Burn Cohort Research Articles

The measured effect magnitude of co-morbidities on burn injury mortality

IntroductionThe ability to better prognosticate burn injury outcome is challenging and historically, most center use the Baux or revised Baux score to help prognosticate burn outcome, however, the weighted contribution of comorbidity on burn mortality has traditionally not been accounted for nor adequately studied. We therefore sought to determine the effect of comorbidities, using the Charlson comorbidity index (CCI) on burn mortality. MethodsThe purpose of this study was to determine the effect of comorbidities on burn injury mortality as determined by the LA50 (lethal TBSA burn at which 50% of the cohort will succumb from the burn injury) in a retrospective analysis of patients admitted to a regional burn center from 2002 to 2012. Independent variables analyzed included basic demographics, burn mechanism, presence of inhalation injury, TBSA (total body surface area), length of hospital stay, and pre-existing comorbidities. Bivariate analysis was performed and logistic regression modeling using significant variables was utilized to estimate odds of death. Results7640 patients were included in this study. Overall survival rate was 96%. 40% of our burn cohort had at least one comorbidity. There was a linear increase in the likelihood of death with an increase in CCI. The logistic regression model for mortality outcomes identified four statistically significant variables: age, TBSA, inhalational injury and the presence of comorbidities (OR=1.59 for each 1 point increase in CCI; 95% CI 1.44–1.77). The unadjusted LA50 was 53% for the entire cohort. Partial adjustment multivariate regression controlling for burn mechanism and inhalation injury only, produced a slight reduction in LA50 for the 0–18 and 19–64 age categories to 76% and 48% TBSA, respectively, but a significant decrease occurred in the ≥65 years age group with a reduced LA50 to 20% TBSA (p<0.001). After full adjustment for all significant covariates, including comorbidities, the independent magnitude of effect of comorbidities on the LA50 was evident in the <65 cohort. The full adjustment showed a LA50 decreased to 61% and 43% TBSA, respectively in the 0–18 and >18–65 age groups respectively (p<0.001), however, in the >65 years age cohort there was no change in the LA50. ConclusionPreexisting comorbidities have a significant effect on burn injury mortality in all age groups, particularly the younger burn population. The measured effect of comorbidities in the >65 yr age cohort was mitigated by the co-linearity between age and comorbidities. The inclusion of CCI is imperative so as to better prognosticate burn outcome and help guide expectations and resource utilization, particularly in the younger burn cohort.

Cost Analysis of 48 Burn Patients in a Mass Casualty Explosion Treated at Chang Gung Memorial Hospital

IntroductionLittle is known about the costs of treating burn patients after a mass casualty event. A devastating Color Dust explosion that injured 499 patients occurred on June 27, 2015 in Taiwan. This study was performed to investigate the economic effects of treating burn patients at a single medical center after an explosion disaster. MethodsA detailed retrospective analysis on 48 patient expense records at Chang Gung Memorial Hospital after the Color Dust explosion was performed. Data were collected during the acute treatment period between June 27, 2015 and September 30, 2015. The distribution of cost drivers for the entire patient cohort (n=48), patients with a percent total body surface area burn (%TBSA)≥50 (n=20), and those with %TBSA <50 (n=28) were analyzed. ResultsThe total cost of 48 burn patients over the acute 3-month time period was $2,440,688, with a mean cost per patient of $50,848 ±36,438. Inpatient ward fees (30%), therapeutic treatment fees (22%), and medication fees (11%) were found to be the three highest cost drivers. The 20 patients with a %TBSA ≥50 consumed $1,559,300 (63.8%) of the total expenses, at an average cost of $77,965±34,226 per patient. The 28 patients with a %TBSA <50 consumed $881,387 (36.1%) of care expenses, at an average cost of $31,478±23,518 per patient. ConclusionsIn response to this mass casualty event, inpatient ward fees represented the largest expense. Hospitals can reduce this fee by ensuring wound dressing and skin substitute materials are regionally stocked and accessible. Medication fees may be higher than expected when treating a mass burn cohort. In preparation for a future event, hospitals should anticipate patients with a %TBSA≥50 will contribute the majority of inpatient expenses.

Increased admissions for diabetes mellitus after burn

BackgroundCurrently, limited long-term data on hyperglycaemia and insulin sensitivity in burn patients are available and the data that do exist are primarily related to paediatric severe burns. The aim of this study was to assess if burn is associated with increased post-burn admissions for diabetes mellitus. MethodsA population-based longitudinal study using linked hospital morbidity and death data from Western Australia was undertaken of all persons hospitalized for a first burn (n=30,997) in 1980–2012 and a frequency matched non-injury comparison cohort, randomly selected from Western Australia's birth registrations and electoral roll (n=123,399). Crude admission rates and summed length of stay for diabetes mellitus were calculated. Negative binomial and Cox proportional hazards regression modelling were used to generate incidence rate ratios (IRR) and hazard ratios (HR), respectively. ResultsAfter adjustment for socio-demographic factors and pre-existing health status, the burn cohort had 2.21 times (95% Confidence Interval (CI): 1.36–1.56) as many admissions and almost three times the number of days in hospital with a diabetes mellitus diagnosis (IRR, 95% CI: 2.94, 2.12–4.09) than the uninjured cohort. Admission rates were significantly elevated for those burned during childhood (<18 years, IRR, 95% CI: 2.65, 1.41–4.97) and adulthood (≥18 years, IRR, 95% CI: 2.12, 1.76–2.55). Incident admissions were significantly elevated in the burn cohort during the first 5 years post-burn when compared with the uninjured (HR, 95% CI: 1.96, 1.46–2.64); no significant difference was found beyond 5 years post-burn (HR, 95% CI: 1.08, 0.82–1.41). ConclusionsFindings of increased hospital admission rates and prolonged length of hospital stay for diabetes mellitus in the burn cohort provide evidence that burns have longer term effects on blood glucose and insulin regulation after wound healing. The first five years after burn discharge appears to be a critical period with significantly elevated incident admissions for diabetes mellitus during this time. Results would suggest prolonged clinical management after discharge and or wound healing to minimise post-burn admissions for diabetes mellitus is required.

Mental health outcomes of burn: A longitudinal population-based study of adults hospitalized for burns

PurposeThis study investigates the increased risk of mental health outcomes and health care utilization associated with burn with two year of follow-up using a longitudinal population-based matched cohort design. MethodsAdult burn survivors (n=157) were identified from a provincial burn registry and matched 1:5 with non-burn control subjects from the general population (matching variables age and gender). The prevalence of mental health outcomes and the rates of health care utilization between the groups were compared for the 2years pre and post index date using anonymously linked population-based administrative health care data. Rates were adjusted for age, gender and sociodemographic characteristics. ResultsWhile the burn cohort had an increased prevalence of mental health problems after burn compared to the control cohort, the burn group also had an increased prevalence of pre-burn depression (16.6% vs 7.8%; p=0.0005) and substance use disorders (8.9% vs 3.2%; p=0.001) when compared to controls. Once the pre-existing prevalence of mental illness was taken into account there was no significant change in the prevalence of mental health problems when comparing the burn group to controls over time. ConclusionsAlthough burns may not increase rates of mental health issues and health care utilization, burn survivors are a vulnerable group who already demonstrate increased rates of psychopathology and need for care. The present study highlights the importance of assessment and treatment of mental health outcomes in this population.

Perineal tap water burns in the elderly: at what cost?

Burn injuries are expensive to treat. Burn injuries have been found to be difficult to treat in elderly patients than their younger counterparts. This is likely to result in higher financial burden on the healthcare system; however, no population-specific study has been conducted to ascertain the inpatient treatment costs of elderly patients with hot tap water burns. Six elderly patients (75-92 years) were admitted for tap water burns at Concord Hospital during 2010. All costs incurred during their hospitalization were followed prospectively, and were apportioned into 'direct' and 'indirect' costs. Direct costs encompassed directly measurable costs, such as consumables used on the ward or in theatres, and indirect costs included hospital overheads, such as bed and theatre costs. Three males and three females admitted with burns to the buttocks, legs or feet. Total burn surface area (TBSA) ranged from 9-21% (mean 12.8%). Length of stay ranged from 26-98 days (mean 46 days). One patient died, and four required surgical management or grafting. Total inpatient costs ranged from $69 782.33 to $254 652.70 per patient (mean $122 800.20, standard deviation $67 484.46). TBSA was directly correlated with length of stay (P < 0.01) and total cost (P < 0.01). Hot water burns among the elderly are associated with high treatment costs, which are proportional to the size of the burn. The cost of treating this cohort is higher than previously reported in a general Australian burn cohort.

Understanding the long-term impacts of burn on the cardiovascular system

BackgroundWhilest the most obvious impact of burn is on the skin, systemic responses also occur after burn that lead to wide-spread changes to the body, including the heart. The aim of this study was to assess if burn in mid-aged and older adults is associated with increased long-term admissions and death due to diseases of the circulatory system. MethodsA population-based longitudinal study using linked hospital morbidity and death data from Western Australia was undertaken of adults aged at least 45 years when hospitalized for a first burn (n=6004) in 1980–2012 and a frequency matched non-injury comparison cohort, randomly selected from Western Australia's electoral roll (n=22,673). Crude admission rates and cumulative length of stay for circulatory diseases were calculated. Negative binomial and Cox proportional hazards regression modelling were used to generate incidence rate ratios (IRR) and hazard ratios (HR), respectively. HR was used as a measure of the mortality rate ratio (MRR). ResultsAfter adjustment for demographic factors and pre-existing health status, the burn cohort had 1.46 times (95% confidence interval (CI): 1.36–1.56) as many admissions and almost three times the number of days in hospital with a circulatory system diagnosis (IRR, 95%CI: 2.90, 2.60–3.25) than the uninjured cohort for circulatory diseases. The burn cohort had higher admission rates for ischaemic heart disease (IRR, 95%CI: 1.21, 1.07–1.36), heart failure (IRR, 95%CI: 2.29, 1.85–2.82) and cerebrovascular disease (IRR, 95%CI: 1.57, 1.33–1.84). The burn cohort was found to have increased long-term mortality caused by circulatory system diseases (MRR, 95%CI: 1.11, 1.02–1.20). ConclusionsFindings of increased hospital admission rates, prolonged length of hospital stay and increased long-term mortality related to circulatory system diseases in the burn cohort provide evidence to support that burn has long-lasting systemic impacts on the heart and circulation.

Outcomes in Adult Survivors of Childhood Burn Injuries as Compared with Matched Controls.

Limited research exists examining long-term mental and physical health outcomes in adult survivors of pediatric burns. The authors examine the postinjury lifetime prevalence of common mental and physical disorders in a large pediatric burn cohort and compare the results with matched controls. Seven hundred and forty five survivors of childhood burns identified in the Burn Registry (<18 years old and total BSA >1% between April 1, 1988 and March 31, 2010) were matched 1:5 to the general population based on age at time of injury (index date), sex, and geographic residence. Postinjury rate ratio (RR) was used to compare burn cases and control cohorts for common mental and physical illnesses through physician billings, and hospital claims. RR was adjusted for sex, rural residence, and income. Compared with matched controls, postburn cases had significantly higher RR of all mental disorders, which remained significant (P < .05) after adjustment (major depression RR = 1.5 [confidence limit {CL}: 1.2-1.8], anxiety disorder RR = 1.5 [CL: 1.3-1.8), substance abuse RR = 2.3 [CL: 1.7-3.2], suicide attempt RR = 4.3 [CL: 1.6-12.1], or any mental disorder RR = 1.5 [CL: 1.3-1.8]). The relative rate of some physical illnesses was also significantly increased in burn survivors: arthritis RR = 1.2 (CL: 1.1-1.4), fractures RR = 1.4 (CL: 1.2-1.6), total respiratory morbidity RR = 1.1 (CL: 1.02-1.3), and any physical illness RR = 1.2 (CL: 1.1-1.3). Adult survivors of childhood burn injury have significantly increased rates of postburn mental and physical illnesses. Screening and appropriate management of these illnesses is essential when caring for this population.

Long-term Effects of Pediatric Burns on the Circulatory System.

The systemic responses to burns (in particular, elevated levels of catecholamines and stress hormones) have been shown to have an impact on cardiac function for at least 3 years in children with burns. However, it is not clear if these changes lead to long-term effects on the heart. The aim of this study was to assess whether pediatric burn injury is associated with increased long-term hospital use for circulatory diseases. A population-based longitudinal study was undertaken using linked hospital and death data from Western Australia for children younger than 15 years when hospitalized for a first burn injury (n = 10 436) in 1980-2012 and a frequency matched noninjury comparison cohort, randomly selected from Western Australia's birth registrations (n = 40 819). Crude admission rates and cumulative length of stay for circulatory diseases were calculated. Negative binomial and Cox proportional hazards regression modeling were used to generate incidence rate ratios and hazard ratios, respectively. After adjustment for demographic factors and preexisting health status, the burn cohort had 1.33 (incidence rate ratio) times (95% confidence interval [CI]: 1.08-1.64) as many circulatory system hospitalizations, 2.26 times the number of days in hospital with a diagnosis of a circulatory disease (2.26, 95% CI: 1.06-4.81), and were at a higher risk of incident admissions (hazard ratio 1.22, 95% CI: 1.03-1.46), compared with the uninjured cohort. Children who sustain burn injury experience elevated hospital admission rates and increased length of hospital stay for diseases of the circulatory system for a prolonged period of time after burn discharge.

Increased admissions for musculoskeletal diseases after burns sustained during childhood and adolescence

BackgroundSevere burn triggers systemic responses that result in reduced muscle mass and bone formation, with recent evidence also suggesting systemic effects on bone after minor burn. The aim of this study was to assess if children and adolescents who are hospitalised with a burn have increased long-term hospital service use for musculoskeletal conditions. MethodsA population-based longitudinal study using linked hospital morbidity and death data from Western Australia was undertaken of those younger than 20 years when hospitalized for a first burn (n=13,244) during the period 1980–2012 and a frequency matched non-injury comparison cohort, randomly selected from Western Australia's birth registrations and electoral roll (n=51,021). Crude admission rates and cumulative length of stay for musculoskeletal diseases were calculated. Negative binomial and Cox proportional hazards regression modelling were used to generate incidence rate ratios (IRR) and hazard ratios (HR), respectively. ResultsAfter adjusting for demographic characteristics and pre-existing health status, those who were hospitalised for a burn had 1.87 times as many hospital admissions for a musculoskeletal disease (95%CI: 1.69–2.08) and spent 2.61 times as long in hospital with musculoskeletal disease (95%CI: 2.09–3.27), than the uninjured comparison cohort. The burn cohort had significantly higher rates of first time admissions over the study period for arthropathies (HR, 95%CI: 1.14, 1.00–1.29, p=0.047), dorsopathies (HR, 95%CL: 1.64, 1.29–2.08) and for soft tissue disorders (HR, 95%CI: 1.33, 1.11–1.60); results were not statistically significant for incident admissions for osteopathies and chrondropathies (HR, 95%CI: 1.07, 0.71–1.59) or connective tissue disorders (HR, 95%CI: 0.54, 0.24–2.09). ConclusionsThese results identified elevated post-discharge hospital service use for diseases of the musculoskeletal system for a prolonged period after discharge for those with both severe and minor burns.

Long-term musculoskeletal morbidity after adult burn injury: a population-based cohort study

ObjectiveTo investigate if adults who are hospitalised for a burn injury have increased long-term hospital use for musculoskeletal diseases.DesignA population-based retrospective cohort study using linked administrative health data from the...

Mortality after burn injury in children: a 33-year population-based study.

To assess the impact of burn injury sustained during childhood on long-term mortality and to quantify any increased risk of death attributable to burn injury. A population-based cohort study of children younger than 15 years hospitalized for burn injury in Western Australia (1980-2012) and a matched noninjured comparison group. Deidentified extraction of linked hospital morbidity and death records for the period 1980-2012 were provided by the Western Australian Data Linkage System. An inception cohort (1980-2012) of burn cases younger than 15 years of age when hospitalized for a first burn injury (n = 10,426) and a frequency matched noninjured comparison cohort (n = 40,818) were identified. Survival analysis was conducted by using the Kaplan-Meier method and Cox proportional hazards regression. Mortality rate ratios and attributable risk percent adjusted for sociodemographic and preexisting heath factors were generated. The median follow-up time for the pediatric burn cohort was 18.1 years after discharge. The adjusted all-cause mortality rate ratios for burn injury was 1.6 (95% confidence interval: 1.3-2.0); children with burn injury had a 1.6 times greater rate of mortality than those with no injury. The index burn injury was estimated to account for 38% (attributable risk percent) of all recorded deaths in the burn injury cohort during the study period. Burn injury sustained by children is associated with an increased risk of long-term all-cause mortality. Estimates of the total mortality burden based on in-hospital deaths alone underestimates the true burden from burn injury.

Tissue expansion for correction of scars due to burn and other causes: A retrospective comparative study of various complications

BackgroundTissue expansion is associated with a relatively high complication rate. The aim of this study was to quantify the complication risk of burn scar patients who underwent tissue expansion in comparison to patients with other indications such as skin tumors. Furthermore it was attempted to compare the complication rates in children and adults. MethodsA retrospective analysis was performed on 148 expanders implanted in 73 patients during the years 1994–2011. Two patient cohorts (burn scar cohort n=31 and other indication cohort n=42) were identified and analyzed. Results27 male and 46 female patients with a median age of 21 years were included. No statistically significant difference for complication risk between the burn and other indication cohorts could be found (p=0.1412). Statistical analyses revealed a higher complication rate (52%) in the lower limb compared to all other anatomic sites (29%) (p=0.1746). In addition, statistical analyses revealed a significantly higher total complication rate in children younger than 10 years (p=0.0043). Moreover a greater TBSA was accompanied by a higher complication rate (p=0.0258). ConclusionThis set of data suggests that the burn scar patient is at no greater risk to suffer complications from tissue expansion. Other factors like age, TBSA and anatomical site have far more influence on the expander complication rate than the initial indication for tissue expansion.

Operative Release of Ankylosis of the Elbow Due to Heterotopic Ossification

BACKGROUND: Although uncommon, complete ankylosis of the elbow secondary to heterotopic ossification results in severe disability. The results of surgical management remain unclear. METHODS: A single surgeon used a consistent operative technique to treat complete osseous ankylosis of the elbow in eleven limbs in seven patients after severe burns and in nine elbows in eight patients after trauma. The elbows in the burn cohort were more often ankylosed in extension (average, 47° of flexion) compared with those in the trauma cohort (66° of flexion), and they had more skin problems (three elbows required a free microvascular muscle transfer for coverage) and associated problems of the shoulder, wrist, and hand. RESULTS: Four patients in the burn cohort and three patients in the trauma cohort failed to regain at least 80° of ulnohumeral motion. After a repeat release in three burn patients and three trauma patients, and at an average follow-up of forty months, the average arc of ulnohumeral motion was 81° in the burn cohort and 94° in the trauma cohort. Six of the eleven limbs in the burn cohort and five of the nine in the trauma cohort had a good result. The average score according to the American Shoulder and Elbow Surgeons elbow assessment form was 72 points for the burn cohort and 76 points for the trauma cohort. CONCLUSIONS: Osseous ankylosis of the elbow is a severely disabling problem, and attempts to regain mobility are both worthwhile and safe. The results are comparable when the ankylosis is caused by burns or trauma despite the greater complexity of osseous ankylosis in the burned arm. Patients and surgeons should be aware of the small risk of recurrent heterotopic ossification and the moderate risk of pain or recurrent contracture after operative release.

Operative release of ankylosis of the elbow due to heterotopic ossification. Surgical technique.

Although uncommon, complete ankylosis of the elbow secondary to heterotopic ossification results in severe disability. The results of surgical management remain unclear. A single surgeon used a consistent operative technique to treat complete osseous ankylosis of the elbow in eleven limbs in seven patients after severe burns and in nine elbows in eight patients after trauma. The elbows in the burn cohort were more often ankylosed in extension (average, 47 degrees of flexion) compared with those in the trauma cohort (66 degrees of flexion), and they had more skin problems (three elbows required a free microvascular muscle transfer for coverage) and associated problems of the shoulder, wrist, and hand. Four patients in the burn cohort and three patients in the trauma cohort failed to regain at least 80 degrees of ulnohumeral motion. After a repeat release in three burn patients and three trauma patients, and at an average follow-up of forty months, the average arc of ulnohumeral motion was 81 degrees in the burn cohort and 94 degrees in the trauma cohort. Six of the eleven limbs in the burn cohort and five of the nine in the trauma cohort had a good result. The average score according to the American Shoulder and Elbow Surgeons elbow assessment form was 72 points for the burn cohort and 76 points for the trauma cohort. Osseous ankylosis of the elbow is a severely disabling problem, and attempts to regain mobility are both worthwhile and safe. The results are comparable when the ankylosis is caused by burns or trauma despite the greater complexity of osseous ankylosis in the burned arm. Patients and surgeons should be aware of the small risk of recurrent heterotopic ossification and the moderate risk of pain or recurrent contracture after operative release.

Operative release of complete ankylosis of the elbow due to heterotopic bone in patients without severe injury of the central nervous system.

Although uncommon, complete ankylosis of the elbow secondary to heterotopic ossification results in severe disability. The results of surgical management remain unclear. A single surgeon used a consistent operative technique to treat complete osseous ankylosis of the elbow in eleven limbs in seven patients after severe burns and in nine elbows in eight patients after trauma. The elbows in the burn cohort were more often ankylosed in extension (average, 47 degrees of flexion) compared with those in the trauma cohort (66 degrees of flexion), and they had more skin problems (three elbows required a free microvascular muscle transfer for coverage) and associated problems of the shoulder, wrist, and hand. Four patients in the burn cohort and three patients in the trauma cohort failed to regain at least 80 degrees of ulnohumeral motion. After a repeat release in three burn patients and three trauma patients, and at an average follow-up of forty months, the average arc of ulnohumeral motion was 81 degrees in the burn cohort and 94 degrees in the trauma cohort. Six of the eleven limbs in the burn cohort and five of the nine in the trauma cohort had a good result. The average score according to the American Shoulder and Elbow Surgeons elbow assessment form was 72 points for the burn cohort and 76 points for the trauma cohort. Osseous ankylosis of the elbow is a severely disabling problem, and attempts to regain mobility are both worthwhile and safe. The results are comparable when the ankylosis is caused by burns or trauma despite the greater complexity of osseous ankylosis in the burned arm. Patients and surgeons should be aware of the small risk of recurrent heterotopic ossification and the moderate risk of pain or recurrent contracture after operative release.