Sprayed cultured autologous keratinocytes in the treatment of severe burns: a retrospective matched cohort study.

The standard treatment of burns is early excision followed by autologous skin grafting. The closure of extensive deep burns poses a considerable challenge. Cultured autologous keratinocytes have been used since 1981 in an effort to improve healing. However, the time required to culture the cells and the lack of a dermal component limit the expectations of outcome. Our aim was to compare the duration of hospital stay between patients who were treated with autologous skin grafts and cultured autologous keratinocytes and those who were treated with autologous skin grafting without cultured autologous keratinocytes. In this retrospective study all patients treated with cultured autologous keratinocytes between 2012 and 2015 were matched by size and depth of burn with patients not treated with cultured autologous keratinocytes. Multivariable regression was used to analyse associations between duration of hospital stay and treatment adjusted for age, mortality, size and depth of the burn. Then, we investigated the possibility of differentiation of human bone marrow stem cell line to keratinocyte- like cells as a future direction. The regression analysis showed a coefficient of 17.36 (95% CI -17.69 to 52.40), p= 0.32, for hospital stay in the treatment group, compared with the matched group. Our results showed no difference in the duration of hospital stay between the two treatments. Autologous stem cells should be considered as a future modality of burn management, although further studies are needed.

Le traitement de référence des brûlures est l'excision- greffe précoce, qui est problématique en cas d'atteinte étendue. La culture de kératinocytes autologues est utilisée depuis 1981 dans le but de répondre à cette problématique mais se heure au temps nécessaire à sa mise en oeuvre, ainsi qu'à l'absence de feuillet dermique, génératrice de séquelles. Cette étude a comparé la durée de séjour des patients traité par excision- greffe et culture de kératinocytes à celle des patients traités de manière conventionnelle. Les patients hospitalisés entre 2012 et 2015 ont été comparés à des patients de même surface et profondeur traités conventionnellement, en utilisant une analyse multivariée ajustée sur l'âge, la mortalité, la surface et la profondeur de la brûlure. L'analyse n'est pas significative (coefficient 17,36 ; IC95 -17,69 à 52,4 ; p= 0,32). Il serait utile d'étudier l'utilisation des cellules souches médullaires, différentiées en kératinocytes, dans un protocole de culture.

Self-inflicted burns in a National Swedish Burn Centre: an overview.

In the Western world, self-inflicted burns are often associated with mental health disorders, and the management, particularly the pain treatment, can often be complicated by the psycho-social background of the patients. The aim was to describe a group of patients with self-inflicted burns by analysing their in-hospital mortality and the use of sedation during procedures. All patients with self-inflicted burns admitted to the Linköping Burn Centre during 2000-2017 were included. The control group consisted of adults (≥17 years) with accidental burns, admitted during the same period. Multivariable logistic and linear regression was used for analysis. Three percent of all patients (47/1601) had self-inflicted burns: most of them were men (60%, 28/47), none was younger than 17 years, and flame was the major cause of injury. Self-inflicted burn patients were younger and had larger burns: mean age (SD) was 42 (16) and 49 (20) years, respectively; mean TBSA (SD) was 29% (26) and 14% (17), respectively. The crude rate of procedures done under sedation was higher (mean (SD) 0.37 (0.23) compared with 0.24 (0.25)) as was crude in-hospital mortality (8/47, 17% compared with 72/1018, 7%). Multivariable analyses showed no difference in the use of sedation for procedures or in-hospital mortality after adjustment for TBSA%, full thickness burns, age and sex. Age and TBSA% were associated with in-hospital mortality, whereas the intentionality of the burn was not. TBSA% and female sex were associated with increased use of sedation for wound care procedures, whereas self-inflicted burns were not.

Dans les pays développés, les brûlures volontaires entrent souvent dans le cadre d'une pathologie psychiatrique, qui peut interférer avec leur traitement, en particulier l'analgésie. Le but de cete étude était de décrire un groupe de patients brûlés par tentative de suicide hospitalisés dans le CTB de Linköping entre 2000 et 2017, en analysant la mortalité et le recours à la sédation, comparativement à une population d'adultes (≥ 17 ans) hospitalisés durant la même période après une brûlure accidentelle. Nous avons utilisé une analyse logistique linéaire multivariée. Les suicidants représentaient 3% des patients (47/1 601), 60% (28/47) étaient des hommes, aucun n'avait moins de 17 ans et une flamme était le plus souvent cause de la brûlure. Les suicidants étaient plus jeunes (42 +/- 16 VS 49 +/- 20 ans) et plus extensivement brûlés (29 +/- 26% VS 14 +/- 17%). Les pansement étaient plus fréquemment réalisés sous sédation (37 +/- 23% des cas VS 24 +/- 25%) et la mortalité était plus élevée (17% - 8/47 VS 7% - 72/1018). En analyse multivariée et après ajustement sur la surface brûlée, on ne trouve pas de différence de mortalité, de recours à la sédation, de brûlures profondes, d'âge ni de sexe, la surface brûlée et l'âge étant associées à la mortalité mais pas le caractère intentionnel. Les femmes avaient plus souvent besoin de sédation que les hommes, le recours à la sédation tant en outre associé à la surface brûlée mais pas l'inentionnalité.

Deaths caused by injury among people of working age (18-64) are decreasing, while those among older people (64+) are increasing.

BACKGROUND: Injury is an important cause of death in all age groups worldwide, and contributes to many losses of human and economic resources. Currently, we know a few data about mortality from injury, particularly among the working population. The aim of the present study was to examine death from injury over a period of 14 years (1999-2012) using the Swedish Cause of Death Registry (CDR) and the National Patient Registry, which have complete national coverage. METHOD: CDR was used to identify injury-related deaths among adults (18 years or over) during the years 1999-2012. ICD-10 diagnoses from V01 to X39 were included. The significance of changes over time was analyzed by linear regression. RESULTS: The incidence of prehospital death decreased significantly (coefficient -0.22, r 2 = 0.30; p = 0.041) during the study period, while that of deaths in hospital increased significantly (coefficient 0.20, r 2 = 0.75; p < 0.001). Mortality/100,000 person-years in the working age group (18-64 years) decreased significantly (coefficient -0.40, r 2 = 0.37; p = 0.020), mainly as a result of decrease in traffic-related deaths (coefficient -0.34, r 2 = 0.85; p < 0.001). The incidence of deaths from injury among elderly (65 years and older) patients increased because of the increase in falls (coefficient 1.71, r 2 = 0.84; p < 0.001) and poisoning (coefficient 0.13, r 2 = 0.69; p < 0.001). CONCLUSION: The epidemiology of injury in Sweden has changed during recent years in that mortality from injury has declined in the working age group and increased among those people 64 years old and over.

Change in child mortality patterns after injuries in Sweden: a nationwide 14-year study.

INTRODUCTION: Sweden has one of the world's lowest child injury mortality rates, but injuries are still the leading cause of death among children. Child injury mortality in the country has been declining, but this decline seems to decrease recently. Our objective was therefore to further examine changes in the mortality of children's death from injury over time and to assess the contribution of various effects on mortality. The underlying hypothesis for this investigation is that the incidence of lethal injuries in children, still is decreasing and that this may be sex specific. PATIENTS AND METHODS: We studied all deaths from injury in Sweden under-18-year-olds during the 14 years 1999-2012. We identified those aged under 18 whose underlying cause of death was recorded as International Classification of Diseases, 10th Revision (ICD-10) diagnosis from V01 to X39 in the Swedish cause of death, where all dead citizens are registered. RESULTS: From the 1 January 1999 to 31 December 2012, 1213 children under the age of 18 died of injuries in Sweden. The incidence declined during this period (r = -0.606, p = 0.02) to 3.3 deaths/100,000 children-years (95 % CI 2.6-4.2). Death from unintentional injury was more common than that after intentional injury (p < 0.0001). There was a reduction in the incidence of unintentional injuries during the study period (r = -0.757, p = 0.03). The most common causes of death were injury to the brain (n = 337, 41 %), followed by drowning (n = 109, 13 %). The number of deaths after intentional injury increased (r = 0.585, p = 0.03) and at the end of the period was 1.5 deaths/100,000 children-years. The most common causes of death after intentional injuries were asphyxia (n = 177, 45 %), followed by injury to the brain (n = 76, 19 %). DISCUSSION: Mortality patterns in injured children in Sweden have changed from being dominated by unintentional injuries to a more equal distribution between unintentional and intentional injuries as well as between sexes and the overall rate has declined further. These findings are important as they might contribute to the preventive work that is being done to further reduce mortality in injured children.

Scald management protocols - outcome differences in two different time periods using different treatment strategies.

Over the years the treatment of scalds in our centre has changed, moving more towards the use of biological dressings (xenografts). Management of scalds with mid dermal or deep dermal injuries differs among centers using different types of dressings, and recently biological membrane dressings were recommended for this type of injury. Here we describe differences in treatment outcome in different periods of time. All patients with scalds who presented to the Linkoping Burn Centre during two periods, early (1997-98) and later (2010-12) were included. Data were collected in the unit database and analyzed retrospectively. A lower proportion of autograft operations was found in the later period, falling from 32% to 19%. Hospital stay was shorter in the later period (3.5 days shorter, p=0.01) and adjusted duration of hospital stay/TBSA% was shorter (1.2 to 0.7, p=0.07). The two study groups were similar in most of the studied variables: we could not report any significant differences regarding outcome except for unadjusted duration of hospital stay. Further studies are required to investigate functional and aesthetic outcome differences between the treatment modalities.

Le traitement des brûlures par liquides chauds a changé avec le temps, évoluant de plus en plus vers l'usage des pansements biologiques (xénogreffes). La prise en charge de ce type de brûlures (de profondeur moyenne ou profonde) diffère suivant les centres qui utilisent différents types de pansements et plus récemment, les membranes biologiques ont été recommandées pour ce type de traumatisme. Dans cette étude, nous décrivons les résultats thérapeutiques obtenus au cours de différentes périodes. Tous les patients avec des brûlures par liquides chauds admis au Centre de brûlés Linkoping pendant deux périodes d'abord de 1997-1998 et plus tard de 2010 à 2012 ont été inclus. Les résultats de notre banque de données ont été recueillis et analysés de façon rétrospective. Une proportion basse de greffes cutanées a été retrouvée dans la dernière période passant de 32% à 19%. Le séjour à l'hôpital a été également raccourci dans cette période (3,5 jours en moins, p= 0,01) et la durée d'hospitalisation en rapport avec l'étendue a diminué (1,2 à 0,7, p=0,07). Les résultats dans les deux groupes étaient semblables dans la plupart des variables étudiées: nous ne trouvons pas de différence significative sur le plan des résultats, excepté pour la durée d'hospitalisation. De nouvelles études sont nécessaires pour évaluer les divers résultats fonctionnels et esthétiques en fonction des modalités thérapeutiques.

Temporary coverage of burns with a xenograft and sequential excision, compared with total early excision and autograft.

During the 80s and 90s, early and total excision of full thickness burns followed by immediate autograft was the most common treatment, with repeated excision and grafting, mostly for failed grafts. It was hypothesized, therefore, that delayed coverage with an autograft preceded by a temporary xenograft after early and sequential smaller excisions would lead to a better wound bed with fewer failed grafts, a smaller donor site, and possibly also a shorter duration of stay in hospital. We carried out a case control study with retrospective analysis from our National Burn Centre registry for the period 1997-2011. Patients who had been managed with early total excision and autograft were compared with those who had had sequential smaller excisions covered with temporary xenografts until the burn was ready for the final autograft. The sequential excision and xenograft group (n=42) required one-third fewer autografts than patients in the total excision and autograft group (n=45), who needed more than one operation (p<0.001). We could not detect any differences in duration of stay in hospital / total body surface area burned% (duration of stay/TBSA%) (2.0 and 1.8) (p=0.83). The two groups showed no major differences in terms of adjusted duration of stay, but our findings suggest that doing early, smaller, sequential excisions using a xenograft for temporary cover can result in shorter operating times, saving us the trouble of making big excisions. However, costs tended to be higher when the burns were > 25% TBSA.

Pendant ces dernières décades, l'excision précoce et totale des brûlures profondes, suivie immédiatement d'autogreffe a constitué le traitement le plus habituel avec souvent, en cas d'échec, des excisions répétées et de nouvelles greffes. Nous avons pensé, cependant, que la couverture par autogreffe retardée, précédée par une couverture temporaire par xénogreffe après des excisions itératives et moins larges permettait d'obtenir un meilleur lit receveur avec moins d'échecs, des sites donneurs plus petits et une durée d'hospitalisation moindre. Nous avons ainsi mené une étude analytique rétrospective dans notre Centre National de Brûlés pendant la période 1997-2011. Les patients qui avaient été traités par une excision précoce totale suivie d'autogreffe ont été comparés à ceux qui avaient eu des petites excisions séquentielles, couvertes de façon temporaire par des xénogreffes jusqu'à ce que la brûlure soit prête pour une autogreffe finale. Le groupe excision séquentielle et xénogreffe (n=42) a nécessité un tiers de moins d'autogreffes que les patients qui avaient une excision totale suivie d'autogreffe (n=45) et plus d'une seule opération (p<0001). Nous n'avons pas remarqué de différence dans la durée d'hospitalisation en fonction de l'étendue de la surface brûlée (durée du séjour TBSA%) (2,0 et 1,8) (p=0,83). Les deux groupes n'ont pas montré de différence majeure en terme de durée d'hospitalisation, mais l'excision précoce, limitée et séquentielle avec une xénogreffe temporaire, permet de réduire le temps opératoire et évite les excisions trop généreuses. Cependant les coûts ont tendance à être plus élevés avec les brûlures de 25% ou plus de TBSA.

Acute kidney injury is common, parallels organ dysfunction or failure, and carries appreciable mortality in patients with major burns: a prospective exploratory cohort study.

INTRODUCTION: The purpose of this study was to determine the incidence, time course, and outcome of acute kidney injury after major burns and to evaluate the impact of possible predisposing factors (age, gender, and depth and extent of injury) and the relation to other dysfunctioning organs and sepsis. METHOD: We performed an explorative cohort study on patients with a TBSA% (percentage burned of total body surface area) of 20% or more who were admitted to a national burn centre. Acute kidney injury was classified according to the international consensus classification of RIFLE (Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease). Prospectively collected clinical and laboratory data were used for assessing organ dysfunction, systemic inflammatory response, and sepsis. RESULTS: The incidence of acute kidney injury among major burns was 0.11 per 100,000 people per year. Of 127 patients, 31 (24%) developed acute kidney injury (12% Risk, 8% Injury, and 5% Failure). Mean age was 40.6 years (95% confidence interval [CI] 36.7 to 44.5), TBSA% was 38.6% (95% CI 35.5% to 41.6%), and 25% were women. Mortality was 14% and increased with increasing RIFLE class (7% normal, 13% Risk, 40% Injury, and 83% Failure). Renal dysfunction occurred within 7 days in 55% of the patients and recovered among all survivors. Age, TBSA%, and extent of full thickness burns were higher among the patients who developed acute kidney injury. Pulmonary dysfunction and systemic inflammatory response syndrome were present in all of the patients with acute kidney injury and developed before the acute kidney injury. Sepsis was a possible aggravating factor in acute kidney injury in 48%. Extensive deep burns (25% or more full thickness burn) increased the risk for developing acute kidney injury early (risk ratio 2.25). CONCLUSIONS: Acute kidney injury is common, develops soon after the burn, and parallels other dysfunctioning organs. Although acute kidney injury recovered in all survivors, in higher acute kidney injury groups, together with cardiovascular dysfunction, it correlated with mortality.

Cardiac dysfunction after burns.

OBJECTIVES: Using transoesophageal echocardiography (TEE) we investigated the occurrence, and the association of possible abnormalities of motion of the regional wall of the heart (WMA) or diastolic dysfunction with raised troponin concentrations, or both during fluid resuscitation in patients with severe burns. PATIENTS AND METHODS: Ten consecutive adults (aged 36-89 years, two women) with burns exceeding 20% total burned body surface area who needed mechanical ventilation were studied. Their mean Baux index was 92.7, and they were resuscitated according to the Parkland formula. Thirty series of TEE examinations and simultaneous laboratory tests for myocyte damage were done 12, 24, and 36h after the burn. RESULTS: Half (n=5) the patients had varying grades of leakage of the marker that correlated with changeable WMA at 12, 24 and 36h after the burn (p< or =0.001, 0.044 and 0.02, respectively). No patient had WMA and normal concentrations of biomarkers or vice versa. The mitral deceleration time was short, but left ventricular filling velocity increased together with stroke volume. CONCLUSION: Acute myocardial damage recorded by both echocardiography and leakage of troponin was common, and there was a close correlation between them. This is true also when global systolic function is not deteriorated. The mitral flow Doppler pattern suggested restrictive left ventricular diastolic function.

Human cardiovascular dose-response to supplemental oxygen.

AIM: The aim of the study was to examine the central and peripheral cardiovascular adaptation and its coupling during increasing levels of hyperoxaemia. We hypothesized a dose-related effect of hyperoxaemia on left ventricular performance and the vascular properties of the arterial tree. METHODS: Oscillometrically calibrated arterial subclavian pulse trace data were combined with echocardiographic recordings to obtain non-invasive estimates of left ventricular volumes, aortic root pressure and flow data. For complementary vascular parameters and control purposes whole-body impedance cardiography was applied. In nine (seven males) supine, resting healthy volunteers, aged 23-48 years, data was collected after 15 min of air breathing and at increasing transcutaneous oxygen tensions (20, 40 and 60 kPa), accomplished by a two group, random order and blinded hyperoxemic protocol. RESULTS: Left ventricular stroke volume [86 +/- 13 to 75 +/- 9 mL (mean +/- SD)] and end-diastolic area (19.3 +/- 4.4 to 16.8 +/- 4.3 cm(2)) declined (P < 0.05), and showed a linear, negative dose-response relationship to increasing arterial oxygen levels in a regression model. Peripheral resistance and characteristic impedance increased in a similar manner. Heart rate, left ventricular fractional area change, end-systolic area, mean arterial pressure, arterial compliance or carbon dioxide levels did not change. CONCLUSION: There is a linear dose-response relationship between arterial oxygen and cardiovascular parameters when the systemic oxygen tension increases above normal. A direct effect of supplemental oxygen on the vessels may therefore not be excluded. Proximal aortic and peripheral resistance increases from hyperoxaemia, but a decrease of venous return implies extra cardiac blood-pooling and compensatory relaxation of the capacitance vessels.

[Burn injuries in Sweden 1987-1996. The number of hospitalized patients has been reduced and the mortality lowered by 70 per cent]. / Brännskador i Sverige 1987-1996. Antalet sjukhusvårdade har minskat och dödligheten sjunkit med 70 procent.

Continuous improvement in burn trauma care has led to decreasing mortality, morbidity, and length of hospital stay. Current data from the Swedish population is lacking, which was the reason for this investigation. Data was gathered from the Swedish database for medical care (based on ICD-9). All Swedish care providers are enrolled and assumed to report data. Hence, the quality of the database is considered reasonably good, although data from individual patients may be incorrectly recorded due to clerical errors. Available data indicate that the number of burn victims seeking medical care has decreased by 16% during the past decade, whereas mortality has decreased by 70%! The demographic data is otherwise similar to what has previously been reported in the international literature.