Wildfire Burn Patients: A Unique Population

Abstract In the past ten years wildfires have burned an average of 6.8 million acres per year and this is expected to increase with climate change. Wildfire burn patient outcomes have not been previously well characterized. Wildfire burn patients from the Tubbs or Camp wildfires and non-wildfire burn matched controls were identified from the burn center database and outcomes were compared. The primary outcome was mortality. Secondary outcomes included length of stay (LOS), intensive care unit (ICU) LOS, readmission and development of wound infections. Time of presentation and operating room use after wildfires was evaluated. Sixteen wildfire burn patients were identified and matched with 32 controls. Wildfire burn patients trended towards higher mortality (19% wildfire vs. 9% non-wildfire, p=0.386), longer LOS (18 days wildfire vs. 15 days non-wildfire, p=0.406), longer ICU LOS (17 days wildfire vs. 11 days non-wildfire, p=0.991), increased readmission (19% wildfire vs. 3% non-wildfire, p=0.080) and higher rates of wound infection (31% wildfire vs. 19% non-wildfire, p=0.468). The majority of wildfire patients (88%) presented within 24 hours of the wildfire reaching a residential area. Operating room time within the first week was 13 hours 44 minutes for the Tubbs Fire and 19 hours 1 minute for the Camp Fire. Patients who sustain burns in wildfires are potentially at increased risk of mortality, prolonged LOS, wound infection and readmission.

Download Full-text

602 Managing Hypothermia in the Surgical Burn Patient

Journal of Burn Care & Research ◽

10.1093/jbcr/iraa024.228 ◽

2020 ◽

Vol 41 (Supplement_1) ◽

pp. S144-S144

Author(s):

Patricia Regojo ◽

Molly Mohan

Keyword(s):

Quality Assurance ◽

Operating Room ◽

Core Body Temperature ◽

Temperature Management ◽

Evidence Based ◽

Burn Patients ◽

Estimated Blood Loss ◽

Increased Risk ◽

Burn Unit ◽

Burn Patient

Abstract Introduction It is known, hypothermia, core body temperature at or below 36oC/96.8oF, can lead to dangerous complications for burn patients. Due to loss of their protective thermoregulation, burn patients are at an increased risk of hypothermia during surgery. Findings from a Quality Assurance audit revealed burn patients were returning from surgery hypothermic and hemodynamically unstable. There was little evidence of intra-operative temperature management in the electronic medical record (EMR) or reported to the nurse upon the patients’ return from the operating room (OR). Only 73% of patients had temperatures recorded during their surgery and of those, 40% had a drop of temperature >2 degrees from their baseline. The purpose of this collaborative evidence-based quality assurance project was to improve temperature management in the operating room and prevent hypothermia in the intra and post operative periods. Our aim was to develop warming methods pre-operatively that would establish a goal for keeping the patients’s temperature within 2 degrees of their baseline preoperative temperature during surgery. Methods A literature search obtained from CINAHL, Cochrane, EMBASE, and MEDLINE from 2010–2018, provided current surgical guidelines and evidence-based practices for managing surgical hypothermia in burn patients (levels of evidence I, III, V, & VI). Recommendations from the burn unit staff for preoperative warming initiatives were listed and shared with the OR staff. Hemodynamic documentation, including core temperature, estimated blood loss, and intra-operative warming methods were monitored for twelve months after the Burn Unit Warming Protocol was implemented. Progress was reported quarterly in our Burn and Trauma Quality Committees. Results After implementing the Burn Unit Warming Protocol, temperature management of the burn patient improved. Intra-operative warming methods were initiated. Patients began returning from surgery warmer with improved hemodynamics. 96% of the patients had their temperatures recorded and managed intra-operatively. Of those patients, only 2.6% had a drop in temperature > 2 degrees from their pre-operative baseline. Conclusions Implementing a nurse-driven warming protocol from the pre-operative stage through surgery can aid in reducing post-operative hypothermia in burn patients. Applicability of Research to Practice Managing hypothermia will help reduce complications that can lead to increase morbidity and mortality in burn patients.

Download Full-text

When More Means Less: The Prognosis of Recurrent Acute Myocardial Infarctions

Journal of Clinical Medicine ◽

10.3390/jcm10245889 ◽

2021 ◽

Vol 10 (24) ◽

pp. 5889

Author(s):

Ygal Plakht ◽

Harel Gilutz ◽

Arthur Shiyovich

Keyword(s):

Primary Outcome ◽

Risk Group ◽

High Risk Group ◽

Myocardial Infarctions ◽

Time Interval ◽

Post Discharge ◽

Risk Of Mortality ◽

Increased Risk ◽

All Cause Mortality ◽

The Mean

Recurrent acute myocardial infarctions (AMI) are common and associated with dismal outcomes. We evaluated the clinical characteristics and the prognosis of AMI survivors according to the number of recurrent AMIs (ReAMI) and the time interval of events (TI). A retrospective analysis of patients who survived following hospitalization with an AMI throughout 2002–2017 was conducted. The number of ReAMIs for each patient during the study period was recorded and classified based on following: 0 (no ReAMIs), 1, 2, ≥3. Primary outcome: all-cause mortality up to 10 years post-discharge from the last AMI. A total of 12,297 patients (15,697 AMI admissions) were analyzed (age: 66.1 ± 14.1 years, 68% males). The mean number of AMIs per patient was 1.28 ± 0.7; the rates of 0, 1, 2, ≥3 ReAMIs were 81%, 13.4%, 3.6% and 1.9%, respectively. The risk of mortality increased in patients with greater number of AMIs, HR = 1.666 (95% CI: 1.603–1.720, p < 0.001) for each additional event (study group), attenuated following adjustment for potential confounders, AdjHR = 1.135 (95% CI: 1.091–1.181, p < 0.001). Increased risk of mortality was found with short TI (<6-months), AdjHR = 2.205 (95% CI: 1.418–3.429, p < 0.001). The risk of mortality following AMI increased as the number of ReAMIs increased, and the TI between the events shortened. These findings should guide improved surveillance and management of this high-risk group of patients (i.e., ReAMI).

Download Full-text

P1478LOWERING PREVALENCE OF ALKALOSIS AND IMPROVING ADHERENCE TO BICARBONATE TARGETS AMONGST HAEMODIALYSIS PATIENTS THROUGH THE USE OF REDUCED DIALYSATE BICARBONATE

Nephrology Dialysis Transplantation ◽

10.1093/ndt/gfaa142.p1478 ◽

2020 ◽

Vol 35 (Supplement_3) ◽

Author(s):

Caroline Tulley ◽

Richard Hull ◽

Martin Ford

Keyword(s):

Patient Outcomes ◽

Patient Survival ◽

Target Range ◽

Serum Bicarbonate ◽

Bicarbonate Concentration ◽

Ongoing Debate ◽

Risk Of Mortality ◽

Increased Risk ◽

The Mean ◽

Small Change

Abstract Background and Aims There is evidence that metabolic alkalosis in haemodialysis patients is harmful. Bommer et al demonstrated association between extremes of bicarbonate and clinical outcomes with significantly increased risk of mortality and hospitalisation with pre-dialysis serum bicarbonate >27mmol/L and <17mmol/L. No overall increased mortality risk was observed with moderate pre-dialysis acidosis (serum bicarbonate 19.1-23.0mmol/L). 2015 Renal Registry Data demonstrated 64.3% of haemodialysis patients overall had bicarbonates within target (18-24mmol/L) compared to 65.7% within our centre. Our reported mean pre-dialysis bicarbonate of 23.7mmol/L was above the mean serum bicarbonate 23.2mmol/L seen nationally. In addition, 33.7% of patients were alkalotic, with bicarbonates >24mmol/L. Given concerns of adverse patient outcomes with extremes of bicarbonate, we aimed to investigate whether reducing our dialysate bicarbonate would culminate in overall attainment of bicarbonate targets. Method Mid-week pre-dialysis bicarbonate levels were measured from in centre haemodialysis patients once monthly, from May to August 2017, across 7 dialysis units within our renal service. Following this, in early 2018, we reduced dialysate bicarbonate concentration from 32mmol/L to 31mmol/L. Monthly midweek pre-dialysis bicarbonate levels were then re-measured in March and April 2019. Results Initial analysis of 2103 pre-dialysis bicarbonate levels across May to August 2017 demonstrated median monthly bicarbonate levels of 24.0–25.0mmol/L. 40.7–54.2% (n=199-322) were alkalotic with pre-dialysis bicarbonates >24mmol/L across this period. Of note, 15-23% (n=66-120) had bicarbonate levels associated with increased mortality and hospitalisation (i.e. <17mmol/L or >27 mmol/L. Subsequent analysis of 1070 bicarbonate levels in March and April 2019 demonstrated a reduction in median pre-dialysis bicarbonate to 22.0mmol/L. Similarly, the proportion of alkalotic patients fell to 11.9–15.3% (n=71-91). 5-9% (n=26-46) bicarbonates were <17 or >27mmol/L. In March 2019, 77.9% of patients had serum bicarbonates in target range compared to 65.7% reported in 2015 overall. Conclusion Initial findings demonstrated substantial alkalosis amongst our dialysis population. A simple measure of altering dialysate by 1mmol/L achieved reductions in overall alkalaemia, and in turn, reduced the percentage of patients with bicarbonate values theoretically correlating with increased mortality and hospitalization risk. We have demonstrated that a small change in dialysate bicarbonate increased concordance with bicarbonate targets, without subsequent increased acidaemia. The extent to which adherence with such targets impacts on patient survival and morbidity remains an ongoing debate.

Download Full-text

Potassium Fluctuations Are Associated With Inhospital Mortality From Acute Myocardial Infarction. Soroka Acute Myocardial Infarction II (SAMI-II) Project

Angiology ◽

10.1177/0003319717740004 ◽

2017 ◽

Vol 69 (8) ◽

pp. 709-717 ◽

Cited By ~ 7

Author(s):

Arthur Shiyovich ◽

Harel Gilutz ◽

Ygal Plakht

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Primary Outcome ◽

Medical Center ◽

Inhospital Mortality ◽

St Segment Elevation ◽

Risk Of Mortality ◽

St Segment ◽

Increased Risk ◽

All Cause Mortality

Potassium levels (K, mEq/L) fluctuate in patients with acute myocardial infarction (AMI). Potassium was reported to be associated with prognosis in patients with AMI; however, studies evaluating the prognostic value of K fluctuations in this setting are scarce. We retrospectively analyzed patients with AMI hospitalized in a tertiary medical center, through 2002 to 2012. Patients on chronic dialysis or mechanical ventilation were excluded. Based on all K values during hospitalization, minimal, maximal, and fluctuation (gap between 2 consecutive K) were recorded. Primary outcome was inhospital all-cause mortality. Overall, 10 032 patients were studied (age 68.1 ± 14.3 years, 65.4% males, 44.2% ST-segment elevation MI), of which 507 (3.7%) died in hospital. Potassium decreased during the first 2 to 3 days ( P for trend <.001), followed by stabilization ( P for trend = .807). Potassium in the extreme categories (<3.8 and ≥4.7) and absolute fluctuations >0.1 mEq/L were more common among nonsurvivors than survivors ( P < .001 each). In a multivariate analysis, combinations of minimal K <3.8 with maximal K ≥4.7 (odds ratio [OR] = 18.1), K ≥4.4 with fluctuation ≥0.1 (OR = 1.74), or <−0.1 (OR = 2.6) and minimal K after the first 2 admission days (OR = 2.07) were associated with increased risk of mortality ( P < .001 each). Potassium fluctuations, peak and nadir K, and its timing independently predict inhospital mortality in patients with AMI.

Download Full-text

Associations of longitudinal D-Dimer and Factor II on early trauma survival risk

BMC Bioinformatics ◽

10.1186/s12859-021-04065-z ◽

2021 ◽

Vol 22 (1) ◽

Author(s):

Richard M. Jiang ◽

Arya A. Pourzanjani ◽

Mitchell J. Cohen ◽

Linda Petzold

Keyword(s):

Risk Prediction ◽

Patient Outcomes ◽

Trauma Patients ◽

Longitudinal Trajectories ◽

Consumptive Coagulopathy ◽

Risk Of Mortality ◽

Increased Risk ◽

Factor Ii ◽

Unit Increase ◽

D Dimer

Abstract Background Trauma-induced coagulopathy (TIC) is a disorder that occurs in one-third of severely injured trauma patients, manifesting as increased bleeding and a 4X risk of mortality. Understanding the mechanisms driving TIC, clinical risk factors are essential to mitigating this coagulopathic bleeding and is therefore essential for saving lives. In this retrospective, single hospital study of 891 trauma patients, we investigate and quantify how two prominently described phenotypes of TIC, consumptive coagulopathy and hyperfibrinolysis, affect survival odds in the first 25 h, when deaths from TIC are most prevalent. Methods We employ a joint survival model to estimate the longitudinal trajectories of the protein Factor II (% activity) and the log of the protein fragment D-Dimer ($$\upmu$$ μ g/ml), representative biomarkers of consumptive coagulopathy and hyperfibrinolysis respectively, and tie them together with patient outcomes. Joint models have recently gained popularity in medical studies due to the necessity to simultaneously track continuously measured biomarkers as a disease evolves, as well as to associate them with patient outcomes. In this work, we estimate and analyze our joint model using Bayesian methods to obtain uncertainties and distributions over associations and trajectories. Results We find that a unit increase in log D-Dimer increases the risk of mortality by 2.22 [1.57, 3.28] fold while a unit increase in Factor II only marginally decreases the risk of mortality by 0.94 [0.91,0.96] fold. This suggests that, while managing consumptive coagulopathy and hyperfibrinolysis both seem to affect survival odds, the effect of hyperfibrinolysis is much greater and more sensitive. Furthermore, we find that the longitudinal trajectories, controlling for many fixed covariates, trend differently for different patients. Thus, a more personalized approach is necessary when considering treatment and risk prediction under these phenotypes. Conclusion This study reinforces the finding that hyperfibrinolysis is linked with poor patient outcomes regardless of factor consumption levels. Furthermore, it quantifies the degree to which measured D-Dimer levels correlate with increased risk. The single hospital, retrospective nature can be understood to specify the results to this particular hospital’s patients and protocol in treating trauma patients. Expanding to a multi-hospital setting would result in better estimates about the underlying nature of consumptive coagulopathy and hyperfibrinolysis with survival, regardless of protocol. Individual trajectories obtained with these estimates can be used to provide personalized dynamic risk prediction when making decisions regarding management of blood factors.

Download Full-text

Factors Associated with Surgical Wound Infection in Patients for Elective Clean Surgery at the “Rafael Ángel Calderón Guardia” Hospital, Costa Rica

Acta Médica Costarricense ◽

10.51481/amc.v52i3.744 ◽

2011 ◽

Vol 52 (3) ◽

Author(s):

Moraima Guevara Rodrìguez ◽

Juan Josè Romero Zúñiga

Keyword(s):

Wound Infection ◽

Operating Room ◽

Costa Rican ◽

Surgical Wound Infection ◽

International Standards ◽

Surgical Wound ◽

Increased Risk ◽

Group A ◽

The Difference ◽

Group B

Aim: Hospital surgical wound infection (SWI) is one of the three most frequent causes of nosocomial infection worldwide, leading to high social and medical costs. This study aims to identify and quantify risk factors for SWI in a Costa Rican hospital. Methods: A cohort study of 488 elective patients operated between April and June 2006. The patients were divided in 2 groups: those in which operating room traffic was restricted, group A, and those in which it was not, group B. The statistical analysis was performed in 2 major phases: descriptive and analytical. In the first one, frequency measures (absolute and relative) were calculated; and the second one was carried out in 2 stages; both of them through unconditional logistic regression, univariate and multivariate analysis. Results: An overall incidence of 35.2 % (172/488) of SWI was found. The cumulative incidence in the unexposed was 31.8% (76/239), while in those exposed, it was 38.6% (96/249) (p=0.12). Only organ and bone/joint surgery presented a higher risk of SWI (OR 2.42; 95% CI:1.5-3.8), surgeries in unrestricted traffic rooms and diabetes had no association with the infection. Conclusion: Diabetes and depth of surgery should be taken into account in the profile of patients with increased risk of suffering SWI; furthermore, even though there was no epidemiological association between restricted operating room traffic and not restricted, and SWI, although the difference in incidence of SWI, was not statistically significant, it is advisable to restrict the transit of persons in operating rooms, according to international standards.

Download Full-text

Cancer and COVID-19: analysis of patient outcomes

Future Oncology ◽

10.2217/fon-2021-0121 ◽

2021 ◽

Author(s):

Mohamed Aboueshia ◽

Mohammad Hosny Hussein ◽

Abdallah S Attia ◽

Aubrey Swinford ◽

Peter Miller ◽

...

Keyword(s):

Regression Analysis ◽

Cohort Study ◽

Hospital Stay ◽

Cancer Patients ◽

Patient Outcomes ◽

Retrospective Cohort Study ◽

Retrospective Cohort ◽

Active Smoking ◽

Risk Of Mortality ◽

Increased Risk

Background: We sought to investigate the outcomes associated with COVID-19 disease in cancer patients. Methods: We conducted a retrospective cohort study of laboratory-confirmed COVID-19 patients. Results: Of the 206 patients included, 57 had at least one preexisting malignancy. Cancer patients were older than noncancer patients. Of the 185 discharged cases, cancer patients had a significantly higher frequency of unplanned reintubation (7.1% vs 0.9%, p < 0.049), and required longer hospital stay (8.58 ± 6.50 days versus 12.83 ± 11.44 days, p < 0.002). Regression analysis revealed that obesity and active smoking were associated with an increased risk of mortality. Conclusion: Outcomes in COVID-19 appear to be driven by obesity as well as active smoking, with no difference in mortality between cancer and noncancer patients.

Download Full-text

A “Reverse July Effect”: Association Between Timing of Admission, Medical Team Workload, and 30-Day Readmission Rate

Journal of Graduate Medical Education ◽

10.4300/jgme-d-13-00014.1 ◽

2014 ◽

Vol 6 (1) ◽

pp. 65-70 ◽

Cited By ~ 8

Author(s):

Yelena Averbukh ◽

William Southern

Keyword(s):

Patient Outcomes ◽

Readmission Rate ◽

Primary Outcome ◽

Readmission Rates ◽

Increased Risk ◽

July Effect ◽

Teaching Team ◽

Independent Association ◽

Time Of Year ◽

Academic Year

Abstract Background High teaching team workload has been associated with poor supervision and worse patient outcomes, yet it is unclear whether this association is more pronounced during the early months of the academic year when the residents are less experienced. Objective We examined the associations between teaching team workload, timing of admission, and the 30-day readmission rate. Methods In this retrospective observational study, all admissions to an urban internal medicine teaching service over a 16-month period were divided into 2 groups based on admission date: early in the academic year (July–September) or late (October–June) and further defined as being admitted to “busy” versus “less busy” teams based on number of monthly admissions. The primary outcome was 30-day readmission rate. Multivariate logistic regression was used to determine the independent association between teaching team workload and readmission rates, stratified by time of year of admission after adjustment for demographic and clinical characteristics. Results Of 12 118 admissions examined, 2352 (19.4%) were admitted early in the year, and 9766 (80.6%) were admitted later. After multivariate adjustment, we found that patients admitted to busy versus less busy teams in the first quarter had similar 30-day readmission rate (odds ratio [OR]adj = 1.03 [0.82–1.30]). Later year admission to a busy team was associated with increased risk of readmission after adjustment (ORadj = 1.16 [1.03–1.30]). Conclusions Admission to busy teams early in the year was not associated with increased odds of 30-day readmission, whereas admission later in the year to busy teams was associated with 16% increased odds of readmission.

Download Full-text

SARS-CoV-2 INFECTION ACCELERATES ATHEROSCLEROSIS AND LEADS TO MYOCARDIAL INFARCTION: HYPOTHESIS OR OBJECTIVE REALITY?

"Medical & pharmaceutical journal "Pulse" ◽

10.26787/nydha-2686-6838-2021-23-3-95-102 ◽

2021 ◽

pp. 95-102

Author(s):

Lozhkina N.G. ◽

Gushchina O.I. ◽

Evdokimova N.E. ◽

Parkhomenko O.M.

Keyword(s):

Coronary Atherosclerosis ◽

Clinical Case ◽

Atherosclerotic Plaques ◽

The Novel ◽

The Past ◽

Risk Of Mortality ◽

Conflicting Evidence ◽

Increased Risk ◽

Coronavirus Infection ◽

Progressive Course

The past 2020 was marked by the SARS-CoV-2 pandemic, which entailed an increased risk of mortality in patients with previous cardiovascular diseases (CVD) or with various risk factors (RF) of atherosclerosis. There is conflicting evidence from clinical and scientific studies of COVID-19-related cardiovascular disease. One of the features of the new SARS-CoV-2 infection is its ability to induce a systemic hyperinflammatory response, accompanied by instability of atherosclerotic plaques. In this sense, the course of atherosclerosis becomes accelerated, or rapidly progressing. The article presents a clinical case demonstrating the progressive course of coronary atherosclerosis in a patient with several interrelated factors, including the novel SARS-CoV-2 coronavirus infection.

Download Full-text

Scottish Index of Multiple Deprivation (SIMD) Indicators as Predictors of Mortality Among Patients Hospitalised with COVID-19 Disease in the Lothian Region, Scotland During the First Wave: A Cohort Study

10.21203/rs.3.rs-1102651/v1 ◽

2021 ◽

Author(s):

Marcello S Scopazzini ◽

Roo Nicola Rose Cave ◽

Callum P Mutch ◽

Daniella A Ross ◽

Anda Bularga ◽

...

Keyword(s):

Cohort Study ◽

Primary Outcome ◽

Multivariable Analysis ◽

Multiple Deprivation ◽

Multiple Risk Factors ◽

Risk Of Mortality ◽

Increased Risk ◽

The Uk ◽

Index Of Multiple Deprivation ◽

Age And Sex

Abstract Background: Sars-CoV-2, the causative agent of COVID-19, has led to more than 100,000 deaths in the UK and multiple risk factors for mortality including age, sex and deprivation have been identified. This study aimed to identify which indicators of Scottish Index of Multiple Deprivation (SIMD), an area-based deprivation index, were predictive of mortality. Methods: This was a prospective cohort study of anonymised electronic health records of 710 consecutive patients hospitalised with Covid-19 disease between March and June 2020 in the Lothian Region of Southeast Scotland. Data sources included automatically extracted data from national electronic platforms and manually extracted data from individual admission records. Exposure variables of interest were SIMD quintiles and more specifically 12 indicators of deprivation deemed clinically relevant selected from the SIMD. Our primary outcome was mortality. Univariable and multivariable logistic regression analyses adjusted for age and sex were used to determine measures of association between exposures of interest and the primary outcome. Results: After adjusting for age and sex, we found an increased risk of mortality in the more deprived SIMD quintiles 1 and 3 (OR 1.75, CI 0.99-3.08, p=0.053 and OR 2.17, CI 1.22-3.86, p=0.009, respectively), but this association was not significant in our multivariable model adjusted for co-morbidities and clinical parameters of severity at admission. Of the 12 pre-selected indicators of deprivation, two were associated with greater mortality in our multivariable analysis: income deprivation rate categorised by quartile (Q4 (most deprived): 2.11 (1.20-3.77) p=0.011)) and greater than expected hospitalisations due to alcohol per SIMD data zone (1.96 (1.28-3.00) p=0.002)). Conclusions: In contrast to other studies, deprivation quintile distribution was not predictive of mortality in our cohort. This possibly reflects the greater affluence and ethnic homogeneity of the Lothian Region compared to the rest of Scotland. We identified an increased risk of mortality in patients residing in areas with greater income-deprivation and/or number of hospitalisations due to alcohol. In areas where aggregate measures fail to capture pockets of deprivation, specific indicators may be helpful in targeting resources to residents at risk of poorer outcomes from Covid-19.

Download Full-text