Blood loss during extensive escharectomy and auto-microskin grafting in adult male major burn patients

Purpose

To improve the accuracy of blood loss estimation during extensive escharectomy and auto-microskin grafting on extremities in adult male major burn patients.

Method

All adult male major burn patients admitted to our center who underwent extensive escharectomy and auto-microskin graft on extremities for more than 10%TBSA during the period 1 January 2008 to 31 December 2009 were involved in this study. The blood loss during the operation was estimated by the surgeons or calculated according to the changes in hemoglobin levels.

Results

The average burn and escharectomy areas for the 64 burn patients included in the study were 74.16 ± 16.96% and 30.27 ± 15.63%TBSA respectively. The auto-microskin donor area was 3.81%TBSA. The volumes of intra-operative calculated and estimated blood losses and transfused blood during the operation were 0.47 ml/cm², 0.13 ml/cm² and 0.20 ml/cm² surgical area 77.29 ml, 20.51 ml and 32.83 ml per 1%TBSA), respectively. Within two weeks after injury surgical blood loss appeared to be greater the later the operation was carried out. Within the first week after injury the mean proportional blood loss was increased with area excised.

Conclusion

In this study the average calculated blood loss for the operation of extensive escharectomy and microskin graft in adult male major burn patient was 0.47 ml/cm² (77.29 ml per 1% TBSA). This result will help us to predict expected blood loss more accurately.     

Body Mass Index (BMI) and mortality in patients with severe burns: is there a "tilt point" at which obesity influences outcome?

Background

Obesity is a serious health hazard. Despite advances in burn care severely obese patients with large burns have higher mortality compared with normal-weight patients. The Body Mass Index is the universal measure to define and classify obesity. This study aims to evaluate the effect of Body Mass Index (BMI) on mortality of severe burn patients.

Methods

A retrospective study of 95 patients treated over 2-year period in a dedicated burn ITU. Mortality was studied in relation to BMI as well as demographic, burn characteristics well as length of hospital stay. Logistic regression model and non-parametric comparison tests were used for analysis.

Results

Mean age was 42 ± 22 years (mean ± SD), Total Burn Surface area (TBSA) 33 ± 16%, BMI 29 ± 7.5 (kg/m²) and hospital stay was 37 ± 33 days. Incidence of inhalation injury was 29% and over all mortality was 19%. By logistic regression age, TBSA and inhalation injury were separately associated with mortality. Patients with BMI ≥ 35 (kg/m²) had significantly higher mortality compared with patients with BMI < 25 (kg/m²) [p = 0.037 (Fisher's exact test)].

Conclusions

Body Mass Index ≥ 35 (kg/m²) is a tilt point, which is associated with a higher than predicted mortality following burns when compared to burned patients with a normal BMI.     

Evaluation of a community-based prevention program for domestic burns of young children in India

Objective

The objective of this study was to measure the effectiveness and utilization of the prevention program for domestic burn prevention for young children in Indore, India.

Methodology

Families with at least one child under 4 years of two low income communities and one middle/high income community were approached for this program. We conducted an experimental pilot study with a pre-post design between February and June 2009. The program consisted of an educational program in combination with the distribution of a barrier or playpen. The effectiveness and utilization of the intervention were measured by a baseline and follow-up questionnaire. A total of 34 families completed the baseline questionnaire as well as the follow-up.

Results

A significant decrease in burns was reported (p < 0.01), from a total of 18 burns before the intervention to 2 burns after the placement. Furthermore, the frequency of dangerous situations occurring in the house, decreased significantly as well (p < 0.01).

Conclusion

The prevention program seems an effective method in the reduction of burns of young children. Additionally, most families were satisfied with the intervention and would like to use it for a longer period of time. However, a large study with multiple evaluation moments would be needed to provide evidence of the effectiveness of this prevention program.     

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.     

Safety of presurgical targeted therapy in the setting of metastatic renal cell carcinoma

Background

In patients with metastatic renal cell carcinoma (mRCC), the timing of systemic targeted therapy in relation to cytoreductive nephrectomy (CN) is under investigation.

Objective

To evaluate postoperative complications after the use of presurgical targeted therapy prior to CN.

Design, setting, and participants

A retrospective review of all patients who underwent a CN at The University of Texas M.D. Anderson Cancer Center from 2004 to 2010 was performed. Inclusion in this study required documented evidence of mRCC, with treatment incorporating CN.

Interventions

Patients receiving presurgical systemic targeted therapy prior to CN were compared to those undergoing immediate CN.

Measurements

Complications were assessed using the modified Clavien system for a period of 12 mo postoperatively.

Results and limitations

Presurgical therapy was administered to 70 patients prior to CN (presurgical), while 103 patients had an immediate CN (immediate). A total of 232 complications occurred in 57% of patients (99 of 173). Use of presurgical systemic targeted therapy was predictive of having a complication > 90 d postoperatively (p = 0.002) and having multiple complications (p = 0.013), and it was predictive of having a wound complication (p < 0.001). Despite these specific complications, presurgical systemic targeted therapy was not associated with an increased overall complication risk on univariable or multivariate analysis (p = 0.064 and p = 0.237) and was not predictive for severe (Clavien ≥3) complications (p = 0.625). This study is limited by its retrospective nature. As is inherent to any retrospective study reporting on complications, we are limited by reporting bias and the potential for misclassification of specific complications.

Conclusions

Despite an increased risk for specific wound-related complications, overall surgical complications and the risk of severe complications (Clavien ≥3) are not greater after presurgical targeted therapy in comparison to upfront cytoreductive surgery.     

Thermal injury within the first 4 months of life

Aim

To determine the incidence, magnitude of injury, fluid management, role of surgery and outcome in newborns and infants under 4 months of age admitted to a Burns Unit.

Method

Retrospective analysis of patient records.

Results

86 patients under the age of 4 months were admitted over a 37 year period (0.34% of admissions). Their injuries were caused by hot water in 45 and fire in 38, primitive heating devices in 2 and non-accidental paraffin burn in 1. Twenty-eight sustained superficial partial thickness burns, 12 deep partial thickness and 46 full thickness injuries. The total body surface area ranged from 1 to 55% with an average of 11.5%. Bacterial contamination of the burn wounds was present on admission in 52.3% and consisted of both gram positive and gram negative organisms. The resuscitation formula of 3.5 ml/kg/% burn on the first day and 1.5 ml/kg/% burn on the second day plus maintenance fluid at 30-120 ml/kg/day was not always adequate in maintaining haemodynamic stability. Three surgical methods were employed in 59 patients (69%). These included early tangential excision in 25, excision with or without allograft and delayed grafting in 27, and conventional therapy with eventual grafting in 7 patients. Releasing escharotomies were required in 9 children. Nineteen children required amputations. Three craniectomies, 2 tracheostomies and 1 colostomy were additional procedures. The mortality was 9.3%. Three causes of death were identified: magnitude of injury, sepsis and inhalation injury.

Conclusion

Neonates and infants are very vulnerable and preventable environmental factors are often implicated. Fire and hot water are the most common causes resulting in significant physical trauma. Resuscitation especially during the first few days of life can be problematic. Wound infection and sepsis are common and surgery should be individualised. Long-term outcome is very satisfactory for those with small burns however those with larger burns may remain permanently disfigured.     

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.     

Cultured epithelial autografts in massive burns: a single-center retrospective study with 63 patients

Cultured epithelial autografts (CEAs) have long been used to tackle limited donor site availability and difficulty of permanent skin coverage in massive burns, but this approach still has limited documentation.

Methods

In this retrospective, single-center study, medical records of patients treated with CEAs in our burn center from 1991 until 2008 were analyzed in search of factors associated with outcome.

Results

Out of 68 patients, 63 records were analyzable. Patients were aged 29 [17-41.5] years (seven children). Total body surface area (TBSA) burned was 81 ± 10%, of which 69 ± 14% TBSA full thickness. CEAs were first applied after 45 ± 34 days, on a surface of 32 ± 14% TBSA. Success rate at take down was 65 ± 19%, correlating only with young age (r² = 0.18; p = 0.0006). At discharge, CEAs covered 26 ± 15% TBSA. Infections (4.3 ± 2 per patient), most frequently of skin, often complicated the clinical course. Mortality was 16% (10 patients). In multivariate analysis, the number of infections was the only factor associated with mortality (OR = 2.05 per single infection, 95%CI 1.03-4.07, p = 0.04).

Conclusion

Although complex and costly, CEAs can be used with reasonable success and satisfying survival results for the treatment of massive burns. In this study, favorable outcome was principally associated with young age and low number of infectious complications.     

Early bioavailability in day surgery: a comparison between orally, rectally, and intravenously administered paracetamol

Purpose:

Compare early bioavailability of rectal, effervescent oral, and i.v. paracetamol.

Scope:

Five groups of N = 7 patients received 1 or 2 g paracetamol orally or rectally or 1 g i.v. immediately after day surgery. Paracetamol concentrations taken after 20, 40 and 80 min. Median plasma paracetamol concentrations for 1 versus 2 g effervescents were 78 (25-114) versus 108 (95-146) μmol L⁻¹ at 80 min and 16 (9-30) versus 17 (10-30) μmol L⁻¹ for 1 versus 2 g suppositories. Paracetamol i.v. gave median 97 (77-135) μmol L⁻¹ after 40 min.

Conclusion:

Only intravenously and 2 g effervescent paracetamol gave therapeutic concentrations during the period studied.     

Burns and fire disasters from leaking petroleum pipes in Lagos, Nigeria: An 8-year experience

Introduction

Petroleum products are mostly inflammable and require strict regulations for safe handling.This study characterises the epidemiology of people who sustained burns from leaking petroleum pipes in Lagos, Nigeria. Risk factors for the leaks were determined and proposals for preventive measures made.

Materials and methods

Records of burn patients treated in our hospital from June 1999 to September 2004 were studied and victims of petroleum pipeline fires treated from October 2004 to May 2007 interviewed.

Results

Nine incidents of pipeline fire disasters occurred during the study period. A total of 646 victims sustained 100% burns and died at the disaster sites. Deliberate pipeline damage caused explosions in 55.6% of the cases and spontaneous ruptures in 44.4%. Forty-eight patients were admitted to our hospital for major burns from pipeline explosions. Their ages ranged from 15 to 50 years with a mean of 25.36 ± 5.62 years. The total body surface area (TBSA) involved in burns ranged from 31% to 100% with a mean of 75.71 ± 18.60. Over 40% of the patients had burns beyond 80% TBSA. Mortality rate was 67.3%. Poverty, irregular supply and high prices of petroleum products were responsible for the deliberate pipeline damage and lack of maintenance and surveillance for the spontaneous ruptures.

Conclusion

The incidents of fire disasters from broken petroleum pipelines increased over the study period with considerable mortality. Programmes to reduce poverty, regular product supply, pipeline maintenance and surveillance may reduce the occurrence of the disasters.     

New biological temporary skin cover Xe-Derma(®) in the treatment of superficial scald burns in children

Background

Xe-Derma^® is a new dry sterile biological cover derived from acellular pig dermis. Hydrated Xe-Derma^® displays bio-mechanical features similar to the normal skin. The aim of the present study was to compare the efficacy of Xe-Derma^® with hydrocolloid dressing Askina THINSite^® for treatment of superficial burns in children in a prospective study.

Materials and methods

In a prospective study, 86 patients (5 months to 7 years of age) with superficial scald burns on a surface area of 1-35% BSA were enrolled. In the course of the study, 43 patients were treated with Xe-Derma^® and 43 patients with Askina THINSite^®. We collected data including the percentage of BSA covered with biological or synthetic material, epithelization time, the number of complete conversions (deepening of 100% of covered area into deep dermal wound) under each cover, the number and extent of partial conversions (deepening of less then 100% of covered area into deep dermal wound), infectious complications, the number of reapplications of the temporary cover and the extent in square centimetres of dressing material needed for successful healing of 1% BSA.

Results

No significant difference in the epithelization time, percentage of conversion from superficial to deep dermal burns and percentage of infectious complication was detected between the two groups. However, patients in the Xe-Derma^® group were burned on a more extensive burn surface area (p ≤ 0.028). Xe-Derma^® showed adherence to the wound and therefore there has been no need to be changed The number of reapplications and therefore also the number of square centimetres needed for successful healing of 1% BSA were statistically higher in the Askina THINSite^® group (p < 0.01) due to increased secretion and accumulation of fluid underneath this hydrocoloid cover. The minimal frequency of changes of this biological cover material brings a significant benefit to pediatric patients.

Conclusion

Acellular pig dermis Xe-Derma^® represents a reliable biological cover material. It is an advantageous alternative to synthetic temporary skin covers in the treatment of superficial scald burns in children.     

Influence of anti-inflammatory and vasoactive drugs on microcirculation and angiogenesis after burn in mice

Objective

The treatment of burns remains a challenge. Besides the administration of physiological saline, local disinfection and symptomatic medications, no causal therapy is known to accelerate angiogenesis and wound healing.The aim of this study was to investigate the influences of dilatative and anti-inflammatory acting drugs on microcirculation, angiogenesis and leukocyte behavior, which had shown positive effects in former burn studies.

Methods

The ears of male hairless mice (n = 47) were inflicted with full thickness burns using a hot air jet. Then the affects of five intraperitoneal injections of either acetylsalicylic acid (ASA), isosorbide dinitrate, prostaglandin E1 (PGE1) or sodium chloride (each administered to one of four corresponding study groups), on microcirculation, leukocyte-endothelial interaction and angiogenesis were investigated over a 12 day period using intravital fluorescent microscopy.

Results

Angiogenesis was slightly improved by PGE1 (0.3 vs. 1.3% non-perfused area in other groups on day 12, p = 0.029). Additionally, blood flow increased and rolling leukocytes decreased compared to other groups. The ASA-group showed best functional vessel density and lowest leukocyte-adhesion. The often described posttraumatic expansion of tissue damage could not be observed in either group.

Conclusion

Prostaglandin E1 improved angiogenesis, increased the blood flow and reduced the number of rolling leukocytes. ASA had positive influences on functional vessel density, edema formation and the number of sticking leukocytes. However, it reduced the blood flow.Overall, out of all the drugs tested, prostaglandin seems to have the greatest positive impact on microcirculation and angiogenesis in burns.     

Reliability of subjective wound assessment

Introduction

Assessment of the take of split-skin graft and the rate of epithelialisation are important parameters in burn surgery. Such parameters are normally estimated by the clinician in a bedside procedure. This study investigates whether this subjective assessment is reliable for graft take and wound epithelialisation.

Methods

Observers involved in the field of burns (experienced, medium-experienced and inexperienced observers), and dermatologists specialized in the field of wound healing evaluated the percentage graft take and epithelialisation in 50 photographic skin-grafted burn wounds. Reliability was tested using the intraclass correlation coefficient (ICC).

Results

Intra- and interobserver reliability of parameter graft take was highest within the experienced observers (ICC average > 0.91), followed by medium- and inexperienced observers (ICC average > 0.80 and ICC average > 0.68). Parameter epithelialisation showed the same pattern of intra- and interobserver ICC scores (experienced > medium > inexperienced). Interobserver ICC single scores of the experienced group were reasonable to good. Interobserver reliability of the dermatologists was similar to medium-experienced observers.

Conclusions

Our data show that one experienced observer can obtain adequate reliable results by means of a single assessment of graft take and epithelialisation. Furthermore, experience of the observer results in an increase of reliability.     

The impact of tumor multifocality on outcomes in patients treated with radical nephroureterectomy

Background

The prognostic impact of multifocal upper-tract urothelial carcinoma (UTUC) is poorly understood.

Objective

To investigate the association between tumor multifocality and clinicopathologic features and outcomes of UTUC in patients managed by radical nephroureterectomy (RNU).

Design, setting, and participants

The study included 2492 patients treated with either open or laparoscopic RNU. Tumor and patient characteristics included tumor stage, tumor grade, lymph node status, lymphovascular invasion (LVI), tumor architecture, tumor location, unifocal or multifocal disease, gender, age, history of bladder cancer (BCa), Eastern Cooperative Oncology Group (ECOG) performance status (PS), and adjuvant chemotherapy. tumor multifocality of UTUC was defined as the synchronous presence of multiple tumors in the renal pelvis or ureter.

Intervention

All patients were treated with either open or laparoscopic RNU.

Measurements

Univariable and multivariable models tested the effect of tumor multifocality on disease progression and cancer-specific mortality.

Results and limitations

Five hundred ninety patients (23.7%) had tumor multifocality at the time of RNU. The median follow-up was 45 mo (interquartile range [IQR]: 0-101). Tumor multifocality was significantly associated with a history of previous BCa (p = 0.032), lymph node involvement (p = 0.036), tumor location in the ureter (p = 0.003), higher tumor stage (p < 0.001), higher tumor grade (p < 0.001), sessile tumor architecture (p = 0.003), and LVI (p = 0.001). In organ-confined patients, tumor multifocality was an independent predictor of both disease progression (hazard ratio [HR]: 1.43; p = 0.019) and cancer-specific mortality (HR: 1.46; p = 0.027). When assessed in all patients, tumor multifocality was associated with both disease progression and cancer-specific mortality in univariable (p = 0.005 and p = 0.006, respectively) but not in multivariable analyses (p = 0.468 and p = 0.798, respectively). The main limitation is the retrospective design of the study.

Conclusions

Tumor multifocality is an independent prognosticator of disease progression and cancer-specific mortality in patients with organ-confined UTUC treated with RNU. Multifocal organ-confined patients with UTUC may need closer follow-up. Integration of tumor multifocality with other factors may help identify those patients who would benefit from multimodal therapy.     

Early depth assessment of local burns by videomicroscopy: 24 h after injury is a critical time point

Purpose

Videomicroscopy has simple and prompt operability, and useful in the burn depth assessment in its early phase. A burn wound is, however, a dynamic environment in the first few days and the critical time to assess a burn wound by videomicroscopy has not been investigated. The aim of this study is to investigate the critical time point to assess the burn depth by videomicroscopy.

Methods

Forty one patients with 44 intermediate depth burns admitted within 7 days after injury were included. Accuracies were assessed by comparison with clinical outcome: healing within 21 days after injury or not with conservative treatment. We prospectively evaluated and compared the accuracy of the videomicroscopy measurements with the clinical assessments. All findings were serialized in order of time after injury and divided into three groups, and we compared the appreciation of burn depth by videomicroscopy findings among groups.

Results

The videomicroscopy measurements is significantly accurate compared with clinical assessments (p = 0.001). The accuracy of videomicroscopy measurements was significantly lower in the post-injury <24 h group compared with post-injury ≥24 h group (p = 0.004).

Conclusion

Videomicroscopy is effective tool in assessment of early burn depth and the critical time point to assess the burn depth by videomicroscopy is 24 h after injury.     

Effect of training in the Emergency Management of Severe Burns on the knowledge and performance of emergency care workers as measured by an online simulated burn incident

Objective

To determine the value of training for the Emergency Management of Severe Burns (EMSB) for medical and nursing staff working in emergency care as measured by their performance in a simulated burn incident online program.

Methods

An Internet-based questionnaire, which included a simulated burn incident, was developed. All of the medical and nursing staff in hospital emergency departments and ambulance services in the Netherlands were invited to complete this questionnaire. The effect of EMSB training on the individual's knowledge of and performance in the emergency management of a burn victim was evaluated because some of the respondents had participated in EMSB training, whereas others had not.

Results

Of the 280 responses received, 198 questionnaires were included in the analysis. The analyzed questionnaires were submitted by nurses (43%), ambulance workers (33%), and physicians (23%). Only 14% of the people in the study had participated in EMSB training, whereas 78% had received other or additional life support training and 22% of respondents had no additional life support training.Medical and nursing staff who had participated in EMSB training performed better in the following subjects: mentioning hypothermia as a focus of attention (70% versus 53%, p = 0.085), correct use of hand size (70% versus 36%, p = 0.001) and use of the correct hand percentage in the estimation of total body surface area (TBSA, 82% versus 57%, p = 0.015), suspicion of no airway obstruction in an outdoor trauma (93% versus 63%, p = 0.002) and referral of functional area burns to a burn center (22% versus 8%, p = 0.04). However, both groups overestimated the TBSA (34% of the total group overestimated ≥20%) and did not know the correct formula for fluid resuscitation (87% of the total group).

Conclusion

There is some evidence that medical staff members who have participated in EMSB training have a better knowledge of emergency management and are more effective in the management of a simulated burn case. However, both individuals who had participated in EMSB as well as those who had not participated in EMSB needed additional training in EMSB.     

Assessing Dexterity Function: A Comparison of Two Alternatives for the NIH Toolbox

Study Design

Clinical measurement.

Introduction

Manual dexterity is an important aspect of motor function across the age span.

Purpose of the Study

To identify a single measure of manual dexterity for inclusion in the National Institutes of Health (NIH) Toolbox Assessment of Neurological and Behavioral Function.

Methods

A total of 340 subjects participated in our study. Two alternatives, Rolyan^® 9-Hole Peg Test (9-HPT) and Grooved Pegboard test, were compared by assessing their score range across age groups (3-85 yr) and their test-retest reliability, concurrent, and known groups validity.

Results

The 9-HPT was a simple, efficient, and low-cost measure of manual dexterity appropriate for administration across the age range. Test-retest reliability coefficients were 0.95 and 0.92 for right and left hands, respectively. The 9-HPT correlated with Bruininks-Oseretsky Test (BOT) of Motor Proficiency, dexterity subscale, at −0.87 to −0.89 and with Purdue Pegboard at −0.74 to −0.75. The Grooved Pegboard had good test-retest reliability (0.91 and 0.85 for right and left hands, respectively). The Grooved Pegboard correlated with BOT at −0.50 to −0.63 and with Purdue Pegboard at −0.73 to −0.78. However, the Grooved Pegboard required longer administration time and was challenging for the youngest children and oldest adults.

Conclusions

Based on its feasibility and measurement properties, the 9-HPT was recommended for inclusion in the motor battery of the NIH Toolbox.

Level of Evidence

NA.     

Risk factors and prognosis of lower digestive tract haemorrhage in severe burns: a 12-year retrospective analysis

Objective

To explore the risk factors relating to lower digestive tract haemorrhage in severe burns and summarise the experience in clinical diagnosis and treatment.

Method

General data of 103 patients with severe extensive burns (EBs) admitted to our burn centre in Shanghai between 1997 and 2009 were reviewed retrospectively. The risk factors relating to EB-complicated lower digestive tract haemorrhage were analysed systematically with respect to the clinical features and experiences in treatment, and prognosis.

Results

Of the 103 severe EBs, five developed lower digestive tract haemorrhage with an occurrence of 4.9%. Four of them were proved to have multiple mucosal erosions in caecum, colon and rectum, and the remaining one was proved rectal ulcerative haemorrhage. In comparison with upper digestive tract haemorrhage, lower digestive tract haemorrhage in the present group was characterised by a longer duration (median 4.0 days, interquartile range (IQR) 1.5-14.5 days vs. median 2.0 days (IQR 1.0-3.0 days), P < 0.05). Deep burns, especially fourth-degree burns, with complications of severe systemic infection, formed the main risk factors relating to lower digestive tract haemorrhage in severe EB patients.

Conclusion

Severe EB-complicated lower digestive tract haemorrhage is a critical condition in burns, which usually have deep wounds with severe infection surfaces that are difficult to deal with. Enteroscopic haemostasis in controlling lower digestive tract haemorrhage is usually ineffective. Clinical experiences indicate that early management of the wound with effective preventive and therapeutive measures for infection control may be a good choice in the prevention and treatment of lower digestive tract haemorrhage leading to improvement in its prognosis.     

A new and highly prognostic system to discern T1 bladder cancer substage

Background

Management of T1 bladder cancer (BCa) is controversial.

Objective

Evaluate the impact of substage on the clinical outcome of T1 BCa.

Design, setting, and participants

The T1 diagnosis of 134 first-diagnosis BCa patients from two university hospitals was confirmed. For the T1 substage, we used a new system that discerns T1-microinvasive (T1m) and T1-extensive-invasive (T1e) tumors. We then determined the invasion of the muscularis mucosae-vascular plexus (MM-VP): T1a (invasion above the MM-VP), T1b (invasion in the MM-VP), or T1c (invasion beyond the MM-VP). If the MM-VP was not present at the invasion front, the case was assigned to T1a or T1c. All patients were initially managed conservatively (with bacillus Calmette-Guérin).

Measurements

Multivariable analyses for progression and disease-specific survival (DSS).

Results and limitations

Median follow-up was 6.4 yr (interquartile range: 3.3-9.2 yr). Progression to ≥T2 was observed in 40 patients (30%), and 19 patients (14%) died of BCa. The MM-VP was not present at the invasion front in 50 patients (37%). T1 substage was as follows: 40 T1m and 94 T1e; 81 T1a, 18 T1b, and 35 T1c. In multivariable analyses, substage (T1m/T1e) was significant for progression (p = 0.001) and DSS (p = 0.032), whereas substage according to T1a/T1b/T1c was not significant. Female gender (p = 0.006) and carcinoma in situ (p = 0.034) were also significant predictors of progression. The main limitation to the study is absence of a repeat transurethral resection.

Conclusions

Substage according to the new system (T1m and T1e) was user-friendly, possible in 100% of cases, and very predictive of T1 BCa behavior. Future studies may ultimately lead to the incorporation of this new substaging system in the TNM classification system for urinary BCa.