Autopsy after traumatic death--a shifting paradigm.

OBJECTIVE: The role of autopsy in evaluating missed injury after traumatic death is well established and discussed in the literature. The frequency of incidental findings in trauma patients has not been reported. We believe that incidental findings are under recognized and reported by trauma surgeons. PATIENTS AND METHODS: This prospective, descriptive, cohort study was conducted at a Level 1 trauma center in a rural state. Four hundred ninety-six deaths over a 4-y period were identified from the trauma registry. Two hundred four complete autopsies were available for review. One thousand eighteen traumatic diagnoses were identified from 204 autopsies and corresponding medical records by trauma surgeons blinded to patient identity. The surgeons recorded missed diagnoses, incidental diagnoses identified at autopsy, and diagnoses known at the time of death confirmed by autopsy. RESULTS: The surgeons had a κ-score of 0.82-0.84. Forty-two patients (21% of patients) had 68 severe missed injuries; 67 patients (33% of patients) had 94 minor missed injuries. Twenty-eight patients (14%) had significant incidental findings including premature atherosclerosis, multiple endocrine neoplasia, tuberculosis, and others. CONCLUSIONS: The autopsy after traumatic death is more than a mechanism of quality control and teaching. A high proportion of patients will have incidental findings important to family members, and have public health importance. Systems need to be developed to review autopsy results with attention to identifying and communicating incidental findings. Given the incidence of significant missed injuries and incidental findings, the autopsy continues to have an important role in health care.

Long-term outcomes of patients with necrotizing fasciitis.

CONTEXT: Necrotizing fasciitis is an aggressive infection affecting the skin and soft tissue. It has a very high acute mortality. The long-term survival and cause of death of patients who survive an index hospitalization for necrotizing fasciitis are not known. OBJECTIVE: To define the long-term survival of patients who survive an index admission for necrotizing fasciitis. We hypothesize that survivors will have a shorter life span than population controls. DESIGN: Long-term follow-up of a registry of patients from 1989 to 2006 who survived a hospitalization for necrotizing fasciitis. Last date of follow-up was January 1, 2008. SETTINGS: A university-based Burn and Trauma Center. PATIENTS: A prospective registry of patients with necrotizing fasciitis has been collected from 1989 to 2006. This registry was linked to data from the Department of Health, Department of Motor Vehicles, and the University Hospital Medical Records Department in January 2008 to obtain follow-up and vital status data. INTERVENTION: None. MAIN OUTCOME MEASURES: Date and cause of death were abstracted from death certificates. Date of last live follow-up was determined from the medical record and by the last driver's license renewal. The death rate of the cohort was standardized for age and sex against 2005 statewide mortality rates. Cause of death was collated into infectious and noninfectious and compared with the statewide causes of death. Statistical analysis included standardized mortality rates, Kaplan-Meier survival curves, and Aalen's additive hazard model. RESULTS: Three hundred forty-five patients of the 377 in the registry survived at least 30 days and were analyzed. Average age at presentation was 49 years (range, 1-86; median, 49). Patients were followed up an average of 3.3 years (range, 0.0-15.7; median, 2.4). Eighty-seven of these patients died (25%). Median survival was 10.0 years (95% confidence interval: 7.25-13.11). There was a trend toward higher mortality in women. Twelve of the 87 deaths were due to infectious causes. Using three different statistical analytic techniques, there was a statistically significant increase in the long-term death rate when compared with population-based controls. Infectious causes of death were statistically higher than controls as well. CONCLUSIONS: Patients who survive an episode of necrotizing fasciitis are at continued risk for premature death; many of these deaths were due to infectious causes such as pneumonia, cholecystitis, urinary tract infections, and sepsis. These patients should be counseled, followed, and immunized to minimize chances of death. Modification of other risk factors for death such as obesity, diabetes, smoking, and atherosclerotic disease should also be undertaken. The sex difference in long-term survival is intriguing and needs to be addressed in further studies.

The evolution of resource utilization in regional burn centers.

Regional burn centers provide unique multidisciplinary care that has been associated with dramatically improved outcomes for burn victims. Patients with complex skin and soft tissue injuries are increasingly admitted to these centers for definitive care. This study was designed to assess current trends in burn center resource utilization. Members of the Multicenter Trials Group of American Burn Association were invited to participate in this retrospective review of all patients admitted to their respective regional burn centers during a 10-year period. Collected data included admission diagnosis, demographics, length of stay (LOS), hospital charges, and mortality. Five regional academic burn centers participated. They collectively admitted 18,246 patients during the study period, of whom 15,219 (83.4%) had a primary burn diagnosis and 3027 (16.6%) were patients with nonburn diagnoses. During this period, annual admissions for the five centers increased by 34.7%, ranging from 19 to 83% for individual centers. Simultaneously, mean burn size decreased from 12.3 to 8.8% TBSA. From 1998 to 2006, admissions for nonburn diagnoses increased by 244.9%, whereas burn admissions increased by 31.1%. Although mean LOS was reduced by >25%, total charges for all patients increased by 37.7% after adjustment for inflation. Nonburn patients had significantly higher mean age, longer LOS, greater mortality, and higher daily charges. This review of admissions to five academic burn centers reveals that these centers are treating more patients with smaller burns and an increasing number of complex nonburn conditions. Nonburn patients represent an older and more debilitated population that consumes disproportionately more resources than burn patients. These data show a dramatic shift in burn center resource utilization and the concurrent evolution of regional burn centers into centers for the care of complex wounds.

Apoptosis is differentially regulated by burn severity and dermal location.

BACKGROUND: The cellular processes that contribute to cell death in burns are poorly understood. This study evaluated the distribution and extent of apoptosis in an established rat model of acute dermal burn injury. MATERIALS AND METHODS: A branding iron (100 degrees C) was applied to the depilated dorsum of seven rats, creating burn contact times of 1-8, 10, 12, and 14 s. Biopsies were collected and immunohistochemistry performed for apoptosis and cell injury/necrosis by detection of terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling (TUNEL) and high-mobility group box 1 (HMGB1), respectively. The slides were scored by evaluating staining in superficial, middle, and deep dermal fields. Within these, basal keratinocytes of the epidermis, mesenchymal cells, adnexal epithelia, and vasculature wall cells were morphometrically analyzed for stain detection of selected markers. RESULTS: TUNEL staining had an inverse relationship with contact time in most fields except in deep dermal mesenchymal cells where it was increased. HMGB1 nuclear staining was significantly decreased with progressive contact time consistent with transition to cell injury/necrosis. CONCLUSIONS: This study is the first to demonstrate that apoptosis rate is dependent on dermal location, cell type, and severity of thermal injury. Furthermore, this work suggests that for most dermal locations increased thermal injury corresponds with decreased apoptosis and increased cell injury/necrosis. Together, these findings indicate that many parameters can regulate apoptosis in burn wounds, and these results will be critical to understanding burn pathogenesis and assessing future therapies.

Pharmacologic modification to resuscitation fluid after thermal injury--is drotrecogin alfa the answer to arrest burn depth progression?

HYPOTHESIS: The addition of drotrecogin alfa (DA), an anti-inflammatory useful in septic shock, to standard burn shock resuscitation fluids will protect burned, injured skin from further injury. METHODS: Anesthetized animals were subjected to a standardized burn pattern by applying a branding iron to 10 different locations on the back of the rat for 1 seconds to 14 seconds, creating a range of burn depths and severities. DESIGN: Animal burn shock and resuscitation model. PARTICIPANTS: Thirty-one male adult Sprague-Dawley rats. INTERVENTIONS: Control animals were resuscitated with lactated Ringer's solution (LRS) at 2 mL/kg/percent total body surface area/24 h; experimental animals received LRS plus DA 24 microg/kg/h (LRS + DA). OUTCOME MEASURES: Perfusion to each burned area was assessed using a laser Doppler imaging technology. Punch biopsies at each burned area were stained with hematoxylin and eosin and assessed for burn depth and for inflammation using previously reported measures. Samples from 14 animals were stained for terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling and caspase-3 (apoptosis markers). RESULTS: Increasing branding iron contact times worsened perfusion, burn depth, and apoptotic ratios. There was no correlation between inflammatory markers and burn contact time. The addition of DA leads to worse perfusion, deeper burns, worse inflammation, and decreased apoptotic ratios. CONCLUSIONS: Laser Doppler imaging is a useful technology to assess burn depth. The addition of DA to traditional resuscitation fluids for burn shock is deleterious to the injured, burned skin. Modifying the traditional burn shock resuscitation fluids, although intellectually attractive, needs to be rigorously studied.

The effect of burn center and burn center volume on the mortality of burned adults--an analysis of the data in the National Burn Repository.

Regional variations of care, and improved outcomes with larger volumes, have been well described in the medical and surgical literature for a variety of conditions including heart surgery, vascular surgery, and orthopedic surgery. Burn care has not been recently subjected to such an analysis. The National Burn Repository (NBR) contains de-identified patient and burn center data to allow this analysis. The NBR was queried for adult burn patients admitted for an acute thermal burn injury. A multivariable regression analysis to identify risk of death was performed incorporating patient characteristics, de-identified burn center, and burn center volume. Patient characteristics such as age, size of burn, mechanism of burn, inhalation injury, race, and sex determine mortality. There is also a statistically significant difference in death rates when individual, de-identified centers are compared. This difference in care persists even when accounting for burn center volume. Analysis of registries like the NBR, insurance claims databases, and statewide hospital discharge databases may help identify opportunities to improve burn care. According to this analysis of data available in the NBR, burn mortality depends not only on patient characteristics but also where the patient is treated. Mortality does not linearly improve with burn center volume and plateaus with increasing burn center size. The optimal burn center size is a complicated and contentious question. Future discussions about burn center size and density should incorporate not only mortality but also the region's ability to absorb surges in volume, and the optimal "staffing" ratios for the multidisciplinary aspects of burn care.

Pancreas transplant and incidental Meckel's diverticulum: not always a straightforward decision.

INTRODUCTION: Unexpected intraoperative findings are not rare in surgical practice. Meckel's diverticulum with a mass is one such example. There are only two previously reported cases of Meckel's in transplantation, and neither involved pancreas transplant. RESULTS AND DISCUSSION: We present a case report of novel surgical technique using a Meckel's diverticulectomy site for the duodeno-enterostomy to managing the exocrine secretions of the transplanted pancreas. We also discuss management of Meckel's diverticulum. The patient tolerated the procedure without complication, and continues to have normal renal and pancreatic function without any gastrointestinal (GI) complaints. The excised Meckel's diverticulum contained both gastric and pancreatic tissue. CONCLUSION: Although uncertainty about the best management practices exists in the general surgery patient population, given the potential complications that may arise from Meckel's diverticulum, in transplant patients the Meckel's should be removed when encountered. The point of excision can safely be incorporated into other intestinal anastomoses.

The efficacy of hair and urine toxicology screening on the detection of child abuse by burning.

Abuse by burning is estimated to occur in 1 to 25% of children admitted with burn injuries annually. Hair and urine toxicology for illicit drug exposure may provide additional confirmatory evidence for abuse. To determine the impact of hair and urine toxicology on the identification of child abuse, we performed a retrospective chart review of all pediatric patients admitted to our burn unit. The medical records of 263 children aged 0 to 16 years of age who were admitted to our burn unit from January 2002 to December 2007 were reviewed. Sixty-five children had suspected abuse. Of those with suspected abuse, 33 were confirmed by the Department of Health and Human Services and comprised the study group. Each of the 33 cases was randomly matched to three pediatric (0-16 years of age) control patients (99). The average annual incidence of abuse in pediatric burn patients was 13.7+/-8.4% of total annual pediatric admissions (range, 0-25.6%). Age younger than 5 years, hot tap water cause, bilateral, and posterior location of injury were significantly associated with nonaccidental burn injury on multivariate analysis. Thirteen (39.4%) abused children had positive ancillary tests. These included four (16%) skeletal surveys positive for fractures and 10 (45%) hair samples positive for drugs of abuse (one patient had a fracture and a positive hair screen). In three (9.1%) patients who were not initially suspected of abuse but later confirmed, positive hair test for illicit drugs was the only indicator of abuse. Nonaccidental injury can be difficult to confirm. Although inconsistent injury history and burn injury pattern remain central to the diagnosis of abuse by burning, hair and urine toxicology offers a further means to facilitate confirmation of abuse.

Morphological parameters for assessment of burn severity in an acute burn injury rat model.

Determination of burn severity (i.e. burn depth) is important for effective medical management and treatment. Using a recently described acute burn model, we studied various morphological parameters to detect burn severity. Anaesthetized Sprague-Dawley rats received burns of various severity (0- to 14-s contact time) followed by standard resuscitation using intravenous fluids. Biopsies were taken from each site after 5 h, tissues fixed in 10% neutral-buffered formalin, processed and stained with haematoxylin and eosin. Superficial burn changes in the epidermis included early keratinocyte swelling progressing to epidermal thinning and nuclear elongation in deeper burns. Subepidermal vesicle formation generally decreased with deeper burns and typically contained grey foamy fluid. Dermal burns were typified by hyalinized collagen and a lack of detectable individual collagen fibres on a background of grey to pale eosinophilic seroproteinaceous fluid. Intact vascular structures were identified principally deep to the burn area in the collagen. Follicle cell injury was identified by cytoplasmic clearing/swelling and nuclear pyknosis, and these follicular changes were often the deepest evidence of burn injury seen for each time point. Histological scores (epidermal changes) or dermal parameter depths (dermal changes) were regressed on burn contact time. Collagen alteration (r(2) = 0.91) correlated best to burn severity followed by vascular patency (r(2) = 0.82), epidermal changes (r(2) = 0.76), subepidermal vesicle formation (r(2) = 0.74) and follicular cell injury was useful in all but deep burns. This study confirms key morphological parameters can be an important tool for the detection of burn severity in this acute burn model.

Rural versus urban trauma: demographic influences on autopsy rates.

BACKGROUND: The autopsy has long been considered the gold standard for quality assurance review. Studies characterizing autopsies have been completed in large urban centers, but there is a paucity of research regarding autopsies at rural trauma centers. This is problematic considering that a majority of preventable trauma deaths occur in rural areas and death rates for unintentional injuries in rural populations are higher than urban populations. Rural trauma centers have differing characteristics warranting further research into the demographic differences between rural and urban trauma patients and the effects on autopsy rates. MATERIALS AND METHODS: This is a demographic study of a rural trauma center, University of Iowa Hospitals and Clinics (UIHC), with the goal of identifying characteristics of trauma patients on whom autopsy was performed. Four hundred ninety-six deaths were identified from the trauma registry between January 2002 and May 2007 (231 of which were autopsied) and demographic data (including age, race, length of hospital stay, etc.) regarding these patients was gathered into a database. Univariate and multivariate linear regression models were used to analyze differences between autopsied and non-autopsied trauma patients. Autopsy rate and basic demographics were also compared with 2 recent reports from urban trauma centers. RESULTS: Autopsied patients were younger than non-autopsied patients (mean age 45 y versus 71 y; P < 0.0001) and have a shorter median length of hospital stay (1 d versus 4 d; P < 0.0001). Autopsy rates for patients with blunt trauma were lower than rates for patients with penetrating or burn trauma (42% versus 67% and 56%; P = 0.004). If patients died while on a subspecialty service, they were less likely to have an autopsy. Compared with urban centers, this rural trauma center had lower autopsy rates, higher rates of blunt trauma, a higher mean age of deceased patients, and a lower percentage of males. CONCLUSIONS: UIHC, a rural trauma center, has a number of demographic characteristics that make it unique from urban trauma centers: an older population, lower percentage of male trauma patients, higher rates of blunt trauma, and lower rates of penetrating trauma. All of these factors influenced the lower rate of autopsies completed at rural trauma centers. Within a rural trauma center, those patients less likely to receive autopsy were older patients, those who died after 48 h in the hospital, and patients who suffered blunt injuries. The demographics of trauma patients most likely to receive an autopsy tend to correspond with those of an urban trauma population, thus providing a demographic explanation for the variation in autopsy rates among trauma systems.

Demographics of pediatric burns in Vellore, India.

The American Burn Association, Children's Burn Foundation, and Christian Medical College in Vellore, India have partnered together to improve pediatric burn care in Southern India. We report the demographics and outcomes of burns in this center, and create a benchmark to measure the effect of the partnership. A comparison to the National Burn Repository is made to allow for generalization and assessment to other burn centers, and to control for known confounders such as burn size, age, and mechanism. Charts from the pediatric burn center in Vellore, India were retrospectively reviewed and compared with data in the American Burn Association National Burn Registry (NBR) for patients younger than 16 years. One hundred nineteen pediatric patients with burns were admitted from January 2004 through April 2007. Average age was 3.8 years; average total body surface area burn was 24%: 64% scald, 30% flame, 6% electric. Annual death rate was 10%, with average fatal total body surface area burn was 40%. Average lengths of stay for survivors was 15 days. Delay of presentation was common (45% of all patients). Thirty-five of 119 patients received operations (29%). Flame burn patients were older (6.1 years vs 2.6 years), larger (30 vs 21%), had a higher fatality rate (19.4 vs 7.7%), and more of them were female (55 vs 47%) compared with scald burn patients. Electric burn patients were oldest (8.3 years) and all male. When compared with data in the NBR, average burn size was larger in Vellore (24 vs 9%). The mortality rate was higher in Vellore (10.1 vs 0.5%). The average mortal burn size in Vellore was smaller (40 vs 51%). Electric burns were more common in Vellore (6.0 vs 1.6%). Contact burns were almost nonexistent in Vellore (0.9 vs 13.1%). The differences in pediatric burn care from developing health care systems to burn centers in the US are manifold. Nonpresentation of smaller cases, and incomplete data in the NBR explain many of the differences. However, burns at this center in Vellore, India were larger, and occurred to younger patients than burns that reported in the NBR. Individualized assessment of care systems are needed when implementing development plans.

The partnership of the American Burn Association, Children's Burn Foundation, and the Pediatric Burn Team in Vellore, India - a progress report.

Foreign medical service trips, though worthy, raise questions about efficacy, durability, and cultural sensitivity. A structured intervention by a multidisciplinary team can lead to sustained and integrated changes in the delivery of burn care. The American Burn Association, Children's Burn Foundation, and other donors have sponsored four interventions with the Pediatric Burn Center at Christian Medical Center in Vellore, India. Using qualitative research methods, we report our interventions and changes in burn care in Vellore. Using a multifaceted intervention over 2 years, there are skilled and practiced changes in burn care in Vellore, India. These changes involved changes in medical care, nursing care, wound care, operative timing, patient activity, and rehabilitation. Protocols and student and staff education tools have been developed and implemented. Major changes in burn care were observed by the visiting burn team. These skills are practiced and routinely used. The Vellore burn team reports an improvement in nursing satisfaction, patient tolerance, cleanliness, decreased antibiotic use, earlier excision and grafting, and more efficient care. Educational partnerships to improve burn care can induce durable changes, regardless of local language, culture, resources, technology, and skill.

Digital photography: a technique to optimize reimbursement.

Insurance companies may reject claims because of inadequate documentation. Dictated notes or an electronic medical record provide an accurate and complete documentation of services. In a paper-based medical record system, significant amounts of professional fees are lost because the insurance companies reject claims without copies of the note. It is onerous to provide copies of the daily progress notes and bedside procedure notes to the billing service. Retrospective review of billing records for a 12-month period was performed. One partner took daily digital photos of all progress notes and made these available to be submitted with the claim. The other partner did not use this technique. Both partners dictated procedure notes which were available to the billing service for submission. The Wilcoxon's rank-sum test compared the reimbursement rates which were stratified for dictated procedures vs daily notes and insurance type between the two partners. More than 5000 billing submissions were analyzed. The reimbursement rate for procedures was similar for each surgeon (mean 18-19%). The reimbursement rate for daily progress notes was significantly higher for the surgeon using digital photography (mean 38% vs 29%, P < .05 by Wilcoxon's rank-sum test). Digital photography provides an easy means of documenting services. This provides proof of service to insurance companies and improves reimbursement. The same result could be provided by an electronic medical record, or by onsite billing personnel copying the medical record.

Seven years' experience with Integra as a reconstructive tool.

The bilayered dermal substitute Integra (Integra Life Sciences Corp., Plainsboro, NJ) was developed and has been widely used as primary coverage for excised acute burns. Our take has been slightly different, finding it most useful in the management of complex soft-tissue loss and threatened extremities as the result of tendon, joint, or bone exposure. Often tasked to fill significant volume loss, we have become adept at stacked multiple-layer applications. Creative use of this material has resulted in unexpected successes with distal limb salvage; the technique takes its place beside adjacent tissue transfer, composite flaps, and vascular pedicle flaps in our burn reconstructive practice. A prospective registry (44 patients) has been kept during the past 7 years that catalogs wounds with complex soft-tissue loss treated with Integra grafts. Many of these patients were at risk of extremity loss because of exposed tendons, joints, or bone. Integra was applied after 1:1 meshing. With profound soft-tissue defects, multiple layers of Integra were serially applied 1 to 2 weeks apart for reconstitution of soft-tissue contours. Local Integra graft infections were managed by silicone unroofing followed by topical sulfamylon liquid dressings. Wounds addressed included fourth-degree burns, necrotizing fasciitis, pit-viper envenomations, and total abdominal wall avulsion in one patient after being run over by a bus. Patients generally were free of pain from their wounds during the maturation phase of the Integra neodermis. Restoration of tissue contour was significantly better when using multiple layers for deep defects. Second and third layers of Integra were successfully applied after an abbreviated first graft maturation period of 7 days. Epithelial autografts on multilayer Integra applications frequently "ghosted"; they would auto-digest to dispersed cells followed subsequently by the reappearance of a confluent epithelial layer. Final grafted skin morphology over palmar and plantar surfaces assumed the type and fingerprint pattern of the original tissues. Infections were readily visible. Early recognition kept them to easily treated circumscribed areas, which did not jeopardize the entire wound. Lengths of stay were long (range, 2-246 days) but not significantly greater than with traditional techniques. The specific reconstructive use of Integra permitted unexpected salvage of several threatened extremities by protecting exposed tendons, bones and joints. Long-term histologic examination revealed unexpected persistence of Integra collagen. Large volume loss wounds benefited from the ability to fill voids with multilayered applications.

Contemplating the Pentagon attack after five years of space and time: unheard voices from the ramparts of our burn center.

Marking the fifth year after the attack on the Pentagon, staff at the burn center in Washington, DC, memorialize in a contemplative frame of mind. These reflections are drawn from members of the extended burn team and render an interwoven sketch in prose that previously has not been heard.

Acute renal transplant rejection possibly related to herbal medications.

Use of herbal and alternative medications in the United States is increasing. Many of these medications have unknown mechanisms of actions, and possible metabolic interactions with prescribed medications. We report a case of late acute rejection after exposure to two popular herbal medications.