A validity review of the National Burn Repository.

Health-related registries arose because of clinicians' desires to improve patient quality of care for a specific disorder. As such, disease registries differ from administrative registries in concept, organization, purpose, data recording, and results. Because of their voluntary nature, health-related disease registries are not regularly audited, have a narrow focus, and are designed for clinicians, not administrators. As part of a Department of Defense initiative, we conducted an intensive qualitative review of the American Burn Association's National Burn Repository (NBR). Our objectives are to inform future users of the NBR of issues that could affect statistical analyses and inferences and assist efforts to improve data collection. We obtained a deidentified copy of the 2009 release of the NBR containing 286,293 records. We reviewed this data set for 1) records lacking vital patient information (age, burn size, survival, gender); 2) inconsistencies between data in different fields of the database; and 3) duplicate values. By restricting our review to records with an admission year of 2000 or later, we found that vital patient information was missing or invalid for about 60,000 records. Data inconsistencies were found in hospital admission status (initial admission or readmission) for about 12,000 records, survival for about 950 records, and burn injury for about 5500 records. Depending on the criterion used to identify duplicate records, we found at least 4000 duplicate records but as many as 14,000 in the database. Finally, significant data quality issues were found for facilities not using the Trauma Registry for the American College of Surgeons (TRACS) software. All health-related disease registries, unlike administrative databases, are voluntary. Anonymity of data is vital, and data auditing and reporting are challenging. The data contained in the NBR is disease-specific, and, as such, has the potential to provide valuable epidemiologic, treatment, and outcome data as reported by clinicians, not registrars. The NBR provides substantive data on burn injury; however, data review needs to precede data analysis. Revisions to NBR data collection have improved the quality of data submitted, yet data quality issues remain in the current database. Investigators are cautioned to thoroughly assess all fields before conducting analyses using the NBR.

Circulating leptin and cortisol after burn injury: loss of diurnal pattern.

Leptin, a hormone involved in appetite and metabolic energy expenditure, could have a role in the reduced appetite and/or energy expenditure after burn injury. In this study, the diurnal pattern of circulating leptin concentrations was compared with body mass index (BMI), sex, glucose, insulin, and the diurnal cortisol rhythm in burn patients. Plasma samples were collected at 12:00 pm and 02:00 am from severely burned adults and children. Circulating leptin, insulin, and cortisol were measured by radioimmunoassay. Results were compared with previously published data from healthy control subjects. Overall, plasma leptin levels were lower in burn patients (5.7 +/- 1.2 ng/mL) compared with control subjects (10.5 +/- 1.7 ng/mL, P = .02). The normal nocturnal increase of circulating leptin concentrations observed in control subjects was completely absent in burn patients. Cortisol levels were higher in burn patients (20.4 +/- 1.0 mg/dL) than in control subjects (9.8 +/- 1.6 mg/dL, P < .0001) and the normal circadian decrease of circulating cortisol levels was markedly blunted in burn patients. Plasma cortisol did not correlate with circulating leptin levels. Plasma insulin and plasma glucose levels were significantly elevated in burn patients and the insulin:glucose ratio was dramatically increased compared with control subjects. Patients with burn injuries exhibited significantly decreased circulating leptin levels. This decrease may be the result of marked insulin resistance, as suggested by the elevated insulin to glucose ratio in burn patients. The loss of the diurnal pattern in burn patients is likely to result from the continuous nutritional supplementation. Because low leptin levels should induce appetite, burn-related anorexia is probably controlled by other regulatory systems.

Temperature threshold for burn injury: an oximeter safety study.

Pulse oximeters have become essential devices for evaluating and monitoring patient oxygenation. The probe emits a small amount of heat into the skin in the process of signal detection. Regulations set by the Food and Drug Administration currently limit the maximum allowable temperature of an oximeter probe to 41 degrees C. As a result of the prolonged exposure of extremities to these devices, we sought to determine the actual temperature threshold for burn injury in patients. Eighteen patients undergoing surgery for removal of redundant skin (abdominoplasty, breast reduction) consented to the application of a temperature-controlled custom probe with four light-emitting diodes that had temperatures set randomly at the expected threshold for burn injury (42.5 degrees C, 43 degrees C, 43.5 degrees C, and 44 degrees C). The probe was left in place for 8 hours (or less if significant pain was noted). The sites covered by the probes were then checked for signs of injury. On the next day, the redundant skin was removed as a scheduled procedure, and histopathology was performed to detect the extent of burn injury. The study was approved by the local institutional research board. Two patients were excluded because of technical problems with the probe, one of whom had the probe turned off because of pain. The only observed sign of injury was either erythema or a superficial blister that was usually unobservable or slightly red at operation. These subtle signs of a burn were noted in one patient at 43 degrees C, four at 43.5 degrees C, and nine at 44 degrees C. No burns were noted in two patients. Minimal or no signs of injury frequently were noted by histopathology. Pulse oximeter probes are safe up to a temperature of 43 degrees C for at least 8 hours in well-perfused skin. Above that temperature, there is a risk of burn injury. Performing temperature threshold tests in redundant skin that is planned for excision is a potential method for testing the safety of devices or materials.

Saturday-morning television: do sponsors promote high-risk behavior for burn injury?

Television has become an important tool for learning and socialization in children. Although television violence has been associated with adverse effects, data on depiction of fire and burn injury are lacking. We sought to determine whether Saturday-morning television programming, viewed primarily by children, depicts fire and burn injury as safe or without consequence, thus potentially increasing the incidence of burn injury in children. This was a prospective observational study. Saturday-morning children's television programs were videotaped from 7 AM to 11 AM for eight different television networks during a 6-month period. Tapes were scored for scenes depicting fire or smoke by independent observers. Recorded items included show category, scene type, gender target, context of fire, and outcome after exposure to flame. Fire events were documented during programs and their associated commercials. A total of 108 hours of children's programs, 16 hours per network, were recorded. Scenes depicting fire or smoke were identified 1960 times, with 39% of events occurring during the program itself and 61% in commercials. Fire was depicted as either safe or without consequence in 64% of incidents. Action adventure stories accounted for 56% of flame depictions. Overall, one incident involving flame and fire was portrayed for each 3 minutes of television programming. Saturday-morning television programming frequently depicts fire as safe, empowering, or exciting. The incidence of flame use in programming varies between stations but is most prevalent in action/adventure stories. Television commercials, although brief, provide the majority of the misinformation regarding fire. Medical professional societies should alert the public to this potential hazard and recommend responsible portrayal of fire in children's television programming.