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Richard J Kagan

Publications and source records attributed to Richard J Kagan.

15 recordsLinked to original sources
PubMed2006

Effect of blood transfusion on outcome after major burn injury: a multicenter study.

OBJECTIVE: To delineate blood transfusion practices and outcomes in patients with major burn injury. CONTEXT: Patients with major burn injury frequently require multiple blood transfusions; however, the effect of blood transfusion after major burn injury has had limited study. DESIGN: Multicenter retrospective cohort analysis. SETTING: Regional burn centers throughout the United States and Canada. PATIENT POPULATION: Patients admitted to a participating burn center from January 1 through December 31, 2002, with acute burn injuries of >or=20% total body surface area. OUTCOMES MEASURED: Outcome measurements included mortality, number of infections, length of stay, units of blood transfused in and out of the operating room, number of operations, and anticoagulant use. RESULTS: A total of 21 burn centers contributed data on 666 patients; 79% of patients survived and received a mean of 14 units of packed red blood cells during their hospitalization. Mortality was related to patient age, total body surface area burn, inhalation injury, number of units of blood transfused outside the operating room, and total number of transfusions. The number of infections per patient increased with each unit of blood transfused (odds ratio, 1.13; p<.001). Patients on anticoagulation during hospitalization received more blood than patients not on anticoagulation (16.3+/-1.5 vs. 12.3+/-1.5, p<.001). CONCLUSIONS: The number of transfusions received was associated with mortality and infectious episodes in patients with major burns even after factoring for indices of burn severity. The utilization of blood products in the treatment of major burn injury should be reserved for patients with a demonstrated physiologic need.

Adult↗
PubMed2006

Norepinephrine modulates the inflammatory and proliferative phases of wound healing.

BACKGROUND: Injury results in the massive release of norepinephrine (NE) into the peripheral circulation. Recent investigations have demonstrated functional adrenoreceptors on the cellular mediators of cutaneous wound healing and NE-induced phenotypic alterations in immune cells have been demonstrated in vitro. Despite this, there is little description of how NE might alter the phases of wound healing in vivo. The purpose of this study was to compare cutaneous wound healing in norepinephrine-intact and norepinephrine-depleted mice. METHODS: Norepinephrine-depleted (NED) mice were generated by chemical axotomy with 6-hydroxydopamine and compared with norepinephrine-intact (NEI) animals (n = 6-12 per group, per time point). Using an excisional wound model, neutrophil recruitment was measured by myeloperoxidase assay. Macrophage recruitment and angiogenesis were measured by immunohistochemistry and re-epithelialization was determined histologically. The development of incisional wound disruption strength was determined over time. Finally, macrophage scavenger function was assessed by an in vitro latex bead phagocytosis assay. RESULTS: Wounds from NEI mice demonstrated greater neutrophil infiltration than NED wounds (24, 72 hours; p < 0.05). Wound macrophage recruitment was initially higher in NEI animals (24 hours, p < 0.05), but was eventually surpassed by that of NED animals (120 hours, p < 0.05). Angiogenesis was decreased while re-epithelialization was accelerated in NEI animals (p < 0.05). Wound disruption strength and macrophage scavenger function were unaltered between NED and NEI mice. CONCLUSIONS: Norepinephrine modulates the inflammatory and proliferative phases of wound healing in a temporally defined, cell-specific manner. By increasing recruitment of innate immune cells and expediting wound closure, norepinephrine appears to play a protective role in defense against infection.

Animals↗
PubMed2006

A microbiologic study of enteral feeding hang time in a burn hospital: can feeding costs be reduced without compromising patient safety?

BACKGROUND: Procedural changes for hospitalized patients must always balance safety with fiscal constraints. Microbiologic contamination of enteral feeding solutions has been previously associated with nosocomial infections. Formula manipulation and hang time contribute to microbial load, and there is considerable variation in hang time recommendations in the medical literature. With cost containment in mind, the purpose of this performance improvement study was to determine if an increase in hang time of a modular tube feeding product would increase microbial load or affect the nosocomial infection rate in pediatric burn patients. METHODS: This biphasic trial initially evaluated the microbial load of the feeding after delivery of two 4-hour aliquots into a container using the same delivery set (total hang time of 8 hours; number of tests = 20). Second, once this feeding procedure was deemed microbiologically safe, tube feedings were administered to patients, and both microbial load and nosocomial infection rate were monitored for 1 year. RESULTS: Contamination levels at the end of the 8-hour period using the same feeding set with 2 consecutive 4-hour feeding aliquots (number of tests = 38) were lower than standard recommendations. The hospital's nosocomial infection rate was not altered by this procedural change, and feeding-set expenses were reduced. CONCLUSIONS: The hang time of our enteral feeding administration set can be increased safely from 4 hours to 8 hours, with the tube feeding preparation added as two 4-hour aliquots without a significant change in microbial load or nosocomial infection rate, thus promoting simultaneous fiscal responsibility and patient safety.

Burn Units↗
PubMed2005

Surgical treatment of hidradenitis suppurativa: a 10-year experience.

BACKGROUND: Hidradenitis suppurativa (HS) is a disease of the apocrine sweat glands resulting in chronic wounds with abscesses, sinuses, and fibrosis. Because many patients referred for treatment have both recurrent and progressive disability, we attempted to determine which factors have the greatest impact on outcome so we could develop an operative treatment algorithm. METHODS: We identified 57 patients with HS who underwent operative treatment for chronic recurrent HS from January 1994 through December 2003. Charts were reviewed for demographic, treatment, and outcome data. RESULTS: The mean age at presentation was 34 years and the average duration of symptoms was 6.7 years. Two thirds of the patients had undergone 1 or more incision and drainage procedures and 90% had received long-term antibiotic therapy. Axillary involvement was present in 88% of women and was bilateral in half of all patients. Inguinoperineal involvement was present in 87% of men and was bilateral in 92% of all patients. An algorithm for operative treatment was developed based on the extent of involvement, chronicity, and comorbid conditions. Ninety-two operative procedures were performed, 50% involved the axilla, 36% involved the perineum, and 14% involved the inguinal region. Excision and primary closure was used for localized disease; wide excision with or without skin grafting was used for diffuse disease. CONCLUSIONS: HS is a chronic relapsing disease that frequently causes disabling pain, diminished range of motion, and social isolation. Definitive treatment involves operative excision of the involved apocrine tissue and should be individualized based on the stage and location of the disease.

Adult↗
PubMed2004

Tracheostomy in thermally injured patients: does diagnosis-related group 483 adequately estimate resource use and hospital costs?

BACKGROUND: This study compares burn and nonburn patients undergoing tracheostomy, all of whom were assigned to diagnosis-related group 483 to determine hospital reimbursement. METHODS: We reviewed the records of all inpatients admitted to our hospital from January 2000 through December 2001 who underwent tracheostomy and who were assigned to diagnosis-related group 483. In addition, we compared our burn patient data with that from three other burn centers and the National Burn Repository. RESULTS: We identified 357 inpatients who had tracheostomies during their hospitalization, only 12 of whom (3.4%) had acute burn injuries. The mean extent of burn in these patients was 43.4% total body surface area. The most frequent primary diagnoses for nonburn patients were injury and poisoning, and circulatory and respiratory disorders. Patients with burn injuries had 39.6 ventilator days, 40.7 intensive care unit days, and 49.2 hospital days compared with 19.8, 17.4, and 29.5 days, respectively, for nonburn patients (p <0.0001). Demographic, resource, and financial data for burn patients treated at the three other burn centers and those reported to the National Burn Repository were not significantly different from burn patients treated at our hospital. Total costs and charges for the care of burn patients were $186,830 and $343,904, respectively, compared with $82,176 and $160,498 for the nonburn patients (p <0.0005). CONCLUSION: Burn patients requiring tracheostomies during their acute hospitalization consume significantly more resources than patients without burn injuries. More appropriate resource-based reimbursement for the care of these patients appears warranted.

Adult↗
PubMed2003

Clinical effects of inhibiting leukocyte adhesion with monoclonal antibody to intercellular adhesion molecule-1 (enlimomab) in the treatment of partial-thickness burn injury.

BACKGROUND: A randomized, prospective, multicenter, double-blind, placebo-controlled, phase II clinical trial was performed to determine whether inhibition of leukocyte adherence by administration of monoclonal antibody directed against intercellular adhesion molecule-1 would improve burn wound healing. METHODS: One hundred ten patients with burn injury ranging from 10% to 30% total body surface area were enrolled. Fifty-six patients received placebo (saline) and 54 patients received murine monoclonal antibody to the human intercellular adhesion molecule-1 (enlimomab). Treatment was initiated within 6 hours of injury. Patients had three distinct partial-thickness wound sites assessed. Laser Doppler flowmetry was used to stratify wounds on the day of injury. Wounds were assessed for healing status on day 21 postburn and categorized as healed, nonhealed, or grafted. RESULTS: Patients treated with enlimomab had a significantly increased percentage of wounds that healed spontaneously in less than 21 days overall and when stratified by burn wound laser Doppler blood flow readings for those wounds at greatest risk for nonhealing. CONCLUSION: These results support the concept that leukocyte adherence is involved in the pathogenesis of burn wound necrosis and suggest a therapeutic mechanism for modulating the inflammatory response after the burn injury that may improve wound healing.

Adult↗
PubMed2002

Cultured skin substitutes reduce donor skin harvesting for closure of excised, full-thickness burns.

OBJECTIVE: Comparison of cultured skin substitutes (CSS) and split-thickness skin autograft (AG) was performed to assess whether donor-site harvesting can be reduced quantitatively and whether functional and cosmetic outcome is similar qualitatively in the treatment of patients with massive cutaneous burns. SUMMARY BACKGROUND DATA: Cultured skin substitutes consisting of collagen-glycosaminoglycan substrates populated with autologous fibroblasts and keratinocytes have been shown to close full-thickness skin wounds in preclinical and clinical studies with acceptable functional and cosmetic results. METHODS: Qualitative outcome was compared between CSS and AG in 45 patients on an ordinal scale (0, worst; 10, best) with primary analyses at postoperative day 28 and after about 1 year for erythema, pigmentation, pliability, raised scar, epithelial blistering, and surface texture. In the latest 12 of the 45 patients, tracings were performed of donor skin biopsies and wounds treated with CSS at postoperative days 14 and 28 to calculate percentage engraftment, the ratio of closed wound:donor skin areas, and the percentage of total body surface area closed with CSS. RESULTS: Measures of qualitative outcome of CSS or AG were not different statistically at 1 year after grafting. Engraftment at postoperative day 14 exceeded 75% in the 12 patients evaluated. The ratio of closed wound:donor skin areas for CSS at postoperative day 28 was significantly greater than for conventional 4:1 meshed autografts. The percentage of total body surface area closed with CSS at postoperative day 28 was significantly less than with AG. CONCLUSIONS: The requirement for harvesting of donor skin for CSS was less than for conventional skin autografts. These results suggest that acute-phase recovery of patients with extensive burns is facilitated and that complications are reduced by the use of CSS together with conventional skin grafting.

Burns↗
PubMedDate not supplied

Invited editorial.

Explore the source record for details and available documents.

Biocompatible Materials↗
PubMedDate not supplied

The 2002 Clinical Research Award. An evaluation of the safety of early vs delayed enteral support and effects on clinical, nutritional, and endocrine outcomes after severe burns.

Early enteral support is believed to improve gastrointestinal, immunological, nutritional, and metabolic responses to critical injury; however, this premise is in need of further substantiation by definitive data. The purpose of this prospective study was to examine the effectiveness and safety of early enteral feeding in pediatric patients who had burns in excess of 25% total body surface area. Seventy-seven patients with a mean percent total body surface area burn of 52.5 +/- 2.3 (range 26-91), percent full thickness injury of 44.7 +/- 2.8 (range 0-90), and age ranging from 3.1 to 18.4 (mean 9.3 +/- 0.5) were randomized to two groups: early (feeding within 24 hours of injury) vs control (feeding delayed at least 48 hours postburn). Nutrient intake was measured daily, indirect calorimetry was performed biweekly, and blood and urine samples were obtained for the assay of cortisol, glucagon, insulin, gastrin, epinephrine, norepinephrine, dopamine, triiodothyronine, tetraiodothyronine, albumin, transferrin, prealbumin, retinol-binding protein, glucose, nitrogen balance, and 3-methylhistidine throughout the study period. Three protocol violations occurred, and two patients were transferred to another hospital; these patients were excluded from the study. No patient in either group experienced tube feeding aspiration. No differences were evident in infection, diarrhea, hospital length of stay, or mortality outcomes. A higher incidence of reportable adverse events coincided with early feeding (22 vs 8%), but this was not statistically significant. The delayed feeding group demonstrated a significant caloric deficit during postburn week (PBW) 1 (P <.0001) and PBW2 (P =.0022). Serum insulin (P =.0004) and triiodothyronine (P =.0162) were higher in the early fed group during PBW1. A decrease in 3-methylhistidine output (suggesting a decrease in protein breakdown) was also evident during PBW1 (P =.0138). No other significant trends in study outcome variables were noted. In conclusion, provision of enteral nutrients shortly after burn injury reduces caloric deficits and may stimulate insulin secretion and protein retention during the early phase postburn. These data, however, do not necessarily reaffirm the safety of early enteral feeding, nor do they associate earlier feeding with a direct improvement in endocrine status or a reduction in morbidity, mortality, hypermetabolism, or hospital stay. Future studies are needed to establish precise feeding implementation times that maximize clinical benefit while minimizing morbidity in the critically injured burn patient.

Adolescent↗
PubMedDate not supplied

Home oxygen therapy: adjunct or risk factor?

The use of home oxygen therapy has become increasingly commonplace and is frequently prescribed by medical specialists. In this study, we have identified a generally unexpected risk of home oxygen therapy. We performed a retrospective review of 3673 consecutive patients treated at our adult burn center over a 10-year period from 1992 to 2001. We identified 27 patients with burns directly attributable to oxygen therapy and also noted an increased incidence of these injuries over the study period. The average age of the patients was 68.1 +/- 9.2 years (range, 40-82 years). Twenty-three were using oxygen at home, three in nursing homes, and one was an inpatient in an acute care facility. Twenty-five patients (93%) were receiving oxygen therapy for the diagnosis of chronic obstructive pulmonary disease. Twenty-four patients (89%) were smoking while using oxygen, two were lighting pilot lights, and one was lighting his wife's cigarette. Four patients (15%) sustained burns greater than 10% TBSA. Seventeen patients (63%) had only partial thickness burns. Thirteen patients (48%) required admission for treatment of their burn injuries. The average length of stay for those admitted was 4.4 days. The average hospital charge for admitted patients was US dollars 8055. There were four deaths (15%), all of which were correlated only with the extent of injury. Although intuitively obvious to most health care professionals, not all patients understand that oxygen therapy and cigarettes or open flame can result in a significant injury. Although some practitioners have advocated not prescribing home oxygen for those who continue to smoke, an alternative means of reducing the incidence of this preventable complication appears warranted. Prevention efforts should focus on the counseling of patients and their caregivers as well as educating primary care physicians, nurses, and home health providers as to the dangers of oxygen use.

Accident Prevention↗
PubMedDate not supplied

Procalcitonin in pediatric burn patients: an early indicator of sepsis?

To determine whether changes in procalcitonin (PCT) could be used to predict the onset of sepsis, daily PCT levels were monitored in 20 burned children. Analysis indicated a PCT rise of 5 ng/ml or greater as the best indication of sepsis. We compared the surgeons' determination of sepsis, which was based on changes in platelet count, C-reactive protein (CRP), and other clinical manifestations, with the prediction of sepsis from PCT. There were 26 septic episodes and 36 nonseptic episodes in the 20 patients. PCT results were classified as to true positives, false positives, true negatives, and false negatives. As an indicator of sepsis, the PCT assay had a sensitivity of 42%, a specificity of 67%, and an efficiency of 57%. Even when the assay correctly identified sepsis, the determination was made an average of 0.8 days after the surgeon had already made the diagnosis based on CRP and/or platelet count. We conclude that PCT is not as effective as CRP and/or platelet count in the early detection of sepsis in burned children.

Burns↗
PubMedDate not supplied

Grease fryers: a significant danger to children.

Scald injuries in children often occur as the result of them pulling a container of hot liquid off a countertop or stove. To date, there have been no studies that have specifically examined the impact of the burning agent after this mechanism of injury on the magnitude of injury or the hospital resources consumed in caring for these patients. In this study, we sought to compare the extent and depth of injury, hospital resources consumed, and outcomes of children burned by pulling a container of grease or other liquid onto themselves. We retrospectively reviewed all cases of children who were admitted to our pediatric burn center from January 1995 through December 2001 who sustained scald injuries as the result of pulling a container of hot liquid onto himself or herself. Patients were evaluated for extent TBSA burned, depth of injury, the need for skin grafts, and the number of ventilator, days in the intensive care unit, and total hospital days (length of stay). We identified 196 children admitted with scald injuries caused by this mechanism. Fifty-four (27.6%) were caused by grease or oil, and 142 (72.6%) were caused by other liquids. The mean age of children burned by this mechanism was approximately 3 years, and slightly more than half were males. The mean TBSA and full-thickness burn was 18.3% and 8.1% for the grease group and 14.4% and 4.5% for the no-grease group, respectively (P <.05). Fifty-six percent of those children burned with grease required skin grafting compared with only 34% of those burned by other liquids. Twenty percent of the patients burned by grease required ventilator support compared with only 6.3% of those burned by other liquids (P <.01). Of those burned by grease, 22.2% required care in the intensive care unit compared with only 6.3% of those burned by other liquids (P <.005). Mean length of stay was 16.8 +/- 2.5 days and 9.1 +/- 1.0 days for the grease and nongrease groups, respectively (P <.001). Scalds caused by children pulling a grease fryer onto themselves result in more extensive and deeper injuries and greater consumption of hospital resources than those from other liquids. These findings support the need for safer product design and more specific warnings in product labeling and instructions as to the danger of severe scald injury to minimize the occurrence of such injuries.

Adolescent↗
PubMedDate not supplied

Reversible cardiomyopathy after severe burn injury.

Cardiomyopathy can result in significant morbidity and mortality, leading to long-term cardiac disability or consideration for transplantation. This study reviewed our experience with pediatric burn patients who developed cardiomyopathy during their acute hospitalization. We identified five patients admitted from 1991 to 2003 who were diagnosed with cardiomyopathy during their initial hospitalization and retrospectively collected data regarding hospital course, cardiac dysfunction, radiographic and echocardiographic studies, pharmacologic treatment, and long-term cardiac function. All children were Caucasian males with extensive full-thickness burns requiring prolonged ventilatory support. Initial signs and symptoms of cardiomyopathy, including radiographic and echocardiographic evidence, were noted greater than 30 days after injury. Patients received a combination of digoxin, diuretics, angiotensin-enzyme converting inhibitor, and beta-blocker therapy. During follow-up over the course of 2 to 11 years, all patients returned to normal cardiac function. Cardiomyopathy after extensive burn injury appears reversible. With prompt diagnosis and treatment, cardiac function normalizes within 9 to 21 months after the initiation of treatment.

Adolescent↗
PubMedDate not supplied

National Burn Repository 2005: a ten-year review.

In the early 1990s, the American Burn Association (ABA) started its first burn registry development initiatives. The impetus for the registry development software originated from several directions, including the following: (1) the recognition that national registries were widespread and of proven benefit; (2) growing demands from accrediting institutions, payers, and patient advocacy groups for objective and verifiable data regarding patient costs, treatments, and outcomes; and (3) the shift toward "evidence-based" medicine and the ongoing analysis of treatment effectiveness. The ABA has issued three calls for burn registry data for its National Burn Repository (NBR): 1994, 2002, and 2005. In 1994, 28 burn centers contributed data for more than 6,400 patients treated from 1991 to 1993. The ABA announced its second call for data in 2001 and distributed the published results of more than 54,000 acute burn admissions treated from 1974 to 2002 at the Association's 2002 Annual Meeting. The third ABA call for data was issued in the Fall of 2005. The results are detailed in this report, which provides a summary of more than a quarter million acute burn admissions from 1995 to 2005, representing 70 hospitals from 30 states plus the District of Columbia. Statistics are presented in chart and table format to illustrate such key factors as patient age, burn size group, types of injuries, mortality rates, and average hospital charges by etiology and length of hospital stay. The data presented herein should help stimulate quality improvement programs in burn care, as burn centers compare their performance with the national data and as research is expanded using the NBR. The NBR will be published annually and, with continued refinements to the registry software, should become of increasing importance to clinicians, payers, researchers, and the public.

Adolescent↗