Analysis of cases of suicide by self-immolation in the post-mortem material of the Department of Forensic Medicine in Cracow. / Analiza przypadków samobójstw przez podpalenie w materiale sekcyjnym Zakladu Medycyny Sadowej w Krakowie.

Aim: Analysis of self-immolation cases and distribution of the resulting burns and their degree. Material and methods: The study included 16 cases from the Department of Forensic Medicine, Jagiellonian University Medical College in Cracow from 2000-2022 in which the cause of death was self-immolation. Based on the analysis of photographs and autopsy reports, drawings were made showing the exact distribution and nature of the injuries, moreover, the approximate percentage of body surface area affected was determined as well as the frequency of involvement of specific areas of the body, and the presence of previous diseases and mental disorders including previous suicide attempts. Results: 81% of victims were male. Two age groups were predominant among the cases analyzed, namely, individuals around the age of 20, and those between 50 and 60 years of age. 44% of the deceased had burns exceeding 80% of total body surface. The most frequently involved body areas were the extremities and chest as well as head and neck. Fourth-degree burns were most prevalent on the head and neck, third-degree burns prevailed on the upper and lower extremities, second-degree burns were mostly found on the chest, and first-degree burns - on the lower extremities. There were no cases of fourth-degree burns of the buttocks. 38% of the subjects had a history of substance abuse, 56% suffered from mental illnesses, whereas 31% attempted suicide in the past. Conclusions: The distribution of burns in self-immolation cases is inhomogeneous. The most frequently affected area was the head, neck, chest and extremities, most likely due to victims dousing themselves with a flammable substance from the top of the head through the chest. In all cases, the immediate cause of death was burn disease, regardless of the size of the body surface area affected by the burns. The majority of victims had a history of mental illness, substance abuse or suicide attempts.

Frequency, complications, and mortality of inhalation injury in burn patients: A systematic review and meta-analysis protocol.

INTRODUCTION: Burns are tissue traumas caused by energy transfer and occur with a variable inflammatory response. The consequences of burns represent a public health problem worldwide. Inhalation injury (II) is a severity factor when associated with burn, leading to a worse prognosis. Its treatment is complex and often involves invasive mechanical ventilation (IMV). The primary purpose of this study will be to assess the evidence regarding the frequency and mortality of II in burn patients. The secondary purposes will be to assess the evidence regarding the association between IIs and respiratory complications (pneumonia, airway obstruction, acute respiratory failure, acute respiratory distress syndrome), need for IMV and complications in other organ systems, and highlight factors associated with IIs in burn patients and prognostic factors associated with acute respiratory failure, need for IMV and mortality of II in burn patients. METHODS: This is a systematic literature review and meta-analysis, according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA). PubMed/MEDLINE, Embase, LILACS/VHL, Scopus, Web of Science, and CINAHL databases will be consulted without language restrictions and publication date. Studies presenting incomplete data and patients under 19 years of age will be excluded. Data will be synthesized through continuous (mean and standard deviation) and dichotomous (relative risk) variables and the total number of participants. The means, sample sizes, standard deviations from the mean, and relative risks will be entered into the Review Manager web analysis software (The Cochrane Collaboration). DISCUSSION: Despite the extensive experience managing IIs in burn patients, they still represent an important cause of morbidity and mortality. Diagnosis and accurate measurement of its damage are complex, and therapies are essentially based on supportive measures. Considering the challenge, their impact, and their potential severity, IIs represent a promising area for research, needing further studies to understand and contribute to its better evolution. The protocol of this review is registered on the International prospective register of systematic reviews platform of the Center for Revisions and Disclosure of the University of York, United Kingdom (https://www.crd.york.ac.uk/prospero), under number RD42022343944.

Prevención de infecciones asociadas a cuidados de la salud en pacientes quemados / Prevention of healthcare-associated Infections in burn patients

Las infecciones asociadas a cuidados de la salud (IACS) son una de las complicaciones más importantes que presentan los pacientes gran quemados. Aumentan su morbimortalidad, la duración de su estadía, el consumo de antimicrobianos y los costos hospitalarios. Las tasas reportadas de IACS son muy variables entre los distintos países y centros de atención.El ánimo de esta publicación es brindar el material necesa-rio y actualizado de las medidas de control de infecciones que se deben implementar en la atención de los quemados ya que no es fácil disponer de información sobre este tema.En la presente revisión se analizaron estudios de distin-tas poblaciones, adultos y niños, con diferentes tipos que-maduras y diversos lugares de atención. Se utilizó como material de referencia las recomendaciones vigentes de la Sociedad Internacional de injurias por Quemaduras (ISBI, por su sigla inglés) y se adicionaron publicaciones y expe-riencias de grupos de trabajo local e internacional referen-tes en el tema.Se describen cinco tipos de medidas de control y preven-ción de IACS: medidas generales, medidas de higiene am-biental, prevención de la infección de los lechos de las que-maduras, profilaxis antibiótica y medidas de prevención de neumonía, infecciones asociadas a catéteres vasculares y vesicales en quemados. Es esencial implementar un enfoque proactivo y multidisci-plinario del control de infecciones en la atención de estos pacientes, generando recomendaciones adaptadas a la realidad de cada centro de salud, destinadas a disminuir las transmisión cruzada de microorganismos, utilizar los antimicrobianos tópicos y sistémicos en forma adecuada, disminuir la multirresistencia, reducir las IACS y su mor-talidad

Healthcare-associated infections (HAIs) are one of the most important complications of severe burn patients. They increase their morbidity and mortality, length of stay, antimicrobial consumption, and hospital costs. Re-ported rates of IACS vary widely across countries and care settings.The purpose of this publication is to provide the nec-essary and up-to-date material on the infection control measures that should be implemented in the care of burn patients, since it is not easy to have information on this subject.In this review, we analysed studies of different popula-tions, adults and children, with different types of burns and different places of care. The current recommenda-tions of the International Society of Burn Injuries (ISBI) were used as reference material, and publications and experiences of local and international working groups on the subject were added. Five types of IACS control and prevention measures are described: General mea-sures, Environmental hygiene measures, Prevention of infection of burn injuries, Antibiotic prophylaxis and pre-vention measures for pneumonia, infections associated with vascular and bladder catheters in burn patients.Conclusion: It is essential to implement a proactive and multidisciplinary approach to infection control in the care of these patients, generating recommendations adapted to the reality of each health center, aimed at reducing cross-transmission of microorganisms, using typical and systemic antimicrobials appropriately, reduc-ing multiresistance, reducing HAIs and their mortality

Mortality prediction models for severe burn patients: Which one is the best?

BACKGROUND: For prediction of mortality and clinical course, various scoring systems had been developed. We choose four well known burn specific scoring systems and a general scoring system that using in Intensive Care Units. The primary outcome of this study was evaluate the predictive performances of this models and define the optimal one for our patient population. METHODS: Variables analyzed were age, gender, burn type, total burned surface area (TBSA), total partial thickness burn area, total full thickness burn area, inhalation injuries, mechanical ventilation supports, blood products usage, total scores of Abbreviated Burn Severity Index (ABSI), revised Baux, Belgian Outcome in Burn Injury, Fatality by Longevity, Acute Physiology and Chronic Health Eval-uation II (APACHE II) score, Measured Extent of burn and Sex (FLAMES) and APACHE II, and their relations with mortality. RESULTS: In our study, a statistically significant relationship was found with mortality between age, TBSA, full thickness burn percent-age, inhalation injury, burn type, and it was similar to literature. Female gender was found to be a significant risk factor for mortality. CONCLUSION: We compared several burn mortality scoring systems and their predictional mortality rates. ABSI scores of patients for estimated mortality rates were similar to our mortality rate. Consequently, it was thought that ABSI was included all mortality-re-lated parameters.

Growth Differentiation Factor-15 Correlates with Mortality and Severity in Severe Burns.

BACKGROUND: Growth differentiation factor-15 (GDF-15) is expressed in almost all tissues of the body and is necessary for the body's defense response to stress such as inflammation. It has been reported to be associated with incidence and mortality in many diseases, including systemic inflammatory response syndromes. There are no reports on GDF-15 in burns. The purpose of this study was to investigate the trend of GDF-15 in blood in patients with severe burns and to determine its relationship with severity and mortality. METHODS: This was a retrospective, observational, single-center study. The level of GDF-15 in the blood was measured and compared with clinical parameters, including prognosis. Time points for sample collection were the day of injury, 4 days after injury, and 1 week after injury. RESULTS: Eighty-three patients were enrolled in the study. At all time points, GDF-15 levels in the nonsurvivor group were significantly higher than those in the survivor group. In the analysis using the ROC curve for 28-day survival, the AUC of the GDF-15 value on the day of injury was 0.798, which was higher than those of % total body surface area, burn index, and Sequential Organ Failure Assessment (SOFA) score. GDF-15 levels correlated positively with SOFA score, and the relationship became stronger along with the time course of severe burn. CONCLUSIONS: In the acute phase of severe burn, GDF-15 levels were associated with mortality and SOFA scores.

Severity of thermal burn injury is associated with systemic neutrophil activation.

Burn injuries elicit a unique and dynamic stress response which can lead to burn injury progression. Though neutrophils represent crucial players in the burn-induced immunological events, the dynamic secretion pattern and systemic levels of neutrophil-derived factors have not been investigated in detail so far. Serum levels of neutrophil elastase (NE), myeloperoxidase (MPO), citrullinated histone H3 (CitH3), and complement factor C3a were quantified in burn victims over 4 weeks post injury. Furthermore, the potential association with mortality, degree of burn injury, and inhalation trauma was evaluated. In addition, leukocyte, platelet, neutrophil, and lymphocyte counts were assessed. Lastly, we analyzed the association of neutrophil-derived factors with clinical severity scoring systems. Serum levels of NE, MPO, CitH3, and C3a were remarkably elevated in burn victims compared to healthy controls. Leukocyte and neutrophil counts were significantly increased on admission day and day 1, while relative lymphocytes were decreased in the first 7 days post burn trauma. Though neutrophil-derived factors did not predict mortality, patients suffering from 3rd degree burn injuries displayed increased CitH3 and NE levels. Accordingly, CitH3 and NE were elevated in cases with higher abbreviated burn severity indices (ABSI). Taken together, our data suggest a role for neutrophil activation and NETosis in burn injuries and burn injury progression. Targeting exacerbated neutrophil activation might represent a new therapeutic option for severe cases of burn injury.

Extracorporeal Membrane Oxygenation for Pediatric Burn Patients: Is Management Improving Over Time?

Over the last few decades, extracorporeal membrane oxygenation (ECMO) has become a lifesaving modality for patients with severe respiratory failure following burn injury. With the advancement in critical care and ECMO management, this study aims to analyze the outcomes of ECMO in pediatric burn patients. The Extracorporeal Life Support Organization database was queried from 1999 to 2018 for patients 18 years old and under with a burn injury. The data were divided into two decades, the first (1999-2008) and the second (2009-2018), for analysis of background characteristics and clinical outcomes. Ninety-five patients met inclusion criteria. The overall use of ECMO increased in the second decade (60 cases) when compared to the first decade (35 cases), and use of venovenous ECMO increased in the second decade from 16 cases to 38 cases. Although more patients survived because of the increased application of venovenous ECMO, the survival rate was unchanged between decades (53.4% vs. 54.3%; P = 0.937). Patients with pre-ECMO cardiac arrest had a significant improvement in mortality during the second decade (54.5% vs. 0%; P = 0.043). Metabolic (P = 0.022) and renal (P = 0.043) complications were most common in nonsurvivors during the first decade whereas cardiovascular (P = 0.031) and neurologic (P = 0.003) complication were higher in the second decade (P = 0.031, 0.003). Use of ECMO after burn injury has become more common; however, overall mortality remains unchanged. The data suggests pre-ECMO cardiac arrest is no longer a contraindication to start ECMO.

Determinando el pronóstico del paciente gran quemado: correlación del Índice de Garcés con el Abbreviated Burn Severity Index (ABSI) / Defining the prognosis of the burned patient: correlation of the Garces Index with the Abbreviated Burn Severity Index (ABSI)

Resumen Introducción: Existen distintos scores pronósticos para determinar probabilidad de muerte en pacientes quemados. El Índice de Garcés (IG) utilizado en Chile, no es aceptado mundialmente. Objetivo: Decidimos evaluar la correlación entre IG y Abbreviated Burn Severity Index (ABSI), de uso generalizado. Materiales y Método Estudio descriptivo analítico transversal de pacientes quemados subidos a la plataforma online "Registro Nacional de Quemados" y luego ingresados a nuestro centro entre julio de 2017 y julio de 2018. Se calculó coeficiente de correlación de Pearson entre IG y ABSI. Se normalizan ambas variables para hacerlas comparables y se calculó concordancia entre estas con coeficiente de correlación de Lin. Con análisis de regresión logística se calculó probabilidad de fallecer asociada para ambas variables y se compararon áreas de las curvas ROC de ambos scores. Resultados: De 141 pacientes, 15 fallecieron durante hospitalización, con medias de IG de 104 ± 49 puntos y ABSI 7 ± 2. El coeficiente de correlación de Pearson entre IG y ABSI demostró ser muy alto con un valor de 0,928. El coeficiente de correlación de Lin entregó concordancia moderada con un valor de 0,93. Al comprobar cuál de las dos puntuaciones predice mejor la probabilidad de muerte mediante análisis de sensibilidad y especificidad, la curva ROC cubre más área en IG (0,82 vs. 0,83), sin ser estadísticamente significativo. Conclusiones: Ambos índices, IG y ABSI, son muy similares para predecir la probabilidad de muerte, por lo cual son equiparables a la hora de compartir resultados de estudios científicos.

Introduction: There are different prognostic scores to determine the probability of death in burned patients. The Garces Index (GI) used in Chile is not accepted worldwide. Aim: We decided to evaluate the correlation between IG and Abbreviated Burn Severity Index (ABSI), which is widely used. Materials and Method: Cross-sectional analytical and descriptive study of burned patients uploaded to the online platform "National Burns Registry" and then admitted to our center between July 2017 and July 2018. Pearson's correlation coefficient between IG and ABSI was calculated. Both variables were normalized to be able to make them comparable and the agreement between them was calculated with Lin's correlation coefficient. With logistic regression analysis, the associated probability of death was calculated for both variables and areas of the ROC curves of both scores were compared. Results: Of 141 patients, 15 died during hospitalization, with a mean GI 104 ± 49 and ABSI 7 ± 2. Pearson's correlation coefficient between GI and ABSI showed a very high correlation with a value of 0.928. Lin's correlation coefficient gave moderate agreement with a value of 0.93. When checking which of the two scores best predicts the probability of death through sensitivity and specificity analysis, the ROC curve covers more area in IG (0.82 vs 0.83) without being statistically significant. Conclusions: Both scores, IG and ABSI, are very similar when it comes to predicting the probability of death, which is why they are comparable at the time of sharing the results in scientific studies.

Magnitude of mortality and its associated factors among Burn victim children admitted to South Gondar zone government hospitals, Ethiopia, from 2015 to 2019.

BACKGROUND: Burn is one of the leading causes of preventable death and disability every year in low and middle-income countries, which mainly affects those aged less than 15 years. Death from burn injuries carries the most significant losses, which often have grave consequences for the countries. Even though data from different settings are necessary to tackle it, pieces of evidence in this area are limited. Thus, this study was aimed to answer the question, what is the Magnitude of Mortality? And what are the factors associated with mortality among burn victim children admitted to South Gondar Zone Government Hospitals, Ethiopia, from 2015 to 2019? METHODS: Institutional-based cross-sectional study design was used to study 348 hospitalized burn victim pediatrics', from 2015 to 2019. A simple random sampling method was used. Data were exported from Epidata to SPSS version 23 for analysis. Significant of the variables were declared when a p-value is < 0.05. RESULT: The mortality rate of burn victim children in this study was 8.5% (95% CI = 5.5-11.4). Medical insurance none users burn victim children were more likely (AOR 3.700; 95% CI =1.2-11.5) to die as compared with medical insurance users, burn victim children with malnutrition were more risk (AOR 3.9; 95% CI = 1.3-12.2) of mortality as compared with well-nourished child. Moreover, electrical (AOR 7.7; 95% CI = 1.8-32.5.2) and flame burn (AOR 3.3; 95% CI = 1.2-9.0), total body surface area greater than 20% of burn were more likely (AOR 4.6; 95% CI 1.8-11.8) to die compared to less than 20% burn area and burn victim children admitted with poor clinical condition at admission were four times (AOR 4.1, 95% CI = 1.3-12.0) of mortality compared to a good clinical condition. CONCLUSION: The mortality among burn victim children was higher than most of the studies conducted all over the world. Medical insurance none users, being malnourished, burned by electrical and flame burn, having total body surface area burnt greater than 20%, and having poor clinical condition at addition were significantly associated with mortality of burn victim pediatrics. Therefore, timely identification and monitoring of burn injury should be necessary to prevent mortality of burn victim pediatrics.

Massive Burns: Retrospective Analysis of Changes in Outcomes Indicators Across 18 Years.

The treatment and management of massive burns, defined as burns affecting at least 50% of total body surface area (TBSA), have considerably changed since the 1990s. This study aimed at analyzing if the length of intensive care unit (ICU) stay, the success of skin grafting operations, and the mortality changed in the past 18 years. Between 2000 and 2018, 77 patients were admitted for massive burns to the ICU of a university hospital. Transfers and early care withdrawal precluded inclusion for 38 patients, leaving 39 for analysis. Study variables were year of admission, demographics, burn characteristics, critical care treatment (fluid resuscitation, ventilation, and nutrition), and surgical therapy. Association between outcomes and year of admission was assessed through correlation and logistic regression analysis. Potential confounders were assessed through stepwise linear regression. Patients' characteristics were stable over time with a median age of 36 (25.0-48.0) years, burns 65% (55.0-83.0) TBSA, and deep burns 55% (50.0-68.0) TBSA. Length of ICU stay remained stable at 0.97 (0.6-1.5) days/%TBSA. Mortality was stable as well. Energy and carbohydrate delivery decreased in parallel with the number of infectious episodes per patient. The number of operations was stable, but the take rate of skin grafts increased significantly. The multivariate analysis retained year of admission, weight, the total number of infections, daily lipid intakes, and fluid resuscitation as independent predicting variables.

Factors Associated With Mortality Following Burns Complicated by Necrotizing Skin and Soft Tissue Infections: A Systematic Review and Meta-Analysis of Individual Participant Data.

We reviewed studies with individual participant data of patients who sustained burn injury and subsequently developed necrotizing skin and soft tissue infections (NSTI). Characteristics and managements were compared between patients who lived and patients who died to determine factors associated with mortality. Six databases (PubMed, EMBASE, Cochrane Library, Web of Science, Scopus, and CINAHL) were searched. PRISMA-IPD guidelines were followed throughout the review. Eligible patients sustained a burn injury, treated in any setting, and diagnosed with a NSTI following burn injury. Comparisons were made between burned patients who lived "non-mortality" and burned patients who died "mortality" following NSTI using non-parametric univariate analyses. Fifty-eight studies with 78 patients were published from 1970 through 2019. Non-mortality resulted in 58 patients and mortality resulted in 20 patients. Patients with mortality had significantly greater median %TBSA burned (45%[IQR:44-64%] vs 35%[IQR:11-59%], P = .033), more intubations (79% vs 43%, P = .013), less debridements (83% vs 98%, P = .039), less skin excisions (83% vs 98%, P = .039), more complications (100% vs 50%, P < .001), management at a burn center (100% vs 71%, P = .008), underwent less flap surgeries (5% vs 35%, P = .014), less graft survival (25% vs 86%, P < .001), and less healed wounds (5% vs 95%, P < .001), compared to patients with non-mortality, respectively. Non-mortality patients had more debridements, skin excised, systemic antimicrobials, skin graft survival, flaps, improvement following surgery, and healed wounds compared to mortality patients. Mortality patients had greater %TBSA burned, intubations, management at a burn center and complications compared to non-mortality patients.

The Impact of Plastic Surgery Volume on Inpatient Burn Outcomes.

BACKGROUND: Acute burn care involves multiple types of physicians. Plastic surgery offers the full spectrum of acute burn care and reconstructive surgery. The authors hypothesize that access to plastic surgery will be associated with improved inpatient outcomes in the treatment of acute burns. METHODS: Acute burn encounters with known percentage total body surface area were extracted from the National Inpatient Sample from 2012 to 2014 based on International Classification of Diseases, Ninth Edition, codes. Plastic surgery volume per facility was determined based on procedure codes for flaps, breast reconstruction, and complex hand reconstruction. Outcomes included odds of receiving a flap, patient safety indicators, and mortality. Regression models included the following variables: age, percentage total body surface area, gender, inhalation injury, comorbidities, hospital size, and urban/teaching status of hospital. RESULTS: The weighted sample included 99,510 burn admissions with a mean percentage total body surface area of 15.5 percent. The weighted median plastic surgery volume by facility was 245 cases per year. Compared with the lowest quartile, the upper three quartiles of plastic surgery volume were associated with increased likelihood of undergoing flap procedures (p < 0.03). The top quartile of plastic surgery volume was also associated with decreased odds of patient safety indicator events (p < 0.001). Plastic surgery facility volume was not significantly associated with a difference in the likelihood of inpatient death. CONCLUSIONS: Burn encounters treated at high-volume plastic surgery facilities were more likely to undergo flap operations. High-volume plastic surgery centers were also associated with a lower likelihood of inpatient complications. Therefore, where feasible, acute burn patients should be triaged to high-volume centers. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Addition of admission lactate levels to Baux score improves mortality prediction in severe burns.

Risk adjustment and mortality prediction models are central in optimising care and for benchmarking purposes. In the burn setting, the Baux score and its derivatives have been the mainstay for predictions of mortality from burns. Other well-known measures to predict mortality stem from the ICU setting, where, for example, the Simplified Acute Physiology Score (SAPS 3) models have been found to be instrumental. Other attempts to further improve the prediction of outcome have been based on the following variables at admission: Sequential Organ Failure Assessment (aSOFA) score, determinations of aLactate or Neutrophil to Lymphocyte Ratio (aNLR). The aim of the present study was to examine if estimated mortality rate (EMR, SAPS 3), aSOFA, aLactate, and aNLR can, either alone or in conjunction with the others, improve the mortality prediction beyond that of the effects of age and percentage total body surface area (TBSA%) burned among patients with severe burns who need critical care. This is a retrospective, explorative, single centre, registry study based on prospectively gathered data. The study included 222 patients with median (25th-75th centiles) age of 55.0 (38.0 to 69.0) years, TBSA% burned was 24.5 (13.0 to 37.2) and crude mortality was 17%. As anticipated highest predicting power was obtained with age and TBSA% with an AUC at 0.906 (95% CI 0.857 to 0.955) as compared with EMR, aSOFA, aLactate and aNLR. The largest effect was seen thereafter by adding aLactate to the model, increasing AUC to 0.938 (0.898 to 0.979) (p < 0.001). Whereafter, adding EMR, aSOFA, and aNLR, separately or in combinations, only marginally improved the prediction power. This study shows that the prediction model with age and TBSA% may be improved by adding aLactate, despite the fact that aLactate levels were only moderately increased. Thereafter, adding EMR, aSOFA or aNLR only marginally affected the mortality prediction.

Adipose browning response to burn trauma is impaired with aging.

BACKGROUNDThe incidence of burn injuries in older patients is dramatically increasing as the population of older people grows. Despite the increased demand for elderly burn care, the mechanisms that mediate increased morbidity and mortality in older trauma patients are unknown. We recently showed that a burn injury invokes white adipose tissue browning that leads to a substantially increased hypermetabolic response associated with poor outcomes. Therefore, the aim of this study was to determine the effect of age on the metabolic adipose response of browning after a burn injury.METHODOne hundred and seventy patients with burn injury admitted to the Ross Tilley Burn Centre were prospectively enrolled and grouped by age as older (≥50 years) and young (≤35 years). Adipose tissue and sera were collected and analyzed for browning markers and metabolic state via histology, gene expression, and resting energy expenditure assays.RESULTSWe found that older patients with burn injury lacked the adipose browning response, as they showed significant reductions in uncoupling protein 1 (UCP1) expression. This failure of the browning response was associated with reduced whole-body metabolism and decreased survival in older patients with burn injury. Mechanistically, we found that the adipose of both aged patients after burn trauma and aged mice after a burn showed impairments in macrophage infiltration and IL-6, key immunological regulators of the browning process after a severe trauma.CONCLUSIONTargeting pathways that activate the browning response represents a potential therapeutic approach to improve outcomes after burn trauma for elderly patients.FUNDINGNIH (R01-GM087285-01), Canadian Institutes of Health Research (grant no. 123336), and Canada Foundation for Innovation Leaders Opportunity Fund (no. 25407).

Characteristics of burn casualties treated at role 2 in Afghanistan.

BACKGROUND: Role 2 medical treatment facilities (MTFs) are frequently located in austere settings and have limited resources. A dedicated assessment of burn casualties treated at this level of care has not been performed. Therefore, the objective of this study was to characterize burn casualties presenting to role 2 MTFs in Afghanistan, along with the procedures they required, complications, and mortality to begin understanding the resources consumed by their care. METHODS: We identified burn casualties from the Department of Defense Trauma Registry (DODTR). The inclusion criteria were (1) experienced burn injuries in Afghanistan between October 2005 and April 2018 and (2) had documentation of treatment at role 2 in the DODTR. We excluded casualties with only first-degree burns, not otherwise specified burns, or only corneal burns. Casualty demographics, injury characteristics, procedures, and outcomes were reported. RESULTS: We identified 453 burn casualties with a median (interquartile range) Injury Severity Score of 10 (4-22) and percent total body surface area burned of 11 (5-30). There were 123 casualties (27.2%) with inhalation injury, and the casualties experienced 3,343 additional traumatic injuries and needed 2,530 procedures. Casualties with documentation of resuscitation information received a median (interquartile range) of 1.9 (0.7-3.7) L of crystalloid fluids. Complications were documented in 53 casualties (11.7%). Final mortality was reported in 36 casualties (8.0%), and mortality at role 2 MTFs was reported in 7 casualties (1.5%). CONCLUSION: Burn casualties had many injuries and needed many procedures, including those related to airway management, resuscitation, and wound care. Given the urgency of these procedures, ensuring that there is enough equipment and supplies will be important in the future. Although infrequent, some casualties experienced complications. Factors that may influence resuscitation include injury severity, concomitant traumatic injuries, and available supplies. Obtaining more contextual information on the patient care environment will be useful going forward. LEVEL OF EVIDENCE: Epidemiological, level III.

Long-term sequelae of critical illness in sepsis, trauma and burns: A systematic review and meta-analysis.

BACKGROUND: Sepsis, major trauma, and severe burn injury are life-threatening critical illnesses that remain significant contributors to worldwide morbidity and mortality. The three underlying etiologies share pathophysiological similarities: hyperinflammation, hypermetabolism, and acute immunomodulation. The aims of this study were to assess the current state of long-term outcome research and to identify key outcome parameters between the three forms of critical illness. METHODS: This systematic review and meta-analysis (MA) were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. PubMed was searched from January 1, 1975, to December 31, 2019. Studies were assessed for eligibility by independent reviewers. Inclusion criteria were studies reporting at least a 6-month follow-up of health-related quality of life and organ-specific sequelae within the three etiologies: severe burn injury, sepsis, and major trauma. RESULTS: In total, 125 articles could be included in the systematic review and 74 in the MA. The mean follow-up time was significantly longer in burn studies, compared with sepsis and trauma studies. The majority of patients were from the sepsis group, followed by burns, and major trauma studies. In the overall health-related quality of life, as assessed by Short Form 36 and European Quality-of-Life Index, the three different etiologies were comparable with one another. CONCLUSION: The effects of critical illness on survivors persist for years after hospitalization. Well-reported and reliable data on the long-term outcomes are imperative, as they can be used to determine the treatment choice of physicians and to guide the expectations of patients, improving the overall quality of care of three significant patient cohorts. LEVEL OF EVIDENCE: Systematic review and MA, level III.

Epidemiology and outcomes of bloodstream infections in severe burn patients: a six-year retrospective study.

BACKGROUND: Infection is the leading cause of morbidity and mortality among burn patients, and bloodstream infection (BSI) is the most serious. This study aimed to evaluate the epidemiology and clinical outcomes of BSI in severe burn patients. METHODS: Clinical variables of all patients admitted with severe burns (≥ 20% total body surface area, %TBSA) were analyzed retrospectively from January 2013 to December 2018 at a teaching hospital. The Kaplan-Meier method was utilized for plotting survival curves. Multivariate logistic regression and Cox regression model were also performed. RESULTS: A total of 495 patients were evaluated, of whom 136 (27.5%) had a BSI. The median time from the patients being burned to BSI was 8 days. For BSI onset in these patients, 47.8% (65/136) occurred in the first week. The most frequently isolated causative organism was A. baumannii (22.7%), followed by methicillin-resistant Staphylococcus aureus (18.7%) and K. pneumoniae (18.2%), in patients with BSI. Multivariate logistic regression analysis showed that %TBSA (p = 0.023), mechanical ventilation (p = 0.019), central venous catheter (CVC) (p < 0.001) and hospital length of stay (27d vs 50d, p < 0.001) were independent risk factors associated with BSI. Cox regression model showed that acute kidney injury (HR, 12.26; 95% CI 2.31-64.98; p = 0.003) and septic shock (HR, 4.36; 95% CI 1.16-16.34; p = 0.031) were identified as independent predictors of 30-day mortality of BSI in burn patients. CONCLUSIONS: Multidrug resistant gram-negative bacteria were the main pathogens of BSI in severe burn patients. Accurate evaluation of risk factors for BSI and the mortality of BSI in severe burn patients may improve early appropriate management.

Effect of comorbidities on clinical outcome of patients with burn injury - An analysis of the German Burn Registry.

BACKGROUND: Severe burn injuries are associated with high morbidity and mortality. Well-implemented scoring systems for patients with major burns exist in the literature. A major disadvantage of these scores is the partial non-consideration of patient-related comorbidities. Published data on this matter is limited to small study cohorts and/or single center studies. Further, the effect of comorbidities on clinical outcome of patients with severe burn injuries has not yet been examined nationwide in a large cohort in Germany. Hence, the aim of this study was to examine the influence of comorbidities on clinical outcome of these patients based on data from the national registry. METHODS: Anonymized data from a total of 3455 patients with documented burns of 1% or more Total Burn Surface Area (TBSA) and over 16 years of age included in the German Burn Registry between 2017 and 2018 were analyzed retrospectively. Data included burn extent, body weight, age, burn depth, inhalation injury, comorbidities, mortality, number of operations and length of hospital stay (LOS). RESULTS: In the logistic regression analysis age (OR 1.07 [1.06-1.09], p < 0.001), TBSA (OR 1.09 [1.08-1.11], p < 0.001), IHT (OR 2.15 [1.44-3.20], p < 0001), third degree burn (OR 2.08 [1.39-3.11], p < 0.001), Chronic Obstructive Pulmonary Disease (COPD) (OR 2.45 [1.38-4.35], p = 0.002) and renal insufficiency (OR 2.02 [1.13-3.59], p = 0.017) influenced mortality significantly. If a patient had more than one comorbidity, mortality was higher and in-hospital length of stay (LOS) longer. Renal insufficiency was significantly (p < 0.001) associated with the most prolonged LOS by 11.44 days. TBSA (p < 0.001), Abbreviated Burn Severity Index (ABSI) > 3 (p < 0.001) and IHT (p = 0.001) correlated with the amount of required surgeries and significantly predicted the need for intubation. Patients with arrhythmia significantly required more surgeries (p = 0.041), whereas patients with COPD required significantly less surgical interventions (p = 0.013). CONCLUSION: Preexisting comorbidities have a significant impact on the clinical outcome of patients with severe burn injuries. Further investigation is warranted in order to supplement existing prognostic scores with new mortality-associated parameters.

Stevens-Johnson syndrome and toxic epidermal necrolysis: a 10-year experience in a burns unit.

OBJECTIVE: Stevens-Johnson syndrome (SJS) and its more severe counterpart, toxic epidermal necrolysis (TEN), are skin hypersensitivity reactions defined by epidermal blistering and necrosis. The exact pathophysiology of SJS/TEN is yet to be deciphered, but a number of risk factors have been identified including adverse drug reactions. The diagnosis of SJS/TEN is made on a clinical basis, and treatment consists of supportive care and occasionally immunosuppressants, such as cyclosporin, high-dose intravenous immunoglobulins and/or corticosteroids. Mortality rates can reach 20-25% in adults but are reduced with early intervention. To identify optimal treatment regimens, to better understand the patient cohort affected, and to help identify key risk factors for mortality, we report our experience with the treatment and management of SJS/TEN patients. METHODS: A retrospective review of consecutive patients with SJS and/or TEN admitted to a single burns centre in Germany, between 2008 and 2018, was conducted. The primary outcomes of demographics, clinical course, treatment and patient-reported outcomes were recorded and compared with a control group of patients with burns without a diagnosis of SJS/TEN. RESULTS: A total of 23 patients with SJS/TEN met the inclusion criteria: 17 (74%) with TEN; four (17%) with SJS/TEN overlap; and two (9%) with SJS. Of the patients, 14 (61%) were female and nine (39%) were male. Patient age ranged from 32-78 years (mean: 52 years). A matched cohort of 23 patients with burns served as the control group. All patients received standard of care with a multidisciplinary team. Compared with the control group, SJS/TEN patients had higher mortality rates (n=6, 26% versus n=8, 35%, respectively). The average age of death was 69 years in SJS/TEN patients versus 63 years in control group patients. Age and SCORTEN scores were significant predictors of mortality. CONCLUSIONS: SJS and TEN are rare but extreme reactions of the skin and mucosa, associated with high disease mortality rates. This 10-year single-centre retrospective review contributes to the bank of information for reviews evaluating the management of SJS/TEN patients.