Prescription opioid use before and after kidney transplant: Implications for posttransplant outcomes.

Evolving literature suggests that the epidemic of prescription opioid use affects the transplant population. We examined a novel database wherein national U.S. transplant registry records were linked to a large pharmaceutical claims warehouse (2007-2015) to characterize prescription opioid use before and after kidney transplant, and associations (adjusted hazard ratio, 95%LCL aHR95%UCL ) with death and graft loss. Among 75 430 eligible patients, 43.1% filled opioids in the year before transplant. Use was more common among recipients who were women, white, unemployed, publicly insured, and with longer pretransplant dialysis. Of those with the highest level of pretransplant opioid use, 60% continued high-level use posttransplant. Pretransplant opioid use had graded associations with one-year posttransplant outcomes; the highest-level use predicted 46% increased risk of death (aHR 1.28 1.461.66 ) and 28% increased risk of all-cause graft failure (aHR 1.17 1.281.41 ). Effects of high-level opioid use in the first year after transplant were stronger, predicting twice the risk of death (aHR 1.93 2.242.60 ) and 68% higher all-cause graft failure risk (aHR 1.50 1.681.89 ) over the subsequent year; increased risk persisted over five years. While associations may, in part, reflect underlying conditions or behaviors, opioid use history is relevant in assessing and providing care to transplant candidates and recipients.

The impact of direct-acting antiviral agents on liver and kidney transplant costs and outcomes.

Direct-acting antiviral medications (DAAs) have revolutionized care for hepatitis C positive (HCV+) liver (LT) and kidney (KT) transplant recipients. Scientific Registry of Transplant Recipients registry data were integrated with national pharmaceutical claims (2007-2016) to identify HCV treatments before January 2014 (pre-DAA) and after (post-DAA), stratified by donor (D) and recipient (R) serostatus and payer. Pre-DAA, 18% of HCV+ LT recipients were treated within 3 years and without differences by donor serostatus or payer. Post-DAA, only 6% of D-/R+ recipients, 19.8% of D+/R+ recipients with public insurance, and 11.3% with private insurance were treated within 3 years (P < .0001). LT recipients treated for HCV pre-DAA experienced higher rates of graft loss (adjusted hazard ratio [aHR] 1.34 1.852.10 , P < .0001) and death (aHR 1.47 1.681.91 , P < .0001). Post-DAA, HCV treatment was not associated with death (aHR 0.34 0.671.32 , P = .25) or graft failure (aHR 0.32 0.641.26 , P = .20) in D+R+ LT recipients. Treatment increased in D+R+ KT recipients (5.5% pre-DAA vs 12.9% post-DAA), but did not differ by payer status. DAAs reduced the risk of death after D+/R+ KT by 57% (0.19 0.430.95 , P = .04) and graft loss by 46% (0.27 0.541.07 , P = .08). HCV treatment with DAAs appears to improve HCV+ LT and KT outcomes; however, access to these medications appears limited in both LT and KT recipients.

Metformin use in the first year after kidney transplant, correlates, and associated outcomes in diabetic transplant recipients: A retrospective analysis of integrated registry and pharmacy claims data.

While guidelines support metformin as a therapeutic option for diabetic patients with mild-to-moderate renal insufficiency, the frequency and outcomes of metformin use in kidney transplant recipients are not well described. We integrated national U.S. transplant registry data with records from a large pharmaceutical claims clearinghouse (2008-2015). Associations (adjusted hazard ratio, 95% LCL aHR95% UCL ) of diabetes regimens (with and excluding metformin) in the first year post-transplant with patient and graft survival over the subsequent year were quantified by multivariate Cox regression, adjusted for recipient, donor, and transplant factors and propensity for metformin use. Among 14 144 recipients with pretransplant type 2 diabetes mellitus, 4.7% filled metformin in the first year post-transplant; most also received diabetes comedications. Compared to those who received insulin-based regimens without metformin, patients who received metformin were more likely to be female, have higher estimated glomerular filtration rates, and have undergone transplant more recently. Metformin-based regimens were associated with significantly lower adjusted all-cause (aHR 0.18 0.410.91 ), malignancy-related (aHR 0.45 0.450.99 ), and infection-related (aHR 0.12 0.320.85 ) mortality, and nonsignificant trends toward lower cardiovascular mortality, graft failure, and acute rejection. No evidence of increased adverse graft or patient outcomes was noted. Use of metformin-based diabetes treatment regimens may be safe in carefully selected kidney transplant recipients.

Predonation Prescription Opioid Use: A Novel Risk Factor for Readmission After Living Kidney Donation.

Implications of opioid use in living kidney donors for key outcomes, including readmission rates after nephrectomy, are unknown. We integrated Scientific Registry of Transplant Recipients data with records from a nationwide pharmacy claims warehouse and administrative records from an academic hospital consortium to quantify predonation prescription opioid use and postdonation readmission events. Associations of predonation opioid use (adjusted odds ratio [aOR]) in the year before donation and other baseline clinical, procedural, and center factors with readmission within 90 days postdonation were examined by using multivariate logistic regression. Among 14 959 living donors, 11.3% filled one or more opioid prescriptions in the year before donation. Donors with the highest level of predonation opioid use (>305 mg/year) were more than twice as likely as nonusers to be readmitted (6.8% vs. 2.6%; aOR 2.49, 95% confidence interval 1.74-3.58). Adjusted readmission risk was also significantly (p < 0.05) higher for women (aOR = 1.25), African Americans (aOR = 1.45), spouses (aOR = 1.42), exchange participants (aOR = 1.46), uninsured donors (aOR = 1.40), donors with predonation estimated glomerular filtration rate <60 mL/min/1.73 m2 (aOR = 2.68), donors with predonation pulmonary conditions (aOR = 1.54), and after robotic nephrectomy (aOR = 1.68). Predonation opioid use is independently associated with readmission after donor nephrectomy. Future research should examine underlying mechanisms and approaches to reducing risks of postdonation complications.

Perioperative Complications After Living Kidney Donation: A National Study.

We integrated the US transplant registry with administrative records from an academic hospital consortium (97 centers, 2008-2012) to identify predonation comorbidity and perioperative complications captured in diagnostic, procedure, and registry sources. Correlates (adjusted odds ratio, aOR) of perioperative complications were examined with multivariate logistic regression. Among 14 964 living kidney donors, 11.6% were African American. Nephrectomies were predominantly laparoscopic (93.8%); 2.4% were robotic and 3.7% were planned open procedures. Overall, 16.8% of donors experienced a perioperative complication, most commonly gastrointestinal (4.4%), bleeding (3.0%), respiratory (2.5%), surgical/anesthesia-related injuries (2.4%), and "other" complications (6.6%). Major Clavien Classification of Surgical Complications grade IV or higher affected 2.5% of donors. After adjustment for demographic, clinical (including comorbidities), procedure, and center factors, African Americans had increased risk of any complication (aOR 1.26, p = 0.001) and of Clavien grade II or higher (aOR 1.39, p = 0.0002), grade III or higher (aOR 1.56, p < 0.0001), and grade IV or higher (aOR 1.56, p = 0.004) events. Other significant correlates of Clavien grade IV or higher events included obesity (aOR 1.55, p = 0.0005), predonation hematologic (aOR 2.78, p = 0.0002) and psychiatric (aOR 1.45, p = 0.04) conditions, and robotic nephrectomy (aOR 2.07, p = 0.002), while annual center volume >50 (aOR 0.55, p < 0.0001) was associated with lower risk. Complications after live donor nephrectomy vary with baseline demographic, clinical, procedure, and center factors, but the most serious complications are infrequent. Future work should examine underlying mechanisms and approaches to minimizing the risk of perioperative complications in all donors.

PROGNOSTIC VALUES OF NEUTROPHIL/LYMPHOCYTE RATIO IN SEVERE BURN PATIENTS.

The aim of this study was to evaluate the characteristics and prognostic value of the neutrophil/lymphocyte ratio (NLR) in patients with severe burns. A retrospective study was conducted on 245 burn patients over 18 years old without comorbidity or combined injury, burn extent ≥20% TBSA, hospitalized within 24 hours after burn. The collected criteria included patient characteristics, NLR on admission, 3rd and 7th day after burn, and outcome. The results showed that NLR was higher than the normal value at all collected times. In addition, compared to the survivor group, NLR on admission, 3rd and 7th day after burn was significantly higher in the mortality group (p <.01). Multivariate analysis found that the NLR on the 7th day postburn was an independent factor associated with mortality (p <.05), along with the increase in age, burn extent, and presence of inhalation injury (AUC = .85; cut off: 14.13; sensitivity: 75% and specificity: 83.43%). In conclusion, NLR on the 7th day post burn may be used as a predictive factor for mortality amongst severe burn patients.

Le but de cette étude est d'évaluer les valeurs et l'intérêt pronostique du rapport neutrophiles/lymphocytes (RNL) chez le patient gravement brûlé. Il s'agit d'une étude rétrospective conduite auprès de 245 adultes (> 18 ans) brûlés sur >20% SCT, sans inhalation de fumée ni comorbidité, hospitalisés dans les 24h suivant le traumatisme. Nous avons examiné les caractéristiques du patient, les RNL à J3 et J7 ainsi que le devenir. Les RNL étaient systématiquement élevés, significativement plus chez ceux destinés à mourir (p <0,01). En analyse multivariée, la valeur de RNL à J7 est significativement corrélée à la mortalité (p <0,05), comme l'âge, la surface brûlée et l'inhalation. Au seuil de 14,13 on obtient une sensibilité de 75%, une spécificité de 83,43% et une AUC/ROC de 0,85. Le RNL à J7 peut être utilisé comme paramètre prédictif de mortalité chez les patients gravement brûlés.

Risk of kidney stones with surgical intervention in living kidney donors.

A kidney stone in a person with a solitary kidney requires urgent attention, which may result in surgical and/or hospital attention. We conducted a matched retrospective cohort study to determine if living kidney donors compared to healthy nondonors have a higher risk of: (i) kidney stones with surgical intervention, and (ii) hospital encounters for kidney stones. We reviewed all predonation charts for living kidney donations from 1992 to 2009 at five major transplant centers in Ontario, Canada, and linked this information to healthcare databases. We selected nondonors from the healthiest segment of the general population and matched 10 nondonors to every donor. Of the 2019 donors and 20 190 nondonors, none had evidence of kidney stones prior to cohort entry. Median follow-up time was 8.4 years (maximum 19.7 years; loss to follow-up <7%). There was no difference in the rate of kidney stones with surgical intervention in donors compared to nondonors (8.3 vs. 9.7 events/10 000 person-years; rate ratio 0.85; 95% confidence interval [CI] 0.47-1.53). Similarly there was no difference in the rate of hospital encounters for kidney stones (12.1 vs. 16.1 events/10 000 person-years; rate ratio 0.75; 95% CI 0.45-1.24). These interim results are reassuring for the safety of living kidney donation.

Risk Factors for Death of Burn Patients With Acute Respiratory Distress Syndrome.

The aim of this study was to investigate factors independently affecting outcomes of post-burn ARDS patients at the time of ARDS onset. A prospective study was conducted on 66 patients with ARDS, treated in the ICU at the Le Huu Trac National Burns Hospital in Hanoi, Viet Nam, from 2014 to 2017. Patients were divided into a survivor and non-survivor group. Demographic criteria, burn severity, inhalation injury, clinical and subclinical features at ARDS onset were compared between the two groups. The results showed that overall mortality of ARDS patients was 62.12%. Logistic regression analysis indicated that at the time of ARDS onset, serum lactate level (OR=6.71), blood platelet count (OR=.99), static lung compliance (OR=.73) and driving pressure (OR=1.69) were independent risk factors for death, while patients' demographics, burn severity and ARDS severity did not significantly affect the mortality rate.

Le but de cette étude est d'évaluer les facteurs indépendants influençant le pronostic d'un SDRA survenant chez un brûlé, présents dès sa survenue. Il s'agit d'une étude prospective conduite sur 66 patients hospitalisés en réanimation de l'hôpital brûlologique national Le Huu Trac de Hanoi entre 2014 et 2017, répartis en groupes survivants et décédés. Nous avons comparé les données démographiques, la gravité de la brûlure, l'existence d'une inhalation de fumée, les données cliniques comme paracliniques au moment du diagnostic de SDRA. La mortalité globale était de 62,12%. En régression logistique, la lactatémie (OR 6,71), le compte de plaquettes (OR 0,99), la compliance pulmonaire statique (OR 0,73) et la pression de travail (OR 1,69) sont des facteurs indépendants de mortalité quand ni les données-patient, ni la sévérité de la brûlure ou celle du SDRA lui-même n'affectent la mortalité.

Cost Analysis and Influencing Factors Amongst Severe Burn Patients.

This study analyzed the structure and determined the factors affecting the cost of treatment of severe burns patients. The results showed that the average total costs for a patient was 3275.9 USD. The daily cost of hospitalization was 113.3 USD, the treatment cost for 1% burn surface area was 109.5 USD with the highest proportion for medication and consumable medical equipment (43.2%), followed by surgery and procedures (30.2%). The treatment costs increased with increasing age, burn extent and deep burn area (p < .05) and were significantly higher in the group of patients with inhalation injury, electrical burns and in non-survivors (p < .01). Multivariate regression analysis found that burn extent, deep burn area and inhalation injury independently influenced the treatment cost of burn patients.

Cette étude a analysé le coût global de la prise en charge d'un brûlé grave ainsi que les imputations et les paramètres associés aux dépenses. Le coût moyen est de 3 275,9$ (113,3$/ % SB/j). Les médicaments et les consommables représentent 43,2 % du total ; le coût des chirurgies 30,2 %. Le coût augmente avec l'âge, la surface brûlée et la profondeur (p < 0,05). Il est significativement plus élevé en cas d'inhalation de fumées, de brûlure électrothermique et en cas de brûlure fatale (p < 0,01). En analyse multivariée, la surface brûlée, la profondeur et l'inhalation de fumée sont des facteurs indépendants d'augmentation du coût de traitement.

Risk Factors For Death And Prognosis Value Of Revised Baux Score For Burn Patients With Inhalation Injury.

A retrospective study was conducted on 314 burn patients with inhalation injury admitted to the National Burn Hospital during the period 2015-2019. The results showed that adult and male was predominant (81.9% and 77.7%), with burns mostly caused by flame (93.6%) and burn extent of 68.6±24.3% and deep burn area of 44.6±25.2% total body surface area. Rate of required mechanical ventilation patients was 95.22%. Common complications were multiple organ failure (41.9%), pneumonia (29.9%), ARDS (25.5%) and septic shock (23.8%), with a mortality rate of 85.4%. Multivariate logistic analysis indicated that burn extent and age were independent risk factors for death of patients with inhalation injury. SMR of rBaux score was 1.01 with AUC of 0.84, Youden index 113, sensitivity 82.09%, specificity 70.21%. The SMR of adult and elderly patients was relatively close to 1 (1 and .97 respectively). In addition, the AUC value for the elderly was highest (.95) followed by adult patients (.84). However, predicting the value of rBaux on children with inhalation injury was quite low (SMR=1.57; AUC = 0.4). There is a need to determine an optimal prognosis score for children with inhalation injury.

Nous avons réalisé une étude rétrospective sur 314 patients ayant inhalé des fumées hospitalisés dans le CTB national entre 2015 et 2019. Les hommes (77,71%), les adultes (81,85%) et les brûlés par flamme (93,6%) étaient majoritaires dans ce groupe. La surface brûlée moyenne était de 68,6 +/- 24,3% dont 44,6 +/-25,2% de profond. Une ventilation mécanique a été nécessaire dans 95,22% des cas. Les complications les plus fréquentes étaient les défaillances multiviscérales (41,9%), les pneumonies (29,9%), le SDRA (25,5%) et les chocs septiques (23,8%). La mortalité était de 85,4%. En analyse multivariée, l'âge et la surface brûlée ressortaient comme des facteurs de risque indépendants de mortalité. Le Baux modifié avait un SMR de 1,01; une AUCROC de 0,84; un index de Youden à 113, une sensibilité de 82,09% et une spécificité de 70,21%. Les SMR étaient proches de 1 chez les adultes (1) et les sujets âgés (0,97). La valeur la plus élevée de l'AUC (0,95) correspondait à la cohorte «sujets âgés¼, suivie de la cohorte «adultes¼ (0,84). Le Baux modifié est peu efficace chez l'enfant (SMR 1,57 ; AUC 0,4). Il est nécessaire de développer un score pronostique pour les enfants brûlés ayant inhalé des fumées.

Influence Of "Open Lung" Recruitment On Ards In Burn Patients With Inhalation Injury.

The aim of this study was to determine the safety and impact of open lung strategy ventilation on inhalation injury patients complicated with ARDS. A prospective study was conducted in 33 inhalation injury patients with ARDS who were randomly divided into a control group (ventilated as ARDS net) and a study group (ventilated with open lung strategy). All patients were ventilated with volume control mode until weaning. The results indicated that open lung procedure was safe in most patients with optimal PEEP of 14.31±1.89 cm H2O. Within the first week of ventilation, respiratory system static compliances and PaO2/FiO2 ratio significantly increased in both groups (p<.05) but at a faster rate for the study group (p<.05). Ventilation duration and length of ICU stay were not significantly different across groups (p>.05). Duration time from ARDS onset to death and from admission to death were remarkably longer in the study group (p<.05). However, mortality rate and cause of death were not significantly different within 28 days post burn injury. Open lung recruitment is feasible and could be applied for inhalation injury induced ARDS to improve oxygenation and survival time. Further trials need to be conducted to find out the effectiveness of this strategy on mortality.

Le but de cet étude était de déterminer l'efficacité et l'innocuité d'une stratégie de ventilation « poumon ouvert ¼ sur le SDRA consécutif à une inhalation de fumées chez les patients brûlés. Elle concernait 33 patients brûlés, ayant inhalé des fumées, en SDRA, séparés après tirage au sort en 1 groupe témoin (T) ventilé selon les recommandations actuelles et 1 groupe (PO) ventilé selon une stratégie à poumon ouvert, les 2 groupes étant sous ventilation contrôlée jusqu'au sevrage. La stratégie PO s'est avérée sans risque pour la majorité des patients. La PEP optimale était de 14,31 +/- 1,89 cm H2O. Pendant la première semaine, la compliance statique et P/F augmentaient significativement (p<0,05) dans les 2 groupes, plus rapidement dans le groupe PO (p<0,05). Ni la durée de ventilation ni celle du séjour en réanimation ne différaient, pas plus que le pourcentage de mortalité, ou sa cause (à J28). En revanche, la mort, quand elle survenait, était plus tardive (comptée à partir de l'entrée ou de la survenue du SDRA) dans le groupe PO (p<0,05). La stratégie de ventilation à poumon ouvert est possible chez le brûlé en SDRA après inhalation de fumés. Elle pourrait améliorer l'oxygénation et retarder le décès mais des études complémentaires sont nécessaires pour déterminer si elle est à même de réduire la mortalité.

Assessment Of Creatine Phosphokinase (CPK) Changes In Patients With High-Voltage Burns.

The aim was to evaluate change in creatine phosphokinase (CK) enzyme in high-voltage burn patients. A retrospective study was conducted of 104 patients (aged from 16 to 83 years old) who suffered from burns due to high voltage and were treated as inpatients at the National Burns Hospital. Patients were divided into two groups: patients with limb amputations in group A and patients without limb amputations in group B. Analysis was conducted on medical records of testing for plasma CK level immediately upon admission and during treatment. Testing of CK plasma enzyme was performed on an AU480 machine manufactured by Beckman Coulter. Data were processed using SPSS 20.0 software. Average plasma CK index increased on the first day of admission. In group B, plasma CK enzyme index increased from 5.5 to 22.4 times, and in group A this index increased from 5.6 to 46.5 times compared with the plasma CK index of normal people (170 U/l). The mean plasma CK enzyme index in the amputation group (n=20) was higher than in the non-amputation group (n=84). In patients with limb amputations, CK levels significantly decreased after deep necrosis incision and after amputation (p=0.00001). In patients with burns due to high voltage, plasma CK levels rise in the first days after burns. Increased plasma CK enzyme levels are directly proportional to total burn surface area (TBSA) and burn depth. After escharotomy and amputation, plasma CK levels decreased significantly compared to preoperation levels.

Cette étude rétrospective a pour but d'évaluer les variations des concentrations de CPK cez 104 patients (de 16 à 83 ans) hospitalisés dans l'hôpital brûlologique national après une électrisation par haut voltage. Ils ont été répartis en 2 groupes, selon qu'ils aient subi (groupe A, 20 patients) ou non (groupe B, 84 patients), une amputation de membre. Nous avons récupéré dans les dossiers et étudié les analyses de CPK, faites par le AU480 de Bekman- Coulter (normale ≤170UI/L), effectuées à l'entrée et durant le séjour. L'analyse statistique a utilisé SSPS 20.0. La concentration de CPK était multipliée par 5,6 à 46,5 chez les amputés, par 5,5 à 22,4 chez les autres. Les concentrations de CPK diminuaient significativement après aponévrotomies et amputations (p=0,00001), comparativement à leur niveau pré- opératoire. Les CPK augmententdans les jours qui suivent l'électrisation et sont proportionnel à la surface atteinte ainsi qu'à la profondeur des lésions.

Characteristics And Outcome Influence Of Increased Plasma Triglyceride Level In Severely Burned Adult Patients.

The aims of this study were to investigate the profile of serum triglyceride level and its influence on outcomes in adult patients with severe burns. An observational study was conducted on 62 patients with burn extent from and over 20% TBSA. Results indicated that serum triglyceride level steadily increased from 1.9mmo/l on the 3rd day to 2.5 mmol/l on the 14th day before reducing on the 21st day after burn. Remarkably higher triglyceride level was seen in patients with full thickness burn area >20% TBSA and in inhalation injury (p < .05). Liver size significantly increased over time and was greater in increased triglyceride patients, but the difference was not significant (p > .05). In addition, patients with elevated serum triglyceride level had significantly higher rates of multiple organ failure and death compared with the remaining group. Further studies need to be conducted to understand and determine intervention for increased plasma triglyceride levels in severely burned patients.

Le but de cette étude était d'évaluer les triglycéridémies et leur influence sur le devenir d'adultes sévèrement brûlés. Il s'agit d'une étude observationnelle réalisée auprès de 62 patients brûlés sur > 20% SCT. La triglycéridémie augmente régulièrement, de 1,9 mmol/L à J3 jusqu'à 2,5 mmol/L à J14 pour diminuer à partir de J21. Des taux particulièrement élevés étaient observés en cas d'atteinte profonde et d'inhalation de fumées (p < 0,05). La taille du foie augmentait au cours du temps et semblait plus élevés chez les patients hypertriglycéridémiques, sans être significative. En outre, les patients hypertriglycéridémiques développaient plus fréquemment une défaillance multiviscérale et leur mortalité était plus élevée. D'autres études sont nécessaires pour comprendre le mécanisme de cette hypertriglycéridémie et proposer une conduite à tenir pour ces patients.

Epidemiology And Risk Factors For Death Of Pediatric Burns In A Developing Country. An Experience From The National Burn Hospital.

This retrospective study investigated burn features and predicted factors for death of pediatric burn patients in Vietnam. The results showed that pediatric burn accounted for 48.1% of total admitted burn patients. Preschool children and boys were predominant, burns were mostly caused by scald (76.2%) and the majority of patients lived in a rural area (64.1%). In addition, 94.5% had burn size less than 30% total body surface area and deep burn injury was seen in 45.5% patients. Moreover, a significantly higher incidence of deep burn injury was recorded in preschool age, patients living in a rural area, and non-scald burn. Overall LA50 was 81.5% and a significantly higher mortality rate was seen in non-scald burns, older children, extensive burn and inhalation injury. Multivariate logistic analysis indicated that only burn extent and inhalation injury were independent risk factors for death. An increased 1% of burn extent resulted in a .7 probability unit of death (OR=1.08) and this was 2.16 in the case of inhalation injury (OR=8.67). This health issue should be highlighted in order to develop appropriate policies and intervention measures in developing countries.

Cette étude rétrospective s'est penchée sur les caractéristiques et les facteurs de risque de mortalité des brûlures de l'enfant au Vietnam. Ces brûlres représentent 48,1% des hospitalisations dans notre centre. Les garçons d'âge préscolaire sont la sous- population prédominante. Les ébouillantements sont majoritaires (76,2%), de même que l'origine ruale (64,1%). L'immense majorité (94,5%) des brûlures touche moins de 30% SCT et l'atteinte n'est profonde que dans 45,5% des cas. Les brûlures sont plus profondes chez les patients ruraux préscolaires non ébouillantés. La SL (Surface Létale) 50 était de 81,5% ; les facteurs de risque de mortalité étant l'âge et la surface plus élevés, l'inhalation de fumées et la brûlure non due à un liquide. En analyse multivariée, seules la surface et l'inhalation de fumée ressortaient. Ainsi, l'augmentation de 1% de SB la probabilté de décès de 0,7 (OR 1,08) quand l'inhalation de fumée l'augmente de 2,16 (OR 8,67). Ce problème de santé publique doit être mis en avant afin de développer une législation et des mesures de protection adaptées dans les pays en développement.

Characteristics and gender influence on outcomes of burns in adolescents.

The aim of this study was to investigate the characteristics and influence of gender difference on the outcome of adolescent burns. A retrospective study was conducted on 641 burn patients (10 - 19 years old) admitted to the Viet Nam National Burn Hospital over a three-year period (2016 - 2018). Demographic data, burn features and outcome including complications, length of hospital stay and mortality of male and female groups were compared. The results indicated that adolescents accounted for 6.5% of total admitted burn patients, with a predominance of males (69.3%). Higher proportions of burn due to dry heat (flame or hot surface contact) and electricity were seen in the male group (p < .001). No significant differences were seen between male and female groups in terms of age, admission time, season of burn and burn severity. Compared to females, males experienced more surgical interventions and stayed longer in hospital with higher LA50 (71.2% vs. 56.5% TBSA). It is necessary to conduct prevention and intervention to improve the outcome of adolescent burns, especially for female patients.

Cet étude rétrospective, réalisée auprès de 641 patients de 10 à 19 ans hospitalisés dans l'hôpital brûlologique national du Vietnam entre 2016 et 2018, a pour but d'évaluer le rôle du sexe sur les caractéristiques et l'évolution des brûlures survenant dans cette tranche d'âge. Les données démographiques, les caractéristiques et l'évolution (survie, complications, durée d'hospitalisations) ont été comparées entre hommes et femmes. Les adolescents représentent 6,5% du total des admissions ; 69,3% des patients étant des hommes. Ils souffrent plus fréquemment (p<0,001) de brûlures par flamme/contact (« chaleur sèche ¼) et électricité. Il n'y a pas de différence, en termes d'âge, de saisonnalité, d'heure de survenue et de gravité, entre femmes et hommes. Les hommes ont besoin de plus d'interventions chirurgicales et sont hospitalisés plus longtemps que les femmes. Toutefois, la surface létale 50 est de 71,2% chez les hommes et de 56,5% chez les femmes. Il est nécessaire de développer des programmes de prévention des brûlures chez les adolescents, en ciblant plus précisément chez les adolescentes.

Influence of inhalation injury on resting energy expenditure and plasma metabolic hormones in adult burn patients.

The aim of this study was to investigate the influence of inhalation injury on resting energy expenditure (REE) and some plasma metabolic hormones in adult burn patients. A prospective study was conducted on 16 adult burn patients admitted to the burn intensive care unit, National Burn Hospital, Vietnam. Eight patients with inhalation injury were matched with 8 non-inhalation injury patients by burn extent and age. REE measurements were obtained within 48h of admission and every week after burn. Plasma levels of epinephrine and cortisol were determined on admission and on the 7th day after burns. The results showed that, apart from REE at admission, all values of REE were significantly higher than basal metabolic rate (BMR) at all time points (p < .005). Over time, REE of both groups significantly increased and reached peak values on the 7th day after burn (1964 ± 300Kcal/m2 and 1991.8 ± 467.8Kcal/m2; REE/BMR: 1.5 vs. 1.6 respectively). These values then steadily reduced, but no remarkable differences of REE and REE/BMR were seen between the two groups at any time point (p > .05). In addition, plasma concentrations of epinephrine and cortisol were not significantly different in each group and between the two groups of patients with and without inhalation injury. In conclusion, inhalation injury may not affect metabolic response state in adult burn patients as measured by REE and metabolic hormones.

Le but de ce travail était d'étudier l'influence de l'inhalation de fumées sur la dépense énergétique de repos (DER) et le niveau plasmatique de certaines hormones « métabolique ¼ chez des adultes brûlés. Elle a été réalisée sur 16 patients hospitalisés dans le service de réanimation de l'hôpital brûlologique national du Viêt- Nam, 8 ayant inhalé de la fumée, 8 n'en ayant pas inhalé, appariés sur la surface brûlée. La DER était mesurée dans les 48 h de l'admission puis toutes les semaines. Les taux plasmatiques de cortisol et d'adrénaline étaient mesurés à l'admission et à J7. Mise part celle mesurée à l'admission, DER était systématiquement supérieure à celle calculée selon la formule de Harris- Benedict (p < 0,005), avec un pic à J7 (1964 +/- 300 Cal/m2 chez les patients avec inhalation de fumées, 1991,8 +/- 467,8 chez les autres soit 1,5 et 1,6 fois la DER supposée. Les valeurs mesurées diminuaient ensuite sans jamais qu'il y ait de différence entre les groupes. Pas plus que ne différaient les taux de cortisol ni d'adrénaline. L'inhalation de fumée semble donc de pas avoir d'impact sur la réponse métabolique, mesurée par calorimétrie ou évaluée sur les taux hormonaux.

ARDS among cutaneous burn patients combined with inhalation injury: early onset and bad outcome.

Our aims are to determine the clinical and preclinical characteristics and outcome of ARDS among burn patients with inhalation injury. A retrospective study was conducted on 66 selected patients with ARDS, treated in the ICU of the National Burns Hospital from 11/2013 to 10/2016. The patients were divided into two groups and matched by age and burn extent: the study group consisted of 33 patients with inhalation injury and the control group 33 patients without inhalation injury. Outcome measures included blood gas criteria and oxygenation state at ARDS onset, mechanical ventilation duration, length of stay in the ICU and in the hospital, ventilation-free time and mortality rate until 28 days postburn. Results showed that ARDS onset was earlier in the study group (5.9 ±.7 vs. 9.2 ± .9 days postburn respectively; p < 0.01) and blood oxygenation disorder was more severe (PaO2/FiO2: 117.8 ± 6.1 vs. 125.9 ± 6.5 respectively; p < .01). There was no significant difference between the two groups (p > .05) regarding incidence of complications, ventilation time, ventilation-free duration, and length of stay in the ICU and in the hospital. Mortality rate until 28 days post burn was significantly higher among the study group (69.7% vs. 54.6% respectively; p < .001). In addition, time from admission and from ARDS onset to death was shorter in the study group (P < .05). In conclusion, compared to cutaneous burn-induced ARDS, ARDS in patients with inhalation injury has earlier onset, causes more severe oxygenation disorder and has a higher mortality rate.

Cette étude rétrospective avait pour but d'étudier les caractéristiques des SDRA survenant chez les patients brûlés ayant inhalé des fumées. Elle a été réalisée sur 66 patients en SDRA hospitalisés dans l'hôpital brûlologique national entre novembre 2013 et octobre 2016. Il ont été répartis en 2 groupes de 33 (avec ­ groupe à l'étude E- et sans inhalation de fumées- groupe témoin T) appariés sur l'âge et la surface brûlée. Les variables étudiées étaient la gazométrie et l'oxygénation lors du diagnostic de SDRA, la durée de ventilation mécanique, la durée sans ventilation, les durées de séjour en réanimation et à l'hôpital, la mortalité à J28. Le SDRA était plus précoce (5,85 +/- 0,65 j VS 9,15 +/- 0,92 ; p<0,01) et plus grave (P/F 117,8 +/- 6,1 VS 125,9 +/- 6,5 ; p<0,01) dans le groupe E. Les durées de ventilation et sans ventilation, de séjour en réanimation comme à l'hôpital et le nombre de complications étaient comparables. La mortalité à J28 était plus élevée dans le groupe E (69,7 VS 54,6% ; p< 0,001), plus précoce après la survenue du SDRA (p<0,05). Les patients brûlés ayant inhalé ont des SDRA plus précoces, plus hypoxémiants et plus souvent mortels que ceux n'ayant pas inhalé.

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.

Le but de cette étude est d'évaluer les caractéristiques, l'évolution et les facteurs de risque de décès chez des personnes âgées brûlées. Il s'agit d'une étude rétrospective concernant 416 patients âgés (≥ 65 ans) hospitalisés dans l'hôpital brûlologique national de Hanoi entre le 1/1/2016 et le 31/12/2018. Les données démographiques, comorbidités, sévérité de la brûlure, complications et mortalité ont été recueillies. Des analyses uni- et multivariées ont été réalisées pour rechercher les facteurs de risque de mortalité. Les patients âgés (74,7 +/- 8,1 ans) représentent 4,2% des admissions. Chez les femmes, la surface atteinte (12,4 VS 7,3% ; p < 0,001) et la surface profonde (5,5 VS 2,5% ; p < 0,001) sont plus étendues que chez les hommes. Des antécédents ont été notés chez 20,9% des patients. Ils étaient le plus souvent cardio-vasculaires (13,2%), neurologiques (8,7%) et diabétiques (7%). Plus de la moitié (51,5%) des patients avaient des brûlures profondes et 6,3% d'entre eux ont subi des complications, le plus souvent pneumonie et défaillance multiviscérale. La mortalité globale était de 9,9%. Elle était considérablement plus élevée en cas d'inhalation de fumées (92,9%), quand la surface totale dépassait 40% (61,2%) et quand plus de 10% de surface était profonde (62,5%). En analyse multivariée, les comorbidités ne sortaient pas, à la différence de l'âge, de la surface brûlée et de l'inhalation de fumées. Malgré les progrès de prise en charge, les brûlures étendues avec inhalation de fumées restent un gros défi au Vietnam.

Infrastructure, resources and preparedness for mass burn injuries in a developing country.

Our aims were to evaluate resources and the preparedness of the health care facilities to respond to mass burn injuries in Vietnam. A survey was conducted in 19 provincial and central/regional hospitals using a questionnaire. The contents of the survey included infrastructure, human resources, medical equipment for burn care, and preparedness of hospitals for mass burn injuries. Results indicated that a variety of burn care facilities were set up, from separate burn departments (42.1%) to burn units (15.8%) or burn beds (42.1%) inside trauma or surgical departments. Medical staff/burn bed ratio was .7 and nurse/physician ratio was 1.7, with 52.7% of nurses having more than 5 years' experience. Infrastructure and medical equipment for burn facilities were limited, with just under half of the hospitals equipped with an air conditioner and heater. Bronchoscopy for diagnosis and management of inhalation injury was available in 6 (31.6%) hospitals. Few health facilities had a mechanical ventilator, fluid warmer, hemofiltration machine, burn theater, electro-dermatome or skin mesher. Only 26.3% hospitals had a plan for the management of mass burn injuries. A burn specialist was a member of the hospital's emergency medical team in 36.8% of the hospitals. Guidelines for burn emergency care were available in 63.2% hospitals. In the last 5 years, 21.1% of health facilities had conducted a drill for mass casualty incident management, but only 1 (5.3%) hospital had conducted a drill for MBI management. In conclusion, facilities, equipment, human resources for burn care and preparedness to manage mass burn injuries in Vietnam are still limited and need to be improved.

Nous avons étudié les capacités du système de santé vietnamien à répondre à un afflux massif de brûlés. Nous avons envoyé un questionnaire à 19 structures provinciales et régionales. Il portait sur les infrastructures, les moyens humains comme matériels, les structures de soins aux brûlés et la préparation à la prise en charge d'un afflux massif de brûlés. Nous avons repéré 3 types de structures de soins aux brûlés : CTB spécifiques (42,1%), unités (15,8%) ou lits (42,1%) pour brûlés dans des services de traumatologie ou de chirurgie. On recense 0,7 médecin par lit et 1,7 infirmière par médecin, 52,7% d'entre elles ayant au moins 5 ans d'expérience. Un peu moins de la moitiés des hôpitaux avaient des systèmes de chauffage ou de climatisation. Seuls 6 (31,6%) des hôpitaux disposaient d'un fibroscope, permettant de diagnostiquer et prendre en charge les inhalations de fumées. Peu de structures disposaient de ventilateurs, réchauffeurs de perfusion, dialyseurs, salle d'opération dédiée, dermatome électrique ou Meshgraft. Seuls 26,3% des hôpitaux avaient élaboré un plan catastrophe spécifique, 36,8% des structures ayant un brûlologue dans leur équipe d'urgences. Des référentiels de prise en charge en urgence existaient dans 62,3% des hôpitaux. 21,1% des hôpitaux avaient réalisé un exercice- catastrophe dans les 5 ans précédant l'étude mais 1 seul (5,3%) avait modélisé un afflux massif de brûlés. En conclusion, les infrastructures, le personnel et l'entraînement vis-à-vis d'un afflux massif de brûlés restent insuffisants au Viêt-Nam et doivent être améliorés.

Influence of gender difference on outcomes of adult burn patients in a developing country.

The aim of this study was to investigate the impact of gender on outcomes among adult burn patients. A retrospective study was conducted on 5061 adult burn patients (16 - 64 years old) admitted to the Vietnam National Burn Hospital over a three-year period (2016 - 2018). Demographic data, burn features and outcome including complications, length of hospital stay and mortality of male and female groups were compared. Results indicated that male patients were predominant (72.8%), younger (35.5 vs. 37.2 years old; p < .001) and admitted sooner to hospital. A greater number of males suffered electrical and flame/heat direct contact injuries, whereas more females suffered scald injury (34.7% vs. 12.2%; p < .001). Burn extent was larger among males (14.9% vs. 12.1%; p < .001). In addition, a higher proportion of deep burn injuries (44.8% vs. 41.2%; p < .05) and number of surgeries (1.2 vs. 1; p < .05), and longer hospital stay (17.8 vs. 15.8 days; p < .001) was recorded among the male group. Post burn complication and overall mortality rate did not differ between the two groups. However, death rate was remarkably higher in the female group when burn extent was ≥ 50% TBSA (72.4% vs. 57.3%; p < .05). In conclusion, burn features and outcomes were not similar between the male and female group. Male patients appear to suffer more severe injury requiring more surgeries and longer hospital stay. However, more attention should be paid to the significantly higher mortality rate among females with extensive burn.

Le but de ce travail était d'étudier l'impact du sexe sur le devenir d'adultes brûlés. Cette étude rétrospective a été conduite sur 5 601 patients âgés de 16 à 64 ans admis dans le CTB national du Vietnam entre 2016 et 2018 inclus. Les données démographiques, celles concernant la brûlure, les complications, la durée d'hospitalisation et la mortalité ont été comparées selon le sexe des patients. Les hommes prédominent (72,8%), sont plus jeunes (35,5 VS 37,2 ans - p<0,001) et sont hospitalisés plus rapidement. Les ébouillantements sont plus fréquents chez les femmes (34,7 VS 12,2% - p <0,001), les autres causes (électriques, flammes, contact) étant donc plus habituelles chez les hommes. Les brûlures des hommes sont plus étendues (14,9 VS 12,1% SCB - p< 0,001), plus profondes (44,8% de profond VS 41,2% - p< 0,05 ; 1,2 séances chirurgicales VS 1 - p< 0,05) et leur durée de séjour est plus longue (17,8 VS 15,8 j - p< 0,001). Le nombre de complications et la mortalité sont comparables. Toutefois, la mortalité des femmes brûlées sur ≥ 50% SCT était nettement plus élevée que celle des hommes (72,4% VS 57,3% - p< 0,05). En conclusion, les hommes ont des brûlures plus sévères nécessitant plus d'interventions chirurgicales et une hospitalisation plus longue. Il faut cependant être attentifs à la mortalité élevée des femmes extensivement brûlées.