Using competing risk and multistate model to estimate the impact of nosocomial infection on length of stay and mortality in burn patients in Southeast China.

OBJECTIVE: Due to the defects in skin barrier function and immune response, burn patients who survive the acute phase of a burn injury are at a high risk of nosocomial infection (NI). The aim of this study is to evaluate the impacts of NI on length of stay (LOS) and hospital mortality in burn patients using a multistate model. DESIGN AND SETTING: A retrospective observational study was conducted in burn unit and intensive care unit in the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China. PARTICIPANTS: Data were obtained from 1143 records of patients admitted with burn between 1 January 2013 and 31 December 2016. METHODS: Risk factors for NIs were determined by binary logistic regression. The extended Cox model with time-varying covariates was used to determine the impact of NIs on hospital mortality, and cumulative incidence functions were calculated. Multiple linear regression analysis was applied to detect the variables associated with LOS. Using a multistate model, the extra LOS due to NI were determined. RESULTS: 15.8% of total burn patients suffered from NIs and incidence density of NIs was 9.6 per 1000 patient-days. NIs significantly increased the rate of death (HR 4.266, 95% CI 2.218 to 8.208, p=0.000). The cumulative probability of death for patients with NI was greater that for those without NI. The extra LOS due to NIs was 17.68 days (95% CI 11.31 to 24.05). CONCLUSIONS: Using appropriate statistical methods, the present study further illustrated that NIs were associated with the increased cumulative incidence of burn death and increased LOS in burn patients.

NGF accelerates cutaneous wound healing by promoting the migration of dermal fibroblasts via the PI3K/Akt-Rac1-JNK and ERK pathways.

As a well-known neurotrophic factor, nerve growth factor (NGF) has also been extensively recognized for its acceleration of healing in cutaneous wounds in both animal models and randomized clinical trials. However, the underlying mechanisms accounting for the therapeutic effect of NGF on skin wounds are not fully understood. NGF treatment significantly accelerated the rate of wound healing by promoting wound reepithelialization, the formation of granulation tissue, and collagen production. To explore the possible mechanisms of this process, the expression levels of CD68, VEGF, PCNA, and TGF-ß1 in wounds were detected by immunohistochemical staining. The levels of these proteins were all significantly raised in NGF-treated wounds compared to untreated controls. NGF also significantly promoted the migration, but not the proliferation, of dermal fibroblasts. NGF induced a remarkable increase in the activity of PI3K/Akt, JNK, ERK, and Rac1, and blockade with their specific inhibitors significantly impaired the NGF-induced migration. In conclusion, NGF significantly accelerated the healing of skin excisional wounds in rats and the fibroblast migration induced by NGF may contribute to this healing process. The activation of PI3K/Akt, Rac1, JNK, and ERK were all involved in the regulation of NGF-induced fibroblast migration.

Temporizing surgical management improves outcome in patients with Vibrio necrotizing fasciitis complicated with septic shock on admission.

BACKGROUND: Necrotizing fasciitis (NF) caused by Vibrio infection is one of the most fatal diseases, resulting in high morbidity and mortality. Early diagnosis and effective surgical intervention are the mainstays for better outcomes for affected patients. Currently, standard surgical management calls for prompt and aggressive debridement and amputation. However, due to its rapid progression and deterioration, 50-60% of Vibrio NF cases present with septic shock and multiple organ dysfunction on admission. These patients, who usually have many surgical contraindications, are unable to tolerate a prolonged aggressive surgical debridement. Therefore, determining the optimal surgical intervention for these particularly severe patients remains a formidable problem in emergency medicine. METHODS: A retrospective study was conducted on patients who underwent surgery for Vibrio NF and septic shock on admission to the emergency room from April 2001 to October 2012. These patients received the same treatment protocol, with the exception of the initial surgical intervention strategy. Nineteen patients were treated with a temporizing strategy, which called for simple incisions and drainage under regional anesthesia, followed by complete debridement 24h later. Another fifteen patients underwent aggressive surgical debridement during the first operative procedure. Basic demographics, laboratory results on admission, clinical course and outcomes were compared to assess the efficacy and safety of two initial surgical treatment methods: the temporizing strategy and the aggressive strategy. RESULTS: Thirty-four patients were included in this study, and the average age was 51.65 years. Chronic liver disease was the most prevalent preexisting condition (50.00%) and the lower limbs were most commonly involved in infection (76.47%). In this patient population, 19 cases underwent surgery with a temporizing therapeutic strategy, while the remaining 15 cases were treated with an aggressive surgical strategy. There were no differences between the two groups with respect to demographics, severity of illness and laboratory data. Compared with those treated with the aggressive strategy, patients treated with the temporizing strategy had shorter operation time (40.79 ± 16.61 vs. 102.00 ± 18.97 min, p<0.001), less bleeding (120.53 ± 67.20 vs. 417.33 ± 134.72 mL, p<0.001), a reduced amount of intraoperatively administrated fluid (3144.70 ± 554.71 vs. 1637.40 ± 302.11 mL, p<0.001), decreased maximum dose of dopamine (15.73 ± 5.64 vs. 10.47 ± 5.61 µg/kg/min, p=0.011) and noradrenaline (20.13 ± 7.50 vs. 13.37 ± 6.18 µg/kg/min, p=0.007), lower arterial lactate values at the end of surgery (5.56±1.99 vs. 8.66 ± 3.25 mmol/L, p=0.004), and, most importantly, lower mortality (26.32% vs. 60.00%, p=0.048). All other treatment conditions, such as duration of vasopressor therapy, number of debridement procedures, rate of amputation, ICU length of stay and hospital length of stay, were the same for both groups. CONCLUSION: The temporizing strategy, with early initiation of simple incisions and drainage under regional anesthesia followed by complete debridement 24h later, is more feasible and effective for patients with Vibrio NF complicated with septic shock, as compared with the aggressive surgical debridement strategy.

Surgical treatment of 19 cases with vibrio necrotising fasciitis.

BACKGROUND: Necrotising fasciitis and sepsis caused by the infection of vibrio is a rare but dangerous clinical emergency, with a mortality of 50-100%. Early diagnosis and surgical treatment may improve the prognosis significantly. However, valid emergency operation indications are scarce and need to be explored, which will be helpful for the early recognition and selection of operational procedures in patients with vibrio necrotising fasciitis. METHODS: We retrospectively analysed the patients with vibrio necrotising fasciitis admitted to the emergency department of our hospital from July 2000 to June 2009. The surgical treatment strategy was summarised in order to provide clinical evidence for surgical treatment of vibrio necrotising fasciitis. RESULTS: A total of 19 cases of vibrio necrotising fasciitis were selected in our study. All the patients were living along the coast, and 68.4% had a history of chronic liver disease, 78.9% had a history of ethanol abuse, 52.6% had fever, 89.5% were complicated with septic shock and 31.6% progressed to multiple-organ dysfunction syndrome. Rapidly progressive local swelling and pain as well as skin superficial venous stasis were the early presentations of vibrio necrotising fasciitis, while skin ecchymosis, blisters or blood blisters, necrosis and subcutaneous crepitation were the presentations of the advanced stage. Seventeen patients received emergency incision and drainage, subcutaneous vein thrombosis, subcutaneous tissue necrosis, muscle and full-thickness necrosis observed in the operation, and necrotising fasciitis was confirmed by exploration or pathologic examination. Selective debridement and skin graft was performed to repair the wound after operation, and amputation was performed on two patients to close the wound. The average length of stay was 21.3 days (1-82 days), and eight patients died, with mortality being 42.1%. CONCLUSION: Rapidly progressive local damage and acute deterioration of the patients are the most distinctive clinical manifestations of vibrio necrotising fasciitis. Recognition of the signs of local skin and tissue damage in early stage is crucial for early diagnosis and surgical intervention. Emergency incision and drainage, combined with selective debridement and skin graft, could improve the prognosis of the patients, and preserve the integrity of the patient's limbs as much as possible.

[Comparison of cost between two ways of skin grafting in the treatment of patients with extensive deep burn].

OBJECTIVE: To evaluate the economic significance of Meek skin grafting and automicrografting combined with large piece of allogenous skin (micrografting in brief) in the treatment of patients with extensive deep burn. METHODS: Twenty-four patients with extensive deep burn admitted to the First Affiliated Hospital of Wenzhou Medical College were divided into Meek skin grafting group and micrografting group, with 12 patients in each group. Statistical comparison between Meek skin grafting group and micrografting group in respect of wound healing time, consumption of each special dressing, total cost of hospitalization, rehabilitation cost during convalescence was made. Then the cost and effect value was compared between two groups. RESULTS: The wound healing time, consumption of each special dressing, total cost of hospitalization and rehabilitation cost in Meek skin grafting group was (14.4 +/- 1.9) d, yen(16 590 +/- 521), yen(421 628 +/- 145), yen(39 571 +/- 225), respectively, and that in micrografting group was (25.6 +/- 4.2) d, yen (136 441 +/- 356), yen(539 526 +/- 686), yen(55 853 +/- 794), respectively. The difference between two groups were statistically significant (P < 0.01). CONCLUSIONS: In a definite range of burn size, Meek skin grafting has a lower therapeutic cost and better therapeutic effects as compared with micrografting.

[A protocol for diagnosis and treatment of Vibrio vulnificus sepsis].

OBJECTIVE: Vibrio vulnificus sepsis is one of the most fatal disease with a high mortality which exceeds 50%. But at present there is no evidence-based guidelines for diagnosis and therapy of Vibrio vulnificus sepsis because of its dispersion in occurrence and low incidence. METHODS: Based on our ten-year research and review of literature, we try to draft a protocol to improve the diagnostic criteria and treatment of Vibrio vulnificus sepsis. Animal experiments and clinical research were undertaken and the related literature from CINK and PUBMED were reviewed. RESULTS: (1)A criterion for early clinical diagnosis of Vibrio vulnificus sepsis was proposed, including an abrupt onset with fever during the months from April to November, characteristic cutaneous lesions (most commonly haemorrhagic bullae on the extremities) or even extensive necrosis of skin and muscular tissue, progressive hypotension or shock accompanied by multiple organ dysfunction syndrome (MODS), preexisting liver disease or chronic abuse use of alcohol, and consumption of raw seafood or contact with seawater within 1-2 weeks. (2)The best antibiotic therapy is early administration of a combination of the third-generation cephalosporins and the quinolones in full dosage. (3)Aggressive wound debridement, appropriate dermoplasty and supportive care contribute to a better outcome. CONCLUSION: This protocol will help improve the outcome of patients with Vibrio vulnificus sepsis. But it is a crude guideline and needs to be updated when some important new knowledge becomes available.

[The influence of combined supplementation of glutamine and recombinant human growth hormone on the protein metabolism in severely burned patients].

OBJECTIVE: To investigate the influence of combined supplementation of glutamine (Gln) and recombinant human growth hormone (rhGH) on the protein metabolism in severely burned patients. METHODS: Sixty severely burned patients were enrolled in the study and were randomly divided into control (C, n = 20) and Gln with rhGH (Gln + rhGH, n = 20) groups. The patients in C group received glycine as the placebo, while those in Gln group took Gln orally in dose of 0.5 g kg(-1) d(-1) during 1-14 postburn days (PBDs). For the patients in Gln + rhGH group rhGH was administered subcutaneously in dose of 0.2 U kg(-1) d(-1) in addition to glutamine in same dosage beginning on the 7 PBD for 7 days. The plasma Gln concentration in the 3 groups of patients was determined on the 1st, 7th and 14th PBD and the plasma albumin level was determined on 14th and 21st PBD. The wound healing rate of the patients within 30 PBSs and the total hospital stay days were recorded. RESULTS: The plasma Gln concentration in Gln + rhGH group of patients was evidently higher than that in C group after 7 PBD[(452.28 +/- 21.72) micromol/L vs(325.12 +/- 25.34) micromol/L, P < 0.05]. The plasma albumin level in Gln + rhGH group was obviously higher than that in C and Gln groups on the 21st PBD (P < 0.05). The wound healing rate in Gln + rhGH group was evidently higher than that in Gln and C groups on the 30th PBD (P < 0.05). The total hospital stay days in Gln + rhGH group were obviously less than that in C and Gln groups (P < 0.05 or 0.01). CONCLUSION: Combined administration of Gln and rhGH could be beneficial to the elevation of plasma Gln level in severely burned patients and the systemic protein synthesis was therefore enhanced and the wound healing rate was improved.