Multi-institutional analysis of independent predictors for burn mortality in the United States

A comparative study of the predictive value of four models for death in patients with severe burns

OBJECTIVE

To assess the prognostic value of the Ryan score, Belgian Outcome of Burn Injury (BOBI) score,revised Baux (rBaux) score, and a new model (a Logit(P)-based scoring method created in 2020) for predicting mortality risk in patients with extremely severe burns and to conduct a comparative analysis.

METHODS

A retrospective analysis was conducted on 599 burn patients who met the inclusion criteria and were admitted to the burn unit of the First Affiliated Hospital of Nanchang University from 2017 to 2022. Relevant information was collected, and receiver operating characteristic (ROC) curves, calibration curves, and decision curve analysis (DCA) were plotted for each of the four models in assessing mortality in these burn patients using both age-stratified and unstratified forms. The ROC curve section was further compared with the area under the curve (AUC), optimal cutoff value, as well as its sensitivity and specificity. Additionally, the quality of the AUC was assessed using the Delong test.

RESULT

Among the patients who met the inclusion criteria, 532 were in the survival group and 67 in the death group. Irrespective of age stratification, the novel model exhibited superior performance with an AUC of 0.868 (95% CI: 0.838-0.894) among all four models predicting mortality risk in included patients, and also demonstrated better AUC quality than other models; the calibration curves showed that the accuracy of all four models was good; the DCA curves showed that the clinical utility of the novel model and rBuax score were better. In the comparison of four scoring models across different age groups, the new model demonstrated the largest AUC in both 0-19 years (0.954, 95% CI 0.914-0.979) and 20-59 years groups (0.838, 95% CI 0.793-0.877), while rBuax score exhibited the highest AUC in ≥ 60 years group (0.708, 95% CI of 0.602-0.800). The calibration curves showed that the four models exhibited greater accuracy within the age range of 20-59 years, while the DCA curves indicated that both the novel model and rBuax score scale displayed better prediction in both the 20-59 and ≥ 60 years groups.

CONCLUSIONS

All four models demonstrate accurate and effective prognostication for patients with severe burns. Both the novel model and rBaux score exhibit enhanced prediction utility. In terms of the model itself alone, the new model is not simpler than, for example, the rBaux score, and whether it can be applied clinicallyinvolves further study.

Examination of Pediatric Burn Incidence and the Impact of Social Determinants of Health in Florida

Introduction Burn injuries are a major mechanism of trauma worldwide, caused by friction, cold, heat, radiation, chemical, or electric sources. Most often, burn injuries occur due to heat contact from hot liquids, solids, or fire, termed scald burns and flame burns, respectively. These types of injuries are complex and carry major injury and mortality risks, especially in pediatric populations. Burn trauma prevention has been a major focus in the US, with initiatives to increase public health outreach and safety measures. Unfortunately, children in socioeconomically disadvantaged situations may face these types of injuries at disproportionately higher rates, and we aim to highlight these disparities, if any, within our Florida community. Materials and methods This study was designed as a retrospective observational analysis using publicly available data from the Florida Health Community Health Assessment Resource Tool Set (CHARTS). Data was extracted for nonfatal burn injuries resulting in ED visits in the years 2018-2020. This data was limited to those ranging from 0 to 19 years old and converted to rates of burn injuries per 100,000. Sociodemographic details for each county were recorded from County Health Rankings & Roadmaps and compared with burn data in each respective county. Frequencies were generated for categorical data, and statistical analyses for burn rates and sociodemographic details were performed with a generalized linear model using a Poisson distribution and bivariate correlation for a p < 0.05. Results In Florida, the median annual burn rate per 100,000 was 136 (IQR: 96-179), with Jackson county holding the highest rate of 323 and Glades, Hardee, and Lafayette each holding a rate of 0. Of the 18 socioeconomic factors examined, a total of five were found to have no statistically significant effect on nonfatal burn injury ED visits: severe housing problems, percentage of Asians, teen births, percentage of children (<18 years) in poverty, and severe housing cost burden. The two most important factors to be found in nonfatal burn ED visits of pediatric patients were the percentage of those younger than 19 years old without health insurance and the average grade level performance of third-grader reading scores. When adjusting for the small sample size using Firth's bias-adjusted estimates and overdispersion, both reading scores and those without insurance play a significant role in pediatric burn injuries. For each increase in a single point in reading scores, the incidence rate ratio decreases by 97.1% (95% CI). For every percentage increase in children insured, there is a 28.8% decrease in pediatric burn injuries (95% CI). Conclusions This analysis highlights increased pediatric burn rates across multiple social determinants of health (SDOH) in all 67 Florida counties. The findings here demonstrate that there may continue to be a disproportionate distribution of burn rates among lower and higher sociodemographic areas. This study further highlights this trend within the Florida community, and continued research will be necessary to meet the needs of lower sociodemographic areas to improve burn rates in vulnerable populations, such as children, who are at increased risk of injury.

Machine learning models for early prediction of mortality risk in patients with burns: A single center experience

Mortality rate is considered as the most important outcome measure for assessing the severity of burn injury. A scale or model that accurately predicts burn mortality can be useful to determine the clinical course of burn injuries, discuss treatment options and rehabilitation with patients and their families, and evaluate novel, innovative interventions for the injuries. This study aimed to use machine learning models to predict the mortality risk of patients with burns after their first admission to the center and to compare the performances of these models. Overall, 1064 patients hospitalized in burn intensive care and burn service units between 2016 and 2022 were included in the study. In total, 40 parameters, including demographic characteristics and biochemical parameters of all patients, were analyzed in the study. Furthermore, the dataset was randomly divided into two clusters with 70% of the data used for artificial neural networks (ANNs) training and 30% for model success testing. The ANN model proposed in this study showed high success across all machine learning methods tried in different variants, with an accuracy of 95.92% in the test set. Machine learning models can be used to predict the mortality risk of patients with burns. This study may help validate the use of machine learning models for applications in clinical practice. Conducting multicenter studies will further contribute to the literature.

3D-printed hydrogels dressings with bioactive borate glass for continuous hydration and treatment of second-degree burns

Recent advances in additive manufacturing have led to the development of innovative solutions for tissue regeneration. Hydrogel materials have gained significant attention for burn wound treatment in clinical practice among various advanced dressings due to their soothing and moisturizing activity. However, prolonged healing, pain, and traumatic removal due to the lack of long-term wound hydration are some of the challenges in the treatment of second-degree burn wounds. In this study, 3D-printed dressings were fabricated using gelatin, alginate, and bioactive borate glass (BBG) using an extrusion-based bioprinter. After ionic crosslinking, the 3D-printed dressings were characterized for mechanical properties, degradation rate, hydration activity, and in vitro cell viability using human fibroblasts. The results demonstrated that in 3D-printed dressings with 20 wt% BBG, Young's modulus increased by 105%, and 10-day degradation rate decreased by 62%. Addition of BBG prevented the burst release of water from hydrogel dressings and enabled the continuous water release for up to 10 days, which is crucial in treating second-degree burn wounds. 3D-printed hydrogel dressings with BBG showed long-term cell viability that can be a result of the accumulative release of therapeutic ions from BBG particulate. The in vivo wound healing functionality of the dressings was investigated using a rat model with a second-degree burn wound. Our animal study showed that the 3D-printed dressings with BBG exhibited faster wound closure, non-adhesive contact, non-invasive debridement, and non-traumatic dressing removal. Histological analysis suggested that 3D-printed dressings contributed to more uniform re-epithelialization and tissue remodeling compared to the non-printed hydrogels of the same compositions. Critically, 3D-printed dressings with BBG led to significant regeneration of hair follicles compared to the 3D-printed hydrogel, non-printed hydrogel, and the control groups. The superior outcome of the 3D-printed hydrogel-BBG20 dressings can be attributed to the bioactive formulation, which promotes moist wound healing for longer time periods, and the non-adhesive porous texture of the 3D-printed dressings with increased wound-dressing interactions. Our findings provided proof of concept for the synergistic effect of bioactive formulation and the porous texture of the 3D-printed hydrogel dressings incorporated with BBG on continuous water release and, consequently, on second-degree burn wound healing.

Epidemiology and mortality in patients hospitalized for burns in Catalonia, Spain

Burn injuries are one of the leading causes of morbidity worldwide. Although the overall incidence of burns and burn-related mortality is declining, these factors have not been analysed in our population for 25 years. The aim of this study has been to determine whether the epidemiological profile of patients hospitalized for burns has changed over the past 25 years. We performed a retrospective cohort study of patients hospitalised between 1 January 2011 and 31 December 2018 with a primary diagnosis of burns. The incidence of burns in our setting was 3.68/105 population. Most patients admitted for burns were men (61%), aged between 35 and 45 years (16.8%), followed by children aged between 0 and 4 years (12.4%). Scalding was the most prevalent mechanism of injury, and the region most frequently affected was the hands. The mean burned total body surface (TBSA) area was 8.3%, and the proportion of severely burned patients was 9.7%. Obesity was the most prevalent comorbidity (39.5%). The median length of stay was 1.8 days. The most frequent in-hospital complications were sepsis (16.6%), acute kidney injury (7.9%), and cardiovascular complications (5.9%). Risk factors for mortality were advanced age, high abbreviated burn severity index score, smoke inhalation, existing cardiovascular disease full-thickness burn, and high percentage of burned TBSA. Overall mortality was 4.3%. Multi-organ failure was the most frequent cause of death, with an incidence of 49.5%. The population has aged over the 25 years since the previous study, and the number of comorbidities has increased. The incidence and severity of burns, and the percentage of burned TBSA have all decreased, with scalding being the most prevalent mechanism of injury. The clinical presentation and evolution of burns differs between children and adults. Risk factors for mortality were advanced age, smoke inhalation, existing cardiovascular disease, full-thickness burn, and high percentage of burned TBSA.

Clinical Outcomes Among Elderly People With Burns

Burns in the elderly are a public health concern. This study aimed to analyze etiology, clinical characteristics, and independent risk factors for outcomes of burns in elderly patients. This retrospective study included elderly patients (65 years and over) admitted to a major burn unit between 2006 and 2016. Demographic data, clinical characteristics and outcomes were analyzed. One hundred and thirty patients were included. Most were female (56.2%) and the highest incidence was among those aged 75-84 years. The median burn area was 10.5%. The incidence in winter (50%) was higher (p<0.001) and flame burns predominated (p<0.001). The mortality rate was 32.3%. Independent risk factors for death were older age, larger extent burns, need for escharotomy, and cardiac disease as comorbidity. Amongst the survivors, the median length of stay was 36 days. Development of pressure sores, need for skin grafts, larger extent burns, presence of full-thickness burns, and cardiac disease were shown to be significantly associated with increased length of stay amongst survivors. Preventive measures should target women aged between 75-84 years. Flame burns occurred more frequently in winter. Prognosis is related to age, extent of burns, need for escharotomy at admission, and cardiac disease.

Use of Female External Urinary Catheters in a Burn Intensive Care Unit: Benefits and Challenges

BACKGROUND

Burn patients have a relatively high rate of indwelling Foley catheter use because of their need for complex fluid management and wound care. However, Foley catheter use is associated with risks, including urinary tract infection. For female patients, an external urinary catheter is an alternative.

OBJECTIVES

To evaluate the use of female external urinary catheters in a burn intensive care unit and to develop a standard protocol.

METHODS

This study involved female patients admitted to a burn intensive care unit from 2017 to 2020. An initiative to increase the use of female external urinary catheters was begun in 2019. A retrospective review of medical records was used to determine rates of indwelling and external catheter use and of catheter-associated urinary tract infection before and after implementation of the initiative.

RESULTS

Of 77 female burn patients admitted to the unit between 2019 and 2020, 56 (73%) required indwelling Foley catheterization, a significant decrease from 94% before the initiative (P = .002). The mean duration of indwelling Foley catheter use decreased significantly from 19.4 days to 10.47 days (P = .049). Female external urinary catheters were used in 21 patients (27%). No patients with female external urinary catheters contracted urinary tract infections, compared with 9 patients with indwelling Foley catheters.

CONCLUSION

The use of female external urinary catheters may help reduce the risk of urinary tract infection in female burn patients. Further research is needed to refine the protocol for use of these devices and determine their safety profile.

EPIDEMIOLOGICAL CHARACTERISTICS AND FACTORS ASSOCIATED WITH MORTALITY IN SEVERELY BURNED PATIENTS - CROATIAN NATIONAL BURN CENTER REPORT

The authors conducted a single-center retrospective study during the last 6.5 years. The study aimed to describe demographic data of burn patients in the Croatian Burn Center and investigate factors affecting mortality for the first time after the Center was established. The study included 109 severely burned patients with a total body surface area (TBSA) burned ≥20%, admitted to the burn intensive care unit. The relationship between the fatal outcome and age, sex, comorbidity, mechanism of injury, TBSA burned, and inhalation injury was investigated. The mean patient age was 54.50±20.21 years and the mean TBSA burned was 42.48±18.64%, with the mortality rate of 50%. The results demonstrated that patients with 2 or more comorbidities compared with those with no comorbidities had a higher chance of lethal outcome (p<0.0001). With an increase of TBSA by 1%, the odds of lethal outcome are expected to increase by 7% (p<0.0001). Other variables included in the analysis did not show statistical significance. TBSA percentage is a well-known predictor of mortality and numerous studies indicate an association between comorbidities and mortality but there are conflicting results about other demographic factors and injury characteristics.

Acute Respiratory Distress Syndrome, Mechanical Ventilation, and Inhalation Injury in Burn Patients

Respiratory failure occurs with some frequency in seriously burned patients, driven by a combination of inflammatory and infection factors. Inhalation injury contributes to respiratory failure in some burn patients via direct mucosal injury and indirect inflammation. In burn patients, respiratory failure leading to acute respiratory distress syndrome, with or without inhalation injury, is effectively managed using principles evolved for non-burn critically ill 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.

Burn Registries State of Affairs: A Scoping review

Registry science allows for the interpretation of disease-specific patient data from secondary databases. It can be utilized to understand disease and injury, answer research questions, and engender benchmarking of quality-of-care indicators. Numerous burn registries exist globally, however, their contributions to burn care have not been summarized. The objective of this study is to characterize the available literature on burn registries. The authors conducted a scoping review, having registered the protocol a priori. A thorough search of the English literature, including grey literature, was carried out. Publications of all study designs were eligible for inclusion provided they utilized, analyzed, and/or critiqued data from a burn registry. Three hundred twenty studies were included, encompassing 16 existing burn registries. The most frequently used registries for peer-reviewed publications were the American Burn Association Burn Registry, Burn Model System National Database, and the Burns Registry of Australia and New Zealand. The main limitations of existing registries are the inclusion of patients admitted to burn centers only, deficient capture of outpatient and long-term outcome data, lack of data standardization across registries, and the paucity of studies on burn prevention and quality improvement methodology. Registries are an invaluable source of information for research, delivery of care planning, and benchmarking of processes and outcomes. Efforts should be made to stimulate other jurisdictions to build burn registries and for existing registries to be improved through data linkage with administrative databases, and by standardizing one international minimum dataset, in order to maximize the potential of registry science in burn care.

Predicting and Estimating Burn Outcomes: An Institutional Analysis of 4622 cases

Advances in burn care have improved patient outcomes, and independently validated indices and predictors of burn outcomes warrant re-evaluation. The purpose of this study is to consolidate predictors of burn outcomes and determine the factors that significantly contribute to length-of-stay (LOS) and mortality. A retrospective review was conducted of all burn patients (n=5778) admitted to a quaternary provincial burn unit from 1973 to 2017. Our inclusion criteria yielded 4622 independent cases. Multivariate linear and logistic regression models were generated, and area-under-receiver-operator-curve (AUROC) analysis was performed. Burn predictors included %TBSA, Baux (classic and revised) index, Abbreviated Burn Severity Index (ABSI), and Ryan score. Primary outcomes were mortality and LOS. Multivariate logistic regression for mortality showed the Baux index to be the best predictor for mortality (OR=1.11, p<0.001). The AUROC for Baux index was 0.95. With regards to LOS, ABSI was the best predictor for LOS (p<0.001). ICU stay, ventilator use, alcoholism, age, significantly associated with increased LOS. Interestingly, hypertension had a protective effect for LOS (p<0.01) and trended towards a protective effect in mortality. Lethal score 50% (LS50) improved over the study period. The regressions show that burn mortality and LOS are best predicted with the Baux index and ABSI, respectively. Hypertension may have a protective effect on burn outcomes and may be attributed to increased perfusion to the periphery. These predictive scores are useful in determining institutional outcomes in burn surgery. Objective benchmarking of improvement in burn care outcomes can be established using LS50 trends.

Burn Outcomes at Extremes of Body Mass Index- Underweight is as problematic as Morbid Obesity

Limited evidence suggests that obesity adversely affects burn outcomes. However, the impacts of body mass index (BMI) across the continuum has not been fully characterized. Therefore, we aimed to characterize outcomes after burn injury across the BMI continuum. We hypothesized that 'normal' BMI (18.5-24.9) would have the lowest mortality and complication rates. The US National Trauma Data Bank (NTDB) was queried for adult burn-injured patients from 2007-2015. Admission BMI was calculated and grouped according to World Health Organization (WHO) classification. The primary outcome was in-hospital mortality. Secondary outcomes of time to wound closure, length of stay (LOS), and inpatient complications were similarly assessed. Of the 116,008 burn patient encounters that were identified, 7,243 underwent at least one operation for wound closure. Mortality was lowest in the overweight (p=0.039) and obese I cohorts (BMI 25-29.9, 30.0-34.9) at 2.9% and increased in both directions of the BMI continuum to 4.1% in the underweight (p=0.032) and 5.1% in the morbidly obese (class III) group (p=0.042). Time to final wound closure was longest in the two BMI extremes. BMI >40 was associated with increased ICU days, ventilator days, renal and cardiac complications. BMI <18.5 had increased hospital days and rates of sepsis. Aberrations in metabolism associated with both increases and decreases of body weight may cause pathophysiologic changes that lead to worsened outcomes in burn-injured patients. In addition to morbidly obese patients, underweight patients also experience increased burn-related death and complications. In contrast, overweight BMI patients may have greater physiologic reserves without the burden of obesity or sarcopenia.

Age and Injury Size Influence the Magnitude of Fecal Dysbiosis in Adult Burn Patients

Clinical studies have demonstrated that age 50 years or older is an independent risk factor associated with poor prognosis after burn injury, the second leading cause of traumatic injuries in the aged population. While mechanisms driving age-dependent postburn mortality are perplexing, changes in the intestinal microbiome, may contribute to the heightened, dysregulated systemic response seen in aging burn patients. The fecal microbiome from 22 patients admitted to a verified burn center from July 2018 to February 2019 was stratified based on the age of 50 years and total burn surface area (TBSA) size of ≥10%. Significant differences (P = .014) in overall microbiota community composition (ie, beta diversity) were measured across the four patient groups: young <10% TBSA, young ≥10% TBSA, older <10% TBSA, and older ≥10% TBSA. Differences in beta diversity were driven by %TBSA (P = .013) and trended with age (P = .087). Alpha diversity components, richness, evenness, and Shannon diversity were measured. We observed significant differences in bacterial species evenness (P = .0023) and Shannon diversity (P = .0033) between the groups. There were significant correlations between individual bacterial species and levels of short-chain fatty acids. Specifically, levels of fecal butyrate correlated with the presence of Enterobacteriaceae, an opportunistic gut pathogen, when elevated in burn patients lead to worsen outcomes. Overall, our findings reveal that age-specific changes in the fecal microbiome following burn injuries may contribute to immune system dysregulation in patients with varying TBSA burns and potentially lead to worsened clinical outcomes with heightened morbidity and mortality.

Rethinking preparedness planning in disaster emergency care: lessons from a beyond-surge-capacity event

Background

Large-scale burn disasters can produce casualties that threaten medical care systems. This study proposes a new approach for developing hospital readiness and preparedness plan for these challenging beyond-surge-capacity events.

Methods

The Formosa Fun Coast Dust Explosion (FFCDE) was studied. Data collection consisted of in-depth interviews with clinicians from four initial receiving hospitals and their relevant hospital records. A detailed timeline of patient flow and emergency department (ED) workload changes of individual hospitals were examined to build the EDs' overload patterns. Data analysis of the multiple hospitals' responses involved chronological process-tracing analysis, synthesis, and comparison analysis in developing an integrated adaptations framework.

Results

A four-level ED overload pattern was constructed. It provided a synthesis of specifics on patient load changes and the process by which hospitals' surge capacity was overwhelmed over time. Correspondingly, an integrated 19 adaptations framework presenting holistic interrelations between adaptations was developed. Hospitals can utilize the overload patterns and overload metrics to design new scenarios with diverse demands for surge capacity. The framework can serve as an auxiliary tool for directive planning and cross-check to address the insufficiencies of preparedness plans.

Conclusions

The study examined a wide-range spectrum of emergency care responses to the FFCDE. It indicated that solely depending on policies or guidelines for preparedness plans did not contribute real readiness to MCIs. Hospitals can use the study's findings and proposal to rethink preparedness planning for the future beyond surge capacity events.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13017-021-00403-x.

Nonmedical Factors Influencing Early Deaths in Burns: A Study of the National Burn Repository

It is well-established that survival in burn injury is primarily dependent on three factors: age, percent total-body surface area burned (%TBSA), and inhalation injury. However, it is clear that in other (nonburn) conditions, nonmedical factors may influence mortality. Even in severe burns, patients undergoing resuscitation may survive for a period of time before succumbing to infection or other complications. In some cases, though, families in conjunction with caregivers may choose to withdraw care and not resuscitate patients with large burns. We wanted to investigate whether any nonmedical socioeconomic factors influenced the rate of early deaths in burn patients. The National Burn Repository (NBR) was used to identify patients that died in the first 72 hours after injury and those that survived more than 72 hours. Both univariate and multivariate regression analyses were used to examine factors including age, gender, race, comorbidities, burn size, inhalation injury, and insurance type, and determine their influence on deaths within 72 hours. A total of 133,889 burn patients were identified, 1362 of which died in the first 72 hours. As expected, the Baux score (age plus burn size), and inhalation injury predicted early deaths. Interestingly, on multivariate analysis, patients with Medicare (p = .002), self-pay patients (p < .001), and those covered by automobile policies (p = .045) were significantly more likely to die early than those with commercial insurance. Medicaid patients were more likely to die early, but not significantly (p = .188). Worker's compensation patients were more likely to survive the first 72 hours compared with patients with commercial insurance (p < .001). Men were more likely to survive the early period than women (p = .043). On analysis by race, only Hispanic patients significantly differed from white patients, and Hispanics were more likely to survive the first 72 hours (p = .028). Traditional medical factors are major factors in early burn deaths. However, these results show that nonmedical socioeconomic factors including race, gender, and especially insurance status influence early burn deaths as well.

Patient Reported Experiences at a Swedish National Burn Centre

Previous studies have shown that burn patients were satisfied with the received care. Satisfaction was not strongly associated to burns or to psycho-social characteristics, suggesting that other factors, related to burn care specific aspects, may be important. The aim of this study was to analyze the independent effect of provided workload on the general satisfaction in adult patients at a Swedish national Burn Centre. The study population (n = 122) included patients ≥18 years, treated at the Linköping Burn Centre between 2016 and 2017. Experienced burn care was evaluated with the PS-RESKA survey (score range: 0–4), and provided workload was scored with the Burn Scoring System (BSC). Groups were compared with χ ² test, MW test, or Fisher´s exact test. Multivariable logistic regression analyzed the independent effect of BSC on the outcome High Satisfaction (= score ≥3 to the survey-question: “How would you score your global experience at the Burn Centre?”). In-patients (n = 60) had more often larger burns and required more workload than out-patients (median[IQR]: TBSA% = 6.3 [3–12.3] % vs. 0.7 [0.3–2] %, p < .001; BSC = 65 [25.5–135.5] vs. 6 [4–9], p < .001). Both groups were highly satisfied with the experienced care (mean score [SD] = 3.68 [0.57] vs. 3.41 [0.77], p = .03). Neither characteristics of the patients (age, sex), nor TBSA% nor provided workload (BSC) were independently associated with High Satisfaction. Regardless of burn severity, demographics and provided workload, adult patients with burns were highly satisfied with the experienced burn care. This finding suggested that the reason of the satisfaction was multifactorial.

A narrative review of changes in microvascular permeability after burn

Objective

We aimed to review and discuss some of the latest research results related to post-burn pathophysiological changes and provide some clues for future study.

Background

Burns are one of the most common and serious traumas and consist of a series of pathophysiological changes of thermal injury. Accompanied by thermal damage to skin and soft tissues, inflammatory mediators are released in large quantities. Changes in histamine, bradykinin, and cytokines such as vascular endothelial growth factor (VEGF), metabolic factors such as adenosine triphosphate (ATP), and activated neutrophils all affect the body’s vascular permeability.

Methods

We searched articles with subject words “microvascular permeability”, “burn” “endothelium”, and “endothelial barrier” in PubMed in English published from the beginning of database to Dec, 2020.

Conclusions

The essence of burn shock is the rapid and extensive fluid transfer in burn and non-burn tissue. After severe burns, the local and systemic vascular permeability increase, causing intravascular fluid extravasation, leading to a progressive decrease in effective circulation volume, an increase in systemic vascular resistance, a decrease in cardiac output, peripheral tissue edema, multiple organ failure, and even death. There are many cells, tissues, mediators and structures involved in the pathophysiological process of the damage to vascular permeability. Ulinastatin is a promising agent for this problem.

Does early bloodstream infection pose a significant risk of in-hospital mortality in adults with burns?

BACKGROUD/PURPOSE

Bloodstream infections (BSI) are common in patients with major burns, but its effect on mortality remains controversial. This study was aimed to investigate if BSI is significant risk factor of mortality?

METHODS

This is a retrospective chart review study included 266 adult patients admitted to our burn center from 2000 to 2019. Age, sex, inhalation injuries, total burn surface area (TBSA), duration of stay in intensive care unit, BSI and mortality were variables studied. Fisher exact test, Mann-Whitney test and logistic regression was used for statistical analysis.

RESULTS

There were 234 survivors and 32 non-survivors. Male was predominant. The overall incidence of BSI was 18.8%, and the overall crude mortality was 12%. Burns ≥30% TBSA and BSI were significant risk factors. A predictive function based on30% TBSA and BSI within 14 days after the onset of burns (BSI-14) was derived. The function has a sensitivity of 0.97, specificity of 0.42 and achieved a maximum Youden Index at functional value ≥0.05727. The mortality probability of BSI-14 in burns ≥30% TBSA was 40.8%.

CONCLUSIONS

BSI and burns ≥30% TBSA were significant risk factors of mortality. Early detection of BSI-14 is critical in burn care as its probability of mortality can be as high as 40% in patients ≥30% TBSA of burns. To reduce the risk of mortality, early in ventilator withdrawal, invasive lines and tubes removal, and early grafting should be emphasized besides infection control and appropriate use of antibiotics.

Impact of the affordable care act's medicaid expansion on burn outcomes and disposition

BACKGROUND

We aimed to analyze the impact of the Affordable Care Act's Medicaid Expansion on clinical outcomes and patient disposition after burn injury. We hypothesized that increased insurance coverage results in improved outcomes and higher rates of discharge to inpatient rehabilitation.

METHODS

We reviewed the University of Washington Regional Burn Center registry data for patients admitted from 2011 to 2018. Patients were grouped into two categories: before (2011-2013) and after (2015-2018) Medicaid expansion; we excluded 2014 data to serve as a washout period. Outcomes assessed included length of hospital stay, patient disposition, and mortality. Multivariable logistic and linear regression models with covariates for sex, age, burn size, ethnicity ethnicity, distance from burn center, etiology of burn, and presence of inhalation injury were used to determine the impact of Medicaid expansion on outcomes.

RESULTS

Rates of uninsured patients decreased while Medicaid coverage increased. Despite increased median burn size after Medicaid expansion, inpatient mortality rates did not change, but average acute care length of stay increased. More patients were discharged to rehabilitation centers.

CONCLUSIONS

Our study corroborates prior findings of increased insurance coverage since Medicaid expansion. Increased insurance coverage is associated with higher rates of discharge to inpatient rehabilitation programs after burn injury.

Validation of four burn-specific prognostic models in a cohort of 9625 cases, and a novel model for prediction of mortality in burn patients

BACKGROUND

Survival after burn injury has steadily improved in recent decades. The models for assessing the severity of burn injury and predicting burn-associated mortality have been used for over 20 years. The predictive accuracy of these models should be reconsidered now.

METHOD

In this retrospective study on all burn patients (n = 9625) admitted to the Burn Department, Southwest Hospital between 2008 and 2017, we compared the predictive performance of the four burn-severity models (Abbreviated Burn Severity Index, Ryan score, revised Baux score and Belgian Outcome of Burn Injury) by area under the receiver operating curve (AUC) and Hosmer-Lemeshow test. We developed a new model with the data from 2008 to 2012 (5006 patients) by logistic regression, data from 2013 to 2017 (4619 patients) were used for validation.

RESULT

The overall mortality rate of the burn patients was 1.14%. The four previously validated burn models showed good discrimination power of death risk (AUC > 0.890) but poor fitness to the observed mortality rate (p < 0.001). Risk factors associated with mortality included sex, age, total burn area, full thickness burn area, and inhalation injury. The new logistic model was devised with high sensitivity and specificity (0.913 and 0.806, respectively) and an AUC of 0.940. The new model also had good fitness to the observed mortality of burn patients (p = 0.588).

CONCLUSION

The four widely used burn models have poor accuracy in predicting burn-associated mortality, and an accurate new model was developed based on simple and objective clinical characteristics of burn patients at admission.

No Difference in Mortality Between Level I and II Trauma Centers for Combined Burn and Trauma

BACKGROUND

Trauma patients with burn injuries have higher morbidity and mortality rates compared with patients who solely experience burn or trauma injuries. There is a paucity of data regarding burn-trauma (BT) patient outcomes at level I (LI) trauma centers compared with level II (LII) centers. We hypothesized that BT patients at LI trauma centers have lower mortality rates than those at LII trauma centers.

METHODS

The Trauma Quality Improvement Program (2010-2016) was queried for patients aged ≥18 y who had BT injuries. Patients treated at an LI were compared with those at an LII center with a primary outcome of in-hospital mortality. Secondary outcomes included hospital length of stay (LOS) and intensive care unit (ICU) LOS. A multivariable logistic regression analysis was used to identify factors associated with all-cause mortality.

RESULTS

From 1971 BT patients, 1540 (78%) were treated at an LI trauma center, and 431 (22%) at an LII center. Compared with LII centers, LI BT patients had a longer median LOS (10 versus 7 d; P < 0.001) and ICU LOS (5 versus 4 d; P < 0.001). Both LI and LII centers had similar mortality rates (8.5% versus 7.0%; P = 0.300). On multivariable analysis, receiving care at an LI trauma center was not associated with decreased mortality (odds ratio 0.79, 95% confidence interval 0.42-1.48; P = 0.456).

CONCLUSIONS

We report that LI trauma center BT patients had an increased hospital and ICU LOS compared with those at LII centers. However, there was no significant difference in mortality between patients cared for at LI and LII trauma centers in risk-adjusted models.

The Impact of the Affordable Care Act on Burn Outcomes

Uninsured and low socioeconomic status patients who suffer burn injuries have disproportionately worse morbidity and mortality. The Affordable Care Act was signed into law with the goal of increasing access to insurance, with Medicaid expansion in January 2014 having the largest impact. To analyze the population-level impact of the Affordable Care Act on burn outcomes, and investigate its impact on identified at-risk subgroups, a retrospective time series of patients was created using data from the Healthcare Cost and Utilization Project National Inpatient Sample database between 2011 and 2016. An interrupted time series analysis was conducted to examine mortality, length of stay, and the probabilities of discharge home, home with home health, and to another facility before and after January 2014. There were no changes in burn mortality detected. There was a statistically significant reduction in the probability of being discharged home (−0.000967, P &lt; .01; 95% confidence interval [CI] −0.0015379 to −0.0003962) or discharged home with home health (−0.000709, P &lt; .01; 95% CI −0.00110 to 0.000317) after 2014. There was an increase in the probability of being discharged to another facility (0.00108, P = .01; 95% CI 0.000282–0.00188). While the enactment of the major provisions of the Affordable Care Act in 2014 was not associated with a change in mortality for burn patients, it was associated with more patients being discharged to a facility: This may represent a significant improvement in access to care and rehabilitation. Future studies will assess the societal and economic impact of improved access to post-discharge facilities and rehabilitation.

A predictive model for prolonged hospital length of stay in surgical burn patients

BACKGROUND

Improvement in the care of burn patients has led to decreased mortality. Length of stay (LOS) has been used as a marker for quality of care in this population. However, the historical association of LOS as correlating only with % burn surface area (BSA) injury has been questioned with retrospective data suggesting other factors may also be associated with LOS. A model to predict prolonged LOS does not exist but could provide important information for clinicians and patients.

METHODS

Data from January 2014 to December 2016 was used to develop a predictive model utilizing multivariable logistic regression. Prolonged hospital LOS was the outcome used with multiple covariates utilized to identify various associations. Odds ratios (OR) and their associated 95% confidence interval (CI) were reported for each covariate in the final regression model. Model performance in both the training and validation sets was evaluated using area under the receiver operating characteristic (ROC) curve (AUC) for discrimination and the Hosmer-Lemeshow (HL) test for goodness-of-fit.

RESULTS

A total of 441 patients was included in the final analysis, 296 (67.1%) of which were in the training set. Within the training set, the median hospital LOS was 14 days with a range of 4 to 205 days. Patient age (in decades), hypertension, total BSA, involvement of perineum, and abnormal white blood cell count were independent risk factors for prolonged hospital length of stay. When using this separate dataset, the model had an AUC of 0.81 (95% CI 0.74-0.88) and had good calibration based on the HL-test (p=0.10).

CONCLUSIONS

Prolonged hospitalization following burns is predicted by patient age (in decades), TBSA, hypertension, perineal involvement, and abnormal white blood cell count.

Bacterial infection profile and predictors among patients admitted to a burn care center: A retrospective study

BACKGROUND

Infection is the main cause of mortality and complications in burn patients. The present study was the first to examine the local profile and antecedents of bacterial infections among patients admitted to a Lebanese burn care center.

METHODS

The present study was a retrospective analysis of the occurrence and recurrence of infection, its characteristics as well as antimicrobial susceptibility among 475 patients admitted to the Burn Centre at the Lebanese Geitaoui Hospital between January 2014 and December 2018.

RESULTS

55% of patients contracted at least one infection during their hospitalization. Length of stay (LOS), sepsis, wound dressing under anesthesia, blood transfusion and female sex independently and positively predicted infection in burn patients. Infection was predominately caused by Staphylococcus aureus (48.7%), followed by Pseudomonas aeruginosa (22.6%) and Acinetobacter baumannii (15.7%). Bacterial isolates were predominately multi-drug or extensively drug resistant and showed variable antimicrobial susceptibility patterns. Recurrent infections occurred in 44.1% of infected burn patients, and were independently predicted by LOS (p = 0.004), sepsis (p = 0.001), surgery (p = 0.003), burn excision and skin grafting (p = 0.019), and central line insertion (p = 0.004).

CONCLUSION

Existing burn management and infection control measures must be revised in order to reduce the incidence and improve the treatment of infections in burn patients.

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.

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.

Outcome and risk factors for death of elderly burn patients: a case series in Vietnam

The aim of this study is to investigate characteristics, outcome and risk factors for death among elderly burn patients. A retrospective study was conducted on 416 elderly (≥ 65 years old) burn patients admitted to the National Burn Hospital, Hanoi, Vietnam from 1/1/2016 to 31/12/2018. Data on demographics, comorbidity, burn severity, complications and mortality were recorded. Bivariate and multivariate analyses were conducted to determine independent risk factors for death. Results indicated that elderly burn patients accounted for 4.2% of total admitted patients with an average age of 74.7 ± 8.1 years old. Significantly higher burn surface area (12.4% vs. 7.3%; p < .001) and deep burn area (5.5% vs. 2.5%; p < .001) were seen in the female group when compared to the male group. Pre-existing medical conditions were recorded in 20.9% of patients, the highest proportion (13.2%) represented by cardiovascular disease followed by neurological and diabetic disease (8.7% and 7% respectively). Over half (51.5%) of the patients had suffered deep burn and 6.3% developed complications, the most common being multiple organ failure and pneumonia. Overall mortality rate was 9.9%. However, death rate was extremely high in patients with inhalation injury (92.9%), burn extent > 40% total body surface area (TBSA) and deep burn > 10% TBSA (61.2% and 62.5% respectively). Comorbidity was not an independent risk factor for death, unlike increased age, burn extent and presence of inhalation injury. In conclusion, we show that despite advances in management, severe burn and inhalation injury in the elderly remains a big challenge in Vietnam.

Novel pharmacotherapy for burn wounds: what are the advancements

INTRODUCTION

The prognosis for severe burns has improved significantly over the past 50 years. Meanwhile, burns have become an affliction mainly affecting the less well-developed regions of the world. Early excision and skin grafting has led to major improvements in therapeutic outcomes.

AREAS COVERED

The purpose of this article is to survey the use of pharmacotherapy to treat different pathophysiological complications of burn injury. The author, herein, discusses the use of drug treatments for a number of systemic metabolic disturbances including hyperglycemia, elevated catabolism, and gluconeogenesis.

EXPERT OPINION

Advancements in personalized and molecular medicine will make an impact on burn therapy. Similarities between severe burns and other critically ill patients will lead to cross-fertilization between different medical specialties. Furthermore, advances in stem cells and tissue regeneration will lead to improved healing and less lifelong disability. Indeed, research in new drug therapy for burns is actively progressing for many different complications.