Predictors of withdrawal of life support after burn injury

Introduction: Discussions regarding withdrawal of life support after burn injury are challenging and complex. Often, providers may facilitate this discussion when the extent of injury makes survival highly unlikely or when the patient's condition deteriorates during resuscitation. Few papers have evaluated withdrawal of life support in burn patients. We therefore sought to determine the predictor of withdrawal of life support (WLS) in a regional burn center. Methods: We conducted a retrospective analysis of all burn patients from 2002 to 2012. Patient characteristics included age, gender, burn mechanism, percentage total body surface area (%TBSA) burned, presence of inhalation injury, hospital length of stay, and pre-existing comorbidities. Patients <17 years of age and patients with unknown disposition were excluded. Patients were categorized into three cohorts: Alive till discharge (Alive), death by withdrawal of life support (WLS), or death despite ongoing life support (DLS). DLS patients were then excluded from the study population. Multivariate logistic regression was used to estimate predictors of WLS. Results: 8,371 patients were included for analysis: 8134 Alive, 237 WLS. Females had an increased odd of WLS compared to males (OR 2.03, 95% CI 1.18–3.48; p = 0.010). Based on higher CCI, patients with pre-existing comorbidities had an increased odd of WLS (OR 1.28, 95% CI 1.08–1.52; p = 0.005). There was a significantly increased odds for WLS (OR 1.09, 95% CI 1.06–1.12; p < 0.001) with increasing age. Similarly, there was an increased odd for WLS (OR 1.08, 95% CI 1.07–1.51; p < 0.001) with increasing %TBSA. An increased odd of WLS (OR 2.47, 95% CI 1.05–5.78; p = 0.038) was also found in patients with inhalation injury. Conclusion: The decision to withdraw life support is a complex and difficult decision. Our current understanding of predictors of withdrawal of life support suggests that they mirror those factors which increase a patient's risk of mortality. Further research is needed to fully explore end-of-life decision making in regards to burn patients. The role of patient's sex, particularly women, in WLS decision making needs to be further explored

Racial and ethnic disparities in discharge to rehabilitation following burn injury

Racial and ethnic disparities in access to inpatient rehabilitation have been previously described for various injury groups; however, no studies have evaluated whether such disparities exist among burn patients. Their aim was to determine if racial disparities in discharge destination (inpatient rehabilitation, skilled nursing facility, home with home health, or home) following burn injury existed in this single-institution study. A retrospective analysis of all adult burn patients admitted to UNC Jaycee Burn Center from 2002 to 2012 was conducted. Patient characteristics included age, gender, burn mechanism, insurance status, percentage total body surface area (%TBSA) burned, presence of inhalation injury, and hospital length of stay. Patients were categorized into one of three mutually exclusive racial or ethnic groups: White, Hispanic, or Black. Propensity score weighting followed by ordered logistic regression was performed in the analytical sample and in a subgroup analysis of patients with severe burns (TBSA > 20%). For analysis, 4198 patients were included: 2661 White, 340 Hispanic, and 1197 Black. Propensity weighting resulted in covariate balance among racial groups. Black patients (OR: 1.58, 95% CI: 1.23-2.03; P <.001) were more likely than Whites to be discharged to a higher level of rehabilitation, whereas Hispanics were less likely (OR: 0.78, 95% CI: 0.38-1.58; P =.448). In their subgroup analysis, Black (OR: 1.88, 95% CI: 1.07-3.28; P =.026) and Hispanic (OR: 1.53, 95% CI: 0.31-7.51; P =.603) patients were more likely to discharge to a higher level of rehabilitation than White patients. Racial and ethnic disparities in discharge destination to a higher level of rehabilitative services among burn-injured patients exist particularly for Hispanic patients but not for Black or White burn patient groups. Further studies are needed to elucidate the potential sources of these disparities specifically for Hispanic patients

Amputation Following Burn Injury

Amputation following burn injury is rare. Previous studies describe the risk of amputation after electrical burn injuries. Therefore, we describe the distribution of amputations and evaluate risk factors for amputation following burn injury at a large regional burn center. We conducted a retrospective analysis of patients ≥17 years admitted from January 2002 to December 2015. Patients who did and did not undergo an amputation procedure were compared. A multivariate logistic regression model was used to determine the risk factors for amputation. Amputations were further categorized by extremity location and type (major, minor) for comparison. Of the 8313 patients included for analysis, 1.4% had at least one amputation (n = 119). Amputees were older (46.7 ± 17.4 years) than nonamputees (42.6 ± 16.8 years; P =.009). The majority of amputees were white (47.9%) followed by black (39.5%) when compared with nonamputees (white: 57.1%, black: 27.3%; P =.012). The most common burn etiology for amputees was flame (41.2%) followed by electrical (23.5%) and other (21.9%). Black race (odds ratio [OR]: 2.29; 95% confidence interval [CI]: 1.22-4.30; P =.010), electric (OR: 13.54; 95% CI: 6.23-29.45; P <.001) and increased %TBSA (OR: 1.03; 95% CI: 1.02-1.05; P <.001) were associated with amputation. Burn etiology, the presence of preexisting comorbidities, black race, and increased %TBSA increase the odds of post burn injury. The role of race on the risk of amputation requires further study

An epidemiological study of the relative importance of damp housing in relation to adult health

STUDY OBJECTIVE—To examine the association between damp housing and adult health, taking into account a wide range of other factors that may influence health and could confound this relation.
PARTICIPANTS AND SETTING—A general population sample of adults, aged 18-64, from Oxfordshire, Buckinghamshire, Berkshire and Northamptonshire.
DESIGN—Secondary analysis of responses to a postal questionnaire survey carried out in 1997 with a 64% response rate (8889 of 13 800). Housing dampness was assessed by self report. Health was measured by responses to a series of questions including presence of asthma and longstanding illness generally, use of health services and perceived health status (the SF-36). The effect of damp was examined using the χ(2) test and one way analysis of variance. Significant associations with the various health outcomes were further explored taking into account 35 other housing, demographic, psychosocial and lifestyle variables using stepwise logistic and linear regression.
MAIN RESULTS—Bivariate analyses indicated that damp was associated with the majority of health outcomes. Regression modelling however, found that being unable to keep the home warm enough in winter was a more important explanatory variable. Worry about pressure at work and to a lesser extent about money, showed an independent association with perceived health status equal to or greater than that of the housing environment, including cold housing, and that of health related lifestyles.
CONCLUSIONS—This study shows that being unable to keep the home warm enough in winter is more strongly associated with health outcomes than is damp housing. However, as cold and damp housing are closely related, it is likely that their combined effects are shown in these results. The importance of worry as an independent predictor of health status needs testing in other studies. Its prevalence and relative importance suggest that it may be a significant determinant of public health.


Keywords: damp housing; cold housing; healt