data on 207 consecutive patients (>18 years old) admitted to a Burn Center with isolated leg or foot burns between 1999 and 2009 was collected and analyzed for this study. Age, gender, ethnicity, total body surface area (TBSA), degree of burn, etiology, hospital and burn intensive care unit (ICU), length of stay (LOS), and status at discharge were reviewed. Patients were grouped as diabetic (DM) or non-diabetic (nDM). Differences were analyzed using either the Student's t-test or Chi-square.

Results

43 DM and 164 nDM patients with isolated lower extremity or foot burns were treated during the study period (1999–2009). The mean age of DM and nDM patients was 54.6 and 43.7 years, respectively (p < 0.001). The most common burn etiology was scalding, flame, or contact burn. Percentage of total body surface area (TBSA) burn in DM patients averaged ± standard deviation 1.8 ± 1.3% compared to 1.8 ± 1.6% in nDM (p < 0.9). Among DM patients, 86% (N = 37) of patients suffered third degree burns and 14% (N = 6) of patients had second degree burns compared to 76% (N = 125) of patients and 24% (N = 39) of patients among nDM patients, respectively (p < 0.16). The DM group had significantly higher burn ICU admission rates, 16.3% of patients versus 8.5% of patients (p < 0.001), total length of hospital stay (mean ± standard deviation), 14.1 ± 10 versus 9.8 ± 9.3 days (p < 0.01) and renal failure, 4.7% of patients versus 0.6% of patients (p < 0.05) compared to the nDM group. 93% of DM patients were discharged to home without further medical attention while 4.7% of patients underwent further treatment. In comparison, 85.4% of the nDM patients were discharged home with no further treatment while 8.5% of patients received home care (p < 0.01).

Conclusion

DM patients who suffer isolated burns to the feet or lower extremities have poorer clinical outcomes and more complicated and protracted hospital courses when compared to nDM patients with similar burns. Although diabetics in the current study did not experience larger or more severe burns than nDM patients, they were nearly twice as likely to be admitted to the ICU, spent an average of four days longer in the hospital, and had a higher likelihood of developing renal failure compared to nDM patients.     

Lack of precision of burn surface area calculation by UK Armed Forces medical personnel

Objective

Accurate determination of the severity of burn is essential for the care of thermally injured patients. We aimed to examine the accuracy and precision of TBSA calculation performed by specialist military burn care providers and non-specialist but experienced military clinicians.

Methods

Using a single case example with photographic montages and a modified Lund and Browder chart, the two cohorts of clinicians were each given 10 min to map and calculate the case example TBSA involvement. The accuracy and precision of results from the two cohorts were compared to a set standard %TBSA.

Results

The set standard %TBSA involvement was 64.5%. Mean %TBSA mapped by non-specialists (52.53 ± 10.03%) differed significantly from the set standard (p < 0.0001). No difference was observed when comparing results from the burn care providers (65.68 ± 10.29%; p = 0.622). However, when comparing precision of calculation of TBSA burned, there was no evidence of a difference in heterogeneity of results between the two cohorts (F test, p = 0.639; Levene's test, p = 0.448).

Conclusions

These results indicate that experienced military burn care providers overall more accurately assess %TBSA burned than relatively inexperienced clinicians. However, results demonstrate a lack of precision in both groups.     

“Is the length of time in acute burn surgery associated with poorer outcomes?”

Background

Acute wound closure surgery improves outcomes, after burn particularly mortality, but also imposes physiological stress on the patient. The duration of surgery is associated with adverse outcomes in other populations. This study aimed to examine if extended acute burn surgery duration was associated with poorer in-hospital outcomes.

Methods

This retrospective cohort study included adult burn patients who required a single wound closure surgery at Royal Perth Hospital between 2004 and 2011. Multivariable regression analyses were used to assess the influence of patient and injury factors on surgery duration and length of stay (LOS).

Results

Surgery duration independently increased LOS (incidence rate ratio [IRR] = 1.004, p < 0.001). This translates to a predicted 13% increase in LOS for a 30 min increase in surgery ‘knife to skin’ time. Total body surface area (TBSA) was identified as a significant predictor of surgery duration (IRR = 1.047, p < 0.001), estimating that a 10% TBSA increase results in a 59% increase in surgery duration.

Conclusion

The results show that surgery duration is associated with LOS after adjusting for size of burn and other factors. The study justifies the need to explore strategies to reduce acute burn surgery duration.     

Hydroxyethylstarch supplementation in burn resuscitation—A prospective randomised controlled trial

Introduction

Hydroxyethylstarches (HES) are thought to be beneficial in trauma and major surgery management, due to their volume expansion and anti-inflammatory properties. This study examined the use of 6% (HES) in burn resuscitation.

Methods

26 adult patients with burns exceeding 15% total body surface area (TBSA) were randomised to either crystalloid (Hartmann's solution) or a colloid-supplemented resuscitation regime, where 1/3 of the crystalloid-predicted requirement was replaced by 6% HES.

Results

There was no difference in age, gender or TBSA between the two groups. The median (95% CI) fluid volume/%TBSA received in the first 24 h was 307 ml and 263 ml for the crystalloid only and HES-supplemented group respectively (p = 0.0234, Mann–Whitney). Body weight gain within the first 24 h after injury was significantly lower in the HES-supplemented group 2.5 kg versus 1.4 kg respectively (p = 0.0039). The median (95% CI) serum C-reactive protein at 48 h after injury was 210(167–257) and 128(74–145) mg/L for the crystalloid only and HES-supplemented group respectively (p = 0.0001). Albumin–creatinine ratio per % burn (ACR, a marker of capillary leak) was lower in the HES-supplemented group at 12 h after burn (p = 0.0310).

Conclusions

Patients treated with HES-supplemented resuscitation required less fluid, showed less interstitial oedema and a dampened inflammatory response compared to patients receiving isotonic crystalloid alone.     

Pathway genetic load allows simultaneous evaluation of multiple genetic associations

Objective

Despite the general success of genome-wide association studies, much heritability remains unidentified in many disease states. Some of this ‘missing’ heritability may lie in epistatic interactions among multiple loci, which are typically ignored. We utilized a method for simultaneous evaluation of epistatic interactions between allelic variations within genes confined to a single pathway, which we have termed as pathway genetic load (PGL).

Methods

In separate analyses, we evaluated the risk for sepsis and for death associated with alleles at six loci in the TLR4 signaling and response pathway previously known or suspected to be linked to the development of sepsis after traumatic injury. We evaluated 155 patients with ≥15% TBSA burns and without significant non-burn trauma [ISS ≤ 16], traumatic or anoxic brain injury or spinal cord injury, who survived >48 h post-admission. Clinical data were collected prospectively and candidate genotypes were determined by TaqMan assay.

Results

After adjustment for burn size, inhalation injury, age, gender and race, PGL was associated with increased probability for complicated sepsis (aOR = 1.59; 95%CI = 1.11–2.29; p = 0.011) and death (aOR = 1.75; 95%CI = 1.11–2.76; p = 0.017).

Conclusion

Relative size and variability of aORs indicate greater power to detect genetic associations with PGL compared to the analysis of loci individually by multivariate logistic regression.