Evaluation of soluble CD14 subtype (presepsin) in burn sepsis

Background

Diagnosing sepsis is difficult in burn patients because of the inflammatory mediators that alter postburn metabolic profile. Here, we compare a new marker presepsin with procalcitonin (PCT), c-reactive protein (CRP) and white blood cell (WBC) in diagnosis and follow up of sepsis in burn patients.

Methods

Patients admitted to burn center of our institute were prospectively investigated. Presepsin, PCT, CRP and WBC levels were measured at admission and every 6 h for first day and daily thereafter. At all timing samples, patients were classified as sepsis or non-sepsis according to the current American Burn Association Consensus Criteria (ABA) 2007.

Result

37 adult patients were evaluated. A total data of 611 time points were supplied. Sepsis time points differ significantly from non-sepsis in presepsin (p < 0.0001), PCT (p = 0.0012) and CRP (p < 0.0001) levels. Non-surviving patient results differ significantly from survivors in presepsin (p < 0.0001), PCT (p = 0.0210) and CRP (p = 0.0008). AUC-ROC % values for diagnosing sepsis were 83.4% for presepsin, 84.7% for PCT, 81.9% for CRP and 50.8% for WBC. Sepsis patients had significantly different presepsin, CRP and WBC but not PCT levels on their first day of sepsis compared to previous days.

Conclusion

Plasma presepsin levels have comparable performance in burn sepsis.     

Urinary neutrophil gelatinase–associated lipocalin,a biomarker for systemic inflammatory response syndrome in patients with nephrolithiasis

Background

The objective of this study was to determine the diagnostic value of neutrophil gelatinase–associated lipocalin (NGAL), C-reactive protein (CRP), and procalcitonin (PCT) in the prognosis of patients presenting with the systemic inflammatory response syndrome (SIRS) with nephrolithiasis.

Methods

Urine NGAL protein levels were measured by enzyme-linked immunosorbent assay in 87 patients presenting with nephrolithiasis who were diagnosed as SIRS. Additionally, 52 patients presenting with nephrolithiasis but without urinary tract infection and 30 healthy controls were also included in the study. Levels of serum CRP and PCT were also taken into consideration.

Results

Median urinary NGAL levels were significantly increased in the SIRS cohorts compared with nephrolithiasis without urinary tract infection patients (4.28 ng/mL versus 2.69 ng/mL, P < 0.001), and NGAL was markedly elevated even in the early stage of SIRS (3.23 ng/mL versus 2.69 ng/mL, P < 0.001). According to the receiver-operating characteristic analysis, NGAL demonstrated a high diagnostic value compared with either PCT or CRP. In the later stage of SIRS, NGAL remained a highly sensitive (76.8%) and specific (86.5%) diagnostic marker compared with either PCT or CRP. Moreover, the area under the curves of NGAL (0.822) were also superior to those seen in either PCT (0.657) or CRP (0.761).

Conclusion

Urinary NGAL is a highly sensitive and specific predictor of SIRS for patients presenting with nephrolithiasis. Further study of NGAL as a reliable biomarker of SIRS is required.     

The utility of C-reactive protein and procalcitonin for sepsis diagnosis in critically burned patients: A preliminary study

OBJECTIVE:

To assess the utility of C-reactive protein (CRP) and procalcitonin (PCT) as biomarkers of infection in patients with severe burn injury.

METHODS:

The present study included severe burn injury patients consecutively admitted to the Virgen del Rocío University Hospital (Andalucia, Spain) intensive care unit during a 12-month period. The variables of interest were: age, sex, mechanism of injury, percentage of burned body surface area, the Abbreviated Burn Severity Index (ABSI) and the absence/presence of sepsis. The authors analyzed serum levels of CRP and PCT at admission and every 48 h thereafter until intensive care unit discharge or death. Each determination was considered to be a sample or unit of analysis.

RESULTS:

A total of 157 determinations were analyzed from 17 severe burn injury patients. Fifty-four samples were considered to be septic, 25 of which corresponded to the first day of a new onset of sepsis. The mean duration of these symptoms was four days (interquartile range two to five days). Significant differences were found in the distributions of CRP and PCT values between sepsis and no-sepsis samples. Analysis of the changes in these biomarkers over time showed that PCT increase (ΔPCT) differentiated these diagnoses, whereas CRP increase (ΔCRP) did not. ROC curve analysis revealed that ΔPCT could predict positive sepsis samples (area under the curve 0.75 [95% CI 0.58 to 0.90]; P=0.003).

CONCLUSION:

These preliminary results showed that PCT had a better discriminatory capacity than CRP for identifying infectious processes in patients with severe burn injury. A larger sample size would be needed to confirm these results.     

心脏术后尿中性粒细胞明胶酶相关脂质运载蛋白和白细胞介素18与急性肾损伤的关系

目的 探讨接受体外循环心脏手术患者尿中性粒细胞明胶酶相关脂质运载蛋白（NGAL）和尿白细胞介素18（IL-18）与急性肾损伤（AKI）的关系。 方法 根据AKI的诊断标准，将33例体外循环心脏手术的患者分为AKI组及非AKI组，分别留取术前及术后不同时间点的血液和尿液标本，测定Scr、尿NGAL和IL-18水平。 结果 33例中有9例发生AKI，发生率为27.27%。AKI组Scr升高峰值出现在12～48 h内。与术前相比， AKI组术后2 h、4 h尿NGAL及IL-18水平升高，差异有统计学意义（P < 0.01）。与非AKI组比较，AKI组术后各时间点的尿NGAL水平、术后2 h及4 h的尿IL-18水平都较高，差异有统计学意义（P < 0.01）。经尿肌酐（Ucr）校正后，相应时间点的NGAL/Ucr和IL-18/Ucr差异仍有统计学意义（P < 0.01）。术后2 h尿NGAL和尿NGAL/Ucr的界定（cutoff） 值分别在250 µg/L和250 µg/mmol时；术后2 h尿IL-18和尿IL-18/Ucr的界定值分别在1800 ng/L和1800 ng/mmol时，体现出较好的敏感性和特异性。 AKI组术后12 h Scr水平与术后2 h尿NGAL水平呈正相关（r = 0.638，P < 0.05）。结论 体外循环下接受心脏手术的患者AKI发生率较高；术后2 h尿NGAL和NGAL/Ucr、术后2 h尿IL-18和尿IL-18/Ucr当达到一定界定值时，均可作为体外循环下心脏手术后AKI发生的早期诊断参考指标，其中术后2 h尿NGAL/Ucr为250 µg/mmol时更敏感。     

Procalcitonina y proteína C reactiva como marcadores precoces de infección intraabdominal postoperatoria en pacientes operados de cáncer gastrointestinal

Aim

to evaluate the association between serum levels of procalcitonin and C-reactive protein, on the first 3 postoperative days, and the appearance of postoperative intra-abdominal infection.

Method

Prospective observational study including 67 patients operated on for colo-rectal, gastric and pancreatic cancer. Serum levels of procalcitonin and C-reactive protein were analyzed before surgery and daily until the third postoperative day. Values of procalcitonin (PCT) and C-reactive protein (CRP) were recorded as well as their accuracy for detection of postoperative intra-abdominal infection (PIAI).

Results

The incidence of postoperative intra-abdominal infection was 13.4%. CRP serum levels at 72 h, PCT serum levels at 24, 48 and 72 h and the ratio between serum levels of CRP at 72 hours and serum levels of CRP at 48 hours (CRP D3/CRP D2) were significantly associated with the appearance of postoperative intra-abdominal infection. The highest sensitivity corresponded to PCT at 72 hours (88.9%); the highest specificity and positive predictive value corresponded to the ratio CRP D3/CRP D2 (96.49% and 71.4%, respectively); the highest negative predictive value to procalcitonin at 72 h and 24 h.

Conclusions

Serum levels of PCT are significantly associated with the appearance of postoperative intra-abdominal infection. Sensitivity and predictive positive values are low, but negative predictive value is high, even at 24 h after surgery.     

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.     

Le dosage plasmatique de Neutrophil Gelatinase-Associated Lipocalin (NGAL) prédit la défaillance rénale au cours du choc septique dès l’admission en réanimation

Purpose

To validate plasma Neutrophil Gelatinase-Associated Lipocalin (pNGAL) as an early biomarker in intensive care unit (ICU) for acute kidney injury (AKI) in critically ill adult with septic shock.

Patients and method

Fifty consecutive patients with septic shock were included in this observational cohort study. AKI was defined if patients met any RIFLE or AKIN criteria. The main objective was to evaluate diagnosis value of pNGAL measured with a point-of-care device at admission (D0), at 24 hours (D1) and at 48 hours (D2).

Results

Among the 50 patients enrolled, 86% had AKI, 48% had persistent renal AKI and 30% required renal replacement therapy (RRT) during their ICU stay. At D0, pNGAL concentration was significantly higher in patients with AKI compared to patients without AKI (471 ng/mL versus 134 ng/mL, P < 0.001). This level remained significantly higher in the AKI population at D1 and D2 and pNGAL concentration at D0 among AKI patients increased with kidney failure level. At D1, pNGAL was significantly higher for persistent renal AKI rather than transient prerenal (570 ng/mL versus 337 ng/mL, P = 0.027). pNGAL concentration below 348 ng/mL at D1 was never seen in patients with RRT.

Conclusion

Plasma NGAL is a useful, sensitive and early biomarker to predict persistent AKI in septic shock at ICU admission and help to discuss RRT.     

Accuracy of commercial reporting systems to monitor quality of care in burns

Introduction

Capse Healthcare Knowledge Systems (CHKS) is a global commercial organisation that operates health benchmarking programmes in the UK and internationally. In absence of a specialty-specific quality monitoring programme for burn services, CHKS has been producing comparative quality data for burn services for a number of years. The major quality indicator reported by CHKS is mortality as a Risk Adjusted Mortality Index (RAMI). The accuracy of RAMI is unknown in comparison to published burn-specific mortality prediction models.

Methods

A retrospective study design was used to collect data for patients admitted to the Adult Burn Service at University Hospital South Manchester (UHSM) between January 2006 and December 2010. Data was collected from two sources, CHKS and Manchester Burn Injury Database (MBID). The demographic and injury characteristics of survivors and non-survivors were compared and Receiver Operator Curve (ROC), equivalence and non-inferiority analyses were used to assess accuracy of RAMI in comparison to Abbreviated Burn Severity Index (ABSI), Belgian Outcome of Burn Injury (BOBI) score, Baux score (Baux) and McGwin score (McGwin).

Results

The accuracy of RAMI to discriminate between survivors and non-survivors (area under curve = 0.79, 95% CI 0.50–0.81) was significantly inferior to that of ABSI, BOBI, Baux and McGwin scores. Equivalence and non-inferiority testing of ROC curves also showed RAMI score to be inferior to ABSI, BOBI, Baux and McGwin scores at 5% significance level.

Conclusion

CHKS RAMI provides an inaccurate and inferior monitoring of mortality as a quality indicator in burn patients compared to burn specific mortality prediction models. This study raises concerns about the ability of commercially reported systems to accurately monitor quality indicators of relevance to burn care.     

Gonadotropin-releasing Hormone Agonists and Acute Kidney Injury in Patients with Prostate Cancer

Background

Androgen deprivation therapy (ADT) might increase the risk of acute kidney injury (AKI) in patients with prostate cancer (PCa).

Objective

To examine the impact of ADT on AKI in a large contemporary cohort of patients with nonmetastatic PCa representing the US population.

Design, setting, and participants

Overall, 69 292 patients diagnosed with nonmetastatic PCa between 1995 and 2009 were abstracted from the Surveillance Epidemiology and End Results–Medicare database.

Outcomes measurements and statistical analyses

Patient in both treatment arms (ADT vs no ADT) were matched using propensity-score methodology. Ten-year AKI rates were estimated. Competing-risks regression analyses tested the association between ADT and AKI, after adjusting for the risk of death during follow-up.

Results and limitations

Overall, the 10-yr AKI rates were 24.9% versus 30.7% for ADT-naive patients versus those treated with ADT, respectively (p < 0.001). When patients were stratified according to the type of ADT, the 10-yr AKI rates were 31.1% versus 26.0% for men treated with gonadotropin-releasing hormone (GnRH) agonists and bilateral orchiectomy, respectively (p < 0.001). In multivariable analyses, the administration of GnRH agonists (hazard ratio [HR]: 1.24; 95% confidence interval [CI], 1.18–1.31; p < 0.001), but not bilateral orchiectomy (HR: 1.11; 95% CI, 0.96–1.29; p = 0.1), was associated with the risk of experiencing AKI. Our study is limited by its retrospective design.

Conclusions

ADT is associated with an increased risk of AKI in patients with nonmetastatic PCa. In particular, the administration of GnRH agonists, but not surgical castration, may substantially increase the risk of experiencing AKI. These observations should help provide physicians with better patient selection to reduce the risk of AKI.

Patient summary

The administration of gonadotropin-releasing hormone agonists, but not bilateral orchiectomy, increases the risk of acute kidney injury (AKI) in patients with prostate cancer (PCa). These observations should help provide physicians with better patient selection to reduce the risk of AKI in PCa patients.     

Interleukin-18, CRP and procalcitonin levels in vesicoureteral reflux and reflux nephropathy

Abstract

Background: Some patients with vesicoureteral reflux (VUR) develop reflux nephropathy (RN) and a number of them progress to chronic kidney disease (CKD). However, it is unclear to predict which patient will develop RN and/or CKD. The aim of this study is to evaluate the role of Interleukin-18 (IL-18), C-reactive protein (CRP) and procalcitonin (PCT) as an indicator of RN in VUR. Methods: Ninety-three children aged 3.5–16 years with primary VUR were enrolled. Patients were divided into two groups according to the presence of renal scarring (RS). CRP, PCT, blood urea nitrogen (BUN), serum creatinine (Scr), urinary protein (Up), creatinine (Ucr) and microalbumin (Umalb), serum and urine IL-18 levels were determined during urinary tract infection (UTI) free episode. Results: BUN, Scr, Up/Ucr and Umalb/Ucr concentrations were higher whereas calculated creatinine clearance (Ccr) values were lower in RS (+) group compared to RS (?) group. CRP, PCT, serum and urine IL-18 levels and mean urine IL-18/Cr concentrations were similar in both groups. Serum and urine IL-18 levels did not differ according to the grade of VUR. No significant correlation was found between CRP, PCT and IL-18. Conclusions: Proteinuria and microalbuminuria are valuable hallmarks of RN. CRP and PCT seem not to be reliable indicators of RN in VUR patients. Moreover, serum and urine IL-18 might not predict RN.     

Correlation between circulating proteasome activity,total protein and c-reactive protein levels following burn in children

Aim of the study

To characterize burn-induced changes following burn in children by analyzing circulating proteasome (c-proteasome) activity in the plasma in correlation with total protein and c-reactive protein levels in the plasma, and the severity of the burn.

Methods

Fifty consecutive children scalded by hot water who were managed at the Department of Pediatric Surgery after primarily presenting with burns in 4–20% TBSA were included into the study. The children were aged 9 months up to 14 years (mean age 2.5 ± 1 years). Patients were divided into groups according to the pediatric injury severity score used by American Burns Association. Plasma proteasome activity was assessed using Suc-Leu-Leu-Val-Tyr-AMC peptide substrate, 2–6 h, 12–16 h, 3 days, 5 days, and 7 days after injury. 20 healthy children consecutively admitted for planned inguinal hernia repair served as controls.

Results

Statistically significant elevation of plasma c-proteasome activity was noted in all groups of burned children 12–16 h after the injury. We found a strong negative correlation of c-proteasome activity with total protein levels, and positive correlation with CRP levels 12–16 h after burn. We also found stronger correlation between c-proteasome activity and severity of burn, than CRP level and severity of burn 12–16 h, and 3 days after the burn. Correlations were statistically significant.

Conclusions

This study characterized circulating 20S proteasome activity levels after burn. C-proteasome activity elevate after burn and correlate negatively with plasma total protein level, thus plasma 20S proteasome activity could be additional biomarker of tissue damage in burn in pediatric population.     

Effect of cholecalciferol recommended daily allowances on vitamin D status and fibroblast growth factor-23: An observational study in acute burn patients

Objective

Burn patients are at risk of hypovitaminosis D. Optimal vitamin D (VD) intakes are not defined in burn nutrition guidelines and studies mostly focused on ergocalciferol (VD2) supplementation in burn children. Aim of our study was to describe adult burns VD status, to measure effects of our cholecalciferol (VD3) supplementation on VD metabolism during acute burn care, and to assess correlation between FGF23 and C-reactive protein (CRP).

Design

Cohort study.

Methods

From March 2012 to January 2013, patients >18 years, admitted within 24 h after injury with burn surface area (BSA) ≥10% were included. Patients daily received VD3 from oral or enteral nutrition (400–600 IU) and from oral or intravenous multivitamin complex (200–220 IU). Serum levels of 25(OH)-D, 1-25(OH)₂-D, 3rd generation PTH, C-terminal FGF23, total calcium, phosphate, albumin and CRP were measured at admission (D0) and every week during 4 weeks of follow-up. Data are expressed as percentage or median (min–max). Paired data were compared using Wilcoxon test. Correlation between CRP and FGF23 was assessed using nonparametric Spearman test. A p value <0.05 was considered to be statistically significant.

Results

We initially included 24 patients. Median age and BSA were, respectively, 46 [19–86] years and 15 [10–85]%. At D0, 75% presented a VD insufficiency (25(OH)-D 21–29 ng/ml) and 17% presented a deficiency (25(OH)-D ≤20 ng/ml). We followed 12 patients until day 28: 25(OH)-D was unchanged while 1-25(OH)₂-D and FGF23 decreased without reaching significance. We observed a significant positive correlation between FGF23 and CRP (r = 0.59, 95% CI: 0.22–0.82, p = 0.0032).

Conclusions

Most of our adult burns presented hypovitaminosis D regardless of age. Nutrition supplemented with low dose of VD3 (intakes reaching recommended daily allowances) was insufficient to correct 25(OH)-D level. Moreover, an interesting correlation between CRP and FGF23 was found.     

Effect of fresh human amniotic membrane dressing on graft take in patients with chronic burn wounds compared with conventional methods

Background

Burns are among the most devastating forms of injury. Nowadays the standard treatment for deep partial thickness and full-thickness burn is early excision and grafting, but this technique is not always feasible; and this leads to chronicity and microbial colonization of burn wounds. Interesting properties of human amniotic membrane made us use it in management of chronic infected burn wounds.

Methods

From January 2008 to September 2010, in a prospective clinical trail, 38 patients (76 limbs) with symmetric chronic burn wounds in both upper or lower limbs included in this study. Tissue cultures were taken from all the wounds. For the right, after debridement of granulation tissue and meshed split thickness skin grafting, the graft surfaces were covered with amniotic membrane dressing and in left limb wounds, after debridement, skin grafting was done in conventional method. 21 days later, the success rate of graft take was compared between two groups.

Results

The study group was composed of 76 limbs in 38 patients with mean age of 27.18 ± 6.38 and burn in 29.18 ± 7.23 TBSA%. The most common causes of the burn wounds chronicity in the selected patients was delayed admission due to poor compliance of the patients (44.8%). Staphylococcus was the most frequent isolate in wounds in our patients (62.85%). Mean graft take was observed in 90.13% of right upper limbs, and 67.36% of left upper limbs; which was significantly different (P < 0.001).

Conclusions

Our study showed that human amniotic membrane dressing significantly increases the success rate of graft take in chronic wounds, and it can be recommended as an important dressing in chronic burn wounds management, due to interesting anti-microbial, and better graft take effects.     

Assessment of mortality prediction models in a Ghanaian burn population

Purpose

Over 40 new or modified outcome prediction models have been developed for severe burns; with age, total burned surface area (TBSA) and inhalation area as major determinants of mortality. The objective of this study was to assess their applicability in a developing country.

Procedures

Data were collected retrospectively of a consecutive series of 261 patients (2009–2011) admitted to a Burns Intensive Care. Five outcome prediction models based on admission criteria were evaluated: Bull grid, Abbreviated Burn Severity Index – ABSI, Ryan-model, Belgian Outcome in Burn Injury – BOBI and revised Baux. Discriminative power and goodness-of-fit were assessed by receiver operating characteristic analyses (area under the curve – AUC) and Hosmer–Lemeshow tests.

Findings

Median age was 10.5 years (IQR: 2.5–27 years), median TBSA 21% (IQR: 11–34%); 55.2% were male, 28 patients died (10.7%). Only 2 patients were intubated (0.8%). The AUC were between 77 and 86%. The ABSI model showed the best calibration (28.7 expected deaths). Ryan, BOBI and rBaux significantly underestimated mortality, whereas Bull showed an overestimation.

Conclusion

This study on a young group of burn patients showed moderate to good discriminative power using all five prediction models. The expected number of deaths tended to be underestimated in the three most recent prediction models.     

Bed net related burns at Mulago National Referral Hospital,Uganda: A case series report

Background

Insecticide-treated bed nets are essential tools to prevent malaria in endemic regions, however, increasing trends in bed net related burns in Kampala, Uganda are concerning.

Methods

Data were collected from burns unit admission records at Mulago National Referral Hospital in Kampala, Uganda for the years 2008–2011 inclusive. Retrospective analyses on the characteristics of patients admitted with bed net related burns within this period were conducted.

Results

A total of 45 patients were admitted to the burns unit with bed net related burns during the study period. Most burns occurred among individuals who were 0–1 years old (33.3%) and 26–35 years old (24.2%) and the majority were male (71%). Bed net related burns at Mulago Hospital are severe, as evidenced by the fact that 15 of 45 patients died (crude mortality rate = 33%) and that 26 patients (57.8%) had total body surface area burn percentages that were greater than 20%. The average length of stay in hospital for patients with bed net related burns was 30.4 days.

Conclusion

Organizations responsible for malaria prevention should consider incorporating fire and burn prevention awareness, strategies and training into their bed net distribution programs.     

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.     

Acute burn induced coagulopathy

Background

Acute traumatic coagulopathy is well described in the trauma population. Major burns are characterised by a similar endothelial injury and cellular hypoperfusion. These features could be a driver for an acute burn induced coagulopathy (ABIC).

Methods

Patients admitted to a regional burn centre over a 71 months period with a total body surface area burn of 30% or more were identified. The metavision electronic patient database was scrutinised for a predetermined list of demographics, interventions and admission investigations to identify any clinically significant ABIC.

Results

On admission 39.3% of the 117 patients analysed met our criteria for a coagulopathy. Of the patients with a coagulopathy, 71.7% had an elevated Prothrombin Time (PT), 2.2% had an elevated Activated Partial Thromboplastin time (APPT) and 26.1% had an elevation of both. Patients with a coagulopathy received a similar volume of fluid (p = 0.08). There was a statistically significant correlation between the PT and the abbreviated burn severity index (p = 0.0013, r = 0.292) and serum lactate (p = 0.0013, r = 0.292). ABIC was an independent predictor of 28 day mortality, OR 3.42(1.11–10.56).

Conclusion

In patients with major thermal injuries a clinically significant ABIC exists. Early diagnosis and treatment of ABIC should be considered particularly in those undergoing total burn wound excision.     

Biological markers of stress in pediatric acute burn injury

Background

Burns and their associated wound care procedures evoke significant stress and anxiety, particularly for children. Little is known about the body's physiological stress reactions throughout the stages of re-epithelialization following an acute burn injury. Previously, serum and urinary cortisol have been used to measure stress in burn patients, however these measures are not suitable for a pediatric burn outpatient setting.

Aim

To assess the sensitivity of salivary cortisol and sAA in detecting stress during acute burn wound care procedures and to investigate the body's physiological stress reactions throughout burn re-epithelialization.

Methods

Seventy-seven participants aged four to thirteen years who presented with an acute burn injury to the burn center at the Royal Children's Hospital, Brisbane, Australia, were recruited between August 2011 and August 2012.

Results

Both biomarkers were responsive to the stress of burn wound care procedures. sAA levels were on average 50.2 U/ml higher (p < 0.001) at 10 min post-dressing removal compared to baseline levels. Salivary cortisol levels showed a blunted effect with average levels at ten minutes post dressing removal decreasing by 0.54 nmol/L (p < 0.001) compared to baseline levels. sAA levels were associated with pain (p = 0.021), no medication (p = 0.047) and Child Trauma Screening Questionnaire scores at three months post re-epithelialization (p = 0.008). Similarly, salivary cortisol was associated with no medication (p < 0.001), pain scores (p = 0.045) and total body surface area of the burn (p = 0.010).

Conclusion

Factors which support the use of sAA over salivary cortisol to assess stress during morning acute burn wound care procedures include; sensitivity, morning clinic times relative to cortisol's diurnal peaks, and relative cost.