Advanced biomarker clustering analysis reveals mortality predictors in burn patients with sepsis.

This study addresses the challenge of predicting mortality in sepsis among burn patients. Given the heterogeneity of sepsis, especially in the context of burn injuries, this study aims to identify reliable biomarkers for mortality prediction. The study is a retrospective review, focusing on the evaluation of various biomarkers and their changes over time in a burn patient cohort. Conducted in the Burn Intensive Care Unit of Hangang Sacred Heart Hospital, the study involved a retrospective review of 1,659 adult burn patients from January 2010 to December 2022. Key biomarkers analyzed include lactate levels, pH, platelets, procalcitonin, and others. Advanced clustering methodologies, such as dynamic time warping and hierarchical clustering, were utilized to classify patients into distinct groups based on their biomarker profiles and clinical outcomes. The study identified four patient clusters with unique lactate level trajectories. Significant findings include the identification of procalcitonin, pH, and platelets as key predictors of mortality, with varying degrees of efficacy across different clusters. For instance, in the "Persistent Rise" cluster, pH and platelet count showed Area Under the Curve (AUC) values of 0.756 and 0.753, respectively, indicating their strong predictive power. The study concludes that a combination of biomarkers, especially lactate dynamics, can effectively predict mortality in burn-induced sepsis. The results advocate for a more personalized approach in managing sepsis in burn patients, considering the specific biomarker trajectories. These findings are crucial for enhancing treatment strategies and improving patient outcomes in burn care.

A deep dive into burn-mediated ARDS severity assessment: a retrospective study on hematological markers.

Acute Respiratory Distress Syndrome (ARDS) is a critical form of Acute Lung Injury (ALI), challenging clinical diagnosis and severity assessment. This study evaluates the potential utility of various hematological markers in burn-mediated ARDS, including Neutrophil-to-Lymphocyte Ratio (NLR), Mean Platelet Volume (MPV), MPV-to-Lymphocyte Ratio (MPVLR), Platelet count, and Platelet Distribution Width (PDW). Employing a retrospective analysis of data collected over 12 years, this study focuses on the relationship between these hematological markers and ARDS diagnosis and severity in hospitalized patients. The study establishes NLR as a reliable systemic inflammation marker associated with ARDS severity. Elevated MPV and MPVLR also emerged as significant markers correlating with adverse outcomes. These findings suggest these economical, routinely measured markers can enhance traditional clinical criteria, offering a more objective approach to ARDS diagnosis and severity assessment. Hematological markers such as NLR, MPV, MPVLR, Platelet count, and PDW could be invaluable in clinical settings for diagnosing and assessing ARDS severity. They offer a cost-effective, accessible means to improve diagnostic accuracy and patient stratification in ARDS. However, further prospective studies are necessary to confirm these findings and investigate their integration with other diagnostic tools in diverse clinical settings.

Deciphering AKI in Burn Patients: Correlations between Clinical Clusters and Biomarkers.

Acute kidney injury (AKI) is a significant complication in burn patients, impacting outcomes substantially. This study explores the heterogeneity of AKI in burn patients by analyzing creatinine time-series data to identify distinct AKI clusters and evaluating routine biomarkers' predictive values. A retrospective cohort analysis was performed on 2608 adult burn patients admitted to Hangang Sacred Heart Hospital's Burn Intensive Care Unit (BICU) from July 2010 to December 2022. Patients were divided into four clusters based on creatinine trajectories, ranging from high-risk, severe cases to lower-risk, short-term care cases. Cluster A, characterized by high-risk, severe cases, showed the highest mortality and severity, with significant predictors being PT and TB. Cluster B, representing intermediate recovery cases, highlighted PT and albumin as useful predictors. Cluster C, a low-risk, high-resilience group, demonstrated predictive values for cystatin C and eGFR cys. Cluster D, comprising lower-risk, short-term care patients, indicated the importance of PT and lactate. Key biomarkers, including albumin, prothrombin time (PT), cystatin C, eGFR cys, and total bilirubin (TB), were identified as significant predictors of AKI development, varying across clusters. Diagnostic accuracy was assessed using area under the curve (AUC) metrics, reclassification metrics (NRI and IDI), and decision curve analysis. Cystatin C and eGFR cys consistently provided significant predictive value over creatinine, with AUC values significantly higher (p < 0.05) in each cluster. This study highlights the need for a tailored, biomarker-driven approach to AKI management in burn patients, advocating for the integration of diverse biomarkers in clinical practice to facilitate personalized treatment strategies. Future research should validate these biomarkers prospectively to confirm their clinical utility.

Central venous catheter tip colonization and associated bloodstream infection in patients with severe burns under routine catheter changing.

BACKGROUND: Although routine changing of central venous catheters (CVCs) is commonly performed in patients with severe burns, information on pathogen colonization of the CVC tip and associated bloodstream infections (BSIs) is limited in those patients. METHODS: The medical records of 214 patients with severe burns who underwent routine CVC changing at 7-day intervals and their results of 686 pairs of CVC tips and concurrent blood cultures were retrospectively reviewed to evaluate the CVC colonization rate and associated BSI pathogens. RESULTS: Of the 686 CVCs, 137 (20.0%) were colonized by pathogens, and 81 (59.1%) of them had BSIs caused by the same pathogen. Nonflame burn (P = .002), total body surface area burn ≥30% (P = .004), femoral catheterization (P = .001), CVC changing during pre-existing BSI (P < .001), and renal replacement therapy (P = .017) were associated with catheter-related BSI in the multivariate analysis. Most BSIs were caused by Gram-negative bacteria (most commonly Acinetobacter baumannii, Klebsiella pneumoniae, and Pseudomonas aeruginosa). CONCLUSIONS: The CVC colonization rate in patients with severe burns and routine CVC changing was not high. Lengthening the CVC duration might be attempted in patients at a lower risk of catheter-related BSI although further prospective studies are necessary.

Pioneering predictions of AKI and AKIN severity in burn patients: a comprehensive CBC approach.

This study aims to evaluate the utility of complete blood count (CBC) markers, in conjunction with the acute kidney injury network (AKIN) criteria, for the early detection, severity assessment, and prediction of mortality outcomes of acute kidney injury (AKI) in burn patients. The research seeks to fill existing gaps in knowledge and validate the cost-effectiveness of using CBC as a routine diagnostic tool for better management of AKI. The study was conducted at Hangang Sacred Heart Hospital. We performed a large-scale retrospective analysis of 2758 adult patients admitted to the burn intensive care unit over a 12-year period. Among these patients, AKI occurred in 1554 patients (56.3%). Based on the AKIN stage classification, 794 patients (28.8%) were categorized as AKIN 1, 494 patients (17.9%) as AKIN 2, and 266 patients (9.6%) as AKIN 3. We defined several ratio markers, including the Neutrophil-to-lymphocyte ratio (NLR), Platelet-to-lymphocyte ratio (PLR), Monocyte-to-lymphocyte ratio (MLR), systemic immune-inflammation index (SII), and various mean platelet volume (MPV) ratios. Our statistical analyses, conducted using the R programming language, revealed significant correlations between these markers and AKI severity. The AUC values for neutrophil count and WBC count were 0.790 and 0.793, respectively, followed by immature granulocyte count with an AUC of 0.727. For red blood cell (RBC)-related parameters, the AUC values for hematocrit (Hct), hemoglobin (Hb), and RBC count were 0.725, 0.713, and 0.713, respectively. Among the platelet-related parameters, only platelet distribution width (PDW) had an AUC of 0.677. Among the ratio markers, the NLR had the highest AUC at 0.772, followed by MPVNR and SII with AUC values of 0.700 and 0.680, respectively. The findings underscore the potential of CBC as an economical, routine test for AKI, thereby paving the way for enhanced patient outcomes. Our study suggests the utility of routine CBC tests, specifically WBC count and PLR, for predicting AKI and platelet, MPV, and NLR for mortality assessment in burn patients. These findings underscore the potential of easily accessible CBC tests in enhancing AKI management. However, further multicenter studies are needed for validation.

Big data insights into the diagnostic values of CBC parameters for sepsis and septic shock in burn patients: a retrospective study.

Sepsis and septic shock are prevalent and life-threatening complications in burn patients. Despite their severity, existing diagnostic methods are limited. This study aims to evaluate the efficacy of Complete Blood Count (CBC) and CBC ratio markers in diagnosing sepsis and septic shock, and in predicting mortality among burn patients. A cohort of 2757 burn patients was examined to ascertain the correlation between various CBC parameters, their ratios, and the incidence of sepsis and related mortality. Key markers analyzed included Red Cell Distribution Width (RDW), Mean Platelet Volume (MPV), Neutrophil-to-Lymphocyte Ratio (NLR), Platelet-to-Lymphocyte Ratio (PLR), and Mean Platelet Volume-to-Platelet Ratio (MPVPR). Our findings indicate that 65.5% of the patients developed sepsis, and 24.3% succumbed to their conditions. The CBC parameters RDW, MPV, NLR, MPVPR, and MPV-to-Lymphocyte Ratio (MPVLR) were significantly associated with sepsis and mortality. These markers showed considerable temporal variation and yielded an Area Under the Curve (AUC) of over 0.65 in an unadjusted Generalized Estimating Equations (GEE) model. This study underscores the potential of RDW, MPV, NLR, MPVPR, and MPVLR as vital prognostic tools for diagnosing sepsis, septic shock, and predicting mortality in burn patients. Although based on a single-center dataset, our results contribute to the enhancement of sepsis management by facilitating earlier, more precise diagnosis and treatment strategies. Further multi-center research is necessary to confirm these findings and broaden their applicability, establishing a solid base for future explorations in this crucial field.

The clinical differentiation of blood culture-positive and -negative sepsis in burn patients: a retrospective cohort study.

Background: Sepsis is a potentially life-threatening condition that occurs when the body's response to infection leads to widespread inflammation and tissue damage. Negative cultures can make it difficult for clinicians to make a diagnosis and may raise questions about the validity of the definition of sepsis. In addition, the clinical distinctions between burn patients with blood culture-positive and -negative sepsis are also poorly understood. Therefore, this study aimed to examine the clinical differences between blood culture-positive and -negative sepsis in burn patients in order to improve the understanding of the pathophysiology and epidemiology of sepsis in this population. Methods: This study had a retrospective design, and the participants were adults aged ≥18 years. Patients diagnosed with sepsis were divided into two groups based on their blood culture results within 1 week of sepsis diagnosis. Results: We enrolled 1643 patients admitted to our institution's burn intensive care unit between January 2010 and December 2021. pH, platelet count, bicarbonate and haematocrit were significant in both the positive and negative groups. However, lymphocyte, red cell distribution width and blood urea nitrogen were significant only in the positive group, whereas lactate dehydrogenase was significant only in the negative group. Acinetobacter baumannii, Pseudomonas aeruginosa, and Klebsiella pneumonia are common gram-negative bacterial species, and Staphylococcus aureus and Staphylococcus epidermidis are common gram-positive bacterial species seen in burn patients with positive blood cultures. Carbapenem resistance was found to be associated with an unfavourable prognosis in gram-negative bacteria, with the exception of P. aeruginosa. Conclusions: pH, platelet count, bicarbonate and haematocrit were routine biomarkers that demonstrated statistical significance in both groups. Lactate dehydrogenase was significant in the blood-negative group, while red cell distribution width, blood urea nitrogen and lymphocyte count were significant in the positive group. Furthermore, the most common causes of sepsis are gram-negative bacteria, including A. baumannii, K. pneumoniae and P. aeruginosa. Additionally, resistance to carbapenems is associated with unfavourable outcomes.

Tracking longitudinal biomarkers in burn patients with sepsis and acute kidney injury: an unsupervised clustering approach.

BACKGROUND: Sepsis is a grave medical disorder characterized by a systemic inflammatory response to infection. Furthermore, it is a leading cause of morbidity and mortality, especially in hospitalized patients. Acute kidney injury (AKI) is a common complication of sepsis and is associated with increased morbidity and mortality. Patients with burns are particularly vulnerable to developing sepsis and AKI due to the extensive tissue damage and immune suppression resulting from burn injury. In this study, unsupervised clustering algorithms were used to track longitudinal biomarkers in patients with burns and assess their impact on mortality. METHODS: This retrospective study included adult patients with burns aged ≥ 18 years, who were admitted to the burn intensive care unit of Hallym University and Hangang Sacred Heart Hospital between July 2010 and December 2021. The patients were divided into two subgroups: those with sepsis (538 patients) and those without sepsis (826 patients). The longitudinal biomarkers were grouped into three clusters using the k-means clustering algorithm. Each cluster was assigned a letter from A to C according to its mortality rate. RESULTS: The odds ratio (OR) of pH was 9.992 in the positive group and 31.745 in the negative group in cluster C. The OR for lactate dehydrogenase (LD) was 3.704 in the positive group and 6.631 in the negative group in cluster C. The OR for creatinine was 2.784 in the positive group and 8.796 in the negative group in cluster C. The OR for blood urea nitrogen (BUN) in the negative group was 0.348, indicating a negative predictor of mortality. Regarding the application of Continuous Renal Replacement Therapy (CRRT) and ventilation, ventilation was significant in both groups. In contrast, CRRT application was not significant in the sepsis-positive group. Furthermore, it was not selected as a variable in the negative group. CONCLUSIONS: The pH, LD, and creatinine were significant in both groups, while lactate and platelets were significant in the sepsis-positive group. In addition, albumin, glucose, and BUN were significant in the sepsis-negative group. Continuous renal replacement therapy was not significant in either group. However, the use of a ventilator was associated with poor prognosis.

Evaluating clinical heterogeneity and predicting mortality in severely burned patients through unsupervised clustering and latent class analysis.

Burn injuries often result in a high level of clinical heterogeneity and poor prognosis in patients with severe burns. Clustering algorithms, which are unsupervised methods that can identify groups with similar trajectories in patients with heterogeneous diseases, can provide insights into the mechanisms of the disease pathogenesis. This study aimed to analyze routinely collected biomarkers to understand their mortality prediction power, identify the clinical meanings or subtypes, and inform treatment decisions to improve the outcomes of patients with burns. This retrospective cohort study included patients aged ≥ 18 years who were admitted between January 2010 and December 2021. The patients were divided into four subgroups based on the time period of their admission: week 1, 2, 3, and 4. The study revealed that 22 biomarkers were evaluated, and the red blood cell distribution width, bicarbonate level, pH, platelets, and lymphocytes were significantly associated with the mortality risk. Latent class analysis further demonstrated that the pH, platelets, lymphocytes, lactate, and albumin demonstrated the lowest levels in the cluster with the highest risk of mortality, with the lowest levels of pH and lactate being particularly noteworthy in week 1 of the study. During the week 2, the pH and lymphocyte levels were demonstrated to be significant predictors of the mortality risk, whereas the lymphocyte and platelet counts were meaningful predictors in week 3. During week 4, pH, platelet count, and albumin level were important predictors of mortality risk. Analysis of routinely collected biomarkers using clustering algorithms and latent class analysis can provide valuable insights into the heterogeneity of burn injuries and improve the ability to predict disease progression and mortality. Our findings suggest that lactate levels are a better indicator of cellular hypoxia in the early stages of burn shock, whereas platelet and lymphocyte levels are more indicative of infections such as sepsis. Albumin levels are considered a better indicator of reduced nutritional loss with decrease in unhealed burn wounds; however, the pH levels reflect the overall condition of the patient throughout the study period. These findings can be used to inform treatment decisions and improve the outcomes of burn patients.

Clinical application of functional near-infrared spectroscopy for burn assessment.

Significance: Early assessment of local tissue oxygen saturation is essential for clinicians to determine the burn wound severity. Background: We assessed the burn extent and depth in the skin of the extremities using a custom-built 36-channel functional near-infrared spectroscopy system in patients with burns. Methods: A total of nine patients with burns were analyzed in this study. All second-degree burns were categorized as superficial, intermediate, and deep burns; non-burned skin on the burned side; and healthy skin on the contralateral non-burned side. Hemodynamic tissue signals from functional near-infrared spectroscopy attached to the burn site were measured during fNIRS using a blood pressure cuff. A nerve conduction study was conducted to check for nerve damage. Results: All second-degree burns were categorized into superficial, intermediate, and deep burns; non-burned skin on the burned side and healthy skin on the contralateral non-burned side showed a significant difference distinguishable using functional near-infrared spectroscopy. Hemodynamic measurements using functional near-infrared spectroscopy were more consistent with the diagnosis of burns 1 week later than that of the degree of burns diagnosed visually at the time of admission. Conclusion: Functional near-infrared spectroscopy may help with the early judgment of burn extent and depth by reflecting differences in the oxygen saturation levels in the skin.

Longitudinal profile of routine biomarkers for mortality prediction using unsupervised clustering algorithm in severely burned patients: a retrospective cohort study with prospectively collected data.

Purpose: Burn injury has high clinical heterogeneity and worse prognosis in severely burned patients. Clustering algorithms using unsupervised methods to identify groups with similar trajectories in heterogeneous disease patients can provide insight into mechanisms of disease pathogenesis. This study analyzed routinely collected biomarkers to evaluate mortality prediction, find clinical meanings for these or their subtypes, and evaluate patterns. Methods: This retrospective cohort study included patients aged >18 years, between July 2012 and June 2021. All eligible patients received fluid resuscitation and survived for at least 7 days. Characteristics of clinical interest to the physician at 4 clinically important time points were evaluated. Results: Eligible patients were divided into 4 subgroups according to these time points: from 1st week to 4th week. Total of 1,249 patients admitted within 2 days after burns and receiving fluid resuscitation were included. Mean Harrell's C-index of pH was the highest (0.816), followed by platelets (0.807), creatinine (0.796), red cell distribution width (RDW, 0.778), and lactate (0.759). Longitudinal profiles among biomarkers were different. Conclusion: The main predictors were pH, platelets, creatinine, RDW, and lactate. Creatinine and RDW showed consistent patterns. The other markers varied according to patient condition. Thus, these markers could provide clues into underlying mechanisms and predict mortality.

Validation of Sepsis-3 using survival analysis and clinical evaluation of quick SOFA, SIRS, and burn-specific SIRS for sepsis in burn patients with suspected infection.

PURPOSE: Sepsis-3 is a life-threatening organ dysfunction caused by dysregulated host responses to infection; and defined using the Sepsis-3 criteria, introduced in 2016, however, the criteria need to be validated in specific clinical fields. We investigated mortality prediction and compared the diagnostic performance of quick Sequential Organ Failure Assessment (qSOFA), systemic inflammatory response syndrome (SIRS), and burn-specific SIRS (bSIRS) in burn patients. METHODS: This single-center retrospective cohort study examined burn patients in Seoul, Korea during January 2010-December 2020. Overall, 1,391 patients with suspected infection were divided into four sepsis groups using SOFA, qSOFA, SIRS, and burn-specific SIRS. RESULTS: Hazard ratios (HRs) of all unadjusted models were statistically significant; however, the HR (0.726, p = 0.0080.001) in the SIRS ≥2 group is below 1. In the adjusted model, HRs of the SOFA ≥2 (2.426, <0.001), qSOFA ≥2 (7.198, p<0.001), and SIRS ≥2 (0.575, p<0.001) groups were significant. The diagnostic performance of dichotomized qSOFA, SIRS, and bSIRS for sepsis was defined by the Sepsis-3 criteria. The mean onset day was 4.13±2.97 according to Sepsis-3. The sensitivity of SIRS (0.989, 95% confidence interval [CI]: 0.982-0.994) was higher than that of qSOFA (0.841, 95% CI: 0.819-0.861) and bSIRS (0.803, 95% CI: 0.779-0.825). Specificities of qSOFA (0.929, 95% CI: 0.876-0.964) and bSIRS (0.922, 95% CI: 0.868-0.959) were higher than those of SIRS (0.461, 95% CI: 0.381-0.543). CONCLUSION: Sepsis-3 is a good alternative diagnostic tool because it reflects sepsis severity without delaying diagnosis. SIRS showed higher sensitivity than qSOFA and bSIRS and may therefore more adequately diagnose sepsis.

Frontal lobe hemodynamics detected by functional near-infrared spectroscopy during head-up tilt table tests in patients with electrical burns.

Significance: Electrical burns can cause severe damage to the nervous system, resulting in autonomic dysfunction with reduced cerebral perfusion. However, few studies have investigated these consequences. Aim: To elucidate changes in prefrontal cerebral hemodynamics using functional near-infrared spectroscopy (fNIRS) during the head-up tilt table test (HUT) for patients with electrical burns. Approach: We recruited 17 patients with acute electrical burns within 1 week after their accidents and 10 healthy volunteers. The NIRS parameters acquired using an fNIRS device attached to the forehead were analyzed in five distinct HUT phases. Results: Based on their HUT response patterns, patients with electrical burns were classified into the group with abnormal HUT results (APG, n = 4) or normal HUT results (NPG, n = 13) and compared with the healthy control (HC, n = 10) participants. We found trends in hemodynamic changes during the HUT that distinguished HC, NPG, and APG. Reduced cerebral perfusion and decreased blood oxygenation during the HUT were found in both the NPG and APG groups. Patients with electrical burns had autonomic dysfunction compared to the HC participants. Conclusions: Using fNIRS, we observed that acute-stage electrical burn injuries could affect cerebral perfusion.

Wound healing ability of acellular fish skin and bovine collagen grafts for split-thickness donor sites in burn patients: Characterization of acellular grafts and clinical application.

Due to its high polyunsaturated fatty acid content, acellular fish skin has emerged as a dermal substitute for the promotion of wound healing as it decreases scar formation while providing pain relief. However, various systematic studies on acellular fish skin, such as its biophysical analysis, in vitro activities, and clinical application, have not been sufficiently investigated. In this study, we conducted a comparative study to evaluate the wound-healing ability of acellular fish skin graft (Kerecis®) with that of the widely used bovine collagen skin graft (ProHeal®). The skin grafts were evaluated not only in terms of their biophysical properties, but also their in vitro cellular activities, using fibroblasts, keratinocytes, and human endothelial cells. The clinical study evaluated wound healing in 52 patients with acute burns who underwent skin grafting on donor sites from January 2019 to December 2020. The study was conducted with two groups; while only Kerecis® was tested in one group, Kerecis® and ProHeal® were compared in the other. In both groups, the application time of the dressing material was one to two days after split-thickness skin grafting to the donor sites. The Kerecis®-treatment group experienced faster healing than the other treatment group. In particular, the average wound healing time using the Kerecis® treatment and the ProHeal® treatment was 10.7 ± 1.5 days and 13.1 ± 1.4 days, respectively. We believe that the faster healing of the Kerecis® treatment, compared to that of the ProHeal® treatment, maybe due to the synergistic effect of the unique biophysical structure and the bioactive components of acellular fish skin.

Clinical Usefulness of Serum (1,3)-ß-D-glucan to predict invasive candidiasis in patients with severe burn trauma.

BACKGROUND: (1,3)-ß-D-glucan (BD) assays were developed as a method to rapidly diagnose invasive candidiasis (IC). The incidence of fungal infections and the demands for BD assay are gradually increasing in patients with severe trauma and under intensive care. However, the ideal BD cut-off value to predict IC has not been clarified. In this study, we evaluate the predictability of the BD assay and investigate the optimal cut-off value in patients with severe burn injuries. METHODS: From July to December 2018, 134 samples from 86 patients with severe burns were analyzed. Serum BD levels were measured utilizing a Fungitell (Cape Cod Inc.) assay. A receiver operator characteristic (ROC) curve was generated, and the cumulative progression of IC was studied using a Cox proportional hazards model. Partial dependence plots (PDP) was applied to predict the risk of IC. RESULTS: Eleven patients were diagnosed with IC. BD over 120 pg/mL (HR = 8.68; P = 0.001) was found to be independent predictor of the occurrence of IC, when the multivariable Cox model was adjusted for age, total body surface area, inhalation injury, and antifungal agents. The area under the ROC curve was 0.658 (95% CI, 0.513-0.803), at an optimal cut-off value of 124.7 pg/mL. PDP analysis showed the higher predicted IC occurrence at a BD level of 120-150 pg/mL and TBSA over 60%. CONCLUSION: Our findings suggest that BD is an independent predictor for IC, and that a BD level between 120 and 150 pg/mL could be utilized for IC prediction.

Time-varying discrimination accuracy of longitudinal biomarkers for the prediction of mortality compared to assessment at fixed time point in severe burns patients.

BACKGROUND: The progression of biomarkers over time is considered an indicator of disease progression and helps in the early detection of disease, thereby reducing disease-related mortality. Their ability to predict outcomes has been evaluated using conventional cross-sectional methods. This study investigated the prognostic performance of biomarkers over time. METHODS: Patients aged > 18 years admitted to the burn intensive care unit within 24 h of a burn incident were enrolled. Information regarding longitudinal biomarkers, including white blood cells; platelet count; lactate, creatinine, and total bilirubin levels; and prothrombin time (PT), were retrieved from a clinical database. Time-dependent receiver operating characteristic curves using cumulative/dynamic and incident/dynamic (ID) approaches were used to evaluate prognostic performance. RESULTS: Overall, 2259 patients were included and divided into survival and non-survival groups. By determining the area under the curve using the ID approach, platelets showed the highest c-index [0.930 (0.919-0.941)] across all time points. Conversely, the c-index of PT and creatinine levels were 0.862 (0.843-0.881) and 0.828 (0.809-0.848), respectively. CONCLUSIONS: Platelet count was the best prognostic marker, followed by PT. Total bilirubin and creatinine levels also showed good prognostic ability. Although lactate was a strong predictor, it showed relatively poor prognostic performance in burns patients.

Trajectories of longitudinal biomarkers for mortality in severely burned patients.

This study aimed to investigate the differences in the trajectory of blood biomarkers routinely assessed through forward- and backward-looking approaches among burn patients. This cohort study included patients above 18 years of age from February 2007 to December 2018. All the biomarkers were estimated from admission to discharge from the intensive care unit. Significant differences were observed in the platelet count at 40 days, prothrombin time (PT) at 32 days, white blood cell count at 26 days, creatinine levels at 22 days, and lactate and total bilirubin levels at 19 days before death. In reverse order, significant differences were observed in the fitted model in platelet count at 44 days and in the platelet count and PT at 33 days. We obtained more valuable information from the longitudinal biomarker trajectory using the backward-looking method than using the forward-looking method. The platelet count served as the earliest predictor of mortality among burn patients.

Changes in the prevalence of causative pathogens isolated from severe burn patients from 2012 to 2017.

Infection is the leading cause of mortality in severe burn patients, benefitting from periodic monitoring of changes in bacterial prevalence and antibiotic resistance trends. This single facility retrospective study evaluated blood culture results for patients hospitalized in the burn intensive care unit (BICU) from January 2012 to December 2017. A total of 969 samples from 420 patients were reviewed. Isolated pathogens were recorded by year and the number of days of hospitalization. Results showed that Acinetobacter baumanni was the most predominant isolated pathogen, followed closely by Pseudomonas aeruginosa, Klebsiella spp., and Enterococcus spp. Throughout this 6-year study, several significant trends were noted; Klebsiella species increased, while P. aeruginosa decreased. Staphylococcus aureus and Klebsiella species gradually increased, and P. aeruginosa doubled as the length of hospital stay increased to 22 days. Interestingly, as the length of the hospital stay increased, the proportion of Carbapenem-resistant Enterobacteriaceae (CRE) significantly increased up to 45.0% at 22 days (P=0.003). Conversely, the proportion of Acinetobacter baumannii gradually decreased as the days hospitalized increased. Overall, the rate of multidrug-resistant (MDR) bacteremia found in burn patients was substantially higher than that in other patients and appeared from the earliest phase of hospitalization. Therefore, early use of antibiotics targeting MDR Gram-negative bacteria in burn patients admitted to the BICU might be warranted. Further, since CRE infections increase in abundance over time, significant effort should be made to manage the initial CRE infections of burn patients before they can multiply into a life-threatening situation.

Retrospective study of prognosis and relating factors of cardiac complications associated with electrical injuries at a single centre in Korea.

OBJECTIVES: To date, no research has investigated the association between cardiac complication and electrical injury; hence, we aimed to assess the consequences and relating factors of cardiac complications from electrical injuries in South Korea. DESIGN: Retrospective single-centre study. PARTICIPANTS: 721 patients who had electrical injury-related admission during 2007-2017. An electronic medical record system was used to extract records of patients admitted for electrical injury treatment. RESULTS: Cardiac complications included abnormal parameters of myocardial damage, abnormal regional wall motion detected via echocardiogram, dysrhythmia (eg, bradycardia, atrial flutter/fibrillation) and ventricular tachycardia or fibrillation. Overall, 107 patients (14.8%) experienced cardiac complications. The average admission duration and intensive care unit stay duration were significantly longer in patients with cardiac complications than in those without them (75.0±45.3 vs 56.6±48.0 days and 19.3±24.1 vs 10.4±15.5 days, respectively, p<0.01 for both). Of the total cardiac cases, 72.9% had Troponin I elevation, 3.7% had regional wall motion abnormality, and 5.6% had atrial flutter/fibrillation. Overall, seven patients from the cardiac complication group and three patients from the control group died (p=0.01). All deaths occurred within 32 days, and the most common cause of death was septic shock. Total body surface area (TBSA) was only positively related factor to cardiac complications. CONCLUSION: This study is the first in South Korea to reveal that electrical accident patients with cardiac complications experience poorer in-hospital prognosis, and TBSA was the only risk factor of cardiac complications. And initial treatment for infection and inflammations could be important in electrical injury.

Development of a risk prediction model (Hangang) and comparison with clinical severity scores in burn patients.

PURPOSE: The purpose of this study was to develop a new prediction model to reflect the risk of mortality and severity of disease and to evaluate the ability of the developed model to predict mortality among adult burn patients. METHODS: This study included 2009 patients aged more than 18 years who were admitted to the intensive care unit (ICU) within 24 hours after a burn. We divided the patients into two groups; those admitted from January 2007 to December 2013 were included in the derivation group and those admitted from January 2014 to September 2017 were included in the validation group. Shrinkage methods with 10-folds cross-validation were performed to identify variables and limit overfitting of the model. The discrimination was analyzed using the area under the curve (AUC) of the receiver operating characteristic curve. The Brier score, integrated discrimination improvement (IDI), and net reclassification improvement (NRI) were also calculated. The calibration was analyzed using the Hosmer-Lemeshow goodness-of-fit test (HL test). The clinical usefulness was evaluated using a decision-curve analysis. RESULTS: The Hangang model showed good calibration with the HL test (χ2 = 8.785, p = 0.361); the highest AUC and the lowest Brier score were 0.943 and 0.068, respectively. The NRI and IDI were 0.124 (p-value = 0.003) and 0.079 (p-value <0.001) when compared with FLAMES, respectively. CONCLUSIONS: This model reflects the current risk factors of mortality among adult burn patients. Furthermore, it was a highly discriminatory and well-calibrated model for the prediction of mortality in this cohort.