The effect of preexisting respiratory co-morbidities on burn outcomes

Introduction Burns cause physiologic changes in multiple organ systems in the body. Burn mortality is usually attributable to pulmonary complications, which can occur in up to 41% of patients admitted to the hospital after burn. Patients with preexisting comorbidities such as chronic lung diseases may be more susceptible. We therefore sought to examine the impact of preexisting respiratory disease on burn outcomes. Methods A retrospective analysis of patients admitted to a regional burn center from 2002–2012. Independent variables analyzed included basic demographics, burn mechanism, presence of inhalation injury, TBSA, pre-existing comorbidities, smoker status, length of hospital stay, and days of mechanical ventilation. Bivariate analysis was performed and Cox regression modeling using significant variables was utilized to estimate hazard of progression to mechanical ventilation and mortality. Results There were a total of 7640 patients over the study period. Overall survival rate was 96%. 8% (n = 672) had a preexisting respiratory disease. Chronic lung disease patients had a higher mortality rate (7%) compared to those without lung disease (4%, p < 0.01). The adjusted Cox regression model to estimate the hazard of progression to mechanical ventilation in patients with respiratory disease was 21% higher compared to those without respiratory disease (HR = 1.21, 95% CI = 1.01–1.44). The hazard of progression to mortality is 56% higher (HR = 1.56, 95% CI = 1.10–2.19) for patients with pre-existing respiratory disease compared to those without respiratory disease after controlling for patient demographics and injury characteristics. Conclusion Preexisting chronic respiratory disease significantly increases the hazard of progression to mechanical ventilation and mortality in patients following burn. Given the increasing number of Americans with chronic respiratory diseases, there will likely be a greater number of individuals at risk for worse outcomes following burn

Burn injury mortality in patients with preexisting and new onset renal disease

Introduction: We sought to examine the impact of preexisting and new onset renal disease on burn injury mortality. Methods: Retrospective analysis of patients admitted to a regional burn center from 2002-2012 was performed. Variables analyzed included demographics, burn mechanism, inhalation injury status, and % TBSA. Poisson regression was performed to estimate risk of in-hospital burn mortality. Results: There were a total of 7640 patients over the study period. The adjusted 60-day risk of in-hospital mortality in patients with preexisting renal disease (PRD was 3 times higher compared to patients with no preexisting renal disease (IRR = 3.22, 95% CI = 1.26–8.25). The adjusted 60-day risk of mortality is 2 times higher for patients with new onset renal disease compared to those without (IRR = 2.11, 95% CI = 1.55–2.87). Conclusion: Preexisting and new onset renal disease results in a significantly higher risk of mortality following burn injury compared to patients without renal disease. Prevention of new onset renal injury and careful management of patients with preexisting renal disease to prevent exacerbation should be pursued

Intentional injury against children in Sub-Saharan Africa: A tertiary trauma centre experience

Background Intentional injuries are the result of violence. This is an important public health issue, particularly in children, and is an unaddressed problem in sub-Saharan Africa. This study sought to describe the characteristics of intentional injury, particularly physical abuse, in children presenting to our tertiary trauma centre in Lilongwe, Malawi and how they compare to children with unintentional injuries. Methods A retrospective analysis of children (<18 years old) with traumatic injuries presenting to Kamuzu Central Hospital (KCH) in Lilongwe, Malawi from 2009 to 2013 was performed. Children with intentional and unintentional injuries were compared with bivariate analysis and multivariate logistic regression modelling. Results 67,672 patients with traumatic injuries presented to KCH of which 24,365 were children. 1976 (8.1%) patients presented with intentional injury. Intentional injury patients had a higher mean age (11.1 ± 5.0 vs. 7.1 ± 4.6, p < 0.001), a greater male preponderance (72.5 vs. 63.6%, p < 0.001), were more often injured at night (38.3 vs. 20.7%, p < 0.001), and alcohol was more often involved (7.8 vs. 1.0%, p < 0.001). Multivariate logistic regression modelling showed that increasing age, male gender, and nighttime or urban setting for injury were associated with increased odds of intentional injury. Soft tissue injuries were more common in intentional injury patients (80.5 vs. 45.4%, p < 0.001) and fist punches were the most common weapon (25.6%). Most patients were discharged in both groups (89.2 vs 80.9%, p < 0.001) and overall mortality was lower for intentional injury patients (0.9 vs. 1.2%, p = 0.001). Head injury was the most common cause of death (43.8 vs. 32.2%, p < 0.001) in both groups. Conclusions Sub-Saharan African tertiary hospitals are uniquely positioned to play a pivotal role in the identification, clinical management, and alleviation of intentional injuries to children by facilitating access to social services and through prevention efforts

Practical and ethical challenges of a North-South partnership

INTRODUCTION The Departments of Surgery at the University of North Carolina (UNC) and Kamuzu Central Hospital (KCH) in Lilongwe, Malawi, formed a partnership of service, training, and research in 2008. We report a case of recurrent pancreatitis leading to pancreatic necrosis treated at KCH. PRESENTATION OF CASE A 42 year-old male presented to KCH with his fourth episode of abdominal pain, nausea and vomiting. He had tachycardia, guarding, rebound tenderness, and free fluid on abdominal ultrasonography. He underwent laparotomy and had fat saponification with pancreatic necrosis. A large drain was placed, he was given antibiotics, and he recovered. He had normal lipids, no gallstones, and did not consume alcohol. He was encouraged to seek further evaluation with endoscopic retrograde cholangiopancreatography or computed tomography in South Africa, however this was prohibitively expensive. DISCUSSION This case illustrates the limitations that are often faced by surgeons visiting developing countries. What we consider standard resources and treatment algorithms in managing necrotizing pancreatitis in developed countries (such as serum lipase and percutaneous interventions) were not available. CONCLUSION Visiting surgeons and trainees must be both familiar with local resource limitations and aware of the implications of such limitations on patient care. To support training and promote advances in health care, local surgeons and trainees should understand optimal treatment strategies regardless of their particular resource limitations. North-South partnerships are an excellent means to uphold our professional obligation to humanity, promote health care as a right, and shape the future of health care in developing countries

The effect of seasonality on burn incidence, severity and outcome in Central Malawi

Introduction In much of the world, burns are more common in cold months. However, few studies have described the seasonality of burns in sub-Saharan Africa. This study examines the effect of seasonality on the incidence and outcome of burns in central Malawi. Methods A retrospective analysis was performed at Kamuzu Central Hospital and included all patients admitted from May 2011 to August 2014. Demographic data, burn mechanism, total body surface area (%TBSA), and mortality were analyzed. Seasons were categorized as Rainy (December–February), Lush (March–May), Cold (June–August) and Hot (September–November). A negative binomial regression was used to assess the effect of seasonality on burn incidence. This was performed using both the raw and deseasonalized data in order to evaluate for trends not attributable to random fluctuation. Results A total of 905 patients were included. Flame (38%) and Scald (59%) burns were the most common mechanism. More burns occurred during the cold season (41% vs 19–20% in the other seasons). Overall mortality was 19%. Only the cold season had a statistically significant increase in burn. The incidence rate ratios (IRR) for the hot, lush, and cold seasons were 0.94 (CI 0.6–1.32), 1.02 (CI 0.72–1.45) and 1.6 (CI 1.17–2.19), respectively, when compared to the rainy season. Burn severity and mortality did not differ between seasons. Conclusion The results of this study demonstrate the year-round phenomenon of burns treated at our institution, and highlights the slight predominance of burns during the cold season. These data can be used to guide prevention strategies, with special attention to the implications of the increased burn incidence during the cold season. Though burn severity and mortality remain relatively unchanged between seasons, recognizing the seasonal variability in incidence of burns is critical for resource allocation in this low-income setting

The effect of incentive spirometry on postoperative pulmonary function following laparotomy a randomized clinical trial

Importance: Changes in pulmonary dynamics following laparotomy are well documented. Deep breathing exercises, with or without incentive spirometry, may help counteract postoperative decreased vital capacity; however, the evidence for the role of incentive spirometry in the prevention of postoperative atelectasis is inconclusive. Furthermore, data are scarce regarding the prevention of postoperative atelectasis in sub-Saharan Africa. Objective: To determine the effect of the use of incentive spirometry on pulmonary function following exploratory laparotomy as measured by forced vital capacity (FVC). Design, Setting, and Participants: Thiswas a single-center, randomized clinical trial performed at Kamuzu Central Hospital, Lilongwe, Malawi. Study participants were adult patients who underwent exploratory laparotomy and were randomized into the intervention or control groups (standard of care) from February 1 to November 30, 2013. All patients received routine postoperative care, including instructions for deep breathing and early ambulation.We used bivariate analysis to compare outcomes between the intervention and control groups. Intervention: Adult patients who underwent exploratory laparotomy participated in postoperative deep breathing exercises. Patients in the intervention group received incentive spirometers Main outcomes and measures: We assessed pulmonary function using a peak flow meter to measure FVC in both groups of patients. Secondary outcomes, such as hospital length of stay and mortality, were obtained from the medical records. Results: A total of 150 patients were randomized (75 in each arm). The median age in the intervention and control groups was 35 years (interquartile range, 28-53 years) and 33 years (interquartile range, 23-46 years), respectively. Men predominated in both groups, and most patients underwent emergency procedures (78.7%in the intervention group and 84.0%in the control group). Mean initial FVC did not differ significantly between the intervention and control groups (0.92 and 0.90 L, respectively; P = .82 [95%CI, 0.52-2.29]). Although patients in the intervention group tended to have higher final FVC measurements, the change between the first and last measured FVC was not statistically significant (0.29 and 0.25 L, respectively; P = .68 [95%CI, 0.65-1.95]). Likewise, hospital length of stay did not differ significantly between groups. Overall postoperative mortality was 6.0%, with a higher mortality rate in the control group compared with the intervention group (10.7%and 1.3%, respectively; P = .02 [95%CI, 0.01-0.92]). Conclusions and Relevance: Education and provision of incentive spirometry for unmonitored patient use does not result in statistically significant improvement in pulmonary dynamics following laparotomy.We would not recommend the addition of incentive spirometry to the current standard of care in this resource-constrained environment. Trial registration: clinicaltrials.gov Identifier: NCT01789177

Burns from e-cigarettes and other electronic nicotine delivery systems

With increasing use of electronic cigarettes (e-cigarettes) and other electronic nicotine delivery systems (ENDS) globally, the debate surrounding the potential harms or benefits may shift to ensuring that the devices are manufactured, marketed, and sold according to standards that reduce harm and promote health

Bacterial Infections after Burn Injuries: Impact of Multidrug Resistance

Patients who are admitted to the hospital after sustaining a large burn injury are at high risk for developing hospital-associated infections. If patients survive the initial 72 hours after a burn injury, infections are the most common cause of death. Ventilator-associated pneumonia is the most important infection in this patient population. The risk of infections caused by multidrug-resistant bacterial pathogens increases with hospital length of stay in burn patients. In the first days of the postburn hospitalization, more susceptible, Gram-positive organisms predominate, whereas later more resistant Gram-negative organisms are found. These findings impact the choice of empiric antibiotics in critically ill burn patients. A proactive infection control approach is essential in burn units. Furthermore, a multidisciplinary approach to burn patients with a team that includes an infectious disease specialist and a pharmacist in addition to the burn surgeon is highly recommended

Injury Characteristics and Outcomes in Elderly Trauma Patients in Sub-Saharan Africa

Background: Traumatic injury in the elderly is an emerging global problem with an associated increase in morbidity and mortality. This study sought to describe the epidemiology of elderly injury and outcomes in sub-Saharan Africa. Methods: We conducted a retrospective analysis of adult patients (≥ 18 years) with traumatic injuries presenting to the Kamuzu Central Hospital (KCH) in Lilongwe, Malawi, over 5 years (2009–2013). Elderly patients were defined as adults aged ≥65 years and compared to adults aged 18–44 and 45–64 years. We used propensity score matching and logistic regression to compare the odds of mortality between age groups using the youngest age group as the reference. Results: 42,816 Adult patients with traumatic injuries presented to KCH during the study period. 1253 patients (2.9 %) were aged ≥65 years with a male preponderance (77.4 %). Injuries occurred more often at home as age increased (25.3, 29.5, 41.1 %, p < 0.001) and falls were more common (14.1, 23.8, 36.3 %, p < 0.001) for elderly patients. Elderly age was associated with a higher proportion of hospital admissions (10.6, 21.3, 35.2 %, p < 0.001). Upon propensity score matching and logistic regression analysis, the odds ratio of mortality for patients aged ≥65 was 3.15 (95 % CI 1.45, 6.82, p = 0.0037) compared to the youngest age group (18–44 years). Conclusions: Elderly trauma in a resource-poor area in sub-Saharan Africa is associated with a significant increase in hospital admissions and mortality. Significant improvements in trauma systems, pre-hospital care, and hospital capacity for older, critically ill patients are imperative

Colonization with Multidrug-Resistant Enterobacteriaceae is Associated with Increased Mortality Following Burn Injury in Sub-Saharan Africa

Background: Multidrug-resistant (MDR) bacteria are an emerging international concern in low- and middle-income countries that threaten recent public health gains. These challenges are exacerbated in immunocompromised hosts, such as those with burn injury. This study sought to describe the epidemiology and associated clinical outcomes of burn wound colonization in a Malawian tertiary burn center. Methods: This is a prospective analysis of burn patients presenting to Kamuzu Central Hospital in Lilongwe, Malawi, within 72 h of burn injury. A swab of each patient’s primary wound was collected at admission and each subsequent week. The primary exposure was burn wound colonization with MDR bacteria, particularly Enterobacteriaceae. The primary outcome was in-hospital mortality. A log binomial model estimated the association between the exposure and outcome, adjusted for confounders. Results: Ninety-nine patients were enrolled with a median age of 4 years (IQR 2–12) and a male preponderance (54%). Median total body surface area burn (TBSA) was 14% (IQR 9–25), and crude in-hospital mortality was 19%. Enterobacteriaceae were the most common MDR bacteria with 36% of patients becoming colonized. Wound colonization with MDR Enterobacteriaceae was associated with increased in-hospital mortality with a risk ratio of 1.86 (95% CI 1.38, 2.50, p < 0.001) adjusted for TBSA, burn type (scald vs. flame), sex, age, length of stay, and methicillin-resistant Staphylococcus aureus colonization. Conclusion: MDR bacteria, especially Enterobacteriaceae, are common and are associated with worse burn injury outcomes. In resource-poor environments, a greater emphasis on prevention of MDR bacterial colonization, improved isolation precautions, affordable diagnostics, and antibiotic stewardship are imperative