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BACKGROUND: Acute myeloid leukemia (AML) is predominantly a disease of older patients with a poor long-term survival. Approval of decitabine (DAC) in the European Union (EU) in 2012 for the treatment of patients with AML ≥65 years marks the potential for hypomethylating agents in elderly AML. Nevertheless the situation is dissatisfactory and the quest for novel treatment approaches, including combination epigenetic therapy is actively ongoing. The given randomized trial should be helpful in investigating the question whether combinations of DAC with the histone deacetylase (HDAC) inhibitor valproic acid (VPA) and/or all-trans retinoic acid (ATRA), which in vitro show a very promising synergism, are superior to the DAC monotherapy. The accompanying translational research project will contribute to find surrogate molecular end points for drug efficacy and better tailor epigenetic therapy. An additional aim of the study is to investigate the prognostic value of geriatric assessments for elderly AML patients treated non-intensively. METHODS/DESIGN: DECIDER is a prospective, randomized, observer blind, parallel group, multicenter, Phase II study with a 2x2 factorial design. The primary endpoint is objective best overall response (complete remission (CR) and partial remission (PR)). The target population is AML patients aged 60 years or older and unfit for standard induction chemotherapy. Patients are randomized to one of the four treatment groups: DAC alone or in combination with VPA or ATRA or with both add-on drugs. One interim safety analysis was planned and carried out with the objective to stop early one or more of the treatment arms in case of an unacceptable death rate. This analysis showed that in all treatment arms the critical stopping rule was not reached. No important safety issues were observed. The Data Monitoring Committee (DMC) recommended continuing the study as planned. The first patient was included in December 2011. A total of 189 out of 200 planned patients were randomized since then (status 31.12.2014). TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT00867672 (registration date 23.03.2009); German clinical trials registry number: DRKS00000733 (registration date 19.04.2011).
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Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Protocolos Clínicos , Leucemia Mieloide Aguda/tratamiento farmacológico , Anciano , Anciano de 80 o más Años , Azacitidina/administración & dosificación , Azacitidina/análogos & derivados , Decitabina , Femenino , Humanos , Quimioterapia de Inducción , Masculino , Persona de Mediana Edad , Tretinoina/administración & dosificación , Ácido Valproico/administración & dosificaciónRESUMEN
OBJECTIVES: Accurate diagnosis of sepsis is difficult in patients post burn due to the large inflammatory response produced by the major insult. We aimed to estimate the values of serum N-terminal pro-B-type natriuretic peptide and procalcitonin and the changes in hemodynamic variables as markers of sepsis in critically ill burn patients. DESIGN: Prospective, observational study. SETTING: A quaternary-level university-affiliated ICU. PATIENTS: Fifty-four patients with burns to total body surface area of greater than or equal to 15%, intubated with no previous cardiovascular comorbidities, were enrolled. INTERVENTIONS: At admission, a FloTrac/Vigileo system was attached and daily blood samples taken from the arterial catheter. Infection surveillance was carried out daily with patients classified as septic/nonseptic according to American Burns Consensus criteria. MEASUREMENTS AND MAIN RESULTS: N-terminal pro-B-type natriuretic peptide, procalcitonin, and waveform analysis of changes in stroke volume index and systemic vascular resistance index were measured within the first 24 hours after burn and daily thereafter for the length of the ICU stay or until their first episode of sepsis. Prevalences of stroke volume variation less than 12% (normovolemia) with hypotension (systolic blood pressure < 90 mm Hg) were recorded. Patients with sepsis differed significantly from "no sepsis" for N-terminal pro-B-type natriuretic peptide, systemic vascular resistance index, and stroke volume index on days 3-7. Procalcitonin did not differ between sepsis and "no sepsis" except for day 3. Area under the receiver operating characteristic curves showed excellent discriminative power for B-type natriuretic peptide (p = 0.001; 95% CI, 0.99-1.00), systemic vascular resistance index (p < 0.001; 95% CI, 0.97-0.99), and stroke volume index (p < 0.01; 95% CI, 0.96-0.99) in predicting sepsis but not for procalcitonin (not significant; 95% CI, 0.29-0.46). A chi-square crosstab found that there was no relationship between hypotension with normovolemia (stroke volume variation < 12%) and sepsis. CONCLUSIONS: Serum N-terminal pro-B-type natriuretic peptide levels and certain hemodynamic changes can be used as an early indicator of sepsis in patients with burn injury. Procalcitonin did not assist in the early diagnosis of sepsis.
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Quemaduras/epidemiología , Quemaduras/fisiopatología , Péptido Natriurético Encefálico/sangre , Fragmentos de Péptidos/sangre , Sepsis/epidemiología , Sepsis/fisiopatología , Adolescente , Adulto , Biomarcadores , Quemaduras/sangre , Calcitonina/sangre , Péptido Relacionado con Gen de Calcitonina , Enfermedad Crítica , Femenino , Hemodinámica , Mortalidad Hospitalaria , Hospitales Universitarios , Humanos , Unidades de Cuidados Intensivos , Masculino , Persona de Mediana Edad , Pronóstico , Estudios Prospectivos , Precursores de Proteínas/sangre , Sepsis/sangre , Adulto JovenRESUMEN
BACKGROUND: Burn injury is responsible for both acute and ongoing inflammation, resulting in systematic changes impacting the cardiovascular, hepatobiliary, endocrine, and metabolic systems, but there is minimal investigation into long-term clinical outcomes. This study aimed to investigate mortality due to cardiovascular related long-term postburn injury. METHODS: This was a retrospective cohort study linking a burns unit database with mortality outcomes from a Registry of Births, Deaths and Marriages. Data were extracted from the Australian Institute of Health and Welfare and stratified into three age groups: 15 to 44 years, 45 to 64 years, and 65+ years. Mortality rate ratios (MRRs) and 95% confidence interval (CI) were calculated to compare the burns cohort mortality incidence rates with the national mortality incidence rates for each of the three age groups. Logistic regression was used to identify demographic and clinical factors associated with cardiovascular mortality. RESULTS: A total of 4,134 individuals in the database were analyzed according to demographic and clinical variables. The 20-year age-standardized cardiovascular mortality rate for the burns cohort was significantly higher compared with the Australian population (250.6 per 100,000 person-years vs. 207.9 per 100,000 person-years) (MRR, 1.21; 95% CI, 1.001-1.45). Cardiovascular mortality was significantly higher in males aged 15-44 and 45-64 years had a cardiovascular mortality rate significantly higher than the Australian population (MRR = 10.06, 95% CI 3.49-16.63), and (MRR = 2.40, 95% CI 1.42-3.38) respectively. Those who died of cardiovascular disease were more frequently intubated postburn injury ( p = 0.01), admitted to intensive care ( p < 0.0001), and had preexisting comorbid physical conditions (60.9% vs. 15.0%, p < 0.0001). CONCLUSION: Survivors from burn injury, especially young males, are at increased long-term risk of death from cardiovascular disease. Increased screening and counseling pertaining to lifestyle factors should be standard management postburn injury. Longitudinal observation of physiological changes, investigation of mechanistic factors, and investigation of interventional strategies should be instituted. LEVEL OF EVIDENCE: Prognostic and Epidemiologic; Level IV.
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Enfermedades Cardiovasculares , Masculino , Humanos , Adolescente , Adulto Joven , Adulto , Estudios Retrospectivos , Australia , Hospitalización , Estudios LongitudinalesRESUMEN
BACKGROUND: Beta-lactams are first-line antibiotics for the management of superficial infections due to burn injury. There is sparse data available on therapeutic drug monitoring (TDM) in patients with burns in a ward setting. This study was conducted to evaluate the utility of a beta-lactam TDM program in a cohort of burn injury patients in a ward environment. METHODS: Steady-state blood samples were collected immediately before a scheduled dose. The therapeutic concentration targets assessed were (1) free antibiotic concentrations exceeding the minimum inhibitory concentration (MIC; fT > MIC) and (2) free concentrations ≥4× MIC of the known or suspected pathogen (fT > 4× MIC). The duration of therapy was also assessed. RESULTS: A total of 50 patients were included for TDM over a 12-month period. The mean (±SD) age was 49 ± 16 years. The mean percent total body surface area burn was 17 ± 13%. The mean serum creatinine concentration was 86 ± 20 µmole/L. Sixty percent of the patients did not achieve fT > MIC, and only 18% achieved the higher target of fT > 4× MIC. Although all the patients achieved a positive clinical outcome, the duration of antibiotic treatment was shorter in patients who achieved fT > MIC compared with those who did not (4.2 ± 1.1 versus 5.3 ± 2.3 days; P = 0.03). CONCLUSIONS: We found TDM to be a reliable intervention for burn injury patients in a ward environment. This study supports pharmacokinetic data that burns patients may be at risk of subtherapeutic dosing, which may prolong the duration of antibiotic therapy.
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Antibacterianos/farmacocinética , Infecciones Bacterianas/tratamiento farmacológico , Quemaduras/complicaciones , beta-Lactamas/farmacocinética , Adulto , Anciano , Antibacterianos/administración & dosificación , Antibacterianos/uso terapéutico , Infecciones Bacterianas/etiología , Infecciones Bacterianas/microbiología , Superficie Corporal , Creatinina/sangre , Monitoreo de Drogas/métodos , Femenino , Humanos , Masculino , Pruebas de Sensibilidad Microbiana , Persona de Mediana Edad , Estudios Prospectivos , Factores de Tiempo , beta-Lactamas/administración & dosificación , beta-Lactamas/uso terapéuticoRESUMEN
The study aim was to document the acute physiological characteristics of swallowing impairment following thermal burn injury. A series of 19 participants admitted to a specialised burn centre with thermal burn injury were identified with suspected aspiration risk by a clinical swallow examination (CSE) conducted by a speech-language pathologist and referred to the study. Once medically stable, each then underwent more detailed assessment using both a CSE and fiberoptic evaluation of swallowing (FEES). FEES confirmed six individuals (32%) had no aspiration risk and were excluded from further analyses. Of the remaining 13, CSE confirmed that two had specific oral-phase deficits due to orofacial scarring and contractures, and all 13 had generalised oromotor weakness. FEES revealed numerous pharyngeal-phase deficits, with the major findings evident in greater than 50% being impaired secretion management, laryngotracheal edema, delayed swallow initiation, impaired sensation, inadequate movement of structures within the hypopharynx and larynx, and diffuse pharyngeal residue. Penetration and/or aspiration occurred in 83% (n = 10/12) of thin fluids trials, with a lack of response to the penetration/aspiration noted in 50% (n = 6/12 penetration aspiration events) of the cases. Most events occurred post swallow. Findings support the fact that individuals with dysphagia post thermal burn present with multiple risk factors for aspiration that appear predominantly related to generalised weakness and inefficiency and further impacted by edema and sensory impairments. Generalised oromotor weakness and orofacial contractures (when present) impact oral-stage swallow function. This study has identified a range of factors that may contribute to both oral- and pharyngeal-stage dysfunction in this clinical population and has highlighted the importance of using a combination of clinical and instrumental assessments to fully understand the influence of burn injury on oral intake and swallowing.
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Quemaduras por Inhalación/complicaciones , Trastornos de Deglución/fisiopatología , Aspiración Respiratoria/fisiopatología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Trastornos de Deglución/etiología , Endoscopía , Femenino , Humanos , Laringe/fisiopatología , Masculino , Persona de Mediana Edad , Boca/fisiopatología , Faringe/fisiopatología , Aspiración Respiratoria/etiología , Adulto JovenRESUMEN
BACKGROUND: Pressure garment therapy (PGT) is well accepted and commonly used by clinicians in the treatment of burns scars and grafts. The medium to high pressures (24-40 mmHg) in these garments can support scar minimisation, and evidence is well documented for this particular application. However, PGT specifically for burn donor sites, of which a sequela is also scarring, is not well documented. This study protocol investigates the impact of a low pressure (4-6 mmHg) interim garment on donor site healing and scarring. With a primary purpose of holding donor dressings in place, the application of the interim pressure garment (IPG) appears to have been twofold. IPGs for donor sites have involved inconsistent application with a focus on securing wound dressing rather than scar management. However, anecdotal and observational evidence suggests that IPGs also make a difference to some patient's scar outcomes for donor sites. This study protocol outlines a randomised controlled trial designed to test the effectiveness of this treatment on reducing scarring to burn donor sites. METHODS/DESIGN: This study is a single-centre, single (assessor)-blinded, randomised control trial in patients with burns donor sites to their thighs. Patients will be randomly allocated to a control group (with no compression to donor sites) or to an experimental group (with compression to donor sites) as the comparative treatment. Groups will be compared at baseline regarding the important prognostic indicators: donor site location, depth, size, age, and time since graft (5 days). The IPG treatment will be administered post-operatively (on day 5). Follow-up assessments and garment replacement will be undertaken fortnightly for a period of 2 months. DISCUSSION: This study focuses on a unique area of burns scar management using a low-pressure tubular support garment for the reduction of donor site scars. Such therapy specifically for donor scar management is poorly represented in the literature. This study was designed to test a potentially cost-effective scar prevention for patients with donor sites to the thigh. No known studies of this nature have been carried out to date, and there is a need for rigorous clinical evidence for low-pressure support garments for donor site scar minimisation. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry identifier ACTRN12610000127000 . Registered 8 Mar 2010.
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Quemaduras/cirugía , Cicatriz/prevención & control , Vendajes de Compresión , Trasplante de Piel/métodos , Herida Quirúrgica/terapia , Sitio Donante de Trasplante , Cicatrización de Heridas , Quemaduras/patología , Cicatriz/etiología , Cicatriz/patología , Protocolos Clínicos , Desbridamiento , Humanos , Presión , Estudios Prospectivos , Queensland , Proyectos de Investigación , Método Simple Ciego , Trasplante de Piel/efectos adversos , Herida Quirúrgica/patología , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: The hypermetabolic state after severe burns is a major problem that can lead to several pathophysiologic changes and produce multiple sequelae. Adrenergic blockade has been widely used to reverse these changes and improve outcomes in burned patients but has not been rigorously evaluated. The aim of this systematic review was to investigate the efficacy and safety of the use of adrenergic blockade after burn injury. METHODS: The databases MEDLINE via OVID, PubMed, EMBASE, CINAHL, Cochrane Library, and Web of Science were searched from inception to December 2014 with search terms including burns and beta-blockers with appropriate synonyms. Articles were restricted to those published in English, French, or Spanish. Randomized controlled trials, nonrandomized controlled trials, and systematic reviews were screened. After an independent screening and full-text review, 10 articles were selected, and an appraisal of risk of bias was performed. RESULTS: From 182 articles screened, 9 randomized controlled trials and 1 nonrandomized controlled trial met the inclusion criteria. Pooled analyses were performed to calculate effect sizes and 95% confidence intervals (CIs). There was a positive effect favoring propranolol use that significantly decreased resting energy expenditure (g = -0.64; 95% CI, -0.8 to -0.5; p < 0.001) and trunk fat (g = -0.3; 95% CI, -0.4 to -0.1; p < 0.001) as well as improved peripheral lean mass (g = 0.45; 95% CI, 0.3-0.6; p < 0.001) and insulin resistance (g = -1.35; 95% CI, -2.0 to -0.6; p < 0.001). Occurrence of adverse events was not significantly different between the treated patients the and controls. CONCLUSION: Limited evidence suggests beneficial effects of propranolol after burn injury, and its use seems safe. However, further trials on adult population with a broader range of outcome measures are warranted. LEVEL OF EVIDENCE: Systematic review and meta-analysis, level III.
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Antagonistas Adrenérgicos beta/farmacología , Quemaduras/tratamiento farmacológico , Quemaduras/fisiopatología , Propranolol/farmacología , Metabolismo Energético/efectos de los fármacos , Metabolismo Energético/fisiología , Humanos , Seguridad del PacienteRESUMEN
PURPOSE: To explore international practices of speech-language pathology (SLP) within burn care in order to provide direction for education, training and clinical practice of the burns multidisciplinary team (MDT). METHOD(S): A 17-item online survey was designed by two SLPs experienced in burn care with a range of dichotomous, multiple choice and open-ended response questions investigating the availability and scope of practice for SLPs associated with burn units. The survey was distributed via professional burn association gatekeepers. All quantitative data gathered were analysed using descriptive statistics and qualitative data were analysed using content analysis. RESULT(S): A total of 240 health professionals, from 6 different continents (37 countries) participated within the study. All continents reported access to SLP services. Referral criteria for SLP were largely uniform across continents. The most dominant area of SLP practice was assessment and management of dysphagia, which was conducted in concert with other members of the MDT. CONCLUSION: SLP has an international presence within burn care that is currently still emerging.
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Quemaduras/rehabilitación , Trastornos de Deglución , Terapia del Lenguaje/organización & administración , Trastornos del Habla , Logopedia/organización & administración , Patología del Habla y Lenguaje/estadística & datos numéricos , Actitud del Personal de Salud , Unidades de Quemados/estadística & datos numéricos , Contractura/complicaciones , Trastornos de Deglución/etiología , Trastornos de Deglución/rehabilitación , Prestación Integrada de Atención de Salud/organización & administración , Accesibilidad a los Servicios de Salud/normas , Humanos , Trastornos del Habla/etiología , Trastornos del Habla/rehabilitaciónRESUMEN
One of the problems with the dermal substitute Integra has been securing the material to the wound bed to prevent shearing and loss. Techniques to achieve stability include staples and elastic netting with an over layer of absorbent dressings that can be changed regularly. We report an effective technique using suction dressings to immobilise Integra. This technique led to firm application underlying tissue, and appeared to decrease fluid collection under the Integra. Earlier mobilisation and discharge from hospital were facilitated.
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Vendajes , Materiales Biocompatibles , Quemaduras/terapia , Niño , Sulfatos de Condroitina , Colágeno , Humanos , Tiempo de Internación , Estudios Prospectivos , SucciónRESUMEN
CONTEXT: Concern engendered by a previous study that showed inadequate first aid for burn injuries was prevalent in the community led to a novel multi-media public health campaign ensued to address the issue. OBJECTIVE: To determine whether this public health campaign influenced behaviour by altering first aid treatment for burn injuries (BFAT). DESIGN, SETTING AND POPULATION: Prospective intervention study. Consecutive patients with acute burn injuries over two 4-month intervals, presenting to a regional burn service, Auckland, New Zealand. This research was ethically approved by the Local Research Ethics Committee. MAIN OUTCOME MEASURES: Demographics, burn size, adequacy of burn first aid, outpatient/inpatient wound care and operative intervention requirement. RESULTS: Adequacy of BFAT improved following the campaign (59% versus 40%, P=0.004). Fewer inpatient admissions (64.4% versus 35.8%, P<0.001) and surgical procedures (25.6% versus 11.4%, P<0.001) were undertaken following the campaign with a corresponding increase in outpatient care. Greatest decreases were observed in Maori and Pacific Islanders, and in children <10 years old. CONCLUSIONS: Adequacy of BFAT together with a reduction in the numbers of patients requiring inpatient surgical care was improved by a multi-media public awareness campaign.
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Quemaduras/terapia , Primeros Auxilios/normas , Promoción de la Salud/métodos , Hospitalización/estadística & datos numéricos , Adolescente , Adulto , Anciano , Quemaduras/etnología , Quemaduras/psicología , Niño , Preescolar , Medios de Comunicación , Femenino , Conductas Relacionadas con la Salud , Conocimientos, Actitudes y Práctica en Salud , Humanos , Lactante , Masculino , Persona de Mediana Edad , Nueva Zelanda/epidemiología , Evaluación de Programas y Proyectos de Salud , Estudios ProspectivosRESUMEN
Scald burns make up more than 75% of the pediatric burns patients who are admitted to our burns unit. A pediatric scald burn pathway was implemented at our center in November 1999, the aim of which was to improve consistency in the management of the acute phase of injury. This study assessed the effectiveness of the first 18 months of this scald burn pathway. Aspects of the management of pediatric scald burn patients were reviewed. This included all the patients admitted over a 6-month period 1 year before the implementation of the pathway and the first 6 months and between 12 and 18 months after the implementation of the pathway. Data collected included patient demographics, total body surface area burned, and key management guidelines, including nasogastric feeding, intravenous cannulation, analgesia prescription, multidisciplinary referrals, and family education Thirty-seven patients were enrolled in the first 6 months of the pathway's use. Between 12 and 18 months, a further 38 patients were enrolled. The patients within the three groups were similar in age and burn size. A comparison among the groups with respect to compliance with the treatment guidelines is presented graphically. In conclusion, the management of pediatric scald burns in the acute phase is more consistent since the implementation of the clinical pathway.
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Quemaduras/terapia , Vías Clínicas , Pediatría/normas , Enfermedad Aguda , Adolescente , Superficie Corporal , Quemaduras/enfermería , Niño , Preescolar , Humanos , Lactante , Nueva Zelanda , Pediatría/métodos , Cirugía Plástica/métodos , Cirugía Plástica/normas , Cicatrización de HeridasRESUMEN
PURPOSE: The objective of this study was to prospectively evaluate the validity and reliability of a risk factor model developed for use in predicting dysphagia risk within the first 24 h after injury/hospitalisation in patients with thermal burns. METHOD(S): Three hundred and fifty six patients with thermal burns, with or without inhalation injury, who were consecutively admitted to and received management at a quaternary state-wide burn center over a 12 month period, were included. Patients were reviewed for dysphagia risk by nursing staff using an established set of predictive factors. If risk factors for dysphagia were present, referral to speech-language pathology was initiated to investigate swallow function. RESULT(S): Of the 356 admissions, 83 patients were identified as meeting one or more risk criteria for dysphagia after burn. Of these, 24.9% (n = 30; 8.42% of the total cohort) presented with dysphagia. Using these criteria, sensitivity and specificity for detection of dysphagia risk were high (100% and 83.74%, respectively). The criteria over identify patients who may be at risk of dysphagia and who require dysphagia assessment (positive predictive value = 36.14%). However, as a set of predictors of dysphagia risk when thermal burn is the only complaint, a negative result reassures that a patient does not have dysphagia (negative predictive value = 100%). CONCLUSION: Overall, the risk factor model provided a valid measure for predicting dysphagia risk. Incorporating these criteria into a dysphagia screening assessment can ensure an evidence-based pathway for early detection and timely referral to speech-language pathology for patients at risk of dysphagia after thermal burns.
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Quemaduras/complicaciones , Traumatismos Craneocerebrales/complicaciones , Trastornos de Deglución/diagnóstico , Traumatismos del Cuello/complicaciones , Lesión por Inhalación de Humo/complicaciones , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Trastornos de Deglución/etiología , Femenino , Humanos , Unidades de Cuidados Intensivos/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Reproducibilidad de los Resultados , Respiración Artificial/estadística & datos numéricos , Medición de Riesgo , Factores de Riesgo , Sensibilidad y Especificidad , Adulto JovenRESUMEN
BACKGROUND: Major burn injuries cause devastating physical and psychosocial morbidity, combined with significant health care and community costs. The aim of this study was to evaluate the effectiveness of a targeted burn prevention message on burn safety knowledge and behavior. METHODS: An 11-year retrospective review of patients admitted to an adult tertiary burn center identified flammable liquid burn injuries in males older than 15 years as 23% of admissions and the most common preventable injury. Burn safety knowledge and experience were measured in a single-blinded, controlled, restricted (male, >15 years), interventional, (therapeutic) prevention study using a total of 2,053 computer-assisted telephone interviews in an intervention region (IR) and control region. A two-week multimedia campaign with the theme "Don't Be a Flamin' Fool" was delivered in the IR. RESULTS: The preintervention survey revealed that 13% (218 of 1,637) reported having previously had a gasoline (petrol) burn. Following the intervention, there was a higher percentage of respondents in the IR that had seen or heard a burn prevention message in the previous 3 months (51% vs. 10%; p < 0.001) and perceived that gasoline was a danger when used to start a fire (97% vs. 91%; p = 0.001), that any volume of gasoline was unsafe (85% vs. 65%; p < 0.001), and that gasoline can explode (96% vs. 92%; p = 0.001). Awareness and memory reverted to preintervention levels at 12 months. Eighty-three percent of respondents (100 of 120) who had seen the "Flamin' Fool" campaign thought it was effective in getting its message across. CONCLUSION: This collaborative study found that a media prevention message had a significant impact on burn safety knowledge, which diminished over time.
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Quemaduras/prevención & control , Promoción de la Salud , Quemaduras/epidemiología , Distribución de Chi-Cuadrado , Aceites Combustibles , Conocimientos, Actitudes y Práctica en Salud , Promoción de la Salud/métodos , Promoción de la Salud/normas , Humanos , Masculino , Medios de Comunicación de Masas , Persona de Mediana Edad , Evaluación de Programas y Proyectos de Salud , Queensland/epidemiología , Estudios Retrospectivos , Método Simple CiegoRESUMEN
AIM: To investigate the expression and clinical relevance of inhibitor of differentiation (ID) proteins in biliary tract cancer. METHODS: ID protein expression was analyzed in 129 samples from patients with advanced biliary tract cancer (BTC) (45 extrahepatic, 50 intrahepatic, and 34 gallbladder cancers), compared to normal controls and correlated with clinical an pathological parameters. RESULTS: ID1-3 proteins are frequently overexpressed in all BTC subtypes analyzed. No correlation between increased ID protein expression and tumor grading, tumor subtype or treatment response was detected. Survival was influenced primary tumor localization (extrahepatic vs intrahepatic and gall bladder cancer, OS 1.5 years vs 0.9 years vs 0.7 years, P = 0.002), by stage at diagnosis (OS 2.7 years in stageâ Iâ vs 0.6 years in stage IV, P < 0.001), resection status and response to systemic chemotherapy. In a multivariate model, ID protein expression did not correlate with clinical prognosis. Nevertheless, there was a trend of shorter OS in patients with loss of cytoplasmic ID4 protein expression (P = 0.076). CONCLUSION: ID protein expression is frequently deregulated in BTC but does not influence clinical prognosis. Their usefulness as prognostic biomarkers in BTC is very limited.
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Neoplasias de los Conductos Biliares/química , Conductos Biliares Extrahepáticos/química , Conductos Biliares Intrahepáticos/química , Colangiocarcinoma/química , Neoplasias de la Vesícula Biliar/química , Proteínas Inhibidoras de la Diferenciación/análisis , Adulto , Anciano , Anciano de 80 o más Años , Neoplasias de los Conductos Biliares/patología , Neoplasias de los Conductos Biliares/terapia , Conductos Biliares Extrahepáticos/patología , Conductos Biliares Intrahepáticos/patología , Colangiocarcinoma/patología , Colangiocarcinoma/terapia , Femenino , Neoplasias de la Vesícula Biliar/patología , Neoplasias de la Vesícula Biliar/terapia , Humanos , Inmunohistoquímica , Proteína 1 Inhibidora de la Diferenciación/análisis , Proteína 2 Inhibidora de la Diferenciación/análisis , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Análisis Multivariante , Clasificación del Tumor , Proteínas de Neoplasias/análisis , Estadificación de Neoplasias , Valor Predictivo de las Pruebas , Modelos de Riesgos Proporcionales , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
The objectives of this study were 1) to establish clinical profiles of dysphagic and nondysphagic individuals following thermal burn injury and 2) to provide a clinical profile of the progression and outcome of dysphagia resolution by hospital discharge for a dysphagic cohort. A total of 438 consecutively admitted patients with thermal burns were included. All patients underwent a clinical swallowing examination. Medical parameters regarding burn presentation and its treatment and speech-language pathology specific variables from admission to discharge were collected for each participant. Dysphagia was identified in 49 patients via clinical assessment, and their course of recovery was followed up until the point of dysphagia resolution or discharge. No significant difference was observed between the dysphagic and nondysphagic groups in age, gender, and injury etiology. However, the dysphagic cohort was significantly different from the nondysphagic group in all variables pertaining to injury presentation and medical management. Individuals with dysphagia took significantly longer to start, and maintain, oral intake and required nonoral supplementation for three and a half times longer than those who were nondysphagic. Length of speech-language pathology intervention averaged 1 month for the dysphagics and increased with dysphagia severity. Return to normal fluid consistencies occurred in >75% of dysphagic individuals by week 7 after injury, although resumption of normal diet textures was more protracted, with 75% resuming normal oral intake by week 9. Dysphagia had resolved in 50% of the cohort by week 6, and by hospital discharge, 85% of the dysphagic individuals had resumed normal oral intake of thin fluids and a general diet. This is the first large prospective cohort study to establish clinical profiles of dysphagic and nondysphagic cohorts and document the nature of dysphagia and patterns of recovery within the thermal burn population. These current data will assist the allocation and planning of speech-language pathology services and provide baseline data on the course of dysphagia resolution in the adult thermal burn population.
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Quemaduras/complicaciones , Quemaduras/diagnóstico , Trastornos de Deglución/diagnóstico , Trastornos de Deglución/etiología , Adolescente , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Quemaduras/terapia , Estudios de Cohortes , Trastornos de Deglución/epidemiología , Trastornos de Deglución/terapia , Progresión de la Enfermedad , Nutrición Enteral/estadística & datos numéricos , Femenino , Estudios de Seguimiento , Humanos , Puntaje de Gravedad del Traumatismo , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Calidad de Vida , Queensland , Medición de Riesgo , Índice de Severidad de la Enfermedad , Factores Sexuales , Adulto JovenRESUMEN
AIMS: The principal aim of this study was to describe infection related characteristics of blood stream infections (BSI) in patients with burns. We sought to determine the organisms that caused BSI and factors that could predict the outcome of BSI. METHODS: Data was collected on admitted patients with burns from January 1998 to December 2008. Selected information from databases was analysed using SPSS version 17 (SPSS Inc., Chicago). Descriptive, univariate and multivariate analysis was undertaken to determine factors predictive of clinical outcome. The factors analysed by univariate analysis were selected on clinical plausibility. Multivariate analysis used a crosstabs procedure initially to estimate maximum likelihood. Factors that were associated with a p value <0.15 were entered into a binary logistic regression to detect which factors were independent predictors of mortality in BSI and outcome according to specific organisms. RESULTS: Ninety-nine out of 2364 (4%) patients developed 212-documented BSI. The median time from burn to BSI was 7 (interquartile range 3-16) days. Gram-positive organisms, in particular Methicillin resistant Staphylococcus aureus and Coagulase negative Staphylococci, were the most common bacteria associated with BSI in the first week of hospital admission. The mortality rate for all admissions over the data collection period was 3%. Of the 99 patients with BSI, 13 died giving a mortality rate, in the presence of BSI, of 13%. Univariate analysis found that the factors predictive of P. aeruginosa mortality were inhalational injury, higher total body surface area burns, total days of antibiotic treatment and elevated Acute Physiological and Chronic Health Evaluation (APACHE) II scores. Multivariate analysis identified inhalational injury to be the only factor associated with BSI-related mortality. CONCLUSION: Whilst the overall mortality in our cohort was low, the presence of BSI increased this four-fold. Whilst infections caused by Gram-positive pathogens occurred earlier in the patient stay than Gram-negative organisms, the highest mortality was associated with P. aeruginosa infections. This study highlights the negative effects of BSI on clinical outcomes in burn patients.
Asunto(s)
Bacteriemia/microbiología , Quemaduras/complicaciones , Bacterias Gramnegativas/aislamiento & purificación , Bacterias Grampositivas/aislamiento & purificación , Adulto , Bacteriemia/mortalidad , Quemaduras/sangre , Estudios de Cohortes , Femenino , Humanos , Tiempo de Internación , Modelos Logísticos , Masculino , Persona de Mediana Edad , Queensland/epidemiología , Estudios Retrospectivos , Factores de RiesgoRESUMEN
The objective of this study is to determine dysphagia incidence for a consecutively admitted population of thermal burn injury patients and to determine admitting characteristics that can be used to reliably predict patients at risk of developing dysphagia after thermal burn. Four hundred thirty-eight patients with thermal burns, with or without inhalation injury, who were consecutively admitted to and received management at a state-wide burn center over a 2-year period (2007-2009) were included. All patients meeting the project's inclusion criteria underwent clinical swallowing assessment to determine the presence or absence of dysphagia. Dysphagia incidence was found to be 11.18% (n = 49) in the admitted population. Dysphagia severity at initial assessment was classified as severe for 40.82%, moderate for 30.61%, and mild for 28.57%. Statistical analysis revealed a core set of statistically significant parameters known within the first 24 hours postinjury that showed strong sensitivity and specificity for detection of dysphagia risk. These include, in isolation or in combination, with the consideration of increasing age, TBSA burnt ≥18%, head and neck burns, need for escharotomy, inhalation injury, need for intensive care admission, and need for mechanical ventilation. This is the first large, prospective cohort study to document dysphagia incidence within the thermal burn population and to validate key predictors for dysphagia risk in this population. These data will assist the allocation and planning of speech pathology services and provide an evidence-based pathway for ensuring early identification and management of patients at high risk of dysphagia after thermal burn injury.
Asunto(s)
Quemaduras/complicaciones , Trastornos de Deglución/etiología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Australia/epidemiología , Intervalos de Confianza , Trastornos de Deglución/epidemiología , Femenino , Indicadores de Salud , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Modelos Estadísticos , Oportunidad Relativa , Estudios Prospectivos , Medición de Riesgo , Índice de Severidad de la Enfermedad , Adulto JovenRESUMEN
The role of the speech pathologist in the burns population is still emerging, with detailed discussion of the assessment and management of dysphagia limited to date. This report describes the case of a 60-year-old man who developed severe contractures of the head and neck and oropharyngeal dysphagia after sustaining 53.5% deep partial- and full-thickness burns. Although some aspects of rehabilitation were confounded by a preexisting mild intellectual disability, the patient was able to participate in an intensive regimen of active and passive exercise to rehabilitate his oropharyngeal dysphagia. Significant oral contractures remained; however, the patient was discharged without tracheostomy and consuming a texture-modified diet with no signs of aspiration. To our knowledge, this is one of a small handful of reports that document speech pathology management of the burns population, and a first that identifies and outlines specific characteristics of, and rehabilitation strategies for, dysphagia in a burned individual.
Asunto(s)
Quemaduras/complicaciones , Trastornos de Deglución/etiología , Trastornos de Deglución/rehabilitación , Quemaduras/terapia , Contractura/etiología , Contractura/rehabilitación , Humanos , Masculino , Persona de Mediana Edad , TraqueostomíaRESUMEN
BACKGROUND: Excessive fluid resuscitation of large burn injuries has been associated with adverse outcomes. We reviewed our experience in patients with major-burn injury to assess the relationship between fluid, clinical outcome and cause of variance from expected resuscitation volumes as defined by the Parkland formula. METHODS: Eighty patients with new burns > or =15% total body surface area (TBSA) admitted to the intensive care unit within 48 h of injury were included. RESULTS: Mean fluid volume was 6.0+/-2.3 mL/kg/% TBSA at 24h. Bolus fluids for hypotension and oliguria explained 39% of excess variance from Parkland estimates and inaccurate burn size and weight assessment explained 9% of variance. Higher fluid volume was associated with pneumonia (adjusted odds ratio [AOR]=2.0; 95% confidence interval [CI] 1.2-3.4) and extremity compartment syndrome (AOR=7.9; 95% CI 2.4-26). Colloid use during the first 24h reduced the risk of extremity compartment syndrome (AOR=0.06; 95% CI 0.007-0.49) and renal failure (AOR=0.11; 95% CI 0.014-0.82). In-hospital mortality was low (10%) and not associated with >125% Parkland resuscitation (P=0.39). CONCLUSIONS: Although fluid resuscitation in excess of the Parkland formula was associated with several adverse events, mortality was low. A multi-centre trial is needed to more specifically define the indications and volumes needed for burns fluid resuscitation and revise traditional formulae emphasising patient outcome. Improved training in burn size assessment is needed.