Longitudinal profile of routine biomarkers for mortality prediction using unsupervised clustering algorithm in severely burned patients: a retrospective cohort study with prospectively collected data

Purpose@#Burn injury has high clinical heterogeneity and worse prognosis in severely burned patients. Clustering algorithms using unsupervised methods to identify groups with similar trajectories in heterogeneous disease patients can provide insight into mechanisms of disease pathogenesis. This study analyzed routinely collected biomarkers to evaluate mortality prediction, find clinical meanings for these or their subtypes, and evaluate patterns. @*Methods@#This retrospective cohort study included patients aged >18 years, between July 2012 and June 2021. All eligible patients received fluid resuscitation and survived for at least 7 days. Characteristics of clinical interest to the physician at 4 clinically important time points were evaluated. @*Results@#Eligible patients were divided into 4 subgroups according to these time points: from 1st week to 4th week. Total of 1,249 patients admitted within 2 days after burns and receiving fluid resuscitation were included. Mean Harrell’s C-index of pH was the highest (0.816), followed by platelets (0.807), creatinine (0.796), red cell distribution width (RDW, 0.778), and lactate (0.759). Longitudinal profiles among biomarkers were different. @*Conclusion@#The main predictors were pH, platelets, creatinine, RDW, and lactate. Creatinine and RDW showed consistent patterns. The other markers varied according to patient condition. Thus, these markers could provide clues into underlying mechanisms and predict mortality.

Multiple Organ Failure Resulted from Chromic Acid Burn

This case is about 68-years old male patients who was exposed to hexavalent chromic acid on whole body. After the accident, he was transferred to burn center and received massive fluid resuscitation. Despite of the resuscitation, renal failure had pro -gressed and pulmonary dysfunction happened subsequently. Pulmonary dysfunction had aggravated that ECMO was required on hospital day 3, the patient had been transferred to other hospital that could manage the condition of the patient. Soon after the transfer, the patient died. We report this case because the acute chromic acid poisoning lead to multiple organ failure including renal impairment.

Intravenous Colistin Therapy for Multidrug-Resistant Gram-Negative Bacterial Infections in Major Burn Injuries

PURPOSE: The aim of this study was to investigate the characteristics of Acute Kidney Injury Network (AKIN)-defined nephrotoxicity in patients undergoing intravenous colistimethate sodium (CMS) therapy for major burns. METHODS: This retrospective study included burn patients who received more than 48 h of intravenous CMS between September 2009 and December 2015. Data collection was performed using the institution's electronic medical record system. Patients assigned to the developed nephrotoxic group experienced aggravation of current AKIN stage during CMS treatment; those assigned to the non-nephrotoxic group experienced no change in current or exhibited improved AKIN stage during CMS therapy. RESULTS: A total of 306 patients were included in this study. All patients were grouped according to AKIN stage: AKIN 0 (n=152); AKIN 1 (n=6); AKIN 2 (n=9); AKIN 3 (n=139). The baseline creatinine (Cr) level was 0.73 mg/dL. The incidence of nephrotoxicity was 50.3% according to AKIN stage; overall mortality was 45.8%. The non-nephrotoxic group consisted of 127 (74.7%) patients and 43 (25.3%) were in the developed nephrotoxic group. In patients requiring continuous renal replacement therapy (CRRT), baseline Cr level was 0.83 mg/dL, pre-CMS Cr level was 1.17 mg/dL, and post-CMS Cr level was 1.34 mg/dL. CONCLUSION: CMS can be administered without signs of nephrotoxicity for a certain period (approximately 1 week), it can be used relatively safely for 2 weeks. Application of CMS is a reasonable option for treating infections caused by multi-drug resistant gram-negative bacteria in patients with major burns. The caution should be exercised nevertheless.

The Clinical Investigation Study of Pancreatitis Developed in Burn Patients

PURPOSE: To find progression and prognosis of pancreatitis developed in massive burn patients through retrospective analysis. METHODS: A retrospective study was conducted on 32 patients with abnormal increase of serum lipase level among 2523 acute burn patients admitted to our burn center from January 1, 2017 to June 30, 2018. Pancreatitis in this study was defined as a serum lipase concentration level that is higher than 180 IU/L which is three times more than the normal level (less than 60 IU/L). In this study, a retrospective analysis was performed on patients with serum lipase level higher than 300 IU/L to better understand causality of burns and pancreatitis. RESULTS: 32 patients (1.27%) had serum lipase level higher than 180 IU/L among 2523 acute burn subjects. And 13 patients (0.52%) of these 32 patients had serum lipase level elevated more than 300 IU/L. The study indicated serum lipase level was increased around 7 days after the injury. It returned to normal level early as after 1 to 2 weeks and late as after 4 to 6 weeks of injury. The serum amylase level was increased as similar modality as to the serum lipase level increase. The serum bilirubin, AST, ALT, LD, and GGT were also observed to be elevated when serum lipase was more than 1000 IU/L. CONCLUSION: The pancreatitis developed in burn patients are mostly as mild symptom. It could due to the ischemic injury and can easily be treated by a temporary fasting, TPN, and Gabexate intravenous injection.

The Clinical Investigation of Necrotizing Fasciitis in Burn Center

Survival Time Analysis of Severly Burned Patients

PURPOSE: The authors analyzed the survival time of severely burned patients who died and reviewed the time of the death after the burn injury. We aimed to determine any relation to the survival time with most important prognostic factors of the surface area burned and the age. METHODS: Statistical analysis was performed on 275 severely burned victims who died at our burn center of Hangang Sacred Heart Hospital from January 1, 2010 to December 31, 2015 for 6 years. RESULTS: 1. The mean age was 50.12±18.2 years and the average burn size was 61.0±27.1% of total body surface area. 2. Most of the patients (90%) died within 45 days, and 80% died within 30 days. 40% of the patients died within 10 days after burn injury, 20% of the patients died between 10 to 20 days after burn injury, 20% of the patients died between 20 to 30 days after burn injury and the rapid decrease in the number of death was observed after 30 days of burn injury time. 3. The shorter survival time (x-axis) time was observed in the patients with larger area of the burned size (y-axis) and the longer survival time was observed with smaller area of the burned size. The negative correlation was shown as figure 1. 4. There was no correlation shown between the age and the survival time of burn victims after burn injury. CONCLUSION: The mortality rate was significantly decreased at 30 to 40 days after burn injury. Therefore, the burn surgeons need more carefully and diversely plan and perform for the initial treatments since the initial surgical procedures determine the survival of severely burned patients.

Clinical Effectiveness of a Newly Developed Collagen Substitute (InsureGraf®)

PURPOSE: Aim of this study was to assess effects of InsureGraf® (SK-Bioland Co., Korea), an artificial dermis developed by using tissue engineering technology in severe burn patients. METHODS: To examine the clinical effectiveness of InsureGraf®, we transplanted them in patients with severe burns. A total of 14 joint regions in 8 patients received InsureGraf® graft selectively from July to December, 2014. The graft results were determined after confirming the take rate of the transplanted skin graft on top of the InsureGraf®. Take rates were examined twice, at 7 and 14 days after grafting. Photographs of the skin grafts were evaluated individually by two burn surgeon specialists, and the mean values were recorded. RESULTS: The take rate was 99% after day 7 and 100% after day 14 respectively. CONCLUSION: InsureGraf® can be used successfully as an artificial dermis that allows one-stage operation in severe burn patients, exhibiting a successful early-stage graft take rate that is close to 100%.

Limitation and Value of Using the Adenoma Detection Rate for Colonoscopy Quality Assurance

No abstract available.

Usefulness of Negative Pressure Wound Therapy (NPWT) in Burn Center

PURPOSE: Negative pressure wound therapy (NPWT) is an adjunct therapy using negative pressure to remove fluid from open wounds through a sealed dressing and a specialized tubing that is connected to a collection container. NPWT is suitable for acute and chronic wound condition because it was designed to accelerate granulation formation on deep wound. Therefore, we performed this study to assess the effectiveness of NPWT for various wound condition in burn center. METHODS: We enrolled 17 patients who were treated with NPWT from January 2014 to April 2016. We analyzed the characteristics and outcomes of the patients through retrospectively. RESULTS: Among 17 patients, there were 13 patients for contact burn, 2 patients for electrical injury, 1 patient for diabetic foot ulcer and 1 patient for Flame burn. Most of the contact burn victims were injured by the exposure of relatively low temperature for a long time and some of them were injured under the condition of sensory deterioration including spinal cord injury, diabetes or sedatives. Wound coverage was accomplished by split thickness skin graft (STSG) in 12 patients. Local flap was done in 1 patient. STSG with local flap was done in 3 patients. And there were 1 patient who got a conservative management. The duration of NPWT application was from 8 days to 101 days (average 36.2 days). CONCLUSION: NPWT showed good clinical outcomes under various wound condition. Therefore, we think that it can be a new treatment paradigm for difficult wound management in burn center.

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 1beta (MIP-1beta), 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 gamma (IFN-gamma), 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.

Effect of Plant Extracts Contained Dressing Material Which Is Rich in Procyanidins for Treatment of Deep Second Degree Burn

PURPOSE: This study was planned to evaluate the effect of plant extracts contained dressing material which is rich in procyanidins for treatment of deep second degree burn. METHODS: This study conducted from September 1, 2013 to February 28, 2014. Patients with the deep dermal burn wound which is larger than 200 cm2 were enrolled in this study. The test material was applied total 3 times every 2 days when the wounds were relatively clean, with thin eschar and scab removed and the dermal layer exposed. The test and control sites were treated with hydro-foam equally. The effectiveness was evaluated by comparing the re-epithelialization rates between the test and control sites. Two burn surgeons blindly evaluated for re-epithelialization. Evaluation of adverse reaction was also performed during study period. RESULTS: Total of 40 patients were enrolled. Mean total body surface area burned% was 12.3+/-5.5% and the test material was first applied at mean post burn day # 7.2+/-2.0.The re-epithelialization period was 9.0+/-1.7 days in the test site and 11.1+/-2.0 days in the control site. In the test site, re-epithelialization was 2.1+/-1.0 days faster than in the control site (P<0.0001). There was no significant adverse reaction during study period. CONCLUSION: The plant extracts contained dressing material which is rich in procyanidins accelerates wound healing time and shows the safety.

Management of neck contractures by single-stage dermal substitutes and skin grafting in extensive burn patients

PURPOSE: Severe neck contracture is a problem that must be resolved by priority. We consider the best contracture treatment to be the full-thickness skin graft. However, clinicians often encounter patients, especially extensive burn patients, who have insufficient donor sites for the full-thickness skin graft. We treated extensive burn patients with neck scar contractures with a split-thickness skin graft (STSG) combined with dermal substitutes. The purpose of this study was to evaluate clinical outcomes of neck contracture treatment in extensive burn patients performing STSG with dermal substitutes as adjuvant treatment. METHODS: We analyzed the retrospective clinical and photographic records of 28 patients with severe neck contracture who were admitted to Hallym University Hangang Sacred Heart Hospital, Seoul, Korea, from January 2012 to December 2012. We performed STSG in combination with dermal substitutes to minimize the degree of contracture. RESULTS: The overall take rate of skin to dermal substitutes was 95.9%, and no grafts failed to affect recontracture except in one patient with a partial loss of artificial dermis who underwent a follow-up skin graft without any problems. Excellent/good outcomes were shown in 27 out of 28 patients. CONCLUSION: In extensive burn patients, skin grafting in combination with dermal substitutes can be an alternative to STSG alone for contracture release.

Effectiveness of Early Enteral Feeding in Major Burn Patient

PURPOSE: Early enteral feeding is recommended in cases of critical illness. However, it is unclear whether this recommendation is of most benefit to extremely ill patients. From our experiences, our authors believed that early enteral nutrition can lead to better prognosis of ICU patients. We aim to clarify the efficacy of early enteral feeding. METHODS: Eighty six critically ill patients were enrolled and grouped as "Early enteral feeding (EF)" and "Delayed enteral feeding (DF)" for this cross-sectional, prospective randomized observational study. To reduce the selection bias, we compare our groups to 20~39% (group A) TBSA (total body surface area, and 40~59% (group B) TBSA burned. BMI (body mass index), length of ICU stay, length of hospital stay, hospital mortality, serum prealbumin, serum transfferin and lymphocyte count data were collected over 28 days. RESULTS: There were no statistical differences in measured outcomes between early and late feeding groups. In serologic test; prealbumin, transferrin and lymphocyte, there is also no statistical difference except 2nd, 4th week of lymphocyte. EF group has higher lymphocyte than DF group. In the group A, however, prealbumin and transferrin was high in EF group during the whole 4 weeks of study. Comparing the ICU stay and hospital mortality, there was also no statistical significance. CONCLUSION: In this study, there is no significant association between hospital outcomes and timing of enteral feeding initiation. More active trials and many-sided studies will be needed to maximize the effect of early enteral nutritional support as a method to improve treatment for major burned patients.

Non-Adherence to Psychiatric Intervention in Work Related Burns

PURPOSE: Patients with work related burns suffer from anxiety, depression, insomnia and suicide ideation etc. Psychiatric symptoms could be reduced by treatment. Almost all patients are referred to psychiatric intervention in our hospital. However, a number of patients show non-adherence. The aim of this study is to figure out the reason of non-adherence and psychiatric symptoms of work related burns patients. METHODS: 123 patients participated in this study. Startle, Physiological arousal, Anger, and Numbness (SPAN), Feeling Suicide, Patient Health Questionnaire-2 (PHQ-2) were administered as screening tool. Questions about psychiatric intervention and reasons to refuse psychiatric intervention were asked. RESULTS: 32% patients were depressed, 34% patients had suicide ideation and 59% had PTSD after work related burns. However, 46% of burn patients had not been treated. Stigma of psychiatric intervention and concerns about dependency were major reasons for non-adherence. CONCLUSION: There are gap between necessity and reality of psychiatric intervention on work related burn patients.

The Effects of Early Tracheostomy in Flame Burned Patients with Inhalation Injury

PURPOSE: We designed our study to find optimal timing for tracheostomy, and to determine the effects of early tracheostomy on clinical courses in flame burned patients with inhalation injury. METHODS: A retrospective chart review was completed for adult patients admitted to Hangang Sacred Heart Hospital Burn Center, Hallym University Medical Center, Seoul, Korea, between March 1, 2004 and February 28, 2009, who were diagnosed with flame burn with inhalation injury and who underwent tracheostomy during their hospitalization. One hundred eighteen patients were enrolled in this study. Patients were assigned to one of three groups based on the timing of tracheostomy: postburn days (PBD) 0 to 7 [Early tracheostomy (ET) group], 8 to 12 [Intermediate tracheostomy (IT) group], and greater than 13 [Late tracheostomy (LT) group]. We compared incidence of pneumonia, duration on mechanical ventilation, length of stay in intensive care unit (ICU LOS), and survival between groups. To assess the effect of tracheostomy on pulmonary function, we analyzed changes of PaO2/Fio2 (P/F) ratio. RESULTS: There were 46 patients in the ET group, 47 in the IT group and 25 in the LT group. Tracheostomy day (PBD) was 5.2+/-1.7 in ET group, 10.0+/-1.5 in IT group, and 14.8+/-1.9 in LT group (P<0.01). Statistics did not show the correlation between the timing of the tracheostomy and the incidence of pneumonia. Also mortality rate in each group showed no significant differences. There were significant differences between groups for duration on mechanical ventilation and ICU LOS (P<0.01). P/F ratio correlated with time flow showed no significant differences (P=0.10). Also there were no differences between groups in changes of P/F ratio (P=0.08). CONCLUSION: In flame burned patients with inhalation injury who require prolonged mechanical ventilation, performing tracheostomy within PBD 7 may shorten the duration on mechanical ventilation and length of stay in intensive care unit.

Analysis of Serum Vitamin C Level Prescribing 1,000 mg of Vitamin C Daily in Major Burn Patient

PURPOSE: Vitamin C (ascorbic acid) is an well known antioxidant capable of scavenging oxygen free radicals. However, suitable amount of vitamin C level in major burn patients is not established until now. The aim of this study was to investigate the serum level of vitamin C with prescribing 1,000 mg of vitamin C daily to the burn patients in the burn intensive care unit. METHODS: A total of thirty eight patients were enrolled retrospectively from August 2010 to March 2011 admitted to Hangang Sacred Heart Hospital Burn Center, Hallym University. The patients were divided by TBSA (total burn surface area), ABSI (abbreviated burn severity index), and the discharge state whether they survived or not. We checked the serum vitamin C level with prescribing 1,000 mg of vitamin C daily. RESULTS: There were no significant differences between the patients groups in their serum vitamin C level. However, the serum vitamin C level was below the normal range in the all patients groups. CONCLUSION: Higher daily dosage of vitamin C than 1,000 mg should be considered to major burn patients.

Analysis of Serum Zinc Level in Major Burn Patient

PURPOSE: Burn is one of the most severe traumatic conditions. In spite of advances in burn treatment, Complications like wound infection have a significant effect on morbidity and mortality. Therefore, we have an effort to find the methods of improving wound healing. There are many factors to improve in wound healing. Among them, Zn is one of the important factors to wound healing. The aim of study is to evaluate serum Zn level to major burn patient. METHODS: This study was carried out in 31 burn patients retrospectively from August 2010 to March 2011 admitted to Hangang Sacred Heart Hospital Burn Intensive care unit, Hallym University. We checked initial serum Zn level within 7 days of admission without parenteral or enteral Zn supplement. The patients were divided by % TBSA burn, ABSI score and inhalation events. RESULTS: There were significant differences between the patients groups in their serum Zn level, except of inhalation events. The serum Zn level was below the normal range in large percentage of TBSA burned patients. CONCLUSION: It is recommended that the supplement of Zn should be initiated at the early stage of treatment in major burn patients.

Clinical Benefit of Cryoderm in Full Thickness Burns

PURPOSE: CryoDerm (CGbio) is derived donated human skin. After removing epidermis and fibroblast of dermal layer, it preserved with cryo-preservation technique using control rate freezer system. To prevent post burn joint contracture in massive burns, we have used CryoDerm in acute stage. METHODS: From January of 2010 to July of 2012, 50 patients who undergone CryoDerm graft with split thickness skin graft were reviewed. The operative method was as follows: 1) Early wound excision and or cadaveric allograft skin coverage was performed within 5 days after burn injury 2) 2~3 weeks after wound excision, split thickness skin graft was performed with CryoDerm graft. Then graft take rate was investigated by inspection. Follow up duration was 3~32 months. RESULTS: Mean age of patients was 42.2 (2~70) years. Mean percentage of total body surface area burned was 27.22% (1~61%). Among 50 patients, 98 joints was operated including 14 hands, 4 wrists, 10 shoulders, 23 elbows, 4 necks, 3 hip joints, 31 knee joints and 9 ankles and feet. Total used graft size of Cryoderm was 10,945 cm2. Average take rate was near 100%. CONCLUSION: Cryoderm graft with split thickness skin graft can be used as a safe and effective operative method for one stage operation in acutely burned patients.

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.

Serum Lactate and Base Deficit: Early Predictors of Morbidity and Mortality in Burn Patients with Inhalation Injury

PURPOSE: The aim of this study was to elucidate whether plasma lactate (PL) and base deficit (BD) are useful early parameters to predict the prognosis of burn patients with inhalation injury. In addition, one of the main objectives was to evaluate if PL and its change, BD and its change due to fluid resuscitation, adds additional information. METHODS: A retrospective review was performed on 151 patients admitted to our burn intensive care unit who were suspected to have inhalation burn injury, and then were confirmed by fibreoptic bronchoscopy between 1 Jan 2008 and 31 Dec 2008. All patients received proper fluid and electrolyte resuscitation, pain management, nutritional support, wound care and surgical debridement of dead tissue by burn surgeon. RESULTS: Initial PL, PL1 (24 hours later) and initial BD show statistical differences between survivors group and non-survivors group. A better chance of survival occurs when resuscitation results in normal PL values within 24 h. Moreover, an outcome predictor of shock and effective resuscitation could be defined by evaluating the changes of BD on Day 1. Normalization of the BD within 24 h is associated with a better chance of survival. CONCLUSION: Measuring PL, BD and their changes may help to identify burn patients either for adequacy of treatment, or selection of other therapeutic options. Therefore titration of burn resuscitation to normalize PL and BD levels may be a reasonable method to improve burn mortality.