Comparative Usefulness of Sepsis-3, Burn Sepsis, and Conventional Sepsis Criteria in Patients With Major Burns.

OBJECTIVES: We evaluated the ability of new sepsis (S3) criteria (compared with previous definitions of sepsis [S1] and burn sepsis criteria) to accurately determine the mortality in severe burns patients with sepsis. DESIGN: This was retrospective cohort study. SETTING: The Burn ICU of Burn Center, Hangang Sacred Heart Hospital, Hallym University, Seoul, Korea. PATIENTS: A total of 1,185 adult patients (mean age, 49.1 yr) were admitted between January 2009 and December 2015. INTERVENTIONS: The 1,185 patients enrolled in the present study and were then re-evaluated based on S1, burn sepsis, and S3 criteria, following which 565 patients, 812 patients, and 809 patients were diagnosed with sepsis based on S1, burn sepsis, S3 criteria, respectively. MEASUREMENTS AND MAIN RESULTS: For diagnostic performance, sensitivity, specificity, predictive value, and likelihood ratio were calculated. The area under the curve of the receiver operating characteristic curve was calculated to determine the accuracy of mortality prediction. The optimal cutoff value of Sequential Organ Failure Assessment score was calculated by the decision tree method. Total body surface area burned was 33.4%. Patients were identified with sepsis using S1 (812), S3 (809), and burn sepsis (565) criteria. Overall mortality was 20.3%, highest (82.2%) and lowest (26.5%) occurred with new septic shock (SH3) and S3, respectively. The sensitivity and specificity for burn sepsis (84.6% and 61.8%) and SH3 (63.1% and 96.5%) were reported. Area under the curve values for Sequential Organ Failure Assessment scores were the highest in all sepsis categories. With Sequential Organ Failure Assessment score greater than or equal to 6 (with infection), the accuracy was 0.86 (95% CI, 0.82-0.89). CONCLUSIONS: The S3 criteria failed to show superior prognostic accuracy for mortality in severely burned patients. Sequential Organ Failure Assessment score greater than or equal to 6 may be a better criterion for the diagnosis of sepsis in burns patients.

Assessment of Plasma Neutrophil Gelatinase-Associated Lipocalin for Early Detection of Acute Kidney Injury and Prediction of Mortality in Severely Burned Patients.

The purpose of this study was to assess the plasma neutrophil gelatinase-associated lipocalin (NGAL) for early detection of acute kidney injury (AKI) and prediction of mortality in severely burned patients. From January 2014 to September 2015, 76 consecutive patients with more than 20% of TBSA burned were enrolled. Blood samples for plasma NGAL were collected at 0, 7, 14, 21, and 28 days after admission and analyzed with injury severity, clinical outcome, and AKI development. Plasma NGAL was significantly affected by the TBSA burned, AKI, and mortality, and it was significantly increased after operation and septic shock. Plasma NGAL was significantly increased within 7 days before AKI development in total patients (P < .001) and septic shock patients (P < .001) but not significantly increased in patients without septic shock (P = .167). Though, in a receiver operating characteristic curve analysis for predicting AKI, continuous renal replacement therapy application, and mortality, plasma NGAL was statistically significant; plasma NGAL was not independently associated with mortality in a multivariate logistic regression analysis. Plasma NGAL should be interpreted carefully in the major burn patients because it can reflect both inflammatory condition and AKI.

Effectiveness and Safety of a Thermosensitive Hydrogel Cultured Epidermal Allograft for Burns.

OBJECTIVE: To retest the safety and effectiveness of a thermosensitive hydrogel-type cultured epithelial allograft (KeraHeal-Allo; MCTT, Seoul, South Korea) and identify the subjective experience of patients and doctors with this product. DESIGN AND SETTING: Prospective interventional phase 3 study in 3 burn centers near Seoul, South Korea. PATIENTS: Thirty-three patients with deep second-degree burns larger than 200 cm (for intervention and control sites of 100 cm each) were enrolled. INTERVENTION: A cultured epithelial allograft containing 2 × 10/1.5 mL keratinocytes was applied to each patient's intervention site. Three principal investigators (1 in each institution) evaluated the effectiveness of the allograft at their institution and the others'. Researchers administered a subjective satisfaction survey during each patient's last visit. MAIN OUTCOME MEASURE: The primary end point of the study was the re-epithelialization period. MAIN RESULTS: The re-epithelialization period for the intervention was 2.8 ± 2.2 days faster than that of control sites at other institutions (P < .001) and 2.5 ± 3.4 days faster than that of control sites in the same institution (P < .001). There were no reported adverse events. Satisfaction scores provided by patients and doctors showed significantly high scores on all items. CONCLUSUIONS: This type of cultured epithelial allograft is safe and well received by patients and providers and promotes re-epithelialization.

Analysis of prognostic factors for acute kidney injury with continuous renal replacement therapy in severely burned patients.

BACKGROUND: Acute kidney injury (AKI) is a critical complications in severely burned patients associated with high morbidity and mortality. The purpose of this study was to investigate the impact of severity of AKI at the time of continuous renal replacement therapy (CRRT) start on patient outcome and to identify the prognostic factors in severely burned patients with CRRT application. METHODS: From January 2007 to June 2010, 84 burn patients with more than 40% of total body surface area (TBSA) burned who treated with continuous renal replacement therapy for acute kidney injury were analyzed retrospectively. RESULTS: There was no significant difference of mortality by the severity of AKI at the time of CRRT start. However, the mean TBSA burned, abbreviated burn severity index, arterial pH, partial pressure of carbon dioxide (PaCO2) and blood urea nitrogen (BUN)/creatinine (Cr) ratio had a statistical significance to predict mortality in receiver operation characteristic curve. In a multivariate logistic regression analysis, only sepsis had an independent association with mortality. CONCLUSIONS: The severity of the AKI at the time of CRRT start did not have significant relationship with patient outcome. CRRT can be applied to minimize the complication of AKI including electrolyte imbalance and volume overload. Because only the presence of sepsis was independently associated with mortality, treatment for sepsis should be focused to improve the survival of the severely burned patients with CRRT.

Development of hepatic blocks using human adipose tissue-derived stem cells through three-dimensional cell printing techniques.

Currently, most acute liver diseases are treated through liver transplantation. However, transplantation is limited by organ donor scarcity and immune rejection response. Moreover, only three types of commercial bio-artificial livers are available, and these have marginal effects on survival rates. Therefore, tissue regenerative medicine using stem cells has been developed to solve such unmet medical needs. In this study, we attempted to differentiate human adipose stem cells (hASCs) into hepatocyte-like cells (AHLCs) and fabricate liver regenerative hepatic block scaffolds, consisting of only hASCs and AHLCs, through three-dimensional cell printing using a neutralized type I atelo collagen solution derived from porcine skin. Hepatic blocks were also treated with genipin, a natural cross-linking reagent, in order to maintain the structure and strength of collagen scaffolds, which contained hASCs and AHLCs. The hepatic blocks were then transplanted into the livers of SD rats to confirm safety and efficiency. The results showed that hASCs and AHLCs inside the hepatic blocks translocated into the portal vein of hepatic lobules in SD rats by 4 weeks after transplantation, as demonstrated by immunohistochemical staining using human nuclear-specific antibodies. Moreover, serum biochemistry, which was altered after induction of acute liver failure by dimethylnitrosamine, returned to normal in hASC scaffold-transplanted rats, and increased levels of interleukin-10 expression were observed in the livers of these rats. Thus, these hepatic blocks consisting of hASCs could be used as alternative bio-artificial livers to facilitate the regeneration of damaged liver tissue.

Evaluation of diagnostic biomarkers for acute kidney injury in major burn patients.

PURPOSE: Acute kidney injury (AKI) in major burn patients is a common complication with high morbidity and mortality. The mainstream treatment is early diagnosis and rapid termination and prevention of the underlying insult. Therefore, it's essential to identify early biomarkers predicting AKI. METHODS: A total of 85 patients who were admitted to the burn intensive care unit from June 2012 to July 2013 were included in this prospective cohort study. Ten biomarkers (blood urea nitrogen, serum creatinine, urine creatinine, cystatin C, cystatin C glomerular filtration rate, AST, lacate dehydrogenase [LD], creatine kinase, lactic acid, and myoglobin) were obtained at time of admission and evaluated as diagnostic biomarkers to predicting AKI and early AKI. RESULTS: Out of 85 patients, 35 patients were dead and overall mortality was 41.2%. The mean age was 49.4 years and mean percentage of total body surface area was 53.2%. Area under the curve (AUC) of receiver operating characteristic curve of biomarkers on predicting AKI were 0.746, 0.718, and 0.717 in LD, lactic acid, and serum creatinine, respectively. AUC of cystatin C predicting AKI was much lower at 0.555. AUC of biomarkers on predicting early AKI were 0.833, 0.816, 0.790, and 0.759 in LD, serum creatinine, AST, and serum myoglobin. CONCLUSION: LD, lactic acid and serum creatinine were acceptable as diagnostic biomarkers of AKI and LD, serum creatinine, AST, and serum myoglobin were reasonable as diagnostic biomarkers of early AKI. However, cystatin C was an unfavorable biomarker in major burn patients.

Serum cystatin C and microalbuminuria in burn patients with acute kidney injury.

BACKGROUND: This study was aimed at evaluating the effectiveness of serum cystatin C and microalbuminuria as diagnostic markers for acute kidney injury (AKI) in major burn patients. MATERIALS AND METHODS: Major burn adult patients admitted to the burn intensive care unit within 24 h from the onset of injury were enrolled. Serum cystatin C and microalbuminuria (albumin-creatinine ratio, ACR) were obtained at postburn days 1, 3, 7, 14, 21 and 28. The patients were divided into two groups of the AKI group and the nonacute kidney injury group. RESULTS: A total of 97 patients were enrolled in this study. Acute kidney injury was diagnosed in 40 patients (41.2%) at postburn day 17.3 ± 7.9. The area under the curve of the receiver operating characteristic curve for serum cystatin C was 0.808 (95% CI, 0.711-0.905, P < 0.001) at postburn day 7 and 0.908 (95% CI, 0.843-0.973, P < 0.001) at postburn day 14. The results were 0.610 (95% CI, 0.497-0.724, P = 0.069) for ACR at postburn day 7 and 0.694 (95% CI, 0.589-0.798, P = 0.001) at postburn day 14. The optimal cut-off value of serum cystatin C at postburn day 14 and ACR at postburn day 14 were 0.85 mg/L (sensitivity, 89.5%; specificity, 82.5%) and 41.51 mg/g cre (sensitivity, 60.5%; specificity, 61.4%), respectively. Serum cystatin C at postburn day 14 was the only significant factor in relation to AKI. CONCLUSIONS: Serum cystatin C is a valuable diagnostic marker, whereas microalbuminuria is a relatively less significant marker for AKI in major burn patients.

The application of cultured epithelial autografts improves survival in burns.

This prospective observational study was performed to analyze the clinical outcomes of patients with massive burns treated using cultured epithelial autografts (CEAs) and to determine the association of this treatment with survival outcomes. During 2006-2013, total 177 massive-burns subjects treated with (96 subjects) or without (81 subjects) CEAs. Data were analyzed using the independent t test or chi-square test. Multivariate logistic regression, Kaplan-Meier survival, and Cox regression analyses were performed to evaluate the factors that influenced mortality. Age, percentage of total body surface area burned, incidence of inhalation injury, allograft-application rate, Abbreviated Burn Severity Index score, length of hospital stay, and mortality significantly differed between the CEA and noncultured epithelial autograft groups. Mortality and other clinical parameters did not differ between the sheet-type and spray-type CEA groups. Allograft application (odds ratio, 4.44; p < 0.01) significantly influenced CEA application. The CEA group showed significantly higher survival rates (p = 0.05). Cultured epithelial autografting had a hazard ratio of 0.55 (p = 0.02) and 0.59 (p = 0.05) according to the uni- and multivariate Cox regression analysis, respectively. In conclusion, early and aggressive allograft application is required to facilitate CEA application. Furthermore, the use of CEAs was associated with a lower mortality, but this result should be interpreted with caution as the groups were not randomized.

Inflammatory cytokines and their prognostic ability in cases of major burn injury.

BACKGROUND: Major burn injuries induce inflammatory responses and changes in the levels of various cytokines. This study was conducted to assess early changes in the serum levels of inflammatory cytokines after burn injury, identify cytokines associated with mortality, and characterize correlations among cytokines. METHODS: Blood samples of 67 burn patients were collected on days 1 and 3 after burn injury, and the concentrations of 27 cytokines were measured using the Bio-Plex Suspension Array System (Bio-Rad Laboratories, USA). Blood samples of 25 healthy subjects were used as controls. We analyzed statistical differences in the concentrations of each cytokine between the control and patient groups, between day 1 and day 3, and between survival and nonsurvival groups. Correlations among 27 cytokines were analyzed. RESULTS: Median concentrations of granulocyte colony-stimulating factor (G-CSF), granulocyte macrophage colony-stimulating factor (GM-CSF), interleukin 1 receptor antagonist (IL-1RA), interleukin 6 (IL-6), interleukin 8 (IL-8), interleukin 10 (IL-10), interleukin 15 (IL-15), monocyte chemoattractant protein-1 (MCP-1), macrophage inflammatory protein 1ß (MIP-1ß), and vascular endothelial growth factor (VEGF) were significantly higher in burn patients than in controls. IL-1RA, IL-6, and MCP-1 levels were significantly higher in the nonsurvival group than in the survival group on day 1 after burn injury. Correlation analysis of 27 cytokines showed different relationships with one another. Stronger correlations among interferon γ (IFN-γ), IL-2, IL-4, IL-7, IL-12p70, and IL-17 were found. CONCLUSIONS: IL-1RA, IL-6, and MCP-1 may be used as prognostic indicators of mortality in burn patients and the increase in cytokine concentrations is induced by interactions within a complex network of cytokine-related pathways.

Epidemiological trends and risk factors in major burns patients in South Korea: a 10-year experience.

PURPOSE: To determine epidemiological trends among burns patients admitted to our burns center during 2003-2012, and the usefulness of the Abbreviated Burns Severity Index (ABSI) for predicting burns-related mortality. METHODS: We retrospectively reviewed the data of 4481 burns patients. We analyzed the epidemiological trends and ABSI scores using Student t-test and one-way analysis of variance (continuous variables), chi-square test (categorical variables) and stepwise logistic-regression analysis (predictors of mortality). RESULTS: The mean age and male-to-female ratio were 39.9±19.7 years and 2.88, respectively. ABSI scores decreased from 7.7±3.0 in 2003 to 6.9±3.0 in 2012. Mortality rate improved from 24.5% in 2003 to 15.8% in 2012. Burns were caused by flames (67.3%), scalding (22.0%) and electrical (7.5%), chemical (1.6%) and contact (1.5%) injuries. Scalding and flames were the most common causes in patients aged ≤20 years and ≥21 years, respectively. Female sex, inhalation injury, full-thickness burns, large total body surface area (TBSA) burned and old age predicted mortality. ABSI scores <4 and >14 were associated with 0.7% and >90% mortality, respectively. CONCLUSIONS: The mortality of major burns has decreased but remains high. ABSI scores predict burns-related mortality.

Inhalation injury in burn patients: establishing the link between diagnosis and prognosis.

This study was to re-evaluate inhalation injury as a prognostic factor in burn patients and to determine the factors that should be considered when refining the definition of inhalation injury. A total of 192 burn patients (152 men, 40 women; mean age, 46.1±13.8 years) who were suspected to have an inhalation injury and underwent bronchoscopy between January 2010 and June 2012 were included in this prospective observational study. All patients underwent bronchoscopy within 24h of sustaining the burn. The bronchoscopic findings were classified as normal, mild, moderate, and severe. Mechanical ventilation was administered, when required. Age, percentage of TBSA burned, ABSI score, requirement of mechanical ventilation and PF ratio, but not inhalation injury, COHb level, and bronchoscopic grades, significantly differed between the survivors and non-survivors (p<0.05). Mechanical ventilation (adjusted odds ratio [OR]: 9.787) and severe inhalation injury on bronchoscopy (adjusted OR: 45.357) were independent predictors of mortality on multivariate logistic regression analysis. Inhalation injury diagnosed through history does not predict mortality from burns. Other components such as severity of inhalation injury determined using bronchoscopy, and administration of mechanical ventilation might help predict the morbidity and mortality of burn patients with inhalation injury and all of the factors should be considered when the definition of inhalation injury is refined.

Assessment of biochemical markers in the early post-burn period for predicting acute kidney injury and mortality in patients with major burn injury: comparison of serum creatinine, serum cystatin-C, plasma and urine neutrophil gelatinase-associated lipocalin.

INTRODUCTION: The reported mortality rates range from 28% to 100% in burn patients who develop acute kidney injury (AKI) and from 50% to 100% among such patients treated with renal replacement therapy. Recently, the serum cystatin C and plasma and urine neutrophil gelatinase-associated lipocalin (NGAL) levels have been introduced as early biomarkers for AKI; the levels of these biomarkers are known to increase 24 to 48 hours before the serum creatinine levels increase. In this study, we aimed to estimate the diagnostic utility of the cystatin C and plasma and urine NGAL levels in the early post-burn period as biomarkers for predicting AKI and mortality in patients with major burn injuries. METHODS: From May 2011 to July 2012, 90 consecutive patients with a burn wound area comprising ≥ 20% of the total body surface area (TBSA) were enrolled in this study. Whole blood and urine samples were obtained for measuring the serum creatinine, serum cystatin C, and urine and plasma NGAL levels at 0, 3, 6, 12, 24, and 48 hours after admission. Receiver operating characteristic curve, area under the curve, and multivariate logistic regression analyses were performed to assess the predictive values of these biomarkers for AKI and mortality. RESULTS: In the multivariate logistic regression analysis, all variables, including age, percentage TBSA burned, sex, inhalation injury, and serum creatinine levels, serum cystatin C levels, and plasma and urine NGAL levels were independently associated with AKI development. Moreover, age, sex, percentage TBSA burned, and plasma and urine NGAL levels were independently associated with mortality. However, inhalation injury and the serum creatinine and cystatin C levels were not independently associated with mortality. CONCLUSIONS: Massively burned patients who maintained high plasma and urine NGAL levels until 12 hours after admission were at the risk of developing early AKI and early mortality with burn shock. However, the plasma and urine NGAL levels in the early post-burn period failed to predict late AKI and non-burn shock mortality in this study. Nevertheless, the plasma and urine NGAL levels were independently associated with AKI development and mortality within 48 hours after admission.

The effect of burn rehabilitation massage therapy on hypertrophic scar after burn: a randomized controlled trial.

OBJECTIVE: To evaluate the effect of burn rehabilitation massage therapy on hypertrophic scar after burn. METHOD: One hundred and forty-six burn patients with hypertrophic scar(s) were randomly divided into an experimental group and a control group. All patients received standard rehabilitation therapy for hypertrophic scars and 76 patients (massage group) additionally received burn scar rehabilitation massage therapy. Both before and after the treatment, we determined the scores of visual analog scale (VAS) and itching scale and assessed the scar characteristics of thickness, melanin, erythema, transepidermal water loss (TEWL), sebum, and elasticity by using ultrasonography, Mexameter(®), Tewameter(®), Sebumeter(®), and Cutometer(®), respectively. RESULTS: The scores of both VAS and itching scale decreased significantly in both groups, indicating a significant intragroup difference. With regard to the scar characteristics, the massage group showed a significant decrease after treatment in scar thickness, melanin, erythema, TEWL and a significant intergroup difference. In terms of scar elasticity, a significant intergroup difference was noted in immediate distension and gross skin elasticity, while the massage group significant improvement in skin distensibility, immediate distension, immediate retraction, and delayed distension. CONCLUSION: Our results suggest that burn rehabilitation massage therapy is effective in improving pain, pruritus, and scar characteristics in hypertrophic scars after burn.

A clinical trial designed to evaluate the safety and effectiveness of a thermosensitive hydrogel-type cultured epidermal allograft for deep second-degree burns.

This study is a phase 1 and 2 clinical trial for investigating the safety profile, effective treatment dose and effectiveness of the newly developed thermosensitive hydrogel-type cultured epidermal allograft. For phase 1, the keratinocytes were divided into 3 groups as follows, with 5 patients in each group: (1) low-dose group (6.7×10(6)/1.5mL), (2) medium-dose group (2×10(7)/1.5mL), and (3) high-dose group (6.0×10(7)/1.5mL). The second phase of the trial proceeded with 10 cases after choosing the most effective dose based on the analysis of the first phase. When comparing re-epithelialization time, medium- and high-dose group showed significantly shorter re-epithelialization time than low-dose group (p=0.003 and p=0.002). A total of 15 cases, 5 cases selected from phase 1 and 10 cases test in phase 2 with the medium dose, were compared with the re-epithelialization period. The re-epithelialization period was 9.6±4.0 days in the test site and 12.4±4.8 days in the control site. In the test site, re-epithelialization was 2.8±1.8 days faster than in the control site (p<0.0001). There was no significant adverse reaction in our clinical trial. In conclusion, this new type of CEAllo accelerates wound healing time and shows the safety.

Serum transthyretin level is associated with clinical severity rather than nutrition status in massively burned patients.

BACKGROUND: The purpose of this study is to clarify the clinical significance of serum transthyretin (TTR) in massively burned patients in nutrition support and clinical severity. METHODS: A retrospective study was performed with 204 patients admitted to Hangang Sacred Heart Hospital's Burn Center September 2010-September 2012 with burn wounds > 20% of total body surface area (TBSA) burned. Serum TTR, C-reactive protein (CRP), lactic acid, and an NST index (calculated by dividing real caloric intake by estimated caloric need for 7 days) were analyzed on a weekly basis for 5 weeks after admission. RESULTS: When we classified patients with severity according to mortality, percentage of TBSA burned, serum lactic acid, and CRP, mean serum TTR level was significantly higher in the less severe patient group than in the severe patient group in each week for every severity index. And the serum TTR level did not show significant differences by NST index in both the severe patient group and the less severe patient group. In a multivariate logistic regression, percentage TBSA burned, TTR, and lactic acid had an independent association with mortality. CONCLUSION: Serum TTR did not show a significant difference by nutrition support in massively burned patients with >20% of TBSA burned. But serum TTR was significantly different by the severity of the patient and independently associated with mortality. Hence, serum TTR level can be 1 of the useful biomarkers for comprehending the severity of the illness in massively burned patients.

Improvement of burn pain management through routine pain monitoring and pain management protocol.

INTRODUCTION: Pain management is an important aspect of burn management. We developed a routine pain monitoring system and pain management protocol for burn patients. The purpose of this study is to evaluate the effectiveness of our new pain management system. METHODS: From May 2011 to November 2011, the prospective study was performed with 107 burn patients. We performed control group (n=58) data analysis and then developed the pain management protocol and monitoring system. Next, we applied our protocol to patients and performed protocol group (n=49) data analysis, and compared this to control group data. Data analysis was performed using the Numeric Rating Scale (NRS) of background pain and procedural pain, Clinician-Administered PTSD Scale (CAPS), Hamilton Depression Rating Scale (HDRS), State-Trait Anxiety Inventory Scale (STAIS), and Holmes and Rahe Stress Scale (HRSS). RESULTS: The NRS of background pain for the protocol group was significantly decreased compared to the control group (2.8±2.0 versus 3.9±1.9), and the NRS of procedural pain of the protocol group was significantly decreased compared to the control group (4.8±2.8 versus 3.7±2.5). CAPS and HDRS were decreased in the protocol group, but did not have statistical significance. STAIS and HRSS were decreased in the protocol group, but only the STAIS had statistical significance. CONCLUSION: Our new pain management system was effective in burn pain management. However, adequate pain management can only be accomplished by a continuous and thorough effort. Therefore, pain control protocol and pain monitoring systems need to be under constant revision and improvement using creative ideas and approaches.

The factors associated with contact burns from therapeutic modalities.

OBJECTIVE: To understand the injury pattern of contact burns from therapeutic physical modalities. METHOD: A retrospective study was done in 864 patients with contact burns who discharged from our hospital from January 2005 to December 2008. The following parameters were compared between patients with contact burns from therapeutic modalities and from other causes: general characteristics, burn extent, cause of burn injury, place of occurrence, burn injury site, treatment methods, prevalence of underlying disease, and length of hospital stay were compared between patients with contact burns. RESULTS: Of the 864 subjects, 94 patients were injured from therapeutic modalities. A hot pack (n=51) was the most common type of therapeutic modality causing contact burn followed by moxibustion (n=21), electric heating pad (n=16), and radiant heat (n=4). The lower leg (n=31) was the most common injury site followed by the foot & ankle (n=24), buttock & coccyx (n=9), knee (n=8), trunk (n=8), back (n=6), shoulder (n=4), and arm (n=4). Diabetes mellitus was associated with contact burns from therapeutic modalities; the odds ratio was 3.99. Injuries took place most commonly at home (n=56), followed by the hospital (n=33), and in other places (n=5). CONCLUSION: A hot pack was the most common cause of contact burns from therapeutic modalities, and the lower leg was the most common injury site. Injuries took place most commonly at home. The patients with contact burns from therapeutic modalities showed high correlation to presence of diabetes mellitus. These results would be helpful for the prevention of contact burns due to therapeutic modalities.

Change of serum phosphate level and clinical outcome of hypophosphatemia in massive burn patient.

BACKGROUND: Hypophosphatemia is relatively common phenomenon in patients with massive burn injury. Therefore, we check serum phosphate level routinely and try to supply phosphate in a timely manner. The purpose of this study was to investigate the change of the serum phosphate level of early postburn period and the impact of hypophosphatemia on the prognosis of patients. METHODS: A total of 227 patients with burn injury were reviewed retrospectively. We performed analysis of serum phosphate level within 20 days from burn injury. RESULTS: Patients' mean (SD) age was 47.0 (14.1) years, and mean (SD) percentage of total body surface area burned were 47.7 (21.9). Severe hypophosphatemia (phosphate < 1.0 mg/dL) was observed in 35 patients (15.8%), and moderate hypophosphatemia (1.0 ≤ phosphate < 2.0 mg/dL) was found in 115 patients (50.6%). Therefore, overall incidence of hypophosphatemia was 66.4%. There was no significant difference in serum phosphate level with survival, total body surface area burned, and mechanical ventilation. Age (odds ratio [OR], 3.180; 95% confidence interval [CI], 1.025-9.871; p = 0.045), total body surface area burned (OR, 20.934; 95% CI, 6.845-64.024; p = 0.000), and mechanical ventilation (OR, 5.581; 95% CI, 2.380-13.085; p = 0.002) were independently associated with mortality. However, serum phosphate level (OR, 0.828; 95% CI, 0.275-2.495; p = 0.737) does not have a statistical significance. CONCLUSION: Although multiple studies have evaluated the efficacy and safety of phosphate repletion regimens, the effect on mortality and morbidity is not well reported. However, our results show that patients with massive burn injury have high incidence of hypophosphatemia, and hypophosphatemia can result in many complications. Therefore, routine check and supply of phosphate can be suggested in patients with massive burn injury. LEVEL OF EVIDENCE: Prognostic study, level II.

Prediction of clinical outcomes for massively-burned patients via serum transthyretin levels in the early postburn period.

BACKGROUND: We observed that serum transthyretin (TTR) levels consistently remain low when patients' general conditions are poor, despite adequate nutritional support. We conducted this study to analyze the changes of serum TTR over time from injury in massively-burned patients and verify the validity of prediction by clinical outcomes, which are assessed via serum TTR in the early postburn period. METHODS: From January 2005 to December 2010, the samples of serum TTR from 471 burn patients (mean % total body surface area [TBSA] burned, 51% ± 20%) were analyzed with time frames from injury retrospectively. RESULTS: Serum TTR significantly decreased during the period from day 5 to day 10 postinjury in both the survival group (n = 290, mean %TBSA burned, 42.9% ± 14.2%) and nonsurvival group (n = 181, mean %TBSA burned, 64.6% ± 20.8%). However, after this period, the serum TTR constantly increased in the survival group but remained low in nonsurvivors. At all time, the levels of serum TTR obtained from survivors were significantly higher than those of nonsurvivors. The serum TTR had weak correlation with the extent of the burn injury (r = -0.234). Survival rates of the patients increased significantly by the increase of the serum TTR of early postburn period. In multivariable model, age (odds ratio [OR], 1.054; 95% confidence interval [CI], 1.043-1.066; p = 0.000), TBSA burned (OR, 1.058; 95% CI, 1.051-1.066; p = 0.000), sex (OR, 0.720; 95% CI, 0.547-0.947; p = 0.019), and serum TTR during early postburn period (OR, 1.05; 95% CI, 0.873-0.972; p = 0.003) were independently associated with mortality. CONCLUSIONS: The serum TTR of early postburn period can be used as a prognostic markers, and low serum TTR can be used as a signal for screening out the patients at risk who need careful assessment and monitoring at an early stage.