Influence of comorbidities and age on outcome following burn injury in older adults

Implementation of a geriatric care bundle for older adults with acute burns

BACKGROUND

Frailty and comorbidities are important outcome determinants in older patients (age ≥65) with burns. A Geriatric Burn Bundle (Geri-B) was implemented in 2019 at a regional burn center to standardize care for older adults. Components included frailty screening and protocolized geriatric co-management, malnutrition screening with nutritional support, and geriatric-centered pain regimens.

METHODS

This study aimed to qualitatively evaluate the implementation of Geri-B using the Proctor Framework. From June-August 2022, older burn-injured patients, burn nurses, and medical staff providers (attending physicians and advanced practice providers) were surveyed and interviewed. Transcribed interviews were coded and thematically analyzed. From May 2022 to August 2023, the number of inpatient visits aged 65 + with a documented frailty screening was monitored.

RESULTS

The study included 23 participants (10 providers, 13 patients). Participants highly rated Geri-B in all implementation domains. Most providers rated geriatric care effectiveness as 'good' or 'excellent' after Geri-B implementation. Providers viewed it as a reminder to tailor geriatric care and a safeguard against substandard geriatric care. Staffing shortages, insufficient protocol training, and learning resources were reported as implementation barriers. Many providers advocated for better bundle integration into the hospital electronic health record (EHR) (e.g., frailty screening tool, automatic admission order sets). Most patients felt comfortable being asked about their functional status with strong patient support for therapy services. The average frailty screening completion rate from May 2022 to August 2023 was 86%.

CONCLUSIONS

Geri-B was perceived as valuable for the care of older burn patients and may serve as a framework for other burn centers.

Associations of urban versus rural patient residence on outcomes after burn: A national inpatient sample database study

INTRODUCTION

Burn patients in rural areas may encounter poorer outcomes associated with barriers to care; however, residence has not been studied in a large sample. The association between rural-versus-urban residence and outcomes after burn was examined using the National Inpatient Sample (NIS) database.

METHODS

Using the 2019 NIS database, patients over 18 years with a primary diagnosis of burn or corrosive injury were included. Level of urbanization was categorized into six groups. Outcomes after burn such as in-hospital mortality, multifactorial shock, prolonged mechanical ventilation, length of stay, and total costs were analyzed after adjusting for demographic factors and hospital characteristics.

RESULTS

We included 4671 records, which represented a weighted population of 23,085 patients. Rural residence was associated with higher percentage of prior transfer but not in-hospital mortality. Compared to the most urbanized counties, encounters from the most rural counties were associated with higher odds of shock (aOR:2.62, 99% CI: 1.04-6.56, p = 0.007).

CONCLUSION

Burn encounters from less urbanized counties did not experience differences in mortality, rates of skin grafting, prolonged mechanical ventilation, length of stay, or overall costs. However, odds of shock were higher among the least urbanized counties. Despite improved triage and transportation systems across the US, disparities and challenges exist for burn patients from rural residence.

Global epidemiology of geriatric burns, capacities of care, and injury outcomes: Perspectives from the World Health Organization global burn registry

BACKGROUND

An increasing aging population alongside a potentially increasing injury risk emphasizes a critical need for evidence-based burn care regarding preventive and therapeutic strategies tailored to the unique needs of older adults. However, we note a critical gap in understanding geriatric burn trends on a global scale and the care capacity across settings. Thus, this study sought to ascertain the global trend of geriatric burns with a focus on patient demographics, injury characteristics, capacities of care, and injury outcomes.

METHODS

A retrospective design focusing on older adults aged ≥ 60 years with burns recorded in the World Health Organization Global Burn Registry as of 31st May 2023 was employed. Descriptive statistics were employed to analyze the data.

RESULTS

Of the 9277 records obtained from the Global Burn Registry, 849 participants (9.2%) were aged ≥ 60 years with the majority of these reported from the Eastern Mediterranean (EMRO) and Southeast Asia (SEARO) regions. More females than males were involved in burn injuries with the most common aetiological factor being flame. Most burns occurred in the home/ domestic setting with a seasonal variation (more injuries occurred in December and January). In terms of burn care capacity, the data suggest the availability of specialized services in most settings albeit the AFRO and SEARO regions still lacked the resources to offer specialized burn care. While most injured older adults were discharged home with no physical impairment (395, 46.5%), a substantial number died (250, 29.4%) during hospitalization, particularly in the African (AFRO) region and 111 (11.1%) left the facility against medical advice with the majority from the SEARO region (88).

CONCLUSION

Burn injuries in older adults remain a public health issue. On the preventive aspect, the results demonstrate a need to intensify safety in the home or domestic setting, and during festive seasons. Therapeutically, the findings underscore a need to consider the inclusion of more specialist geriatric and palliative care services in the burn management process. Additionally, we identified a need to strengthen burn care capacity in the AFRO and SEARO regions.

Factors Associated with the Rehabilitation of the Older Adult Burn Patient

The number of older people is increasing and as a result so will the number of older adult patients who present with a burn injury. There are distinct differences between older and younger burn patients, particularly with respect to skin anatomy and physiology and frailty. These are 2 important factors that influence the rehabilitation efforts with respect to older adult burn patients. There has been minimal work done studying the specific rehabilitation of older adult burn patients. More work is needed to fully understand the rehabilitation needs of older adult burn patients.

Impact of elevated body mass index on burn injury-associated mortality in a representative US sample

BACKGROUND

The impact of obesity on burn-related mortality is inconsistent and incongruent; despite being a risk factor for numerous comorbidities that would be expected to increase complications and worsen outcomes, there is evidence of a survival advantage for patients with high body mass index-the so-called obesity paradox. We used a national data set to explore further the relationship between body mass index and burn-related mortality.

METHODS

Deidentified data from patients with second and third-degree burns between 2014 and 2018 were obtained from the Cerner Health Facts Database. Univariate and multivariate regression models were created to identify potential factors related to burn-related mortality. A restricted cubic spline model was built to assess the nonlinear association between body mass index and burn-related mortality. All statistical analyses were conducted using R (R Foundation for Statistical Computing).

RESULTS

The study included 9,405 adult burn patients. Univariate and multivariate analyses revealed that age (odds ratio = 2.189 [1.771, 2.706], P < .001), total burn surface area (odds ratio = 1.824 [1.605, 2.074], P < .001), full-thickness burns (odds ratio = 1.992 [1.322, 3.001], P < .001), and comorbidities (odds ratio = 2.03 [1.367, 3.014], P < .001) were associated with increased mortality. Sensitivity analysis showed similar results. However, a restricted cubic spline indicated a U-shaped relation between body mass index and burn-related mortality. The nadir of body mass index was 28.92 kg/m², with the lowest mortality. This association persisted even after controlling for age, total burn surface area, full-thickness burns, and comorbidities, which all remained significant.

CONCLUSION

This study confirms a U-shaped association between body mass index and burn-related mortality along with age, total burn surface area, full-thickness burns, and comorbidities as risk factors.

The modified 5-item frailty index as a predictor of complications in burn patients

The modified 5-item frailty index (mFI-5), as a measure of frailty and biological age, has been shown to be a reliable predictor of complications and mortality in a variety of surgical specialties. However, its role in burn care remains to be fully elucidated. We, therefore, correlated frailty with in-hospital mortality and complications after burn injury. The medical charts of all burn patients admitted between 2007 and 2020 who had ≥ 10 % of their total body surface area affected were retrospectively reviewed. Data on clinical, demographic, and outcome parameters were collected and evaluated, and mFI-5 was calculated on the basis of the data obtained. Univariate and multivariate regression analyses were used to investigate the association between mFI-5 and medical complications and in-hospital mortality. A total of 617 burn patients were included in this study. Increasing mFI-5 scores were significantly associated with increased in-hospital mortality (p < 0.0001), myocardial infarction (p = 0.03), sepsis (p = 0.005), urinary tract infections (p = 0.006), and perioperative blood transfusions (p = 0.0004). They were also associated with an increase in the length of hospital stay and the number of surgical procedures, albeit without statistical significance. An mFI-5 score of ≥ 2 was a significant predictor of sepsis (odds ratio [OR] = 2.08; 95% confidence interval [CI]: 1.03 to 3.95; p = 0.04), urinary tract infection (OR = 2.82; 95% CI: 1.47 to 5.19; p = 0.002), and perioperative blood transfusions (OR = 2.61; 95% CI: 1.61 to 4.25; p = 0.0001). Multivariate logistic regression analysis revealed that an mFI-5 score of ≥ 2 was not an independent risk factor for in-hospital mortality (OR = 1.44; 95% CI: 0.61 to 3.37; p = 0.40). mFI-5 is a significant risk factor for only a few select complications in the burn population. It is not a reliable predictor of in-hospital mortality. Therefore, its utility as a risk stratification tool in the burn unit may be limited.

Does early excision or skin grafting of severe burns improve prognosis? A retrospective cohort study

The present study aimed to investigate the appropriate timing of excision or skin grafting of burn wounds in patients with severe burns. We retrospectively analyzed data from the Diagnosis Procedure Combination Database, a nationwide inpatient database in Japan. Patients with severe burns (burn index ≥10) who underwent excision or skin grafting within 7 days from September 2010 to March 2019 were included. We defined the early surgery group as patients who underwent excision or skin grafting within 2 days of admission and the delayed surgery group as those who underwent surgery within 3-7 days of admission. Propensity score matching was used to compare the in-hospital mortality between the two groups, yielding a cohort of 389 pairs. A total of 2362 eligible patients were categorized into the early surgery group (n = 626) and delayed surgery group (n = 1736). The overall in-hospital mortality was 19.6%. In-hospital mortality did not differ significantly between the early surgery (15.9%) and the delayed surgery groups (17.2%; p = 0.70). These results suggest that excision or skin grafting within 2 days of admission was not associated with improved in-hospital mortality compared with surgery thereafter for patients with severe burns.

Outcome of burn injury and associated factor among patient visited at Addis Ababa burn, emergency and trauma hospital: a two years hospital-based cross-sectional study

BACKGROUND

Burn is one of the critical health problems worldwide. Developing countries with sub-Saharan and Asian populations are affected more. Its mortality and non-fatal complications depend on several factors including age, sex, residency, cause, the extent of the burn, and time and level of care given.

OBJECTIVE

The purpose of this study was to assess the outcome of burn injury and its associated factor among patients who visited Addis Ababa burn emergency and trauma hospital.

METHODS

The institutional-based, retrospective cross-sectional study design was conducted from April 1, 2019, to March 30, 2021. After checking the data for its consistency the data were entered and analyzed by using SPSS version 25. A total of 241 patients who had visited Addis Ababa burn, emergency and trauma Hospitals after sustained burn injury were recruited through convenience sampling method for final analysis. Model goodness-of-fit was checked by Hosmer and Lemeshow test (0.272). After checking multi-collinearity both the bi-variable and multivariable logistic regression model was fitted and variables having a p-value less than or equal to 0.05 at 95% CI in the multivariable analysis were considered statistically significant.

RESULT

Adults (age 15 to 60 years) are the most affected groups accounting for 55.2% followed by pediatric age groups (age <15 years) (43.6%) and the elderly (age > 60 years) (1.2%). Scald burn was the major cause accounting for 39 % followed by Flame burn (33.6%), Electrical burn (26.6%), and chemical burn (0.8%). The mean TBSA% was 15.49%, ranging from1% to 64%. Adult males are more affected by electrical burns while adult females and the elderly encounter flame burn. 78.4% of patients were discharged without complications, 14.9% were discharged with complications and 6.6% died. The commonest long-term complication is the amputation of the extremity (19, 7.9%). Age greater than 60 years and TBSA% greater than 30% is a strong predictors of mortality with odds of 2.2 at 95% CI of [1.32, 3.69] and 8.7 at 95% CI of [1.33, 57.32] respectively.

CONCLUSION AND RECOMMENDATION

The mortality rate show decrement from previous studies. Overall scald burn is common in all age groups but electrical burns and flame burns affected more adult and elderly age groups. Extremities were by far, the commonest affected body parts. The extent of burn injury and the age of the patient independently predict mortality. Early intervention will reduce mortality and complications.

Comparative Analysis of Composite Mortality Prediction Scores in Intensive Care Burn Patients

Multiple outcome scoring models have been used in predicting mortality in burn patients. In this study, we compared the accuracy of five established models in predicting outcomes in burn patients admitted to the intensive care unit and assessed risk factors associated with mortality. Intensive care burn patients admitted between March 2007 and December 2020 with total body surface area (TBSA) affected ≥ 10% were analyzed. Multivariate analysis was conducted to examine variables associated with mortality. The ABSI, Ryan, BOBI, revised Baux and BUMP scores were analyzed by receiver operating characteristics. A total of 617 patients were included. Morality was 14.4%, with non-survivors being significantly older, male, and having experienced domestic burns. Multivariate analysis identified age, TBSA, full-thickness burns and renal insufficiency as independent mortality predictors. The BUMP score presented the highest mortality prognostication rate, followed by ABSI, revised Baux, BOBI and Ryan scores. BUMP, ABSI and revised Baux scores displayed AUC values exceeding 90%, indicating excellent prognostic capabilities. The BUMP score showed the highest accuracy of predicting mortality in intensive care burn patients and outperformed the most commonly used ABSI score in our cohort. The older models displayed adequate predictive performance and accuracy compared with the newest model.

A National Analysis of Discharge Disposition in Older Adults with Burns—Estimating the Likelihood of Independence at Discharge

Whereas older age predicts higher burn mortality, the impact of age on discharge disposition is less well defined in older adults with burns. This investigation assesses the relationship between older age and discharge disposition after burns in a nationally representative sample. We queried the 2007-2015 National Trauma Data Bank for non-fatal burn hospitalizations in older adults. Pre-defined age categories were 55-64 years (working-age comparison group), 65-74 years (young-old), 75-84 years (middle-old), and 85+ years (old-old). Covariables included inhalation injury, comorbidities, burn total body surface area, injury mechanism, and race/ethnicity. Discharge to non-independent living (nursing home, rehabilitation, and other facilities) was the primary outcome. Logistic regression assessed the association between older age and discharge to non-independent living. There were 25,840 non-fatal burn hospitalizations in older adults during the study period. Working-age encounters comprised 53% of admissions, young-old accounted for 28%, middle-old comprised 15% and old-old comprised 4%. Discharge to non-independent living increased with burn TBSA and older age in survivors. Starting in young-old, the majority (65 %) of patients with burns ≥20% TBSA were discharged to non-independent living. Adjusted odd ratios for discharge to non-independent living were 2.0 for young-old, 3.3 for middle-old and 5.6 for old-old patients, when compared to working-age patients (all p&lt;0.001). Older age strongly predicts non-independent discharge after acute burn hospitalization. Matrix analysis of discharge disposition indicates a stepwise rise in discharge to non-independent living with higher age and TBSA, providing a realistic discharge framework for treatment decisions and expectations about achieving independent living after burn hospitalization.

Impact of community-level socioeconomic disparities on quality of life after burn injury: A Burn Model Systems Database study

INTRODUCTION

Individual-level socioeconomic disparities impact burn-related incidence, severity and outcomes. However, the impact of community-level socioeconomic disparities on recovery after burn injury is poorly understood. As a result, we are not yet able to develop individual- and community-specific strategies to optimize recovery. Therefore, we aimed to characterize the association between community-level socioeconomic disparities and long-term, health-related quality of life after burn injury.

METHODS

We queried the Burn Model System National Longitudinal Database for participants who were > 14 years with a zip code and who had completed a health-related quality of life (HRQOL) questionnaire (VR-12) 6 months after injury. BMS data were deterministically linked by zip code to the Distressed Communities Index (DCI), which combines seven census-derived metrics into a single indicator of economic well-being, education, housing and opportunity at the zip code level. Hierarchical linear models were used to estimate the association between community deprivation and HRQOL 6 months after burn injury, as measured by mental (MCS) and physical (PCS) component summary scores of the SF12/VR12.

RESULTS

342 participants met inclusion criteria. Participants were mostly male (n = 239, 69 %) and had a median age of 48 years (IQR 33-57 years). Median %TBSA was 10 (IQR 3-28). More than one-third of participants (n = 117, 34 %) lived in a community within the highest two distress quintiles. After adjusting for age, race/ethnicity, number of trips to the operating room (OR) and pre-injury PCS, neighbourhood distress was negatively associated with 6-month PCS (ß-0.05, 95 % CI [-0.09,-0.01]). Increasing age and lower pre-injury PCS were also negatively associated with 6-month PCS. There was no observed association between neighbourhood distress and 6-month MCS after adjustment for age, participant race/ethnicity, number of trips to the OR and pre-injury MCS. Higher pre-injury MCS was associated with 6-month MCS (ß0.54, 95 % CI [-0.41,0.67]).

CONCLUSIONS

Community distress is associated with lower PCS at 6 months after burn injury but no association with MCS was identified. Pre-injury HRQOL is associated with both PCS and MCS after injury. Further study of the factors underlying the relationship between community distress and physical functional recovery (e.g., access to rehabilitation services, availability of adaptations) is required to identify potential interventions.

Comparing Auditory and Visual Distractions for Reducing Pain Severity and Pain Anxiety in Older Outpatients with Burn: A Randomized Controlled Trial

Pain and anxiety are major issues among older patients with burn injuries. Complementary medicine and non-pharmacological methods can relieve pain and anxiety in older people, but comparison of the effects of these methods needs further research. This study aimed to compare the effects of auditory and visual distractions on pain severity and pain anxiety in older outpatients referred to a burn clinic for dressing change. In this randomized controlled clinical trial, older men were randomly assigned to three groups as auditory distraction, visual distraction, and control (n = 45 in each group). The Visual Analogue Scale (VAS) and the Burn Specific Pain Anxiety Scale (BSPAS) were used to asses pain severity and pain anxiety before and immediately after the interventions, and after wound dressing. Reduction in pain severity and pain anxiety after visual distraction was reported. Auditory distraction only reduced pain anxiety. Therefore, visual distraction had a better effect on alleviating pain anxiety compared with auditory distraction. Visual distraction is suggested to be used during dressing changes for older outpatients with burn injuries in outpatient clinics in order to reduce their burn-related suffering and improve their collaboration with the therapeutic regimen.

Aging Impairs the Cellular Interplay between Myeloid Cells and Mesenchymal Cells during Skin Healing in Mice

Impaired wound healing is a major issue in the elderly population and is associated with substantial health and economic burden, which is exponentially increasing with the growing aging population. While the underlying pathobiology of disturbed skin healing by aging is linked to several genetic and epigenetic factors, little is known about the cell-cell interaction during the wound healing process in aged individuals, particularly the mesenchymal stem cell (MSCs)-macrophages axis. In this study, by using a thermal injury animal model in which we compared the wound healing process of adult and young mice, we found that the insufficient pool of MSCs in adult animals are deficient in migrating to the wound bed and instead are restricted to the wound edge. We identified a deficiency of a CD90-positive MSC subpopulation in the wounds of adult animals, which is positively correlated with the number of F4/80+ macrophages. In vitro, we found that CD90+ cells preferentially adhere to the myeloid cells forming doublet cells. Thus, our findings highlight that in adult mice subjected to a thermal injury, impaired wound healing is likely mediated by a disturbed cellular interplay between myeloid cells and mesenchymal cells.

Wound Healing in Older Adults With Severe Burns: Clinical Treatment Considerations and Challenges

Background:

The older adult population continues to rapidly expand in number, with a projection by the United States (US) Census Bureau that there will be more individuals older than > 65 years (77.0 million) than those younger than < 18 years (76.5 million) by 2034. This review provides an overview of aging as it relates to wound healing and burn injuries in older adult patients, summarizes current treatment practices, and addresses the key challenges and considerations for treating severe burn injuries in this specific patient population.

Materials and methods:

A narrative literature search was conducted, focusing on recent primary literature on burns and wound healing in elderly patients.

Results:

Studies showed that the aging process results in both physiologic (eg, nutritional and metabolic status) and anatomic changes (eg, thinning dermis) that contribute to a reduced capacity to recover from burn-injury trauma compared with younger patients. Owing to impaired vision, decreased coordination, comorbidities, and medication-induced side effects, older adults (ie, > 65 years) are susceptible to severe burn injury (deep-partial thickness and full-thickness), which is associated with significant morbidity and mortality.

Conclusion:

A better understanding of the effects of age-related changes regarding wound healing in older adult patients who incur severe burn injuries may provide insight into clinical strategies to improve outcomes among this population.

The Role Of Comorbidities On Outcome Prediction In Acute Burn Patients

Burn trauma is a leading cause of mortality and morbidity. None of the currently available formulas for mortality prediction take into account the impact of comorbidities on burn patients' outcome. In this study, we evaluate the impact of comorbidities on in-hospital mortality and prolonged length of hospital stay (≥30 days). A retrospective analysis of burn patients' medical records, over a 5-year period, was undertaken. A total of 677 patients were included. The mortality rate was 6.5%. Deceased patients and survivors with length of hospital stay (LOS) of 30 or more days were significantly older, had larger %TBSA burned, were more likely to have inhalation injury and comorbidities, and had higher Charlson Comorbidity Index (CCI) scores. On the multivariate logistic regression models, age, %TBSA burned, CCI score and the presence of inhalation injury were independently associated with mortality and prolonged LOS. In conclusion, the authors suggest that the inclusion of comorbidities should be considered on burn admission scores in an attempt to better predict burn mortality.

Association between adjunct clindamycin and in-hospital mortality in patients with necrotizing soft tissue infection due to group A Streptococcus: a nationwide cohort study

Necrotizing soft tissue infection (NSTI) due to group A Streptococcus (GAS) is a severe life-threatening microbial infection. The administration of adjunct clindamycin has been recommended in the treatment of NSTIs due to GAS. However, robust evidence regarding the clinical benefits of adjunct clindamycin in NSTI patients remains controversial. We aimed to investigate the association between early administration of adjunct clindamycin and in-hospital mortality in patients with NSTI attributed to GAS. The present study was a nationwide retrospective cohort study, using the Japanese Diagnosis Procedure Combination inpatient database focusing on the period between 2010 and 2018. Data was extracted on patients diagnosed with NSTI due to GAS. We compared patients who were administered clindamycin on the day of admission (clindamycin group) with those who were not (control group). A propensity score overlap weighting method was adopted to adjust the unbalanced backgrounds. The primary endpoint was in-hospital mortality and survival at 90 days after admission. We identified 404 eligible patients during the study period. After adjustment, patients in the clindamycin group were not significantly associated with reduced in-hospital mortality (19.2% vs. 17.5%; odds ratio, 1.11; 95% confidence interval, 0.59-2.09; p = 0.74) or improved survival at 90 days after admission (hazard ratio, 0.92; 95% confidence interval, 0.51-1.68; p = 0.80). In this retrospective study, early adjunct clindamycin does not appear to improve survival. Therefore, the present study questions the benefits of clindamycin as an adjunct to broad spectrum antibiotics in patients with NSTI due to GAS.

The length of stay and cost of burn patients and the affecting factors

BACKGROUND

Burn trauma is a significant health problem that has physical, psychological, and economic reaction on affected patients. Burn patients have different length-of-stay (LOS) due to the complexity of the injury itself. This study aimed to find factors affecting the LOS and cost of burn patients (2017-2018) in Guilan province, north of Iran.

MATERIALS AND METHODS

This cross-sectional study includes all 899 hospitalized burn patients who were admitted for the first time (first visit). Data about cost, LOS, and demographic variables were extracted from the hospital registry system. Data were analyzed using t-test, ANOVA, and Linear regression by SPSS 22 software.

RESULTS

Nearly 62% of the burn patients were male, and 38% were female. Hot liquid or vapor were the leading causes for burns hospitalization (n = 345; 39.07%). The majority of patients (n = 465; 52.31%) were at level three of burn (total thickness). The upper limb that included head, neck, shoulder, back, hand (45.44%), lower limb (38.25%), multiple or total body (11.36%) were the most organs that were affected by burning. Direct medical costs for patients varied from 0 to 18,550 US$, which was 1489 US$ on average. Patients' length of stay ranged from 1 to 47 days, which was 3.22 days on average.

CONCLUSION

The result showed Adverse consequences burned hot liquid and hot steam burns most common reason that it is important to take preventative methods for this type of patient. Improved patients with the third level cost more and stay longer. Other factors such as underlying disease, urbanity, used antibiotics, sex, and insurance coverage can also be decisive. The burnt percentage also has a direct and significant relationship with medical costs and length of stay. Insurance organization has a direct and significant relationship with the length of stay. Also there was a direct relationship between multiple burns and the patients' length of stay and hospitalization costs.

Dexmedetomidine use and mortality in mechanically ventilated patients with severe burns: A cohort study using a national inpatient database in Japan

BACKGROUND

Dexmedetomidine is an alpha 2-adrenergic receptor agonist. Apart from its sedative effects, dexmedetomidine can potentially reduce mortality through its anti-inflammatory effect. However, the impact of dexmedetomidine on in-hospital outcomes of patients with severe burns remains unclear. Therefore, we aimed to elucidate the association between dexmedetomidine use and mortality in mechanically ventilated patients with severe burns, using a Japanese nationwide database of in-hospital patients.

METHODS

We included adults with severe burns (burn index ≥ 10) who were registered in the Japanese Diagnosis Procedure Combination national inpatient database from 2010 to 2018, started mechanical ventilation within 3 days of admission, and received any sedative drug (dexmedetomidine, midazolam, or propofol). One-to-one propensity score matching was performed between patients who received dexmedetomidine on the day of mechanical ventilation initiation (dexmedetomidine group) and those who did not receive dexmedetomidine (control group). The primary outcome was all-cause 30-day in-hospital mortality. Secondary outcomes were length of hospital stay and duration of mechanical ventilation in patients and survivors.

RESULTS

Eligible patients (n = 1888) were classified into the dexmedetomidine group (n = 371) or the control group (n = 1517). After one-to-one propensity score matching, we compared 329 patients from both groups. No significant difference was observed in the 30-day mortality between patients in the dexmedetomidine and control groups (22.8% vs. 22.5%, respectively; odds ratio, 1.02; 95% confidence interval, 0.71-1.46). Moreover, there were no significant differences between patients in the dexmedetomidine and control groups in terms of the length of hospital stay or the duration of mechanical ventilation.

CONCLUSIONS

We found no significant association between dexmedetomidine use and in-hospital outcomes (mortality, length of hospital stay, and length of mechanical ventilation) in mechanically ventilated patients with severe burns. Dexmedetomidine use may not improve the aforementioned outcomes; therefore, its selection should be based on the patient's general condition and the target level of sedation.

Exploring The Background, Context And Stressors Of Caregiving To Elderly Burned Patients: A Qualitative Inquiry

Elderly persons are at risk of experiencing burns and require support from both formal and informal caregivers. Informal caregiving in this situation has been minimally explored. Guided by the Stress Process Model, this study aimed at exploring the background, context, and stressors of informal caregivers of elderly burned persons during hospitalisation. A qualitative descriptive design was utilised. Purposive sampling approach was used to recruit fourteen (14) informal caregivers who rendered care to elderly burned persons during hospitalisation. Interviews were conducted and transcribed verbatim following which directed content analysis was undertaken deductively. Three categories and six sub-categories emerged which characterise the background, context, and stressors of informal caregiving to elderly burn patients. All the injuries occurred in the home setting and its sudden nature led to varied post-burn emotional responses which characterised the context of burns caregiving. Primary stressors that emerged were related to the injury, actual caregiving demand, and concerns regarding increasing frailty levels. Secondary stressors identified were financial concerns and lifestyle changes. The findings suggest that the occurrence of burn injury served as a precursor to post-burn stress response among informal caregivers. Increasing frailty levels, adequacy of household safety measures and financial issues were key concerns which emphasise the need for psychosocial/ transitional support, innovative healthcare financing measures and continuing education on burns prevention in the home setting.

No Difference in Morbidity or Mortality Between Octogenarians and Other Geriatric Burn Trauma Patients

BACKGROUND

Geriatric burn trauma patients (age ≥65 years) have a 5-fold higher mortality rate than younger adults. With the population of the US aging, the number of elderly burn and trauma patients is expected to increase. A past study using the National Burn Repository revealed a linear increase in mortality for those >65 years old. We hypothesized that octogenarians with burn and trauma injuries would have a higher rate of in-hospital complications and mortality, than patients aged 65-79 years old.

METHODS

The Trauma Quality Improvement Program (2010-2016) was queried for burn trauma patients. To detect mortality risk a multivariable logistic regression model was used.

RESULTS

From 282 patients, there were 73 (25.9%) octogenarians and 209 (74.1%) aged 65-79 years old. The two cohorts had similar median injury severity scores (16 vs. 15 in octogenarians, P = .81), total body surface area burned (P = .30), and comorbidities apart from an increased smoking (12.9% vs. 4.1%, P = .04) and decreased hypertension (52.2% vs. 65.8%, P = .04) in the younger cohort. Octogenarians had similar complications, including acute respiratory distress syndrome, pulmonary embolism, deep vein thrombosis (P > .05), and mortality (15.1% vs. 10.5%, P = .30), compared to the younger cohort. Octogenarians were not associated with an increased mortality risk (odds ratio 1.51, confidence interval 0.24-9.56, P = .67).

DISCUSSION

Among burn trauma patients ≥65 years, age should not be a sole predictor for mortality risk. Continued research is necessary in order to determine more accurate approaches to prognosticate mortality in geriatric burn trauma patients, such as the validation and refinement of a burn-trauma-related frailty index.

Circulating sFasL Levels Predict the Severity and Outcome of Burn Injury: A Prospective Observational Study

BACKGROUND

Severe burn injury activates shock, inflammation, and blood cell system, but inappropriate reactions may lead to adverse outcomes. Soluble Fas ligand (sFasL) participates in apoptosis and inflammatory response. The circulating sFasL levels we investigated in association with the burn severity, shock, inflammation, blood cells, and mortality in patients with severe burns.

METHODS

A total of 56 patients with severe burns were recruited. The levels of sFasL and the biomarkers reflecting shock, organ damage, inflammation, and blood cells at 48 h postburn were analyzed. We compared the practical situation of patients that stratified by median sFasL levels and investigated the predictive value of sFasL for mortality.

RESULTS

High circulating sFasL levels were associated with the higher degrees of burn index, shock index, lactate, N-terminal probrain natriuretic peptide, total bilirubin, blood urea nitrogen, creatinine, tumor necrosis factor-α, interleukin-1β, interleukin-8, intercellular adhesion molecule 1, and complement 3, and the lower degrees of oxygenation index, lymphocytes, and platelets. Multiple linear regression analysis showed that the higher tumor necrosis factor-α (P < 0.001) and the lower oxygenation index (P = 0.031) and lymphocytes (P = 0.043) were associated with the higher sFasL. High sFasL (a unit is 50 ng/L) (odds ratio [OR] 5.50 [95% CI 1.04-29.20], P = 0.045) was an independent predictor of increased mortality by multivariate logistic regression analysis.

CONCLUSIONS

High circulating sFasL at 48 h postburn in patients with severe burns reflect shock, proinflammatory response, organ damage, and lymphocyte reductions and predict 30-day mortality.

In-hospital mortality among patients with invasive non-group A β-hemolytic Streptococcus treated with clindamycin combination therapy: a nationwide cohort study

Aim

Combination treatment with clindamycin is recommended in patients with invasive group A Streptococcus infection; however, whether the same treatment is effective in invasive group B Streptococcus and S. dysgalactiae subspecies equisimilis infections remains unknown. We aimed to investigate whether clindamycin added to standard of care therapy would be effective in patients with invasive non-group A β-hemolytic Streptococcus infections.

Methods

This was a nationwide retrospective cohort study using the Japanese Diagnosis Procedure Combination inpatient database focusing on the period between 2010 and 2018. We extracted data on patients diagnosed with sepsis due to non-group A β-hemolytic Streptococcus. One-to-four propensity score-matching was undertaken to compare patients who were treated with clindamycin within 2 days of admission (clindamycin group) and those who did not (control group). The primary outcome was in-hospital mortality.

Results

We identified 3754 eligible patients during the study period. The patients were divided into the clindamycin (n = 296) and control groups (n = 3458). After one-to-four propensity score matching, we compared 289 and 1156 patients with and without clindamycin, respectively. In-hospital mortality did not significantly differ between the two groups (9.7% versus 10.3%; risk difference 0.3%; 95% confidence interval, -3.5% to 4.2%).

Conclusions

This nationwide database study showed that combination therapy involving the use of clindamycin was not associated with lower in-hospital mortality in patients with invasive non-group A β-hemolytic Streptococcus.

Age-dependent influence of premorbid underweight status on mortality in severe burn patients: An administrative database study

PURPOSE

To examine the associations between premorbid nutritional status and in-hospital mortality in severe burn patients according to age in Japan.

METHODS

We retrospectively extracted the data of 14,345 patients aged 18-84 years admitted for burns from April 1, 2014, to March 31, 2018, using the Japanese Diagnosis Procedure Combination database. The exclusion criteria were out-of-hospital cardiac arrest, death in the emergency room, readmission, and planned admission. We collected data on age, sex, height, weight, comorbidities, burn index, and mechanical ventilation use and performed age-stratified multilevel logistic regression analyses to estimate associations between premorbid body mass index (BMI) and in-hospital mortality.

RESULTS

We analyzed 2968 patients with a burn index ≥10, including 831 elderly aged 75-84 years. In patients aged 18-74 years, being underweight (BMI < 18.5) significantly decreased mortality (0.34 [0.15-0.77]; P = 0.010). In contrast, in patients aged 75-84 years, being underweight significantly increased mortality (2.11 [1.05-4.25]; P = 0.036). Being overweight (BMI >25) increased mortality in both age groups, but not significantly.

CONCLUSIONS

The results suggest that pre-morbidly underweight elderly patients aged 75-84 years with severe burns have high mortality risks. Further research is needed to identify optimal care strategies for this population.

Mortality prognostication scores do not predict long-term, health-related quality of life after burn: A burn model system national database study

OBJECTIVE

Despite improved mortality rates after burn injury, many patients face significant long-term physical and psychosocial disabilities. We aimed to determine whether commonly used mortality prognostication scores predict long-term, health-related quality of life after burn injury. By doing so, we might add evidence to support goals of care discussions and facilitate shared decision-making efforts in the hours and days after a life-changing injury.

METHODS

We used the multicenter National Institute of Disability, Independent Living and Rehabilitation Research Burn Model System database (1994-2019) to analyze SF-12 physical (PCS) and mental component (MCS) scores among survivors one year after major burn injury. Ninety percent of the observations were randomly assigned to a model development dataset. Multilevel, mixed-effects, linear regression models determined the relationship between revised Baux and Ryan Scores and SF-12 measures. Additionally, we tested a model with disaggregated independent and other covariates easily obtained around the time of index admission: age, sex, race, burn size, inhalation injury. Residuals from the remaining 10% of observations in the validation dataset were examined.

RESULTS

The analysis included 1606 respondents (median age 42 years, IQR 28-53 years; 70% male). Median burn size was 16% TBSA (IQR 6-30) and 13% of respondents sustained inhalation injury. Higher revised Baux and Ryan Scores and age, burn size, and inhalation injury were significantly correlated with lower PCS, but were not correlated with MCS. Female sex, black race, burn size, and inhalation injury correlated with lower MCS. All models poorly explained the variance in SF-12 scores (adjusted r² 0.01-0.12).

CONCLUSION

Higher revised Baux and Ryan Scores negatively correlated with long-term physical health, but not mental health, after burn injury. Regardless, the models poorly explained the variance in SF-12 scores one year after injury. More accurate models are needed to predict long-term, health-related quality of life and support shared decision-making during acute burn care.

Modified abbreviated burn severity index as a predictor of in-hospital mortality in patients with inhalation injury: development and validation using independent cohorts

PURPOSE

The ability to accurately evaluate the severity of inhalation injury can help to optimize patient care. However, there is no accepted severity grading system, especially for inhalation injury.

METHODS

We screened a multicenter burn registry and included adult patients who required oxygen treatment or mechanical ventilation. After the patient data were divided into development and validation cohorts, missing values were replaced with multiple imputation. Twelve potential predictors were analyzed using multivariate logistic regression to identify prognostic variables for in-hospital mortality and scores were assigned to each predictor based on odds ratios to develop the Modified Abbreviated Burn Severity Index, mABSI. The mABSI was validated using c-statistics and calibration curves.

RESULTS

We randomly assigned 1377 and 919 patients to the development and validation cohorts, respectively. Age, self-inflicted injury, cutaneous burn area, and mechanical ventilation requirement were identified as independent predictors, and the mABSI (1-17 scale) was, thus, developed. The mABSI has a high discriminatory power (c-statistic = 0.94; 95% CI 0.92-0.97), and both estimated and observed in-hospital mortalities increased from 1% at score ≤ 5 to almost 100% at score ≥ 14 with linear calibration plots.

CONCLUSIONS

We developed and validated the mABSI which accurately predicts in-hospital mortality.

Angiography versus colonoscopy in patients with severe lower gastrointestinal bleeding: a nation-wide observational study

Aim

Clinical guidelines for acute lower gastrointestinal bleeding (LGIB) recommend non‐endoscopic treatment when endoscopic treatment is difficult or the patient is hemodynamically unstable. The aim of this study was to investigate whether angiography should be prioritized as initial treatment for severe LGIB patients over colonoscopy.

Methods

We undertook a retrospective cohort study using the Japanese Diagnosis Procedure Combination inpatient database. We compared adult patients who underwent colonoscopy or angiography within 1 day of admission for severe LGIB from 2010 to 2017. The primary outcome was in‐hospital mortality. Secondary outcomes included surgery carried out within 1 day after admission and surgery carried out between 2 and 7 days of admission. Propensity score‐matched analyses were undertaken to adjust for confounders.

Results

We identified 6,546 eligible patients. The patients were divided into the colonoscopy group (n = 5,737) and angiography group (n = 809). After one‐to‐four propensity score matching, we compared 3,220 and 805 patients who underwent colonoscopy and angiography, respectively. The angiography group was not significantly associated with reduced in‐hospital mortality compared with the colonoscopy group. In contrast, the number of patients who underwent surgery within 1 day of admission was significantly lower in the angiography group than in the colonoscopy group.

Conclusions

The present study revealed that in‐hospital mortality did not significantly differ between colonoscopy and angiography, even in severe LGIB patients. Although this study was unable to identify which subgroups should undergo angiography for primary hemostasis, angiography might be a better option than colonoscopy for initial hemostasis in more severe cases of LGIB.

Early Enteral Nutrition in Geriatric Burn Patients: Is There a Benefit?

Nutrition is a critical component of acute burn care and wound healing. There is no consensus over the appropriate timing of initiating enteral nutrition in geriatric burn patients. This study aimed to assess the impact of early enteral nutrition on outcomes in this patient population. We performed a 1-year (2017) analysis of the American College of Surgeons Trauma Quality Improvement Program and included all older adult (age ≥65 years) isolated thermal burn patients who were admitted for more than 24 hr and received enteral nutrition. Patients were stratified into two groups based on the timing of initiation of feeding: early (≤24 hr) vs late (>24 hr). Multivariate logistic regression was performed to control for potential confounding factors. Outcome measures were hospital and intensive care unit lengths of stay, in-hospital complications, and mortality. A total of 1,004,440 trauma patients were analyzed, of which 324 patients were included (early: 90 vs late: 234). The mean age was 73.9 years and mean TBSA burnt was 31%. Patients in the early enteral nutrition group had significantly lower rates of in-hospital complications and mortality (15.6% vs 26.1%; P = 0.044), and a shorter hospital length of stay (17 [11,23] days vs 20 [14,24] days; P = 0.042) and intensive care unit length of stay (13 [8,15] days vs 17 [9,21] days; P = 0.042). In our regression model of geriatric burn patients, early enteral nutrition was associated with improved outcomes. The cumulative benefits observed may warrant incorporating early enteral nutrition as part of intensive care protocols.

Burns in the Elderly: Potential Role of Stem Cells

Burns in the elderly continue to be a challenge despite advances in burn wound care management. Elderly burn patients continue to have poor outcomes compared to the younger population. This is secondary to changes in the quality of the aged skin, leading to impaired wound healing, aggravated immunologic and inflammatory responses, and age-related comorbidities. Considering the fast-growing elderly population, it is imperative to understand the anatomic, physiologic, and molecular changes of the aging skin and the mechanisms involved in their wound healing process to prevent complications associated with burn wounds. Various studies have shown that stem cell-based therapies improve the rate and quality of wound healing and skin regeneration; however, the focus is on the younger population. In this paper, we start with an anatomical, physiological and molecular dissection of the elderly skin to understand why wound healing is delayed. We then review the potential use of stem cells in elderly burn wounds, as well as the mechanisms by which mesenchymal stem cell (MSCs)-based therapies may impact burn wound healing in the elderly. MSCs improve burn wound healing by stimulating and augmenting growth factor secretion and cell proliferation, and by modulating the impaired elderly immune response. MSCs can be used to expedite healing in superficial partial thickness burns and donor site wounds, improve graft take and prevent graft breakdown.

The Impact of Comorbid Conditions on Long-Term Patient-Reported Outcomes From Burn Survivors

Preburn comorbidities increase the risk of death in the acute phase, and negatively impact quality of life among survivors. Investigations to date have only evaluated comorbidities as indices, limiting the ability to target conditions and develop strategies for risk reduction. Therefore, we aimed to evaluate the differential effects of specific conditions on long-term, patient-reported outcomes after burn injury. A prospectively maintained trauma registry was merged with a longitudinal database of patient-reported outcomes from a regional burn center from 2007 to 2018. Demographic data, injury-specific information, and the prevalence of 20 comorbidities were systematically documented. The impact of comorbidities on responses to Short Form-12/Veterans RAND 12 (SF/VR-12) health surveys at 6, 12, and 24 months postinjury was evaluated with generalized linear models. The merged dataset included 493 adult participants. Median age was 46 years (interquartile range, IQR 32-57 years), and 72% were male. Median burn size was 14% TBSA (IQR 5-28%). Seventy percent of participants had ≥1 comorbidity (median 1 comorbidity/participant; IQR 0-2 comorbidities). SF/VR-12 mental component summary scores at 6 and 12 months postinjury were negatively associated with mental illness (P < .001, P = .013). SF/VR-12 physical component summary (PCS) scores were negatively associated with smoking (P = .019), diabetes (P = .001), and alcohol use disorder (P = .001) at 6-month follow-up. Twelve-month SF/VR-12 PCS scores were negatively associated with prior trauma admission (P = .001) and diabetes (P = .042). Twenty-four-month SF/VR-12 PCS scores were negatively associated with mental illness (P = .003). Smoking, alcohol use disorder, and diabetes were associated with lower PCS scores 6 months after injury; diabetes persisted as a negatively associated covariate at 12 months. Mental component summary scores were negatively associated with mental illness 6 and 12 months postinjury. Integrated models of postdischarge comorbidity management need to be tested in burn patients.

Prevalence and prognostic impact of inhalation injury among burn patients: A systematic review and meta-analysis

BACKGROUND

The objective of our study was to perform a systematic review and meta-analysis aimed at assessing the prevalence of inhalation injury in burn patients and its prognostic value in relation to in-hospital mortality.

METHODS

We searched the PubMed and EMBASE databases for noninterventional studies published between 1990 and 2018 investigating in-hospital mortality predictors among burn patients.The primary meta-analysis evaluated the association between inhalation injury and mortality. A secondary meta-analysis determined the global estimate of the prevalence of inhalation injury and the rate of mortality. Random effects models were used, and univariate meta-regressions were used to assess sources of heterogeneity. This study is registered in the PROSPERO database with code CRD42019127356.

FINDINGS

Fifty-four studies including a total of 408,157 patients were selected for the analysis. A pooled inhalation prevalence of 15.7% (95% confidence interval, 13.4%-18.3%) was calculated.The summarized odds ratio of in-hospital mortality secondary to an inhalation injury was 3.2 (95% confidence interval, 2.5-4.3). A significantly higher odd of mortality was found among the studies that included all hospitalized burn patients, those that included a lower proportion of male patients, those with a lower mean total body surface area, and those with a lower prevalence of inhalation injury.

CONCLUSION

Despite our study's limitations due to the high risk of bias and the interstudy heterogeneity of some of our analyses, our results revealed a wide range of prevalence rates of inhalation injury and a significant association between this entity and in-hospital mortality in burn patients. However, this association is not significant if adjusted for disease severity.

LEVEL OF EVIDENCE

Systematic review/meta-analysis, level III.

Epidemiological Investigation of Elderly Patients with Severe Burns at a Major Burn Center in Southwest China

Background

The treatment of elderly patients with severe burns is difficult and the mortality rate is high. The aim of this study was to investigate the epidemiological features of elderly patients with severe burns.

Material/Methods

Data from 109 elderly patients with severe burns between January 2009 and December 2018 were retrospectively analyzed. Demographic data, clinical characteristics, treatments, and outcomes were statistically analyzed.

Results

Among the 109 elderly patients with severe burns, the male-to-female ratio was 1.73: 1.0. The median age of the elderly patients was 67 years, and the median total body surface area (TBSA) burned was 42%. Notably, 67.9% of burns occurred at home and most frequently occurred in summer (38.5%) and winter (28.4%); flame and flash burns predominated (83.4%). The incidence of inhalation injury was 35.8%, and pre-existing comorbidities were observed in approximately 51.4% of the patients. The median length of stay in the hospital per TBSA burned was 0.4 days. The mortality rate in the elderly patients was 24.8%, and the mortality rates in the ≥70% TBSA group, inhalation injury group, and patients with 3 or more pre-existing comorbidities were significantly higher than in the other groups. The risk of death increased with an increase in the number of pre-existing comorbidities (odds ratio: 2.222; 95% confidence interval: 1.174–4.205).

Conclusions

At a major burn center in Southwest China, the incidence and mortality of elderly patients with severe burns displayed no downward trend. There are etiological characteristics of these age groups that should be considered for prevention. Meanwhile, multidisciplinary treatment in a hospital and an increase in the social support for the elderly population might improve outcomes.

Epidemiology of burn injury in older adults: An Australian and New Zealand perspective

INTRODUCTION

The ageing global population presents a novel set of challenges for trauma systems. Less research has focused on the older adult population with burns and how they differ compared to younger patients. This study aimed to describe, and compare with younger peers, the number, causes and surgical management of older adults with burn injuries in Australia and New Zealand.

METHODS

The Burns Registry of Australia and New Zealand was used to identify patients with burn injuries between 1 July 2009 and 31 December 2018. Temporal trends in incidence rates were evaluated and categorised by age at injury. Patient demographics, injury severity and event characteristics, surgical intervention and in-hospital outcomes were investigated.

RESULTS

There were 2394 burn-injured older adults admitted during the study period, accounting for 13.4% of adult admissions. Scalds were the most common cause of burn injury in older adults. The incidence of older adult burns increased by 2.96% each year (incidence rate ratio = 1.030, 95% confidence interval = 1.013-1.046, P < 0.001). Compared to their younger peers, a smaller proportion of older adult patients were taken to theatre for a surgical procedure, though a larger proportion of older adults received a skin graft.

DISCUSSION

Differences in patient and injury characteristics, surgical management and in-hospital outcomes were observed for older adults. These findings provide the Australian and New Zealand burn care community with a greater understanding of burn injury and their treatments in a unique group of patients who are at risk of poorer outcomes than younger people.

LAY SUMMARY

The number and proportion of older persons in every country of the world is growing. This may create challenges for healthcare systems. While burn injuries are a unique subset of trauma that affect individuals of all ages, less is known about burns in older adults and how they differ from younger patients.We wanted to look at the number, type, management, and outcomes of burns in older adults in Australia and New Zealand. To do this, we used data from the Burns Registry of Australia and New Zealand, or BRANZ. The BRANZ is a database that collects information on patients that present to Australian and New Zealand hospitals that have a specialist burns unit.Our research found that one in eight adult burns patients was over the age of 65, and that the rate of burn injuries in older adults has increased over the last decade. Older adult burns patients were most commonly affected by scalds after coming in contact with wet heat such as boiling liquids or steam. Fewer older adults went to theatre for an operation or surgical procedure compared to their younger counterparts. However, a larger proportion of older adults that went to theatre had a skin graft (where skin is removed from an uninjured part of the body and placed over the injured part).This research provides important information about a unique and growing group of patients to the local burn care community. It also highlights potential avenues for injury prevention initiatives.

Influence of pre-existing medical condition and predicting value of modified Elixhauser comorbidity index on outcome of burn patients

OBJECTIVES

To evaluate the impact of comorbidity and predicting value of the modified Elixhauser comorbidity index score on the outcome of burn patients.

METHODS

A retrospective study was conducted on 5480 patients admitted during 24 h after burn to the National Burn Hospital from 1/1/2016 to 31/12/2018. Demographic data and pre-existing medical conditions were collected. Modified Elixhauser comorbidity index (ECI) score developed by Walravel et al. was calculated for each patient. The score was the weighted sum of comorbid conditions. Outcomes measured included hospitalization, complication and mortality.

RESULTS

Among 5480 patients, 345(6.3%) had at least one pre-existing medical condition. Most common comorbidities were neurological disorder, diabetes, hypertension and psychoses. Pre-existing medical conditions were more common in elderly (25% vs. 4.8%; p < .001) and female (7.5% vs. 5.8%; p < .05). Moreover, significantly larger burn extent, higher rate of inhalation injury (p < .01) and complication (12.8% vs. 6.1%; p < .001), longer time of hospitalization (21.4 vs. 17.1 days; p < .001) were recorded in comorbidity group. It is noted that higher ECI score was remarkably higher in patients who developed complication (.6 vs. .3 respectively, p < .05) and death (.5 vs. .3; p < .05). Multivariate analysis indicated that apart from presence of inhalation injury, increased burn extent, full thickness burn area, ECI score was an independently predicted factor for prolonging the time of staying, for the development of complication and death. Each score of ECI results in increased probability unit of complication to .13 and probability unit of death to .11.

CONCLUSION

Pre-existing medical conditions lead to more severe and worse outcomes among burn patients. Modified Elixhauser comorbidity index score should be used as a prognosis factor for outcomes of burn patients.

Genome-wide comparisons of gene expression in adult versus elderly burn patients

Purpose

Mortality and morbidity rates of elderly burn patients remain high despite numerous advancements in modern burn care. While prior studies have offered first insights on the biochemical changes in elderly burn patients compared to adults, the underlying cellular responses remain largely unknown. In this study, we aim to characterize the transcriptome of elderly burn patients and compare it to adult burn patients to obtain insights into the underlying molecular responses post-burn and to elucidate the effect of advanced age on the acute burn response.

Materials and methods

Microarray data obtained from the Glue Grant Trauma-Related Database was obtained from blood specimens for ten elderly patients (n = 10), each with a set of two sex and total body surface area (TBSA) matched adult controls (n = 20), during the acute phase post-burn. Adult and elderly demographics and clinical outcomes were contrasted using using the Chi-Square test, Fisher’s Exact Test, or two-sample t-tests, as appropriate (p<0.05). Enrichment and heat maps were generated to compare gene expression in elderly versus adult burn patients.

Results

Supervised analysis identified multiple genes that were differentially expressed between the elderly and adult groups. Pathway analysis and heatmap generation suggest that elderly patients share a distinct hypo-inflammatory response in the acute post-burn phase with downregulation of a number of immune-related pathways, including those related to antigen processing, specifically via MHC class I, ubiquitination and proteasome degradation (p<0.001, FDR < .001). Cell signalling pathways, such as NF-κB, C-type lectin receptor, and T cell receptor signalling were also significantly downregulated in elderly burn patients, as well as those relating to antiviral immunity (p<0.001, FDR < .001). Many genes which were observed to be upregulated in elderly patients with high TBSA burn injuries were associated with destruction-related cellular pathways such as complement activation and immunoglobulin production (p<0.005, FDR <0.01).

Conclusions

The altered inflammatory and immune responses at the transcriptome level in elderly patients after burn are indicative of a failure in elderly burn patients to initiate an appropriate inflammatory and stress response during the acute phase post-burn.

Effect of high-dose vitamin C therapy on severe burn patients: a nationwide cohort study

BACKGROUND

Vitamin C is a well-documented antioxidant that reduces oxidative stress and fluid infusion in high doses; however, the association between high-dose vitamin C and reduced mortality remains unclear. This study evaluates the effect of high-dose vitamin C in severe burn patients under two varying thresholds.

METHODS

We enrolled adult patients with severe burns (burn index ≥ 15) who were registered in the Japanese Diagnosis Procedure Combination national inpatient database from 2010 to 2016. Propensity score matching was performed between patients who received high-dose vitamin C within 1 day of admission (vitamin C group) and those who did not (control group). High-dose vitamin C was defined as a dosage in excess of 10 g or 24 g within 2 days of admission. The primary outcome was in-hospital mortality.

RESULTS

Eligible patients (n = 2713) were categorized into the vitamin C group (n = 157) or control group (n = 2556). After 1:4 propensity score matching, we compared 157 and 628 patients who were administered high-dose vitamin C (> 10-g threshold) and controls, respectively. Under this particular threshold, high-dose vitamin C therapy was associated with reduced in-hospital mortality (risk ratio, 0.79; 95% confidence interval, 0.66-0.95; p = 0.006). In contrast, in-hospital mortality did not differ between the control and high-dose vitamin C group under the > 24-g threshold (risk ratio, 0.83; 95% confidence interval, 0.68-1.02; p = 0.068).

CONCLUSIONS

High-dose vitamin C therapy was associated with reduced mortality in patients with severe burns when used under a minimum threshold of 10 g within the first 2 days of admission. While "high-dose" vitamin C therapy lacks a universal definition, the present study reveals that different "high-dose" regimens may yield improved outcomes.

[Not Available]

Psychiatric disorders in burn victims are well known and studied, but few articles treat the impact of pre-existing psychiatric pathologies on the evolution of burns. The aim of our study is to compare the evolution in terms of complications, length of stay and survival between patients with and without pre-existing mental disorders. This is a bi-centric case-control study (N = 92), conducted at the Plastic Surgery Department of Rabat University Hospital, and the Plastic Surgery Department of the Tangier-Morocco Regional Hospital, between January 2012 and February 2018. Characteristics of the patients were collected and two groups of patients were identified and compared (n = 67): a preexisting mental disorder group (n = 22) and a control group (n = 45). TBSA (total body surface area) burned and 2nd and 3rd degree burned TBSA were significantly greater in the group with a history of mental disorders compared to the control group (p = 0.012, p <0.001, p = 0.014). Mean length of stay before discharge was greater (p = 0.005). Finally, mortality in the group with pre-existing mental illness was 31.8% versus 6.7% in the control group (p = 0.011). Patients with pre-existing mental disorders seem to present worse burns and need more time to recover from them, resulting in higher morbidity and mortality and a higher cost of care. The systematic screening of burned patients in search of a psychiatric diagnosis and early management of these disorders could improve the prognosis and quality of life of these patients.

Factors affecting length of stay among pediatric and adult patients admitted to the Lebanese Burn Centre: a retrospective study

Burn injuries are serious lesions requiring specialized medical care, and are associated with prolonged length of hospital stay (LOS). This study aims to elucidate the epidemiological and clinical factors affecting the LOS of pediatric and adult patients with burn wounds. A single-centre retrospective study was conducted at the Hopital Libanais Geitawi Burn Centre in Lebanon. Medical records of patients admitted to the centre between January 2014 and December 2018 were retrieved. Epidemiological and clinical data, such as age, gender, LOS, co-morbidities, and clinical burn and operative characteristics were collected and subjected to statistical analysis. A total of 321 adult and 154 pediatric patients met the inclusion criteria. Mean LOS in the total population was 23.58 days. Univariate analysis revealed inconsistent correlations between the studied factors and the LOS of pediatric and adult patients. Factors positively affecting both populations were: undergoing an operation, number of operations, burn degree, infection, blood transfusion, and need for burn excision and grafting. Additionally, among pediatric patients LOS significantly increased with age, total body surface area (TBSA) burn wound, cause of burn, sepsis, wound dressing under anaesthesia, and escharotomy. On the other hand, female gender and fever were significant additional positive influencers of adult LOS. Multivariate analysis showed that both pediatric and adult LOS was significantly associated to number of operations, need for burn excision and skin grafting, and receiving a blood transfusion. Adult LOS was further affected by mechanical ventilation, infection and age. Our study demonstrated the differential influence of epidemiological and clinical factors among adult and pediatric populations, which allows better prediction of LOS and management of patients with burn injuries.

Predictors of mortality in cases of thermal burns admitted to Burn Unit, Ain Shams University Hospitals, Cairo

In cases of death due to burn injury, it may be of great medico-legal importance to determine if the death is caused by fatal burn injury or due to other factors related to treatment. Therefore, this study aimed to investigate early predictors of mortality in patients with thermal burns admitted to Burn Unit, Ain Shams University Hospitals during a period of one year (2011). The study included 152 cases, mortalities represented 20.4% of the included cases (31 cases). Binary logistic regression analysis showed that, total body surface area (TBSA) of the burns and APACHE III score were significant predictors of mortality. This model resulted in accurate classification of 95.9% of the cases. Further multi-centric studies on larger sample sizes are recommended to validate the results of this study. Also, it is important to study the effect of co-morbidities as confounding factors on the prediction of mortality in patients with thermal burns.

The prevalence of comorbidities among acute burn patients

Introduction

The elderly population in Iran is growing, and more medical comorbidities can be identified, so hospital admissions of burn patients with associated medical comorbidities are expected to rise as well. As these medical comorbidities may affect the prognosis of burn patients, additional health care services are likely to be required. Therefore, the aim of this study was to determine the prevalence of comorbidities among patients with burn injury.

Methods

A retrospective study of all burn patients admitted to the Motahari Burn Hospital, Iran over a 14-month period was conducted. Variables gathered from patients’ medical record files were demographic characteristics, clinical burn features, hospital course, and preexisting comorbidities. The comorbidity score of patients was calculated by using the updated Charlson comorbidity index.

Results

A total of 732 patients were hospitalized, 136 (18.5%) patients had comorbidities, and more than 57% of elderly people (≥61 years) had one or more comorbid conditions. The most common cause of burn injury among the comorbid patients was scald (38.2%) injury. The two most frequent comorbid conditions among all cases were congestive heart failure (25.8%) and diabetes (23.5%), respectively. As patients got older, the Charlson score also increased. There were no significant differences between comorbid and noncomorbid patients in terms of hospitalization period and mortality rate. Those comorbid patients who died had significantly higher Charlson score and larger mean burn sizes compared to surviving comorbid patients; they were also significantly older.

Conclusion

The prevalence of comorbidities in burn patients was 18.5% and among older burn patients rose to 57%. Diabetes and congestive heart failure were the two most common comorbid conditions.

Hyperbaric oxygen therapy and mortality from carbon monoxide poisoning: A nationwide observational study

BACKGROUND

The effects of hyperbaric oxygen therapy (HBOT) on mortality or morbidity in patients with carbon monoxide (CO) poisoning remain unknown. We examined the effects of HBOT on CO poisoning and further strived to delineate its inherent effects on specific subgroups of patients using a nationwide inpatient database.

METHODS

We identified adult patients with CO poisoning who were registered in the Japanese Diagnosis Procedure Combination inpatient database from 2010 to 2016. Propensity score-matching was performed to compare patients who received HBOT within 1 day of admission (HBOT group) with those who did not receive HBOT (control group). The primary outcome was in-hospital mortality. The secondary outcomes were a depressed mental status and reduced activities of daily living (ADL) at discharge. We also performed subgroup analyses divided according to severity of CO poisoning.

RESULTS

Eligible patients were categorized into the HBOT group (n = 2034) or the control group (n = 4701). One-to-one propensity score-matching created 2034 pairs. In-hospital mortality was not significantly different between the HBOT and control groups (0.8% vs. 1.2%, risk difference: -0.4%, 95% confidence interval: -1.0 to 0.2). Patients in the HBOT group had significantly lower proportions of a depressed mental status and reduced ADL at discharge than did those in the control group. Similar associations were shown in the non-severe poisoning subgroup.

CONCLUSIONS

Although HBOT was not significantly associated with reduced mortality, it was significantly associated with a favorable consciousness level and ADL in patients with CO poisoning. HBOT may be beneficial even for patients with non-severe CO poisoning.

Periorbital lesions in severely burned patients

PURPOSE

This study aimed to characterize the injuries involving periorbital region in our severely burned patients.

METHOD

A 2 years retrospective study was conducted with a total of 210 severe burns admissions. Periorbital burn injuries (all produced in association with facial injuries) were encountered in 126 patients, representing the study group that was further analyzed for multiple parameters: demographics, mechanism of injury, TBSA (total body surface area), burn depth, inhalation injury, need for intubation and mechanical ventilation. The presence and severity of ocular injuries were also evaluated.

RESULTS

Analyzing our study group (n=126), we observed the presence of multiple negative prognosis factors: elderly patients, extensive burns, deep burns affecting functional areas, unfavorable mechanism (electric, chemical or explosions), inhalation injuries, need for intubation and mechanical ventilation, leading to severe morbidity and high mortality level. Ocular injuries were encountered in 37 patients (30 primary and 7 secondary lesions). The predominance of primary ocular lesions is explained trough high severity burns encountered in our patients with high mortality and lack of long-term clinical observations.

CONCLUSION

The clinical outcome for periorbital burn injuries depends on patient characteristics, etiology, burn extension and depth, associated lesions, infectious risk and the quality of the treatment applied. Presence of ocular injuries in various severity degrees impose an adequate evaluation and specialized treatment, being associated with important morbidity. In severely burned patients, it is mandatory to apply preventive measures to avoid ocular complications. If exposure keratopathy is detected, prompt ophthalmologic treatment is essential to avoid functional impairment including loss of vision. Abbreviations: TBSA = total body surface area, MSOF = multisystem organ failure, OCS = orbital compartment syndrome, AION = anterior ischemic optic neuropathy.

Predictors of withdrawal of life support after burn injury

INTRODUCTION

Discussions regarding withdrawal of life support after burn injury are challenging and complex. Often, providers may facilitate this discussion when the extent of injury makes survival highly unlikely or when the patient's condition deteriorates during resuscitation. Few papers have evaluated withdrawal of life support in burn patients. We therefore sought to determine the predictor of withdrawal of life support (WLS) in a regional burn center.

METHODS

We conducted a retrospective analysis of all burn patients from 2002 to 2012. Patient characteristics included age, gender, burn mechanism, percentage total body surface area (%TBSA) burned, presence of inhalation injury, hospital length of stay, and pre-existing comorbidities. Patients <17years of age and patients with unknown disposition were excluded. Patients were categorized into three cohorts: Alive till discharge (Alive), death by withdrawal of life support (WLS), or death despite ongoing life support (DLS). DLS patients were then excluded from the study population. Multivariate logistic regression was used to estimate predictors of WLS.

RESULTS

8,371 patients were included for analysis: 8134 Alive, 237 WLS. Females had an increased odd of WLS compared to males (OR 2.03, 95% CI 1.18-3.48; p=0.010). Based on higher CCI, patients with pre-existing comorbidities had an increased odd of WLS (OR 1.28, 95% CI 1.08-1.52; p=0.005). There was a significantly increased odds for WLS (OR 1.09, 95% CI 1.06-1.12; p<0.001) with increasing age. Similarly, there was an increased odd for WLS (OR 1.08, 95% CI 1.07-1.51; p<0.001) with increasing %TBSA. An increased odd of WLS (OR 2.47, 95% CI 1.05-5.78; p=0.038) was also found in patients with inhalation injury.

CONCLUSION

The decision to withdraw life support is a complex and difficult decision. Our current understanding of predictors of withdrawal of life support suggests that they mirror those factors which increase a patient's risk of mortality. Further research is needed to fully explore end-of-life decision making in regards to burn patients. The role of patient's sex, particularly women, in WLS decision making needs to be further explored.

Dysphagia in older persons following severe burns: Burn location is irrelevant to risk of dysphagia and its complications in patients over 75 years

BACKGROUND

Management of burns in older persons is complex with evidence indicating advanced age is associated with elevated risk for morbidity and mortality. Dysphagia and its sequelae may further increase this risk.

AIMS

(1) Determine the prevalence, and (2) identify risk factors for dysphagia in patients admitted with severe burn injury over 75 years.

METHODS

All patients >75 years admitted to Concord Repatriation General Hospital with severe burn injury over a 4-year period (2013-2017) were assessed for dysphagia on presentation and continually monitored throughout their admission. Burn injury, demographic and nutritional data were captured and analysed for association with and predictive value for dysphagia.

RESULTS

Sixty-six patients (35 male; 31 female) aged 75-96 years (median 82 years) were recruited. Dysphagia was identified in 46.97% during their hospital admission. Dysphagia was significantly associated with burn size, pre-existing cognitive impairment, mechanical ventilation, duration of enteral feeding, hospital length of stay, in-hospital complications and mortality. No association was identified between burn location, burn mechanism, surgery and dysphagia. Burn size and Malnutrition Screening Tool score were found to be independent predictors for dysphagia.

CONCLUSIONS

Dysphagia prevalence is high in older persons with burns and is associated with increased morbidity and mortality, regardless of burn location.

Evaluation of prognostic factors affecting lenght of stay in hospital and mortality rates in acute burn patients

Burns are considered mostly a serious illness with devastating consequences and prolonged length of hospital stay. Moreover, burns are among the traumatic lesions with the highest costs for care due to their hospitalization time, treatment required and the need for rehabilitation therapy. This study aims to evaluate the factors affecting length of hospital stay and mortality rates in acute burn patients. The study was conducted on 82 patients who presented with acute burn and were admitted to the Plastic and Reconstructive Surgery Department Burn Unit, Tanta University Hospital, in the period from June 2016 to June 2017. A prospective study was carried out using the data of acutely burned patients, and a statistical analysis conducted with the data collected on different factors affecting burn patient length of hospital stay and mortality. The mean age of our patients was 16.5 years, mean LOS was 24.23 days and mortality rate was 9.8% of the total admitted cases, with half of the cases with inhalation injury dying in hospital. The most influencing factors on prediction of length of hospital stay were: incidence of infection, wound depth, TBSA% and inhalation injury. The most influencing factors on patient mortality were: TBSA%, age of the patient, cause of burn and inhalation injury, therefore these factors should be carefully evaluated in every burn patient.

Burn wounds in the young versus the aged patient display differential immunological responses

BACKGROUND

Individuals in the geriatric age range are more prone than younger individuals to convert their partial thickness thermal burns into full thickness injuries. We hypothesized that this often observed clinical phenomenon is strongly related to differential local injury responses mediated by the immune system.

MATERIALS & METHODS

Skin samples from areas with partial thickness thermal burns were obtained during routine excision and grafting procedures between post burn days 2-6. Tissue samples were grouped by age ranges with young patients defined as <30 years of age or aged patients defined as >65. Formalin fixed samples were used to confirm depth of burn injury and companion sections were homogenized for multiplex analysis using a Luminex platform. Immunohistochemical staining was used to quantify total macrophage numbers as well as the M1 and M2 subpopulations.

RESULTS

Our analysis includes samples derived from 11 young subjects (mean age=23) and 3 aged subjects (mean age=79.2). Our initial survey of analytes examined 31 cytokines/chemokines. Twelve were excluded from consideration as they were present in concentrations either above or below the optimal detection range. Two analytes emerged as candidate molecules with significant differences between the young and the aged patient responses to burn injury. EGF levels were on average 21.69pg/ml in young vs 14.87pg/ml in aged (p=0.032). RANTES/CCL5 levels were on average 14.86pg/ml in young vs 4.26pg/ml in aged (p=0.026). Elevated macrophage numbers were present within wounds of younger patients compared to the old (p<0.01), with a higher concentration of the M1 type in the elderly (p>0.05).

CONCLUSION

Our study has identified at least 2 well known cytokines, CCL5 (RANTES) and EGF, which are differentially regulated in response to burn injury by young versus aged burn victims. Evidence suggests that a proinflammatory environment can explain the high conversion rate from partial to full thickness burns. Our data suggest the need for future studies at the point of injury (cutaneous targets) that may be modulated by post burn release of cytokines/chemokines.