Cost Analysis of 48 Burn Patients in a Mass Casualty Explosion Treated at Chang Gung Memorial Hospital

IntroductionLittle is known about the costs of treating burn patients after a mass casualty event. A devastating Color Dust explosion that injured 499 patients occurred on June 27, 2015 in Taiwan. This study was performed to investigate the economic effects of treating burn patients at a single medical center after an explosion disaster.MethodsA detailed retrospective analysis on 48 patient expense records at Chang Gung Memorial Hospital after the Color Dust explosion was performed. Data were collected during the acute treatment period between June 27, 2015 and September 30, 2015. The distribution of cost drivers for the entire patient cohort (n = 48), patients with a percent total body surface area burn (%TBSA) ≥ 50 (n = 20), and those with %TBSA <50 (n = 28) were analyzed.ResultsThe total cost of 48 burn patients over the acute 3-month time period was $2,440,688, with a mean cost per patient of $50,848 ±36,438. Inpatient ward fees (30%), therapeutic treatment fees (22%), and medication fees (11%) were found to be the three highest cost drivers. The 20 patients with a %TBSA ≥50 consumed $1,559,300 (63.8%) of the total expenses, at an average cost of $77,965 ± 34,226 per patient. The 28 patients with a %TBSA <50 consumed $881,387 (36.1%) of care expenses, at an average cost of $31,478 ± 23,518 per patient.ConclusionsIn response to this mass casualty event, inpatient ward fees represented the largest expense. Hospitals can reduce this fee by ensuring wound dressing and skin substitute materials are regionally stocked and accessible. Medication fees may be higher than expected when treating a mass burn cohort. In preparation for a future event, hospitals should anticipate patients with a %TBSA ≥ 50 will contribute the majority of inpatient expenses.     

Incidence and risk factors for deep vein thrombosis among pediatric burn patients

BackgroundPatients with major burns covering a large total body surface area (%TBSA) fulfill all the criteria of Virchow’s triad, as a sequela of their injury. This places these patients at increased risk for developing deep vein thrombosis (DVT). However, data regarding the incidence of DVT in burn patients are minimal, especially in the pediatric age group. Therefore, the aim of this study is to determine the incidence of DVT in pediatric burn patients, identify possible risk factors for developing DVT, and explore the need for prophylactic treatment.MethodsA retrospective chart review of 95 patients admitted to our Burn Unit was conducted. We included all pediatric patients with second- and third-degree burns admitted to the unit. Exclusion criteria were adult patients, those with first-degree burns and admitted to the unit for <72 h, patients discharged against medical advice, those admitted for elective reconstructive surgery, secondary admissions for non-healing/infected burns, and patients with trauma-induced skin loss. A data collection sheet was utilized.ResultsThe total incidence of thrombosis in our population was 4.2% (DVT, 3.1%; arterial thrombosis, 1.1%). Factors significantly associated with DVT included length of hospitalization (p = 0.012), central venous catheter placement (p = 0.013), and %TBSA (p = 0.004). Unlike adult patients, weight for age (percentile) and body mass index were not significant risk factors for DVT in our patients.ConclusionBurns are a major risk factor for DVT, especially when covering large surface areas (≥40% TBSA) and combined with other factors (i.e., prolonged hospitalization and central lines). Thus, investigations for DVT and prophylactic anticoagulation should be considered for pediatric burn patients with these risk factors, even if they are asymptomatic.     

Longitudinal burn scar quantification

Quantitative studies of the clinical recovery of burn scars are currently lacking. Previous reports validate the objective, precise, diagnostic capabilities of high-frequency ultrasound to measure thickness, the Cutometer^® to measure pliability and the Mexameter^® to measure erythema and pigmentation of scars. Thus, we prospectively quantified clinical characteristics of patient-matched, after burn hypertrophic scar (HSc), donor site scar (D) and normal skin (N) using these instruments. One investigator measured 3 sites (HSc, D, N) in 46 burn survivors at 3, 6, and 12 months after-burn. A mixed model regression analysis, adjusting p-values for multiplicity of testing, was used to compare means among sites and time points. Participants were 41.2 ± 13.5 years old, 87% males, predominantly Caucasian, with an average of 19.5% body surface area burned. HSc thickness decreased significantly between 3 and 6, 6 and 12, and 3 and 12 months (all p < 0.0001), but remained thicker than D and N skin (all p < 0.0001). Pliability differed significantly between HSc, D and N sites at all time points (all p < 0.0001), with HSc and D increasing between 3 and 12 months (p < 0.05) but not reaching normal. HSc and D sites were significantly more erythematous than normal skin (p < 0.05) at 3 and 6 months but D sites approached normal by 12 months. The only time points at which pigmentation significantly differed were the HSc and D sites at 6 months. Thickness, pliability, erythema and pigmentation of N skin remained similar over the 12 months. We found that post-burn HSc thickness, pliability and erythema differed significantly from D and N skin at 3, 6, and 12 months and does not return to normal by 12 months after-injury; however, significant improvements towards normal can be expected. Donor sites are redder than normal skin at 3 and 6 months but can be expected to return to normal by 12 months. Although the color of HSc and D sites change markedly with time these color changes are primarily due to changes in redness of the site, not melanin in this primarily Caucasian population.     

Assessing opioid administration in pediatric burn patients with nonsurgical management

BackgroundDespite the vast literature studying the opioid crisis, sparse data describe this in the pediatric burn population. This study sought to assess patient-level characteristics and their potential effects on opioid administration in nonsurgical pediatric burn inpatients.MethodsAdmitted burn patients from 2013 to 2018 with nonsurgical management at an American Burn Association (ABA) verified pediatric burn center were retrospectively identified. Morphine milligram equivalents by weight (MME/kg) per admission were evaluated through a multiple loglinear regression with race, sex, age, total body surface area burned (TBSA), and burn depth as predictors. Simple linear regression was used to evaluate the temporal trend of median opioid utilization.ResultsA total of 806 patients (55% White, 35% Black, 5% Hispanic, 5% Other) were included. In an adjusted analysis, no differences in opioid administration were seen by sex, burn degree, or for Blacks and Hispanics when compared with Whites. Increased MME/kg was associated with older age (10–18 years; p < 0.0001) and larger burns (>5% TBSA burned; p < 0.0001). From 2013 to 2018, median MME/kg per admission declined significantly (2013:0.21, 2018:0.09; p = 0.0103).ConclusionsNonsurgical burn patients who were older and presented with larger TBSA experienced marked increases in opioid utilization. Overall, opioid administration decreased over time.     

Safety and efficacy of excision and direct closure in acute burns surgery: Outcome analysis in a prospective series of 100 patients and a survey of UK burns surgeons’ attitudes

Many burns surgeons avoid excision and direct closure of acute burns owing to concerns over wound dehiscence, scarring and infection. There is no evidence in the literature to support this practice. We present outcomes of a prospective series of 100 patients who underwent excision and direct closure of 138 burns over a 2-year period, along with results from a survey sent to 33 senior burns surgeons to gauge attitudes towards direct closure in burns surgery. 47% of survey respondents never perform direct closure. Dehiscence was cited as the most common concern, followed by hypertrophic scarring (HTS). In our cohort, the superficial dehiscence rate was 12% and the HTS rate was 16%, with no scarring contractures. Patients with healing time greater than 14 days were more likely to develop HTS (p = 0.008), as were those with wound dehiscence (p = 0.014). Patients undergoing part-grafting in addition to direct closure took significantly longer to heal than those undergoing direct closure alone (p = 0.0002), with the donor site or graft delaying healing in the majority. Excision and direct closure of acute burn wounds avoids donor site morbidity and has an acceptable complication rate. It is a safe and effective treatment for full thickness burns in selected cases.     

Absence of pathological scarring in the donor site of the scalp in burns: An analysis of 295 cases

AimThis study aims to describe the incidence of complications on scalp from which a thin split-skin graft was harvested (0.005–0.007 in.) of the donor site in children and adult burn victims.MethodsWe reviewed the medical records of 295 burn patients admitted in the Burn Unit of the Clinical Hospital of the Faculty of Medicine of Ribeirão Preto, from January 1998 to December 2007, whose scalps were used as donor site for grafts. Skin-graft thickness varied from 0.005 in. to 0.007 in. The occurrence of pathological healing was evaluated clinically and the time of epithelisation by the main surgeon and a plastic surgeon or a staff nurse.ResultsOf the 295 patients whose scalps were used as donor site, 274 were followed from 6 months to 10 years after the procedure (median 18.2 months). Twenty-one patients were lost to follow-up in the first 6 months. No hypertrophic scarring or keloids on the donor site was observed. Five patients (1.82%) presented with folliculitis and two of them were evaluated with small areas of alopecia (0.7%), treated with resection of these areas and primary suture. The average time of epithelisation of the donor site was 7 days.ConclusionThe harvest of thinner split graft from the scalp is a safe procedure.     

Intraoperative liposomal bupivacaine for skin graft donor site analgesia: A retrospective cohort study

IntroductionBurn injury and reconstructive operations often result in severe pain, particularly at skin graft donor sites. Traditional local anesthetics administered intraoperatively control pain at donor sites, but the duration of action is short. Liposomal bupivacaine, a novel local anesthetic, can provide sustained-release analgesia for 72 h. The primary aim of this study was to describe the efficacy of liposomal bupivacaine for postoperative donor site pain control for patients undergoing skin graft procedures.MethodsA retrospective cohort study was performed on patients who received a donor site liposomal bupivacaine field block and was compared to a matched control. Patients rated donor site pain on post-operative day 0 and 1, and stated whether the donor or graft site was more painful.ResultsFifty-eight patients were included. Twenty-nine patients received liposomal bupivacaine. Eighty-six percent of patients in the treatment group rated donor site pain as three or less on postoperative day 0 and 1, compared to 3.4% in the control (p < 0.0001). Also, 76% of patients in the treatment group stated donor site pain was less than graft site pain, compared to 3.4% in the control (p < 0.0001).ConclusionPatients who received liposomal bupivacaine reported less postoperative donor site pain and found the donor site to be less bothersome without major complications. Liposomal bupivacaine may be a safe and promising agent for prolonging postoperative analgesia and minimizing donor site pain.     

Acute Kidney Injury: It's not just the ‘big’ burns

BackgroundAcute Kidney Injury (AKI) complicates the management of at least 25% of patients with severe burns and is associated with long term complications. Most research focuses on the patients with more severe burns, and whether the same factors are associated with the development of AKI in patients with burns between 10 and 19% total body surface area (TBSA) is unknown. The aims of this study were to examine the incidence of, and factors associated with, the development of AKI in patients with %TBSA ≥ 10, as well as the relationship with hospital metrics such as length of stay (LOS).MethodsRetrospective medical record review of consecutive burns patients admitted to The Alfred Hospital, the major adult burns centre in Victoria, Australia. Demographic and injury details were recorded. Factors associated with AKI were determined using multiple logistic regression.ResultsBetween 2010 and June 2014, 300 patients were admitted with burn injury and data on 267 patients was available for analysis. Median age was 54.5 years with 78% being male. Median %TBSA was 15 (IQR 12, 20). The AKI incidence, as measured by the RIFLE criteria, was 22.5%, including 15% (27/184) in patients with %TBSA 10–19. Factors associated with AKI included increasing age and %TBSA (OR 1.05 p < 0.001) as well as increased surgeries (p < 0.041) and a cardiac comorbidity (p < 0.01). All patients with renal comorbidity developed AKI. In the %TBSA 10–19 cohort, only increasing age (OR 1.05 p < 0.001) was associated with AKI. After accounting for confounding factors, the probability of discharge from hospital in Non-AKI group was greater than for the AKI patients at all time points (P < 0.001).ConclusionThis is the first study to show an association between patients with %TBSA 10–19 and AKI. Given the association between AKI and complications, prospective research is needed to further understand AKI in burns with the aim of risk reduction.     

Fluid volumes infused during burn resuscitation 1980–2015: A quantitative review

Introduction‘Fluid creep’ or excessive fluid delivered to burn patients during early resuscitation has been suggested by several studies from individual burn centers.MethodsWe performed a Medline search from 1980 to 2015 in order to identify studies of burn patients predominantly resuscitated with lactated Ringers with infusion adjusted per urinary output. Data was abstracted for 48 publications (3196 patients) that met entry criteria.ResultsHigher resuscitation volumes compared to Parkland estimates were reported, but the trend of increasing resuscitation volumes over the last 30 years is not supported by regression of total fluid infused versus year of study. Mean 24 h fluid infused for all studies was 5.2 ± 1.1 mL/kg per %TBSA. The mean 24 h urinary output reported in 30 studies was 1.2 ± 0.5 mL/kg per hr. Burns with inhalation injuries (5 studies) received significantly more fluid than non-inhalation injured burn patients (5.0 ± 1.3 versus 3.9 ± 0.9 mL/kg per %TBSA). Fluid infused and urinary outputs were similar for adults and pediatric patients. The most striking finding of our analyses was the great ranges of the means and high standard deviations of volumes infused compared to the original Baxter publication that introduced the Parkland formulaConclusionsThese analyses suggest that burn units currently administer volumes larger than Parkland formula with great patient variability. Individual patient hourly data is needed to better understand the record of burn resuscitation and Fluid Creep.     

Variation in acute fluid resuscitation among pediatric burn centers

BackgroundAccurate resuscitation of pediatric patients with large thermal injury is critical to achieving optimal outcomes. The goal of this project was to describe the degree of variability in resuscitation guidelines among pediatric burn centers and the impact on fluid estimates.MethodsFive pediatric burn centers in the Pediatric Injury Quality Improvement Collaborative (PIQIC) contributed data from patients with ≥15% total body surface area (TBSA) burns treated from 2014 to 2018. Each center's resuscitation guidelines and guidelines from the American Burn Association were used to calculate estimated 24-h fluid requirements and compare these values to the actual fluid received.ResultsDifferences in the TBSA burn at which fluid resuscitation was initiated, coefficients related to the Parkland formula, criteria to initiate dextrose containing fluids, and urine output goals were observed. Three of the five centers’ resuscitation guidelines produced statistically significant lower mean fluid estimates when compared with the actual mean fluid received for all patients across centers (4.53 versus 6.35 ml/kg/% TBSA, p < 0.001), (4.90 versus 6.35 ml/kg/TBSA, p = 0.002) and (3.38 versus 6.35 ml/kg/TBSA, p < 0.0001).ConclusionsThis variation in practice patterns led to statistically significant differences in fluid estimates. One center chose to modify its resuscitation guidelines at the conclusion of this study.     

Bismuth/petroleum gauze plus high density polyethylene vs. bismuth/petroleum gauze: A comparison of donor site healing and patient comfort

IntroductionSkin grafting continues to be a fundamental component of burn treatment and inherently, a donor site must be created and treated. Burn surgeons agree that specific dressings may have a significant affect on donor site healing, but we have no consensus as to which dressing provides maximum benefit.MethodsRetrospective analysis of prospectively collected data from an observational, within-patient controlled assessment of a practice pattern intervention. The project compared donor sites treated with high-density polyethylene plus an overlying layer of bismuth/petroleum gauze to donor sites treated with bismuth/petroleum gauze alone. The primary endpoint was patient reported pain using a standard visual analog scale from 0 (no pain) to 10 (worst possible pain). A 2-point reduction in pain was considered clinically significant. Healing was defined as complete detachment of the dressings and> 95% wound re-epitheliazation.ResultsA total of 30 patients were observed and analyzed. Both dressings were associated with a mean pain rating of 6 out of 10 (STD = ± 2) and a median pain rating of 6 out of 10 (range = 0–10). Additionally, both dressings were associated with a mean healing time of 20 days (SEM = 1.1). The subjective dressing preference showed that a majority of patients had no preference between the two modalities (n = 20). However, when an actual preference was stated (n = 10), bismuth/petroleum gauze alone was preferred by 9 out of 10 patients.ConclusionClinically and subjectively, we found no discernible differences between the 2 dressing regimens. Thus, bismuth/petroleum gauze alone is the more cost effective dressing choice. Our burn center continues to use bismuth/petroleum gauze alone as its standard of care for donor site dressings and will continue to try to define the optimal donor site dressing.     

Long term sensory function after minor partial thickness burn: A pilot study to determine if recovery is complete or incomplete

BackgroundAcute burn damages skin architecture, including nerve endings, altering sensation and influencing recovery of quality of life and participation. It is established that sensation is reduced in scars after deep burn. However, it is unclear if sensory deficits exist in mild scars. The aim of this trial was to determine if sensory deficits persist in mature scars after minor partial thickness burn.MethodsThis observational pilot involved 30 patients with ‘good quality’ scars (defined as VSS ≤5 at ≥6 months post-burn). Sensory function was compared in scars and site matched uninjured skin using von Frey filaments and two-point discrimination (2-PD). Multivariable regression was used to predict the influence of burn and confounders on sensory outcomes.ResultsBoth pressure and 2-PD distance were significantly greater in scar compared to uninjured sites, indicating reduced sensory function. For von Frey filaments, the median was 3.84 (IQR = 1) in scars and 3.22 (IQR = 1) for uninjured (p = 0.001). For 2-PD, the median was 3.9 cm (IQR = 1.8) for scars and 2.6 cm (IQR = 1.6) for control sites (p = 0.001).ConclusionMeasureable sensory deficits persist in mature, good quality burn scars. These deficits may influence long-term recovery after minor partial thickness burn.     

Pediatric traumas and neighborhood socioeconomic characteristics: A population based study

BackgroundIdentifying pediatric populations at risk for traumas would enable development of emergency medical services and emergency departments for children. Elucidation of the nature of socioeconomic differences in the incidence of pediatric out-of-hospital emergencies is needed to overcome inequities in child health.MethodsWe retrieved all ambulance contacts during 17.12.2014–16.12.2018 involving children (0–15 years) in Helsinki, Finland and separated traumatic and nontraumatic emergencies. We compared the incidences of these emergencies in the pediatric population with socioeconomic markers of the scene of the emergency and of the residential area of the child.ResultsOf 11,742 ambulance contacts involving children 4113 (35.0%) were traumatic. Traumatic emergencies occurred more often in neighborhoods with lower median income/household (P = 0.043) and were more common in children living in areas with lower median income/inhabitant (P = 0.001), higher unemployment (P < 0.001), and lower education (P < 0.001). The associations were weaker for traumatic than nontraumatic emergencies. Higher proportion of a pediatric population in a residential area (P = 0.005) had a protective effect. Exclusion of clinically unnecessary ambulance responses did not change the results.ConclusionTraumatic emergencies in children are more common in areas with lower socioeconomic status.The possible protective effect of urban planning merits further studies.Type of studyPrognostic.Level of evidenceII.     

De Ritis ratio as a predictor of 1-year mortality after burn surgery

BackgroundBurn is an overwhelming injury. The De Ritis ratio, defined as aspartate aminotransferase to alanine aminotransferase ratio, can be used to predict poor outcomes. We evaluated the risk factors, including the De Ritis ratio, associated with 1-year mortality after burn surgery.MethodsPatients who underwent burn surgery from 2009 to 2019 were retrospectively evaluated. Multivariate Cox regression analysis was conducted to evaluate the risk factors for 1-year mortality after burn surgery. Receiver operating characteristic (ROC) curve analysis of the De Ritis ratio was performed to predict postoperative 1-year mortality. Kaplan–Meier survival analysis was also conducted. Other postoperative outcomes, such as durations of hospital and intensive care unit stays, acute kidney injury, and major adverse cardiac events, were evaluated.ResultsOne-year mortality after burn surgery occurred in 247 (19.9%) of 1244 patients. The risk factors for 1-year mortality after burn surgery were the De Ritis ratio, age, American Society of Anesthesiologists physical status, diabetes mellitus, total body surface area burned, inhalation injury, serum creatinine level, and serum albumin level. The area under the ROC curve for the De Ritis ratio was 0.716 (optimal cutoff = 1.9). The 1-year mortality rate after burn surgery was significantly higher in patients with a De Ritis ratio >1.9 than in those with a De Ritis ratio ≤1.9 (35.8% vs. 11.8%, P < 0.001). The survival rate was significantly higher in patients with a De Ritis ratio ≤1.9 than in those with a De Ritis ratio >1.9 (log-rank test, P < 0.001). Intensive care unit stay, acute kidney injury, and major adverse cardiac events were significantly higher in patients with a De Ritis ratio >1.9 than in those with a De Ritis ratio ≤1.9 (P = 0.006, P < 0.001, and P < 0.001, respectively).ConclusionsThe preoperative De Ritis ratio was a risk factor for 1-year mortality after burn surgery. The De Ritis ratio >1.9 was significantly associated with an increased 1-year mortality after burn surgery. These findings emphasized the importance of identifying burn patients with an increased De Ritis ratio to reduce the mortality after burn surgery.     

Bypass of an anesthesiologist-directed preoperative evaluation clinic results in greater first-case tardiness and turnover times

Study objectiveWe evaluated 4 hypotheses related to bypass of an anesthesiologist-directed preoperative evaluation clinics (APEC): 1) first-case tardiness and turnover times increased; 2) turnover times increased more than first-case tardiness; and higher American Society of Anesthesiologists Physical Status (ASA PS) resulted in both an ordered increase among ASA PS and within ASA PS in 3) first-case tardiness; and 4) turnover times.DesignRetrospective observational study using electronic health records.SettingOne large, teaching hospital.PatientsAn average of 14,310 patients per year undergoing elective surgery in the hospital's main opera rating rooms who were not inpatients preoperatively between 2006 and 2016.InterventionsNone.MeasurementsAverage increases in first-case tardiness and turnover times between patients seen or not seen preoperatively in the APEC.Main resultsAPEC bypass increased first-case tardiness 2.58 min per case (CI 1.55–3.61; P < 0.0001) and turnover times by 7.49 min (CI 6.79–8.19; P < 0.0001). The increase in mean turnover time was greater than mean first-case tardiness (difference = 4.91 min; CI 3.76–6.06; P < 0.0001). Had all patients bypassed the APEC, the increase in total minutes OR− 1 workday− 1 for turnover times would have been larger than the increase in first-case tardiness (difference = 5.71, CI 3.17–4.72; P < 0.0001). There was an ordered increase with APEC bypass for both first-case tardiness and turnover times with increasing ASA PS (P < 0.0001). Within ASA PS, first-case tardiness (all P-values < 0.003) and turnover times (all P-values < 0.0001) also increased with APEC bypass. All 4 hypotheses were accepted.ConclusionsOverall and with control for ASA PS, APEC bypass increases first-case tardiness and turnover times. A strategy of selective bypass of ASA PS 1–2 patients would not be effective economically because of substantial delays from ASA PS 2 patients.     

Ultrasound evaluation of synovitis in RA: Correlation with clinical disease activity and sensitivity to change in an observational cohort study

ObjectiveTo evaluate the correlation between clinical measures of disease activity and a ultrasound (US) scoring system for synovitis applied by many different ultrasonographers in a daily routine care setting within the Swiss registry for RA (SCQM) and further to determine the sensitivity to change of this US Score.MethodsOne hundred and eight Swiss rheumatologists were trained in performing the Swiss Sonography in Arthritis and Rheumatism (SONAR) score. US B-mode and Power Doppler (PwD) scores were correlated with DAS28 and compared between the clinical categories in a cross-sectional cohort of patients. In patients with a second US (longitudinal cohort), we investigated if change in US score correlated with change in DAS and evaluated the responsiveness of both methods.ResultsIn the cross-sectional cohort with 536 patients, correlation between the B-mode score and DAS28 was significant but modest (Pearson coefficient r = 0.41, P < 0.0001). The same was true for the PwD score (r = 0.41, P < 0.0001). In the longitudinal cohort with 183 patients we also found a significant correlation between change in B-mode and in PwD score with change in DAS28 (r = 0.54, P < 0.0001 and r = 0.46, P < 0.0001, respectively). Both methods of evaluation (DAS and US) showed similar responsiveness according to standardized response mean (SRM).ConclusionsThe SONAR Score is practicable and was applied by many rheumatologists in daily routine care after initial training. It demonstrates significant correlations with the degree of as well as change in disease activity as measured by DAS. On the level of the individual, the US score shows many discrepancies and overlapping results exist.     

Calcaneal spurs: Examining etiology using prehistoric skeletal remains to understand present day heel pain

BackgroundCalcanei are the most common sites for bony spurs. Although calcaneal enthesophytes have been extensively researched, many unknowns remain. Whether biological factors, such as age, weight and genetics, play a greater role in calcaneal spur etiology than activity is still unknown.ObjectivesThe current study examines 121 adults from a prehistoric hunter-gatherer population to aid in understanding bony spur etiology.MethodsCalcaneal spurs are scored as present or absent on the dorsal or plantar side; they are analyzed in regards to their relationships with age, sex, osteoarthritis, cortical index, femoral head breadth and muscle markers.ResultsDorsal and plantar spurs frequencies increase with age (chi-squares = 16.90, 7.268, Ps < 0.05, respectively). Dorsal spurs were more frequent than plantar spurs (chi-square = 38.000; P < 0.0001). There is a positive relationship with calcaneal spurs and upper limb and lower limb osteoarthritis (chi-squares = 5.587, 7.640, Ps < 0.05, respectively).ConclusionsThe data presented support that dorsal spurs are in part the result of activities, but plantar spurs may be a more modern phenomena resulting from long periods of standing and excess weight.     

Étude comparative de l’insuffisance rénale aiguë communautaire chez le sujet VIH positif et le sujet VIH négatif : expérience d’un service de médecine interne à Abidjan (Côte d’Ivoire)

BackgroundAcute kidney injury (AKI) is commonly associated with HIV infection.ObjectivesTo describe the profile of AKI in HIV infected versus non-infected persons.Patients and methodsThis is a prospective study that was carried out during the study period from January 2010 to December 2015 in the department of nephrology-internal medicine D of Treichville University Hospital (Côte d’Ivoire).ResultsThe prevalence of HIV infection was 35.2% in the population of AKI. The average age of patients was 42 ± 18 years in the HIV positive group against 51 ± 18 years in the HIV negative group (P = 0.0001). Etiologies were infections in 65.1% in the HIV positive group against 38.8% in the HIV negative group (P = 0.0001) and water loss in 24.7% in the HIV positive group against 7.8% in the HIV negative group (P = 0.0001). Factors such as the AIDS stage (P = 0.002), severe sepsis (P = 0.002) and acute pyelonephritis (P = 0.001) were associated with mortality in HIV positive patients against severe anemia (P = 0.0001) and severe sepsis (P = 0.0001) in the HIV-negative group.ConclusionHIV positive patients are younger with a female predominance. The mortality rate is identical in both groups.     

Correlation of hip fracture with other fracture types: Toward a rational composite hip fracture endpoint

PurposeWith ethical requirements to the enrollment of lower risk subjects, osteoporosis trials are underpowered to detect reduction in hip fractures. Different skeletal sites have different levels of fracture risk and response to treatment. We sought to identify fracture sites which cluster with hip fracture at higher than expected frequency; if these sites respond to treatment similarly, then a composite fracture endpoint could provide a better estimate of hip fracture reduction.MethodsCohort study using Veterans Affairs and Medicare administrative data. Male Veterans (n = 5,036,536) aged 50–99 years receiving VA primary care between 1999 and 2009 were included. Fractures were ascertained using ICD9 and CPT codes and classified by skeletal site. Pearson correlation coefficients, logistic regression and kappa statistics were used to describe the correlation between each fracture type and hip fracture within individuals, without regard to the timing of the events.Results595,579 (11.8%) men suffered 1 or more fractures and 179,597 (3.6%) suffered 2 or more fractures during the time under study. Of those with one or more fractures, the rib was the most common site (29%), followed by spine (22%), hip (21%) and femur (20%). The fracture types most highly correlated with hip fracture were pelvic/acetabular (Pearson correlation coefficient 0.25, p < 0.0001), femur (0.15, p < 0.0001), and shoulder (0.11, p < 0.0001).ConclusionsPelvic, acetabular, femur, and shoulder fractures cluster with hip fractures within individuals at greater than expected frequency. If we observe similar treatment risk reductions within that cluster, subsequent trials could consider the use of a composite endpoint to better estimate hip fracture risk.